Wellstar Cobb Medical Center

“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: 46188 Based on a review of medical records, facility policies and procedures, and staff interviews, it was determined that the facility failed to document daily wound assessments and treatments including repositioning per the plan of care for one patient (P) (P#1) of five patients reviewed. This failure has to the potential to negatively impact the progression of P#1’s pressure injury. Findings included: A review of “Wound Care” note dated 12/31/25 at 1:29 p.m. by a Wound Ostomy and Continence Nurse (WOC) Registered Nurse (RN) revealed a sacral wound was first assessed on 12/31/25 at 11:52 a.m. with an image of the wound. The WOC RN noted that P#1 had a deep tissue pressure injury (DTPI) with maceration (softening and breakdown of skin due to excess moisture) at the groin and inner thigh. The WOC RN treated the area with triad cream and noted a plan to turn the patient every two hours, offload P#1’s heels, and to avoid head of bed (HOB) elevation greater than 35 degrees to minimize friction and shear to the sacral area. The WOC RN documented relevant facility wound care policies. The WOC RN discussed the plan of care (POC) with P#1, an MD, and RN. A review of a “Wound Care” note dated 1/6/26 at 9:45 a.m. revealed a sacral wound assessment and photograph of P#1. The WOC RN entered in wound care orders for P#1 for daily dressing changes and as needed with drainage and soiling and to turn P#1 every two hour along with routine pressure injury preventative measures. A review of a “Wound Care” note dated 1/12/26 at 9:55 a.m. revealed a follow up reassessment of P#1’s sacral wound. RN FF noted that the state of healing for the wound was deteriorating with the wound now unstageable pressure injury, adipose developed into non-viable slough, and the wound care orders were modified to aid in debridement of slough. The modified wound care orders were entered for daily dressing changes and as needed with drainage and soiling and to continue routine pressure injury preventative measures. RN FF discussed the plan of care with P#1, P#1’s family member, and an RN. A review of P#1’s medical record revealed an order titled “Wound Care for Bedside Nurse,” ordered by RN FF on 1/12/26 at 1:34 p.m. and signed by an MD on 1/15/26 at 11:31 p.m. The orders were to clean the sacral wound with Vashe (wound cleanser), protect the periwound with a zinc-based product, apply nickel-thick layer of Santyl (ointment that removes dead tissue) to the wound bed, and a dressing/treatment schedule for daily and as-needed with drainage/soiling. A review of a “Wound Care,” note dated 1/16/26 at 2:01 p.m. by RN FF revealed that RN FF received notification that P#1’s periwound was showing some signs of early maceration. RN FF modified wound care for bedside nurse orders to improve and protect the status of the periwound. The modified wound care orders were entered for daily dressing changes and as needed with drainage and soiling. A review of a “Wound Care,” note dated 1/21/26 at 9:45 a.m. by RN FF revealed a reassessment of P#1’s sacral wound along with a photograph of the wound. RN FF noted that P#1’s primary RN and P#1’s family member was present at bedside. RN FF communicated the wound and treatment plan with the primary RN. The modified wound care orders were entered for daily dressing changes and as needed with drainage and soiling. RN FF noted RN FF discussed the plan of care with P#1’s family member and RN. A review of P#1’s medical record revealed an order titled “Wound Care for Bedside Nurse,” ordered by RN FF on 1/21/26 at 11:39 a.m. and signed by an MD on 1/26/26 at 12:08 a.m. The orders were to clean the sacral wound with Vashe (wound cleanser), protect the periwound with a skin barrier and then apply a zinc-based product, lightly fill the wound cavity with a Vashe-moistened gauze, and a dressing/treatment schedule for daily and as-needed with drainage/soiling. A review of a “Consult” dated 1/28/26 at 3:00 p.m. revealed that Burn Surgery services was consulted by a physician for evaluation of a sacral wound. The provider noted that P#1’s family member was at bedside and a discussion was conducted for wound healing. The provider noted P#1 had a stage three sacral wound with pink tissue, no exposed bone, no surrounding erythema, and no signs of active infection. The provider noted a plan for daily wound cleansing with Vashe (a wound solution) and as needed with soiling. The provider discussed the plan with P#1’s family member, recommended frequent repositioning every two hours, optimizing nutrition, maintaining good hygiene, and wound care. A review of P#1’s medical record failed to reveal wound assessment documentation, including but not limited to site assessment, dressing assessment, treatment, and changing, on the following dates: 1/5/26 from 7:00 a.m. to 7:00 p.m., 1/6/26 from 7:00 a.m. to 7:00 p.m., 1/7/26 complete day, 1/8/26 complete day, 1/9/26 from 7:00 p.m. to 7:00 a.m., 1/10/26 from 7:00 a.m. to 7:00 p.m., 1/13/26 from 7:00 a.m. to 7:00 p.m., 1/14/26 complete day, 1/15/26 complete day, 1/17/25 from 7:00 p.m. to 7:00 a.m., 1/19/26 from 7:00 a.m. to 7:00 p.m., 1/20/26 complete day, 1/21/26 from 7:00 p.m. to 7:00 a.m., 1/22/26 from 7:00 p.m. to 7:00 a.m., 1/23/26 complete day, 1/24/26 from 7:00 a.m. to 7:00 p.m., 1/25/26 complete day, 1/27/26 from 7:00 a.m. to 7:00 p.m., 1/28/26 from 7:00 a.m. to 7:00 p.m., 1/30/26 from 7:00 a.m. to 7:00 p.m., 1/31/26 from 7:00 a.m. to 7:00 p.m., 2/1/26 from 7:00 a.m. to 7:00 p.m., and 2/2/26 from 7:00 p.m. to 7:00 a.m. A review of P#1’s medical record failed to reveal turn repositioning documentation for every two hours on the following dates: 1/3/26 for 12:00 a.m., 2:00 a.m., and 10:00 p.m., 1/4/26 for 12:00 a.m., 2:00 a.m., 6:00 a.m., and 10:00 a.m., 1/6/26 2:00 a.m., 4:00 a.m., 12:00 p.m. and 4:00 p.m., 1/9/26 at 12:00 a.m., 2:00 a.m., 10:00 a.m., and 12:00 p.m., 1/10/26 for 2:00 a.m., 6:00 a.m., 8:00 a.m., 12:00 p.m., 2:00 p.m., and 6:00 p.m., 1/14/26 at 4:00 a.m. and 6:00 a.m., 1/17/26 at 6:00 p.m. and 8:00 p.m. A review of the facility’s policy titled “Nursing Plan of Care for High-Risk Pressure Injury Prevention Job Aid,” policy # PS-48-02, last revised 2/12/24, revealed, for patients with Braden score of 17 or less or Braden score greater than or equal to 13: “ If the patient has impaired mobility, reposition every two hours “ Use proper positioning “ Use foam dressings, pillows, wedges or blankets to pad skeletal prominences from direct pressure “ Float heels off bed A review of the facility’s policy titled “Wound, Ostomy, Continence Nursing Consultation, Assessment and Evaluation,” policy #PS-22, last revised 7/11/22, revealed that the purpose of the policy was to define a process for initiation of wound care assessment and treatment by a wound, ostomy, and continence registered nurse (WOC RN). Continued review revealed, Procedure: Consultation, consultation with WOC RN may be initiated by physician, patient, or any member of the healthcare team within 72 hours of request. The WOC RN will develop a comprehensive wound management/skin care plan. Continued review revealed, Plan of Care (POC): The WOC RN develops POC and initiates wound treatment as appropriate and will consult the provider if the POC extends beyond usual nursing scope of practice. The WOC RN will discuss patient concerns, recommendations, and/or orders with the provider ass needed prior to implementation. The WOC RN will review the POC with the nurse caring for the patient, place orders as appropriate in the patient’s medical record, and provide a discharge plan and referrals based on patient needs. During an interview on 2/4/26 at 1:10 p.m. in an office, Wound Care (WOC) Registered Nurse (RN) FF said that for patients with a pressure injury that could progress, staff should be repositioning them at least every two hours unless medically indicated to prevent further breakdown. An interview was conducted on 2/4/26, at 1:30 p.m. in the facility conference room with the Director of Nursing (DON BB). DON BB stated that the P#1’s family had not raised concerns related to wound dressing changes not being performed as ordered. During a telephone interview on 2/4/26 at 1:39 p.m., Registered Nurse (RN) DD said that when a patient has a pressure ulcer, they should be repositioned at least every two hours to prevent any further breakdown. RN DD said that this may not always fix the problem but it does aid in prevention of progression in combination with other treatment. RN DD said that staff should conduct and document a wound assessment every shift and follow the wound treatment plan of care when caring for any pressure injury. During an interview on 2/4/26 at 2:10 p.m., Charge Nurse (CN) AA said that floor nursing staff should document a skin assessment, including wounds, every shift. CN AA said that not all wounds are to be changed daily and that staff should follow whatever order is entered by another discipline or provider. CN AA said that staff are also to document the patient’s repositioning status per the plan of care.