Caldwell Medical Center

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 28734 Based on interview, record review, review of the facility “New Hire Checklist” and review of the facility “Adult Abuse, Neglect and Exploitation” policy, the facility failed to have mechanisms in place to ensure patients were free of all forms of abuse, neglect, or harassment. 1. Review of the Human Resources (HR) files revealed both past and present direct care employees were not screened through the Nurse Abuse Registry of Kentucky (KY) (the Nurse Abuse Registry is part of the broader caregiver misconduct registry, which includes names of caregivers with substantiated claims of abuse or neglect) prior to their employment with the facility or throughout their employment at the facility. 2. The facility failed to remove the alleged perpetrator in order to protect patients, and failed to conduct a thorough investigation when 1 of 5 sampled patients, Patient(P)1, alleged Registered Nurse (RN)1 hurt her. The findings include: Review of the facility’s policy and procedure titled, “Adult Abuse, Neglect and Exploitation”, dated 09/29/2022, revealed “This policy is designed as a guideline for use in dealing with the adult patients who have been suspected of being abused, neglected or exploited. It is not intended to be all inclusive and further information may be obtained from sources such as the [Kentucky] KY Revised Statutes, the Department of Social Services, and Law Enforcement Agencies.” Continued review revealed the policy was related to patient’s who presented at the hospital for admission with “recognizable suffering from abuse, neglect or exploitation.” Review of “KY 209.030 Administrative Regulations” amended on 07/15/1998, and dated/amended on 06/20/2005, revealed “Reports of adult abuse, neglect, or exploitation -- Cabinet actions -- Status and disposition reports. (1) The secretary may promulgate administrative regulations in accordance with [Kentucky Revised Statutes] KRS Chapter 13A to effect the purposes of this chapter. While the cabinet shall continue to have primary responsibility for investigation and the provision of protective services under this chapter, nothing in this chapter shall restrict the powers of another authorized agency to act under its statutory authority. (2) Any person, including but not limited to physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter. Death of the adult does not relieve one of the responsibility for reporting the circumstances surrounding the death. (3) An oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult. (4) Any person making such a report shall provide the following information, if known: (a) The name and address of the adult, or of any other person responsible for his care; (b) The age of the adult; (c) The nature and extent of the abuse, neglect, or exploitation, including any evidence of previous abuse, neglect, or exploitation; (d) The identity of the perpetrator, if known; (e) The identity of the complainant, if possible; and (f) Any other information that the person believes might be helpful establishing the cause of abuse, neglect, or exploitation.” Review of the Centers for Medicare and Medicaid Services “State Operations Manual”, A-0145 (Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08) 42 CFR §482.13(c)(3) revealed, “The patient has the right to be free from all forms of abuse or harassment. Interpretive Guidelines §482.13(c)(3) revealed: The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. The hospital must have mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect, or harassment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish ...The following components are suggested as necessary for effective abuse protection: Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. Report. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. As a result of the implementation of this system, changes to the hospital’s policies and procedures should be made accordingly.” Review of the facility’s yearly on-line training and education module contents titled “Abuse, Neglect and Exploitation”, undated, revealed the following: “At the completion of this course, you will be able to: Define abuse, neglect and exploitation, identify and assess a victim of abuse and neglect, recognize signs of abuse including physical, emotional, sexual, financial, domestic, and elder abuse, recognize signs of neglect, and appropriately report abuse and neglect.” Continued review of the course content revealed, “Reporting Abuse and Neglect- You must immediately report any event or occurrence that may involve or contrive to abuse ...so it can be investigated, and appropriate actions taken. External agencies must also be notified ...” 