Uchicago Medicine Adventhealth Bolingbrook

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39802 A. Based on document review and interview, for 2 of 6 inpatient records (Pts. #1 and #8) reviewed for falls, the Hospital failed to ensure that the patient’s fall risk was reassessed every shift and post fall. Findings include: 1. The Hospital’s policy titled, “Adult Fall Risk Assessment - Fall Prevention Program” (effective 04/23/2025), was reviewed and required, “ ...Assessment: The nurse will complete the Fall Risk Assessment on admission, transfer, and during shift assessment; after any change in the patient’s conditoin or orientation; and after a fall has occurred... After a fall occurs: ...Reassessment of fall risk and added interventions are performed and documented...” 2. The clinical record of Pt. #1 was reviewed on 05/26/2026. Pt. #1 was admitted on 03/10/2026 with a diagnosis of acute respiratory failure with hypoxia (inadequate supply of oxygen to tissues). The record indicated that on 03/17/2026 at 11:00 PM, Pt. #1 had an unwitessnessed fall. Fall risk assessments from 03/10/2026-03/19/2026 (discharge) were reviewed, and lacked documentation of a fall risk reassessment after the fall on 03/17/2026 or during the next shift on 03/18/2026 from 7:00 AM to 7:00 PM. 3. The clinical record of Pt. #8 was reviewed on 05/27/2027. Pt. #8 was admitted on 05/04/2026 with a diagnosis of tongue swelling. The record indicated that on 05/12/2026 at 4:30 AM, Pt. #8 had a witnessed fall. Fall risk assessments from 05/04/2026-05/15/2026 (discharge) were reviewed, and lacked documentation of a fall risk reassessment after the fall on 05/12/2026 or during the entire shift on 05/12/2026 from 7:00 AM to 7:00 PM. 4. A telephone interview was conducted with the Nurse (E#1) on 05/27/2026, at approximately 10:00 AM. E#1 stated that the patient’s fall risk score should be assessed upon admission, each shift (12 hour shifts), after a fall, and if the patient’s condition changes. 34411 B. Based on document review, observation, and interview, for 1 of 4 (Pt #3) patients observed for fall risk precautions, the Hospital failed to ensure that preventive measures were in place, to reduce or prevent falls, as required per policy. Findings include: 1. The Hospital ’ s policy titled, “Adult Fall Risk Assessment - Fall Prevention Program” (effective 04/23/2025), was reviewed and required, “ ...Moderate/High Fall Risk [Hester Davis score 11 or greater]: When the patient is determined to be at high risk for fall, whether by the Hester Davis score of 11 or greater or by clinical judgement, the following interventions should be considered in addition to the interventions listed previously in Low Risk: Interventions: ...Bed Alarm set to Zone 2 ...” 2. The clinical record for Pt #3 was reviewed on 5/26/2026. Pt #3 was admitted to 3 East on 5/25/2026, with a diagnosis of gastrointestinal hemorrhage (bleeding). The clinical record included fall risk assessments (Hester Davis), on admission and every shift (every 12 hours). Pt #3’s initial fall risk assessment (dated 5/25/2026 at 1:33 PM), included a fall risk score of 19/high (greater than 14 indicates high fall risk). Subsequent fall risk assessments were: high on 5/25/2026 at 5:00 PM; 5/26/2026 at 8:00 AM; and moderate on 5/25/2026 at 8:18 PM. 3. On 5/26/2026 at 10:45 AM, an observational tour of 3 East Medical/Surgical Unit was conducted. During the tour, Pt #3, who was identified as a high fall risk at the time of the tour, was observed for the required fall risk interventions. Pt #3 was lying in the bed, and the internal bed/fall alarm was not activated, as required. 4. On 5/26/2026 at approximately 11:25 AM, an interview was conducted with a 3 East Registered Nurse (E #5). E #5 stated that fall risk interventions include hourly rounding, having bed alarms set, locating the high fall risk patient near the nurse’s station, and fall risk bracelets on. E #3 stated that any patient that is scored as a moderate or high fall risk, should have their bed alarm set while lying in bed.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 3 of 12 (Pts. #3, #5, and #6) emergency department (ED) patients who presented to the ED after 01/13/2026 reviewed, the Hospital failed to ensure that patients’ vital signs were reassessed while in the ED and again prior to discharge, in accordance with policy. Findings include: 1. The Hospital’s policy titled, “Patient Assessment and Reassessment” (effective 01/13/2026), was reviewed and required, “...Appendix B: ...Minimum documentation requirements: Vital signs to include heart rate, respiration, blood pressure, oxygen saturation, heart rhythm, and temperature... Emergency Department: Triage, 30 minutes prior to discharge. Reassessment as appropriate [see interviews below for stated practice]...” 2. The clinical record of Pt. #3 was reviewed on 04/14/2026. Pt. #3 presented to the ED on 02/15/2026 at 8:32 AM for nausea, vomiting, back pain, and headache during pregnancy at 9 weeks gestation. Vitals signs were taken during triage on 02/15/2026 at 8:44 AM and included: Temperature/T = 98.9 F (Fahrenheit) [normal range 97-99 F]; Heart Rate/HR = 72 [normal range 60-100]; Respirations/RR = 18 [normal range 12-20]; Blood pressure/BP = 131/77 [normal range 90/60-120/90]; Oxygen Saturations/SpO2 = 100% on room air [normal range 94-100%]. Pt. #3 was scored at an ESI [emergency severity index] of 3 [on a scale of 1 to 5 where 1= resuscitation, 2 = emergent, 3 = urgent, 4 = less urgent, 5 = not urgent]. Pt. #3 was discharged on 02/15/2026 at 12:30 PM (nearly 4 hours later) without any documentation of reassessment of vital signs. 