Ingalls Memorial Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. 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: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 39802 Based on document review, video review, and interview, for 1 of 5 sitters (Nurse E#13) for behavioral health patients, the Hospital failed to ensure that all staff had current training in techniques to identify and address patient behaviors that may require the use of restraint or seclusion, in accordance with hospital requirements. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion” (dated 01/15/2023), was reviewed and required, “...Appendix A: Education and Data Collection and Reporting: ... 2. All staff who have direct patient contact must have ongoing education and training in... techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of Restraints or Seclusion... At a minimum, those healthcare providers identified in Section 2 above will be trained and will demonstrate knowledge based on the specific needs of the patient population, but all training will include at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a Restraint or Seclusion. (ii) The use of non-physical intervention skills. (iii) Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical or behavioral status or condition...” 2. The clinical record of Pt. #1 was reviewed on 04/30/2026. Pt. #1 presented by ambulance to the Hospital’s emergency room (ED) on 03/16/2026 at 9:45 PM with a chief complaint of psychiatric evaluation. The record include a Petition for Involuntary/Judicial Inpatient Admission, dated 03/16/2026 at 2:47 PM, that indicated that Pt. #1 had a history of elopement. The record indicated that Pt. #1 was placed on a hallway bed near the desk by the designated psychiatric rooms in the southeast corner of the ED. Orders for 1:1 Observation were placed on 03/16/2026 at 10:23 PM and a sitter was put in place at the time of the order. The Assessment & Referral, dated 03/17/2026 at 2:01 PM, included “Presenting Problems: Pt arrived at ED via ambulance from home. Pt appears to be guarded and a poor historian. Pt presents with bizarre and erratic behavior. Pt denies mental health current mental health concerns. Pt states that he had been hospitalized, “years ago.” Pt appears to be alert and oriented times 3. Pt presents with poor judgment and poor insight. Pt appears to be highly impulsive and highly unpredictable... Pt’s mother completed a petition through the court due to concerns of AH, erratic behavior, paranoia, and suicidal and homicidal thoughts. Per reports pt had been urinating and defecating in buckets in his basement room and refuses to dispose of it ... Precipitating events: Pt denies any mental health concerns. Per reports, pt complained of AH [auditory hallucinations] and was observed yelling at the voices. Per reports pt endorsed VH [visual hallucinations] seeing angels. Reportedly, make comments that pt is the son of Satan. Reportedly pt recently pt was shown a handgun and pt commented that pt needed a gun because of pt’s enemies. Per reports, pt went on to add that pt must get pt’s enemies before they get pt. Reportedly, pt endorses SI and stated that pt should have killed self a long time ago. Per reports pt endorsed SI due to the intensity of the voices .... Level of Care Recommendation: Inpatient Behavioral Health.” ED Nurse (E#10) Note, dated 03/17/2026 at 2:58 PM included “Patient to bathroom with sitter then patient bolted running out of bay area. Staff and security followed patient.” Nurse/Sitter (E#14) Note, dated 03/17/2026 at 3:00 PM included “Patient was standing for past 15 minutes while continuing to look around. Requested to go to the bathroom which I agreed to go with [Pt. #1]. Patient then attempted to go through locked double doors but ran back past me since they were locked. Patient ran to the EMS ambulance bay then ran out of the doors there. Security and staff has been alerted and are searching for patient for elopement.” 3. The Job Descriptions of Patient Safety Attendants and all ED Nurses and Technicians required certification in CPI/Crisis Prevention Institute (training to identify, prevent, and de-escalate crises which may include verbal de-escalation; recognizing and responding to crisis situations; and physical interventions for both non-violent and violent behaviors). 4. The personnel file of Nurse/Sitter (E#13) was reviewed on 05/05/2026 and lacked training in CPI or on sitter/patient safety attendant responsibilites. 5. The Sitter Education In-Service (effective 12/09/2025) was reviewed and lacked acknowledgement by E#13 that E#13 received education on the standards of work and expectations for sitters. 6. Patient Safety Attendant/PSA Education materials (dated 04/2023) that are required for all ED staff and PSAs was reviewed on 05/05/2026 and included, “ ...While always providing direct visualization, the safety attendant should also: Monitor for changes in their mental status (i.e. more depressed, manic, increase in hallucinations) and report these to the primary RN. These changes may or may not be self-reported by the patient. Verbally engage with the patient when appropriate ...” 7. Quality Safety Committee Meeting Minutes from January (28th) 2026-March (25th) 2026, were reviewed and indicated that the Hospital has been tracking CPI training completion for ED, Security, and BH staff with a notation that staff not trained in CPI are not to be assigned to 1:1 cases. The tracking did not include staff that float to the ED. 8. Video of the ED on 03/17/2026 was reviewed with the Director of Public Safety (E#19) on 04/30/2026 as follows: - At approximately 2:40 PM - Pt. #1 is sitting on the ED cart/bed at the corner of the nurses station by the psych designated rooms at the southeast corner of the ED. The sitter (Nurse E#13) is present sitting behind the patient’s cart (at head of the bed), behind a work station on wheels, approximately 7 feet away. - 2:44:49 PM - Pt. #1 is standing at the foot of the cart (opposite end of where E#13 is sitting) and is facing away from E#13, toward the direction of where the ambulance bay doors are (northwest). For nearly 10 minutes, Pt. #1 continues to stand and look around the ED during this time, turning Pt. #1’s head back and forth. E#13 remains sitting behind Pt. #1 approximately 7 feet away without a direct view of Pt. #1’s face. - 2:53:20 PM - Pt. #1 walks toward the bathroom with E#13 following behind while Public Safety Officer (E#9) enters the ED and tries to approach Pt. #1 from the front. - 2:53:39 PM - Pt. #1 then tries to push through locked doors by the bathroom (per interview) and then runs past E#9 and elopes out of the ambulance bay doors. 9. An interview was conducted with the Public Safety Officer/PSO (E#9) on 04/30/2026, at approximately 2:00 PM. E#9 stated that during the change of shift debriefing, they were told that Pt. #1 was a “runner” or elopement risks. E#9 stated that it wasn’t until closer to 3:00 PM that Pt. #1 eloped. E#9 stated that E#9 was just coming back into the main ED area from the waiting area (northwest corner close to the ambulance bay doors) when E#9 locked eyes on Pt. #1 as Pt. #1 was walking towards the bathrooms at the northeast corner of the main ED, away from the designated psych area at the southeast corner. E#9 stated that E#9 was not sure why the patient was going to the farther bathroom from Pt. #1’s bed and stated that the sitter was following behind the patient. E#9 stated that after locking eyes with the patient, E#9 walked towards the bathroom to intercept the patient and then Pt. #1 then tried to run towards the double doors near the bathrooms that lead to the imaging area, then ran past E#9 and out of the ambulance bay doors. E#9 stated that the patient knew to push the button to open the door. E#9 stated that some signs that a patient might be trying to elope is a change in behavior such as getting antsy, getting up, looking around trying to find a way out or asking a lot of questions. E#9 stated that if E#9 notices those behaviors, E#9 would try to redirect the patient and possibly notify dispatch that they might need backup in case. E#9 stated that they were not notified by nursing staff of any escalating or concerning behaviors for Pt. #1. 10. An interview was conducted with the Nurse/Sitter (E#13) on 05/04/2026 at approximately 11:00 AM. E#13 stated that E#13 is an agency nurse that typically works on the medical-surgical unit and that on the day E#13 was sitting for Pt. #1, and that was the first time E#13 had worked in the ED. E#13 stated that they (ED staff) didn’t tell E#13 too much about the patient. E#13 stated that a security guard in passing did tell E#13 to be careful because Pt. #1 was a runner. E#13 stated that Pt. #1 asked to use the bathroom for a third time and E#13 followed the patient to the bathroom. E#13 stated that suddenly the patient started to run and then tried to push past the locked double doors. E#13 stated that when the patient couldn’t get through, the patient ran past E#13 and then out the ambulance bay doors. E#13 stated that for most of the time, Pt. #1 had been cooperative besides the few requests to use the bathroom. E#13 stated that in the last 15 minutes, Pt. #1 did start getting restless and was looking around. E#13 stated that the patient stated that they wanted to stand for a while to stretch which seemed reasonable at the time. E#13 stated that E#13 has not received any specific training on how to work with behavioral health patients in terms of what behaviors to look for. E#13 stated, “Normally I’m not a sitter and they didn’t give me any training on it besides to observe them every 15 minutes.” 11. An interview was conducted with the ED Manager (E#2) on 05/04/2026, at approximately 1:00 PM. E#2 stated in December 2025, they started mandatory training for staff that sit for patients in the ED. E#2 stated that all ED staff and float sitters are required to sign off an acknowledge that they have received training on the standard of work/expectations of the sitter as well as the SBAR (situation, background, assessment, recommendation) hand-off process. E#2 stated that all ED staff are required to have CPI/de-escalation training as well. E#2 stated that E#2 is not sure if float staff are required to have CPI; however, stated that they should have it if they need to work with behavioral health patients. E#2 stated that if they need a sitter, they will call the staffing office who will find a sitter through the float pool and send them to the ED. E#2 stated that they do have a very psych heavy population and do have quite a few patients that have need for a sitter to ensure patient safety. 12. An interview was conducted with the Manager of the Staffing Resource Office (E#16) on 05/04/2026, at approximately 3:15 PM. E#16 stated that their office is available to reach 24/7 (24 hours a day/7 days a week) for units/departments that need to request additional staff. E#16 stated that they first look at who is present in-house to see where they can pull from. E#16 stated that at this time they do not have any information on which staff have CPI or training to work with behavioral health patients and will just pull whoever is available.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34411 Based on document review, obsrevation, video review and interview, the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights. Findings include: 1. The Hospital failed to maintain ordered safety precautions, to ensure that appropriate monitoring was in place for patients who required a 1:1 sitter. See deficiency at A-144. 2. The Hospital failed to remove a staff member from direct patient care, following notification of an abuse allegation and pending investigation. See deficiency at A-145 A. 3. The Hospital failed to ensure that an allegation of abuse was addressed and investigated. See deficiency at A-145 B.”

