University of Kansas Hospital

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 52070 Based on interview, record review, audio review and facility document and policy review, the facility failed to accept the transfer of a patient who had an emergency medical condition from a referring hospital that did not have the capability to treat the patient for 1 (Patient 21) of 11 patients reviewed for transfers. The failure had the likelihood of resulting in patient care being delayed during a medical emergency. Findings Include: A facility policy titled, “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” revised in 08/2023, indicated, “Accepting Patient Transfers. It is the policy of [hospital name] to accept patients in emergency transfer from within the boundaries of the United States who are suffering from Emergency Medical Conditions that are in need of stabilizing treatment within the capabilities and capacity of this Hospital but not available at the original facility treating the patient. Such acceptance will be without regard to the financial ability or method of payment of the patient, or the age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient. The procedures in this policy apply to all departments of the Hospital and Medical Staff. 1. Requests for transfer will be referred to the Transfer Center. The Transfer Center will determine the caller and the subject of the call. When the caller is a health care provider requesting to transfer a patient from another hospital, the Transfer Center will specifically ask the caller if the patient has an emergency medical condition. If yes, the Transfer Center will ask if the transferring Hospital has the capability and/or capacity to care for the patient. 2. When the caller requests to transfer a patient with an emergency medical condition from a Hospital that does not have capability or capacity to care for the patient, the Transfer Center will automatically accept the transfer or page the appropriate attending based on the on call list and the requested service. The attending will speak with the caller requesting transfer.” Further review revealed “5. Only an Attending physician can decline transfer of patient with an emergency medical condition from a hospital without capability or capacity to care for the patient. 6. The Nursing Director or designee, in collaboration with the medical staff or Administrator on call can make the determination on behalf of the Hospital that Hospital does not have capability and/or capacity to accept the patient. The Nursing Director will notify Transfer Center prospectively of any limits on Hospital capability and/or capacity. 7. Before denying transfer of a patient with an emergency medical condition from a hospital without capability or capacity to provide care, the Transfer Center will consult the Nursing Director or Administrator. 8. If there is a question of capacity, the accepting attending will immediately verify with the Nursing Director or designee whether this facility has the capacity to accept the patient. 9. When the Nursing Director is notified that a transfer may be declined under circumstances where the hospital may be obligated to accept the patient or the transfer request has not been appropriately responded to in timely manner, the Nursing Director will contact the responsible physician and follow chain of command as necessary. 10. Once the patient has been accepted, the Transfer Center will facilitate the transfer including bed assignment, communication between providers, and notification of the Emergency.” Patient 21 Review of a recorded conversation from the above-named hospitals transfer center regarding stroke consultation and transfer request for Patient 21 dated 12/24/24 revealed Staff G, Physician from Facility A, Staff I Physician, and Staff F, Registered Nurse (RN) from the above named hospital were on the call together. Staff G asked to transfer Patient 21, Staff I accepted the transfer, and Staff F began coordinating the transfer. The recording revealed Staff I asked Staff G if he usually cared for stroke patients after giving tenecteplase at Facility A and Staff G responded by saying he usually admitted them to ICU, but he did not have any ICU beds available, he did not have the resources to care for Patient 21 at Facility A, and if they declined his request for transfer he would have to find another facility to accept the patient. The recording revealed Staff I stated she did not see a large vessel occlusion on the CTA, then Staff F, RN stated that if there was no intervention indicated that perhaps Staff G could call Facility C or somewhere else to request transfer for Patient 21. Staff G, then thanked those on the call and added that he would try Facility C, and the call ended. Review of the Transfer Center Report from the above-named hospital dated 12/24/24 at 1:47 PM, revealed Staff G, Physician from Facility A called the Transfer Center on 12/24/224 at 1:47 PM to request transfer of Patient 21. Staff I consulted with Staff G to discuss the patient’s condition; Staff I reviewed images and found that there was no large vessel occlusion, and it was noted by Staff F, RN that the patient would go to another facility for monitoring. Review Patient 21’s “H&P [History and Physical]” from Facility A, dated 12/24/24, revealed the patient arrived at the Emergency Department (ED) on 12/24/24 at 1:11 PM for stroke-like symptoms. Review of Patient 21’s “ED Provider Note” from Facility A, dated 12/24/24 at 1:49 PM, revealed that Patient 21’s initial head CT was consistent with an acute left middle cerebral artery (MCA) stroke. Review of Patient 21’s “ED Provider Note” from Facility A, dated 12/24/24 at 1:55 PM, revealed that Staff G, Physician from Facility A discussed Patient 21’s medical emergency with Staff I, Physician, from the above-named hospital. Per the note, Staff I reviewed the images that were electronically sent to above-named hospital, and Staff I directed Staff G to administer tenecteplase (medication used to break up blood clots) to the patient after their blood pressure had improved. The note indicated that, after tenecteplase was administered and more images were reviewed, the above-named hospital declined transfer of the patient and recommended transfer to another intensive care unit (ICU). Patient 21’s “ED Provider Note” from Facility A, dated 12/24/24 at 2:24 PM, revealed that Staff G discussed the case with Staff H, Physician, at Facility C, and he accepted Patient 21 for transfer. Review of the Neuro ICU Staffing for 12/24/24 indicated that the unit was staffed with 8 nurses during the daytime shift. The Neuro ICU census indicated that on 12/24/24 at 5:00 AM there was a total of 16 patients. Review of the Neurology Schedule indicated that a Neurology Stroke Attending physician was available on 12/24/24 from 7:00 AM to 6:00 PM and a Neurology ICU Resident was available on 12/24/24 from 7:00 AM to 5:00 PM. During an interview on 04/16/25 at 10:49 AM, Staff I, Physician stated that tenecteplase was given to Patient 21, noting the patient was at risk of hemorrhaging due to the mass that was still present per imaging. Staff G stated that he called the above-named hospital to request transfer but was denied, noting Facility A did not have the ability provide the care Patient 21 needed. Staff G stated that he called Facility C to request a transfer and they accepted the transfer of Patient 21. During an interview on 04/15/25 at 4:52 PM, Staff F, RN stated that he suggested Staff G call Facility C because that was Facility A’s associated facility. During an interview on 04/15/25 at 3:33 PM, Staff E, Nurse Manager for Patient Placement and Transfer Center (NMTC) for the above-named hospital stated that, when a facility called for a consultation or a transfer, the call went to a transfer nurse in the Transfer Center. Staff E stated that the transfer nurse could speak to the sending provider, but the attending physician would ultimately accept or deny the transfer. Staff E stated that a nurse should never make the determination regarding whether a patient should be accepted as a transfer or make recommendations for transfer to other facilities. During an interview on 04/16/25 at 3:50 PM, Nurse Manager of Neuro Intensive Care Unit stated that the unit has a total of 28 beds. She indicated her review of staffing records for 12/24/24 showed that the unit was staffed with 8 RNs, one unit clerk, and one stroke nurse who typically did not carry a patient assignment and was available to assist other RNs with their patients. She also stated on 12/24/24, the unit was fully staffed based on the unit census, and they had to float one of the assigned nurses to another unit during that day shift. She stated from 7:00 AM to 3:00 PM on 12/25/24, there were 18 patients on the unit, and from 3:00 PM to 7:00 PM, there were still 18 patients on the unit. She stated that on 12/24/24, there were open beds in the neuro ICU.