Spectrum Health

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36887 Based on observation, interview, and record review, the facility failed to resolve a controlled substance discrepancy in the automated dispensing cabinet (ADC) for 1 (Emergency Department cabinet) of 3 cabinets observed for discrepancies, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: 50585 On 2/5/2026 at 1130, during a tour of the Emergency Department, the discrepancy icon was observed on the screen on the Automated Dispensing Cabinet (ADC) in medication room number 1305. The discrepancy revealed that the cabinet had two discrepancies for controlled substances that were stored within the cabinet. One discrepancy was for Midazolam 2 mg / 2 mL injection with a discrepancy date of 11/14/2025. The other discrepancy was Oxycodone 5 mg immediate release tablet with a discrepancy date of 11/30/2025. A controlled substance discrepancy resolution report was requested before exiting , and was provided three days after exit and the report revealed the Midazolam 2 mg/ 2 mL injection discrepancy was resolved on 2/5/2026 at 1750 (83 days after the discrepancy date identified on the cabinet’s screen) with the discrepancy quantity “-5 Vial” and a resolution description “user miscounted pocket contents” from a transaction date of “11/14/2025 at 0721.” The resolution date of the Oxycodone 5 mg immediate release tablet was 2/5/2026 at 1750 (67 days after the date of the discrepancy date identified on the cabinet’s screen) with the discrepancy quantity “-1” and a discrepancy resolution description “user miscounted pocket contents” from a transaction that occurred on “11/30/2025 at 0346.” On 2/6/2026 at 1145, ED Nurse Manager Staff W was queried of their responsibilities for resolving controlled substance discrepancies. Staff W revealed “delegate to my charge nurses” and they check “once per shift.” When queried if they were aware of two controlled substance discrepancies that still existed that were created back in November 2025, Staff W acknowledged the discrepancies existed and were now “resolved.” According to the facilities’ policy “Management of Controlled Substances,” dated 7/21/2024: “Automated Dispensing Cabinet (ADC): A computerized drug storage device or cabinet which allow medications to be stored and dispensed near the point of care while controlling and tracking drug distribution.” The policy also revealed that: “Discrepancies in Controlled Substance Inventory B. For ADC discrepancies in the (facility) setting: 1. The user creating the discrepancy must present the discrepancy to a manager or supervisor or charge nurse if a miscount is not the cause of the discrepancy. 2. The manager/supervisor is responsible for investigating an unresolved discrepancy during their next shift following the discrepancy. 3. Discrepancies that cannot be resolved must be escalated to the pharmacy manager.”

“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: 53475 Based on interview and record review, the facility failed to ensure staff followed facility policy for 1 patient (P-1) of 14 patients reviewed, resulting in the lack of monitoring and assessment for P-1. Findings include: The review of the medical record on 2/5/2026 at 1438 for P-1, a 31-year-old female, showed an Emergency Department (ED) encounter on 7/13/2025. She was subsequently admitted to the ED Observation (ED OBS) unit on 7/14/2025 at 0126 with pyelonephritis (kidney infection) and sepsis. On 7/14/2025 at 0028, orders were placed by the ED OBS Physician Assistant Staff PP for the ED OBS unit. They included amongst others “Nursing - Intake and Output (I+O).” A review of the nursing flow sheets on 2/5/2026 at 1438 for the ED OBS unit stay from 7/14/2025-7/15/2025 listed only a one-time documented 650 ml urine output among other non-fluid related entries: Date Time Urine Output in Milliliter (ml) Characteristics 7/14/2025 0142 7/14/2025 0450 7/14/2025 0510 7/14/2025 0821 cloudy 7/14/2025 1215 cloudy 7/14/2025 1306 cloudy 7/14/2025 1700 cloudy 7/14/2025 2010 cloudy, dark, yellow 7/14/2025 2015 7/15/2025 0027 cloudy, dark, yellow 7/14/2025 0256 7/14/2025 0455 cloudy, dark yellow 650 ml 7/14/2025 0502 7/14/2025 0811 cloudy, dark 7/15/2025 0812 During interview on 2/6/2026 at 0946, Staff X was queried about Registered Nurse (RN) and Nurse Technician (NT) competencies regarding I+O management. Staff X shared that I+O management, such as the collection of urine samples, the assessment of urine characteristics, and the recording of the collected volume, could be completed by either an RN or an NT and was considered a nursing standard. The Unit Manager Staff VV on 2/10/2026 at 1145 when queried about Registered Nurse (RN) and Nurse Technician (NT) competencies regarding I+O management validated the same process as Staff X. A review of the “Policy Vital Signs and I & O Monitoring” effective 7/21/2024 states, “1. Measurements are documented in milliliters (mL) a. Body fluids as defined above: i. Counts should only be used for spills or when output will not be accurate and should not replace other accurate ways to measure output (weighing brief/diaper, urinals, hats, etc.) ii. When intake/output is assessed and there is no intake or output, a zero (0) should be documented iii. Documentation should be done as soon as possible to ensure accurate trending in electronic health record iv. 1g [gram]= 1mL... Standard I&O Values for Provider Notification ...2. Adult: Notify provider when urine output is assessed and measurement is less than 0.5 mL {milliliter}//kg {kilogram}/hr {hour}.