“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: 34411 Based on document review, observation, video review, and interview, for 4 of 7 (Pt #9, #10, Pt #13, and Pt #15), patients reviewed for precautions, the Hospital failed to maintain ordered safety precautions, to ensure that appropriate monitoring was in place for patients who required a 1:1 observation, in accordance with hospital policy. Findings include: 1. The Hospital’s policy titled, “Precautions and Observations” (dated 9/3/25) was reviewed, and required, “A patient assessed to be at risk to self or others will be identified as needing special observation and assessment as a precaution against acting on the risky behavior. This is called being placed on precautions ...A patient may be placed on a precaution for assault, elopement, suicide, sexual acting out, arson, seizures, fall, or other identified risk ...Precautions will be assigned a level of observation that corresponds with the risk associated with the behavior. This will ensure that adequate monitoring and assessment occurs. There are three levels of observation: q15 minutes [every], Line of Sight (LOS) and one to one (1:1). Procedure: The physician will order one of three levels of observation at time of admission and as the patient’s condition warrants a change ...One to One (1:1). The physician will order a specific precaution for: suicide ...elopement ...other specified risk factors... A specified and dedicated staff member will stay within approximately one arm’s length of the patient” 2. The Hospital’s policy titled, “Suicide/Homicide/Safety Precautions/Video Monitoring” (dated 7/17/2024), “ ...Definitions: Suicide/Homicide Ideations Precautions: Measures that are implemented for patients assessed as being potentially harmful to him/her-self or others ...Petition: A document that is signed when an involuntary admission for immediate hospitalization is necessary for the protection of such persons or others from physical harm. Certification: A document filed by a qualified examiner that allows for continued hospitalization against a person’s will ...Non-behavioral health units: All patients with an active petition and/or certification are placed on 1:1 observation. The patient will remain on 1:1 observation until the patient no longer requires a petition and/or certificate for admission or until the patient is transferred/discharged ...” 3. On 10/28/2025 at 12:05 PM, an observational tour of the ED was conducted. During the tour, it was noted that 2 patients (Pt #9, Pt #10) who presented with behavioral health complaints, and were assigned a 1:1 Patient Safety Companion (E #11). Pt #9 was in Room 12 and Pt #10 was on a hallway cart. E #11 was stationed in the hallway outside of Room 12. E #11 was not within arm’s length of Pt #9 and was unable to visualize Pt #10 on the hallway cart from where E #11 was sitting (blocked by the height of the nurse’s station desk). E #11 stated that E #11 was assigned to sit for both Pt #9 and Pt #10 (this negated the required 1:1 order). E #11 acknowledged that E #11 was not able to physically see Pt #10 (on the hallway cart) unless E #11 stands up to see the patient. E #11 stated that E #11 stands up every 15 minutes to check on Pt #10. 4. The clinical records for Pt #9 and Pt #10 were reviewed on 10/29/2025 and included orders for 1:1 monitoring, as follows: - Pt #9 presented to the ED on 10/27/2025 at 7:48 PM, for a mental health evaluation. The Columbia Suicide Screening (suicide risk assessment) was completed on 10/27/2025 at 8:10 PM and indicated that Pt #9 was assessed as a high suicide risk. 1:1 observation order for suicide precautions was placed on 10/27/2025 at 8:29 PM. - Pt #10 presented to the ED on 10/28/2025 at 10:32 AM, for a psychiatric evaluation. The Columbia Suicide Screening was completed on 10/28/2025 at 10:53 AM and indicated that Pt #10 was assessed as a high suicide risk. 1:1 observation order for suicide precautions, was placed on 10/28/2025 at 10:53 AM. 5. On 10/29/2025 at 10:25 AM, a video surveillance review of the video footage from the ED between 9/26/2025 at 5:00 PM - 9/27/2025 at 7:00 AM was conducted with the Security Director (E #16). During the video review, two psychiatric patients (Pt #13 and Pt #15) were present in the ED. Between 9/26/2025 at 5:00 PM and 11:00 PM, there was one sitter who was monitoring both Pt #13 and Pt #15 (this negated the required 1:1 order). There were times when the sitter was not present/observing patients or was intermittently walking throughout the ED doing other tasks. When the sitter was present, the sitter was not within arm’s length of Pt #13 or Pt #15. On the night shift (11 PM 9/26/2025 -7 AM 9/27/2025), there was no sitter seen on video/on duty while the 2 patients remained in the ED. 6. The clinical records for Pt #13 and Pt #15 were reviewed on 10/30/2025 and included 1:1 observation orders, as follows: - Pt #13 presented to the ED on 9/22/2025 at 9:45 AM, for a psychiatric evaluation. A 1:1 observation order was placed for suicide precautions on 9/22/2025 at 8:24 PM. The comments under the order include, “Patients with suicidal ideations or intentions require 1:1 continuous monitoring by a qualified person who will implement direct, constant visual observation of the patient at ALL times.” - Pt #15 presented to the ED on 9/16/2025, from a group home and found wandering down the street without shoes or clothes. ED Course timeline indicated that patient was boarded in the ED pending placing to a skilled nursing facility. ED Provider note by the Attending Physician (dated 10/9/2025), indicated that patient with a diagnosis of autism and schizoaffective disorder. 1:1 sitter observation was RN initiated on 9/17/2025. 7. On 10/29/2025 at approximately 3:15 PM, an interview was conducted with the ED Director (E #15). E #15 stated that if patient is either assessed as high risk for suicide or homicide; has been petitioned and certified (involuntary admission); a high elopement risk; or is developmental delayed, they are required to have a 1:1 sitter. E #15 stated that regarding Pt #15 (in the ED on 9/26/2025/observed during video review), Pt #15 was developmentally delayed with no guardian at the time. E #15 stated that the nurses initiated a 1:1 sitter for Pt #15 since Pt #15 wandered a lot and was a high risk for elopement. E #15 stated that if a patient has an order for a 1:1 sitter/patient care companion or has a nurse-initiated 1:1 sitter in place, then the sitter should have direct visualization and always be within arm’s length of the patient. E #15 acknowledged that during the ED tour (on 10/28/2025) and during the ED video review (of 9/26-9/27/2025), there were times when the assigned sitters were not present; did not have direct visualization of the patients; and one sitter was assigned to 1:1 observation for more than one patient.”

“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: 39802 A. Based on document review and interview, for 1 of 6 staff-to-patient (Pt. #5) allegations of abuse at the Hospital reviewed, the Hospital failed to ensure that the suspected violator was removed from further contact with any patient or patients during the review process/investigation, in accordance with hospital policy. Findings include: 1. The Hospital’s policy titled, “Patient Protection from Abuse” (dated 11/2024), was reviewed and required, “ ...Patients will be protected form abuse in the hospital ... Upon receiving a report, the Risk Management Department will ensure the alleged victim’s safety. Measures to protect the alleged victim, as deemed necessary, should be taken immediately ... A rapid investigation will be conducted by a member of the Risk Management Department ... a determination of reasonable cause, allegation substantiation, and appropriate measures to take to protect the alleged victim (e.g. removing suspected violator(s) from further patient contact during the review process, assurance the suspected violator(s) is not left alone with any patient or patients during the review process, temporary relief of duties that require patient interactions or contact during the review process, etc.) will be made ...” 2. The clinical record of Pt. #5 was reviewed on 10/28/2025. Pt. #5 presented to the Hospital’s emergency department (ED) on 06/20/2025 at 3:20 AM with a chief complaint of abdominal pain. A nurse’s note, dated 06/20/2025 at 4:00 AM, included “Pt [Pt. #5] placed on cardiac, bp [blood pressure] and spO2 [oxygen saturation] by ED tech. Pt reports to this RN [registered nurse] that ED tech [identified as E#14] was being inappropriate during application of equipment. This RN was present the entire time tech was present in pt’s room. Tech never returned to pt’s room after applying appropriate monitoring...” A physician’s note, dated 06/20/2025 at 4:55 AM included, “Pt later states that staff member was ‘kissing and licking me’ while placing telemetry stickers on [Pt. #5’s] lower legs. Pt admits [Pt. #5’s] eyes were closed and [Pt. #5] was ‘zoned out a little’ during the incident...” Pt. #5’s disposition was set to left before treatment on 06/20/2025 at 5:10 AM. 3. The Hospital’s final abuse allegation report for Pt. #5, dated 07/17/2025, included “...Patient alleged an Emergency Room Care Technician exhibited inappropriate behavior during an EKG [heart rhythm monitoring]... Risk Management/Patient Safety, Emergency Department Leadership, and the Hospital Operation Administrator (HOA) were notified of the allegation. The care technician was re-assigned to a different location of the emergency department. Staff was interviewed... Based upon our review and investigation of this incident, there was no reasonable cause to suspect abuse of this patient occurred...” 4. E#14’s timesheets from 06/19/2025-07/17/2025 were reviewed and indicated that E#14 worked the remainder of the shift on 06/20/2025 until 7:27 AM and worked again the next evening on 06/20/2025 from 7:01 PM to 06/21/2025 at 7:25 AM. 5. On 10/29/2025 at 9:45 AM, a phone interview was conducted with an ED Technician (E #14). E#14 stated that there was a allegation of abuse where the patient stated (E #14) touched the patient inappropriately. E#14 stated that the nurse who was present vouched for E#14 and stated that the patient’s son then came in and was causing a problem and they (patient and patient’s son) were then escorted out. E#14 stated that E#14 worked the rest of the shift as usual that evening and has never been taken off duty pending an abuse allegation. E #14 stated that if there is an allegation against a staff member, the staff member should be taken off work during the investigation. 6. An interview was conducted with the ED Director (E#15) on 10/30/2025 at 9:45 AM. E#15 stated that if staff receive an allegation of abuse or suspect abuse of a patient, they should notify the charge nurse immediately who will then notify the unit manager and an event report is filed right away. E#15 stated that in cases of abuse, besides filing the event report, they will call the Risk Department representative on-call to initiate the investigation right away. E#15 stated that if the staff member is caring for that patient at the time of the report/allegation of abuse, the staff member will be removed immediately from the patient and sent home. E#15 stated that the manager of the unit/department in addition to HR will then talk to all the people on shift and get statements. E#15 stated that the Security Director is usually notified as well to start reviewing video. E#15 stated that the staff member will be suspended off the schedule until the investigation is completed. E#15 stated that in the case of Pt. #5, E#15 stated that E#14’s shift was already over by the time E#15 was notified and they started to review video of the incident. E#15 stated that the video showed that E#14 was never alone in the room with Pt. #5 and matched the statements given by E#14 and the assigned nurse. E#15 stated that they reviewed the video the morning of 06/20/2025 and could not substantiate the allegation so E#14 was not suspended/taken off the schedule and was able to work the next shift that evening. E#15 stated that if they know who the alleged offender is, they will send them home right away. E#15 stated that if a name is not given or they don’t know who it is, once they review and have an idea who it could be, they may suspend that employee if the investigation is still ongoing. B. Based on document review and interview, for 1 of 6 staff-to-patient (Pt. #8) allegations of abuse at the Hospital reviewed, the Hospital failed to ensure that an allegation of abuse was addressed and investigated, in accordance with hospital policy. Findings include: 1. The Hospital’s policy titled, “Patient Protection from Abuse” (dated 11/2024), was reviewed and required, “ ... any hospital administrator, agent, employee or medical staff member who has reasonable cause to believe that a patient with whom he or she has direct contact has been subjected to abuse in the hospital will promptly report the abuse to hospital administration ... A rapid investigation will be conducted by a member of the Risk Management Department ... a determination of reasonable cause, allegation substantiation... will be made ... All internal review findings must be documented and made available to the Illinois Department of Public Health (IDPH) upon request ...” 2. The Complaints & Grievance log from 07/27/2025-10/27/2025 was reviewed on 10/27/2025. There was one complaint reported on 10/16/2025 which included, “[Pt. #8] encountered an unprofessional nurse while admitted to [Hospital] on 09/29/2025. The patient alleges the nurse threw [Pt. #8’s] phone at [Pt. #8] and told [Pt. #8] ‘to get up and get it [themselves]’ and pushed [Pt. #8].” 3. Reports, investigation documentation, and all follow-up conducted were requested for this complaint on 10/27/2025 at approximately 3:30 PM, again on 10/28/2025 at approximately 9:30 AM, and again at 4:00 PM. An email communication chain was presented on 10/29/2025 at 9:30 AM and indicated that the complaint was acknowledge by the Hospital on 10/17/2025; however, there were no further updates after 10/17/2025 to indicate whether an investigation was initiated or completed. 4. Per the Director of Regulatory (E#1) on 10/29/2025 at approximately 9:35 AM, E#1 stated that this was not reported/filed as an allegation of abuse and was missed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. 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: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 6 of 10 personnel files (E#11, #14, #17, and #22-24) reviewed for staff that may have direct contact with behavioral health patients, the Hospital failed to ensure that staff had current training in techniques to identify and address patient behaviors that may require the use of restraint or seclusion, in accordance with hospital requirements. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion” (dated 01/15/2023), was reviewed and required, “...Appendix A: Education and Data Collection and Reporting: ... 2. All staff who have direct patient contact must have ongoing education and training in... techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of Restraints or Seclusion... At a minimum, those healthcare providers identified in Section 2 above will be trained and will demonstrate knowledge based on the specific needs of the patient population, but all training will include at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a Restraint or Seclusion. (ii) The use of non-physical intervention skills. (iii) Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical or behavioral status or condition...” 2. The Job Descriptions of Public Safety Officers (PSOs), Behavioral Health Technicians (BHTs), and Emergency Technicians required certification in CPI/Crisis Prevention Institute (training to identify, prevent, and de-escalate crises which may include verbal de-escalation; recognizing and responding to crisis situations; and physical interventions for both non-violent and violent behaviors). 3. The personnel files of 3 Public Safety Officers, 1 Emergency Technician, 2 Behavioral Health Technicians, and 2 Patient Safety Attendants (who monitor behavioral health patients in the ED) were reviewed on 10/30/2025 at approximately 12:00 PM. The following was noted: - 2 of 3 of the Public Safety Officers (E#24 hired 12/16/2024 and E#17 01/06/2025) lacked CPI certifications. - 1 of 1 Emergency Technician (E#14 hired 02/03/2025) lacked CPI certification. - 1 of 2 BHT (E#23) had CPI certification that had expired 10/16/2025. - 1 of 2 patient safety attendant/sitter (E#11) had an expired (10/02/2025) CPI certification, while the other (E#22) lacked CPI certification. 4. An interview was conducted with the Security Director (E#16) on 10/30/2025, at approximately 1:00 PM. E#16 stated that back when the two PSOs were hired, they didn’t have a CPI instructor. E#16 stated that they never got back to having them take the CPI course after they hired a new instructor. 5. An interview was conducted with the Director of People Strategy & Operations (E#21) on 10/30/2025 at approximately 2:24 PM. E#21 stated that the requirement for CPI certification is department/unit specific. E#21 stated that the job descriptions for security, behavioral health, and ED staff include the requirement for CPI certification.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 482.43, Discharge Planning. Findings include: 1. The hospital’s behavioral health department failed to demonstrate periodic assessment of the discharge planning process, including a review of patients admitted within 30 days of previous admission were conducted. See A-803.”