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47234 Based on record review, policy review, document review, and interview, the hospital failed to ensure it followed requirements for grievance procedures, failed to ensure an environment free of ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation), failed to ensure patients’ right to remain free from abuse and harassment, failed to ensure restraints were ordered by a physician, and failed to ensure that patients in restraints received a face-to-face evaluation. The cumulative effects of this deficient practice resulted in two Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situations. Findings Include: 1. The hospital failed to provide patients and or their representative with written notice of its decision, steps taken on behalf of the patient to investigate the grievance, and the results of the grievance process for 1 of 22 sampled patients (Patient 11). (Refer to A0123) 2. The hospital failed to ensure an environment free of ligature risks for 6 of 6 sampled patients (Patient 1, 2, 3, 4, 5, and 6) that were at risk for self-harm/suicidal ideation. (Refer to A0144) On 09/25/24 at 5:36 PM, Staff E, Senior Director Regulatory and Risk Management, was notified that an immediate jeopardy (IJ) existed at 42 §482.13(c)(2), requirements for Patient Rights: Care in a Safe Setting. The hospital submitted an acceptable Plan of Removal (POR) on 09/26/24 at 9:29 PM. The hospital was notified the written POR was accepted on 09/27/24 at 11:20 AM and removal was validated by surveyors prior to exit on 10/21/24 at 12:30 PM. The POR included the following: “Immediate Jeopardy Removal Plan - Care in a safe setting The [hospital] will take long term corrective action to abate the ligature risk points on 20 identified doors. In the interim, effective immediately, [the hospital] has taken the following actions to remove the Immediate Jeopardy at its [C2] location: Initiated 24/7 rounds on 20 doors with identified potential ligature risk every 15 minutes to ensure no patients are harming themselves. Rounding staff are educated on documenting these rounds - indicating no patients are harming themselves with the doors, on either side. On 9/26/2024 the hospital’s facilities team began removing the ligature points on the doors. The doors are not fire doors and will continue to meet all life safety requirements. The panic/crash bar assembly is being removed from the doors and hard plastic locking plugs are being placed in the screw holes. It is expected all doors will be complete today, 9/26/2024. Rounding on incomplete doors continue.” 3. The hospital failed to ensure patients remained free from all forms of abuse or harassment for 1 of 22 sampled patients (Patient 1). (Refer to A0145) On 09/25/24 at 5:31 PM, Staff E, Senior Director Regulatory and Risk Management, was notified that an immediate jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) existed at 42 §482.13(c)(3), requirements for Patient Rights: Free from Abuse and Harassment. The hospital provided an acceptable POR on 09/26/24 at 11:39 AM and removal was validated by surveyors prior to exit on 10/21/24 at 12:30 PM.” The POR included the following: “Immediate Jeopardy Removal Plan -Protecting Patients from Abuse or Harassment The [hospital] has taken the following actions to remove the Immediate Jeopardy at its [C2] location, effective immediately: Developed a policy to provide steps to take after knowledge of an alleged assault. This Responding to Allegations of Assault policy includes: Instructions to increase the observation level for alleged perpetrator of assault to 1:1 and to separate the alleged perpetrator from other patients. Provide increased observation to 1:1 for the patient reporting the assault. A requirement to contact [police department], Risk Management, forensic nurse leader on call, and clinical leadership. Notifying the covering physician of all patients involved in the allegation. Conducting an immediate assessment of the alleged victim. Notifying appropriate authorities, Kansas Department of Health & Environment. Steps to take to investigate the allegation. Guidance for documentation. A requirement to submit an event report. Clinical staff and physicians working at Strawberry Hill will receive education on the Responding to Allegations of Assault policy. Education will be completed by October 1st or prior to working their next shift. Hereafter, education will be provided during orientation and annually. Developed a risk management guideline to provide investigative steps to take after knowledge of an alleged assault. The clinical risk management team and individuals who take risk management call will receive education on the Investigating Allegations of Assault guideline. Education will be completed by October 1st or prior to the next time they take call.” 4. The hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 3 of 22 sampled patients (Patient 6, 19 and 21) reviewed with restraints. (Refer to A0168) 5. The hospital failed to ensure that a physician, licensed practitioner, or appropriately trained registered nurse performed a face-to-face evaluation within one hour after the initiation of restraint when used for the management of violent behavior for 4 of 22 sampled patients (Patient 6, 15, 19, and 21). (Refer to A0178)”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47233 Based on observation, document review, and interview, the hospital failed to ensure the environment provided safe sleeping suites for patients with safe exit access in case of a fire. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) applicable to the provisions of the Life Safety Code National Fire Protection Association (NFPA) 101, 2012, section 19.2.2.2. Findings Include: The hospital failed to maintain keyless sleeping room doors that do not restrict egress from two patient rooms associated with the Psychiatric Liaison Services (PLS) Unit in the main emergency department (ED) under the 2012 Edition NFPA 101 regarding LSC requirement for Patient Sleeping Room Doors. (Refer to LSC Tag K221) On 10/18/24 at 9:42 AM, Staff E, Senior Director Regulatory and Risk Management, was notified that an IJ existed applicable to the provisions of the Life Safety Code NFPA 101, 2012, section 19.2.2.2. The hospital provided an acceptable plan of POR on 10/18/24 at 6:03 PM and removal was validated by surveyors prior to exit on 10/21/24 at 12:30 PM. The POR included but is not limited to the following: “1. Immediate Closure of the 2 PLS Rooms 2. PLS staff have been reassigned to manage behavioral health patients in the emergency department. 3. When a patient arrives for behavioral health services, staff will conduct an environmental risk assessment prior to rooming the patient to ensure the room is psych safe. 4. Upon arrival in triage, a team member will provide constant observation (CO) for the patient presenting for behavioral health services. The patient will remain on constant observation until discharged or admitted and transported to a ligature safe room. 5. Once the final plan is determined, the facilities team will seek approval of the final plan from a KDHE life safety member. 6. All behavioral health staff and emergency department staff and physicians will be notified via email of the temporary closing of PLS.””

