West Suburban Medical Center

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 34411 Based on document review and interview, the Hospital failed to comply with the Condition of Participation 42 CFR 482.21 Quality Assessment and Performance Improvement Program. Findings include: 1. The Hospital failed to ensure an ongoing Quality Assurance & Performance (QAPI) Plan/Program was in place to monitor the effectiveness and safety of services and quality of care, including readmissions and patient safety, with designated timeframes, frequency and detail of data collection, and measure, analyze and track data collected. See A-273.”

“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: 20224 The Life Safety Code portion of a Full Survey Due to a Complaint survey was conducted August 4 - 6 , 2025. The requirements of 42 CFR Subpart 482.41 Physical Environment are NOT MET as evidenced by the deficiencies cited under the K-Tags.”

“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: 32741 Based on document review and interview, the hospital failed to comply with the Condition of Participation 42 CFR 482.42 Infection Prevention Control Antibiotic Stewardship. Findings include: 1. The hospital failed to ensure infection control surveillance and maintenance a clean and sanitary environment, and addressing any infection control issues identified by the hospital, including temperature/humidity levels in the operating rooms (OR) and stains on ceiling in patient care areas related to lack of ventilation system cleaning/preventive maintenance. See A-750 A. 2. The Hospital failed to evaluate and analyze infection control data for the infection prevention and control program, per hospital’s infection and control plan. See A-750 B.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 27125 Based on document review and interview, for all hospital contracted services the Hospital failed to ensure the governing body evaluated the contracts to ensure that services are provided in a safe and effective manner. Findings included: 1. A list of hospital contracted vendors was reviewed on 8/6/2025. The hospital was unable to provide an evaluation of the services provided for any contract. 2. During an interview on 8/6/2025 at approxiamtley 2:30 PM , the Executive Director of Operations (E#25). E#25 stated, “Contracts are not evaluated to ensure quality service is provided. The list of vendors has not been reviewed and I’m unsure if the list is current.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 39802 Based on observation, document review, and interview, for 2 of 4 patients (Pt’s. #24 and #25) observed with all four side rails up, the Hospital failed to ensure that hospital devices used to prevent a patient from voluntarily getting out of bed was considered a restraint. Findings include: 1. During a tour of the Progressive Care Unit (PCU) on 08/04/2025, between approximately 11:00 AM and 1:00 PM, two patients (Pt’s. #24 and #25) were observed to be laying in bed with all 4 bed side rails up. 2. The Hospital’s policy titled, “Restraint Management Policy” (revised 04/2022), was reviewed and required, “...Manual Restraint: Any manual method, physical or mechanical device, material, equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely and cannot be removed by the patient. These may include: ...Soft Restraint Devices... Enclosure beds or net beds are considered a restraint if: It is used to prevent the patient from exiting the bed...” 3. The clinical records of Pt’s. #24 and #25 were reviewed on 08/04/2025 and indicated that both patients needed assistance with ambulation and activities of daily living but were not completely immobile (unable to get out of bed on their own). The records lacked orders to use all 4 side rails up. 4. An interview was conducted with Nurse (E#10) on 08/04/2025, at approximately 1:05 PM. E#10 stated that they use side rails up to prevent the patients from getting up and falling out of the bed. E#10 stated that some of their patients experience sun downing (dementia that occurs at dusk through the night) and don’t want them getting out of the bed when they are confused as they may potentially fall. E#10 stated that they do not obtain orders for using 4 side rails.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 2 of 5 patients (Pts. #28 and #29) reviewed for restraint use, the Hospital failed to ensure that less restrictive measures were attempted prior to restraint use. Findings include: 1. The Hospital’s policy titled, “Restraint Management Policy” (revised 04/2022), was reviewed and required, “...It is the objective of our hospitals to limit and/or eliminate the use of restraint. Conversely, clinically and developmentally appropriate alternatives to restraint are to be attempted, documented and found to be ineffective prior to use of restraint if possible...” 2. Restraint Logs from July and August 2025 were reviewed and indicated the following: - Pt. #28 was placed in non-violent wrist restraints on 07/30/2025 from 5:00 AM to 6:00 AM due to being impulsive and taking off monitoring and pulling IV (intravenous access). - Pt. #29 was placed in non-violent wrist restraints on 07/30/2025 starting around 5:00 AM due to being very confused and pulling out lines. 3. The clinical records of Pts. #28 and #29 were reviewed on 08/04/2025 and lacked documentation of less restrictive measures attempted prior to use of restraint. 4. An interview was conducted with Nurse (E#10) on 08/04/2025, at approximately 12:10 PM. E#10 stated that attempts to redirect and reorient the patient should be attempted and documented prior to resorting to restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 2 of 5 patients (Pts. #28 and #29) reviewed for restraint use, the Hospital failed to ensure that restraints were utilized in accordance with a physician’s order and that the orders included the type of restraints to utilize. Findings include: 1. The Hospital’s policy titled, “Restraint Management Policy” (revised 04/2022), was reviewed and required, “...Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient’s ongoing care. The order shall include the type of restraint... For the restraint applied for non-violent or non-self-destructive behavior... Physician’s order: If the physician or authorized licensed practitioner is not present a verbal/telephone order must be obtained and entered into the patient’s medical record as soon as possible but not more than 12 hours after the initiation of non-violent, non-self-destructive restraints...” 2. Restraint Logs from July and August 2025 were reviewed and indicated that Pts. #28 and #29 were placed in non-violent wrist restraints on 07/30/2025 starting around 5:00 AM. 3. The clinical record of Pt. #28 was reviewed on 08/04/2025 and lacked orders for restraint use. 4. The clinical record of Pt. #29 was reviewed on 08/04/2025 and included orders for non-violent restraints, dated 07/30/2025 at 5:35 AM with a discontinuation date of 07/31/2025 at 5:35 AM. The orders lacked the specific type of restraints to use (i.e. bilateral soft wrist, ankle, mittens, side rails, etc.). 5. An interview was conducted with Nurse (E#10) on 08/04/2025, at approximately 12:10 PM. E#10 stated that all non-violent restraints should have an order placed. E#10 stated that typically they need a new order every 24 hours. E#10 stated that the type of restraint needs to be entered in manually by the doctor or nurse entering a verbal order, as the system doesn’t have a selection to choose from. E#10 stated that the order should include the exact type/location (i.e. mitt, wrists, ankle, etc.) of the restraint to use.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 1 of 5 patients (Pt. #29) reviewed for restraint use, the Hospital failed to ensure that the patient was monitored every 2 hours as required by policy while in restraints. Findings include: 1. The Hospital’s policy titled, “Restraint Management Policy” (revised 04/2022), was reviewed and required, “...Non-Violent, Non-Self Destructive: ... The patient shall be monitored at regular intervals, not to exceed every 2 hours interval, to be determined consistent with physician orders and/or patient condition and will have documented assessments to assure patient is free from adverse events and to determine if restraint shall be continued...” 2. The clinical record of Pt. #29 was reviewed on 08/04/2025 and included orders for non-violent restraint use with every 2 hour monitoring, dated 07/30/2025 at 5:35 AM. Restraint flow sheets indicated that the patient remained in restraints from 07/30/2025 at 5:36 AM until 07/31/2025 at 2:19 PM. The record lacked every 2 hour assessments as follows: - Between 07/30/2025 at 5:00 PM to 07/31/2025 at 4:20 AM (over 11 hours) - Between 07/31/2025 at 4:20 AM to 8:14 AM (nearly 4 hours) - Between 07/31/2025 at 8:14 AM to 12:16 (about 4 hours) 3. An interview was conducted with Nurse (E#10) on 08/04/2025, at approximately 12:10 PM. E#10 stated that patients in restraints should be monitored minimally every 2 hours for condition and offering of tilting, hydration, and nutrition. E#10 stated that the nurses should document these checks in the medical record. E#10 confirmed there were gaps in the documentation of the restraint checks.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 34411 Based on document review and interview, the Hospital failed to ensure an ongoing Quality Assurance & Performance (QAPI) Plan/Program was in place to monitor the effectiveness and safety of services and quality of care, including readmissions and patient safety, with designated timeframes, frequency and detail of data collection, and measure, analyze and track data collected. Findings include: 1. The Hospital’s “Quality Assurance & Performance Improvement (QAPI) plan” (not dated, Board of Directors’ meeting minutes included that this plan was presented during 1/2025 meeting), was reviewed and included, “The purpose of the QAPI program at [Hospital] is to take a continuous and proactive approach to establish a systemic, data driven decision making to ensure the delivery of high-quality patient care, improving organizational performance, and meeting regulatory and accreditation standards...Feedback, Data Systems, and Monitoring: The QAPI committee at [Hospital] will decide on the data that will be monitored routinely. This data provides the foundation for identifying opportunities for improvement, tracking progress and ensures that the intervention[‘s] effectiveness and is continuously improving the quality of care and safety for the patients and staff satisfaction. Some key performance indicators are: Clinical care areas (Door to needle, Door to EKG [electrocardiogram], Door to CT [computerized tomography], Door to TNK [Tenecteplase - medication used to treat stroke], ED throughput, HAI [hospital aquired infection], VTE [venous thromboembolism - blood clot], STK [streptokinase - medication to treat blood clots], STEMI-door to balloon time [treatment of type of sever heart attack], Sepsis, Fall with injury, Opioid on discharge); Patient Safety Incidences; medication incidences; Lab result time; Patient demographics, social determinants of health (SDOH). Data will be collected from electronic health records, incident reporting software, and financial systems. The QAPI team will regularly review data to identify trends and patterns. The team will set targets for the measures based on internal criteria and state and national averages... Performance Improvement Projects (PIPs): A robust QAPI plan helps to identify gaps or patterns in the system of care and thus pointing at opportunities for improvements. Considerations for PIPs: When selecting a measure and running a PIPs, it is important to ensure that the decision is data driven, in an area tha is at high risk, high volume or problem prone, evidence based, has a measureable goal, can be monitored regularly and is sustainable... Systemic Analusis and Systemic Action: this is a crucial component of a QAPI plan as it involves a structured approach to identify problems, understand the root causes, and implement sustainable solutions while addressing the underlying issue. [Hospital name] adopted the Lean Six Sigma approach for its PIPs thereby reducing waste and variation and improving workflow and quality... Systemic actions: ...Creating, updating and revising policies and procedures... process improvement... continuous data monitoring and identifying trends... Documentation and Communication of Performance Improvement and Trends in Performance Measures: To ensure transparency, alignment, and sustained progress in performance improvement efforts it is imperative that there is effective documentation and communication... Maintain detaled records for each PIPs... Sharing information in board of directors’ meetings. Monitoring trends in Performance Measures: Data analysis-trend analysis... Benchmarking-comparing performance against internal target, historical data and state and national averages...” Under the section “ Performance Improvement Projects (PIPs)”, there were no PIPs listed. The plan did not include designation of whom would be responsible for data collection or types of data to be collected and did not include frequency of quality data collection or review. The key performance indicators did not include hospital readmissions. 