3. The clinical record of Pt. #5 was reviewed on 04/14/2026. Pt. #5 presented to the ED on 02/16/2026 at 8:11 PM for vaginal bleeding during pregnancy at less than 6 weeks gestation. Vital signs were taken at triage on 02/16/2026 at 8:37 PM and included: T = 98 F; HR = 114; RR = 18; BP = 123/76; SpO2 = 100%. Another set of vitals on 02/16/2026 at 10:30 PM included: HR = 84; RR = 14; SpO2 = 100%. Pt. #5 was scored as ESI 3. Pt. #5 was discharged from the ED on 02/16/2026 at 11:46 PM without documentation of a set of vital signs 30 minutes prior to discharge. 4. The clinical record of Pt. #6 was reviewed on 04/14/2026. Pt. #6 presented to the ED on 02/16/2026 at 5:25 PM with cramping/bleeding at 15 weeks gestation (pregnant). Vitals were taken at triage on 02/16/2026 at 5:52 PM and included: T = 99; HR = 104; RR = 20; BP = 118/68; SpO2 = 100% on room air. Pt. #6 was scored as ESI 3. Pt. #6 was discharged from the ED on 02/16/2026 at 11:43 PM (nearly 6 hours later) without any documentation of reassessment of vital signs. 5. On 4/13/2026 at 1:35 PM, an interview was conducted with the Triage Nurse (E #2). E #2 stated that for a patient with ESI level 3, vitals are assessed at least every 2 hours by the technician. 6. On 4/13/2026 at 3:10 PM, an interview was conducted with Assistant ED Manager (E #3). E #3 stated that a patient with an ESI level 3 should have vital signs taken every 1 to 2 hours. 7. On 4/14/2026 at 11:15 AM, an interview was conducted with the ED Medical Director (MD #1). MD #1 stated that ideally patients (including those in the waiting room) should be reassessed, including vital signs, every one hour.”

“EMERGENCY SERVICES READINESS CFR(s): Effective July 1, 2025, in accordance with the complexity and scope of services offered, there must be adequate provisions and protocols to meet the emergency needs of patients. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 7 of 8 obstetric (OB) patient emergency departent (ED) clinical records (Pt. #1, Pt. #2, Pt. #3, Pt. #4, Pt. # 5, Pt. #6 and Pt. #7) reviewed, the Hospital failed to ensure that ED staff notified the OB Hospitalist Group for OB patients less than 16 weeks pregnant, in accordance with the emergency department’s triage algorithm/protocol for OB patients. Findings include: 1. On 4/13/2026, the Hospital’s Algorithm for “Triage of Obstetrical Patient in the Emergency Department” (undated) indicated: Pregnant Patient - Assessed by ED Triage RN - assess patient chief complaint - assess gestational age: use EDD (estimated due date) if seen by provider, use LMP (last menstrual period) if not seen. <16 weeks - Patient to be seen in Main ED, OBHG (OB Hospitalist Group) to be immediately notified at X2330 for consult after initial ED Provider assessment.” 2. On 4/13/2026, Pt. #1’s clinical record from Hospital A(dated 1/16/2026 through 1/17/2026) was reviewed and indicated: Pt. #1’s ED Care Timeline - Pt #1 care timeline (1/16/2026 at 6:27 PM to 1/17/2026 at 12:16 AM) -6:27 PM - Pt. #1 arrived in ED -6:27 PM - arrival complaint - vaginal bleeding (12 weeks pregnant) -6:35 PM - Primary assessment - airway - within defined limits, breathing - within defined limits, circulation - within defined limits, allergies reviewed -6:38 PM - triage completed by E #2 (Triage Nurse) patient acuity 3 (signifies an urgent patient in emergency department triage -require multiple resources such as blood tests, x-rays, etc. for diagnosis or treatment) vital signs - temperature 97.3 (normal temperature ranges from 97 to 99 degrees), heart rate 87 (normal heart rate is 60 to 100 beats per minute), respirations 18 (normal respirations is 12 to 20 breaths pers minute), blood pressure 112/74 (normal blood pressure generally less than 120/80z), oxygen saturation sP02 100% (normal oxygenation between 95%-100%). Chief complaint updated - vaginal bleeding for 20 minutes prior to arrival at ED - pregnant. Pt. #1 is 12 weeks pregnant, denies abdominal pain and nausea. -6:38:51 PM - orders included: labs - urinalysis, HCG (human chorionic gonadotropin is a hormone produced during pregnancy) comprehensive metabolic panel, CBC (complete blood count), abor for rhig evaluation (Rh immune globulin evaluation - to determine if an Rh negative patient requires Rhig, to prevent sensitization to D-positive fetal cells), and an Ultrasound OB <14 weeks single baby -6:39:27 PM - ED Provider filed by PA #1. ED Triage Note written by PA #1 on 1/16/2026 at 6:38 PM noted, “Chief complaint - Pt. #1 presents with vaginal bleeding -pregnant - vaginal bleeding for 20 minutes prior to admission. Pt. #1 is 12 weeks pregnant. Denies abdominal pain. No fever, chills. Endorses nausea, denies vomiting. Pt. #1 was seen for a cursory exam in triage in an attempt to expedite diagnostic testing and start therapeutic interventions within a limited scope. The expectation is that Pt. #1 will be fully examined in the main department by physician as soon as possible. Physical exam - alert, no acute distress, GI (gastrointestinal) - abdomen is nondistended, Pulmonary - respirations