Vista Medical Center East

“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 A. Based on document review and interview, it was determined that for 2 of 2 records reviewed (Pts. #3 and #10) for enteral (delivered to stomach/small intestine through a tube) feeding administration, the Hospital failed to ensure that tube feedings were administered without delay and as ordered. Findings include: 1. The Hospital’s policy titled, “Enteral Feedings” (revised 02/2025) was reviewed and required, “Policy: Enteral Nutrition and Parenteral [administered intravenously] Nutrition solutions are available upon physician’s order. Purpose: To provide nourishment to patients who are unable to orally meet their nutritional needs... Enteral nutrition orders should include: Product’s name; Rate (cc/hr) [milliliters per hour]; Strength, and Infusion schedule (continuous, cyclic, intermittent, bolus)...” The Hospital could not provide a policy for enteral feedings effective prior to 02/2025. 2. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED on 01/28/2025, with a chief complaint of respiratory concerns. The Medical Screening Exam, dated 02/18/2025, indicated that the decision to admit Pt. #3 to the ICU (intensive care unit) was made on 01/28/2025 at 9:45 AM. - The Dietician Evaluation, dated 01/28/2025 at 2:58 PM, included “ ...Patient triggers a consult due to TF [tube feeding] ...Nutritional Diagnosis: Inadequate protein/energy intake related to decreased ability to consume sufficient protein and/or energy as evidence by estimated energy intake from diet less than estimated recommended levels ... Nutrition Prescription: ... Diet: NPO [nothing by mouth] ... Recommend starting patient on Vital [tube feeding formula] ... at 15 ml/hr [milliliters per hour] continuous, advance as tolerated by 10 ml Q4 [every 4 hours] to reach the goal rate of 65 ml/hr continuous with FWF [free water flushes]: 90 ml Q4 or per MD ...” - A physician’s order was placed on 01/28/2025 at 3:07 PM to start the Vital HP tube feeding as recommended by the dietician. - ED Nursing Notes from 01/28/2025-01/29/2025 were reviewed and indicated that they (staff) could not find a feeding pump to start the tube feedings for Pt. #3. - The record indicated that Pt. #3 was transferred to the ICU on 01/29/2025 at 8:09 AM. - Enteral Feeding Administration Records from 01/28/2025-02/04/2025 were reviewed and indicated that tube feeding was initiated on 01/29/2025 at 8:00 PM (nearly 29 hours after tube feeding was ordered) and was started at a rate of 10 ml/hr (not 15 ml/hr as ordered). The record lacked documentation as to why tube feedings were delayed on 01/29/2025 when the patient was transferred to the ICU (day shift). 3. The clinical record of Pt. #10 was reviewed. Pt. #10 was admitted on 04/08/2025 with a diagnosis of possible stroke. - The Dietician (E#15) Evaluation, dated 04/09/2025 at 7:57 AM, included “...Patient triggers consult due to TF... Nutritional Diagnosis: ...Inability to consume orally related to stroke/dysphagia [difficulty swallowing] as evidence by need for enteral nutrition... Nutrition Interventions: ...Diet: NPO... Recommend starting patient on Jevity 1.5 [tube feeding formula] at 30 ml/hr continuous, advance as tolerated by 10 mL Q4 to reach the goal of 45 ml/hr continuous with FWF: 130 ml Q4 or per MD...” - A physician’s order was placed on 04/09/2025 at 8:09 AM to start the Jevity tube feeding as recommended by the dietician. - Enteral Feeding Administration and Intake records from 04/09/2025-04/14/2025 were reviewed and indicated that the tube feeding was initiated on 04/09/2025 at 10:00 PM (nearly 14 hours after the tube feeding was ordered) and was started at a rate of 40 ml/hr (not 30 ml/hr as ordered). The record lacked documentation as to why tube feedings were delayed on 04/09/2025. Additionally, the record lacked documentation that tube feedings were administered as ordered on 04/12/2025 and 04/13/2025 and did not include any documentation to indicate why feedings were not administered as ordered. 4. An interview was conducted with Dietician (E#15) on 04/15/2025, at approximately 1:00 PM. E#15 stated that to maintain Pt. #3’s nutritional needs, they placed orders to start the patient on tube feedings. E#15 did not recall being notified that there were no feeding pumps available for this patient. E#15 stated that they generally have enough feeding pumps, and they will check central supply and all the units to find a pump. E#15 stated that once in a while a patient in the ED will need a feeding pump so don’t usually keep any on hand in the ED. E#15 stated that they may or may not start the feeding in the ED, depending on how long the patient stays in the ED, even after being admitted. E#15 stated that if they are only going to be there for an hour, they may not start it right away. E#15 stated that if it was reported to E#15 that staff didn’t have a feeding pump available to start the tube feeding, E#15 could have ordered bolus feedings for the patient in the meantime. 5. An interview was conducted on 04/16/2025 at approximately 9:15 AM with the ICU Nurse (E#13) who was assigned to work with Pt. #3 on the morning of 01/29/2025 when Pt. #3 was transferred to the ICU. E#13 stated that when Pt. #3 was transferred to the ICU, it was reported that there was some issues/delay starting the tube feeding. E#13 stated that it was reported that the supervisor and nurses couldn’t locate a pump. E#13 stated that during rounds, the doctor (E#13 did not recall who) was upset why the feeding was not started. E#13 stated that E#13 went around the unit and found a feeding pump and the feeding was initiated right away. E#13 started that they would document the initiation of the tube feeding in the clinical record. E#13 believed that the feeding was started as soon as Pt. #3 arrived to the unit but wasn’t entirely sure. 6. An interview was conducted with ICU Nurse (E#16) on 04/16/2025, at approximately 12:50 PM. E#16 stated that if there is an issue with administering a feeding with a pump, they can call the dietician and ask if they can give a feeding by bolus; and if yes, they would have to place an order for bolus feedings. E#16 stated that if an ICU patient is boarding in the ED for a while, sometimes they will send down a nurse to care for the patient or the ED staff will resume care until the patient is transferred to the unit. E#16 stated that if orders are placed for treatment whether the patient is still in the ED or up on the ICU, the orders should be executed right away. 7. An interview was conducted with the Quality Manager (E#24) on 04/17/2025 at approximately 12:15 PM. E#24 was reviewing the record of Pt. #10 and stated that E#24 could not find any documentation of why the feedings weren’t administered on 04/12/2025 and 04/13/2025. E#24 stated that it should have been documented in the GI (gastrointestinal) tube section and/or on the Intake & Output flowsheets. 