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47234 Based on observation, policy review, document review, and interview, the hospital failed to ensure staff adhered to nationally recognized infection prevention and control guidelines. The hospital failed to ensure staff performed proper hand hygiene, used appropriate personal protective equipment, followed food handling guidelines, maintained a clean and sanitary environment, and collaborated with its QAPI program for infection control. This deficient practice has the potential to place all patients, visitors, staff, and the community at risk to contract and spread infectious and/or communicable diseases. Findings Include: 1. The hospital failed to ensure hospital staff followed their Infection Control policies and procedures. (Refer to A0749) 2. The hospital failed to maintain a clean and sanitary environment. (Refer to A0750) 3. The hospital failed to provide evidence of collaboration with the hospital’s QAPI program on infection control issues. (Refer to A0774)”

“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: 47234 Based on record review, policy review, documentation review, and interview, the hospital failed to provide patients and/or their representative with written notice of its decision on a filed grievance, steps taken on behalf of the patient to investigate the grievance, and the results of the grievance process for 1 of 22 sampled patients (Patient 11). This deficient practice has the potential to place patients or representatives at risk for unresolved grievances/complaints and systemic issues that could lead to harm and other adverse outcomes. Findings Include: Review of a hospital policy titled, “Management of Patient/Family Complaints and Grievances,” revised 06/2021, showed, “...Issues or complaints that are not resolved as just described, are then to be considered grievances. Patients and families have the right to voice complaints and grievances without the fear of recrimination ... PROCEDURE: A. Time Frame: Grievances are to be resolved as soon as possible upon receipt by Patient Relations: i.e. within seven days if possible. For grievances requiring more complex follow-up, resolution is to occur within forty-five days. B. Written response(s): Acknowledgment Letter: If patient’s grievance cannot be resolved within seven days of Patient Relations’ receipt of the grievance, a letter is to be sent to the patient or representative within this time frame with the purpose of acknowledging the grievance and indicating that appropriate follow-up will occur. Resolution Letter: 1. If the patient’s grievance can be resolved within the initial seven-day period following receipt of the grievance by Patient Relations, a resolution letter only will be sent. 2. For those circumstances requiring more extensive follow-up and in which an acknowledgement letter was sent, a resolution letter will also be sent when the follow-up has been completed. 3. A resolution letter is to contain the following information: name of the hospital contact person(s), steps taken on behalf of the patient to investigate the grievance, results of this process, and date of completion. C. Prioritization of complaints and grievances: The most urgent priority is given to complaints or grievances relating to alleged patient harm or abuse. Upon receiving such a complaint or grievance, Patient Relations will immediately notify Risk Management for investigation, unit and/or department management, Human Resources as appropriate, and the Administrative Team ...” Patient 11 Review of Patient 11’s medical record showed a 47-year-old admitted on 02/12/19 at 11:42 PM with a chief complaint of right shoulder pain and a past medical history of intravenous methamphetamine use and osteomyelitis of the cervical spine (rare spine infection). Review of a hospital document titled, “[Staff X2] HR [Human Resources]” undated and untimed, showed that Patient 11 had filed a police report alleging assault while she was a patient at the hospital. Review of a hospital document titled, “Complaints and Grievances,” dated 01/01/19 to 03/30/19 failed to show evidence that the hospital documented that Patient 11 had filed a complaint or grievance with the hospital. During an interview on 10/10/24 at 12:30 PM, Staff E, Senior Director Regulatory and Risk Management, stated, “...I was driving on 2/13/19 at 10:30 AM and got a call from [Local Police Department] regarding [Patient 11] ...” Staff E stated that the incident was not put on the incident log. On 10/09/24 at 2:08 PM, surveyors requested Patient 11’s complete medical record with documented evidence of an investigation and grievance response letter that was provided in response to Patient 1’s grievance. On 10/09/24 at 4:19 PM, surveyors received Patient 11’s medical record without documented evidence of an investigation or grievance response letter. On 10/10/24 at 9:51 AM, surveyors made a second request for documentation of an investigation and grievance response letter. On 10/11/24 at 9:13 AM, surveyors made a third request for documentation of an investigation and grievance response letter. On 10/12/24 at 11:15 AM, surveyors made a fourth request for documentation of an investigation and grievance response letter. After four requests, the hospital failed to provide documented evidence that an investigation was completed or that a grievance response letter was provided to Patient 11.”

“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: 47234 Based observation, policy review, and interview, the hospital failed to ensure the environment at Campus 2 (C2) Behavioral Health was free of ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation). This deficient practice resulted in potential harm for 4 of 6 sampled patients (Patients 2, 3, 4, and 5,) at risk of suicidal ideation, and placed any patient with ideation of self-harm/suicide that received services at C2 at risk for serious injury, harm, or death. Findings Include: Review of the hospital’s policy titled, “Suicide Prevention,” dated 04/2024, showed, “Ligature Risk: a ligature point is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. In order to be considered a risk, the ligature point must be accessible to the patient during a period of time that the patient is not under the continuous observation of staff . . . The hospital conducts environmental risk assessments in areas that might house a patient at high risk for suicide on a routine basis that identifies features in the physical environment that could be used to attempt suicide. . .” Patient 2 Review of Patient 2’s discharged clinical record showed that Patient 2 was voluntarily admitted to C2 on 09/13/24 at 2:55 AM. Patient 2 was admitted for the management of alcohol intoxication without complications, moderate PCP (Phencyclidine, a dangerous illegal hallucinogen drug) use disorder, suicidal ideation, homicidal ideation, auditory hallucination, major depressive disorder, severe alcohol use disorder, and moderate cannabis use disorder. Patient 3 Review of Patient 3’s discharged clinical record showed that Patient 3 was voluntarily admitted to C2 on 08/13/24 at 7:40 AM for treatment of depression, suicidal ideation, unspecified fall, overdose of undetermined intent, severe episode of recurrent major depressive disorder (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world) without psychotic features, borderline personality disorder (a mental health condition that affects the way people feel about themselves and others), generalized anxiety disorder (worrying constantly and can’t control it), and opioid disorder (compulsive use of opioid drugs in increased amounts to achieve the desired effect). Review of Patient 4’s discharged clinical record showed that Patient 4 was admitted to C2 on 07/29/24 at 2:25 PM for the treatment of polysubstance abuse (cannabis, methamphetamine, PCP), dystonia (movement disorder that causes the muscles to contract), substance induced mood disorder, substance induced psychotic disorder (hallucinations and/or delusions due to the direct effects of substance or withdrawal from a substance in the absence of delirium), post-traumatic stress disorder (PTSD, psychiatric disorder in people that have experienced traumatic event resulting in heightened anxiety and flashbacks), ADHD (attention deficit hyperactivity disorder, inattention, hyperactivity, and impulsivity that interferes with everyday life) mood disorder, and personality disorder (lifelong pattern of seeing themselves and reacting to others in ways that cause problems). Patient 5 Review of Patient 5’s inpatient medical record showed that Patient 5 was admitted to C2 on 06/14/24 at 6:39 AM with a diagnosis of suicidal ideation. Past medical history includes Severe episode of recurrent major depressive disorder, without psychotic features; anxiety disorder; PTSD; recurrent falls; and neurocognitive disorder (decreased mental function due to medical disease other than a psychiatric illness). Observation of the hospital’s Campus 2 (C2) for behavioral health on 09/25/24 between 11:22 AM and 2:10 PM showed a 3-floor facility with two units, Unit 2/second floor and Unit 3/third floor. Each unit had two areas divided by patient acuity. The higher acuity area known as the “Red Zone” is dedicated to patients that struggle with appropriate boundaries or aggressive behaviors. Double doors separate the general milieu and the Red Zone. Observation of the units showed each unit with 10 double doors (total of 20 doors) with a square metal bar, approximately one-half inch, attached at the center of the door to the locking mechanism at the top left edge of the door. Behind the square metal bar was a gap large enough to allow the surveyor’s hand to slide through flatly, posing a ligature risk. Further observation showed that the same bar was present on each side of the door. Observation of the patient areas showed that patients had access to their clothing, towels, blankets, and sheets that could be slid under the bar and used for strangulation/hanging oneself. During an interview on 09/25/24 at 11:22 AM, Staff F, Director of Mental and Behavioral Health Operations, was informed of the doors posing a ligature risk and acknowledged the finding and confirmed the doors posed a ligature risk and opportunity for patients to perform self-harm/strangulation.”