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40979 Based on review of medical records, policy and procedures, video recording, and staff interviews it was determined that the facility failed to conduct an appropriate medical screening examination to rule out an emergency medical condition and ensure that the risks and benefits of continued treatment was reviewed with the patient and documented in the medical record for one (P#1) of 20 sampled patients. Specifically, P#1 arrived at the facility via ambulance on 5/20/25 at 11:00 p.m. for a mental health examination and headaches. A medical screening examination was initiated 5/21/25 at 12:21 a.m. Local law enforcement was called to escort P#1 from the property after staff reported that P#1 refused treatment and was disruptive in the lobby. An attempt to obtain a signed refusal of care or against medical advice, including the risks and benefits of treatment was not obtained. P#1 was discharged AMA at 3:27 a.m. on 5/21/25 accompanied by local law enforcement. Findings included: Cross refer to A2406 as it relates to the facility’s failure to ensure that the risks and benefits were explained to a patient prior to being discharged against medical advice.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 40979 Based on review of medical records, policy and procedures, video recording, and staff interviews it was determined that the facility failed to conduct an appropriate medical screening examination to rule out an emergency medical condition and ensure that the risks and benefits of continued treatment was reviewed with the patient and documented in the medical record for one (P#1) of 20 sampled patients. Specifically, P#1 arrived at the facility via ambulance on 5/20/25 at 11:00 p.m. for a mental health examination and headaches. A medical screening examination was initiated 5/21/25 at 12:21 a.m. Local law enforcement was called to escort P#1 from the property after staff reported that P#1 refused treatment and was disruptive in the lobby. An attempt to obtain a signed refusal of care or against medical advice, including the risks and benefits of treatment was not obtained. P#1 was discharged AMA at 3:27 a.m. on 5/21/25 accompanied by local law enforcement. Findings: A review of Patient (P) #1’s medical record revealed that she arrived at the facility via Emergency Medical Services (EMS) on 5/20/25 at 11:00 p.m. with chief complaint of mental health evaluation and headaches. A review of the nursing triage note dated 5/20/25 at 11:10 p.m. revealed that P#1 requested admission to an inpatient psychiatric facility. Continued review of nursing note dated 5/20/25 at 11:40 p.m. revealed that P#1 refused to have vital signs taken and was yelling in the lobby. At 11:53 p.m. facility staff spoke with P#1 about her yelling and disruptive behavior in lobby. Staff was unable to de-escalate. Security was called to speak with P#1. P#1 was observed spilling food and belongings in the ED lobby. P#1 agreed to have vital signs taken. Review of physician medical screening note dated 5/21/25 at 12:21 a.m. revealed that P#1 presented with a headache and MHE (mental health exam). MSE was initiated and diagnostic testing was ordered. Continued review of a nursing note dated 5/21/25 at 1:15 a.m. revealed that P#1 tolerated medication given. A review of the ED Flowsheets dated 5/21/25 at 1:14 a.m. failed to reveal any documentation of observed behaviors. A nursing note dated 5/21/25 at 2:28 a.m. revealed that radiology staff attempted several times to take P#1 to radiology. P#1 shouted at the radiology technician that ‘I am sleeping, get out of my face’. Staff attempted to redirect P#1. P#1 observed pacing in the lobby and shouting. Security staff attempting to de-escalate P#1. Continued review of nursing note dated 5/21/25 at 2:36 a.m. revealed that P#1 refused vital signs and security staff continued to speak with her. ED provider notified, who stated that P#1 could leave AMA (against medical advice) if she continued to refuse treatment. A nursing note dated 5/21/25 at 3:19 a.m. revealed that PAS (patient access services) attempted to register P#1. P#1 shouted at PAS clerk that she was sleeping. Continued review of nursing note dated 5/21/25 at 3:24 a.m. revealed that P#1 paced the lobby and was shouting. Security staff redirected P#1 to sit in a chair. P#1 sat in a chair and laid on another patient in the seat next to her. P#1 began to scatter her belongings in the lobby. Security staff then called local law enforcement. Continued review of nursing notes dated 5/21/25 at 3:24 a.m. revealed that P#1 was escorted to the Emergency Department (ED) exit by law enforcement. Continued review of nursing note dated 5/21/25 at 3:27 a.m. revealed that P#1 was discharged. A review of the “Emergency Medical Treatment and Labor Act - EMTALA” policy, #LD-108, last revised 5/6/22 revealed that it was the policy of the facility to comply with the Emergency Medical Treatment & Active Labor Act (EMTALA) 42 CFR § 489.24, 42 CFR § 489.20 and subsequent federal interpretive guidelines and state regulations. Step Five. Refusal of Treatment. 5.1 Refusal of Treatment. If the Hospital offered the MSE, further examination and treatment and informed the individual or the person acting on the individual’s behalf of the risks and benefits of not receiving the examination and treatment, but the individual or person acting on the individual’s behalf refuses the examination and treatment, the hospital shall take all reasonable steps to have the individual or the person acting on the individual’s behalf acknowledge their refusal of further examination and treatment in writing (against medical advice form). Documentation in the medical record should include information provided to the individual or to the person acting on the individual’s behalf. Documentation in the medical record should include information related to the MSE, further examination, and treatment that is being offered to the individual including the risk and benefits of not continuing the examination and treatment. Step Twelve. 12.1 Enforcement. All staff include the procedures described above are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate disciplinary action pursuant to all applicable policies and procedures, up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards. A review of the “Leaving Against Medical Advice (AMA)” policy, number #PE-14-01, last revised 9/20/22 revealed the purpose was to define a process for working with adult patients with decision making capacity who wish to leave against the medical advice of a provider while respecting the patient’s right to reuse any medical treatment. Step One. Patient Refusal of Treatment. An adult patient with decision-making capacity had the right to refuse any medical treatment. 1.1 Advise patient of risks involved in discontinuing treatment or leaving before being discharged. Treating or attending provider, Registered Nurse (RN) or Paramedic: Encourage patient to continue in his/her prescribed course of medical treatment. 