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“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: 53828 Based on policy review, record review, document review, observation, and interview, the hospital failed to provide 24-hour nursing services under the direction of a registered nurse that was well organized and in accordance with hospital policy and procedure. These deficient practices placed patients receiving care at risk for potential injury or harm. Findings Include: 1. The hospital failed to require that a registered nurse assign emergency department (ED) patients to nursing personnel. (Refer to tag A-0397). 2. The hospital failed to ensure that nursing staff adhered to its policies and procedures regarding fall risk screening and fall prevention for 5 out of 30 patient records reviewed. (Refer to tag A-0398).”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 53828 Based on document review, observation, and interview, the hospital failed to require that a registered nurse (RN) assign emergency department (ED) patients to nursing personnel. The hospital’s failure to ensure that patients are assigned to nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the available nursing staff puts patients at risk of harm. Findings Include: Review of a document titled “ED Triage Policy”, last approved 07/10/25, showed “ ...The patient will be placed in a bed as soon as possible in all circumstances. There may be times the patient is placed in a bed and the triage will be performed after bed placement. If the patient is not placed directly in a bed, once a triage level is assigned the charge nurse and/or triage nurse will determine patient bed placement.” Review of a document titled “Provision of Interdisciplinary Inpatient and Outpatient Care” approved 06/08/22, showed “ ...All patients being assigned to an accountable RN ...” as a guiding principle within the hospital’s philosophy of care. An observation of the ED on 04/17/26 at 9:25 AM showed that an unidentified patient who presented to the front desk with a chief complaint of abdominal pain. The patient was able to walk, and Staff S, RN, triaged the patient in a dedicated triage room. The patient’s vital signs were obtained, and the RN asked a variety of questions about the patient’s condition. The patient was taken back to an ED room in the “green” section of the ED, where the patient was left and told, “A nurse will be here soon to see.” The surveyor did not observe a nurse manager or any other staff member assigning the unidentified patient to an RN. During an interview on 04/16/26 at 3:30 PM, Staff P, RN, stated that ED patients were not triaged by a triage nurse, but were sent to a patient room to be triaged by a nurse from that section of rooms. Staff P reported sometimes being unaware that a patient had been roomed and needed triage. Staff P reported having no prior experience with triaging patients and denied receiving hospital resources to assign ED patients an Emergency Severity Index (ESI) rating (a 5-level triage step-by-step procedure used in emergency departments to categorize patient severity, ranging from Level 1 being the most urgent to Level 5 being the least urgent). During an interview on 04/17/26 at 7:10 AM, Staff N, RN, stated that the ED nurses choose which patients to pick up, and patients are not assigned to a specific nurse by a charge nurse or other member of leadership. Staff N described the ED patient assignment process as a “free-for-all.” Staff N reported that the ED sorting nurse (a nurse who acts as the first point of contact in an emergency room) places the patient in the room, and the staff nurses perform triage. During an interview on 04/17/26 at 9:20 AM Staff S, RN stated that ED charge nurse assigns staff members to an area or “zone” (green, yellow, red or the sorting nurse) at the beginning of a shift, but there is no leadership involvement in assigning patients; either a patient is assessed and triaged by the sorting nurse, or a patient is brought back to a bed, based on a brief visual assessment and the patient’s chief complaint. If the ED is full, patients will be triaged at the front by the sorting nurse and prioritized for bed placement based on the severity or ESI level. When patients are brought back to a room, any nurse from that area will take over the patient’s triage and care if they are available. During an interview on 4/17/26 at 9:20 AM, Staff L, Emergency Department Clinical Educator, stated that ED nurses within the zone pick their own patients and decide amongst themselves who the primary nurse for each patient will be. Staff L stated there is no designated team leader in each zone, and the charge nurse only gets involved in patient assignments if a nurse is not picking up enough patients relative to the rest of the nurses in a zone. Staff L reported that patients assigned ESI levels 1, 2, and 3 are roomed throughout the “red” and “yellow” zones, and patients in the “green” zone are mostly ESI levels 4 and 5. However, because most patients are triaged after being taken to a room, some have an ESI level higher or lower than originally expected.