Guam Memorial Hospital Authority

“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: 22198 Based on transfer and emergency department (ED) medical record review, Emergency Department (ED) Central Log review, Emergency Medical Treatment and Active Labor Act (EMTALA) education review, EMTALA policies review, and interviews, the facility failed to ensure six of six Registered Nurse (RN) House Supervisors (6, 7, 8, 9, 10, and 15) solely responsible for all patient transfers in and out of the hospital received EMTALA training to prevent delays in patient transfers. The hospital failed to develop an escalation policy when transfer concerns or delays occurred to include the chain of command to notify to ensure transfers were safe and timely. Failure to meet the EMTALA requirements could potentially compromise the health and safety of patients with an identified emergency medical condition or who required the hospital’s specialized services. These failures resulted in an Immediate Jeopardy. A conference was held with hospital leadership Management Analyst IV (20) to be notified an Immediate Jeopardy (IJ) existed under 42 CFR 489.20 and 42 CFR 489.24 for failure of the hospital to have a policy for Nursing House Supervisors responsible to coordinate from a transferring hospital all patients with an emergency medical condition (EMC) or who required specialized pediatric service had Emergency Medical Treatment and Labor ACT (EMTALA) training and education on the hospital’s obligation under EMTALA law to prevent transfer delays and how to initiate or escalate transfer concerns. The hospital failed to have an escalation policy to define acceptable timeframes for transfer, the structure of escalation through hospital leadership, responsibility for chain of command for reporting, and escalating delayed transfer concerns for any unresolved communication concerns for interfacility transfers. This failure potentially jeopardized the health and safety of patients with an EMC or required specialized pediatric service. The IJ template was provided to the hospital on 12/18/25 at 8:37 AM and a signed copy of the IJ template was received at 8:45 AM. The Plan of Removal was verified as implemented to remove the immediacy, and the Immediate Jeopardy was removed on 12/1925 at 3:39 PM. Findings include: Review of RN House Supervisor 6’s training personnel files revealed RN House Supervisor 6 was hired for the position of House Supervisor on 08/21/21. Review of the training personnel files did not reveal documentation RN House Supervisor 6 received EMTALA training. Review of RN House Supervisor 7’s training personnel files revealed RN House Supervisor 7 was hired for the position of House Supervisor on 08/21/24. Review of the training personnel files did not reveal documentation RN House Supervisor 7 received EMTALA training. Review of RN House Supervisor 8’s training personnel files revealed RN House Supervisors 8 was hired for the position of House Supervisor on 08/01/17. Review of the training personnel files did not reveal documentation RN House Supervisor 8 received EMTALA training. Review of RN House Supervisor 10’s training personnel files revealed RN House Supervisor 10 was hired for the position of House Supervisor on 09/30/15. Review of the training personnel files did not reveal documentation RN House Supervisor 10 received EMTALA training. Review of RN House Supervisor 15’s training personnel files revealed (RN House Supervisor15 was hired for the position of House Supervisor on 01/09/20. Review of the training personnel files did not reveal documentation RN House Supervisor 15 received EMTALA training. During an interview on 12/16/25 at 9:00 AM, the Quality, Patient Safety and Regulatory Compliance Administrator (QPSARCA) (1) confirmed that the House Supervisors 6, 7, 8, 9, 10, and 15 did not receive EMTALA training, and it would not be in their competency or required for the role as a House supervisor. During an interview on 12/16/25 at 1:35 PM, RN House Supervisor 9 confirmed he/she receives EMTALA training annually because it is required as a part of working in Labor and Delivery (L&D). RN House Supervisor 9 stated he/she holds two positions in the hospital, one on the L&D unit and one as a House Supervisor. RN House Supervisor 9 stated as a House Supervisor he/she was never required to take EMTALA training. There was a hospital transfer policy updated this year in September, but that is the only training the House Supervisor’s received regarding EMTALA. RN House Supervisor 9 stated examples of delays in a pediatric patient transfer to the hospital included, if the hospital was waiting for laboratory results, if there was a change in condition, or if the hospital was on diversion. RN House Supervisor 9 confirmed the hospital did not have an escalation policy when there are transfer concerns. During an interview on 12/17/25 at 11:30 AM, RN House Supervisor15 confirmed he/she had never received a formal EMTALA training. RN House supervisor 15 stated the hospital had a transfer policy that was updated this year that House Supervisors had to be training on to ensure transfers out met all the EMTALA criteria, but that was all. When asked if there was a policy to escalate transfer concerns, RN House Supervisor 15 stated, “No there was no policy for escalating our concerns, we [House Supervisors] put it in SLS [safety learning system].” RN House Supervisor 15 stated there was no documented structure to address transfer concerns, it is at nursing’s discretion, based on our knowledge. During an interview on 12/17/25 at 12:11 PM, RN House Supervisor 8 confirmed he/she had not received EMTALA training but there was a transfer policy update this year that the House Supervisors were trained on to ensure transfers out met all the EMTALA criteria and that they could not refuse transfers. RN House Supervisor 8 stated the hospital has SLS where reports or transfer issues are documented and later addressed. During an interview on 12/17/25 at 12:58 PM, RN House Supervisor6 confirmed he/she had not received EMTALA training but there was a transfer policy update this year that the House Supervisors were trained on to ensure transfers out met all the EMTALA criteria. During an interview on 12/17/25 at 2:07 PM, RN House Supervisor 7 confirmed he/she had not received EMTALA training but there was a transfer policy update this year that the House Supervisors were trained on to ensure transfers out met all the EMTALA criteria. Based on assessment and nursing judgement if the hospital can accept a patient, and if there are concerns our counterparts and leadership are contacted through internal chat. Also, to one talk with leadership on a group chat can be used, but that is up to each individual House Supervisor. There is no structure for escalation related to transfer issues, we address it based on nursing judgement. During an interview on 12/17/25 at 4:00 PM, Assistant Administrator Nursing Services (17) the hospital’s Director of Nursing confirmed the House Supervisors do not receive formal EMTALA training. Assistant Administrator Nursing Services (17) stated they do discuss the SLS reports. Review of the documentation from the SLS reports revealed it is in graft form from 12/24 