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide information in the medical record regarding patient care provided for 3 (P-2, P-12, P-13) of 14 patients whose medical records were reviewed resulting in incomplete medical records. Findings include: Review of the medical record for P-2 revealed she was a newborn who had an apneic episode with emesis on 1/1/2026 at approximately 0419. She was taken to the nursery, suctioned, and placed on a CPAP (continuous positive airway pressure) prior to a newborn RAP (rapid assessment protocol - rapid response) being called. Once stabilized, P-2 was transferred to the neonatal intensive care unit (NICU). On 2/10/2026 at 1446, RN Staff LL stated she responded to P-2’s room after an emergency alert went out to the portable phones. Upon arrival, she saw P-2 on her father’s lap with “no rise and fall of the chest... She was pink...” Staff LL immediately turned P-2 to her side and requested a pulse oximeter from other staff on their arrival while she continued her assessment. She stated the oxygen saturation read 74%; however, she was not getting a good waveform. She picked up P-2 and rapidly walked to the nursery, closely followed by other nursing staff. P-2 was placed on the warmer and suctioned. “We decided to call a RAP as the respiratory effort was not good.” A nursing note by RN Staff MM dated 1/1/2026 at 0428 stated, “ Pt having deep retractions and SpO2 (oxygen saturation) 80% after choking on spit-up. Needing deep suction. Starting CPAP (continuous positive airway pressure) now.” No documentation was found in the medical record of CPAP settings, monitoring, or discontinuation. On 2/6/2026 at 0930, Chief Nursing Officer (CNO) Staff X stated it was her expectation that staff should follow the policies and procedures. Regarding documentation, she stated, “... They should document what they do... If a patient had a high degree of angst or worry, I would hope there would be documentation for voiced concern.” Facility policy #21727 titled “Nursing Documentation Policy” effective 7/21/2024 states, “Documenting Nursing Care i. In the moment documentation is essential to the patient’s plan of care - to inform the interprofessional care team and trend information. All nursing documentation will be completed as close to real time as possible... Patient assessments will be performed and documented according to the ‘Assessment Standards for Nursing’ and ‘Nursing Standards in the Event of a Disaster.’ iv. All patient care interventions will be documented by the individual performing the care... Patient/family education will be documented in the education record...” Facility policy #10022 titled “Neonatal and Infant Noninvasive Ventilation-Inpatient” effective 7/21/2024 states, “Documentation... Chart NPCPAP [nasal continuous positive airway pressure] parameters on the NIPPV Flow sheet in the EHR [electronic health record] 1)Flow rate/Slope 2) Circuit Temperature and humidification 3) CPAP/PEEP [positive end expiratory pressure] level 4) FIO2 [fraction of inspired oxygen] 5) Total Respiratory Rate 6) Oxygen Saturation 7) Prong size 8) Mask size 9) Flextruck size 10) Bonnet or Headgear size 11) Patient assessment including breath sounds and work of breathing. 12) Use of chin strap 13) Suction route with secretion amount, color, consistency and patient tolerance. 14) Any abnormal findings 15) Oxygen Saturation High/Low limits 16) Heart Rate 17) Mode of Ventilation.” 50585 On 2/6/2026 at 0940, P-13’s medication infusion pump was observed and the pump revealed the medication Dexmedetomidine was infusing at 0.4 microgram/kilogram/hour. Nurse Staff V confirmed the setting at the time of observation and was queried what the current medication order was for dexmedetomidine, Staff V revealed Dexmedetomidine infusion, 400 mcg in 100 mL sodium chloride at 0.1 -1.5 mcg/kg/hr and titrate to sedation level. When queried when was the last infusion rate change, Staff V demonstrated using P-13’s medical record that the previous shift documentation revealed an infusion rate of 0.2 microgram/kilogram/hour on 2/6/2026 at 0517 and the rate was increased to 0.3 microgram/kilogram/hour on 2/6/2026 at 0545. Staff V verified the current rate of 0.4 microgram/kilogram/hour was initiated before their shift start at 0700. When queried if the rate should have been documented on the previous shift, Staff V revealed “yes.” On 2/10/2026 at 0730, P-13’s medical record was reviewed and P-13’s nursing note on 2/6/2026 at 1005 revealed “dose