Ephraim Mcdowell Regional Medical Center

“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: 47852 Based on interview, record review, review of Patient Guide, review of the facility investigation, and review of the facility’s policies, it was determined the facility failed to ensure patients received adequate nursing supervision to provide a safe environment for one (1) of 23 sampled patients, Patient (P) 12. P12 was not provided adequate supervision when she was left on a bedpan for an extended length of time and developed a pressure ulcer as a result. The findings include: Review of the facility’s “Patient Guide”, undated, revealed the nurse or patient care tech (PCT) would perform purposeful rounding, which meant the nurse or PCT would come to the patient’s room every hour to assess pain and assist with bathroom needs and positioning. Further review revealed, during the night, the nurse or PCT would check on the patient hourly without waking the patient up. Continued review revealed the patient had the right to be free from all forms of abuse and neglect. Review of the facility’s policy, “Patient Rights and Responsibilities,” approval date 05/24/2024, revealed the patient has the right to be treated in a dignified and respectful manner and be free from all forms of abuse and neglect. Review of the facility’s policy, “Provision of Care, Treatment, and Services,” with an origination date of 03/2013 and an approval date of 05/2025, revealed patient services are planned, coordinated, provided, delegated, and supervised by professional health care providers who recognize the unique physical and emotional needs of each person as they are assessed and re-assessed. Further review revealed patient care was delivered through the collaborative interdisciplinary care delivery system, an approach in which the Registered Nurse (RN) was the primary care nurse responsible to oversee and initiate the patients’ individual plan of care. The RN coordinated team care and was responsible to follow up on delegated tasks and ensure completion by team members. Continued review revealed the main goal of care of the facility was to provide best practice nursing care and to foster a safe and healing environment. Additionally, the RN prescribes, delegates, and coordinates the nursing care provided to the patient. Review of the facility investigation revealed staff had documented a Situation-Background-Assessment-Recommendation (SBAR), dated 06/14/2024 at 2:20 AM, which documented P12 had blisters on her bottom from the bedpan. Further review revealed multiple staff had been in P12’s room while she was on the bedpan. Continued review revealed a wound consult was made. Additionally, the wound care nurse had documented on 06/14/2024 at 1:36 PM that staff had informed the wound care nurse that P12 had a wound to her sacrum due to having sat on a bedpan for three (3) to four (4) hours during the night. The facility did not recognize a need to provide any associate with education/follow up/disciplinary action as a result of the incident. Review of the facility’s PowerPoint titled “Hourly Rounding/Activities of Daily Living (ADLs) and every (q) two (2) hour turns,” undated, revealed it was important to provide these services to reduce hospital acquired conditions, promote safety, and improve clinical outcomes. Further review revealed the five (5) “Ps” to hour rounding included pain, potty, positioning, personal needs, and pump. Continued review revealed the importance of every two (2) turns was changing a patient’s position in bed every two (2) hours helped to prevent pressure ulcers/injuries, repositioning a patient relieved pressure on one area of the body, which could restore blood flow and keep skin healthy, and turning a patient was a good time to check for redness and sores. Review of P12’s Patient Registration Form revealed the facility admitted P12 on 06/09/2024 for encephalopathy (any condition that causes damage or disease affecting the brain and could manifest as an altered mental state, confusion, or memory loss) and Urinary Tract Infection (UTI). Further review of the Emergency Department (ED) record revealed the ED Physician had documented P12’s daughter stated P12 had demonstrated intermittent periods of confusion 06/08/2024 night and 06/09/2024 day. Review of P12’s ED Discharge Summary, dated 06/09/2024 at 7:32 PM, revealed P12 did not appear encephalopathic at the time of ED discharge but was likely due to UTI. Review of P12’s Hospitalist Progress Note, dated 06/13/2024 at 6:41 PM, revealed P12’s skin was normal color. Review of P12’s Skin Assessment/Braden Scale, dated 06/13/2024 at 10:08 PM, revealed the facility assessed P12 to have a potential problem for friction risk which indicated the patient moved feebly or required minimum assistance and, during a move, skin probably slid to some extent against the sheets or chair. Further review revealed the facility assessed P12 to very limited in mobility which indicated the patient made occasional slight changes in body or extremity position but was unable to make frequent or significant changes in body extremity position independently. Continued review revealed the facility assessed P12 not to have a pressure ulcer present. Review of P12’s Hourly Rounding Assessments revealed P12 “Back Side Lying” on 06/13/2024 at 6:35 PM, 7:26 PM, 8:39 PM, 10:00 PM. Further review of P12’s Hourly Rounding Assessments P12 “Back Side Lying” on 06/14/2024 at 12:00 AM and 2:00 AM. Review of P12’s Intake and Output, dated 06/13/2024 at 10:18 PM revealed P12 