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 53828 Based on document review, record review, observation, and interview, the hospital failed to ensure that nursing staff adhered to its policies and procedures regarding fall risk screening and fall prevention for 5 out of 30 patient records (Patients 6, 7, 23, 24, and 28) reviewed. This failure led to falls that resulted in injuries for 2 patients (Patients 6 and 28) and put patients at risk of injury or harm. Findings Include: Review of a document titled “Fall Prevention Policy 1010-022” approved 11/19/24, showed that for all standard and low fall risk patients, a call light, if available, should be kept visible and within the patient’s reach. This policy also stated that for high-fall-risk patients, a fall risk sign, wristband, and yellow socks are to be used. Additional interventions listed for high fall risk patients included assisting them to and from the toilet, staying with the patient while toileting, and moving them closer to the nurses’ station. Review of a document titled “Call light maintenance log” dated 10/01/25 - 04/10/26, showed no maintenance tickets for the call light in the emergency department (ED) room 16. Patient 6 Review of Patient 6’s medical record dated 01/18/26 at 9:59 AM showed that Patient 6 arrived at the emergency department with concerns of lethargy (weakness, decrease in consciousness) and a history of colon cancer. The patient was placed in ED room 16. Review of Patient 6’s hospital document titled “ED Assessment Adult” dated 01/18/26 at 10:15 AM, showed that the patient was alert and oriented and was scored a Morse Fall Risk (a method of assessing a patient’s likelihood of falling) score of 30, indicating the patient was at a low fall risk. Review of Patient 6’s medical record failed to show further nursing documentation or assessments after 01/18/26 at 10:15 AM. Based on the patient’s medical record and “Current summary Provisions of Care Event,” Patient 6’s status changed, and the calculated Morse Fall Risk score for a patient with the above risk factors should have been scored a 60, high fall risk, before Patient 6’s fall. The medical record failed to show that fall interventions were in place prior to Patient 6’s fall. Review of a Patient 6’s hospital document titled “Progress Note,” signed by Staff R, DO on 01/19/26 at 4:36 AM, showed “ ...At approximately 0415, patient was on bedside commode when [he/she] experienced a mechanical fall. The fall was unwitnessed but RN did hear the commode crash with the fall and immediately responded. Patient was found sitting on ground next to bed with commode flipped over. Patient required 4 person lift to get back into bed. [He/She] was not able to help get into bed and was not following commands while on ground. Once back in bed, [he/she] was able to answer my questions and follow commands. [He/She] is complaining of lower back pain from fall. Does say [he/she] hit [his/her] head but denies LOC ...” Review of Patient 6’s hospital document titled “Computerized Tomography (CT),” dated 01/19/26 at 5:37 AM, showed Patient 6 developed a 2 mm intrafalcine (inside the process separating the two hemispheres of the brain) subdural hematoma (a pool of blood between the brain and its outermost covering). Review of a hospital document titled “Current Summary Provision of Care Event,” dated 01/20/26, showed that Patient 6 had been confused during their ED stay, unable to follow simple commands, and too weak to stand without a 2-person assist. The night shift RN was not informed of Patient 6’s confusion or non-functional call light. Patient 6 was placed on a commode and left alone, resulting in a fall that caused a brain injury and resulted in Patient 6 being admitted to the intensive care unit instead of intermediate care. During an observation in the emergency department on 4/16/26 at 2:20 PM, one surveyor stood in the doorway of ED room 16, while a second surveyor went to the “yellow” zone nurses’ station, which is the closest to that room. The surveyor at ED room 16 attempted to call out to the surveyor at the nurses’ station in a normal speaking voice and then in a moderate shouting voice multiple times. The surveyor at the nurses’ station was not able to hear the surveyor at the door of ED room 16. There was also no line of sight from any ED staff workstation to room 16. During an interview on 04/17/26 at 7:08 AM, Staff N, RN, reported being the primary nurse for Patient 6 on 01/19/26. Staff N reported being advised by Patient 6’s prior nurse that the patient was a little weak, but able to use the commode independently. Staff N stated that after assisting Patient 6 to the bedside commode, he/she gave the patient the call light and told Patient 6 he/she would “be right back.” Staff N stated they were unaware that the call light was nonfunctional, and upon Staff N’s return, Patient 6 had already fallen. Staff N also stated that the patient was in room 16, which is “tucked away” and does not allow easy access or visualization of the patient. Staff N denied receiving further education on patient fall risks after Patient 6’s fall. During an interview on 04/17/26 at 8:22 AM, Staff T, Risk Management Analyst, stated that Patient 6’s medical record and nursing documentation did not reflect that Patient 6’s mental status was confused. Staff T stated that nursing reassessment hadn’t occurred since approximately 10:00 AM and that documentation of Patient 6’s confusion and a change in fall status could have led to the implementation of fall interventions, which would have been appropriate in reducing or preventing Patient 6’s fall. Patient 7 Review of Patient 7’s medical record dated 01/19/26 at 7:20 PM, showed that the patient was evaluated in the emergency department for an injury to the head after falling from a standing position. The medical record also indicated that Patient 7 had cardiomyopathy (heart disease, enlarged heart muscles), aortic insufficiency (cardiac system failure that results in increased heart workload) and hypertension (high blood pressure). A nursing assessment on 01/19/26 at 7:46 PM showed that Patient 7 was assigned a Morse Fall Risk score of 0, or low fall risk after the nurse answered that the patient had no history of falls in the last 3 months. However, based on the information in Patient 7’s medical record, the calculated Morse Fall Risk score for a patient with the above risk factors is 40, indicating a moderate risk for falls. Patient 7 had no additional fall risk assessments documented. Patient 7 had no moderate or high-risk fall precautions ordered. Patient 23 Review of Patient 23’s medical record dated 01/01/2026 7:37 PM showed that the patient was evaluated in the emergency department