“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: 47234 Based on policy review, record review, video surveillance review, and interview, the hospital failed to ensure that patients were free from abuse, mistreatment, neglect, and/or exploitation when they failed to ensure thorough investigations of all allegations of abuse, failed to report allegations of abuse to the state agency, and failed to show evidence that patients were protected during their investigation for 2 of 22 sampled patients (Patient 1 and 11). This deficient practice placed any patient receiving services at this hospital at risk for serious injury and harm. Findings Include: Review of a hospital policy titled, “Abuse Assessment Program: Key Components For Preventing, Protecting/ Investigating, And Reporting Abuse In Patients and Employees,” revised 09/2022, showed, “ ...Require Social Worker involvement and facilitation of follow-up for suspected or verified abuse. Initiate an immediate investigation when there is an incident/complaint of patient harm or reported abuse with the involvement of unit/department management, medical staff, Risk Management, Human Resources, as appropriate, and the Administrative team. Patients are supported during the investigation processes and are made aware of their right to speak to the [police department] ... Reporting/Responding ...Maintain a policy which places accountability for mandatory reporting with all members of the clinical care team and involvement with the Department of Case Management/Continuum of Care/Department based (Social Workers) to assure consistent, expert reporting in accordance with State and Federal law. Activate response (via Social Work, [advocacy groups], Nursing, and Security as needed) to facilitate patient/employee safety and/or secure shelter ...” Review of an attachment titled, “Patients’ Rights Document (Adult)”, undated, to the facility’s policy titled, “Patient Rights and Responsibilities,” revised 11/2023, failed to show that patients have a right to care in a safe setting, including the right to be free from abuse or harassment. Patient 1 Review of Patient 1’s inpatient medical record showed a 21-year-old that was admitted to the hospital’s Campus 2 (C2) behavioral health on 09/06/24 with a diagnosis of adjustment disorder with mixed disturbance of emotions and conduct (a response to a stressful point in one’s life that involves a combination of emotional and behavioral challenges). Patient 1 had a past medical history of intellectual disability (a condition that limits a person’s mental, functioning, and skills, such as learning, communicating, and take care of one-self) and depression. Patient 1 had a documented mentality between 8-14 years of age. Review of a surveillance video dated 09/16/24 at 9:06:29 PM through 9:08:53 PM, showed Patient 1 leaning up with arms on table and appeared that Patient 2 placed his hand under the table near Patient 1. The video appeared to show Patient 2 placed his hand/arm under the table and touched Patient 1’s groin area. Review of a document titled, “Progress Notes,” dated 09/17/24 at 1:28 PM showed, “Patient [Patient 1] asked this RN [registered nurse] to have a private conversation. Once in the patient’s room she disclosed that a male peer on the unit [Patient 2] inappropriately touched her “down there” and indicated to her vagina. She said that this occurred 2x [twice] on 9/16, once after lunch and once at around 2100 [9:00 PM]. She said that she felt uncomfortable by his advances but was unable to say no or set boundaries due to being scared. The male patient [Patient 2] that she was engaging with has a history of angry outbursts. [Patient 1] also told me that this patient [Patient 2] has told her that he loves her, that he wants to marry her, that she is welcome to come live with him after discharge, that he wants her to have his baby, and that he will attempt to sneak into her room at some point to sleep with her. [Patient 1] later said that during the first occurrence after lunch that the male patient told her to take off her panties and she did. Staff have been alerted to the situation and the necessary actions are being carried out. Will closely monitor to ensure no further inappropriate contact occurs.” Review of a document titled, “Psychiatry Progress Note,” dated 09/17/24 at 2:47 PM showed, “ ...PLAN ... 5. Implement a behavioral plan due to inappropriate boundaries regarding peers 6. Transfer to ED [emergency department] for SANE [sexual assault nurse examiner] evaluation 7. RISK management has been contacted and patient is on an IO due to inappropriate sexual behaviors ...” Review of a document titled, “In-Hospital Transfer Note,” dated 09/17/24 at 2:48 PM showed, “ ...Patient is being transferred to the ED for a SANE evaluation after another patient at [Hospital] reportedly inappropriately touched her in the genital region ...” Review of a document titled, “ED Initial Provider Note,” dated 09/17/24 at 9:17 PM showed, “ ...5. Patient is medically stable for discharge back to [campus], swabs from SANE nurse will result and SANE nurse will follow ...” During an interview on 09/24/24 at 3:43 PM, Staff E, Registered Nurse (RN ) stated, “ ...we do not do our own risk investigation unless it had staff involved, with this we immediately got police involved ...” During an interview on 09/24/24 at 3:46 PM, Staff H, Behavioral Health Case Manager stated that [sexual assault advocacy group] was not involved in this case and unaware of any policy related to sexual assault. During an interview on 09/09/24 at 4:08 PM, Staff I, RN, stated that a physician was not notified that Patient 1 had complained of inappropriate touching by Patient 2 because “no harm was done to the patient.” Staff I stated that a physical assessment of Patient 1 was not performed because they had reviewed camera footage and “it didn’t look like we needed to do an assessment of her body ... it [touching] was very brief and over the pants.” Patient 11 Review of Patient 11’s medical record showed a 47-year-old admitted to Campus 1 (C1) on 02/12/19 at 11:42 PM with a chief complaint of right shoulder pain. A past medical history showed intravenous methamphetamine use and osteomyelitis of the cervical spine (rare spine infection). Review of Patient 11’s medical record showed that the patient was taken to the radiology department on 02/13/19 for a Magnetic Resonance Imaging (MRI). Review of a hospital document titled, “[Staff X2] HR [Human Resources]” undated and untimed showed, “Issue: Patient filed a police report indicating that this employee [Staff X2] sexually assaulted her when she was at the hospital for an MRI ...” Further review of the document showed that Patient 11 had alleged that Staff X2 had touched her nipple. Staff X2 was interviewed by the facility about the alleged incident. Staff X2 stated that Patient 11’s top half was exposed when she changed gowns and when EKG leads had to be removed from her chest. Staff X2 stated, “The only contact I would have had with a nipple would be inadvertent brushing to reach down and getting a lead. It is a blind reach to grab at the lead. If I was moving her where my arm might have been across her breast, it was just moving her ...” Review of