2. On 8/5/2025, the Hospital presented the Quality Council Meeting monthly minutes from 2025 (dated 5/7/2025, 6/4/2025, and 7/2/2025). There was no meeting minutes provided/available prior to 5/7/2025. The meeting minutes were reviewed and indicated the team members from various departments were present and the topics discussed. The 5/7/2025 meeting included 2 topics (electronic medical record/EMR concerns and infection prevention concerns). The 6/4/2025 meeting included discussion on complied dashboard data from various departments. The 7/2/2025 meeting included discussion on the Nursing Quality dashboard and discussion on infection prevention. The meeting minutes lacked any action or performance improvement plans. There was no documentation of evaluation of the indicators, in order to measure and trend the outcomes of the data collected. The meeting minutes lacked frequency of review of the collected data, and did not include any improvement activities. 3. On 8/6/2025 at 1:15 PM, an interview was conducted with the Executive Director of Quality (E #13). Electronic data compiled from different departments, that is submitted to the Quality department, was reviewed with E #13 on the computer. The data included areas from infection control; hospital acquired pressure ulcers; stroke, and emergency department. E #13 stated that the data from the different departments are discussed during the leadership departmental meetings. When asked how data and frequency of collection from each department was determined, E #13 stated that each department collects data related to their department, but E #13 does not assign/designate data collection to the departments. When asked to show how data is analyzed and tracked to determine improvements, E #13 stated that no goals or benchmarks had been determined based on hospital or national standards yet. When asked to see patient safety quality indicators, such as falls and hospital incidents, E #13 could only show that a list of falls and incidents was maintained. However, E #13 could not show any review, analysis, or trending/tracking of this data. When asked to show data for readmissions, E #13 could not provide any data collection or review. E #13 stated that however, the topics that have been actually discussed and incorporated into the monthly QAPI meeting minutes at this point, includes only infection prevention dashboard and concerns with the new EMR system. E #13 stated that there has only been one established quality indicator that has a performance improvement plan (PIP) approved. E #13 stated that the performance improvement plan developed is related to infection prevention (CLABSI) and has just been approved/initiated as 8/2025. E #13 stated that a PIP related to hospital length of stay is being drafted due to information that was received verbally from the discharge department. E #13 stated that E #13 generally gathers and receives areas of concerns from department leaders and then decides if this information will be shared during the Quality meetings. E #13 acknowledged that there were no PIPS developed related to patient safety events or any other areas beside than infection control, and no quality improvement measures had been identified or implemented, based on data collected.”

“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: 39802 Based on document review and interview, for 6 of 12 records (Pts. #8-#11, #32 and #33) reviewed for pain management, the Hospital failed to ensure that pain assessments were completed as required by policy. Findings include: 1. The Hospital’s policy titled, “Pain Management” (dated 01/2025), was reviewed and required, “...Inpatients will be reassessed for the presence of pain no less frequently than the minimum requirements for the taking of vital signs (5th vital sign) in the are setting... Patients seen in the Emergency Department shall receive a screen during the triage or initial assessment process to identify the presence of pain...” 2. The clinical record of Pt. #33 was reviewed on 08/04/2025 at approximately 12:49 PM, with Charge Nurse (E#10). Pt. #33 was admitted on 08/01/2025 at 5:06 PM to the Progressive Care Unit/PCU with a diagnosis of hematuria (blood in the urine). Pain assessment flow sheets from 08/01/2025-08/04/2025 were reviewed and indicated that only one pain assessment was completed on 08/02/2025 at 2:35 PM. The record lacked any other assessments of pain during this admission. 3. The clinical record of Pt. #32 was reviewed on 08/04/2025 at approximately 1:25 PM, with E#10. Pt. #32 was admitted on 06/17/2025 with a diagnosis of altered mental status and desaturation. Pain assessment flow sheets from 07/29/2025-08/04/2025 were reviewed and indicated that the last pain assessment was completed on 07/29/2025 at 4:18 PM. No further assessments of pain had been documented in the record since. The record indicated that Pt. #32 had been on the PCU since 07/19/2025. 4. On 08/05/2025, at approximately 10:50 AM, four current Emergency Department (ED) patient medical records were reviewed and 3 of the 4 records reviewed (Pts. #8, #10, and #11) lacked a pain assessment completed on initial assessment. 5. An interview was conducted with the PCU Charge Nurse (E#10) on 08/04/2025, at approximately 1:00 PM. E#10 stated that they should assess for pain every time they assess for vital signs, which is every 4 hours on the Progressive Care Unit. 6. The E#4 (ED Charge Nurse) was interviewed on 08/05/2025 at 11:10 AM. E#4 said it is an expectation that all patients receive a pain assessment on presentation to the ED. 50411 Based on document review, observation and interview, it was determined that for 2 of 4 patients with IV (intravenous) access sites observed, the hospital failed to ensure that the IV accesses were labeled and dated with the insertion date, in accordance with policy. Findings include: 1. The Hospital’s policy titled, “Peripheral Intravenous Catheter Placement and Management” review date 1/2025 included “... IV Procedure: Intravenous cannula/needle: ...document date and time of insertion ...” 2. During an observational tour of the 4 North Medical Surgical Unit on 8/4/2025 between 10:00 AM and 11:00 AM, 2 patients (Pt.#4 and Pt.#5) had IV access sites that were not labeled with date of insertion. 3. An interview was conducted with the 4 North Medical Surgical Unit Charge Nurse (E#3) during the tour. E#3 stated that all IV access sites should be dated and labeled when it was inserted.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 3 of 3 clinical records (Pts.#4-6) reviewed, on the 4 North Medical Surgical Unit, the hospital failed to ensure that a general informed consent was obtained upon admission. Findings include: 1. The Hospital’s policy titled, “Informed Consent” Reviewed Dates: June 2025 included, “... II. Policy: Any health care relationship, treatment or refusal with a known or appreciable risk to the patient requires documented evidence of an informed consent form executed by the patient or legally authorized representative...” 2. The clinical records of Pts. #4-6 was reviewed on 8/4/2025. -Pt.#4 was a 59 year-old who was admitted on 8/3/2025 for chest pain. -Pt.#5 was a 65 year-old who was admitted for post fall and hematoma (bruising) on right hip. -Pt.#6 was a 77 year old who was admitted for dementia and Parkinson’s disease. All clinical records reviewed lacked the general informed consent for treatment upon admission to the Hospital. 3. On 8/4/2025 at approximately 10:45 AM, an interview was conducted with the 4 North-Charge Nurse (E#3). E#3 stated that Consents should be in the patient’s medical record either scanned or paper copy.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 50411 Based on document review and interview, the Hospital failed to ensure that patient medical records are completed within 30 days of discharge. Findings include: 1. The Hospital’s “Medical Staff Rules and Regulations” - effective 4/2/2025 included, “... Section 1.8 Medical Records - Accurate, timely, and complete medical records shall be maintained in accordance with the Health Information Management Policies approved by the MEC...” 2. An attestation letter was provided on 8/7/2025 that included the hospital currently has 2,540 delinquent medical records. 3. On 8/7/2025 at approximately 9:45 AM, an interview was conducted with the executive director of nursing (E#9). E# 9 stated that the records should be completed within 30 days. E#9 stated, “I was informed that we have delinquent records because of the way Paragon [computer system] requires physicians to cosign orders.””

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, for 1 of 3 patient rooms observed for respiratory supplies, the Hospital failed to ensure that medications were secured and not left unattended. Findings include: 1. The Hospital’s policy titled, “Storage of Medications in Patient Care Areas” (dated 01/2025), was reviewed and required, “...Medications that are not securely locked must be under constant surveillance... Medications removed from a medication storage area must remain with the individual at all times and are not to be left unattended... If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only or discarded after use...” 2. During a tour of the Progressive Care Unit on 08/04/2025, at approximately 10:55 AM, 3 vials of acetylcysteine (mucolytic agent) were noted in a plastic bag with a nebulizer kit in patient room #4430. The vials were not attended to or secured by a staff member at all times. 3. An interview was conducted with Respiratory Therapist (E#21) on 08/04/2025, at approximately 11:05 AM. E#21 stated that each vial contains enough medication for two nebulizer treatments so E#21 saves the rest of the medication for the next treatment. E#21 stated that the vial cannot be returned to the Pxyis (medication storage machine) once it’s entered the patient’s room and stated that there is no secure cabinet in the patient room to store the left over medication.”