for dizziness, feeling unsteady, and difficulty ambulating or sitting upright. The medical record also indicated that Patient 23 used a walker, and the patient had pre-existing diagnoses of chronic (long-term, ongoing) pain, essential hypertension, peripheral artery disease (reduced blood flow to limbs), obesity (a disorder involving excessive body fat that increases the risk of health problems), and osteoarthritis (deterioration of bone cartilage, causing pain and stiffness). For Patient 23 on 01/01/26 at 7:48 PM, an intravenous (IV) saline lock was ordered. An ED nursing assessment conducted on 01/01/26 at 8:35 PM documented Patient 23 as having a low fall risk, with a Morse Fall Risk score of 0. However, based on the information in Patient 23’s medical record, the calculated Morse Fall Risk score for a patient with the above risk factors was 60, indicating a high risk for falls. Patient 23’s medical record showed no additional Morse Fall Risk assessments, and there were no High Fall Risk orders placed. Patient 24 Review of Patient 24’s medical record dated 02/26/2026 7:16 AM showed that the patient was evaluated in the emergency department for weakness and abdominal pain. The medical record also indicated that Patient 24 arrived with a Foley urinary catheter (a small flexible tube into the bladder to drain urine) in place, the patient used a cane, and the patient had pre-existing diagnoses of chronic pain, opiate (narcotic) dependence, hypertension, type 2 diabetes mellitus (a disease that affects how the body produces or uses blood sugar), and TIA (transient ischemic attack, a stroke-like attack that resolves within minutes or hours). For Patient 24 on 02/26/26 at 7:39 AM, blood tests and intravenous (IV) medications were first ordered. An ED nursing assessment on 02/26/26 at 7:21 AM described Patient 24 as being a low fall risk, without a numerical Morse Fall Risk score being assigned. However, based on the information in Patient 24’s medical record, the calculated Morse Fall Risk score for a patient with the above risk factors should have been 60, indicating a high risk for falls. Several hours later, on 02/26/26 at 3:15 PM, Patient 24 had an additional fall risk assessment completed. Patient 24’s fall risk score was high at 75, and high fall risk orders were entered on 02/26/26 at 4:24 PM. Patient 28 Review of Patient 28’s medical record dated 03/05/26 at 7:44 PM showed that Patient 28 arrived to the ED by ambulance with facial injuries from falling at a nursing facility. Patient 28 had an order placed on 03/05/26 at 7:59 PM to apply a fall risk band and post a sign on Patient 28’s door due to the patient being a high fall risk. Review of Patient 28’s ED Assessment dated 03/05/26 at 7:59 PM showed that Patient 28’s fall risk score was listed as being high. Review of a Nursing Clinical Note on 03/06/26 at 1:23 AM showed that Patient 28 was found in ED room 24, face down on the floor, bleeding. Review of Patient 28’s History and Physical dated 03/06/26 at 6:38 am, showed that Patient 28 had significant dementia (a loss of thinking abilities and memory), was essentially non-verbal (not able to converse) at baseline, was non-ambulatory (not able to stand or walk), and had a history of repeated prior falls. This record showed that Patient 28 fell face-first onto the ground in the ED, requiring “Trauma One” activation, STAT (immediate) CTs of the patient’s head, facial structures, cervical spine (neck region of the spine), and thoracic spine (the middle portion of the spine), and an emergency ophthalmic (medical and surgical care of the eyes and vision) exam to evaluate the patient’s orbital (eye socket) trauma. Patient 28’s facial trauma from a pre-hospital fall was described as “worsened from injuries from fall in ED.” Review of a hospital document titled “Current Summary Fall Event” dated 03/06/26, showed Patient 28’s placement in ED room 24 and a lack of fall risk interventions, including a bed alarm, which was a deviation from expectations for a patient with dementia who was a high fall risk. The document also listed missed care opportunities, including using a low bed or cart, placing the patient in a room closer to a nurses’ station, or using a hall bed, and keeping the room curtain open for visibility. Review of security video from ED East Hallway dated 03/06/26 from 1:23 AM to 1:33 AM showed the area outside Patient 28’s room (room 24). Room 24 lacked a yellow light above the door and a fall risk sign outside the room. The door to room 24 was open, the lights were off, and the privacy curtain was closed over the room’s entrance and window. At 1:24 AM, a security staff member and an ED staff member were seen standing outside room 24, and the security staff member pointed at the floor beneath the curtain at the entrance to room 24. The ED staff member entered room 24, turned on the light, and appeared to be calling for additional assistance. At 1:32 AM, the patient was moved from room 24 and was observed wearing white socks, not the hospital’s yellow fall-risk socks. An observation in the emergency department on 4/16/26 at 2:18 PM showed that ED room 24 was not easily visible from any ED staff workstations. During an interview on 4/17/26 at 7:45 AM, Staff E, Director of Risk Management, reported that the investigation of Patient 28’s fall found that no bed alarm had been in use, and that Patient 28 would not have been able to operate a call light. An observation in the emergency department on 4/16/26 at 2:30 PM showed that ED rooms 5, 13, 17, and 18 had a yellow light above the door and the curtains closed without any ED staff in the room with the patients. A sign on these ED room doors stated, “If the yellow light above the door is on or the patient is identified as a fall risk, PLEASE leave the curtain open.” During an interview on 04/15/26 at 10:50 AM, Staff F, Emergency Department Director, stated that in the Emergency Department ED