Piedmont Hospital, Inc.

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47718 Based on review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility failed to ensure that two (P1, P2) of three patients (P) (P1, P2, P3) reviewed received the required Important Message from Medicare (IMM) prior to discharge. Findings included: A review of P1’s medical record failed to reveal an IMM (Important Message from Medicare) given at the time of discharge on 03/06/2026 at 10:40 AM. An onsite review of P2’s medical record failed to reveal that an IMM was provided at discharge. The facility submitted an IMM after the survey exit via email. The submitted IMM failed to include a legible date and time. A review of the facility’s policy titled “Rights and Responsibilities of Patients,” policy #16455823, last revised 8/22/24, revealed it was the policy of the facility that all patients had the right to considerate, respectful care always and under all circumstances, with recognition of their personal dignity and autonomy. Within the capacity and scope of its mission and services, the facility respected and supported the patient’s right to impartial access to treatment and services that were consistent with relevant laws and regulations and medically indicated. The patient had a right to have his/her pain assessed and managed appropriately. The patient has the right to be actively involved in his/her medical care and to make decisions concerning that care, including the right to execute informed consent or refuse care. Patients, their family members/legal representatives, and the public had a right to register a complaint or grievance regarding services, patient safety, or quality of care. An interview was conducted in the facility’s conference room on 03/17/2026 at 2:00 PM with Director of Care Management (DCM) JJ, who stated that the facility currently had processes in place to mitigate issues related to IMM (Important Message from Medicare) at discharge. DCM JJ acknowledged that improvements have been made and the facility is currently working towards better coordination; however, the process was still evolving and “not yet where it needs to be.””

“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: 47718 Based on review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility’s nursing staff failed to provide appropriate wound assessment, intervention, and follow-up care for one patient (P) (P1) of three patients (P1, P2, and P3) reviewed after acquiring a skin tear on the sacrum. Findings included: A review of the P1’s operative notes dated 3/3/26 at 12:00 AM revealed that P1 had a bilateral laminectomy (a surgical procedure that removes the back part of a vertebra from both sides to relieve spinal cord or nerve compression), which started on 03/02/2026 11:29 AM and ended at 3:20 PM with no complications. A continued review of the brief operative notes dated 03/02/2026 at 4:00 PM revealed that P1 had an incision site on the back and a Xerofoam (a non-adherent, petrolatum-based sterile dressing), Gauze, ABD (abdominal) Pad, and Tape-Medipore documented under the dressing. A review of the nursing flow sheets dated 03/04/2026 at 8:30 AM revealed that P1 had a surgical incision on the lower back. A skin tear on the gluteal area was documented in the section titled skin integrity (page #283). Documentation failed to reveal any intervention or wound care consultation regarding the skin tear. A review of the Care Management Initial Assessment notes by Social Worker (SW) CC on 03/04/2026 at 9:13 AM revealed that the discharge plan and information were reviewed with the patient and she was agreeable with the discharge plan to return to her current housing with home health services. A review of the Care Management Final Discharge Notes by SW CC on 03/06/2026 at 9:02 AM revealed that skilled home health care, physical therapy and occupational therapy was arranged with a home health company which was anticipated to start within two to three days following discharge. Durable Medical Equipment of a RW (Rolling Walker) was arranged with a durable medical equipment (DME) company and delivered to P1’s bedside at the facility. A review of the nursing notes by a virtual nurse on 03/06/2026 at 9:33 AM revealed that discharge education was completed as per protocol; all questions and concerns were addressed; and P1 verbalized understanding. A continued review of the nursing notes by RN BB on 03/06/2026 at 10:30 AM revealed that no acute changes were noted from the previous physical assessment. Documentation revealed that AVS (after visit summary) discharge instructions had been provided by a virtual nurse. P1 was discharged home on 03/06/2026 at 10:40 AM. Discharge documentation failed to reveal any wound assessment or wound care orders regarding the skin tear. A review of the facility’s policy titled “Nursing Documentation,” policy #19565377, last revised 1/23/26, revealed that it was the policy of the facility that nursing documentation reflected an accurate picture of the nursing care that was provided, outcomes of that care, and the treatments and education that a patient may still need. Documentation should be concise, factual, and occur in a timely manner. The policy outlined the minimum documentation requirements; however, based on the patient’s condition, situation, and complexity, clinical judgment and critical reasoning were employed to determine the need for additional data collection and or more frequent monitoring and documentation Documentation should reflect the nursing process and include assessment, planning, intervention, and patient response. A review of the facility’s care intervention procedure titled “Lumbar Laminectomy Interventions” revealed that interventions focused on maintaining tissue perfusion and neurological function, promoting comfort and healing, preventing/minimizing complications, restoring original function, and providing patient/family education. A review of the facility’s care intervention procedure titled “Pressure Injury Interventions, Adult,” revealed that interventions for adults with pressure injury included managing pain, promoting wound healing, and preventing infection and further injury. The immediate goal post-pressure injury was to identify and eliminate or modify the main causes/risk factors contributing to pressure injury development. Subsequent care goals were to: - Manage pain - Promote optimal wound healing and prevention of subsequent pressure injuries - Prevent and/or minimize complications - Improve patient/family self-care knowledge A review of the facility’s policy titled “Nursing Patient Assessment/Reassessment,” policy #18266318, last revised 6/6/25, revealed that it was the policy of the facility to ensure that all patients received the appropriate assessment (including initial screening and reassessment) provided by qualified individuals within the organization, that the assessment process was multi-disciplinary, interdisciplinary, and that assessing patients was a continuous, collaborative effort with all departments functioning as a team. Patients, their families, and significant others were considered integral to the process. The assessment began at admission and continued throughout the patient’s hospital stay. Assessments were completed upon admission and at various entry points throughout the hospital stay. Individual services would define specific requirements for reassessments based on nursing care needs. The nurse would review assessment data collected each shift to determine the patient’s progress toward discharge and to identify any additional problems that require new or modified interventions. Plans of Care would be updated to reflect any newly identified problems. Care plans would be reprioritized as necessary based on the patient’s condition. The complainant was interviewed by telephone on 03/17/2026 at 9:27 AM. The complainant recalled that she first noticed the wound on P1’s sacrum on Saturday (3/8/26); however, another family member had noticed it on Thursday (3/5/26) and had asked the nurse about it, who stated that it was the wound from her (P1) surgery. The complainant continued to state that another nurse had stated that they had put a band aid on P1’s buttocks for protective measures and when they took off the band aid, it ripped off P1’s skin. An interview was conducted in the facility’s conference room on 03/17/2026 at 10:00 AM with Registered Nurse (RN) BB, who could not recall if P1 had any sacral wounds at discharge, as there was no clear documentation in the medical record supporting the presence, assessment, or treatment of any sacral wounds. RN BB stated that if a patient had a skin tear, a wound care consultation would have been ordered and treatment measures would have been put in place. An interview was conducted in the facility’s conference room on 03/17/2026 at 10:30 AM with Nurse Director, of Acute Care and Critical Care (ND) FF, who confirmed that wound care consultation processes are expected when skin integrity issues, such as skin tear are identified. ND FF acknowledged that nursing documentation should reflect wound assessment interventions and any changes in condition. ND FF continued to state that the absence of such documentation did not align with facility expectations for patient care and record accuracy. An interview was conducted in the facility’s conference room on 03/17/2026 at 11:00 AM with Patient Care Technician (PCT) GG, who could not recall P1. PCT GG stated that when a patient was admitted, two staff members conducted a head-to-toe assessment and documented if there were any concerns for appropriate treatment measures. However, she could not specifically remember if P1 had any wounds on her sacrum during the assessment. A telephone interview was conducted on 03/17/2026 at 11:20 AM with Registered Nurse (RN) EE, who could not recall if P1 had any sacral wounds. RN EE stated that she could only recall changing the dressing on P1’s surgical site (on the back) and ensuring that pain was managed. management She did not remember seeing any dressing on P1’s sacrum. A telephone interview was conducted on 03/1720/26 at 11:45 AM with Registered Nurse (RN) DD, who could not recall P1. She explained that if a patient presents with a wound or skin tear; it should be documented in the medical record and a wound care consultation should be ordered. An interview was conducted in the facility’s conference room on 03/17/2026 at 12:00 PM with Patient Care Technician (PCT) HH, who could not recall P1. However, after the initial skin assessment on admission, she usually paid attention to patients’ skin during routine care and would notify the nurse if there were any concerns. A telephone interview was conducted on 03/17/2024 at 12:30 PM with Registered Nurse (RN) II, who stated that orders are typically in place to direct staff on patient care needs following procedures. RN II continued to state that if a skin tear was identified, an incident report would be completed and a wound care consultation would be initiated. She could not recall if P1 had wounds on her sacrum. An interview was conducted in the facility’s conference room on 03/17/2026 at 1:00 PM with Social Worker (SW) CC, who stated that P1 was discharged home with home health and PT (physical therapy). However, there was not a consultation/order for wound care. If there had been an order for wound care at home, it would have been included with the home health services. SW CC continued to state that the case management assistant obtained a start date from the home health agency, which was usually 24-48 hours following discharge. The home health services for PT was secured and P1 was accepted. SW CC further explained that P1 had a rolling walker delivered to her bedside that she took home with her at discharge. An interview was conducted in the facility’s conference room on 30/17/2026 at 2:00 PM with Director of Care Management (DCM) JJ, who stated that the facility currently had processes in place to mitigate issues related to IMM (Important Message from Medicare) at discharge. DCM JJ acknowledged that improvements have been made and the facility is currently working towards better coordination; however, the process was still evolving and “not yet where it needs to be.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49398 Based on a review of Governing Body Bylaws, medical records, policy and procedures, and staff interviews, it was determined that the facility’s Governing Body failed to: 1. Ensure that the medical staff were accountable to the governing body for providing patients with full disclosure of potential risks and outcomes after an adverse event to one patient (P#2) of the three sampled patients (P#1, P#2, P#3) reviewed. Specifically, MD FF failed to discuss and document the risks and potential outcomes with P#1 when P#1’s baby (P#2) was misidentified by facility staff and given to the wrong mother, who breastfed P#1’s baby (P#2). 2. Ensure that an investigation and corrective actions were completed in response to a reported incident when it was determined that one (P#2) patient was misidentified and given to the wrong mother, and breastfed. Findings Included: Cross refer to A0049 as it relates to the Governing Body’s failure to ensure that patients are being informed of potential risks and outcomes during an adverse event. Cross refer to A0309 as it relates to the Governing Body’s failure to ensure that patient incidents are investigated and corrective actions implemented.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49398 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that patient’s rights were promoted and protected, and care was received in a safe setting when one (P#2) of three (P#1, P#2, P#3) patients reviewed was misidentified by staff who gave P#2 to the wrong mother, resulting in an unintended breastfeeding incident. Findings Included: Cross refer to A0144 as it relates to the failure of the facility to ensure that care was received in a safe setting, which resulted in P#2’s unintended exposure to bodily fluid through breastfeeding.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 49398 Based on a review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to: 1. Ensure that nursing services followed facility policies and procedures for newborn identification verification when facility staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluid through breastfeeding. 2.Ensure that nursing services documented important medical information related to an adverse medical event when staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluid through breastfeeding. 3. Ensure that patient’s rights were promoted and protected, and care was received in a safe setting when one (P#2) of three (P#1, P#2, P#3) patients reviewed was misidentified by staff who gave P#2 to the wrong mother, resulting in an unintended breastfeeding incident. Findings Included: Cross refer to A0398 as it refers to the facility’s failure to ensure that all licensed nurses adhered to the facility’s policies and procedures when staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluid through breastfeeding. Cross refer to A0467 as it relates to nursing staff failing to document an adverse medical event. Cross refer to A0144 as it relates to the failure of the facility to provide care in a safe environment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 49398 Based on a review of policies and procedures, facility documents, and staff interviews, the facility failed to maintain infection prevention standards in the Family Center Unit. Specifically, the facility failed to protect patients from infection exposure after staff improperly identified P#2, leading to P#2 being breastfed by the wrong mother. Findings Included: Cross refer to A0750 as it relates to the facility’s failure to identify or correct the patient identification verification gap, resulting in an avoidable exposure.