“POLICIES FOR LABORATORY SERVICES CFR(s): 482.27(a)(4) The medical staff and a pathologist must determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examinations. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, for 1 of 1 urine specimen observed in the emergency department (ED), the Hospital failed to ensure that lab specimen was labeled in accordance to laboratory services policies. Findings include: 1. The Hospital’s policy titled, “Labeling of Specimens” (dated 01/2025), was reviewed and required, “...Specimen Labeling: ... Date and Time of Draw, Initials of the Person Drawing Specimen...” 2. During a tour of the ED on 08/05/2025, at approximately 10:32 AM, a urine specimen was observed in the point of care testing room. The urine cup had a patient label on it; however, lacked the date/time it was collected and the initials of the person that collected the specimen. 3. An interview was conducted with the ED Manager (E#16) and the EMS (emergency medical services) Coordinator (E#17) on 08/05/2025 at approximately 10:33 AM. E#16 stated that any specimen should be labeled with the date, time, and who collected at the time it is collected. E#17 stated that ED staff collect lab specimens for ED patients and bring it down to the lab. E#17 stated that specimens should not just be left in the room. 4. An interview was conducted with the Lab Supervisor (E#22) on 08/05/2025, at approximately 2:30 PM. E#22 stated that laboratory staff collect specimens for the inpatient units and will bring them back to the lab for testing. E#22 stated that lab orders in the ED are collected by the ED staff and they are responsible for bringing them to the laboratory for testing. E#22 stated that the specimens must be labeled with the date and time it was collected as some tests are time sensitive and may affect the results of the tests.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 50411 Based on document review, observation, and interview, the Hospital failed to ensure that Dietary staff adhered to appropriate hair covering and glove guidelines during food preparation, in accordance with hospital policy. Findings include: 1. The Hospital’s policy titled, “Uniform Policy” - Revision dates: 9/2024 included, “... III. All food handlers must wear a clean hat with appropriate hair covering underneath said hat or use other appropriate hair coverings. This includes individuals who are bald when: IV. Prepping food, V. Working in prep areas... VII. Note: Food handlers with facial hair must also wear a beard restraint ...” 2. The Hospital’s policy titled, “Personal Hygiene & Attire” - Revision Dates: 9/2021 included, “... 6. Gloves will be always used and will be changed often ... “ 3. During an observational tour of the Food and Dietetic Services on 8/5/2025 from 10:30 AM to 12:15 PM, 2 dietary staff were observed in the food preparation area - 1 dietary staff with facial hair (E#6) was observed with no hair covering and and no beard restraint; another 1 dietary staff (E#7) with facial hair was observed at the end of the food preparation tray line handling food trays without wearing gloves. 4. During the observational tour on 8/5/2025 at approximately 12:00 PM, an interview was conducted with the Director of Dietary Services (E#5). E#5 stated that all staff should wear appropriate hair covering and beard restraint (if with facial hair) and must always wear gloves when handling food trays.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 20224 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on August 4 - 6, 2025. the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, for 2 or 3 inpatient units and 1 of 1 emergency department (ED) toured, the Hospital failed to ensure that emergency/crash carts were maintained with the supplies/equipment necessary in case of medical emergencies. Finding include: 1. On 08/05/2025, the Hospital presented educational material on crash cart contents (dated 05/2023) which indicated that each crash cart should contain a full oxygen tank, defibrillator, and portable suction machine. The Hospital did not have a policy regarding crash cart use and management. 2. During tours of the Progressive Care Unit and the 4 North Medical Surgical Unit on 08/04/2025, at approximately 10:00 AM, there was one crash cart located on each of these units; however, the crash carts did not have portable suction machines. 3. During a tour of the ED on 08/05/2025 at approximately 10:00 AM, there were 5 adult crash carts, 1 pediatric crash cart, and 1 neonatal crash cart present; however, only 3 of the adult crash carts had a defibrillator, only 2 of the adult crash carts had an oxygen tank, and none of the crash carts had a portable suction machine. The pediatric and neonatal crash carts did not have defibrillators or oxygen tanks. In addition, the only portable suction machine that was set up and ready to use in the ED, was sitting on the wall of the nurse’s station plugged into the electrical outlet (not directly associated with any of the crash carts). To note, each patient room did have a built-in suction apparatus on the wall. Additionally, it was noted that one drawer of the pediatric crash cart (for patients between 30-36 kilograms) had a supply expiration date of 08/01/2025. 4. An interview was conducted with the ED Manager (E#16) and EMS (emergency medical services) Coordinator (E#17) on 08/05/2025, at approximately 10:00 AM. E#16 stated that they should be checking the crash carts daily and completing the logs that check for defibrillator functioning, suction machine functioning, oxygen tank levels, and outdates of supplies. E#17 stated that a while ago they used to have more defibrillators but many of them broke after being pulled with the crash cart and dropping on the ground.”

“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: 32741 A. Based on document review, observation, and interview, the hospital failed to ensure infection control surveillance and maintenance a clean and sanitary environment, and addressing any infection control issues identified by the hospital, including temperature/humidity levels in the operating rooms (OR) and stains on ceiling in patient care areas related to lack of ventilation system cleaning/preventive maintenance. Finding include: 1. On 8/4/2025, the Hospital’s Infection and Control Plan (dated 2025) was reviewed and required, “purpose is to promote safe and quality care to our patients, healthcare workers and visitors through the prevention and control of infections ...The purpose of the Infection Control Committee is to evaluate the data and provide input into the Infection Prevention and Control Program. The Committee is responsible for: Review and approve all policies and procedures related to infection surveillance, prevention and control activities in all department/services. Review the infection surveillance data and recommend methods for the preventions and control of infections in the hospital. The Infection Control Committee meets quarterly unless the committee determines otherwise. Will maintain minutes of findings, proceedings, and action.” 2. On 8/4/2025, the Staff Rules & Regulations (dated 4/2/2025) was reviewed and required, “...The duties of the Infection Control Committee shall be to: 1) Maintain surveillance over the Hospital Infection Control program... 4) Develop, evaluate and revise preventive, surveillance and control policies and procedures relating to all phases of the Hospital’s activities, including, but not limited to: operating rooms, delivery rooms, special care units; central service, housekeeping and laundry; prevention of cross-infection by anesthesia apparatus or inhalation therapy equipment; testing of Hospital personnel for carrier status; disposal of infectious material; food sanitation and waste management; select community acquired infections and, when appropriate, employee infections; and other situations as requested... 7) Maintain a record of all activities relating to Infection Control and report to the MEC (Medical Executive Committee), CEO, and Performance Distinction Council...” 3. On 8/4/2025, the Hospital’s policy titled, “Temperature and Humidity Control” (dated 7/2024) was reviewed and required, “This policy describes the requirement and procedures for maintaining proper ventilation, temperature, and humidity control in procedural suites. The purpose of this policy is to provide basic guidelines and criteria for keeping the ventilation, temperature and humidity within acceptable range which will promote a safe and functional environment for our patients following recommended guidelines...If any area is 10 degrees plus or minus the acceptable range, the finding will be escalated immediately up the chain of command with the potential to close the area and move equipment, supplies and procedures to a different room within acceptable ranges...acceptable normal ranges: temperature 68-76 degrees; humidity: 30-60%...” 4. On 8/4/2025, the maintenance “daily temperature/humidity log” (dated July 2025 and August 2025) was reviewed. The ranges and directives on the log included, “*Readings must be taken between 4:00 AM - 6:00 AM daily. **Acceptable ranges = 68-73 degrees F. [Fahrenheit] & 30-60% RH [relative humidity] *** Unacceptable ranges must be reported to the House Manager and/or Department Manager.” The only dates where the temperature and humidity were within acceptable ranges in the OR rooms [OR-1 - OR-8] were the following:7/7/2025 (OR-3, OR-4 and OR-7), 7/8/2025 (OR-6), 7/10/2025 (OR-OR-6), 7/11/2025 (OR-6), 7/12/2025 (OR-6 and OR-7), 7/13/2025 (OR-6), 7/27/2025 (OR-6), 7/27/2025 (OR-6), 7/29/2025 (OR-6), 7/31/2025 (OR-6), 8/5/2025 (OR-6), and 8/6/2025 (OR-6). Of note, the temperature/humidity was not documented for any of the ORs on 7/30/2025. The log included that on July 4th, OR #5 (OR #5 was the location where Pt. #7 has surgery) humidity -73% (normal range is 20 % - 60%) and temperature 70 degrees (within range). 5. On 8/6/2025, the surgery schedule was reviewed for June through August 2025. The schedules indicated that surgeries were cancelled on all dates where the temperature and/or humidity levels were out of range, except for an emergency surgery which was performed in OR- 5 on 7/4/2025 when humidity levels were out of range. 6. On 8/4/2025, Pt. #7’s clinical record (dated 7/3/2025 through 7/4/2025) was reviewed and indicated: “Pt. #7 came to the ED (Emergency Department) on 7/3/2025 for persistent worsening right knee pain. Aspiration (the act of withdrawing the fluid, tissue, or other substance through a needle) completed in the ED. Nonoperative versus operative options were discussed. Pt. #7 acknowledged understanding and wished to proceed with operative intervention. Pt. #7’s “intraoperative case report) dated 7/4/2025 noted that Pt. #7’s surgery was performed by MD #2 (surgeon) at 9::11 AM. Pt. #7’s pre-operative and post-operative diagnosis dated 7/4/2025 was right septic knee, advanced tricompartmental OA (osteoarthritis). Brief description of procedure - knee arthroscopic (a minimally invasive procedure used to diagnose and treat knee problems) extensive synovectomy/debridement (a surgical procedure to remove the synovium, the lining of the knee - debridement removes dead, damaged or infected tissue from a wound to promote healing and knee aspiration).” 7. A tour of the Emergency Department (ED) was conducted on 08/05/2025, at approximately 9:45 AM. During the tour, it was noted that there was a black substance (in a speck like pattern) around each of the ceiling air vents by the nurses’ stations, in the medication preparation areas, and in some of the unoccupied patient rooms (i.e. #5, #20, #23). There were also some stains which appeared to be dried liquid marks (black and/or brown in color) by the nurses’ station in the fast-track area and in unoccupied patient rooms #3 and #21. 8. On 8/5/2025 at 2: 10 PM, an interview was conducted with the MD #1 (Surgeon - partner/associate of MD #2). MD #1 stated that the Hospital is not a safe place to perform surgery. MD #1 wasn’t told about the humidity until after surgery had started [Referencing July 4, 2025 - this surgery was performed by MD #1’s partner/associate, MD #2.]