a hospital document titled; “Event Log” dated 02/2019 failed to show any alleged abuse occurred on 02/13/19. Review of a hospital document titled, “Complaints and Grievances” dated 01/01/19 to 03/30/19 failed to show evidence that the hospital documented that Patient 11 had filed a complaint or grievance with the hospital. During an interview on 10/10/24 at 12:30 PM, Staff E, Senior Director Regulatory and Risk Management, stated, “ ...I was driving on 2/13/19 at 10:30 AM and got a call from [Local Police Department] regarding [Patient 11] ...” Staff E stated that the incident was not put on the incident log. On 10/09/24 at 2:08 PM, surveyors requested Patient 11’s complete medical record with any investigation or grievance response letter the hospital documented on Patient 1’s grievance. On 10/09/24 at 4:19 PM, surveyors received Patient 11’s medical record without documented evidence of an investigation or grievance response letter. On 10/10/24 at 9:51 AM, surveyors made a second request for documentation of an investigation and grievance response letter. On 10/11/24 at 9:13 AM, surveyors made a third request for documentation of an investigation and grievance response letter. On 10/12/24 at 11:15 AM, surveyors made a fourth request for documentation of an investigation and grievance response letter. After four requests, the hospital failed to provide evidence that an investigation was completed or that a grievance response letter was provided to Patient 11. The hospital failed to show evidence a complete investigation was conducted for the alleged sexual abuse to Patient 11.”

“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: 47233 Based on policy review and document review, the hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 3 of 22 sampled patients (Patient 6, 19 and 21) reviewed with restraints. This deficient practice placed any patient receiving services at this hospital at risk of unauthorized restraints that may lead to serious injury and harm. Findings Include: Review of a Hospital policy titled, “Restraint/Seclusion Use for Violent/Self-Destructive Behavior,” revised 02/2023, showed, “ ...For the purpose of this policy, restraint refers to both mechanical restraints and physical holds ... 2. The order for restraint or seclusion shall be documented in the medical record. Restraint/seclusion shall not be ordered PRN or as a standing order. The LIP [Licensed Independent Provider] who orders the safety intervention and/or the nurse that obtains a verbal/telephone order in an emergency shall document the following in the order: a. Type of restraint 1. Mechanical restraints, physical hold, or seclusion ... Physical Holding - Patients who are physically held in order to restrict the patient’s movement against the patient’s will is considered a restraint ...” Patient 6 Review of Patient 6’s medical record showed a 24-year-old admitted to Campus 2 (C2) on 09/13/24 at 9:01 AM with a diagnosis of Mania (display an over-the-top level of activity or energy, mood, or behavior). Patient 6 has a past medical history of bipolar disorder (mental health condition that causes extreme mood swings). Review of a document titled, “Progress Notes,” dated 09/14/24 at 7:33 AM, showed, “ ...He attempted to push a BHT [Behavioral Health Technician] who was trying to verbally deescalate him. Provider notified and Stat [immediate] order for Zyprexa 10mg [antipsychotic medication] received. [Police Department] called to assist with IM [intramuscular] injection. Patient postured at PD [Police Department], threatened, attempted to reach for their taser, and required a hold [type of physical restraint] while IM was given ...” Review of a document titled, “Psychiatry History & Physical,” dated 09/14/24 at 10:49 AM, showed, “ ...He has been given Zyprexa for agitation. Patient has also postured at [Police Department], attempted to reach for the taser and was required to hold [type of physical restraint] while the intramuscular [IM] injection was given. Zyprexa 5 mg injection also given. Patient is tangential [communication of the speaker wanders and shows a lack of focus] hyperverbal [excessive speaking] and has delusions that are ongoing...” Review of a document titled, “Progress Notes,” dated 09/14/24 at 9:05 AM, showed, “Patient observed banging on the Red Zone [secured, high acuity behavioral unit area] Exit door and ultimately broke the door. Patient has been yelling incessantly. It was explained to patient that his behavior would result in additional PRN’s [as needed medication] being given. [Police Department (PD)] was called. Patient refused PO [oral] medication. IM was given while patient was held [type of physical restraint] because he was struggling with PD [Police Department].” Review of Patient 6’s medical record failed to show documented evidence of a Physician’s order to physically hold (type of physical restraint) Patient 6 for the administration an IM injection as required per hospital policy. Patient 19 Review of Patient 19’s medical record at Campus 2 (C2) showed a 37-year-old that was admitted on 02/23/24 with a diagnosis of post-traumatic stress disorder (PTSD, a mental health condition caused by a traumatic event). Review of an Emergency Department note dated 02/24/24, showed, “IM Zyprexa given and patient placed in restraint chair @ 0704 [at 7:04 AM].” Review of Patient 19’s medical record failed to show a Physician’s order to physically hold (type of physical restraint) Patient 19 for the administration an IM injection and failed to show an order for Patient 19 to be placed in a restrain chair as required per hospital policy. Patient 21 Review of Patient 21’s medical record at Campus 1 (C1) showed a 52 -year-old that was admitted on 09/27/24 with a diagnosis undifferentiated schizophrenia (a mental health disorder that affects the ability to think, feel, and behave clearly.) Review of an incident report dated 10/08/24 at 3:19 PM, showed on 10/02024 at 9:39 AM, “ ...Patient [Patient 21] was placed in restraints during a BRT [Behavioral Response Team] and there was not an order placed. Based on the documented behavior, there should have been a violent restraint order placed ...” Review of a document titled, “Progress Notes,” dated 10/02/24 at 11:14 AM, showed, “Behavior Response Team (BRT) Activation BRT Start Time 0939 [9:39 AM] ...placed pt [patient] in two-point restraints, both wrists ...” Review of Patient 21’s medical record failed to show documented evidence of a Physician order for the use of violent restraints on Patient 21 as required per hospital policy and procedure.