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 49398 Based on a review of Governing Body Bylaws, Medical Staff Bylaws/Rules and Regulations, medical records, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that P#1 was provided full disclosure of the potential risks and outcomes after an adverse event to one patient (P#2) of the three sampled patients (P#1, P#2, P#3) reviewed. Specifically, MD FF failed to discuss and document the risks and potential outcomes with P#1 when P#1’s baby (P#2) was misidentified by facility staff and given to the wrong mother, who breastfed P#1’s baby (P#2). Findings Included: A review of the facility’s “Bylaws,” last adopted 3/17/20, no number, revealed in Article IV that the affairs of the Corporation were governed by the Board of Directors. The Corporation Board directed and oversaw the Corporation’s affairs. Responsibilities included: a.Providing general strategic, managerial, operational, financial, and clinical oversight of the Corporation. A review of “MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF PIEDMONT HEALTHCARE”, no number, approved 3/21/2023, revealed Article 4, Clinical Departments; 4.C. Functions of Departments., 4.C. The departments shall be organized for the purpose of implementing processes (i) to monitor and evaluate the quality and appropriateness of the care of patients served by the departments; (ii) to monitor the practice of all those with clinical privileges or a scope of practice in a given department. Continued review revealed Article IX, Section 1, Medical Staff. The medical staff of the facility would be organized according to a set of bylaws recommended by the facility medical staff executive committee, by a vote of the medical staff, and approved by the facility Board. The medical staff would have appropriate authority and responsibility for the care of patients, subject to the ultimate authority of the facility Board. A review of Patient (P) #1’s medical record revealed that P#1 was a 29 year-old-female who was admitted to the facility on 2/9/26 with a plan to induce labor due to a new diagnosis of gestational hypertension (blood pressure greater than or equal to 140mmHg systolic or 90mmHg diastolic on 2 separate occasions at least 4 hours apart after 20 weeks of pregnancy when previous blood pressure was normal). A review of “Progress Notes”, dated 2/13/26 at 10:11 a.m., noted that P#1 stated that she didn’t sleep much and was crying yesterday due to the unplanned breastfeeding that occurred with another mother (see infant’s records). Further review of the medical record failed to reveal any additional documentation about the identification issue noted in the facility incident report dated 2/12/26. A review of the facility’s policy titled “Disclosure/Communication of Adverse Event or Unanticipated Outcome”, policy number13696101, last revised 5/29/23, revealed that the purpose of the policy was to establish guidance for effective patient communication in the event of an Adverse Event and/or Unanticipated Outcome, including Disclosure of the event and the facts surrounding it. 3. Definitions “ Adverse Event - A patient safety event that results in harm to a patient. “ Disclosure -Timely and truthful communication of information regarding an adverse event or unanticipated outcome, to a patient and/or the family/legal representative. “ Unanticipated Outcome - An outcome that differs significantly from the anticipated outcome of a treatment, procedure, or care. 1. Policy It was the policy of the facility to inform patients who have experienced an Adverse Event or Unanticipated Outcome of all known facts related to the event in an honest, empathetic, and supportive manner. 6. Procedures 6.1. Response to an Adverse Event or Unanticipated Outcome A. The attending/treating physician(s), manager/supervisor of the area and Risk Management should be notified immediately of an Adverse Event or Unanticipated Outcome to initiate: o Appropriate treatment for the patient. o Investigation and corrective/remedial measures as appropriate. B. Disclosure should be made as soon as possible. 6.2. Preparation for Disclosure “ Responsibility for disclosing the occurrence of an Adverse Event or Unanticipated Outcome generally rests with the attending/treating physician(s). Full Disclosure may require time to investigate to fully understand all facts, the causes of the event and to develop a plan for remediation. However, Disclosure of the event itself should be made as soon as possible after it is identified. Continuing Disclosure of facts and findings should be made as information becomes known and may involve the attending/ treating physician(s), Risk Management, or others with appropriate knowledge of the facts and findings. 6.3. Content of the Disclosure C. A compassionate, honest acknowledgement and description of the Adverse Event or Unanticipated Outcome should be provided, including: “ The time, place, and circumstances “ Cause(s) to the extent known (avoiding speculation) “ Potential consequences for the patient “ A description of measure(s) taken to prevent/correct/minimize harm to the patient. “ A description of measure(s) taken to prevent a recurrence of the event. “ Specific description of resources available for counseling/assistance. 6.4. Documentation of the Disclosure D. Documentation of the Disclosure in the medical record should at least include the following: “ Date and time of the Disclosure; “ Name, title, and relationship of staff and family present; “ Content of the Disclosure; “ Treatment, if any, to mitigate the harm; and “ Any future plan of care related to the Adverse Event or Unanticipated Outcome. A review of the facility’s policy number 16455823, “Rights and Responsibilities of Patient Policy,” last revised 8/22/24, revealed that the purpose of the policy was to acknowledge patients’ rights and responsibilities and the facility’s responsibility to respond to each patient with personal dignity and respect. Patients had the right to: H. The patient had the right to access complete and current information regarding his/her diagnosis, treatment, any known prognosis, and the outcomes of care, including unanticipated outcomes. During an interview on 2/25/26 at 9:10 a.m. with Neonatologist (MD) FF in a conference room, MD FF explained that she reviewed P#3’s admission bloodwork results and had no concerns. Once she finished reviewing the record, she spoke with P#1 and her family to explain that their baby (P#2) had been breastfed by another mother, but that she did not find any health concerns that could affect the baby (P#2) as a result. MD FF said the family did not ask many questions; it seemed they were processing the information they were given. MD FF explained that P#3 is a doctor, and typically, doctors are aware of how to prioritize their health. P#3 attended all prenatal visits, and MD FF did not find any risk factors that required additional infectious disease screening. MD FF also noted that there was no clinical reason to monitor the baby (P#2), as there were no concerns about infection. MD FF acknowledged that P#3 was diagnosed with Group B Streptococcus (GBS) (a common bacterium (usually harmless in healthy adults) found in the gut or genital tract that can cause serious, life-threatening infections in newborns, such as sepsis, pneumonia, or meningitis) but it is only concern during vaginal delivery and P#3 delivered her baby via cesarean section (C-section) (a surgical procedure to deliver a baby through incisions in the mother’s abdomen and uterus). She said P#3 was on prophylactic antibiotics (medications administered before surgical procedures or to high-risk individuals to prevent infections) for GBS. During an interview on 2/25/26 at 10:42 a.m. with Nurse Practitioner (NP) AA in a conference room, NP AA explained that she had just finished P#2’s pediatric exam when CN DD took the baby (P#2) back to her mother. NP AA reported that MD FF told her the obstetrics provider reviewed the medical records for both P#1 and P#3 and found no concerns. MD FF also spoke with P#1 and her family about the situation. NP AA added that MD FF asked her to write the assessment summary, which MD FF then cosigned. NP AA explained that prophylactic antibiotics stay in the body for about four hours before being cleared. Azithromycin takes about 72 hours to leave the system and may appear in small amounts in breast milk. NP AA also said that Dilaudid has a half-life of two to three hours and can be found in breast milk in small amounts, but none of these medications cause harmful effects. During an interview on 2/25/26 at 1:45 p.m. in a conference room with the Chief Executive Officer (CEO) KK and the Chief Medical Officer (CMO) JJ, CMO JJ explained that ultimate authority over the facility resides with the CEO and the Governing Board. During an interview on 2/26/26 at 10:30 a.m. in a conference room with Chief Medical Officer (CMO) JJ, CMO JJ explained that her expectation is for providers to disclose information to patients. She stated that this is provider-driven communication and that the disclosure’s content is outlined in the facility policy. She added that she felt MD FF provided an appropriate disclosure to P#1 per facility policy. CMO JJ said MD FF gave her a medical opinion and disclosed what she felt was most important to the patient: her concern about communicable diseases. CMO JJ explained that providers are responsible for determining which potential consequences or risks are most relevant to disclose to patients. CMO JJ stated that she spoke with MD FF and noted that the documentation of the disclosure discussion in the medical record could have been improved. She acknowledged that MD FF later added an addendum to reflect the disclosure discussion. MD FF was asked by this surveyor to review P#3’s medical record and review the medications P#3 was taking during her admission. MD FF said P#3 was taking Tylenol, stool softeners, ibuprofen, Toradol (a powerful, non-narcotic NSAID used for short-term management of moderate-to-severe pain, commonly after surgery), penicillin (antibiotic used to treat various bacterial infections), azithromycin ( macrolide antibiotic used to treat a wide range of bacterial infections), and Dilaudid (a potent prescription opioid analgesic (narcotic) used to treat moderate to severe pain). MD FF stated that there was no concern about the medications P#3 was taking passing into breast milk. She did not disclose this information or discuss any risks to the baby (P#2) from the unintended exposure to P#1 or her family during their conversation. MD FF said she wanted to add that P#1 was taking Wellbutrin (an antidepressant used to treat major depressive disorder (MDD), seasonal affective disorder (SAD), and aid in smoking cessation) at the time for anxiety. MD FF explained that, from an infection-control perspective, the baby (P#2) was in good health. Standard tests were done. P#1 and her family were invited to ask questions, but they had none, so MD FF said there was nothing else to discuss.”

“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: 49398 Based on a review of medical records, policies and procedures, facility documents, and staff interviews, it was determined that the facility failed to ensure that patients’ rights were promoted and protected, and care was received in a safe setting. Specifically, facility staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluid through breastfeeding. Findings Included: A review of Patient (P) #1’s medical record revealed that P#1 was a 29 year-old-female who was admitted to the facility on 2/9/26 with a plan to induce labor due to a new diagnosis of gestational hypertension (blood pressure greater than or equal to 140mmHg systolic or 90mmHg diastolic on 2 separate occasions at least 4 hours apart after 20 weeks of pregnancy when previous blood pressure was normal). A review of “Flowsheets” revealed that P#1’s nutrition plan for her newborn (P#2) was breastfeeding. A review of “Progress Notes”, dated 2/13/26 at 10:11 a.m., noted that P#1 stated that she didn’t sleep much and was crying yesterday due to the unplanned breastfeeding that occurred with another mother (see infant’s records). Further review of the medical record failed to reveal any additional documentation about the identification issue noted in the facility incident report dated 2/12/26. A review of the facility’s nursing skill document titled “Identifying Newborns and Implementing Security Precautions”, no number, no date, revealed that the purpose of the document was to reduce the risk of accidental switching of infants, infant abductions, and misidentification of infants by Identifying the newborn in the delivery room by placing identical identification bands on the infant, birthing parent, and non-birthing parent. A reliable identification system is necessary to prevent harm to the newborn and parental distress. Red Flags: Be aware that misidentification of newborns can result in patient errors, such as an infant receiving the wrong stored human milk, leading to a risk of bloodborne illnesses, blood being administered to the wrong infant, or specimens being obtained from the wrong infant. POSTPROCEDURE STEP When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band matches the information on the birthing parent’s identification. 4. When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band is the same as the information on the birthing parent’s identification band. 6. Check newborn’s identification bands and electronic tags every shift and each time care would be provided. 1. Be aware that misidentification of newborns could result in patient errors, such as an infant receiving wrong stored human milk, leading to risk of bloodborne illnesses, blood being administered to the wrong infant, or obtaining specimens from the wrong infant. -See other wrong patient errors that could occur in newborns. Care Considerations o Factors that increase the risk of wrong-patient errors in NICUs include the use of nondistinctive temporary first names for newborns (such as “Babyboy” or “Babygirl”), and medical records with sequential numbers assigned, particularly with birth of multiples. 