1. Review of the “New Hire Checklist” undated stated ... “New hire completes paperwork for ...background checks, submit background check to Office of Inspector General (OIG) ...” Review of the log listing, provided by the facility’s Compliance Officer, undated, revealed 56 Registered Nurses (RNs) and 14 Certified Nursing Assistants (CNAs) who either had worked, or currently worked in direct patient care at the facility between 1991 until current had not been verified with the Kentucky (KY) State Abuse Registry to query the Cabinet for Health and Family Service as to whether a validated substantiated finding of adult abuse, neglect or exploitation had been entered against an individual who is a prospective employee. During an interview with the Human Resources (HR) Manager, on 01/07/2026 at 11:30 AM, he stated he answered directly to the Chief Executive Officer (CEO). He stated prior to the employment of perspective new hires, a resume or an application for employment along with two (2) forms of identification (ID) were required. He further stated new employees were also run through a criminal background check through a contracted agency, and Human Resources verified the sex offender status. In further interview, the HR Manager stated he utilized the Office of Inspector General (OIG) website to ensure all licensed staff had a valid license. He stated he was in the process of looking into a good system to check for a probable new hire abuse history. He further stated he became aware in 12/2025, verification of the abuse registry was not being completed prior to hire. In continued interview, the HR manager stated he had started in his HR position in 11/2025, and had not received any training on how to do his job. He further stated he had been offered on-line classes to complete; however, he had not started the classes yet. During a telephonic interview with the Director of Nursing (DON), on 01/08/2026 at 12:08 PM, she stated she was very surprised to know there had been no abuse registry checks completed for new employees. She stated this was very concerning as staff working directly with the patients should not have a history of having committed crimes related to abuse. The DON stated by checking the abuse registry prior to hire, it would protect the patients from staff with known abuse issues. During an interview on 01/08/2026 at 3:04 PM, with the Administrator, he stated he would have expected the HR department to complete the abuse registry checks because the facility needed to know if a perspective hire had a history of abuse. He stated he would not hire a person with a history of abuse. 2. Review of Patient (P)1’s Emergency Room (ER) “Face Sheet”, revealed the facility admitted P1 on 12/23/2025. Review of P1’s “History and Physical”, signed and dated by a physician on 12/23/2025 at 6:43 PM, revealed the patient presented for rehabilitation in swing bed after (R THA) [total hip arthroplasty]. Having some swelling in the right leg from the foot all the way up to the thigh, concerned it might be cellulitis. On aspirin for deep vein thrombosis (DVT) prophylaxis. Assessment: Status post (S/P), swelling right lower extremity. Plan: will place on Lovenox (anti-coagulant that prevents blood clots), venous doppler in the morning. Plan: Physical Therapy (PT) and Occupational Therapy (OT). Review of the “Current Summary, Provision of Care Event”, dated 01/06/2026 and submitted by the Emergency Department (ED) Manager, revealed P1 called for assistance to the bathroom, and Registered Nurse (RN)1 came in to assist the patient. “Patient reported he jerked the pillow out from under the right hip causing increased pain to the hip. The patient is here for rehab for (R) THA...” Patient stated, “she did not want them back in her room to take care of her again, and she would call the police if he was to come back into her room, he caused so much pain in her hip.” P1’s primary nurse stated she would call the patient’s provider and get additional pain medication for the patient. Per the Summary, the ED Manager spoke with RN1 and asked him not to be a part of the patient’s care team for the remainder of the day as she did not want him back in her room. Continued review revealed the event stated, “Resolutions and Outcomes of the Event ...staff reassigned.” Continued review of the “Current Summary, Provision of Care Event”, dated 01/06/2026, revealed a Resolution Comment provided by the Medical/Surgical Nurse Manager, dated 12/29/2025 at 7:30 AM-7:45 AM, which stated, he was notified of the patient complaint and went to P1’s bedside regarding her concerns. P1 requested the nurse not be involved in her care today. Per the Summary, the Medical/Surgical Nurse Manager discussed P1’s concerns and spoke with RN1. Explained to the patient that today RN1 was the only nurse available to provide care, but “we would minimize interactions per her request.” Explained RN1 would need to perform a daily assessment and administer medications throughout the day, but otherwise we would have a certified nursing assistant (CNA) respond to her call light requests. Complaints were that when RN1 removed her pillow from her right hip on 12/28/2025, it resulted in pain. No indication on medication administration record (MAR) or order chronology to indicate a call to the medical doctor had been made for additional pain medication after interaction, only that ordered pain medication was given. Discussion