changed prior to shift” for the 0.4 mcg/kg/hour dose of Dexmedetomidine. The medical record also revealed P-13’s initial fall risk assessment was performed on 2/4/2026 at 0415 and the assessment revealed P-13 was high risk. On 2/6/2026 at 1300, P-12’s medical record was reviewed and P-12 had a medication order for fentanyl 25 mcg every 3 hours prn for severe pain( (pain scale 7 - 10) or patient description. The order also indicated “May Give 25 to 50 mcg. Start with 25 mcg. If inadequate pain relief, may give 50 mcg for subsequent doses unless oversedation noted.” On 2/5/2026 at 2106, P-12 received Fentanyl 25 mcg intravenously and P-12’s documented pain score prior to the Fentanyl dose was 7 on 2/5/2026 at 2106. P-12’s next pain assessment was performed on 2/6/2026 at 0133 with the documented pain score of 8. Clinical Regulatory Specialist Staff C confirmed the findings at the time of discovery that a pain reassessment was not completed in a timely manner after the administration of the Fentanyl dose. According to the facility’s policy, “Intravenous Push and Infusion Preparation and Administration,” dated 11/4/2025, revealed: “Documentation 1. All IV solutions administered to patients must be documented in the patient chart on the medication administration record (MAR) or other designated documentation record per the Medication Administration policy. 2. Documentation shall include: a. Dose and/or rate )pediatric documentation requires both) b. Concentration of solution c. Time infusion initiated or rate changed including when an infusion is held or stopped (chart a rare of zero).” According to the facility’s policy “Pain/Comfort Assessment and Intervention,” dated 7/1/2024, “reassess pain and sedation within 30-60 minutes of pain intervention.””

“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: 36887 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases, specifically the failure to provide an appropriate, comprehensive medical screening exam for 1 (P-1) of 50 patients reviewed resulting in unrecognized, unmet patient needs and the potential for poor patient outcomes. Findings include: See Specific Tags: A-2406 Failure to provide an appropriate, comprehensive medical screening exam.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to perform an appropriate, comprehensive medical screening exam for 1 (P-1) of 50 patients reviewed resulting in unrecognized, unmet patient needs and the potential for poor patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 39-year-old male who presented to the Emergency Department (ED) on 9/2/2025 at 1440 via private car with a chief complaint of abdominal pain. At 1441, P-1 was assigned an acuity (severity or urgency) of 2 (the emergency severity index level/acuity 2 means “high risk” and would include a patient with chest pain; patient should be seen within 10-15 minutes) by RN (Registered Nurse) Staff S who was working triage and assisting the primary triage nurse Staff U. The primary assessment showed respirations, skin, cardiac, peripheral, and cognitive assessments to be within normal limits. Vital signs were as follows: Pulse (P)-64, Respirations (R)-22, Blood Pressure (BP)-132/100; Pulse Oximeter (SpO2)-99% on room air. Pain level was not assessed. RN Staff U documented the “Patient Stated Reason for Visit” at 1441 which stated, “pt presents with upper abd pain and nausea for the past three days.per (sic) pt (history of GERD-gastroesophageal reflux disease). pt arrives with pts dad; History Obtained From : patient” At 14:41:45, Staff U changed the acuity level to 3 (2 or more resources needed; should be seen within 60 minutes). At 1500, Staff U documented an “update” which stated, “pt (sic) threw up on the ground. pt (sic) given emesis bag. pt (sic) restless and anxious. pt (sic) acuity changed and redirected to his chair.” At 15:08:08, the acuity level was changed by Staff S back to a level 2. At 15:09:52 the following labs were ordered by Provider Staff V triggered by Chief Complaint of Abdominal Pain and ESI of 2 without a medical screening exam other than the one completed by the Triage RN: Urinalysis, Lipase Levels, Comprehensive Metabolic Panel, Complete Blood Count (CBC). It was noted that Troponins labs and an EKG were not included. P-1 was called by staff to go back to an ED room at 1639, 1659, and 1714 without response. He was “dismissed” from the system and disposition was selected as “LWBS (left without being seen” at 17:15:25. During interview on 12/18/2025 at 1640, P-1 stated he went to the ED with chest pain and abdominal pain. He noticed they had only put abdominal pain into the computer and told the nurse he was also having chest pain and felt he was having a heart attack, but they did not change what was there. P-1 stated the ED was “packed” and he was told there would be a one and a half-hour wait. After waiting for an hour and a half, he chose to leave and go to another acute care hospital that was nearby. Assistant Triage Nurse Staff S was interviewed 12/19/2025 at 0900 and stated she