to 12/25 and showed four transfer concerns were reported. Assistant Administrator Nursing Services (17) confirmed that the review is overtime, and not in real time. Assistant Administrator Nursing Services (17) confirmed the hospital did not have a formal process to escalate RN House Supervisors to report up to hospital leadership in real time to ensure a safe transfer is initiated if the House Supervisors at each hospital are having concerns. Assistant Administrator Nursing Services (17) stated the hospital’s current process is during weekends and holidays, and after hours, everything that should be escalated up to the Chief Executive Officer (CEO) of the hospital goes to the House Supervisors to be addressed. Even if the hospital had a policy to escalate concerns after hours it would go back to the House Supervisors. The Recipient hospital failed to prevent delays in transfers for six of nine pediatric patients (P) (P1, P3, P5, P7, P8, and P9) with an emergency medical condition or requiring specialized pediatric services when the hospital had capability and capacity in a total sample of 19. (Cross reference A2411).”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 22198 Based on medical record review, observation, interview, policy review, and Emergency Department (ED) Central Logs review, the recipient hospital failed to prevent delays in transfer for six of nine pediatric Patients (P) (P1, P3, P5, P7, P8, and P9) who required transfer to the hospital for an emergency medical condition (EMC) or who required pediatric specialized services when the hospital had capability and capacity. These failures resulted in significant delays in care, and for (P1) the transfer did not occur prior to the patient ’ s death. Findings include: Review of the hospital policy titled, “On-Island Safe Transfer And Receipt Of Patient To And From Another Healthcare Facility” dated 09/25 revealed, “The purpose of the policy and procedure is to: Establish a mechanism for safe transfer between Healthcare Facilities on the island of Guam ...Clarify roles and responsibilities of the Hospital, the Physician, Nursing, Professional Support Clinical Staff and the Patient Escort (if any). ... The receiving facility a. Has available space and qualified personnel for the treatment of the individual; b. Has agreed to accept transfer of the individual and to provide appropriate medical treatment; ...” Review of the hospital’s policy titled, “Patient Classification And Nurse Staffing Pattern” dated 05/22 revealed, “. . . acuity level define I: Minimal Nursing Care, II: Partial Nursing Care, III: Full Nursing Care, and IV: Complex Nursing Care. Responsibilities: ...The Unit Supervisors have the oversight in patient classification and staffing needs, and safe staffing patterns, ensuring fiscal responsibility. ...” During an interview on 12/17/25 at 10:55 AM, the RN Pediatric Unit Supervisor (19) was asked how the pediatric unit staffs nurse to patient ratio and RN Pediatric Unit Supervisor (19) stated two RNs to six pediatric is reasonable and manageable. Review of the hospital’s policy titled, “PICU [Pediatric Intensive Care Unit] Staffing Acuity” dated 10/21 revealed, “The PICU will be staffed with minimum of two nurses regardless of the census or acuity. ... A. Two nurses to one patient. Unstable patients. Open heart patients. Unstable oncology patients. B. One nurse to one patient Ventilator patients that need close observation. Patients receiving medications that require additional monitoring. Oncology patients. Trauma patients with frequent vital signs and neuro checks. Unstable patients with respiratory distress without a ventilator. Patients with central lines or multiple lines that require close monitoring. Unstable neurological patients. C. One Nurse to two patients. Stable patients. Ventilator patients or patients receiving oxygen support, Patients with central lines. Stable Neurological.” Observation and bed count on 12/17/25 at 10:00 AM of the pediatric unit revealed there were 12 beds and four beds in the PICU. During an interview on 12/16/25 at 10:00 AM, RN Pediatric Unit Supervisor (19), confirmed the pediatric unit does have 12 beds with 12 patient capacity and the PICU has four beds and four patients is the maximum capacity. Review of the hospital’s ED Central log titled, “GMHA Interfacility ‘Transfer In’ Log Sheet” from 07/02/25 through 12/15/25 showed a pattern of delayed or failed transfers despite capacity as follows: 1. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed on 10/26/25, the hospital was notified at 7:40 PM that P1 required pediatric specialty care. The physician accepted P1 transfer at 8:31 PM. The log indicated P1 was assigned a room (452c) in the PICU. P1 expired 8 and three quarters of an hour after the receiving hospital’s House Supervisor was notified of the pediatric transfer, and 8 hours after the receiving hospital accepted P1. P1 expired and was not transferred to the receiving hospital with pediatric capabilities. No transfer medical record for P1 was available to review. Review of the staffing and bed capacity on 10/26/25 from 7:40 PM to 10/27/25 at 4:29 AM revealed there were two RNs on duty in the PICU and two PICU beds available when the House Supervisor received the call on 10/26/25 at 7:40 PM from the transferring hospital. The PICU census was three patients on 10/26/25 from 11:00 PM until 10/27/25 at 7:00 AM, with one PICU bed open. During an interview on 12/16/25 at 10:15 AM, RN Pediatric Unit Supervisor (19) confirmed the PICU had capacity, both nursing and beds on 10/26/25 from 7:40 PM through 10/27/25 at 4:29 AM to accept P1 During an interview 12/17/25 at 3:08 PM, Medical Chair of Pediatric Services (18) confirmed after reviewing the “GMHA Interfacility ‘Transfer In’ Log Sheet” and the staffing and census, stated, “ If one of the four PICU beds is opened and there are two nurses there are no restrictions, we should have had that patient [P1] transferred in.” 2. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed on 10/07/25 the hospital was notified at 5:00 PM P3 required pediatric specialty care and was assigned to the PICU. The “Comment” section of the log had documented “intubated.” The transfer medical record was not legible. The inpatient medical record revealed the first qualified medical professional time stamp in the medical record was by a physician who started a history and physician (H&P) on 10/07/25 at 3:21 PM. P3 was not admitted until 10/07/25 at 11:21 PM, eight hours after the receiving hospital’s Qualified medical personnel (QMP) started an H&P, and six and three quarters of an hour after the Nursing House Supervisor documented knowledge of the pediatric transfer. Review of the staffing and census for the PICU on 10/07/25 revealed there were two RNs and the patient census was three. During an interview on 12/19/25 at 10:10 AM RN Pediatric Unit Supervisor (19), confirmed the PICU had capacity, they PICU had one available bed and two RNs. 3. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed on 10/05/25 the hospital was notified at 8:00 AM P5 required pediatric specialty care and was assigned to PEDS (pediatric unit). The “Comment” section of the log had documented, “pneumonia on RA [room air].” P3 was not admitted until 10/06 at 11:10 PM (39 hours after the Nursing House Supervisor documented knowledge of the pediatric transfer. Review of P5’s transfer medical record revealed the accepting physician accepted P5 at 10/05/25 at 8:07 PM, with the benefits documented, “pediatric care,” The Reason for Transfer: “need peds seizures.” Review of the staffing and census for the PEDS unit on 10/05/25 from 8:00 AM until 10/06/25 at 11:10 PM revealed there was capacity on the day shift with nine patients and two RNs, Swing Shift had eight patients and two RNs, night shift had eight patients and three RNs. On 10/06/25, there were eight patients and two RNs, for both days and swing shift. On the night shift there were three RNs and went down to five patients. During an interview on 12/19/25 at 10:05 AM, RN Pediatric Unit Supervisor (19) confirmed the PEDS had capacity on both 10/05/25 and 10/06/25 and could have accepted P5. 4. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed on 11/25/25 at 9:22 PM the hospital was notified of the pending pediatric transfer. The “Comment” box on the log documented, “respiratory failure”. The transfer in log failed to document the time P7 was transfer inpatient to the hospital pediatric unit or PICU. Review of P7’s transfer medical record revealed the diagnosis was “bronchitis, hypoxia”. On 11/25/25 at 10:35 PM, the accepting physician accepted the transfer. Reason for Transfer was documented, “medically indicated”. Medical Benefits for Transfer was documented, “Peds inpatient ICU”. During an interview on 12/19/25 at 9:25 AM, RN Pediatric Unit Supervisor (19) confirmed that although it was not clear on the ED log of transfers in, P7 had been admitted to the PEDS unit on 11/26/25 at 1:35 AM (4 hours after the hospital was notified). RN Pediatric Unit Supervisor (19) stated the hospital had the capacity and staffing to accept P7. Review of the staffing and census for 11/26/25 from 9:22 PM until 11/27/25 on the night shift patient census was seven patients and three RNs. 5. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed the hospital was notified on 10/23/25 at 10:22 PM that P8 required transfer into the PEDS unit and was assigned PED bed 462A. Under the column titled, “Date/Time Arrival To Unit” was documented 10/24/25 at 3:10 PM (4 and a half hours after the hospital was notified and 5 hours after the pediatric specialist accepted P8) Review of P8’s transfer medical records revealed P8’s chief complaint was “shortness of breath”. “Medical Condition-Diagnosis, “Flu A Pneumonia” and Reason For Transfer, “Medical Benefits” “higher level of care” on 10/23/25 at 10:10 PM the accepting physician accepted P8’s transfer. Review of the staffing and census for 10/23/25 night shift to 10/24/24 at 7:00 AM revealed the pediatric census was 10 and staffing was three RNs. During an interview on 12/19/25 at 10:20 AM, RN Pediatric Unit Supervisor (19) confirmed that the PEDS unit capacity was 12. 6. Review of the “GMHA Interfacility ‘Transfer In’ Log Sheet” revealed the hospital was notified on 11/27/25 at 12:48 AM P9 required a transfer to the pediatric unit for care. On the transfer log under the column “Date/Time Arrival to Unit”11/27/25 at 6:43 AM” was documented. (Six hours after the hospital was notified of the required transfer). The comment box “DX (diagnosis): Cyanosis in setting of Influenza A+” Room assigned “PEDS 467.” Review of P9’s transfer medical record revealed, the reason for transfer, “Medically indicated Ped [pediatric] inpatient.” Review of the census on 11/26/25 into 11/27/25 from 2:00 AM through 7:00 AM revealed the census was seven patients and three RNs. During an interview on 12/19/25 at 9:25 AM, RN Pediatric Unit Supervisor (19) confirmed that on 11/27/25, the hospital had capacity and staffing was sufficient to accept P9 for transfer. During an interview on 12/17/25 at 11:30 AM, RN House Supervisor (15) confirmed the House Supervisors are responsible for determining capacity with all transfers into the hospital. During an interview on 12/17/25 at 12:11 AM, RN House Supervisor (8) confirmed the House Supervisors are responsible for determining capacity for all transfers into the hospital. During an interview on 12/17/25 at 12:58 AM, RN House Supervisor (6) confirmed the House Supervisors are responsible for determining capacity for all transfers into the hospital. During an interview on 12/17/25 at 12:58 AM, RN House Supervisor (7) confirmed the House Supervisors are responsible for determining capacity for all transfers into the hospital. During an interview on 12/17/25 at 3:08 PM, Medical Chair of Pediatric Services (18) confirmed House Supervisor to House Supervisor determine capacity and space for transfer patients. Medical Chair of Pediatric Services (18) confirmed the House Supervisors should have guidance and structure to know when to escalate transfer concerns. “I think two hours to transport would be acceptable depending on GFD (Guam Fire Department) the only community ambulance. The hospital is working in silos doctors and specialists accept pediatric patients, but we do not know capacity. The House Supervisor’s determine capacity but might not know the medical necessity. Medical Chair of Pediatric Services (18) confirmed he/she was not aware of the House Supervisors making decision on hospital capacity as it applies to EMTALA without receiving formal EMTALA training. During a telephone interview on 12/18/25 at 9:09 AM, Tele-Health Pediatric Intensivist (5) stated, “I have no control over the transfers, and I am at the ‘will’ of the House Supervisors. They control the transfer process.” We (the hospital) have had “issues like this before and there is no formal process to have our concerns addressed.” “I wonder why we have such delays in getting especially pediatric patients transferred over here.” During an interview on 12/18/25 9:46 AM, the Chief Medical Officer (CMO) (11) confirmed “there are no formal structures or policy for escalating physician concerns when there are delays in transfers or any concerns.” CMO 11 stated, “Yes, I understand we have unwritten rules and processes, and we can do better.” CMO (11) confirmed that they have gone through several CEOs and the current CEO is only interim. “It’s political, that is all I can say.””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 28154 Based on observation, interview, document review, environmental testing results, and policy review, the facility failed to meet the Condition of Participation (CoP) for Physical Plant and Environment respective to applicable CoPs under 42 CFR 482.41. The facility failed to ensure areas of probable mold, first identified in a 10/30/23 mold spore testing report, were managed according to a mold remediation plan dated 01/30/24 in multiple public and patient care units resulting in visible mold around windows and on ceiling tiles. This failure increased the risk of a new onset of respiratory and skin conditions, the exacerbation of chronic asthma/ bronchitis, and other long term health problems. patients, staff, and/or visitors of the hospital as mold spores carry with air movement. Findings include: 1. The facility failed to act when visible mold was identified as an ongoing issue. Refer to A-0701.”