with RN1 indicated P1 did complain of pain when the pillow was removed; however, RN1 denied forceful removal. Nurse performed assigned duties and limited patient interaction as requested. Telephonic interview with P1, on 01/07/2026 at 12:20 PM and on 01/08/2026 at 12:07 PM, revealed she encountered no issues with any of the staff except for RN1. She stated when she was in bed her hip had to have a pillow for support and one pillow had to be under her knees. However, when she tried to roll over to her side so RN1 could assist with removing the pillows in order to go to the bathroom, he pulled the pillow out from behind her hip before she could support it with her hand. P1 stated she yelled out in pain and CNA1 came into her room. She stated she told the nursing assistant the nurse had jerked the pillow out and “hurt me.” P1 stated the next day RN1’s son, who was the Medical/Surgical Nurse Manager, came into her room and informed her RN1 was the only nurse working that day. P1 stated she told the Medical/Surgical Nurse Manager she did not want RN1 in her room, alone, or she would call the police. P1 stated RN1 came into her room several times, unattended, and she had been furious with him. During a telephonic interview on 01/08/2026 at 12:55 PM, with RN1, he stated he had provided care to P1 a few times. He stated he recalled he pulled a pillow out from under the patient’s legs while she was sitting up in a Broda chair (specialized wheelchair), and she told him it hurt her. He recalled telling P1 he was “so sorry.” RN1 stated the event occurred on 12/28/2025, while he was still in orientation. He further stated he attempted to “make peace” with P1; however, she stated she did not want him in her room. RN1 stated once the complaint had been made, he did not go back into her room. However, he stated on Monday, 12/29/2025, he had to go into P1’s room because he was the only nurse on duty. He stated he did go into her room that day (12/29/2025) to administer her medications. He stated he had no intent to hurt P1 when he removed the pillow from underneath the patient’s legs. Review of the “Both Courses and Events” logs, revealed RN1 completed training on abuse, neglect and exploitation on 12/10/2025. During an interview with CNA1, on 01/06/2026 at 2:44 PM, and 01/08/2026 at 10:46 AM, she stated she had been a caregiver to P1 on 12/28/2025. She stated P1 informed her she did not like RN1 because he had done things to her, and said things to her that she did not like. She further stated P1 had been very upset because RN1 yanked a pillow from underneath her knee which hurt her. CNA1 stated P1 told her she did not want RN1 in her room anymore. CNA1 stated she then went to Licensed Practical Nurse (LPN)1 and informed her of what P1 had told her. She further stated she informed the Medical/Surgical Nurse Manager the following morning about the patient’s concerns with her care. Review of the “Both Courses and Events” logs revealed CNA1 had received and completed training on abuse, neglect and exploitation on 02/10/2025. During an interview with LPN1, on 01/06/2026 at 1:32 PM and on 01/08/2026 at 11:30 AM, she stated she had spoken with P1 right after the event happened on 12/28/2025, and the patient told her she felt uncomfortable with RN1 caring for her. The LPN further stated P1 had informed her RN1 had yanked her leg after a hip replacement when he had helped her transfer, and RN1 had also dropped her leg causing her to experience extreme pain. She stated she let the Emergency Department (ED) Manager know about the occurrence on the day it happened, right after it happened. In continued interview, LPN1 stated staff received abuse training, and if abuse was suspected, she would first speak with one of her co-workers to see what they thought, or she could “Google” to see if it could be abuse, and then she would call a supervisor. She stated it was about four (4) hours after the event when the ED Manager came to the floor to speak with P1. Review of the “Both Courses and Events” logs, revealed LPN1 had received and completed training on abuse, neglect, and exploitation on 08/11/2025. During an interview with the ED Manager, on 01/06/2026 at 2:00 PM, she stated the event occurred on Sunday, 12/28/2025. She stated a staff member called her to let her know there had been a patient complaint related to RN1. P1 had alleged RN1 had hurt her, injured her hip area, and the patient was a post hip repair. The ED Manager further stated at the specific time she was notified of the allegation, she had been very busy in the ED, so she physically went to RN1, because he was supposed to be a House Supervisor, and told him of the complaint. In continued interview, the ED Manager stated she did not have time to go and talk to P1 until about five (5) hours after the complaint, but she informed RN1 prior to that not to go back into P1’s room. She stated when she finally made it to the patient’s room, the patient did not want to talk with her behind a closed door, but she finally agreed to let her shut the door. She further stated the patient