triage, the staff RN uses the Morse Fall Screening tool. If a patient is considered to have a moderate to high fall risk, measures may be initiated, including yellow (“grippy”) socks, fall signs, placement of a commode, bed and chair alarms, 1:1 supervision, and/or bringing the patient close to the nurses’ station. During an interview on 4/16/26 at 2:35 PM, Staff M, Emergency Department Manager, stated that the sign on the ED patient room doors that reads “If the yellow light above the door is on or the patient is identified as a fall risk, PLEASE leave the curtain open” applies to patients who score in the high-risk category. When asked whether a different Morse Fall Risk score applied to patients with the yellow light on than those who needed their curtains kept open, Staff M reported not being aware of the Morse Fall Risk score cutoff for keeping the curtains open. When asked why high fall-risk ED patients with yellow lights above their doors had their curtains closed even when privacy wasn’t required, Staff M was unsure.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 52070 Based on interview, record review, and facility policy review, the facility failed to ensure timely completion of a stroke assessment and administration of ordered medications for 1 (Patient 2) of 4 sampled patients. Findings include: A facility policy titled, “Acute Stroke Policy and Procedure for Management through Continuum of Care,” approved 02/21/23, indicated, “Purpose: to define the criteria used to triage stroke patients and outline the one call code stroke activation alert. To define roles and responsibilities of the interdisciplinary clinical team that will be caring for the acute stroke patient throughout the continuum of care. Policy: This policy applies to all members of the interdisciplinary stroke team who are involved in the acute work-up of the suspected stroke patient at [facility name]. It is the policy of [facility name] to treat all stroke patients according to consensus-based national standards for stroke care. All patients, 18 years of age and older, exhibiting stroke-lie symptoms will be managed utilizing clinical practice guidelines in an organized approach. [Facility name] is committed to meeting the patient’s individual needs, either onsite or by transferring to a facility capable of providing services to optimize the patient’s outcome.” A patient demographic sheet revealed Patient 2 arrived at the facility on 05/05/25 at 7:13 PM with a chief complaint of numbness on the left side of their face and arm. Patient 2’s triage assessment dated 05/05/25, revealed Registered Nurse (RN) #5 triaged Patient 2 on 05/05/25 at 7:15 PM, with a triage acuity level of two and a National Institute of Health Stroke Scale (NIHSS) assessment that was partially done to reveal a score of one. Patient 2’s “Code Stroke Documentation” revealed RN #4 documented that a code stroke was entered on 05/05/25 at 10:31 PM; however, there was no documented evidence that a full NIHSS assessment was completed. Patient 2’s physician orders and medication administration record revealed sodium chloride intravenous fluids were ordered for the patient on 05/06/25 at 2:56 AM and administered to the patient on 05/06/25 at 10:31 AM. During a concurrent interview and record review on 08/26/25 at 2:59 PM, RN #3 stated she did not remember Patient 2. RN #3 reviewed Patient 2’s medical record and acknowledged the order was placed around 3:00 AM on 05/06/25 and IV fluids were not administered until 10:31 AM. RN #3 confirmed IV fluids or medications, in general, should be administered within an hour of the order. During an interview on 08/26/25 at 2:25 PM, RN #2 stated her expectations were IV fluids be administered within an hour after the order was placed. During an interview on 08/27/25 at 2:40 PM, RN #5 stated during triage staff usually performed a brief NIHSS assessment and emergency severity index to get patients to a bed as soon as possible for imaging. RN #5 stated she no longer worked at the facility but knew that the process changed to allow nurses to call stroke codes, whereas previously only providers could do so. She explained that around June 2025 the process changed to zones and providers were then assigned patients. She stated she did not recall caring for Patient 2 on 05/05/25 or notification of the provider of stroke symptoms. During an interview on 08/27/25 at 11:48 AM, RN #4 stated a full NIHSS assessment should have been completed immediately once a nurse was assigned to the patient. During an interview on 08/27/25 at 9:08 AM, the Emergency Department Director (EDD) reviewed Patient 2’s medical record and stated the patient arrived at 7:13 PM, was triaged at 7:20 PM, and assigned a bed at 7:23 PM. The EDD stated a code stroke was called at 8:52 PM according to the ED activity log. The EDD stated providers at that time were only able to call a code stroke; however, now the nurses were able to call code strokes as well. The EDD stated changes were made in May 2025 to allow nurses and providers to active a code stroke and inform the pharmacy if tenecteplase (an injection medication that dissolved blood clots in certain blood vessels in the body) was required. She explained Medical Doctor (MD) #1 assigned himself to Patient 2 at 8:14 PM and saw the patient at 8:25 PM. Per the EDD, RN #5 performed an abbreviated NIH which yielded a score of one during triage, which was documented as a note in the triage record. She stated her expectations was for RN #5 to have notified the provider immediately of the stroke like symptoms. The EDD stated a full NIHSS assessment was not completed until 11:30 PM. According to the EDD, her expectations was for a full NIHSS assessment to be completed upon triage. She clarified that the triage nurse’s role was to place the patient in a triage room and complete an initial triage while the assigned RN was responsible for completing the NIHSS assessment.”

