Ascension Via Christi Hospitals Wichita, Inc.

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29047 Based on interview and record review, the hospital failed to ensure an appropriate medical screening examination (MSE) was provided for one patient (Patient #22), and failed to ensure stabilization of patients who were determined to have an emergency medical condition (EMC), within the capacity and capability of the hospital for one patient (Patient #18), of 22 records reviewed of patients who presented to the hospital Emergency Department (ED) for emergency care. Findings included: 1. Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA), dated 04/17/23, showed that: - Patients who come to a Dedicated ED requesting examination and treatment will be triaged and receive a MSE by a Qualified Medical Professional (QMP). - The MSE extends until the point that the QMP determines that an EMC does or does not exist. A patient should continue to be monitored based on the patient’s needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred. - When an individual presents with psychiatric symptoms, the MSE should include an assessment of suicide (ending one’s own life) or homicide (ending another’s life) attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the hospital determines that an individual poses a danger to self or others, this is considered an EMC. - A minor may request examination or treatment for an EMC. The hospital should not delay an MSE by waiting for parental consent. - When the MSE reveals that the person has an EMC, the hospital will provide stabilizing treatment as required to stabilize the medical condition or will transfer the patient. Stabilizing treatment is ongoing and must be continued until the patient is stabilized or appropriately transferred. - Capability of the hospital includes (in part) services available at the hospital as a whole, including ancillary services routinely available. 2. Patient #22, a 15 year old minor, presented to the hospital ED on 03/15/25, after he took six oxycodone (very potent pain medication, normal dose is one or two). The patient reported he obtained the drugs from the street (illegally obtained), which made him feel numb all over, anxious, and like his heart was pounding, and was concerned that the drug he had taken was not oxycodone. When the emergency department physician (EDP) entered the patient’s examination room, he requested social work to be contacted, which scared the patient. The patient collected his belongings, exited triage, and walked out of the hospital. Although it was documented that attempts were made to get security involved, security indicated they could not assist, and the patient was allowed to leave without completion of the MSE. There were no documented attempts made by the hospital to encourage the minor patient to stay, no attempts by staff or security to physically prevent the patient from leaving, and no documented informed refusal of examination and treatment before the patient was allowed to walk out of the hospital. Review of a hospital incident report dated 03/31/25, showed that the hospital had identified and corrected failures that led to the patient’s elopement, and subsequent failure to provide an appropriate MSE, by escalating all elopements to leadership per policy and reporting the incident in the event reporting system to allow for full investigation per the Risk Management process. 3. Patient #18 presented to the ED on 02/21/25 at 5:36 PM by ambulance, after ambulance staff had responded to reports of an overdose. The patient complained of a severe headache, a head injury, and a broken nose due to an assault. The patient’s mother reported he was non-compliant with his psychiatric medications, paranoid and irrational, had five hospital visits within seven days, and was potentially a harm to himself and others. She feared he was being assaulted on the streets, and stated he was medicating with illegal substances. Upon EDP examination, the patient complained of a headache with noted bruising to the patient’s right eye and a scab on his nose. He would not answer questions appropriately or cooperate. He was confirmed to have a broken nose, as well as a skin injury to his fingers which were believed to be burns. He appeared paranoid and psychotic and was not alert, was medically cleared for transfer for inpatient psychiatric care, and was placed on a psychiatric hold (ability to prevent a patient from voluntarily leaving due to risk to self or others). Over the course of four days in the ED, the patient was documented as anxious, uncooperative and unable to be directed. He would escalate and required the assistance of security, the use of restraints, and medication. The patient was placed in a room in a secluded hallway that was between two exit doors, and was allowed to leave his room even though he was placed on continuous observation. On 02/24/25, the psychiatric hold by the ED was ordered by the courts (court ordered psychiatric hold) and the patient continued to wait in the ED to be transferred to an available inpatient psychiatric bed. On that evening, the patient was found standing in front of, and staring at, an “alarmed” exit door. He was redirected back to his room but still allowed to come and go, in and out of his room. Later that same evening, the patient eloped from the same door, which failed to alarm, and the staff observing the patient remotely, failed to immediately notify ED staff until four minutes after the patient had eloped from the hospital. Review of a hospital incident report dated 03/10/25, showed that the hospital had identified and corrected failures that led to the patient’s elopement, and subsequent failure to stabilize the patient’s EMC through the following actions: - The ED exit door which failed to alarm when the patient eloped, was repaired. - All behavioral health patients holding in the ED for greater than 24 hours are reported during a daily “Tiered Safety Huddle” in which the information is escalated to leadership. - A report titled, “Virtual Safety Monitoring Alerts for Patients out of Camera View” was distributed and reviewed by all telesitter staff with attestation of receipt by 03/24/25. - Implementation and oversight of the implementation, monitoring and sustainment of the actions was the responsibility of the Chief Nursing Officer.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29047 Based on interview and record review, the hospital failed to ensure an appropriate medical screening examination (MSE) was provided for one patient (Patient #22), of 22 records reviewed of patients who presented to the hospital for emergency care. Findings included: Review of the hospital policy titled, “Patients Leaving Against Medical Advice and Elopement,” dated 01/15/25 showed: - For patients with questionable decision making capacity, or a belief that the patient’s decision to leave will pose an imminent risk to the health and safety of the patient, the provider should consider efforts to physically detain the patient. - For patients under the influence of alcohol or drugs, the provider will need will need to make a determination regarding whether the level of intoxication would prohibit the patient from making informed decisions regarding their discharge against medical advice and/or whether it could place the patient at imminent risk of harm to self or others. - For minors who insist on leaving despite verbal encouragement efforts, If it is determined by the provider that there is an imminent risk of harm, the provider should consider efforts to physically detain the minor patient. Security may be contacted if available to assist, and may assist in the application of restraints. Review of an emergency department (ED) record for Patient #22, showed the 15-year-old presented to the ED on 03/15/25 at 1:36 PM, with a chief complaint of oxycodone (prescription pain medication that his high risk for addiction and abuse) overdose. Triage Nurse O documented at 2:08 PM, that the patient had been dropped off by a friend after he had taken oxycodone he obtained from the street (illegally) for back pain related to scoliosis (abnormal curvature of the spine). EDP P documented a note at 1:45 PM, that the patient reported the pills he had taken that day made him feel numb all over, anxious, and like his heart was pounding. EDP P documented that he spoke to the nurse to get social work involved, and the patient overheard and understood that it meant a referral to the Division of Child and Family (DCF). The patient became concerned that he would be taken away from his mother, picked up his belongings and left. EDP P documented that security was notified but they were unable to keep the patient in the ED. There was no documentation that the EDP examined the patient or ordered testing, and the patient was documented as left AMA at 1:50 PM. During an interview on 06/27/25 at 2:00 PM, Triage Nurse O stated that Patient #22 presented to the ED for concerns that he had overdosed after taking six-20 milligram (mg) oxycodone. The patient stated that he didn’t feel right and believed that the drug he had taken wasn’t oxycodone. The patient appeared anxious and scared, and his heart rate and blood pressure were elevated. Triage Nurse O stated that when the physician entered the room, he commented that social work needed to get involved, and when the patient heard this, he picked up his belongings. Triage Nurse O said to the patient, “Dude, please don’t leave,” but the patient started walking very rapidly, and before security could get their hands on him, he was out the door. “There was no way to retain the kid. Locking him in the room would be considered imprisonment, and restraints would not have been warranted with his behavior.” Triage Nurse O reported that he was unaware if the patient was ever found, or his outcome. During an interview on 06/30/25 at 9:00 AM, EDP P stated that Patient #22 reported he felt weird after ingesting six - 20 mg oxycodone, “which is an excessive amount.” The patient was complaining of heart palpitations (the sensation of feeling your heart beating too fast, fluttering, or pounding) and was tachycardic (a heart rate that is faster than normal, specifically over 100 beats per minute at rest). EDP P stated that when he told the nurse to call social work and informed the patient he was a mandated reporter, the patient picked up his belongings and started to walk out of the open triage door, through the ED entrance doors, and out of the hospital within a minute. “It didn’t seem to me that he was about to be voluntarily restrained,” and when EDP P shouted into the waiting room for security officers to assist, they responded that they couldn’t prevent him from leaving because he wasn’t on a court ordered psychiatric hold. EDP P explained that if he wanted to prevent a patient from leaving, he would get security involved, and the police if necessary, and get the patient escorted to a safe place where medications could be administered and the patient could be evaluated by psychiatry on-call, if necessary. During an interview on 07/02/25 at 9:30 AM, Security Officer (SO) Q stated that he did not have any interaction with Patient #22, but while staged in the area, he heard, “Security, come here.” By the time he turned around, he didn’t have time to respond because the patient was too quick to stop, and ran down the street. SO Q added that a patient does not have to be on a psychiatric hold to “have a hold on them, they just must be deemed to be unsafe to themselves or others.” SO Q stated that hospital staff should do everything they can to prevent a patient from eloping, but to physically prevent a patient from leaving would be criminal. “We do whatever we can to keep them from leaving in the first place, but if all else fails, we call the police to bring them back in.””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 29047 Based on interview and record review, the hospital failed to ensure patients who were determined to have an emergency medical condition (EMC), were stabilized within the capacity and capability of the hospital for one patient (Patient #18), of 22 records reviewed of patients who presented to the hospital for emergency care. Findings included: 1. Review of the hospital’s policy titled, “Behavioral Health Patient Involuntary Admission Policy,” dated 02/21/25, showed that staff shall take all reasonable precautions to prevent the elopement of patients deemed a mentally ill person, subject to involuntary commitment for care and treatment. Review of the hospital policy titled, “Patients Leaving Against Medical Advice and Elopement,” dated 01/15/25 showed that factors impacting elopement risk identification include if the patient is a legal hold for risk of harm to self or others or needs to remain in the facility for their safety or the safety of others. If a patient identified as being at risk for elopement has made an active attempt to elope during the current encounter, they will be deemed high risk for elopement, and a 1:1 constant observer should be placed with the patient. Review of the hospital’s policy titled, “Continuous Visual Monitoring for the Adult Patient Safety using TeleSitters,” dated 11/07/24 showed: - The purpose of the telesitter services was to provide continuous visual monitoring of patients to ensure patient safety. - Continuous visual monitoring was appropriate for patients who were at risk for elopement, those who are potentially violent or self-destructive, and moderate suicide risk. - It was not recommended to utilize telesitter monitoring outside of the room, in the hall, or across the hall for the flight risk patient. - Notify the telesitter monitor technician when the patient is removed from the room for walks, etc. - The telesitter monitor technician places the patient under continuous visual monitoring, calls the nursing staff directly if an issue arises with the patient that needs staff response, activates the alert alarm when a patient being monitored for suicide precautions is not visible, and documents verbal cues to the patient as well as calls to the nursing staff. 2. Review of an emergency medical services (EMS, ambulance and staff) report dated 02/21/25 at 5:17 PM, showed EMS responded to Patient #18, a 27 year old male, for reports of an overdose. The patient had used K2 (synthetic marijuana) and complained of tooth pain in the lower right side of his mouth. The patient informed EMS that he was unable to walk due to “broken bones” in his legs, yet ambulated without difficulties. He appeared in mild distress due to the tooth pain and was transported to Ascension Via Christi St. Francis campus emergency department (ED). Review of the ED record for Patient #18 showed he presented to the ED on 02/21/25 at 5:36 PM. The patient was triaged at 6:00 PM and complained of a headache. ED Physician (EDP) F documented an examination at 6:34 PM, with a history of homelessness, multiple psychiatric disorders, polysubstance (drugs and or alcohol) abuse, and kidney failure due to a drug overdose. The patient complained he had a head injury and a broken nose due to an assault, which was confirmed by computerized tomography (CT, detailed computerized x-ray). The patient’s skin was noted to have bruising to the patient’s right eye, a scab on his nose, and the patient would not answer questions appropriately. He appeared paranoid and psychotic and was not alert. His judgement was impaired by abnormal thoughts, he was delusional (having a false or unrealistic belief that is not based on reality), tangential (unable to connect with what is being asked), and with a flight of ideas (rapid thoughts and speech, with difficulty maintaining focus). Per the patient’s request, the patient’s mother was contacted, who expressed concern about the patient’s psychiatric illness, medication non-compliance and reported he was not safe on his own and a potential harm to himself or others. At 7:23 PM, the EDP determined the patient was medically stable for psychiatric evaluation and transfer. Throughout the evening, the patient would escalate, was unable to be redirected, and required the assistance of security officers, restraint, and medications to help him calm. An application for a court ordered psychiatric hold, was signed by the EDP, and on 02/22/25 at 12:33 AM, an order for admission to behavioral health was placed. Throughout the night, the patient would not follow commands and was verbally abusive towards staff. He was placed on a suicide risk protocol, which required the patient to leave his exam room door open, however, he repeatedly closed the door and attempted to flood the room with sink water. He required security response and medication. At 8:40 AM, a consultation was conducted by Telepsychiatrist G, who documented the patient appeared to be responding to internal stimuli (sensations or perceptions that originate from within one’s own mind, rather than from something happening in the outside world), and had limited insight, judgement, and impulse control. He was unable to be assessed for suicide due to the patient’s agitation, and a recommendation was made to involuntarily admit the patient to behavioral health. Throughout the remainder of the patient’s stay in the ED, he continued to escalate, failed to be redirected, and required medication. The patient was moved to a room where he could watch television, and per documentation, was allowed to sit outside of his examination room. On the evening of 02/24/25, the patient was medicated for agitation. His pulse and blood pressure were elevated, and security was called when the patient began yelling profanities outside of his room and was unable to be redirected. At 11:15 PM, ED Registered Nurse (RN) A documented that nursing staff responded to the telesitter alarm sounding in the patient’s room, and the patient was unable to be found. Law enforcement later contacted the ED and reported the patient had been located, was booked on charges, and would not be returned to the hospital. During an interview on 06/27/25 at 1:15 PM, ED RN C stated Patient #18 was on moderate suicide risk and needed to be within eyesight at all times. ED RN C stated he had no concerns that the patient would elope. During an interview on 07/02/25 at 1:00 PM, Security Officer H stated “ ...there is not enough staff for sitters” so ED staff will watch patients who require constant observation, but when ED staff get up to do something, they don’t ask for another staff member to watch the patient. On 02/23/25, the patient was standing in his room entrance, cussing at the nurses and yelling, and he was able to calm the patient down. Security Officer H stated, “I never felt” the patient was going to elope. During an interview on 06/27/25 at 7:30 AM, ED RN A stated that while Patient #18 remained in the ED under a court ordered psychiatric hold, instead of 1:1 monitoring, he was monitored virtually in his examination room by staff located on the 8th floor. The patient’s room was located in a secluded hallway that contained two exit doors. The patient would come out of his room, come to the nurses’ desk, and required frequent redirection back to his room, however, she was not concerned he would elope. During an interview on 07/01/25 at 7:30 AM, ED RN B stated the patient was in a hallway bed when he first presented to the ED, and “it was reported that he had tried to walk out, which was why he was made a court ordered psychiatric hold.” He would be calm and then become very antsy and it was reported that he had required restraints at some point. By the time ED RN B took over care of the patient, he had been medically cleared and was awaiting a bed in the psychiatric unit at the St. Joseph campus. He had a court ordered hold and was located in a psychiatric safe room (all items in the room are secured to prevent patient access, for safety) with a telesitter. The telesitter was able to watch him and they are able to call and alert ED staff if needed, however, the patient wouldn’t stay in his room, and the room was not visible at the nurses’ station. Additionally, the patient’s room was located near the emergency medical services (EMS, ambulance staff) doors, and in a zone that was not staffed that night. The patient required redirection several times. He was standing outside of his room door, he was yelling at everyone who tried to talk to him, and he was antsy and wouldn’t sit still. He repeatedly walked up to the nurses’ station desk, but never indicated he was going to leave. He informed us that he was anxious, his heart rate and blood pressure were elevated, and he requested medication. Ativan (medication used to calm patients) was ordered because he was yelling profanities, and security was required to come to the patient’s bedside. ED staff unsuccessfully attempted to verbally redirect the patient, and security was on standby for safety in the patient’s room, and once we administered the Ativan, he laid down quickly. Between the medication administration at 8:59 PM, and 9:50 PM, the patient began to come out of his room again, and security voluntarily indicated that they would stay with the patient while he was allowed to walk around in the hall. The Ativan had worn off by that time, and the patient would get “very, very antsy,” but there was no concern that the patient would leave because he did not indicate he was going to leave. There were a few times that the telesitter monitor staff could not see the patient in his room and would either sound the alarm on the telesitter camera, call the ED, or do both, and ED staff would confirm that the patient was out of his room and that staff had eyes on him. At some point (time unknown), security waved to us, indicating an unofficial handoff of the patient. At 9:50 PM, while walking down the patient’s hallway (area that was not staffed), the patient was found at the end of the hall, staring at an alarmed exit door (door the patient later eloped from). The patient was easily redirected back to his room and remained in his room except for a couple times that he walked out to use the bathroom. While assisting staff in a critical patient’s room, ED RN B’s hospital phone (personal work phone that allows for quick communication between staff) rang and the alarm went off in the patient’s room simultaneously, notifying us that the patient could not be seen by the telesitter. No one could find the patient. ED staff reviewed the video footage, and it showed that he had stepped out of his ED room and saw there was no one at the nurses’ station, walked back into his ED room, and then left his room and ran out of the ED at 11:11 PM. He was wearing a gown assigned to psychiatric patients, an armband that indicated he was a psychiatric patient, and hospital socks. He then ran across the street and jumped the fence and ran onto the roadway. Police were contacted, and later reported they had located him, and she was unsure what happened to the patient after that. The hospital followed all policies and did everything possible to prevent the patient’s elopement. The patient just happened to be in a location for an extensive amount of time where it was not the safest for him, and he should have been in a locked unit. During an interview on 07/03/25 at 7:00 AM, Telesitter T stated that on 02/24/25, the patient was allowed to stand in his doorway while he was observed by telesitter staff. The telesitter staff were short staffed with only two core staff that night, and the person who was sent to assist with telesitter staffing was not well trained, and there were too many patients to monitor when a staff member went to lunch. This led to a delay in notification of the patient’s elopement. Review of the hospital’s internal investigation showed that the patient was last seen at 11:10 PM by the remote telesitter, and the telesitter alarm was not activated until 11:15 PM, which she heard coming from the patient’s room. Security determined the patient had exited through door 10. Review of an event report systems report showed four narratives dated 02/24/25. According to the narratives, Patient #18 eloped through “Door #10” which was “supposed to be alarmed.” Patient #18, a patient who was under a court ordered psychiatric hold and awaiting transfer for inpatient psychiatric care, was placed in a room that was not visible to the nurses and in an area that was not staffed. The patient, who was reported to have attempted to elope during his stay, was not “deemed high risk for elopement” or placed with “a 1:1 constant observer,” per policy. The patient was allowed to repeatedly stand in the doorway of his room, and leave his room, at times without staff awareness, and subsequently eloped without stabilization of his EMC.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46640 Based on document review, record review, policy review and interview the Hospital failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to perform an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking emergency medical care. Failure to perform an appropriate MSE and provided stabilizing treatment places all patients presenting at this hospital at risk for harm and injury up to an including death. Findings Include: The hospital failed to perform an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed for 3 of 28 patients (P1, P2 and P14) who presented to the emergency department (ED) seeking medical care. (Refer to A2406) The hospital failed to provide stabilizing treatment for 2 of 28 patients (P2 and P14) who presented to the emergency department seeking medical care. (Refer to A2407)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 17281 Based on record review, interview, and policy review, the hospital failed to perform an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed for 3 of 28 patients (P1, P2 and P14) who presented to the emergency department (ED) seeking medical care. Failure to perform an appropriate MSE has the potential to place patients at risk for harm or injury up to and including death. Findings Include: Review of a document titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)” revised on 04/17/23 showed, “The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ... Standards for Medical Screening Examinations 1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional]. 2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient’s needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred. 3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition [EMC]. 4. If the Medical Screening Examination [MSE] does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital’s facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures .... ...DEFINITIONS “ ...Capacity” means the ability of the hospital to accommodate the individual requesting examination, or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, equipment, and the hospital’s past practices of accommodating additional patients. “Comes to the Emergency Department” means an individual: 1. Has presented at a Hospital’s Dedicated Emergency Department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition ... 2. Has presented on Hospital property, other than the Dedicated Emergency Department, and requests examination or treatment for what may be an Emergency Medical Condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual’s appearance or behavior, that the individual needs emergency examination or treatment. “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy. Serious impairment to any bodily functions. Serious dysfunction of any bodily organ or part ... Some intoxicated individuals may meet the definition of “emergency medical condition” because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ. Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or to others, would be considered to have an emergency medical condition ...” “Medical screening examination” is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient’s presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves ancillary studies and/or diagnostic tests and procedures. A medical screening examination is not an isolated event, but an ongoing process. The medical record shall include continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be documentation in the medical record of an evaluation prior to discharge or transfer. Review of the hospital’s “Guided Criteria for Obstetric Patients” indicated “. . . Hypertensive, pregnant patients less than 20 weeks will need evaluation in the ED first. If treatment requires Magnesium, then they will transfer to LDR [labor department room]. Hypertensive pregnant patients that are greater than 20 weeks will transfer to LDR. . .” Patient 1 (P1) Review of the “Arrival Section” in P1’s Electronic Medical Record (EMR) revealed P1 presented to the ED on 07/23/24 at 9:35 PM with a chief complaint of headache. Review of the “ED Note- Physician” dated 12/24/24 at 12:23 AM and electronically signed by Staff K, Physician, located in P1’s EMR revealed, “[Patient name] ...presents to the ED for evaluation for multiple issues as well as a headache. Patient was unable to keep calm in the waiting room and was escorted out by security before I had the opportunity to gather more history or exam. I did not have an opportunity to assess capacity. No phone number other than [P1’s] son’s number was listed for contact. Patient-provider relationship was not established. No PCP listed ... Psychiatric: agitated, yelling. Medical Decision Making ...Documents reviewed: Emergency department nurses’ notes, emergency department records, prior records. Impression and Plan: Patient left before evaluation by physician. ...” Review of the “Disposition Documentation” by Staff I, Registered Nurse (RN), dated 07/23/24 at 10:07 PM located in P1’s EMR revealed, “ ...Discharge Comments: Patient was escorted out before being seen by provider. Patient screaming at this RN [Registered Nurse]and [Staff H2] was threatening to “kick your asses, [profanity] America, I’ll [profanity] all you Americans up” Security called.” The hospital failed to perform an MSE to determine if P1 had an EMC. The medical record failed to show an MSE had been performed. During an interview on 10/22/24 at 10:17 AM, Staff F, Risk Management, stated that he/she became aware of an incident that occurred with P1 on 07/23/24 in the ED when Staff G2, RN and Staff H2, emergency medical technician (EMT) submitted a report to the hospital event reporting. Staff F stated an investigation was initiated and several interviews were conducted with staff and a review of the patient’s medical record was conducted. When asked what the conclusion of the investigation was, Staff F stated, “It was brought to the SA [State Agency] because the group agreed an EMTALA violation occurred.” During an interview on 10/22/24 at 1:50 PM, Staff H, Security Manager, stated that an officer was called to assist with a patient who was yelling profanities in the ED. When Staff V walked into the triage area and tried to use the de-escalation techniques learned in training, the triage nurse (Staff G2) kept interrupting and interjecting with his/her efforts. Staff H stated, “the nurse [Staff G2] said, “get [P1] the [profanity] out of here.” Staff H stated [Staff V name], “deferred to the triage nurse - trusted the process and that care was received. The security officer did not verify whether the patient was screened.” During an interview on 10/22/24 at 3:30 PM, Staff K, Physician stated, “What I recall is what is documented in the medical record. I was told by the triage nurse [name] that the patient was unable to keep calm and was escorted out of the hospital by security before an MSE was done. I did not have any contact with the patient and did not conduct an MSE. The patient left before the MSE could be done. What I documented [in the medical record] is what was told to me and information populated from the patients visit.” During an interview on 10/22/24 at 4:15 PM, Staff G2, RN stated, “I went into the waiting area to get the patient and bring [him/her] back to triage. The patient was mumbling something, but I didn’t know what it was. I told [him/her] to get on the scale so I could weigh [him/her], and [he/she] started yelling at me. I tried to tell [him/her] to stop, ‘that we would not be doing this,’ but [he/she] kept on ‘yelling [profanity] Americans and [profanity] America.’ An EMT [emergency medical technician] came in the area and the patient continued yelling. [The EMT] said to just call security, so we did.” Staff G2 stated there were no other providers in the triage area during the incident. Staff G2 stated, “When security arrived, I asked [him/her] to escort the patient out. You can’t have a patient in here [ER] acting like that. I did not mean out of the hospital, but security escorted the patient out of the hospital. There was nothing else I could do.” Staff G2 stated he/she has certification in managing assaultive behaviors, but he/she did not make any attempt to de-escalate the situation. Staff G2 stated, “It would not have worked. The patient was not going to listen. I told security several times that the patient would not listen to anything [he/she] was trying to say or do.” Staff G2 stated he/she did not report to the security officer that P1 did not have an MSE completed. During an interview on 10/23/24 at 8:30 AM, Staff V, Security Officer stated, “I was called to the ED around 9:50 PM [on 07/23/24]. A patient was being verbally aggressive, and I was called to assist. When I arrived in triage the patient was arguing with the nurse. I tried twice to talk to the patient, but the triage nurse kept interrupting and saying take [him/her] off the property. There was an escalation between the nurse and the patient, so I decided to remove the patient from the ED to defuse everything. I was never given the chance to use any de-escalation techniques because the nurse [Staff G2] kept interrupting and telling me to ‘get [him/her] out’ ‘get [him/her] out.’ I should have verified the patient received an MSE, but I did not.” Patient 2 (P2) Review of P2’s medical recorded showed P2 was a 7 day old female brought to the ED by her parents on 07/02/24 at 12:35 AM with chief complaint of not eating. P2’s medical record showed a document titled, “ED Note-Physician” by Staff R, Physician, dated 07/02/24 at 1:19 AM, “ ...The patient presents with Not eating/vomiting (eject matter from the stomach thru the mouth) ...Additional history: Patient is a 7 day/old female that was brought in by parents for concern of jaundice (yellow color of the skin)/decreased p.o. [oral] intake and lethargy (feeling of being tired). Denies any fever/and was seen in the clinic recently and had a bilirubin (the breakdown of red blood cells in the blood) of 13. Patient is bottle-fed and parents have been unable to get her to eat. She did have 1 episode of emesis (matter ejected from the stomach when vomiting) that was noted to be yellow ...Reexamination/Reevaluation Will repeat bilirubin level/pediatric team consulted/ labs currently pending at time of admit Will admit for observation/ discussed with admitting team. HPI (History of Present Illness) assisted via translation service from iPad. Impression and Plan Neonatal jaundice... Vomiting ... Plan Condition Stable Disposition: Admit to Observation Unit ...” Review of Staff G, Physician, Pediatric Hospitalist’s order dated 07/02/24 at 2:31 AM for P2, showed “Order: Place in Observation.” Review of P2’s Gastrointestinal Assessments dated 07/02/24 at 1:30 AM to 07/03/24 at 12:00 AM showed P2 vomited 10 times. Review of a documents titled, “Provider Notification,” dated 07/02/24 at 6:05 PM, showed Staff I2 documented, “pt has vomited x 3 since started formula.” Review of P2’s “Nutrition Progress Note,” dated 07/03/24 at 9:51 AM, showed Staff L2, Registered Dietician (RD) documented, “ ...Nutrition Related History Current Presentation Nutrition: Pt admitted [sic] for vomiting and inability to tolerate feeds. Had UGI (upper gastrointestinal test)- no obstruction, indicated reflux and gastroenteritis (inflammation and infection of the stomach). Feeding tube placed to duodenum with Pedialyte (sic) (oral electrolytes) running, continuing to vomit @6 milliliters/hour (ml/hr) ... Weight History Nutrition: 9% below birth wt (sic) on admit, significant ... Enteral Nutrition Recommendation (use of a tube to deliver nutrition to people who are unable to eat or swallow safely): trial Similac Alimentum @ 5ml/hr, if tolerated advance slowly towards 23 milliliters/hour (ml/hr) to provide 150 ml/kg; reflux (spitting up gastric contents) precautions. Meal and Snack Delivery Recommendation: NPO (nothing by mouth), when starting feeds will need to titrate up slowly, start with 20ml q2-3 hrs TPN [total parenteral nutrition -feeding that provides nutrients through a vein] - IV [intravenous] Fluids Recommendation: if unable to tolerate EN (enteral nutrition), will need to consider PN (parenteral nutrition) in 2-3days TPN - IV Fluids Recommendation-cont: continue IV fluids with dextrose (sugar water) until tolerating feeds ...” Review of P2’s Gastrointestinal Assessments dated 07/03/24 at 12:00 AM to 07/04/24 at 12:00 AM showed P2 vomited 8 times. Review of a “Provider Notification” dated 07/03/24 at 7:53 PM, showed Staff J2, Bachelor of Science in Nursing (BSN) documented, “notified provider episode of emesis. “Provider Requested Interventions ...Other: continue tube feeding at 20ml/hr.’” Review of P2’s Gastrointestinal Assessments dated 07/04/24 at 12:00 AM to 07/05/24 at 12:00 AM showed P2 vomited 6 times. Review of P2’s “Progress Note- Generic” dated 07/04/24 at 4:16 PM, showed Staff K, Physician documented, “Called by RN that patient has not taken bottle all day successfully w/o [sic] [without] vomiting all formula up. Discussed case with [Physician], will switch to Alimentum formula via NJ tube (nasojejunal- a tube that goes in the nose and passes thru the stomach to a portion of the intestine) starting at rate of 15 ml/hr for first 1-2 hours. Then increase to 20 ml/hr for 4 hours, increase to goal rate of 25 ml/hr. Discussed instructions with nursing team. Orders placed and verified by nursing team.” Review of a “Provider Notification,” dated 07/04/24 at 8:00 PM, showed Staff M2, RN documented “patient vomited large amount about 30 minutes after increase tubefeed (sic).” Review of a “Provider Notification” dated 07/05/24 at 2:50 AM, showed Staff M2, RN documented, “ ...Patient continues to vomit overnight. Will vomit about every 2 hours, and then will have episodes of vomiting every 30 minutes. vomit does not look normal-almost looks like stool. Has had one stool smear that is orange/clay looking.” Review of a “Progress Note” dated 07/05/24 at 3:05 AM, showed Staff N2, Physician documented, “As emesis has significantly increased in frequency and volume after increasing to 25 ml/hr, will decrease formula TF [tube feeding] to 20 ml/hr for the next 2 hours. Following may trial increase back to 25 ml/hr.” Review of a “Provider Notification,” dated 07/05/24 at 7:50 AM, showed, Staff M2, RN documented, “ ...resident finished rounds, and this RN let the resident know that there was great concern about the patient. This RN really believes that the patient is throwing up stool, not just bile like it was believed. Patient vomited at least 10 times over night.” Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 8:32 AM, showed Staff S, RN documented, P2’s abdomen was soft and appeared appropriate for age and size, round and symmetric and continued to vomit. Review of P2’s “Nutrition Progress Note,” dated 07/05/24 at 10:24 AM, showed Staff L2, RD documented, “ ...Assessment Nutrition Related History Current Presentation Nutrition: Pt is fussy this morning, vomited all night. Attempted oral feeds yesterday, pt did not cue and was uninterested. Pt is elevated in crib this morning, mother at bedside. Diet History Nutrition: per mom, pt has not taken a full bottle since birth. First feeds after birth were not tolerated well, produced odd noise then would stop eating ...Nutrition Dx/Intervention/Goals TPN - IV Fluids Recommendation: continue to recommend TPN with poor nutrition since birth (10 days minimal nutrition) ...” Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 12:00 PM, showed Staff S, RN documented, P2’s abdomen was distended and continued to vomit. Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 5:20 PM, showed Staff S, RN documented P2’s abdomen was distended, firm and had bile/mucous emesis. Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 12:00 AM to 07/06/24 at 3:44 AM showed P2 vomited 8 times. Review of the medical record showed that P2 vomited 32 times between 07/02/24 and 07/06/24. Further review of the medical record showed staff failed to notify or document the physician/provider was notified 28 of 32 times on 07/02/24, 07/03/24, and 07/05/24. Review of the medical record showed P2 weighed 3.7 kilograms (kg), (8 pounds 3 ounces) at birth; on admission to observation on 07/02/24 P2 weighed 3.47 kg (7 pounds 10 ounces) and on 07/05/24, P2 weighed 3.12 kg (6 pounds 8 ounces). Review of a document titled, “Neurological Assessment,” dated 07/05/24 at 8:32 AM, showed Staff S, RN documented P2’s anterior and posterior fontanels (soft spots in front and back on a newborns head where the suture lines meet) were flat and soft (a normal assessment for a newborn). Further review of the medical record on 07/05/24 at 8:00 PM showed Staff Y documented that P2’s anterior and posterior fontanels were sunken and depressed (an abnormal sign that could indicate the patient is not getting enough fluids). Review of a “Progress Note-Addendum” dated 07/05/24 at 12:49 PM, Staff G, Physician, documented that a conversation with P2’s parents discussed the deep concern that patient was down 15% total from birth weight. The documentation showed that if no improvement was seen in the next 24-48 hours the patient would be sent to a Kansas City hospital for a comprehensive, multidisciplinary assessment and treatment. Review of a Progress Note Addendum dated 07/05/24 at 1:06 PM by Staff G, Physician showed, “Upgrade to inpatient status as pt has failed oral challenge several times and remains NJ dependent with ongoing weight loss. I do not anticipate a d/c [discharge] in the next 48hr.” Even though H1 has a Pediatric General Medical floor and a Pediatric Intensive Care Unit (PICU) available for ill and critically ill pediatric patients and H2 has a level 3 (ability to care for critically ill neonates) Neonatal Intensive Care unit (NICU), P2 was placed on observation status on 07/02/24 at 2:03 AM and moved to the Pediatric Unit on 07/02/24 at 2:22 AM for continued observation. During observation status from 07/02/24 to 07/05/24, documentation showed P2 was noted to have a significant loss in body weight of 15 %; inability to adequately tolerate or consume oral intake or nasogastric (NG- a tube is passed in the nose to a portion of the stomach to deliver feedings) feedings; loss of a functioning IV on 07/03/24; excessive sleepiness and drowsiness; poor cueing ability; lack of desire for oral feedings; poor sucking; minimal rooting reflex; vomiting with all feedings; and reported vomiting of stool. The hospital failed to perform an appropriate MSE for P2 to determine if an EMC existed including, but not limited to, the fact that labs were not obtained or completed between the dates of 07/02/24 and 07/05/24 even though P2 continued to have poor nutritional and fluid intake, loss of a functioning IV, vomiting and weight loss. Patient 2 died on 07/06/24 at 3:44 AM. During an interview on 10/22/24 at 3:49 PM, Staff R, Physician, stated that, P2 was a 6- or 7-day old infant. The mother carried the patient to full term. The patient had an elevated bilirubin level at birth. The patient presented with difficulty feeding and vomiting and slightly jaundiced but was below bilirubin light level. P2 would cry and was making tears. The mother was notified that we would do an IV and check blood levels. Wanted to get her admitted to the pediatric floor. No abdominal distension noted. ED doctors do not have admitting privileges, pediatrics was consulted. There was no trouble with bed availability. Pediatric patients get beds quickly usually. Staff R stated that the actual provider decides the admission status. The hospitalist makes the admitting determination and decides on observation or actual admission. The pediatricians take over and write admitting orders. The expectation is the consulting physician will follow up with care needed after leaving the ED. Staff R stated that admitting observation status verse inpatient status is a billing issue, the patient must stay two midnights for inpatient status. Staff R stated that if they go inpatient first, then it causes billing issues. Usually, they start with observation then change to inpatient if needed. Staffing plays a big part of bed availability. During an interview on 10/22/24 at 4:07 PM, Staff Q, RN stated that the infant had bilious emesis (vomit that contains bile); the parents spoke very broken English, pediatrics was instantly contacted. The pediatric resident came down and IV access was not able to be established. IV team was called for assistance. The mother tried to feed and P2 still couldn’t hold anything down. PICU nursing staff were informed the patient did not have an IV site and needed one. The patient was sick with a weak little cry. Vital signs were stable when transferred to the pediatric floor. P2 was only in the ED about 1 or 2 hours total. Pediatric beds are usually available quickly. During an interview on 10/22/24 at 2:45 PM, Staff L, RN, stated that their job consists of going thru the medical records and identifying a change in patient status by reviewing clinical VS, lab work, etc. An algorithm is used based on the payor or insurance type and it identifies if the patient would benefit from being made inpatient status. The physician will be called and transfer orders to change the patient to inpatient status are entered. Staff L went on to state that if the patient is self-pay the same algorithm that is used for Medicare and Medicaid is used so it makes the transition smoother if they apply for the insurance later. During an interview on 10/22/24 at 4:25 PM, Staff S, RN, stated that on 07/05/24, day shift (7 AM to 7 PM) the [Physician] was called while still on the Pediatric floor. The [Physician] was notified that the infant was breathing funny with subcostal (a breathing condition when the abdomen pulls into the ribcage) retractions and desaturating (low oxygen level). P2 was suctioning and placed on an oxygen mask and then a cannula (device used to administer oxygen). P2 responded a little with oral suctioning and with decompressing (removing air from stomach) her stomach. Oxygen saturations’ (level of oxygen in the blood) were in the 90’s (normal range for patient age is > or = to 93%). The [Physician] called the pediatric intensivist (critical care physician). The PICU charge nurse was notified that P2 needed sent right away to a higher level of care. Staff S stated that she thought P2 was stable that day until she wasn’t. During an interview on 10/22/24 at 3:00 PM, Staff N, Physician, stated that she was the on call as the Pediatric Intensivist the night P2 was transferred to the PICU. She stated that she was involved in the care the end on 07/05/24 at around 7:00 PM. She stated the infant was not doing well when arriving in the PICU due to breathing difficulties and still vomiting. During an interview on 10/23/24 at 10:20 AM, Staff Y, RN, stated that when arriving on shift P2 had just vomited. A NG was placed and copious amount of stool as return. P2’s tongue was brown and sandpaper from stool emesis. The NG returned about 500 ml of brown, thick liquid and it appeared to be stool. While attempting to intubate (place a breathing tube in the airway) the patient projectile vomited more brown fluid. It appeared she aspirated (inhaled into the lungs) the contents. There was concern P2 had been vomiting stool prior to arriving in the PICU. Staff Y stated that the patient’s eyes were sunken in and eyes rolled back in the head. A urinary catheter (a tube inserted in to the bladder to drain urine) was placed and no urine output was present. When P2 was intubated, she was somewhat stabilized however unable to keep the blood pressures up in an acceptable range, so we started an epinephrine (medication to increase heartrate) drip. She had a single lumen Peripherally Inserted Central Catheter (PICC) in the right lower leg. The decision was made to transfer her to [H3]. The H3 transport team arrived about midnight. The transport team immediately took over and assumed the care of the patient. While attempting to transfer P2 to transport incubator, P2 had no heartbeat. CPR (cardiopulmonary resuscitation) was started. Staff Y stated that the fact P2 was vomiting stool at least 20 times during that day was concerning. Communication with the parents was difficult, we did have someone who could translate working on the unit and then we used the iPad translator too. Patient 14 (P14) Review of P14’s electronic medical record (EMR), with Staff C and Staff E assisting with navigation of the EMR, indicated P14 was triaged on 09/24/23 at 9:24 AM by Staff NN, Physician Assistant, with the chief complaint of “lower abd [abdominal] pain that started when she woke up this morning, took 2 [two] tylenol this morning, vomiting x [times] 3 times, last bm [bowel movement] 9/23 [09/23/23] reports normal, LMP [last menstrual period] 2 days ago.” Review of P14’s history of present illness indicated “The patient presents with Abdominal pain. The onset was 2 hours ago. The course/duration of symptoms is constant. Location: Generalized abdomen. The character of symptoms is pain. Risk factors consist of hypertension. Therapy today: see nurses notes. Associated symptoms: nausea, vomiting, Constipation, Blood when wiping, Denies dysuria and denies fever. 38-year-old female patient with a history of HTN [hypertension] on Ozempic presenting to the ED for evaluation of generalized abdominal pain. Patient reports 2 hours ago constant generalized abdominal pain began with associated vomiting x 3, nausea, constipation, and blood when wiping today but denies any associated fevers, back pain, or dysuria. Patient states that she took 2 Tylenol 1.5 [one and a half] hours ago with no relief. Patient reports her last normal bowel movement was yesterday and she normally has bowel movements every other day but this episode is different because of associated pain. She endorses a history of hidradenitis [sic] [painful, long-term skin condition that causes skin abscesses and scarring on the skin] surgery around the abdominal area but denies any abdomen surgery. . .” Review of P14’s review of systems indicated “. . . Gastrointestinal symptoms: Abdominal pain, diffuse, pain, nausea, vomiting, constipation. . .” Review of P14’s vital signs indicated blood pressure 116/80, heart rate 107, respiratory rate 18, and oxygen saturation 100%. Review of Staff K’s (ED Physician/Director) ED note dated 09/24/23 at 10:32 AM indicated “The patient presents with abdominal pain. The onset was 3 hours ago. The course/duration of symptoms is constant. . . A 38-year-old female patient with a PMHx [prior medical history] of PCOS [polycystic ovary syndrome] with baseline irregular periods, prior miscarriages, hidradenitis suppurativa with bilateral axillary and pelvic excisions, and DM [diabetes mellitus] on Ozempic arrives to the ED for evaluation of a constant suprapubic abdominal pain beginning 3 hours ago 0700 [7:00 AM]. She states that when she woke up this morning, she felt a cramping sensation in her abdomen, which felt as if her bladder was full. She reports dysuria with associated hematuria. She states that when she wiped she had some vaginal bleeding. She states that while in the bathroom, she developed nausea with 1 [one] episode of vomiting and diaphoresis. Here in the ED she reports chills. Patient states that her LMP ended 2 days ago. She is sexually active. She states her and her husband are trying for a baby. Patient states that she still has her gallbladder, appendix, uterus, and ovaries. She reports that she felt normal and at her baseline yesterday. VS [vital signs] upon evaluation include HR [heart rate] 100, O2 sat [oxygen saturation] 100% on RA [room air], BP [blood pressure] 113/73. Additional Hx [history] was provided by the patient’s friend. . . No OB/GYN.. .” Review of P14’s lab results on 09/23/23 at 12:15 PM indicated Beta hCG POC [quantitative human chorionic gonadotropin (HCG or hCG) blood test measures the specific level of HCG in the blood during pregnancy] was greater than 2000.0 Intl [international] Units/mL [per milliliter] ABN [abnormal]; Pregnancy screen, Urine positive; UA [urinalysis] blood positive 3+; UA WBC [white blood cells] 6-10 /HPF [high power field] ABN; UA RBC [red blood cells] greater than 50 /HPF ABN; epithelial cells 11-20 /HPF ABN; UA Hyal [hyaline] Cast 3-5 [LPF] [low power field] ABN. Review of the ultrasound obstetric less than 14 (fourteen) weeks performed transvaginally performed on 09/23/23 at 11:22 AM indicated “PROCEDURE: US [ultrasound] Pregnancy 1st [first]Trimester. FINDINGS: Uterus measures 9.7 x 5.1 x 4.6 cm [centimeters]. Endometrial thickness is 1.2 cm. There are Nabothian [a tiny bump that forms when skin cells trap mucus inside the glands in the cervix] cysts in the cervix. There is a questionable fibroid in the anterior lower uterine segment measuring 1.9 x 2.1 x 1.8 cm. There is no evidence of an intrauterine or extrauterine pregnancy. The left ovary normal in size and morphology. Right ovary is not visualized. IMPRESSION: No evidence of intrauterine or extrauterine pregnancy. Recommend continued correlation with serial beta-hCGs and followup [sic] ultrasound as warranted. Small fibroid uterus as well as some nabothian cyst.” Review of P14’s EMR indicated lab staff reported “. . . the patient’s exact hCG is 20,891.” Average hCG levels in blood during pregnancy of 200 - 32,000 µ/L indicates a 6 week pregnancy and an hCG level of 3,000 - 160,000 µ/L indicates a 7 week pregnancy. Review of Staff K’s medical decision making indicated “patient presents with lower abdominal pain. The patient turned out to have a positive pregnancy test. Beta hCG is over 20,000. The patient had a sonogram which was unremarkable. Patient advised to get a repeat beta-hCG in 48 hours. Patient advised to get a repeat sonogram in 7 [seven] days. Patient advised to call for an appointment with OB/GYN tomorrow. [Staff K documented in ED physician note that P14 did not have an obstetrician/gynecologist] Patient agrees to do so. I have answered all of the patient’s questions. I have given the patient’s strict return precautions. Patient is aware that this could be an abnormal pregnancy.” Staff K’s documentation indicated the treatment and disposition was P14 “will be discharged home. The patient is comfortable and agrees with the disposition plan. All questions have been answered and strict return precautions have been given.” Staff K’s documentation on 09/24/23 at 12:37 PM indicated “Discussion of pertinent results, Dx [diagnosis], and plan of discharge with patient. I state that she will need to be started on prenatal vitamins, acquire an OB/GYN, and cease all smoking or drinking. Patient verbalizes agreement with this plan. Patient is clinically stable for discharge. All questions and concerns have been addressed. Patient is comfortable with discharge. They have been given strict return precautions. Notes: On serial evaluation in the emergency department, the patient has remained stable and well appearing. The patient has been in no acute distress.” The hospital failed to perform an appropriate MSE to determine if an EMC existed including, but not limited to, use of the on-call and available OB/GYN physician and other capabilities and services routinely available to the emergency department to provide reasonable clinical confidence that P14’s signs and symptoms were not a manifestation of ectopic pregnancy. Ectopic pregnancy occurs when a pregnancy implants outside the uterus and can be associated with life-threatening hemorrhage, loss of future fertility, infection, coagulopathy (dysfunction of the body’s blood clotting organs and system), and damage or dysfunction to the uterus, fallopian tubes, ovaries, and/or other abdominal and pelvic organs. During a telephone interview on 10/22/24 at 2:07 PM, Staff K stated Staff NN, Physician Assistant, was no longer employed at the hospital and was not available to be interviewed. Staff K asserted he/she reviewed the medical record and stated he/she typically orders a transvaginal ultrasound, because one can visualize the intrauterine pregnancy and ovaries the best. He/She stated for 12 to 20 weeks gestation, he/she would do a transabdominal ultrasound. Staff K stated the recommendation at discharge was appropriate. Staff K stated if the repeat hCG rises, he/she would expect an ectopic pregnancy, and the patient may need to see an OB/GYN sooner. If the hCG drops, he/she would expect a miscarriage.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 25065 Based on record review, document review, policy review and interview the Hospital (H1) failed to provide stabilizing treatment for 2 of 28 patients (P2 and P14) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death. Findings Include: Review of a document titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)” revised on 04/17/23 showed, “The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ... ...Stabilizing Treatment Where the MSE reveals that the person has an EMC, the Hospital will provide Stabilizing Treatment as required to stabilize the medical condition or will transfer the patient in accordance with the Transfer provisions below. Stabilizing treatment is ongoing and must be continued until the patient is Stabilized or appropriately Transferred ... “Qualified Medical Person or Personnel” (QMP) refers to physician and non-physician individuals defined by the medical staff’s bylaws, rules, and regulations or other document approved by the Hospital’s governing body to perform the medical screening examinations for those individuals that present to a Dedicated Emergency Department and request examination and treatment ...” Review of a policy titled, “Level of Service,” revised 07/20/22, showed, “Policy: All [H1 and H2] facilities have established processes to ensure that patients are admitted and maintained at the appropriate patient status and clinical level of care ...The patient status and level of care is reflected in the medical record and on all billing documentation to ensure proper billing to all payers ...b. Observation Level of Care: Hospital outpatient services furnished by a hospital on the hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing staff that are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient if medically necessary ...C. Inpatient Level of Care: 1. Hospital inpatients are admitted to the hospital for purposes of receiving acute inpatient hospital services.” Patient 2 (P2) Review of P2’s medical recorded showed P2 was a 7 day old female brought to the ED by her parents on 07/02/24 at 12:35 AM with chief complaint of not eating. Review of P2’s medical record showed a document titled, “ED Note-Physician” by Staff R, Physician, dated 07/02/24 at 1:19 AM, “ ...The patient presents with Not eating/vomiting (eject matter from the stomach thru the mouth) ...Additional history: Patient is a 7 day/old female that was brought in by parents for concern of jaundice (yellow color of the skin)/decreased p.o. [oral] intake and lethargy (feeling of being tired). Denies any fever/and was seen in the clinic recently and had a bilirubin (the breakdown of red blood cells in the blood) of 13. Patient is bottle-fed and parents have been unable to get her to eat. She did have 1 episode of emesis (matter ejected from the stomach when vomiting) that was noted to be yellow ...Reexamination/Reevaluation Will repeat bilirubin level/pediatric team consulted/ labs currently pending at time of admit Will admit for observation/ discussed with admitting team. HPI (History of Present Illness) assisted via translation service from iPad ...” Review of Staff G, Physician, Pediatric Hospitalist’s order dated 07/02/24 at 2:31 AM for P2, showed “Order: Place in Observation.” Review of P2’s Gastrointestinal Assessments dated 07/02/24 at 1:30 AM to 07/03/24 at 12:00 AM showed P2 vomited 10 times. Review of a “Provider Notification,” dated 07/02/24 at 6:05 PM, showed Staff I2 documented, “pt has vomited x 3 since started formula.” Review of P2’s “Nutrition Progress Note,” dated 07/03/24 at 9:51 AM, showed Staff L2, Registered Dietician (RD) documented, “ ...Nutrition Related History Current Presentation Nutrition: Pt admitted [sic] for vomiting and inability to tolerate feeds. Had UGI (upper gastrointestinal test)- no obstruction, indicated reflux and gastroenteritis (inflammation and infection of the stomach). Feeding tube placed to duodenum with Pedialyte (sic) (oral electrolytes) running, continuing to vomit @6 milliliters/hour (ml/hr) ... Weight History Nutrition: 9% below birth wt (sic) on admit, significant ... Enteral Nutrition Recommendation (use of a tube to deliver nutrition to people who are unable to eat or swallow safely): trial Similac Alimentum @ 5ml/hr, if tolerated advance slowly towards 23 milliliters/hour (ml/hr) to provide 150 ml/kg; reflux (spitting up gastric contents) precautions. Meal and Snack Delivery Recommendation: NPO (nothing by mouth), when starting feeds will need to titrate up slowly, start with 20ml q2-3 hrs TPN [total parenteral nutrition -feeding that provides nutrients through a vein] - IV Fluids Recommendation: if unable to tolerate EN (enteral nutrition), will need to consider PN (parenteral nutrition) in 2-3days TPN - IV Fluids Recommendation-cont: continue IV fluids with dextrose (sugar water) until tolerating feeds ...” Review of P2’s Gastrointestinal Assessments dated 07/03/24 at 12:00 AM to 07/04/24 at 12:00 AM showed P2 vomited 8 times. Review of a “Provider Notification” dated 07/03/24 at 7:53 PM, showed Staff J2, Bachelor of Science in Nursing (BSN) documented, “notified provider episode of emesis. “Provider Requested Interventions ...Other: continue tube feeding at 20ml/hr.’” Review of a document titled, “Gastrointestinal Assessment,” dated 07/04/24 at 12:00 AM to 07/05/24 at 12:00 AM showed P2 vomited 6 times. Review of P2’s “Progress Note- Generic” dated 07/04/24 at 4:16 PM, showed Staff K, Physician documented, “Called by RN that patient has not taken bottle all day successfully w/o [sic] [without] vomiting all formula up. Discussed case with [Physician], will switch to Alimentum formula via NJ tube (nasojejunal- a tube that goes in the nose and passes thru the stomach to a portion of the intestine) starting at rate of 15 ml/hr for first 1-2 hours. Then increase to 20 ml/hr for 4 hours, increase to goal rate of 25 ml/hr. Discussed instructions with nursing team. Orders placed and verified by nursing team.” Review of a “Provider Notification,” dated 07/04/24 at 8:00 PM, showed Staff M2, RN documented “patient vomited large amount about 30 minutes after increase tubefeed (sic).” Review of a “Provider Notification” dated 07/05/24 at 2:50 AM, showed Staff M2, RN documented, “ ...Patient continues to vomit overnight. Will vomit about every 2 hours, and then will have episodes of vomiting every 30 minutes. vomit does not look normal-almost looks like stool. Has had one stool smear that is orange/clay looking.” Review of a “Progress Note” dated 07/05/24 at 3:05 AM, showed Staff N2, Physician documented, “As emesis has significantly increased in frequency and volume after increasing to 25 ml/hr, will decrease formula TF [tube feeding] to 20 ml/hr for the next 2 hours. Following may trial increase back to 25 ml/hr.” Review of a “Provider Notification,” dated 07/05/24 6:34 AM, showed Staff M2, RN documented, “Physician notified that the patient was weighed this morning and weighed 3.12 kg.” Review of a “Provider Notification,” dated 07/05/24 at 7:50 AM, showed, Staff M2, RN documented, “ ...resident finished rounds, and this RN let the resident know that there was great concern about the patient. This RN really believes that the patient is throwing up stool, not just bile like it was believed. Patient vomited at least 10 times over night.” Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 8:32 AM, showed Staff S, RN documented, P2’s abdomen was soft and appeared appropriate for age and size, round and symmetric and continued to vomit. Review of P2’s “Nutrition Progress Note,” dated 07/05/24 at 10:24 AM, showed Staff L2, RD documented, “ ...Assessment Nutrition Related History Current Presentation Nutrition: Pt is fussy this morning, vomited all night. Attempted oral feeds yesterday, pt did not cue and was uninterested. Pt is elevated in crib this morning, mother at bedside. Diet History Nutrition: per mom, pt has not taken a full bottle since birth. First feeds after birth were not tolerated well, produced odd noise then would stop eating ...Nutrition Dx/Intervention/Goals TPN - IV Fluids Recommendation: continue to recommend TPN with poor nutrition since birth (10 days minimal nutrition) ...” Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 12:00 PM, showed Staff S, RN documented, P2’s abdomen was distended and continued to vomit. Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 5:20 PM, showed Staff S, RN documented P2’s abdomen was distended, firm and had bile/mucous emesis. Review of P2’s “Gastrointestinal Assessment,” dated 07/05/24 at 12:00 AM to 07/06/24 at 3:44 AM showed P2 vomited 8 times. Review of the medical record showed P2 weighed 3.7 kilograms (kg), (8 pounds 3 ounces) at birth; on admission to observation on 07/02/24 P2 weighed 3.47 kg (7 pounds 10 ounces) and on 07/05/24, P2 weighed 3.12 kg (6 pounds 8 ounces). Review of the medical record showed that P2 vomited 32 times between 07/02/24 and 07/06/24. Further review of the medical record showed staff failed to notify or document the physician/provider was notified 28 of 32 times on 07/02/24, 07/03/24, and 07/05/24. Review of P2’s “Intake and Output” showed the following: 07/01/24 at 7:00 PM to 07/02/24 at 7:00 AM - Intake by IV fluid 95.4167 ml Output 31, with 1 emesis. 07/02/24 at 7:00 AM to 07/03/24 at 7:00 AM - Intake by IV fluid 200.75, Tube feed 163, Output 124 with 10 emesis. 07/03/24 at 7:00 AM to 07/04/24 at 7:00 AM - Intake by IV fluid 48 ml, Tube feed 387, Output 90 with 9 emesis. 07/04/24 at 7:00 AM to 07/05/24 at 7:00 AM - Intake by IV none, Tube feed 432.5, Output 93 with 15 emesis. Review of Vascular Access notes dated 07/05/24 at 4:08 PM showed Staff RN documented, Peripheral IV Number of Attempts: “1, won’t thread, site dc’d [discontinued]” Review of a physician’s order dated 07/05/24 at 4:16 PM entered by Staff G, Physician, showed, “Order: Consult to Pharmacy (TPN Pharmacy Consult) ...Order Details: ...Routine, TPN Pharmacy Dosing and Level, Daily ...” Review of P2’s Vascular Access notes dated 07/05/24 at 5:00 PM showed Staff O2, RN documented, Central IV Activity: “Insert new site”, Central IV Procedure Type: “Non-emergent” Review of a document titled, “Neurological Assessment,” dated 07/05/24 at 8:32 AM, showed P2’s anterior and posterior fontanels (soft spots in front and back on a newborns head where the suture lines meet) were flat and soft (a normal assessment for a newborn). Further review of the medical record on 07/05/24 at 8:00 PM showed that P2’s anterior and posterior fontanels were sunken and depressed (an abnormal sign that could indicate the patient is not getting enough fluids). Review of a “Progress Note-Addendum” dated 07/05/24 at 12:49 PM, Staff G, Physician, documented that a conversation with 2’s parents discussed the deep concern that patient was down 15% total from birth weight. The documentation showed that if no improvement was seen in the next 24-48 hours the patient would be sent to a Kansas City hospital for a comprehensive, multidisciplinary assessment and treatment. Review of a Progress Note Addendum dated 07/05/24 at 1:06 PM by Staff G, Physician showed, “Upgrade to inpatient status as pt has failed oral challenge several times and remains NJ dependent with ongoing weight loss. I do not anticipate a d/c [discharge] in the next 48hr.” The hospital failed to provide stabilizing treatment to P2 who continued to have poor nutritional and fluid intake. Tube feedings continued although the infant continued to vomit. The record showed P2 received 48 ml of IV fluids on 07/03/24 and then did not receive any IV fluids until after 7:00 PM on 07/05/24 as indicated in the Intake and Output documentation. TPN was recommended on 07/03/24 and 07/05/24 by Staff L2, RD and an order was not placed until 07/05/24 at 4:16 PM. Patient 2 died on 07/06/24 at 3:44 AM. During an interview on 10/22/24 at 3:49 PM, Staff R, MD, stated that, P2 was a 6- or 7-day old infant. The mother carried the patient to full term. The patient had an elevated bilirubin level at birth. The patient presented with difficulty feeding and vomiting and slightly jaundiced but was below bilirubin light level. P2 would cry and was making tears. The mother was notified that we would do an IV (when a tube is inserted into a vein to deliver fluids) and check blood levels. During an interview on 10/22/24 at 4:07 PM, Staff Q, RN stated that the infant had bilious emesis (vomit that contains bile); the parents spoke very broken English, pediatrics was instantly contacted. The pediatric resident came down and IV access was not able to be established. IV team was called for assistance. The mother tried to feed and P2 still couldn’t hold anything down. PICU (pediatric intensive care unit) nursing staff were informed the patient did not have an IV site and needed one. The patient was sick with a weak little cry. Vital signs were stable when transferred to the pediatric floor. P2 was only in the ED about 1 or 2 hours total. Pediatric beds are usually available quickly. During an interview on 10/22/24 at 4:25 PM, Staff S, RN, stated that on 07/05/24, dayshift (7 AM to 7 PM) the [Physician] was called while still on the Pediatric floor. The [Physician] was notified that the infant was breathing funny with subcostal (a breathing condition when the abdomen pulls into the ribcage) retractions and desaturating (low oxygen level). P2 was suctioning and placed on an oxygen mask and then a cannula (device used to administer oxygen). P2 responded a little with oral suctioning and with decompressing (removing air from stomach) her stomach. Oxygen saturations’ (level of oxygen in the blood) were in the 90’s (normal range for patient age is > or = to 93%). The [Physician] called the pediatric intensivist (critical care physician). The PICU charge nurse was notified that P2 needed sent right away to a higher level of care. Staff S stated that she thought P2 was stable that day until she wasn’t. During an interview on 10/22/24 at 3:00 PM, Staff N, MD, stated that she was the on call as the Pediatric Intensivist the night P2 was transferred to the PICU. She stated that she was involved in the care the end on 07/05/24 at around 7:00 PM. She stated the infant was not doing well when arriving in the PICU due to breathing difficulties and still vomiting. During an interview on 10/23/24 at 10:20 AM, Staff Y, RN, stated that when arriving on shift P2 had just vomited. A NG was placed and copious amount of stool as return. P2’s tongue was brown and sandpaper from stool emesis. The NG returned about 500 ml of brown, thick liquid and it appeared to be stool. While attempting to intubate (place a breathing tube in the airway) the patient projectile vomited more brown fluid. It appeared she aspirated (inhaled into the lungs) the contents. There was concern P2 had been vomiting stool prior to arriving in the PICU. Staff Y stated that the patient’s eyes were sunken in and eyes rolled back in the head. A urinary catheter (a tube inserted in to the bladder to drain urine) was placed and no urine output was present. When P2 was intubated, she was somewhat stabilized however unable to keep the blood pressures up in an acceptable range, so we started an epinephrine (medication to increase heartrate) drip. She had a single lumen Peripherally Inserted Central Catheter (PICC) in the right lower leg. The decision was made to transfer her to [H3]. The H3 transport team arrived about midnight. The transport team immediately took over and assumed the care of the patient. While attempting to transfer P2 to transport incubator, P2 had no heartbeat. CPR (cardiopulmonary resuscitation) was started. Staff Y stated that the fact P2 was vomiting stool at least 20 times during that day was concerning. Communication with the parents was difficult, we did have someone who could translate working on the unit and then we used the iPad translator too. Patient 14 (P14) Review of P14’s electronic medical record (EMR), with Staff C and Staff E assisting with navigation of the EMR, indicated P14 was triaged on 09/24/23 at 9:24 AM by Staff NN, Physician Assistant, with the chief complaint of “lower abd [abdominal] pain that started when she woke up this morning, took 2 [two] tylenol this morning, vomiting x [times] 3 times, last bm [bowel movement] 9/23 [09/23/23] reports normal, LMP [last menstrual period] 2 days ago.” Review of P14’s history of present illness indicated “The patient presents with Abdominal pain. The onset was 2 hours ago. The course/duration of symptoms is constant. Location: Generalized abdomen. The character of symptoms is pain. Risk factors consist of hypertension. Therapy today: see nurses notes. Associated symptoms: nausea, vomiting, Constipation, Blood when wiping, Denies dysuria and denies fever. 38-year-old female patient with a history of HTN [hypertension] on Ozempic presenting to the ED for evaluation of generalized abdominal pain. Patient reports 2 hours ago constant generalized abdominal pain began with associated vomiting x 3, nausea, constipation, and blood when wiping today but denies any associated fevers, back pain, or dysuria. Patient states that she took 2 Tylenol 1.5 [one and a half] hours ago with no relief. Patient reports her last normal bowel movement was yesterday and she normally has bowel movements every other day but this episode is different because of associated pain. She endorses a history of hidradenitis [sic] [painful, long-term skin condition that causes skin abscesses and scarring on the skin] surgery around the abdominal area but denies any abdomen surgery. . .” Review of P14’s review of systems indicated “. . . Gastrointestinal symptoms: Abdominal pain, diffuse, pain, nausea, vomiting, constipation. . .” Review of P14’s vital signs indicated blood pressure 116/80, heart rate 107, respiratory rate 18, and oxygen saturation 100%. Review of Staff K’s (ED Physician/Director) ED note dated 09/24/23 at 10:32 AM indicated “The patient presents with abdominal pain. The onset was 3 hours ago. The course/duration of symptoms is constant. . . A 38-year-old female patient with a PMHx [prior medical history] of PCOS [polycystic ovary syndrome] with baseline irregular periods, prior miscarriages, hidradenitis suppurativa with bilateral axillary and pelvic excisions, and DM [diabetes mellitus] on Ozempic arrives to the ED for evaluation of a constant suprapubic abdominal pain beginning 3 hours ago 0700 [7:00 AM]. She states that when she woke up this morning, she felt a cramping sensation in her abdomen, which felt as if her bladder was full. She reports dysuria with associated hematuria. She states that when she wiped she had some vaginal bleeding. She states that while in the bathroom, she developed nausea with 1 [one] episode of vomiting and diaphoresis. Here in the ED she reports chills. Patient states that her LMP ended 2 days ago. She is sexually active. She states her and her husband are trying for a baby. Patient states that she still has her gallbladder, appendix, uterus, and ovaries. She reports that she felt normal and at her baseline yesterday. VS [vital signs] upon evaluation include HR [heart rate] 100, O2 sat [oxygen saturation] 100% on RA [room air], BP [blood pressure] 113/73. Additional Hx [history] was provided by the patient’s friend. . . No OB/GYN.. .” Review of P14’s lab results on 09/23/23 at 12:15 PM indicated Beta hCG POC [quantitative human chorionic gonadotropin (HCG or hCG) blood test measures the specific level of HCG in the blood. HCG is a hormone produced in the body during pregnancy] was greater than 2000.0 Intl [international] Units/mL [per milliliter] ABN [abnormal]; Pregnancy screen, Urine positive; UA [urinalysis] blood positive 3+; UA WBC [white blood cells] 6-10 /HPF [high power field] ABN; UA RBC [red blood cells] greater than 50 /HPF ABN; epithelial cells 11-20 /HPF ABN; UA Hyal [hyaline] Cast 3-5 [LPF] [low power field] ABN. Review of the ultrasound obstetric less than 14 (fourteen) weeks performed transvaginally performed on 09/23/23 at 11:22 AM indicated “PROCEDURE: US [ultrasound] Pregnancy 1st [first]Trimester. FINDINGS: Uterus measures 9.7 x 5.1 x 4.6 cm [centimeters]. Endometrial thickness is 1.2 cm. There are Nabothian [a tiny bump that forms when skin cells trap mucus inside the glands in the cervix] cysts in the cervix. There is a questionable fibroid in the anterior lower uterine segment measuring 1.9 x 2.1 x 1.8 cm. There is no evidence of an intrauterine or extrauterine pregnancy. The left ovary normal in size and morphology. Right ovary is not visualized. IMPRESSION: No evidence of intrauterine or extrauterine pregnancy. Recommend continued correlation with serial beta-hCGs and followup [sic] ultrasound as warranted. Small fibroid uterus as well as some nabothian cyst.” Review of P14’s EMR indicated lab staff reported “. . . the patient’s exact hCG is 20,891.” Review of Staff K’s medical decision making indicated “patient presents with lower abdominal pain. The patient turned out to have a positive pregnancy test. Beta hCG is over 20,000. The patient had a sonogram which was unremarkable. Patient advised to get a repeat beta-hCG in 48 hours. Patient advised to get a repeat sonogram in 7 [seven] days. Patient advised to call for an appointment with OB/GYN tomorrow. [Staff K documented in ED physician note that P14 did not have an obstetrician/gynecologist] Patient agrees to do so. I have answered all of the patient’s questions. I have given the patient’s strict return precautions. Patient is aware that this could be an abnormal pregnancy.” Staff K’s documentation indicated the treatment and disposition was P14 “will be discharged home. The patient is comfortable and agrees with the disposition plan. All questions have been answered and strict return precautions have been given.” Staff K’s documentation on 09/24/23 at 12:37 PM indicated “Discussion of pertinent results, Dx [diagnosis], and plan of discharge with patient. I state that she will need to be started on prenatal vitamins, acquire an OB/GYN, and cease all smoking or drinking. Patient verbalizes agreement with this plan. Patient is clinically stable for discharge. All questions and concerns have been addressed. Patient is comfortable with discharge. They have been given strict return precautions. Notes: On serial evaluation in the emergency department, the patient has remained stable and well appearing. The patient has been in no acute distress.” During a telephone interview on 10/22/24 at 2:07 PM, Staff K stated Staff NN, Physician Assistant, was no longer employed at the hospital and was not available to be interviewed. Staff K stated he/she reviewed the medical record and stated he/she typically orders a transvaginal ultrasound, because one can visualize the intrauterine pregnancy and ovaries the best. He/She stated for 12 to 20 weeks gestation, he/she would do a transabdominal ultrasound. Staff K stated the recommendation at discharge was appropriate. Staff K stated if the repeat hCG rises, he/she would expect an ectopic pregnancy, and the patient may need to see an OB/GYN sooner. If the hCG drops, he/she would expect a miscarriage. Documentation in the medical record reflected the hospital understood P14’s signs and symptoms to be a manifestation of pregnancy of unknown location, including a potential ectopic pregnancy. Review of the entire EMR indicated the available on-call OB/GYN physician was not consulted, despite the hospital’s knowledge that P14 did not already have an OB/GYN with whom she could follow-up as advised, and there were no specific arrangements made for P14 to return to the ED, her recommended follow-up care for pregnancy of unknown location. The discharge instructions were unclear as to how or where P14 was to follow-up with an OB/GYN in 1-2 days.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45841 Based on facility policy review, record review, and interview, the facility failed to ensure restraints were implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy for 4 (Patient #2, Patient #3, Patient #5, and Patient #6) of 6 sampled patients reviewed for restraints. Findings include: A facility policy titled, “Restraints and Seclusion Policy,” revised on 02/03/22, indicated “The RN [Registered Nurse] documents the time the restraint or seclusion is discontinued.” The policy indicated, “Patients who are severely agitated or intoxicated, are undergoing alcohol or drug withdrawal, or can’t follow safety directions may require arm and leg restraints, such as nylon or locked restraints.” The policy indicated, “RN will document the type of restraint used.” The policy also indicated under Violent, self-destructive restraint use, “If they can be removed, document final removal in the appropriate place in the Electronic Medical Record”. The policy indicated, “When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, [sic] and document in the electronic medical record.” Patient #2 An order for “Restraint Initiate Violent 18 Year and Older” for Patient #2 was placed on 08/05/24 at 1:20 PM for keyed poly plastic restraints to the upper and lower extremities. “Restraint Episode” showed the restraints were initiated on 08/05/24 at 1:15 PM, and “Restraint Evaluation” revealed the nurse documented the patient was in nylon locked restraints, not keyed poly plastic restraints. “Restraint Evaluation” also revealed that the last documentation for the nylon locked right upper extremity and left lower extremity was on 08/05/24 at 2:45 PM, and the restraint activity type was “Release/Reapply, same episode.” The last documentation for the nylon locked left upper extremity and right lower extremity was on 08/08/24 at 3:30 PM, and the restraint activity type was “Release/Reapply, same episode.” There was no documentation to show when the restraints were discontinued. During an interview on 08/19/24 at 3:08 PM, Clinical Informatics #3 stated she did not see any discontinuation documentation for the locked, nylon restraints on 08/05/24 and that the ordered restraint type for keyed poly plastic was different than the documented locked nylon restraints for Patient #2’s restraints on 08/05/24. During an interview on 08/20/24 at 10:48 PM, Nurse Manager #4 stated they do not have keyed poly plastic restraints. They only have locked nylon, so they chose the wrong type in the order. During an interview on 08/20/24 at 10:52 AM, Assistant Nurse Manager #5 stated Patient #2 would have been released from the restraints on 08/05/24, but it was not documented. Patient #3 An order for “Restraint Initiate Violent 18 Years and Older” for Patient #3 was ordered on 06/13/24 at 1:36 PM for a physical hold. “Restraint Episode” revealed the restraint was initiated on 06/13/24 at 12:42 PM. “Restraint Evaluation” on 06/13/24 at 12:42 PM showed the restraint type was a physical hold but did not specify where the hold was. During an interview on 08/20/24 at 10:59 AM, Assistant Nurse Manager #5 stated the nursing documentation for the physical hold on Patient #3 on 06/13/24 at1 :36 PM did not specify where the patient was held. Patient #5 An order for “Restraint Initiate Violent 9-17 Years” for Patient #5 was placed on 08/04/24 at 10:00 AM for nylon locked restraints. “Restraint Episode” revealed a restraint was initiated on 08/04/24 at 9:52 AM, but documentation did not specify what type of restraint. During an interview on 08/19/24 at 1:56 PM, Clinical Informatics #3 stated nursing did not document the type of restraint for Patient #5 on 08/04/24. During an interview on 08/20/24 at 11:19 AM, Assistant Nurse Manager #5 stated the nurse did not document the type of restraint for Patient #5 in the restraint flowsheet or a note for the restraint episode on 08/04/24 at 10:00 AM. Patient #6 An order for “Restraint Initiate Violent 18 Years and Older” for Patient #6 was placed on 06/28/24 at 5:36 PM for a physical hold. “Restraint Episode” revealed an initiated episode on 06/28/24 at 5:03 PM. “Restraint Evaluation” revealed the restraint was a physical hold of the right and left upper extremities on 06/28/24 at 5:03 PM. There was no documentation of the discontinuation of the restraint. During an interview on 08/20/24 at 10:49 AM, the Chief Nursing Officer (CNO) stated that it was identified from record review on 08/19/24 that they needed to go through and clean it up the selection for restraint types that providers may choose from based on what was available. The CNO stated there was no selection to say discontinued or released for individual limb restraints without release/reapply, same episode. The CNO stated staff should use release/reapply, same episode for when the patient was released for skin and mobility check, and the restraint was reapplied. The CNO stated because there was no other discontinue or release option, staff were using release/reapply, same episode as the restraint being discontinued. During an interview on 08/20/24 at 10:57 AM, the CNO stated the current policy did not require the specific location of the restraints in the order, but it was required for the nursing documentation.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47233 Based on record review, policy review, document review, and interview the hospital failed to ensure it met the requirements for Patient Rights Condition of Participation by failing to protect and promote patient rights. Findings Include: 1. The hospital failed to provide/inform patients or patient ’ s representative of Patient Rights in advance of furnishing patient care for 1 of 3 sampled patients. (Refer to Tag A0117) 2. The hospital failed to ensure nursing staff followed policy and procedures to protect and promote each patient ’ s rights resulting in elopement of an elderly patient. (Refer to tag A0144)”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and interview, the hospital failed to ensure it informed each patient, or when appropriate, the patient ’ s representative of the patient ’ s rights, in advance of furnishing or discontinuing patient care for 1 of 3 sampled patients (Patient 1). This deficient practice places any patient at risk of not understanding their individual rights as required per regulation requirements 42 CFR §482.13(a)(1). Findings Include: Review of a hospital policy titled, “Guidelines for Determining Order of Consent for Treatment,” revised, 1/11/2022, showed, “ Purpose: As a ministry of the Catholic Church, Ascension Via Christi adheres to the Ethical and Religious Directives for Catholic Health Care Services. Consistent with this guidance, Ascension strives to provide exceptional care to each patient in alignment with their human dignity. This obligation is heightened for vulnerable patients who have been determined to lack decision-making capacity. The attached Ethical Framework for Decision-Making Capacity document provides expanded guidance to the concepts below ... The purpose of these guidelines is to support the clinician’s determination of decision-making capacity for adult and minor patients and provide the order in which individuals may provide authorization/consent for treatment ... B. Adult patient without decision-making capacity who has declared his or her wishes through an advance directive (including, but not limited to, an agent designated pursuant to a durable power of attorney for health care decisions (DPAHCD); Declaration made pursuant to the Kansas Natural Death Act [Living Will]; Transportable Physician Orders for Patient Preferences (TPOPP); or signed driver ’ s license marked for organ donation, as recognized under state law) ...” Patient 1 Review of Patient 1 ’ s Emergency Department Medical Record dated 06/24/24 showed Patient 1 a 77-year-old female with a diagnosis of syncope. Past medical history of dementia (memory loss) (w/o behavioral disturbance); major depression (a feeling of sadness, hopelessness); generalized anxiety disorder (feelings of worry and/or fear); hypertension (high blood pressure); chronic sinusitis (inflammation of the sinus cavity); dyspepsia (stomachache and bloating), and Epilepsy (seizure disorder). Patient 1 currently resides in a locked Memory Care Unit. Review of a document titled “Admission Consent, Promise To Pay for Services and Assignment of Insurance Benefits” dated 06/24/24 showed Patient 1 signed consent agreement, No witness signatures on form. Review of a document titled, “Order Appointing Guardian and Conservator,” dated 11/22/22, showed, “ ...After examining the files, and hearing the evidence, statements and arguments of counsel, the Court finds that: By clear and convincing evidence, [Patient 1] is an adult with impairments and lacks the capacity to meet essential needs for physical health, safety or welfare, should not be permitted to make any decisions which affect her person, and the Guardian herein appointed shall be possessed of all the powers and duties of a Guardian as set out in K.S.A. §59-3075 and the Letters of Guardianship to be issued herein shall so state ...” During an interview on 06/25/24 at 3:23 PM, Staff I, RN Emergency Department Manager stated that the patient should not sign her own 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: 47233 Based on policy review, document review, record review, interview and surveillance video review, the hospital failed to ensure the patient right to receive care in a safe setting as required per 42 CFR §482.13(c)(2). This deficient practice resulted in potential and/or actual harm for 1 of 3 sampled patients (Patient 1) and places any patient receiving services at this hospital at risk for harm or injury. Findings Include: Review of a hospital policy titled, “Patient Elopement,” revised, 1/26/2022, showed, “POLICY: a. To provide guidance for security officers and other associates who are requested to locate, detain, restrain, return or otherwise provide assistance with patients who elope, or attempt to elope from Ascension Via Christi Hospitals. PROCEDURE: a. For the purposes of this policy, “Elopement” is defined as a patient who leaves, or attempts to leave the hospital when doing so may present an imminent threat to the patient’s health or safety because the patient (1) has been deemed too ill or impaired to make a reasoned decision to leave or (2) due to their legal status because they are under orders by a physician or court to receive mandatory treatment. Elopement does not include events involving competent adults with decision-making capacity who leave against medical advice (AMA), voluntarily leave without being seen, or leave prior to treatment completion. b. If a patient elopes or attempts to elope, all reasonable efforts should be made to locate, redirect, and if necessary detain the patient for his or her safety and so that treatment can be provided or resumed. c. In cases where patients are being seen in the emergency department or other areas of the hospital and are assessed for high risk for suicide or homicide, security officers or other associates will be requested by qualified medical personnel to remain with the patient while a determination of the patient’s medical/legal status is completed. d. If an eloping patient attempts to leave but is still located on Ascension Via Christi Hospital property, security officers or other associates should attempt to persuade the patient to voluntarily return to the unit he or she left. e. If the patient cannot be located, or is known to have left hospital property, the appropriate Law Enforcement Agency shall be notified. f. The reporting nursing unit, a member of Security, or the House Manager may discuss the situation and identify pertinent information to be shared in compliance with policy PC-14: Use and Disclosure of Protected Health Information for Law Enforcement Purposes when making the Law Enforcement notification. g. If the patient has eloped and has been located but is not on Ascension Via Christi property, the security officer will, if warranted, keep the patient in sight and notify 911 for assistance and/or provide the patient’s current or last known location and direction of travel. The security officer will avoid detaining, pursuing, or otherwise making contact with the patient while off property, unless the patient initiates contact and agrees to return voluntarily. h. If deemed necessary and appropriate to use physical force to return an eloping patient, only the reasonable amount of force necessary shall be used to restrain and return the patient. If necessary, Security may notify 911 for assistance, particularly if the patient threatens or exhibits extreme violent or combative behavior, or threatens or displays a weapon. Avoiding injury to the patient, staff and others should be the highest priority and may on occasion result in an elopement rather than injuries to staff or patients ...” Review of a hospital policy titled, “Missing Adult Patient Policy,” revised, 4/19/2021, showed, “ ...PURPOSE: The purpose of this policy is to outline the steps taken when an adult patient is missing. SCOPE: This policy applies to adult patients 18 years and older in all areas of the Hospital. DEFINITIONS: Missing Patient: A patient missing from a care area without associate knowledge or permission ...c. At-Risk: A patient missing from a care area without associate knowledge or permission and who is identified by a clinical associate as at-risk for harm should he/she not be returned to the room. This may include ...2. Patients who are confused because of a physical condition, including but not limited to: dementia, traumatic brain injury, metabolic changes, anesthesia, and/or drug/alcohol abuse ...4. Patients who have physical or mental impairments that jeopardize their safety ... PROCEDURE: a. Upon identification of a missing adult patient, the patient’s nurse should: 1. Monitor all unit exits, and nearby stairwells and elevators. 2. Perform an immediate search of the floor. 3. Call Security by dialing 100 from a house phone or by dialing 268-5092 and provide a brief description of the missing patient and details if patient is observed leaving. Security will ask if the patient is deemed At-Risk by the clinical team. It is critical for the nurse and physicians caring for the patient to be aware of the patient’s at-risk status as designated above. Security will attempt to locate and return patients who are At-Risk, whereas a patient not deemed at risk will be encouraged to return to the room. 4. Notify Clinical Coordinator or designee. b. If the patient is found after an initial search, the unit will notify security and resume normal activity. If the patient is not found: 1. Patient ’ s Registered Nurse (RN) or designee will contact the House Supervisor to activate a Critical Communication. The nurse will provide a description of the missing patient. 2. House Manager Posts a Critical Communication that includes who to contact should the patient be found ...e. If the patient is not located after a house-wide search: 1. Patient’s RN notifies the attending physician and emergency contacts. 2. House Supervisor notifies law enforcement by dialing 911 and requests a welfare check. A. The information that is provided to law enforcement is based on the circumstances of the situation and the patient’s condition. ii. For individuals considered missing persons for law enforcement purposes (including individuals reported by law enforcement as a “missing person” or adults with dementia): refer to Via Christi policy PC-14, Use and Disclosure of Protected Health Information for Law Enforcement Purposes. iii. For individuals considered a danger to self or others: the minimum necessary standard is applied to the amount of information needed for law enforcement to locate the individual. 3. House Supervisor contacts the AOC, ACNO, Security, Risk Management, and Public Relations on-call associate. 4. Patient’s RN documents detailed actions taken in medical record. 5. Patient’s RN submits an entry into the Event Reporting System. . Patient 1 Review of Patient 1 ’ s Emergency Department Medical Record dated 06/24/24 showed Patient 1 a 77-year-old female with a diagnosis of syncope. Past medical history of dementia (memory loss) (w/o behavioral disturbance); major depression (a feeling of sadness, hopelessness); generalized anxiety disorder (feelings of worry and/or fear); hypertension (high blood pressure); chronic sinusitis (inflammation of the sinus cavity); dyspepsia (stomachache and bloating), and Epilepsy (seizure disorder). Patient 1 currently resides in a locked Memory Care Unit. Further review of the ED log disposition showed Patient 1 eloped from the ED at the Hospital on 06/24/24 at 11:30 AM. Review of a document titled, “Order Appointing Guardian and Conservator,” dated 11/22/22, showed, “ ...After examining the files, and hearing the evidence, statements and arguments of counsel, the Court finds that: By clear and convincing evidence, [Patient 1] is an adult with impairments and lacks the capacity to meet essential needs for physical health, safety or welfare, should not be permitted to make any decisions which affect her person, and the Guardian herein appointed shall be possessed of all the powers and duties of a Guardian as set out in K.S.A. §59-3075 and the Letters of Guardianship to be issued herein shall so state ...” Review of “Video Surveillance” dated 06/24/24 at 11:25:39 through 11:28:10 showed an unidentified staff in navy blue scrubs interacting with Patient 1 in the ED waiting room. Review of “Video Surveillance” dated 06/24/24 at 11:28:12 through 11:28:29 showed Staff J, RN interacting with patient in the ED waiting room. Review of “Video Surveillance” dated 06/24/24 at 11:29:34 showed Patient 1 walking towards registration desk and exit doors. Review of “Video Surveillance” dated 06/24/24 at 11:29:44 showed Staff K, PCT passing directly beside Patient 1, staff continues to walk to area where patient was previously sitting and proceeds to clean up the area. Review of “Video Surveillance” dated 06/24/24 at 11:30:07 showed Patient 1 walking out ED entrance turned West. Patient 1 seen looking around and then proceeds to turn and go South on St. Francis Street to Murdock street. Review of “Video Surveillance” dated 06/24/24 at 11:34:48 showed Patient 1 walking East on Murdock street. Review of “Video Surveillance” dated 06/24/24 at 11:36:22 showed Patient 1 walking East on Murdock street then under the train bridge and off camera view. Review of a document titled, “V3.4 Prehospital Care Report,” showed, “ ...HPI: EMS [Emergency Medical Service] arrives on scene to find the patient on the floor of her memory care facility where staff report the patient appeared Like she ‘was wilting’. Staff states she assisted the patient to The floor where she is reported to have had a ‘less than thirty second seizure’. The seizure was described as the patient gritting her teeth and having her lips closed. Staff report the patient remained on the floor and was alert immediately after the event. dispatch advised the patient stay there until EMS arrived. Upon our arrival the Patient is conscious and alert to EMS arrival. She denies any pain and no obvious discomfort is found on physical assessment. Patient appears calm in demeanor. No immediate life threats are observed ...” Review of a document titled, “Emergency Documentation,” on 06/24/24 at 2:37 PM showed, Staff H, Doctor of Medicine (MD) documented, “ ...Reexamination/ Reevaluation Patient’s emergency department evaluation was unremarkable. She did get some IV [intravenous] fluid, and was taking oral fluid and ambulating in the ER [emergency room]. At 1157 I called and updated the patient’s daughter about her negative workup, I do feel the patient is stable to be discharged back to the facility. The daughter said she would plan to come and pick her up but it would be about 1:30 PM and she had to go to the lunch meeting first. I informed her that patient will be in the waiting room and to check-in and we can get her out of the car at that point. I was later informed that when the patient’s daughter came to pick her up, they were unable to find the patient in the waiting room. Our security team was alerted to find the patient on camera, the patient’s daughter was going to look for her and the police were notified to try to help find this patient who apparently wandered outside.” During an interview on 06/26/24 at 8:01 AM, Staff H, MD stated that when I spoke to Patient 1 ’ s daughter on 06/24/24 at approximately 11:50 AM, “ ...I had no reason to think she wasn’t still just pleasantly sitting in the waiting room which it sounds like she had been the entire time so once her testing and everything was back I called her daughter back to let her know like her testing was great and this was I think shortly before noon that I called the daughter whom stated she would be there around 1:30 PM. I told her that should be fine she’s just in the waiting room let staff know when you get here. I did not go back to the waiting room. If a patient has underlying dementia they’re not going to remember anything that I tell them if their families coming it just saves time till the family gets there to touch base with everybody at the same time so I don’t have to go and repeat myself so no unfortunately at that point I did not go back to the waiting room to check on her. I had you know just recently had that interaction with the nurse about her like getting the water I mean I guess my understanding was she was out there drinking her water kind of sitting there quietly ... you could tell she didn’t really know much about her history but like she knew she was at the hospital and you know I asked her what happened and she couldn’t tell me anything about what happened that day so I mean I feel it’s pretty typical of dementia patients. I don’t know that there’s a specific process for a patient that could be at risk for wandering, it was not on my radar that this lady was at risk to just get up and walk out of the department on the hottest day of the year. During an interview on 06/25/24 at 2:18 PM, Staff C, Armed Security stated that he was walking through the ER at approximately 1:05 PM to 1:10 PM on 06/24/24 and the charge nurse stopped him and said we need to find Patient 1, she was a patient in the waiting room that is missing. We reviewed video footage and learned that Patient 1 walked out of the ER off camera view about 11:30 AM on 06/24/24. During an interview on 06/25/24 at 3:08 PM F1, Durable Power of Attorney for Patient 1 stated that she received a call on 06/24/24 at 11:56 AM from the doctor saying that they were going to discharge Patient 1. I said I will be there I ’ m in the middle of doing something, when I got there I could just tell something was wrong the waiting room was chaotic and that’s when I said did she walk away they wouldn’t really tell me anything I said she has Alzheimer’s. It was my understanding they would keep her and they would watch her until I got there. During an interview on 06/25/24 at 3:23 PM, Staff I, RN Emergency Department Manager stated that, she was informed that staff were unable to locate Patient 1 and that she had Dementia. Security staff reviewed video surveillance and determined Patient 1 left the ED entrance around 11:30 AM and headed East on Murdock Street. We called the police department, and I went driving around to try and locate Patient 1 and was unable to locate her. Staff I went on to state, “ ...we failed her [Patient 1] miserably ...” During an interview on 06/25/24 at 3:53 PM Staff J, RN stated, “ ...about 11:15 the tech come and told me that the patient’s IV had come out, I informed the doctor and then asked if she wanted the IV [intravenous] restarted, the doctor said no if she will drink water for us then we don ’ t need to. I told the tech [Staff D] get her a glass of water. I went on about my business and then at some point somebody told me that [Patient 1 ’ s] daughter was coming at 1:30 PM to pick her up. Later someone said to me that they had called for [Patient 1] and they didn’t answer and I said well let me go find her because I know what she looks like and I’ll go find her and bring her back so you guys can get stuff ready for her daughter to get here. They told me she was from a memory care unit in report but she didn’t have a wander bracelet on ...she had a history of dementia lots of people have a history of dementia doesn’t mean that she was going to wander off ...” During an interview on 6/25/24 at 4:23 PM, Staff D, Patient Care Technician-Certified (PCT-C), stated that Patient 1 ’ s IV was bleeding, and the decision was made to discontinue the IV and offer oral fluids. Staff D stated, “ ...I went to get [Patient 1] water and I waited for her to come back out but I was taking care of many patients at that time and I stopped thinking about it. About an hour or two went by, [Staff J, RN] asked if I had seen [Patient 1] and I stated that I thought she was taken to the back and had not seen her. During an interview on 06/25/24 at 4:48 PM, Staff E, RN Risk Manager when surveyors asked if the hospital had identified any fallouts with the event with Patient 1 Staff E stated, “ ...volumes were high which happens especially on Mondays, she was a dementia patient, and she came from a place that is known for having dementia patients ...” Review of Patient 1 ’ s medical record dated 06/24/24 failed to show documented evidence that Patient 1 eloped the ED. Failed to show documentation that the provider, family and administration was notified that Patient 1 was missing per hospital policy. Failed to show documentation of when, where, whom and in what condition the patient was found. Review of a document titled, “Wichita Police Department Incident,” dated 06/24/24, reported time 1:39 PM, showed, “ ...[Police Department] responded and checked [Patient 1] out and they advised her blood pressure was slight[sic] up but it was to be expected given she has been out walking for over 3 hrs[sic] and the temperture [sic] outside is 103 degrees ...I asked her if she would like something to eat and she declined just wanting the water for now. I gave her a second bottle of water and after a bit her daughter 01[Patient 1 ’ s daughter] showed up .... I advised dispatch I had [Patient 1] at Yale and Mossman at approximately 1504 hrs. [3:04 PM] ...”(3 hours and 34 minutes after patient eloped ED) During an interview on 07/02/24 at 3:03 PM, Staff K, PCT stated, “ ...I didn’t see her after I cleaned her IV up, I just cleaned it up and then we got busy ...later my coworker said “this water is for [Patient 1]” ...later we still don’t know where she’s at and then even later on my coworkers like oh she actually has dementia, they couldn’t find her and so they went to look for her and later her daughter came and asked where she was at ...” Review of “www.weatherspark.com” on 06/24/24 showed a reported temperature of 97.0 degrees Fahrenheit at 11:53 AM; 99.0 degrees Fahrenheit at 12:53 PM; 99.0 degrees Fahrenheit at 1:53 PM; 99.0 degrees Fahrenheit at 2:53 PM. Review of “Wichita could see high heat, rain and thunderstorms Tuesday | Wichita Eagle (kansas.com)” on 06/24/24 at 3:45 PM showed a reported heat index of 106 degrees Fahrenheit. Patient 3 Review of Patient 3 ’ s Emergency Department Medical Record showed a 34 year old male date of birth 08/20/1989 admitted to the Emergency Department on 06/24/24 at 7:45 PM with a diagnosis of Alcohol intoxication and Heat exposure. Past medical history includes Traumatic Brain Injury (A head injury causing damage to the brain by external force or mechanism), hypertension (high blood pressure in arteries), obesity, major depressive disorder (a persistent feeling of sadness and loss of interest), bipolar disorder (A serious mental illness characterized by extreme mood swings), borderline personality disorder (affects the way people feel about themselves and others, making it hard to function in everyday life) and alcohol withdrawal seizures. Medical record shows Patient 3 eloped from the ED on 6/25/24 at 12:00 AM. Review of a document titled “ED Note-Nursing” on 6/24/2024 at 11:56 PM showed, Staff L, RN documented, “At 2310 [11:10 PM] charge RN was notified pt was unable to be found in waiting room. This RN attempted to locate pt [patient] and was unable to find him. At this time charge RN called [Police Department] to notify them of pt [patient] elopement. Information and description of pt were given to PD [Police Department] along with contact information for Pts [patient ’ s] guardian (mom) name, number, and address were given to PD [Police Department]. PD [Police Department] planned to contact her and attempt to locate pt [patient]. Patient 3 ’ s medical record failed to show documentation that the provider, family, and administration was notified that Patient 1 was missing per hospital policy. Failed to show documentation of when, where, whom and in what condition the patient was found. During an interview on 07/03/24 at 1:24 PM with Staff L, RN stated that she was charge nurse on 06/24/24 at the time Patient 3 was admitted. Staff L went on to state that Patient 3 had become agitated pulled out his IV, staff took him into the triage room to talk to him and tell him that he needed to stay and at that point he said that he was going to stay. Then he was put back into the waiting room and when someone went to call him back about 10 minutes later, they could not find him. Staff L stated, “I only called my manager and [police department] to do a welfare check, I never heard back if they found him.” During an interview on 07/03/24 at 4:20 PM with Staff A, RN Quality Manager stated, “ ...there is not an incident nor security report for the elopement. There were security officers stationed in the ED at the time and WPD was notified per the medical record ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47233 Based on record review, policy review, document review, interview, and video surveillance review, the hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 2 of 29 patients (Patient 1 and Patient 22) who presented to the emergency department (ED) seeking emergency medical care. The hospital’s failure to perform an appropriate MSE has the potential for all patients to be discharged with an unidentified Emergency Medical Condition (EMC) which has the potential to delay necessary stabilizing treatment and may lead to deterioration of the patient’s condition, including harm and death.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47233 Based on record review, policy review, document review, interview, and video surveillance review, the hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 2 of 29 patients (Patient 1 and Patient 22) who presented to the emergency department (ED) seeking emergency medical care. The hospital’s failure to perform an appropriate MSE has the potential for all patients to be discharged with an unidentified Emergency Medical Condition (EMC) which has the potential to delay necessary stabilizing treatment and may lead to deterioration of the patient’s condition, including harm and death. Findings Include: Review of “Medical Staff Bylaws: Governance and Credentialing Manual” Approved 04/18/24 showed, “ ...IV.8. Emergency Clinical Privileges. For the purpose of this Section, an “emergency” is defined as a condition in which serious or permanent harm would result to a patient or bystander or in which the life of a patient or bystander is in immediate danger and any delay in administering treatment would add to that danger. In the case of an emergency, any Practitioner shall be permitted and assisted to do everything possible (within the scope of the Practitioner’s license) to save the life of a patient or prevent serious harm, using every facility of the Hospital necessary, including the calling of any consultation necessary or desirable, regardless of his or her Department, Section, Medical Staff status, or Clinical Privileges. The Practitioner shall make every reasonable effort to communicate promptly with the appropriate individuals concerning the need for emergency care and assistance by Members of the Medical Staff with appropriate Clinical Privileges, shall promptly yield such care to qualified Members of the Medical Staff when it becomes reasonably available, and once the emergency has passed or assistance has been made available, shall defer to the appropriate Department Chairperson and/or Section Chairperson (as applicable) with respect to further care of the patient ...” Review of a document titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)” revised on 04/17/23 showed, “The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ... Standards for Medical Screening Examinations 1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional]. 2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient’s needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred. 3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition [EMC]. 4. If the Medical Screening Examination [MSE] does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital’s facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures .... “Qualified Medical Person or Personnel” (QMP) refers to physician and non-physician individuals defined by the medical staff’s bylaws, rules, and regulations or other document approved by the Hospital’s governing body to perform the medical screening examinations for those individuals that present to a Dedicated Emergency Department and request examination and treatment ...” “Comes to the Emergency Department” means an individual: 1. Has presented at a Hospital’s Dedicated Emergency Department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition; 2. Has presented on Hospital property, other than the Dedicated Emergency Department, and requests examination or treatment for what may be an Emergency Medical Condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual’s appearance or behavior, that the individual needs emergency examination or treatment; “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy; Serious impairment to any bodily functions; Serious dysfunction of any bodily organ or part ... Some intoxicated individuals may meet the definition of “emergency medical condition” because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ. Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or to others, would be considered to have an emergency medical condition ...” “Hospital Property” means the entire main campus of the Hospital, including the sidewalks, parking lots and driveways or hospital departments, including any building owned by the hospital that are within 250 yards of the hospital. The term “Hospital Property” does not include other areas or structures that are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately under Medicare, or restaurants, shops, or other non-medical facilities. Ministry-specific details may be attached to this policy. If you have questions about whether your location meets this definition, please contact the Compliance or Legal Department. “Medical screening examination” is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient’s presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves ancillary studies and/or diagnostic tests and procedures. A medical screening examination is not an isolated event, but an ongoing process. The medical record shall include continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be documentation in the medical record of an evaluation prior to discharge or transfer. Review of a document titled “EMTALA Training” undated showed, “ ...Providing the MSE. When an individual “Comes to the Emergency Department” and EMTALA applies, the hospital must: “Conduct a MSE to determine if an EMC exists; and “Provide stabilizing treatment, or an appropriate transfer if the hospital lacks the capability and capacity to provide stabilizing treatment. A MSE must be provided for any patient who comes to the Emergency Department, or other applicable hospital property, and requests or appears to need emergency care. Even if it appears that the medical condition is not an emergency, the hospital must still conduct a MSE to verify that an EMC does not exist ... When is an MSE Provided? A MSE should be provided as soon as possible when: “An individual presents to a hospital DED and requests or appears to need examination or treatment for a medical condition. “An individual presents elsewhere on Hospital Property (not a DED) and requests or appears to need examination or treatment for what may be an EMC ... How is an MSE Conducted? The MSE should be specific to the type of services needed by the individual. Documentation in the medical record must reflect the type and scope of exam performed: For Medical Conditions: o History and physical exam, treatments, and medications. o Medically indicated screenings, diagnostic tests or procedures. o Physician impressions, diagnoses, and outcomes. o Mental status evaluation. o Vital signs and oral medical history and mental status evaluation ... Psychiatric/Substance Related Conditions: o Assessment of suicidal or homicidal attempt and/or risk. o Assessment of orientation or assault behavior that poses a risk to the patient or others ... Hospital Property Examples So how does “Hospital Property” affect the hospital’s EMTALA obligation? Click on each example below to see the different requirements: An individual presents to a location on “Hospital Property” other than a Dedicated Emergency Department When an individual presents at a location on Hospital Property that is not a Dedicated Emergency Department and requests an examination or treatment for what may be an Emergency Medical Condition, EMTALA apples (sic). The hospital must have policies and procedures for the screening and necessary stabilizing treatment required by EMTALA ...” Review of a policy titled, “ED Dismissal Process-Work Instruction” Revised 4/7/2023 showed, “PURPOSE: A. To outline the RN role in dismissal of the Emergency Department (ED) patient. PATIENT POPULATION: ED patients triaged with the Emergency Severity Index (ESI) level of 1, 2 or 3. ESI level 4 and 5 ED patients per RN judgment. H. Patient or guardian acknowledges understanding by signing dismissal paperwork. I. Copy of instructions given to patient or guardian. J. RN or designee provides assistance needed to facilitate patient dismissal from ED. K. RN will document the process to include patient condition on dismissal, interventions and dismissal disposition ...” Review of a policy titled, “Discharge Dispositions” Revised 2/14/2022 showed, “ POLICY To define and standardize inpatient and emergency department patient discharge dispositions; including Against Medical Advice (AMA), Eloped, and Left Without Being Seen (LWBS); for use in related policies and procedures. PROCEDURE Against Medical Advice (AMA) - An adult or emancipated minor who has been seen by a physician or licensed practitioner (LP) and chooses to terminate treatment and leave the facility against the advice of the physician or LP. To leave AMA requires decision-making capacity, which includes the ability to understand the nature and consequences of a decision about treatment options and the ability to make and communicate a decision based on that understanding. Applicability - Inpatient and Emergency Department Eloped - A patient who leaves or attempts to leave the hospital when doing so may present an imminent threat to the patient’s health or safety because (1) the patient has been deemed too ill or impaired to make a reasoned decision to leave, (2) the patient is under orders by a physician or court to receive mandatory treatment, or (3) the patient has a court-appointed guardian for health care decisions. Applicability - Inpatient and Emergency Department Eloped incidents do not include events involving competent adults or emancipated minors with decision-making capacity who leave against medical advice (AMA) or left without being seen (LWBS). Left Without Being Seen (LWBS) - A patient who leaves before a triage assessment is complete. Applicability - Emergency Department. Patient 1 Review of video surveillance, involving Patient 1, dated 06/03/24 showed: 08:11:24 PM - Patient 1 exiting main lobby of the hospital via wheelchair. From 08:34:07 PM through approximately 11:03:00 PM - Patient 1 remained in a transportation vehicle (van) in front of the hospitals main entrance. 11:03:12 PM - The van was seen pulling up to ED sidewalk. From 11:03:12 PM - 11:59:59 PM - Patient 1 remained in vehicle. Review of video surveillance, involving Patient 1, dated 06/04/24 showed: From 12:00:00 AM - 12:08:30 AM - Five security officers and one associate in ceil blue scrubs were seen removing Patient 1 by the arms from the vehicle (Patient 1 had remained in the transportation vehicle for approximately 4 hours). 12:12:16 AM- The van pulls away leaving Patient 1 face down on the curb. From 12:12:16 AM - 12:24:50 AM - Patient 1 remained face down on the curb. 12:24:54 AM - Five security officers, five mental health safety associates (MHSAs) staff, three in ceil blue scrubs, two in navy blue scrubs were noted to assist Patient 1 into a wheelchair. 12:41:00 AM- Patient 1 was seen entering the ED entrance via wheelchair with three security and one staff in ceil blue scrubs. Further review of video showed the following: 12:41:46 AM- Patient 1 was seen entering Zone 2 (locked psychiatric area) of the ED. 12:51:35 AM - Patient 1 was seen being pushed via wheelchair into Room 5 of Zone 2. 12:51:35 AM - 04:39:35 AM - Patient 1 remained in Room 5. 04:21:19 AM - Multiple staff were observed entering Room 5 with a gurney. 