“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: 28154 Based on observation, record review, and interviews, the facility failed to meet the Condition of Participation (CoP) for Infection Prevention and Control respective to the applicable CoPs under 42 CFR 482.42 for one patient (Patient (P) 15 out of a sample of 42 patients reviewed. The facility failed to ensure a plan for alternate placement for dialysis access was developed and implemented which increased the risk of potential infection, sepsis, and possible death. Findings include: 1. The facility failed to ensure a new hemodialysis patient P15, admitted on 02/03/25, with a tunneled central venous catheter hemodialysis access placed on 02/10/25, received the vein mapping and alternate access (arteriovenous graft (AVG) or fistula (AVF) placement even after an inpatient stay of greater than six months. Refer to A-0776.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 28154 Based on record review, interview, and facility policy review, the facility failed to ensure a patient (Patient (P) 23) was monitored per protocol while in the Emergency Department. This failure had the potential for changes in condition not to be identified and treatment provided. Findings include: Review of the facility policy titled “Fundamental Standards of Care in the Emergency Department,” reviewed 10/2024, revealed: “Policy: Fundamental Emergency Department nursing interventions include, but are not limited to the following: ESI [Emergency Severity Index] Acuity Level 1: Vital signs every 5-15 minutes and/or unless ordered more frequently ESI Acuity Level 2 &3 : Vital signs every 30-60 minutes and/or unless ordered more frequently ESI Acuity Level 4 & 5: Vital signs every 60-120 minutes and/or unless ordered more frequently” Review of P23’s record showed an admission to the hospital on 08/03/25 and discharge on 08/05/25 after being seen in the Emergency Department. Review of the Emergency Department (ED) “Nursing Chart” with Clinical Nurse Informatics Specialist (CNIS) showed an arrival to the ED at 6:22 PM on 08/03/25 after a near drowning incident and the triaged acuity was “1 (Resuscitation).” P23’s vital signs were taken at: 6:22 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 10:37 PM CNIS stated on 08/09/25 at 10:49 AM stated P23 was “ESI 1” and there was no order for less frequent vital signs. CNIS stated perhaps there were manual vital signs and would check the other charting documentation. During an interview on 08/12/25 at 2:40 PM regarding additional vital sign documentation for P23, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) stated she had “checked the documentation and even on manual form, the protocol for frequency [of vital signs] would have been non-compliant.””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 28154 Based on observation, interview, and checklist review, the facility failed to ensure expired medications and vacutainers (for blood collection / testing) were not in the emergency department “Malignant Hyperthermia” response cart. This failure had the potential to affect a successful outcome in an emergent event. Findings include: Observation of the Emergency Department (ED) “Malignant Hyperthermia” (MH, a potentially fatal genetic condition that causes a rapid body temperature increase with muscle contracture triggered by certain anesthetics) cart on 08/05/25 at 1:06 PM revealed four pediatric sized vacutainer blood tubes with an expiration date of 06/20/25. The Emergency Department Manager (EDM) confirmed the expiration date on the tubes at 1:08 PM. Further observation of the “Malignant Hyperthermia” cart revealed two 2% lidocaine injectable 100 milligram in 5 milliliters (5mg/5mL) with an expiration date of 08/01/25; confirmed by the Deputy Assistant Nursing Services (DANS) on 08/05/25 at 1:10 PM. A policy regarding medications was requested. Review of the facility “Malignant Hyperthermia Cart Monthly Checklist Month of: August 2025” showed “2% Lidocaine 5ml Inj [injection],” handwritten 100mg with a quantity of “2” and an expiration date handwritten of “9/1/25 & 9/25.” The form was not dated when the checklist was completed, just had a handwritten “Expired 8/31/25/[signature of RN1].” A policy was not received. Review of the Association of Peri-Operative Registered Nurses (AORN) website regarding “Best Practices for MH Crisis Response” (https://www.aorn.org/outpatient-surgery/article/best-practices-for-mh-crisis-response) revealed “Deeper quarterly inspections of your MH cart should include checking for missing or expired medications ...” Review of the Joint Commission “Crash Cart Preparedness,” issued April 2017, stated: “ ...Contributing factors to patient safety events related to crash carts include, but are not limited to: Medication errors and mix-ups Missing, expired, damaged, contaminated, and unavailable equipment or medications””

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 28154 Based on observation, interview, and policy review, the facility failed to ensure proper handling of bakeware and failed to ensure a cook contained facial hair while in the kitchen. These failures had the potential to have bacteria grow in the bakeware or contaminate food with facial hair. Findings include: During the observation of the kitchen on 08/06/25 at 1:50 PM, the Dietary Manager (DM) picked up a stack of eight quarter sheet pans and water streamed out from the stack, indicative that the pans were turned upside down and stacked while still wet; at another shelf, the DM lifted two full size steam table pans to reveal water droplets between the pans. The DM confirmed they had not been fully air-dried before stacking. At 2:10 PM, Cook 1 was observed preparing food with uncontained facial hair. When asked about it, the DM identified him, confirmed he did not have a facial hair cover, and immediately went over to Cook 1 and advised him to cover his facial hair. During an interview on 08/12/25 at 3:18 PM, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC), provided the policy below stating, “they can’t have facial hair” and stated there was no policy regarding the wet-stacking but that it was in the Public Health regulations. Review of the facility “Dietic Services Department” policy titled “Professional Image and Hygienic Practices,” effective 09/30/21, revealed: “Procedure: 1. General Principles A. General Dress Code ... 