unlabored.” -6:58:26 PM - Specimens collected - CBC and differential, Comprehensive metabolic panel, HCG, Aborh for RHIG evaluation -7:07 PM - Urine clean catch, urine culture 7:15:48 PM - lab resulted - WBC 6.90 (reference range 4.50 -10.50), RBC - red blood cells 4.27 (reference range 4.00 -5.40), hemoglobin 12.7 (reference range 12.1 -16.4), hematocrit 37.5 (reference range 38.0 -50). Comprehensive Metabolic Panel - sodium 133 (reference range 133-144), Potassium 3.5 (reference range 3.5 -5.1), Chloride 102 (reference range 98-107), Carbon dioxide 23.2 (reference range 21 - 31), Creatinine 0.46 (reference range 0.60 - 1.20), Glucose 94 (reference range 70-99) 7:40 PM - Microscopic urine result - RBC urine > 50 (reference range none seen), WBC urine 0-5 (reference range none seen 0-5), Bacteria urine few (reference range none seen) 7:41 PM - Urinalysis - leukocyte esterase urine 1+ (reference range negative), protein urine 2+ (reference range negative), blood, urine 3+ (reference range negative) 9:39:49 PM - Imaging Exam arrived for ultrasound 11:23:25 PM - Imaging Exam arrived for ultrasound 12:16:03 AM on 1/17/2026 - ED disposition set to Eloped. Pt. #1 was never roomed in ED. Pt. #1 remained in waiting area. Labs were drawn in triage. There was no documentation in Pt. #1’s ED clinical record that Pt. #1 came back to triage with new/worsening symptoms. There was no documentation that attempts to call for Pt. #1 to bring back prior to disposition changing. Pt. #1 left Hospital A prior to being roomed. Pt #1’s record lacked documentation that the OB Hospitalist was consulted per the algorithm. 3. On 4/13/2026, Pt. #2’s ED clinical record (dated 2/15/2026) was reviewed and indicated: Pt. #2’s chief complaint vaginal bleeding, 5 weeks pregnant. Pt. #2’s arrival date/time was 2/15/2026 at 7:46 AM, triaged at 8:03 AM, roomed at 8:11 AM and disposition time was 11:24 AM with departure/discharged to home time 11:30 AM. ED Physician (MD#3) notes/summary of visit included, “28-year-old female gravida 2 para 1, last menstrual period 01/12/2026 presents emergency department with mild pelvic cramping and vaginal bleeding this not this morning. CMP and CMP unremarkable. Serum hCG 21,455. Urinalysis has pyuria and bacteriuria. [Transabdominal Transvaginal] Ultrasound shows an intrauterine gestational sac and yolk sac at this time. Differential diagnosis includes early pregnancy versus threatened miscarriage. Plan will be to discharge home and patient has been instructed to keep her appointment with OBGYN on 02/23/2026. Pelvic rest was discussed. Given the patient’s urinalysis, will treat with Keflex for asymptomatic bacteriuria. Parameters for urgent evaluation discussed.” However, there was no OBHG (OB Hospitalist Group) notification noted in the record. 4. On 4/13/2026, Pt. #3’s ED clinical record (dated 2/15/2026) was reviewed and indicated: Pt. #3’s chief complaint was nausea, vomiting, back pain, headache, 9 weeks pregnant. Pt. #3’s arrival date/time was 2/15/2026 at 8:32 AM, triaged at 8:45 AM, roomed at 8:48 AM and disposition time/departure time/discharge to home was 12:30 PM. MD#3’s notes included, “ Patient is a 26-year-old female who is G3P1, approximately 9 weeks pregnant, who presents with complaints of intractable nausea and vomiting since last night. She reports he is unable to keep down p.o. [by mouth] ... She reports this morning she noticed low back pain and occasional pelvic pain. She does report history of hyperemesis with prior pregnancies. She reports that she has been taking OTC vitamin B6 with minimal improvement. She denies abdominal pain, diarrhea, vaginal bleeding, and urinary symptoms. Reports she is scheduled for her 1st ultrasound with [OB doctor] on 3/3. Pt #3 had blood work, pregnancy testing, urine testing, transabdominal transvaginal ultrasound. Discharge instructions included, “Please follow-up with your OB as scheduled. Please call sooner for any worsening symptoms... Return to the ER for any worsening symptoms including intractable nausea and vomiting, abdominal or pelvic pain, vaginal bleeding, flank pain, or any other concerning symptoms. There was no OBHG (OB Hospitalist Group) notification noted in the record. 5. On 4/13/2026, Pt. #4’s ED clinical record (dated 1/17/2026) was reviewed and indicated: Pt. #4’s chief complaint was vaginal bleeding, 8 weeks pregnant. Pt. #4’s arrival date/time was 1/17/2026 at 11:18 PM, triaged at 11:34 PM, roomed at 11:37 PM and disposition date/time was 1/18/2026 at 6:01 AM with departure/discharge to home time 7:15 AM. ED Physician (MD#4) notes included, “The patient ... G3 P2 twin gestation at 8 weeks who presents emergency department for evaluation of vaginal bleeding for the entire week. She has been seen and evaluated at an outside hospital previously had an ultrasound and was told that everything was ‘okay’. Bleeding was worse today, she has gone through 2 pads in the last 24 hours and she feels some pain in her lower pelvis. So she presents the emergency department for further evaluation. Pt #4’s ED course included pregnancy testing, blood work, urinalysis, transabdominal ultrasound, and received Tylenol for pain. There was no OBHG (OB Hospitalist Group) notification noted in the record. 