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and interview, the hospital failed to ensure a patient in restraints was assessed face to face by a physician or other trained licensed practitioner after the initiation of restraints/seclusion for violent/self-destructive behavior as required per hospital policy for 4 of 22 sampled patients (Patient 6, 15, 19 and 21). This deficient practice placed any patient placed in restraints at this hospital at risk for serious injury and harm. Findings Include: Review of a hospital policy titled, “Restraint/Seclusion Use for Violent/Self-Destructive Behavior,” revised 08/2021, showed, “ ...A face-to-face evaluation by the LIP [Licensed Independent Provider] must be performed as soon as possible but no later than one hour after the initiation of the restraint for violent/self-destructive behavior. A face-to-face evaluation by the LIP must be completed even if the restraint episode ended prior to the LIP’s arrival ...” Patient 6 Review of Patient 6’s medical record showed a 24-year-old admitted to Campus 2 (C2) on 09/13/24 at 9:01 AM with a diagnosis of mania (over-the-top level of activity or energy, mood, or behavior). Patient 6 had a past medical history of bipolar disorder (mental health condition that causes extreme mood swings). Review of a physician order dated 09/14/24 at 9:15 AM showed that Patient 6 was placed in seclusion for having violent behavior. On 09/14/24 at 9:45 AM, Staff M, Registered Nurse (RN) documented a face-to-face evaluation on Patient 6. On 09/15/24 at 2:15 AM, Staff B, RN documented a face-to-face evaluation on Patient 6. On 09/15/24 at 4:54 AM, Staff N, RN documented a face-to-face evaluation on Patient 6. Patient 15 Review of Patient 15’s medical record showed a 21-year-old that was admitted to Campus 1 (C1) on 05/21/22 with a diagnosis of aggressive behavior. Past medical history included cerebral palsy with anoxic brain injury (lack of oxygen to the brain); obsessive compulsive disorder (OCD) (pattern of unwanted thoughts and fears known as obsessions); and attention deficit hyperactivity disorder (ADHD) (mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity, and impulsive behavior). Patient 15 was transferred to C2 on 11/14/22 for continued aggressive behaviors. Review of Patient 15’s medical record showed from 11/06/22 at 5:47 PM through 02/05/23 at 9:15 PM Patient 15 was placed in Violent Restraints/Seclusion 81 times. Review of the face-to-face evaluations showed the evaluations were completed by an RN 77 of 81 times. Patient 19 Review of Patient 19’s medical record showed a 37-year-old that was admitted to C2 on 02/23/24 with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition caused by a traumatic event). Review of an order dated 02/24/24 at 7:15 AM, showed Patient 19 was placed in restraints for aggressive behavior. On 02/24/24 at 7:50 AM, Staff Q2, RN, performed a face-to-face evaluation while Patient 19 was in restraints. Patient 21 Review of Patient 21’s medical record at Hospital 1 showed a 52 -year-old that was admitted on 09/27/24 with a diagnosis undifferentiated schizophrenia. Review of Patient 21’s medical record failed to show a one-hour face to face was completed for the use of violent or self-destructive behavior. During an interview on 09/24/24 at 4:08 PM, Staff I, RN, stated that no official training for face-to-face evaluations for patients in restraints/seclusion had been provided to nursing staff. During an interview on 09/24/24 at 4:40 PM, Staff J, RN stated, “I have had no training on face-to-face [evaluations]. Another nurse that was not involved in the restraints would complete it. I would not know how to document a face-to-face [evaluation].” During an interview on 09/25/24 at 12:11 PM, Staff K, Doctor of Osteopathic Medicine (DO) stated that nurses complete the face-to-face evaluations for patients in restraints/seclusion and stated, “ ...physician never has to see the patient while in restraints ...” During an interview on 09/26/24 at 4:12 PM, Staff G, RN stated that staff don’t receive on-board training for face-to-face evaluations for patients in restraint/seclusion and stated, “ ...it [training] wouldn’t be until it’s happening ...” The hospital failed to ensure that patients received a face-to-face evaluation by a qualified Licensed Independent Provider while in restraints/seclusion as required per hospital policy.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47233 Based on observation, document review, and interview, the hospital failed to maintain keyless sleeping room doors that do not restrict egress from two patient rooms associated with the Psychiatric Liaison Services (PLS) Unit in the main emergency department (ED) under the 2012 Edition NFPA 101 regarding LSC requirement for Patient Sleeping Room Doors. This deficient practice placed any patient receiving services at this hospital at risk for potential injury, harm, or death. Findings Include: On 10/14/24, between 11:48 AM and 1:56 PM, the following observations were made in the Psychiatric Liaison Service (PLS) Area at Campus 1 (C1): The PLS area is a secured unit within the hospital’s Emergency Department (ED) for the observation and care of behavioral health patients. The secured unit contains a Nurses’ Station with two (2) single occupancy patient rooms, one on each side of the Nurses’ Station. Each patient room features two doors, each equipped with three deadbolt locks that require a physical key to unlock. In case of a fire or emergency staff would have to use a single key and unlock a total of 12 deadbolt locks between the two rooms to evacuate patients. During an interview on 10/15/24 at 12:46 PM, Staff G2, Registered Nurse (RN), stated that the key to the deadbolts is located on a keyring at the whiteboard in the nurses’ station. Staff G2 stated that there is only one (1) key available to PLS staff for unlocking the individual deadbolts. During an interview on 10/16/24 at 1:53 PM, Staff V2, Director of Maintenance, stated that the master key does not unlock the deadbolts to the two (2) patient rooms in the PLS area. Staff V2 stated that if access to PLS patient rooms is needed the only key available is in the nurses’ station. If a key breaks in the deadbolt, maintenance would be called to force the door open if necessary. The requirements for door locking arrangements per, “NFPA 101, 2012, section 19.2.2.2,” showed, “Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met: (1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6. (2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space. (3) * The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1. (4) The locks are electrical locks that fail safely, releasing upon loss of power to the device. (5) The locks release by independent activation of each of the following: (a) Activation of the smoke detection system required by 19.2.2.2.5.2(2) (b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)” During an interview on 10/16/24 at 1:30 PM, Staff T2, Assistant Director, stated that fire drills are conducted in the core area of the Emergency Department approximately every 18 months. Staff with patients during a fire drill are not required to participate. Fire drills specifically for the PLS area are not conducted. Staff T2 was uncertain if the master key would unlock the deadbolts in the PLS area. When asked what would happen if a key broke off in a deadbolt lock, Staff T2 was unable to provide an answer. The hospital could not provide documented evidence of emergency evacuation drills conducted specifically for the PLS unit that included behavioral health patients. During an interview on 10/11/24 at 10:10 AM, Staff G2, RN, stated that the PLS unit is always at full capacity except during room cleaning between patients. During an interview on 10/15/24 at 2:18 PM, Staff W2, Director of Security, stated that security may or may not have keys to the PLS area. The hospital failed to comply with its policy regarding a Code Red Event by not ensuring that each staff member working in the PLS area had the required key on their person.