2 o Wrongful administration of human milk could occur in newborns, which could require extensive testing and evaluation of the infant. Strategies to avoid misuse include using bar coding and printers to label the bottles right at the bedside. Nursing staff and parents could then double-check the labels. Patient Outcomes o The newborns, birthing parent, and nonbirthing parents receive identical identification bands. o Patient security and safety were maintained, avoiding harm and potential harm to the newborn, as well as parental distress. o Parents were knowledgeable about and adhered to the postpartum unit’s policies for newborn safety and security. A review of the facility’s policy number 16455823, “Rights and Responsibilities of Patient Policy,” last revised 8/22/24, revealed that the purpose of the policy was to acknowledge patients’ rights and responsibilities and the facility’s responsibility to respond to each patient with personal dignity and respect. Patients had the right to: F. The patient had the right to the provision of care in a safe setting. The Patient Safety Committee, the Environment of Care Committee, the Infection Control Committee, the Security Department, and the facility Risk Management Programs seek to eliminate risks to patients. H. The patient had the right to access complete and current information regarding his/her diagnosis, treatment, any known prognosis, and the outcomes of care, including unanticipated outcomes. A review of “Maternal/Child Event (822096)”, dated 2/12/26, authored by CN DD, revealed a specific reported event related to “Breast Milk/Formula Issue” with a severity level of “no harm - reached patient no monitoring required”. Continued review revealed a brief description, “Patient called primary RN to ask for infant to come back to the room from nursery. Primary RN called to the desk and asked me to take infant to room 52. I grabbed the infant with crib card 52 and took infant to the room. I verified bands at the bedside. Mom called the ID band number, and I called it back out. The infant breastfed for 10-15 mins until the primary RN noticed it was the incorrect infant. We discovered the crib card was changed in pencil from 50 to 62. So, the 6 looked like a 5. The ID bands were almost identical 92032 and 92033. My manager was notified immediately. Both pediatricians and doctors for both couplets were notified. My manager and I explained the incident to both parents.” During an interview on 2/24/26 at 1:12 p.m. with Clinical Manager (CM) CC in a conference room, CM CC explained that on 2/12/26, Registered Nurse BB, the primary nurse for P#3, received a call from P#3 requesting that their baby be brought from the nursery. RN BB asked the front desk if someone could bring the baby to the patient’s room because she had just sat down for lunch. Charge Nurse (CN) DD answered the request and brought P#2, the newborn, to P#3’s room. She checked P#2’s band number against P#3’s band number. The ID number was 92033, and during the verbal check, neither the nurse nor the parents noticed that the last digit was off by one number. CM CC said that approximately 15 minutes later, RN BB received a call from P#3 requesting pain medication. When RN BB entered the room, she noticed that the name on the crib card did not match P#3 and asked to see the baby. After checking the arm band on P#2, she saw it did not match P#3’s band. RN BB then took P#2 back to the nursery and told the charge nurse that P#3 had been given the wrong baby (P#2), and that P#2 had been breastfed by P#3. During an interview on 2/25/26 at 9:10 a.m. with Neonatologist (MD) FF in a conference room, MD FF explained that on 2/12/26, she learned of an incident in which P#3 breastfed the wrong baby (P#2) during the morning huddle. The mistake happened because of a one-digit misidentification in the baby’s band number. She said the nurse who brought P#2 and P#3’s family member both thought the numbers matched. Subsequently, the nurse handed the baby (P#2) to P#3, who then began breastfeeding. During an interview on 2/25/26 at 9:46 a.m. with Charge Nurse (CN) DD in a conference room, Charge Nurse DD said she was working in the Family Center Unit on 2/12/26 when RN BB called the nurses’ station to ask if someone could take P#3’s baby to room #52. RN BB explained that when she picked up the baby from the nursery and brought it to the room, she asked P#3 to say the five-digit identification number. RN BB repeated the number, and both she and P#3 confirmed it was correct. CN DD reported that after she returned to the nurses’ station, about 10 to 15 minutes later, RN BB went to room #52 to give medication to P#3. RN BB noticed the crib card was incorrect, informed P#3 that the baby (P#2) was not theirs, returned the baby (P#2) to the nursery, and told CN DD about the mistake and that the baby (P#2) had been breastfed by P#3. During an interview on 2/25/26 at 11:56 a.m. in a conference room with Clinical Supervisor (CS) II, CS II recalled that on 2/12/26, RN BB called out to the nurses’ station, asking for P#3’s baby to be brought to the mother. CN DD took the baby (P#2) to P#3’s room. CS II said the crib card was hard to read because it had been written over in pencil. CN DD and P#3 checked the bands, and CN DD left the room. About 10 minutes later, RN BB went to P#3’s room and discovered the mistake and informed CN DD. During an interview on 2/25/26 at 2:29 p.m. in a conference room with Chief Nursing Officer (CNO) GG, CNO GG said that the staff involved in the unintended breastfeeding event on 2/12/26 should have followed the patient identification verification process and properly identified the baby (P#2). During an interview on 2/25/26 at 3:06 p.m. in a conference room with RN BB, RN BB explained that she was the primary nurse assigned to P#3 and had just sat down in the breakroom when P#3 called her phone and asked for her baby. RN BB called the nurses’ station to request that P#3’s baby be brought to her room while she was on break. About 10 to 15 minutes later, P#3 called again to request pain medication. RN BB ended her break early and went to P#3’s room to administer the medication. She noticed the crib card appeared incorrect and approached P#3 to observe the baby. Simultaneously, P#3 expressed happiness that the baby (P#2) had finally latched and fed. RN BB found this concerning because P#3’s baby had not been taking the bottle well, making the sudden change unusual. RN BB recalled asking P#3 for the baby (P#2). She asked P#3 if both her bands and the baby’s bands had been checked with the staff, and P#3 said they had. RN BB noticed that the baby (P#2) did not look like P#3’s baby. Because of this and other discrepancies, she checked the baby’s (P#2) ID band and confirmed it was not P#3’s baby. RN BB recalled in that moment, P#3 said, “It’s not my baby, is it?” RN BB said she told P#3 she needed to take the baby back to the nursery and would return momentarily.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 49398 Based on a review of Governing Body Bylaws, Medical Staff Bylaws/Rules and Regulations, facility document, policy and procedures, and staff interviews, it was determined that the facility’s Governing Body failed to ensure that an investigation and corrective actions were completed in response to a reported incident when it was determined that one (P#2) patient was misidentified by facility staff and given to the wrong mother, and breastfed. Findings Included: A review of the facility’s “Bylaws,” last adopted 3/17/20, no number, revealed in Article IV that the affairs of the Corporation were governed by the Board of Directors. The Corporation Board directed and oversaw the Corporation’s affairs. Responsibilities included: a.Providing general strategic, managerial, operational, financial, and clinical oversight of the Corporation. A review of “MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF PIEDMONT HEALTHCARE”, no number, approved 3/21/2023, revealed Article 4, Clinical Departments; 4.C. Functions of Departments., 4.C. The departments shall be organized for the purpose of implementing processes (i) to monitor and evaluate the quality and appropriateness of the care of patients served by the departments; (ii) to monitor the practice of all those with clinical privileges or a scope of practice in a given department. Continued review revealed Article IX, Section 1, Medical Staff. The medical staff of the facility would be organized according to a set of bylaws recommended by the facility medical staff executive committee, by a vote of the medical staff, and approved by the facility Board. The medical staff would have appropriate authority and responsibility for the care of patients, subject to the ultimate authority of the facility Board. A review of “Maternal/Child Event (822096)”, dated 2/12/26, authored by CN DD, revealed a specific reported event related to “Breast Milk/Formula Issue” with a severity level of “no harm - reached patient no monitoring required”. Continued review revealed a brief description, “Patient called primary RN to ask for infant to come back to the room from nursery. Primary RN called to the desk and asked me to take infant to room 52. I grabbed the infant with crib card 52 and took infant to the room. I verified bands at the bedside. Mom called the ID band number, and I called it back out. The infant breastfed for 10-15 mins until the primary RN noticed it was the incorrect infant. We discovered the crib card was changed in pencil from 50 to 62. So, the 6 looked like a 5. The ID bands were almost identical 92032 and 92033. My manager was notified immediately. Both pediatricians and doctors for both couplets were notified. My manager and I explained the incident to both parents.” Further review failed to reveal any documented follow-up actions. A review of the facility’s policy number 13696207 titled “Safety Event Reporting Policy,” last revised 5/22/23, revealed that all Safety Events involving patients, visitors, or others would be documented by the submission of a Safety Event Report. Procedures included: E. Appropriate and timely care should have been rendered if an actual or potential injury was suspected. REPORTING ANALYSIS Trending reports and analyses were generated as part of the ongoing quality improvement process. Reports were reviewed, and additional action should have been taken by directors/committees as appropriate. During an interview on 2/24/26 at 1:12 p.m. with Clinical Manager (CM) CC in a conference room. This surveyor asked CM CC to explain what action the facility had taken since the reported incident on 2/12/26. CM CC stated that an email was sent the following day to describe the incident, and staff were informed during the morning huddle. She reported that a review of the band identification verification process was in progress and that staff education would begin this week. When asked for a specific date, CM CC responded, “Tomorrow.” This surveyor requested the educational materials for Women’s Services staff, but CM CC indicated they had not yet been created. This surveyor also requested all internal investigative notes related to the incident reported on 2/12/26. The facility could not provide these documents and instead provided the filed incident report. CM CC acknowledged that little progress had been made since the incident on 2/12/16. During an interview on 2/25/26 at 1:45 p.m. in a conference room with the Chief Executive Officer (CEO) KK and the Chief Medical Officer (CMO) JJ, CMO JJ explained that ultimate authority over the facility resides with the CEO and the Governing Board. CEO KK stated that the Governing Board should be informed of efforts to address variances, to ensure oversight, and prevent future occurrences. He added that safety event arbitration that reaches a patient and results in injury falls within the Governing Board’s purview. CEO KK further stated that this was his first time hearing about the incident in which a baby (P#2) was brought to and fed by the wrong mother (P#3) on 2/12/26. He added that he had a call scheduled in a couple of hours with the facility’s Board Chair to bring him up to date on the situation.”

“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: 49398 Based on a review of a medical record, facility policy, facility document, and staff interviews, it was determined that the facility failed to ensure that nursing services followed facility policies and procedures related to newborn identification verification when staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluid through breastfeeding. Findings Included: A review of Patient (P) #1’s medical record revealed that P#1 was a 29 year-old-female who was admitted to the facility on 2/9/26 with a plan to induce labor due to a new diagnosis of gestational hypertension (blood pressure greater than or equal to 140mmHg systolic or 90mmHg diastolic on 2 separate occasions at least 4 hours apart after 20 weeks of pregnancy when previous blood pressure was normal). A review of “Flowsheets” revealed that P#1’s nutrition plan for her newborn (P#2) was breastfeeding. A review of “Progress Notes”, dated 2/13/26 at 10:11 a.m., noted that P#1 stated that she didn’t sleep much and was crying yesterday due to the unplanned breastfeeding that occurred with another mother (see infant’s records). A review of the facility’s nursing skill document titled “Identifying Newborns and Implementing Security Precautions”, no number, no date, revealed that the purpose of the document was to reduce the risk of accidental switching of infants, infant abductions, and misidentification of infants by Identifying the newborn in the delivery room by placing identical identification bands on the infant, birthing parent, and non-birthing parent. A reliable identification system is necessary to prevent harm to the newborn and parental distress. Red Flags: Be aware that misidentification of newborns can result in patient errors, such as an infant receiving the wrong stored human milk, leading to a risk of bloodborne illnesses, blood being administered to the wrong infant, or specimens being obtained from the wrong infant. Procedure: Steps: 4. Place identification bands on newborn, birthing parent, and non-birthing parent immediately following birth in the delivery room and before they are separated. a. Be aware 2 identification bands were placed on the newborn. Placement can include 1 identification band on the ankle and 1 band on the wrist, or 1 on each ankle, per facility practice. PATIENT/FAMILY EDUCATION o Advise parents regarding the need and reason for identical identification bands for parents and newborn. o Educate parents to confirm nurses and other hospital personnel have identification badges and advise parents not to hand over their infant to anyone who does not have identification. Also, if the infant is being transported for imaging/testing, instruct parents to ask where their infant is being taken and, if possible, to accompany their infant to other departments. o Educate birthing parents to be watchful and not to leave the newborn alone in the bassinet or crib while using the bathroom. If they are alone, advise them to ask a nurse or other health care provider to stay with the infant. POSTPROCEDURE STEP When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band matches the information on the birthing parent’s identification. 4. When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band is the same as the information on the birthing parent’s identification band. 6. Check newborn’s identification bands and electronic tags every shift and each time care would be provided. 1. Be aware that misidentification of newborns could result in patient errors, such as an infant receiving wrong stored human milk, leading to risk of bloodborne illnesses, blood being administered to the wrong infant, or obtaining specimens from the wrong infant. -See other wrong patient errors that could occur in newborns. DOCUMENTATION Update the patient’s plan of care and medical record, as appropriate. Include: Any unexpected patient events or outcomes, interventions performed, and whether the treating clinician was notified Care Considerations o Factors that increase the risk of wrong-patient errors in NICUs include the use of nondistinctive temporary first names for newborns (such as “Babyboy” or “Babygirl”), and medical records with sequential numbers assigned, particularly with birth of multiples. 