6. On 4/13/2026, Pt. #5’s ED clinical record (dated 2/16/2026) was reviewed and indicated: Pt. #5’s chief complaint was vaginal bleeding. Pt. #5’s arrival date/time was 2/16/2026 at 8:11 PM, triaged at 8:37 PM, roomed at 10:13 PM and disposition date/time was 2/16/2026 at 11:49 PM and departure/discharge to home at 11:46 PM. ED Physician (MD#5) notes included, “ ...presents to the emergency department with chief complaint of Vaginal Bleeding - Pregnant (Vaginal bleeding that started yesterday. Denies pelvic pain or cramping. Is pregnant but unsure LMP or EDD. G2P1.) ... otherwise healthy G2P1 with recent positive pregnancy test unsure of LMP here for vaginal bleeding that feels like menstruation yesterday and today. No other acute complaints ... Beta HCG 61, below discriminatory threshold, [transabdominal transvaginal] ultrasound antibiotic notable for changes consistent with a pregnancy without IUP, also no specific ectopic pregnancy visible. Discussed weeks you possibility of early pregnancy, ectopic or miscarriage. Recommended 48 hour repeat HCG. Instructed to follow up with PCP, OB. Questions answered. Return precautions given. Safe for discharge.” There was no OBHG (OB Hospitalist Group) notification noted in the record. 7. On 4/13/2026, Pt. #6’s ED clinical record (dated 2/16/2026) was reviewed and indicated: Pt. #6’s chief complaint was cramping/bleeding, 15 weeks pregnant. Pt. #6’s arrival date/time was 2/16/2026 at 5:25 PM, triaged at 5:51 PM, roomed at 9:06 PM and disposition/departure time was 11:43 PM. MD#5’s notes included, “[Pt #6 presents to the emergency department with chief complaint of Vaginal Bleeding - Pregnant (Patient presents to ER with concern for vaginal bleeding- patient is approx 15 weeks pregnant, 1st pregnancy. Bleeding started half hour ago, has slowed down since arrival. + abdominal cramping.) ddx includes but is not limited to threatened miscarriage. Plan includes symptomatic treatment labs imaging.” ED course included, blood work, urinalysis, pregnancy testing, Ultrasound OB limited. There was no OBHG (OB Hospitalist Group) notification noted in the record. 8. On 4/13/2026, Pt. #7’s ED clinical record (dated 10/16/2025) was reviewed and indicated: Pt. #7’s chief complaint was vaginal bleeding (6 weeks pregnant). Pt. #7’s arrival date/time was 10/16/2025 at 8:38 AM, triaged at 8:48 AM, roomed at 9:19 AM and disposition time was 1:41 PM and departure at 2:10 PM. Physician Assistant (PA#3) notes included, “ ...G3P1101, 1 spontaneous miscarriage, LMP 9/2, presents ambulatory to the department with spotty vaginal bleeding that began last night. States that she has not needed a pad for the bleeding. Also reports some intermittent abdominal cramping, but denies any pain at present. Denies any fevers. States that she has dysuria at baseline; denies any recent change in this symptom. Has had positive pregnancy test at home and in clinic, but has not yet had an OB appointment. A&O x3 and in no acute distress, conversing comfortably. Declining pain medication at present. Pt #7’s ED course included bloodwork, urinalysis, pregnancy testing, transabdominal and transvaginal ultrasound, and also a renal ultrasound for left flank pain. Pt #7 was given antinausea medication and started on an antibiotic for a urinary tract infection. Discharge instructions included, “Follow-up with your OB to have repeat blood pregnancy test performed in 48 hours. Take Zofran as needed for nausea/vomiting. Finish your entire antibiotic, even if you begin to feel better. Return to the emergency department if your symptoms worsen or if you develop any new symptoms. There was no OBHG (OB Hospitalist Group) notification noted in the record. 9. On 4/13/2026 at 1:35 PM, an interview was conducted with the Triage Nurse (E #2). E #2 stated that if a pregnant patient comes to the ED, the patient is triaged and sent back for a medical screening exam as soon as possible. E #2 stated that if a patient is greater than 16 weeks pregnant, the patient goes straight to the OB department. E #2 stated that if a pregnant patient is less than 16 weeks, the physician/PA will contact the OB physician for a consult. 10. On 4/13/2026 at 2:00 PM, an interview was conducted with Physician Assistant -PA #1. PA #1 stated that PA #1 did a medical screening on Pt. #1. PA #1 stated that PA #1 did not know that the Hospital’s OB protocol was to contact the OB doctor after the initial ED provider assessment was completed. 11. On 4/14/2026 at 11:15 AM, an interview was conducted with the ED Medical Director (MD #1). MD #1 stated that the Hospital OB protocol means that OB should be consulted when the patient is seen in the main ED. 12. An interview was conducted with the Physician Assistant (PA#2). PA#2 stated that if the patient is <16 weeks pregnant, the patient will remain in the ED regardless of complaints. PA#2 stated that The OB Hospitalist would be consulted in all instances and will manage the patient based on the OB Hospitalist recommendations. 13. An interview was conducted with the OB Hospitalist (MD#2) on 4/14/2026 at approximately 9:40 AM. MD#2 stated that there is always a OBHG on duty on-site 24/7 to screen patients presenting to OB Triage/ED. MD#2 stated that they see all patients over 16 weeks unless they have a serious medical concern (not OB related) that is better treated in the ED. MD#2 stated that for patients less than 16 weeks gestation, the provider can call for consult if they feel they need to.”