3. Hair should be neat and clean. Sideburns are allowed and must be well trimmed. Mustaches and beards are not permitted.” Review of the “Guam Food Code,” (https://dphss.guam.gov/wp-content/uploads/2019/05/Guam-Food-Code-with- revealed: Drying 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. . . . (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying . . . “”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 28154 Based on observation, interview, document review, environmental testing results, and facility policy review, the facility failed to ensure areas of probable continued mold, first identified in a 10/30/23 mold spore testing report were managed according to a mold remediation plan dated 01/30/24 in multiple public and patient care units, along with other environmental issues. The effect of the deficient practices in environmental containment with mold throughout the hospital due to the ongoing water and moisture issues, visible mold around windows and on ceiling tiles, could potentially jeopardize the health and safety of any patients, staff, or visitors of the hospital as mold spores carry with air movement. Findings include: During the facility tour on 08/05/25 at 1:50 PM by door “EMB 295B/CDR1,” in between the surgical area and labor and delivery units, moisture, black areas, and cobwebs were noted around the window frames and walls. At 2:07 PM, exiting the nursery area, the cove base was noted to be held together with tape by Door EM-C270B. The Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) confirmed the presence of mold, moisture, cove base taping, and cobwebs. Numerous areas of the hospital had wet floor signs on the floor with blue material on the floor near the sign to absorb water, first observed through the doors to enter the elevator commons area. During the facility tour of the third floor on 08/06/25 at 12:05 PM the ceiling tiles outside the Medical/Surgical department had black circular growths with an additional three tiles noted with a black substance down the hall, with one ceiling tile appeared wet; the AQPSRC confirmed the moisture related areas. Continuing on the third floor to the Telemetry unit at 2:20 PM, broken ceiling tiles and tiles with a black substance were observed and confirmed by the AQPSRC. On to the fourth floor at 2:28 PM, outside the pediatric unit doors, stained and buckling ceiling tile were observed; inside the unit doors broken ceiling tiles, stained ceiling tiles and dark areas next to a sprinkler head; in the playroom area, the ceiling tiles were water stained but not currently wet. During the tour of the surgical unit at 2:40 PM, the output ceiling vent (air flow noted from the vent) by the nurse’s station was noted to have dark streaking and dust buildup; an intake ceiling vent (no airflow noted) outside of patient rooms 437/438 was noted to have fuzzy black dots on the metal. Outside of patient room 433 the drywall was noted to be buckling with a blue absorbent cloth on the floor along the cove base and in the patient room bathroom one of the tiles at the bottom near the floor under the sink on the outside of the shower was missing (appeared to be eroded) and was no longer secured to the wall; outside of room 419 there were five water stained ceiling tiles; the cove base was detached away from the wall in room 417 and four ceiling tiles had water damage; and two ceiling tiles outside of room 418 were water stained. All observations were confirmed by the AQPSRC on the tour. Review of the facility provided “Indoor Air Quality/Airborne Mold Spore Testing Report,” dated 10/30/23, revealed: “Results ... Based on the visual inspection, mold growth and signs of water intrusions/water leaks were observed throughout the inspected areas as well as the hallways throughout the building. According to facility management personnel, ceiling tiles are regularly changed out when potential old growth is observed. However, in conjunction with the high relative humidity throughout the building, if the source(s) of water intrusions/water leaks are not properly addressed, mold will continue to proliferate throughout the building.” Review of the facility provided “Typhoon Mawar Mold Remediation Plan of Corrective Action,” dated 01/30/24, revealed: “ ...Intermediate POC (3 - 9 months post typhoon passage) ... -Continue monitoring for and detection of visible mold; and perform visible mold cleaning on floors/walls/doors/surfaces and replace visibly moldy ceiling tiles.” During an interview on 08/07/25 at 8:55 AM regarding the observed mold, the Plant Manager (PM) stated, “It’s because of the dripping condensation from the water lines.” When asked if they were aware of the issue, the PM stated, “we have a PIP [performance improvement plan] for the HVAC system, was supposed to be replaced by December 2023, but I believe we are still looking for funding.” When shown pictures of the ceiling tiles with the black substances, the PM confirmed it was mold. When queried about the mold mitigation plan frequency of monitoring, the PM responded, “We go around daily.” When asked if there were any logs of the monitoring, the PM said there were no logs and confirmed he had no idea how long the ceiling tiles had been there and was unaware of the last time it was checked. “We’re the one [responsible] for public areas. Sometimes work orders are placed and sometimes we just replace it.” Review of the facility provided “Environment of Care Committee” minutes revealed: 09/26/24 “I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF [Skilled Nursing Facility] 22). 16 at GMH ...were not in recommended range.” 12/05/24 “I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range.” 01/03/25 “I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range.” 02/27/25 “I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range.” 04/01/24 “I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored. GMHA 8 out of the 47 locations are not in the recommended range. . . . 06/26/25 “6. Facilities Maintenance b) Utilities Management -Indoor Air Quality (IAQ) . . . Mold Monitoring Results GMHA: 12 out of 47 failed . . .” Review of the facility policy titled “Water Infiltration, Flooding and Sewer Backup Response,” revised 03/2010, revealed: “ ...V. Area Cleanup [sic] Water damaged building materials and furnishings, if not appropriately handled, can become significant sources of microbiological contamination. This is true even if the water damage occurs from exposure to clean water. ...B. Remove all wet ceiling tiles, bag them, and place in the regular trash.””