informed her, RN1 had jerked a pillow from out behind her hip and it hurt her, and her hip hurt more now than it did before. The ED Manager stated she informed the patient at that time the facility did not condone that type of behavior from staff and informed her RN1 would not be coming back into her room to care for her. During continued interview with the ED Manager, on 01/06/2026 at 2:00 PM, she stated she did not know RN1 well, but felt like he would not do anything intentional to hurt a patient. She stated she only spoke with one other patient on the floor after she had spoken with P1, and that patient basically revealed she did not like being cared for by a male nurse. The ED Manager stated she had not documented the encounter interview with the other patient. The ED Manager further stated P1 had been very angry with RN1, and she continued to apologize and inform the patient RN1 would not be a part of her care team any longer. She stated the next day, someone had already found out about the incident before she could talk to the Medical/Surgical Nurse Manager, and the Chief Executive Officer (CEO), but she did not know who informed them. Record review of the “Both Courses and Events” log, revealed the ED Manager received and completed training on abuse, neglect and exploitation on 02/14/2025. Record review of the “Patient Admission/Discharge” log, revealed there was a total of six (6) patients on the Medical/Surgical floor on 12/28/2025. During an interview with the Medical/Surgical Nurse Manager, on 01/06/2026 at 3:54 PM, and 01/08/2026 at 1:37 PM, he stated he began employment at the facility 08/2025. He further stated he had completed an incident report on an interaction between P1 and RN1 last week. He stated P1 informed him RN1 had removed a pillow from her right hip which caused her pain. He further stated he had been informed of the complaint the morning of 12/29/2025 by some nurses in the hallway that were giving report to each other, and the event occurred on 12/28/2025. The Medical/Surgical Unit Manager stated at that time he spoke with P1, and she informed him she felt it was an intentional act. He stated he informed P1 he doubted it had been intentional, but the patient was insistent that it was intentional. In continued interview, he stated he had not received specific training on how to conduct an abuse investigation and he could seek assistance from the Director of Nursing (DON); however, she had been off work. Review of the “Both Courses and Event” logs revealed the Medical/Surgical Nurse Manager received and completed training on abuse, neglect and exploitation on 08/11/2025. During an interview, on 01/06/2026 at 1:00 PM, with a House Supervisor, she stated all staff had to complete annual “Care Learning” on abuse. She stated there were different types of abuse such as physical, financial, neglect and sexual abuse. She stated she had not been involved with an abuse allegation, but it was important to immediately separate the patient from the alleged abuse. She further stated anytime there was an allegation of abuse, a supervisor and the floor manager should be notified, and they would then ensure notifications through the chain of command. Review of the “Both Courses and Event” logs, revealed the House Supervisor had received and completed training on abuse, neglect, and exploitation on 02/10/2025. During an interview with RN2, on 01/06/2026 at 1:24 PM, she stated there were different types of abuse to include physical, restraints, verbal, financial and medical. She stated any suspected abuse should be immediately reported to a supervisor. She further stated she had cared for P1 in the past, and she had been a very pleasant and sweet patient. During an interview with a Certified Occupational Therapy Assistant (COTA) on 01/06/2026 at 3:15 PM, she stated she had participated in the care of P1. She stated the patient had complained to her that a nurse had pulled a pillow out from under her leg and caused it to hurt more than it already did. The COTA stated she did not tell anyone about P1’s concern because P1 had already informed others about what had happened to her. During an interview, on 01/06/2026 at 3:45 PM, with a Physical Therapy Assistant, she stated she had been involved with P1’s care. She stated P1 complained about a staff person a few times and hinted to not caring for “certain people”, but was not specific with who those certain people were. She further stated if a patient told her someone had hurt them, she would report this immediately to her supervisor, and to the floor manager. She stated staff had to complete a yearly training on abuse and neglect. During an interview with P1’s Physician, on 01/07/2026 at 2:00 PM, he stated he had been P1’s physician for a very long time. He stated P1 had informed him she did not want RN1 back into her room because he had pulled a pillow out from under her and hurt her hip. He further stated when P1 made the allegation that staff had hurt her, an investigation should have been started right away by the facility. During a telephonic interview, on 