“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: 34411 Based on document review, video review, and interview, for 1 of 4 (Pt #4) psychiatric patient’s clinical records reviewed, the hospital failed to increase the precaution level after a safety event, in order to ensure that appropriate monitoring was in place. As a result, a patient was physically assaulted by another patient in the behavioral health unit. Findings include: 1. The hospital’s policy titled, “Patient Observation Rounds” dated 8/5/2024, was reviewed and required, “A patient is assessed to be at risk to self or others will be identified as needing special observation and assessment as a precaution... Precautions are specified by the type of behavior that puts the patient at risk to harm self or others ...Precautions will be assigned a level of observation that corresponds with the risk associated with the behavior. This will ensure that adequate monitoring and assessment occurs ...There are three levels of observation: q [every] 15 minutes, Line of Sight (LOS) and One to One (1:1). The Physician will order one of four levels of observation at time of admission and as patient’s condition warrants a change ...An RN [registered nurse] may increase the level of observation if the patient’s condition changes. The physician will be notified as soon as possible of the change in condition ...Line of Sight: behaviors that demonstrate moderate to high risk of harm to self or others and qualify the patient for constant visual monitoring through direct observation: Assault-Patient has difficulty maintaining control either verbally or physically and has exhibited recent act(s) of physical aggression that could have possibly resulted in serious injury to others ...Guidelines for LOS : Patient very unpredictable ...” 2. An IDPH (Illinois Department of Public Health) notification letter regarding two behavioral health patients (Pt #3 and Pt #4), dated 8/29/2025, included, “On 8/28/2025, Risk Management was notified [Pt #4] physically struck [Pt #3] unprovoked. Immediate Response/Summary: The two patients were immediately separated and their safety was immediately ensured. Public Safety was notified...[Pt #4] had no signs of injury or complaints. [Pt #3] was evaluated and treated in the emergency department and then relocated to a different floor. [Pt #3] filed a police report with local law enforcement. [Pt #4] required behavioral interventions to ensure safety and the safety of others on the unit.” 3. The clinical record for Pt #3 was reviewed on 9/19/2025. Pt #3 was transferred from [affiliated outside hospital] emergency department [ED], on 8/25/2025 at 4:55 PM. Pt #3 was admitted to 2B Behavioral Health Unit (as of 9/19/2025, remains admitted). A nursing note (dated 8/28/2025 at 5:46 PM), documented by the RN (E #11), included, “Patient was in the milieu [common area] socializing with peers when [Pt #3] was attacked from behind unprovoked by a ...peer [Pt #4]. Pt was quickly removed from the area and assessed by this nurse... [Psych Resident/MD #2] was notified of incident, [MD #3/medical] was made aware via [electronic medical chat], patient’s [family member] made aware and [Assistant Patient Care Manager/E #12] notified. Pt spoke with [local police department] regarding pressing assault charges and was then transferred to ED for further medical evaluation...” - The ED Care timeline indicated that Pt #3 was transferred to the Hospital’s ED, for assessment after the physical assault. Pt #3 arrived at the ED on 8/28/2025 at 7:01 PM. - ED Provider note (dated 8/28/2025 at 10:45 PM), included, “ ...presents to ED from [2B behavioral health unit] for eval (evaluation) after being assaulted at facility. [Pt #3] stated another pt came up from behind [Pt #3], pulled [Pt #3’s] hair and started to punch and kick [Pt #3]. Pt states [Pt #3] was mostly hit in the head, no LOC [loss of consciousness]. Also with pain to R[right] as [Pt #3] fell on that knee and pain to L [left] wrist and elbow ...Musculoskeletal: Mild tenderness to the left wrist ...Mild tenderness over elbow on the left side ...Also with tenderness to bilateral [both] knees..” - Imaging was ordered and completed in the ED (8/28/2025): Knee Xray; Venous Duplex Scan for deep vein thrombosis; CT Cervical Spine; Wrist Xray, Elbow Xray. The images were all resulted with no acute findings. 4. The clinical record for Pt #4 was reviewed on 9/20/2025. Pt #4 presented to the ED on 8/13/2025 at 4:45 PM. Pt #4 was admitted to WG [behavioral health unit] on 8/14/2025 and was discharged on 9/8/2025. - ED Provider note (dated 8/13/2025 at 7:08 PM), included, “ ...presents to ED via EMS [emergency medical service] with c/o [complaints of] needing a psychiatric evaluation. Per triage note the pt comes from group home and was experiencing SI [suicidal ideation] onset this morning with no plan ...Accepted to WG [behavioral health unit] ...” Behavioral Health Nursing notes, from 8/14/2025-9/8/2025, included the following: - 8/23/2025 at 5:20 PM: “Patient received in hallway, alert, BHT [behavioral health technician] on duty report to the writer that patient went to other patient’s room [Pt # 16] and physically assaulted [Pt #16] stated that [Pt #16] offended [Pt #4] and later came back to apologize to peer. Patient redirected to [Pt #4] room ...Will continue to monitor for safety as the plan of care ongoing”. There is no documentation indicating that a Psych or medical provider was notified of the incident. Pt #4’s precaution orders were not increased (either to Line of Sight or 1:1) after the physical assault on another patient. In addition, Pt #16’s provider was not notified of the event. - 8/28/2025 at 5:27 PM, documented by the 2B RN (E #5/cared for Pt #4), included, “unwitnessed by writer, staff witnessed [Pt #4] standing behind pt [Pt #3], unprovoked, grabbed pt [Pt #3] by hair, and swung multiple times to pts back, side and top of head. PRN [as needed] medication administered by nurse manager. Ativan 2 mg [milligrams] IM [intramuscular], Benadryl 50 mg IM and Haldol 5 mg IM [psychotropic medications]. When asked why pt assaulted pt, pt stated because [Pt #4] is here...” -8/28/2025 at 7:58 PM, documented by the Assistant Pare Care Manager (E #12), included, “Patient is on LOS due to multiple physical attacks on other patients in the unit. [Advanced Practice Nurse/Psych NP#1] is aware of this situation.” Pt #4’s orders from 8/14/2025-9/8/2025, were reviewed, Pt #4’s admission orders included assault and suicide precautions, requiring 15-minute checks. Pt #4 was involved in an incident in which Pt #4 physically attacked another patient (Pt #16), on 8/23/2025. There was no documentation indicating that either Pt #4’s or Pt #16’s physician was notified the day of incident. There was no change in the level of precaution for Pt #4 until 8/28/2025 at 9:06 PM (after Pt #4’s 2nd physical attack). The assault precaution order was now changed from the standard every 15 minutes Assault precaution, to Line of Sight Assault precautions. 5. The Adverse Event (incident) log, (dated 6/2025-9/19/2025), was reviewed on 9/19/2025. The event log included 2 safety events involving Pt #4 (dated 8/23/2025 and 8/28/2025). 6. On 9/19/2025 at 11:45 AM, a video surveillance review was conducted with the Assistant Chief Nursing Officer (E #19) and the Behavioral Health Coordinator (E #20). The video footage was from 2 views (2B TV room and the West Exterior entrance). The following was observed from the video on 8/28/2025 at: - 5:25 PM: 4 patients (including Pt #3) observed in the TV room interacting - 5:26 PM: A Behavioral Health Technician (BHT/E #21) walked into the TV room and left back out in less than 30 seconds, leaving the 4 patients unattended. - 5:27 PM: Another patient (Pt #4) enters the TV room and immediately lunges at Pt #3, then struck the Pt #3 a total of 6 times in the head. Pt #4 then pulled Pt #3’s hair. Pt #3 fell to the ground. Another patient assisted Pt #3 up from the floor. Both Pt #3 and Pt #4 left the room at the same time, going in opposite directions. Pt #3 was tended to by staff. Pt #4 walked back to Pt #4’s room unaccompanied. - 5:28 PM: Two BHTs (E #21, E #22) and 1 RN (E #11) came to the TV room’s entrance to assist. - 5:29 PM: 3 patient safety officers entered Pt #4’s room. No clinical staff present. - 5:30 PM: The Assistant Patient Care Manager (E #12) looked into Pt #4’s room. However, E #12 did not enter. - 5:42 PM: E #12 enters Pt #4’s room with a syringe in hand. Security officers remain in room with E #12. On 9/19/2025 at 12:25 PM, during video review, E #20 stated that a staff member should be in the TV room when patients are present. 7. On 9/19/2025 at 2:45 PM, an interview was conducted with Pt #3. Pt #3 stated that a couple weeks back, Pt #3 was in the lounge area talking with other patients, when another patient (Pt #4) walked in and started hitting Pt #3 in the head and pulling Pt #3’s hair. Pt #3 stated that no staff helped immediately and that another male patient had to help Pt #4 to get off Pt #3. Pt #3 stated that the other patient (Pt #4) walked away after Pt #4 hit Pt #3. Pt #3 stated that Pt #3 did go to the emergency room after Pt #3’s (family member) came to the Hospital. Pt #3 stated that the emergency room did some testing, but I (Pt #3) refused testing of the head. Pt #3 stated that Pt #3 did not return to the same unit (2B) after leaving the ER. 8. On 9/19/2025 at 3:15 PM, an interview was conducted with the 2B RN (E #5)/cared for Pt #4). E #5 stated that E #5 was the assigned nurse for Pt #4 the day an incident happened involving Pt #3 and Pt #4. E #5 stated that E #5 did not actually witness the incident but was told about it when got off break. E #5 stated that E #5 was told that Pt #4 punched another patient (Pt #3), while in the day room. E #5 was told that the Pt #4 was unproved when striking Pt #3. E #5 stated that all patients on the behavioral health unit come in on suicide and aggression precautions, which is every 15-minute rounding. E #5 stated that after a physical altercation, the precaution level can be increased to 1:1 (within arm’s length monitoring) or LOS (line of sight/observation where patient is in constant visual field). 9. On 9/20/2025 at 10:58 AM, an interview was conducted with the Assistant Patient Care Manager (E #12). E #12 stated that on 8/28/2025, E #12 was in E #12’s office and overheard a loud commotion. E #12 stated that when E #12 came out to see what was going on, E #12 was told that Pt #3 was just physically attacked in the dayroom, by another patient (Pt #4). E #12 stated that E #12 tended to Pt #3 first and assessed Pt #3 for injuries. E #12 stated that Pt #3 was advised that it would be best for Pt #3 to go to the ED for assessment. E #12 stated that Pt #3 agreed to go once Pt #3’s (family member) comes to the Hospital. E #12 stated that Pt #3 voiced that Pt #3 wanted to press charges against Pt #4 for the assault. E #12 stated that after E #12 saw Pt #3, E #12 then went in to see Pt #4. E #12 stated that E #12 asked Pt #4 why Pt #4 attacked Pt #3. E #12 stated that Pt #4 stated that because Pt #4 was just upset because Pt #4 wants to be discharged. E #12 stated that Pt #4 went back to Pt #4’s room immediately after the incident (with Pt #3), unaccompanied. E #12 stated that a clinical staff member should have assisted/escorted back to Pt #4’s room right after the incident. E #12 stated that Pt #3 was taken to the (ED) emergency department for assessment (approximately an hour after the incident). E #12 stated that Pt #3 did not return to 2B (acute behavioral health unit) after being discharged from the ED. E #12 stated that Pt #3 went to 2A (Early Psychosis), and Pt #4 remained on 2B due to Pt #4 needing the more acute unit. E #12 stated that E #12 was told that Pt #4 had another incident prior (to 8/28/2025), where another patient was struck by Pt #4. E #12 stated that generally if a patient strikes another patient, the patient is put on 1:1 or Line of Sight. 10. On 9/20/2025 at 1:10 PM, a phone interview was conducted with the Psychiatric Advanced Practice Nurse (NP #1/cared for Pt #4). NP #1 stated that Pt #4 originally came in with depressive symptoms. NP #1 stated that throughout the course of hospitalization, Pt #4 developed mood swings and became more withdrawn. NP #1 stated that NP #1 was made aware by staff of a physical altercation involving Pt #4 and another patient (Pt #3), on 8/28/2025. NP #1 stated that NP #1 was told that Pt #4 physically attacked (Pt #3), unprovoked. NP #1 stated that the next day when NP #1 saw Pt #4, Pt #4 stated that Pt #4 attacked (Pt#3), because Pt #4 was ‘just angry’. NP #1 stated that NP #1 was not made aware of a prior incident (8/23/2025), where Pt #4 physically attacked another patient (Pt #16). NP #1 stated that the staff told NP #1 about the 1st incident (8/23/25), after the 2nd incident occurred (8/28/25). NP #1 stated that the normal protocol is to call the NP or MD at the time the incident occurs. NP #1 stated that if NP #1 was made aware of the 1st incident with Pt #4, then NP #1 would have ordered 1:1 or LOS monitoring. NP #1 stated that the medical provider should be contacted after a physical altercation, in order to assess the patient(s). 11. On 9/22/2025 at 10:50 AM, an interview was conducted with the Department Chair of Behavioral Health (MD #4). MD #4 stated that MD #4 has oversight over inpatient and outpatient. MD #4 stated that when a physical assault occurs, the aggressor patient should be placed on either 1:1 or Line of Sight until re-assessed to lessen the precautions.”