“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: 28154 Based on observation, interview, and policy review, the facility failed to ensure patient equipment was maintained in a manner to allow for/maintain disinfection. This failure had the potential to subject patients to cross contamination which could result in healthcare acquired infections. The survey census was 149. Findings include: 1. Observation of operating room 3 on 08/07/25 from 9:50 AM to 11:40 AM revealed the two IV stand bases by the anesthesia area, the trash bag rolling carts, and over bed table (used by nurse for charting) had rusted, uncleanable surfaces. During an interview on 08/07/25 at 11:44 AM, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) confirmed the presence of rust on the identified surfaces. Observation of operating room 1 on 08/07/25 at 12:20 PM revealed the presence of rust on the rolling trash bag cart, IV pole stand, and around the window. During an interview on 08/07/25 at 12:42 PM, the AQPSRC confirmed the presence of rust on the identified surfaces. 2. During the observation of endoscopic equipment cleaning on 08/07/25 at 11:45 AM, a clean scope was noted to be hanging (done to drain any residual water from the scope) open to the air at the end of the table where the scope rinsing was done. At the time of this observation, a dirty scope was being processed in the open sink in the room. During an interview on 08/07/24 at 11:47 AM, Medical Equipment Tech (MET) 1 and MET2 confirmed the hanging scope had been disinfected. 3. During the laboratory tour on 08/08/25 at 12:20 PM, an observation of the laboratory patient blood station on 08/08/25 at 12:24 PM revealed the upholstered arm rest (where a patient would rest their arm for tourniquet application, site cleaning, and blood sample draw) revealed an open area with exposed foam padding. A rusty table was observed in the chemistry processing area and rust was observed on cabinet doors below the sink in the histology area. During an interview on 08/08/24 at 12:24 PM, the Lab Manager confirmed the chair was used for blood draws of patients and at 12:40 PM and 12:45 PM the AQPSRC confirmed the presence of the rust in the chemistry and histology areas. Review of the facility policy titled “Environmental Maintenance (EM) Program,” approved 04/28/22, revealed: “Purpose: The purpose of this policy is to describe and outline the process by which maintenance work within defined environmental units is assigned, performed, and documented. Policy: 1. The Hospital will maintain its physical plan in accordance with a recommended schedule that will serve to provide a safe, functional, and aesthetically pleasing environment. . . . Attachment 1 Items Included in Environmental Maintenance ...Bedside Tables ...Counters/Closets/Chairs ...Sinks ...Windows” Review of the facility policy titled, “Guidelines for Environmental Infection Control,” effective date 03/17/23, revealed: “Purpose: Our hospital must manage its environment (to include utilities, surfaces, medical devices) in a way to reduce potential risks of hospital associated infections and transmission of infections. This policy provides guidelines for management of the environment to reduce those risks associated with air handling and ventilation systems, water distribution systems, housekeeping, laundry, and service animals. . . . XIII. Carpeting and Cloth Furnishings ...C. Avoid using upholstered furniture and furnishings in high-risk patient-care areas and in areas with increased potential for body substance contamination . . . D. Maintain upholstered furniture in good repair. A. Maintain the surface integrity of the upholstery by repairing tears and holes.” Review of the facility policy titled “Guidelines for High Level Disinfection of Semi-Critical Devices Using Medline OPA/28 Solution, Leak Testing, Quality Control Testing, Neutralization for OPA Disposal, and OPA Spills,” reviewed 09/2023, revealed: “ ...XVI. Post-Processing Handling and Storage of Reusable Devices: Disinfected reusable devices are either to be immediately used or stored in a manner to minimize recontamination. . . .””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 28154 Based on observations, record review, and interviews, the facility failed to ensure alternate forms of access were provided to reduce the risks of tunneled central venous catheter (CVC) infection for one patient (Patient (P) 15) out of a total sample of 42 patients reviewed. This failure resulted in a tunneled CVC being in place for dialysis access for six months with no plans for placement of an alternate vascular access. On August 11, 2025, at 8:15 PM, an Immediate Jeopardy (IJ) situation was declared in the presence of the hospital Administrator, Quality Patient Safety & Regulatory Compliance (AQPSRC) after the Centers for Medicare and Medicaid Services (CMS) agreed to the IJ through surveyor observations, interviews, and record review. The hospital failed to protect one identified patient at risk for infection, sepsis, and potential death from a long-term use of a tunneled CVC. On August 13, 2025, at 4:52 PM, the Immediate Jeopardy situation was removed via email with the AQPSRC. The facility was informed that the hospital’s Removal Plan was approved and implementation was verified as effective on 08/13/25 at 4:52 PM upon completion of 80% staff / practitioner education was achieved. Findings include: During an interview on 08/09/25 at 11:35 AM, P15 stated the hospital hemodialysis nurses were asking him about having the CVC for six months. When asked if he had completed the vein mapping for alternate access placement, P15 responded “No” and stated he did not know what the plans were and he was confused by the nurses asking about having the CVC for six months. Review of P15’s medical record “Consultation Sheet” showed an admission date of 02/03/25 and the Nephrologist documented on 02/03/25 at 9:46 PM “Plan: Rec [recommend] Quinton Cath Placement HD tomorrow 1st Rx [first prescription for dialysis] Recommend to place Permacath [tunneled CVC] Consult Surgery for AVF placement while IP [In Patient], as he has good veins.” During interviews on 08/11/25 at 10:18 AM and 11:14 AM, Medical Doctor (MD)1 and MD2 (both nephrologists that have seen P15), confirmed the discharge of a patient with a Central Venous Catheter (CVC) increased the risk of infection. MD1 stated the discharge of a patient with a CVC increased the risk of infection and death by 50% (due to the Guam environment and socioeconomic issues). Both doctors noted vein mapping and alternate site placement changed to an “elective procedure” during the COVID pandemic and have remained classified as elective procedures even though the Public Health Emergency (PHE) ended in May of 2024. During an interview on 08/11/25 at 11:14 AM, the Chief Medical Officer (CMO) stated he completed 90% of the