04:39:35 AM to 04:39:44 AM - Patient 1 exited Room 5 and exited Zone 2 via a gurney. Patient 1 had remained in Zone 2/Room 5 for approximately 4 hours. H2 Staff failed to perform an appropriate MSE for Patient 1 even though his behaviors changed prior to discharge from the hospital and during an attempt to transfer him to H3 (state psychiatric hospital). Review of Patient 1’s H3 medical record showed Patient 1 was admitted on 06/04/24 at 7:20 AM. During an interview on 06/12/24 at 3:30 PM with Staff H, Manager of Transportation Company stated that our company received a call to transport Patient 1 to Hospital 3 (H3 - a state psychiatric institution) with restraints. The hospital reported that Patient 1 was non-violent and would be transported in clothing. We accepted the transfer and sent our two drivers to pick up the patient. The drivers arrived around 8:00 PM on 06/03/24 to H2. About 8:30 PM one driver called for advice. The driver said that Patient 1 did not have pants on and that he was just in a gown. It took the drivers and hospital security about 30 minutes to get the patient downstairs to the van because of the patient’s behavior and once they finally got him loaded into the vehicle the patient refused to sit in the seat and so he’d been kneeling on the floor of the vehicle for about 30-45 minutes. Patient 1 was screaming and wasn’t coherent at all. The driver said that the patient was about 500 lbs. and the restraints didn’t fit Patient 1 properly. The drivers didn’t even get out of the parking lot and the patient had broken his restraints. The driver called for advice again, “ ...you need to go back immediately to the hospital, make sure you’re safe and go to security see if they can help you and you need to contact the police ...” As the transportation company we decided that we could not transport this patient safely. transport was unsafe and the hospital needed to obtain other transportation. Staff I, RN came outside and stated that H2 was refusing to take Patient 1 back stating, “ ...we aren’t taking him back ...” The driver reminded Staff I that H2 was a public service and can’t refuse care to a patient. Staff I stated, “ ...well he’s discharged we don’t have to take him ...” The driver told Staff I we needed to drop Patient 1 back off into the emergency department so he can go back through the process. Staff I stated, “ ...no we have 100 rooms upstairs for psych and they’re full there’s no there’s no room for him and we have 28 patients waiting in the emergency department to go up to psych we don’t have room for him we aren’t taking him ...Staff O stated, “ ...our computer systems are down so we aren’t doing the best of job of caring for the patient ...” During an interview on 06/12/24 at 3:15 PM, Staff Z, Security Officer, stated that on one of his rotations there was a lady walking out of the ED and a van sitting right there with Staff U, Security Officer and Staff I, RN. They told me the story briefly and went back to my post. Eventually before the shift was over, they pulled the van around to the ER so they could readmit the patient. They couldn’t transport the patient because of his size and not being able to transport him in the van safely. During an interview on 06/11/24 at 11:09 AM Staff J, Assistant Manager of Behavioral Health stated that she told the House Supervisor, that you know the process once a patient is discharged, if they need to be seen again then they need to go through the ED. During an interview on 06/11/24 at 11:57 AM Staff K, Director of Behavioral Health stated, “ ...It was my understanding that the patient was going to go back to the emergency department ...” During an interview on 06/12/24 at 2:17 PM, Staff BB, Registered Nurse, stated that, she had noticed that there were security personnel out in front of the ED and then noticed that there was a patient lying face down on the concrete right next to the curb and kind of hanging off the curb and into the street of the EMS driveway. The patient had pulled up his gown and his rear end was showing.. The patient would intermittently arch his back and put his arms out in front of him and raise his legs behind him. He was looking around and he was just kind of mumbling and making just kind of weird noise. They said well because he refused to transport we are trying to figure out how we are going to get the patient to a H3. I asked why don’t we take him upstairs until we can figure out what we are doing for him and not out here mooning everyone. They [Staff I and Staff CC] said that they couldn’t take him back upstairs because he was a discharged patient ...I’m not quite sure exactly how long the patient was outside before being brought into the zone 2 the locked unit of the ED, he was outside a significant amount of time. The floor nurse said that they couldn’t accept him back because they had discharged the patient and it was the ED personnel’s responsibility to essentially figure out what else to do for the patient. During an interview on 06/11/24 at 1:38 PM Staff I, RN stated, “we’re taking the patient over to the ER [Emergency Room] and getting him readmitted to the hospital, the Emergency Room staff had already listed the patient on the board, produced a FIN [encounter number] number so we were in action with admission process for him. Leadership had also spoken with bed placement to secure his previous bed upstairs ... the patient exited the van and we brought him into the ER [Emergency Room] zone two ...he wasn’t under any physician’s care. During an interview on 6/11/24 at 2:08 PM, Staff M, Director of Nursing of H2 stated that if a patient comes to be seen or to receive any treatment, we have to provide initial screening and make sure that they are stable. It’s not just if they come to be seen but also if they are within 200 yards. If an average person looks at a person and thinks they need help or medical attention we are to check on the patient. Obviously, Patient 1 met these criteria because his mind was not right. During an interview on 06/12/24 at 1:36 PM, Staff A, Registered Nurse (RN) ED Director of H2 stated that if we reprocessed them through the emergency department, he would lose his bed at H3. The patient was being non-compliant with a lot of things because he’s sick. He needs help so we were trying to work through all of the pieces. During an interview on 06/12/24 at 2:40 PM, Staff AA, Medical Doctor (MD), overheard the staff talking about the condition and the situation. I was available if the patient needed anything, but it sounded like it was an inpatient going to an inpatient situation not an ED patient. I was available to be to be there to help out, but it didn’t sound like there was an emergent condition. I know that the patient had been registered. I did not know I needed to see him. He didn’t show up on the tracking board because we didn’t have a tracking board at the time. During an interview on 06/12/24 at 5:20 PM Staff CC, Charge RN stated that Staff I, RN stated that they were going to drop Patient 1 off to be admitted through the ED. Staff I went on to state that Patient 1’s just going to be held in Zone 2; we are not seeing him as a patient. Staff CC stated that the ED staff were told Patient 1 was eating the bars on the bed but didn’t do anything directly to harm himself or others. During an interview on 6/13/24 at 9:00 AM Staff GG and HH, Transportation Company Drivers stated that we were told to take the patient to the ED entrance. We drove to the entrance and security was there waiting they attempted to get Patient 1 out of the van but were unsuccessful. A police officer showed up and they were able to pull Patient 1 out of the van by his arms where he then was laid face down on the curb. Staff HH went on to state that they spoke with Staff I about Patient 1 being readmitted to the emergency department and Staff I stated that [H2] couldn’t do that because he’s been discharged, and he has to be brought in by law enforcement. During an interview on 06/13/24 at 1:52 PM, Staff JJ, MD ED Medical Director, stated that, if a patient presented to the emergency department and was on our grounds or in our emergency department we would certainly comply with EMTALA. If the patient shows up to be seen it would require registration and a medical screening exam documentation and then stability to the best of our capability. During an interview on 06/13/24 at 2:30 PM, Staff LL, stated that he registered Patient 1 on 06/04/24 however unable to remember the exact time. The patient was discharged from 6 West and was supposed to be transported to another facility out of town. Staff LL went on to state that he didn’t remember exactly what time the incident happened but the transport service that was there to pick up Patient 1 did not have the correct equipment to safely transport the patient and the transport staff refused to transport Patient 1. So [The Hospital] had to maintain custody of the patient until another transport company could come and take the patient. Staff CC, Registered Nurse (RN), instructed Staff LL to re-admit them through the Emergency Room (ER) so that the patient could be taken back to the 6th floor and the patient room was still available. During an interview on 06/13/24 at 2:41 PM, Staff MM, RN Zone 2, stated that Patient 1 was brought back to zone 2 on the night of the 06/03/24 into 06/04/24 and no nurse was assigned to his care. No one was assigned to monitor him. We were told that he was there awaiting transport, so nobody was really watching him. We were only watching him because we have cameras in the room that he was in, but we weren’t doing 15-minute checks, assessments, or medications. During an interview on 06/14/24 at 8:00 PM, Staff NN, MHSA, stated that: “We got called that secure transport was there for [Patient 1], so we showed up on 6 West, and we helped get him transferred over to a wheelchair, which was an ordeal on itself. [Patient 1] was very sick this is the worst I’ve seen him. It was almost to the point where he’s non-verbal he was mobile while he was staying at the hospital.” During an interview on 06/14/24 at 8:13 AM, Staff CCC, Behavioral Health Technician (BHT), stated that we were just doing some visual checks here and there but not like the documentation that we would normally.. Patient 1 failed to have a medical record for this encounter in the emergency department. The hospital failed to conduct an appropriate MSE for Patient 1 to determine whether he had an emergency medical condition (EMC). Patient 22 Review of Patient 22’s medical record showed a 33-year-old-male who presented to the ED on 06/12/24 at 2:45 AM by EMS with a chief complaint of alcohol intoxication. Patient 22 had a past medical history of Traumatic Brain Injury, hypertension, obesity, major depressive disorder, bipolar disorder, borderline personality disorder and alcohol withdrawal seizures. Patient 22 had a pattern of being brought to the ED due to public intoxication. Review of Patient 22’s record dated 06/12/24 at 2:45 AM showed Staff RR, MD documented that he completed an MSE on 6/12/24 at 3:00 AM. Further review of the medical record dated 06/12/24 at 3:00 AM, showed Staff RR, documented the following physical examination findings: Cardiovascular: Regular rate and rhythm, No murmur, No edema. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. Chest wall: No tenderness. Back: Nontender. Musculoskeletal: Normal ROM, normal strength, no tenderness. Gastrointestinal: Soft, Nontender, Non distended, Signs: McBurney’s negative, Murphy’s negative. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed, normal motor observed, normal speech observed. Review of video surveillance dated 06/12/24 from 2:45 AM thru 06/12/24 at 09:56:50 AM failed to show Staff RR performing a physical exam on Patient 22 including listening to lung sounds, cardiac heart tones, or palpitating abdomen. Staff RR failed to complete a physical examination of Patient 22 even though it is documented in Patient 22’s record. The hospital discharged Patient 22 to home on 06/12/24 at 11:05 AM. The hospital failed to notify his guardian of this admission or his discharge. During an interview on 06/18/24 at 7:18 AM with Staff RR, MD stated, “ ...I’m extremely familiar with [Patient 22], he is one of our frequent flyers and goes through spurts we’ll have him for a couple days or weeks ...for discharge if it’s an adult male who is clinically sober and wishes to leave there is no indication for me to keep him so there’s no reason to engage the guardian ...he’s had a TBI so has that affected him ...it’s hard to get a baseline ...” During an interview on 06/20/24 at 3:07 PM, Staff XX, RN, stated that Patient 22 comes in drunk, they put him on the stretcher and let him sleep it off. When he gets to a point where he’s sober and can walk, eat, and drink they discharge him. During an interview on 06/17/24 at 5:57 PM with F1, Patient 22’s Guardian stated, “ ...problem is the legal guardianship, they never call me and tell me when he’s in there ...I call when I don’t hear from [Patient 22] and check to see if he has been admitted or is there, when I called to find out they had told me he had been there, they’ll tell me that but they won’t call me knowing I have guardianship ...[Patient 22] has a mental illness, traumatic brain injury and severe alcoholism because of being on the streets ...he needs treatment that’s what they should be there to do that’s their job ...” During an interview on 06/20/24 at 12:07 PM, Staff UU, MD, stated that I think he’s just an alcoholic typically just knowing [Patient 22] the way we know him we would just allow him time to sober up. I suppose if he’s not sobering up as expected then I might add on some lab at that point but it’s not standard to do a blood alcohol level. We should not be doing too many blood alcohol levels because that get you medical legal trouble if you discharge. We try to base discharge disposition on clinical sobriety so it’s when they are no longer cognitively impaired or psychotic and the patient has no psychomotor impairment. 06/12/24 at 8:44 PM, when he arrived in the ED by EMS. The staff did not triage the patient. No provider saw this patient. The hospital did not get any lab studies, imaging, cardiovascular tests, and/or neurological testing. Patient 22 left the ED without being seen (LWBS) on 06/12/24 at 9:07 PM. Even though the hospital is aware the patient has a guardian, they failed to notify F1 of his admission or that he LWBS. Patient 22 had a pattern of being brought to the ED due to public intoxication, the ED allowed him to sober up, and then dismiss the patient. Documentation failed to show hospital staff notified the guardian five out of five times of his admission or discharge disposition. The records showed that the hospital did not complete a community mental health screen on Patient 22 four of the five ED visits. Discharge documentation on all visits contained written information for community resources to help Patient 22 with his substance abuse disorder, however, it is not clear whether Patient 22 had any ability to read or understand written words secondary to his traumatic brain injury. Documentation showed lack of any social work involvement to assist Patient 22 in obtaining community resources regarding substance abuse disorder so the ED was not the place where he sought primary care.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47233 Based on observation, document review, record review, policy review, video surveillance and interview, the Governing Body failed to function effectively and failed to ensure that hospital staff followed policies and procedures to provide oversight for the Conditions of Participation (CoP) of Patient Rights; Nursing Services; Physical Environment; Infection Control; and Surgical Services. The cumulative effects of the Governing Body’s systemic failures to function effectively resulted in multiple Immediate Jeopardy situations and inability to meet the required Hospital Conditions of Participation for Governing Body at 42 CFR 482.12, Patient’s Rights at 42 CFR 482.13, Nursing Services at 42 CFR 482.23, Infection Control at 42 CFR 482.41, Physical Environment at 42 CFR 482.42 and Surgical Services at 42CFR 482.51. Findings Include: 1. The Governing Body failed to ensure the hospital met the requirements for the Patient Rights Condition of Participation by failing to provide care in a safe setting free from abuse, neglect, and exploitation. (Refer to A0115) 2. The Governing Body failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for each patient. (Refer to A0385) 3. The Governing Body failed 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. (Refer to A700) 4. The Governing Body failed to ensure staff adhered to nationally recognized infection prevention and control guidelines and adhered to hospital policies and procedures for infection control and prevention such as proper hand hygiene, appropriate use of personal protective equipment, and inappropriate handling and/or storing of blood products and food handling. (Refer to A0747) 5. The Governing Body failed to ensure services were well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. (Refer to A0940)”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47233 Based on policy review, record review, and interview, the hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient’s rights. 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) situation. Surveyors notified Staff Q, Chief Administrator Officer, on 12/07/23 at 1:35 PM, that an immediate jeopardy (IJ) existed related to 42 CFR 482.13 Patient Rights. The hospital submitted a plan of removal (POR) on 12/12/23 at 9:36 AM. On 12/13/23 at 3:16 PM, the hospital was notified the written POR was accepted. The POR included the following: Oversight and Reporting: The Executive Sponsor will oversee the implementation, monitoring, and sustainment of the actions described in the plan of correction. Ongoing compliance will be reported through the Quality and Safety Committee of the Board of Directors. Once compliance is met, monitoring will continue through the continuous readiness program for sustainability. Recognition of Potential Abuse Corrective Action: Effective 12/7/23 the use of Mental Health Protection Workers (MHPW) for assistance with patient transfers hospital-wide is halted until appropriate training and competency is completed. Beginning 12/8/23 the Physical Therapy Department developed training and competency validation related to safe patient transfers for Mental Health Protection Workers (MHPW). On 12/8/23 the SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication) titled “Behavioral Health Patient Transfers and Fall Algorithm” was sent electronically and discussed during shift huddles to [H2] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed. On 12/12/23 the SBAR titled “[H1] Fall Algorithm” was sent electronically and discussed during shift huddles to [H1] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed. Effective 12/7/23 nurses and behavioral health staff who were involved in the incident of alleged abuse received verbal coaching by the Chief Nursing Officer to review and ensure understanding of opportunities identified related to staff response, including an incomplete patient assessment, leaving the patient unattended, and the potential to cause injury or worsening of an injury sustained in a fall during the transfer of the patient during the event. Discussion also included the need to speak up and immediately intervene at the time of any activity which could cause harm. The remaining staff involved in the incident will receive the same verbal coaching and education before the start of their next scheduled shift. Beginning 12/11/23 Behavioral Health associates were assigned an Abuse, Neglect and Exploitation web-based training. Beginning 12/11/23 [H2] and [H1] employed associates, including department and hospital leadership, were assigned an Abuse, Neglect and Exploitation web-based training. Recognition of Potential Abuse Monitoring for Sustainment/Reporting: Mental Health Protection Workers (MHPW) education completion will be validated by competency documentation. SBAR titled “Behavioral Health Patient Transfers and Fall Algorithm” during their next scheduled shift. [H2] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. SBAR titled “[H1] Fall Algorithm” during their next scheduled shift. [H1] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. The Chief Nursing Officer will validate and log the completion of verbal coaching with the seven staff members involved in the event. Behavioral Health associates will complete the web-based training by 12/15/23 or during their next scheduled shift. [H2] and [H1] employed associates will complete the web-based training by 12/31/23. Recognition of Potential Abuse Evidence of Compliance: 12/7/23 Email communication. MHPW safe patient transfer competencies. [H2] nursing staff roster to validate receipt and understanding of SBAR communication. [H1] nursing staff roster to validate receipt and understanding of SBAR communication. Log of Chief Nursing Officers verbal coaching with the seven staff. Web-based training roster. Unwitnessed fall assessment Corrective Action: On 12/8/23 the SBAR titled “Behavioral Health Patient Transfers and Fall Algorithm” was sent electronically and discussed during shift huddles to [H2] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed. Unwitnessed fall assessment Monitoring for Sustainment/Reporting: Behavioral Health nursing associates will acknowledge the SBAR titled “Behavioral Health Patient Transfers and Fall Algorithm” during their next scheduled shift. [H2] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. Completion of the post-fall assessment will be monitored through the post-fall auditing process. Unwitnessed fall assessment Evidence of Compliance: [H2] BH nursing staff roster to validate receipt of SBAR communication. Post-fall audits. Risk Investigation Corrective Action: On 12/7/23 the Abuse and Neglect - System policy was reviewed with all of the [Hospital] Risk Managers by the Risk Management Director via Google Meet. All Risk Managers attested to the policy review and have passed an education post-test. Beginning 12/8/23 all [Hospital] Risk Management associates were assigned an Abuse, Neglect and Exploitation web-based training. On 12/7/23 the “Allegation of Associate Misconduct Process Flow” was reviewed with all the [Hospital] Risk Managers by the Risk Management Director via Google Meet. The expectation was set that all allegations of misconduct will follow the “Allegation of Associate Misconduct Process Flow.” All Risk Managers attested to the policy review and have passed an education post-test. Beginning 12/7/23 a daily report of events categorized as behavioral will be sent to Risk Managers for review and correction of the classification in the Event Reporting System, if needed, to correctly identify and classify the nature of potential caregiver misconduct events. Education was completed on 12/7/23 about the expectation of reviewing the report by the Risk Management Director via Google Meet. All Risk Managers attested to the policy review and have passed an education post-test. On 12/7/23 a multidisciplinary team, including representation from Legal, Corporate Compliance, Quality, and Behavioral Health, was identified to review and validate the reports of potential caregiver misconduct weekly. The first meeting is scheduled for 12/12/23. On 12/7/23 the elements of an investigation of harm events were reviewed with all of the [Hospital] Risk Managers by the Risk Management Director via Google Meet. The elements of an investigation of harm include a medical record review, timeline of care, interviews and video surveillance. All Risk Managers attested to the process and have passed an education post-test. Risk Investigation Monitoring for Sustainment/Reporting: Risk Managers have attested to the policy review and passed the education post-test with a score of 100%. All [Hospital] Risk Management associates will complete the web-based training by 12/15/23. An audit of abuse/neglect incidents in which a caregiver is alleged to have caused the abuse/neglect will be conducted for six months to ensure 100% compliance with policy. An account of caregiver abuse/neglect allegations will be presented to the Board of Directors’ Quality and Patient Safety subcommittee every 2 months until 100% compliance with accurate classification and investigation is achieved. Beginning 12/12/23 the Risk Management Director or designee will lead the weekly meeting to review reported behavioral events. If an event is identified that had not been identified by Risk Management during their daily review, a risk manager will be assigned to begin an immediate investigation. The multidisciplinary team will meet until full compliance with accurate classification is achieved for 4 consecutive months. The Risk Management Director or designee will audit 10 harm events per month until 100% compliance of all applicable elements of an investigation are present and documented for 6 consecutive months. Then random audits will occur to ensure sustainment. Risk Investigation Evidence of Compliance: Attestation and post-test results. Web-based training roster. Abuse/neglect incident audits. Board of Directors’ Quality and Patient Safety meeting minutes. Multidisciplinary team meeting minutes. Harm event investigation audits. Findings Include: 1. The hospital failed to provide/inform patients or patient’s representative of Patient Rights in advance of furnishing patient care for 8 of 50 sampled patients. (Refer to Tag A0117) 2. The hospital failed to ensure that any patient and/or patient’s representative was informed of the hospital’s internal grievance process, including whom to contact to file a grievance. The hospital failed to ensure that as part of its notification of patient rights, the hospital must provide the patient and/or the patient’s representative a phone number and address for lodging a grievance with the State Agency. The hospital failed to inform any patient that he/she may lodge a grievance with the State Agency directly, regardless of whether he/she had first used the hospital’s grievance process. The hospital failed to follow its grievance process policy and failed to classify an allegation of abuse as a grievance. (Refer to Tag A0118) 3. The hospital failed to ensure the patients’ right to receive care in a safe setting as required per 42 CFR §482.13(c)(2). (Refer to Tag A0144) 4. The hospital failed to ensure that 2 of 50 sampled patients were free from all forms of abuse and harassment. (Refer to Tag A0145) 5. The hospital failed to ensure the use of restraints was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient for 1 of 1 patient in restraints. (Refer to Tag A0168) 6. The hospital failed to ensure the monitoring of a patient for 1 of 1 patient in restraints as required per hospital policy. (Refer to Tag A0175) 7. The hospital failed to ensure that a physician or other licensed practitioner performed a face-to-face evaluation within one hour after the initiation of restraint when used for the management of violent behavior for 1 of 1 sampled patient in restraints. (Refer to Tag A0178)”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47233 Based on record review, policy review, document review and interview the hospital failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for each patient. The cumulative effects of this deficient practice resulted in the continuance of 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) situation. On 12/11/23 at 2:34 PM, Surveyors notified hospital administration (Staff Q, Chief Administration Officer) that an immediate jeopardy (IJ) existed related to 42 CFR 482.23 Nursing Services. The hospital submitted a plan of removal (POR) on 12/12/23 at 9:36 AM. On 12/13/23 at 3:07 PM, the hospital was notified the written POR was accepted. The POR included but was not limited to the following: Opportunity: Triage process Corrective Action: Beginning 12/12/2023, the SBAR titled “ACS Initiation For Rapid Evaluation and Assessment” was sent electronically to St. Francis and St. Joseph Emergency Department (ED) nursing associates, nursing support services, registration, Physicians, or LIPs, and will be discussed during department huddles. The SBAR includes education on the expectation that triage is initiated within 15 minutes of arrival. When the ED team cannot meet the 15-minute triage expectation, they should escalate to their leader or designee. Monitoring for Sustainment/Reporting St. Francis and St. Joseph ED nursing Associates, nursing support services, registration, Physicians, and LIPs will acknowledge receipt of the SBAR titled “ACS Initiation for Rapid Evaluation and Assessment” by 12/22/23 or before their next scheduled shift. Audit a sample of 10 charts per day on each campus of patients who present to the emergency department with a chief complaint of Chest Pain, epigastric pain, Nausea/Vomiting, Arm Pain, Diaphoresis, Fatigue, or shortness of breath for triage completed within 15 minutes. Date of Implementation: 12/12/2023 Evidence of Compliance: St. Francis and St. Joseph staff roster to validate receipt and understanding of SBAR communication. Opportunity: Door to ECG time Corrective Action Beginning 12/12/2023, the SBAR titled “ACS Initiation for Rapid Evaluation and Assessment” will be sent electronically to St. Francis and St. Joseph ED nursing Associates, nursing support services, registration, and Physicians, and LIPs and discussed during department huddles. The SBAR includes information about the AHA/ACC guidelines for Acute Coronary Syndrome (ACS). This SBAR was distributed to re-educate and obtain Associate attestation and establish the ACS criteria that would initiate a stat ECG to be completed and interpreted within 10 minutes in accordance with the AHA/ACC guidelines. Monitoring for Sustainment/Reporting St. Francis and St. Joseph ED nursing associates, nursing support services, registration, and Physicians and LIPs will acknowledge receipt of the SBAR titled “ACS Initiation for Rapid Evaluation and Assessment” by 12/22/23 or before their next scheduled shift. Audit a sample of 10 charts per day on each campus who present to the emergency department with a chief complaint of Chest Pain, Epigastric pain, Nausea/Vomiting, Arm Pain, Diaphoresis, Fatigue, or Shortness of Breath unless not deemed clinically necessary by the Physician or LIP. Date of Implementation: 12/12/2023 Evidence of Compliance: St. Francis and St. Joseph staff roster to validate receipt and understanding of SBAR communication. The hospital’s plan of removal was not able to be validated prior to survey exit on 01/28/24 at 4:34 PM, and the Immediate Jeopardy remained in place. Findings Include: 1. The hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care when the nursing staff failed to complete assessments as required, failed to notify physician of critical results and/or delay of care, failed to administer medication as ordered, failed to complete vitals as required, failed to document repositioning of patients at risk for skin break down every two hours or more frequently as ordered by the physician and failed to provide daily bathing as ordered. (Refer to A0395) 2. The hospital failed to ensure nursing care plans were kept current for each patient when nursing staff failed to followed the Patient Assessment and Reassessment, Nursing documentation guidelines, and Fall Risk policies of updating the patients interdisciplinary plan of care with interventions, short term goals, and long-term goals. (Refer to A0396)”

“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, policy review, interview and review of the Life Safety Code (LSC) complaint investigation findings (KS00182852), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC). The hospital failed to ensure safe sleeping suites for patients, safe exit access, adequate hallway clearance, and appropriate removal of biohazard and trash collection. The cumulative effect of this deficient practice places any patient, staff or visitor at the hospital at risk for serious injury, serious harm, serious impairment or death and resulted in three Immediate Jeopardies (IJ a situation in which the providers noncompliance with one or more requirements of participation caused or is likely to cause serious injury, harm, impairments or death to a patient). The hospital administration was notified on 12/14/23 at 2:05 PM that three IJ’s existed: 1. K232 - 2012 Edition National Fire Protection Association (NFPA) 101 LSC - Aisle, Corridor or Ramp Width, 2. K256 -2012 Edition NFPA 101 LSC - Sleeping Suites, and 3. K754 - 2012 Edition NFPA 101 LSC - Soiled Linen and Trash Containers. The hospital submitted a plan of removal (POR) on 12/14/23 at 9:39 PM. On 12/15/23 at 1:28 PM the hospital was notified the written POR was accepted. The POR included the followingbut is not limited to: Tag K232 Opportunity: Obstructed Egress Date of Implementation: 12/14/23 Corrective Action On 12/14/23, unoccupied recliners and chairs were removed from the space and the tables and chairs were relocated to provide the required 48 inch exit access width. On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage. These items were relocated to other appropriately rated separate locations. On 12/15/23, an SBAR communication will be distributed through the hospital safety huddle that the egress corridor outside the POU cannot be used for storage. Monitoring for Sustainment/Reporting Observation audits of the POU to monitor for appropriate storage and required 48 inch exit access width will be conducted two times every 24 hours until there are no longer patients in the POU. Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours. Evidence of Compliance POU observation audits POU egress corridor observation audits SBAR communication K256 Opportunity: Sleeping Suites Date of Implementation: 12/14/23 Corrective Action Effective 12/14/23, admissions to the Psychiatric Observation Unit (POU) were halted. Patients currently in the POU will be moved to appropriate locations for continued care as soon as reasonably possible and no later than 12/18/23. Until all patients are moved to appropriate locations for continued care, Consult 1 was secured and not available for patient care. On 12/15/23, the lock on the door will be exchanged to a new unique-key lock. On 12/14/23, the room labeled “staff only” was updated on the life safety code plans with the correct name of the room. The shelves in the room labeled “staff only” were modified so no items could be stored closer than 18 inches to the ceiling or to the bottom of the sprinkler head. On 12/14/23, the Director of Environmental Services was verbally notified and electronically communicated with by the Regional Safety Officer that waste containers greater than 64-gallons are not allowed in a room without a fire-rating of 1 hour. The waste container was immediately removed from the soiled hold room. On 12/14/23, unoccupied recliners and chairs were removed from the space and the tables and chairs were relocated to provide the required 48 inch exit access width and ensure the emergency exit door is free of obstructions. On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage. On 12/14/23, the east and west 90-minute fire rated doors outside the POU were repaired and subsequently functioned correctly when drop tested. Monitoring for Sustainment/Reporting A daily report out of the Capacity Management System will demonstrate that no patients were placed in the POU after 12/14/23 at 1642. A daily census report will demonstrate that there were no patients in the POU after 12/18/23. Observation audits of the POU to monitor for appropriate waste storage and required 48 inch exit access width will be conducted two times every 24 hours until there are no longer patients in the POU. Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours. Evidence of Compliance Capacity Management Report with last admission to POU Census reports each day Completed maintenance work order for unique-key lock Updated life safety code plans Completed maintenance work order for rack modifications. Copy of Email between the Regional Director of Emergency Management to the Director of Environmental Services POU observation audits POU egress corridor observation audits Completed maintenance work order for the repair of the 90-minute fire rated doors. Tag K754 Opportunity: Soiled Linen and Trash Containers Date of Implementation: 12/14/23 Corrective Action On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage. Removal of these items ensures unobstructed access to the fire extinguisher and appropriate clearance of the fire sprinklers. Monitoring for Sustainment/Reporting Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours. Evidence of Compliance POU egress corridor observation audits The POR corrective actions to remove the immediacy for the three IJs were verified on 12/15/23 at 4:45 PM by Life Safety Code Surveyor.”

“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: 47233 Based on document review, record review, policy review, surveillance video, observation, and interview the hospital failed to ensure staff adhered to nationally recognized infection prevention and control guidelines and adhered to hospital policies and procedures for infection control and prevention such as proper hand hygiene, appropriate use of personal protective equipment, and inappropriate handling and/or storing of blood products and food handling. The cumulative effect of this deficient practice places all patients, visitors, staff, and community at risk to contract and spread communicable diseases. Findings Include: 1. The hospital failed to ensure hospital staff followed Infection Control policies and procedures, for 4 of 54 patient (Patient 7, 16, 21, and 48) records reviewed. (Refer to tag A0749) 2. The hospital failed to maintain a clean and sanitary environment. (Refer to tag A0750)”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 47233 Based on record review, policy review, document review, staff and patient interviews, the hospital failed to ensure surgical services were provided in accordance with acceptable standards of practice when staff failed to follow policy and acceptable standards of practice to maintain safety, to provide supervision, and to prevent anesthesia medication administration errors. The cumulative effect of this deficient practice places all patients at risk for physical injury and increased anesthesia related harm. Findings Include: 1.The hospital failed to ensure staff followed policies and procedures to achieve and maintain patient care that meets the standards of medical practice and patient care. (Refer to A-0951)”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47233 Based on observations, document review, record review, policy review and interview, the Governing Body failed to ensure the hospital followed its policies and procedures. Failure of the governing body to provide oversight of the medical staff for the quality of care provided to patients places all patients at risk for inadequate medical care resulting in harm, further injury, ongoing pain, or death. The governing body must ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The governing body is responsible for the conduct of the hospital and this conduct includes the quality of care provided to patients. Findings Include: Review of the hospital’s document titled, “MEDICAL STAFF BYLAWS: Governance and Credentialing Manual,” dated 12/3/21, showed ...Establish, maintain, amend, and enforce Medical Staff Bylaws for the self- governance of the Medical Staff ...Develop clinical policy, monitor, evaluate, and improve the quality of care provided in associated hospital areas ... Review of the hospital’s document titled, “BYLAWS OF VIA CHRISTI HOSPITALS WICHITA, INC.,” dated 9/10/15, showed...”System Policy” shall mean all policies, procedures, technical manuals, and other written guidance established, adopted, or issued from time to time by Ascension that are intended to apply to all organizations within the System, including without limitation, the Governance Authority Matrix ... The hospital’s Governing Body failed to ensure it protected: Patient’s Rights; (refer to A-0115, A-0117, A-0118, A-0144, A-0145, A-0168, A-0175, and A-0178); Nursing Services; (refer to A-0385 and A-0395); Physical Environment; fire (refer to A-0700 and A-0709); Infection Control; (A-0747, A-0749, and A-0750); Surgical Services; (A-0940 and A-0951). During an interview on 12/07/23 at 1:52 PM with Staff Q, Chief Administration Officer stated, “I feel like we are doing everything we can to keep patients safe at this time.” During an interview on 1/5/23 at 3:52 PM with E6, Chief Executive Officer (CEO), E6 stated that the video of a physician laughing at Patient 33 after they fell out of bed while restrained was disheartening. During an interview on 1/5/23 at 8:01 AM Staff D, Director of Quality stated that the hospital has provided all they will be providing on investigations at this time. During an interview on 01/08/24 at 10:02 AM, Staff T4, RN/Risk Manager, stated, “...I don’t know what disciplinary action was done for the physician staff, we are not part of that process.” Staff T4 stated that the hospital did not start an investigation into Patient 33’s incident until surveyors requested the medical record on 12/11/23 at 1:29 PM.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 47233 Based on policy review, document review, record review, and interview, the hospital failed to ensure that services furnished under contract complied with all applicable conditions of participation and acceptable standards of practice as evidenced by the failure of a medical provider to provide a physical examination for 1 of 1 patient (Patient 33) that was brought to the Emergency Department (ED) for evaluation of a possible emergency medical condition, and failed to ensure acceptable standards of practice were followed for a 1 of 1 patient (Patient 33) that was placed in restraints. This deficient practice places any patient receiving services at the hospital at risk for serious injury or harm. Findings Include: Review of a policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA),” revised 04/17/23, showed, “ ...The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment, and when applicable, safe transfer of a patient...Standard for Medical Screening Examinations: 1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional.] 2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient ’ s needs, and monitoring should continue until the individual is stabilized or admitted ...” Review of a policy titled, “Patient Rights and Responsibilities,” revised 01/21/22, showed, “ ...Be treated in a dignified and respectful manner and receive care by competent personnel ...Receive care in a safe setting and be free from physical, verbal, emotional/psychological, and sexual abuse, and harassment ...” Review of a policy titled, “Restraints and Seclusion Policy,” revised 02/03/22, showed, “ ...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient ...” The policy showed that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour after restraint initiation and must include the patient’s immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, and document in the electronic medical record. Review of a policy titled, “Code of Conduct- Behaviors that Undermine a Culture of Safety,” revised 12/23/20, showed, “ ...Other behaviors which impair the reasonable skill and safety of patients, due to mental or physical disabilities, alcohol and/or drug abuse, deterioration of skills due to the aging process, or lack of documenting patient care are also of our utmost importance. There are three types of behaviors that undermine a culture of safety that will be considered: A. Actions, B. Impairment, C. Non-compliance...It is expected that everyone will be treated with dignity and respect. There will be no toleration of unprofessional behavior...Violation of the Code of Behavior will be reported to the Professional Review Committee...Actions of Behaviors: Definition: an action that undermines a culture of safety occurs in varying degrees, which are classified into three levels of severity. Level III behavior is the most severe violation of this Policy and could result in immediate suspension. Any corrective action will be commensurate with the nature and severity of the disruptive behavior...Level II: A. Serious Non-compliance is defined as the failure to adhere to the laws, regulations, or policies governing [The Hospital] that: 1. Results in substantive harm or damage (or risk of substantive harm or damage) to the safety, rights, or welfare of the patient...” Patient 33 Review of Patient 33’s discharged medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior. Review of a documented titled, “Prehospital Care Report Summary,” by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33 ’ s care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM. Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses’ desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses’ station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At that time, Patient 33’s feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses’ station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera /view. At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses’ station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33’s left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses’ desk watching patient, however no staff attempted to intervene with Patient 33’s behavior or assess the patient. Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, “Physical Examination Eye: Pupils are equal, round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal.” The documentation failed to show evidence of Patient 33’s facial trauma, altered mental status, and failed to show evidence of a “plan of treatment” for Patient 33. Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33’s eyes and listening to heart and lung sounds as documented. Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33’s movements had resulted in the patient’s lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33’s fall, ~20 hospital staff were in the nurses’ station and within line of site of the patient. Staff S2, Physician, got up from a chair behind the nurses’ station, walked to edge of nurses’ station, looked at Patient 33 on the floor, laughed and returned behind the nurses’ station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33’s fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed. Video review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient’s condition, possible injury, or change in condition. Review of the hospital’s incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33’s medical record failed to show any documentation that a fall had occurred. Review of an “ED Note-Physician,” by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, “...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient’s physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient’s plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion ...” Review of the video footage failed to show evidence that hospital staff attempted non-physical interventions prior to using restraints and that Staff A6, Physician, ensured the safe and appropriate use of restraints to keep Patient 33 safe from harm as documented in the medical record. Staff A6, Physician, failed to ensure that appropriate and safe application of restraints were followed by allowing Patient 33 to be restrained to a slide board instead of the bed. Review of the ED video showed that Staff A6, Physician at no time provided an actual physical examination of Patient 33. Further review of the medical record showed that Staff A6, Physician, documented the “Face to Face” evaluation at 4:05 PM, prior to the completion of Patient 33 being placed in restraints. Review of the medical record failed to show documented evidence that Staff A6, Physician, evaluated Patient 33’s immediate situation, reaction to restraint interventions, medical and behavioral condition, and the need to continue/discontinue restraint after Patient 33 was placed in restraints. Review of Patient 33’s medical record failed to show documented evidence of a written order for restraints by a physician or other licensed practitioner as required per hospital policy and regulation requirements 42 CFR §482.13(e)(5). During an interview on 12/07/23 at 1:52 PM with Staff Q, Chief Administration Officer stated, “I feel like we are doing everything we can to keep patients safe at this time.” During an interview on 1/5/23 at 8:01 AM Staff D, Director of Quality stated that the hospital has provided all they will be providing on investigations at this time. During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED, and it was disheartening. During an interview on 01/08/24 at 10:02 AM, Staff T4, RN/Risk Manager, stated, “...I don’t know what discipline action was done for the physician staff, we are not part of that process.” Staff T4 stated that the hospital did not start an investigation into Patient 33’s incident until surveyors requested the medical record on 12/11/23 at 1:29 PM. In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33’s medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival by a QMP. Staff A6, Physician, failed to ensure that Patient 33 was properly restrained to ensure safety and prevent a fall while in restraints. Review of the video and medical record showed Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The hospital failed to ensure that Patient 33 was treated with dignity and respect as required per hospital policy as evidenced by Staff S2, Physician, laughing at Patient 33 when he sustained a fall.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and interview, the hospital failed to ensure it informed each patient, or when appropriate, the patient’s representative of the patient’s rights, in advance of furnishing or discontinuing patient care for 8 of 53 sampled patients (Patient 1, 2, 4, 5, 9, 16, 26, and 33.) This deficient practice places any patient at risk of not understanding their individual rights as required per regulation requirements 42 CFR §482.13(a)(1). Findings Include: Review of a hospital policy titled, “Admissions Consent Agreement,” revised 02/26/14, showed, “...It is the responsibility of the Admissions management team to ensure the completed Admissions consent forms are either faxed directly into the document Imaging system or manually scanned into the system where they will be stored within the specified patient ’ s electronicfolder indefinitely ...An “Admissions Consent Agreement” form shall be obtained for all patients receiving services from [The Hospital]...Acknowledgement of Receipt of Patient Rights and Responsibilities; Decreasing Your Risk of Infection; and Privacy, Payment, and Billing - Signature acknowledges my receipt of Patient Rights and Responsibilities; the Notice of Privacy Practice; Decreasing Your Risk of Infection; and Privacy, Payment, and Billing Information...Advance Directives - This section confirms that the patient has received general information about advance directives, as included in the Patient Rights & Responsibilities brochure, and that [The Hospital] will provide specific information and materials for a Living Will and/or Durable Power of Attorney upon request from the patient...All Ancillary areas should forward the original copy of the Admissions consent form to Admissions by day end of the day services were rendered by [The Hospital]. Admissions will be responsible for assuring these Admissions consent forms get appropriately scanned into the imaging system...” Review of the medical record for Patients 1, 2, 4, 5, 9, 16, 26, and 33 failed to show evidence that the Admissions Consent Agreement containing acknowledgement of Patient Rights was received by the patient and/or a patient’s representative and placed in the medical record as required per hospital policy. During an interview on 11/29/23 at 12:58 PM, Staff B, Quality Manager, was asked if surveyors were provided the complete medical record for the sample patients requested. Staff B stated that each record requested “should be the complete medical record”.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47233 Based on policy review, document review, and interview, the hospital failed to ensure 50 of 50 sampled patients and/or patient’s representative was informed of the hospital’s internal grievance process, including whom to contact to file a grievance. The hospital failed to ensure that as part of its notification of patient rights, the hospital must provide the patient and/or the patient’s representative a phone number and address for lodging a grievance with the State Agency. The hospital failed to inform any patient that he/she may lodge a grievance with the State Agency directly, regardless of whether he/she had first used the hospital’s grievance process. The hospital failed to ensure that an allegation of abuse or neglect was classified as a grievance for 1 of 53 sampled patients (Patient 2.) This deficient practice places any patient at risk of not understanding their individual rights to file a grievance and with whom to contact to file a grievance as required per regulation requirements 42 CFR §482.13(a)(2) and places any patient at risk for not having an allegation of abuse or neglect thoroughly investigated and resolved. Findings Include: 1. Failure to inform patients of right to file a grievance: Review of a hospital policy titled, “Patient Rights and Responsibilities,” revised 01/21/22, showed, “Per CMS’ (Center for Medicare and Medicaid Services) Condition of Participation §482.13, a hospital must protect and promote each patient’s rights ...[The Hospitals] have made a commitment as part of their mission to recognize and support patient rights, including the patient’s right to ...Consult with a member of the Ethic Committee regarding any question or conflict by and among persons about your medical care...Patients and/or families are educated about basic patient rights in the following manner...Written information containing a copy of patients ’ rights and patients ’ responsibilities related to their rights is provided upon admission...Associates assist with conflicts, concerns, or complaints during the patient’s stay...” The policy failed to include the patient’s right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights. Review of a document/brochure titled, “Patient Admission Information,” dated 06/2019, showed, “...Patient rights and responsibilities; You have the right to ...Consult with a member of the Ethics Committee regarding any question or conflict by and among persons about your medical care...You are responsible for...Making your concerns and complaints known...” The brochure failed to include the patient’s right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights. Review of a hospital policy titled, “Grievance Resolution/Patient Feedback/Complaint Resolution,” revised 08/24/23, showed, “...Each patient is provided with the Patient Rights and Responsibilities Brochure upon admission that includes information regarding how to file a grievance directly with the hospital as well as contact information for filing a grievance with the [State Agency]...” The brochure failed to include the patient’s right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights. Review of medical records for all sampled patients (Patient 1 - 53), failed to show documented evidence that any patient was informed of the right to file a grievance, education on the process of filing a grievance, and the right to file a grievance directly with the State Agency, including the contact phone number and address for the State Agency. During an interview on 12/05/23 at 10:45 AM, Staff A, Quality Manager was asked to review the hospital policy titled, “Patient Rights and Responsibilities,” and the hospital’s admission packet titled, “Patient Admission Information.” After reviewing the policy and admission packet, Staff A was asked if a patient’s right to file a grievance was listed as a patient right. Staff A refused to answer the question. Staff A was asked again to review the hospital policy and admission packet if he/she was unsure if the right to file a grievance was listed as a patient right. Staff A refused to review the documents a second time and stated that he/she would refer the question to Staff A4, Consumer Experience Director, and stated, “[Staff A4] is the owner of that policy.” During an interview on 12/05/23 at 11:05 AM, Staff A4, Consumer Experience Director, was asked to review the hospital policy titled, “Patient Rights and Responsibilities.” Staff A4 confirmed that the right to file a grievance was not listed as a patient right. Staff A4 was asked to review the listing of patient rights as printed in the hospital’s admission brochure titled, “Patient Admission Information”. Staff A4 confirmed the right to file a grievance was not listed as a patient right and stated, “I don ’ t see it in that list [list of patient rights].” Staff A4 stated that it is a “patient’s responsibility” to notify the hospital of a concern with care. Staff A4 also confirmed that the admission brochure failed to inform patients of the right to file a grievance directly with the State Agency and that language in the admission brochure never mentioned “grievance.” 2. Failure to follow the hospital’s grievance policy and procedure as required for an allegation of abuse and/or neglect: Review of a hospital policy titled, “Grievance Resolution/Patient Feedback/Complaint Resolution,” revised 08/24/23, showed, “...Grievances about situations that endanger the patient such as abuse or neglect are investigated immediately...The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Verbal responses are provided by authorized representatives and the interaction is documented on the Patient Concern Form by the authorized representative...acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days, as well as hospital contact information. If the investigation is not or will not be completed within 30 working days, the Consumer Experience Department or designee will inform the patient or patient’s representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital’s grievance policy. The hospital must attempt to resolve all grievances as soon as possible. The Consumer Experience Department coordinates with Department Leadership on the investigations of grievances. A letter is sent to patients and/or their representatives at the conclusion of all grievance investigations. The letter is sent by the Consumer Experience Department or designee following the receipt of the investigative findings, conclusions and actions from the involved departments’ leadership...The response letter includes the name and contact information of the hospital’s authorized representative, the steps taken on behalf of the patient to investigate the grievance, the results of the investigative process and date of completion...Ethic Consultation are available for problem-solving and conflict resolution...Definitions: ...Grievance - Grievances may be presented verbally or in writing...A grievance is an issue presented to any hospital employee, regarding the patient’s care; abuse or neglect; issues related to the hospital’s compliance with the [CMS] Hospital Conditions of Participation (CoPs) ...The following describes grievances for purposes of this policy: ...abuse or neglect, or the hospital’s compliance with Medicare Conditions of Participation ...” Review of Patient 2’s discharged medical records showed a 60-year-old admitted for suicidal ideation (SI), threatening behavior, recent seizure (sudden, uncontrolled burst of electrical activity), and homelessness. Patient 2 suffered an unwitnessed fall on 08/23/23 at 4:38 PM that was recorded on hospital security footage. Patient 2 voiced an allegation that she was the victim of abuse by hospital staff after her fall. Review of a document titled, “[H2] Grievance and Complaint Log,” dated 03/01/23 - 11/27/23, showed an entry for Patient 2 as “received” on 09/07/23. The classification was documented as a “complaint” and the issue type and nature were documented as “behavioral issue.” Case detail documentation showed the following, “... [Patient 2] admitted 2 weeks ago to [H2]. She presented in person to [H1] asking for follow up in regard to being ‘mishandled physically’ by security and nursing on 6W. If you could please call for further follow up. Thanks [House Supervisor]...Connected with patient regarding the message from House Sup. When I connected with the patient and informed her who I was she disconnected the call. I called her right back and this time she spoke with me and said that she has retained an attorney and would not provide me with any details about the incident. She asked if she could get the names of the security officers involved in this incident and the “nurses that instigated the incident”. I informed her that I cannot provide her with this information myself and before I could say anything else she said “oh yes you will, this is public information” and disconnected the call. I tried calling her again but she disconnected the call once again.” Further review showed the “complaint” was documented as “closed” on 09/08/23 at 6:51 PM (approximately 24 hours from time the “complaint” was received.) Review of Patient 2’s discharged medical record failed to show documented evidence of a hospital investigation upon an allegation of abuse as required per hospital policy. Further review of the medical record also failed to show documented evidence that the hospital followed its policy and grievance procedure, including providing a letter to Patient 2 with a response letter that provided the steps taken on behalf of the patient to investigate the grievance, the results of the investigation, and its date of completion. During an interview on 12/06/23 at 9:20 AM, Staff A4, Consumer Experience Director, was asked why Patient 2’s allegation of abuse was classified as a “complaint” versus a “grievance.” Staff A4 stated, “As I’m looking at this [Grievance and Complaint Log], the reason why it was not classified as a grievance is because when my team connected with the patient by phone call to gather information and confirm her concerns, she disconnected the call and when we called back, she would not provide me any details about the incident.” Staff A4 was asked why refusing to give information would prevent the hospital from performing an investigation or classifying the allegation as a grievance. Staff A4 reviewed the hospital policy and confirmed that a verbal accusation of abuse or concern of care is, by definition, a grievance and stated that Patient 2’s allegation should have been classified as a grievance and not a complaint. Staff A4 stated that a grievance resolution letter was not sent to Patient 2 because the hospital incorrectly deemed her allegation as a complaint and not a grievance. Staff A4 confirmed that the hospital did not follow the proper grievance resolution procedure as required per hospital policy.”