could not recall P-1. She stated it was their practice to work together as a team, so it was possible she was assisting with documentation while Primary Triage Nurse Staff U was doing hands on tasks. Staff S further stated all triage staff, including nurses and ED technicians, were responsible for watching patients in the ED waiting area for symptom management. Primary Triage Nurse Staff U was unavailable for interview. Review of the medical record for P-1 from the receiving hospital revealed he arrived to the ED 9/2/2025 at 1645 with an arrival complaint of “acid reflex (sic), causing chest pain and sob (shortness of breath).” Vital signs were obtained at 1657 as follows: P-71, R-18, BP-151/106, SpO2-99% on room air. A first provider assessment was conducted at 16:59:12 and orders were placed for medication, labs, an IV (intravenous line) and an EKG. Triage started at 17:01:07 and the chief complaint was updated to “Chest Pain (Woke up this morning feeling some reflux. Feels a sharp pain in chest... Pt reporting nausea and vomiting in triage).” The first EKG was performed at 17:02. He was assigned an acuity of 2 at 17:09:49. ED Provider notes dated 9/2/2025 at 1645 indicated P-1 had a normal review of systems; however, he stated he was having chest “discomfort” that felt like “acid, but has not had acid problems in quite some time... Substernal in nature but does not go to his jaws or his back... has been having this discomfort on and off throughout the day and feels a burning, at times squeezing and tightness.” Labs and a chest x-ray were obtained. An EKG (electrocardiogram) was performed that showed sinus rhythm with ST-elevation in leads V2, V3, and V4. An emergent consult was done with cardiology and the cardiac catheterization lab was activated. P-1 was prepped for an emergent cardiac catheterization. A repeat EKG was performed showing sinus tachycardia with ST-elevation in leads V2, V3, V4, Lead I, and a “small amount of elevation in lead aVL.” P-1 was taken back to an ED room at 1718 and was taken to the cardiac catheterization lab at 1801. Cardiology Notes dated 9/3/2025 at 1553 stated P-1 had “a tight occluded LAD (Left Anterior Descending artery of the heart-largest artery of the heart) with thrombus that was successfully stented... 50% stenosis in the mid left circumflex (major heart artery that supplies blood to the left ventricle), 60% stenosis in the ostium (small opening) of the PDA (patent ductus arteriosus - connection to the pulmonary artery and aorta)...” P-1 was diagnosed with “Acute ST elevation myocardial infarction (heart attack).” Of note, the admitting history and physical (H&P) dated 9/2/2025 at 2139 stated, “He went to (subject facility) ED but was not able to be seen so he came to (receiving hospital).” Additionally, an Internal Medicine Progress Note dated 9/3/2025 at 1127 stated, “He presented here after he was not able to be seen at (subject facility) ED.” Facility policy #9646 titled “POLICY Emergency Department Triage and ED Management of Non-traumatic Chest Pain” effective 7/21/2024 states, “Atypical Presentation: Symptoms that may be associated with ACS (acute coronary syndrome) other than pain in the chest. These may include the presence of shortness of breath, dyspnea (difficult in breathing), diaphoresis (sweating), fatigue, nausea, vomiting, and/or pain/discomfort reported in the jaw, epigastric area, shoulder, neck, or back... The definitive criteria for determining risk for patients with chest pain upon presentation are determined from a 12-lead ECG (electrocardiogram)... The decision to obtain a 12-lead ECG is based upon presenting symptoms and history... Emergency Department RNs will utilize the Emergency Department Interdisciplinary Protocols to provide acuity-based interventions for patient presenting with chest pain as able... Patients presenting with chest pain/symptoms suggestive of ACS... are immediately assigned a bed and triage is completed concurrently with the obtainment of a 12-lead ECG and physician assessment or immediate provider evaluation of the 12 lead ECG and RN initiation of the Emergency Department Interdisciplinary Protocols... In the event that a bed is not immediately available when a patient presents with symptoms suggestive of ACS, it is the triage nurse’s responsibility to ensure that a 12-lead ECG is obtained as outlined in the Emergency Department Interdisciplinary Protocols... A 12-lead ECG is to be obtained and given to the physician for review within 10 minutes of arrival... Cardiac symptoms may be evidenced by symptoms other than chest pain. Women, persons with diabetes and older adults may present with atypical presentations that are more prevalent than a complaint of chest pain or discomfort which may include the sudden onset of: Dyspnea/shortness of breath, weakness/fatigue, diaphoresis, nausea/vomiting, epigastric pain or discomfort, palpitations or near syncope...ESI -Level 2: classification will be assigned to any patient with any positive indicators of ACS as indicated by the presence of typical or atypical signs and symptoms confirmed by objective data. 12-lead ECG may demonstrate ST-segment depression, new left bundle branch block, dynamic T-wave inversions or be ‘non-diagnostic’... ESI-Level 3: classification will be assigned to those patients with a stable clinical presentation who present with a history suspicious for ischemic pain and who are currently pain free, or who have a complaint of chest pain which is not typical for ischemic pain but who have a positive medical history for ischemic disease, or fever. 