fistulas/grafts on the island but vein mapping must be done first. The CMO related he had not received a consultation for in-patient AVG/AVF placement since the end of the PHE and 100% of patients leave with a catheter because they (hospital departments) do not allow it. The CMO stated, “Patients sent home with a CVC [tunneled] because of the environment in Guam, survival of dialysis patients decrease by 50%. It will take more than three months to place [AVF/AVG] and three months to mature; more than six months has shown to decrease survival. I see infected [tunneled catheters] because they [patients] come back to the hospital with readmissions. Fistulas and grafts do better. [Vein] Mapping and placement [AVF/AVG] are lifelines, but they [hospital departments] say they are elective [procedures].” During an interview on 08/11/25 at 3:10 PM, the Hemodialysis Unit Supervisor (HDUS) stated, “The use of a Permacath [tunneled CVC for dialysis] goal is three months or less. However, because most of their patients do not stay that long [in the hospital], there is no policy [for long term use of CVC]” The facility provided a list of 30 patients discharged with a CVC in the past six months. During an interview on 08/11/25 at 6:14 PM, the Infection Preventionist verified that two of the patients discharged with a CVC in the past six months were known to have had CLABSI (Central Line-Associated Blood Stream Infection) making the CLABSI rate 6.67%.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 28154 Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner, in accordance with the hospital’s own policies, acceptable national standards of practice, and in a manner to prevent the risk of cross contamination (the transfer of harmful bacteria from one person, object, or place to another), when 1. one of two surgical pre-procedure time-outs did not address the fire risk for one patient (Patient (P) 3) out of a sample of 42 residents reviewed and 2. the facility failed to ensure documentation of intervention or closure of surgical suites when the temperatures and/or humidity levels were not within the correct range. Findings include: 1. The hospital did not ensure a fire risk assessment was conducted prior to a fluoroscopy scope procedure for one of two sampled surgical patients P 3. Review of P3’s “Operative/Invasive Procedure Verification Checklist” form, revealed the patient procedure was for a “Repeat endoscopic retrograde cholangiopancreatography [procedure to examine the bile ducts, pancreatic duct, and related structures],” dated and signed 08/06/25 at 6:35 AM. Observation of P3’s procedure on 08/07/25 at 10:05 AM revealed the pre-procedure “Time-Out” did not address the patient’s fire risk. During an interview on 08/07/25 at 11:57 AM, the Surgical Manager (SM) and Administrator, Quality, Patient Safety & Regulatory Compliance (APQSRC) both confirmed the surgical pre-procedure time-out did not address the fire risk and should have. Review of the facility policy titled “Patient Safety in Anesthetizing Locations,” “Interim Approved May 02, 2019,” revealed: “ ...VI. Prevention of burns/ fires: . . . 6. The Surgical team shall conduct a “time out” before the start of surgery to ensure: a. The surgical site shall be dry before draping and before the use of the electrosurgical unit, cautery, and/or laser. b. There shall be no pooling of the prep solution around the patient” Review of the Association of peri-Operative Registered Nurses (AORN) website (https://www.aorn.org/article/the-importance-of-the-fire-risk-assessment) revealed: “A fire risk assessment should be done prior to the start of every case, and the fire risk should be discussed with the entire surgical team during the time out. This will keep everyone aware of how elevated the risk for a fire is during each procedure and what aspects of the procedure the risks are coming from, both of which can help prevent a fire from happening. Staff should also have, at a minimum, yearly fire safety education. This will give staff direction as to what to do should a fire start. A properly trained, quick-thinking surgical team can make all the difference in the event of an OR fire.” Review of the National Institute of Health (NIH) (https://www.ncbi.nlm.nih.gov/books/NBK544303/) revealed: “Nursing, Allied Health, and Interprofessional Team Interventions An interprofessional team approach is required to prevent the outbreak of a surgical fire. Good communication between all the OR members is a must. Surgical time-out is the most critical time point for detailing all the sources of fuels, oxidizers, and specific ignition sources within a procedure.” 2. Review of the “Temperature and Humidity Tracking Log Sheet for Operating Rooms” (different pages for each room) revealed at the top of the page, before the “Month” was handwritten in, was “Normal Ranges: Temperature: 68oF [Fahrenheit] to 75oF” and “Normal Ranges: Humidity: 30 - 60%.” The page had two columns, titled “AM 07-15 [7:00 AM - 3:00 PM] Shift” and “PM 15 - 23 [3:00 PM - 11:00 PM” with the dates prefilled and blank columns for the “Temperature,” “Humidity,” and an “Initial” column. At the bottom of each log was a box that stated “If temperature or humidity is out-of-range, contact Facilities Management (FM) at [phone number] on regular workdays or [phone number] on weekends, holiday and after hours. If unable to contact FM, call Communication Center [phone number]. Log ALL corrective actions on the back side of this form.” The back side of the form had boxes for which was out-of-range, the FM notification date and time, the name of the FM Personnel notified, who notified them, the corrective action taken, the FM actions taken by who, date, time; and if the problem was rectified (Yes/No) and who concurred with the rectified status. Review of the log sheets for “Operating Room Suite 1,” April 2025, revealed: 6 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective actions, or Operating Room (OR) closure. 1 of 30 days the PM temperature was below the minimum temperature; and one day was crossed out with no other data input, with no documentation of FM notification, corrective action, or OR closure. For May 2025, the log sheets revealed: 13 of 31 days the AM temperatures were below the minimum temperature and 2 of 31 days the humidity was above the maximum allowed, with no documentation of FM notification corrective action, or OR closure. 3 of 31 days the PM temperatures were below the minimum temperatures and 2 of 31 days the humidity was above the maximum allowed, with no documentation of FM notification, corrective action, or OR closure. For June 2025, the log sheets revealed: 14 of 30 days the AM temperatures were below the minimum temperatures and 3 of 30 days the AM humidity levels were above the maximum allowed with no documentation of FM notification, corrective action, or OR closure. 