30461 B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) patients reviewed for intravenous (IV) assessments, the Hospital failed to ensure that IV assessments were completed and documented. Findings include: 1. On 04/14/2025, the hospital’s policy titled, “IV Peripheral Therapy Policy” (effective 02/2021) was reviewed and included, “ .... Insertion site should be inspected prior to each use and at least once every shift .... Flush every 12 hours with 10 milliliter of 0.9% Normal Saline for 31 days old to adults .... Documentation: Discontinuation: date and time, condition of site ...” 2. On 04/15/2025 2:30 PM, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to 5th floor Medical-Surgical Telemetry Unit with a diagnosis of new onset diabetes with bilateral swollen legs. Pt.#1 had an IV placed on the left mid forearm on 2/12/2025 at 8:00 PM. Another IV was placed on 2/11/2025 at 2:43 PM on the right antecubital (inner front forearm). On 2/14/2025 at 2:35 PM, it was documented that both IVs were discontinued; however, the record lacked documentation of the condition of the IV sites at discontinuation as required. 3. On 4/15/2025 at approximately 10:12 AM, an interview was conducted with the Registered Nurse (E#2). E#2 stated that IV assessments are done every 12- hour shift, when medication is administered, and during endorsement. E#2 stated that IV sites must be checked for infiltration (leaking), swelling, or redness. E#2 stated that E#2 would discontinue the IV(s) and then document the removal in the record. E#2 stated that assessment of the IV site’s condition should be documented at the time of discontinuation for every patient.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Findings include: 1. The hospital failed to ensure that the designated Chief Nursing Officer/CNO (E #20) responsible for the practice of nursing services in the hospital, was qualified, as required. See A-386.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to ensure that the designated Chief Nursing Officer/CNO (E #20) responsible for the practice of nursing services in the hospital, was qualified, as required. 1. On 7/16/2024, the hospital’s “Governing Body Meeting Minutes” (3/15/2024) was reviewed and indicated, “(Name of the Hospital’s CEO/E #17) reported that (E #21/Chief Operating Officer) has resigned (as the Chief Nursing Officer) effective (March 25, 2024)...a new CNO should be announced in the next 2 weeks...” 2. On 7/16/2024, the personnel file for E #20 (Chief Nursing Officer) was reviewed. The file indicated the following: - A letter from E #17, dated April 23, 2024, that indicated, “To (E #20)... Your position will be Chief Nursing Officer (Full-Time...) reporting to (E #17)... “ - A job description titled, “Chief Nursing Officer” indicated, “... The Chief Nursing Officer is responsible for the practice of Nursing by ensuring consistence in the standard of practice across clinical settings... The CNO supports and facilitates an interdisciplinary team approach to the delivery of care... Minimum Qualifications... Certification/Licensure: License Registered Nurse in Illinois...” - E #20 lacked an Illinois license as a Registered Nurse. 3. On 7/16/2024 at approximately 12:00 PM, an interview was conducted with E #20 (Chief Nursing Officer). E #20 stated that E #20 does not have a current Illinois license.”

“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: 36774 Based on document review and interview, it was determined that the hospital failed to ensure that the ED (emergency department) log included disposition for all patients seeking care in the ED. Findings include: 1. On 7/09/2024, the hospital’s policy titled, “Emergency Medical Treatment and Patient Transfer Policy” (7/2023) was reviewed and included, “... Definitions... Central log means a log of the Hospital maintains of all individuals who present to the Hospital seeking emergency medical assistance and the disposition of such individuals, whether the person refused treatment, was transferred, was admitted and treated...” 2. On 7/10/2024, the hospital’s ED logs from February 1, 2024, through July 9, 2024, were reviewed. The ED logs indicated the following: - On 2/13/2024, there were three patients who presented to the ED with no disposition. - On 7/02/2024, there were five patients who presented to the ED with no disposition. - On 7/05/2024, there were two patients who presented to the ED with no disposition. - On 7/06/2024, there were two patients who presented to the ED with no disposition. 3. On 7/11/2024 at approximately 11:00 AM, findings were discussed with E #1 (ED Director) and E #10 (Director of Risk and Quality). E #1 and E #10 agreed that the ED logs lacked disposition for the patients who presented to the ED. E #10 stated that moving forward, a staff will be assigned to ensure that the ED logs are complete.”

“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: 30461 Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to ensure that the on-call /coverage list of physicians included the following specialty services: Vascular Surgery; Urology; ENT/Ear/Nose/Throat; Oral and Maxillofacial Surgery; and Neurosurgery. See A-2404. 2. The hospital failed to provide a medical screening exam, including assessment or reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. See A-2406.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that the hospital failed to ensure that the on-call /coverage list of physicians included the following specialty services: Vascular Surgery; Urology; ENT/Ear/Nose/Throat; Oral and Maxillofacial Surgery; and Neurosurgery. This has the potential to affect any patient that presents to the ED requiring specialty services. Findings include: 1. On 1/31/2024, the hospital’s application for thier scope of services were reviewed and indicated, “As a Center for Medicare and Medicaid (CMS) accredited hospital, the hospital’s emergency department is a Level 2 Trauma Center. A Level II Trauma Center initiates the treatment of all trauma patients coming into the ED.” (emergency department) (NIH.gov, 2023) 2.On 1/31/2024, the hospital’s scope of services included the following, but not limited to: Neurosurgery, Ear/Nose/Throat, Gastroenterology, Urology, and Vascular surgery. 3. On 1/31/2024, the on-call coverage from January 2023 through January 2024 was reviewed. The log did not include physician coverage for the following services: Vascular Surgery; Urology; ENT/Ear/Nose/Throat; Oral and Maxillofacial Surgery; and Neurosurgery. 4. On 1/31/2024 between approximately 10:30 AM, an interview with the ED Medical Director (MD #1) was conducted. MD #1 stated that currently, the hospital does not have physician coverage for the following services: Neurosurgery; ENT; Urology; and Vascular Surgery. MD #1 stated that patients requiring those services would need to be transferred to another facility providing the services needed.”