. MD #1 stated that MD #1 doesn’t schedule anything at the Hospital anymore. [MD #2 was not available for interview during dates of this survey.] 9. On 8/6/2025 at 10:00 AM, an interview was conducted with the Interim PeriOperative Director/Manager (E #14). E #14 stated that the temperature/humidity is checked in each OR room by OR staff at 6:00 AM and 1:00 PM, and if the humidity/temperature is out of range, the surgery is cancelled. E #14 stated that MD #2 [surgeon who actually performed the surgery referenced in the allegation on 7/4/2025] was informed by the OR staff that the humidity was out of range on 7/4/2025, but MD #2 proceeded to do the surgery for Pt. #7. E #14 stated that when E #14 asked MD #2 why MD #2 did Pt. #7’s surgery, MD #2 stated that Pt. #7’s case was emergent. [Of note, E #14 was not working on 7/4/2025. Therefore, E #14 did not inform MD #2 of the out-of-range humidity.] 10. On 8/7/2025 at 10:15 AM, an interview was conducted with the OR Registered Nurse (E #24) who was working on 7/4/2025. E #24 stated that E #24 was the OR Circulating Nurse on 7/4/2025 during the surgery for Pt #7. E #24 stated that E #24 was not aware that the humidity was out of range on 7/4/2025. E #24 stated that E #24 did not know how MD #2 (surgeon) knew that the humidity was out of range. 11. On 8/4/2025 at 11:00AM and 8/6/2025 at approximately 10:00 AM, interviews were conducted with the Infection Control Nurse (E #1). E #1 stated that E #1 has had this position since October 2024. E #1 stated that E #1 has the infection control oversight over the entire hospital. E #1 stated that E #1 has not had any Infection Control Meetings yet [since October 2024]. E #1 stated that there was an Infection Control Meeting scheduled for July, but the meeting was cancelled. E #1 stated that E #1 monitors infection control in the surgical area. E #1 stated that E #1 works with E #14 (Interim PeriOperative Director/Manager) and monitors patients who had surgery with out-of-range humidity. However, E #1 does not review the temperature/humidity logs to ensure that they are being monitored or track when surgeries were cancelled due to temperature/humidity. E #1 stated that E #14 informed E #1 after Pt #7 had surgery while the humidity level was out of range. E #1 stated that EVS and maintenance report any issues with the physical environment, including stains on ceiling tiles. E #1 stated that work orders are submitted, and E #1 does rounds to check the status of work orders/maintenance. E #1 stated that the stains on the ceiling tiles are likely from the ventilation system, as they appear to be in a pattern of air flowing outward from vents onto ceiling tiles. When asked to provide the preventive maintenance schedule and date of last vent cleaning and documentation of rounds regarding the status of work orders/maintenance, E #1 stated that maintenance was responsible for that and could not provide a schedule of cleaning, last date of ventilation system cleaning by survey exit date on 8/7/2025. 12. On 8/7/2025 at approximately 10:00 AM, during an interview with the Executive Director of Operations (E #25), E #25 stated that there were no records of the last cleaning of the ventilation system. E #25 stated, “I know they haven’t been cleaned since I started here in 2021.” 13. On 8/7/2025 at approximately 10:30 AM, an interview was conducted with the Executive Director of Nursing (E #9). E #9 stated that when the temperature and/or humidity is out of range, E #14 calls E #9, and E #9 directs E #14 to cancel/reschedule surgeries on those dates in effected OR rooms. E #9 stated that E #9 does not relay this information to E #1 to ensure E #1 receives this information. E #9 stated that E #9 had sent daily reports of the temperature/humidity in the OR to the Department for a while [6/28/2025 - 7/7/2025], which included which surgeries were performed. However, E #9 stated that other than these reports, they do not keep specific records/tracking of when surgeries were cancelled due to temperature/humidity levels and could not provide this information. E #9 stated that they would have to go through all the surgery schedules, and see which surgeries were marked as cancelled. B. Based on document review and interview, the Hospital failed to evaluate and analyze infection control data for the infection prevention and control program, per hospital’s infection and control plan. Findings include: 1. On 8/4/2025, the Hospital’s Infection and Control Plan (dated 2025) was reviewed and required, “purpose is to promote safe and quality care to our patients, healthcare workers and visitors through the prevention and control of infections ...The purpose of the Infection Control Committee is to evaluate the data and provide input into the Infection Prevention and Control Program. The Committee is responsible for: Review and approve all policies and procedures related to infection surveillance, prevention and control activities in all department/services. Review the infection surveillance data and recommend methods for the preventions and control of infections in the hospital. The Infection Control Committee meets quarterly unless the committee determines otherwise. Will maintain minutes of findings, proceedings, and action.” 2. On 8/4/2025, the Staff Rules & Regulations (dated 4/2/2025) was reviewed and required, “Section 5.7 Infection Control Committee - Composition - The Infection Control Committee shall consist of a Chairperson and five (5) members appointed from the Department of Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Surgery. The following non-medical staff members shall serve as adjunct members: the Infection Control nurse and one (1) representative each from Hospital Administration, Microbiology, Pharmacy and Patient Care Services, one of whom may be delegated to keep the minutes of the Committee meetings. The duties of the Infection Control Committee shall be to: 1) Maintain surveillance over the Hospital Infection Control program. 2) Develop a system for reporting, identifying and analyzing the incidence and cause of selected infection. 3) Implement a preventive and corrective program designed to minimize infection hazards, including establishing, reviewing and evaluating aseptic, isolation and sanitation techniques. 4) Develop, evaluate and revise preventive, surveillance and control policies and procedures relating to all phases of the Hospital’s activities, including, but not limited to: operating rooms, delivery rooms, special care units; central service, housekeeping and laundry; prevention of cross-infection by anesthesia apparatus or inhalation therapy equipment; testing of Hospital personnel for carrier status; disposal of infectious material; food sanitation and waste management; select community acquired infections and, when appropriate, employee infections; and other situations as requested; 5) Coordinate action on findings from the Medical Staff’s review of the clinical use of antibiotics. 6) Act upon recommendations related to Infection Control received from the President of the Medical Staff, Medical Executive Committee, Departments and other Medical Staff and Hospital Committees. 7) Maintain a record of all activities relating to Infection Control and report to the MEC (Medical Executive Committee), CEO, and Performance Distinction Council; and 8) Promote educational endeavors on infection control for the medical and nursing staffs and other appropriate personnel.” 3. On 8/4/2025, an interview was conducted with the Infection Control Nurse (E #1). E #1 stated that E #1 reviews culture reports. E #1 stated that there have not been any Infection Control meetings since they started in October 2024, and E #1 has yet to evaluate and analyze infection control data. 39802 C. Based on document review, observation, and interview, for 2 of 2 staff (E#20 and E#21) observed on the Progressive Care Unit, the Hospital failed to ensure that medications were handled in a manner to prevent cross-contamination. Findings include: 1. The Hospital’s policy titled, “Storage of Medications in Patient Care Areas” (dated 01/2025), was reviewed and required, “...The medication should not be left on or in any area exceeding 77 degrees Fahrenheit, including an individual’s pocket or in any carrying apparatus (i.e. fanny packs or pouches) that remains in contact with the person... Multi-dose vials are dated with the beyond use date in accordance with facility policy...” 2. The Hospital’s policy titled, “Medication Administration” (dated 06/2025), were reviewed and required, “...Personnel authorized to administer medications receiving training during orientation and ongoing education about topics related to safe medication handling, preparation, administration, and patient monitoring...” The policy did not specifically outline infection control practices expected when administering medications. 3. The Hospital’s policy titled, “Transmission Based Precautions” (revised 2023), was reviewed and required, “... Droplet Precautions - used to prevent spread of infections by droplets... Dedicated patient care equipment will be used for all patients on precautions. Disposable items... will be used whenever possible... Avoid bringing carts and equipment into the room whenever possible...” 4. During a tour of the Progressive Care Unit on 08/04/2025, the following was observed: - At approximately 9:52 AM, a Nurse (E#20) was observed administering some IV (intravenous) medications to a patient that was on droplet precautions. E#20 did not wipe the top of the vials (single-dose) prior to withdrawing the medications with a syringe. Additionally, E#20 had an oral medication for the patient left by the sink in the room. E#20 did not administer the medication, and put it back into E#20’s pocket which also contained common supplies such as alcohol wipes and saline syringes. - At approximately 10:55 AM, 3 opened vials of acetylcysteine (mucolytic agent) were noted in a plastic bag with a nebulizer kit in patient room #4430. The manufacturer’s label on the vials included to discard the medication within 96 hours after opening. The vials were not labeled with the date opened. 5. An interview was conducted with Nurse (E#10) on 08/04/2025, at approximately 11:07 AM. E#10 stated that the oral medication is best to given with a meal so E#10 will come back to give it later when the lunch tray arrives. E#10 stated that E#10 was taught in nursing school that the vials do not have to be wiped if it’s a brand new vial. 6. An interview was conducted with Respiratory Therapist (E#21) on 08/04/2025, at approximately 11:05 AM. E#21 stated E#21 only uses each vial two times and discards the vial after that. E#21 stated that they should label the vials with the date/time so that know when it was opened/used. 7. An interview was conducted with the Executive Director of Nursing (E#9) on 08/05/2025, at approximately 3:30 PM. E#9 stated that they do not have a policy that medication vials (whether single or multi-dose) need to be disinfected prior to use, as this should be general infection control knowledge.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that the hospital failed to demonstrate periodic assessment of the discharge planning process, including an internal audit of closed medical records and review of patients admitted within 30 days of previous admission were conducted. Findings include: 1. On 8/07/2025, the hospital’s policy titled, ‘Case Management Discharge Planning’ (revised 1/27/2025) was reviewed and did not include a process for review of discharge plans or readmissions within 30 days. 2. On 8/07/2025, the hospital’s 2025 Utilization Review Committee meeting minutes were reviewed and included readmission data (January 2024-June 2025), however the data was combined with the hospital’s sister/affiliated hospital. No readmission assessment to ensure discharge planning needs were met was available for this hospital. 