2 o Wrongful administration of human milk could occur in newborns, which could require extensive testing and evaluation of the infant. Strategies to avoid misuse include using bar coding and printers to label the bottles right at the bedside. Nursing staff and parents could then double-check the labels. Patient Outcomes o The newborns, birthing parent, and nonbirthing parents receive identical identification bands. o Patient security and safety were maintained, avoiding harm and potential harm to the newborn, as well as parental distress. o Parents were knowledgeable about and adhered to the postpartum unit’s policies for newborn safety and security. A review of “Maternal/Child Event (822096)”, dated 2/12/26, authored by CN DD, revealed a specific reported event related to “Breast Milk/Formula Issue” with a severity level of “no harm - reached patient no monitoring required”. Continued review revealed a brief description, “Patient called primary RN to ask for infant to come back to the room from nursery. Primary RN called to the desk and asked me to take infant to room 52. I grabbed the infant with crib card 52 and took infant to the room. I verified bands at the bedside. Mom called the ID band number, and I called it back out. The infant breastfed for 10-15 mins until the primary RN noticed it was the incorrect infant. We discovered the crib card was changed in pencil from 50 to 62. So, the 6 looked like a 5. The ID bands were almost identical 92032 and 92033. My manager was notified immediately. Both pediatricians and doctors for both couplets were notified. My manager and I explained the incident to both parents.” During an interview on 2/24/26 at 1:12 p.m. with Clinical Manager (CM) CC in a conference room, CM CC explained that on 2/12/26, Registered Nurse BB, the primary nurse for P#3, received a call from P#3 requesting that their baby be brought from the nursery. RN BB asked the front desk if someone could bring the baby to the patient’s room because she had just sat down for lunch. Charge Nurse (CN) DD answered the request and brought P#2, the newborn, to P#3’s room. She checked P#2’s band number against P#3’s band number. The ID number was 92033, and during the verbal check, neither the nurse nor the parents noticed that the last digit was off by one number. CM CC said that approximately 15 minutes later, RN BB received a call from P#3 requesting pain medication. When RN BB entered the room, she noticed that the name on the crib card did not match P#3 and asked to see the baby. After checking the arm band on P#2, she saw it did not match P#3’s band. RN BB then took P#2 back to the nursery and told the charge nurse that P#3 had been given the wrong baby (P#2), and that P#2 had been breastfed by P#3. During an interview on 2/25/26 at 9:10 a.m. with Neonatologist (MD) FF in a conference room, MD FF explained that on 2/12/26, she learned of an incident in which P#3 breastfed the wrong baby (P#2) during the morning huddle. The mistake happened because of a one-digit misidentification in the baby’s band number. She said the nurse who brought P#2 and P#3’s family member both thought the numbers matched. Subsequently, the nurse handed the baby (P#2) to P#3, who then began breastfeeding. During an interview on 2/25/26 at 9:46 a.m. with Charge Nurse (CN) DD in a conference room, Charge Nurse DD said she was working in the Family Center Unit on 2/12/26 when RN BB called the nurses’ station to ask if someone could take P#3’s baby to room #52. RN BB explained that when she picked up the baby from the nursery and brought it to the room, she asked P#3 to say the five-digit identification number. RN BB repeated the number, and both she and P#3 confirmed it was correct. CN DD reported that after she returned to the nurses’ station, about 10 to 15 minutes later, RN BB went to room #52 to give medication to P#3. RN BB noticed the crib card was incorrect, informed P#3 that the baby (P#2) was not theirs, returned the baby (P#2) to the nursery, and told CN DD about the mistake and that the baby (P#2) had been breastfed by P#3. CN DD explained that after reviewing the delivery summaries for both P#1 and P#3, she realized she had accidentally brought the wrong baby (P#2) to the wrong room. While looking into the situation, she noticed that someone had changed the number 52 to 62 in pencil on the crib card. This made it difficult to see that the five was meant to be a six. She also saw that the five-digit identification number for baby (P#2) was in sequential order with P#3’s, which made it easy to overlook the one-digit difference. During an interview on 2/25/26 at 11:16 a.m. in a conference room with Registered Nurse (RN) HH, RN HH stated that she was the primary nurse assigned to P#1. RN HH recalled that on 2/12/26, she had sent P#1’s baby (P#2) to the nursery for a newborn assessment, and sometime later, she was told by CN DD that the baby (P#2) had been returned to the wrong mother, and she breastfed the baby (P#2). During an interview on 2/25/26 at 2:29 p.m. in a conference room with Chief Nursing Officer (CNO) GG, CNO GG said that the staff involved in the unintended breastfeeding event on 2/12/26 should have followed the patient identification verification process and properly identified the baby (P#2). During an interview on 2/25/26 at 3:06 p.m. in a conference room with RN BB, RN BB explained that she was the primary nurse assigned to P#3 and had just sat down in the breakroom when P#3 called her phone and asked for her baby. RN BB called the nurses’ station to request that P#3’s baby be brought to her room while she was on break. About 10 to 15 minutes later, P#3 called again to request pain medication. RN BB ended her break early and went to P#3’s room to administer the medication. She noticed the crib card appeared incorrect and approached P#3 to observe the baby. Simultaneously, P#3 expressed happiness that the baby (P#2) had finally latched and fed. RN BB found this concerning because P#3’s baby had not been taking the bottle well, making the sudden change unusual. RN BB recalled asking P#3 for the baby (P#2). She asked P#3 if both her bands and the baby’s bands had been checked with the staff, and P#3 said they had. RN BB noticed that the baby (P#2) did not look like P#3’s baby. Because of this and other discrepancies, she checked the baby’s (P#2) ID band and confirmed it was not P#3’s baby. RN BB recalled in that moment, P#3 said, “It’s not my baby, is it?” RN BB said she told P#3 she needed to take the baby back to the nursery and would return momentarily.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 49398 Based on medical record review, policies and procedures, and interviews, the nursing staff failed to document treatment reports and nursing notes, indicating that staff misidentified P#2, resulting in P#2 being given to the wrong mother and unintended exposure to bodily fluids through breastfeeding. Findings Included: A review of Patient (P) #1’s medical record revealed that P#1 was a 29 year-old-female who was admitted to the facility on 2/9/26 with a plan to induce labor due to a new diagnosis of gestational hypertension (blood pressure greater than or equal to 140mmHg systolic or 90mmHg diastolic on 2 separate occasions at least 4 hours apart after 20 weeks of pregnancy when previous blood pressure was normal). A review of “Flowsheets” revealed that P#1’s nutrition plan for her newborn (P#2) was breastfeeding. A review of “Progress Notes”, dated 2/13/26 at 10:11 a.m., noted that P#1 stated that she didn’t sleep much and was crying yesterday due to the unplanned breastfeeding that occurred with another mother (see infant’s records). A review of Patient (P) #2’s medical record revealed that a two-day-old newborn girl was admitted to the facility on 2/10/26 at 5:34 a.m. via liveborn vaginally delivery. A continued review of P#2’s medical record revealed P#2 had a generally normal physical exam. Her vital systems, including head/neck, chest, heart, abdomen, genitalia, extremities, neurologic function, and skin, were noted to be normal, with good perfusion, normal reflexes, and no abnormalities aside from cranial molding (cone-shaped head) with caput (soft, puffy) and the presence of milia (white, yellow bumps often found on the nose, cheeks and forehead) (very common, benign (harmless), and temporary conditions in newborns that often appear together shortly after birth.) Further review revealed that P#2 was breastfeeding, voiding, and awaiting the first stool. Additionally, P#2 was noted to be at risk for hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range) due to maternal hypertension (blood pressure greater than or equal to 140mmHg systolic or 90mmHg diastolic on 2 separate occasions at least 4 hours apart after 20 weeks of pregnancy when previous blood pressure was normal). A review of “Orders” revealed the following orders: “Newborn nursery feeding”, dated 2/10/26, with instructions for breastfeeding every two to three hours. “Verify identification of infant”, dated 2/10/26, until discharge. “Place security banding on baby”, dated 2/10/26, until discharge. “Follow-up with pediatrician in 3 days unless earlier follow-up is ordered by physician”, dated 2/10/26. “Vital signs per ordered frequency: Q4H For risk of infection”, dated 2/10/26. A review of “Flowsheets - NB Daily Cares/Safety”, dated 2/10/26, revealed that P#2’s identification (ID) band number was 92032, and ID bands were secured to P#2’s wrist and ankle. ID bands were also secured to the wrists of P#2’s father and mother. Further review of the medical record revealed that the facility sent an incomplete certified medical record, even though the survey team had requested a true certified copy of the complete record. The certified record did not include discharge information, provider notes, or subsequent admission flowsheets. Additionally, the medical record failed to reveal documentation about the identification issue noted in the facility incident report dated 2/12/26. There was no record of the event, assessment, actions taken, or follow-up related to this concern. A review of Patient (P) #3’s Medical Records revealed that she was admitted to the facility on 2/9/26 for gestational hypertension affecting her first pregnancy. A review of P#3’s medication orders revealed that she was on the following medications: “ Zofran (used to treat nausea) - 2/9/26 - 9:14 a.m. “ Oxytocin infusion (used to induce labor) - 2/9/26 11:30 p.m. to 2/10/26 2:05 p.m. “ Zithromax (antibiotic used to treat bacterial infections) - 2/10/26 - 3:21 p.m. - one dose. “ Penicillin (treats bacterial infections) - 2/9/26 3:21 p.m. - 11:35 p.m. and 2/10/26 11:23 p.m. “ Dilaudid (used to manage severe, persistent pain) - 2/12/26 - 2:05 a.m., 9:57 a.m., 2:58 p.m., 7:01 p.m., 10:56 p.m. “ Lidocaine patch (local anesthetics used to relieve localized pain), - 2/12/26 11:20 a.m. “ Ibuprofen (reduce fever and relieve mild to moderate pain) - 2/12/26 - 6:20 a.m., 12:41 p.m., 6:16 p.m., 11:52 p.m. “ Tylenol (pain reliever) - 2/12/26 - 6:20 a.m. 1000 mg tablet, 2:58 p.m., 9:59 p.m. “ Colace (stool softener) - 2/12/26 - 9:57 a.m., 9:00 p.m. A review of a progress note documented on 2/10/26 at 1:36 p.m. revealed that P#3 was on penicillin prophylaxis for Group B Streptococcus (GBS) (a common bacterium, often harmless in adults, that can cause serious infections in newborns, such as sepsis or meningitis). A review of the discharge summary documented by the MD on 2/14/26 at 5:36 p.m. revealed that P#3 was discharged home with instructions to monitor her blood pressure and follow up with outpatient appointments. Review of P#3’s medical record revealed no documentation regarding the identification issue referenced in the incident report dated 2/12/26. The medical record did not reflect acknowledgment of the event, assessment findings, interventions implemented, or follow-up actions related to the reported identification concern. A review of the facility’s nursing skill document titled “Identifying Newborns and Implementing Security Precautions”, no number, no date, revealed that the purpose of the document was to reduce the risk of accidental switching of infants, infant abductions, and misidentification of infants by Identifying the newborn in the delivery room by placing identical identification bands on the infant, birthing parent, and non-birthing parent. A reliable identification system is necessary to prevent harm to the newborn and parental distress. DOCUMENTATION Update the patient’s plan of care and medical record, as appropriate. Include: Any unexpected patient events or outcomes, interventions performed, and whether the treating clinician was notified Care Considerations o Factors that increase the risk of wrong-patient errors in NICUs include the use of nondistinctive temporary first names for newborns (such as “Babyboy” or “Babygirl”), and medical records with sequential numbers assigned, particularly with birth of multiples. 2 o Wrongful administration of human milk could occur in newborns, which could require extensive testing and evaluation of the infant. Strategies to avoid misuse include using bar coding and printers to label the bottles right at the bedside. Nursing staff and parents could then double-check the labels. Patient Outcomes o The newborns, birthing parent, and nonbirthing parents receive identical identification bands. o Patient security and safety were maintained, avoiding harm and potential harm to the newborn, as well as parental distress. o Parents were knowledgeable about and adhered to the postpartum unit’s policies for newborn safety and security. During an interview on 2/25/26 at 9:46 a.m. with Charge Nurse (CN) DD in a conference room, Charge Nurse DD said that she created an incident report in the system. She wanted to document the incident in the medical record, but the Clinical Supervisor II told her not to and to only file an incident report. CN DD said that any unplanned care or exceptions needed to be recorded in the medical record, especially since this could put the baby (P#2) at risk. During an interview on 2/25/26 at 11:16 a.m. in a conference room with Registered Nurse (RN) HH, RN HH stated that she was the primary nurse assigned to P#1. RN HH explained that she did not document the incident in the medical record because she was not involved. During an interview on 2/25/26 at 11:56 a.m. in a conference room with Clinical Supervisor (CS) II, CS II stated she has never directed staff to omit any information about this incident from the medical record. She reported that CN DD asked whether to document the incident; she advised CN DD to consult CM CC, who could best advise her due to her contact with Risk Management. During an interview on 2/25/26 at 2:29 p.m. in a conference room with Chief Nursing Officer (CNO) GG stated there is a misunderstanding among staff regarding documentation of the incident in the medical record. Some staff members fear that documenting the event could expose the facility to liability. However, she expects staff to accurately document all events that occur during patient care. CNO GG emphasized that Clinical Managers and Clinical Supervisors should never instruct staff to omit documentation of any incident. During an interview on 2/25/26 at 3:06 p.m. in a conference room with RN BB, RN BB explained that she was the primary nurse assigned to P#3. RN BB said she wanted to document the incident in the medical record, but CS II told her not to. She then asked CN DD for advice, who suggested she speak to CM DD. When she asked CM DD if she should document the incident, CM DD told her no. During a follow-up interview on 2/26/26 at 10:50 a.m. in a conference room with CM CC, CM CC said she expected her nursing staff to document the exposure incident from 2/12/26 in the medical record. She also mentioned that the nursing staff seems confused about what should be recorded in the medical record and what should be documented in an incident report. CM CC stated she did not instruct staff to omit documentation of a patient care incident from the medical records. CM CC could not recall whether staff had requested guidance on documentation at that time because she was focused on getting the situation under control and communicating with Risk Management. CM CC explained that anytime a charge nurse has to get involved in patient care, they are trained to enter a note in the medical record, but she thinks that CN DD was overwhelmed in the moment and overlooked the documentation. CM CC stated that she did not consider it unusual that none of the nursing staff documented the incident in the medical records. She indicated this underscores the need for additional training on documenting significant events.