“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: 36774 Based on document review and interview, it was determined that for 5 of 20 clinical records reviewed (Pt. #1 - Pt. #5) for patients seeking care in the emergency department (ED), the hospital failed to provide a medical screening exam, including assessment or reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. Findings include: 1. The hospital’s policy titled, EMTALA (Emergency Medical Treatment and Labor Act) (7/2023) included, “ ... Medical Screening ... 3. Individuals coming to the Emergency Department must be provided a Medical Screening Examination. Triage is not equivalent to a Medical Screening Examination ... “ 2. The hospital’s bylaws, rules, and regulations (7/2022) included, “ ... Article VI ... 6.1 (a) ... (3) All patients shall be examined by qualified medical personnel, which shall be defined as (I) a Physician; (ii) AHPs (allied health professional) where permitted by State law and Hospital policy ...” 3. The hospitals policy titled, “VISTA Assessment and Reassessment” (4/2021) included, “ ... Definitions: 1. Vital Signs (blood pressure, heart rate, respiratory rate Procedure ... VI. ED patients are re-assessed at intervals based on patient condition, response to intervention ... any change in condition, and at least at the following intervals: a. upon triage ... b. On admission to the ED, c. After any intervention. d. With any change in caregiver. e. Upon discharge from the ED ... VIII. Assessment, reassessment, and vital signs are documented in the medical record ... “ 4. Out of 2366 patients who came to the ED from 1/1/2024 through 1/24/2024, 121 patients (5.11 %) LWBS (left without being seen). Five of five (100%) LWBS medical records reviewed had incomplete assessments or reassessments. Subsequently, the five patients left the ED without receiving a medical screening examination: - On 1/03/2024 at 2:23 PM, Pt. #1 came to the ED due to vomiting and abdominal pain for 3 days. At 2:31 PM, Pt. #1 was triaged with an ESI (emergency severity index) of 3 (urgent). There were no nursing reassessments for pain or vital signs from 6:30 PM through 10:10 PM (3 hours and 40 minutes). Pt. #1 left the ED at 10:10 PM. - On 1/19/2024 at 11:39 PM, Pt. #2 came to the ED due to left foot pain and swelling for 2 days. On 1/20/2024 at 12:02 AM, Pt. #2 was triaged with an ESI of 4 (less urgent). There were no nursing reassessments for pain or vital signs from 12:03 AM through 5:03 AM (5 hours). Pt. #2 left the ED at 5:03 AM. - On 1/01/2024 at 12:34 AM, Pt. #3 was brought to the ED by EMS (emergency medical service) ambulance due to acute pain from blunt trauma. For 1 hour and 25 minutes, Pt. #3 did not receive RN triage assessment. Pt. #3 left the ED at 1:59 AM. - On 1/05/2024 at 2:12 PM, Pt. #4 was brought to the ED due to possible seizures. Pt. #4 has a history of stroke and right sided weakness. Pt. #4 was triaged with an ESI of 3. There were no nursing reassessments from 2:29 PM through 7:03 PM (4 hours and 34 minutes). Pt. #4 left the ED at 7:03 PM. - On 1/19/2024 at 4:49 PM, Pt #5 was brought to the ED due to headache for 6 days. At 5:08 PM, Pt. #5 was triaged with an ESI of 3 with pain of 8/10 (severe pain). There was no nursing reassessment for pain or vital signs from 5:09 PM through 9:16 PM (4 hours and 7 minutes). Pt. #5 left the ED at 9:16 PM. 5. On 1/30/2024, E #1 (ED Manager) was interviewed. E #1 stated that at the minimum, all patients in the ED are assessed by a registered nurse every 30 minutes. E #1 stated that assessments include documentation of vital signs and pain assessments. E #1 stated that nurses monitor and evaluate patients to ensure that the patient’s condition is not deteriorating. To complete the medical screening examination process, E #1 stated that assessments and reassessments are important. 6. On 1/30/2024, E#2 (ED Director) was interviewed, E #2 stated that full audit of all LWBS patient was done in November 2023. E #2 stated that the hospital’s goal for LWBS is 2%. E #2 is not aware of any problem regarding patients LWBS.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.12 Governing Body. Findings include: 1.The hospital failed to ensure anesthesiology service was available, as required. See A-0048. 1. The hospital failed to ensure that on-call /coverage for the needed services were available, causing delay in the care and treatment of the patients. See A-0067. 2. The hospital failed to ensure that the hospital has an institutional plan and budget. See A-0073. 3. The hospital failed to ensure the contracted services were evaluated as required. See A-0084. The Immediate Jeopardies (IJs) were identified on 1/30/2024 at 42 CFR 482.12 Governing Body, due to: (1) the hospital’s failure to ensure appropriate providers are available to provide necessary services for it’s patients treatment; (2) the hospital’s failure to ensure an institutional plan and budget exist. This impacted the availability of services and supplies necessary for patient care. The IJ’s were announced 01/30/2024 during a meeting at 4:00 PM with the Chief Executive Officer, the Chief Financial Officer, the Chief Operational Officer. the Assistant Chief Executive Officer, the Risk Manager and the Manager of Quality. The IJs were not removed by the survey exit date of 1/30/2024.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined for 5 of 5 patients’ (Pt. #11-Pt. #15) outpatient surgical procedures reviewed, the hospital failed to ensure anesthesiology service was available, as required. Findings include: 1. On 1/23/2024, the hospital’s “Bylaws Rules and Regulations” (approved 7/2022) was reviewed and included, “ ... Article XI ... 11.3. Services. In addition to the departments of the Medical Staff, there shall be services within the department of the medical staff. The various services within the Medical Staff (e.g., anesthesiology service... The purpose of the services shall be to provide specialized care within the Hospital...” 2. On 1/24/2024, the coverage schedule for the anesthesia services were reviewed with E #4 (Director of Surgical Services). E #4 stated that on 1/22/2024, one elective outpatient orthopedic surgery case was canceled due to not having enough anesthesia providers. On 1/23/2024, four elective outpatient colonoscopies (examination of the colon) were also canceled. 3. On 1/24/2024, the operating room schedules on 1/22/2024 and 1/23/2024 were reviewed and indicated the following procedures were canceled due to lack of anesthesia services: - On 1/22/2024, Pt. #11 was scheduled for outpatient right shoulder arthroplasty (removal of portions of the shoulder). - On 1/23/2024, Pt. #12, Pt. #13, Pt. #14, and Pt. #15 were scheduled for colonoscopy (examination of the colon). 4. On 1/24/2024 at approximately 12:40 PM, an interview was conducted with E #4 (Director for Surgical Services). E #4 stated, “I received a call on Sunday (1/21/24) that there will not be enough anesthesiologists to cover for elective cases due to non-payment to the group. E #4 stated that this has causes delay and discomfort to patients.” E #4 stated that the canceled cases were not rescheduled.”