3. On 8/07/2025 at approximately 9:45 AM, any documentation or data collected to indicate that the hospital conducted an internal audit of closed medical records and patients admitted within 30 days of previous admission was requested of the Director of Patient Access (E #26). However, no documentation was provided. 4. On 8/07/2025 at approximately 10:00 AM, an interview with the Director of Patient Access (E #26) was conducted. E #26 stated that utilization meetings are conducted and include metrics including readmissions, and chart audits of closed medical records including readmissions have been conducted. However, E #26 was unable to provide documentation of this. 5. On 8/07/2025 at approximately 10:35 AM, an interview with the Executive Director of Nursing (E #9) was conducted. E #9 stated that after communication between E #9 and E #26, it was confirmed that utilization review has not conducted audits of readmissions nor closed medical records. E #9 stated that readmissions within 30 days are not triggered in the hospital’s new EMR (electronic medical records) system, so discharge planner would have to review each patient’s admission history to identify if they had been admitted within the last 30 days, for purposes of tracking/trending readmissions.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 39802 A. Based on document review, observation, interview, for 2 of 2 nebulizer kits observed on the Progressive Care Unit/PCU, the Hospital failed to ensure that nebulizer kits were labeled to ensure that the kits were changed every 48 hours as required. Findings include: 1. The Hospital’s Respiratory Care Policy titled, “Infection Control” (dated 06/2025), was reviewed and required, “...Handheld Nebulizer Set-Ups: Replace complete neb circuit at least every 48 hours...” 2. During a tour of the PCU on 08/04/2025, between approximately 10:00 AM and 11:00 AM, nebulizer kits kept in patient rooms #4430 and #4443 were not labeled with the date used/changed. 3. An interview was conducted with Respiratory Therapist (E#21) on 08/04/2025, at approximately 11:05 AM. E#21 stated that they do not typically label the nebulizer kits with a date opened or changed. E#21 stated that nebulizer kits are changed weekly on Fridays. E#21 stated that without a date, E#21 does not know when the kits were last changed. B. Based on document review and interview, for 1 of 2 records (Pt. #32) reviewed for respiratory treatments, the Hospital failed to ensure that respiratory treatments were completed as ordered. Findings include: 1. The Hospital’s policy titled, “Chest Physio Therapy [CPT] Procedure (Percussion & Vibration)” (dated 06/2025), was reviewed and required, “...Check patient’s chart for complete physician’s orders. A complete order shall include: Type of therapy... frequency... A descriptive entry shall be made in the Respiratory Progress Notes sheet in the patient’s chart following each treatment...” 2. The clinical record of Pt. #32 was reviewed on 08/04/2025 at approximately 1:25 PM, with E#10. Pt. #32 was admitted on 06/17/2025 with a diagnosis of altered mental status and desaturation. Physician orders for CPT were placed on 07/23/2025 to start on 07/24/2025 at 12:00 AM with a frequency of 3 times a day. CPT flowsheets from 07/24/2025 were reviewed and indicated that 1-3 treatments were missed everyday except for on 7/29/2025 and 08/01/2025. The record lacked any respiratory progress notes indicating CPT was completed as ordered. 3. An interview was conducted with the Respiratory Therapy Supervisor (E#18) on 08/05/2025, at approximately 3:00 PM. E#18 stated that when CPT is ordered, respiratory staff will document performance of the CPT in the medical record in the CPT flowsheets.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #21) clinical records reviewed regarding care planning, the hospital failed to ensure that Pt. #21’s guardian participated in the development and implementation of Pt. #21’s transfer to another hospital. Findings include: 1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record included: - A document titled, “Order Appointing Limited Guardian of a Person with a Disability” (effective 9/2023) that indicated, “ ... (Pt. #21) A Person with a Disability ... for the appointment of (Pt. #21’s Mother) as Limited Guardian of the person of (Pt. #21 the Respondent) ... 6. The appointment of a Guardian ad litem (court-appointed legal advocate) WAS necessary for the protection of the Respondent or to make a reasonably informed decision...” - The crisis worker’s (E #20) progress note on 8/12/2024 at 9:30 AM, indicated, “... (Pt. #21) has now accepted that (Pt. #21) will be transferred to (psychiatric) unit, requesting to go to (Hospital B)...” At 12:34 PM, Pt. #21 was transferred to (Hospital B). However, there was no documentation that Pt. #21’s mother/guardian was informed or participated in the transfer of Pt. #21 to another hospital. 2. On 4/09/2025, the hospital’s document titled, “Your Patient Rights and Responsibilities” (undated) was reviewed and indicated, “... You have the right to... participate in your care plan...” 3. On 4/10/2025 at approximately 10:00 AM, an interview was conducted with MD #8 (ED Medical Director). MD #8 stated that patient’s legal guardian should be informed and be allowed to participate in the discharge planning.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that least restricve interventions were used before initiation of violent restraints. Findings include: 1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record indicated that Pt. #21 was placed in violent restraints on 8/09/2024 from 3:00 PM through 4:00 PM (one hour). There was no documentation that least restrictive interventions were used before initiation of violent restraints. 2. On 4/09/2025, the hospital’s policy titled, “Restraint Management Policy” (3/2019) was reviewed and indicated, “... III. Policy: It is the objective of our hospitals to lmit and/or eliminate the use of restraint. Conversely, clnically and developmentally appropriate alternatives to restraint are to be attempted, documented and found to be ineffective prior ot use of restraint...” 3. On 4/09/2024 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that least restrictive intervention should be used before initiation of violent restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on doucment review and interview, it was determined that for 1 of 3 patients’ (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that restriction of rights was provided to Pt. #21 and/or Pt. #21’s guardian, in accordance with the hospital’s policy. Findings include: 1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis. The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no restriction of rights provided to Pt. #21 or Pt. #21’s guardian. 2. On 4/09/2025, the hospital’s policy titled, “Restraint Management” (3/2019) was reviewed and included, “... V. Procedure... D. Violent, Self Destructive... 4. A Restriction of Rights form for the patient must be completed for each restraiont... with copies given to the patient’s designated person... legal guardian, if applicable...” 3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that restriction of rights should be given to the patient and guardian.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #21) clinical records reviewed regarding restraints, the hospital failed to ensure a physician’s order was obtained. Findings include: 1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis. The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no physician’s order regarding use of restraints. 2. On 4/09/2025, the hospital’s policy titled, “Restraint Management” (3/2019) was reviewed and included, “... V. Procedure: Each episode of restraint... must be ordered by a physician or an authorized licensed practitioner responsible for the patient’s ongoing care...” 3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that a phyhsician’s order should be obtained when a patient is placed in restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that a physician or licensed practitioner conducted the required face-to-face evaluation. Findings include: 1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no face-to-face evaluation by a physician or licensed practitioner within one hour after the application of restraints. 2. On 4/09/2025, the hospital’s policy titled, “Restraint Management” (3/2019) was reviewed and included, “... V. Procedure... D. Violent, Self-destructive, or Seclusion. 1... a. When restraint... is used for the emergency management of violent or self-destructive behaviors that jeopardize the immediate physical safety of the patient... the patient must be seen face-to-face within one hour after initiation of the intervention by a physician, authorized licensed practitioner, or a trained supervisory nurse...” 3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that a face to face evaluation should be completed within one hour of placing the patient in restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(ii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (ii) The use of nonphysical intervention skills. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 3 of 3 ED/Emergency Department RNs/Registered Nurses’ (E #1, E #44, and E #45) and 4 of 4 ED Technicians’ (E #7, E #41, E #42, and E #43) personnel files reviewed, the hospital failed to ensure that the ED staff had training regarding use of de-escalation techniques. Findings include: 1. On 4/14/2025, the job description for ED RNs (undated) was reviewed. The job description indicated, “...Effectively delivers patient care through the nursing process of assessment, planning, intervention, implementation, and evaluation...” 2. On 4/14/2025, the job description for ED Technicians (undated) was reviewed. The job description indicated, “... Provides all services in accordance with established hospital/departmental policies and procedures...” 3. On 4/14/2025, the personnel files for E #1, E #7, E #41, E #42, E #43, E #44, and E #45, were reviewed. The personnel files lacked training/certification regarding use of de-escalation techniques/nonphysical intervention. 4. On 4/14/2025 at approximately 3:00 PM, findings were discussed with E #14 (Chief Nursing Officer). E #14 stated that ED nurses and technicians are supposed to be certified regarding use of de-escalation techniques for patients with aggressive behaviors. E #14 stated that the CPI (crisis prevention intervention/de-escalation) trainer no longer worked at the hospital since December 2024, and the hospital had not found someone to do the CPI training since that time.”

“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: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #24) records reviewed regarding fall, the hospital failed to ensure care of Pt. #24 was supervised and evaluated by completing an incident report following a fall. Findings include: 1. On 4/08/2025, the clinical record of Pt. #24 was reviewed. On 12/12/2024, Pt. #24 presented to the hospital’s emergency department by ambulance due to chest pain. The clinical record indicated that while in the ED, Pt. #24 fell. 2. On 4/08/2025, the hospital’s policy titled, “Fall Risk Assessment and Prevention” (3/2023) was reviewed and included, “... III... 7. An RN is responsible for implementation and oversight of individualized patient fall prevention...” 3. On 4/08.2025, the hospital’s policy titled, “Event and Incident Reporting” (3/2021) was reviewed and included, “... IV... Examples of events to be reported... falls (patient)... V. A...1... Hospital Staff Members must complete and submit an event report as soon as possible...” 4. On 4/09/2025, the hospital’s incident report/falls log for 12/2024 was reviewed. There was no event/incident report completed for Pt. #24. 5. On 4/14/2025 at approximately 1:00 PM, an interview was conducted with E #3 (ED Director). E #3 stated that there was no incident report completed for Pt. #24. E #3 stated that if the assigned nurse did not do an incident report, the charge nurse should have completed one.”