1.2 Document in the medical record the patient who insists on leaving against medical advice. Documentation occurs within 24 hours. Patient-provider consultation where patient was advised against leaving and discontinuing treatment. 1.3 Attempt to obtain patient signature on AMA acknowledgement form. Signature acts as patient’s acknowledgement of patient’s awareness of risks for leaving AMA. Patient refusal to sign AMA acknowledgement form does not relieve the provider of the responsibility for explanation of documentation of risks. A review of the security incident report #COBB IR-2025-0350 revealed a report by security officer (SO) LL. revealed an incident occurred 5/21/25 at 3:11 a.m. in the ED lobby. Continued review revealed that charge nurse (CN) FF refused to see a patient (P#1) and requested that the patient be removed. CN FF approached me as well as officers SO GG and SO HH and stated that she needed SO GG to come to the ED lobby to remove P#1, whom she stated was being belligerent, laying on other patients, and cursing at staff. When security staff arrived at the ED lobby, P#1 was asleep. Local law enforcement had been notified while security was enroute to the lobby. Law enforcement officers arrived at 3:12 a.m. and was directed to speak with CN FF. Law enforcement escorted P#1 off the property after speaking with CN FF. A review of the video surveillance of the ED lobby dated 5/20/25 beginning at 10:55 p.m. ending 5/21/25 at 3:23 a.m. revealed the following: Video dated 5/20/25 beginning at 10:55 p.m. of the ED ambulance bay. At 10:55:28 p.m. P#1 arrived on EMS stretcher At 10:57:14 p.m. EMS Paramedic placed P#1’s personal belongs next to the stretcher At 11:01:44 p.m. P#1 transferred from the stretcher to a wheelchair At 11:03:05 p.m. P#1 was escorted from the ambulance bay to the lobby Video dated 5/20/25 beginning at 11:03 p.m. of the ED lobby. At 11:03:06 p.m. P#1 was observed being transported into the lobby via wheelchair. At 11:04:30 p.m. P#1 was placed in right side corner of the lobby Video dated 5/20/25 beginning at 11:40 p.m. of the ED Triage Area At 11:40:06 p.m. CN FF was observed standing next to P#1 who was sitting in wheelchair At 11:40:11 p.m. SO GG walked over to CN FF and P#1 At 11:42:07 p.m. CN FF escorted P#1 to the triage area Video dated 5/21/25 beginning at 12:55 a.m. of the ED Hallway At 12:55:19 a.m. P#1 observed sitting in a wheelchair At 12:55:23 a.m. RN MM escorted P#1 down the hall Video dated 5/21/25 beginning at 12:55 a.m. of the ED Lab Area At 12:55:31 a.m. RN MM escorted P#1 to lab room T#3 Video dated 5/21/25 beginning at 2:22 a.m. of the ED Triage Desk At 2:22:12 a.m. P#1 observed walking to the triage desk and appeared to be talking to staff. At 2:22:16 a.m. CN FF walked past P#1 At 2:22:25 a.m. P#1 was observed standing at the triage desk and CN FF sat at the triage desk At 2:22:39 a.m. P#1 turned to SO JJ and appeared to have a conversation Video dated 5/21/25 beginning at 2:28 a.m. of the ED Triage Area At 2:28:08 a.m. P#1 observed sitting in the triage waiting area At 2:28:18 a.m. P#1 appeared to speak with CN FF and SO JJ At 2:28:22 a.m. P#1 stood up from her chair and spoke with SO JJ At 2:28:35 a.m. SO JJ appeared to speak with CN FF At 2:28:42 a.m. P#1 and SO JJ appeared to have a conversation At 2:29:59 a.m. P#1 returned to her seat in the lobby and SO JJ returned to the weapons detection area at the front door of the ED Video dated 5/21/25 beginning at 3:13 a.m. At 3:13:06 a.m. P#1 was observed sitting in far-right hand corner alone with her personal items At 3:13:10 a.m. A law enforcement officer was observed entering the ED Lobby At 3:13:13 a.m. SO LL escorted law enforcement officer to CN FF who sat at the triage desk At 3:14:47 a.m. Law enforcement officer walked over to P#1 At 3:15:02 a.m. A 2nd law enforcement officer walked over to P#1 At 3:15:14 a.m. SO LL walked over to the two officers and P#1 At 3:18:04 a.m. P#1 stood up from her chair and gathered her personal belongings At 3:20:31 a.m. Law enforcement officers escorted P#1 out of the ED lobby Video dated 5/21/25 beginning at 3:21 a.m. of the outside of the ED entrance At 3:21:05 a.m. P#1 observed walking out of the ED doors At 3:21:07 a.m. Law enforcement officer observed carrying P#1’s personal belonging in a plastic bag At 3:23:46 a.m. P#1 observed getting in the backseat of the police vehicle. An interview was conducted with Charge Nurse (CN) FF on 6/4/25 at 8:30 a.m. in the administration conference room. After CN FF reviewed her notes in P#1’s medical record she stated that she did recall P#1. She stated that she was familiar with P#1 because she (P#1) came to this facility often. She continued to explain that on the day of this incident, P#1 was constantly being loud and disruptive in the Emergency Department (ED) lobby. She continued to explain that P#1 was yelling at the staff in the back that her testing could not be completed. CN FF stated that if a patient is yelling and being disruptive that the staff does not have to deal with that. She continued to explain that she recalled P#1 laying all her personal belongs all over the floor in the ED lobby, spilling her popcorn on the floor and laying on other patients in the lobby. CN FF stated that staff made numerous attempts to continue with P#1’s treatment per the provider’s order but P#1 continuously told staff to leave her alone because she was sleeping. CN FF continued to explain that P#1 would not cooperate with anyone and continued to be loud and disruptive. She continued to explain that when there are disruptive patients in the ED sometimes, she would ask the provider to come lay eyes on the patient. She continued to explain that because P#1 continued to refuse treatment she asked hospital security to call local law enforcement to have P#1 removed from the facility. CN FF stated that she advised the provider of P#1’s refusal to continue with treatment and the provider agreed to discharge P#1 against medical advice (AMA).CN FF stated that she did not review the AMA form or discuss the risks of discontinuing care with P#1. She continued to explain that the facility security officers tried to de-escalate P#1 several times prior to the police being called. CN FF did not recall speaking with law enforcement when they arrived at escort P#1 from the ED. CN FF stated that she was familiar with EMTALA and received EMTALA training annually. A telephone interview was conducted with Security Officer (SO) GG on 6/4/25 at 12:00 p.m. SO GG recalled P#1, and the night law enforcement arrived at the facility Emergency Department (ED) to escort P#1 off the property. SO GG recalled that CN FF notified him that P#1 was being disruptive in the ED lobby. SO GG continued to explain that when he, SO HH, and SO LL arrived at the ED, he witnessed P#1 sitting quietly in the ED lobby and was not displaying any disruptive behaviors. He continued to explain that CN FF stated that P#1 had to go because she was laying on other patients, was being combative, and cursing at the staff. SO GG stated that he did not witness any of this behavior. He continued to explain that he went with SO LL to review the camera footage to determine if P#1 was being disruptive in the ED lobby. SO GG stated that after reviewing the camera footage, they determined that P#1 was not disrupting the waiting room in the manner that CN FF stated. He continued to explain that they could see P#1 sleeping at times, getting up to speak with SO JJ, and trying to maintain her personal belongings. SO GG stated that he did not feel law enforcement should have been called for P#1. He continued to say that he did not have to de-escalate P#1 at any time. He continued to explain that once the police arrived, they asked security what was going and was referred to CN FF because she had them dispatched to the facility for P#1. He continued to explain that after the police officers spoke to CN FF, they escorted P#1 from the ED. A telephone interview was conducted with Security Officer (SO) HH on 6/4/25 at 12:30 p.m. SO HH stated that he did recall the incident concerning P#1 however, he was not involved in having P#1 removed from the Emergency Department (ED). He continued to explain that he was present when CN FF