“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: 47233 Based on policy review, document review, record review, surveillance video review, and interview, the hospital failed to ensure the patients’ right to receive care in a safe setting as required per 42 CFR §482.13(c)(2). This deficient practice resulted in potential and/or actual harm for 12 of 50 sampled patients (Patients 38, 27, 2, 33, 24, 9, 31, 14, 54, 25, 52, and 42) and places any patient receiving services at this hospital at risk for serious injury, harm, or death. Findings Include: Review of a hospital policy titled, “Fall Risk,” revised 03/21/23, showed the hospital uses the “Morse Fall Scale (0-24 Low risk; 25-44 Moderate; 45 or > High.) ...Critical thinking skills may place a patient in the “High Fall Risk” protocol at any time based on clinical judgement...Patients will be assessed using the Fall Risk Assessment every shift and at any time there is a change in the patient’s condition...If a fall occurs a. assess the patient for injury and mental/physical of patient and compared to pre-fall assessment, b. Notify the physician of the fall, e ...notify family of the patient’s fall...” Review of a document titled, “Morse Interventions by Scale,” showed the universal precautions for all patients include education regarding fall risk, orientation to room and call light upon admission. The document included precautions that staff are to follow including assess toileting needs, personal items and call light within reach, bed locked in low position and hourly rounding. For moderate Fall Risk Precautions in addition to the Universal Fall Precautions staff are to use a gait belt or lift equipment when mobilizing patients from bed or chair. High Fall Risk Precautions in addition to above Universal & Moderate Fall Precautions include, yellow High Fall Risk armband, gown, non-slip socks, and door sign in place. Patients are to be supervised when in the restroom or on bedside commode. Patient room placement near nurses’ station, where available. The door to the patient’s room should remain open when isolation status allows. Bed and chair exit alarms are to be activated. All inpatient medical beds currently have exit alarm capability. Review of a hospital policy titled, “Patient Assessments and Reassessments,” revised 08/17/23, showed that Registered Nurses (RNs) are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. The RN may delegate aspects of data collection to LPN, CNA, or Behavioral Health Tech. The RN must then analyze the data and set care priorities, formulate diagnosis, plan of care, and initiate referrals...Emergency Services: Initiation of assessment within 15 minutes for triage and completion of admission assessment within 30 minutes for Level 1 and 2; within three hours for Level 3, 4, and 5...Emergency Department: Content/Parameters: (not defined). Minimum Reassessment Timeframes: Focused reassessment minimally every hour and by specific need ...Operating Room: Content/Parameters: Defined by surgical checklist and perioperative assessment form. Minimum Reassessment Timeframes: Ongoing monitoring by CRNA (Certified Registered Nurse Anesthetist)/anesthesiologist...” Review of the hospital policy titled, “Chest Pain Program” revised 10/24/2023 showed, “...Patients receive rapid evaluation for intervention to minimize acute coronary syndrome (ACS) morbidity and mortality...The program evaluated patients with signs and symptoms of chest pain or acute coronary syndrome. These signs include but are not limited to: ... arm pain...other non cardiac presentation especially in women. If these signs or symptoms are present, staff obtains a STAT electrocardiogram (ECG)...” Review of a hospital policy titled, “CPG [Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain”, revised 02/07/2023 showed, “In all patients who present with acute chest pain regardless of the setting, an ECG [electrocardiogram] should be acquired and reviewed for STEMI [ST Elevation Myocardial Infarction] within 10 minutes of arrival.” Further review of the document showed, “Chest pain or chest pain equivalent will be referred to in these guidelines as “Chest pain” ... Regardless of the setting, an ECG should be obtained and interpreted within 10 minutes of arrival ...” Review of hospital policy titled “Suicide Prevention” revision 11/07/22 showed “Policy: A. This policy is used to plan for care and management of a suicidal patient. Patients may be identified to be at risk of suicide either through patient-initiated statements/behaviors or through caregiver interactions. The intent of identifying a patient with suicide risk is to discern the imminent need for environmental safety measures to reduce the potential attempts and to activate level of care necessary to mitigate the overall risk and offer resources available in the community at large...C. Inpatient and non-inpatient non-behavioral health care setting that provide care to those at risk of harm e.g. emergency departments, intensive care units, medical-surgical units and other inpatient and outpatient locations: “Safer” environment.Remove objects from the room that can be used for self-harm and monitor the patient per patient observation orders while awaiting transfer to a higher level of care. Potential risks include but are not limited to those from ligature, sharps, harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags (for suffocation), oxygen tubing, bell cord, etc. Review of a hospital policy titled, “Restraints and Seclusion Policy,” revised 02/03/2022, showed, “...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient...” The policy stated that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour of restraint initiation and must include the patient’s immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint. The use of restraints requires assessment/monitoring to be documented within one (1) hour of initiation, or more often as determined by the patient’s condition. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, and document in the electronic medical record...RN will document they type of restraint used...The RN will document the patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention...Immediately checks the patient to ensure that the restraints were properly and safely applied...Document the patient’s response to and effectiveness of the restraint ...Assess/monitor/document the patient ’ s condition in at least 1 hour, or more often as determined by the patient’s condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient...” The condition of a patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria. “...Training will be conducted...As part of orientation...On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients...Staff will be trained on the safe application of all types of restraint...Staff will be trained and demonstrate competency in monitoring the physical and psychological well-being of a patient who is restrained...include but not limited to respiratory and circulatory status, skin integrity, vital signs ...” Review of a hospital fall log provided on 11/27/23, showed a total of 225 falls from 03/01/23 through 11/26/23 at Hospital 1 (H1- the above named hospital) and showed a total of 231 falls from 03/01/23 through 11/26/23 at Hospital 2 (H2 - an off campus hospital location). Review of a document titled, “Nursing Staffing Matrix” undated showed, “Department Type: ICU: Day: 2:1 (2 patients to 1 Nurse) Night: 2:1 (2 patients to 1 Nurse)...” Patient 38 Review of Patient 38’s medical record showed a 74-year-old female that arrived to the ED at H1 via ambulance on 08/21/23 at 12:14 PM with complaints of worsening numbness to her left hand for the past 3 weeks. Patient 38 noticed that the pain has been radiating into her mid back and she doesn’t feel she has been getting much relief. Patient 38 had a history of Chronic Obstructive Pulmonary Disease (disease of the airway), Hyperlipidemia (high levels of fats in blood), Chronic Kidney Disease (ineffective functioning of the kidneys), Hypertension (high blood pressure), and prediabetes. The hospital failed to ensure nursing services provided a rapid and appropriate evaluation of Patient 38, including an ECG within 10 minutes of arrival per policy. ED Staff didn’t complete the ECG until over 6 hours later and it showed ischemia (a condition in which blood flow (and thus oxygen) is restricted or reduced) to the heart muscle. At that time, the hospital staff sent the patient to the cardiac catheterization lab to initiate intervention to minimize acute coronary syndrome (ACS). Subsequently following the cardiac catheterization Patient 38 underwent an emergent Coronary Artery Bypass Graft (CABG). Following the procedure patient was moved to the Cardiac Intensive Care Unit with a balloon pump. Delay in ECG places all patients with potential cardiac issues at risk for receiving care in an unsafe setting. Patient 38 died 08/22/23 at 12:11 PM, 23 hours and 57 minutes after she presented in the Emergency Department. Patient 27 Review of Patient 27’s medical record showed a 76-year-old male admitted to H1 on 10/19/23 at 5:22 PM with a diagnosis of Urinary tract infection, Hypotension (low blood pressure), dehydration, Chronic Kidney Disease, Altered Mental Status (AMS). Patient 27 had a past medical history of right above/below the knee amputation (absence of leg), hypertension (high blood pressure), and diabetes type 2 (too much sugar in the blood). Review of Patient 27’s Morse Fall Risk on 10/19/23 at 11:31 PM showed a fall risk score of 20 [low fall risk]. Review of this assessment failed to identify patient had a secondary diagnosis which would have increased his score by 15 points and mental status fall risk Morse was scored as 0 however further documentation in the medical record showed patient forgets limitations increasing fall risk score by 15 which in turn would have been a score 50 indicating a high risk for falls. Review of a “ED Note-Nursing” dated 10/20/23 at 6:37 AM, showed, “ ... pt (sic) was alert, pleasant, confused, disoriented, bedbound due to recent rt (sic) AKA (Above Knee Amputation) and weakness...pt (sic) required frequent redirection and reorientation...including pt requiring reorientation after calling 911 from personal cell phone, pt (sic) believed he was driving a school bus and “needed help with the kids”. Pt (sic) frequently removed monitor leads, bp (sic) cuff and nasal canula. Pt (sic) did not display the ability to reposition himself in bed, side rails x2 remained up to prevent fall...aprox (sic) 0414 staff from another department stated pt (sic) appeared to be out of bed, this RN went to pt (sic) room, pt (sic) was found at foot of bed, did not respond to his name, pt (sic) breathing was agonal, pulse was slow, weak. Code button was pressed, crash cart brought bedside. Compressions started at 0415. During code, at 0437 this RN spoke to family, during call [Return of Spontaneous Circulation] ROSC was achieved. Post code, report was called, CT [Computed Tomography] scan completed and pt (sic) was transferred to ICU. C-collar was placed during code, small abrasion noted to left lower leg, no other injuries noted.” Review of video footage dated 10/20/23 at 4:10 AM showed that an unidentified Staff entered Patient 27’s room (5 minutes after documentation showed patient was found on the floor) further review of the video showed the unidentified Staff exiting the patient room at 4:15 AM. After what appears to be a visitor or patient in room next to Patient 27’s room notified a staff member coming out of the CT room that Patient 27 needed assistance. An unidentified Staff entered the room at 4:10 AM. The nurse noted to exit room at 4:15 AM and retrieved crash cart. Further review of the video footage showed that Patient 27 had not been checked on by hospital staff from 10/20/23 at 2:00 AM until alerted by unknown visitor/patient at 4:10 AM. Review of a document titled, “VCH SF: FY 2023 Daily Staffing Report”, dated 10/19/23 into 10/20/23 at 7:00 AM showed a total of 6 RN’s. Further review of the document showed multiple critical patients, three patients on ventilators and one patient on bi-pap. During an interview on 11/08/23 at 4:00 PM, Staff D8, ED Manager stated that on 10/20/23 at approximately 4:00 AM there were 6 RN’s and at minimum 36 patients. She went on to state that she was unsure of what the exact census was but the patient to nurse ratio was at least a 6:1 (6 patients to 1 RN). Emergency Nursing Association (ENA) standards are 4:1 (four patient to 1 RN). Further review of the medical record showed that Patient 27 expired on 10/20/23 at 10:29 PM. The hospital failed to ensure that staff provided necessary supervision for Patient 27, who was confused, disoriented, and required frequent redirection. Ultimately, Patient 27 experienced an unwitnessed fall, and a visitor notified staff that Patient 27 needed assistance. Patient 27 coded and died following the fall. Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted to H2 with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis was schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident (CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of security video footage on the 6th floor west north hall of the Behavioral Health Unit at the Hospital 2 (H2 - off campus hospital location of H1) campus dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse’s station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Registered Nurse (RN), Staff O4 RN, and unidentified staff member in gray shirt came out of the nursing station and walked down to Patient 2. Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurses’ station, leaving the patient unattended. At 4:42 PM an unidentified male staff came into the hall and walked straight by Patient 2 without even looking at her. At 4:43 PM, Staff O4, Staff C4, Staff U3, Behavioral Health Technician (BHT) and an unidentified female staff member return to Patient 2 with a vitals machine and was observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT was observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2’s face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers (MHPW) entered the hall and approached Patient 2. None of the staff standing around Patient 2 attempted to reposition her, she remained face down in a semi fetal position. Her body appeared to be heaving in a slight up and down motion. Staff Q4 and Staff R4, picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2’s body hung limply, and she made no attempts to move or reposition herself. As Staff Q4 and Staff R4 picked her up, she was flipped over mid-air causing her wrists to cross over one another while dangling face-up. The MHPW’s then carried Patient 2 by her wrists and ankles into a room. The facility failed to initiate universal fall precautions including non-slip socks, which may have contributed to the patient’s fall. Review of Patient 2’s medical record status post unwitnessed fall on 08/23/23 failed to show documented evidence that a post fall injury evaluation and neurological assessment were completed to include a Glasgow coma scale (measures the extent of impaired consciousness, in all types of acute medical and trauma events), any changes in eye opening, best verbal response and best motor response per hospital policy. The record failed to show a description of her level of consciousness, headache, pain, extremity movement and hand grasp. Failure to assess the patient for injury following an unwitnessed fall and leaving the patient unattended on the floor places the patient at risk for further harm from unidentified potential injuries. Failure of staff to appropriately transfer a patient who had an unwitnessed fall has the potential to cause further injury and harm. These deficient practices create an unsafe care environment. Patient 33 Review of Patient 33’s medical record showed a 38-year-old male that arrived at the ED at H1 on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior. Review of a documented titled, “Prehospital Care Report Summary,” by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33’s care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM. Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses’ desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses’ station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At that time, Patient 33’s feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses’ station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view. Review of the medical record failed to show any nursing notes on Patient 33 to document interventions and application of restraints. At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses’ station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33’s left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses’ desk watching patient, however no staff attempted to intervene with Patient 33’s behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. This was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge. Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33’s medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33’s pupils and did not listen to heart or lung sounds as documented. Further review of the video showed that between time of arrival at 3:52 PM to 10:41 PM, Staff A6, Physician, never approached Patient 33 to perform a physical exam. At 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33’s movements had resulted in the patient’s lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33’s fall, 20 hospital staff were in the nurses’ station and within line of site of the patient. Numerous staff pointed and laughed at Patient 33 while on the floor, restraints still attached to the slide board, laying on left side, on his shoulder with left arm behind him and left side of head on the floor. Staff S2, Physician, got up from a chair behind the nurses’ station, walked to edge of nurses’ station, looked at Patient 33 on the floor, laughed and returned behind the nurses’ station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33’s fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed. Further review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient’s condition or possible injury. Review of the hospital’s incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33’s medical record failed to show any documentation that a fall had occurred. Review of the “ED Triage Note,” showed, “ ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST [4:00 PM] by [Staff Z5, RN].” Staff Z5 documented the following vitals: Blood pressure 114/74, Pulse 104, Respiratory rate 16, and Oxygen saturation 94%. Review of the video footage showed these vital signs were obtained at 7:07 PM. Review of a document titled, “Alleged ED Caregiver Misconduct-Patient Timeline,” undated, showed an interview with Staff Z5, RN. “...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs]...” Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, “Physical Examination: Eye: Pupils are equal, round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal “ The documentation failed to show evidence of Patient 33’s facial trauma, altered mental status, and failed to show evidence of a “plan of treatment” for Patient 33. Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33’s eyes and listening to heart and lung sounds as documented. During an interview on 12/0723 at 4:15 PM, Staff C5, stated that he has several concerns with staffing, the ED is expected to do more with less constantly. Staffing has been this way for multiple years. States people will continue to have adverse outcomes if they do not fix their staffing. States that some days staffing is unacceptable. States when staffing is bad, they try to go on diversion. States that managers rarely come in when they are short staffed. States he has absolutely had a bad outcome for short staffing. Patient 24 Review of Patient 24’s medical record showed an 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of Patient 24’s medical record showed a Morse Fall Risk score of 50 on 11/01/23 at 9:00 PM indicating high risk for fall. Review of Patient 24’s medical record showed a documented fall on 11/05/23 at 4:38 PM by staff L5, RN. Further review of the medical record showed an order for CT Head or Brain with and without Contrast on 11/05/23 at 4:36 PM (2 minutes prior to documented fall). Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/05/23 16:38:00 CST (4:38 PM), q1hr, 4, hr, Stop date 11/05/23 20:59:00 CST (8:59 PM).” Review of Patient 24’s medical record failed to show documented evidence of a Neurological Assessment between 4:38 PM and 6:38 PM every one hour as ordered. (2 of 4 assessments) Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/5/23 8:38:00 PM CST, q4hr, 20, hr, Stop date 11/6/23 4:59:00 PM CST.” Review of Patient 24’s medical record failed to show documented evidence of a Neurological Assessment for the following dates/time: From 11/05/23 at 9:10 PM to 11/06/23 at 2:19 AM (~5 hours) From 11/06/23 at 2:19 AM to 11/06/23 at 9:00 AM (~7 hours) During an interview on 12/12/23 at 1:25 PM, Staff L5, Registered Nurse (RN) stated that when Patient 24 fell, she hit the left side of her forehead and maybe hit the top of her head on something. Staff L5 stated that she was not present at time of fall. Staff L5 stated that Patient 24 had a small laceration to her forehead, was on a blood thinner, and that a large hematoma developed rather quickly. Review of the medical record failed to show documented evidence nursing staff completed a full post fall assessment including but not limited to: vital signs, provider notification, and family notification. During an interview on 12/12/23 at 12:35 PM Staff K5 stated that, she has noticed an increase in falls due to lack of staffing. She went on to state it is because staff cannot respond to the bed alarms soon enough, or staff do not know where the alarms are coming from, sometimes it comes to the nurses’ phone and sometimes it does not because the bed’s do not have the correct cords. In the Intensive Care Unit (ICU) we often have three patients and at times we are unable to leave a room to respond to an audible bed alarm. Patient 9 Review of Patient 9’s medical record showed a 63-year-old male, admitted to H1 on 11/18/23 at 11:41 PM with a diagnosis of sepsis (infection in the blood), cellulitis (bacterial skin infection), leukopenia (low white blood cells), alcohol intoxication, and hypokalemia (low potassium). Review of Patient 9’s Morse Fall Risk on 11/19/23 at 9:00 AM showed a fall risk score of 60 [high fall risk]. Review of “Environmental Safety Management,” dated 11/19/23 at 9:00 AM, 8:08 PM, and 8:40 PM, showed, “...Personal items within reach...Supervision with toileting...” Review of “Post Fall Information,” dated 11/19/23 at 8:08 PM, documented that Patient 9’s urinal was out of his reach, as required by “Environmental Safety Management.” Patient 31 Review of Patient 31’s medical record showed a 73-year-old male that arrived at the ED at H2 via EMS on 10/06/23 at 10:59 PM with a diagnosis of Altered Mental Status of unknown onset. Patient 31 has a past medical history of diabetes mellitus and renal impairment. Patient 31 was then transferred to H1 on 10/12/23 at 11:59 PM for a higher level of care. Review of Patient 31’s medical record showed an initial Morse Fall Risk score of 50 on 10/07/23 at 5:35 AM indicating high risk for fall. Patient Morse Fall Risk score indicated high risk for fall throughout admission with discharge score on 10/19/23 at 9:25 AM with a score of 95 (high risk 45 and above). Review of the medical record showed that Patient 31 had falls on the following dates: 10/08/23 at 4:15 AM at H2, 10/09/23 at 11:02 AM at H2, 10/16/23 at 7:25 AM at H1 and 10/16/23 at 4:03 PM at H1. (4 falls in 12 days) Review of a document titled, “[Hospital 1] Incident Log” dated 03/01/2023 - 11/26/2023 showed, “...10/16/23 This RN (not RN caring for patient) heard a thud and then an “ow” coming from pt room in X. This RN does not see patient in bed or chair, then sees patient on floor near bed. This RN immediately calls RN who is caring for patient (X) and notifies RN manager XX. Pt vitals taken - see chart. RN X notified of events. No bed exit/chair exit alarms going off at time of incident, all four rails of bed noted to be in up position also. No immediate/obvious injuries noted by this RN...” Review of the medical record dated 10/15/23 at 8:00 PM showed that the following interventions were as required per facility Fall Bundle protocol: “... Exit alert on...Upper/Half length side rails for bed mobility...” Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall. Review of the medical record dated 10/16/23 at 4:03 PM showed that the following interventions were in place per facility Fall Bundle protocol: “... Exit alert on ...Upper/Half length side rails for bed mobility...”Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall. Review of an order dated 10/08/23 at 4:15 AM stated, “Order: Neurological Assessment High Risk for Injury ...Order Details 10/8/23 4:15:00 AM CDT, q1hr, 4, hr, Stop date 10/8/23 8:29:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 1 hour per orders between 10/08/23 at 4:15 AM to 10/08/23 at 8:29 AM. Review of an order dated 10/08/23 at 6:27 AM stated, “Order: Neurological Assessment High Risk for Injury ... 10/8/23 8:15:00 AM CDT, q4hr, 20, hr, Stop date 10/9/23 4:59:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 4 hours per orders between 10/08/23 at 8:15 AM to 10/09/23 at 4:59 AM. Failure to complete neurological checks places any patient at risk for neurological decline (i.e.. Change in mental alertness, brain bleeding, and/ or decrease in strength) after a fall. Patient 14 Review of Patient 14’s medical record showed a 69-year-old female that presented to the ED at H2 on 11/20/23 at 3:52 AM via private vehicle. Patient was admitted with diagnosis frequent falls, hematoma to right knee region, long term use of anticoagulant (medicine that helps prevent blood clots) and Atrial Fibrillation (irregular often rapid heart rate that cause poor blood flow). Patient has history of chronic obstructive pulmonary disease (COPD), status post right upper lobectomy (removal of one of the 3 right lung lobes), hypertension (HTN) (elevated blood pressure), hyperlipidemia (high cholesterol in blood). Review of “ED- Triage- Adult” on 11/20/23 at 3:52 AM showed “Chief Complaint: Fell out of bed and landed on right knee twice. Noted swelling right below right kneecap ...” Review of “ED Note - Physician” on 11/20/23 at 4:08 AM showed “...Patient states she has been falling out of bed frequently. States she fell out twice tonight when she got back up and into bed and then fell out again. Family is trying to get rails for the bed but has been unable to. Patient is noted swelling and bruising right hand pain with palpation and movement. Patient is currently on Plavix and Xarelto. Patient states that her knee hurts all the way down to her ankle... Review of “Emergency Documentation” on 11/20/23 at 7:00 AM showed “Reexamination/ Reevaluation; Assessment: Notified by nursing that patient had fallen out of bed. Left side rail had been left up and patient states she just fell to the side while she was sleeping. Patient thinks she did hit her head. She does not have any neck pain. Obtain stat CT head and neck.” Review of H2 “Incident Log” on 11/20/23 showed “Patient 14...event types Falls & Slips (patient)...Event Occurrence Department; Emergency department; Narrative Pt had unwitnessed fall in room. Pt told multiple times to stop getting out of bed. Pt was acutely aware that nursing staff wanted her to in where she was. Severity D - No Harm Severity Category No Harm.” Review of Patient 14’s medical record showed initial Morse Fall Risk score of 110 on 11/20/23 at 9:14 AM indicating high risk for fall entered 3 hours and 8 minutes after was triaged for multiple falls. Review of the medical record failed to show any documented evidence nursing staff completed a documentation of a fall or post fall assessment including but not limited to; following interventions were in place per facility such education regarding fall risk, orientation to room and call light within reach, bed locked and in low position, patient room placement near nurses ’ station, the door to the patient’s room remaining open, yellow high fall risk armband, gown, non-slip socks, and door sign in place and bed alarms are to be activated. This places any patient at risk for a fall that could result in serious injury, harm, and/or death. Patient 54 Review of Patient 54’s discharge medical record was a 61-year-old male admitted to H2 on 01/19/23 for a Colonoscopy (procedure that checks your entire colon using a long flexible tube put in your rectum) and Endoscopy (EGD) (procedure inserting a long flexible tube down your throat into your esophagus). Patient 54 has a history of Cirrhosis (diseased liver), iron deficiency anemia (low red blood cells and iron in the body), Gastroesophageal Reflux (GERD) (stomach acid flows into the food pipe and irritates the lining), history of colon polyps (small clump of cells that form in the lining of the colon). Per Staff M7, DO’s progress note at 5:25 PM, “During the EGD (shortly after duodenal biopsy was performed), while in the left lateral recumbent position, patient rolled backwards on the stretcher and slid slowly onto the floor ... The patient was lifted back onto the bed with assistance of additional staff members ... The gastroscope was reinserted for a quick examination to ensure no trauma or bleeding had occurred ... He complained of some minor neck stiffness but reported that he does feel that way after laying for a long time ... He was discharged to home in stable condition ...” Review of anesthesia record dated 01/19/23 “free notes” by Staff V7, CRNA, revealed at “16:28 [4:28] PM Filling additional propofol [a short acting intravenous anesthetic] syringe. Standing at pyxis [a drug supply management machine]. Surgeon and scrub started to yell for help. When turning to assist, patient was rolling backwards on bed from force of surgeon advancing scope. Bed rail on back of patient was not in place. Scrub indicated that this is for the scope to be able to reach patient for procedure. Immediately protected patient’s head and held it securely as he started to roll off the bed. Assisted patient in guided fall to floor. Notified [Staff K6] of current situation at 1629 [4:29 PM]. Discontinued propofol gtt [drip] after patient stabilized on floor.” “Transport at 16:57 [4:57] CRNA VSS (vital signs stable) upon PACU [post anesthesia care unit] arrival. Patient neurologically intact. Able to move hands and feet. Denies numbness/tingling in extremities. Patient stated he did have a headache that was increasing. [Staff K6] notified of patient status. Will continue to follow up as indicated.” Failure of staff to remain at the bedside of a sedated patient during a procedure resulted in the patient falling off bed. Patient 25 Review of Patient 25 ’ s medical record showed a 61-year-old female who present to the ED at H1 via EMS on 11/08/23 at 1:37 PM and was admitted to inpatient status at 4:12 PM with the following diagnosis Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 had a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated blood pressure). Review of an order dated 11/08/23 at 3:54 PM showed, “Order: Restraint Initiate Violent 18 Years and Older ...Order Details: 11/8/23 3:54:00 PM CST, Injury to self, Soft limb, Order valid for 3 hour. Evaluate patient and order Restraint Continue if indicated ...” Review of Patient 25 ’ s medical record showed a note by Staff U5, MD, on 11/09/2023 at 9:27 PM that states, “11/8/2023 15:25:56 ... At this time, patient is pulling off her bipap mask. Due to this, placing patient in soft restraints ...” Review of Patient 25 ’ s medical record failed to show documented evidence of ongoing patient monitoring and documentation by nursing staff in the electronic medical record. Failure to monitor the patient appropriately per hospital policy places any patient in soft limb restraints at risk for but not limited to compromised circulatory complications, pulling out lines and devices, and appropriately secured to the bed. Patient 52 Review of Patient 52 ’ s medical record showed a 21-year-old female admitted on 12/30/23 at 9:30 AM to the ED at H2 via private vehicle. She had a diagnosis of Schizoaffective disorder bipolar type (experiences symptoms of delusions, hallucinations, disorganized speech, grossly disorganized behavior) and intellectual developmental disorder (disorder having trouble with learning, communicating, thinking rationally, making judgments and planning). Patient 52 had a history of a suicide attempt and physical and verbal aggression. Review of “ED Triage- Adult” on 12/30/23 at 9:59 AM showed “ ...Chief Complaint: Chief Complaint: Reports SI (thoughts of suicide) and HI (thoughts of killing others), brought in by [community mental health]. Reports that she wants to hurt her roommate (sic) because they tried to hurt herself. Reports she would jump in front of a train or a car, strangle herself or jump off a bridge ...” Review of “Consultation Notes” on 12/30/23 at 3:11 PM showed “HPI: (History of Present Illness) ... brought in for “suicidal homicidal thoughts” and lists plans for both. She would “hang, suffocate, jump out of a car, jump in front of a car, drown” and for HI (homicidal ideation) toward her roommate she would “choke or suffocate” him ... Review of “CSSRS Screen- Adult” on 12/30/23 at 9:59 AM showed “CSSRS (Columbia-Suicide Severity Rating Scale) Last Visit Wish to be Dead : Yes; CSSRS Last Visit Suicidal Thoughts : Yes; CSSRS Last Visit Idea w-Method No Intent : Yes; CSSRS Last Visit Idea w-Intent No Plan : Yes; CSSRS Last Visit Suicide Intent w-Plan : Yes; CSSRS Last Visit Suicide Behavior : Yes; CSSRS Screen Suicide Behavior Timeline : Yes; Suicide Risk Level Screen Result Adult : High ...” During an observation at H2 on 11/28/23 at 11:13 AM in Zone 2 ER. a locked psychiatric zone, showed a large grey trash can, with a plastic bag lining the can and an unused plastic bag hanging down under the other trash bag in the patient hallway. This trash can was located outside of the locked nurses’ station door close to the nourishment room.” A trash bag could be used by a patient to hang themselves or suffocate themselves. During an interview on 12/11/23 at 10:30 AM Staff H5, BHT (Behavior Health Tech), stated “. We allow plastic bags in the trash bag in the unit in the hallway. Because patients will use a sheet before a trash bag and it ’ s what the custodian allow. There is only one trash can in the hallway so we can kinda see what is going on with that trash can.” During an interview on 12/12/23 at 8:36 AM Staff M4, RN ED Charge Nurse, stated “Zone 2 is a unit only used for psychiatric patients that might elope if a door opens. The area is for patients that are going to cause harm to themselves or others or have suicidal thoughts needing more monitoring with cameras in room. Ligature risk anything to use to put around their neck, or a plastic bag can cause suffocation. During an interview on 12/14/23 at 9:56 AM D2, RN, Vice President Nursing, stated, “Ligature risk anything that could wrapped around that could cause strangulation or harm around the neck, plastic bag would be more a suffocating.” Patient 42 Review of Patient 42’s Medical Record showed a 75-year-old male that presented to H2, Pre-op at 12/28/23 at 5:44 AM. His admitting diagnosis was renal cysts. The admitting physician, Staff L8, MD, completed a History and Physical on 12/28/23 at 7:52 AM. A nursing assessment was completed at 6:07 AM Documentation identified no known drug allergies. A pre-anesthesia assessment was completed by Staff K6, MD at 6:46 AM. The following procedures were documented: Cystoscopy (a hollow tube equipped with a lens is inserted into your urethra and slowly advanced into your bladder), intravesical gemcitabine instillation (chemotherapy drug used to treat bladder cancer), Complex closure of right soft palate (the soft tissue constituting the back of the roof of the mouth) laceration (a deep cut or tear in flesh). Time out was documented at 8:40 AM and OR team identified. Primary procedure was attempted by L7, CRNA and completed by Staff K6. A laceration occurred during the initial intubation attempt and clotted until extubating at 8:56 AM. Staff K6 consulted an completed from 8:30 AM to 8:40 AM. Intubation ENT and also attempted to stop bleeding. An ENT arrived in room 10:13 and completed suture of laceration to right lateral soft palate. Staff K6 communicated with patient’s wife throughout and completed post-op evaluation at 11:59 PM. Patient discharged at 12:26 PM with discharge instructions, medication instructions and a pain medication prescription. Patient discharged to home via private vehicle with spouse. During an interview on 01/05/24 at 2:20 PM, Staff L7, CRNA stated that because they are new, having graduated mid-November, the anesthesiologists are in the operating room [OR] for all inductions. The anesthesiologist, [Staff K6], was not in the OR until the intubation got more “challenging” and came in to assist. “Once airway was secured, we noticed more bleeding. It was clear the laceration occurred during my attempt . . . active bleeding stopped once airway was secured. When waking up and he started moving his mouth, then it was really bleeding. [Staff K6] made the decision to consult ENT [ear, nose, throat] when the bleeding wasn’t stopping . . . The patient was obese with a long tongue . . . The [supply] person is working on getting brand removed. It’s more rigid and pointier . . .” During an interview with Staff K ,Anesthesiologist on 01/03/24 at 1:15 PM he stated, “I am not required to be in the room, but for general (anesthesia) I always am.” This statement contradicts the information Staff L7, CRNA provided in her interview above regarding Patient 42 on 01/05/24 at 2:20 PM. During an interview on 01/04/24 at 4:13 PM, Staff K6, Anesthesiologist stated “CRNA had a difficult time getting in place and was using a different ET [endotracheal] tube. 7.5 tube had been auto substituted and the point comes to a sharper point and it’s more rigid. She tried once and then I took a second look and placed it. He was a large guy, doesn’t extend neck well. Sleep apnea. Redundant tissue. It happened in part, because of the ET tube. We notified [supply staff] and asked them to remove them from stock. It was a recent change and suppliers; we get no say in the stock. Took opportunity to instruct CRNA about ET tubes. She was brand new. It started bleeding again after case. I attempted pledgets (wad of absorbent cotton). I knew someone else would have to come in. Dr. [ENT] put some stitches in. I called him [patient] yesterday. He was mostly concerned about his foley [catheter].” Staff K6 stated that he had never had a patient require sutures before or have a laceration that large. Staffing Concerns During an interview on 12/07/23 at 11:33 AM, Staff X4, Physician Assistant (PA) stated that she primarily works in triage and that she was the only provider in triage until about a month ago and now they have a physician that comes in. The PA stated that she has a lot of concerns about staffing and her concerns are more so related to the nursing side. She stated there are numerous shifts that patients sit in the waiting room for hours waiting for a bed. Stated patients in the waiting room are only getting repeat vitals if she asks. The PA has seen patients decompensate in the waiting room (seizures, pass out). Stated she had a patient die in the waiting room a year ago in May. Stated he coded in the hallway and died. She stated that at H2, they have techs that get too excited and she does not feel like the patients are prioritized appropriately. States that she is sure she has had patients that have a delay in care due to the techs not prioritizing care appropriately. During an interview on 11/27/23 at 12:32 PM Staff K, RN stated that the nurses have been tripled in the Surgical Intensive Care Unit (SICU) at least 1 time per week, night shift likely more. States there are concerns for unsafe staffing and acuity, no manager over SICU recently, house supervisor makes assignments, push back from directors on staffing. During an interview on 11/29/23 at 3:31 PM with Staff N2, RN and O2, RN both stated that that the short staffing has caused negative outcomes for patients. They have seen pressure injuries that have gotten worse due to lack of staffing. Stated that they provide education to RN’s regarding that if the patient is refusing, they need to be documenting it. Stated they can ’ t directly correlate short staffing with infection. Stated that they have concerns with staffing and think that it causes a top to bottom problem throughout the system. During an interview on 12/12/23 at 12:35 PM Staff K5, RN stated that, she has noticed an increase in falls due to lack of staffing. She went on to state it is because staff cannot respond to the bed alarms soon enough, or staff do not know where the alarms are coming from, sometimes it comes to the nurses phones and sometimes it does not because the bed ’ s do not have the correct cords. In the Intensive Care Unit (ICU) we often have three patients and at times we are unable to leave a room to respond to an audible alarm. ICU nurses are tripled on almost a weekly basis. Staffing is not adjusted according to patient acuity. I have been doubled with two 1:1 patients and she didn’t ’ t think the care was the best because the patients were too sick. Stated she had to lean on the charge nurse. She stated she believes one of her patients died due to her inability to leave another patient room to care for a critical patient needing a Heparin drip restarted post-operatively and she died of a blood clot. She went on to state she has never had any managers come down to help nursing staff when they are critically low staffed. During an interview on 11/27/23 at 11:45 AM, Staff G, Patient Care Technician, stated that that the 5 East hallway of the floor is unsafe as the nurses assigned to that area often have patients that are not close in proximity to their other assigned patients, which places this population of patients at high risk for harm. She went on to state patient safety is a large concern due to short staffing and no effort has been seen from administration to improved patient safety. During an interview on 11/27/23 at 12:02 PM, Staff H, stated more than not the intensive care unit nurses are tripled with patients compromising patient safety daily. During an interview on 12/0723 at 4:15 PM, Staff C5, stated that he has several concerns with staffing, the ED is expected to do more with less constantly. Staffing has been this way for multiple years. States people will continue to have adverse outcomes if they do not fix their staffing . States that some days staffing is unacceptable . States when staffing is bad, they try to go on diversion. States that managers rarely come in when they are short staffed. States he has absolutely had a bad outcome for short staffing . Kitchen: Review of hospital policy titled “Infection Prevention and Control Program” revised 02/03/22 showed “Policy; 4. The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide leadership in the following activities: e. Maintain a sanitary hospital environment. f. Develop and implement infection control measures related to healthcare workers. Healthcare workers, for infection control purposes, includes all hospital associates, medical staff, contract workers, (e.g. agency nurses, environmental staff, facilities staff etc.), and volunteers ... k. Monitor compliance with all policies, procedures, protocols, and other infection control program requirements 2. All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations . 14. Environmental Services/ Touchpoint; a. Maintain a clean and sanitary environment free of risk of infection ... Kitchen: Review of hospital policy titled “Infection Prevention and Control Program” revised 02/03/22 showed “Policy; 4. The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide leadership in the following activities: e. Maintain a sanitary hospital environment. f. Develop and implement infection control measures related to healthcare workers. Healthcare workers, for infection control purposes, includes all hospital associates, medical staff, contract workers, (e.g. agency nurses, environmental staff, facilities staff etc.), and volunteers... k. Monitor compliance with all policies, procedures, protocols, and other infection control program requirements 2. All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations.14. Environmental Services/ Touchpoint; a. Maintain a clean and sanitary environment free of risk of infection ... Review of hospital document titled “Food Storage Chart” undated showed “Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer ’ s date is earlier. The day of opening/preparation counts as Day 1. Dry Storage ...30 days. Oil, 60 days, Syrup, Peanut butter, 6 Months, or the manufacturer ’ s expiration date, if sooner ...Honey ...Rice, pasta, flour, dehydrated potatoes, sugar; Within 1 Year of delivery, or the manufacturer ’ s expiration date, if sooner, All unopened canned, carton boxed, or bottled goods, Spices; Refrigerated Storage; ...4 days Unused portions of foods prepared on site that are reheated for service, such as rice, vegetables, soups, gravies and meat sauces ...7 days Cheese - all cheeses except hard cheese (14 days), ...30 days; Salad dressings, mayonnaise, tartar sauce, Cake icing (shortening based) ...60 days; Ketchup, BBQ, Tabasco, steak sauce, mustard, horseradish, Relish, pickles, Natural peanut butter, Sauces - chocolate, caramel, strawberry ... Review of hospital policy titled “Production, Purchasing, Storage” revised 12/2017 showed “Subject: Food Handing Guidelines (HACCP); Preparation of Produce; Wash hands and wear disposable gloves when handling raw produce or ready to eat foods...Inspect all produce for damage. Discard severely damaged produce or remove damaged areas plus one inch beyond damaged area. If damaged area can not be removed without contaminating the remainder of product, discard product. Prepare produce using clean, sanitized utensils, sanitized cutting board, work areas and sinks ... During an observation on 11/28/23 at 11:32 AM, of the kitchen area located in the basement, showed food debris and trash on the sticky floor. Opened personal drinks were located in the cooking area. Cooking pots and pans (that had already been cleaned) on a large rolling stainless-steel cart had visible food debris on cart and in/on pots and pans. Cutting boards (that were designated as clean) were stacked on a stainless steel shelf with visible food debris. A stainless-steel cart had food debris and a spray bottle labeled sanitizer with a box of food service plastic cups. A stainless steel coffee maker and stainless-steel tea dispenser had visible food debris; liquid smeared on the dispenser handles with visible debris. On a shelf below the coffee and tea dispenser was a plastic container with a brown liquid substance at bottom of container labeled regular. The stainless steel shelf was visibly soiled with food debris and there was one large white safety and sanitation dispenser for plastic film and foil that had visible food debris and opened plastic replacement filters. The next shelf below had visible food debris on containers next to a spray bottle and red bucket labeled Kleen-Pail sanitizer. The bucket had brown liquid half way up the bucket. On a rolling stainless steel cart was a large plastic container with several brown spotted bananas with no label and large plastic container of red grapes with no label. A clear plastic container with red lid that was visibly dirty had what appeared to be a white chocolate chips with no label. There was a clear plastic container with an open red lid with chocolate chips, and an open baking soda box with a best if used by July 22, 2023, date. There was a stainless-steel container with visible food debris containing multiple knifes with visible food debris on them. There was also an opened used container of peanut sauce with approximate ¼ used on the lower shelf of stainless-steel counter showing refrigerate after opening, there was no date of when the peanut sauce was opened. The microwave had visible food debris on door and button controls and visible food debris under and around microwave. During an observation on 11/28/23 at 11:39 AM of Kitchen refrigerator located in basement, showed, a used bottle of salsa 1/3 full, with plastic saran wrap attached to upper part of bottle that had a hospital sticker label that showed a good thru date of 11/23/23. There was sliced yellow cheese in plastic bag with use by date of 11/21/23 and what appeared to be white and purple frosting in plastic bags that was undated. During an observation on 11/28/23 at 11:41 AM in the Kitchen walk in cooler located in the basement showed: 1. A “Garlic in Oil” container with a hospital sticker label good thru date of 10/28/23 and manufacture best by showed 09/23/23. 2. An opened rice vinegar with hospital sticker label good thru date of 09/29/23. 3. A container of ham base with hospital sticker label good thru date of 10/22/23, 4. A container of chipotle base with hospital sticker label good thru date of 10/22/23. 5. A container of horseradish sauce with hospital sticker label good thru date of 10/08/23. 6. A container of sweet and sour sauce with hospital sticker label good thru date of 11/20/23 7. A container of Worcestershire sauce with hospital sticker label of good thru date of 09/02/23 8. A container of Dijon mustard with hospital sticker label of good thru date of 09/08/23. 9. A container of vinegar with hospital sticker label of good thru date of 09/02/23. 10. A container of Mayonnaise with hospital sticker label of good thru date of 11/19/23 11. A stainless steel container with partially covered black beans with hospital sticker good thru date of 11/23/23. 12. A stainless steel container of gravy with a crusty top partially opened with hospital sticker label good thru date of 12/01/23. 13. A clear container of sausage patties partially covered with hospital sticker label good thru date of 11/30/23 14. A plastic bag of cooked rice with a hospital sticker label with good thru date of 11/27/23. 15. A covered plastic container of cooked pasta with hospital sticker label good thru date of 11/24/23. 16. A partially covered stainless steel container of cooked pasta with hospital sticker label of good thru date of 11/24/23. 17. A stainless steel container of chicken gravy with hospital sticker label of good thru date of 11/27/23. 18. A box of celery with stalks that have brown film down the entire stalk, wilted brownish yellow leaves with date of 11/08/23 on box. 19. A box of 1/8 shred lettuce 4/5 lbs. bags with best used by date of 11/25/23 showing brownish wilted lettuce in bags. 20. A bag labeled “Fresh Thyme” dated 09/29/23 showed wilted brownish sprags of thyme. 21. A bag labeled “Fresh Mint” dated 11/10/23 showed wilted shriveled up brownish green leaves. 22. A bag labeled “Fresh Oregano” dated 11/15/23 showed condensation in bag with shriveled up brownish leaves. 23. A bag labeled “Fresh Sage” dated 10/30/23 showed shriveled up brownish leaves. During an observation at H2 on 11/29/23 at 8:15 AM, Staff H2, Cook was handing food without gloves. Staff H2, cook, stated “I’m making Chinese food today for lunch.” During an observation at H2 on 11/29/23 at 8:15 AM, Staff I2, Cook was only wearing one glove while handling food. During an interview on 11/28/23 at 11:32 AM Staff U, Food Service Director, stated “We will do better and get it cleaned up. I will throw away all the expired food.” Failure to throw out expired food items and failure to have a clean kitchen area has the potential to cause gastrointestinal illnesses and spread food borne illnesses. Review of an “ED Note-Physician,” by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, “ ...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient ’ s physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient ’ s plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion ...” Review of the video footage failed to show evidence that hospital staff attempted non-physical interventions prior to using restraints and that Staff A6, Physician, ensured the safe and appropriate use of restraints to keep Patient 33 safe from harm as documented in the medical record. Review of Patient 33 ’ s medical record failed to show evidence of a physician order for patient restraints as required per hospital policy. During an interview on 01/05/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED and it was disheartening. In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33 ’ s medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival, including vital signs and a nursing assessment. Staff A6, Physician, failed to ensure that Patient 33 was properly restrained to avoid patient injury. The hospital staff failed to provide ongoing monitoring of a patient in restraints as required per facility Restraints and Seclusion Policy, including 15-minute monitoring with required documentation, and failed to ensure the safety of a patient to prevent a fall. Review of the video and medical record showed nursing staff and Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The hospital failed to ensure that Patient 33 received care in a safe setting, when the hospital staff restrained him to a slide board, failed to provide ongoing monitoring of a patient in restraints and did not protect him from a fall, off the end of an ED bed, tied to a slide board, in sight of 20 staff in the nurse station. Patient 24 Review of Patient 24’s medical record showed an 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of Patient 24’s medical record showed a Morse Fall Risk score of 50 on 11/01/23 at 9:00 PM indicating high risk for fall. Review of Patient 24 ’ s medical record showed a documented fall on 11/05/23 at 4:38 PM by staff L5, RN. Further review of the medical record showed an order for CT Head or Brain with and without Contrast on 11/05/23 at 4:36 PM (2 minutes prior to documented fall). Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/05/23 16:38:00 CST (4:38 PM), q1hr, 4, hr, Stop date 11/05/23 20:59:00 CST (8:59 PM).” Review of Patient 24’s medical record failed to show documented evidence of a Neurological Assessment between 4:38 PM and 6:38 PM every one hour as ordered. (2 of 4 assessments) Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/5/23 8:38:00 PM CST, q4hr, 20, hr, Stop date 11/6/23 4:59:00 PM CST.” Review of Patient 24’s medical record failed to show documented evidence of a Neurological Assessment for the following dates/time: From 11/05/23 at 9:10 PM to 11/06/23 at 2:19 AM (~5 hours) From 11/06/23 at 2:19 AM to 11/06/23 at 9:00 AM (~7 hours) During an interview on 12/12/23 at 1:25 PM, Staff L5, Registered Nurse (RN) stated that when Patient 24 fell, she hit the left side of her forehead and maybe hit the top of her head on something. Staff L5 stated that she was not present at time of fall. Staff L5 stated that Patient 24 had a small laceration to her forehead, was on a blood thinner, and that a large hematoma developed rather quickly. Review of the medical record failed to show documented evidence nursing staff completed a full post fall assessment including but not limited to: vital signs, provider notification, and family notification. During an interview on 12/12/23 at 12:35 PM Staff K5 stated that, she has noticed an increase in falls due to lack of staffing. She went on to state it is because staff cannot respond to the bed alarms soon enough, or staff do not know where the alarms are coming from, sometimes it comes to the nurses ’ phone and sometimes it does not because the bed ’ s do not have the correct cords. In the Intensive Care Unit (ICU) we often have three patients and at times we are unable to leave a room to respond to an audible bed alarm. Refer to the following policies [Fall Risk, Morse Interventions by Scale, Patient Assessments and Reassessments] Patient 9 Review of Patient 9’s medical record showed a 63-year-old male, admitted to H1 on 11/18/23 at 11:41 PM with a diagnosis of sepsis (infection in the blood), cellulitis (bacterial skin infection), leukopenia (low white blood cells), alcohol intoxication, and hypokalemia (low potassium). Review of Patient 9’s Morse Fall Risk on 11/19/23 at 9:00 AM showed a fall risk score of 60 [high fall risk]. Review of “Environmental Safety Management,” dated 11/19/23 at 9:00 AM, 8:08 PM, and 8:40 PM, showed, “ ...Personal items within reach ...Supervision with toileting ...” Review of “Post Fall Information,” dated 11/19/23 at 8:08 PM, documented that Patient 9’s urinal was out of his reach, as required by “Environmental Safety Management.” Patient 31 Review of Patient 31’s medical record showed a 73-year-old male that arrived at the ED at H2 via EMS on 10/06/23 at 10:59 PM with a diagnosis of Altered Mental Status of unknown onset. Patient 31 has a past medical history of diabetes mellitus and renal impairment. Patient 31 was then transferred to H1 on 10/12/23 at 11:59 PM for a higher level of care. Review of Patient 31’s medical record showed an initial Morse Fall Risk score of 50 on 10/07/23 at 5:35 AM indicating high risk for fall. Patient Morse Fall Risk score indicated high risk for fall throughout admission with discharge score on 10/19/23 at 9:25 AM with a score of 95 (high risk 45 and above). Review of the medical record showed that Patient 31 had falls on the following dates: 10/08/23 at 4:15 AM at H2, 10/09/23 at 11:02 AM at H2, 10/16/23 at 7:25 AM at H1 and 10/16/23 at 4:03 PM at H1. (4 falls in 12 days) Review of a document titled, “[Hospital 1] Incident Log” dated 03/01/2023 - 11/26/2023 showed, “ ...10/16/23 This RN (not RN caring for patient) heard a thud and then an “ow” coming from pt room in X. This RN does not see patient in bed or chair, then sees patient on floor near bed. This RN immediately calls RN who is caring for patient (X) and notifies RN manager XX. Pt vitals taken - see chart. RN X notified of events. No bed exit/chair exit alarms going off at time of incident, all four rails of bed noted to be in up position also. No immediate/obvious injuries noted by this RN ...” Review of the medical record dated 10/15/23 at 8:00 PM showed that the following interventions were as required per facility Fall Bundle protocol: “ ... Exit alert on ...Upper/Half length side rails for bed mobility ...” Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall. Review of the medical record dated 10/16/23 at 4:03 PM showed that the following interventions were in place per facility Fall Bundle protocol: “ ... Exit alert on ...Upper/Half length side rails for bed mobility ...” Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall. Review of an order dated 10/08/23 at 4:15 AM stated, “Order: Neurological Assessment High Risk for Injury ...Order Details 10/8/23 4:15:00 AM CDT, q1hr, 4, hr, Stop date 10/8/23 8:29:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 1 hour per orders between 10/08/23 at 4:15 AM to 10/08/23 at 8:29 AM. Review of an order dated 10/08/23 at 6:27 AM stated, “Order: Neurological Assessment High Risk for Injury ... 10/8/23 8:15:00 AM CDT, q4hr, 20, hr, Stop date 10/9/23 4:59:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 4 hours per orders between 10/08/23 at 8:15 AM to 10/09/23 at 4:59 AM. Failure to complete neurological checks places any patient at risk for neurological decline (i.e.. Change in mental alertness, brain bleeding, and/ or decrease in strength) after a fall. Patient 14 Review of Patient 14’s medical record showed a 69-year-old female that presented to the ED at H2 on 11/20/23 at 3:52 AM via private vehicle. Patient was admitted with diagnosis frequent falls, hematoma to right knee region, long term use of anticoagulant (medicine that helps prevent blood clots) and Atrial Fibrillation (irregular often rapid heart rate that cause poor blood flow). Patient has history of chronic obstructive pulmonary disease (COPD), status post right upper lobectomy (removal of one of the 3 right lung lobes), hypertension (HTN) (elevated blood pressure), hyperlipidemia (high cholesterol in blood). Review of “ED- Triage- Adult” on 11/20/23 at 3:52 AM showed “Chief Complaint: Fell out of bed and landed on right knee twice. Noted swelling right below right kneecap ...” Review of “ED Note- Physician” on 11/20/23 at 4:08 AM showed “ ...Patient states she has been falling out of bed frequently. States she fell out twice tonight when she got back up and into bed and then fell out again. Family is trying to get rails for the bed but has been unable to. Patient is noted swelling and bruising right hand pain with palpation and movement. Patient is currently on Plavix and Xarelto. Patient states that her knee hurts all the way down to her ankle ... Review of “Emergency Documentation” on 11/20/23 at 7:00 AM showed “Reexamination/ Reevaluation; Assessment: Notified by nursing that patient had fallen out of bed. Left side rail had been left up and patient states she just fell to the side while she was sleeping. Patient thinks she did hit her head. She does not have any neck pain. Obtain stat CT head and neck.” Review of H2 “Incident Log” on 11/20/23 showed “Patient 14 ... event types Falls & Slips (patient) ... Event Occurrence Department; Emergency department; Narrative Pt had unwitnessed fall in room. Pt told multiple times to stop getting out of bed. Pt was acutely aware that nursing staff wanted her to in where she was. Severity D- No Harm Severity Category No Harm.” Review of Patient 14 ’ s medical record showed initial Morse Fall Risk score of 110 on 11/20/23 at 9:14 AM indicating high risk for fall entered 3 hours and 8 minutes after was triaged for multiple falls. Review of the medical record failed to show any documented evidence nursing staff completed a documentation of a fall or post fall assessment including but not limited to; following interventions were in place per facility such education regarding fall risk, orientation to room and call light within reach, bed locked and in low position, patient room placement near nurses ’ station, the door to the patient ’ s room remaining open, yellow high fall risk armband, gown, non-slip socks, and door sign in place and bed alarms are to be activated. This places any patient at risk for a fall that could result in serious injury, harm, and/or death. Patient 54 Review of Patient 54’s discharge medical record was a 61-year-old male admitted to H2 on 01/19/23 for a Colonoscopy (procedure that checks your entire colon using a long flexible tube put in your rectum) and Endoscopy (EGD) (procedure inserting a long flexible tube down your throat into your esophagus). Patient 54 has a history of Cirrhosis (diseased liver), iron deficiency anemia (low red blood cells and iron in the body), Gastroesophageal Reflux (GERD) (stomach acid flows into the food pipe and irritates the lining), history of colon polyps (small clump of cells that form in the lining of the colon). Per Staff M7, DO’s progress note at 5:25 PM, “During the EGD (shortly after duodenal biopsy was performed), while in the left lateral recumbent position, patient rolled backwards on the stretcher and slid slowly onto the floor ... The patient was lifted back onto the bed with assistance of additional staff members ... The gastroscope was reinserted for a quick examination to ensure no trauma or bleeding had occurred ... He complained of some minor neck stiffness but reported that he does feel that way after laying for a long time ... He was discharged to home in stable condition ...” Review of anesthesia record dated 01/19/23 “free notes” by Staff V7, CRNA, revealed at “16:28 [4:28] PM Filling additional propofol [a short acting intravenous anesthetic] syringe. Standing at pyxis [a drug supply management machine]. Surgeon and scrub started to yell for help. When turning to assist, patient was rolling backwards on bed from force of surgeon advancing scope. Bed rail on back of patient was not in place. Scrub indicated that this is for the scope to be able to reach patient for procedure. Immediately protected patient’s head and held it securely as he started to roll off the bed. Assisted patient in guided fall to floor. Notified [Staff K6] of current situation at 1629 [4:29 PM]. Discontinued propofol gtt [drip] after patient stabilized on floor.” “Transport at 16:57 [4:57] CRNA VSS (vital signs stable) upon PACU [post anesthesia care unit] arrival. Patient neurologically intact. Able to move hands and feet. Denies numbness/tingling in extremities. Patient stated he did have a headache that was increasing. [Staff K6] notified of patient status. Will continue to follow up as indicated.” Failure of staff to remain at the bedside of a sedated patient during a procedure resulted in the patient falling off bed. Patient 25 Review of Patient 25 ’ s medical record showed a 61-year-old female who present to the ED at H1 via EMS on 11/08/23 at 1:37 PM and was admitted to inpatient status at 4:12 PM with the following diagnosis Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 had a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated blood pressure). Review of an order dated 11/08/23 at 3:54 PM showed, “Order: Restraint Initiate Violent 18 Years and Older ...Order Details: 11/8/23 3:54:00 PM CST, Injury to self, Soft limb, Order valid for 3 hour. Evaluate patient and order Restraint Continue if indicated ...” Review of Patient 25 ’ s medical record showed a note by Staff U5, MD, on 11/09/2023 at 9:27 PM that states, “11/8/2023 15:25:56 ... At this time, patient is pulling off her bipap mask. Due to this, placing patient in soft restraints ...” Review of Patient 25 ’ s medical record failed to show documented evidence of ongoing patient monitoring and documentation by nursing staff in the electronic medical record. Failure to monitor the patient appropriately per hospital policy places any patient in soft limb restraints at risk for but not limited to compromised circulatory complications, pulling out lines and devices, and appropriately secured to the bed. Patient 52 Review of Patient 52 ’ s medical record showed a 21-year-old female admitted on 12/30/23 at 9:30 AM to the ED at H2 via private vehicle. She had a diagnosis of Schizoaffective disorder bipolar type (experiences symptoms of delusions, hallucinations, disorganized speech, grossly disorganized behavior) and intellectual developmental disorder (disorder having trouble with learning, communicating, thinking rationally, making judgments and planning). Patient 52 had a history of a suicide attempt and physical and verbal aggression. Review of “ED Triage- Adult” on 12/30/23 at 9:59 AM showed “ ...Chief Complaint: Chief Complaint: Reports SI (thoughts of suicide) and HI (thoughts of killing others), brought in by [community mental health]. Reports that she wants to hurt her roommate (sic) because they tried to hurt herself. Reports she would jump in front of a train or a car, strangle herself or jump off a bridge ...” Review of “Consultation Notes” on 12/30/23 at 3:11 PM showed “HPI: (History of Present Illness) ... brought in for “suicidal homicidal thoughts” and lists plans for both. She would “hang, suffocate, jump out of a car, jump in front of a car, drown” and for HI (homicidal ideation) toward her roommate she would “choke or suffocate” him ... Review of “CSSRS Screen- Adult” on 12/30/23 at 9:59 AM showed “CSSRS (Columbia-Suicide Severity Rating Scale) Last Visit Wish to be Dead : Yes; CSSRS Last Visit Suicidal Thoughts : Yes; CSSRS Last Visit Idea w-Method No Intent : Yes; CSSRS Last Visit Idea w-Intent No Plan : Yes; CSSRS Last Visit Suicide Intent w-Plan : Yes; CSSRS Last Visit Suicide Behavior : Yes; CSSRS Screen Suicide Behavior Timeline : Yes; Suicide Risk Level Screen Result Adult : High ...” During an observation at H2 on 11/28/23 at 11:13 AM in Zone 2 ER. a locked psychiatric zone, showed a large grey trash can, with a plastic bag lining the can and an unused plastic bag hanging down under the other trash bag in the patient hallway. This trash can was located outside of the locked nurses’ station door close to the nourishment room.” A trash bag could be used by a patient to hang themselves or suffocate themselves. During an interview on 12/11/23 at 10:30 AM Staff H5, BHT (Behavior Health Tech), stated “. We allow plastic bags in the trash bag in the unit in the hallway. Because patients will use a sheet before a trash bag and it ’ s what the custodian allow. There is only one trash can in the hallway so we can kinda see what is going on with that trash can.” During an interview on 12/12/23 at 8:36 AM Staff M4, RN ED Charge Nurse, stated “Zone 2 is a unit only used for psychiatric patients that might elope if a door opens. The area is for patients that are going to cause harm to themselves or others or have suicidal thoughts needing more monitoring with cameras in room. Ligature risk anything to use to put around their neck, or a plastic bag can cause suffocation. During an interview on 12/14/23 at 9:56 AM D2, RN, Vice President Nursing, stated, “Ligature risk anything that could wrapped around that could cause strangulation or harm around the neck, plastic bag would be more a suffocating.” Patient 42 Review of Patient 42’s Medical Record showed a 75-year-old male that presented to H2, Pre-op at 12/28/23 at 5:44 AM. His admitting diagnosis was renal cysts. The admitting physician, Staff L8, MD, completed a History and Physical on 12/28/23 at 7:52 AM. A nursing assessment was completed at 6:07 AM Documentation identified no known drug allergies. A pre-anesthesia assessment was completed by Staff K6, MD at 6:46 AM. The following procedures were documented: Cystoscopy (a hollow tube equipped with a lens is inserted into your urethra and slowly advanced into your bladder), intravesical gemcitabine instillation (chemotherapy drug used to treat bladder cancer), Complex closure of right soft palate (the soft tissue constituting the back of the roof of the mouth) laceration (a deep cut or tear in flesh). Time out was documented at 8:40 AM and OR team identified. Primary procedure was attempted by L7, CRNA and completed by Staff K6. A laceration occurred during the initial intubation attempt and clotted until extubating at 8:56 AM. Staff K6 consulted an completed from 8:30 AM to 8:40 AM. Intubation ENT and also attempted to stop bleeding. An ENT arrived in room 10:13 and completed suture of laceration to right lateral soft palate. Staff K6 communicated with patient’s wife throughout and completed post-op evaluation at 11:59 PM. Patient discharged at 12:26 PM with discharge instructions, medication instructions and a pain medication prescription. Patient discharged to home via private vehicle with spouse. During an interview on 01/05/24 at 2:20 PM, Staff L7, CRNA stated that because they are new, having graduated mid-November, the anesthesiologists are in the operating room [OR] for all inductions. The anesthesiologist, [Staff K6], was not in the OR until the intubation got more “challenging” and came in to assist. “Once airway was secured, we noticed more bleeding. It was clear the laceration occurred during my attempt...active bleeding stopped once airway was secured. When waking up and he started moving his mouth, then it was really bleeding. [Staff K6] made the decision to consult ENT [ear, nose, throat] when the bleeding wasn’t stopping...The patient was obese with a long tongue...The [supply] person is working on getting brand removed. It’s more rigid and pointier...” During an interview with Staff, Anesthesiologist on 01/03/24 at 1:15 PM he stated, “I am not required to be in the room, but for general (anesthesia) I always am.” This statement contradicts the information Staff L7, CRNA provided in her interview above regarding Patient 42 on 01/05/24 at 2:20 PM. During an interview on 01/04/24 at 4:13 PM, Staff K6, Anesthesiologist stated “CRNA had a difficult time getting in place and was using a different ET [endotracheal] tube. 7.5 tube had been auto substituted and the point comes to a sharper point and it’s more rigid. She tried once and then I took a second look and placed it. He was a large guy, doesn’t extend neck well. Sleep apnea. Redundant tissue. It happened in part, because of the ET tube. We notified [supply staff] and asked them to remove them from stock. It was a recent change and suppliers; we get no say in the stock. Took opportunity to instruct CRNA about ET tubes. She was brand new. It started bleeding again after case. I attempted pledgets (wad of absorbent cotton). I knew someone else would have to come in. Dr. [ENT] put some stitches in. I called him [patient] yesterday. He was mostly concerned about his foley [catheter].” Staff K6 stated that he had never had a patient require sutures before or have a laceration that large. Staffing Concerns During an interview on 12/07/23 at 11:33 AM, Staff X4, Physician Assistant (PA) stated that she primarily works in triage and that she was the only provider in triage until about a month ago and now they have a physician that comes in. The PA stated that she has a lot of concerns about staffing and her concerns are more so related to the nursing side. She stated there are numerous shifts that patients sit in the waiting room for hours waiting for a bed. Stated patients in the waiting room are only getting repeat vitals if she asks. The PA has seen patients decompensate in the waiting room (seizures, pass out). Stated she had a patient die in the waiting room a year ago in May. Stated he coded in the hallway and died. She stated that at H2, they have techs that get too excited and she does not feel like the patients are prioritized appropriately. States that she is sure she has had patients that have a delay in care due to the techs not prioritizing care appropriately. During an interview on 11/27/23 at 12:32 PM Staff K, RN stated that the nurses have been tripled in the Surgical Intensive Care Unit (SICU) at least 1 time per week, night shift likely more. States there are concerns for unsafe staffing and acuity, no manager over SICU recently, house supervisor makes assignments, push back from directors on staffing. During an interview on 11/29/23 at 3:31 PM with Staff N2, RN and O2, RN both stated that that the short staffing has caused negative outcomes for patients. They have seen pressure injuries that have gotten worse due to lack of staffing. Stated that they provide education to RN’s regarding that if the patient is refusing, they need to be documenting it. Stated they can ’ t directly correlate short staffing with infection. Stated that they have concerns with staffing and think that it causes a top to bottom problem throughout the system. During an interview on 12/12/23 at 12:35 PM Staff K5, RN stated that, she has noticed an increase in falls due to lack of staffing. She went on to state it is because staff cannot respond to the bed alarms soon enough, or staff do not know where the alarms are coming from, sometimes it comes to the nurses phones and sometimes it does not because the bed’s do not have the correct cords. In the Intensive Care Unit (ICU) we often have three patients and at times we are unable to leave a room to respond to an audible alarm. ICU nurses are tripled on almost a weekly basis. Staffing is not adjusted according to patient acuity. I have been doubled with two 1:1 patients and she didn’t think the care was the best because the patients were too sick. Stated she had to lean on the charge nurse. She stated she believes one of her patients died due to her inability to leave another patient room to care for a critical patient needing a Heparin drip restarted post-operatively and she died of a blood clot. She went on to state she has never had any managers come down to help nursing staff when they are critically low staffed. During an interview on 11/27/23 at 11:45 AM, Staff G, Patient Care Technician, stated that that the 5 East hallway is unsafe as the nurses assigned to that area often have patients that are not close in proximity to their other assigned patients, which places this population of patients at high risk for harm. She went on to state patient safety is a large concern due to short staffing and no effort has been seen from administration to improve patient safety. During an interview on 11/27/23 at 12:02 PM, Staff H, stated more often than not the intensive care unit nurses are tripled with patients compromising patient safety daily. During an interview on 12/0723 at 4:15 PM, Staff C5, stated that he has several concerns with staffing, the ED is expected to do more with less constantly. Staffing has been this way for multiple years. States people will continue to have adverse outcomes if they do not fix their staffing . States that some days staffing is unacceptable . States when staffing is bad, they try to go on diversion. States that managers rarely come in when they are short staffed. States he has absolutely had a bad outcome for short staffing . Kitchen: Review of hospital policy titled “Infection Prevention and Control Program” revised 02/03/22 showed “Policy; 4. The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide leadership in the following activities: e. Maintain a sanitary hospital environment. f. Develop and implement infection control measures related to healthcare workers. Healthcare workers, for infection control purposes, includes all hospital associates, medical staff, contract workers, (e.g. agency nurses, environmental staff, facilities staff etc.), and volunteers...k. Monitor compliance with all policies, procedures, protocols, and other infection control program requirements 2. All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations. 14. Environmental Services/ Touchpoint; a. Maintain a clean and sanitary environment free of risk of infection... Review of hospital document titled “Food Storage Chart” undated showed “Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer ’ s date is earlier. The day of opening/preparation counts as Day 1. Dry Storage...30 days. Oil, 60 days, Syrup, Peanut butter, 6 Months, or the manufacturer’s expiration date, if sooner...Honey...Rice, pasta, flour, dehydrated potatoes, sugar; Within 1 Year of delivery, or the manufacturer’s expiration date, if sooner, All unopened canned, carton boxed, or bottled goods, Spices; Refrigerated Storage; ...4 days Unused portions of foods prepared on site that are reheated for service, such as rice, vegetables, soups, gravies and meat sauces...7 days Cheese - all cheeses except hard cheese (14 days), ...30 days; Salad dressings, mayonnaise, tartar sauce, Cake icing (shortening based) ...60 days; Ketchup, BBQ, Tabasco, steak sauce, mustard, horseradish, Relish, pickles, Natural peanut butter, Sauces - chocolate, caramel, strawberry ... Review of hospital policy titled “Production, Purchasing, Storage” revised 12/2017 showed “Subject: Food Handing Guidelines (HACCP); Preparation of Produce; Wash hands and wear disposable gloves when handling raw produce or ready to eat foods...Inspect all produce for damage. Discard severely damaged produce or remove damaged areas plus one inch beyond damaged area. If damaged area can not be removed without contaminating the remainder of product, discard product. Prepare produce using clean, sanitized utensils, sanitized cutting board, work areas and sinks... During an observation on 11/28/23 at 11:32 AM, of the kitchen area located in the basement, showed food debris and trash on the sticky floor. Opened personal drinks were located in the cooking area. Cooking pots and pans on a large rolling stainless-steel cart had visible food debris on cart and in on cooking pans. Cutting boards were stacked on stainless steel shelf with visible food debris. A stainless-steel cart had food debris and a spray bottle labeled sanitizer with a box of food service plastic cups. A stainless steel coffee maker and stainless-steel tea dispenser had visible food debris; liquid smeared on the dispenser handles with visible debris. On a shelf below the coffee and tea dispenser was a plastic container with a brown liquid substance at bottom of container labeled regular. The stainless steel shelf was visibly soiled with food debris and there was one large white safety and sanitation dispenser for plastic film and foil that had visible food debris and opened plastic replacement filters. The next shelf below had visible food debris on containers next to a spray bottle and red bucket labeled Kleen-Pail sanitizer. The bucket had brown liquid half way up the bucket. On a rolling stainless steel cart was a large plastic container with several brown spotted bananas with no label and large plastic container of red grapes with no label. A clear plastic container with red lid that was visibly dirty had what appeared to be a white chocolate chips with no label. There was a clear plastic container with an open red lid with chocolate chips, and an open baking soda box with a best if used by July 22, 2023, date. There was a stainless-steel container with visible food debris containing multiple knifes with visible food debris on them. There was also an opened used container of peanut sauce with approximate ¼ used on the lower shelf of stainless-steel counter showing refrigerate after opening, there was no date of when the peanut sauce was opened. The microwave had visible food debris on door and button controls and visible food debris under and around microwave. During an observation on 11/28/23 at 11:39 AM of Kitchen refrigerator located in basement, showed, a used bottle of salsa 1/3 full, with plastic saran wrap attached to upper part of bottle that had a hospital sticker label that showed a good thru date of 11/23/23. There was sliced yellow cheese in plastic bag with use by date of 11/21/23 and what appeared to be white and purple frosting in plastic bags that was undated. During an observation on 11/28/23 at 11:41 AM in the Kitchen walk in cooler located in the basement showed: 1. A “Garlic in Oil” container with a hospital sticker label good thru date of 10/28/23 and manufacture best by showed 09/23/23. 2. An opened rice vinegar with hospital sticker label good thru date of 09/29/23. 3. A container of ham base with hospital sticker label good thru date of 10/22/23. 4. A container of chipotle base with hospital sticker label good thru date of 10/22/23. 5. A container of horseradish sauce with hospital sticker label good thru date of 10/08/23. 6. A container of sweet and sour sauce with hospital sticker label good thru date of 11/20/23. 7. A container of Worcestershire sauce with hospital sticker label of good thru date of 09/02/23. 8. A container of Dijon mustard with hospital sticker label of good thru date of 09/08/23. 9. A container of vinegar with hospital sticker label of good thru date of 09/02/23. 10. A container of Mayonnaise with hospital sticker label of good thru date of 11/19/23. 11. A stainless steel container with partially covered black beans with hospital sticker good thru date of 11/23/23. 12. A stainless steel container of gravy with a crusty top partially opened with hospital sticker label good thru date of 12/01/23. 13. A clear container of sausage patties partially covered with hospital sticker label good thru date of 11/30/23. 14. A plastic bag of cooked rice with a hospital sticker label with good thru date of 11/27/23. 15. A covered plastic container of cooked pasta with hospital sticker label good thru date of 11/24/23. 16. A partially covered stainless steel container of cooked pasta with hospital sticker label of good thru date of 11/24/23. 17. A stainless steel container of chicken gravy with hospital sticker label of good thru date of 11/27/23. 18. A box of celery with stalks that have brown film down the entire stalk, wilted brownish yellow leaves with date of 11/08/23 on box. 19. A box of 1/8 shred lettuce 4/5 lbs. bags with best used by date of 11/25/23 showing brownish wilted lettuce in bags. 20. A bag labeled “Fresh Thyme” dated 09/29/23 showed wilted brownish sprags of thyme. 21. A bag labeled “Fresh Mint” dated 11/10/23 showed wilted shriveled up brownish green leaves. 22. A bag labeled “Fresh Oregano” dated 11/15/23 showed condensation in bag with shriveled up brownish leaves. 23. A bag labeled “Fresh Sage” dated 10/30/23 showed shriveled up brownish leaves. During an observation at H2 on 11/29/23 at 8:15 AM, Staff H2, Cook was handing food without gloves. Staff H2, cook, stated “I’m making Chinese food today for lunch.” During an observation at H2 on 11/29/23 at 8:15 AM, Staff I2, Cook was only wearing one glove while handling food. During an interview on 11/28/23 at 11:32 AM Staff U, Food Service Director, stated, “We will do better and get it cleaned up. I will throw away all the expired food.” Failure to throw out expired food items and failure to have a clean kitchen area has the potential to cause gastrointestinal illnesses and spread food borne illnesses.”

“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: 47233 Based on interview, record review, document review, and policy review the hospital failed to ensure that patients were free from abuse, mistreatment, neglect, and 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 50 patients (Patient 2 and 33). 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) situation. Findings Include: Review of the hospital policy titled “Abuse and Neglect - System” Revised 07/17/23 showed, “...D. Patient/family Allegation of Provider Abuse/Neglect: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Examples of abuse include, but are not limited to physical, sexual, verbal/emotional, injury or intimidation of one patient by another...” 2. Any associate who witnesses or receives a report of alleged abuse or neglect from a patient/family, other patient, staff member, visitor, or other person should immediately notify the on-duty department leader and Risk Management. 3. The department leader and/or House Supervisor will ascertain the safety of the patient and initiate any needed interventions to maintain patient safety. 4. Risk Management initiates the Allegation of Associate Misconduct Process Flow and includes other departmental leaders in the investigation of the allegation. 5. Human Resources should be notified of the allegation of abuse as soon as possible to facilitate placing the associate on administrative leave until the investigation has concluded. 6. The associate’s disposition at the close of an investigation will be determined in accordance with all applicable local, state, and federal laws...” Review of a policy titled, “Patient Rights and Responsibilities,” revised 01/21/22, showed, “...Be treated in a dignified and respectful manner and receive care by competent personnel...Receive care in a safe setting and be free from physical, verbal, emotional/psychological, and sexual abuse and harassment...” Review of a policy titled, “Restraints and Seclusion Policy,” revised 02/03/2022, showed, “...When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, and document in the electronic medical record...RN will document they type of restraint used...The RN will document the patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention...Immediately checks the patient to ensure that the restraints were properly and safely applied ...Document the patient’s response to and effectiveness of the restraint...Assess/monitor/document the patient’s condition in at least 1 hour, or more often as determined by the patient’s condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient...” Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted on 08/22/23 with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident (CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of security video footage on the 6th floor west north hall of the Behavioral Health Unit at the Hospital 2 (H2 - off campus hospital location of H1) campus dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse’s station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Registered Nurse (RN), Staff O4 RN, and unidentified staff member in gray shirt came out of the nursing station and walked down to Patient 2. Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurse’s station, leaving the patient unattended. At 4:42 PM an unidentified male staff came into the hall and walked straight by Patient 2 without even looking at her. At 4:43 PM, Staff O4, Staff C4, Staff U3, Behavioral Health Technician (BHT) and an unidentified female staff member return to Patient 2 with a vitals machine and was observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT was observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2’s face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers (MHPW) entered the hall and approached Patient 2. None of the staff standing around Patient 2 attempted to reposition her, she remained face down in a semi fetal position. Her body appeared to be heaving in a slight up and down motion. Staff Q4 and Staff R4, picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2’s body hung limply, and she made no attempts to move or reposition herself. As Staff Q4 and Staff R4 picked her up, she was flipped over mid-air causing her wrists to cross over one another while to dangling face-up. The MHPW’s then carried Patient 2 by her wrist and ankles into a room. During an interview on 12/05/23 at 10:59 AM Patient 2 stated, “I was in my bed the whole day then I got up to go to the bathroom and by that time I felt like I might be having a seizure, so I went into the hallway. I don’t remember some of it, but they were sprinkling water on my face.” Patient 2 stated, her right arm was currently sore, and that hospital staff broke her hand. Patient 2 stated that one of the staff lost their grip on her hand, so they grabbed it and flung her onto the bed. the staff broke my hand, the guy was losing grip on one of my hands and he grabbed my hand again and they flung me onto the bed.” Patient 2 stated that she reported the pain in her right hand to her nurse. Patient 2 stated “They taped my hand together knowing my hand was broke.” Patient 2 stated that after she discharged from the facility, she went to the emergency room at another facility and her arm currently was in a cast or a sling due to the injury. Review of Patient 2’s hand X-rays after the fall revealed a 5th metacarpal, nondisplaced fracture of the hand (Boxer Fracture). During an interview on 12/05/23 at 9:10 AM Staff T3 RN stated, “I did not witness [the initial incident] I was on lunch, when I came back, she [Patient 2] was on the floor. Staff T3 stated that the staff got vital signs, a blood sugar and MHPW’s was called to get the patient back into bed. Staff T3 stated that Patient 2’s oxygen saturation was good. I did not think she was having a seizure, at least she did not appear to be having a seizure. The doctor and the house manager were notified. Staff T3 stated that the protocol with finding someone on the floor, witness/unwitnessed fall is whoever finds the patient is able to complete the incident report and the incident would still be treated as a fall. During an interview on 12/05/23 at 8:55 AM Staff U3 BHT stated that, ... If we are unable to deescalate a patient after multiple attempts or interventions, then the staff will call the “the guys up” or the mental health protection workers (MHPW). Patient 2 said she had a seizure, but she did not look like she had anything medical going on. During a subsequent interview on 12/13/23 at 1:11 PM Staff U3 BHT stated, “regarding the incident with Patient 2 it did take us a long time to get to Patient 2.” Staff U3 stated that Patient 2 has a habit of acting like she is falling. Staff U3 stated that the staff checked on her and she wouldn’t get up off the floor. Staff U3 stated, “I flicked water in her face to startle her, sometimes if you flick water in their face, it will wake them.” Staff U3 stated that she learned about flicking the water in their face, from a nurse. Review of Staff T3 RN progress note dated 08/23/2023 at 7:02 PM showed, “On 08/23/23 at approximately 5:00 PM a peer came to the nurses’ station to inform staff that patient is laying on the floor in the hallway patient will not respond verbally. Patient 2 vital signs were obtained and are within normal limits (WNL), no injuries observed by this staff. The patient is assisted to her bed by mental health protection workers (MHPW)s. A short time later pt (sic) comes out of her room to the nursing station to say that her “hand is broke.” Staff H4 MD is notified, and orders received for x-ray of the patient’s right hand. Review of Patient 2 ’ s Diagnostic Impression Right hand 2 views Xray dated 08/23/23 at 6:03 PM showed an acute nondisplaced transverse fracture of the proximal diaphysis of the right 5th metacarpal. During an interview on 12/04/23 at 3:49 PM Staff H4, Medical Doctor (MD) stated that with boxer fractures we can consult occupational therapy and apply a wrist splint. Staff H4 stated, “I usually order a CT of head, a c-spine, and also there can be delayed injuries discovered later when the patient complains of pain that might not have been present on the initial assessment.” Review of Staff W3, Advanced Practice Registered Nurse, (APRN) progress note dated 08/25/23 at 4:41 PM showed on 08/24/23 “Patient 2 was having a difficult morning. Today she is in bed, hyperventilating, crying, spitting into a basin. Sobbing “I will be good; I won’t do it again.” She [Patient 2] reports she was abused by security. “ Review of Staff W3, APRN’s progress note dated 08/26/23 at 9:54 AM; “She [Patient 2] had seen a security guard and started to shake and become hysterical. Encouraged her to deep breathe and to go to her room if she becomes scared but that no one will hurt her on the unit. The patient is displaying symptoms of post-traumatic stress disorder (PTSD) at this time. Did note bruise on the right side of her face by her eye. Eye is mildly swollen. She believes she was bruised when she had her seizure and the mental health workers were handling her.” During an interview on 12/04/23 at 3:05 PM Staff W3, APRN stated, “I remember Patient 2 being mad because security was being mean or rough with her on 08/23/23.” Review of Staff Y3, mental health worker’s (MHW)/BHT progress note” dated 08/24/23 at 6:10 PM showed, “She [Patient 2] is loud, disorganized, moaning, repeats statements about MHPWs, says “Don’t call the guys. I’ll do whatever you want, just don’t call the guys. I don’t wanna be hurt no more!” Patient 2 whispers “Shh, they’re out there!” Says I’ll stay in my room and be quiet, just don’t call the guys!” Complains of...MHPWs hurting her hand. Patient 2 stated, “...I had a seizure yesterday, they picked me up and turned me over, they didn’t have to do that to me!!” During an interview on 12/06/23 at 5:23 PM Staff Y3 MHW/BHT stated, “I’ve known [Patient 2] for many years.” When asked if Patient 2 told her anything about being mishandled by “the guys” or the MHPW’s injuring her hand? Staff Y3 stated “[Patient 2] did mention that to me, and I talked with someone who was there the day it happened, and the person reassured me nothing like that happened, the patient was handled very gently and there was no way she was injured then.” Staff Y3 stated that as a BHT my responsibility in reporting abuse is to let the charge nurse know. During an interview on 12/06/23 at 8:36 AM, Staff Q4, MHPW, who was seen in the video, criss crossing Patient 2’s arms while lifting/moving the patient, stated that MHPWs offer to assist with lifting for mental health patients who pretend they can’t walk. He stated that MHPWs do not do anything without the nurses approval and nursing staff present. During an interview on 12/06/23 at 8:36 AM Staff Q4 MHPW stated, “going on 2 years, help with patient with escorting, lift to assist, help walker and wheelchair, medication assist we help. Lift assist overweight or mental health patients who pretend they can’t walk, no walker or fall risk. We are trained with MOAB technique and use of force; MOAB teaches you to make sure that they not laying on stomach make sure that they on side or back to breathe and do what the nurse says. We try not to be aggressive with moving we try to help the patient. Weight and size manpower and aggression or are they hurt anywhere, you would have someone look at the footage and more than often the nurse has already seen the footage. We don’t do anything without nurses’ approval and her being present. That’s how we were trained. She’s not the lightest person and there was no lifting apparatus. We just try to make sure she’s safe. Get her to the room as safely as possible.” During an interview on 12/13/23 at 12:52 PM, Staff R4, MHPW stated that MHPWs were never taught how to lift patients. Staff R4 stated that MHPWs get called a couple of times a week to help with lifting patients. Staff R4 stated that it should be an RN that tells MHPWs how to lift or transfer a patient. If a patient accused a staff member of abuse, the house supervisor would be notified, and the facility would separate the patient from he accused staff member. Then the alleged incident would be investigated by risk management. The investigation could include a video review and staff interview. Staff C2 stated “let me refer to the Abuse/Neglect policy...”let me pull it up.” The policy states, “that any action taken on a suspected abuse, or neglect to be clearly noted in medical record in suspected abuse neglect or exploitation.” “I’m speaking from a general nursing unit perspective. If a patient said they’d been hit or abused, then it would be documented.” Staff C2 stated that notifying law enforcement, adult protective services and KDHE would be handled post investigation by the risk management team. Staff C2 stated that she is always notified of an abuse investigation. Staff C2 stated “I don’t recall being notified of an abuse allegation. Staff C2 stated that as far as an appropriate transfer like a certified nursing assistant (CNA) or nurse would complete, I wouldn’t expect that from the MHPW staff members. During an interview on 12/06/23 at 2:20 PM with Staff C, Director of BHU, stated, “...they would have been trained for face up. That’s a big thing. We don’t want anyone face down. From what you’re describing, and without seeing the video, I can’t say that’s an approved technique. Typically, if nursing staff present, we would do an appropriate transfer to bed. But in my experience there are patients that are not compliant with what we’re trying to do. But that’s not at the risk of the safety of the patient. They’re taught to avoid close physical contact to avoid getting spit on or hit. Transfers are not necessarily, like I would not expect a MHPW to know how to properly transfer a patient. If their role is...they’re not in a clinical setting or the only time I would expect them to get involved in a transfer from floor to bed, there should have been some reason staff called them to transfer. There would have been a history for the patient. I know they’re trained to keep patients safe and face up. I’m trying to not make assumption without video in front of me...” (this staff was on vacation at this time). During an interview on 12/06/23 at 10:27 AM, Patient 2 was handled by hospital staff. He stated that there was opportunity for improvement and education. Nursing staff failed to intervene or prevent MHPW’s from moving Patient 2 in a way that could cause serious injury or worsening of an injury sustained in her fall. During an interview on 12/06/23 at 11:46 AM, Staff S4, RN/Risk Manager, stated that she reviewed the video footage of Patient 2’s fall on 08/30/23 and had concerns that Patient 2 could have received an injury or worsening of an injury by the way she was picked up and that Patient 2 was treated without dignity by hospital staff. Staff S4 stated that she did not make a report of ANE on behalf of Patient 2 because of the lack of documentation. S4 confirmed that the video indicated Patient 2’s treatment was consistent with abuse, neglect, and exploitation (ANE). During an interview on 12/06/23 at 1:18 PM, Staff T4, RN/Director of Risk of Management, stated he reviewed the security footage of Patient 2’s fall. Risk gets involved in safety reporting events that are entered, may get a phone call from the house mgr. I don’t recall exactly when I got involved. PreSert meeting is not available (protected by Patient Safety Organization).T4 refused to answer the following question: “Did you have concerns with regarding the way the staff carried the patient back to the bed and did it looked like a potential risk for harm to the patient? T4 responded to the following question: “Do you feel the hospital did what should have been done?” by saying, “I think there was opportunity for us to do things differently. Staff T4 was asked if he had a concern on how Patient 2 was treated by hospital staff and if it could have put Patient 2 at risk for harm. Staff T4 stated, “I think there was opportunity for us to do things differently.” The hospital failed to complete a thorough investigation by failing to recognize the incident seen in the video footage as potential abuse. The hospital failed to protect all patients from further potential abuse by failing to adequately investigate allegations of abuse regarding improper use of transfer techniques of a patient that had the potential to resulted in bodily harm or have other adverse outcomes including death. The video footage was review by the hospitals leadership team and the hospital failed to implement corrective actions of involved staff members seen in video footage and failed to report and provide a summary of their investigation to the state agency. Patient 33 Review of Patient 33’s discharged medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior. Review of a documented titled, “Prehospital Care Report Summary,” by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33’s care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM. Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses’ desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses’ station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At that time, Patient 33’s feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses’ station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view. Review of Patient 33’s medical record failed to show any nursing notes or documented interventions and application of the restraints. At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses’ station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33’s left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses’ desk watching patient, however no staff attempted to intervene with Patient 33’s behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. 7:07 PM was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge. Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33’s medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33’s pupils and did not listen to heart or lung sounds as documented. The video showed that between time of arrival at 3:52 PM to 10:41 PM, Staff A6, Physician, never approached Patient 33 to perform a physical exam. Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33’s movements had resulted in the patient’s lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33’s fall, About 20 hospital staff were in the nurses’ station and within line of site of the patient. Numerous staff pointed and laughed at Patient 33 while on the floor, restraints still attached to the slide board, laying on left side, on shoulder with left arm behind him and left side of head on the floor. Staff S2, Physician, got up from a chair behind the nurses’ station, walked to edge of nurses’ station, looked at Patient 33 on the floor, laughed and returned behind the nurses’ station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33’s fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed. During an interview on 01/08/24 at 12:45 PM with Staff D8, Emergency Manager of ED showed the corrective action plan for primary nurse involved in the incident with Patient 33. Staff Z5 was ultimately the nurse assigned to the patient and responsible for the fall, therefore the decision was made to discipline the primary nurse. The ED manager went on to say that the employee stated she was only laughing at the irony of the situation and that her intention was not to laugh at the patient. She went on to say that Chaplain services came in to do Compassionate Care training with ED staff and to date not all ED employees have received the training and that she as the ED manager is supposed to be scheduling the remaining staff. At the time of this interview this has not been completed.” Video review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient’s condition or possible injury after the fall. Review of the hospital’s incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33’s medical record failed to show any documentation that a fall had occurred. Review of the “ED Triage Note,” showed, “ ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST [4:00 PM] by [Staff Z5, RN].” Staff Z5 documented the following vitals: Blood pressure. Review of the video footage showed these vital signs were obtained at 7:07 PM. Review of a document titled, “Alleged ED Caregiver Misconduct-Patient Timeline,” undated, showed an interview with Staff Z5, RN. “...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs] ..” Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, “Physical Examination Eye: Pupils are equal, round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal” The documentation failed to show evidence of Patient 33’s facial trauma, altered mental status, and failed to show evidence of a “plan of treatment” for Patient 33. Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33’s eyes and listening to heart and lung sounds as documented. Review of an “ED Note-Physician,” by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, “...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient s physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient’s plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion...” Review of the video footage failed to show evidence that hospital staff attempted non-physical interventions prior to using restraints and that Staff A6, Physician, ensured the safe and appropriate use of restraints to keep Patient 33 safe from harm as documented in the medical record. During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED, and it was disheartening. In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33’s medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival, including vital signs and a nursing assessment. Staff A6, Physician, failed to ensure that Patient 33 was properly restrained to avoid injury. The hospital staff failed to provide ongoing monitoring of a patient in restraints as required per the facility “Restraints and Seclusion” Policy, including 15-minute monitoring with required documentation, and failed to ensure the safety of a patient to prevent a fall. Review of the video and medical record showed nursing staff and Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The hospital failed to ensure that Patient 33 was treated with dignity and respect as required per hospital policy titled, “Patient Rights and Responsibilities” as evidenced by staff and providers laughing at Patient 33 when he sustained a fall.”