“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: 50411 Based on document review an interviews, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to maintain an accurate ED Log. Refer to A-2405. 2. The Hospital failed to ensure that a medical screening examination was completed to determine if a medical emergency existed. Refer to A-2406 A. and A-2406 B.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 34411 Based on audio recording, document review and interview, it was determined that for one patient (Pt #1) who presented to Emergency Department (ED) on 2/14/2025, the Hospital failed to ensure that the ED’s central log included an individual who presented to the ED seeking treatment, as required. Findings include: 1. The Hospital’s policy titled, “The Hospital’s policy titled, “EMTALA” (Emergency Medical Treatment and Labor Act), dated 1/2025, was reviewed, and required, “ ...C. Central Log. 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE [medical screening examination]...” 2. On 4/7/2025, the ED Director (E #3) presented an EMS run sheet for Pt #1 (dated 2/14/2025 at 7:10 AM), which was reviewed. The EMS Run Sheet for Pt #1 indicated that Pt #1 was transported to Hospital A’s ED via ambulance. The EMS Run Sheet included, “Possible Injury: Yes: Car driver injured in collision with sport utility vehicle in traffic accident. Summary, crew dispatched to the scene for the accident. Upon arrival crew found patient ambulatory on scene, patient is alert X3 [person, place, time] and complains of head pain after being involved in a low impact MVC [motor vehicle crash] ...Patient was restrained and no airbag deployment ...Patient secured inside ambo and performed secondary assessment without further findings noted. [Hospital A] contacted with pre notification. Patient transported with ongoing assessment enroute without incident or change in condition. Patient transferred to ER Triage Area [Hospital A] per charge flow nurse and report given to receiving RN [registered nurse] ...” - The EMS Run Sheet indicated that Pt #1 arrived at Hospital A on 2/14/2025 at 7:15:59 AM. The EMS Run Sheet was signed and dated by the 2 EMS crew members and by Pt #1, confirming the time of arrival to Hospital A’s ED. 3. The ED Centralized log from 2/14/2025 was reviewed. The ED Centralized log did not include Pt #1. 4. On 4/8/2025 at approximately 10:30 AM, an interview was conducted with the ED Director (E #3). E #3 reviewed the ED Centralized log and acknowledged that Pt #1 was not on the log on 2/14/2025. 5. On 4/8/2025 at approximately 11:30 AM, a phone interview was conducted with a Patient Access Clerk (E #8/assigned on 2/14/2025 day shift). E #8 stated that any patient that comes in from EMS or walks in and wants to be seen, should be registered and are put on the tracking board and log.”

“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: 34411 A. Based on document review, audio recording review, and interview, it was determined that for 1 of 4 (Pt #1) patients presenting with obstetrical issues/pregnancy (of a total ED record sample of 22 patients), the Hospital failed to ensure an appropriate medical screening exam was performed to determine if an emergency medical condition existed. Findings include: 1. The Hospital’s policy titled, “EMTALA” (Emergency Medical Treatment and Labor Act), dated 1/2025, was reviewed, and required, “If an individual comes to the Emergency Department: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists ...Triage and Registration. 1a. As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination ...” 2. The Hospital’s “ED Labor Patient Assessment” form (undated) was reviewed on 4/7/2025 and included fillable lines to enter date, time, patient name, date of birth, primary care physician/obstetrician, due date, gestational age, arrival mode, vital signs. The form included the following directives: “[arrival by] Ambulance: Admitting RN - If patient is pregnant and/or states has recently delivered (within the last 3 months): After taking VS [vital signs] and brief history call OB Charge Nurse at [extension] and inform ED doctor at the same time to decide on next step; Fellow/OB Charge [nurse]; If patient stable will bring up to OB ED triage; If patient unstable fellow will come to see patient in the ED ...” 3. A “Care Point Radio” recorded audio EMS call (Emergency Medical Services Call System/alerts inbound patient transfers), from 2/14/2025 at 7:14 AM, was reviewed with the ED Director (E #3) on 4/8/2025 at approximately 10:10 AM. The call was made by the local fire department’s EMS crew to Hospital A’s ED (emergency department). The call was regarding the anticipated arrival of a patient (Pt #1) to Hospital A’s ED. The call indicated that Pt #1 was enroute to the Hospital and the chief complaint was that Pt #1 was a 6-month pregnant patient who was involved in a motor vehicle accident. The Hospital staff (could not determine which staff) who received the call, verbally acknowledged the EMS crew’s report prior to ending the call. 4. On 4/7/2025, the ED Director (E #3), presented an EMS run sheet for Pt #1 (dated 2/14/2025 at 7:10 AM). The EMS Run Sheet for Pt #1 indicated that Pt #1 was transported to Hospital A’s ED via ambulance. The EMS Run Sheet included, “Possible Injury: Yes: Car driver injured in collision with sport utility vehicle in traffic accident. Summary, crew dispatched to the scene for the accident. Upon arrival crew found patient ambulatory on scene, patient is alert X3 [person, place, time] and complains of head pain after being involved in a low impact MVC [motor vehicle crash] ...Patient was restrained and no airbag deployment ...Patient secured inside ambo and performed secondary assessment without further findings noted. [Hospital A] contacted with pre notification. Patient transported with ongoing assessment enroute without incident or change in condition. Patient transferred to ER Triage Area [Hospital A] per charge flow nurse and report given to receiving RN [registered nurse - no name documented] ...” The EMS Run Sheet indicated that Pt #1 arrived at Hospital A on 2/14/2025 at 7:15:59 AM. The EMS Run Sheet was signed and dated by the 2 EMS crew members and by Pt #1, confirming the time of arrival to Hospital A at 7:15 AM on 2/14/2025. [The EMS run sheet did not include that Pt #1 was 6 months pregnant as stated on the recorded/received EMS call.] 5. On 4/7/2025, Pt #1’s clinical record from Hospital A was requested. The Hospital was unable to provide a clinical record for 2/14/2025, as there was no encounter history or registration for Pt #1 in the Hospital’s EMR (electronic medical record) system. There was no documentation indicating that after Pt #1’s arrival to Hospital A’s ED, Pt #1 received a triage assessment, vital signs taken, or received a medical screening examination to determine if an emergency medical condition existed for an OB patient with twins, status post a motor vehicle accident. 6. The clinical record for Pt #1, from Hospital B (receiving Hospital) was obtained, and reviewed on 4/9/2025, and included: Pt #1’s OB Triage Notes (dated 2/14/2025 at 9:53 AM), included, “Patient brought by EMS to [Hospital A] where [Pt #1] waited several hours in the waiting room to be seen. [Pt #1’s spouse] then drove [Pt #1] to Hospital B.” OB Triage Notes included the following on 2/14/2025 at: -10:00 AM: “Pain in lower back after MVA [motor vehicle accident]. MVA around 730 this am. Patient was driving 25-30 mph when t-boned by a car who was turning slowly. Patient reported intermittent pain primarily on [Pt #1] left lower back. Patient reports feeling a couple of cramps around 7:50 [AM], but currently denies feeling any cramping or contractions. Patient denies any other injuries during the car accident, denies losing consciousness, and denies any bumps or direct injury to her abdomen. Patient was initially brought to [Hospital A] and was waiting in the waiting room for several hours, so her husband brought her to [Hospital B]. In between [Hospital A] and [Hospital B], patient stopped for food. Patient stated that she debated whether or not she should come to the hospital because she and her babies “felt fine” Patient reports slight cramping around 07:50 after the car accident, but currently denies contractions; Rupture of membranes: Denies; Vaginal bleeding: None; Vaginal Discharge: Denies; Recent Sexual Intercourse: Denies; Abdominal Trauma: Motor Vehicle Accident, Annotation: Abdomen soft to palpation; Patient Complaints: Back Pain; Triage Level: Priority 3 require evaluation (within 30 minutes) by the Healthcare Provider ...” - 10:18 AM (Per external ultrasound/monitor) - Fetus B Comments: Inconsistent tracing baby B during possible variable for baby A ...” - 10:45 AM - “Fetal Assessment A ... FHR Baseline Rate: 155 ... Decelerations: none ... Fetal Assessment B ... FHR Baseline Rate: 145 ... Decelerations: none ...” - 11:00 AM - “Fetus B Comments: deceleration x2 noted, unspecified due to absence of contractions.” - 11:10 AM - “Provider [MD/Pt #1’s OB] at Bedside” - 11:14 AM - “[MD] performing bedside ultrasound” - 11:24 AM, “RN at bedside; RN reviewed strip; Provider at bedside. Provider at bedside discussing potential need for c-section. Patient visibly distressed about discussion and asking if babies are viable at 24 weeks. [MD] told patient the risks of injury after car accident and potential need for c-section.” - 11:29 AM, included, “[MD] verbalized need for c-section.” - 11:40 AM - “Patient signed consents for emergency c-section.” The Delivery Summary (dated 2/14/2025), included, “[Pt #1] at 24.1/7 wks [gestational age] iup [intrauterine pregnancy] who was in a serious car accident where [Pt #1] was T-boned and the car hit [Pt #1] on [Pt #1] side of the car as [Pt #1] was the driver and after the accident the ambulance took [Pt #1] to the nearest hospital [Hospital A] and [Pt #1] sat there for 4 hours and [Pt #1] came to the hospital [Hospital B] because [Pt #1] is my patient from the clinic. When Pt #1 was in triage [MD] noted that [Pt #1] was having late decels [abnormal low fetal heart rate] for baby B and baby B is the one moving less ...[MD] spoke to the patient quickly and detailed and [Pt #1’s spouse] consented for a C/S [cesarean section] due to concern for an abruption [placenta detaches from uterus] ...Classical C/S ...Baby A delivered ... Delivery Date: 2/14/2025 at 12:03 PM ...Apgars 5/8 [quick assessment of newborn at birth at 1 and 5 minutes of birth/normal 1 minute is 7 or above] ... Baby B: Delivery Date: 2/14/2025 at 12:04 PM ...Baby B delivered Apgars 5/8 ...” Baby A and Baby B were transferred to NICU (neonatal intensive care unit).” There is no further documentation in Pt #1’s clinical record regarding Baby A and Baby B. 7. On 4/7/2025 at approximately 12:00 PM, an interview was conducted with Attending Physician (MD #2) stated that every patient should receive a medical screening exam. MD #2 stated that when a pregnant patient presents to the ED, who was in a motor vehicle accident, the patient should be medically cleared in the ED before going to the OB unit. MD #2 stated that at minimum if the patient hits her head during the collision, CT (cat scan imaging) will be done to rule out head trauma. MD #2 stated that also, the ED will get fetal heart tones via ultrasound to check on the well-being of the fetus. MD #2 stated that the other usual course of treatment for the OB patient in the ED, would include obtaining blood work, doing a full comprehensive assessment, and administering Tylenol for pain if needed. 