requested SO GG to come to the ED to remove a patient from the ED and when he arrived at the ED several minutes later, police officers were already on the scene. SO HH stated that during the few minutes he was present in the ED, P#1 did not display any behaviors and was not disruptive at the time. An interview was conducted with Emergency Department Executive Director (ED) II on 6/4/25 at 2:15 p.m. in the administration conference room. ED II confirmed that after review of the video surveillance that there were no visual attempts from RN FF to explain to P#1 the risks of discontinuing her medical treatment and leaving the hospital. ED II confirmed there is no record or visual attempt from the provider to explain the risks of discontinuing medical treatment. ED II stated that P#1 had been seen several times in the ED for various reasons. He continued to explain that she had been seen in the past by Care Coordinators to assist with resources and in getting help for her circumstances. He confirmed that Care Coordination (CC) did not see her in person during this visit to the Emergency Department (ED); however, there was a note from her previous visit that CC did reach out to her by telephone with no luck in reaching her. ED II stated that all ED staff were required to complete EMTALA training annually as well as attend staff meetings where EMTALA was reviewed periodically. A telephone interview was conducted with Security Officer (SO) JJ on 6/4/25 at 3:00 p.m. SO JJ stated that she did recall P#1, and she is familiar with her from this incident and past visits to the Emergency Department (ED). SO JJ stated that on the evening of 5/20/25 into the morning of 5/21/25 she worked in the ED at the weapons detection area at the front door. She continued to explain that she recalled P#1 in the ED lobby and sleeping most of the time. She continued to explain that at one point during the evening a tech came to the waiting room to get P#1 for a test, and she had to wake up P#1 and as a result P#1 refused to have the test saying that she (P#1) was sleeping. SO JJ continued to explain that after P#1 refused to wake up to get a test done, CN FF said that P#1 had to go. SO JJ stated that CN FF continued to say that P#1 was combative in the back and disruptive in the lobby and there was no evidence of P#1 doing any of those things. She continued to explain that CN FF said that P#1 refused to get her test, and SO JJ only observed P#1 refusing once. SO JJ stated that CN FF continued to complain that P#1 was laying on other patients in the waiting room and spilling her popcorn. She continued to explain that during the time P#1 was in the waiting she did not witness her laying on other patients, and she did not spill any food while in the waiting room. SO JJ stated that she had to speak to P#1 once when she came to the triage desk where CN FF was sitting because she (P#1) was talking loudly. SO JJ recalled telling P#1 that if she refused treatment then she will have to leave the ED and that is when P#1 sat in the chair closest to CN FF and said okay, I’m ready for the test now. SO JJ stated that when P#1 agreed to have the testing done, CN FF said no she had to leave because she (P#1) had been disruptive. SO JJ stated that CN FF was wrong, and that P#1 may have raised her voice, but she was not disruptive and should not have been made to leave the ED by the police when she came to the hospital seeking treatment. A telephone interview was conducted with Security Officer (SO) KK on 6/4/25 at 3:30 p.m. SO KK recalled the incident involving P#1’s most recent visit to the Emergency Department (ED) when she was escorted out by law enforcement He continued to say that he was in the waiting room when P#1 arrived and that she (P#1) was little loud at first but not disruptive in anyway. He continued to explain that CN FF called security to have P#1 removed from the ED for no reason, P#1 was not doing anything. He continued to explain that CN FF went to speak with SO LL again to have P#1 removed and at the time P#1 was sitting in a corner with the blanket over her head not bothering anyone waiting her turn to be called to the back. SO KK stated that at some point, CN FF requested law enforcement be called to come to the ED, wake up P#1, and have her removed. SO KK stated during his shift in the ED he did not witness P#1 being disruptive, spilling food, or bothering other patients in the waiting area. A telephone interview was conducted with Security Officer (SO) LL on 6/4/25 at 6:00 p.m. SO LL stated that she did recall P#1 and the incident where the police escorted her from the Emergency Department (ED). SO LL went to the ED with SO GG and SO HH to see what they could do to help with P#1 at CN FF’s request. SO LL stated that when they arrived at the ED, P#1 was sitting in the corner and appeared to be asleep. She continued to explain that CN FF stated that P#1 was being disruptive, loud, cursing at staff, spilling popcorn on the floor, and bothering other patients in the ED. She continued to say that when they arrived at the ED, P#1 was not displaying any of these behaviors. SO LL stated that when law enforcement she directed them to CN FF since she was complaining about P#1. SO LL stated that she remained on the scene while the police officers were in the ED. She continued to explain that after the police officers spoke with CN FF, they approached P#1 and informed her (P#1) that she was being requested to leave the facility. In summary, the hospital failed to complete an appropriate medical screening examination for P#1. There was no documentation in the medical record of a psychiatric evaluation, neurological exam, testing to rule out a myocardial infarction, evidence a qualified medical person determined P#1 to be competent to refuse care and no documentation of an informed refusal.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49398 Based on a review of medical records, facility policy and procedures, staff and patient interviews, and observations, it was determined that the facility failed to ensure that nursing services assessed and documented activities of daily living (ADL) for three patients (P) (P#1, P#2, and P#3) of four sampled medical records. Specifically, nursing staff failed to ensure oral care was provided or documented for patients that require ADL assistance. Findings included: 1. A review of P#1’s medical record revealed that P#1 was admitted to the facility on 3/2/25. A review of “General Surgery Note” dated 3/3/25, revealed that P#1 is fairly independent at home. She uses a cane and occasionally requires assistance from her husband or daughter for activities of daily living (ADL) care (basic self-care tasks individuals perform daily to maintain independence). A review of “Order,” dated 3/5/25, revealed that an order for Occupational Therapy (OT) was placed due to P#1’s impaired activities of daily living (ADL) functionality. A review of the “Physical Therapy Initial Assessment,” dated 3/6/25, revealed that P#1 was independent with ADL care at home before admission. During admission, P#1 required using a PureWick (female external catheter that wicks urine away using low pressure suction) and maximum assistance with a bedside commode, with perineal hygiene assistance post-bowel movement. Further review failed to reveal documentation that P#1 received daily ADL oral care from 3/2/25 through 3/8/25. 2. A review of P#2’s medical record revealed that P#3 was admitted to the facility on 3/4/25. A review of “Physical Therapy Initial Assessment,” dated 3/10/25, revealed that ADL care required maximum assistance. Further review failed to reveal documentation that P#3 received daily ADL oral care on 3/5/25, 3/6/25, 3/7/25, 3/9/25, 3/12/25, and 3/14/25. 