“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: 40079 Based on document review and interview, it was determined that for 2 of 3 patients (Pt. #2 and Pt. #10) clinical records reviewed for turning/repositioning, the hospital failed to ensure that nursing care was provided to turn patients at least every 2 hours as required to prevent skin breakdown. Findings include: 1. The hospital’s policy titled, “Skin/Pressure Injury Risk/Wound Assessments and Care” (revised 11/08/24) was reviewed and required, “3. Any patient assessed to be at risk for skin breakdown or identified with an alteration in skin integrity will have appropriate interventions implemented based on wound care RN (Registered Nurse) and/or provider orders. This will include turning and/or repositioning every 2 hours.” 2. Pt. #2’s Hospital Encounter list was reviewed on 09/20/25 and indicated that Pt. #2 was admitted to East 6 on 07/20/25 and transferred to the Inpatient Rehabilitation Unit on 08/12/25 and discharged on 09/06/25. The clinical record included the following: -History and Physical, dated 7/20/25 at 11:27 AM, “ (Pt.#2) developed sudden right leg numbness ... no evidence of stroke on CT (computed tomography/images of organ) ... “ -Neurologist Progress Note, dated 07/22/25, “ ... still complain of BLE (bilateral lower extremities) and now feels weaker on left leg ... no sensation to left leg ... today says that cannot feel anything on whole entire left leg and is still weak ... Day 3 of IVIG (intravenous immunoglobulin - treatment for autoimmune disease) ... today’s examination is slightly weaker in the lower extremities .. does not have any knee or ankle tendon reflexes on today’s examination. Sensory testing progress today compared to yesterday ... 7/26/25: Day 1 of plasmaphereses (treats autoimmune disease) has improvement in movement of BLE ... blisters over sacral area and small blister over left knee, pressure can contribute to sacral blister ... unclear if it is autoimmune related considering there may be autoimmune etiology to transverse myelitis (inflammation of the spinal cord), already on steroids ... “ -Braden Score (scale used to predict risk for developing pressure ulcers- 19-23=no risk, 15-18 mild; 13-14-moderate; 10-12 high) Flowsheets dated 07/20/25 to 07/28/25, were reviewed. From 7/20/25 to 7/25/25 a 9:46 PM, Pt.#2’s was stratified as a mild risk, after 7/26/25 Pt.#2’s score was moderate to high. -Position/Mobility/Activity Flowsheets dated 07/20/25 to 08/13/25, were reviewed. The flowsheets lacked documentation that Pt.#2 was repositioned every 2-hours while Pt.#2 was in bed the following days and times: 07/20/25 at 9:48 AM to 7/21/25 at 10:03 PM; 7/21/25 at 10:03 PM to 7/22/25 at 12:45 PM; 7/25/25 9:00 AM to 3:00 PM; 7/26/25 at 2:00 AM to 7/28/25 at 8:00 PM; 7/29/25 at 6:00 AM to 7/29/25 at 8:00 PM; 7/30/25 at 6:00 AM to 7/30/25 at 8:00 PM; 7/31/25 at 6:00 AM to 8:00 PM; 8/01/25 at 5:15 PM to 8/01/25 at 10:00 PM; 8/03/25 at 2:00 AM to 7:26 AM; 8/09/25 at 6:00 AM to 7:23 PM; 8/10/25 at 6:00 AM to 7:00 PM; and 8/11/25 at 5:00 PM to 8/12/25 at 8:00 AM. -Position/Mobility/Activity Flowsheets dated 08/13/25 to 09/06/25, were reviewed. The flowsheets lacked documentation that Pt.#2 was repositioned every 2-hours while Pt.#2 was in bed the following days and times: 08/24/25 at 7:06 AM to 08/24/25 at 6:55 PM, and on 09/02/25 at 5:55 AM to 7:00 PM. -Skin/Wound Assessment Flowsheets dated 7/20/25 to 8/06/25, were reviewed. The flowsheets indicated that on 07/25/25 at 6:30 PM, a pressure injury was evaluated by (E #10/Wound Care-RN) in the sacrum. -Wound Care Consult Note, dated 08/19/25 at 8:40 AM, “ ... Sacrum with full thickness wound s/p (status post) surgical debridement on 8/8/25 ...wound with increase in necrotic tissue with strong malodor now detected. Bone is exposed centrally...edges separate from base and superior peri-wound is maroon and blistering concerning of increased pressure to the area. Wound is characteristic of stage IV pressure injury. Culture was obtained, wound MD notified of worsening wound ...will need frequent turning and repositioning and with pressure relief plan in place ....” 3. On 9/20/2025, the clinical record for Pt. #10 was reviewed. On 9/14/2025, Pt. #10 was admitted to the hospital due to altered mental status. On 9/15/2025, Pt. #10’s skin assessment indicated that Pt. #10 was high risk for skin breakdown. The clinical record indicated that interventions included every two hour repositioning. The clinical record lacked documentation that Pt. #10 was repositioned every two hours from 9/15/2025 at 11:00 AM through 9/17/2025 at 4:00 PM. 4. An interview was conducted with E #14 (Unit Manager) on 9/20/2025 at approximately 10:00 AM. E #14 stated that there should be documentation of every two hour repositioning when a patient is identified as high risk for skin breakdown. 5. An interview was conducted with the Wound Care Nurse (E#10) on 09/22/25 at 10:42 AM. E#10 stated (Pt.#2) developed a wound while hospitalized... Staff are required to turn and reposition patients that require assistance, this is standard care for patients with existing wounds or at risk for skin breakdown. 6. An interview was conducted with the Internal Medicine Physician (MD #6) on 09/22/25 at 2:40 PM. MD #6 stated that for patients that are incontinent or unable to move they are at risk for developing bed pressure ulcers. It is recommended that staff follow preventive measures like repositioning and keeping the skin clean and dry.”

“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: 36774 Based on document review and interview, the hospital’s behavioral health department failed to demonstrate periodic assessment of the discharge planning process, including a review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the behavioral health units. Findings include: 1. On 9/22/2025, the hospital’s policy titled, “Discharge Planning” (undated) was reviewed and indicated, “... Policy: Discharge Planning will begin at the time of admission and be continuously updated throughout the patient’s stay... Interpretation, Implementation, and Revision: The Director of Behavioral Health is responsible for the interpretation, implementation, and revision of this policy...” The policy does not describe assessment of the discharge planning process of the behavioral unit patients. 2. On 9/20/2025 at approximately 9:00 AM and on 9/22/2025 at approximately 10:00 AM, any documentation, meeting minutes, or data collected to indicate that the behavioral health units/department conducted periodic review of the discharge planning program was requested. As of survey date 9/22/2025, no available information was provided. 3. On 9/22/2025 at 10:22 AM and at approximately 1:35 PM, interviews were conducted with E #1 (Executive Director of Behavioral Health Unit). E #1 stated that the behavioral health unit/department has a separate discharge planning program evaluation from the medical center. E #1 stated that the behavioral health department do not have a formal structure or documentation of evaluating the discharge planning program. E #1 stated that moving forward, they will implement a more structured process for evaluating the discharge program that would include review of new admits, daily readmission, as well as high acuity patients.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 36774 Based on documentation review and interview, for 1 of 4 patients (Pt. #1) reviewed for discharge planning, the hospital failed to ensure a discharge planning evaluation was made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge. Findings include: 1. On 9/20/2025, the hospital’s document titled, “Program Therapist” (undated) indicated, “ ... Key Responsibilities ... Provides quality documentation for psychosocial assessments ... discharge planning, staffing ... within required timeframes. 1. Completes psychosocial assessment within 72 hours. 2. Completes (treatment) plans within 72 hours, discharge plans ... 2. On 9/20/2025, the clinical record for Pt. #1 was reviewed. On 7/4/2025, Pt. #1 was brought to the hospital’s ED for psychiatric evaluation. On 7/8/2025, E #24 (Therapist /Social worker) initiated the psychosocial assessment/initial discharge plan (4 days after Pt. #1’s admission). 3. On 9/20/2025 at approximately 10:30 AM and on 9/22/2025 at approximately 9:46 AM, findings and interviews were conducted with E #13 (Director of Behavioral Health Unit). E #13 stated that the initial discharge planning completed for Pt. #1 was delayed and should have been completed within 72 hours of admission.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 36774 Based on document review and interview, for 1 of 4 patients (Pt. #1) reviewed for discharge planning, the hospital failed to ensure that Pt. #1’s guardian was made aware of the discharge plan. Findings include: 1. On 9/20/2025, the hospital’s policy titled, “”Discharge Planning” (undated) was reviewed and indicated, “ ... Policy: Discharge planning will begin at the time of admission and be continuously updated throughout the patient’s stay. The plan will be developed based on input from the patient, natural supports or significant others, physician, and member of the multidisciplinary team. If a guardian ... is identified, they will be included in the decision-making process ... Procedure ... 3. A discharge plan will be initiated during the initial treatment planning session and reviewed weekly in multidisciplinary team meetings... The discharge plan will be reviewed with the patient and their guardian ...” 2. On 9/20/2025, the clinical record for Pt. #1 was reviewed. On 7/4/2025, Pt. #1 was brought to the hospital’s ED for psychiatric evaluation. The clinical record included: - A document titled, “Letters of Office - Plenary Guardian of a Disabled Person.” The document, dated 12/17/2010, indicated, “ ... (Name of Pt. #1’s mother) has been appointed plenary guardian of ... (Pt. #1, a disabled person), and is authorized to have under the direction of the court of the custody of the ward and to do all acts required by law ...” - On 7/11/2025, E #7’s (Therapist/Social Worker) progress note indicated, “(Pt. #1) was denied by all SMHRF (Specialized Mental Health Rehabilitation Facility) at this time...” The clinical record lacked documentation that the discharge plan to place Pt. #1 to SMHRF was discussed with Pt. #1’s guardian. - On 8/29/2025, E#7’s progress note indicated, “This writer spoke with mother regarding (Pt. #1’s) acceptance into the facility (skilled nursing facility) ...” The clinical record lacked documentation that prior to acceptance into the skilled facility, Pt. #1’s mother was made aware and agreed with the plan to discharge Pt. #1 to (Name of Skilled Nursing Facility A). 3. On 9/20/2025 at approximately 10:30 AM and on 9/22/2025 at approximately 9:46 AM, findings and interviews were conducted with E #13 (Director of Behavioral Health Unit). E #13 stated that prior to referral to SMHRF and Skilled Nursing Facility, the clinical record lacked documentation regarding discussion with Pt. #1’s mother regarding placement of Pt. #1 to SMHRF and Skilled Nursing Facility.”