had a bowel movement. Review of P12’s SBAR, dated 06/14/2024 at 2:20 AM, revealed P12 called for help and was assessed to have blisters on her bottom from the bedpan. Further review revealed multiple staff had been in P12’s room during her time on the bedpan and P12 had failed to alert staff to be taken off the bedpan. Review of P12’s Skin Assessment/Braden Scale, dated 0614/2024 at 6:33 AM, revealed the facility assessed P12 to have a potential problem for friction risk which indicated the patient moved feebly or required minimum assistance and, during a move, skin probably slid to some extent against the sheets or chair. Further review revealed the facility assessed P12 to very limited in mobility which indicated the patient made occasional slight changes in body or extremity position but was unable to make frequent or significant least changes in body extremity position independently. Continued review revealed the facility assessed P12 not to have a pressure ulcer present. Review of P12’s orders revealed a wound care order, dated 06/14/2024 at 1:47 PM, to apply hydrophilic paste to the sacrum daily and as needed and to ensure P12 was turned at every two (2) hours while in the bed. Review of a picture of P12’s sacrum, dated 06/14/2024, revealed a reddened, blistered area that appeared to be the shape and outline of a bedpan. During an interview, on 01/14/2026 at 2:30 PM, the Chief Nursing Officer (CNO) stated the facility had completed an investigation at the time of the incident and determined facility staff did leave P12 on a bedpan for an extended period of time (some staff stated one (1) to two (2) hours and other staff stated three (3) to four (4) hours) which did lead to P12’s pressure ulcer. He further stated it appeared to be miscommunication between staff and the facility did not discipline any staff members regarding the incident. He continued to state it was his expectation staff would check on a patient shortly after placing them on a bedpan to prevent a pressure ulcer. Additionally, he stated nursing should identify any concerns with patient care and address them immediately. SSA was unable to interview P12 or her daughter due to the phone number given being disconnected.”

“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: 47852 Based on observation, interview, record review, and facility policy review, the facility failed to ensure an effective infection control program was maintained to ensure infections and communicable diseases were controlled. On 01/13/2026, Environmental Services Technician (EST) 1 was observed to be cleaning the room of a patient in contact isolation precautions without wearing the appropriate personal protective equipment (PPE). The findings include: Review of the facility’s policy, “Standard (Universal) Precautions and Transmission-Based Precautions”, approved 11/2024, revealed the purpose of the policy was to describe methods used to prevent the spread of communicable and other infectious diseases and to provide a guide for health care workers (HCW) to reference when caring for patients. Further review revealed all healthcare workers, including Environmental Services, should be responsible for complying with Standard and Transmission-Based Precautions. Continued review revealed the policy defined Indirect Contact Transmission as involving the transfer of an infectious agent through a contaminated intermediate object or person (hands of healthcare personnel might transmit pathogens after touching a contaminated inanimate object if hand hygiene was not performed before touching another patient). Additionally, gloves potentially soiled with any body fluid should be removed before touching any environmental surface and handwashing should be performed after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, after removing gloves, and immediately upon exiting a patient’s room or patient care area. Review of the policy revealed types of personal protective equipment (PPE) vary based on the type of precautions required and the isolation sign would depict what PPE needs to be worn). Further review revealed contact precautions were used for patients with known or suspected infections or evidence of syndromes that represented an increased risk for contact transmission. Continued review revealed all healthcare workers must wear an impervious gown and gloves when entering the room and gowns and gloves must be removed prior to leaving the patient room and perform hand hygiene on departure. Review of the Environmental Services Policy, “Infection Control,” approved 10/2025, revealed the department should follow all the proper isolation procedures for cleaning as well as the proper dress required while performing duties within an isolation area. Further review revealed areas should be cleaned according to procedure which included dress as required by signage posted outside the room for isolation rooms and remove the protective clothing and discard inside the room, remove gloves and sanitize hands. Review of the facility policy, “Hand Hygiene,” approved 04/2024, revealed cleansing of hands ensures hands are clean and must be completed upon entering and exiting a patient’s room and after removal of gloves. Further review revealed all associates and contract staff would complete hand hygiene immediately when exiting a patient’s room or patient care area. Review of facility education, undated, revealed staff should always wear the appropriate PPE per the type of isolation hanging on the door. Further review revealed appropriate PPE for contact