8. On 4/8/2025 at approximately 10:10 AM, an interview was conducted with the ED Charge RN (E #12). E #12 stated the E #12 was the dayshift Charge RN on 2/14/2025. E #12 stated that E #12 does not recall Pt #1. E #12 stated that if a pregnant patient who was in a motor vehicle accident, presents to the ED, she should be triaged right away. E #12 stated that more than likely, the patient would be triaged as an ESI 2 (high risk situation/scale 1-5). E #12 stated that patients triaged as ESI 2, should be taken to the back (ED treatment area), and not placed in the waiting room if possible. E #12 stated that these patients would be considered as high priority to be seen. E #12 stated that the ED doctor would look at the OB patient first to determine if they need to stay in the ED or get sent to the OB department (if over 16 weeks gestation). E #12 stated that the RN would get an abdominal ultrasound on the patient to check fetal well-being. E #12 stated that the OB triage sheet [ED Labor Patient Assessment] should be completed on arrival for all pregnant patients presenting to the ED, and the ED Charge Nurse will contact the OB Charge Nurse. 9. On 4/8/2025 at approximately 10:10 AM, an interview was conducted with the ED Director (E #3). E #3 stated that when any OB patient presents to the ED, the OB triage sheet should be completed, and an assessment should be done right away. E #3 stated that the ED Charge RN will contact the L & D (Labor and Delivery) Charge RN to inform them of the pregnant patient in the ED. E #3 stated that if the patient was in a motor vehicle accident, the patient would be assessed to see if their belly was hit by the steering wheel or feeling dizzy. E #3 stated that if the mother is complaining of symptoms related to the baby, then the pregnant patient goes straight up to OB. E #3 confirmed that there was no documentation indicating that Pt #1 received a medical screening exam. 10. On 4/10/2025 at 10:23 AM, a phone interview was conducted with the Director of Women’s Health Physician (MD #3). MD #3 stated that if a pregnant patient presents to the ED following a motor vehicle accident, and is conscious and stable, the patient should come straight up to OB. MD #3 stated that the ED should call the OB unit even prior to the mother arriving to make the OB unit aware. MD #3 stated that the priority once knowing that the mother is stable, is to put fetal monitoring on the babies. MD #3 stated that the baby/babies should remain on the monitor for at least 6 hours to assure fetal well-being. MD #3 stated that even if the mother was in a “fender bender” (minor car accident), there is still a possibility of placenta abruption. MD #3 stated that assessment timing is critical in this scenario, as 24-week babies are viable, and an emergency C-section could be done if warranted. MD #3 stated that this patient scenario should be at the top of the list, as far as priority in being seen. B. Based on document review and interview, it was determined that for 1 of 3 (Pt #24) patients presenting with chest pain (of a total ED record sample of 22 patients), the Hospital failed to ensure an appropriate medical screening exam was performed to determine if an emergency medical condition existed. Findings include: 1. On 4/09/2025, the hospital’s policy ‘Triage Process for Patients in the Emergency Department’ (reviewed 3/2023) included, “ ...V. Procedure: ...2. If a bed is not immediately available ...the triage nurse will evaluate each patient in the order determined by a quick look triage process based on age and presenting complaint ...Test ordering: ...3. EKGs will be done using “STAT” EKG protocol for patient with chest pain ...”. 2. On 4/10/2025, the hospital’s ‘General Approach to ED Chest Pain’ (revised/reviewed 9/23) included, “ ...start ECG in Triage by ED staff or immediately upon placement on ED cart. < (less than) ten minutes (STAT ECG may be initiated at any time) ...ECG immediately shown to ED attending who interprets, signs and times ECG ...” 3. On 04/08/2025, the clinical record of Pt. #24 was reviewed. On 12/12/2024 at 6:01 PM, Pt. #24 presented to the hospital’s emergency department by ambulance for prolonged chest pain. The medical record included: The ‘ED Triage- Part 1 and 2’ documents on 2/12/2024 indicated that triage was performed at 6:39 PM and included, “ ...chief complaint: chest pain ...Tracking Acuity: 3-Urgent ...Pain location: Chest ...Numeric Pain Score: 8 (out of 10) ...Falls Risk: Not a fall risk ...Assessment: ...Level of Consciousness: Alert ...Orientation: Oriented x4 (person, place, time, and situation) ...”. The Registered Nurse’s (E #38) ‘ED Nursing Note’ timeline on 12/12/2024 as follows: -At 6:18 PM included, “ ...[Pt. #24] received from CFD (Chicago Fire Department) with complaints of chest pain. [Pt. #24] attached to monitor (cardiac monitoring) and EKG (also called ECG/test to record the heart’s electrical activity/heart rhythms) completed. [Pt. #24] immediately asked to be removed from the monitor to use the restroom. [Pt. #24] ambulated to restroom with stand by assist. [Pt. #24] in NAD (no acute distress) at this time ...” -At 6:28 PM included, “ ...[Pt. #24] ambulated back to room with standby assist. [Pt. #24] positioned in bed and reattached to the monitor ...” -At 6:30 PM included, “ ...[Pt. #24] states need to use the restroom again. [Pt. #24] ambulated to restroom ...” -At 6:42 PM included, “ ...[Pt. #24] ambulated back to restroom with standby assist. [Pt. #24] positioned in bed, reattached to the monitor ...” -At 6:45 PM included, “[Pt. #24] requesting to use the restroom again. [Pt. #24] removed self from monitor leads and ambulated to restroom ...” -At 6:50 PM included, “ ...[Pt. #24] ambulated back to room unassisted. [Pt. #24] states no further needs at this time ...”. -At 9:29 PM included, “ ...ME (medical examiner) office notification of [Pt. #24] death. Spoke with (medical examiner) ...[medical examiner] states [Pt. #24] manner of death is concurrent with medical history and are releasing the body to the family ...” The ED Physician’s Orders indicated that the following were ordered on 12/12/2024 at 6:22 PM and 6:23 PM: EKG-stat, B-type Natriuretic Peptide (blood test to measure the BNP level that could indicate heart function), Troponin (blood test to indicate heart muscle damage), CBC (complete blood count/blood test looked at for one’s overall health and or conditions) and CMP (Comprehensive Metabolic Panel/blood test that measure your liver, kidney, and electrolyte functions). The Diagnostic Tests-Procedures on 12/12/2024 at 6:22 PM included, “ ...Cardiology procedures: ...routine ECG 12 lead/15 lead tracing only.” The clinical record did not contain results for any of the orders. The ‘EKG Documentation’ section of the record, dated 12/12/2024 at 6:22 PM, indicated that an EKG was recorded by the ED Technician (E #7) and (MD #4) was notified. However, the clinical record did not include a copy of the EKG that was performed, printed, reviewed by physician/MD #4, and signed by MD #4. The Physician’s (MD #4) ‘ED Note Physician’ on 12/12/2024 included: 6:30 PM, “ ...[MD #4] seen: 12/12/2024 6:21 PM ...History of present illness: ...includes HFrER (heart failure with reduced ejection fraction/heart pumps less blood than normal) LV EF 35-40% (left ventricle ejection fraction-normal 55% to 70%) ...[Pt. #24] underwent ptca (percutaneous transluminal coronary angioplasty/minimally invasive procedure that opens blocked coronary arteries to improve blood flow) earlier this month due to cardiomyopathy (disease of heart muscle) and positive stress test (test to show how the heart works during physical activity) ...[Pt. #24] here with 1-2 hours of central chest squeezing/pressure ...slight sob (shortness of breath) with pain ...asa (aspirin) and nitroglycerin (medication to treat chest pain) en route (by EMS/emergency medical services) with no change in discomfort ...Procedure: ekg from ambulance. Poor quality, question changes in III (lead 3), no stemi (severe type of heart attack) ...Medical Decision Making: chest pain with burning in the throat. Cath within the past days with no critical stenosis (narrowing of the artery, blocking blood flow) ...question (differential diagnosis): gi (gastrointestinal), msk (musculoskeletal), pna (pneumonia), acs (acute coronary syndrome/heart condition with blocked blood flow) doubt pe (pulmonary embolism/blood clot in the lungs), dissection (tear in wall of heart artery) ...plan: ekg, labs, xray (test to image a part of the body), gi(gastrointestinal) cocktail, re-evaluation, asa already given ...(addendum) at 8:31 PM: ...ekg was done on the room monitor but was not able to be printed, per nursing read on monitor was NOT stemi (acute ST-segment elevation myocardial infarction/a type of heart attack). [E #38] was attempting to print the ekg and settle [Pt. #24] and [Pt. #24] took off all leads and monitoring off and insisted that [Pt. #24] go to the bathroom against [E #38] trying to convince [Pt. #24] not to ...[E #38] saw [Pt. #24] go into the room and then shortly after heard [Pt. #24] fall. [MD #4] was called to the room. [Pt. #24] was bleeding from where [Pt. #24] struck her face in the fall directly into the ground. [Pt. #24] was moved to the bed and noted to have agonal respirations ...[Pt. 24] looked to be in v-tach (ventricular tachycardia/fast, irregular heartbeat) ...ACLS (advanced cardiac life support) initiated ...[pt. #24] lost pulse and remined in vtach that showed no response to several shocks ...after several sequential shocks [Pt. #24] went into asystole (without pulse) with epi (epinephrine) reinitiated. ...[pt. #24] went into sinus brady (low heart rate) with a rate in the 40’s ...[Pt. #24] degraded into asystole despite these measures ...after close to an hour twenty minutes the efforts were stopped ...” The ‘Code Resuscitation’ document indicated that a code was called at 7:07 PM and CPR (Cardiopulmonary Resuscitation) and life saving measures were performed, however (Pt. #24) remained with PEA (pulseless electrical activity/without a pulse) and death was pronounced. The ‘Record of Death’ document included, “ ...Date of death: 12/12/24 ...Time of Death: 8:19 PM ...Is patient’s death reportable to Medical Examiner: Yes ...Does Medical Examiner (ME) want the patient: No ...Time ME called: 9:15 PM ...” - Although not included in Pt #24’s medical record, on 4/14/2025 at approximately 1:25 PM, the ED Director (E #3) presented an EKG printout for Pt #24, dated 12/12/2024 at 6:21 PM. The EKG printout was reviewed, yet did not include the cardiac rhythm readings nor a physician signature to indicate that the EKG had been read by the physician. 4. On 4/8/2025 at approximately 3:30 PM, an interview with the ED Attending Physician (MD #4) was conducted. MD #4 stated (Pt. #24) presented to the hospital via EMS with reported chest pain. MD #4 stated that an EKG was not provided to or reviewed by (MD #4) prior to (MD #4’s) assessment of (Pt. #24). MD #4 stated that orders for an EKG and lab work were entered post assessment. MD #4 stated that (MD #4) was called to another patient emergency when (MD #4) was called and notified of (Pt. #24’s) fall and subsequent code blue. 5. On 4/10/2025 at approximately 10:30 AM, an interview with the ED Technician (E #7) was conducted. E #7 stated that all ED rooms have cardiac monitoring which can be printed. E #7 stated that if the monitor is not printing or working, then an EKG should be performed on a portable EKG machine. E #7 stated all chest pain patients receive a stat EKG which should be performed within ten minutes and provided to an attending physician within one minute of printing. E #7 stated there should be no delay in providing the EKG results to the physician. 6. On 4/14/2025 at approximately 1:25 PM, an interview was conducted with the ED Director (E #3). E #3 stated, after review of the EKG within (Pt. #24’s) record, that an EKG should have been performed and included the rhythm readings and presented to the ED physician for review and signature and confirmed that (Pt. #24’s) EKG did not include either component. 7. On 4/10/2025 at approximately 11:15 AM, an interview with the ED Medical Director (MD #8) was conducted. MD #8 stated that it is hospital protocol for an EKG to be performed on a patient with reported chest pain in less than ten minutes from time of arrival as part of the medical screening.”