“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: 39802 Based on document review and interview, for 1 of 3 (Pt. #1) clinical records reviewed for patients requiring discharge transportion via advanced life support ambulance, the Hospital failed to ensure that review of transportation arrangements made by the contracted ambulance service was included as part of the discharge planning department’s ongoing assessment of the discharge planning process. Findings include: 1. The Hospital’s policy, “Non-Emergent Ambulance Transport Policy” (effective 07/29/2022), was reviewed on 01/22/2026 and required, “The purpose of this clinical policy is to provide a guide to medical necessity for non-emergent ambulance transport or Medicar transport of a discharged acute care hospital patient to a designated post-hospital environment ... Procedure/Guideline: Acute care hospital is required to complete the Physician Certification Certificate (PCS) Ambulance form at the time of non-emergent ambulance request for all payors ... [and] provide ambulance personnel with completed PCS form at time of transport ... [and] retain a copy of completed PCS form in electronic medical record ...” 2. The clinical record of Pt. #1 was reviewed on 01/21/2026. Pt. #1 was admitted to the Hospital’s ICU (intensive care unit) on 11/09/2025 with a chief complaint of fever and diagnoses of urinary tract infection, cerebral palsy (condition affecting movement and posture resulting from damage to the nervous system), and ventilator dependent. The record indicated that case management arranged for critical care transport of the patient to home on the day of discharge on 11/12/2025; however, the ambulance records indicated that a basic life support transport arrived to pick up the patient and subsequently the patient was sent home without ventilator. 3. On 1/21/2026, the Incident Log (last 6 months) was reviewed and included an incident on 11/12/2025 which involved Pt.#1. The Hospital provided a letter dated 12/31/2025 addressed to Pt. #1’s Insurance Company which was sent in response to a complaint filed by the Insurance Company on behalf of Pt.#1. The letter included - “ ...Summary of Concern from [Insurance Company]: “Customer [POA - Power of Attorney] reported that [Pt.#1] was admitted to this hospital instead of [Hospital] because it was closer. [Pt.#1] was diagnosed with a UTI (Urinary Tract Infection) and did not require a higher level of care. The physician called customer on Wednesday regarding discharge... the [POA] noted that Pt.#1 typically requires transport by critical care ambulance because Pt.#1 is on 24/7 ventilator support. Instead, Pt.#1 was transported home via BLS ambulance without a ventilator, which worsened suctioning after arrival ...Analysis of Concern: ... Superior Ambulance critical care transport was requested to the residence for 7 PM with the following settings and details: trach vent ACVC 10/450/=5/21%, trach bovina 7.0 bedbound, candida auris, with ramp to enter home. This was communicated to the Superior Ambulance Coordinator. When Superior Ambulance BLS transport arrived to transport the patient home, they arrived without a ventilator. Patient was transported to home residence, approximately 3.5 miles away. Shortly after Pt.#1 arrival home, a phone call was received by the ICU RN from [POA] stating that a ventilator was not present. Staff spoke with the patient’s stepfather who confirmed that Pt.#1 was medically stable with no distress. Superior ambulance was contacted on 11/12/2025 following the notification of missing transport ventilator to verify details of the transport request. Superior ambulance did confirm an internal error with placement of the transport request by their coordinator, which resulted in an ambulance without a transport ventilator being sent by Superior. The ICU RN validated a lack of confirmation of the ventilator status with the transport team prior to discharge stating [the RN] had received communication from the prior shift that all necessary transport details and paperwork had been arranged. The ICU manager and Director of Nursing contacted [POA] on 11/13/2025 at approximately 1 PM to apologize, assuring POA that the matter was being taken seriously, had been escalated to executive leadership, a full investigation would take place, and this situation would not be repeated. [POA] thanked the [Hospital] team for reaching out and declined to continue any further communications. An event review and analysis has been completed in collaboration with nursing leadership, Quality and Patient Safety, and Superior Ambulance. To prevent recurrence, the need to complete a thorough SBAR (situation, background, assessment, recommendations) handoff for every patient at shift change regardless of imminent discharge status has been reinforced with all ICU team members. Additionally, moving forward the patient’s RN and Assistant Nurse Manager (ANM) are to complete an additional check prior to discharge transport ensuring all necessary support is in place ...” 4. On 1/21/2026, the Utilization Management Committee meeting minutes from January 2025-December 2025 were reviewed and included tracking of utilization review, length of stay, and readmissions. However, the meeting minutes did not include an ongoing review/assessment of transportation arrangements made by the contracted ambulance service. 