3. A review of P#3’s medical record revealed that P#3 was transferred and admitted to the facility on 4/23/25. A review of “Orders,” dated 4/23/25 at 2:56 a.m., revealed that an active order for oral care was placed. Further review failed to reveal documentation that P#3 received daily ADL oral care from 4/23/25 through 4/29/25. Observation of P#3 on 4/29/25 at 8:40 a.m., revealed patients teeth with a film and buildup, long fingernails with dark brown matter caked underneath them, and white crust around his eyes and nose. Observation of P#3’s room revealed a bedside table that was out of P#3’s reach. Further observation of the bathroom failed to demonstrate oral hygiene care supplies. P#3 at this time requested to have his teeth brushed. Observed a Care Partner (CP) bring two toothbrushes and two toothpaste tubes into P#3’s room. This surveyor stepped out of the room to allow P#3 privacy. Nurse Manager (NM) AA was present at this time and explained that P#3 had been provided oral care, but that staff failed to document it in the medical record. Observation of P#3 on 4/30/24 at 9:30 a.m. with NM AA revealed the same unopened two toothbrushes and toothpaste tubes in the bathroom. When the NM AA was asked to explain why these supplies were unused after P#3 requested oral care on 4/29/25, she explained that P#3 had not had his teeth brushed in such a long time that staff chose to throw the toothbrush and toothpaste away after the first use and the supplies in the bathroom were new. She continued to explain that he is a confused patient. When this surveyor asked NM AA what P#3’s neurological assessment was for that day, she explained that it had not been completed then and that his nightshift neurological assessment revealed that P#3 was within normal limits. Further observation of P#3’s room revealed a strong urine odor. It was also revealed that P#3’s gown and linen were urine-saturated. A review of the facility’s policy titled “PS-51 Nursing Plan of Care,” policy # PS-51, last revised 6/16/23, revealed that the policy was to provide safe, effective Nursing care to all patients. PROCEDURE: NOTE: The POC is individualized to meet patient needs based on data collected from nursing assessment and includes involvement of the patient, family, and/or significant other. Care planning, treatment, and services are collaborative and interdisciplinary. Initiation of Care: o Step One: “ Assess patients on admission and select/initiate POC based on appropriate diagnoses “ 1.2 Establish patient goals Implementation: o Step Two: “ 2.1 Document interventions implemented to meet individualized patient needs “ 2.2 Reassess patients at specified times based on the level of care or when there is a significant change in patient condition Evaluation: o Step Three: “ 3.1 Revise and reprioritize POC based on assessment or change in patient condition and diagnosis “ 3.3 Continue, revise, or resolve POC interventions to achieve established goals A review of the facility’s “Skills: Activities of Daily Living (ADL): Adaptive Equipment for Personal Hygiene (Rehabilitation Nursing) - CE/NCPD,” dated 9/17/24, revealed; 13. Integrate the therapist’s recommendations and plan of care. 16. Complete grooming tasks with the patient, assisting as needed. During an interview on 4/29/25 at 12:26 p.m., with P#3 in a patient room, P#3 explained that he had been admitted for approximately a week for a wound on his left foot. He had previously had his right leg amputated due to it becoming gangrenous and is unable to ambulate due to the painful sores that have developed on his left foot. P#3 expressed frustration that he had not washed his face for a week. He said that the staff would come in to clean his body but never wash his face or brush his teeth. When asked if he had been provided a toothbrush and toothpaste, he explained that no one had ever brought him toothpaste or a toothbrush, much less offered to brush his teeth, and it would make him feel better to have his teeth brushed. P#3 said that staff do not ensure he can reach his water or juice because they position the bedside table in a manner that makes it difficult for him to get his drinks. P#1 added that he is unable to walk due to his amputation and the sore on his left foot; therefore, he has a condom catheter in place for when he needs to urinate and when he has a bowel movement he goes on the pads underneath him due to his inability to leverage the weight of his body upward to sit on a bedpan. He added that sometimes the condom catheter fails, and urine will saturate the pads and linen in the bed. He continued explaining that when he calls out for assistance, staff will come in and tell him they will be back shortly to change his bedding and clean him up, and they do not return for sometimes an hour or longer. During an interview on 4/29/25 at 12:55 p.m. with P#6 in a patient room, P#6 stated that he had been admitted for a couple of weeks due to pneumonia and was waiting to secure a full-time home health aide that could assist him with daily living before he could be discharged. P#6 explained that he was bedbound, unable to get to the bathroom, and required assistance for all his hygiene care. He said that overall, the staff has been responsive to his calls when he experiences incontinence and grooming needs. He said the night shift is slower to respond, but he did not feel he was left wet or dirty for an extended time. He added that the staff would comply if asked to brush his teeth, but he could not recall when he last had oral care. A follow-up interview was conducted on 4/30/25 at 8:30 a.m. with P#3 in a patient room. P#3 was asked if he was provided oral care. P#3 explained that the staff brought supplies but never assisted him with brushing his teeth. He added that in addition to not getting to brush his teeth, they had not come to clean him up since he had called out before the sun came up to alert staff that the condom catheter was not working, and urine had soaked onto him and the bedding and at 9:30 he still and not been cleaned up. He continued to say that they brought his food in and placed it on the bedside table, which he could not reach. P#3 expressed that he was frustrated because he felt as if staff only cared about getting vital signs done and not about providing him with assisted care. A telephone interview was conducted on 4/30/25 at 9:17 a.m. with Licensed Practical Nurse (LPN) EE. LPN EE explained that she could not recall P#1 because she filled in briefly when P#1 was admitted there. LPN EE stated that nurses and care partners (patient care technicians) are responsible for providing patients with activities of daily living (ADL) care. She said that whoever performs the care documents it in the patient’s medical record, but the nurses oversee the care partners’ patient care. LPN EE explained that after she receives report during shift change, she will notify the care partner if a patient needs ADL care, especially for non-ambulatory patients, and most times is present in the room when the CP is bathing and changing the patient’s linens because it allows her an opportunity to conduct a thorough skin assessment and address any patient concerns. She said she will document the ADL care at that time, and then throughout the shift, she will confirm patient ADL care is being provided by speaking with the care partner and confirming with the patient directly, and then she will double-check the medical record to ensure it was documented. She added that patient hygiene, including oral care, should be provided to patients every shift. During an interview on 4/30/25 at 9:49 a.m. with Care Partner (CP) FF in a conference room, CP FF explained that her duties include providing patients with hygiene such as bathing, brushing teeth, and cleaning fingernails. Additionally, she assists with turning, feeding, changing, and providing patients with nutrition. CP FF explained that she has been assigned to P#3 several times since his admission. She explained that he is sometimes confused, alert, and oriented. She said that P#3 is capable of brushing his teeth independently. She added that she keeps a toothbrush and toothpaste on his bedside table so that he can brush his teeth at his discretion, but often he does not, and that she forgot to document during the times that he did. She added that when she does anything for a patient, she is required to document it. CP FF said that CPs are responsible for documenting the ADL care they provide, but it is supposed to be a shared responsibility