01/08/2026 at 12:08 PM, with the DON, she stated during any allegation of abuse, staff should interview the victim, any staff that were on duty the day the allegation occurred and several patients. She stated RN1 should have been removed from duty immediately and should not have provided any care to patients until an investigation had been completed by the facility. The DON further stated after the allegation was made, RN1 should not have gone into P1’s room at all, even with an escort. She stated an investigation should have been initiated by the facility within one (1) hour after the allegation had been made by P1. Review of “Both Courses and Events” logs, revealed the DON completed training on abuse, neglect and exploitation on 11/12/2025. During an interview with the Compliance Officer, on 01/08/2026 at 3:00 PM, she stated all staff received training on abuse and neglect upon hire. She further stated she had not been notified immediately of the allegation of abuse made by P1. During an interview, on 01/08/2026 at 3:04 PM, with the Administrator, he stated anytime an allegation of abuse was made by a patient, the staff person named as the alleged perpetrator should not go back into that patient’s room. He stated he had not been notified of the allegation P1 made towards RN1, but he should have been called and an investigation should have been initiated. He further stated he believed he became aware of the situation through the Medical Director. In continued interview, the Administrator stated he did not know the patient stated she would call the police if RN1 came into her room again. He further stated he had been told by the ED Manager, she had spoken with several other patient’s after the allegation had been made. He stated the facility participated in Quality Meetings at least monthly, and patient care audits were frequently done.”

“RESTRAINT AND SECLUSION CFR(s): 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 their arms, legs, body, or head freely; or This Standard is not met as evidenced by: 28734 Based on interview, record review, and review of facility policy, the facility failed to ensure one (1) of five (5) sampled patients, Patient (P)1, had the right to be free from restraints related to bed, and chair alarms. The findings include: Review of the facility’s policy titled, “Restraints”, dated 04/04/2023, revealed “Restraints may only be used to ensure the safety of the patient, staff or others and must be discontinued at the earliest possible time. Alternative ...interventions must be attempted prior to the use of restraints. Example of restraints: ...restraint used to keep mentally incapacitated patient with a broken hip from getting out of bed ...Patient Rights Statement:... 3. The patient has the right to request or refuse the use of restraint but must be informed of the risks associated with refusing the use of the restraint. This does not apply if the patient has violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. 1. [The facility] is committed to: Discontinue the restraint at the earliest possible time, raising awareness among staff of how restraint usage may be experienced by the patient... 3. Prior to the use of a restraint, consideration shall be given to the utilization of alternative, less restrictive methods of altering patient behavior. Alternative methods, which may be employed singularly or in combination, include: Verbal instructions/frequent re-orientation of the patient, asking family or friends to stay with the patient, and increasing frequency of patient observation by the staff. Non-violent Restraints Procedure: to discontinue restraints, the patient must meet the following criteria: Patient is able to contract for safety, he or she is oriented to the environment.” Review of Patient (P)1’s Emergency Room (ER) “Face Sheet”, revealed the facility admitted the patient on 12/23/2025. Review of P1’s “History and Physical”, signed and dated by a physician on 12/23/2025 at 6:43 PM, revealed the patient presented for rehabilitation in swing bed after (R THA) [total hip arthroplasty]. Having some swelling in the right leg from the foot all the way up to the thigh, concerned it might be cellulitis. On aspirin for deep vein thrombosis (DVT) prophylaxis. Assessment: Status post (S/P), swelling right lower extremity. Plan: will place on Lovenox (anti-coagulant that prevents blood clots), venous doppler in the morning. Plan: Physical Therapy (PT) and Occupational Therapy (OT). Review of P1’s “Physician’s orders”, dated 12/23/2025 at 10:51 AM, revealed orders for a bed alarm and chair alarm. Review of P1’s “Glasgow Coma Scale” (tool used by healthcare providers to measure a decrease in consciousness), dated 12/23/2025 at 9:15 PM, by a Registered Nurse (RN), revealed an assessment score of 15, which indicated P1 was fully conscious and alert. Review of P1’s “Glasgow Coma Scale”, dated 12/24/2025 at 8:15 AM, by a RN, revealed a score of 15, which indicated P1 was fully conscious and alert. “Oriented to own ability.” Review of the patient progress notes section, revealed “Alert