precaution rooms included gown and gloves. Continued review revealed staff should remove PPE before leaving the patient’s room and perform hand hygiene immediately after leaving the room. Observation, on 01/13/2026 at 11:15 AM, revealed EST1 cleaning a patient’s room which had signage posted outside the room door that the patient was in contact precautions and required staff to wear a gown and gloves while in the room. Further observation revealed EST1 was not wearing a gown and was cleaning the room in the vicinity of the patient’s bed. Continued observation revealed EST1 leave the patient’s room and enter the hallway and touch her cleaning cart without removing her gloves or performing hand hygiene. Additionally, EST1 touched hallway railings while wearing the same gloves. During an interview, on 01/13/2026 at 11:20 AM, EST1 stated she had received education on infection control and proper use of PPE and should have worn a gown to protect the patient from germs from outside the room and protect others from any germs the patient had when leaving the room. She further stated isolation precautions are in place if the patient “has something” so PPE can be worn. She continued to state she should remove her gloves and hand sanitize prior to leaving the patient’s room. During an interview, on 01/13/2026 at 11:30 AM, the Chief Nursing Officer (CNO) stated staff, including Environmental Services staff, receive infection control education and were educated on the use of proper PPE for each type of isolation. He further stated he expected all staff to wear the appropriate PPE when in an isolation room and sanitize their hands upon entering and exiting a patient’s room. During an interview, on 01/14/2026 at 9:30 AM, the Infection Prevention Specialist stated she educated all staff on infection control practices and proper use of PPE and handwashing. She further stated she expected all staff to wear the appropriate PPE for each type of isolation and to perform hand hygiene appropriately. She continued to state she rounded the hospital daily Monday through Friday to ensure any patient who required isolation had the appropriate signage posted outside their doors and observed staff wearing PPE and performing hand hygiene. Additionally, she stated if any staff were observed not wearing the appropriate PPE or performing hand hygiene appropriately, she educated them immediately on the proper procedure.”

“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: 29137 Based on interview, record review, review of Facility #1’s policies, medical staff by-laws, and review of Patient #1’s medical record from Facility #2, it was determined the the on-call physician failed to present to the Emergency Department (ED), when requested, to evaluate and treat Patient #1, one (1) of twenty-five (25) sampled patients. Cross Refer to the findings in Tag A-2404.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 29137 Based on interview, record review, and review of Facility #1’s policies, and medical staff by-laws, it was determined the facility failed to comply with 42 CFR 489.24(j)(1) related to an On Call General Surgery Physician declining to provide a consult for a patient with an Emergency Medical Condition (EMC), for one (1) of twenty-five (25) sampled patients, Patient #1. The findings include: Review of the facility’s policy #EMHSWH010, approval date 05/24/2022, titled “Treatment and Transfer of Individuals Who Request Emergency Medical Services”, revealed On-call Physicians would respond to the emergency department (ED) within time if they were requested to do so. In this case, the response time for the General Surgeon to respond to the request to consult Patient #1 was thirty (30) minutes. Review of the Facility’s Policy #EMRMC0MS023, approval date 09/2023, revealed all Active Staff members were responsible for coverage for their in-patients and for those patients that presented to the ED as a condition of maintaining their Active Medical Staff membership and Clinical privileges. Review of the facility’s By-Laws, dated 09/28/2022, revealed if a STAT (immediate) request was made to the on-call Physician, the response time was expected to be as soon as the requested Physician could arrive to the facility. Further review of the By-Laws revealed if the request was not STAT, the on-call Physician response time was thirty (30) minutes. Review of General Surgeon (GS) #1’s surgical privileges, dated 05/25/2022, revealed GS #1 had privileges for extremity amputations through the next review period of April 30, 2024. Review of Patient #1’s clinical record from Facility #1 revealed he/she presented to the emergency department (ED) on 08/23/2023 from his/her primary care physician’s (PCP) office, as a walk-in, at 10:10 AM. The Chief Complaint was an infected foot. Review of the physical exam (PE) revealed Patient #1 was thin, with a chronically ill appearance. He/she was lethargic but was oriented to person, place, and time. Continued review of the PE revealed dorsal and pedal pulses could not be palpated (examined by touch) in the right foot. Additional review revealed Patient #1’s foot had a seven by three (7 x 3) centimeter area of ulceration down to the subcutaneous (under the skin) tissues of the foot, ulcerations between the toes had maggots in the wound, and the foot was dusky and cool to the touch. Further review of the PE revealed he/she was hypotensive (low blood pressure) with a systolic B/P (the upper number, the force the heart exerts on the walls of the arteries each time it beats) was in the low 