“CARE OF PATIENTS - MD/DO ON CALL CFR(s): 482.12(c)(3) [ ...the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is on duty or on call at all times. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 patients’ (Pt. #1) clinical records reviewed, the hospital failed to ensure that the on-call /coverage for the needed services were available, causing delay in the care and treatment of the patient. This has the likelihood to cause serious harm to any patient seeking care and treatment in the hospital. Findings include: 1. On 1/23/2024, the hospital’s scope of services included the following, but not limited to: cardiovascular, ear/nose/throat surgery, gastroenterology, and neurosurgery. 2. On 1/23/2024, the on-call coverage from January 2023 through January 2024 was reviewed with the Quality Manager (E #3). E #3 stated the following services are no longer available at the hospital, and that’s why no one is scheduled as on-call to provide consultation for the following: Vascular Surgery (since 4/8/2023); Urology (since 12/18/2023); ENT/Ear/Nose/Throat (since 10/2023); Oral and Maxillofacial Surgery (since 11/2023); and Neurosurgery (since 01/01/2024). -There was also no gastroenterology consultation coverage/on-call on the following dates: 11/18/2023 through 11/19/2023 (2 days); 11/23/2023 through 11/26/2023 (4 days); 12/23/2023 through 12/31/2023 (9 days); and 1/1/2024 (1 day). 3. On 1/24/2024, the hospital “Bylaws Rules and Regulations” (approved 7/2022) included, “ ... Article 2 ... 2.6 Consultations. Consultations shall be obtained through the written order of the Attending Practitioner. The consultation report shall include evidence of review of the patient’s record by the consultant ... The Attending Practitioner ... shall obtain consultation in the following circumstances ... B. The diagnosis is unclear following standard diagnostic procedure ...” 4. On 1/25/2024, the clinical record for Pt. #1 was reviewed. On 1/19/2024, Pt. #1 was admitted to the hospital’s intensive care unit for evaluation of angioedema (swelling under the skin) and suspect anaphylactic reaction: -On 1/20/2024, the physician’s progress notes included that CT (computerized tomography/imaging studies) indicated concern for thyroid malignancy. Recommendation was made to transfer Pt. #1 to another hospital with ENT/Ear/Nose/Throat for evaluation due to not having coverage for ENT. The notes indicated that Pt. #1 was at risk for further deterioration. On 1/23/2024 (3 days after the needed consultation), Pt. #1 was able to speak with an ENT provider from another hospital to identify plan of care for Pt. #1. 5. On 1/23/2024 at approximately 12:30 PM, interviews were conducted with MD #1 (Pt. #1’s Attending Physician) and MD #2 (Medical Oncologist). MD #1 stated that Pt. #1 had to be transferred because the patient needed an ENT consultation. MD #1 stated that the hospital does not have neurosurgery, vascular, urology, and ENT services causing delay in the care and treatment of patients. MD #2 stated, “There is lack of available services in the hospital to ensure that all patients receive comprehensive care, which affects the course of treatment of patients. 6. On 1/24/2024 between approximately 2:09 PM and 2:30 PM, interviews were conducted with E #2 (Assistant Chief Executive Officer) and MD #3 (Chief Medical Officer). E #2 stated that the hospital is trying to recruit physicians to cover on-call/coverage for the hospital. However, it is still not enough. MD #3 admitted being unaware of the hospital lacking services other than ENT.”