“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 the right to patient privacy and failed to obtain written consent for treatment in advance of furnishing or discontinuing patient care for 1 of 5 sampled patients (Patient 1). This deficient practice places any patient at risk of not understanding their individual rights. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities,” approved on 09/19/23 showed, “ ...We respect and value our patient’s role in making decisions about their health care, and we are committed to protecting their rights as a patient ...The patient has the following rights regarding information about their care:...To accept or refuse any procedure, drug or treatment and to be informed of the consequences of any such refusal ...To be informed of any hospital policies, procedures, rules or regulations that apply to their care ... The patient has the following rights regarding privacy surrounding their care: ...To personal privacy. Discussions about their care, consultations, exams and treatments will be conducted as discreetly as possible and on a need to know basis ...” Patient 1 Review of Patient 1’s medical record showed a 25-year-old admitted on 04/05/25 at 1:25 AM with a diagnosis alcohol intoxication. No past medical history. Review of Patient 1’s medical record failed to show a signed consent for treatment or Notice of Patient Privacy Practices prior to Patient 1 discharging home on 04/05/2025 at 11:18 AM. During an interview on 04/08/2025 at 9:07 AM, Staff B, Director of Organizational Outcomes, verified Patient 1 did not have a signed consent to treat or Notice of Patient Privacy Practices in the medical record.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47233 Based on observation, record review and interview, the hospital failed to protect patient privacy rights by failing to notify the patient/patient’s representative of video monitoring for 2 of 2 sampled patients (Patient 4 and 5) and failed to post signage that video monitoring in progress as required per hospital policy. This deficient practice places patients and visitors receiving services at this hospital at risk for having their rights to personal privacy violated. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities,” approved on 09/19/23 showed, “ ...We respect and value our patient’s role in making decisions about their health care, and we are committed to protecting their rights as a patient ...The patient has the following rights regarding privacy surrounding their care: ...To personal privacy. Discussions about their care, consultations, exams and treatments will be conducted as discreetly as possible and on a need to know basis ...” Review of a hospital policy titled, “Med Sitter,” approved on 12/19/23 showed, “ ...Policy: Mobile video monitoring may be initiated for at-risk patients who meet inclusion criteria, after other safety interventions have been trialed and have not been successful ...The patient and/or legally authorized representative will be notified of the monitoring. Cameras will provide 24/7 live feed of the patients being monitored ... Signage inside and outside the patient’s room will serve to notify families, nursing and ancillary departments that the patient is being monitored ... RN: Notify the patient and/or legally authorized representative that mobile video monitoring has been implemented for safety. Provide patient/family with education document, and orient patient/family to mobile video monitoring rationale/procedure. Amend patient’s plan of care (Injury Prevention Plan) to reflect use of mobile video monitoring for safety ...” Patient 4 During an observation on 04/07/25 at 10:48 AM, the video monitoring room showed that Patient 4 was being monitored by Mobile Video Monitoring (a portable video monitor screen with camera and microphone abilities that allows one-way and/or two way video and audio communication.). During an observation on 04/07/25 at 10:56 AM of Patient 4’s room, no signage was posted that video monitoring was in progress as required per policy. During an observation on 04/08/25 at 9:23 AM, the video monitoring room showed three unidentified patients being monitored by Mobile Video Monitoring. During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician, identified the patient in room 208 as Patient 4. During an observation on 04/08/25 at 9:59 AM of Patient 4’s room, no signage was posted that video monitoring was in progress as required per policy. Review of Patient 4’s live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 4 was admitted on 03/31/25 to the medical surgical floor. Further review of the medical record failed to show documented evidence that Patient 4 or Patient 4’s representative was notified of video monitoring in progress. During an interview on 04/08/25 at 3:49 PM, Staff A, CNO and Staff B, Director of Organizational Outcomes, stated that the hospital did not follow policy when they failed to document notification to the patient and/or patient representative of video monitoring and failed to update the care plan for Patient 4 to include the use of video monitoring. During an interview on 04/08/25 at 3:49 PM, Staff A, CNO, stated that there was no signage posted outside the patient room notifying any staff or visitor that video monitoring was in progress as required per hospital policy. Patient 5 During an observation on 04/07/25 at 10:48 AM, the video monitoring room showed that Patient 5 was being monitored by Mobile Video Monitoring. During an observation on 04/07/25 at 10:56 AM of Patient 5’s room, no signage was posted that video monitoring was in progress as required per policy. During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 207 as Patient 5. Review of Patient 5’s live medical record showed Patient 5 did not have a durable power of attorney (DPOA) on file. Review of Patient 5’s live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 5 was admitted on 03/10/25 to the medical surgical floor. Further review of Patient 5’s medical record failed to show documented evidence that Patient 5 or Patient 5’s representative was notified of video monitoring in progress. Further review of Patient 5’s medical record failed to show documented evidence that the plan of care (Injury Prevention Plan) was updated to reflect the use of mobile video monitoring for safety as required per hospital policy. During an interview on 04/08/25 at 3:49 PM Staff A, CNO and Staff B, Director of Organizational Outcomes, stated that the hospital did not follow policy when they failed to document notification to the patient and/or patient representative of video monitoring and failed to update the patients care plan for Patient 5. During an interview on 04/08/25 at 3:49 PM, Staff A, CNO, stated that there was no signage posted outside Patient 5’s room notifying any staff or visitor that video monitoring was in progress as required per hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 47233 Based on interview, record review, and facility policy review, the hospital failed to ensure that the use of restraints was in accordance with regulation and hospital policy as evidenced by the use of four bed rails to prevent a patient from being able to freely exit his or her bed for 1 of 5 (Patient 4) sampled patients observed for restraints. This deficient practice is a violation of patient rights and places any patient receiving services at this hospital at risk of unauthorized use of restraints that may lead to serious injury and harm. Findings Include: Review of a hospital policy titled, “Restraint Policy,” approved 09/14/22, showed, “ ...Physical restraint: Any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. (CMS CoPs 482.13) This includes: a. The use of side rails to prevent a patient from exiting a bed ...” Patient 4 An observation on 04/07/25 at 10:48 AM of the video monitoring room, showed a Patient in room 208 observed via video monitoring with four bed rails up. An observation on 04/07/25 at 10:56 AM of the second floor, showed a patient in room 208 with four bed rails up. An observation on 04/08/25 at 9:23 AM of the video monitoring room, showed a Patient in room 208 observed via video monitoring with four bed rails up. During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 208 as Patient 4. An observation on 04/08/25 at 9:59 AM of the second floor, showed Patient 4 with four bed rails up. An unidentified Registered Nurse (RN) verified that Patient 4 did not have an order for restraints. Review of Patient 4’s live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 4 was admitted on 03/31/25 to the medical surgical floor. During the record review, Staff A and Staff B confirmed that the medical record failed to show documented evidence that Patient 4 had an order for restraints.”