“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, document review, and security video review, the hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 1 of 1 patients (Patient 33) reviewed with restraints. This deficient practice violated the Patient 33 rights and places any patient receiving services at this hospital at risk for serious injury and harm. Findings Include: Review of a policy titled, “Restraints and Seclusion Policy,” revised 02/03/2022, showed, “...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient...” Review of Patient 33’s medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses station at 3:58 PM. At 4:00 PM, Staff E8, RN, arrives with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. At 4:11 PM, staff completed the process of restraining Patient 33 arms and legs to the slide board. Further review of the security footage showed that Patient 33 remained restrained to the slide board until 7:24 PM when he sustained a fall and an unidentified nurse removed Patient 33’s restraints at 7:25 PM. Review of Patient 33’s medical record failed to show documented evidence of a written order for restraints by a physician or other licensed practitioner as required per hospital policy and regulation requirements 42 CFR §482.13(e)(5).”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and security video review, the hospital failed to ensure the condition of a patient in restraints was monitored at intervals required by hospital policy for 1 of 1 (Patient 33) patients reviewed with restraints. This deficient practice places any patient in restraints at risk for injury and harm. Findings Include: Review of a policy titled, “Restraints and Seclusion Policy,” revised 02/03/2022, showed, “...The use of restraints requires assessment/monitoring to be documented within one (1) hour of initiation, or more often as determined by the patient’s condition. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, and document in the electronic medical record ...RN will document they type of restraint used...The RN will document the patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention ...Immediately checks the patient to ensure that the restraints were properly and safely applied...Document the patient’s response to and effectiveness of the restraint...Assess/monitor/document the patient’s condition in at least 1 hour, or more often as determined by the patient’s condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient...” Review of Patient 33’s medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 was noted be combative towards staff and placed in 4-point restraints (restraints applied to both arms and both legs). Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed... At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At that time, Patient 33’s feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view. Review of Patient 33’s medical record failed to show any nursing notes or documented interventions and application of the restraints per hospital policy. At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses’ station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33’s left hand, however, did not apply a blood pressure cuff or obtain vitals. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses’ desk watching patient, however no staff attempted to intervene with Patient 33’s behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. Further review of the video and medical record failed to show evidence that Staff Z5 performed a restraint assessment. At 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33’s movements had resulted in the patient’s lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33’s fall, about 20 hospital staff were in the nurses’ station and within line of site of the patient. At 7:25 PM, an unidentified RN responded to Patient 33’s fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed. In summary of the ED video footage from time of Patient 33’s arrival at 3:52 PM to 10:41 PM, and review of Patient 33’s medical record showed the hospital failed to provide ongoing monitoring of a patient in restraints as required per facility policy [Restraints and Seclusion] and failed to ensure Patient 33 was properly restrained to avoid falls and injury.”

“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 document review, policy review, and security video review, the hospital failed to ensure a patient in restraints was assessed face to face by a physician or other licensed practitioner after the initiation of the intervention as required per hospital policy for 1 of 1 (Patient 33) patient reviewed with restraints. This deficient practice resulted in Patient 33 suffering a fall and places any patient receiving services at this hospital at risk for serious injury and harm. Findings Include: Review of a policy titled, “Restraints and Seclusion Policy,” revised 02/03/22, showed, “...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient...” The policy showed that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour after restraint initiation and must include the patient’s immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient’s condition at a minimum every 15 minutes, and document in the electronic medical record. Review of Patient 33’s medical record showed a 38-year-old male, arrived at the ED on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in facial injury. Patient 33 received a CT of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 was noted be combative towards staff and placed in restraints. Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. Staff A6, Physician, walked up to nurses’ desk and watched numerous staff and security working to restrain Patient 33, and then walked away 15 seconds later. At 4:04 PM, Staff A6, approached and stood at nurses’ station while two security staff and two RNs continued to hold patient. At 4:06 PM, Staff A6, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At 5:54 PM, Staff A6, Physician approached Patient 33 with an unidentified staff member and appeared to look at the patient’s facial injury. Patient 33 continued to be restrained to the slide board. Staff A6, laughed and walked away 30 seconds later. Review of an “ED Note-Physician,” by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, “...Document Subject: Face to Face...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient’s physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient’s plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion...” Staff A6, Physician, failed to ensure that appropriate and safe application of restraints were followed by allowing Patient 33 to be restrained to a slide board instead of the bed. Review of the ED video showed that Staff A6, Physician at no time provided a physical examination of Patient 33. Further review of the medical record showed that Staff A6, Physician, documented the “Face to Face” evaluation at 4:05 PM, prior to the completion of Patient 33 being placed in restraints. Review of the medical record failed to show documented evidence that Staff A6, Physician, evaluated Patient 33’s immediate situation, reaction to restraint interventions, medical and behavioral condition, and the need to continue/discontinue restraint after Patient 33 was placed in restraints. Review of a document titled, “Alleged ED Caregiver Misconduct-Patient Timeline,” undated, showed a hospital interview with Staff A6, Physician. “...Interview [Staff A6], Primary physician...He does remember this patient ...He puts them in restraints right away. He remembers ordering this. He then gives Geodon so that imaging can be done. The restraints are left in place and he gives the nurse instructions that when the Geodon takes effect and the patient gets back from CT you can remove the restraints. He did not give instruction to continue restraints for the patient. He was surprised to learn that the patient was still in restraints after he left.” Review of the security video showed that Staff A6, Physician was at Patient 33’s bedside after returning from CT and remained in restraints.”

“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: 47233 Based on policy review, record review, and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 22 of 50 patients when the nursing staff failed to: 1. Complete assessments as required. (Patients 38, 2, 33, 4, 5, 7, 23, 24, 25, and 31) 2. Notify physician of critical results and/or Delay of Care (Patients 6, 3, 7, and 24) 3. Administer medication as ordered. (Patient 6 and 2) 4. Complete vitals as required. (Patients 2, 3, 15, 16, 20, 23, 24, 25, 26, 29, 30, and 46) 5. Document repositioning of patients at risk for skin break down every two hours or more frequently as ordered by the physician. (Patients 4, 5, 7, 9, 22, 24, 25, and 31) 6. Provide daily bathing as ordered. (Patients 1, 4, 5, 7, 8, 24, 25, and 31) 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. Findings Include: 1. Assessments: Review of a hospital policy titled, “Patient Assessments and Reassessments,” revised 7/29/20, showed that Registered Nurses (RNs) are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. Nurses must document an assessment with “a change of shift or hand off; when there are significant changes in patient condition (requires provider notification); undesired response occurs (requires provider notification)...” Nursing initial assessments and reassessment requirements and time frames showed the following: Behavioral Health Initial Assessment: Initiation of assessment within 15 minutes for triage assessment and completion of admission assessment within 24 hours. Behavioral Health Reassessment: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per adult admission assessment criteria in EHR (Electronic Health Record); Systems review per admissions assessment criteria and flow sheet. Minimum Reassessment Timeframes: Every shift; As indicated by need focused reassessment; Vital signs minimally every 8 hours. Med Surg Initial Assessment: Initiation of assessment within one (1) hour and completion of admission assessment within 24 hours. Routine Adult Med Surg Patients: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per adult admission assessment criteria in EHR; Systems review per admissions assessment criteria and flow sheet. Minimum Reassessment Timeframes: Every shift; As indicated by need focused reassessment; Vital signs minimally every shift. Post-Surgical Adult: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per post-operative orders and adult admission assessment criteria if it’s a new admission. Minimum Reassessment Timeframes: Vital signs and focused assessment every 15 minutes x 4, every 30 minutes x 2, every hour x 4, then every 4 hours for 36 hours; As indicated by need focused reassessment; Every 12 hours, at the start of each nurse shift or by specific need. Critical Care Initial Assessment: Initiation of assessment within one (1) hour and completion of admission assessment within 24 hours. Critical Care: Content/Parameters: Initial vital signs, pain assessment, baseline physiological status before collection and review of data per Adult Admission criteria; System review per Adult Admission Assessment criteria. Minimum Reassessment Timeframes: Every 4 hours minimum for the ICU (Intensive Care Unit); Start of each shift; As indicated by need focused reassessment. Emergency Services: Initiation of assessment within 15 minutes for triage and completion of admission assessment within 30 minutes for Level 1 and 2; within three hours for Level 3, 4, and 5. Emergency Department: Content/Parameters: (not defined). Minimum Reassessment Timeframes: Focused reassessment minimally every hour and by specific need. Operating Room: Content/Parameters: Defined by surgical checklist and perioperative assessment form. Minimum Reassessment Timeframes: Ongoing monitoring by CRNA (Certified Registered Nurse Anesthetist)/anesthesiologist. Post Anesthesia Care Unit: Initiation of assessment immediately upon admission to unit. Post Anesthesia Care Unit: Content/Parameters: Physiological and mental status, pain level; Data collected by criteria defined on PACU (Post Anesthesia Care Unit) flow sheet. Minimum Reassessment Timeframes: Every 15 minutes until stable and specific focused reassessment per departmental policy. Review of the hospital policy titled, “Patient Assessments and Reassessments”, revised 08/17/2023 showed, “...Emergency Services...Initiation of Assessment Within...15 minutes for triage assessment...” Review of the hospital policy titled, “Chest Pain Program” revised 10/24/2023 showed, “...Patients receive rapid evaluation for intervention to minimize acute coronary syndrome (ACS) morbidity and mortality...The program evaluated patients with signs and symptoms of chest pain or acute coronary syndrome. These signs include but are not limited to: ...arm pain...other non-cardiac presentation especially in women. If these signs or symptoms are present, staff obtains a STAT electrocardiogram (ECG)...” Review of a hospital policy titled, “CPG [Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain”, revised 02/07/2023 showed, “In all patients who present with acute chest pain regardless of the setting, an ECG [electrocardiogram] should be acquired and reviewed for STEMI [ST Elevation Myocardial Infarction] within 10 minutes of arrival.” Further review of the document showed, “Chest pain or chest pain equivalent will be referred to in these guidelines as “Chest pain” ...Regardless of the setting, an ECG should be obtained and interpreted within 10 minutes of arrival...” Review of a hospital policy titled, “Fall Risk”, revised 03/21/23 showed, “...b. Patients will be assessed using the Fall Risk Assessment every shift and at any time there is a change in the patient’s condition... F. If a fall occurs, a. Assess the patient for injury and mental/ physical status of patient and compare to pre-fall assessment. b. Notify the physician of the fall. c. Notify House Manager. d. Implement necessary measures to decrease risk of fall. e. With patient permission, notify family of the patient’s fall. f. Complete and submit ERS (Event reporting system) report. g. Initiate Post-Fall Assessment IPOC in Electronic Medical Record (EMR)...” Patient 38 Review of Patient 38’s medical record showed a 74-year-old female that arrived to the ED at Hospital 1 (H1) via ambulance on 08/21/23 at 12:14 PM with complaints of worsening numbness to her left hand for the past 3 weeks. Patient 38 noted that the pain has been radiating into her mid back and she doesn’t feel she has been getting much relief. Patient 38 had a history of Chronic Obstructive Pulmonary Disease (disease of the airway), Hyperlipidemia (high levels of fats in blood), Chronic Kidney Disease (ineffective functioning of the kidneys), Hypertension (high blood pressure), and prediabetes. Review of Patient 38’s “Prehospital Care Report Summary” (Emergency Medical Service - EMS report) dated 08/21/23 documented, EMS was dispatched at 11:36 AM, “Dispatch Reason...Chest Pains.” The report documented “pt (patient) complains of pain to left hand and arm that began approximately 20 minutes ago. Pt reports pain is sharp in nature and rated pain at 9/10. Pt reports she has chronic pain and the pain has been intermittent over the last 6 months...” Further review of the “Prehospital Care Report Summary” revealed an Abnormal, 12-Lead 1, electrocardiogram (ECG) dated 08/21/23 at 11:59 AM that showed Sinus rhythm, and “Widespread ST-T abnormality may be due to myocardial ischemia [MI - occurs when the blood flow through one or more of your coronary arteries is decreased).” Manual interpretation by the EMS professional documented “NRS no ST elevation or ectopy” The “Prehospital Care Report Summary” documented, Patient 38 transferred to facility bed in “[H1] er triage” EMS handoff report was given to Staff C5, RN at 12:11 PM. Review of the hospital policy titled, “Patient Assessments and Reassessments”, revised 08/17/2023 showed, “...Emergency Services...Initiation of Assessment Within...15 minutes for triage assessment...” Patient 38 waited in the triage waiting area from 12:14 PM through 1:10 PM. Patient 38’s documented triage time showed 1:10 PM (54 minutes after arrival). The medical record showed that nursing staff failed to initiate a triage assessment within 15 minutes of patient arrival to the emergency department as required per facility policy. The nursing staff’s failure to initiate a triage assessment within 15 minutes caused a delay in recognition of Patient 38’s acute coronary syndrome (ACS - any condition brought on by a sudden reduction or blockage of blood flow to the heart. ACS is most often caused by plaque rupture or clot formation in the heart’s arteries. Symptoms may include heart attack-like chest pressure, chest pressure while resting or doing light activity, or sudden heart stoppage. This condition is treatable if diagnosed quickly). During an interview on 12/07/23 at 11:33 AM, Staff X4, PA (Physician Assistant) stated she was not present during triage but had she been aware of the patient’s radiating pain, she would have ordered a STAT (immediate) ECG and labs. Staff X4 went on to state that after viewing the ECG obtained by EMS, she would have definitely ordered a STAT ECG. The medical record failed to show that the ED staff completed an ECG within 10 minutes of Patient 38’s arrival as required by hospital policy, CPG Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain”] for patients presenting with signs and symptoms of ACS and failed to show rapid evaluation and intervention to minimize ACS morbidity and mortality as required per facility policy. Review of Patient 38’s medical record documented Staff K8, MD, ordered an initial ECG at 6:35 PM. Staff completed initial ECG 53 minutes after order at 7:28 PM (7 hours, 14 minutes after arrival to emergency department). Staff K8, MD, ordered a repeat Stat (immediate) ECG at 7:41 PM due to an abnormal initial ECG. ED staff completed the ECG 25 minutes later at 8:04 PM. The repeat ECG unequivocally showed, “ST Elevation Myocardial Infarction.” The nursing staffs’ failure to provide a rapid and appropriate evaluation of Patient 38, including an ECG within 10 minutes of arrival, per policy, resulted in a treatment delay to minimize the effects of acute coronary syndrome. Review of The American College of Cardiology (ACC), American Heart Association (AHA) and the European Society of Cardiology have all recommended a door to balloon (D2B) time of 120 minutes from the first medical contact or 90 minutes from the patient presentation to the first balloon inflation. Further review of Patient 38’s medical record showed patient arrived at the cardiac catheterization lab on 08/21/23 at 9:17 PM (about 9 hours after arrival to the ED) with a finding of a critical 99% thrombotic left main lesion with probable blood clot. At 11:15 PM (about 11 hours after arrival to the ED), Patient 38 was transferred to the operating room for an emergent coronary artery bypass graft surgery. Patient 38 received two grafts to restore blood flow around the blocked heart arteries and a balloon pump to help the heart pump more blood. Following the surgery Patient 38 transferred to the cardiothoracic intensive care unit and the record showed she was hemodynamically unstable until her death. Patient 38 died on 08/22/23 at 12:11 PM, 23 hours and 57 minutes after she presented in the Emergency Department. During an interview on 12/07/23 at 4:15 PM, Staff C5, RN (Registered Nurse) stated that he thinks that ECGs, labs, radiology, etc. are getting missed due to the lack of staffing. Staff C5 stated that the hospital policy states door to ECG time is 10 minutes. Staff C5 went on to state he obtains an ECG on patients with arm pain especially if it radiates and especially women over the age of 40. Staff C5 stated that Patient 38 did not have an ECG due to patient EMS brought her in for hand pain that radiated up into her back and in triage she said she had been taking gabapentin for nerve pain that has been going on for years and requested to be admitted for pain control. Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of Patient 2’s nursing admission assessment dated 08/22/23 at 6:31 PM showed Staff T3 RN staff failed to document a cardiovascular or gastrointestinal assessment. Review of nursing shift assessments from 08/22/23 - 08/29/23 showed no documented evidence of a cardiovascular or gastrointestinal assessment. Failure to complete a head-to-toe assessment places patients at risk for deterioration of current illness, ineffective management of care needs and other adverse outcomes. Review of security video footage dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse’s station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Staff O4, and Staff U3 came out of the nursing station and walked down to Patient 2. Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurse’s station, leaving Patient 2 laying on the floor unattended. At 4:43 PM, Staff O4, Staff C4, Staff U3 and unidentified staff member return to Patient 2 with a vitals machine and can be observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT is observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2’s face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers entered the hall and approached Patient 2. Without attempting to reposition the patient, who remained facedown her stomach in a semi fetal position, body appeared to be heaving in a slight up and down motion. The workers picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2’s body hung limply, and she made no attempts to reposition herself or otherwise move. As the staff picked her up by her wrists and ankles, Patient 2’s wrists were crossed over one another and she was flipped mid-air to dangle face-up. Patient 2 was then carried into a room by her wrist and ankles. Review of Patient 2 medical record on 08/23/23 failed to show documented evidence that the Staff T3 RN conducted a post fall injury evaluation and neurological assessment including a Glasgow coma scale (measures the extent of impair consciousness in all types of acute medical and trauma events), any changes in consciousness, headache, pupil response, etc. The nursing staff failed to assess airway, breathing, circulation, activate the rapid response team, assess injury to cervical spine and assist patient to move using safe handling practices. Further review of Patient 2’s medical record dated 08/23/23 showed the nursing staff failed to complete vital signs and the post fall neurological assessment at least hourly for 4 hours. Failure of the nursing staff to conduct and document continued observation of Patient 2 at least every 4 hours for 24 hours status post unwitnessed fall could result in missing signs/symptoms of a head injury. During an interview on 12/06/23 at 2:20 PM Staff C2, Director of Behavioral health unit (BHU) stated that regarding our fall policy if it is determined to be a fall, we would start with an assessment by a nurse. The staff would complete a post fall debriefing, notify the house supervisor, complete the Morse fall risk scale, and update the plan of care. Staff C2 stated that with an unwitnessed fall sometimes patients with behaviors will put themselves on the floor but that does not mean we should dismiss it. Staff C2 stated that the post fall debriefing is a form that is used hospital wide not just for psychiatric units. The Post fall form includes a fall risk assessment, obtaining vital signs and updating the care plan. Patient 33 Review of Patient 33’s medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior. Review of a documented titled, “Prehospital Care Report Summary,” by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33’s care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM. Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses’ station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses’ desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33’s arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses’ station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33’s arms and legs to the slide board. At that time, Patient 33’s feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses’ station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view. Review of Patient 33’s medical record failed to show any nursing notes or documented interventions and application of the restraints. At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses’ station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33’s left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses’ desk watching patient, however no staff attempted to intervene with Patient 33’s behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. 7:07 PM was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge. Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33’s medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33’s pupils and did not listen to heart or lung sounds as documented. Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33’s movements had resulted in the patient’s lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. Review of the “ED Triage Note,” showed, “ ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST [4:00 PM] by [Staff Z5, RN].” Staff Z5 documented the following vitals: Blood pressure 114/74, Pulse 104, Respiratory rate 16, and Oxygen saturation 94%. Review of the ED video at 4:00 PM, showed that Staff Z5, RN, approached Patient 33’s bedside and assisted other staff members with placing a slide board under patient. At 4:01 PM, Staff Z5 walked away from Patient 33. Staff Z5 did not assess Patient 33 and did not obtain vitals at 4:00 PM as documented in the medical record. Review of a document titled, “Alleged ED Caregiver Misconduct-Patient Timeline,” undated, showed an interview with Staff Z5, RN. “ ...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs] ...” Review of Patient 33’s medical record failed to show documentation that Patient 33 had a fall during his hospitalization. The medical record failed to show evidence that nursing staff or Staff S2, Physician, performed a post fall evaluation on Patient 33 to assess for injury and mental/physical status of the patient compared to pre-fall status. In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33’s medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival, including vital signs and a nursing assessment. The hospital staff failed to provide ongoing monitoring of a patient in restraints as required per the facility “Restraints and Seclusion” Policy, including 15-minute monitoring with required documentation, and failed to ensure the safety of a patient to prevent a fall. Review of the video and medical record showed nursing staff and Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The failure of the hospital to ensure that nursing staff used appropriate application of restraints, provided ongoing monitoring and assessment of a patient, and followed best practices to protect and prevent a patient from harm, places patients at risk for serious injury. During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED and it was disheartening. Patient 4 Review of Patient 4’s medical record showed a 75-year-old female, admitted to H1 on 04/30/23 at 9:30 PM with left distal third spiral tibial shaft fracture (complex broken leg). Patient reported she tripped at home and fell on her left side. Patient 4 underwent surgical repair of the fracture on 05/03/23 at 10:15 AM. Review of an order dated 05/03/23 at 11:32 AM, showed, “Neurovascular Assessment Lower Extremity ... q4hr (every 4 hours) for 48hrs (48 hours) ... stop 05/05/23 at 11:59 AM.” Review of Patient 4’s medical record failed to show documented evidence that nursing staff conducted any neurovascular assessment on Patient 4’s lower extremity as ordered. Failure to perform neurovascular checks as ordered has the potential for the nurse to miss symptoms of compromised blood flow or nerve damage to the ted limb. Patient 5 Review of Patient 5’s medical record showed an 83-year-old female that was transferred to H1 via EMS on 07/28/23 at 5:46 PM after an elective hip surgery with a diagnosis of hypotensive episodes post-operative and concern for sepsis due to unclear infection source. A Computed Tomography Scan (CT) was concerning for duodenal abnormality (Duodenal disease can include inflammatory lesions, strictures, and fistulas, and long-standing disease increases the risk of duodenal cancer). Review of an order dated 07/28/23 at 10:29 PM, showed, “Penlight Pupil Check q12hr, ...observe for purulent discharge/infiltrates. For worsening peripheral eye infiltrates, consult ophthalmology to evaluate.” Review of Patient 5’s medical record showed the nursing staff failed to document Penpoint pupil checks as ordered on 08/02/23, 08/06/23, and 08/07/23. Failure of the nursing staff to document Penpoint pupil checks as ordered places the patient at risk for unrecognized neurological impairment. Review of Patient 5’s medical record showed the nursing staff failed to document evidence of these assessments for the following dates/shift: 08/02/23: Respiratory assessment (night shift). 08/02/23: Cardiovascular assessment (night shift). 08/06/23: Cardiovascular assessment (day shift). 08/06/23: Respiratory assessment (day shift). 08/07/23: Pain assessment (night and day shift). 08/10/23: Respiratory assessment (night and day shift). Failure of the nursing staff to conduct and document respiratory, cardiovascular, and pain assessments as ordered places the patient at risk for unrecognized patient decline or death. Review of the medical record showed nursing staff failed to document a reassessment with change of shift as required per facility policy, “Patient Assessments and Reassessments.” Patient 7 Review of Patient 7’s medical record showed a 40-year-old female that presented to the Emergency Department (ED) on 11/14/23 at 8:12 PM, via Emergency Medical Services (EMS) with Altered Mental Status (AMS) and an elevated heartrate of 144 [60-100] beats per minute. Past medical history included Diabetes Mellitus type 2 (high blood glucose), Chronic Kidney Disease Stage III (moderate kidney damage), and visual blindness. Further review of the medical record showed a patient representative for Patient 7 reported fever and increased confusion at home. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache. Review of an order dated 11/19/23 at 8:43 PM, showed, “NIH (National Institutes of Health) Stroke Scale (tool used to measure impairment caused by a stroke) BID (twice daily)”. Per the NIH website, the Stroke Scale Severity rating: 0 = no stroke; 1-4 = minor stroke; 5-15 = moderate stroke; 15-20 = moderate/severe stroke; 21-42 = severe stroke. Review of Patient 7’s medical record showed an initial NIH assessment was completed 11/20/23 at 12:30 AM (~ 4 hours after order) with a score of 27 [severe stroke]. Further review showed only one NIH assessment was completed on 11/21/23, 11/22/23, 11/24/23, 11/25/23, and 11/26/23. Failure of nursing staff to conduct and document NIH assessment as ordered placed the patient at risk for unrecognized neurological decline. Patient 23 Review of Patient 23’s medical record showed a 37-year-old that arrived at the ED at H1 via ambulance on 11/02/23 at 11:47 PM with a diagnosis of seizure disorder, alcohol withdrawal, chronic alcohol abuse and hypokalemia (high potassium). Patient 23 was admitted on 11/03/23 at 1:54 AM to the intensive care unit. Review of an order dated 11/03/2023 at 2:01 AM showed, “Neurological Checks, q4hr (every four hours) ...” Review of Patient 23’s medical record showed nursing staff failed to document evidence of a neurological check on 11/10/23 between 12:00 AM and 6:02 AM (6 hours and 2 minutes). Failure of nursing staff to conduct and document neurological checks as order places the patient at risk for unrecognized neurological decline. Review of an order dated 11/03/23 at 6:24 PM showed, “Order: Restraint Initiate Non-Violent Behavior...Order Details: Interfering with medical care devices, soft limb...Evaluate patient, replicate restraint continue phase if indicated.” Review of Patient 23’s medical record showed nursing staff failed to document evidence of hourly extremity and skin assessments for the following dates/times: 11/04/23: 2:00 PM and 6:00 PM 11/05/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM 11/06/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM 11/07/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM 11/08/23: 12:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM 11/09/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM 11/10/23: 12:00AM, 2:00AM, 4:00AM and 6:00AM Failure of nursing staff to conduct and document extremity and skin checks as ordered while Patient 23 was restrained places patient at risk for unrecognized skin breakdown and impaired neurovascular functioning. Patient 24 Review of Patient 24’s medical record showed an 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 had a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of an order dated 11/02/23 at 8:52AM showed, “Order: Penlight Pupil Check...Order Details:...q12hr Observe for purulent discharge/ infiltrates. For worsening peripheral eye infiltrates...” Review of Patient 24’s medical record failed to show Nursing Staff documented evidence of Penlight Pupil Check every 12 hours as ordered on the following dates: 11//09/23, 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23 and 11/21/23 (17 of 40 assessments). Failure of nursing staff to conduct and document pupil checks as ordered places the patient at risk for unrecognized neurological impairment. Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/05/23 16:38:00 CST, q1hr, 4, hr, Stop date 11/05/23 20:59:00 CST (8:59 PM).” Review of Patient 24’s medical record failed to show documented evidence of a Neurological Assessment between 4:38 PM and 6:38 PM every one hour as ordered (2 of 4 assessments). Review of an order dated 11/05/23 at 6:57 PM showed, “Order: Neurological Assessment High Risk for Injury... Order Details: 11/5/23 8:38:00 PM CST, q4hr, 20, hr, Stop date 11/6/23 4:59:00 PM CST.” Review of Patient 24’s medical record failed to show Nursing Staff documented evidence of a Neurological Assessment for the following dates/ time: 11/05/23: 9:10 PM to 11/06/23 at 2:19 AM (~5 hours) 11/06/23: 2:19 AM to 11/06/23 at 9:00 AM (~7 hours) Failure of nursing staff to conduct and document neurological assessments as ordered places the patient at risk for unrecognized neurological decline. Patient 25 Review of Patient 25’s medical record showed a 61-year-old female who present to the ED at H1 via ambulance on 11/08/23 at 1:37 PM and was then admitted to inpatient status at 4:12 PM with the following diagnosis Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 with a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated blood pressure). Review of an order dated 11/08/23 at 6:20 PM stated, “Penlight Pupil Check...q12 hr (every 12 hours)...” Review of Patient 25’s medical record failed to show documented evidence of a pupil check for the following dates/times: 11/12/23: 8:00 PM until 11/13/23 at 8:00 PM (~24 hours). 11/13/23 8:00 PM until 11/14/23 at 8:00 PM (~24 hours). Failure of nursing staff to conduct and document pupil checks places the patient at risk for unrecognized neurological decline. Patient 31 Review of Patient 31’s medical record showed a 73-year-old male that arrived at the Emergency Department at H1 via ambulance on 10/06/23 at 10:59 PM with a diagnosis of Altered Mental Status of unknown onset. Patient 31’s has a past medical history of diabetes mellitus and renal impairment. Review of an order dated 10/08/23 at 4:15 AM stated, “Order: Neurological Assessment High Risk for Injury ...Order Details 10/8/23 4:15:00 AM CDT, q1hr, 4, hr, Stop date 10/8/23 8:29:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 1 hour per orders between 10/08/23 at 4:15 AM to 10/08/23 at 8:29 AM. Review of an order dated 10/08/23 at 6:27 AM stated, “Order: Neurological Assessment High Risk for Injury...10/8/23 8:15:00 AM CDT, q4hr, 20, hr, Stop date 10/9/23 4:59:00 AM CDT.” Review of Patient 31’s medical record failed to show documented evidence of Neurological Assessment every 4 hours per orders between 10/08/23 at 8:15 AM to 10/09/23 at 4:59 AM. Failure of nursing staff to complete and document neurological checks as ordered placed the patient at risk for unrecognized neurological decline. 2. Physician notification of critical results and/or Delay of Care: Review of hospital policy titled, “Critical Finding and Values Reporting,” revised 05/31/22, showed, “This policy is to improve the effectiveness of communication among caregivers, and to promote patient safety...Licensed Provider (LP) responsible for patient care is to be notified of critical results of tests and diagnostic procedures within 60 minutes of test results availability...The licensed caregiver, caring for the patient, shall notify the ordering or covering LP upon receipt of the critical results...Documentation of critical values will be completed in the electronic health record by the person reporting the results to the LP...If unable to give the result to an LP who can take action, elevate nonresponse through the chain of command. Document all attempts...Near Patient/Point of Care Testing (e.g. glucometer, iSTAT) critical values must be communicated immediately to a licensed caregiver. If the licensed care giver is also performing the test, then they are to follow the physician orders or hospital protocol for treatment and document...Critical test results are defined as findings or values that reflect a potential life-threatening situation and immediate medical intervention may be required ...” Review of a document titled, “Vital Signs Quick Guide,” dated 04/2023, showed that vital signs are required every shift on the Medical Surgical Unit; minimum of every four hours for Intensive Care Units (ICUs); every four hours for Pediatrics; minimum of every eight hours for Behavioral Health; and all vital signs are to be documented in the electronic medical record. Any vital signs outside of normal limits are to be reported to the nurse. Abnormal vital signs include any heartrate < 60 and > 100 beats per minute; systolic blood pressure >140 or <100, diastolic <60 or >90, or blood pressure > 20 from previous readings; oxygen saturation <93%; respiratory rate <12 or >20 breath per minute, or abnormal depth and pattern; oral temperature >37.5 Celsius or <36.4, axillary temperature >37 Celsius or <35.8. Review of hospital policy titled “Rapid Response Team ’ revised 02/27/23 showed “Policy: The Rapid Response Team (RRT) will support the early recognition of and response to a real or perceived decline in a patient or visitor’s condition. The RRT responds to both inpatient and outpatient units within the hospital and may be activated by any associate, the patient, or the patient’s family...PROCEDURE: Initiating ADULT Rapid Response Team: Following the criteria below, any nurse, physician, associate, or family member may call for the RRT when rapid assessment and intervention is deemed necessary for a declining patient. 1. Criteria for Initiating the Adult Rapid Response Team including but not limited to: ...b. Acute change in HR (heart rate) (<40 or >130 or 20% change from base line). Review of hospital document, “PCT Resource Website,” showed, “Vital Signs Schedule & Reportable Concerns...Report abnormal vital signs to the nurse immediately...Vital Sign Normal Limits...Heart Rate, 60-100 beats per minute...” Patient 6 Review of Patient 6’s medical record showed a 50-year-old male admitted on 10/30/23 at 2:07 PM with an admission diagnosis of End Stage Renal Disease (ESRD), Vomiting, Nausea, Diarrhea, and lethargy. On 10/30/23 at 2:25 PM (18 minutes after arrival) patient had an abnormal Electrocardiogram (ECG) a diagnostic test to evaluate the heart rhythm with sinus tachycardia (abnormally fast heart rhythm). Admission laboratory results showed abnormal potassium blood levels. Patient was transferred to the medical surgical floor on 10/30/23 at 4:29 PM. Further review showed that Patient 6 suffered respiratory arrest on 10/31/23 at 4:29 AM and required intubation (a tube to assist with breathing) and subsequent transfer to the Cardiac Intensive Care Unit (CICU). Review of a document titled “[Hospital 1] Incident Log” dated 03/01/2023 - 11/26/2023 showed, “Patient [Patient 6] was transferred from ED to 7SE. Patient gasping and agitated and moaning loudly. Received report from ER nurse. Stated that patient was in this condition since arrival to ER from SNU [skilled nursing unit]. Patient is a diabetic. 7se [southeast] nurse asked what was his last glucose check. ER nurse stated that she didnt [sic] know that the patient was an accucheck. Last glucose lab drawn at approx [sic]1500 [3:00 PM] on 10/30/23 was above 300. No Inventions [sic] performed. Patient arrived to the floor glucose was 340s. Insulin given. ER nurse stated that o2 [oxygen] was between 89-90s on room. also stated that patient doesn’t look too good and she would recommend that O2 is place on patient. Patient came to the floor on room air. Patient alert to self and able to follow commands (grips hands on command, eyes follow). Patient stated that his buttocks hurts and moaning in pain. Repositioned patient with pillow applied Mepilex border [multilayer foam dressings designed for use to prevent pressure ulcers]. administered PRN [as needed] pain medication. Patient calm and resting. two hours later. RN enters room to hang IV potassium. Upon arrival Patient began agonal breathing. RN calls staff assist and code blue. Patient is apneic. Pulse still present. RRT [registered respiratory therapist] to bedside. Transfered [sic] to the ICU [intensive care unit].” Review of Patient 6’s medical record showed a Rapid Response was initiated on 10/31/23 at 4:37 AM for staff concern of compromised airway. Respiratory rate was found to be less than 8 breaths per minute, SpO2 [measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry] less than 90%, and systolic blood pressure less than 90 mmHg. Interventions bag mask ventilation, intubation, respiratory therapy, IV fluid bolus, chest x-ray, pulse oximetry, continuous heart monitoring, and transfer to ICU at 4:45 AM. Achieving and maintaining proper ETT (endotracheal tube) insertion depth are challenging but critical for safe and effective care . Significant morbidity and mortality are associated with improperly positioned ETTs, including atelectasis, hypoxemia, pneumothorax, hypotension, and cardiac arrhythmias. ETT depth guidelines were designed to minimize the risk of placing an ETT in an improper position within the trachea. A chest x-ray report, dated 10/31/23 at 5:15 AM, showed, “...The endotracheal tube is about 9 cm [centimeters] above the carina (a cartilage situated at the point where the trachea (windpipe) divides into the lungs)...Recommend 4 cm of advancement...Report called to [floor nurse], by [technologist] at 6:33a.m...” The medical record failed to show documented evidence that the nursing staff or respiratory therapist notified a provider of the critical findings as required per facility policy, “Critical Finding and Values Reporting,” and failed to show documented evidence that anyone advanced the endotracheal tube 4 cm per radiologist recommendation. Review of an “Arterial Blood Gas,” dated 10/31/23 at 4:51 AM, showed the following critical results: pH 7.14 [Normal: 7.35-7.45]; pCO2 49 [Normal: 35-45]; pO2 549 mmHg [Normal: 80-100]; Bicarbonate 16 mEq/L [Normal: 22-26]; Base Excess Art -12 [Normal: -2-2]; O2 Sat Art 99.8% [Normal: 90.0-97.0]. The medical record failed to show documented evidence that the nursing staff notified the provider of the critical lab results as required per facility policy, “Critical Finding and Values Reporting.” Further review showed that Patient 6 suffered respiratory arrest on 10/31/23 at 4:29 AM and required intubation (a tube to assist with breathing) and subsequent transfer to the Cardiac Intensive Care Unit (CICU). Patient 6 expired on 10/31/23 at 11:43 AM with a preliminary cause of death attributed to respiratory arrest. Patient 27 Review of Patient 27’s medical record showed a 76-year-old male admitted on 10/19/23 at 5:22 PM with a diagnosis of Urinary tract infection, Hypotension (low blood pressure), dehydration, Chronic Kidney Disease, Altered Mental Status (AMS). Patient 27 had a past medical history of right above/below the knee amputation (absence of leg), hypertension (high blood pressure), and diabetes type 2 (too much sugar in the blood). Review of Patient 27’s Morse Fall Risk on 10/19/23 at 11:31 PM showed a fall risk score of 20 [low fall risk]. Review of this assessment failed to identify patient had a secondary diagnosis which would have increased his score by 15 points and mental status fall risk Morse was scored as 0 however further documentation in the medical record showed patient forgets limitations increasing fall risk score by 15 which in turn would have been a score 50 indicating a high risk for falls. Review of a “ED Note-Nursing” dated 10/20/23 at 6:37 AM, showed, “...pt (sic) was alert, pleasant, confused, disoriented, bedbound due to recent rt (sic) AKA (Above Knee Amputation) and weakness...pt (sic) required frequent redirection and reorientation...including pt requiring reorientation after calling 911 from personal cell phone, pt (sic) believed he was driving a school bus and “needed help with the kids”. Pt (sic) frequently removed monitor leads, bp (sic) cuff and nasal canula. Pt (sic) did not display the ability to reposition himself in bed, side rails x2 remained up to prevent fall...aprox (sic) 0414 staff from another department stated pt (sic) appeared to be out of bed, this RN went to pt (sic) room, pt (sic) was found at foot of bed, did not respond to his name, pt (sic) breathing was agonal, pulse was slow, weak. Code button was pressed, crash cart brought bedside. Compressions started at 0415. During code, at 0437 this RN spoke to family, during call [Return of Spontaneous Circulation] ROSC was achieved. Post code, report was called, CT [Computed Tomography] scan completed and pt (sic) was transferred to ICU. C-collar was placed during code, small abrasion noted to left lower leg, no other injuries noted.” Review of video footage dated 10/20/23 at 4:10 AM showed that an unidentified Staff entered Patient 27’s room (5 minutes after documentation showed patient was found) further review of the video showed the unidentified Staff exiting the patient room at 4:15 AM. After what appears to be a visitor or patient in room next to Patient 27’s room notified a staff member coming out of the CT room that Patient 27 needed assistance. An unidentified Staff entered the room at 4:10 AM. The nurse noted to exit room at 4:15 AM and retrieved crash cart. Further review of the video footage showed that Patient 27 had not been checked on by hospital staff from 10/20/23 at 2:00 AM until alerted by unknown visitor/patient at 4:10 AM. Review of a document titled, “VCH SF: FY 2023 Daily Staffing Report”, dated 10/19/23 into 10/20/23 at 7:00 AM showed a total of 6 RNs. Further review of the document showed multiple critical patients, three patients on ventilators and one patient on bi-pap. During an interview on 11/08/23 at 4:00 PM, Staff D8, ED Manager stated that on 10/20/23 at approximately 4:00 AM there were 6 RNs and at minimum 36 patients. She went on to state that she was unsure of what the exact census was but the patient to nurse ratio was at least a 6:1 (6 patients to 1 RN). Emergency Nursing Association (ENA) standards are 4:1 (four patients to 1 RN). Further review of the medical record showed that Patient 27 expired on 10/20/23 at 10:29 PM. Patient 3 Review of Patient 3’s discharge medical record was a 49-year-old female admitted to a Behavior Health Unit on 04/12/23 for Psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality) and Flight of Ideas (thoughts rapidly flow, often involving fast-paced speech, topic jumping and difficulty maintaining focus). Patient 3 had a history of Diabetes Mellitus (DM) (high blood glucose), Hypertension (HTN)(high blood pressure), Post traumatic stress disorder (PTSD) (Anxiety and flashbacks triggered by a traumatic event) and Insomnia (sleep disorder). Review of “Vital signs” on 04/27/23 at 9:08 AM showed “Peripheral Pulse Rate 209” by staff Y3, Mental Health Worker (MHW). Review of “Vital signs” on 04/27/23 at 11:03 AM showed “Peripheral Pulse Rate 211” by Staff X3, RN. Review of “Behavioral Health Progress Note” dated 04/27/23 at 1:21 PM showed “Vital signs obtain routine per orders. Pulse elevated...VS rechecked. 