between the CPs and the nurses to document it. A telephone interview was conducted on 4/30/25 at 10:09 a.m. with Registered Nurse (RN) CC. RN CC recalled caring for P#1 because his Nurse Manager had notified him that P#1’s husband had called the facility and made a violent threat against him. RN CC explained that P#1 had been on the unit for a few days before he was assigned to her, and he had her for two nights. RN CC said he could not explain why oral hygiene care had not been documented for P#1, but didn’t believe she had never received it because she was alert and oriented and could brush her teeth. He continued to explain that ADL care is the responsibility of the CP and that they are expected to document it anytime they perform it. RN CC said that nurses provide oversight of the CPs they have delegated responsibility to and should review their documentation periodically throughout the shift. Additionally, nurses should assess and follow up with the patient to ensure they have been receiving ADL care delegated to the CP. A telephone interview was conducted on 4/30/25 at 10:39 a.m. with Care Partner (CP) HH. CP HH explained that her duties include taking patient vital signs, providing ADL care, feeding, housekeeping as needed, and any additional patient needs. CP HH explained that she can be assigned 10 to 11 patients each shift. She begins her shift by taking report and going room by room to greet each patient. She said hygiene should be provided every shift and as needed, including linen changes, peri care, foley care, Purewick change, oral care, and bathing. CP HH stated that hygiene is very important because patients are human beings and should be provided the same care that we provide ourselves. She added that she must document every time she gives hygiene care, but sometimes she does not because she has to document every two hours anyway, so she will wait to do it then. CP HH recalled caring for P#3 because she recalled he was a diabetic and had an amputated leg. She said that he is occasionally confused but is alert and oriented overall. CP HH explained that he can brush his teeth and that she would offer him opportunities to brush his teeth because he cannot ambulate to the bathroom, but she failed to document it. She added that when she changes his linen, she always does an oral swab and applies ointment to his lip but failed to document those occurrences as well. During an interview on 4/30/25 at 11:18 a.m. with the Director of Nursing (DON) GG in a conference room, DON GG explained that the nurses oversee CPs and delegate specific nursing tasks to them based on what is within the CPs’ scope of practice. The RN ensures the delegated tasks are performed and documented appropriately. She added that she expects ADL care to be provided to every patient, every shift, and as needed. DON GG said that the charge nurses conduct weekly audits of medical records and review ADL care to ensure it is being provided and documented. Prior to the survey, she would have been surprised if medical records were missing documented ADL care. DON GG stated that she expects the primary nurse to ensure that their patients receive ADL care, and that it’s documented in the medical record. Still, the unit leader and she are responsible for providing nursing oversight to ensure patients receive appropriate care. During an interview on 4/30/25 at 11:35 a.m. with the Chief Nursing Officer (CNO) II. CNO II explained that during this survey, they have identified opportunities to improve documentation. She acknowledged that if something was not documented in the medical record, it did not occur. She continued to explain that CPs are under the nurses’ supervision. She expects nursing staff to review their patients’ medical records by the end of every shift and validate that ADL care has been provided and documented. CNO II acknowledged that the Nurse Managers, the executive DONs, and she share accountability for nursing services.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 47718 Based on the review of the facility’s policies/procedures, medical record review, and staff interviews, it was determined that the facility failed to safely discharge one (P#1) of eight sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) P#1’s change in condition was not identified before discharge, which resulted in P#1 being re-admitted immediately after discharge to the facility. Findings include: Cross refer to A-0396 as it relates to the nursing staff’s failure to follow the plan of care when nursing staff failed to follow the plan of care for P#1. Cross refer to A-0398 as it relates to nursing staff’s failure to follow policies and procedures when P#1’s change in condition was not identified prior to discharge. Cross refer to A-0802 as it relates to the facility’s failure to follow the discharge planning process by not identifying and re-evaluating changes in P#1’s condition that required modification of the discharge plan.”

“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: 47718 Based on the review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that nursing staff and other personnel adhered to the facility’s policy, procedures and protocols when it was determined that four (P#2, P#3, P#4, and P#6) of eight sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) were not turned and repositioned every two hours. Findings included: A review of the facility’s “Wound, Ostomy, Continence Nursing Consultation, Assessment, and Evaluation policy”, Policy #PS-22, last reviewed December 2021, stated that the purpose of the policy was to define a process for initiation of wound care assessment and treatment by a wound, ostomy, and continence registered nurse (WOC RN). The WOC RN develops a plan of care and initiates wound treatment as appropriate; consults the provider if the plan of care (POC) extends beyond the usual nursing scope of practice; May place photographs of a wound in the patient’s progress notes with other WOC RN documentation; Assess patient and develop patient plan of care; Discuss patient concerns, recommendations and/or orders with provider as needed prior to implementation of POC; Implement nursing interventions as needed for Pressure Injury Prevention and/or Treatment; Review plan of care with nurse caring for patient. A review of the facility’s “Prevention of Pressure Injuries policy”, Policy #PS-48, last revised 12/29/2021 stated that the purpose of the policy was to define a process for the promotion and maintenance of skin integrity. Assess all skin surfaces (including skeletal prominences) on admission and every shift. Utilize the appropriate Skin Assessment Form or Pressure Injury Assessment Form. Assess patient risk for developing pressure injury using Braden or Braden QD Scale depending on the patient population. Implement interventions for low-risk patients. See PS-48-03 Maintenance of Skin Integrity “ Braden Score greater than or equal to 18 “ Braden QD Score less than 13. “ Implement interventions for high-risk patients. “ Refer to the computerized nursing plan of care for Impaired Skin Integrity. “ Braden Score less than or equal to 17 or other clinical indicators of high risk of impaired skin integrity. “ Braden QD Score greater than or equal to 13 or other clinical indicators of high risk of impaired skin integrity. “ Clinical indicators of high risk of impaired skin integrity include (but are not limited to): the use of 2 or more vasopressors, prone positioning, prematurity, and utilization of medical devices. A review of the facility’s “Maintenance of Skin Integrity Job Aid policy”, Policy #PS-48-03, last reviewed 12/29/2021 stated that: “ Provide care to patients as listed below to prevent skin breakdown: “ Assess for reddened areas over bony prominences “ Reposition patient in bed or chair every two hours if unable to reposition self “ Instruct patient on causes and prevention of skin breakdown “ Keep skin clean, dry, and moisturized “ Use skin protective wipes or skin sealant under tape with dressing changes “ Use moisturizers or emollient lotions for dry skin “ Maintain the head of the bed at the lowest degree