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49398 Based on a review of policies and procedures, facility documents, and staff interviews, the facility failed to identify or correct the patient identification verification gap, resulting in an avoidable exposure. Specifically, the facility failed to protect patients from infection exposure after staff improperly identified P#2, leading to P#2 being breastfed by the wrong mother. Findings Included: A review of the facility’s nursing skill document titled “Identifying Newborns and Implementing Security Precautions”, no number, no date, revealed that the purpose of the document was to reduce the risk of accidental switching of infants, infant abductions, and misidentification of infants by Identifying the newborn in the delivery room by placing identical identification bands on the infant, birthing parent, and non-birthing parent. A reliable identification system is necessary to prevent harm to the newborn and parental distress. Red Flags: Be aware that misidentification of newborns can result in patient errors, such as an infant receiving the wrong stored human milk, leading to a risk of bloodborne illnesses, blood being administered to the wrong infant, or specimens being obtained from the wrong infant. POSTPROCEDURE STEP When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band matches the information on the birthing parent’s identification. 4. When returning the infant to the birthing parent’s room, confirm that the information on the newborn’s identification band is the same as the information on the birthing parent’s identification band. 6. Check newborn’s identification bands and electronic tags every shift and each time care would be provided. 1. Be aware that misidentification of newborns could result in patient errors, such as an infant receiving wrong stored human milk, leading to risk of bloodborne illnesses, blood being administered to the wrong infant, or obtaining specimens from the wrong infant. -See other wrong patient errors that could occur in newborns. Care Considerations o Factors that increase the risk of wrong-patient errors in NICUs include the use of nondistinctive temporary first names for newborns (such as “Babyboy” or “Babygirl”), and medical records with sequential numbers assigned, particularly with birth of multiples. 2 o Wrongful administration of human milk could occur in newborns, which could require extensive testing and evaluation of the infant. Strategies to avoid misuse include using bar coding and printers to label the bottles right at the bedside. Nursing staff and parents could then double-check the labels. Patient Outcomes o The newborns, birthing parent, and nonbirthing parents receive identical identification bands. o Patient security and safety were maintained, avoiding harm and potential harm to the newborn, as well as parental distress. o Parents were knowledgeable about and adhered to the postpartum unit’s policies for newborn safety and security. A review of the facility’s policy titled “Bloodborne Pathogen Exposure Control Plan”, policy number18267245, last revised 10/10/25, revealed that Bloodborne Pathogens are pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus HCV), and human immunodeficiency virus (HIV). Continued review revealed: B. Evaluation of Exposure Incidents The circumstances of each exposure incident would be documented as an employee/affiliate event in RL Safety Solutions. The event would be reviewed to identify and correct existing problems and prevent the recurrence of similar incidents. Employee Health & Safety would report findings to the facility’s Infection Prevention Committee, if necessary. Post-Exposure Evaluation: “ Appropriate follow-up would be made and include: “ The employee would be counseled in relation to source patient results and post exposure prophylaxis provided when indicated. This would be at no cost to the employee. When indicated, the exposed employee would be offered a baseline collection for hepatitis B (if not already immune) and hepatitis C virus antibody and HIV antibody. The employee had the right to refuse these tests. “ Documentation of the route of exposure and how the exposure took place. “ Employee vaccination status would be reviewed. “ For each exposure evaluation, the facility would provide a copy of the health care professional’s written opinion within 15 working days of the completion of the evaluation and include: GLOSSARY OF TERMS “ Biohazard - Substances that pose a significant risk (e.g., chemicals, blood, or other potentially infectious material). “ Bloodborne Pathogens - Pathogenic microorganisms that are present in human blood and can cause disease in humans. Bloodborne pathogens include hepatitis B virus (HBV), hepatitis C virus (HCV), and Human Immunodeficiency Virus (HIV). A review of “Maternal/Child Event (822096)”, dated 2/12/26, authored by CN DD, revealed a specific reported event related to “Breast Milk/Formula Issue” with a severity level of “no harm - reached patient no monitoring required”. Continued review revealed a brief description, “Patient called primary RN to ask for infant to come back to the room from nursery. Primary RN called to the desk and asked me to take infant to room 52. I grabbed the infant with crib card 52 and took infant to the room. I verified bands at the bedside. Mom called the ID band number, and I called it back out. The infant breastfed for 10-15 mins until the primary RN noticed it was the incorrect infant. We discovered the crib card was changed in pencil from 50 to 62. So, the 6 looked like a 5. The ID bands were almost identical 92032 and 92033. My manager was notified immediately. Both pediatricians and doctors for both couplets were notified. My manager and I explained the incident to both parents.” During an interview on 2/24/26 at 1:12 p.m. with Clinical Manager (CM) CC in a conference room. This surveyor asked CM CC to explain what action the facility had taken since the reported incident on 2/12/26. CM CC stated that an email was sent the following day to describe the incident, and staff were informed during the morning huddle. She reported that a review of the band identification verification process was in progress and that staff education would begin this week. When asked for a specific date, CM CC responded, “Tomorrow.” This surveyor requested the educational materials for Women’s Services staff, but CM CC indicated they had not yet been created. This surveyor also requested all internal investigative notes related to the incident reported on 2/12/26. The facility could not provide these documents and instead provided the filed incident report. CM CC acknowledged that little progress had been made since the incident on 2/12/16. During an interview on 2/25/26 at 9:46 a.m. with Charge Nurse (CN) DD in a conference room, Charge Nurse DD said she was working in the Family Center Unit on 2/12/26 when RN BB called the nurses’ station to ask if someone could take P#3’s baby to room #52. RN BB explained that when she picked up the baby from the nursery and brought it to the room, she asked P#3 to say the five-digit identification number. RN BB repeated the number, and both she and P#3 confirmed it was correct. CN DD reported that after she returned to the nurses’ station, about 10 to 15 minutes later, RN BB went to room #52 to give medication to P#3. RN BB noticed the crib card was incorrect, informed P#3 that the baby (P#2) was not theirs, returned the baby (P#2) to the nursery, and told CN DD about the mistake and that the baby (P#2) had been breastfed by P#3. CN DD explained that after reviewing the delivery summaries for both P#1 and P#3, she realized she had accidentally brought the wrong baby (P#2) to the wrong room. During an interview on 2/25/26 at 2:29 p.m. in a conference room with Chief Nursing Officer (CNO) GG, CNO GG said that the staff involved in the unintended breastfeeding event on 2/12/26 should have followed the patient identification verification process and properly identified the baby (P#2). During an interview on 2/25/26 at 3:06 p.m. in a conference room with RN BB, RN BB explained that she was the primary nurse assigned to P#3 and had just sat down in the breakroom when P#3 called her phone and asked for her baby. RN BB called the nurses’ station to request that P#3’s baby be brought to her room while she was on break. About 10 to 15 minutes later, P#3 called again to request pain medication. RN BB ended her break early and went to P#3’s room to administer the medication. She noticed the crib card appeared incorrect and approached P#3 to observe the baby. Simultaneously, P#3 expressed happiness that the baby (P#2) had finally latched and fed. RN BB found this concerning because P#3’s baby had not been taking the bottle well, making the sudden change unusual. RN BB recalled asking P#3 for the baby (P#2). She asked P#3 if both her bands and the baby’s bands had been checked with the staff, and P#3 said they had. RN BB noticed that the baby (P#2) did not look like P#3’s baby. Because of this and other discrepancies, she checked the baby’s (P#2) ID band and confirmed it was not P#3’s baby. In that moment, RN BB recalled, P#3 said, “It’s not my baby, is it?” RN BB said she told P#3 she needed to take the baby back to the nursery and would return momentarily. During an interview on 2/26/26 at 9:45 a.m. in a conference room with Infection Control Preventionist (ICP) MM, ICP MM stated that exposure to bodily fluids increases the risk of communicable diseases due to bacteria and other organisms, which may lead to further complications. ICP MM reported that infection control was notified on 2/12/26 about an exposure incident where P#3 breastfed a baby (P#2) who was not her own. ICP MM said her team checked with the MD FF to see if additional testing was required, but MD FF did not recommend any additional testing. ICP MM explained that when a patient is exposed, staff need to follow the bloodborne pathogen exposure plan. Standard protocols should be used regardless of the type of body fluid the patient was exposed to. ICP MM said the baby (P#2) should have received some follow-up care after being exposed to P#3’s breast milk.”

“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: 52673 Based on review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to ensure safety for one patient (P) (P#1) of eight sampled patients (P#2, P#3, P#4, P#5, P#6, P#7, P#8, and P#10). Specifically, on 8/4/25, P#1 failed to have a sitter as ordered by the provider and subsequently eloped from the hospital grounds, placing P#1 at risk for harm. Findings included: P#1 was admitted to the facility on 7/31/25 with the diagnosis of dementia (decline in memory, thinking, and judgement) in Alzheimer’s disease (type of dementia). A review of a provider order dated 7/31/25 at 5:22 p.m. revealed an order for patient monitoring one staff: one patient (1:1). Frequency was routine until discontinued. The order was discontinued on 8/4/25 at 11:21 p.m. Review of nurse note for P#1 revealed note from Registered Nurse (RN) BB on 8/4/25 at 6:42 p.m. narrated that around 4:00 p.m., RN BB was notified by Patient Care Technician (PCT) CC that P#1 was not in her room. and wanted to know if P#1 went for a test. RN BB explained to PCT CC that P#1 did not have any test ordered. RN BB notified security about P#1’s absence from her room. RN BB and other staff members checked the rooms on 4 north. Facility security was notified at 4:13 p.m. along with nursing supervisor, director and other leadership team members. A message was sent to medical doctor (MD) GG regarding P#1, MD GG called back at 5:52 p.m. and spoke with RN BB for more report. RN BB gave update with information received from Director of Medical Services (DMS) FF that P#1 was located at her old apartment a mile away from the facility and was transported back to the facility emergency department by an ambulance service. A review of the “Sitter Assignment List,” revealed that P#1 was not assigned a sitter for the 7:00 a.m. to 7:00 p.m. shift on 8/4/25. A review of the facility’s “Safety/Security Event,” for P#1 revealed that RN BB described that P#1 had dementia and wandered off. RN BB reported that she called security to report the incident and that P#1 was last seen at around 3:35 p.m. A review of the facility’s policy titled “Sitters Policy,” policy #17436766, last revised 3/31/21, revealed that the sitter shall ensure the patient’s safety and care. A review of the facility’s policy titled “Rights and Responsibilities of Patients Policy,” policy #16455823, last revised 8/22/24, revealed that the patient had a right to the provision of care in a safe setting. A telephone interview was conducted with RN AA on 9/3/25 at 10:30 a.m. RN AA stated that she had a clear recollection of P#1 whom she cared for during her shift. RN AA said that P#1 was identified as both an elopement risk and a fall risk during her oncoming shift report. RN AA explained that if sitters were unavailable through the float pool, the unit may assign patient care technicians (PCTs) or other staff to sit with the patient. An interview was conducted with PCT CC on 9/3/25 at 11:40 a.m. in the unit nurse manager’s office. PCT CC explained that she was assigned to P#1 on 8/4/25, the day of P#1’s elopement. She stated that when she entered P#1’s room that morning, no sitter was present at the bedside. She recalled that P#1 appeared somewhat confused and had difficulty maintaining her train of thought during conversation. PCT CC added that while assisting P#1 with a bath, she continued to observe signs of confusion. PCT CC further revealed that at approximately 3:00 p.m., the nurse assigned to P#1 made rounds and confirmed that the patient was in her room. Around 3:30 p.m., PCT CC returned to the room and discovered that P#1 was no longer present. At approximately 4:30 p.m., the Director of the Medical-Surgical Unit (DMS) FF, informed staff that P#1 had been located at her former residence. PCT CC explained that, according to report from the previous night shift PCT, P#1 was confused, a fall risk, and an elopement risk. PCT CC said there was no 1:1 sitter available for P#1 during day shift on 8/4/25. During an interview conducted on 9/3/25 at 12:00 p.m. in the manager’s office, RN BB confirmed that she was assigned to P#1 on the day that P#1 eloped. RN BB stated that P#1 had a sitter the previous day but did not have one the day of the incident (8/4/25). RN BB reported that she had spoken with P#1 shortly before she was discovered missing. RN BB then received a call from PCT CC reporting that P#1 was missing. RN BB stated that she alerted security personnel that P#1 was missing and then informed the charge nurse. RN BB stated that she questioned the reporting shift nurse as to why P#1 did not have a sitter, and the reporting shift nurse responded that she did not know. RN BB explained that she was busy, having just starting her shift, and was unaware that P#1 had an order for a sitter. An interview was conducted with the Director of the Medical-Surgical Unit (DMS) FF on 9/3/25 at 3:34 p.m. in the facility conference room. DMS FF reported that he was not familiar with P#1 but was notified of the elopement event on Monday, 8/4/25. DMS FF stated that he was informed by the charge nurse that a 1:1 sitter order had been in place for P#1; however, no sitter was available that day. DMS FF explained that when sitters were not available for float pool assigners to give to patients, units were expected to pull unit staff to provide 1:1 monitoring as needed. DMS FF acknowledged that the elopement could have been avoided if a PCT staff member had been pulled to sit with P#1. An interview was conducted with the Unit Nurse Manager (NM) HH on 9/3/25 at 3:45 p.m. in the facility conference room. NM HH stated that she was off on the day of P#1’s elopement event and was informed of the incident when she returned to work. She explained that when a provider ordered a 1:1 sitter for a patient, the hospital’s Clinical Staffing Office (CSO) was responsible for assigning sitters daily. If a sitter was unavailable, CSO notified the charge nurse, who may then implement other safety measures. According to NM HH, alternative options included placing the patient on a bed or chair alarm (if they met fall-risk criteria), moving the patient to a room closer to the nurses’ station, or assigning available staff to provide sitter coverage, depending on staffing levels. NM HH confirmed that P#1 did not have a sitter assigned on the day of the elopement. She further stated that CSO was aware of this and that the unit charge nurse did not assign staff to provide 1:1 observation for P#1.”