1150 (11:50 AM) Dr [H4] notified. Stat EKG ordered. Pt denies chest pain, back pain or dizziness. 1225 (12:25 PM) Dr. [H4] notified of EKG result. 1226 (12:26 PM) Rapid Response called. 1230 (12:30 PM) BS [blood sugar] 325. Declined IV...See MAR [Medication Administration Record] for medications administered. Ice pack applied to head and neck per physician recommendation. 1253 Accepted IV start with much encouragement from staff...1314 (1:14 PM) transferred to CCU (Coronary Intensive Care Unit)... Review of patient 3’s “EKG (electrocardiogram)” on 04/27/23 at 12:17 PM showed “Rate 195...Supraventricular Tachycardia (rapid heartbeat when the normal electrical impulses of heart are disrupted) Nonspecific ST & T-wave Abnormality, Abnormal ECG (electrocardiogram)... During an interview on 12/04 23 at 3:38 PM Staff H4, MD stated “The nurse is not taking the vitals the PCT (patient care tech) takes the vitals, I tell them what to call me on. The nurse follows the protocols, A heart rate of 200 is not real.” During an interview on 12/05/23 at 1:11PM with Staff X3, RN, stated, “I remember the situation the vital signs were taken that morning and was told that they were elevated. We were getting elevated reading notified [Staff H4, MD] the patient was not cooperative because she stated we gave too much of heart medicine. The charge nurse and me tried to talk to her, Patient 3 didn’t want us to check her blood press and [Staff H4, MD] told us to call the Rapid Response Team...” During an interview on 12/06/23 at 5:24 PM Staff Y3, MHW, stated that, I take vital signs once a shift, soon as I have finished with all the vital signs, I copy vital signs and give it to the nurses. Usually, a heart rate number of 190 is not accurate, they call it false artifact or patient movement which can read higher number.” During an interview on 12/14/23 at 9:56 AM Staff D2, RN, CNO, stated that per the policy if heart rate is outside normal range the nurse should be notified within 15 minutes or immediately. Review of medical record showed Patient 3’s a rapid response was called at 12:26 PM, 3 hours and 18 minutes after “Peripheral Pulse Rate 209” by Staff Y3 MHW was documented. Review of the medical record showed Patient 3 was admitted to Coronary Intensive Care Unit (CCU) on 04/27/23 at 1:14 PM from 6 West Behavior Health. Discharged on 05/01/23 at 10:14 PM from CCU to 6 West Behavior Health. Patient was admitted to CCU for 4 days and 9 hours for Supraventricular Tachycardia. Review of Patient 3’s medical record failed to show documented evidence in reporting abnormal vital signs immediately. Failure to notify the provider of abnormal vital signs as ordered has the potential for the patient to have adverse outcome and increased mortality rate. Patient 7 Review of Patient 7’s medical record showed a 40-year-old female that presented to the Emergency Department (ED) on 11/14/23 at 8:12 PM, via Emergency Medical Services (EMS) with Altered Mental Status (AMS) and an elevated heartrate of 144 [60-100] beats per minute. Past medical history included Diabetes Mellitus type 2 (high blood glucose), Chronic Kidney Disease Stage III (moderate kidney damage), and visual blindness. Further review of the medical record showed a patient representative for Patient 7 reported fever and increased confusion at home. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache. Review of an order dated 11/15/23 at 8:20 AM, showed, “Notify Provider Vital Signs Order: HR (Heart Rate) greater than 120...” Review of Patient 7’s vital signs from 11/15/23 - 11/25/23 showed 30 instances of a documented heart rate >120 beats per minute. Further review of the medical record failed to show documented evidence that a licensed nurse or provider was notified of a heart rate >120 beat per minute as required as ordered. Patient 24 Review of Patient 24’s medical record showed a 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of an order dated 11/01/23 at 1:12 PM showed, “Order: Vital Signs ...Order Details: ...q1hr.” Review of Patient 24’s medical record failed to show documented evidence of blood pressures for the following dates/times: From 11/01/23 at 4:15 PM until 11/01/23 at 9:00 PM (~5 hours) From 11/01/23 at 10:00 PM until 11/02/23 at 12:00 AM (~2 hours) 3. Medication Administration Patient 6 Review of Patient 6’s medical record showed a 50-year-old male admitted on 10/30/23 at 2:07 PM with an admission diagnosis of End Stage Renal Disease (ESRD), Vomiting, Nausea, Diarrhea, and lethargy. On 10/30/23 at 2:25 PM (18 minutes after arrival) patient had an abnormal Electrocardiogram (ECG) a diagnostic test to evaluate the heart rhythm with sinus tachycardia (abnormally fast heart rhythm). Admission laboratory results showed abnormal potassium blood levels. Patient was transferred to the medical surgical floor on 10/30/23 at 4:29 PM. Review of Patient 6’s lab result, dated 10/30/23 at 2:40 PM, showed a low potassium level of 3.4 (normal range 3.5-4.5) Review of an order dated 10/30/23 at 9:25 PM showed, “potassium chloride (potassium chloride 20 mEq/100 mL intravenous solution)...Order Details: 20 mEq = 100 mL, IV Piggyback, Once, infuse over 2 hr, First Dose: 10/30/23 10:00 PM, Stop Date: 10/31/23 8:00 AM” Review of Patient 6’s Medication Administration Record (MAR), dated 10/30/23 at 10:00 PM, by Staff V5, RN, showed that potassium chloride was not administered, “Admin Details: (Not Done) on night shift, not given”. Review of a “Nurse Progress Note,” 10/31/23 at 4:29 AM (about 6.5 hours after the order was written), by Staff W5, RN, showed, “Nurse entered room to hang IV potassium. Patient began agonal breathing...full code...began ambu bag patient...pending transfer to ICU.” Review of Patient 6’s lab result, dated 10/31/23 at 5:20 AM, showed a critical potassium level of 2.9 (normal range 3.5-4.5). Further review of Patient 6’s record showed that Patient 6 suffered respiratory arrest on 10/31/23 at 4:29 AM and required intubation (a tube to assist with breathing) and subsequent transfer to the Cardiac Intensive Care Unit (CICU). Patient 6 expired on 10/31/23 at 11:43 AM with a preliminary cause of death attributed to respiratory arrest. Further review of Patient 6’s medical record failed to show documented evidence that nursing staff administered potassium chloride as ordered . The failure of the hospital to ensure nursing staff administered the medication as ordered places patients at risk for adverse outcome. Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of Patient 2’s “pharmacy medication order” dated 08/24/23 at 10:05 AM showed an order for Lorazepam (Ativan - sedative hypnotic or anxiolytic medication) 2 mg/1 ml, intravenous push once, by Staff V3 MD. The documentation showed Licensed practical nurse (LPN) Staff administered Lorazepam 2 mg intravenous push. According to the Kansas Nurse Practice Act, the Licensed practical nurse shall not perform any of the following by intravenous route to include antianxiety or sedatives. Further review of Patient 2’s medical record shows that the patient did not have intravenous access. Documentation shows the staff LPN documented the incorrect route of administration of Lorazepam 2 mg IV dose. 4. Vital Signs: Review of a hospital policy titled, “Nursing Documentation Guidelines,” revised 8/22/17, showed that Registered Nurses are responsible and accountable for review of the documentation of unlicensed assistive staff and LPN (Licensed Practical Nurse) and that documentation in the patient’s medical chart should be completed during the following events: Physical/psychosocial reassessment each shift. Review of a document titled, “Vital Signs Quick Guide,” dated 04/2023, showed that vital signs are required every shift on the Medical Surgical Unit, minimum of every four hours for Intensive Care Units (ICUs), every four hours for Pediatrics, minimum of every eight hours for Behavioral Health, and all vital signs are to be in the electronic medical record. Any vital signs outside of normal limits are to be reported to the nurse. Abnormal vital signs include any heartrate < 60 and > 100 beats per minute; systolic blood pressure >140 or <100, diastolic <60 or >90, or blood pressure > 20 from previous readings; oxygen saturation <93%; respiratory rate <12 or >20 breath per minute, or abnormal depth and pattern; oral temperature >37.5 Celsius or <36.4, axillary temperature >37 Celsius or <35.8. Review of a policy revised 10/15/21 titled, “Transfusion of Blood/Blood Components/Autotransfusion,” showed that, “...assess vital signs at baseline, 15 minutes after baseline, then hourly from baseline until blood infused (temperature, pulse, respirations, and blood pressure)...” Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of Patient 2’s vital sign records from 08/23/23 - 08/29/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital guidelines for patients admitted to Behavioral Health. Patient 3 Review of Patient 3’s medical record showed a 49-year-old female admitted to the Behavior Health Unit on 04/12/23 for Psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) and Flight of Ideas (thoughts rapidly flow, often involving fast-paced speech, topic jumping and difficulty maintaining focus). Review of Patient 3’s vital sign records from 04/14/23 - 04/26/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital guideline for patients admitted to Behavioral Health. During an interview on 12/05/23 at 1:11 PM, Staff X3, RN, stated, “Vital signs are done every shift or every 12 hours unless they have different order.” During an interview on 12/13/23 at 1:11 PM, Staff U3, MHW (Mental Health Worker), stated, “We take vital signs every 12 hours at the beginning of shift at 7:30 AM and at 7:00 PM, which is blood pressure, oxygen saturation, temperature and respirations.” During an interview on 12/14/23 at 9:56 AM, Staff D2, RN, CNO, stated that Behavior Health vital signs are temperature, pulse, respirations, and blood pressure and are required every 8 hours, but the policy changed on 12/13/23 to vital signs once a shift. The failure to obtain vital signs as required has the potential for nurses to miss critical changes in blood pressure, heart rate, oxygen saturation, temperature, and pain that could result in rapid deterioration of patient health status, including serious injury and/or harm. Patient 13 Review of Patient 13’s medical record showed a 58-year-old female admitted to Hospital 2 Behavioral Health Unit on 11/26/23 for intellectual disability and agitation. Patient 13 has a history of Schizophrenia, Diabetes Mellitus (DM) (high blood glucose), Seizures (uncontrolled burst of electrical activity in the brain can cause changes in movement), Severe intellectual disability (major delays in development and limited communication skills), Psychiatric problems, agitation (state of excitement, disturbance or worry), aggressiveness (hostile or violent behavior) and Anoxic brain injury (brain loses oxygen supply and causing permanent brain damage). Review of Patient 13’s vital sign records from 11/16/23 - 11/27/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital guidelines for patients admitted to Behavioral Health. Patient 15 Review of Patient 15’s current medical records show an 88-year-old admitted with chief complaint of increased agitation and confusion over the last few weeks. The admitting diagnosis is aggressive behavior and altered mental status with a past medical history (PMH) of anemia (not having enough healthy red blood cells to care oxygen to the body’s tissue), atrial fibrillation (an irregular and often very rapid heart rhythm), benign essential hypertension (mild to moderate high blood pressure that has no identifiable cause), coronary artery disease (CAD- caused by plaque buildup in the wall of the arteries that supply blood to the heart), hearing loss, hiatal hernia (stomach protrudes up into the chest) with gastroesophageal reflux disease (GERD- stomach acid flows back into the mouth and stomach), hyperlipidemia, pericardial effusion (buildup of extra fluid in the space around the heart), major depressive disorder (MDD - persistent feeling of sadness and loss of interest) and prediabetes. Review of Patient 15’s vital sign records from 11/11/23- 11/27/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital policy for patients admitted to Behavioral Health. Patient 16 Review of Patient 16’s medical record showed that a 72 year old male admitted to Hospital 2 on 11/22/23 with diagnoses of COVID-19, confusion, and weakness. Patient 16 had a history of Traumatic Brain injury (TBI), Hypertension (HTN)(high blood pressure), Atrial Fibrillation (irregular heart rate that causes poor blood flow),Cerebral Vascular Accident (CVA) (Stroke) and Spinal Stenosis (spinal narrowing). Review of Patient 16’s vital sign records from 11/24/23 - 11/27/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital guideline for patients admitted to Behavioral Health. Patient 20 Review of Patient 20’s current medical records show a 37-year-old who admitted with chief complaint of “very intelligent and a high functioning adult” psychosis. The admitting diagnosis is schizoaffective disorder with a past medical history (PMH) of schizoaffective disorder (chronic condition includes symptoms of hallucinations, delusions, mania, and depression), Obstructive sleep apnea (decrease in oxygen saturation during sleep), cardiac pacemaker, Overweight. The consent to treat and patient’s rights forms were signed electronically on 11/17/23 and 11/21/23. Review of Patient 20’s vital sign records from 11/17/23 - 11/27/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital policy for patients admitted to Behavioral Health. Patient 23 Review of Patient 23’s medical record showed a 37-year-old that arrived at the ED at H1 via ambulance on 11/02/23 at 11:47 PM with a diagnosis of seizure disorder, alcohol withdrawal, chronic alcohol abuse and hypokalemia (low potassium). Patient 23 was admitted on 11/03/23 at 1:54 AM to the intensive care unit. Review of an order dated 11/3/2023 at 2:01 AM states, “Weight...Daily...” Review of Patient 23’s medical record failed to show documented evidence of patient weight for the following dates: 11/01/23, 11/04/23, 11/05/23, and 11/10/23 (4 of 8 days). Patient 24 Review of Patient 24’s medical record showed a 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with diagnoses of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of an order dated 11/07/23 at 10:44 AM, showed, “Order: Vital Signs...Order Details: 11/7/23 10:44:00 AM CST, Stop date 11/27/23 7:01:36 PM CST, per blood administration protocol...” Review of an order dated 11/08/23 at 7:03 AM, showed, “Order: Vital Signs...Order Details: 11/8/23 7:03:00 AM CST, Stop date 11/27/23 7:01:37 PM CST, per blood administration protocol...” Review of an order dated 11/14/23 at 10:06 AM, showed, “Order: Vital Signs...Order Details: 11/14/23 10:06:00 AM CST, Stop date 11/27/23 7:01:29 PM CST, per blood administration protocol...” Review of an order dated 11/16/23 at 4:36 AM, showed, “Order: Vital Signs... Order Details: 11/16/23 4:41:00 AM CST, Stop date 11/27/23 7:01:46 PM CST, per blood administration protocol...” Review of Patient 24’s medical record failed to show documented evidence of vital signs per blood administration policy [Transfusion of Blood/Blood Components/Autotransfusion] on the following dates: 11/07/23; 11/08/23; 11/14/23; and 11/16/23. Failure of nursing staff to complete vital signs per blood administration policy places patient at risk for unrecognized complications related to blood administration and transfusion. Patient 25 Review of Patient 25’s medical record showed a 61-year-old female who present to the ED at H1 via ambulance on 11/08/23 at 1:37 PM and was then admitted to inpatient status at 4:12 PM with diagnoses of Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 had a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated blood pressure). Review of an order dated 11/08/23 at 6:20 PM showed, “Weight...Daily...” Review of Patient 25’s medical record failed to show documented evidence of a daily weight on 11/09/23, 11/10/23, 11/12/23, and 11/13/23. (4 of 7 days) Failure to perform a daily weight as ordered places the patient with a diagnosis of CHF in fluid overload. Patient 26 Review of Patient 26’s current medical records show a 25-year-old admitted with a diagnosis of bipolar I disorder (causes extreme mood swings with emotional highs and lows)most recent episode Manic (abnormally high level of energy). Severe with psychotic (suggestive of mental or emotional instability) features. Review of Patient 26’s vital sign records from 11/16/23 - 11/28/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital policy for patients admitted to Behavioral Health. Patient 28 Review of Patient 28’s medical record showed an 88-year-old male admitted 10/30/23 with a diagnosis of depression (persistent low mood). Patient 28 had history of Dementia (memory and judgment loss), suprapubic catheter (tube that drains urine from your bladder), and Celiac Disease (immune reaction to eating gluten). Review of Patient 28’s vital sign records from 10/30/23 - 11/29/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital guidelines for patients admitted to Behavioral Health. Patient 29 Review of Patient 29’s medical record showed a 64-year-old male admitted to Hospital 2 Behavioral Health Unit on 11/29/23 with a diagnosis of Pneumonia, Congestive Heart Failure, and elevated Troponin (a protein that’s released into the bloodstream during a heart attack). Past medical History Benign Essential Hypertension and Traumatic brain injury. Further review of this medical record showed that staff failed to obtain a full set of vital signs a minimum of every eight hours from 11/19/23 to 11/27/23 per hospital guideline for Behavioral Health. Patient 30 Review of Patient 30’s current medical records show a 75-year-old admitted with Chief Complaint of Wound evaluation for post operative amputation (surgical removal of a limb), and an admitting diagnosis of cellulitis (serious bacterial skin infection) of the right foot, self-care failure schizophrenia (severe, lifelong brain disorder that causes people to interpret reality abnormally) vs bipolar disorder, most recent episode manic (grandiosity, paranoia, with psychotic features. A Past Medical History (PMH) of acute osteomyelitis (inflammation or swelling that occurs in the bone) of the right foot, hypertension, and MRSA (Methicillin-resistant Staphylococcus aureus - bacterial infection). Surgical history includes amputation of the right foot, excision of left foot subcutaneous tissue and fascia (thin, fibrous connective tissue that wraps around and supports every structure in your body). Review of Patient 30’s vital sign records from 11/22/23 - 11/28/23, showed that hospital staff obtained vitals once per shift instead of a minimum of every 8 hours as required per hospital policy for patients admitted to Behavioral Health. Patient 46 Review of Patient 46’s medical record was a 28- year-old male admitted on 12/30/23 at 8:50 PM to the Emergency Department at H2 via private vehicle. With a diagnosis Psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality). Past medical history of Drug abuse, Cannabinoid hyperemesis syndrome (long term user of marijuana that leads to bout of vomiting), anxiety (intense, excessive worry and fear about everyday situations) and depression (lowering of a person mood). Review of Patient 46’s medical record showed, “Order: Vital Signs...Order Details: 12/30/23 at 9:48 PM, q1hr (every hour)...” Review of Patient 46’s ED record from 12/30/23 - 12/31/23 failed to show documented evidence of hourly vital signs as ordered from 9:38 PM until admitted as Behavioral Health inpatient on 12/31/23 at 2:36 AM. Review of Patient 46’s vital sign records from 12/31/23 - 01/02/24, showed that hospital staff obtained only one full set vital signs per shift instead of a minimum of every 8 hours as required per hospital guidelines for patients admitted to Behavioral Health. 5. Repositioning Patients Review of a document titled, “Skin Assessment and Pressure Injury Prevention at [The Hospital]” showed, “...Perform and document a thorough skin assessment daily...Utilize the SKIN bundle - tasked every 2 hours for Braden (a screening tool used to identify patients at risk for skin breakdown) = 18...Reposition the patient at least every two hours when in bed...” Review of a document titled, “Skin Care Protocol Tasking Q2H”, dated 03/04/19, showed that patient repositioning is required for any patient with a documented Braden score of =18 at a minimum of every 2 hours. Patient 4 Review of Patient 4’s medical record showed a 75-year-old female, admitted to Hospital 1 (H1) on 04/30/23 at 9:30 PM with left distal third spiral tibial shaft fracture. Patient reported she tripped at home and fell on her left side. Patient 4 underwent surgical repair of the fracture on 05/03/23 at 10:15 AM. Patient 4’s initial Braden Risk/Skin Assessment on 04/30/23 at 11:07 PM, showed a score of 18 indicating patient at risk for skin break down. Review of an order dated 05/01/23 at 8:35 AM, showed, “Skin Care Protocol...reposition q2hr (every two hours)...” Review of Patient 4’s medical record failed to show documented evidence of repositioning every two hours as ordered for the following dates/times: 05/01/23 from 10:00 PM - 1:00 AM (~3 hours) 05/03/23 from 9:02 AM - 2:00 PM (~ 5 hours) 05/03/23 from 2:00 PM - 6:00 PM (~4 hours) 05/04/23 from 12:42 AM - 7:39 AM (~7 hours) 05/04/23 from 7:39 AM - 9:00 PM (~13 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 5 Review of Patient 5’s medical record showed an 83-year-old female that was transferred to H1 on 07/28/23 at 5:46 PM after an elective hip surgery with a diagnosis of hypotensive episodes post-operative and concern for sepsis due to unclear infection source. A Computed Tomography Scan (CT) was concerning for duodenal abnormality. Patient 5’s initial Braden Risk/Skin Assessment on 07/28/23 at 5:57 PM showed a score of 15 indicating patient at risk for skin break down. Review of an order dated 07/28/23 at 6:28 PM, showed, “Skin Care Protocol...reposition q2hr (every two hours)...” Review of Patient 5’s medical record failed to show documented evidence of repositioning every two hours as ordered for the following dates/times: 07/29/23 from 8:00 PM - 07/30/23 at 12:00 AM (~4 hours) 07/30/23 from 12:00 AM - 4:00 AM (~4 hours) 07/30/23 from 4:00 AM - 8:00 AM (~4 hours) 07/30/23 from 10:00 AM- 8:00 PM (~10 hours) 07/30/23 from 8:00 PM - 07/31/23 at 1:30 AM (~5 hours) 07/31/23 from 1:30 AM - 8:00 AM (~7 hours) 07/31/23 from 8:00 AM - 8:00 PM (12 hours) 07/31/23 from 8:00 PM - 08/01/23 at 8:00 PM (24 hours) 08/01/23 from 8:00 PM - 08/03/23 at 8:00 AM (36 hours) 08/03/23 from 6:00 PM - 08/10/23 at 8:00 AM (~7 days) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 7 Review of Patient 7’s medical record showed a 40-year-old female that presented to the Emergency Department (ED) on 11/14/23 at 8:12 PM, via Emergency Medical Services (EMS) with Altered Mental Status (AMS) and an elevated heartrate of 144 [60-100] beats per minute. Past medical history included Diabetes Mellitus type 2 (high blood glucose), Chronic Kidney Disease Stage III (moderate kidney damage), and visual blindness. Further review of the medical record showed a patient representative for Patient 7 reported fever and increased confusion at home. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache. Patient 7’s initial Braden Risk/Skin Assessment on 11/15/23 at 7:04 PM showed a score of 16 indicating patient at risk for skin break down. Review of an order dated 11/15/23 at 7:51 PM, showed, “Skin Care Protocol...reposition q2hr (every 2 hours)...” Review of Patient 7’s medical record failed to show documented evidence of repositioning every two hours as ordered for the following dates/times: 11/15/23 from 10:08 AM - 11/16/23 8:00 PM (~33 hours) 11/17/23 from 12:00 PM -4:00 PM (4 hours) 11/17/23 from 4:00 PM -8:00 PM (4 hours) 11/18/23 from 8:00 AM - 11/19/23 at 10:15 AM (~26 hours) 11/19/23 from 10:15 AM - 9:00 PM (~11 hours) 11/19/23 from 10:00 PM - 11/20/23 at 8:56 PM (~23 hours) 11/20/23 from 8:56 PM - 11/22/23 at 7:00 PM (~48 hours) 11/22/23 from 9:05 PM - 11/25/23 at 8:25 AM (~59 hours) 11/25/23 from 8:25 AM - 11:03 AM (~3 hours) 11/25/23 from 11:03 AM - 11/27/23 at 9:20 AM (~46 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 9 Review of Patient 9’s medical record showed a 63-year-old male, admitted on 11/18/23 at 11:41 PM with a diagnosis of sepsis (infection in the blood), cellulitis (bacterial skin infection), leukopenia (low white blood cells), alcohol intoxication, and hypokalemia (low potassium). Patient 9’s initial Braden Risk/Skin Assessment on 11/18/23 at 4:30 AM showed a score of 18 indicating patient at risk for skin breakdown. Review of an order dated 11/20/23 at 3:14 AM, showed, “Skin Care Protocol...reposition q2hr (every two hours)...” Review of Patient 9’s medical record failed to show documented evidence of repositioning every two hours as ordered for the following dates/times: 11/18/23 from 4:30 AM to 11/21/23 at 10:50 AM (~ 78 hours) 11/21/23 from 10:40 AM to 11:23 PM (~ 13 hours) 11/21/23 from 11:23 PM to 11/22/23 at 9:15 AM (~10 hours) 11/22/23 from 9:15 AM to 10:09 PM (~13 hours) 11/22/23 from 10:09 PM to 11/23/23 at 8:30 AM (~10 hours) 11/23/23 from 8:30 AM to 11/24/23 at 10:25 AM (~26 hours) 11/24/23 at 10:25 AM to 10:57 PM (~12 hours) 11/25/23 at 6:00 PM to 11/26/23 at 7:00 AM (13 hours) 11/26/23 at 10:00 AM to 2:00 PM (4 hours) 11/26/23 at 2:00 PM to 8:00 PM (6 hours) 11/27/23 at 4:00 AM to 12:20 PM (~8 hours) 11/27/23 at 1:37 PM to 4:00 PM (~3 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 22 Review of Patient 22’s medical record showed a 75-year-old female admitted on 11/27/23 at 10:34 AM to H1 via private vehicle with a diagnosis of open wound of buttocks requiring surgical intervention. Review of an order dated 11/27/23 at 11:41 AM, showed, “Skin Care Protocol...reposition q2hr (every two hours)...” Patient 22’s initial Braden Risk/Skin Assessment on 11/27/23 at 11:17 AM showed a score of 13 indicating patient at risk for skin break down. Review of Patient 22’s medical record failed to show documented evidence of repositioning every two hours as orders for the following dates/times: 11/27/23 from 9:00 PM-11/17/23 at 12:08 am (~3 hours) 11/28/23 from 12:08 AM - 4:05 AM (~4 hours) 11/28/23 from 4:05 AM - 8:00 AM (~4 hours) 11/28/23 from 8:00 PM - 11/29/23 at 12:00 AM (~4 hours) 11/29/23 from 12:00 AM- 4:06 AM (~4 hours) 11/29/23 from 4:06 AM - 8:00 AM (~4 hours) 11/29/23 from 8:00 AM - 12:00 PM (~4 hours) 11/29/23 from 8:00 PM - 11/30/23 at 12:00 AM (~4 hours) 11/30/23 from 12:00 AM - 4:15 AM (~4 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 24 Review of Patient 24’s medical record showed a 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of an order dated 11/02/23 at 08:12 AM, showed, “Skin Care Protocol...reposition q2hr (every two hours)...” Patient 24’s initial Braden Risk/Skin Assessment on 11/01/23 at 9:00 PM showed a score of 14 indicating patient at risk for skin break down. Review of Patient 24’s medical record failed to show documented evidence of repositioning every two hours as orders for the following dates/times: 11/10/23 from 4:32 AM to 8:00 AM (~4 hours) 11/11/23 from 2:16 AM to 6:08 AM (~4 hours) 11/11/23 from 2:00 PM to 7:45 PM (~6 hours) 11/12/23 from 12:00 PM to 3:00 PM (3 hours) 11/15/23 from 7:22 AM to 10:40 AM (~4 hours) 11/16/23 from 4:26 PM to 8:00 PM (~4 hours) 11/19/23 from 2:21 AM to 8:00 AM (~6 hours) 11/19/23 from 2:42 PM to 9:30 PM (~7 hours) 11/23/23 from 4:30 AM to 9:34 AM (~5 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. Patient 25 Review of Patient 25’s medical record showed a 61-year-old female who present to the ED at H1 via EMS on 11/08/23 at 1:37 PM and was admitted to inpatient status at 4:12 PM with the following diagnosis Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 with a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated Review of an order dated 10/09/23 at 6:32 AM showed, “Skin Care Protocol...reposition q2hr (every 2 hours)...” Patient 25’s Braden Risk/Skin Assessment on 10/08/23 at 7:45 PM showed a score of 15 indicating patient at risk for skin break down. Review of Patient 25’s medical record failed to show documented evidence of repositioning every two hours as orders for the following dates/times: 10/08/23 from 7:45 PM to 10/09/23 at 7:00 AM (~12 hours) 10/09/23 from 12:11 PM to 10/09/23 at 3:45 PM (~4 hours) 10/10/23 from 6:35 AM to 10/10/23 at 9:00 AM (~3 hours) 10/10/23 from 9:00 AM to 10/10/23 at 12:00 PM (~3 hours) 10/10/23 from 2:00 PM to 10/10/23 at 7:30 PM (~6 hours) 10/11/23 from 6:38 AM to 10/11/23 at 9:56 AM (~4 hours) 10/11/23 from 11:12 PM to 10/11/23 at 2:34 AM (~3 hours) 10/11/23 from 2:34 AM to 10/11/23 at 5:10 AM (~3 hours) 10/12/23 from 2:25 PM to 10/12/23 at 5:40 PM (~3 hours) 10/12/23 from 5:40 PM to 10/12/23 at 10:11 PM (~5 hours) 10/13/23 from 6:38 AM to 10/13/23 at 9:37 AM (~3 hours) Failure to turn and reposition the patient has the potential to cause skin break down and or infection. 6. Bathing: Review of a policy titled, “Patient Hygiene,” dated 03/18/23, showed, “Purpose: To ensure skin cleanliness, promotion of patient comfort, independence, skin integrity, and reduction of infection risk ...Essential patient hygiene care will be documented in the patient ’ s Electronic Medical Record (EMR) ...Essential hygiene care includes ...bathing ...Essential hygiene care will be offered on a daily basis ...” Review of a document titled, “Navel to Knee Chlorhexidine Gluconate (CHG),” showed that Patients greater than 2 months of age with invasive lines (central line or indwelling catheter)...When: On day of admission and every 24 hours...” Patient 1 Review of Patient 1’s medical record showed a 62-year-old female that presented to the ED via private vehicle on 03/09/23 at 8:33 PM with neck pain and concern for cerebrospinal fluid (CSF) leak (leaking of fluid that surrounds the brain and spinal cord). Past medical history of multiple cervical spine surgeries (surgery of neck area of spine). Patient 1 was admitted on 03/10/23 at 7:13 PM with a diagnosis of neck pain with post operative complications (complications following surgical procedure). Review of an order dated 03/10/23 at 3:24 PM, showed, “Perform bath daily.” Review of Patient 1’s medical record failed to show documented evidence that a bath was provided as ordered on the following dates: 03/10/23, 03/13/23, 03/15/23, 03/16/23, 03/18/23, 03/20/23, and 03/23/23 (7 of 15 days). Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection. Patient 4 Review of Patient 4’s medical record showed a 75-year-old female, admitted to Hospital 1 (H1) on 04/30/23 at 9:30 PM with left distal third spiral tibial shaft fracture. Patient reported she tripped at home and fell on her left side. Patient 4 underwent surgical repair of the fracture on 05/03/23 at 10:15 AM. Review of an order dated 05/03/23 at 4:36 PM, showed, “Perform bath daily.” Review of Patient 4 s medical record failed to show documented evidence that a bath was performed from date of admission to discharge (5 days). Failure to perform a daily bath as ordered has the potential to place the patient at risk for skin breakdown and or infection. Patient 5 Review of Patient 5’s medical record showed an 83-year-old female that was transferred to H1 on 07/28/23 at 5:46 PM after an elective hip surgery with a diagnosis of hypotensive episodes post-operative and concern for sepsis due to unclear infection source. A Computed Tomography Scan (CT) was concerning for duodenal abnormality. Patient 7 Review of Patient 7’s medical record showed a 40-year-old female that presented to the Emergency Department (ED) on 11/14/23 at 8:12 PM, via Emergency Medical Services (EMS) with Altered Mental Status (AMS) and an elevated heartrate of 144 [60-100] beats per minute. Past medical history included Diabetes Mellitus type 2 (high blood glucose), Chronic Kidney Disease Stage III (moderate kidney damage), and visual blindness. Further review of the medical record showed a patient representative for Patient 7 reported fever and increased confusion at home. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache. Review of an order dated 11/16/223 at 1:35 PM showed, “Perform bath daily”. Review of Patient 7’s medical record failed to show documented evidence that a bath was provided for the following dates: 11/14/23, 11/15/23, 11/16/23, 11/21/23, 11/24/23, 11/25/23, and 11/26/23 (7 of 12 days). Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection. Patient 8 Review of Patient 8’s medical record showed a 69 year old female admitted on 06/02/23 at 4:08 PM to H1 via private vehicle with a diagnosis of breast cancer, metastasized to the thoracic spine with possible spinal cord involvement. Review of an order dated 06/04/23 at 12:59 PM, showed, “CHG Bath ...Perform CHG bath daily...” Discontinued on 06/08/23 at 8:02 PM. Review of Patient 8’s medical record failed to show documented evidence that a bath was performed on 06/04/23, 06/05/23, 06/06/23 and 06/08/23 as ordered (4 days). Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection. Patient 24 Review of Patient 24’s medical record showed a 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle. With a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN). Review of an order dated 11/02/23 at 12:58 AM, showed, “CHG Bath...Perform CHG bath daily...” Review of Patient 24’s medical record failed to show documented evidence that a bath was performed on 11/02/23, 11/04/23, 11/05/23, 11/07/23, 11/08/23, 11/09/23, 11/12/23, 11/13/23, 11/17/23, 11/18/23, 11/19/23, and 11/20/23 as ordered (12 days). Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection. Patient 25 Review of Patient 25’s medical record showed a 61-year-old female who present to the ED at H1 via ambulance on 11/08/23 at 1:37 PM and was admitted to inpatient status at 4:12 PM with a diagnosis of Respiratory Failure and Respiratory Acidosis (accumulation of acid in the blood). Patient 25 has a medical history of Chronic Obstructive Pulmonary Disease (disease of the airway), Congestive Heart Failure (failure of the heart to pump blood), Diabetes (too much sugar in the blood), and Hypertension (elevated blood pressure). Review of an order dated 11/08/23 at 9:54 PM showed, “Perform CHG bath daily.” Review of Patient 25’s medical record failed to show documented evidence of a CHG bath being completed for 11/15/23. (1 day) Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection. Patient 31 Review of Patient 31’s medical record showed a 73-year-old male that arrived at the ED at H1 via ambulance on 10/06/23 at 10:59 PM with a diagnosis of Altered Mental Status of unknown onset. Patient 31’s has a past medical history of diabetes mellitus and renal impairment. Review of Patient 31’s medical record failed to show documented evidence of a daily bath on the following dates: 10/07/23, 10/08/23, 10/09/23, 10/10/23, 10/12/23, and 10/14/23. (6 of 12 days) Failure to perform a daily bath has the potential to place the patient at risk for skin breakdown and or infection.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47233 Based on policy review, document review, and interview the hospital failed to ensure nursing care plans were kept current for each patient when nursing staff failed to followed the Patient Assessment and Reassessment, Nursing documentation guidelines, and Fall Risk policies of updating the patients interdisciplinary plan of care with interventions, short term goals, and long-term goals for 2 of 50 Patients reviewed (Patient 2 and 15). This deficient practices has the potential to place patients at risk for deterioration of current illness, ineffective management of care needs and other adverse outcomes. Findings Include: Review of hospital policy titled “Patient Assessment and Reassessment” revised 08/17/2023 showed, “...Interdisciplinary plan of care (for admitted patients). Each admitted patient will have a comprehensive, integrated, multidisciplinary plan of care, which is developed from the initial patient assessment. This plan of care will include, at minimum, physician, and nursing components. Initial patient assessments provide the baseline of the patient at the time of admission. From these assessments, the needs of the patient are identified, and the plan of care is developed. A. The plans of care focus on: 1. Immediate needs. The RN assessment results in a listing of patient problems, needs or nursing diagnoses. 2. The patient’s needs for education regarding the diagnosis, treatment, and continuing management of health care problems and the maintenance of health; and discharge planning. B. RNs are expected to review the plan of care at least daily. C. Updates or modifications to the plan of care occur whenever there is: 1. A significant change in the patient’s condition or status 2. At specified time intervals, to include: b. Nurses, at least daily; and c. Other support staff with each observation...” Review of the hospital policy titled, “Nursing Documentation Guidelines,” revised 03/01/2023, POLICY: The main purpose of the medical record is to accurately and adequately document a patient’s health history, including past and present illness(es) and treatment(s), with emphasis on the events affecting the patient during the current episode of care. The Documentation Guidelines outline how to appropriately provide nurse documentation in the electronic health record (EHR). IPOC (Interdisciplinary Plan of Care): IPOCs are suggested based on assessment findings. Suggested IPOCs must be accepted and personalized (goals, indicators, interventions) based on the individual needs of the patient. Proceed to: ... Review current care plan and implement additional fall prevention strategies. ... Provide fall prevention information (Tool 3J). Review of hospital policy titled, “Fall Risk,” revised 03/21/23 showed, “F. If a fall occurs... g. Initiate Post-Fall Assessment Interdisciplinary plan of care (IPOC) in Electronic Medical Record (EMR).” Patient 2 Review of Patient 2’s discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits. Review of Patient 2’s “History and Physical,” dated 08/23/23 at 4:19 PM showed a diagnosis of status epilepticus on 08/21/23 with a known history of seizures. Review of Patient 2’s “Interdisciplinary Plan of Care (IPOC)” dated 08/22/23 failed to show a plan of care initiated that focused on Patient 2’s problem with increased risk for seizure like activity. The plan of care did not include any interventions to implement seizures precautions that would keep the patient safe and reduce the risk for harm. During an interview on 12/14/23 at 10:21 AM, Staff CC, Director of Behavioral health unit stated that if staff knew a patient had a seizure disorder noted, or other medical condition the expectation would be to include the medical condition in the plan of care. During an interview on 12/05/23 at 4:23 PM Staff O4, RN house supervisor (day shift) for 6 west was asked if a patient with a known history of seizure would require seizure precautions. Staff O4 RN stated, “I guess but on a psychiatric floor it is tricky, but we do have the mats we can put on the side of the bed to prevent a fall out of the bed or something like that.” During an interview on 12/05/23 at 10:59 AM, Patient 2 stated “on 08/23/23, I was in my bed the whole day then I got up to go to the bathroom and by that time I felt like I might be having a seizure, so I went into the hallway. I don ’ t remember some of it, but they were sprinkling water on my face.” Patient 2 stated her “right arm is sore, the staff broke my hand, the guy was losing grip on one of my hands and he grabbed my hand again and they flung me onto the bed.” Review of Staff T3, RN progress note dated 08/23/23 at 7:02 PM showed, “On 08/23/23 at approximately 5:00 PM a peer came to the nurses’ station to inform staff that [Patient 2] is laying on the floor in the hallway patient will not respond verbally, vital signs obtained and are within normal limits (WNL) no injuries observed by this staff.” Further review of Patient 2’s medical record showed that nursing staff failed to follow the hospitals fall risk policy and did not initiate the Post Fall assessment IPOC. The nursing staff failed to include interventions, measurable goals and outcomes that address Patient 2’s safety needs post fall. During an interview on 12/14/23 at 11:19 AM, Staff T3, RN stated that the plan of care is completed when the patient first admits, and the nurse can update it whenever new problems are identified. During an interview on 11/29/23 at 3:00 PM Staff V2, RN stated, “I would add the fall IPOC to the patient’s plan of care.” During an interview on 12/06/23 at 2:20 PM, Staff CC Director of Behavioral health unit (BHU) stated that regarding our fall policy if it is determined to be a fall, we would start with an assessment by a nurse. The staff would complete a post fall debriefing, notify the house supervisor, complete Morse fall risk scale, and update plan of care. Patient 15 Review of Patient 15’s current medical records show an 88-year-old admitted with chief complaint of increased agitation and confusion over the last few weeks. The admitting diagnoses included aggressive behavior and altered mental status with a past medical history (PMH) of anemia (not having enough healthy red blood cells to care oxygen to the body ’ s tissue), atrial fibrillation (an irregular and often very rapid heart rhythm), benign essential hypertension (mild to moderate high blood pressure that has no identifiable cause), coronary artery disease (CAD- caused by plaque buildup in the wall of the arteries that supply blood to the heart), hearing loss, hiatal hernia (stomach protrudes up into the chest) with gastroesophageal reflux disease (GERD- stomach acid flows back into the mouth and stomach), hyperlipidemia, pericardial effusion (buildup of extra fluid in the space around the heart), major depressive disorder (MDD - persistent feeling of sadness and loss of interest) and prediabetes. Review of Patient 15’s “Braden Assessment” dated 11/27/23 showed a Braden skin assessment score of 13 indicating a moderate risks for skin integrity. The Braden assessment scale measures sensory perception, activity, mobility, moisture, nutrition, and friction. The Braden scale score ranges: low risk score (19-23), mild to moderate risk score (13-18) high risk score (10-12) and a severe score is (less than 9). The facility failed to update Patient 15’s plan of care with new problem to include at risk for impaired skin integrity. Review of Patient 15’s “Nutrition ADLs” from 11/14/23 to 11/21/23 showed the patient consistently had poor oral intake; less than 50% per meal for greater than 3 days. Review of Patient 15’s interdisciplinary plans of care failed to show initiation of a nursing care plan to include inadequate nutritional intake less than 50% placing the patient at risk for dehydration and malnutrition.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47233 Based on policy review, document review and interview, the hospital failed to ensure that life safety from fire requirements were met for all patients, visitors, and staff at the hospital. The cumulative effects of this deficient practice resulted in three Immediate Jeopardies (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). (Refer to Life Safety Code Tags K754, K232, and K256) Findings Include: On 12/07/23 between the hours of 9:15 AM and 9:45 AM the following observations were made: Observation of the Psychiatric Observation Unit (POU) suite revealed that based on the size of the suite, two compliant exits from the POU suite are required. One of the two provided exits is obstructed by furniture and lockers. This exit is labelled as the Emergency Exit. When interviewed Staff A5, RN stated this is the exit they would use in the event of an emergency requiring evacuation. Patient census at the time of observation was 6. Observation of the POU suite revealed that patients are being housed in a suite not designed for sleeping. Patients were observed sleeping in chairs and on the floor. Sleeping rooms and beds are not provided. Observation of the POU suite revealed that patients may be restrained to a bed in the “Consult 1” room. It was observed that the “Consult 1” room is not equipped with smoke detection as required. Staff interview revealed that this room is used for restraining patients and/or sleeping patients. Observation of the POU suite revealed that rooms within the suite are being used for purposes other than their intended use. The “Staff Only” room is used as a storage room for patient belongings, miscellaneous equipment, sleeping mats, ect. Storage was observed stacked higher than allowed and within 18 inches of the ceiling and sprinkler heads. The room labeled “Staff Only” is indicated as a “restraint room” on the 2023 Life Safety Code Plans. This room is designed as a psych anti ligature room not a storage room. Observation of the “Soiled Hold” room inside the POU suite revealed that over 64 gallons of waste were contained in the room without a fire rating of 1 hour. Storage consisted of waste, bio-hazard waste, soiled linens, mop bucket and mop heads. Observations of the POU suite revealed that the emergency exit door is impeded by tables and chairs and lockers reducing the exit access width to less than required. The size of the suite requires two exits be provided. One of the two required exits is obstructed. Observation of the egress corridor outside the POU suite revealed excessive storage in the egress corridor outside of the POU emergency exit door. Signage is in place stating, “Do not block”. Observation of the egress corridor outside the Psychiatric Observation Unit (POU) suite revealed excessive obstructive storage throughout the egress corridor. This egress corridor could be used by patients, staff, and visitors within smoke compartments (SC), SC-L.2, SC-L.3, SC-L.6, and SC-L.7. It should be noted that smoke compartment SC-L.7 contains the cafeteria so additional staff and visitors could be affected by this obstructed egress corridor. Storage consists of unused beds, unused equipment, combustibles, trash, laundries, and soiled linens. Beds were observed stacked two deep on one side of the corridor. Full clean and soiled linen carts were observed on one side of the corridor blocking a fire extinguisher cabinet and multiple signs stating, “No Storage by order of the Fire Marshal.” Full and soiled linen carts were filled and stacked within 18 inches of the ceiling and fire sprinklers. On 12/12/23 between the hours of 12:45 PM and 2:00 PM the following observations were made: Observation of the facility’s 2023 Life Safety Code Plans revealed that the corridor outside the POU is a designated egress corridor and is referenced as such on the facility’s 2023 Life Safety Code Plans. This egress corridor is accessible to other smoke compartments. This egress corridor takes occupants to the tunnel system beneath/adjacent to the hospital. Observation of the facility’s 2023 Life Safety Code Plans revealed that the POU suite is designed and designated as a “patient- care, non-sleeping suite”. However, based on interview of both patients and staff, patients are held within the POU suite for 48+hours or until evaluated and released by a psychiatrist. Observation of the egress corridor outside the POU suite revealed storage outside the emergency exit door from POU suite. Signs posted on door, “Do not block this door. Emergency Exit.” Observation of the egress corridor outside the POU suite revealed Hazardous/Soiled/Combustible storage in the corridor outside the emergency exit from the POU suite. Over approximately 20 full linen carts lined the egress corridor. Observation of the egress corridor outside the POU suite revealed unused beds, two deep, restricting egress beyond the 90-minute fire rated doors in the tunnel. During an interview on 12/13/23 at 9:48 AM, when asked about the storage in the egress corridor, Staff M5, EVS (Environmental Services) stated “My shift is 5:00 AM-1:30 PM, I am the only one who works with the linen. The carts are in hallway because it is where Linen King delivers and picks ups the carts, since there is not enough room in the Linen Room. I am the only person that has access to this room besides security and supervisor after 1:30 PM.” The facility failed to ensure proper storage of unused beds, unused equipment, combustibles, trash, laundries, and soiled linens. Continued observation of the space revealed continuous storage of these items exceeding the allowable quantities. The time frame of the storage does not equate to “in-use”. These items are all being stored in the basement west egress corridor.”