of elevation consistent with a medical condition. “ Use proper positioning, transferring, and turning techniques to prevent injury or friction “ Limit the use of adhesive products on thin, fragile skin “ Avoid the use of donut devices; may use pressure reduction chair cushion “ Avoid massage over skeletal prominences and discolored/hyperemic areas “ Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage “ Document areas of redness that do not disappear within 30 minutes or any breaks in the skin. “ Notify Wound Care when assistance is needed. A review of the facility’s “Treatment of Pressure Injuries policy”, Policy #PS-49, last reviewed 12/09/2021 stated that the purpose of the policy was to define a process for treatment of pressure injuries and prevention of further impairment of skin integrity. Interventions include: Assess all skin surfaces (including skeletal prominences, skin folds, and under medical devices) on admission and every shift. Implement Wound Care Treatment Guidelines Initiate Nurse-driven wound treatment protocol in Electronic Medical Record (EMR) as applicable. Consult Wound, Ostomy, Continence (WOC) Nurse regarding altered skin integrity or for additional assistance. Contact the Medical Doctor (MD) if the WOC Nurse is unavailable. A review of Patient (P)#2’s medical record revealed that P#2 was admitted to the facility on 4/11/2023 at 1:51 p.m. via the Emergency Department (ED) with the chief complaint of Shortness of Breath. A review of the History and Physical (H&P) on 4/11/23 at 10:13 p.m. revealed that P#2 had a past surgical history of sacral wound debridement (a procedure that involves removing dead or infected tissue from the area around the lower back and buttocks) on 3/17/23. A review of the Plan of Care in the H&P notes revealed: falls/aspiration precautions, supplemental oxygen, intravenous antibiotics, telemetry monitoring, consider palliative care, and wound/dietician evaluation. A review of the wound care nursing notes on 4/12/23 at 8:44 a.m. revealed that multiple pressure ulcers were present on admission on the sacrum, right back, right hip, right chest, and right arm. Staples were present on AKA site. A review of the wound care consult notes on 4/13/23 at 5:46 p.m. revealed a Braden score (an assessment tool used to assess a patient’s risk of developing a pressure ulcer) of 11. Documentation revealed a Wound Pressure Injury Sacrum, which was first assessed on 2/28/23, at a previous admission with a measurement of 10 cm in length by 8 cm in width, and a depth of 3.2 cm. Documentation revealed a site assessment of Brown; Black; Eschar; Nongranular; Pink; Red; Slough; and Tan with exposed structures of Adipose and muscle. Documentation revealed that drainage amount was moderate, and wound dressing was done with foam, moist to moist temporary dressing. Continued review of the wound care consult notes revealed that P#2 should be turned every two hours due to the Braden score. Continued review of P#2’s medical record revealed that wound care routine per protocol was ordered on 4/13/23 at 6:00 p.m. An electronic medical record revealed that P#2 was not turned on: 4/13/23, from 4:23 a.m. to 8:00 a.m. 4/14/23, from 8:00 p.m. to 5:00 a.m. 4/15/23, from 5:00 p.m. to 9:00 p.m. 4/16/23, from 9:00 p.m. to 7:00 a.m. 4/16/23, from 11:30 a.m. to 4:30 p.m. 4/17/23, from 12:00 a.m. to 8:00 a.m. 4/17/23, from 9:00 p.m. to 8:00 a.m., 4/18/23 4/18/23, from 12:00 p.m. to 4:00 p.m. 4/20/23, from 12:00 p.m. to 4:00 p.m., and then from 4:00 p.m. to 9:00 p.m. 4/21/23, from 12:00 p.m. to 5:00 a.m. 4/22/23, from 4:00 a.m. to 9:30 a.m., and then 9:30 a.m. to 10:00 p.m. 4/22/23, from 10:00 p.m. to 8:00 a.m. on 4/23/23 4/23/23, from 1:00 p.m. to 5:00 p.m. 4/23/23, from 9:00 p.m. to 8:00 a.m., 4/24/23 4/24/23, from 8:00 a.m. to 12:00 p.m. 4/24/23, from 12:00 p.m. to 4:00 p.m. 4/25/23, from 4:00 a.m. to 8:00 a.m., and from 8:00 a.m. to 1:00 p.m. 4/26/23, from 8:00 p.m. to 6:00 a.m., 4/27/23 4/27/23, from 5:00 p.m. to 7:55 a.m., 4/28/23 4/28/23, from 9:00 p.m. to 8:00 p.m., 4/29/23 4/30/23, from 4:00 a.m. to 9:00 a.m. 4/30/23, from 9:00 a.m. to 6:39 a.m., 5/1/23 5/1/23, from 12:00 p.m. to 4:00 p.m. 5/1/23, from 9:00 p.m. to 6:00 a.m., 5/2/23 5/2/23, from 12:00 p.m. to 4:00 p.m., and from 4:00 p.m. to 8:00 p.m. 5/2/23, from 8:00 p.m. to 4:00 a.m. 5/3/23 5/3/23, from 4:00 p.m. to 8:00 p.m. 5/3/23, from 8:30 p.m. to 6:00 a.m., 5/4/23 5/4/23, from 4:00 p.m. to 8:30 p.m. 5/5/23, from 12:00 a.m. to 4:45 a.m. 5/5/23, from 4:00 p.m. to 8:00 p.m. 5/6/23, from 3:50 a.m. to 8:00 a.m., and from 10:00 a.m. to 4:00 p.m., and from 4:00 p.m. to 9:00 p.m. 5/6/23, from 9:00 p.m. to 8:00 a.m., 5/7/23 A review of Patient (P)#3 ‘s record revealed that P#3 was admitted to the facility on 10/08/23 at 3:48 p.m. via the Emergency Department (ED) with the diagnosis of Acute Kidney Injury (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Documentation revealed that P#3 had multiple wounds present on admission. Documentation revealed that P#3 had the following wounds present on admission: - Wound Pressure Injury, Coccyx, first assessed on 4/13/21 on a previous admission. - Wound Skin Tear, Shoulder left, first assessed 10/9/23, present on original admission. - Wound Skin Tear, Shoulder right, first assessed 10/9/23, present on original admission. - Wound pressure Injury, Heel right, first assessed 10/9/23, present on original admission. - Wound pressure injury, left, first assessed 10/9/23, present on original admission. An electronic medical record review of the record revealed that P#3 was not turned and repositioned: On 10/14/23 from midnight to 7:47 a.m., and from 8:00 p.m. to 7:55 a.m. on 10/15/23 On 10/15/23, from 8:40 p.m. to 4:00 a.m. on 10/16/23 On 10/16/23, from 10:16 p.m. to 3:39 a.m. on 10/17/23 A review of Patient (P)#4’s medical record revealed that P#4 was admitted to the facility on 1/6/24 at 12:21 a.m. via the Emergency Department (ED) post-fall with Altered Mental Status. A review of the skin assessment on admission revealed that P#4 had a wound, pedal anterior right, first assessed on 1/6/24 at 2:30 p.m.; Wound Ankle Anterior, left, first assessed on 1/6/24 at 2:30 p.m.; Wound skin tear knee left, lateral, first assessed 1/6/24 at 2:30 p.m.; Wound Leg anterior, distal, right, first assessed 1/6/24 at 2:30 p.m., and Wound Leg anterior, distal right upper, first assessed 1/6/24 at 2:30 p.m. A review of the nursing notes on 1/9/2024 at 9:22 a.m. revealed a wound consult for multiple sores to bilateral lower extremities was ordered for P#4. Continued review of the nursing notes revealed a wound pressure injury on the left heel, first assessed on 1/9/24 at 9:22 a.m. Documentation revealed that the site assessment was purple with a measurement of 3.5 cm in length, and 2 cm in width. Documentation revealed a wound pressure injury, to the right heel, first assessed 1/9/24 at 9:22 a.m. with a measurement of 6 cm by 5 cm and a purple site assessment. Continued review of the nursing notes on 1/9/2024 at 9:22 a.m. revealed the plan was to continue skin pressure injury preventive measures, turn the patient every two hours, and PRN (as required). An electronic medical record review of the nursing progress notes revealed that P#4 was not turned as per order on the following days: 1/6/24, from 11:00 p.m. to 8:00 a.m. on 1/7/24 1/7/24, from 4:00 p.m. to 8:10 p.m. 1/8/24, from 6:02 a.m. to 2:00 p.m. and at 6:00 p.m. 1/8/24, from 10:00 p.m. to 8:00 a.m. on 1/9/24 1/10/24, turnings were missed at 10:00 a.m., 12:00 p.m., and 3:00 p.m. 1/12/24, from 2:00 p.m. to 9:16 p.m. 1/13/24, turnings were missed at 2:00 a.m. and 8:00 a.m. 1/13/24, from 10:00 a.m. to 9:30 p.m. 1/15/24, turning was missed at 6:00 p.m. 1/20/24, turning was missed at 6:00 a.m. 1/22/24, from 4:00 p.m. to 10:28 p.m. A review of P#6’s medical record revealed that P#6 was admitted to the facility on 1/15/24 at 3:12 p.m. via the Emergency Department (ED) with the diagnosis of Peripheral Artery Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of the nursing notes on 1/22/24 at 10:15 a.m. revealed that P#6 had a wound pressure injury coccyx, first assessed 1/21/24 at 1:11 