“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: 32741 Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #3) reviewed for restraint documentation, the Hospital failed to ensure a physician order was obtained for a violent restraint. Findings include: 1. On 8/6/2024, the Hospital’s policy titled, “Restraint and Seclusion” (reviewed by hospital 1/18/2021) was reviewed and indicated, “...Violent restraint -if the use of restraint is necessary, an order for violent restraints must be placed within 1 hour of initiation (includes physical hold of patient)...” 2. On 8/6/2024, Pt. #3’s clinical record (dated 7/2/2024) was reviewed and indicated: -Pt. #3 was seen in the ED (emergency department) on 7/2/2024 with a diagnosis of psychosis (thoughts not based in reality). -Pt. #3’s ED course note dated 7/2/2024 indicated, “Pt. #3 attempted to elope. Pt. #3 is now in 4 point (both ankles and both wrists) restraints.” -Pt. #3 was placed in violent 4 point restraints (locked) on 7/2/2024 at 2:00 PM until 2:51 PM. -Pt. #3’s clinical record lacked documentation of a physician’s order for the violent restraints. 3. On 8/7/2024 at 11:45 AM, an interview was conducted with the ED Charge Nurse (E #10). E # 10 stated that there should be a physician’s order for violent restraints.”

“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: 32741 Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #3) reviewed for violent restraint documentation, the Hospital failed to ensure every 15 minute monitoring was documented, as required. Findings include: 1. On 8/6/2024, the Hospital’s policy titled, “Restraint and Seclusion” (reviewed by hospital 1/18/2021) was reviewed and indicated, “Violent Restraints - locked -A sitter must provide continuous supervision and must document every 15 minute checks on the behavioral health flowsheet (location/activity/behavior)...” 2. On 8/6/2024, Pt. #3’s ED (Emergency Department) clinical record (dated 7/2/2024) was reviewed and indicated: -Pt. #3 was seen in the ED on 7/2/2024 with the diagnosis of psychosis (thoughts not based in reality). -Pt. #3’s ED course note dated 7/2/2024 indicated, “Pt. #3 attempted to elope. Pt. #3 is now in 4 point (both ankles and both wrists) restraints.” -Pt. #3’s restraint documentation dated 7/2/2024 noted violent (locked - 4 points) restraints were applied on 7/2/2024 at 2:00 PM and discontinued at 2:51 PM. -Pt. #3’s restraint flowsheet documentation dated 7/2/2024 noted initiation of violent (4 point) restraint at 2:00 PM. The restraint flowsheet documented 15 minute checks at 2:15 PM but lacked documentation of 15 minute checks from 2:15 PM - 2:51 PM. The restraints were discontinued at 2:51 PM. 3. On 8/7/2024 at 11:45 AM, an interview was conducted with the ED Charge Nurse (E #10). E #10 stated that a patient in violent restraints should be monitored continuously and documented every 15 minutes.”

“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: 27125 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 a suicidal patient was monitored for safety and a medical screening examination was completed to determine if a medical emergency existed. (A-2406 A.) 2. The Hospital failed to ensure that a patient who presented to the emergency department and had a security incident was provided a medical screening examination. (A-2406 B.) The immediate jeopardy (IJ) began on 3/31/2024, due to the hospital’s failure to monitor the patient for safety and conduct a medical screening examination to determine if a medical emergency existed for 1 of 4 patients (Pt #21) who presented to the hospital’s emergency department (ED) with suicidal ideation. Subsequently, Pt #21 was able to leave the ED and did not receive a medical screening examination. The IJ was announced on 7/2/2024 at 2:40 PM during a meeting with the Director of Regulatory, Manager of Regulatory Compliance, the hospital’s Executive Director Chief Nursing Officer, and Executive Director Chief Nursing Officer (from affiliated hospital). The IJ was not removed by the survey exit date of 7/2/2024.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 27125 A. Based on document review, observation and interview, it was determined that the Hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the emergency department and the wording was in languages of the population served by the hospital. Findings included: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Labor Act: EMTALA (5/17/2017)” was reviewed on 6/26/2024 and included, “Posted Signs: The hospital, ... shall post conspicuous signs, specifying the rights of individuals under EMTALA who come to the Emergency Department seeking treatment with emergency medical conditions and indicate whether or such facility participants in the Medicaid program. See Exhibit C for sign requirements. Exhibit C included EMTALA language in English and Spanish.” 2. A tour of the emergency department (ED) was conducted with the Patient Care Manager for the ED (E#9) on 6/24/2024 from 1:00 PM - 2:30 PM. The EMTALA signage (in English) was located on a pillar at the walk-in entrance to the ED, at the registration desk and on a pillar, below desk level in the ED by the registration desk for ambulance entrance. The signs were approximately 8 by 11 inches and blended in with other signage. During another tour of the ED, conducted on 6/26/2024 at 9:20 AM, the EMTALA sign by the registration desk was observed to be blocked by a computer on wheels and was not visible to patients. 3. The Hospital’s Fiscal Year Equity & Opportunity Lens graph was reviewed on 6/26/2024 and indicated that English speaking and Spanish speaking are the top two demographic populations that the Hospital serves. 4. The Medical Chair of the Emergency Department (MD#4) was interviewed on 7/1/2024 at 9:45 AM. MD#4 stated that the hospital’s patient population is 95-97% English speaking, but there is a very small percentage of patients for whom Spanish is their spoken language. MD#4 stated, “I suppose we could look into posting a Spanish sign. The requirement is that the sign is visible. We are the safety net for the community, and no one is ever turned away.””

“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: 27125 Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) reviewed for disposition code of ‘Arrived in Error’, the Hospital failed to ensure that the disposition code on the emergency department log was defined and universally used. Findings included: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Labor Act: EMTALA (5/17/2017)” was reviewed on 6/26/2024 and required, “Central Log: A central log must be maintained in the hospital Emergency Department. ... The log must include: name of each individual seeking treatment for an emergency condition; date; time; and disposition (i.e.., transferred, admitted, discharge, left against advice, left without treatment).” 2. The clinical record of Pt. #1 was reviewed on 6/24/2024. The timeline from Pt. #1’s emergency department (ED) visit on 3/24/2024 indicated that Pt. #1 arrived and was checked-in by Financial Counselor (E#7) to the ED on 3/24/2024, at 5:28 AM with a chief complaint of MVA (motor vehicle accident). The ED timeline included that Pt. #1’s disposition was set to “Arrived in Error” on 3/24/2024 at 5:51 AM by Charge Nurse E#6 and was marked as “Patient dismissed” on 3/24/2024 at 6:43 AM by ED Nurse (E#8). 3. The Hospital’s disposition (discharge code) key was reviewed on 6/26/2024. The code ‘Arrived in Error” was included on the list. There was no definition for the use of the disposition code ‘Arrived in Error’. 4. The triage nurse (E#14) was interviewed on 6/24/2024 at 2:10 PM. E#14 stated, “We have many patients that request to be seen just to come in because they want shelter or food. Once we do that the patient leaves without being seen. Sometimes we use the code ‘Arrived in Error’ for patients who really don’t need to be seen.” 5. The Patient Care Manager (E#9) was interviewed on 6/24/2024 at 3:00 PM. E#9 stated that the patient is entered in the log starting at registration and finished at disposition. The disposition codes are a drop-down selection in the computer. E#9 stated, “ ‘Arrived in Error’ is a code used when someone presents to the registration desk and really wanted to go to another department, like ultrasound or x-ray. The patient might have already been entered, but really didn’t need to be seen in the ED.” 6. The Director Emergency Service Line (E#16) was interviewed on 6/26/2024 at 9:00 AM. E#16 stated that the discharge disposition on the ED log is entered by the nursing staff from a standardized list of EPIC (computer system) codes. Three of the codes are monitored formally for quality purposes: 1. Left Without Being Seen, 2. Left Before Triage, and 3. Left before Treatment Complete. E#16 stated, “I review/audit these codes daily and if the wrong code has been entered, I will change and enter the correct code into the system.” E#16 stated the two other discharge codes that are reviewed but not reported are: 1. Arrived in Error and 2. AMA (against medical advice). E#16 stated, “I look at those codes to see if they are being used correctly, but do not report on them for quality. The disposition ‘Arrived in Error’ is used when a patient registers then decides not to be seen by a physician, and that code can only be entered by the charge nurse.” 7. The Medical Chair of the Emergency Department (MD#4) was interviewed on 7/1/2024 at 9:45 AM. MD#4 stated that the disposition code ‘Arrived in Error’ is used to remove the patient from the active board. The name remains on the log. MD#4 stated, “I’m not sure there is a real definition for Arrived in Error.””