“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: 47233 Based on document review, record review, policy review, review of surveillance video, observation, and interview the Hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines and hospital policies and procedures for infection control and prevention when staff failed to perform proper hand hygiene, use appropriate personal protective equipment, inappropriately handled and/or stored blood products and use appropriate food handling for Hospital 1 and Hospital 2 through multiple observations on numerous patient care areas of unidentified direct care staff throughout both facilities. 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: Review of a hospital policy titled, “Hand Hygiene” revised 06/19/19, showed, “All members of the health care team will comply with current Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. A. Indications for hand washing and hand antisepsis: 1. When entering the patient care area/before patient contact. 2. When exiting the patient care area/after patient contact... 4. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. 5. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 6. If hands will be moving from a contaminated body site to a clean body site during patient care. 7. After glove removal... C. Hands should be washed with soap and water in the following situations: 1. When hands are visibly dirty or contaminated with blood or other body fluids...” Review of a hospital policy titled, “Standard and Isolation Precautions,” revised 10/23/20, showed, “...2. The type of Personal Protective Equipment (PPE) used during patient care is determined by the nature of the healthcare worker (HWC) - patient interaction and the extent of anticipated blood body fluid, or pathogen exposure...a. Gloves: worn when there is the possibility of hand contact with blood or body fluids, mucous membranes, non-intact skin, or when performing vascular access procedures, phlebotomy procedures, and when handling contaminated items or surfaces. b. Gowns: worn if contact with blood or bodily fluids may occur. c. Mask: worn when there is potential contact with respiratory secretions and sprays of blood or bodily fluids...d. Face shield/eye protection (goggles): full coverage eye protection is worn during aerosol generating procedures (AGP) and other patient-care activities that are likely to generate splashes or sprays of blood or other body fluids to prevent exposure of mucous membrane of the mouth, nose, and eyes to patient’s body fluids...1. Contact/Contact Plus Precautions: used to reduce the spread of microorganisms (germs) by direct (patient to patient) or indirect (HCWs hands or patient care equipment to patient) contact ...c. PPE: the HCW is required to wear gloves and gown for contact with the patient and/or the environment of care. 2. Droplet Precautions: are implemented for patients with suspected or confirmed respiratory viral illnesses to reduce the risk of diseases that are spread through microorganisms (germs) transmitted by respiratory droplets that travel short distances as a patient coughs, sneezes, or talks. Pediatric droplet precautions are a combination of droplet and contact precautions used for all pediatric respiratory illnesses ...b. PPE: requires the HCW wear a mask prior to fully entering the patient’s room...d. N-95 mask/Powered Air Purifying Respirator (PAPR), or Controlled Air Purifying Respirator (CAPR), and eye protection are indicated when performing...open suctioning of airways...3. Airborne Precautions are used for patients known or suspected to be infected with microorganisms (germs) transmitted person-to-person by the airborne route...b. N95/PAPR or CAPR is required of the HCW when caring for patients in Airborne Precautions...10. Communication...a. Place appropriate Isolation Precautions sign on door. Do not remove sign until room has been cleaned by Environmental Services...Documentation: Per authority statement, an order for specific required isolation will be generated to reflect isolation precaution status...” Review of a hospital policy titled, “Infection Prevention and Control Program” revised 02/03/22, showed, “...The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable disease and provide primary leadership in the following activities: ...g. Mitigate risks associated with patient infections present upon admission...i. Mitigate risks contributing to healthcare-associate infections...All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations ...Department director/manager will...Monitor associate compliance with infection prevention and control policies and procedures, including but not limited to appropriate use of personal protective equipment, engineering controls, work practice controls, and hand hygiene practices...” Review of a hospital policy titled, “Infection Control Guidelines for Patient Care Areas and Clinical Support Areas - Work Instruction” revised 07/22/19, showed, “...1. All body fluids / substances should be considered potentially infectious materials. Standard Precautions should be instituted for all patients regardless of their diagnosis...3. Personal Protective Equipment (PPE) is to be removed and discarded prior to leaving the patient room (exception: N95 mask or PAPR for Airborne Precautions should be removed after exiting the room) ... 4. Duration of precautions...a. For most conditions, precautions will continue for duration of illness or until dismissal...6. Ensure that necessary PPE is readily accessible...c. Patient Care...1. Complete Infectious Disease Screening in the Electronic Medical Record on all patients admitted to the nursing unit. Assess all patients for presence of an infectious disease or condition requiring transmission based precautions...2. Implement evidence-based practice measures to prevent hospital acquired infections...d. Patient Care Environment ... 1. Maintain a clean and sanitary environment. All staff are responsible for ensuring high standards of cleanliness regarding patient care equipment, medical devices, and the environment of care...g. Linen...1. Clean linen should be stored in a covered cart or within a cabinet...o. Food and Drink ... 6. Staff may only eat in clean designated areas. Covered drinks should be in a designated area of the unit. Food and drink is not allowed in areas where work involving exposure or potential exposure to blood or other potentially infectious material may occur or where the potential for contamination of work surfaces exists, i.e. where specimens are placed, stored or processed...c. Isolation Precautions...2. If the patient’s behavior (e.g. wandering) or health status poses a significant risk of disease transmission, room isolation precautions may be necessary)...a. Patient Care...1. During triage, assess patients for presence of infectious disease or condition requiring isolaton precautions...c. Masks should be work when there is a suspicion that a patient may have an airborne transmissible disease (e.g. TB, varicella) or droplet transmissible (e.g. influenza, pertussis, meningitis)...” Review of a hospital policy titled, “Housekeeping Procedures, Patient / Residential Room Cleaning” issued 02/01/22, showed, “...Isolation Discharge Room Cleaning Procedure...Equipment:...Gloves and other PPE in accordance with posted standard precaution signs...Procedure: 1. Put on appropriate PPE and follow proper hand hygiene protocol...” Patient 7 Review of Patient 7’s medical record showed a 40-year-old female that presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 11/14/23 at 8:12 PM. Patient 7 was admitted inpatient on 11/15/23 at 10:08 AM with diagnoses of pharyngitis (inflammation of back of throat) and altered mental status (AMS) (change in normal mental function). During an observation on 11/30/23 at 1:47 PM, Staff J3, Patient Care Technician (PCT), entered Patient 7’s room with “Contact Precaution Plus” signage. Staff J3 failed to perform hand hygiene on entrance and failed to don required Personal Protective Equipment (PPE) (gown and gloves) and proceeded to assist Patient 7 with her bedding and adjusting a pillow, potentially contaminating her scrubs and her hands. Staff J3 then proceeded to exit the room without washing hands and entered another patient room without performing hand hygiene upon entrance or exit. Staff J3, with potentially contaminated hands, then walked down the hall to the Nourishment Room. She obtained food and a utensil from the Nourishment Room and returned to Patient 7’s room. Without donning PPE, performing hand hygiene, or applying PPE, Staff J3 opened the food container and handed it to Patient 7. Staff J3 then exited the room without washing hands with soap and water as required per hospital policy. During an interview on 11/30/23 at 1:53 PM, Staff J3 stated that Patient 7 was on Contact Precautions for C-diff (Clostridium difficile - a germ that causes diarrhea and inflammation of the colon) and stated that those precautions included hand hygiene, gloves, and gown and acknowledged that she did not follow infection control policy. Upon acknowledging that she had violated infection control policy, Staff J3 continued down the hall and failed to wash her hands. During an interview on 11/30/23 at 4:00 PM, Staff E, Infection Control, stated that C-diff requires, “Contact Precautions Plus” and includes mandatory glove and gown use and requires hand hygiene upon entering room and washing hands with soap and water upon exiting. Staff E stated that failure to follow required contact precautions could lead to spread of a highly contagious bacterial infection to other patients, staff, or visitors. Review of a document titled, “Active Isolation Line List”, provided by the hospital on 11/30/23 at 3:35 PM, showed that Patient 7 was on Contact Plus Precautions with an isolation start date and time of 11/15/23 at 11:47 AM. Review of Patient 7’s medical record failed to show documented evidence of an isolation order to reflect isolation precaution status as required per hospital policy. Review of a document titled, “Active Isolation Line List,” provided by the hospital on 12/05/23 at 11:42 AM, showed Patient 7 as a Clostridium difficile (C. diff) patient on contact plus precautions (infection control prevention guidelines used in cases of C-diff that includes the following: upon entrance - perform hand hygiene, put on and tie gown, cover cuffs with gloves. To exit - remove gloves, remove gown, wash with soap and water). Patient 16 Review of Patient 16’s medical record showed a 72-year-old male admitted to Hospital 2 (H2 - an off-campus hospital location) Behavioral Health Unit on 11/22/23 with diagnoses of COVID-19 (severe acute respiratory infection), confusion and weakness. During an observation at on 11/27/23 at 12:20 PM, showed Contact Droplet signage on Patient 16’s door. Staff S, PCT, was observed sitting in room with door shut with a surgical mask under her chin, not covering her nose or mouth. Staff S, PCT, failed to follow infection prevention guidelines by failing to wear PPE appropriately for a COVID-19 patient as required per facility policy. Patient 21 Review of Patient 21’s medical record showed a 29-year-old female that presented to the ED on 09/21/23 at 1:01 PM and was admitted inpatient on 09/21/23 at 10:44 PM, with diagnoses of atrial flutter with 2:1 block (heart murmur centered in upper chambers of heart causing irregular heart rhythm), lightheadedness, and sepsis (infection in blood stream). Review of a document titled, “Active Isolation Line List”, showed Patient 21 positive for CRE (Carbapenem-resistant Enterobacterales (CRE) are a serious threat to public health. Infections with CRE are difficult to treat and have been associated with mortality rates of up to 50% for hospitalized patients) on 11/22/23 as a fourth patient identified as contracting hospital acquired CRE. Review of Patient 21’s medical record failed to show documented evidence of an Infectious Disease Screening or screening of the patient for condition requiring transmission-based precautions upon patient admission as required per facility policy. Patient 48 Review of Patient 48’s medical record showed a 46-year-old male that presented to the ED on 01/01/24 at 8:06 PM with a chief complaint of suicidal ideation (thoughts about ending one’s own life) and psychosis (severe medical condition where thoughts and emotions are affected, and patients have trouble differentiating between real and what is not real). Further review of the medical record showed that Patient 48 was positive for COVID-19 on 01/01/24 at 11:28 AM. During an observation at H2 on 01/02/24 at 3:40 PM, showed Patient 48 moving around a closed unit of the ED, Zone 2 (an area in the ED that is locked to prevent patient elopement) without a mask covering the mouth and nose. Observation of the nursing care area failed to show PPE present including gown, face shields, or N95 masks for staff use and failed to show signage present on Patient 48’s door identifying isolation precaution as required per facility policy. During an interview on 01/02/24 at 3:40 PM, Staff Q6, RN, confirmed that Patient 48 was not to be out of his room without wearing a mask. During an observation on 11/27/23 at 11:00 AM at H1, an unidentified staff member was observed starting an IV (intravenous - a device placed into a vein and used to administer medications) on an unidentified patient with a partially ungloved hand. This same staff was then observed touching the Computer on Wheels with a dirty gloved hand. No hand hygiene was observed after direct patient contact. During an observation on 11/27/23 at 11:12 AM at H1, an unidentified RN was observed starting an IV on a patient in the ED. Unidentified RN then observed removing IV after unsuccessful placement and, without removing or changing gloves and without performing hand hygiene, proceeded to touch computer on wheels in patient care area with contaminated gloves. During an observation on 11/27/23 at 11:15 AM at H1 Emergency Department Room 42, a food tray of uneaten food was observed on top of a dirty linen cart. Staff were unsure if the patient had refused the food tray or not. During an observation on 11/27/23 at 11:49 AM at H1, a housekeeping staff member was observed touching cleaning items on environmental services (EVS) cart and without changing gloves or performing hand hygiene, placed contaminated gloved hands onto top of dietary cart containing patient meal trays being delivered by dietary services staff member. During an interview on 11/30/23 at 1:41 PM at H2, Staff K3, Touchpoint Patient Services Manager stated that she manages the culinary ambassadors and they put the food trays together and deliver to patients. The expectations are to wash hands prior to taking a cart to the floor. The expectations is for the staff to foam in and foam out, verify the patient, and go over the meal with the patient. The staff are to follow signage on the doors of isolation rooms and put on proper PPE. They are not to go into rooms with “blue/purple” airborne or COVID rooms. We leave trays in rooms. They receive annual blood borne pathogens education and upon hire. They are to only place the food tray on the bedside table and are to never leave their food cart unattended. During an interview on 11/30/23 at 2:02 PM at H1, Staff L3, Touchpoint Assistant Director Food Nutritional Services stated that it is the expectation that hand hygiene is always performed when preparing, touching, serving or handling of any foods. Gloves are always to be worn during food handling and tray preparation. There is no exception this is the expectation. I usually do rounds to observe twice daily on staff. During an observation on 11/29/23 at 1:30 PM at H1, Staff N2, RN, and O2, RN, were observed in the Emergency Department (ED) performing wound care with no gloves and failed to perform hand hygiene after patient contact. During an interview on 11/29/23 at 3:31 PM H1, Staff NN, Wound Care RN, and Staff O2, Wound Care RN, stated that glove use is required with any patient contact and failure to do so would be a direct violation of facility infection control policies and would pose a risk of infection to patients. During an observation on 11/29/23 at 1:41 PM at H1, two unidentified staff members were observed handling blood specimens without gloves and placed blood specimens on a computer without performing hand hygiene. During an observation in the Coronary Intensive Care Unit (CICU) on 11/27/23 at 12:01 PM at H1, an unidentified RN was seen providing oral suctioning for a patient on contact precautions. The unidentified RN failed to don appropriate gown as required for contact precautions per facility policy. The unidentified RN then removed gloves and exited room failing to perform hand hygiene. During an observation in the Medical Intensive Care Unit (MICU) on 11/27/23 at 12:08 PM at H1, Staff W7, DO, was observed in a patient room that was in contact/airborne precautions. Staff W7, exited room and removed N95 mask, holding it in ungloved hands while speaking with other staff in hallway. Staff W7 threw mask in trash after approximately 1 minute and then proceeded to touch non-disposable stethoscope and white coat without performing hand hygiene. During an observation on 11/27/23 between 12:18 PM and 12:40 PM showed multiple hospital staff in contact precaution rooms, including patients with positive cases of COVID-19, Methicillin-Resistant Staphylococcus Aureus (infection that is resistant to some antibiotics) (MRSA), and Hepatitis C (viral infection that causes liver swelling), without wearing required PPE, failed to wear face masks appropriately, and failed to perform hand hygiene when exiting patient rooms. Staff C, RN, confirmed that patient rooms observed were under contact precautions for COVID-19, MRSA, and Hepatitis C. During an observation on 11/27/23 at 12:18 PM at H2, Staff E2, Radiology Student, was observed walking out of an ED room wearing contaminated gloves and holding contaminated linens. Staff E2 was then observed putting the contaminated linens in adjacent room, grabbed papers and carried them with the contaminated gloved hands. Staff E2 failed to perform hand hygiene. Review of Patient 29’s medical record showed a 64-year-old male admitted to H2 Behavioral Health Unit on 11/29/23 with an admitting primary diagnosis of Pneumonia. During initial tour on 11/27/23 at 12:35 PM at H2 with Staff C and Staff D2 on Floor 7 East, also known as 7PI [Psychiatric Intermediate], this surveyor observed patient 29’s room to have an unidentified patient sitter and a telesitter [mobile video monitoring device] present in the room. Patient door was identified with a contact precautions placard on door. No personal protective equipment [PPE] was observed. Sitter was in chair next to patient at window. Door to room closed. The unidentified patient sitter did not have appropriate PPE on while sitting next to the patient, as required per facility policy. During tour on 11/28/23 at 11:05 AM at H2, Patient 16’s room now empty and being cleaned. Staff C2, Director of BHU, stated that the patient was discharged this AM The patient had a diagnosis of COVID which is why he was on contact precautions on 11/27/23. Housekeeping was observed throughout cleaning process via in room camera transmitting to the nurses station. Housekeeping staff was observed wearing gloves but no other PPE. When cleaning the bed, for example, the cleaning occurred from the inside out. The center of the mattress to the edge of the mattress, thus causing the clothing being worn by housekeeping staff to come in contact with the uncleaned portion of the mattress and railing. Cleaning then continued to the inside of the railing, with housekeeping staff leaning over and coming in full contact with the outside of the railing. The outside of the railing was the last contact surface to be cleaned on the bed. Cleaning continued throughout the room with some surfaces cleaned more thoroughly than others. During an observation on 11/28/23 at 11:05 AM at H2, 7 East Psychiatric Intermediate Unit, observation continued in the nourishment room. During observation the refrigerator, microwave, sink, ice maker, and refreshment cart, were dirty. A stained incontinence cloth was being used as tablecloth. The nourishment cart lacked organization, the second shelf of the cart had multiple zip lock bags and cup lids that were uncovered. The third shelf had a bath basin filled with zip lock bags of sweeteners, cleansing wipes, and paper and plastic bags. Review of refrigerator log for 11/2023 showed there were 6 times (11/01/23, 11/10/23, 11/21/23, 11/22/23, 11/29/23, and 11/30/23) that a temperature was not recorded. Further review of the temperature log showed 4 days where the refrigerator temperature log was out of range. There were three days 11/03/23, 11/17/23, and 11/18/23 where the temperature range was below 34 degrees. There was one day 11/08/23 where the temperature was above the recommended temperature of 41. The thermostat regulator but was malfunctioning on 7 days where the nursing staff was unable to clear the minimum or maximum temperature range. There was no documented evidence of actions taken to correct improper temperatures or the thermostat malfunction. During an observation on 11/28/23 at 11:06 AM at H2, 7 East Psychiatric Intermediate Unit (PIU) showed Staff R, RN, exiting Patient 30’s room and she did not remove her gloves, Staff R walked down the hall and went to another area of the unit, exchanged something and came back to the room with the same gloves on. Staff R failed to remove gloves and perform adequate hand hygiene. During an interview on 11/28/23 at 4:59 PM, Staff R, RN stated that she has been with this hospital since September 2023, and she has been a nurse for over 4 years. Staff R stated that with Contact precautions the staff would only need to wear gloves, the staff would only wear a gown if there was drainage or a chance for staff to encounter bodily fluids. Staff R stated that with Droplet precautions the staff would wear gloves, gown, and masks. When asked specifically about Patient 30, Staff R stated that Patient 30 is in just contact precaution, and that she did his dressing change for his surgical incision, and it was not draining. Staff R stated, “So, I didn’t think I needed to wear an isolation gown. If his wound was draining or I anticipated encountering other bodily fluid, then I would have worn an isolation gown and the other necessary PPE’s.” Staff R stated that staff normally take off the plastic isolation gowns in the brown paper trash bag room and will wash their wash their hands in the sink in the patient rooms. Staff R stated that the trash is usually emptied after meals, with gown changes, or changing the patients briefs and we take it with us to the soiled utility room and discard. During an observation on 11/28/23 at 11:59 AM at H2, in room 613 had a strong odor of urine, the bed was disheveled, and the linen thrown on the floor and in the plastic chair. The failure to maintain a clean environment has the potential to place the patient at risk for infection. During an observation on 11/28/23 at 12:25 PM at H1, Staff P, RN, was assisting with a sterile procedure in a contact precaution room that requires use of gown and gloves. Staff P was not wearing proper PPE (gown) as required per hospital policy. During an observation on 11/29/23 at 1:35 PM at H1, an unidentified housekeeping staff member was observed emptying trash and changing trash bag without donning gloves. The unidentified housekeeping staff member was then observed touching her personal cell phone without performing hand hygiene as required by hospital policy. During an observation on 11/29/23 at 1:38 PM at H1, an unidentified ED, RN was seen coughing into open hand and then touched computer on wheels without performing hand hygiene as required by hospital policy. During an observation on 11/29/23 at 1:45 PM at H1, an unidentified physician was seen touching an unidentified patient for assessment without gloves as required by hospital policy. During an observation on 11/29/23 at 1:41 PM at H1, one unidentified RN and one unidentified paramedic observed in the ED handling blood specimens without gloves. The unidentified paramedic was seen placing the blood specimens on computer on wheels without performing hand hygiene or donning gloves as required by hospital policy. During an observation in H1’s ED on 11/29/23 at 1:46 PM, an unidentified RN was observed walking out of an unidentified patient room with a mask under her chin and without gloves. The unidentified patient was in contact/droplet precautions. The unidentified RN failed to wear the mask appropriately and failed to perform hand hygiene before entering or exiting the patient room as required by hospital policy. During an observation on 11/29/23 at 1:46 PM at H1, Staff J2, Physician, Staff K2, Physician Assistant (PA) student and another unidentified provider were seen exiting patient room 6041 without performing hand hygiene as required by hospital policy. During an interview at the time of the observation, Staff K2 stated that all staff must “foam in and foam out” (hand hygiene) when entering and exiting a patient room. Staff K2 stated that failing to perform hand hygiene places patients and others at risk for the spread of infection and other blood borne pathogens. Staff K2 acknowledged he failed to perform hand hygiene when exiting a patient’s room but did not explain why he failed to follow hospital policy. During an observation on 11/29/23 at 1:52 PM, at H2, Staff M2, RN, performed direct patient care and then failed to perform hand hygiene when exiting the patient room as required by hospital policy. During an interview at the time of the observation, Staff M2 stated that she did not perform hand hygiene when exiting the patient room as required by hospital policy because she did not touch the patient. She went on to state she only had the patient sign a document with her personal pen and then placed the pen back in her pocket. During an observation on 11/29/23 at 2:52 PM at H2, Staff D3, RN was observed walking out of a patient room wearing a surgical face mask and gloves. The patient’s door showed an Airborne and Contact Precaution sign and an N-95 box tape to door. Staff D3 failed to don proper PPE for an Airborne Contact Precaution patient as required by hospital policy. During an interview at the time of the observation, Staff D3, RN, stated that the unidentified patient had a diagnosis of COVID-19. Staff D3 went on to state that Airborne and contact precautions require the staff to wear googles, gown, gloves and N-95 mask. Staff D3 stated, “I have been working here for about a month, I’m a traveler. Hand hygiene is in and out of rooms washing hands for 45 seconds, after contact with patient or body fluids and always between patients. So you don’t spread germs.” During an observation on 12/05/23 at 10:49 AM at H1, an RN entered an unidentified patient’s room who was on contact/droplet precautions. During an interview at the time of the observation, the unidentified RN stated that the patient was positive for COVID-19 and was on a ventilator (machine to help individuals breathe). The unidentified RN failed to don appropriate PPE and failed to perform hand hygiene prior to entering or upon exiting the patient room as required by hospital policy. During an observation on 12/05/23 at 10:49 AM at H1, Pediatric Intensive Care Unit (PICU) an unidentified RN was seen providing direct patient care to a patient in contact/droplet isolation precautions with no gown or gloves. An unidentified RN identified the patient had a diagnosis of Respiratory Syncytial Virus (RSV - contagious infection of the respiratory tract). There were no accessible PPE available at the entrance of the patient’s door for staff members as required by hospital policy. During an observation on 12/05/23 at 11:03 AM at H1, ED showed an unidentified RN starting an IV on an unidentified patient. During the procedure, the RN ’ s gloves were contaminated with the patient’s blood. The RN failed to remove and discard the contaminated gloves or perform hand hygiene as required per hospital policy. The RN then attempted to clean the bloody gloves with a cotton ball and retrieved laboratory specimen tubes from a clean supply cart sitting adjacent to the nurse. The RN passed the laboratory tubes to another RN who took the tubes without wearing gloves. Both RNs failed to put on and remove gloves and failed to perform appropriate hand hygiene as required by hospital policy. During an observation 12/05/23 at 11:07 AM at H1’s, ED an unidentified male RN was observed holding blood specimens with contaminated gloves. The unidentified RN placed blood specimens on computer at nursing station where open drinks were present before placing specimens in bag for transport to laboratory. During an observation on 01/02/24 at 10:28 AM at H1, Staff, U7, Certified Registered Nurse Anesthetist (CRNA) was observed giving IV medications and then touching computer without donning gloves or performing hand hygiene as required by hospital policy. During an interview on 11/27/23 at 4:07 PM at H2, Staff E, Director of Infection Control, stated that the hospital had observed and identified areas for improvement in infection control, specifically cleaning of equipment, hand washing and hand hygiene, and room cleaning. Staff E was unable to identify when deficiencies in infection control became an issue and stated, “it has been ongoing.” During an interview on 11/28/23 at 11:06 AM at H2, Staff C2, Director of Behavioral Health, stated that personal protective equipment (PPE) is stored in the Ante Room, and staff should put on and take off PPE in the Ante room. The staff try to keep patients in isolation near the Ante Room but if the staff are not able to do that then they will put on the PPE in the Ante Room then walk down the hall to the room. During an interview on 11/29/23 at 1:50 PM, Staff Z2, Phlebotomist, stated, “...You use hand hygiene going in and out of rooms and if you don’t it spreads germs to everyone.” During an observation leaving room 501, Staff Z2 exited room pushing cart with no hand hygiene noted as required by hospital policy. During an interview on 11/29/23 at 3:00 PM at H2, Staff T2, Chief Nursing Officer (CNO), stated that it is the expectation for all employees to follow infection control practices and that every staff member should, “foam in and foam out” when entering or exiting a patient room. He stated that failure to perform hand hygiene increases the risk of patient infection. During an interview on 11/29/23 at 3:21 PM, with Staff E, Infection Control, and Staff R2, Environmental Services (EVS) Director, Staff E stated that after every isolation, there is a terminal clean completed. Staff E stated that the expectation for staff is to keep the room clean with no trash on the floor, even while patient is in isolation. Staff R2 stated that the process is the same for most isolation terminal cleans but they change the chemicals depending on what the patient is on isolation for. Staff R2 stated that EVS dons appropriate PPE prior to entering room and stated that the expectation is for EVS is to bag equipment if it needs to be transported to another location for cleaning, or to clean it while in room. Staff R2 states they get the page for the terminal clean which states what type of clean needs to be completed. Staff R2 stated that if there is confusion on what terminal cleaning policy to follow, EVS is required to go ask staff on unit to ensure proper cleaning is completed. Staff R2 also stated that EVS is required to put on gloves when emptying any trash at the facilities. During an interview on 12/04/23 at 2:37 PM, with Staff T2, CNO, Staff Q, Chief Administrator Officer, and Staff E, Infection Control, Staff Q stated that there was a campaign a few months prior that showed a need for an increase in hand hygiene education. Staff Q stated that they started a program that included a video every week. Staff Q stated that because of observations completed by state surveyors, they have decided to implement a more aggressive action plan. Staff Q stated that the week prior, they started to complete rounding and put together a competency sheet for observations. Staff T2 stated that they complete rounding 24 hours a day, 7 days a week, and the sheets completed during rounding are going to quality to trend.”

“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: 47233 Based on observation, interview, policy and document review the hospital failed to provide an adequate clean and sanitary environment for all patients currently at this hospital receiving dietary services. This deficient practice effects all patients receiving dietary services at this hospital and has the potential to place them at risk for food borne infection, or other adverse outcomes. Findings Include: Review of hospital policy titled “Infection Prevention and Control Program” revised 02/03/22 showed “Policy; 4. The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide leadership in the following activities: e. Maintain a sanitary hospital environment. f. Develop and implement infection control measures related to healthcare workers. Healthcare workers, for infection control purposes, includes all hospital associates, medical staff, contract workers, (e.g. agency nurses, environmental staff, facilities staff etc.), and volunteers...k. Monitor compliance with all policies, procedures, protocols and other infection control program requirements...2. All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations...14. Environmental Services/ Touchpoint; a. Maintain a clean and sanitary environment free of risk of infection... Review of hospital document titled “Food Storage Chart” undated showed “Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer’s date is earlier. The day of opening/preparation counts as Day 1. Dry Storage...30 days. Oil, 60 days, Syrup, Peanut butter, 6 Months, or the manufacturer’s expiration date, if sooner...Honey ...Rice, pasta, flour, dehydrated potatoes, sugar; Within 1 Year of delivery, or the manufacturer’s expiration date, if sooner, All unopened canned, carton boxed, or bottled goods, Spices; Refrigerated Storage; ...4 days Unused portions of foods prepared on site that are reheated for service, such as rice, vegetables, soups, gravies and meat sauces...7 days Cheese - all cheeses except hard cheese (14 days),...30 days; Salad dressings, mayonnaise, tartar sauce, Cake icing (shortening based) ...60 days; Ketchup, BBQ, Tabasco, steak sauce, mustard, horseradish, relish, pickles, natural peanut butter, Sauces - chocolate, caramel, strawberry...” Review of hospital policy titled “Production, Purchasing, Storage” revised 12/2017 showed “Subject: Food Handing Guidelines (HACCP); Preparation of Produce; Wash hands and wear disposable gloves when handling raw produce or ready to eat foods ...Inspect all produce for damage. Discard severely damaged produce or remove damaged areas plus one inch beyond damaged area. If damaged area can not be removed without contaminating the remainder of product, discard product. Prepare produce using clean, sanitized utensils, sanitized cutting board, work areas and sinks... During an observation on 11/28/23 at 11:32 AM, of the kitchen area located in the basement, showed food debris and trash on the sticky floor. Opened personal drinks were located in the cooking area. Cooking pots and pans on a large rolling stainless-steel cart had visible food debris on cart and in on cooking pans. Cutting boards were stacked on stainless steel shelf with visible food debris. A stainless-steel cart had food debris and a spray bottle labeled sanitizer with a box of food service plastic cups. A stainless steel coffee maker and stainless-steel tea dispenser had visible food debris, liquid smeared on the dispenser handles with visible debris. On a shelf below the coffee and tea dispenser was a plastic container with a brown liquid substance at bottom of container labeled regular. The stainless steel shelf was visibly soiled with food debris and there was one large white safety and sanitation dispenser for plastic film and foil that had visible food debris and opened plastic replacement filters. The next shelf below had visible food debris on containers next to a spray bottle and red bucket labeled Kleen-Pail sanitizer. The bucket had brown liquid half way up the bucket. On a rolling stainless steel cart was a large plastic container with several brown spotted bananas with no label and large plastic container of red grapes with no label. A clear plastic container with red lid that was visibly dirty had what appeared to be a white chocolate chips with no label. There was a clear plastic container with an open red lid with chocolate chips, and an open baking soda box with a best if used by July 22, 2023 date. There was a stainless-steel container with visible food debris containing multiple knifes with visible food debris on them. There was also an opened used container of peanut sauce with approximate ¼ used on the lower shelf of stainless-steel counter showing refrigerate after opening, there was no date of when the peanut sauce was opened. The microwave had visible food debris on door and button controls and visible food debris under and around microwave. During an observation on 11/28/23 at 11:39 AM of Kitchen refrigerator located in basement, showed, a used bottle of salsa 1/3 full, with plastic saran wrap attached to upper part of bottle that had a hospital sticker label that showed a good thru date of 11/23/23. There was sliced yellow cheese in plastic bag with use by date of 11/21/23 and what appeared to be white and purple frosting in plastic bags that was undated. During an observation on 11/28/23 at 11:41 AM in the Kitchen walk in cooler located in the basement showed: 1. A “Garlic in Oil” container with a hospital sticker label good thru date of 10/28/23 and manufacture best by showed 09/23/23. 2. An opened rice vinegar with hospital sticker label good thru date of 09/29/23. 3. A container of ham base with hospital sticker label good thru date of 10/22/23, 4. A container of chipotle base with hospital sticker label good thru date of 10/22/23. 5. A container of horseradish sauce with hospital sticker label good thru date of 10/08/23. 6. A container of sweet and sour sauce with hospital sticker label good thru date of 11/20/23 7. A container of Worcestershire sauce with hospital sticker label of good thru date of 09/02/23 8. A container of Dijon mustard with hospital sticker label of good thru date of 09/08/23. 9. A container of vinegar with hospital sticker label of good thru date of 09/02/23. 10. A container of Mayonnaise with hospital sticker label of good thru date of 11/19/23 11. A stainless steel container with partially covered black beans with hospital sticker good thru date of 11/23/23. 12. A stainless steel container of gravy with a crusty top partially opened with hospital sticker label good thru date of 12/01/23. 13. A clear container of sausage patties partially covered with hospital sticker label good thru date of 11/30/23 14. A plastic bag of cooked rice with a hospital sticker label with good thru date of 11/27/23. 15. A covered plastic container of cooked pasta with hospital sticker label good thru date of 11/24/23. 16. A partially covered stainless steel container of cooked pasta with hospital sticker label of good thru date of 11/24/23. 17. A stainless steel container of chicken gravy with hospital sticker label of good thru date of 11/27/23. 18. A box of celery with stalks that have brown film down the entire stalk, wilted brownish yellow leaves with date of 11/08/23 on box. 19. A box of 1/8 shred lettuce 4/5 lbs. bags with best used by date of 11/25/23 showing brownish wilted lettuce in bags. 20. A bag labeled “Fresh Thyme” dated 09/29/23 showed wilted brownish sprags of thyme. 21. A bag labeled “Fresh Mint” dated 11/10/23 showed wilted shriveled up brownish green leaves. 22. A bag labeled “Fresh Oregano” dated 11/15/23 showed condensation in bag with shriveled up brownish leaves. 23 A bag labeled “Fresh Sage” dated 10/30/23 showed shriveled up brownish leaves. During an observation at Hospital 2 (H2 - an off-campus hospital location) on 11/29/23 at 8:15 AM, Staff HH, Cook was handling food without gloves. Staff HH, cook, stated “I’m making Chinese food today for lunch.” During an observation at H2 on 11/29/23 at 8:15 AM Staff II, Cook was only wearing one glove while handling food. During an interview on 11/28/23 at 11:32 AM Staff U, Food Service Director, stated “We will do better and get it cleaned up. I will throw away all the expired food.” During an interview on 11/28/23 at 11:40 AM with Staff V, Head Chef, stated “we just got behind throwing food away with expiration dates since it was over the weekend.” During an interview on 11/29/23 at 9:20 AM, Staff V Executive Chef, was asked about his understanding of the hand hygiene policy, stated, “staff should change their gloves and wash their hands whenever they change task or walk away from your station.” Staff V Executive Chef stated, “the staff are expected to wash their at least three times or every half hour.” Staff V stated that if an employee is observed no following hand hygiene guideline the employee will first get a verbal warning, if the behavior continues then it would be a written write up. When asked about what the risks are regarding staff following proper hand hygiene Staff V stated, “the patients are risk for developing a food borne illness.” During an interview on 12/14/23 at 9:56 AM Staff DD, RN CNO (Chief Nursing Officer) stated, “I have not been downstairs to the kitchen, but I expect it to be clean and sanitary with expired food to be removed.””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 47233 Based on document review, record review, staff and patient interview, the hospital failed to ensure staff followed policy and procedure to achieve and maintain patient care that meets the standards of medical practice and patient care for 3 of 8 patients surgical records reviewed (Patients 54, 39, and 42). This deficient practice has the potential to place patients at risk for physical harm during surgical procedures. Findings Include: Patient 54 Review of Patient 54’s medical record revealed the patient was seen on 01/19/23 for outpatient surgery at Hospital 2 [H2 - an off-campus hospital location] for a planned Esophagogastroduodenoscopy [EGD] [a test to examine the lining of the esophagus, stomach, and the first part of the small intestine, the duodenum] and a Colonoscopy [a test to examine the entire colon, large intestine, and rectum]. Review of the pre anesthesia note dated 01/19/23 at 1:07 PM by Staff K6, Anesthesiologist, included history of “seizure + CVA [Cardiovascular accident] 2001 left side loss of sensation uses cane.” Problem list included “morbid obesity” [129.4 kg or 285lbs] and “chronic neck pain, coronary artery disease, enlarged heart.” Review of progress note dated 01/19/23 at 5:25 PM by Staff M7, Surgeon, revealed “During the EGD [shortly after duodenal biopsy was performed], while in the left lateral recumbent position, patient rolled backwards on the stretcher and slid slowly onto the floor. The bed rail was down in order for accommodate the position of the endo cart. His head and neck were supported by CRNA [Certified Registered Nurse Anesthetist] and did not hit the floor. The scope was withdrawn from the patient and the exam was aborted. The patient was lifted back onto the bed with assistance of additional staff members. He remained hemodynamically stable [blood pressure and heart rate] throughout. The gastroscope was reinserted for a quick examination to ensure no trauma or bleeding had occurred. Upon awakening, patient was assessed by anesthesia and myself. . .” Review of anesthesia record dated 01/19/23 “free notes” by Staff V7, CRNA, revealed at “16:28 [4:28] PM Filling additional propofol [a short acting intravenous anesthetic] syringe. Standing at pyxis [a drug supply management machine]. Surgeon and scrub started to yell for help. When turning to assist, patient was rolling backwards on bed from force of surgeon advancing scope. Bed rail on back of patient was not in place. Scrub indicated that this is for the scope to be able to reach patient for procedure. Immediately protected patient’s head and held it securely as he started to roll off the bed. Assisted patient in guided fall to floor. Notified [Staff K6] of current situation at 1629 [4:29 PM]. Discontinued propofol gtt [drip] after patient stabilized on floor.” “Transport at 16:57 [4:57] CRNA VSS (vital signs stable) upon PACU [post anesthesia care unit] arrival. Patient neurologically intact. Able to move hands and feet. Denies numbness/tingling in extremities. Patient stated he did have a headache that was increasing. [Staff K6] notified of patient status. Will continue to follow up as indicated.” Review of note from Staff M7, Surgeon, on duodenum biopsy report dated 01/22/23 revealed “I believe that the polyp in the stomach is contributing to the iron deficiency anemia. I have requested my procedure scheduler reach out to you to schedule another EGD so that I can remove the polyp.” Review of document titled “Staff Meeting - February 2023” revealed “Patient Safety Changes: Remember on Endoscopy cases either the scrub or RN is to remain on the backside of the patient at all times if the bedrail is down. NO EXCEPTIONS.” During a telephone interview on 01/05/24 at 9:18 AM, Staff M7, Surgeon, stated “We had just started and he had woken up and started moving around. He was under sedated. I don’t know what happened, why he was waking up, but he woke up, rolled over and slid off the bed in the middle of my exam. It was like a slow roll and not fast with a thump. So, the way the bed is set up, the tower is positioned behind the bed then the patient on the bed and endoscopist behind patient on the other side. So, me, on one side, the tower is on the other side. I guess you could say the tower caught his fall. So, rather he slid off bed and wedged between the bed and the tower. But he eventually ended up on the floor...oh the other thing, the CRNA used both hands to catch his head, so his head never hit the floor. Obviously, we ended the procedure and got him off the floor. It took quite a few of us. We got him back up. Obviously, the procedure didn’t proceed...Since that procedure [colonoscopy] not done, it was rescheduled.” During an interview on 01/05/24 at 11:15 AM Staff V7, CRNA, stated...”Usually there’s someone on that side of the cart. I had turned to go to the pyxis to get more propofol. The surgeon had shoved the scope and there was no one behind the patient and the patient started to roll and I ran over and assisted patient to floor...he was under a total IV [intravenous] anesthetic...he was completely sedated. Not conscious of his surroundings...Typically, in these cases, there’s a roll behind patient. There was no roll. The scrub went to surgeon’s side without placing bedrail up...he rolled into the endoscopy cart. That’s probably what gave me time to get over there and help him down and support his head and neck.” During an interview on 01/04/24 at 11:34 AM Staff J7, Certified Surgical Technician [CST] stated...”doing the EGD portion of it and surgeon, [Staff M7] was wanting to take biopsies. I’ve done specialty GI [gastroenterology] for the past 3 years...I had positioned the patient so we could go from the EGD to the colonoscopy and [surgeon] was complaining that biopsy forceps weren’t going down scope the way [surgeon] wanted and [surgeon] wanted me on the other side of the patient bed. I refused and [surgeon] was getting irritated. So finally, I went over and the patient’s arm which I will usually position in front of them so it will counterbalance weight and it had been moved on their side and was falling off. The patient was a large patient...but I saw him starting to go and I actually went over the bed with the patient and had a hold of his neck and his body. He fell into the cart. It was up next to the bed. It blocked him and it was moving backwards, and I was lowering him to the ground as best I could. The CRNA was assisting as well. The surgeon wanted to continue, and anesthesia said no. That’s what stuck out to me was [surgeon] wanted to continue. No bleeding. He said he was sore. As far as I know, he wasn’t hurt. We woke him up completely in the room. The anesthesiologist [Staff K6] came in room and did neuro check. I believe patient even went up for imaging...” During an interview on 01/05/24 at 10:58 AM, Patient 54 stated that when he woke up they told him he fell. After he complained of his head hurting, a CT [computed tomography - imaging used to detect injury] scan was done. He confirmed he was not awake during the EGD. He was told he rolled off the table, but no one knew why. The pain in his head and back along with the bruising on his hip and back lasted for weeks but he did not know what to do about it. He stated he did not receive any pain management after the fall. No one called to follow up with him regarding the incident. The facility did not provide evidence of investigation regarding this incident. The incident log documented a recap of events with a designation of “E - Mild Harm.” During an interview on 01/04/24 at 1:40 PM with Staff S6, RN Director of Surgical Services stated that the following measures have been implemented. “If a person has to leave and the rail needs to be down, then someone else has to assist or they call another scrub in...Unfortunately, that doctor was new to us. She doesn’t come to this facility anymore. We just had a short period of time when a different GI [gastrointestinal] group was coming here. Now they’re not.” When asked if there were policy changes Staff S6 responded “I would call it more of a workflow change.” The hospital failed to provide any policy and procedure that addressed safety precautions related to gurney size, safety straps or adequate staffing in surgical suite to monitor patient safety. Patient 54 fell from the gurney in the middle of a procedure while sedated causing pain and bruising to patient’s head, hip and back. Patient 54 had to reschedule both the EGD and Colonoscopy, the EGD was repeated for polyp removal not completed and the colonoscopy which was not done at all. This resulted in additional anesthesia exposure and increased risk to a patient with history of multiple cardiac diagnoses as well as risk for aspiration or pneumonia. Patient 39 Review of Patient 39’s medical record revealed the patient was seen on 11/20/23 for outpatient surgery at H2 for a planned Laparoscopic Cholecystectomy [a procedure to remove the gallbladder]. Review of Preop Allergy List dated 11/17/27 at 10:07 AM completed by Staff RN, included “Anectine - [succinylcholine chloride is a skeletal muscle relaxant for IV administration indicated as an adjunct to general anesthesia] Reaction - Severe.” Review of Pre-Anesthesia record dated 11/20/23 at 6:30 AM by Staff K6, Anesthesiologist, anesthesia history included “patient’s history: pseudocholinesterase deficiency, [a rare disorder that makes you sensitive to certain muscle relaxants - succinylcholine - used during general anesthesia] delayed emergence separate from pseudo choline...Severe reaction to: Anectine”” Review of Anesthesia Record page 3 dated 11/20/23 revealed a time listing that includes the following “7:12 . . . chart review; 7:19 intubated; 7:34 surgery start; 8:15 surgery stop.” “Free Notes” by Staff J6, CRNA revealed “8:41 - Delayed waking up. Case discussed with [Staff K6, anesthesiologist]. Decision to continue sedation for prolonged wake up made. Awaiting further instruction for post op care. 8:53 - Sedation with propofol gtt determined, will remain on ventilator in PACU. 9:07 - Patient remains paralyzed, decision to go to PACU on propofol gtt awaiting reversal of NMB [neuromuscular blockade aka anesthesia]. Report given to RN. Patient remains of[sic] 30 mcg/kg/min of propofol. MDA [medical doctor of anesthesia] aware.” Review of Anesthesia Record dated 11/20/23 revealed the following drugs utilized between the surgical stop time of 8:15 AM and transfer to PACU at 9:07 AM. 8:19 AM Sugammedex 200 mg IV [to reverse sedation] 8:30 AM Naloxone .4 mg IV [to reverse sedation] 8:32 AM Naloxone .4 mg IV 8:51 AM Phenylephrine .1 mg IV [treat hypotension, low blood pressure, during anesthesia] Review of Medication Record dated 11/20/23 revealed the following Propofol [anesthetic] detail following transfer to PACU. 9:03 AM Propofol 30 mcg/min 9:55 AM Propofol 35 mcg/min 12:00 PM Propofol Discontinued Review of Assessment Notes dated 11/20/23 revealed the following: 10:45 AM moves 4 extremities voluntarily or on command [continued status from this point on] 12:00 PM can maintain greater than 92% O2 Sat [Oxygen saturation] on room air 12:00 PM Extubated 1:10 PM 2 person assist with ambulation 1:10 PM left extremities; active movement with decreased strength 2:10 PM 1 person assist with ambulation 2:45 PM left extremities; active movement with decreased strength Review of Document titled Surgical Services Safety Huddle Notes dated January 2024, the following Action Item was included, “Anesthesia Timeout will go into effect 1/5/2024” Review of Document titled “Ascension Via Christi Surgical Services, Anesthesia Time Out - SBAR” [situation, background, assessment, recommendation] revealed the instruction to “Implement the Anesthesia Time Out for AVC [Ascension Via Christi] Wichita hospitals...in any procedural areas requiring anesthesia services.” The SBAR instructs that the anesthesia time out should be led by the anesthesia attending or designee, documented by the RN circulator and be completed while patient is awake with review of name, date of birth, procedure, allergies, type of anesthesia plan and any other relevant anesthesia concerns. During an interview on 01/05/24 at 10:29 AM with Staff J6, [CRNA], stated...”When ready for induction, hook up to monitors, call to anesthesia and we’ll be told to proceed, generally. Then we’ll proceed. Generally, they’ll [anesthesiologist] be in the room but it doesn’t occur all the time. Anesthesiologists will put a note in chart essentially past medical history, allergies, and I’ll review that chart prior to induction.” Staff J6, CRNA verbalized knowledge of contraindications of succinylcholine being pseudocholinesterase deficiency, [a rare disorder that makes you sensitive to certain muscle relaxants - succinylcholine - used during general anesthesia]...Staff J6 stated “Upon wake-up patient didn’t have amount of twitches I would normally experience. Weakness. I called [Staff K6, Anesthesiologist] We devised plan that we would continue to sedate on propofol and remain intubated and when she...would be extubated.” Staff J6, CRNA, acknowledged allergies were listed on patient’s chart, including Anectine [another name for Succinylcholine]. Staff J6 verbalized that some items in the precheck list are prepopulated and appear in a different format on the monitor utilized during surgery, smaller and boxed in, but would include anesthesia history. Staff J6 stated “there’s a possibility that when I was reading this chart, I was asked a question. Perhaps I went back to the more bold part here. [referring to another section of chart]” Staff J6 stated that the anesthesiologist was not present during induction or throughout the procedure until he [Staff J6] contacted Staff K6, Anesthesiologist. Inquiry as to whether Staff K6 was contacted prior to induction, Staff J6 stated “I attempted but called the wrong anesthesiologist. The surgeon was coming into the room and so I went ahead. Mornings are very rushed. Sometimes I am gathering induction meds prior to the anesthesia record getting completed. I believe that is where part of the fail safe could have occurred. I prepared the succinylcholine prior to knowing [patient’s allergy]. So, in addition to the anesthesia time out, I have made it my practice to not pull up any induction meds prior to reading the chart fully. I think it was muscle memory that made me push that. I have also started seeing my own patients. I felt after this incident it was important to start putting things into my own hands.” During an interview on 01/03/24 at 1:15 PM with Staff K6, Anesthesiologist, stated...”My job is to make sure patients are adequately worked up and ready to have anesthesia in surgery. Then to deal with any complications that might arise. There’s only one [anesthesiologist] at a time here at [H2]. I have CRNAs that are in the surgery. They maintain airway, anesthesia, supply any supplemental medications, [pain or neuromuscular] or reversal agents. I am not required to be in the room, but I am. For the colonoscopies, EGD’s, I don’t necessarily go in for those, and those are short. It can be challenging to get to all of them. For general, I always go to the room. Someone gives me a call and says “”we’re about to go to sleep in whatever the room is and I go back.”” I try to check on the cases as they’re going and check in. Making sure they’re on time, no issues and anything needed help managing or issues with. . . Succinylcholine...No. That’s a big no no. It’s a contraindication...I honestly don’t know why she was given that drug. No. I wasn’t notified that they were in the room or the case was started. That’s our protocol to get a call prior to induction...In endoscopy, I don’t have them call. But with general, they’ll call. It’s a rare occasion [when they don’t]. I allow them [CRNA’s] leeway and breadth. Normally I don’t pick induction drugs for them to use. But most of the time, I allow them to operate within the fullest extent of their training.” Staff K6, CRNA found out Succinylcholine had been given “when the CRNA [Staff J6] called me and she wasn’t waking up. After the case was over. I asked if he [Staff J6] gave succinylcholine. I reminded him [Staff J6] of it, the Pseudocholinesterase Deficiency.” Staff K6 stated “They started doing an anesthesia time out to review allergies. So, it is an extra step prior to induction.” During an interview on 01/04/24 at 4:13 PM with Staff K6, Anesthesiologist, stated...”I’ll be honest [Staff J6] didn’t give me a satisfactory answer. When he [Staff J6] called me, I asked him [Staff J6] about the allergy list he [Staff J6] said “I guess I missed it.”” During an interview on 01/03/24 at 3:45 PM with Staff N6, RN, stated that she participated in Patient 39’s care in PACU. Allergies are listed in patient’s charts. They wear an allergy bracelet, put on in pre-op. “Doctor [Staff K6] said keep her intubated until she was not paralyzed anymore and was ready to be extubated...maybe about 2 hours, maybe a little longer.” During an interview on 01/03/24 at 3:54 PM with Staff L6, RN, stated that she participated in Patient 39’s care in PACU Phase II where the patient has to be oriented to person, place, time and event and able to hold a conversation. Staff L6 remembered that patient “did complain that one of her sides still felt numb.” Asked about leadership or manager addressing the incident... “collectively we all talked about it. But not leadership.” During an interview on 01/04/24 at 10:30 AM with Staff H6, RN, stated that anesthesiologists are “sometimes” in the operating room during induction but “they don’t have to be. Most of them [CRNA’s] will call when they’re doing induction or I’ll ask them to call. During an interview on 01/04/24 at 10:04 AM with Staff I6, CST [Certified Scrub Technician], stated...”it wasn’t recognized until the case was over. We go over patient, allergies, what we’re doing, fire risk, any concerns... in surgical time out. Usually, the anesthesiologist shows up after the patient is asleep. I don’t know the policy, but this new group, it seems the anesthesiologist is in the room after the induction. The other group was in the room before induction.” During an interview on 01/04/24 at 3:51 PM with Staff G6, Surgeon, stated “I was not aware until recovery. Dr. [Staff K6] told me “”she inadvertently got succinylcholine. She’s on a ventilator in recovery and I’m going out to talk to family now.”” She came for follow up in 2 weeks. We discussed it. It upset me. We discussed it quite a while. She was upset, understandably. I apologized. I don’t know how I could have prevented it but...it’s really not an allergy it’s a deficiency. She could still have a bad outcome, but not an allergic reaction...but until 6 months to a year, it seems they’ve [anesthesiology group] gone more to a medical supervision model...I know that they allow CRNA’s to do induction without anesthesiologists in room. Now they get them intubated and then anesthesiologist comes in. If he had been at bedside, it wouldn’t have happened. Time out typically occurs before incision. Everything else is already done. I’m all about perfect outcome. When I look retrospectively, had he been in there, this wouldn’t have happened. They see them before, and then roll them back. Exactly. I don’t know [if anesthesiologist’s notes are being read] With 2 people, it can get lost. Having both of them in the room is better always. Then there’s accountability.” The facility did not provide evidence of investigation regarding this incident. The incident log documented a “brief overview” of events with a designation of “D - No Harm.” During an interview on 01/04/24 at 1:40 PM with Staff S6, RN Director of Surgical Services stated, “we’re working on an anesthesia stop, review patient name, date of birth, allergies...” Staff S6 stated “...believe they call the anesthesiologists before induction. If the physician wants to be in there.” Staff S6 stated that there are around 8 anesthesiologists that rotate, setting their own schedules. Approximately ten to twelve CRNA’s rotate. Patient was identified to have pseudocholinesterase deficiency and allergy to Anectine. The facility failed to provide any policy and procedure that addressed safety precautions related to allergy review by the anesthesia provider prior to intubation resulting in Patient 39 remaining intubated for an additional 3.75 hours after surgery was complete increasing risk for complications, aspiration or pneumonia and induced temporary paralysis to patient. Patient 42 Review of Patient 42’s medical record revealed the patient was seen on 12/28/23 for outpatient surgery at H2 for a planned Cystoscopy with Transurethral Resection of Bladder Tumor [utilizes a long thin tool with a camera on it to find the bladder tumor and cut it out]. Review of Assessment form dated 12/26/23 revealed patient with weight of 121 kg [266 lb]; history of tobacco use; daily alcohol use. Review of Anesthesia Records Pre-Anesthesia note dated 12/28/23 revealed patient with a history that included: Coronary Artery Disease, Complex sleep apnea syndrome, Dyspnea [shortness of breath], coronary artery bypass surgery, hypertension, ADD/AHA stage C heart failure [Structural heart disease with prior or current symptoms of heart failure]. Patient’s airway had Mallampati classification: IV (hard palate only) [indicates the highest classification indicating the most difficult airway to intubate]. Review of Anesthesia Record page 3 dated 12/28/23 revealed a time listing that included the following: 8:16 Orotracheal Intubation Grade 2a [partial view of glottis]; Difficulty with intubation: No; Traumatic: Yes - laceration to upper lip and near base of tongue; CRNA - 1 attempt; Anesthesiologist - 1 attempt; 8:30 - Surgery start; 8:40 - Surgery Stop; “Free Note” at 8:56 - Examined the soft palate and noted laceration to right side. Will attempt to stop bleeding with nasal pledgets and Afrin but feel an ENT evaluation will be needed. Asked charge to call on-call ENT. 8:56 - Laceration inside mouth clotted after intubation, no issues with bleeding during the case. Once patient was reversed, gas off, and started to swallow, bleeding resumed prior to extubation of ETT [endotracheal tube]. Bleeding not slowing, patient re-sedated for airway protection and ENT [Ear, Nose, Throat] called for consult. 9:27 - Using videoscope, Afrin-soaked pledgets [compress or pad] were applied to laceration. 9:28 - Afrin administered to laceration using cotton administrators by Dr. [Staff K6]. 9:34 - Reevaluation of laceration with videoscope. Bleeding continued. Reapplied Afrin and pledgets. Will wait for ENT evaluation. 10:13 - ENT in room. 10:15 - Notified wife of soft palate laceration. Discussed with her the plan to treat. 10:25 - patient out of room. 10:40 - Emergence from anesthesia. Extubated Awake. 10:44 - Transport to PACU. Patient stable, awake and following commands, swallowing and breathing without issue, no bleeding noted at handoff. Review of Operative Document dated 12/28/23 at 1:38 PM revealed a diagnosis and repair of right soft palate laceration with a complex closure of right soft palate laceration...1.5 x 1 cm right soft palate laceration posterior and medial to the right maxillary alveolar ridge. Review of Anesthesia Record dated 12/28/23 revealed the following anesthesia drugs utilized between the first surgical stop time of 8:40 AM and transfer to PACU at 10:44 AM. 8:40 AM Sugammedex 200 mg IV [to reverse anesthesia] 8:58 AM Ephedrine 10 mg IV [treat hypotension - low blood pressure - during anesthesia] 9:00 AM Ephedrine 10 mg IV 9:03 AM Glycopyrrolate .2mg IV [decrease saliva] 9:28 AM Propofol 50 mg [anesthesia] 10:13 AM Propofol 50 mg 10:15 AM Propofol 50 mg Review of Assessments dated 12/28/23 pain documented at 11:22 AM at level 3 - location mouth; 12:22 at level 3 - location throat. 1:15 - able to maintain oxygen level on room air. 2:04 - able to drink fluids. Review of Personnel File for Staff L7, showed clinical privileges approved for 12/01/23 to 03/31/25 “Granted with supervision” in all categories. During an interview on 01/05/24 at 2:20 PM, Staff L7, CRNA stated that because they are new, having graduated mid-November, the anesthesiologists are in the operating room [OR] for all inductions. The anesthesiologist, [Staff K6], was not in the OR until the intubation got more “challenging” and came in to assist. “Once airway was secured, we noticed more bleeding. It was clear the laceration occurred during my attempt...active bleeding stopped once airway was secured. When waking up and he started moving his mouth, then it was really bleeding. [Staff K6] made the decision to consult ENT [ear, nose, throat] when the bleeding wasn’t stopping...The patient was obese with a long tongue...The [supply] person is working on getting brand removed. It’s more rigid and pointier...” During an interview on 01/04/24 at 4:13 PM, Staff K6, Anesthesiologist stated “CRNA had a difficult time getting in place and was using a different ET [endotracheal] tube. 7.5 tube had been auto substituted and the point comes to a sharper point and it’s more rigid. She tried once and then I took a second look and placed it. He was a large guy, doesn’t extend neck well. Sleep apnea. Redundant tissue. It happened in part, because of the ET tube. We notified [supply staff] and asked them to remove them from stock. It was a recent change and suppliers; we get no say in the stock. Took opportunity to instruct CRNA about ET tubes. She was brand new. It started bleeding again after case. I attempted pledgets [wad of absorbent cotton]. I knew someone else would have to come in. Dr. [ENT] put some stitches in. I called him [patient] yesterday. He was mostly concerned about his foley [catheter].” Staff K6 stated that he had never had a patient require sutures before or have a laceration that large. The facility did not provide evidence of investigation regarding this incident. The incident log documented a recap of events with a designation of “E - Mild Harm.” Review of document titled Submit a Product Failure, dated 01/04/24 revealed that a product failure notification was submitted to the manufacturer of the ETT used during intubation for Patient 42. Patient was identified at risk for challenging intubation in pre-anesthesia assessment. The facility failed to provide any policy and procedure that addressed safety precautions or staff supervision when a new CRNA is orienting. This failure caused the patient to have prolonged anesthesia with known health factors increasing cardiac failure risk, risk for aspiration or pneumonia as well as pain in throat and mouth.”