“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, Medical Staff Bylaws, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an individual received an appropriate, ongoing medical screening examination within the capabilities of the hospital’s emergency department for one (P#1) of 20 sampled patients. Specifically, P#1 presented to the facility’s emergency department (ED) with a chief complaint of leg pain. P#1 had a history of psychiatric conditions and was transferred via ambulance to a psychiatric facility on 5/14/25 at 8:00 p.m. The facility failed to ensure that P#1’s medical records were transferred with P#1. P#1 was returned to the ED on 5/15/25 at 12:15 a.m. The facility failed to conduct an MSE after P#1 was returned to the ED. In addition, P#1 was discharged to home on 5/16/25 despite recommendations from a psychiatry consultant to transfer P#1 to an inpatient psychiatric facility for stabilization. Findings included: Cross refer to A-2406 as it relates to the facility’s failure to provide a Medical Screening Examination for P#1 after she was transported back to the ED. Cross refer to A-2407 as it relates to the facility’s failure to effect an appropriate disposition for P#1. Cross refer to A-2409 as it relates to the facility’s failure to ensure that P#1’s medical records were transferred to the receiving facility.”

“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, Medical Staff Bylaws, policy and procedures and staff interviews, it was determined that the facility failed to ensure that one (P#1) out of 20 sampled patients received an appropriate medical screening examination within the facility’s capacity and capability to determine whether an emergency medical condition existed. Specifically, the facility failed to discharge and readmit P#1 after she (P#1) was transferred out of the ED and was then returned to the ED after approximately four hours, which resulted in P#1 not receiving a medical screening examination after return. Findings include: A review of P#1’s medical record revealed she arrived at the ED on 5/13/25 at 5:14 a.m. with a chief complaint of leg pain and bilateral foot pain. The triage nurse documented that P#1 barely answered questions in triage and that P#1 denied suicidal or homicidal ideations. P#1 reported that she was eight weeks pregnant. An MSE was initiated by medical doctor (MD) AA on 5/13/25 at 6:30 a.m. An order for a psychiatric consult was entered at 1:27 p.m. P#1 was evaluated by a Licensed Professional Counselor (LPC) with Psychiatry at 2:50 p.m. who recommended transfer to an inpatient psychiatric facility with a diagnostic impression of schizophrenia. Continued review of the record revealed that at 1:29 p.m. P#1 had been accepted for transfer to Facility#2. At 4:45 p.m. P#1’s physician spoke with her sister on the phone and updated her on plans for transfer to Facility#2. At 5:39 p.m. report was given to personnel at Facility#2 by P#1’s nurse. At 8:15 p.m. Emergency Medical Services (EMS) arrived to transport P#1 to Facility #2. A further review of P#1’s chart revealed on 5/15/25 at 12:15 a.m. P#1 was brought back to the facility by EMS after Facility#2 declined to accept P#1 stating they had no knowledge of P#1 being accepted there. P#1 was placed back in an ED room upon arriving back from Facility#2. On 5/15/25 at 7:34 a.m. a consult for psychiatry was ordered. A review of psychiatry progress notes dated 5/15/25 at 2:30 p.m. revealed: Impression: Schizophrenia Polysubstance use disorder History of Anxiety Psychosocial stressors Plan, Recommendations, and Comments: 1. Recommendation to maintain 1013 (involuntary hold). 2. Recommendation to continue to follow-up with inpatient psychiatric hospitalization for continued stabilization 3. Recommendation to continue to assess mood, thoughts, behavior, sleep, appetite. 4. Recommendation to hold medication for now. 5. Psychiatry will continue to follow on an as needed basis and make recommendations. Final disposition to be determined by Primary team as we are a consult team. A review of the ‘Medical Staff Bylaws and Rules and Regulations’ approved 3/21/23 revealed that: Article XI Emergency Services 11.A General Emergency services and care will be provided to any person who comes to the emergency department, as that term is defined in the EMTALA regulations, whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient’s insurance status, economic status, or ability to pay for medical services. 11.B Medical Screening Examinations (1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel (“QMP “) who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (a) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Active Staff members; and (iii) appropriately credentialed Advanced Practice Professionals. (2) The results of the medical screening examination must be documented by the end of the next calendar day. A review of the facility’s policy titled “Emergency Medical Treatment and Active Labor (EMTALA)”, PolicyStat ID 18039982, last reviewed 4/24/25, revealed the purpose was to ensure that the facility’s dedicated emergency department would comply with the Emergency Medical Treatment and Labor Act (EMTALA) and all Federal regulations and interpretive guidelines promulgated thereunder, would provide appropriate medical screening and necessary stabilizing treatment to anyone seeking emergency care. The facility’s Emergency Department would ensure that all individuals who requested an examination for a possible Emergency Medical Condition (EMC), including women in Labor, would be provided with an appropriate Medical Screening Examination (MSE) and Stabilizing treatment prior to discharge or transfer. MSEs and Stabilizing treatment would be provided regardless of an individual’s ability to pay, age, race, sex, color, religion, national origin, citizenship, pre-existing medical condition, physical or mental handicap or insurance status, whether the individual was in the hospital’s DED or elsewhere on Hospital Property. An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA recalled that P#1 came into the ED barefooted and ambulatory. MD AA stated that the triage nurse requested that she come to assess P#1 as she (P#1) exhibited odd behavior. During a review of the electronic medical record, MD AA learned that P#1 was pregnant. MD AA recalled that P#1 seemed like she was under the influence of something. MD AA stated P#1 slept a lot the first day she was in the ED. MD AA stated she talked to P#1’s sister twice during the encounter to update, get the history and a list of medications that P#1 had been prescribed. P#1 was unable to provide any history. MD AA learned from P#1’s sister that P#1 had recently been discharged from psychiatric inpatient treatment after a two month stay. P#1’s sister also informed MD AA that she (P#1) was supposed to be living with her (sister) but had been missing for five days. MD AA stated P#1’s sister did not mention having Medical Power of Attorney (POA) over P#1. MD AA further stated that she ordered for P#1 to have placed her on a 1013. During P#1’s first visit MD AA performed a Medical Screening Examination on P#1 with a medical workup and ultrasound and fetal heart tones. MD AA stated that P#1 appeared to be around 20 weeks pregnant. MD AA recalled that on P#1’s day two in the ED, an inpatient facility had still not been found. MD AA stated when she left her shift around 8pm on 5/15/25 Emergency Medical Services (EMS) was on the way to pick up P#1 to take her to Facility#2. MD AA stated that was the last contact she had with P#1. MD AA stated she was not sure what the protocol was if a patient was returned to the ED regarding the medical record. MD AA stated she would talk to her medical director and see what to do if the patient returned. MD AA stated physicians must do a face to face every four hours for patients who are on 1013. Face to face involves seeing the patient in person. An interview was conducted in the conference room on 6/3/25 at 11:32 a.m. with Registered Nurse (RN) BB. RN BB stated she was the nurse who discharged P#1 from the ED on 5/16/25. RN BB stated it was time to renew the 1013. RN BB stated MD GG, and his scribe went in to reassess P#1 and he (MD GG) felt like P#1 could go home. RN BB stated P#1 wanted to go home. P#1 was calm and cooperative. RN BB stated she did not talk to P#1’s sister. RN BB stated that she gave P#1 her belongings that had been locked up and P#1 left ambulatory out of the ED. An interview was conducted in the conference room on 6/3/25 at 1:30 p.m. with ED Nursing Director (ND) DD. ND DD stated she did not have any contact with P#1. ND DD stated that a 1013 order was good for 72 hours. If the medical provider determined that the patient could go home, then the patient was discharged. ND DD stated that if a patient was transferred to another facility, the patient was discharged out of the facility. ND DD stated if a patient returned to the facility, the patient was re-admitted. ND DD also stated when a patient was readmitted to the ED, the provider would do another MSE. ND DD stated that a face to face was not an MSE. An interview was conducted with Medical Doctor (MD) GG via telephone on 6/3/25 at 3:30 p.m. MD GG stated that when P#1 returned to the ED from Facility #2, P#1 should have had a new encounter with a new MSE conducted. MD GG further stated that if a patient had a medical POA, it was activated only when the patient becomes incapacitated and not able to make decisions on her own. MD GG stated P#1’s sister was not her legal guardian. An interview was conducted with the Medical Director (MD) HH of the Emergency Department on 6/3/25 at 2:50 p.m. via telephone. MD HH stated that his staff did not notify him when P#1 was in the ED or after being returned from Facility#2. MD HH stated when a patient leaves the ED and returns for any reason, a new chart or encounter would be initiated. MD HH stated that the process would start all over including a new MSE. MD HH stated that a face to face was not considered an MSE. An interview was conducted via telephone on 6/3/25 at 3:38 p.m. with RN II. RN II recalled that she was assigned P#1 for a short time prior to EMS transport to Facility #2. RN II stated that if a patient was returned to the ED after being transferred out, she was unsure how to handle the paperwork concerning readmitting the patient to the ED. An interview was conducted via telephone on 6/3/25 at 4:07 p.m. with RN JJ. RN JJ stated she recalled P#1. P#1 was gone from the ED approximately four hours before returning after Facility #2 declined to accept her. RN JJ stated the person at Facility#2 said they had rescinded the acceptance due to P#1’s high risk pregnancy. RN JJ stated P#1 was already discharged from the ED and requested that the chart be repopulated back into the ED log. RN JJ stated the physician saw P#1 after she (P#1) returned to the ED. RN JJ stated that she contacted the behavioral health intake to let them know P#1 had returned so they could try to get her placed under a 1013.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47717 Based on review of medical records, policy and procedures and interviews with staff, it was determined that the facility failed to ensure an appropriate disposition when P#1 was discharged from the facility on 5/16/25 at 9:36 a.m. despite recommendations for inpatient psychiatric treatment from a psychiatric consultation. Findings included: A review of P#1’s medical record revealed a progress note by psychiatry dated 5/15/25 at 2:30 p.m. that P#1 had impaired attention, concentration and memory with poor insight of her current health needs. P#1’s reliability was uncertain, and she was noted to be paranoid and delusional. P#1 was determined to be high risk for suicide and violence at the time of the examination. The consultants’ recommendations were to maintain the involuntary hold; inpatient psychiatric hospitalization for stabilization; and continue to assess P#1’s mood, thoughts, behavior, sleep and appetite. A review of nursing notes revealed that P#1 exhibited paranoid delusions and impaired judgement on 5/15/25 at 1:52 p.m. A physician note on 5/15/25 at 4:00 p.m. revealed that a referral for inpatient placement at another facility was made. All facility’s contacted thus far had declined to accept P#1. A review of physician progress notes on 5/15/25 at 6:14 p.m. revealed that an inpatient transfer was still being pursued. P#1’s involuntary hold remained active, and the patient had a sitter for one-to-one observation. On 5/16/25, a physician note at 9:00 a.m. revealed that P#1 denied suicidal or homicidal ideations, agreed to stop using drugs and was stable for discharge. The record failed to reveal a psychiatric or neurological examination by the physician. The involuntary hold was rescinded, and P#1 was discharged at 9:36 a.m. without family contact. A review of the facility’s policy titled “Authorizing Transport to Emergency Receiving Facility for Mental Health and/or Addictive Diseases Policy”, PolicyStat ID 15342117, last reviewed 3/6/24 revealed that patients who accessed care at the facility who required psychiatric treatment would be managed through referral and transferred to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. Patients who demonstrated behaviors suggestive of risk for suicide, risk of harm to others, substance abuse / addiction, or other behaviors that posed a serious and significant safety risk to the patient, staff, other patients, visitors and/or the community would be assessed and would have a Form 1013 or Form 2013 executed to effectuate transfer to an ERET facility. Execution of Form 1013 A Certifying Professional, who had personally examined a patient within the previous 48-hour period, would execute a Form 1013 if the following conditions* are met: The patient appeared, in the opinion of the Certifying Professional, to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill; AND: EITHER The patient presented a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which presented a probability of physical injury to self or other persons; OR The patient appeared to be so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis. Upon execution of Form 1013 and pending transfer to an ERET facility, appropriate safety precautions would be implemented in accordance with this policy. *The Certifying Professional would include specific observations when completing Form 1013 that support the finding that the necessary conditions exist for issuing Form 1013. A Form 1013 would expire seven (7) days after being signed by a Certifying Professional. If the Form 1013/2013 expired, the original form must be maintained with the patient’s medical record with “Expired “written across the front of the original document. If the form expired, a note would be entered in the patient’s medical record by the attending physician documenting the reasons for non-renewal. An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA stated that P#1 came into the ED barefooted and ambulatory. MD AA stated she was called to triage by the triage nurse stating P#1 was not acting right. A review of the electronic medical record documented that P#1 was pregnant. MD AA stated P#1 seemed like she was under the influence of something. MD AA stated P#1 slept a lot the first day she was in the ED. MD AA further stated she ordered for P#1 be placed on a 1013. MD AA stated she performed a Medical Screening Examination on P#1 with a medical workup and ultrasound. MD AA stated she obtained fetal heart tones from P#1 and P#1 appeared to be around 20 weeks pregnant. MD AA stated the second day she saw P#1 she had still not been assigned to an inpatient facility. MD AA stated physicians must do a face to face