“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: 30195 A. Based on document review and interview, it was determined that for 1 of 4 (Pt #21) records reviewed for patients presenting to the emergency department (ED) for suicidal ideation who scored a high risk for suicide on assessment during triage, the hospital failed to ensure that the patient was monitored for safety and a medical screening examination was completed to determine if a medical emergency existed. Subsequently, Pt #21 left the ED waiting room without being seen by a qualified medical provider. Findings include: 1. On 6/25/2024 at approximately 2:00 PM, a security incident report, dated 3/31/2024, was reviewed and included, “In summary on 3/31/24 at approximately 18:57 hours officers were dispatched to the emergency room waiting area for the patient elopement. The patient [Pt #21], was who was in the emergency waiting area, Left the emergency room waiting area with an unknown male ... The patient was wearing a red top and has blond hair. Per the nursing staff the patient was here for suicidal ideation ...After a search of the area, we [were] unable to locate the patient on or around hospital premises. Nothing further to report at this time.” 2. The clinical record for Pt #21’s ED visit on 3/31/2024 was reviewed on 6/25/2024 and included that Pt #21 presented to the ED on 3/31/2024 at 6:11 PM for psychiatric evaluation. The RN’s (E #20) triage note on 3/31/2024 at 6:23 PM included, “Patient presents with complaint of positive suicidal ideation and states feeling depressed. Patient states came here to stop it before it happens. AOX4 [alert and oriented to person, place, time, and situation].” Pt #21’s vital signs in triage were: heart rate 91, blood pressure 164/106, respiratory rate 18, temperature 97.5, and SpO2 96% on room air. Pt #21’s suicide risk screening was completed by E #20 at 6:27 PM and included that Pt #21 was a high risk for suicide. The suicide screening included, “ ... suicidal intent with specific plan: Yes (overdose on pills)”. The triage note included Pt #21’s ED Acuity was “2” (1-5 scale; 2 being high risk situation). The record indicated that orders were placed by E #20 (Nursing order set for behavioral health patients that can be placed by nursing in triage) at 6:29 PM for: point of care urine pregnancy test; lab-blood - CBC [complete blood count] and differential; comprehensive metabolic panel; serum alcohol; urine toxicology screen; COVID-19 Rapid Respiratory. The record indicated that all labs were collected by E #20 by 6:38 PM. There was no documentation in the record that Pt #21 was taken into the main ED or placed in a bed/room. The next nursing note was on 3/31/2024 at 7:05 PM which included, “ED Disposition set to Left Before Treatment Complete.” The record did not include documentation of Pt #21 being monitored or Pt #21 receiving a medical screening exam by a qualified practitioner from the time of triage at 6:23 PM through time Pt #21 left at 7:05PM. 3. The hospital’s policy titled, “Triage” (ED-033) (reviewed 5/25/2021) was reviewed on 7/1/2024 and required, “ ...Route patients to the appropriate location: ... b. Take critical patients, including those who are suicidal or homicidal, into the Emergency Department treatment area immediately. c. All suicidal or homicidal patients should be triaged at an ESI [emergency severity index] 2 ...” 4. The hospital’s policy titled, “Psychiatric Patient Care” (ED-024 - reviewed 12/27/2019) was reviewed on 7/1/2024 and required, “ ...1. Patient arriving to the Emergency Department with psychiatric complaints should be placed in the Emergency Department and should be assessed whether the need for continuous observation is required. If required, follow hospital policy. A. During the triage assessment, all patients are screened by the RN for suicidal intention using the Columbia-Suicide Severity Rating Scale ...” The policy did not include procedures for monitoring patients in the waiting room when no ED beds are available. 5. The hospital’s policy titled, “Suicide/Homicide/Safety Precautions/Video Monitoring” (reviewed 5/15/2022) was reviewed on 7/1/2024 and required, “ ... It is a hospital wide policy that applies to any department providing patient care ... 1. All patients during the emergency department/urgent aid triage process and/or admission onto the medical units will undergo a suicide and homicidal ideation risk screening. 2. The Columbia-Suicide Severity Rating Scale should be utilized for suicidal risk screening. 3. The person conducting the screen is responsible for notifying the licensed independent practitioner (LIP) of any positive findings. 4. Suicide or Homicidal Ideation Precautions will be implemented for all patients at risk as identified by suicide screening, integrated assessment, psychiatric evaluation, and/or physician order. 5. An RN or LIP may initiate Precautions ...” 6. On 6/26/2024 at approximately 12:16 PM, an interview was conducted with the ED RN (E #20) who triaged Pt #21 on 3/31/2024. E #20 stated that E #20 conducted the triage for Pt #21 on 3/31/2024 and entered the standing order set for behavioral health patients (labs, pregnancy test, COVID test, urine toxicology). E #20 stated that a suicide risk assessment was completed, and Pt #21 was a high risk for suicide. E #20 stated that the lab tests were collected in triage, and Pt #21 was placed in the waiting room after triage because no beds were available in the ED at the time. E #20 stated that the provider can review the record and order a psychiatric assessment and referral consult, and the patient will be placed in a bed as soon as one becomes available. E #20 stated that they were not aware of any measures in place to stop a patient from walking out the door of the ED waiting room. E #20 stated that when they called for Pt #21 in the waiting room on 3/31/2024, the patient did not respond. E #20 stated that they checked the waiting room, both bathrooms, and looked out the front door of the ED, and Pt #21 was not to be found. E #20 then called Security to locate Pt #21. 7. On 6/26/2024 at approximately 11:00 AM, an interview was conducted with the ED Manager (E #9). E #9 stated that the hospital’s ED gets a lot of walk-in patients. E #9 stated that there is always a greeter and a Triage RN in the waiting room that can see the patients in the waiting area. E #9 stated that they try to room behavioral health/suicidal patients if a bed is available. E #9 stated that if the patient is known to ED staff and no bed is available, the patient will sit by the triage room, and there is a Security staff posted in the ED waiting room. E #9 stated that the Charge Nurse is notified if a suicidal patient presents and is triaged, but “if ED is full, we do the best we can.” E #9 stated that they try to recruit Security staff to keep an eye on the patient until a bed can be secured, or the patient can stay with the triage nurse in the triage room, if possible. E #9 stated that they do not assign sitters to patients in the waiting room. E #9 stated that Pt #21 frequently comes to the ED. E #9 stated, “Patient [Pt #21] is delightful, and staff is very familiar with her.” E #9 was unable to provide a policy/procedure/stated practice for the monitoring of behavioral health/suicidal patients in the ED waiting room to ensure that patients are monitored for safety and receive a medical screening exam when no beds are available in the main ED. 8. On 6/26/2024 at approximately 11:15 AM, an interview was conducted with the ED Director (E #16). E #16 stated that if a psychiatric or suicidal patient elopes from the ED and Security cannot find the patient, then the police department should be contacted to do a wellness check on the patient. E #16 was unable to provide a policy/procedure/stated practice for the monitoring of behavioral health/suicidal patients in the ED waiting room to ensure that patients are monitored for safety and receive a medical screening exam when no beds are available in the main ED. 9. On 7/1/2024 at approximately 10:19 AM, an interview was conducted with the Public Service Officer (E #27) who completed the Security incident report regarding Pt #21 on 3/31/2024. E #27 stated that E #27 was notified by clinical staff after Pt #21 had been gone a while on 3/31/2024. E #27 stated that Security got the description of the patient from ED clinical staff. Security staff then checked the entire hospital property for Pt #21, then contacted ED staff to report that Security could not find Pt #21. E #27 stated that ED clinical staff will then contact the police department if indicated, and Security does the incident report. E #27 stated that the ED waiting room is usually monitored by contracted security staff who sit at the ED waiting area security desk which is located just inside the main ED entrance. E #27 stated that Security staff does not monitor the patients in the ED waiting room. Medical/clinical ED staff monitor the patients in the waiting room. 10. On 7/1/2024 at approximately 10:00 AM, an interview was conducted with the ED Medical Director (MD #4). MD #4 stated that patients who present to the ED for psychiatric evaluation/suicidal ideation should be taken directly to the main ED from triage, and if there are no beds available, patients should be placed in beds in the hallway in the main ED. MD #4 stated that if a psychiatric/suicidal patient leaves the hospital from the waiting room or elopes from the main ED, clinical staff would notify Security right away to look for the patient. If Security is unable to locate the patient, then clinical staff could notify the police department to look for the patient and check on their wellbeing. MD #4 stated that Pt #21 was a “frequent flyer” in the ED who presented with different complaints all the time. MD #4 stated that ED staff was very familiar with Pt #21. MD #4 stated that if Pt #21 presented with a complaint of suicidal ideation with a plan and was a high risk for suicide, then Pt #21 should be taken directly to the main ED in a bed if available or placed in a hallway bed. MD #4 stated that suicidal patients should not be left in the ED waiting room. MD #4 stated that if Security is unable to locate a suicidal patient who left the ED waiting room, then clinical staff should document in the record if police were contacted. 11. On 7/1/2024 at approximately 9:15 AM, an interview was conducted with the Director of Environmental Health Safety & Security (E #19). E #19 stated that clinical staff should monitor patients (including behavioral health patients) in the ED waiting area. Security staff do not monitor patients in the waiting area. If a patient leaves the ED waiting area, clinical staff will notify Security if they are looking for a patient with a clinical concern who has left. Security will check the immediate area around the ED and expand to check the hospital’s campus, which includes an approximate 1 square mile area [North - South from 157th Street to 154th Street and West - East from Lincoln Avenue to Ashland Avenue]. If Security locates the patient, then they will try to talk to the patient to get them to return to the ED and prevent the patient from leaving. 39802 B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) emergency department clinical records reviewed for patients who had security incidents, the Hospital failed to ensure that individuals presenting to the emergency department (ED) seeking treatment were provided a medical screening examination. Findings include: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act: EMTALA” (revised 5/17/2017), was reviewed and required, “...II. Obligations to Emergency Patients under EMTALA: A. Screening requirments: 1. The hospital (including dedicated emergency departments) shall provide an appropriate medical screening examination (“MSE”) to all inviduals who come to the facility seeking treatment for an emergency medical condition, whether or not they are eligible for benefits under Medicare/Medicaid programs...” 