“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 interview, the hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 1 of 5 (Patient 4) sampled patients reviewed for restraints. This deficient practice violated patient rights and places any patient receiving services at this hospital at risk for serious injury and harm. Findings Include: Review of a hospital policy titled, “Restraint Policy,” approved 09/14/22, showed, “ ...1. Each episode of restraint use requires an order from the licensed independent practitioner (LIP) responsible for the patient’s care. Patient 4 An observation on 04/07/25 at 10:48 AM of the video monitoring room, showed four unidentified patients being monitored by Mobile Video Monitoring. Monitoring showed a patient in room 208 with all four bed rails up. An observation on 04/07/25 at 10:56 AM of the second floor, showed a patient in room 208 with four bed rails up. During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 208 as Patient 4. An observation on 04/08/25 at 9:23 AM of the video monitoring room, showed Patient 4 in room 208 observed via video monitoring at this time with bed all four bed rails up. An observation on 04/08/25 at 9:59 AM of the second floor ,showed Patient 4 with four bed rails up. At the time of observation an unidentified Registered Nurse (RN) verified that Patient 4 did not have an order for restraints. Review of Patient 4’s live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes showed that Patient 4 was admitted on 03/31/25 to the medical surgical floor. During the record review Staff A and Staff B confirmed that the medical record failed to show documented evidence that Patient 4 had an order for restraints.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45841 Based on record review, interview, and facility policy review, the Hospital failed to protect and promote the patient’s rights for 1 (Patient 6) of 3 sampled patients reviewed for restraints. This deficient practice has the potential to place patients at risk for harm and injury. Findings Included: 1. The hospital failed to ensure that the use of restraints was in accordance with a written modification to the patient’s plan of care. (A-0166) 2. The hospital failed to ensure that patients who were restrained were monitored as required by hospital policy. (A-0205)”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45841 Based on interview, record review, and facility policy review, the facility failed to ensure that the use of restraints was in accordance with a written modification to the patient’s plan of care for 1 (Patient 6) of 3 sampled patients reviewed for restraints. Findings Included: A facility policy titled, “Restraint Policy,” approved 09/14/22, indicated, “Each restraint episode will be documented in the patient’s medical record, and will include: “1. In-person evaluations by the LIP(s) [licensed independent practitioner].” The policy specified, “13. Revisions to the patient’s plan of care, in accordance with restraint use.” Review of Patient 6’s “History & Physical,” dated 07/13/24 at 11:04 PM, revealed the facility admitted the patient on 07/13/24 for syncope (fainting or passing out). Patient 6’s “Order Detail” flowsheet revealed an order for “Restraint Initiate Violent 18 Years and Older.” The Order Detail contained an order for “4-Point Hard” restraints dated 07/16/24 at 4:17 AM. The Order Detail flowsheet contained an order, dated 07/16/24 at 4:17 AM, that indicated “Document restraint monitoring every 15 minutes or more frequent if needed.” The Order Detail revealed a stop date of 07/16/24 at 8:16 AM. Patient 6’s “Restraint Face to Face Evaluation Violent” note indicated an evaluation was performed on 07/16/24 at 5:20 AM. The Restraint Face to Face Evaluation Violent note revealed that 4-point hard restraints were on and that the restraints were to be continued. Patient 6’s “Restraints” flowsheet dated 07/16/24 at 5:20 AM, revealed 4-point hard restraints were on and indicated they were to continue. Patient 6’s “Interdisciplinary Care Plan” flowsheets revealed no evidence that restraints were included in the patient’s plan of care. During an interview on 12/10/24 at 3:08 PM, Nursing Director (ND) 1 stated that if the restraints were not placed on the patient, the nurse would not have initiated the care plan. ND 1 stated that Patient 6 may have been “talked down,” and the restraints were never placed on them. ND 1 stated that she did not see a care plan related to restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vi) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 45841 Based on interview, record review, and facility policy review, the facility failed to ensure patients who were restrained were monitored as required by hospital policy for 1 (Patient 6) of 3 sampled patients reviewed for restraints. Findings Included: A facility policy titled, “Restraint for Violent and or Self-Destructive Behavior,” approved 09/14/22, indicated, “Patient Care Management” included “C. Ongoing care while patient is restrained: 1. Assign a staff member for continuous observation. Document monitoring/ interventions at the following frequencies: a. Every 15 minutes: i. Physical restraints are secure ii. Patient is safely positioned iii. Physical restraints: circulatory status not impaired iv. Patient’s behavior b. Every 30 minutes: i. Respiratory rate ii. Pulse c. Every hour (for physical restraints only): Skin condition of restraint contact areas. d. At least every two hours, when patient’s behavior allows, and while ensuring adequate staff assistance: i. Release physical restraints (one limb at a time). Assist with active or passive range of motion (ROM) to each extremity, and repositioning. ii. Offer food or fluids, if diet permits. If patient is not allowed oral intake, offer oral hygiene. iii. Offer assistance with elimination needs.” Review of Patient 6’s “History & Physical,” dated 07/13/24, revealed the facility admitted the patient on 07/13/24 for syncope (fainting or passing out). Patient 6’s “Order Detail” flowsheet revealed an order for “Restraint Initiate Violent 18 Years and Older.” The Order Detail contained an order for “4-Point Hard” restraints dated 07/16/24 at 4:17 AM. The Order Detail flowsheet contained an order, dated 07/16/24 at 4:17 AM, that indicated “Document restraint monitoring every 15 minutes or