and oriented x 4, cooperative, assistance and equipment- Assist with one (1), rolling walker, and gait belt.” “High fall risk.” Review of P1’s “Glasgow Coma Scale”, dated 12/25/2025 at 9:30 AM, by a RN, revealed a score of 15, which indicated P1 was fully conscious and alert. Review of the progress note section, revealed P1 was alert and oriented x 4, cooperative, and required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. “High fall risk.” Further review of the progress notes section, revealed the patient was assessed again by a RN at 9:12 PM with no changes. Review of P1’s “Glascow Coma Scale”, dated 12/26/2025 at 11:35 AM and 7:25 PM, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4 and was a high fall risk. Review of P1’s “Glasgow Coma Scale”, dated 12/27/2025 at 8:00 AM and again at 8:02 PM by a RN, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4, cooperative, and required the assistance of one (1) staff member with ambulation, as well as a rolling walker and a gait belt. Review of P1’s “Nurse’s Note”, dated 12/27/2025 at 1:11 PM, by Licensed Practical Nurse (LPN)1, revealed the patient was observed ambulating in room with a walker without staff assistance; husband present assisting patient with ambulation. Patient returned to her room and transferred to bed with staff assistance. No bed alarm sounding at the time of ambulation without staff. Patient stated she did not call out for staff and did not verify with any staff member to ambulate independently. Educated on importance of notifying staff if she needed to ambulate out of bed. Patient stated she had just asked her husband to walk in the hallway with her. Patient verbalized understanding of compliance with notifying staff to ambulate. Patient left in bed with bed alarm on, and functioning properly. Husband present in room. In an interview, on 01/06/2026 at 1:32 PM, with LPN1, she stated she had cared for P1 at least two (2) days during her admission. The LPN stated, anytime P1 would reposition herself in her bed, the bed alarm would sound. She stated the only time she knew of P1 ambulating without staff was one (1) time when she had ambulated in the hallway with her husband. LPN1 stated, as P1 neared her discharge date, she was able to ambulate with only stand-by assistance. LPN1 further stated she had been trained on the use of restraints. Review of the “Both Courses and Events” log, revealed LPN1 had received and completed training on restraint use on 06/26/2025. Review of P1’s “Glasgow Coma Scale”, dated 12/28/2025 at 8:51 AM, and 8:29 PM by a RN, revealed a Glascow Score of 15. Review of the progress note section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of a “Note”, dated and signed by a Certified Nursing Assistant (CNA)1, on 12/29/2025 at 8:25 AM, revealed, P1 was sitting up in her chair and asked to use the bathroom. Stayed in patient’s room to clean and mop her floor since she dropped her powder on the floor. Patient did good to walk out of the bathroom and sat in her chair which “now has a chair alarm on it since the chair alarm was placed on the nightstand.” Patient is aware she has to leave it (chair alarm) on at all times. “She is not happy about it but understands.” In an interview, on 01/08/2026 at 10:46 AM, with CNA1, she stated she had been a caregiver for P1 and never knew of a time where the patient tried to get out of the bed or the chair by herself, except for the one time when she had ambulated in the hallway with a family member. She further stated anytime P1 moved in her bed, the bed alarm would sound. The CNA stated the patient had asked staff to turn the sensitivity of the alarms down; however, they did not know how to do adjust the sensitivity. CNA1 further stated, chair alarms and bed alarms were both utilized at the facility to keep patients safe from falls, and P1 had both chair and bed alarms in use until the day she was discharged home with her family. The CNA stated P1 had never been a complicated or difficult patient. Review of the “Both Courses and Activity” log, revealed CNA1 had received and completed training and education on restraint use on 03/03/2025. Review of P1’s “Glasgow Coma Scale”, dated 12/29/2025 at 9:00 AM, and 7:55 PM by a RN, revealed a score of 15. Review of the progress note section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of P1’s “Glasgow Coma Scale”, dated 12/30/2025 at 8:28 AM, and 7:28 PM, by a RN, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of P1’s “Glasgow Coma Scale”, dated 12/31/2025 at 7:28 PM, by a RN, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of P1’s “Glasgow Coma Scale”, dated 01/01/2026 at 8:35 AM and 9:02 PM, by a RN, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. Further review revealed P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of P1’s “Glasgow Coma Scale”, dated 01/01/2026 at 8:41 AM, by a RN, revealed a score of 15. Review of the progress notes section, revealed P1 was alert and oriented x 4, cooperative, and was a high risk for falls. Further review revealed P1 required the assistance of one (1) staff