12-lead ECG may be ‘non-diagnostic’ or ‘normal’ as determined by the provider. Patient will be placed on continuous ST-segment monitoring with repeat 12-lead ECGs obtained as appropriate for return of pain or change in ST-segments... Patients may be cared for in any area of the department and all patients presenting with chest pain will receive a screening ECG...” Facility policy #8583 titled “PROTOCOL Emergency Department Interdisciplinary Protocols” effective 7/21/2024 had tables that state, “Appendix A ADULT ABDOMINAL /GASTROINTESTINAL PROTOCOL Inclusion Criteria: Patients presenting to the ED with abdominal/gastrointestinal complaints ESI Level 1 or 2 Initial Interventions Initiate O2 (oxygen) per hospital policy Oxygen Therapy, Establish cardiac monitoring and pulse oximetry, Establish peripheral IV, Obtain ECG if indicated, Administer IV fluid bolus if indicated. Initial Interventions ESI Level 3 Establish cardiac monitoring and pulse oximetry if indicated, Establish peripheral IV if indicated, Obtain ECG if indicated... Appendix B ADULT CARDIOVASCULAR PROTOCOL Inclusion Criteria: Patients presenting to the ED with cardiovascular complaints, which includes acute coronary syndrome (ACS), heart failure, heart transplant and patients with a Ventricular Assist Device (VAD) ESI Level 1 or 2 Initial Interventions Initiate O2 per hospital policy Oxygen Therapy; Establish cardiac monitoring and pulse oximetry; Establish peripheral IV; Obtain ECG; Administer IV fluid bolus if indicated ESI Level 3 Initial Interventions Initiate O2 per hospital policy Oxygen Therapy; Establish cardiac monitoring and pulse oximetry; Establish peripheral IV; Obtain ECG... “”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 15195 Based on interview and record review, the facility failed to promptly report and/or investigate an allegation of neonate mistreatment/abuse for 1 (#4) of 2 pediatric allegations of abuse, resulting in the potential for less-than-optimal patient outcomes. Findings include: Medical record review revealed patient #4 was a premature infant born at 26 weeks and was hospitalized in the neonatal intensive care unit (NICU) from 9/12/24 - 11/21/24. On 6/20/25 at 1300, interview with Confidential Informant P revealed that on the night of 10/13/24 - 10/14/24 Nurse N mistreated the baby (tossed baby harshly on his side twice) and they reported it to Social Worker M and said the mother did not want Nurse N to take care of the baby anymore. However, Nurse N took care of the baby again later in the infant’s stay. This was verified in the Nurses’ Notes dated 10/27/24 - 10/28/24. On 10/14/2024, the Social Work note documented that the mom had concerns related to care of her baby at the bedside by Nurse N. Phone interview with Social Worker, on 6/25/25 at approximately 1200, revealed that she did not report the issue to the nurse manager or anyone else because she thought it was just a clash of personalities and “it’s not our protocol.” On 6/23/24 at approximately 1130, interview with Nurse Manager C revealed that she was unaware of any issues of staff mistreating babies and/or any issue with Nurse N. On 6/24/25 at 1030, interview with Patient Relations Manager G revealed that she was not aware of this allegation of baby mistreatment/abuse. On 6/24/25 at approximately 1130, interview with NICU Risk Manager I revealed she was unaware of the allegation of baby mistreatment/abuse. On 6/25/25 at 1345, phone interview with Nurse N revealed that she did not recall the neonate or the mother and this was the first she had heard about an issue. Review of the facility policy titled “If a Physical Assault or Other Allegations of Misconduct Involving Patient-Investigating Allegation and Notification, dated 3/25/22” documented, “Inpatient and outpatient allegations of physical or other misconduct will immediately be reported to the entity leader as defined for the area where the allegation is made... An investigation should be initiated when: An allegation of physical or other misconduct involving a patient is made...” This had not been done.