more frequent if needed.” The Order Detail revealed a stop date of 07/16/24 at 8:16 AM. Patient 6’s “Restraint Face to Face Evaluation Violent” note indicated an evaluation was performed on 07/16/24 at 5:20 AM. The Restraint Face to Face Evaluation Violent note revealed that 4-point hard restraints were on and that the restraints were to be continued. Patient 6’s “Restraints” flowsheet dated 07/16/24 at 5:20 AM, revealed 4-point hard restraints were on and indicated they were to continue. Patient 6’s medical record revealed no evidence to indicate documentation of initiation, monitoring, or discontinuation of the restraints. During an interview on 12/10/24 at 3:06 PM, the Chief Nursing Officer (CNO) stated it appeared that the nurse asked for restraint order for Patient 6 and an order was placed. The CNO stated that there was no nursing documentation on the restraints, but the face-to-face evaluation indicated that the restraints were on. During an interview on 12/11/24 at 12:35 PM, Medical Doctor (MD) 9 stated that he was made aware of the question regarding Patient 6’s restraints on 12/10/24, after staff completed chart review, and he did go back and look at the chart and records to re-familiarize himself. MD 9 stated that he did not recall the patient. MD 9 stated that he was night coverage that shift and was “running around.” MD 9 stated that the patient had been admitted, and their withdrawal symptoms escalated. Per MD 9, he knew especially in the case of hard restraints, that documentation was required. MD 9stated that he assumed he was there, saw the patient, and the record indicated the restraints were on the patient would have been an error, but that would be “mere surmising and speculation.” MD 9stated that he did not remember the encounter at all. MD 9 stated that he knew that if the patient had restraints on, it would have required more documentation to show as such.”

“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: 47234 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 provide stabilizing treatment for an emergency medical condition. Failure to provided stabilizing treatment places patients at risk for deterioration of an emergency medical condition resulting harm and injury up to an including death. Findings Include: Review of hospital policy titled “EMTALA-Inter-hospital Transfer-Emergency Response” revised July 2018 showed, “Policy Statement; It is the policy of Lawrence Memorial Hospital (LMH) to comply with all applicable laws and regulations relating to the provision of emergency services and transfer of patients, including requirements as defined in EMTALA regulations. ... Campus means the physical area immediately adjacent to the hospital’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings ... ...”Comes to the Emergency Department” with respect to an individual requesting examination and treatment for what may be an emergency medical condition, means that the individual is on the hospital property or premises including off-campus facilities ... ...If an individual arrives at the hospital and is not technically in the emergency department but is on hospital property or premises and requests emergency care, he or she is entitled to a medical screening examination ... ...3. A hospital must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the hospital for examination and treatment ... Review of hospital document titled “Medical Staff Bylaws Credentialing Procedures Manual Fair Hearing Plan And Rules and Regulations (The Governing Documents) of Lawrence Memorial Hospital” updated December 2023 showed “ ...In the event an emergency medical condition is determined to exist, then the Hospital will provide such further medical examination and treatment as is available at the Hospital to stabilize the medical condition or will appropriately transfer the patient to another facility after consideration of the risks and benefits of transfer ... Render any care in a life-threatening emergency. Review of hospital policy titled “Medical Evaluation Team (MET) Adult Adolescent Protocol” approved 11/2023 showed “PURPOSE: To outline actions of the MET team for rapid and proactive patient evaluation ...The function of the MET team is to rapidly assemble a group of specialized healthcare professionals in response to acute clinical deterioration before cardiopulmonary arrest occurs. The MET team is called to perform a rapid assessment and obtain standard objective clinical data for the attending physician. Anyone (e.g. patient, employee, volunteer, family, law enforcement officers) may summon the MET for assistance in assessment, evaluation and stabilization of the patient ...PATIENT CARE MANAGEMENT: The MET Team will A. ASSESSMENT: ...2. Implement further assessment based on patient’s status to evaluate need for interventions ...The MET team will proceed with the following interventions as indicated by the evaluation process until physician is present, or individual has been transported to the ED for medical evaluation ...” The hospital failed to provide stabilizing treatment of an emergency medical condition (EMC) for 1 of 20 patients (Patient 1). (Refer to tag A2407)”

“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: 47234 Based on record review, policy review, document review and interview the Hospital failed to provided stabilizing treatment of an emergency medical condition (EMC) for 1 of 20 patients (Patient 1) reviewed. The hospital’s failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition resulting harm and injury up to an including death. Findings Include: Patient 1 Review of Patient 1’s medical record showed, a 24-year-old female, presented to the above named hospital cardiology department on 09/01/22 for 12:27 PM for an outpatient echocardiogram (Echocardiogram is a test to diagnosis with ultrasound by creating pictures of your heart valves and chambers). Review of Patient 1’s “Transthoracic Echocardiogram Report” dated 09/01/22 showed, “ ...summary: ... 7. Severe aortic root and severe ascending aorta dilation (Otherwise known as an aortic root aneurysm, a dilated aortic root is when the first section of the aorta, where the aortic valve resides, becomes enlarged. When this enlargement reaches a critical size, there is a risk of it rupturing or tearing, leading to a life-threatening situation). The aortic arch is incompletely visualized but appears to be normal diameter 8. Aortic valve is not well visualized but appears to have a moderate degree of insufficiency without stenosis. 