“On March 28, 2025, the Life Safety Code portion of Compliant Investigation 187950 was conducted. The surveyor was accompanied during the survey walk-through by the following provider representatives: Executive Director Operations (EDO) Facility Staff (FS). The building was surveyed as existing healthcare under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. The requirements of 42 CFR Subpart 482.41, Physical Environment are MET; only standard-level deficiencies were cited. Refer to the deficiencies cited under the K-Tags.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 45373 Based on observation and document review, building services are not addressed in accordance with Code requirements. Failure to maintain building services and provide multiple safe guards may compromise the safety of any building occupants during a fire emergency. Finding includes: On 3/28/2025 while accompanied by the EDO the handling of and disposal of garbage, refuse and solid waste does not comply with 19.1 and 4.5 for any and all means of safe guards from a potential fire emergency. The amount of material waste and combustibles located within areas of the facility and the location of the exterior dumpsters does not provide for an environment that is maintained to prevent fire and other hazards to personal safety to comply 4.5.2. Refer to the following: 1. Due to the condition of the exterior dumpsters near the receiving dock as overflowing their capacity with general and medical waste disposal the condition is not in compliance with grounds and building maintenance and the handling and disposing of waste. 2. Due to the condition of the exterior dumpsters, Trash room and Receiving area used as storage of general and medical waste, The conditions at this facility are conducive to the harborage or breeding of vermin. The hospital site is not in compliance with 4.5.1.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45373 Based on observation, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained. Findings include: On 3/28/2025 while accompanied by the EDO, observation determined that means of egress are not maintained continuously free of obstructions, as required by 7.1.10.2.1. The means of egress outside of the trash room near the recieving dock was observed to be overflowing with trash, thus presenting a hazard in the egress path.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 45373 Based on observation, not all doors required to be self closing are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if self closing doors not maintained. Findings include: On 3/28/2025, while accompanied by the EDO, observation determined that fire and smoke doors are not maintained in accordance with code requirements (NFPA 80, 2010, 5.1.1.1, NFPA 101, 2012, section 19.3.2.1.3, 7.2.1.7 and 8.7. Failure to maintain door assemblies can compromise the safety of any building occupants if the function of the door to restrict the spread of fire & smoke during a fire emergency is undetected. Example location, the Trash room (“Compactor room”?) contained entry doors which did not provide the following: 1. Maintain the required fire rating for the room. 2. There is visible structural damage to the door leaf and door frame. 3. The doors did not self-close or self-latch. 4. The door hardware does not meet the requirements for fire rated assemblies. 5. The door hardware is damaged. 6. Visible large gaps surround the door and frame.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 45373 Based on observation during the survey walk-through,Sprinklered hazardous areas are not separated by a minimum fire resistance construction. Failure to separate hazardous areas (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material compromising the use of the adjacent means of egress for exiting. Finding includes: On 3/28/2025 while in the company of the EDO it was observed that the condition of the Trash room had been deficient for a period of time and the amount of trash built up. The Trash room contained an immense accumulation of combustibles. Material included cardboard, fabric and plastics when burned releases harmful chemicals all piled within 3- 5 feet of the approximate 10-foot ceiling height. This trash filled the room and is deemed by this AHJ to exceed that required for a healthcare building NFPA 101 19.3.2.1, 19.7.5.7 and 8.7.1.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 45373 Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency. Finding includes, A. On 3/28/2025, while in the company of the EDO, documentation review for the Annual Fire and Smoke Door Inspections was not complete to comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2. The latest Annual Fire and Smoke Door Inspection report was performed in house in January 2025. There is no indication that the door to the Trash room was inspected. The door contains numerous deficiencies that inhibit its function as a self-closing self-latching fire rated assembly. B. On 3/28/2025 while in the company of the EDO, Review of the Annual Fire and Smoke Door Inspection indicates an incomplete document and does not comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.1 and 5.2.4.2. refer to the following: 1. The latest Annual Fire and Smoke Door Inspection report appears incomplete - there are no doors indicated for the hospital other than one on the first floor, penthouse, two doors on the second floor. Due to the number of “pass” comments it appears that these doors are not adequately inspected. 2. For the 2 - 3 doors which indicated “Fail” for item #6 or #8 there is no indication that these failures were corrected. 3. There is no indication on the inspection report that door assemblies are inspected from both sides to access the overall condition (NFPA 80, 2010, 5.2.4.1.) 4. Task comment # 10 “Is the door locking in the path of egress for the clinical needs of the patient?” This door is indicated to have “passed”. It is located in the POB lower level there is no information as pertaining to the locking of a door in a means of egress for patient care. From information provided there is no indication of how this door functions to comply with 19.2.2.2.2, 19.2.2.2.5, 19.2.2.2.6. 5. Task comment #15 “Is there only one delayed egress panic bar in the path of egress” there is a note “can apply for waiver” this statement within the inspection report does not comply Part 250 Hospital Licensing Requirements Section 250.2450 c) 2) O). 6. There is no indication that the personnel inspecting the doors qualifies per NFPA 101 2012, section 7.2.1.15.5, NFPA 80, 2010 section 3.3.95.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 4 patients’ (Pt. #1 and Pt. #2) clinical records reviewed requiring constant observation/one-to-one monitoring (one staff assigned to one patient providing monitoring), the hospital failed to ensure constant observation/one-to-one monitoring, was implemented as ordered. Findings include: 1. On 5/28/2024, the hospital’s policy titled, “Care for Patient with Behavioral Health Needs” (7/2023) reviewed and indicated, “ ... To assure that patients who need psychiatric care will be safely cared for ... 6. Emergency Department (ED) procedure as follows ... 6.1.2 The ED Charge Nurse will complete the Constant Observer request form ... Addendum ... Constant Observer Roles and Responsibilities ... Patients’ nurse will assign level of constant observation for patient. One-to-One observation: One competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room ...Document on Constant Observer Flow Sheet every 15 minutes ...” 2. On 5/28/2024, the clinical record for Pt. #1 was reviewed. On 3/12/2024, Pt. #1 was brought to the hospital by paramedics due to hearing voices and having homicidal ideation. A physician’s order dated 03/12/24 at 9:35 PM, was placed to start Pt. #1 on constant observation (one to one observation) and suicide precaution.The constant observation sheet was also left blank from Pt. #1’s arrival to the ED through discharge from approximately 10:00 PM on 3/12/2024 through 4:30 AM on 3/13/2024 (six hours and 30 minutes). 3. On 5/28/2024, the clinical record for Pt. #2 was reviewed. On 5/26/2024, Pt. #2 was brought to the ED due to suicidal attempt. On 5/26/2024 at 11:00 AM, a physician’s order was placed to start patient on constant observation/one-to-one monitoring. However, on 5/26/2024, the constant monitoring sheet was left blank from 7:15 PM through 8:30 PM (one hour and fifteen minutes). 4. On 5/28/2024 at approximately 2:00 PM, an interview was conducted with E #3 (ED Director). E #3 confirmed that there was no documentation to demonstrate that Pt. #1 was placed on one-to-one monitoring. To ensure safety of patient in the ED, E #3 stated that there is no other mechanism to identify who was monitoring Pt. #1 since the constant observation monitoring sheet was left blank/incomplete. E #3 also added that the ED assignment sheet do not reflect who was assigned to monitor Pt. #1. E #3 stated that the monitoring sheet should be completed every-15 minutes.”