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to perform a comprehensive medical screening exam for 1 (P-1) of 37 patients reviewed resulting in unrecognized, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 13-year-old male who presented to Facility B, an acute care hospital within the same healthcare system, on 2/22/2024 with a chief complaint of a headache. It was noted that P-1 had been seen at the local children’s hospital (Facility A) on 2/19/2025 and 2/21/2025 for a headache as well. A CT scan (computerized tomography-“cat scan”) was ordered at the 2/19/2025 visit and resulted with “No acute intracranial abnormality.” Triage notes indicated the mother reported P-1 was “unable to get out of bed d/t (due to) intensity of h/a (headache); ct scan at (Facility A) x 2 days ago; endorses nausea, weakness, and lightheadedness.” P-1 rated his pain 9/10. Triage assigned him an ESI (Emergency Severity Index-a five-level triage algorithm used in the emergency department to quickly assess and prioritize patients based on the severity of their condition and the resources needed for their care) acuity level 4 (Non-urgent. Patient only needs one resource to be treated and discharged.) During an interview on 4/29/2025 at 1109, Confidential Informant #1 stated P-1 lost the ability to walk at home and his older brother had to carry him around the house and help him to the bathroom and was brought to Facility B. Confidential Informant #1 stated when the facility asked why P-1 was there, the mom told them it was because (Facility A) was not doing anything (to help P-1). Review of provider notes from Physician Assistant (PA) Staff I revealed the provider was aware P-1 had been seen twice before at Facility A for a headache and had a negative CT scan of the head. P-1 had not received the Depakote that had been previously prescribed for the patient by neurology at Facility A nor had he followed up with the neurologist as instructed as the discharge paperwork had been misplaced. The notes stated, “Complains of a headache not able to sleep. No reported fevers falls injuries no chills coughing wheezing chest pain shortness of breath no major abdominal pain there has been nausea vomiting per patient (sic). No swelling edema numbness or tingling no recent weight loss (sic).” Under the “Review of Systems” portion of the provider notes, the constitutional, eyes, respiratory, cardiovascular, genitourinary, musculoskeletal, endo/heme/allergy, psychiatric/behavioral sections were all listed as “negative.” The gastrointestinal was positive for nausea and vomiting the neurological section was positive for headaches. Physical exam revealed under constitutional, “General: He is not in acute distress.” The neurological section stated, “Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.” No mention was made in the provider notes regarding P-1’s inability to walk or having weakness as was mentioned in the triage notes. No further neurological exam was done after a third admission for the same problem in three days. No labs or further imaging were obtained. No further consults were placed. P-1 was given Benadryl, Reglan, Toradol, Depakote, and a liter of normal saline while in the ED. His pain decreased to 6/10. A diagnosis of “Acute nonintractable headache, unspecified headache type” was given. In the ED course portion of the provider notes, PA Staff I stated, “Do not feel any further imaging at this time as needed (sic). Patient will be discharged stable... Patient will be discharged stable and improved.” On 5/1/2025 at 1024, PA Staff I stated during interview P-1 had come in for a headache, was seen twice previously at Facility A, had a CT scan that was unremarkable, neurology had been consulted and had recommended Depakote. He presented at Facility B with headache, nausea/vomiting, and insomnia. Staff I stated mom had lost the discharge papers and script that had been given to her from Facility A and had come in “for another script.” He stated P-1 “looked good” and was “non-toxic.” He gave a “migraine cocktail” and on re-examination, P-1 was “resting comfortably and looked much improved.” Staff I also stated “the discharge papers were a big thing. I really stressed the importance of seeing neurology and getting the medications that had been prescribed.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide adequate communication and documentation for 2 (#6, 13) of 2 patients reviewed for suicidal ideation resulting in elopement and potential for poor patient outcomes. Findings include: On 8/19/2024 at 1450, review of the medical record for P-6 revealed he was a 22-year-old male who presented to the ED (emergency department) via EMS (emergency medical services) on 8/15/2024 at 0147. The chief complaint stated, “INGESTION (From home, ingested 70 DXM [dextromethorphan] pills over the course of 3 days (1000 mg [milligrams] total possible) called police and made SI [suicidal ideation] threats. Per EMS trying to self harm (sic), depressed. PD [police department] on scene, cooperative with EMS. Hx [history] anxiety and depression, and drug use. Aox4 [alert and oriented to person, place, time, and situation], diaphoretic, enlarged pupils, HTN [hypertension-high blood pressure] 161/114, HR [heart rate] -100, BG [blood glucose] 115...” Review of the EMS run sheet dated 8/15/2024 revealed, “Pt stated that he was feeling depressed and anxious and called PD and made suicidal threats during the phone call...” On 