70’s (normal systolic range for Patient #1’s age was 110-145); hypothermic (low body temperature) with a core temperature of 95 degrees Fahrenheit (F); normal is 98.6 degrees F; and tachycardic (fast heartrate) in the low 100’s (normal adult heart rate was 60-100 beats per minute). Continued review of Patient #1’s ED record revealed immediate interventions included initiating a Sepsis Alert that included starting intravenous fluids (IVF) and antibiotics. A warming blanket was applied to warm Patient #1’s body. Patient #1’s clinical record included a diagnosis of septic shock. Review of the workup in the medical record included basic labs of complete blood count (CBC) that could help detect a variety of disorders including infections, anemias, immune diseases, and blood cancers, C-reactive protein (CRP) to check for an inflammation response; venous blood gases (VGB) to check for low blood flow in the lower extremities, and blood cultures to check for a blood infection. Additionally, an abdominal computed tomography angiography (CTA) with run-off to the bilateral lower extremities to check for peripheral artery disease was completed. Review of Physician’s Assistant-Certified (PA-C) #1’s progress note (dictation date/time of 08/23/2023/11:23 AM), revealed General Surgeon (GS) #1 was available for consultation but declined to see Patient #1 because she did not consult for foot and ankle wounds and recommended transfer to another acute care facility. Continued review of PA-C #1’s progress notes revealed an outside facility had accepted Patient #1 for a Podiatry consult. Further review of Patient #1’s ED record documented that Patient #1’s clinical picture was consistent with septic shock (the most serious stage of sepsis with some mortality rates as high as fifty percent (50%), wound to the right lower extremity, acute kidney injury, and hyponatremia (low sodium level in the blood). The record also documented that prior to Patient #1’s transfer, he/she acutely decompensated (a worsening of a patient’s clinical status that posed a substantial increase to an individual’s short-term risk of death or serious harm) and needed increasing dosages of Levophed (a blood pressure medication) to keep blood pressure stable. Further review of PA-C #1’s progress note, dated 08/23/2023 at 11:23 AM, revealed General Surgeon (GS) #1 was again notified of Patient #1’s decompensation and requested her to consult Patient #1. It was documented GS #1 again stated she did not do amputations and did not come to see Patient #1. Per the note, PA-C #1 documented she contacted Facility #2 but they were on diversion also. She again contacted one (1) of the nearby facilities to explain Patient #1’s critical status and requested to see if they could over-ride the diversion. The facility reported they would speak to the Chief Medical Officer but stressed the importance of a surgeon evaluating Patient #1. PA-C #1 documented that she had relayed that a request had been made of GS #1 twice, but she had declined both times because she did not do amputations. The nearby facility again stated they would try to over-ride the diversion as Patient #1 was unstable and had been in the emergency department (ED) for nine (9) hours by that time. Additional review of PA-C #1’s progress note, dated 08/23/2023 at 11:23 AM, revealed Patient #1 continued to need increasing doses of Levophed and had consented for a Central intravenous (IV) catheter (a longer, larger tube that was placed in a large vein in the neck, upper chest, or groin to receive fluids, medications, blood, and nutrition). It was during this time that Facility #2 called back and stated they had a Critical Care bed and had accepted Patient #1 for transfer. During an interview on 01/17/2024 at 7:37 PM via phone with PA-C #1, she stated she had requested General Surgeon #1 (GS #1) to evaluate Patient #1 twice on 08/23/2023. She stated GS #1 was the on-call Physician for General Surgery for 08/23/2023 and should have come to evaluate Patient #1. She stated the on-call medical provider process was that if a medical provider was on call, they had to respond within a certain time frame; and, that time frame for General Surgery was thirty (30) minutes. PA-C #1 stated the first time she notified GS #1 of the consult for Patient #1, GS #1 was in the building, finishing surgery cases. PA-C #1 stated that GS #1 told her (PA-C #1), that she (GS #1) did not do amputations, and the Orthopaedic on-call person should be consulted because they did amputations. PA-C #1 stated the second time she notified GS #1, GS #1 stated to transfer Patient #1 because she did not do amputations. During the interview on 01/17/2024 at 7:37 PM via phone with PA-C #1, PA-C #1 stated she had conferred with Emergency Department (ED) Physician #1 during Patient #1’s visit on 08/23/2023. She stated that the ED had to follow the treating Physician’s orders, so Patient #1 was transferred to Facility #2 later that evening. PA-C #1 stated that while arrangements for Patient #1’s transfer were being made, he/she sustained a cardiac medical incident that needed to be treated. PA-C #1 stated the cardiac medical incident was stabilized, and Patient #1 was transferred. During an interview on 01/18/2023 at 8:47 AM with the Vice-President of Clinical Effectiveness and the Director of the Emergency Department, they both stated that any time a consult was made in the Emergency Department, the Consultant needed to see the patient, especially if it was emergent. On 01/18/2024 at 10:43 AM, General Surgeon (GS) #1 stated