5. Interviews were conducted with the On-site Coordinator from Superior [contracted employees through hospital contract with the ambulance company who arrange medical transportation services] (Z#1) and the Superior Risk Manager (Z#3) on 01/21/2026, at approximately 1:45 PM. Z#1 stated that as the coordinator, Z#1 sets up transports by medicar, ambulance or flight for this Hospital. Z#1 stated that Z#1 coordinates between the drivers, paramedics, and EMTs and the Hospital’s nurses and case managers to make sure rides are setup and everything goes smoothly. Z#1 stated that Z#1 was informed of what happened when Z#1 returned to work after the incident. Z#1 stated that after reviewing it, Z#1 discovered that Z#1 missed a question about what is needed for transport which made the request default to BLS. Z#1 stated that in cases where there is a mix-up with the transport requested and the one that arrives, they need to cancel the original request and send out another team. Z#3 stated that following this incident, there is now a double check of the questions in the system to ensure they are all accurately completed. E #3 stated that the ambulance crew/staff were educated on the expectation of the crew to call their safety control line if any issues or concerns regarding type of transportation, to verify arrangements and ensure appropriate transportation was sent. 6. An interview was conducted with ICU Manager (E#2) on 01/21/2026, at approximately 12:16 PM. E#2 stated that E #2 was involved in the investigation of this incident, and it was found that the ambulance company Coordinator (Z#1) had missed one crucial click when completing the request form which made the transport request default to BLS. E#2 stated that ICU staff are now aware that after this incident, staff must be informed of all crucial information including a full SBAR (situation, background, assessment, recommendation) report and review of all discharges. E#2 stated that the Assistant Nurse Manager on duty along with the primary nurse must review all discharges to confirm the discharge plans. E#2 stated that the expectations were communicated verbally during daily huddles to the staff. E#2 stated that they have not had any reoccurrence since this happened. 7. An interview was conducted with the Director of Care Management (E#8) and the Manager of Care Management (E#9) on 01/22/2026, at approximately 9:40 AM. E#8 stated that E#8 has been in this role since about 07/27/2025. E#8 stated that their departments meets monthly to review metrics for discharge planning evaluations and completion of required forms. E#8 stated that they do not track metrics or data related to transportation arrangements made through the contracted ambulance service/coordinators. E#8 and E#9 stated that they were both made aware of what happened with Pt. #1. E#9 stated that E#9 reviewed the case management notes and they did not find any concerns with how the case manager handled the case, as the correct transportation arrangements were made and notes were documented in the record. E#8 stated that E#8 spoke with the ICU Director at the time (no longer works here) and told them that the floor nurses need to make sure to confirm that the correct transportation comes for the patient. E#8 stated that Care Management staff is not on-site 24/7 and therefore it is more on the nursing side to ensure that these verifications are done at the actual time of discharge. E#8 stated they have four Regional Managers who are on-call 24/7 in 2-week rotations that are available to be reached if any concerns with case management (i.e. transportation arrangements) arise when a case manager is not physically on-site (i.e. after hours). E#8 stated that their department was not formally involved in developing the action plan in response to this event, but E #8 was able to verbalize the actions taken to ensure contracted Superior staff double check all requests for appropriate transportation when arranging transportation services, and that nursing staff was informed to verify correct transportation arrives and contact Care Management if any issues. E#8 stated that their system for transportation requests (Aidin) has a report that they can run to see when requests are made, accepted, and then reserved, but this is not something that Case Management reviews as part of their discharge planning process assessment.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 4 (Pt #1) clinical records of minors who presented to the ED (emergency department) for treatment, the hospital failed to ensure that informed consent regarding care of patient seeking psychiatric care, was obtained as required. Findings include: 1. The hospital’s policy titled, “Informed Consent for Non-Experimental Procedures or Treatments (11/22/2024), was reviewed, and required, “ ...Who Must Provide Consent ...Exception Based on Type of Treatment. d. i. A minor sixteen (16) years of age or older may give his or her own consent for voluntary inpatient mental health treatment and execute the application ...” 