p.m. Documentation revealed a wound measurement of 6 cm in length, 5 cm in width, and 0.3 cm in depth. Documentation revealed that the wound was cleansed, and dressing applied. A review of the nursing progress notes on 1/24/24 at 11:57 a.m. revealed a wound care consult for 1/23/24 at 12:09 p.m. for pressure injury to the sacrum/coccyx. Documentation revealed the dressing on the sacrum was saturated with bloody stool; cleansed, peri care was provided, and pads were changed. Documentation revealed that zinc oxide was applied on Vaseline gauze as the wound was wet and Z-guard ointment (medication to treat and prevent skin irritations) was not sticking well. Documentation revealed a plan to continue skin preventive measures; turn the patient every two hours and PRN (as required). An electronic medical record review revealed that P#6’s Braden Score on 1/15/24 at 7:30 p.m. was 17. On 1/16/24 at 7:15 p.m., documentation revealed a Braden score of 15 with Redness on Sacrum. Continued review revealed P#6 was not turned on: 1/16/24 from 8:00 a.m. to 7:15 p.m. 1/17/24, from 8:30 a.m. to 7:05 p.m. Documentation revealed a foam dressing was applied on the sacrum. On 1/18/24 at 9:15 a.m., Documentation revealed that P#6’s Braden score was 18. On 1/19/24 at 11:07 a.m., turning was missed. During the electronic medical record review, CC SS stated that patients are not required to be turned/repositioned by the facility’s staff every two hours if they have a Braden score of 18 and above. CC SS stated that such patients are expected to turn and reposition themselves. A review of the nursing progress notes on 1/31/24 at 11:20 a.m. revealed a Wound Pressure Injury, Coccyx, first assessed 1/21/24 at 1:11 p.m. now measuring 8 cm by 4.7 cm, and a depth of 0.3 cm. Documentation revealed to continue 2 hourly turns. An interview took place in the conference room on 3/26/24 at 12:06 p.m. with Nurse Manager (NM) RR (Burn Unit/Inpatient Wound Care) who stated that clinical Coordinator (CC) SS was the first point of contact if there were any concerns regarding pressure injuries/ulcers, or wound care. NM RR stated that part of her duties is to educate staff, round on patients, and address any concerns about wound care. NM RR also stated that each unit leader is responsible for the chart audits. An interview took place in the conference room on 3/26/24 at 12:15 p.m. with Clinical Coordinator (CC) SS, Wound Care who stated that she coordinated inpatient wound care and checked back on rounding for wound care. CS SS stated that she could only remember P#2 vaguely and could recall P#2’s family did not want her (P#2) to have a colostomy, and the family was informed the wound might not heal. An interview took place in the conference room on 3/26/24 at 1:10 p.m. with Assistant Nurse Manager (ANM) OO for the 2-North Unit who stated that the Care Partners do the turning and documented it every two hours. ANM OO stated that if the patient required the assistance of two staff, a care partner would go in with a buddy, which could either be another care partner or a Registered Nurse. ANM OO also stated that each patient’s room had a turn clock, which helped to remind staff to strictly follow the two-hourly turn. An interview took place in the conference room on 3/26/24 at 1:18 p.m. with Nursing Director (ND) PP, for the 2-North and 2-South units, who stated that processes are in place for audits for patients at high risk for skin breakdown. ND PP stated that a readiness meeting took place every morning to discuss patients at high risk for skin breakdown and to put necessary interventions in place. An interview took place in the conference room on 3/26/24 at 1:43 p.m. with Registered Nurse (RN) QQ who stated that she personally worked with care partners to get things done. RN QQ stated that she usually reminded the care partners about turning/repositioning patients as she (RN QQ) did her hourly rounds on patients. RN QQ also stated that there are set parameters to follow as per wound care on the electronic medical record system. A telephone interview took place on 3/28/24 at 9:30 a.m. with Care Partner (CP) VV who stated that there are “turn teams” on the units who specifically assist in turning patients with Braden scores of 17 or less. CP VV stated that the care partners do not work on weekends, and turning could be missed sometimes, especially if they are short-staffed.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 47718 Based on review of the facility’s policies/procedures, medical record review, and staff interviews, the facility’s discharge planning process failed to include a re-evaluation for one four (P#1) of eight patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) for one (P#1) sampled patients. P#1’s temperature on 2/26/24 at 4:02 p.m. 101.2 degrees. P#1 was discharged on 2/26/24 at 8:20 p.m. P#1 arrived back to the facility’s ED on 2/26/24 at 9:12 p.m. with hypotension and a temperature of 101.3 degrees. P#1 was re-admitted with sepsis. Findings: Review of the “Assessment of the Patient” policy #PE-05-01, revised 11/1/22, revealed that patients would be reassessed after procedures, changes in condition, upon transfer to a different level of care, and at specified times based on the discipline and patient location. Review of the “Nursing Plan of Care” policy #PS-51, revised 8/27/20, revealed that a Plan of Care (POC) was a process that included nursing assessments, diagnosis, interventions, goals, and evaluation of the patient’s progress toward established goals. Patients would be assessed at admission then reassessed at specific times based on the level of care or when there was a significant change in the patient’s condition. Review of the “Disposition Planning” policy CC-15-01, revised 1/2017, revealed that all patients would be screened at the time of initial contact and at regular intervals during the hospitalization to identify continuing healthcare needs. The registered nurse would assess patients for potential post-hospital care needs. The patient’s condition and disposition plan would be monitored to ensure the services arranged would meet the patient’s healthcare needs at the time of discharge. A review of an Emergency Department (ED) Report revealed that P#1 arrived at the ED on 1/30/24 at 2:19 p.m. with low blood pressure. P#1 was admitted as inpatient at 7:55 p.m. A review of a nursing flowsheet on 2/26/24 at 4:02 p.m. by the Care Partner (CP) BB revealed that P#1 had a temperature of 101.2 degrees. Review of nursing documentation failed to reveal that the physician had been notified of the increased temperature. A review of the Discharge Information revealed that P#1 was discharged with Home Health Services on 2/26/24 at 8:20 p.m. A review of the Emergency Department (ED) Care Timeline revealed that P#1 arrived at the ED on 2/26/24 at 9:12 p.m. with hypotension (low blood pressure). The Quick Look vital signs at 9:42 p.m. revealed that P#1’s temperature was high at 101.3 degrees. A review of a Discharge Summary Note by MD EE 3/11/24 at 3:42 a.m. revealed that P#1 had sepsis due to recurrent urinary tract infections. A telephone interview took place with the Registered Nurse (RN) GG on 3/27/24 at 11:10 a.m. RN GG said P#1 was discharged and had already left the unit by the time RN GG discovered the elevated temperature. If a patient was ready for discharge and presented like something was wrong, there would be a complete reassessment prior to letting the patient leave the facility. Patients were routinely assessed every two to four hours depending on their condition, including vital signs. RN GG said P#1 did not have any complaints and her condition seemed satisfactory at the time of discharge. RN GG did not notice the elevated temperature. A telephone interview took place with RN HH on 3/27/24 at 2:59 p.m. RN HH said she was coming on evening shift and received a report from the previous nurse that P#1 was waiting for transport off the unit. All discharge paperwork had been completed. The charge nurse took over the discharge for P#1 since RN HH was tending to an emergency at the time. RN HH said nobody told her P#1 was running a fever.”