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d) The institution must have an overall institutional plan that meets the following conditions: (1) The plan must include an annual operating budget that is prepared according to generally accepted accounting principles. (2) The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense. (3) The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable. (4) The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following: (i) Acquisition of land; (ii) Improvement of land, buildings, and equipment; or (iii) The replacement, modernization, and expansion of buildings and equipment. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that the hospital failed to ensure an institutional plan and budget. This has the potential to affect the hospital’s operation and ability to provide the required safe and quality care for all patients. Findings include: 1. On 1/25/2024 at approximately 9:30 AM, the hospital presented a document including the forecasted budget for fiscal year 2024. The forecasted budget did not include capital expenditures for at least a 3-year period. The provided budget was not approved by an agency at the time of review. 2. On 1/25/2024 at approximately 9:30 AM, the hospital provided a document including an email dated 1/02/2024, from the hospital’s Chief Legal Officer to the hospital’s Chief Executive Officer and Financial Officer, which included, “ ...requested financial documents from you all (hospital’s administration staff) for the last couple of months ...has not received ...These documents are essential for our bank, and (bank) have been hounding us for a while now ...(hospital) have significant financial issues that (hospital) are trying to resolve ...” 3. On 1/25/2024 at approximately 9:40 AM, an interview with the Assistant Chief Executive Officer (E #3) was conducted. E #3 stated the hospital is without an approved institutional plan and budget for the 2024 fiscal year. 4. On 1/30/2024 at approximately 10:30 AM, Director of Pharmacy (E #32 ) was interviewed. E #32 stated that on January 17, 2024, a request to order Rophylac (used to prevent autoimmune response to Rh positive blood patients) was in low quantity (only five remaining vials). E #32 stated that Rophlylac was not requested until January 22, 2024, because the hospital is on credit hold with Cardinal (pharmaceutical vendor). E #32 stated that Rophylac is ordered based on request from the blood bank supervisor who knows when available vials are low. Use of Rophylac can be unpredictable, and can be used up when quantities are low. 5. An email from E #32 to the pharmaceutical vendor on 1/22/2024 indicated, “ ... Was wondering if you might be able to advise us - account has been blocked/frozen pending the payments towards past due for the month ...” Response from the pharmaceutical vendor on 1/22/2024 indicated, “Hi (E #32), They just reopened the account, not sure if you can order via (OE/order express) of if it has to update overnight for OE to work.” 6. On 1/30/2024 at approximately 11:00 AM, E #36 (Blood Bank Specialist) stated that on the following dates, blood products were low in quantity to fill a PAR (Periodic Automatic Replacement) level and were not replenished/delivered because the hospital is on credit hold: January 17, 2024 (need 3 units of B- positive packed red blood cells/RBC and one unit of platelet); January 18, 2024 (needs seven units A-positive RBC and three units of B-positive RBC) ; January 19, 2024 (needs three units B-positive RBC). 7. On 1/30/2023 an email from Versiti (blood bank vendor) dated 1/16/2023 to the hospital was reviewed. The email indicated, “Good morning (E #14 /Chief Financial Officer) ... As we did not receive payment yesterday, we have discontinued service and supply as of midnight until we do. Please advise your blood bank staff of this as we did get a request for product ... which was denied ...” 8. On 1/30/2024 at approximately 11:15 AM, the Director of Central Supply (E #37) was interviewed. E #37 stated concerns of a possible depletion of supplies due to continuing to provide CRRT (Continuous Renal Replacement Therapy for (Pt. #20). Currently the hospital has a 3-day supply. I have been made aware by phone from Baxter (the vendor) the requested supplies will not be delivered due to “credit hold”. E #37 stated “I have escalated the request for the supplies to the comptrollers, but I don’t know when it will be received.””

“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: 48264 Based on document review and interview, it was determined for 10 of 10 contracted services, the hospital failed to ensure the contracted services were evaluated as required. Findings include: 1. On 1/25/2024 at approximately 11:30 AM, the hospital’s contracted service contracts were reviewed. The 10 contracted services reviewed were the following: Fresenius (Dialysis), VRAD (Virtual Teleradiology), VRAD (Health agreement), Aramark (Housekeeping/Dietary), SOS (Security), Shared Medical (Mobile PET Service), Teleneurology, G & G Anesthesia, Versiti (Blood supply) and Pulmonology Locum tenens. 2. On 1/25/2024 at approximately 12:30 PM, the hospital’s document titled, “Omnibus Action by Written Consent of the Sole Member of (hospital company)” (11/18/2023) was reviewed and indicated, “... RESOLVED, the new Governing Body shall have all duties and responsibilities normally granted to the Governing Body pursuant to CMS (Centers for Medicare & Medicaid Services) Conditions of Participation ...”. 3. On 1/25/2024 at approximately 2:00 PM, the Quality Assurance and Performance Improvement (QAPI) meeting minutes from January 2023 to January 2024 were reviewed. The meeting minutes did not include evaluation of the hospital’s contracted services. 4. On 1/25/2024 at approximately 2:45 PM, an interview with the Quality Manager (E #3) was conducted. E #3 stated that the hospital did not have a process for evaluating contracted services nor were the contracted services reviewed during the hospital’s QAPI meetings.