every four hours for patients who are on 1013. Face to face involves seeing the patient in person and the sitter to see if there are any concerns. An interview was conducted in the conference room on 6/3/25 at 11:32 a.m. with Registered Nurse (RN) BB. RN BB stated she was the nurse who discharged P#1 from the ED on 5/16/25. RN BB stated it was time to resign the 1013. RN BB stated MD GG, and his scribe went in to reassess P#1 and he (MD GG) felt like P#1 could go home. RN BB stated P#1 wanted to go home. P#1 was calm and cooperative. RN BB stated she did not talk to P#1’s sister. RN BB stated she gave P#1 her belongings that had been locked up and P#1 left ambulatory out of the ED. An interview was conducted via telephone with Nurse Practitioner (NP) EE on 6/3/25 at 2:03 p.m. NP EE stated she was familiar with P#1. NP EE stated a psychiatric consult was ordered on 5/14/25 early in the morning. NP EE stated she evaluated P#1 on 5/14/25 around 4 p.m. The evaluation was for psychosis. NP EE stated P#1 was pregnant and was delusional. NP EE further stated P#1 was positive for Cocaine and Amphetamines. NP EE stated P#1 had just recently left a psychiatric facility. NP EE stated P#1 told her that she was on injections for psychiatric medication. NP EE said P#1 informed her that she came to the ED to gets antipsychotic medication injection. NP EE stated she recommended to continue the 1013 for P#1. NP EE stated when she went to the ED the following day P#1 was still there but in a different room. NP EE asked staff members why P#1 was still there in the ED. NP EE stated she was informed by the staff that P#1 was transported to Facility#2 and Facility#1 rescinded the transport. NP EE was consulted again by the ED physician to evaluate P#1. NP EE stated she evaluated P#1 on 5/15/25 at 2:30 p.m. NP EE stated when she evaluated P#1 on 5/15.25 she was not talking to her much. NP EE was trying to determine what medications to order for P#1. NP EE stated she asked P#1 if it was okay to talk to her sister. P#1 agreed for NP EE to call her sister. NP EE spoke with the nurse taking care of P#1 and the sitter. NP EE called the P#1’s sister and left a message. NP EE stated P#1’s sister returned her call, and she asked her to bring P#1’s medication list and the discharge summary from the last facility. They continued to look for a facility for her. NP EE stated she recommended that P#1 stay on the 1013 due to lack of medication and being pregnant. NP EE stated P#1 could not tell her about any details regarding her health and P#1 stated she did not know how she got pregnant. NP EE stated P#1 finally did admit that she used cocaine for pain relief. An interview was conducted with Medical Doctor (MD) GG via telephone on 6/3/25 at 3:30 p.m. MD GG stated he remembered P#1. MD GG stated P#1 was pregnant and had a history of polysubstance abuse. MD GG stated P#1 placed under a 1013 while she was in the ED. MD GG stated upon review of the records P#1 never said she was suicidal or homicidal. MD GG stated P#1 was confused. MD GG stated that NP EE consulted for a psychiatric evaluation of P#1 and documented that P#1 was alert and oriented times three, but she had delusions. MD GG stated NP EE recommended to continue P#1 on 1013, but MD GG stated there was not documentation backing this. MD GG stated when he saw P#1 she had been there for over 72 hours. P#1 was cooperative and calm and never exhibited psychotic behavior. MD GG stated he interviewed P#1, and she expressed some remorse and agreed not to use drugs anymore.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47717 Based on review of medical records, policy and procedures and interviews with staff, it was determined that the facility failed to ensure that an appropriate transfer was effected on 5/14/25 at 8:15 p.m. when P#1, a psychiatric patient was transferred to a receiving psychiatric facility. Specifically, the facility failed to ensure that a copy of P#1’s medical records either accompanied the patient or was sent electronically to the receiving facility. In addition, the facility failed to ensure that a transfer certification form that included the risks and benefits of transfer was included in the medical record. Findings included: A review of P#1’s medical record failed to reveal documentation that medical records were provided to the receiving facility at transfer on 5/15/25 at 8:15 p.m. A further review failed to reveal documentation of a transfer certification form that included the risks and benefits of transfer and signed by the Emergency Department (ED) physician. A review of the facility’s policy titled “Emergency Medical Treatment and Active Labor (EMTALA)”, PolicyStat ID 18039982, last reviewed 4/24/25. A. Appropriate Transfers. A facility would not transfer to a non-Stabilized patient unless all the following conditions had been met: 3. The facility had provided all available medical records related to the EMC (Emergency Medical Condition) for which the individual had presented, including documentation related to observation of signs or symptoms, preliminary diagnosis provided, treatment provided, result of diagnostic studies or telephonic reports of the studies and the informed written consent for transfer or certification to do so. Any other records that were not readily available at the time of transfer would be sent as soon as practicable after the transfer. An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA stated when she left her shift around 8pm on 5/15/25 Emergency Medical Services (EMS) was on the way to pick her up to take her to Facility#2. MD AA stated that was the last contact she had with P#1. MD AA stated that patients are transferred out with an EMTALA form. An interview was conducted via telephone on 6/3/25 at 3:38 pm with RN II. RN II stated she was familiar with P#1. RN II stated she was assigned to P#1 for a short time then EMS came to transport her to Facility#2 and then RN II stated she remembers the charge nurse saying P#1 was coming back to the ED. RN II stated the day shift nurse said he called report to the accepting facility. An interview was conducted via telephone on 6/3/25 at 4:07 p.m. with RN JJ. RN JJ stated she did remember P#1. RN JJ stated she works the night shift. RN JJ stated the day shift had already given report to Facility#2, where P#1 was being transferred. RN JJ stated when EMS arrived, she reviewed the transferring paperwork. RN JJ stated it had been approximately four ish hours when the ambulance service brought P#1 back. Facility #2 denied having documentation that P#1 had been accepted at their facility. RN JJ stated she told the person that she had an accepting MD and that he had spoken to the MD there and the RN in the ED had given report to a nurse at Facility #2. RN JJ stated the person at Facility #2 said they had rescinded the acceptance due to P#1’s high risk pregnancy.”

“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: 47718 Based on review of policies and procedures, video recording and staff interviews, it was determined that the facility failed to ensure that one (P#2) of 20 patients reviewed received an appropriate medical screening examination. Findings included: Cross refer to A2406 as it relates to the facility’s failure to provide a Medical Screening Examination when P#2 was informed that minor children were not allowed in the Emergency Department by hospital staff.”

“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: 47718 Based on review of policies and procedures, video recording and staff interviews it was determined that the facility failed to provide a medical screening examination for one (P#2) of 20 sampled patients when P#2 presented to the emergency department for complaints of an increased blood pressure and facility staff turned her away because she had minor children with her. The findings include: A review of the facility’s “Emergency Department Continuum of Care Policy” policy #14063113, last revised 6/18/21 revealed that the policy’s purpose was to define patient care management as part of the integrated system moving across the continuum and to coordinate all process and activities along the continuum of patient care. 1. Access to Appropriate Care: the Emergency Department (ED) would accept patients based on presentation to the department, by physician order and by the scope of services needed. This process is carried out in a timely manner. 2. Assessment: Patients entering the department receive a medical screening exam. Their visit will include determining their needs and the care setting in which it may take place. A review of the facility” Emergency Department Scope of Care” policy #17049248, last revised 3/23/21 revealed that the purpose of the policy was to define the scope of care facility Emergency Department would provide, and to define procedures not performed in the Emergency Department. Scope of Care: The scope of service provided by facility’s Emergency Department (ED) would include assessment of the patient complaint, appropriate medical screening examination by qualified medical provider, treatment based on assessment, drug therapy, management of critically ill patients, and patient education for care upon discharge in the event the patient does not require hospitalization. A review of the facility’s “Emergency Department Physician and Advanced Practice Provider Responsibilities Policy” policy #14063125, last revised 6/18/21 revealed that the facility would adhere to all ED and provider policies and procedures and adhere to the regulations of the current EMTALA regulations. Evaluate all patients that register as emergency department patients and assist as requested by private staff or attending physicians and assist in the management and disposition of those patients. Evaluate patients in the ED as requested by the RN if they appear too ill to wait for the private physician to arrive. Speak to any ED patient who calls back if requested by the RN. A review of the facility’s “Triage Policy” policy #14063255, last revised 3/12/24 revealed that the primary goals of triage were to quickly assign those patients with emergent, life limb threatening conditions to expedite the flow of patient through the Emergency Department (ED), and to assist visitors to the ED or other health care professionals. It was the policy of the facility that all patients presenting to the ED for evaluation will be triaged by a qualified RN. It will be necessary for ED personnel to identify all patients presenting complaints in a manner best preserving the confidentiality of said patients. A review of a video recording of the outside ED entrance revealed the following: The video recording was dated 11/1/24. At timestamp 8:21 a.m. P#2 was seen arriving at the ED via the valet lane accompanied by two children (minors). At timestamp 8:22 a.m., P#2 was observed talking to the valet service representative. At timestamp 8:22:19 a.m., Public Safety Officer (PSO) GG was seen at the entrance of the ED (by the door) and appeared to be talking to P#2 while she (P#2) remained at the valet desk. At timestamp 8:23 a.m., P#2 was seen walking back to her vehicle with two children and drove off. Further review of the video revealed that P#2 came back to the ED alone at timestamp 8:55 a.m. An interview took place during the tour on 11/1/24 at 10:30 a.m. with Public Safety Officer (PSO) BB who stated that they do not allow kids to come into the ED due to the severity of the cases seen at the ED. PSO BB stated that if a patient presented to the ED with minor children, and the patient stated she had no one to pick up the children, she (PSO BB) would talk to the medical staff (nurses), and make informed decisions based on what the nursing/medical staff told her (PSO BB) to do. An interview took place during the tour with ED Medical Director (MD) AA on 11/1/24 at 10:45 a.m. who stated that patients with children were allowed to come in and would still be seen, that the facility did not exclude a patient with children. MD AA stated that he would expect the public safety officers to know that they do not turn away patients from the ED because the patients have minors with them. An interview took place at the facility’s board room on 11/12/24 at 3:02 p.m. with Nurse Manager, Daytime (NM) DD who stated that the facility’s staff do not turn away patients with children. NM DD stated that patients with minors would still be taken care of, and she (NM DD) would expect that the public safety officers would know not to turn away patients for that reason. An interview took place at the facility’s board room on 11/12/24 at 3:20 p.m. with Nurse Manager, Night (NM) EE who stated that public safety officers do not have the authority to turn back patients because the patients have minors with them. NM EE stated that they would ask the patient if they had someone that could come pick up the children, and if the patient said no, they would still allow the children to stay with the parent (patient). An interview was conducted on 11/12/24 at 3:30 p.m. with Manager, Public Safety (MPS) FF who stated that during COVID there were restrictions on children in the Emergency Department and these restrictions remained in place. MPS FF said that generally, families were discouraged from bringing children into the ED, but he was unaware that persons seeking emergency care were being prevented from entering the ED. An interview was conducted on 11/12/24 at 4:00 p.m. with Public Safety Officer (PSO) GG who confirmed that he told P#2 that children were preferably not allowed in the ED, and he (PSO GG) put it forward as a suggestion to P#2 to find an alternative place for her children. PSO GG stated that shortly after his interaction with P#2, she (P#2) got back in her car with the children and left the facility. PSO GG stated that he did not talk with medical staff before he told P#2 that the children were not allowed in the ED because it was his understanding that children were not allowed in the ED and that visitors were limited to one person per patient. An interview took place at the facility’s board room on 11/13/24 at 10:00 a.m. with Director of Operations (DO) MM who stated that since Covid, the facility limits the number of visitors at the bedside due to infection prevention. However, patients were allowed to come to the ED with their children. DO MM stated that she did not expect PSO GG to send P#2 away from the ED because she had her children with her. An interview took place at the facility’s board room on 11/13/24 at 10:20 a.m. with Registered Nurse (RN) JJ who stated that she was not aware of P#2’s initial visit, and did not know the security sent her (P#2) back. RN JJ stated that even though the facility had visitor’s restrictions, there were exceptions to the rule. A telephone interview took place on 11/13/24 at 1:00 p.m. with Registered/Charge Nurse (RN) OO who stated that she was not aware of any incident where a patient was told she could not come into the ED because she had minors with her. RN OO stated that anyone that presented to the ED had to be seen even though there’s no one that could take care of their children (if they presented to the ED with children). RN OO stated that the general rule post-COVID was one care partner per patient, but it was based on discretion, and the security officers had no authority to send a patient back because they (security officers) are not clinical and cannot decide any medical emergency interventions. A telephone interview took place on 11/13/24 at 1:52 p.m. with Registered Nurse (RN) II who stated that she was not aware P#2 was at the ED prior and had been refused entry into the ED because she had minors with her. RN II stated that the security officer should not have turned P#2 back.”