9. The aortic valve pressure half-time is approximate 436 msec (A pressure half-time of greater than 500 milliseconds (ms) is consistent with mild aortic regurgitation, from 500 to 200 ms with moderate, and of less than 200 ms with severe) .... Aortic Root (Mmode) 5.7 (2.4-3.7 (Ascending aortic aneurysm greater than 5.5 centimeters requires surgery for all patients) ...” During an interview on 06/10/24 at 2:48 PM, Patient 1, stated, “I had appointment with [Staff I, MD (Doctor of Medicine)] because I couldn’t even make it from my bed to my couch without passing out and being out of breath, so he scheduled an echo (Echocardiogram) on 09/01/22. During the echo, I could tell that something was up since the echo tech demeanor changed. She didn’t tell me anything, but she told [Staff I, MD] the cardiologist. I was put into the waiting room while [Staff I, MD] was texting a doctor at [Hospital B] to schedule an appointment. [Staff I, MD] had me give him my personal number so that he could text me and check on me and get updates. While driving home, I had to pull over, because I could feel the aneurysm shredding, I thought I was going to die so I called 911. [Hospital C] got me stabilized best they could and transferred to [Hospital D]. I had my open-heart surgery at [Hospital D] where I received a mechanical heart valve for the repair for aortic dissection. [Hospital D] was the only hospital in the whole state of Kansas that could actually work on me that night.” During an interview on 06/11/24 at 4:11 PM, Staff H, Cardiac Sonographer (operate ultrasound equipment that provides moving images of the heart and chambers), stated “[Patient 1], the echo, showed ascending aorta was like giant dilated to something like 6.5 cm (centimeters) or something crazy and 3.5 cm normal. [Patient 1] was really young that’s not normal. Notified the cardiologist [Staff I, MD], he came over and talked to her about what was going on and trying to figure out what the next steps for her care.. But I was very adamant that she shouldn’t be leaving, and she should be going straight to the ER [emergency room]. It did not look like she was dissecting at that moment the aorta was very enlarged. She was complaining was getting dizzy and was having chest pain. I sent over my images to [Staff I], I think he looked at them on his own. He was talking about sending her to [Hospital B]. She was getting ready to leave too and told her if you’re gonna leave you need to be aware of symptoms, if you start like tasting blood, feeling really bad or like a ripping sensation in your chest call 911 like immediately because those are all signs of a dissection.” During an interview on 06/12/24 on 06/12/24 at 8:42 AM, Staff I, MD, stated, “Enlarged aorta we will ask for conformation of CT [cat scan] chest we would correlate with CT. I f the aorta reaches 5.3 cm we get very concerned for women and send them for surgical consultation, only would be emergent if had symptoms otherwise it would be in office consultation. [Patient 1] was young and had shortness of breath. The echo tech came and got me because aorta was 5.6, I did not look at the echo. I explained to [Patient 1] that she had a very large aneurysm, critical in size, but she denied symptoms. I called [Hospital B] doctor, was told if not symptomatic then no reason to send here and that they would see her in the office. I told her drive over to the [Hospital B] emergency room to be seen, since I felt uneasy about letting her go. [Patient 1] stated she had something to do first and, I explained the critical size of the aneurysm. That day she started to have chest pain and went to ER with pericardial effusion (buildup of extra fluid in the space around the heart, putting pressure on the heart and prevent it from pumping normally) with a dissection (medical emergency in which the inner layer of the large blood vessel branching off the heart (aorta) tears). I did not document any of the conversation with [Patient 1] or [Hospital B].” During an interview on 06/12/24 at 9:33 AM, Staff D, MD, Chief Medical Officer (CMO) stated “ ... All doctors would need to document any contact with patient and doctor if it was in a clinic. If there was an emergency in the clinic or on the premises, they would call the MET [Medical Evaluation Team] team for response. It is the physician’s responsibility to respond or whoever it was the nearest physician to respond to the emergency. [Patient 1’s] ECHO was significant study; the cardiologist is to notify the physician of any study if there is abnormal finding there is a policy to this. It should be related immediately, and I did not see that in her chart. I also did not see a follow up note from [Staff I, MD] he should have documented the conversation with the doctor at [Hospital B] and with the patient. The echo is moderate to severe especially with the size of and the dilation of the vessels, the aorta was dilated, was leaking and had backflow.” Review of a document titled “[County 1] County EMS [Emergency Medical Services] Prehospital Care Report” dated 09/01/22 at 4:12 PM showed, “Narrative: ...patient stated that she was driving home from [Above Named Hospital] where she got EKG done, when she felt a sharp pain in her chest.” ...Complaint pain going through my back and chest “ Review of Patient 1 medical record from Hospital C dated 09/01/22 at 5:07 PM showed Patient 1 arrival to ER via EMS and transferred to Hospital D via EMS on 09/01/24 at 10:22 PM with diagnosis of Type 1 dissection of ascending aorta and Ascending aortic aneurysm. Review of Patient 1’s medical record from Hospital C dated 09/01/22 at 5:07 PM showed “ ...The CTS [cardiothoracic] surgeon. He is aware of the patient and feels that emergent surgery is indicated ... He recommends ED to ED transfer and then go directly to the operating room ...CTA [cat scan] Chest, Abdomen and Pelvis With IV Contrast ...Impression: Fusiform Aneurysm (rare sausage like expansion of the entire blood vessel on all sides)of the ascending thoracic aorta measuring 6.3 X 6.0 with a subtle dissection (tear) flap (Stanford type A)(occurs in the first part of the aorta closer to the heart and can be immediately life threatening) ...”