member, rolling walker, and gait belt with ambulation. Review of a “Patient Progress Note”, dated 01/02/2026, revealed P1 was discharged to her home at 11:00 AM. A comprehensive chart review of P1’s “Progress Notes”, revealed the patient had chair and bed alarms in place since admission; however, there was no documented evidence P1 attempted to get out of her bed or chair or ambulate without assistance. A telephonic interview, on 01/08/2026 at 12:07 PM, with P1, revealed staff required her to have both bed, and chair alarms to alert them if she was attempting to get out of the bed or chair on her own. She stated these alarms sounded anytime she moved and tried to get comfortable. Continued interview revealed she knew she could not ambulate independently, and no one told her that her family could not assist her to ambulate in the hallway. She stated staff informed her after she had ambulated in the hallway with family, that she was not supposed to ambulate or get up without staff assistance. She stated once staff had informed her of this, she never attempted to ambulate without staff again. In an interview, with the Director of Nursing (DON), on 01/08/2026 at 12:08 PM, she stated both bed and chair alarms were used frequently with patients who had undergone hip surgery and were considered a high fall risk. She stated an alarm would alert staff if a patient had gotten up on their own. She further stated patients were assessed upon admission, and daily for their risk for falls. The DON stated if a patient was not at risk for falls, they should not have these alarms. She further stated she had not been notified the beds were overly sensitive to movement in the bed such as when a patient turned in the bed. In an interview, with the Administrator, on 01/08/2026 at 3:04 PM, he stated he could see how an alarm that sounded every time a patient tried to move in their bed could be considered a psychological restraint.”

“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: 52040 Based on interview, record review, and review of facility policies, it was determined the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether or not an emergency medical condition existed for one (1) of twenty (21) sampled patients. Patient (P) 1 presented to the ED on 09/15/2025 at 8:39 AM with complaints of mouth pain. The facility failed to provide P1 with an appropriate MSE, an ED Registered Nurse (RN) told the patient he “did not need to be here.” The findings include: Cross Refer to A2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 52040 Based on interviews, record review, and review of facility policies, it was determined the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether or not an emergency medical condition existed for one (1) of twenty-one (21) sampled patients. Patient (P) 1 presented to the ED on 09/15/2025 at 8:39 AM with complaints of mouth pain. The facility failed to provide P1 with an appropriate MSE, an ED Registered Nurse (RN) told the patient he “did not need to be here.” The finding include: Review of the Patient Demographics revealed Patient (P) 1 presented to the ED on 09/15/2025 at 8:39 AM with complaints of mouth pain. Review of Miscellaneous Nursing Note revealed the patient had exited the building before 8:49 AM. Review of Miscellaneous Nursing Note dated 09/15/2025 revealed, “Pt (patient) opted to not be seen. Spoke with him in lobby before coming thru the door. He has appt (appointment) with dentist Friday and on antibiotic. He decided not to be seen and wait for appt. When I asked registration what to do the pt has already exited the building. Suggested by co-worker to make a note.” Review of facility policy titled, “Standards of Care Emergency Nursing Practice”, last amended on 03/28/2017, revealed, “the standards of practice include elements reflecting the delivery of care by emergency nurses.” Emergency nurses collect comprehensive data pertinent to the patient’s health and/or situation. The emergency nurse triaged each patient using age, developmentally appropriate, and culturally sensitive practices to prioritize and optimize patient flow. Patient’s requiring immediate care would take priority. Review of facility policy titled, “Emergency Assessment Guidelines”, last amended on 07/26/2025, revealed, “all patients presenting to the ED shall receive an appropriate assessment and documentation.” The assessment began with triage and assign the Emergency Severity Index (ESI) level. The nursing assessment will be documented in the electronic medical record and the assessment will be based on the presenting complaint. The nurse may elect to use the general nursing assessment for non-specific complaints or the trauma assessment for multi systems trauma patients. Review of facility policy titled, “Emergency Severity Index (ESI) Five-Level Triage System”, last amended on 09/29/2022, revealed, “Caldwell Medical Center ED had adopted the ESI five-level triage system. Triage is used to prioritize patients that come to the ED for treatment and to recognize those patients that need immediate treatment. The ESI categorizes emergency department patients by evaluating both patient acuity and resource needs. The five-levels of triage are (1) resuscitation, (2) emergent, (3) urgent, (4) semi-urgent, and (5) non-urgent.” There are four critical questions that the nurse should ask and decide when triaging a patient: 1. Does this patient require immediate life-saving intervention? 