8/15/2024 at 0154, the triage nursed used the Columbia Suicide Severity Rating Scale to assess suicide risk. P-6 answered yes to having suicidal ideations in the past month with thoughts of method to use. Suicide intent without a specific plan, and suicidal behavior in the past 3 months and in his lifetime. The level of risk from the screening was listed as “High.” On 8/15/2024 at 0157, orders were placed by Internal Medicine Resident Staff II for “Safety Attendant at Bedside High risk (sic) suicide 1:1; Secured Environment Precautions; Consult to Social Work.” The orders were acknowledged at the same time and the patient was placed in a “Behavioral Health Hold; Safety Attendant at Bedside High risk (sic) suicide 1:1; Secured Environment Precautions; Consult to Social Work.” P-6 was evaluated in the ED by Physician Staff X. She documented on 8/15/2024 at 0238 that P-6 had been taking “copious amounts of dextromethorphan” for the past 3 days and was taking it for “the 4th dimension.” He denied he was trying to hurt himself. Staff X stated she was “Unable to perform ROS (review of systems)” due to mental status change. Physical exam revealed pupils dilated “at 5” (5 millimeters in size), normal thought processes, and P-6 was alert and oriented to person, place, and time. His affect was described as flat, but it is noted that he was answering questions appropriately. He denied being suicidal. On 8/20/2024 at 0948, Staff X stated she remembered P-6 and described him as “calm, cooperative, definitely out there, and intoxicated on dextromethorphan. His pupils were huge, but he was cooperative.” P-6 told her he was not trying to hurt himself. When asked why he took so much dextromethorphan, he replied he was trying to attain “the fourth dimension.” Staff X further stated she had a toxicology consult to see how long it would take P-6 to clear the dextromethorphan from his system and was told it would take longer than 24 hours. Staff X also explained the process in the ED with a patient that had overdosed was to wait until they were sober before having the social worker and/or psychiatric consult. The social work consult had not yet taken place yet because the P-6 was not yet sober. ED Physician note from 8/15/2024 at 0238 also revealed lab work showed the urine drug screen was negative as well as the salicylate and acetaminophen levels. His CK levels were somewhat elevated. Blood pressure was elevated, and the patient was tachycardic. The patient was admitted to observation for dextromethorphan toxicity. The history and physical (H&P) done on 8/15/2024 at 0303 had a plan of keeping the patient on a cardiac monitor; monitoring for altered mental status, seizures, autonomic instability, and muscular hypertonicity; monitoring for rhabdomyolysis (breakdown of muscle tissue), monitoring and medicating for high blood pressure, social work/behavioral health consult, and toxicology consult. Attending Physician Staff KK signed an attestation to the H&P on 8/19/2024 at 1451 which stated, “I have personally interviewed and examined the patient on the date of service of the attached note. Management was discussed with (Resident II). I agree with the documented findings and plan of care in their note...” The toxicology consult from 8/15/2024 at 0714 stated “reported ingestion of approximately 1300 mg (milligrams) of dextromethorphan ... we do feel that he is likely still suffering from the effects of this ingestion and will likely have more apparent amnestic effects once he is more lucid, likely tomorrow.” On 8/20/2024 at 1323, Registered Nurse (RN) Staff Y stated prior to his arrival on shift on 8/15/2024 P-6 had been caught vaping in his room. They explained hospital policy did not permit vaping and the vape was taken away and secured in an orange box in the patient’s room. At approximately 0730-0800, Staff Y entered P-6’s room and found him trying to access the orange box in the room to get his vape. When told it was against hospital policy to vape, “His immediate response was ‘I want to leave.’” Resident Staff DD and Resident Staff JJ went in to speak with the patient, stated medications could be administered to replace the vape, and encouraged P-6 to stay. The patient was agreeable. Shortly after, P-6 was found trying to access the orange box again and said he wanted to leave. Staff Y then opened the box, gave P-6 his belongings, reviewed the risks of leaving against medical advice (AMA), and had P-6 sign the AMA form. P-6 left the hospital on 8/15/2024 at 0840. Further review of the medical record revealed a social work note from Social Worker (MSW) Staff EE dated 8/15/2024 at 0840 titled “Social Work Behavioral Health Assessment” and the reason for the consult was listed as “Behavioral Health/Suicide.” In the consult note, Staff EE documented a county deputy had completed a petition for P-6 after he made multiple suicidal statements and said he wanted to kill himself. She wrote, “The petition was uploaded to Careport. It should be noted that Careport is visible to the care