2. The clinical record of Pt. #1 was reviewed on 6/24/2024. The timeline for Pt. #1’s first ED visit on 3/24/2024 indicated that Pt. #1 arrived and was checked-in by Financial Counselor (E#7) to the ED on 3/24/2024, at 5:28 AM with a chief complaint of MVA (motor vehicle accident). The record lacked any documentation that Pt. #1 was triaged or seen by a physician. The ED timeline included Pt #1 was documented as “Patient dismissed” by ED Nurse (E #8), and Pt. #1’s disposition was set to “Arrived in Error” on 3/24/2024 at 5:51 AM by the Charge Nurse E#6. The record lacked documentation of Pt #1 receiving a medical screening exam. 3. Public Safety Department Incident Reports from 3/20/2024-3/31/2024 were reviewed on 6/24/2024 and included one incident report involving Pt. #1 that was filed by Public Safety Officer (E#2) on 3/24/2024 at 6:30 AM. The report indicated that an incident involving Pt. #1 and Officer [E#2] occurred on 3/24/2024 at 5:30 AM in the ER [emergency room] waiting area, The report included, “On 3/24/2024 at 05:30 AM, Officer [E#1] informed me of a banned individual [Pt. #1] was in the ER triage with a friend [identified as Pt. #2]. When we approached them, I [E#2] asked [Pt. #1] was [Pt. #1] here to see a doctor and [Pt. #1] stated ‘No, I’m with [friend], why[?].’ I informed [Pt. #1] that [Pt. #1] would have to leave the property if not seeking medical treatment. [Pt. #1] began to record the waiting area shouting and crying that [Pt. #1] does not have to register in order to stay in the ER. At that moment, I [E #2] called [E#5] the House Manager to be a witness for this incident. [Pt. #1] also stated that [Pt. #1] called the police on me and Officer [E#3] for telling [Pt. #1] to leave. [Pt. #1] registered and we [Officers] were about to leave when [Pt. #1] began to threaten the ER Tech[nician] in the waiting area. The House Manager and Officers [E#3] & [E#4] also witnessed this incident. We went to speak to the Charge Nurse [E#6] and told [E#6] of the events that had just occurred and it was decided that [Pt. #1] should be escorted out for making threats to staff. I informed [Pt. #1] that [Pt. #1] would have to leave the property immediately and [Pt. #1] did so while calling [Local] P.D. [police department]...” 4. A telephone interview was conducted with ED Charge Nurse (E#6) on 6/25/2024, at approximately 9:00 AM. E#6 stated that EMTALA means that every patient that comes through our door will be seen. E#6 stated that every patient that comes in to be seen will be screened by a provider and provided treatment until they are stable or need to be admitted or transferred. E#6 stated that a person becomes a patient the moment that check-in and are registered to be seen by the doctor. E#6 stated that if a patient that comes to be seen becomes aggressive or combative, they will call security for the safety of staff and other patients. E#6 stated that the Hospital has a zero tolerance policy (for violent/threatening behavior) and that is discussed with the patient. E#6 stated that they will try to talk with the patient and calm them down; however, if they can’t de-escalate, security will get involved. E#6 stated that if the patient is alert and oriented, not altered, and not a harm to themselves, and are of competent mind, and still are threatening staff, they may be escorted out of the hospital and in that case it should be documented in the medical record. E#6 stated that Pt. #1 did come to the Hospital at some point but did not recall speaking to Pt. #1. E#6 stated that there was some incident between Pt. #1 and security but was not sure how it all escalated. E#6 stated, “I didn’t know [Pt. #1] was officially a patient” at that time. E#6 stated that a patient’s disposition can be set to “arrived in error” when registration typed in something wrong (i.e. date of birth), the patient already has an account, or may have just clicked the wrong thing. E#6 did not recall why Pt. #1’s disposition was set to arrived in error. 5. A telephone interview was conducted with Public Safety Officer/PSO (E#2) on 6/25/2024, at approximately 9:20 AM. E#2 stated that the only time a person may be escorted out for threatening or aggressive behavior is when that are not a patient. E#2 did recall Pt. #1 and stated that Pt. #1 came to the Hospital with a friend and Pt. #1 said the friend had been in a car accident and that Pt. #1 came to check on the friend. E#2 stated that Pt. #1 had a previous history of trying to break into the ER and trying to grab an officer’s gun. E#2 told Pt. #1 that if Pt. #1 was not here to see a doctor, Pt. #1 was not allowed to stay. E#2 stated that Pt. #1 stated, “I don’t have to do any of that” and E#2 responded, “Then there is no reason for you to be here.” E#2 stated that as Pt. #1 was about to leave, Pt. #1 stated that Pt. #1 now wanted to see a doctor. E#2 stated that Pt. #1 then went to register to see a doctor and E#2 stated that they (security) broke off engaging with Pt. #1. E#2 stated that Pt. #1 registered and made it to triage. E#2 stated, “We didn’t stop her at that point.” E#2 stated that Pt. #1 then started to threaten a staff member (ER Tech, identified as E#15 by E#2) and wouldn’t calm down. E#2 stated Pt. #1 was threatening to kill the ER Tech. E#2 stated that the ER Tech went back and told the charge nurse and who talked to Pt. #1 as well as with the House Manager. E#2 stated Pt. #1 was there for 5-10 minutes and would not calm down. E#2 stated the House Manager and Charge Nurse were involved and they let us know that they wouldn’t want Pt. #1 to be at the Hospital. E#2 stated at this point they refused service to Pt. #1, and the doctor (possibly identified as MD#2 by E#2) agreed, as well. E#2 stated that Pt. #1 was doing it just to stay in the hospital and we all agreed upon her leaving. E#2 stated, “I’m not sure if the doctor went to see the patient as Pt. #1 didn’t even make it to the back.” 6. A telephone interview was conducted with ED Physician (MD#2) on 6/26/2024, at approximately 3:26 PM. MD#2 stated that EMTALA requires every patient to have a medical screening exam. MD #2 stated that they did not recall Pt #1. MD#2 stated that MD#2 will see every patient before making a medical decision. MD#2 stated that even if the patient doesn’t want to be seen, MD#2 will do a mental status exam to ensure that patient is capable of making a decision. MD#2 stated that even if the patient becomes a physical threat, “we would have to assess if they’re competent and whether they have a life-threatening condition. There should be documentation of this in the record. Aggression could be a sign of altered mental status.” 7. An interview was conducted on 6/25/2024, at approximately 2:00 PM with the ED Nurse (E#8) in triage the morning of 3/24/2024. E#8 stated that E#8 was told that Pt. #1 was a former staff member who isn’t allowed to come on premises anymore after making threats to another employee. E#8 stated that if Pt. #1 comes to seek treatment, Pt. #1 can stay. E#8 stated that Pt. #1 came in with a friend who stated that they were in a car accident. E#8 stated that the friend was getting seen as a patient, but Pt. #1 wasn’t. E#8 stated that around 5:30 AM (close to shift change at 7:00 AM), security staff came to the triage room and stated that Pt. #1 wasn’t allowed on premises and was asked to leave. E#8 stated that Pt. #1 started to record them and was threatening to harm staff. E#8 stated that security came and escorted Pt. #1 away, while E#8 completed triage for the friend. E#8 stated that E#8 overheard that Pt. #1 was going to get registered as patient but did not know if Pt. #1 ever did check-in, as E#8 did not end up triaging Pt. #1. E#8 stated that at some point Pt. #1 left. E#8 stated that if a patient is waiting to be seen but starts to become aggressive or threatening, they are still seen, but will be seen in the psychiatric part of the ED for their safety and the safety of others. E#8 stated that even if the patient becomes threatening, they are still a patient and need to be seen by a physician or PA (Physician Assistant).”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 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. #2) complaints/grievances reviewed, the hospital failed to ensure that the process for resolving grievance was followed, as required. Findings include: 1. On 2/13/2024, the hospital’s policy titled, “Complaint and Grievance” (6/2022) was reviewed and indicated, “ ... Grievance: A formal or informal written or verbal complaint that is made to the organization by a patient ... Grievance Process: Any complaint that cannot be resolved in a timely manner will be resolved through the grievance process ... Grievance Resolution: 1. The Patient Experience Department, in consultation with the Department of Risk Management, is responsible for the submission of response letter .... 2. The patient will receive a written acknowledgement of the complaint within 7 days ... 3. The written resolution will include the following elements: Identification of a contact person for follow-up; Steps taken during the investigation; Results of the investigation and any actions taken; Date of completion ...” 2. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital’s ED for possible fluid overload. On 11/28/2023 at 11:25 PM, Pt. #2 was admitted to E527. On 12/2/2023 at 4:36 AM. Pt. #2 was transferred from E527 to E405. Pt. #2 was discharged on 12/2/2023. 3. On 2/13/2024, Pt. #2’s grievance to the hospital was reviewed. On 12/3/2023 at 11:53 AM, Pt. #2 sent an email to E #21 (House Operations Administrator/Nursing Supervisor) that indicated, “Good Morning, (E #21), My name is (Pt. #2). I was admitted to East 527 for period of six days. During that stay, the housekeeping regiment was almost non-existent. And as if you know that evening, a mouse was running around my room, Before I release any video of the mouse running around, and the total disregard for cleanliness in that room, I would like to know what your plans are to alleviate this problem ... Feel free to contact me at any time to tell me what the hospitals intentions are to rectify the situation ...” - There was no written response provided to Pt. #2 regarding the following: Identification of a contact person for follow-up; Steps taken during the investigation; Results of the investigation and any actions taken; and Date of completion. 4. On 2/15/2024 at approximately 2:00 PM, E #23 (Director of Regulatory) stated that a written response was not provided to Pt. #2’s grievance.”

“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: 37971 Based on document review and interview, it was determined that for 1 of 2 (Pt. #9) clinical records reviewed for violent restraints the hospital failed to ensure every 15-minutes monitoring was documented and assessed while on violent restraints as required. Findings include: 1. On 02/15/2024 at approximately 2:05 PM, the hospital’s policy titled, “Restraints and Seclusion” dated 01/18/2021 was reviewed and included, “ ...Violent Restraint: Emergency measure, violent and/or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others ...A 1:1 sitter order is required for all patients immediately upon initiation of violent restraints ...and must document Q15 minutes checks on the ...observation flowsheet ...” 2. On 02/15/2024 at approximately 10:30 AM, Pt. #9’s clinical record was reviewed. Pt. #9 was admitted to the emergency room with a diagnosis of major depressive disorder on 01/05/2024 at 11:56 AM. - Pt. #9’s ED physician order dated 01/05/2024 at 7:32 PM, included, “Violent Restraints/Self-Destructive -Four Point Hard Restraints for 4 hours.” The one-hour face-to-face evaluation included clinical justification for behavioral restraint: violent and/or destructive behavior towards self and other; criteria to discontinue restraints: patient non longer at risk of preventing medical or surgical healing; RN to monitor according to patient care policy; Attestation: ...completed a face-to-face assessment of this patient.” - Pt. #9’s restraints flowsheet documentation included: 01/05/2024: 19:00 [7:00 PM] initiation of four-point restraints, Locking Left Upper extremity, Locking Right Upper Extremity, Locking Left Lower Extremity, and Locking Right Lower Extremity. At 1959 [7:59 PM] Restraints continued to be used: Yes; Right, left - Upper and Lower Extremity: Continued - checked-off as Yes. - On 01/05/2024, at 2010 [8:10 PM] Restraints Discontinued. Pt. #9’s restraints flowsheet lacked the documentation of every 15-minute monitoring while on four-point hard restraints for violent behavior (total of 70 minutes). 3. On 02/15/2024 at approximately 2:30 PM, the ED Nurse Manager (E #5) was interviewed. E #5 stated the documentation was not completed by the sitter. E #5 stated anytime there is a violent restraints in the emergency department, they arrange for a sitter at the bedside, so the sitter did not document the every 15-minutes monitoring for this patient in the flowsheet.”