“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: 42060 Based on review of security reports, staff interviews and policy and procedures it was determined that the facility failed to ensure that care was provided in a safe setting for one (P#1) of five sampled patients when P#2 repeatedly entered P#1’s room without permission. During one such incident, P#2 inappropriately touched P#1 on 4/17/23. Findings include: Review of medical record revealed P#1 was a 79 -year-old female with past medical history of Lupus (a disease that occurs when your immune system attacks your own tissues and organs) , Diabetes (high blood sugar levels), deep vein thrombosis (a blood clot forms in a deep vein) , Lung Disease, and Gastrointestinal Reflux Disease (GERD- a condition where stomach acid repeatedly flows back into the esophagus causing irritation and discomfort) who presented to the Emergency Department (ED) on 3/31/23 at 7:00 p.m. for evaluation of gradual worsening moderate weakness that started multiple months ago. The patient further reported appetite decrease, fatigue, weight loss, cough, shortness of breath, and inability to walk due to weakness. On 4/18/23 lung medicine saw P#1 and noted that the treating team provided psychiatry evaluation today 4/18/23 to P#1 following yesterday’s assault incident; Doctor’s progress notes stated revealed P#1 seemed to be coping well and is eager to go home with family. On 4/18/23 at 12:38 p.m. P#1 was discharged home with palliative care with instructions for follow-up with outpatient Psychiatric, Pulmonology, and Nephrology services. Review of a facility report dated 4/16/23 revealed that a male patient (P #2), was observed wandering from his assigned room to other patient’s rooms. Facility security was called for assistance. Security staff informed P#2 that his unacceptable behavior would not be tolerated. A review of an incident report revealed that on 4/17/23 at approximately 11:30 a.m. P#2 entered P#1’s room, exposed himself and attempted to grab P#1. Security and assigned RN intervened. Review of facility document titled “Safety/Security Event” dated 4/17/2023 revealed P#2 repeatedly gained access to P#1’s room. P#2 was observed self-pleasuring, reached under P#1 gown, and grabbed P#1 in the genital area. During an interview on 4/22/24 at 11:15 a.m. with the Director of Public Safety (DPS) AA in a conference room, DPS AA stated that he has been employed with the facility for 12 years. DPS AA said that when security is called to a unit for patient disturbances, security would speak with the patient and remind the patient of facility policy regarding patient safety and responsibility. DPS AA stated that it is not security’s responsibility to sit with patients who require continuous observation. If a patient requires continuous observation, patient sitters should be requested by a charge nurse through the carelink department. DPS AA said that for every encounter security is called to, a report is written up. When the City Police Department was called, facility security added the officer’s name, badge number, and case number to the facility security report. During an interview on 4/22/24 at 2:00 p.m. with Risk Manager (RM) BB in a conference room, RM BB stated that she was notified of the sexual assault event involving P#1 on 4/17/23 while the events were unfolding in real-time. RM BB along with her team responded immediately to the incident. She said when security arrived on the unit, they did not go straight to P#1’s room, they followed the nurses back to the nurse’s station to obtain the patient’s face sheets and that was when P#2 had the opportunity to sexually assault P#1 for a second time. RM BB said that her first order of business was to ensure that P#1 was okay. She added that P#1 wanted to press charges against P#2 and the facility called the City Police Department to assist in the investigation. RM BB added that the facility put a hold on P#1’s financial account and offered to move P#1 to another room. She said that P#1 did not want to move rooms and felt comfortable staying because P#2 was being arrested. RM BB added that risk management decided not to conduct a root cause analysis (RCA) because there had not been any harm to P#1. RM BB added that there had not been penetration or skin-to-skin contact and that P#2 had grabbed P#1’s crotch through her gown and sheet therefore the facility did not feel there had not been any harm to P#1. RM BB further stated that P#1 made a joke about the incident which further solidified to RM BB that P#1 was okay and not harmed. She added that since the incident occurred the facility had begun conducting threat assessments immediately following any reported risk of violence. Prior to the event, threat assessments would be conducted within several hours or days after a reported risk of violence was reported. RM BB said that the facility has educated staff during staff huddles on the importance of identifying and reporting any incident of violence promptly. An interview with Lead Investigator for Campus CC took place on 4/22/24 at 2:10 p.m. in the conference room. Investigator CC said he remember the incident in question. Investigator CC said he received a call from dispatch, and it was a floor RN that placed the call. He heard the call and went to the floor. The nurse reported to him that P #2 was going to P #1’s room and was sexually aggressive and exposing himself. Investigator CC said he secured P #2 and called the Police (APD). Investigator CC said security remained on the unit until the police arrived and took the patient into police custody. Lead Investigator CC said prior to the incident involving P #1, there were two incidents/complaints with P #2 and security had been to the floor to talk to and redirect P #2. Lead Investigator CC explained that in the two incidents security explained the expectations as far as patient’s behavior was concerned. Lead Investigator CC said P #2 was never seen as a threat by staff, he needed more to be redirected that anything else. Lead Investigator CC said when it came to patient and staff safety, they had zero tolerance and they never hesitated to call the police when a patient’s behavior threatened safety. During an interview on 4/22/24 at 2:55 p.m. with Clinical Manager (CM) JJ in a conference room, CM JJ stated that she has been employed with the facility for seven years. She said that she was not made aware of the prior incidents involving security being called to P#2’s room on 4/14/23 and 4/16/23. She was made aware only of the event that occurred on 4/17/24 while it was happening in real time. CM JJ said that she notified risk management of the incident immediately. CM JJ said that sexual assault or battery is a crime, and she expects her staff to report it immediately. She further stated that it is especially important to report any type of abuse to staff because if it can happen to staff, it can happen to patients. During an interview with Charge Nurse DD on 4/22/24 at 3:15 p.m. in the conference room, Charge Nurse DD said that P #2 (male patient) was confused and was not in his full mental state. Charge Nurse DD said P #1 was confined to her room because of her illness. Charge Nurse DD said P #2 was so confused that he was constantly getting out of his bed and was found frequently in the hallway. Charge Nurse DD said on one occasion, P #2 crossed over to a female patient’s (P #1) room and exposed himself to the patient (P #1). CN DD said staff called security immediately and reported the incident to campus security. CN DD said security arrived within minutes and took control of the environment until police arrived. CN DD said P #1 never realized what happened because of his dementia. Charge Nurse DD said the nursing staff never considered P #2 a high risk. CN DD said staff was more concerned for P #2’s safety because he would not stay in his room, and he was very mentally confused but never displayed sign of violence. CN DD said the main challenge was how to keep that P #2 in his room. CN DD said after the incident they educated staff about detecting hidden risk behavior and how to be more proactive by reporting all events, small or major before they escalated to more unfortunate incidents. They educated staff about what level of behavior was unacceptable regardless of mental states. During an interview with Public Safety Officer EE on 4/22/24 at 3:50 p.m. in the conference room, Officer EE said he recalled the incident with P #1 and P #2. Officer EE said during that weekend, security was called to the unit in regard to the male patient (P #2) inappropriate language toward staff. Officer EE said when he went to the floor, he talked to P #2 and explained the behavior expectations to him as an inpatient. Officer EE said he was not sure P #2 understood the conversation because he was just looking at him and did not have any reaction nonetheless, he took the time to explain the unit rules to him. Officer EE said staff did not express any safety concerns because P #2 was only using language that was inappropriate other than that he was not a high risk. During an interview with Public Safety Officer/Lieutenant FF on 4/22/24 at 4:02 p.m. in the conference room, Lieutenant FF said he recalled the incident with P #1 and P #2. Officer EE said during that weekend he responded to a dispatch call on Friday when security was called to the unit in regard to the male patient (P #2) inappropriate and sexual language toward staff. Lieutenant FF said he along with other officers went to the unit and talked to the male patient (P #2) about what was expected from him and the type of behavior that would not be tolerated. Lieutenant FF said he basically explained the policy and procedures related to safety on campus and on the units to P #2. Lieutenant FF said P #2 clearly did not seem able to process policy and procedures, but he tried his best to explain the code of conduct in clear terms to him. Lieutenant FF said it was not reported as sexual assault, but he was more like harassing a female nurse and the nurse did not feel threatened. Lieutenant FF said they had a zero tolerance for sexual assault. If it reported as sexual assault, they would have detained the patient and called City Police to arrest him. Lieutenant FF said the policy was cut and dry when it came to sexual assault and physical threat; they just made sure the police came to apprehend the person. Lieutenant FF said he was a public safety Officer with the facility for five years. An interview with Public safety Officer GG took place on 4/22/24 at 4:30 p.m. in the conference room. Officer GG said when the call came in on the radio, he and other officers went to the unit, and he saw the male patient with a confused look on his face. Officer GG said P #2 was unable to answer questions when they tried to talk to him. Officer GG said they spoke with the nurse (RN HH), and she said that P #2 was using inappropriate language to her as she entered his room. Officer GG said he specifically asked the nurse if the male patient (P #2) touched her, and the nurse (RN HH) said no he did not, but he was making sexual comment, and she was just upset about the nature of his comments. Officer GG said they spoke with the male patient (P #2) about his behavior and what the expectations were in term of conduct. An interview with Registered Nurse (RN) HH took place on 4/23/24 at 10:30 a.m. in the conference room. RN HH confirmed that she was the staff that the male patient (P #1) was making sexual comment to and was trying to grab a hold of. RN HH said all the staff nurse and herself including considered the male patient harmless; he was like a child and was not acting at his age level at all. RN HH said P #2 did not even know the time of the day and that he only responded to his name when you called him. RN HH said P #2 had dementia and could not remember a conversation that took place a minute ago. RN GG said as he entered the patient’s room to care for wounds he had on his hand, he was talking to her in gross sexual terms; and considered the language inappropriate. RN HH said P #2 touched her in the buttocks and she called security. RN HH said security arrived right away. RN HH said security talked to the patient and the security officer that was in the room followed her to the nurse station to get a face sheet to write the incident report. RN HH said they heard female patient (P #1) yelling and they rushed to her room and saw the male patient (P #2) standing in the patient’s room exposing himself. RN HH said at that point, the officer got P #2 out of the room, called the city Police, and remained on the unit until police arrived. RN HH said P #1 said P #2 touched her in her gown, but he did not grab her. RN HH said they contacted P #1’s family member, the provider, and reported the incident to the Charge Nurse who then reported all incidents to the Nurse Manager. RN HH said she did think P #2 knew what he was doing and that she was not upset but just wanted him to see security and that would make him stop. RN HH said they talked to P #1 (female patient), and she appeared to be fine, and she was not upset about it. RN HH said P #1 was not in any distress when she talked to her. RN HH said the facility instructed them to report all incidents and not to hesitate to call security whenever they felt unsafe. RN HH said security patrolled the unit and she always saw their presence. RN HH said security was always available and responded to call in a timely manner. A review of the facility’s policy titled, “Rights and Responsibilities of Patients Policy”, last revised 2/6/23, revealed that all patients have the right to considerate, respectful care at all times and under all circumstances, with recognition of their personal dignity and autonomy. Piedmont Healthcare will develop, implement, and adhere to policies intended to assure practices that will respect the rights of all patients regardless of race, creed, sex, sexual orientation, gender identity or expression, national origin, religion, age, disability, diagnosis, or sources of payment for care A patient’s right to personal, visual, and auditory privacy will be honored to the extent reasonable and possible. A patient’s right to privacy may be limited when the patient must be continuously observed (at risk of harming self or others). Safety/Security The policy delineated that “The patient has a right to the provision of care in a safe setting” . The Patient Safety Committee, Environment of Care Committee, Infection Control Committee, the Security Department, and PHC Risk Management Programs seek to eliminate risks to the patient. A review of the facility’s policy titled, “Targeted Violence and Threats of Violence Policy”, last revised 9/13/21, revealed that it was the policy of the facility that all persons have the right to an environment free of harassment, threat, and violence. Threats of violence and acts of violence, whether expressed or implied, will not be tolerated. All reports of and / or observations of workplace violence would be taken seriously and addressed as such. Procedures The three major functions of a threat assessment are identification of the perpetrator(s), assessment of the risks of violence posed by a given perpetrator at a given time, and management of both the subject and the risks that he or she presents to a given target. The level of threat will help determine the scope and timing of the response. Threat Levels: There are four defined threat levels used to indicate the level of protection needed with a specific person or incident. Each threat level is color-coded to help with ease of visual recognition by staff. o Low-Level Threat (Yellow): A subject or incident that presents minor disruptions to normal facility operations and presents a low threat of violence. o Medium Level Threat (Orange): A subject or incident that presents major disruptions to normal operations and presents the possibility for violent action. o High-Level Threat (Red): A subject or incident that presents major disruptions to normal operations and has a verified history of violent action. o Critical Level Threat (Black): A subject or incident that presents a known and immediate threat of significant bodily harm or death to patients, staff, or visitors. The entity procedure should identify the responsibility of staff to report any risk of targeted violence to Public Safety as quickly as possible so the threat can be assessed, and preventative measures can be initiated. o Protocols should be in place to require reporting of threats where personal safety may be at risk. o All identified threats of targeted violence should be treated seriously, in accordance with entity procedure, and assessed through a process that analyzes the threat and recommends the appropriate level or type of intervention to be initiated. o The entity’s Public Safety Leader should play a leading role in the threat assessment process and the design of any safety plan. o Where appropriate, the Public Safety Leader will collaborate with Risk, Compliance, or Employee Relations as dictated by the situation. o Entity staff involved in assessing the threat to determine the appropriate level and type of intervention required should receive training for this role. o Where warranted by the risk of violent action within specific circumstances, the Entity should Targeted Violence and Threats of Violence Policy. The policy delineated that “The safety of the individuals, including the potential target, staff, patients, and visitors should be always of primary concern.””