2. The clinical record for Pt #1 was reviewed on 3/17/2025. Pt #1 presented to the ED (emergency department) on 12/18/2024 at 1:27 PM, via EMS (emergency medical services), for a psychiatric evaluation. Pt #1 was transferred to a psychiatric facility on 12/19/2024. - Pt #1’s Treatment and Consent Agreement was reviewed. The consent was signed on 12/18/2024 at 4:52 PM by the Consumer Access Specialist (E #9). The consent included, “Patient is a minor unable to obtain.” The consent was not obtained by Pt #1 [self], as required per policy. The clinical record did not contain any additional consent forms. -The ED Triage note (dated 12/18/2024 at 1:32 PM), included, “Chief Complaints: Psychiatric Evaluation (Patient with suicidal ideation X (times) 2 days, denies plan or intent at this time ...)” - An ED Note documented by the A & R (Assessment and Referral) Social Worker/E #4, (dated 12/18/2024 at 3:20 PM), included, “Per school counselor ... pt’s [parent] (Z #2) was informed that pt was reporting SI [suicide ideation] and that [Z #2] would need to come to the school, [Z #2] refused and counselor stated pt would be taken in ambulance to ED and [Z #2] ‘said go ahead and send [Pt #1]’, still refusing to come to ED to meet pt here. Spoke with [Z #2] on phone, [Z #2] provided verbal consent for treatment stating pt does not need anyone with [Pt #1] because this is a mental health issue. This writer and DON [Director of Nursing] informed [Z #2] that pt is a minor, [Pt #1] is not petition-able ...DON informed pt we are here to take care of the pt and that we would see [Z#2] when [Z #2] presents to the ED...” - An ED note documented by the ED Charge RN (E #3), dated 12/18/2024 at 3:46 PM, included, “This RN received a phone call from the parent of this patient who was very upset. Parent was told there need to be a guardian present to make medical decisions for the patient. Parent then explained that neither their mother or father would not be coming because (Pt. #1) is over 12 years old and can therefore make medical decisions for [self] regarding mental health exam. This RN explained I am not informed of that Law and our policy is we need a guardian to be present or we are to inform DCFS (Department of Children and Family Services)...Parents were ultimately requested to be present ...” The clinical record lacked an informed consent signed by Pt #1. 3. On 3/17/2025 at 3:07 PM, an interview was conducted with the Consumer Access Specialist (E #9). E #9 acknowledged that E #9 signed Pt #1’s Hospital consent and HIPPA (Health Insurance Portability and Accountability Act) form. E #9 stated that E #9 signed Pt #1’s consent form since Pt #1 was unable to sign as a minor. 4. On 3/17/2025 at 11:30 AM, an interview was conducted with the ED Manager (E #2). E #2 stated that at the time when Pt #1 presented to the ED, the patient was 16. E #2 stated that the staff would usually get consent for treatment of minors from the parents. E #2 stated that E #2 is now aware that patients16 and over can consent for psychiatric care. E #2 stated that there has not been any formal education on the consent process since the incident with Pt #1. 5. On 3/17/2025 at 1:15 PM, the Regional Director of Accreditation and Regulatory (E #1), confirmed with the ED Educator (E #8) that education has not been provided following Pt #1’s ED encounter. 6. On 3/18/2025 at 10:25 AM, an interview was conducted with the A & R Manager (E #12). E #12 stated that a patient that presents to the ED who is 16 years or older seeking psychiatric treatment, can consent on their own. E #12 stated that attempts are still made to contact the family/guardian to keep them informed of the care that the patient is receiving.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 3 clinical records (Pt #1) reviewed for psychotropic medication consents, the Hospital failed to ensure Pt. #1 had consents for psychotropic medication. Finding include: 1 .On 4/16/2024, the Hospital’s policy titled, “Administration of Psychotropic Medication” (dated 7/1/2022) was reviewed and indicated, “Purpose of this policy is to ensure patients receiving mental health services are advised of their rights to refuse generally accepted mental health or developmental disability services, including psychotropic medications and to provide written information about treatments and to obtain appropriate informed consent prior to administering these medications other than in an Emergency ... Patients Lacking Capacity - The physician or the physician’s designee shall provide to the patient’s guardian or substitute decision maker, if any, the same written information that is required to be presented to the patient. The consent or refusal of the psychotropic medication will be noted in the medical record.” 2. On 4/15/2024, Pt. #1’s clinical record (dated 1/6/2024 thru 1/23/2024) was reviewed and included: -Pt. #1 with a history of dementia and Parkinson’s disease who presents from the nursing home with worsening mood, increased agitation and aggressive behaviors. -Physician orders (dated 1/6/2024 thru 1/23/2024) noted the following psychotropic medication orders: Seroquel (antipsychotic medication) 25 mg every night (ordered on 1/7/2024 and discontinued on 1/9/2024) Seroquel 37.5 mg TID (three times a day) ordered on 1/11/12024 and discontinued on 1/16/2024. The medication administration record indicated that Seroquel was administered as ordered. However, there was no documentation of consent for administration of psychotropic medication for Seroquel. 3. On 4/16/2024 at 10:45 AM, an interview was conducted with the Regional Director of Regulatory & Compliance (E #1). E #1 stated that Pt. #1 came to the Hospital on Seroquel, so there was no need to get a consent.”