she remembered Patient #1. She stated Physician’s Assistant-Certified (PA-C) #1 had called her about an amputation patient. She stated, prior to this patient, the Emergency Department (ED) was aware she did not do amputations. When asked how they were aware she did not do amputations, GS #1 stated she had specifically told PA-C #1 several times, but PA-C #1 continued to consult her for foot and ankle concerns. GS #1 stated she had done a handful but none in the three (3) years she had been at Facility #1. She stated the orthopaedic surgeons had privileges to do them, and she did not think she was best prepared to do it. GS #1 stated she had encouraged PA-C #1 to check if an orthopaedic surgeon was available and that she (PA-C #1) had called her twice. When asked about the responsibility of being on-call, she stated that if they called with a general surgery consult, she could provide advice. She stated, if a patient was going to be admitted, they received a face-to-face consult. She stated sometimes they call General Surgery about things when they just need direction. GS #1 stated routinely she did not have a problem with pointing them in the right direction of which service they might need. She stated if it was a trauma case, the on-call service would have to be at the facility in person within thirty (30) minutes. During the interview, GS #1 stated if she was called with a General Surgery consult, she would come in. She stated if she directed them (ED) to another service, her expectation would be that the other service would be contacted for the consult. Further, while interviewing GS #1, she stated if she did not have privileges to do the surgery, she could give them advice. GS #1 stated she was aware Patient #1 had decompensated and that the outside facility that had agreed to accept Patient #1 had to refuse the transfer because they did not have a Critical Care bed available. She stated that if she did not have privileges to do the surgery, she really could not do anything for the patient. Additionally, GS #1 stated her request to have amputations removed from her Credentialing list was made before 08/23/2023. In the continued interview on 01/18/2024 at 10:43 AM, General Surgeon (GS) #1 stated she was told the patient needed an amputation, and she did not do that. She stated it was well-known among ED providers that she did not do amputations. GS #1 continued the interview by stating she reviewed her privileges the night of 08/23/2023 but did not remember amputation privileges were still on there because she had never done them. While interviewing ED Physician #1 on 01/18/2024 at 12:47 PM, he stated Patient #1 had presented to the ED with a diabetic septic wound and was transferred. ED Physician #1 stated he worked the 7:00 PM to 7:00 AM shift and recalled he had received Patient #1 in hand-off from the Medical Director. He stated he thought the ED had contacted the on-call General Surgery surgeon earlier before Patient #1 required pressors (low blood pressure medications), but she declined to see Patient #1. He stated he believed right around the time he arrived at the facility at 7:00 PM was when staff put Patient #1 on the pressors. He stated PA-C #1 called the on-call surgeon back and got the same response, that Patient #1 needed to be transferred. He stated PA-C #1 had made it clear that Patient #1 had decompensated further and needed more urgent treatment. ED Physician #1 stated he did not have any hands on with Patient #1, that PA-C #1 was taking care of Patient #1, and he was supervising and conferring with her the entire time. ED Physician #1 stated that a possible EMTALA violation would be hard to defend in this case because Patient #1 had a diabetic foot wound and was septic from the wound. He stated it would also be hard to argue that the patient’s management had included source control. He stated a primary thing needed to stabilize Patient #1 would have been to remove the source of the continuing infection. He stated Patient #1’s medical decompensation was a direct result of his/her foot. He stated this situation was emergent, and the General Surgeon should have consulted with Patient #1 because he/she had septic shock from the foot infection. In an interview with the Medical Director (MD) of the ED on 01/18/2024 at 1:15 PM, he stated that PA-C #1 had been the medical provider for Patient #1, but he was supervising her work. He stated, if he remembered correctly, PA-C #1 spoke with General Surgeon (GS) #1 twice, requesting the consult. He stated when a provider requested on-call service, the expectation was they came to see the patient. He stated ED Staff tried not to call the on-call services for non-emergent concerns, but this was emergent. He stated ED Staff saw a lot of concerns we were not comfortable dealing with, but if an on-call service was requested and they were privileged to address the concern, the expectation was for them to come and lay eyes on the patient. He stated, as Medical Director of the ED, his expectation for this scenario was that the on-call physician should have come and seen the patient. By his interpretation of EMTALA, he stated, if there was a procedure needed and the facility had established capability, GS #1 should have come in. Concerning the case of Patient #1, he stated, GS #1 had stated before that she did not do amputations, but her privilege card indicated at the time she could. He stated the facility was an Emergency Department in a rural setting, and the ED was going to sometimes see things that made us uncomfortable.”