2. Is this a patient who shouldn’t wait? 3. How many resources will this patient need? 4. What are the patient’s vital signs? Review of an email dated 09/15/2025 from ER Admissions Clerk (AC) 1 to Director of Revenue Cycle (DRC), Registration Manager (RM), and Admission Supervisor (AS), and forwarded to ED Nurse Manager, revealed “RN1 came to the waiting room and told a patient that I had checked in for mouth pain that he didn’t need to be here because he was on antibiotics and he had an appointment with his dentist scheduled for Friday but it was up to him on what he wanted to do. The patient told myself and RN1 that he also had other symptoms like a headache and that he had surgery on 08/07/2025 here at Caldwell Medical Center (CMC) by a Medical Doctor (MD) 1. It was obvious that the patient was in pain but she talked him into leaving without being seen after she told him that there was a wait, which there was not at that time. No vitals, nothing.” Review of counseling documentation dated 09/16/2025 by ED Nurse Manager to RN1 revealed “called RN1 into my office to discuss complaints received from Registration and Nursing. Educated RN1 on EMTALA not to go to registrations desk and ask several triaging questions. We cannot convince patients to leave. If patient decides to leave prior to being seen then they are a LWBS (Left Without Being Seen). If they are seen by a doctor, then they are an AMA (Against Medical Advice). Patient has to be seen by Midlevel or provider to count as the medical screening. She reported she was unaware of all EMTALA details but understands and will not do it again.” In an interview on 11/18/2025 at 2:35 PM with Registered Nurse (RN) 1, she stated she has never told anyone that they can’t be seen. She stated that she does not want people to wait because they get angry. Additionally, RN1 did remember a talk with the ED Nurse Manager regarding a patient that left without being seen. She did not remember the date, or the name of the patient involved, but it was someone that came in with mouth pain. She remembered that she was honest with him and told him since he already had a dental appointment scheduled, he should just wait for that. RN1 confirmed that EMTALA training had been part of her orientation but since she had never worked in an Emergency Room before that she “guessed she didn’t understand the complete scope it covered.” She now understands that she cannot tell anyone to go elsewhere or turn anyone away. In an interview on 11/18/2025 at 6:15 PM, Patient (P) 1 stated he went to the ED on 09/15/2025 complaining of mouth pain. He further stated that “a nurse lady came out to the waiting room and told me I should go to the dentist because there wasn’t anything they could do for me there but give me a list of dentists, so I left.” In an interview on 11/19/2025 at 4:09 PM with AC1, she recalled a conversation she overheard between RN1 and a patient that she had registered. The patient complained of mouth pain and was concerned about having a fever and high heart rate. RN1 talked to him in the waiting room at the registration desk. RN1 asked the patient if he had a doctor appointment, and she then told him that there was nothing that could be done for him in the ED. She told him to go home and take Tylenol and Motrin. AC1 stated she had witnessed similar incidents to this “like three times before.” She further stated that she reported this to supervisors, including the ED Nurse Manager. In an interview on 11/20/2025 at 8:23 AM with Admission Supervisor, he stated that he did have a registration clerk report to him that a particular nurse dissuaded a patient but does not remember specifics. In an interview on 11/20/2025 at 8:58 AM with ED Nurse Manager she stated that EMTALA training is part of ED orientation and there is annual training through care learning. She described that to her, EMTALA means every patient has the right to be seen regardless, must have a Medical Screening Exam (MSE) and determine a need for stabilization. She additionally stated that no one can be encouraged to leave, and the labor part is about pregnant women. Furthermore, she stated that there had been a few concerns brought to her attention from registration clerks and other nurses regarding RN1 encouraging patients to leave. When she addressed the concerns with the nurse, RN1 stated she had only responded to waiting patients’ questions and had never encouraged patients to leave. In an interview on 11/20/2025 at 9:15 AM with Patient Experience Manager, she stated she was aware of one situation that could be considered an EMTALA violation, and it was “a couple months ago, maybe September”. She stated that she referred it to the ED Nurse Manager.”