“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: 39802 Based on document review and interview, it was determined that for 1 of 1 Behavioral Health Unit/BHU (Older Adult/Geriatric), the Hospital failed to ensure that the environment of care rounds were completed daily, at each change of shift, per policy. This had the potential to affect all patients on census in the BHU. Findings include: 1. The Hospital’s policy titled, “Patient Safety Rounds Environment of Care Safety Rounds” (effective 1/11/2024) was reviewed and required, “...At each change of shift patient safety and environment of care safety rounds will be performed by two staff members, one from present shift and one from incoming shift... b. Environment of care rounds...” 2. During a tour of the Older Adult BHU on 4/15/2024, the Change of Shift Rounds were reviewed from 4/8/2024 to 4/15/2024. The form, dated 4/12/2024, lacked documentation of room checks for contraband during the evening shift at 7:00 PM. Environment of care rounds for March and early April 2024 were requested from the Director of Behavioral Health Services (E#11) on 4/15/2024, at approximately 11:00 AM. No records were provided by the end of day on 4/15/2024, at approximately 3:30 PM. 3. An interview was conducted with the Assistant Manager of Behavioral Health (E#9) on 4/15/2024, at approximately 10:47 AM. E#9 stated that they conduct the environmental contraband rounds at change of shift every day. E#9 stated that they work 12-hour shifts, so these rounds are done at 7:00 AM and 7:00 PM. 4. On 4/15/2024, at approximately 3:30 PM, the Regional Director of Regulatory and Compliance (E#1) stated that the older logs are destroyed every week after they are reviewed. E#1 stated they keep no record that the logs were reviewed before they are destroyed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 1 of 2 non-violent restraint records (Pt. #9) reviewed, the Hospital failed to ensure that restraints were used in accordance with a physician’s order. Findings include: 1. The Hospital’s policy titled, “Restraint Management” (dated 11/28/2023), was reviewed and required, “...Each episode of restraint... must be ordered by a physician or an authorized licensed practitioner responsible for the patient’s ongoing care. The order shall include the type of restraint...” 2. The clinical record of Pt. #9 was reviewed on 4/16/2024. Pt. #9 was admitted on 3/20/2024 with a diagnosis of altered mental status. Physician’s orders for non-violent restraints for bilateral (right and left) soft wrist restraints was placed on 3/21/2024 at 3:42 AM. Restraint flowsheets indicated that Pt. #9 was placed in bilateral soft wrist restraints, bilateral soft mitt restraints, and side rails up x4 starting on 3/20/2024 at 9:00 PM. The record lacked physician’s orders for use of bilateral mitt restraints and side rails (x4) as restraints. 3. An interview was conducted with the Patient Safety Specialist (E#12) and Assistant Nurse Manager (E#13) on 4/16/2024, at approximately 10:00 AM. E#13 stated that there were no orders in the system for the mitts and side rails. E#12 stated that if all 4 side rails are up, they are considered restraints and require an order for use.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) record reviewed, the Hospital failed to ensure that orders were renewed when the episode of restraint exceed 4 hours for an adult patient. Findings include: 1. The Hospital’s policy titled, “Restraint Management” (dated 11/28/2023), was reviewed and required, “...No event of restraint and/or seclusion of the patient with violent or self-destructive behaviors shall be continued beyond the patient’s age-defined limit unless orders are renewed: a. Four (4) hours for an adult age 18 years or older...” 2. The clinical record of Pt. #8 was reviewed on 4/16/2024. Pt. #8 presented to the Hospital’s emergency department on 3/29/2024 with paranoia. Physician’s orders for violent 4 point locking restraints were placed on 3/30/2024 at 5:05 AM. Restraint flowsheets indicated that Pt. #8 was placed into the restraints on 3/30/2024 at 4:25 AM. The restraint orders were not renewed until 3/30/2024 at 9:26 AM, approximately 5 hours after the restraint episode was initiated. 3. An interview was conducted with the Regional Director of Regulatory and Compliance (E#1) on 4/16/2024, at approximately 2:10 PM. E#1 stated that the restraint order should be renewed before exceeding 4 hours since the time of initiation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) records reviewed, the Hospital failed to ensure that restraints were discontinued at the earliest possible time. Findings include: 1. The Hospital’s policy titled, “Restraint Management” (dated 11/28/2023), was reviewed and required, “...Restraint and seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others... and 3) must be discontinued at the earliest possible time once the unsafe situation ends regardless of the scheduled expiration of the order...” 2. The clinical record of Pt. #8 was reviewed on 4/16/2024. Pt. #8 presented to the Hospital’s emergency department on 3/29/2024 with paranoia. Physician’s orders for violent 4 point locking restraints were placed on 3/30/2024 at 5:05 AM with a renewal order on on 3/30/2024 at 9:26 AM. Restraint flowsheets indicated that Pt. #8 was placed into the restraints on 3/30/2024 at 4:25 AM. At 7:15 AM, the record indicated that Pt. #8 was asleep and remained asleep until 10:00 AM (nearly 3 hours later) when the restraints were discontinued. The record lacked documentation as to why the restraints were not removed earlier when the patient no longer exhibited dangerous behaviors. 3. An interview was conducted with the Assistant Nurse Manager (E#13) on 4/16/2024, at approximately 9:32 AM. E#13 stated that ideally restraints should be discontinued when the patient no longer exhibits the need for them.”