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 27125 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services. Findings include: 1. The hospital failed to ensure incidents of elopement of behavioral health patients from the Emergency Department (ED) were reviewed to analyze the effectiveness and/or need for revision of policies/procedures. (See A-1104 A) 2. The hospital failed to ensure processes were in place and evaluated for the monitoring of patients in the ED waiting room, during an extended wait time. (see A-1104 B)”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 1 (Pt #3) clinical record reviewed for sexual abuse allegation, the hospital failed to remove the accused staff member from patient care immediately following allegations of abuse to protect patients during an investigation of alleged sexual abuse. Findings include: 1. On 11/1/2023, the Hospital’s “2023 Orientation Reference Guide” (dated 2023) were reviewed and indicated, ... “Free from All Forms of Abuse & Harassment - Components of effective protections -prevent ...screen ...identify ...train ...protect: during investigation of any allegation of abuse or neglect or harassment, the patient must be protected. Investigate: investigations should be timely, thorough, and objective ...Report: all events are reported and analyzed, and the appropriate corrective, remedial or disciplinary action has been taken in accordance with local, state or federal law.” 2. On 11/1/2023, the Hospital’s policy “Discipline and Termination of Employment” (dated 7/2022) was reviewed and indicated, “Suspensions - Investigative Suspensions -An investigative suspension may be necessary based on the circumstances ...” 3. On 11/1/2023, the Hospital Bylaws (dated 7/2022) was reviewed and indicated: “Routine Corrective Action - Criteria for Initiation - Whenever activities, omissions, or professional conduct of a Practitioner with clinical privileges are detrimental to patient safety, to the delivery of quality of patient care, are disruptive, undermine a culture of safety or interfere with Hospital operations ...corrective action against such Practitioner may be initiated ...” 4. On 11/1/2023, Pt #3’s clinical record (dated 10/24/2023 thru 10/27/2023) was reviewed and indicated: -Pt #3’s ED documentation dated 10/24/2023 noted “Pt #3 presents to ED with complaint of left shoulder, chest, flank pain after 1 week ago from moving something. Pt #3 complains of 10 out of 10 sharp pain ... Medication administration -Dilaudid (pain medication) 0.5 mg, IV push and Valium (sedative medication) 10 mg oral ...” Pt #3 admitted to 2nd floor Medical/Surgical unit under the care of Hospitalist (MD #1). -MD #1’s history & physical dated 10/24/2023 noted, “Pt #3 developed multiple bouts of sharp shooting pain to the posterior aspect of the neck radiating to the left shoulder and causing significant amount of discomfort ...Pt #3 will be admitted for further evaluation and treatment with neurological consult ...” -Discharge Documentation dated 10/27/2023 at 3:15 PM noted, “Admission diagnosis - Severe shooting neck pain. Discharge Diagnoses -Severe shooting neck due to cervical radiculopathy (a disease of the root of the nerve) improved ...Disposition - Discharge the patient home. Discharge instructions - Follow up with Neurosurgery in 1 month. Hospital course -Pt #3 came with severe multiple bouts of sharp shooting pain of the left posterior and lateral neck. Due to the severity of the symptoms, we admitted Pt #3 to Med/Surg floor, started her on IV Dilaudid and IV Ativan (antianxiety medication). We obtained Neurology consult followed by CT C-spine myelogram (diagnostic imaging test), CT left shoulder with contrast, which basically showed some degenerative changes of the C-spine per Neurosurgery. Pt #3’s neurological exam was grossly unremarkable. No neurological intervention at this time ...Pt #3 will be discharged home with appropriate follow-up by Neurosurgery with some improvement of her symptoms ...” -Pt #3’s record did not include any documentation of Pt #3 reporting any allegations of abuse to staff. 5. On 11/1/2023, the Hospital’s investigation report (dated 10/30/2023 thru 11/1/2023) indicated: “-10/30/2023 at 2:30 PM - Received patient complaint alleging sexual misconduct by a staff member during hospitalization. Event occurred on 2W on the 27th of October prior to discharge. -Event was reported to an outpatient scheduler when Pt #3 called to schedule an outpatient MRI [on 10/30/2023]. Pt #3 informed the scheduler that she was awakened with a thumb in her mouth and two (2) fingers in her vagina by a tall brown man with short dark hair on the day of discharge. The scheduler informed the caller she would report and someone will be calling her. -10/30/2023 at 4:00 PM - E #3 placed call to the patient to discuss the event. Spoke with patient approximately thirty (30) minutes. Pt #3 told E #3 the following, I was violated twice. The first time was on Wednesday (10/25) when I awoke with a man’s hand down in my panties and his fingers in my vagina. I asked [What are you doing?] He responded “no worries.” -Pt #3 described the alleged perpetrator as being tall dark skinned (not African American) male with short dark hair, box hair style. -Pt #3 stated Pt #3 saw him three (3) times while in the Hospital and he wore nice suits each time. -Pt #3 stated there were no witnesses but a nurse came into my room with discharge papers while he was still in my room on day of discharge. -Pt #3 stated that when Pt #3 got home, Pt #3 googled the name of the doctor who gave Pt #3 discharge medications and the picture on line looked like the man who violated me. Pt #3 spelled MD #1’s name. -10/30/2023 at 4:30 PM - E #3 called the number to report sexual abuse in IL per Google search 877-236-7703. -Notified CEO (E #7) of allegation. -10/31/2023 - E #3 received call from the IL Dept of Human Rights, caller stated that the report made on 10/30 needed to be made somewhere else that they did not handle sexual abuse cases only sexual harassment and discrimination ...11:15 AM - IDPH surveyor provided an email dph.hospitalreports.illinois.gov to submit a summary of the event on letterhead paper ... -Notified chief of medical staff and medical director of the hospitalist of allegation -10/31/2023 - Physician interview - Discussed the allegation with Pt #3. Explained to MD #1 that based on the seriousness of the allegation, we would not be able to let MD #1 continue to see patients until an investigation was completed and a decision was made as to whether allegation was substantiated or not. MD#1 denied any touching of Pt #3 except in the neck and shoulder area ...Interviews were conducted E#5 (Registered Nurse on 2nd floor) and E #6 (Patient Advocate). Each interview (E #5 and E #6) noted that staff members did not receive any complaints of abuse from Pt #3 or witness any abuse. 6. On 11/1/2023, the Hospital’s suspension letter to MD #1, dated 10/30/2023 (per interview with E #3/Chief Quality Officer, date letter drafted), was reviewed and indicated, “A complaint has been submitted to the Quality Department which alleges sexual misconduct toward a female patient under your care. Because of seriousness of the accusation, we will be suspending you until the investigation is concluded and the determination made whether the allegation is substantiated or not substantiated.” 