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47234 Based observation, policy review, and interview, the hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines. The hospital failed to ensure staff performed proper hand hygiene, used appropriate personal protective equipment, handled and/or stored blood products per policy, and failed to provide appropriate food handling at Campus 1 (C1), Kitchen 2. This deficient practice had the potential to place all patients, visitors, staff, and the community at risk to contract and spread infectious and/or communicable diseases. Findings Include: Review of a hospital policy titled, “General Food Preparation and Handling,” dated 2021, showed, “Procedure: 1. The kitchen will be kept neat and orderly. 2. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate ...” Review of hospital policy titled, “Accepting Food Deliveries,” dated 2021, showed, “... Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate...” Review of hospital policy titled, “Hand Hygiene,” dated 9/2021, showed, “[Hospital] to minimize risk factors for transmission of infectious organisms from the hands of health care providers ...hand washing with soap and water is required when hands are visibly soiled...should be washed for at least 20 seconds. In all other situations, hand hygiene with either alcohol hand rub ...” Review of hospital policy titled, “5.02 Standards of Appearance,” revised 08/2024, showed, “ ... Footwear is to be appropriate for the work area. Shoes must be professional, in good condition, clean, polished, tied and properly fitted. Safety is to be the major factor when selecting footwear for work. For this reason, shoes in patient-care areas and other areas that may pose a safety hazard are to have a solid, impermeable top and closed toes. Socks are to be worn with professional-style Crocs (professional crocs are specified on the store label). In patient-care areas, shoes must be impermeable to liquids (shoes with mesh must have a liner); open-heel shoes are acceptable. House slippers, flip flops, light-up shoes, excessively high platform shoes or stiletto heels (higher than 4 inches) are not allowed in any unit or department ...” Review of hospital policy titled, “Laundry Handling and Processing,” dated 9/2022, showed, “Collection: Soiled laundry from patient care areas is handled as little as possible and is bagged in location of use. Leak-proof bags are used to contain and transport contaminated laundry, to prevent soak through and leakage of fluids...Clean linens will be covered or in a closed cabinet to prevent contact with airborne or surface contaminants...” Review of hospital policy titled, “Inventory and Cost Control,” dated 2021, showed, “The director of food and nutrition services or designee will ...Follow the “first in, first out: method to use all food before it expires ...Review menus prior to completing food orders...” A tour of Campus 1 (C1) Emergency Department, on 10/09/24 at 9:45 AM, showed significantly soiled flooring from entry door to main desk area. A tour of C1’s Burn Unit on 10/09/24 at 9:45 AM, showed a shared bathroom had dirty linens and towels from the previous patient on the floor. During the observation Staff A2, Registered Nurse Manager (RNNM) reported being unaware of how long items were left in the bathroom. Staff A2, RNNM, stated that the bathroom is cleaned between every patient use. A tour of C1 Hematology, Oncology, and Bone Marrow unit on 10/10/24 at 1:25 PM, showed a sign posted outside the entry door of the unit that stated, “Follow the instructions on the monitor to clean your hands and any belongings.” Staff G2, Registration, entered the unit with a computer on wheels (COW). Staff G2 did not wipe down the COW cart prior to unit entry. During an interview on 10/10/24 at 1:46 PM, Staff D2, Registered Nurse (RN), stated that protocol requires all visitors and staff to wash hands, put on a surgical mask, and wipe down any items prior to entering the unit. Staff D2, RN, stated that all staff and family should be following this protocol but the cleaning of items entering the unit is often missed by staff and family. During an interview on 10/10/24 at 2:00 PM, Staff F2, Registration Manager, stated that the COW should not be taken into a room for a patient on contact precautions. Staff F2 stated that staff are trained to gown and glove up properly and should utilize a tablet instead of the COW for any documentation required in an isolation room. Staff F2 denied any designated unit specific COW used for the Hematology, Oncology, and Bone Marrow Units. Staff F2, stated that all COWs are cleaned daily when returned to registration. An observation at C1 Unit 46, on 10/11/24 at 1:33 PM, showed the following: 1. A soiled bedside commode was stored in the hallway for an extended period of time which included two separate observations on different days. 2. Dirty linens were left on discarded equipment in breezeway. 3. Unattended and unlocked housekeeping carts 4. An open trash can over flowing with trash and one additional bag on the floor next to trashcan. 5. A dirty hand sanitizer dispenser with debris and hair in the drip catcher 6. Debris on floor, stains, and aged smears throughout units and hallways. 7. A Clean Linen cart uncovered in breezeway. An observation of C1 Emergency Room on 10/11/24 at 9:55 AM, showed a fire door being propped opened by an unattended EVS cart, a large trash can, and two rolling carts that hold soiled laundry. During an interview on 10/10/24 at 10:58 AM, Staff C2, Housekeeping Manager, stated that housekeeping staff are in the building 24 hours a day. Staff C2 stated, “We do the cleanings in between patients, discharges, admissions, isolation, etc. We staff two housekeepers per floor. We clean between patients with a turnover time of 10-15 minutes. We clean and scrub our floors and pick up what we see. No cart should be left in hallways. If parked while cleaning they should be locked, but never unlocked or unattended.” During an interview on 10/10/24 at 11:30 AM, Staff R2, Manager of Infection Prevention, stated that the root cause of hand hygiene concerns is due to this being a teaching hospital. “We’ve got high volumes of students in addition to staff that affects hand hygiene compliance.” An observation on 10/15/24 at 11:28 AM, showed M2, RN was wearing traditional Crocs in violation of the hospital dress code policy. During an observation on 10/16/24 at H1 at 9:48AM, the room has Contact Precaution Plus on door, Staff B3, Nutrition Assistant, walked into room carrying food tray with only surgical mask and gave patient tray and walked out of room without washing hands or using hand sanitizer.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47234 Based on observation, policy review, and interview, the hospital failed to provide an adequate clean and sanitary environment for all patients currently at this hospital receiving dietary services. This deficient practice placed any patient receiving dietary services at risk for food borne infection or other adverse outcomes. Findings Include: Review of hospital policy titled, “Accepting Food Deliveries,” dated 2021, showed, “...Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate ...” Review of hospital policy titled, “Food Storage,” dated 2021, showed, “Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination...Food should be dated as it is placed on the shelves if required by state regulation ...Date marking should be visible on all high-risk food to indicate the date by which ready-to-eat...Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated...Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code...All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded...All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded...” Review of hospital policy, “General Food Preparation and Handling,” dated 2021, showed, “Procedure: 1. The kitchen will be kept neat and orderly. 2. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate ...” An observation of Campus 1 (C1) Kitchen 1 on 10/08/24 at 9:52 AM, showed the following: Walk in Refrigerator 1. 17 unlabeled and undated plastic containers with perishable fruit 2. Unlabeled and undated plastic container with unknown thick orangish substance 3. Unlabeled and undated plastic container with an unknown thick white substance 4. Unlabeled and undated plastic container with an unknown solid yellowish substance 5. Green onions with date in 07/24 (expired) 6. Unlabeled and undated plastic container with sliced black olives 7. Unlabeled and undated stainless-steel container with cut tomatoes. 8. Unlabeled and undated stainless-steel container with blueberries 9. Unlabeled and undated plastic container with meat crumbles covered with plastic wrap Work Area 10. Tabasco Sauce not dated 11. Unlabeled and undated stainless-steel container with butter 12. Unlabeled and undated stainless-steel container with yellow clear liquid 13. Plastic container with Chia Seeds Use By: 10-20-23 (expired) Whole Bay Leaves Use By: 08-07-24 10:49 AM (expired) 14. Undated plastic container of Thyme 15. Buns in clear plastic bag labeled BEST BY SEP [September] 27, 2024. (expired) 16. Chia Seeds in a plastic container use by Oct [October] 05, 2024 (expired) During an observation of C1 Kitchen 2 on 10/09/24 at 10:00 AM, surveyors and staff escorts walked thru food preparation area without being instructed to wear hair nets. Staff T, Assistant Director of Production, was asked by surveyor if hair nets were required to walk past the food production line. Staff T stated that hair nets are required and handed them out to staff and surveyors. An observation of Campus 2 (C2) Kitchen 3 on 10/08/24 at 12:35 PM, showed the following: Walk In Refrigerator 1. Unlabeled and undated bag of ham trimmings. 2. Unlabeled and undated cooked potatoes. 3. Unlabeled and undated open bag of cilantro. Walk-in Freezer 1. Unlabeled and undated bag of cinnamon rolls. Work Area 1. An unlabeled and undated open bottle of Chai seasoning. 2. An unlabeled and undated open bottle of Italian Seasoning. An observation of C1 Kitchen 2 on 10/11/24 at 10:31 AM, showed the following: 1. A stainless steel metal container labeled, “Spice Dry Taco” had plastic wrap with dried, reddish substance on plastic wrap and stainless-steel container. 2. An unlabeled and undated clear container of white powered substance. 3. A dirty linen cart overflowing with multiple dirty rags being held up by the wall next to sink. 4. Floor going into food storage area showed debris on floor and a wet substance was smeared across the floor. 5. Sink with open trash can underneath and paper trash on floor with used gloves and other debris on the floor. 6. Debris on floors located in food preparation area. During an interview on 10/10/24 at 10:59 AM, Staff C2, Housekeeping Manager, stated that housekeeping mops the kitchen floors once a day at an unspecified time. During an interview on 10/09/24 at 12:35 PM, H2, Staff Y, Dietary Supervisor (DS), C2 Kitchen 3, stated that all items received from the food vendors have the received date written on the item with a marker. When a food item is opened it must be labeled with a “use by” date. Staff Y, DS, stated that the dairy food vendor is responsible for rotating stock and removing expired dairy product. Staff Y, DS, stated that the food vendor is not responsible for rotating stock. Kitchen staff is responsible for rotating and checking stock for expiration and disposal dates. Staff Y, DS, stated that uncovered containers and opened bags of food in the refrigerator should result in a disciplinary write up for any staff member who leaves an item opened.”

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 47234 Based on observation, interview, policy, and document review, the hospital failed to provide evidence of collaboration with the hospital’s Quality Assurance and Performance Improvement (QAPI) program for infection control issues to reduce the risks of acquiring and transmitting infection among patients, workers, and visitors. This deficient practice placed all patients, visitors, staff, and community at risk to contract and spread communicable diseases. Findings Include: Review of hospital plan titled, “FY2025 Infection Prevention and Control Plan,” dated 09/2024, showed, “The goal of The Infection Prevention and Control Plan (IPAC) program is to identify and reduce risks of acquiring and transmitting infections ...The person with clinical authority and day-to-day management for the health system’s IPAC program is the Infection Prevention and Control Manager ...IPAC activities are performed by a team of trained and certified Infection Preventionists who collaborate with others to meet the goals and objectives of the IPAC program. The IPAC Committee has the responsibility for directing and monitoring the activities of the IPAC Program...The IPAC Committee meets at least four times per year ...The committee maintains electronic minutes of proceedings and submits them to the Medical Staff Office for access to the Executive Committee of the Medical Staff (ECMS) ...The IPAC Committee and its sub-committees are responsible for evaluating the effectiveness of it IPAC plan ...This evaluation includes ...review of the IPAC risk assessment, regular monitoring of surveillance program activity outcomes ...promotion of continuous quality improvement ...and communication of findings to the Hospital Quality and Safety Council ...” On 10/09/24 at 8:30 AM, surveyors requested the hospital’s QAPI plan and meeting minutes for the last 24 months. On 10/10/2024 at 11:30 AM, surveyors made a second request for the hospital’s QAPI plan and meeting minutes for the last 24 months. On 10/11/24 at 9:13 AM, surveyors made third request for the hospital’s QAPI plan and meeting minutes for the last 24 months. The hospital provided the meeting minutes on 10/11/24. Review of the hospital’s QAPI meeting minutes failed to show documented evidence of meeting minutes from May 2024 through September 2024. During an interview on 10/11/24 at 11:30 AM, Staff D, Accreditation and Regulatory Compliance Manager, stated that minutes were not kept for QAPI. Staff D provided no explanation why the hospital didn’t have QAPI meeting minutes from May 2024 through September 2024.”