“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 A. Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #2) clinical records reviewed for nursing admission assessments, the hospital failed to ensure that respiratory assessment was completed, as required. Findings include: 1. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital’s ED for possible fluid overload. The clinical record included the following: - On 11/28/2023 at 9:15 AM, the attending physician’s notes indicated, “ ... Assessment and Plan: chronic Hypoxemic Respiratory Failure, COPD (Chronic Obstructive Pulmonary Disease) ... (Pt. #2) ... presents with shortness of breath ... Physical Exam: Pulmonary ... Respiratory distress present ... wheezing ...” -On 11/28/2023 at 11:25 PM, Pt. #2 was admitted to E527. The registered nurse admission assessment on 11/28/2023 lacked documentation of the required respiratory assessment. 2. On 2/14/2023, the hospital’s policy titled, “Admission Assessment and Further Reassessment Process” (12/2019) was reviewed and included, “... Registered Nurse (Admission Assessment)... This assessment should include appropriate physical observation and/or examination procedures and documenting... of data...” 3. On 2/13/2024 at approximately 2:30 PM, findings were discussed with E #9 (5 East Patient Care Manager). E #9 stated that the nursing admission assessment lacked the required respiratory assessment. B. Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #2) clinical records reviewed for intake and output monitoring, the hospital failed to ensure that the registered nurse followed the documentation guidelines. Findings include: 1. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital’s ED for possible fluid overload. On 11/28/2023, Pt. #2 was admitted to E527. On 11/30/2023, a physician’s order to monitor strict intake and output every eight hours was placed for Pt. #2. The clinical record lacked documentation that intake and output were measured every-eight hours on 12/1/2023 and 12/2/2023. 2. On 2/14/2024, the hospital’s policy titled, “Documentation Guidelines” (9/2019) was reviewed and include, “RN (Registered Nurse) Documentation... Assure that... intake/outputs are charted... as ordered...” 3. On 2/13/2024 at approximately 2:30 PM, findings were discussed with E #9 (5 East Patient Care Manager). E #9 stated that documentation for intake and output monitoring on 12/1/2023 and 12/2/2023 were missing. 37971 c. Based on document review and interview, it was determined that for 3 of 3 (Pt. #1, Pt. #5, and Pt. #6) clinical records reviewed for pain assessment and re-assessment, while in the emergency department, the hospital failed to ensure the pain level was assessed, re-assessed after medication administration, and documented as required. Findings include: 1..On 02/13/2024 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought into the ED (Emergency Department) with a chief complaint of hit and run on 12/24/2023, at 4:03 PM. Pt. #1’s clinical record included the following: - The ED Physician Assistant (MD #1) Rapid Assessment note dated 12/24/2023 at 4:22 PM, included, “ ...(Pt. #1) driver wearing seatbelt, no loc [loss of consciousness], notes head injury ...denies neck, chest or abdominal pain ...pain in the right hand and wrist ...patient [Pt. #1] medically screened and orders initiated ...to be placed in WR [waiting room] for further treatment ...” -The ED arrival and triage nurse (E #15) note dated 12/24/2023 at 4:24 PM, included, “ ...patient [Pt. #1] arrived to triage via EMS [emergency medical services] sp [status post] MVA with laceration to face and right-hand injury. Pt. [Pt. #1] was restrained driver with airbag deployment, denies loss of loc [level of consciousness] or neck pain ...no altered mental status ...eye opening response ...best motor response ...verbal response ...infection screening - no history of isolation ...Triage Acuity: 2 ...” -Pt. #1’s medication administration record included the administration of Acetaminophen (Tylenol) 1000 mg [milligram] on 12/24/2023 at 20:00 [8:00 PM] and the administration of Norco [analgesic] 1 tablet on 12/25/2023 at 12:52 AM.” - Pt. #1’s nursing flowsheet dated 12/24/2023 at 4:33 PM through 12/25/2023 3:24 PM, was reviewed and lacked documentation indicating patient assessment for pain screening, reassessment after medication administration. 2. On 02/15/2024 at approximately 10:45 AM, Pt. #5’s clinical record was reviewed. Pt. #5 was admitted to the emergency room with a chief complaint of chest pain and shortness of breath on 02/12/2024 at 7:23 AM. -Pt. #5’s triage nurse notes at 7:27 AM, included, “Vital signs: Temperature: 97.7 (normal 98.4); Heart Rate: 132 (Normal 60-100); Respiration: 22 (Normal 16-18); Blood Pressure: 134/88 (normal 120/80), oxygen saturation: 97 percentage (normal 98-100). Triage Acuity Level -2.” -Pt. #5’s clinical record from 02/12/2024 8:00 AM through 02/13/2024 11:00 AM, lacked the assessment and documentation of scoring of chest pain assessment throughout Pt. #5’s stay in the ED. 3. On 02/15/2024 at approximately 11:00 AM, Pt. #6’s clinical record was reviewed. Pt. #6 was admitted to the emergency room with a chief complaint of seizures on 02/11/2024 at 11:46 AM. -Pt. #6’s triage nurse notes at 12:18 PM, included, “Patient (Pt. #6) is having grand mal seizures. (Pt. #6) brought from home by EMS (Emergency Medical Services) for AMS (altered mental status) and hyperglycemia (high blood glucose levels, above 125) ; Vital Signs: Heart Rate: 113; Respiration: 26; Blood Pressure: 117/62; and oxygen saturation: 95 percentage. Triage Acuity Level -2.” -Pt. #6’s clinical record from 02/11/2024 11:46 AM through 02/13/2024 11:00 AM, lacked the assessment and documentation of pain scoring and assessment throughout Pt. #6’s stay in the ED. 4. On 02/15/2024, the hospital’s policy titled, “Pain Assessment” dated 05/21/2019, was reviewed and included, “ ... Approved self-report tools include: Numeric Rating Scale 0-10 (recommended for ages 12 and older) ...Initial assessment for all patients ...a comprehensive pain assessment should be conducted upon admission ...a comprehensive pain assessment includes: location, characteristics (type/quality of pain) intensity, onset, duration, aggravating and relieving factors ...conduct a focused pain assessment in an ongoing fashion and as part of routine care ...Patients can expect to receive prompt, safe and effective pain management ...pain relief is an important part of the treatment ...Reassessment after pain treatment is a cornerstone to effective and safe pain management ...reassessment is dependent on the intervention and is timed ...PO [per orally] at least 60 minutes following administration ...” 5. On 02/15/2024 at approximately 1:30 PM, hospital’s ESI [emergency severity index] handbook’s screenshot, was reviewed and included, “ ...ESI Triage Algorithm ... Emergency severity index: Level 1: Requires immediate life-saving intervention; Level 2: Consider severe lethargy, high risk situation; Level 3: Danger zone check vitals; Level 4 and Level 5: monitor for different resources that are needed ...Triage nurses should assign ESI level 2 if the patient reports a pain rating 7/10 or greater and triage nurse’s subjective and objective assessment confirms that the patient’s pain requires interventions that are beyond the scope of triage. The triage nurse concludes that it would be inappropriate for this patient to wait and would assign this patient to the last open bed.” 6. On 02/14/2024 at approximately 11:14 AM, the ED Registered Nurse (E #16) was interviewed. E #16 stated that in general pain assessment must be done upon initial nursing assessment, while admitting the patient in the ED. E #16 stated that the pain level is re-assessed after administration of pain medication. E #16 stated that she (E #16) does not recall administering Norco (analgesic) to patient (Pt. #1) and perhaps, forgot to assess and re-assess the pain level scores. 7. On 02/14/2024 at approximately 12:30 PM, the Triage Nurse (E #15) was interviewed. E #15 acknowledged that pain must be assessed and documented, before and after administration of medication. 8. On 02/14/2024 at approximately 1:30 PM, the ED Nurse Manager (E #5) was interviewed. E #5 stated that anytime patients with triage level 2, that requires immediate care, pain level scoring must be assessed. E #5 stated that in-general pain scoring must be assessed before administration of pain medication and 30 minutes to an hour after administration of medication.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 36774 Based on documentation review and interview, it was determined that for 3 of 7 patients’ rooms (E507, E563, and E559) observed in 5 East Medical Surgical/Telemetry Unit, the hospital failed to ensure that equipment inside the patient’s rooms were maintained, as required. Findings include: 1. On 2/13/2024 between approximately 10:40 AM through 12:30 PM, an observational tour of the hospital’s 5 East (Medical-Surgical-Telemetry Unit) was conducted. During the tour, three of the seven rooms observed (E507, E563, and E559) did not have thermostat covers. 2. On 2/16/2024, the hospital’s document titled, “Environment of Care Management Plan Utility Systems” (2023) included, “... The program is also designed to assure effective preparation of staff responsible for the use and for the maintenance and repair of the equipment...Inspecting, Maintaining, and Testing of Utility Systems... Plant Operations maintains a current documented inventory of all of the utility system... This inventory includes all equipments maintained by (Name of the Hospital)...” 3. On 2/14/2024 at approximately 9:20 AM, an interview was conducted with E #17 (Director of Plant Operations). E #17 stated that the thermostat cover protects the metal strip that controls the thermoregulation of the room. E #17 stated that the thermostat inside the patient’s rooms should be covered.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 37971 A. Based on document review, observation, and interview, it was determined that for 2 of 2 (Room #4 and Room #14) ED rooms observed for cleaning and disinfection, the hospital failed to ensure that the high and low dusting was completed to avoid infection. Findings include: 1. On 02/15/2024 at 11:55 AM, the hospital’s environmental services vendor policy titled, “Emergency Room Cleaning” dated 10/01/2023, was reviewed and included, “ ...Procedure: Follow enhanced Discharge Cleaning Procedures ...high dust and disinfect vertical surfaces including doors, walls ...switches, IV [intravenous] poles etc. 6. Disinfect horizontal surfaces including bed side tables, ledges, sink surfaces, dispensers, etc ...” 2. On 02/13/2024 between approximately 10:00 AM through 12:45 PM, an observational tour of the hospital’s emergency department (ED) was conducted along with ED Nurse Manger (E #5). During the tour following was observed: -At approximately 10:30 AM, the two (2) ED Rooms - Room #14 and Room #4 were checked for cleaning, disinfection, and dusting. Both Room #14 and Room #4, were empty with no patients and cleaned by the housekeeping staff, however, there were dust found on the overhead light, over the medication cart, over the supply cart, and on the thermostat covers. 3. On 02/13/2024 at approximately 11:30 AM, the Housekeeping Staff (E #6) was interviewed. E #6 stated that she (E #6) was cleaning the rooms quickly after patient discharge and was not focusing on the doing high and low dusting. B. Based on observation, document review, and interview, it was determined that for 2 of 2 (E #4/Safety Attendant and E #8/ED Registered Nurse) observed for infection control practices, the hospital failed to ensure the staff adherence to dress code policy while working in the patient care area. Findings include: 1. On 02/13/2024 between approximately 10:00 AM through 12:45 PM, an observational tour of the hospital’s emergency department (ED) was conducted along with ED Nurse Manager (E #5). During the tour the following was observed: -At approximately 10:50 AM, the ED Registered Nurse (E #8) was seen getting ready with the paperwork for blood administration at the nurses station and had artificial fingernails approximately 2-inches long. -At approximately 11:10 AM, the Safety Attendant (E #4) was seen with artificial fingernails approximately 2-inches long, conducting one-to-one patient monitoring at the bedside in the ED hallway. 2. On 02/15/2024 at approximately 2:00 PM, the hospital’s policy titled, “Dress Code and Uniform Requirements” dated 11/4/2019 was reviewed and included, “ ...Fingernails shall be clean, trimmed, and at a length that does not interfere with the job. Fingernails may not exceed one-quarter (1/4) inch in length. Based on CDC (Centers for Disease Control and Prevention) guidelines do not wear artificial fingernails or extenders when having direct contact with patients.” 3. On 02/13/2024 at approximately 10:55 AM, the ED Registered Nurse (E #8) was interviewed. E #8 stated that the infection control education and training was provided annually. E #8 denied that E #8 was wearing artificial fingernails. E #8 stated “I have to hurry up to give blood for the patient.” 4. On 02/13/2024 at approximately 11:00 AM, the ED Nurse Manager (E #5) was interviewed. E #5 acknowledged that the fingernails were artificial and more than 2-inches long, and should not have been worn as part of the staff uniform policy in emergency department. E #5 stated that it causes cross contamination, and infection prevention concerns. 5. On 02/13/2024 at approximately 11:15 AM, the ED Safety Attendant (E #4) was interviewed. E #4 acknowledged wearing artificial fingernails that were approximately two (2) inches and stated that they would be removed as soon as the shift was over. 36774 C. Based on observation, document review, and interview, it was determined that for 1 of 5 patients’ (Pt. #3) in isolation precautions observed, the hospital failed to ensure that the procedure for preventing infection was followed, as required. Findings include: 1. On 2/13/2024 between approximately 10:40 AM through 12:30 PM, an observational tour of the hospital’s 5 East (Medical-Surgical-Telemetry Unit) was conducted. During the tour, five patients were in isolation precautions (E523, E527, E529, E545, and E569). One of the five rooms (Pt. #3 in E523) did not have a room signage to indicate that Pt. #3 was in contact isolation. 2. On 2/13/2024, the hospital’s policy titled, “Isolation Patients” (12/1/2023) was reviewed and included, “... to ensure proper implementation of precautions and isolation techniques... to prevent the spread of healthcare associated infections... Types of Isolation... Contact-MDRO (multi-drug resistant organism)... Isolation Responsibilities... It is the responsibility of the primary nurse to ensure appropriate isolation is ordered, signs are hanging up... outside of the patient’s room...” 3. On 2/13/2024, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 2/10/2024 for chest pain. On 2/10/2024, Pt. #3 had a physician’s order to place Pt. #2 on contact isolation for MDRO (multi-drug resistant organism). 4. On 2/13/2024 at approximately 11:00 AM, findings were discussed with E #9 (5 East, Patient Care Manager). E #9 stated that the room should have a signage to indicate that Pt. #3 is in contact isolation. E #9 stated that the signage is important to ensure that anyone going inside Pt. #3’s room is aware of necessary precautions to take to prevent spread of infection.”