7. On 11/1/2023 at 9:00 AM, an interview was conducted with the Chief Quality Officer (E #3). E #3 stated that a complaint regarding Pt #3 came on 10/30/2023 at 9:30 AM. E #3 stated that the complaint came through the Hospital Registration for outpatient testing. E #3 stated that Pt #1 was scheduling an outpatient MRI on 10/30/2023 via telephone. Pt #3 told the Hospital scheduler that on the day of discharge (10/27/2023), Pt #3 had been violated. E #3 stated that Pt #3 told the scheduler that the man who violated Pt #3 was brown in color (not African American). E #3 stated that Pt #3 told the scheduler that while Pt #3 was in the Hospital, the man put his finger in her mouth and private area. E #3 stated that the scheduler told Pt #3 that the scheduler would report this incident to her supervisor immediately. E #3 stated that E #3 found out about this incident from the CFO on 10/30/2023 at 2:30 PM. E #3 stated that she (E #3) called Pt #3 at 3:30 PM on 10/30/2023. E #3 stated that Pt #3 told E #3 that a tall, dark skin male (not African American) woke Pt #3 up the day of discharge with his thumb in her mouth and 2 fingers in her vagina. E #3 stated that Pt #3 told her that the man violated Pt #3 one other time. E #3 stated that E #3 asked Pt #3 how she responded. E #3 stated that Pt #3 asked the man what he was doing. E #3 stated that Pt #3 stated that Pt #3 did not mention this to anyone while Pt #3 was in the hospital. E #3 stated that E #3 reported the incident to the State on 10/30/2023. E #3 stated that she thought that MD #1 was not the Hospitalist on duty the week of the 30th, so would not be in the hospital seeing patients. E #3 found out on 10/31/2023 that MD #1 was on duty on 10/31/2023 and had already done rounds on patients that morning. E #3 stated that she talked to MD #1 on 10/31/2023 around 10:00 AM. E #3 stated that MD #1 was verbally told that he could not work or be at the hospital until investigation was complete on 10/31/2023, but a letter of suspension was not provided or sent to MD #1 at that time. E #3 stated that MD #1 should have been suspended immediately. E #3 stated MD #1 told her that he did not sexually abuse Pt #3. E #3 stated that MD #1 stated, “You’re kidding me.” E #3 stated that she had drafted the suspension letter for MD #1 on 10/30/2023; spoke to MD #1 on 10/31/2023; and would be mailing the suspension letter today (11/1/2023). On 11/2/2023 at 2:20 PM, an additional interview was conducted with E #3. E #3 stated that she asked the administrative assistant to mail the letter on 11/1/2023, but the administrative assistant did not mail it on 11/1/2023. E #3 mailed the suspension letter this morning 11/2/2023 to MD #1. On 11/6/2023 at 9:00 AM, E #3 stated that the investigation was over, and the findings were unsubstantiated. E #3 stated that MD #1 was not back at work yet. 8. On 11/1/2023 at 2:30 PM, an interview was conducted with MD #1. MD #1 stated that MD #1 admitted Pt #3 to a medical/surgical unit for pain control and imaging. MD #1 stated that Pt #3 had severe pain on left side of neck and shoulder. MD #1 stated that imaging was done, and the imaging noted that there was no serious damage to neck or shoulders. MD #1 stated that Pt #3’s pain improved. MD #1 stated that he did the discharge instructions for Pt #3. MD #1 stated that Pt #3 wanted MD #1 to be her primary doctor. MD #1 stated that he explained to Pt #3 that he was a Hospitalist and does not follow patients after discharge. MD #1 stated that his relationship was “purely professional.” MD #1 stated that Pt #3 was awake and alert and oriented each time he saw Pt #3 and stated that he does patient rounds around 2:00 PM each day. MD #1 stated that he did not put his finger in Pt #3’s mouth and did not place his fingers in Pt #3’s vagina. MD #1 stated that he was verbally informed yesterday by the Chief Quality Officer (E #3) that he was suspended until the investigation was completed. MD #1 stated that MD #1 had already made rounds on patients yesterday on 10/31/2023 prior to being informed that he was suspended. MD #1 stated that he has worked at the Hospital for 20 years and has received abuse training. 9. On 11/1/2023 at 3:00 PM, an interview was conducted with the CEO (E #7). E #7 stated that E #7 was informed about the sexual abuse allegation against MD #1 on 10/30/2023. E #7 stated that MD #1 was suspended on 10/31/2023. E #7 stated that MD #1 did rounds in the Hospital on 10/31/2023 prior to notification of his suspension due to a scheduling oversight. E #7 stated that MD #1 should have been suspended immediately following the notification of the allegation of sexual abuse. E #7 stated that not suspending MD #1 immediately was a hospital error.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 27125 A. Based on document review and interview, it was determined that for 3 of 3 (Pt. #4, Pt. #6 and Pt. #7) behavioral health patients presenting to the ED who eloped, the hospital failed to ensure incidents of elopement of behavioral health patients from the Emergency Department (ED) were reviewed to analyze the effectiveness and/or need for revision of policies and procedures. Findings include: 1. The ED quality meeting minutes for 2023 were reviewed on 11/2/2023. The quality indicators reported each quarter with a plan included barcoding of medication and left without being seen statistics. The other indicators tracked for data only included left against medical advice, eloped, door to doctor wait times, admit wait times and EMS calls. However, the data had not been analyzed for trends or effectiveness of ED policies and procedures. 2. The ED elopement log from May 2023 to present was reviewed on 11/1/2023. Three patients with a behavioral health diagnosis were identified on the log (Pt. #4, Pt. #6, and Pt. #7), and these records were reviewed. 3. On 11/1/2023, the ED record for Pt #4 was reviewed and included: -The Triage note, dated 6/30/2023 at 12:32 AM, included, “Pt brought by EMS (emergency medical services) with a manic episode. On arrival pt is uncooperative.” -The ED Nurse Practitioner ’ s note, dated 6/30/2023 at 12:21 AM, included, “[Pt] with a history of bipolar, depression, presents to the emergency department with aggressive behavior towards her mother. Patient brought in by EMS, accompanied by her significant other ... Upon arrival to ED patient was verbally aggressive and threatening towards staff and security. Patient was yelling at myself, and was not forthcoming with history. Patient requiring chemical and physical restraints due to threatening behavior. Patient denies suicidal and homicidal ideations.” Nurses notes included: -6/30/2023 at 9:10 AM, “Called SASS [Screening, Assessment Support Services - provides assessment of children and adolescent mental health patients] to inquire about follow up with pt regarding when an evaluator would be coming to ED since pt is refusing to speak to them over the phone ...” -6/30/2023 at 10:01 AM, “ ... SASS present in ED now. Petition and Certificate filled out.” -6/30/2023 at 