1 of 30 days the PM temperature was below the acceptable level with no documentation of FM notification, corrective action, or OR closure. For July 2025, the log sheets revealed: 22 of 31 days the AM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure. 1 of 31 days the PM temperatures was below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. Review of the log sheets for “Operating Room Suite 2” April 2025 revealed: 18 of 30 days the AM temperatures were below the minimum temperatures and two of 30 days the humidity was above the acceptable level with no documentation of FM notification, corrective action, or OR closure. One of 30 days the PM temperature was below the minimum temperature allowed, one had no documentation at all, and three of 30 days the humidity was above the maximum humidity allowed with one date having no documentation, with no documentation of FM notification, corrective action, or OR closure. Review of the May 2025 log sheets revealed: 13 of 31 days the AM temperatures were below the minimum temperatures and one of 31 days the humidity was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure. Six of 30 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure. Review of the June 2025 log sheets revealed: 13 of 30 days the AM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure. Five of 30 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure. Review of the July 2025 log sheets revealed: 24 of 31 days the AM temperatures were below the minimum temperatures, and one of 31 days had a humidity level above the acceptable level with no documentation of FM notification, corrective action, or OR closure. Three of 31 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure. Review of the log sheets for “Operating Room Suite 3” April 2025 revealed: 14 of 30 days the AM temperatures were below the minimum temperature, one of 30 days the temperature was above the maximum temperature with no documentation of FM notification, corrective action, or OR closure. 3 of 30 days the PM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. Review of the May 2025 log sheet revealed: 12 of 31 days the AM temperatures were below the minimum temperature, one of 31 days the temperature was above the maximum temperature; and two of 31 days the humidity level was above the maximum level allowed with no documentation of FM notification, corrective action, or OR closure. Four of 31 days the PM temperatures were below the minimum temperature, one of 31 days the temperature was above the maximum temperature, and two of 31 days the humidity level was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure. Review of the June 2025 log sheet revealed: 15 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. Five of 30 days the PM temperatures were below the minimum temperature, and one of 30 days the humidity was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure. Review of the July 2025 log sheet revealed: 22 of 31 days the AM temperatures were below the minimum temperature, and one of 30 days the humidity was above the maximum humidity with no documentation of FM notification, corrective action, or OR closure. Review of the log sheets for “Operating Room Suite 4” April 2025 revealed: Eight of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. Four of 30 days the PM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. Review of the May 2025 log sheet revealed: Six of 31 days the AM temperatures were below the minimum temperature and one of 31 days humidity was above the maximum allowable humidity with no documentation of FM notification, corrective action, or OR closure. Review of the June 2025 log sheet revealed: 11 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure. One of 30 days the PM temperature was below the minimum temperature with no documented FM notification, corrective action, or OR closure. Review of the July 2025 log sheet revealed: 15 of 31 days the AM temperatures were below the minimum temperature with no documented FM notification corrective action, or OR closure. During an interview on 08/08/25 at 9:54 AM regarding documentation of interventions, the SM stated she was aware of the out-of-range values but “I have no documentation of the room corrective actions on most of the days. There is an issue with form [not being completed] and I need to re-educate the staff.” SM provided email work orders for one room humidity level, dated and responded to by FM 05/28/25; one for humidity level dated 06/02/25 and responded to by FM on 06/13/25; and one dated 06/11/25 responded to by FM on 06/14/25 for the recovery room. A review of the hospital’s Policy and Procedure titled “Air Control in the OR,” reviewed 08/2021, revealed: “Policy: Temperature of the operating room will be maintained at 68 to 75 degrees F [Fahrenheit] (AORN [Association of Operating Room Nurses] Guidelines for Perioperative Practices, 2019 Edition) ... Procedure: Temperature and humidity will be monitored daily and logged in an Air Control Book by Operating Room Staff A. If the temperature is above 75oF maintenance will be notified. B. If the humidity is above 60%,[sic] Facilities Maintenance will be notified.” Review of the Centers for Disease Control (CDC) website revealed, (https://www.cdc.gov/infection-control/media/pdfs “ ...Cool temperature standards (68°F-73°F [20°C-23°C]) usually are associated with operating rooms, clean workrooms, and endoscopy suites ...Relative humidity levels >60%, in addition to being perceived as uncomfortable, promote fungal growth.””

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 28154 Based on observation, interview, and policy review, the facility failed to ensure medication drawn up into a syringe to induce anesthesia was labeled. This failure had the potential to contribute to medication errors and increase the chance of an adverse outcome to patients. The survey census was 149. Findings include: Observation of the Certified Registered Nurse Anesthetist (CRNA) cart on 08/07/25 at 9:52 AM in the operating room, CRNA showed a drawer with medications drawn up in syringes with all but one, filled with a white fluid. CRNA confirmed it was Propofol, looked through the boxes with medication labels on the top of the cart and stated he had no labels for Propofol but “it’s the only white one.” CRNA proceeded to apply a yellow label and handwrote the drug name. In an interview on 08/07/25 at 9:56 AM regarding the lack of a label on the syringe, Surgical Manager (SM) stated, “Anytime you take medication out of the original container it needs to be labeled. Review of the facility policy titled, “Patient Safety in Anesthetizing Locations,” effective date 05/02/19, revealed: “Procedure: VIII. Administration of drugs: ... C. All medication on and off the sterile field must be labeled. This includes medications used by the anesthesia provider. . . .””