1:45 PM, “Pt accepted at Riveredge Hospital in Forest Park, accepted by [psychiatrist ’ s name].” -6/30/2023 at 2:50 PM, “Pt updated by Provider that she is being transferred to [behavioral health hospital in another suburb]. Pt became very upset and yelling that she does not want to go to [behavioral health hospital in another suburb] and that she wants to go to [different behavioral health hospital]. Pt then threatened the sitter, saying she was going to punch her in the face when she tried to stop her from eloping. Security and PA [physician ’ s assistant] attempted to stop pt but she ran out onto [Name of road next to hospital]. Pt obtained a red sweatshirt from somebody in the waiting room. Security called [local] PD.” 4. On 11/1/2023, the clinical record for Pt. #6 was reviewed. Pt. #6 was brought by an ambulance to the hospital’s ED on 6/17/2023 at 3:55 PM, and the record included the following: - The triage nurses note, dated 6/17/2023 at 4:39 PM included, “Chief Complaint: [Nursing Home] would like a psychiatric evaluation for erratic behavior.” Sitter placed at bedside. - The ED physician note, dated 6/17/2023 at 9:01 PM included, “Discharge patient [back to nursing home]. - The discharge information included, “Disposition: eloped”. No other information was included, i.e. witnessed, when. 5. On 11/1/2023, the clinical record for Pt #7 was reviewed. Pt #7 was brought by police to the hospital ’ s ED on 6/8/2023 at 11:43PM, and the record included the following: -The Triage Nurse ’ s note, dated 6/8/2023 at 11:53 PM, included, “Chief Complaint: Patient pulled over by police and told police he tried to kill himself by hanging.” -The CSSRS (Columbia Suicide Severity Rating Scale), completed on 6/9/2023 at 1:15 AM, indicated, “Level of Suicide Risk: High risk.” Nurse ’ s notes included: -6/9/2023 at 1:55 AM, “Pt was on the phone and saw both doors to the lobby open and ran through the open door out the main ED entrance. He ran through the parking lot east on Glen Flora and got in a vehicle and drove away.” -6/9/2023 at 1:58 AM, “PD [police department] was contacted and asked to try [to] locate [Pt #7]. The PD checked the pt address ... and was unable to locate the pt.” -6/9/2023 at 2:20 AM, “Pt has not been located [by PD]” The ED record included that Pt #7 ’ s elopement was witnessed, however, did not include any documentation of attempts to prevent the patient from eloping by the sitter; sitter reporting that Pt #7 had left the patient room; or notification to security to assist is preventing the patient from eloping. 6. The Director of the ED (E#8) was interviewed on 11/2/2023 at 3:30 PM. E#8 stated that elopement data has been collected but has not been analyzed. The above cases have not been reviewed for the events that occurred or for process improvement. E #8 stated that there is no policy/procedure related to elopement available. E #8 stated, “Our Director of Security just started approximately 3 weeks ago. I have had one meeting with the Director of Security to look at what can be done with security coverage to assist the ED staff a little more.” E#8 stated that other than the meeting with security, nothing has been done to evaluate/improve the process to prevent elopements. 7. The Chief Quality Officer (E#3) was interviewed on 11/2/2023 at 10:00 AM. E#3 stated that the number of patient elopements should be zero. Especially for psychiatric patients. E#3 stated, “The ED has not included elopements in their monitoring or action plans.” E #3 stated that there has been no investigation or analysis of the behavioral health patients’ elopements. B. Based on document review and interview, it was determined that 1 of 1 patients (Pt. #1) waiting in the emergency department (ED) for an extended wait time, the hospital failed to ensure a process was in place for the monitoring of patients while in the waiting room between triage and admission to the ED. Findings include: 1. The Hospital policy titled, “Assessment and Reassessment of the Patient in the ED (4/2021)” was reviewed on 10/31/2023 and required, “ED patients are reassessed at intervals based on patient condition, response to intervention, diagnostic testing results, any change in condition, and at least at the following intervals: a) upon triage/arrival, b) on admission to the ED ...” The policy did not include frequency of monitoring/assessment of patients while in the waiting room between triage and admission to the ED. 2. The clinical record of Pt. #1 was reviewed on 10/31/2023. Pt. #1 arrived at the ED on 9/12/2023 at 2:44 PM via ground ambulance. The triage note (E#2), dated 9/12/2023 at 2:55 PM included, “Chief complaint: Patient [Pt. #1] arrived via EMS [emergency medical services] for Foley catheter leaking for 2 days.” Vital signs were blood pressure 110/69, temperature 98.1 degrees, pulse 70 and respirations 18 on room air. Repeat vital signs at 9:05 PM were blood pressure 104/69, pulse 76, respirations 20. The clinical record did not include monitoring in the waiting room from arrival time of 2:55 PM until 9:05 PM (6 hours/10 minutes later). 3. The ED quality meeting minutes for 2023 were reviewed on 11/2/2023. The quality indicators reported each quarter with a plan included barcoding of medication and left without being seen statistics. The other indicators tracked for data only included left against medical advice, eloped, door to doctor wait times, admit wait times and EMS calls. However, the data did not include monitoring of patients in the waiting room, and collected data had not been analyzed for trends or effectiveness of ED policies and procedures. 4. The ED staff huddle minutes dated September and October were reviewed on 11/2/2023 and included that the goal is to get patients into the ED within 30 minutes. “This might not always be possible, when there are longer wait times, we must monitor these patients for any change in status. Patients need to be kept current on wait times, so round frequently.” 5. The charge nurse (E#1), who worked the night shift 7:00 PM - 7:00 AM on 9/12/2023, was interviewed on 11/1/2023 at 7:30 AM. E#1 was unaware of any policy related to required monitoring in the ED. E#1 stated, “I would think vital signs should be taken every 2 hours while waiting to ensure there has been no change in the patients’ condition.” 6. The Director of the ED (E#8) was interviewed on 11/1/2023 at approximately 1:45 PM. E#8 stated that a lot of work has been done to decrease wait times. E#8 stated that staff had been educated on faster ED throughput [the time from patient arrival to time of discharge]. Patients in the waiting room are to be rounded on to see if they need anything and let them know about wait times [not hard wired yet - no documentation]. E #8 stated that there is not a policy on rounding on patients in the waiting room.”