management department, however all other departments (nursing, providers, etc.) do not have access to Careport and therefore could not see petition. Patient transferred from emergency department to 7HC overnight. The petition was not brought up with patient. There was no documentation of a petition having been completed. There was no social work note indicating high risk suicide or recommended safety precautions. By the time unit MSW began shift at 0800, there was no safety attendant or secured environment precautions in place.” When interviewed on 8/20/2024 at 1134, Staff EE, stated social work had been consulted for a suicide assessment through the ED. When she went in to review the chart, she noticed there were no increased risk precautions in place, like sitters. She went to inform the charge nurse and was informed the patient had left AMA. She had also noticed within the system that another MSW had acknowledged the order, but nothing had been done from there. Staff EE contacted her manager for direction. They called security as well as city and county police departments and requested a welfare check was done. Staff EE stated she did receive word back from the county police that contact had been made with a family member and there were no concerns. The police informed her they would not be bringing the patient back to the hospital. On 8/20/2024 at 1444, Manager of Clinical Care Management Staff FF stated the original petition usually originates from the ED. It is then carried to the inpatient unit on admission. Careport was an area that was only available to care management. She stated, “We are very well aware standard practice was not followed in this case. Gaps have been identified ... The social worker in the ED had the petition but was unable to see (P-6) because of altered mental status. Had she written a note into the medical record about the presence of the petition, this wouldn ’ t have happened.” When queried as to why the petition and/or clinical certification was not made a part of the medical record, Staff FF stated it was not part of their workflow process. Review of the workflow process on 8/20/2024 at 1610 revealed in task description number 7, “When there is a concern that a patient is at risk for self-harm, a Behavioral Health hold should be ordered by the RN until a full assessment can be completed. The Behavioral Health hold allows the hospital to ‘hold’ the at-risk patient. This patient will not be able to leave the hospital Against Medical Advice (AMA) until the patient has been cleared by the social worker and physician and is no longer considered to be At-Risk.” Information was present about hand-carrying the petition and/or clinical certification to the inpatient unit; however, nothing was present about making it part of the medical record. Further review of the discharge summary dated 8/15/2024 at 0840 revealed there was an attestation present by Attending Physician KK which stated, “ED MSW (social worker) documented suicidal thought, and started petition and uploaded info to Careport. This information were not passed to RN at floor during call, nor to attending physician or admitting physician. Patient left AMA in am.” Review of the Incident Report Log for for the past six months revealed an entry for P-6 which indicated a safety attendant was present on admission; however, between the time of admission and prior to the arrival of first shift staff, “the safety attendant and monitoring were cancelled for unclear reason.” Review of facility policy “Care of The Suicidal/Potentially Suicidal Patient” effective 7/19/2024 states, “I. Purpose: To identify the process for maintaining the safety of patients who are expressing and/or demonstrating suicidal or potentially suicidal behavior. II. Responsibilities: Registered Nurse (RN) Physicians, Advanced Practice Provider (APP), Social Worker (SW), Safety Attendant (SA), Medical Assistant (MA), Any health care professional or care giver who may encounter a patient who expresses suicidal ideation and/or suicidal behaviors...Behavioral Health Hold: An order placed in the EHR [electronic health record] that identifies a patient as unsafe to leave the ED until clinical evaluation and discontinuation of the order by a provider; often done in collaboration with social work. The order is placed for patients experiencing a certain risk level for suicidal ideation...The order may also be placed for patients presenting with a completed petition, a court ordered metal [sic] health pick-up order, those presenting from a psychiatric hospital or crisis residential center, or those referred by a community agency or provider for medical clearance prior to transfer to a higher level of psych care... A patient at risk is identified by one or more of the following: 1. Completed risk screening 2. Presenting complaint/admitting diagnosis (i.e. intentional overdose, self-inflicted injury) 3. Patient actions that are concerning for patient safety. 4. Concerns or comments expressed by patient, family, friends, significant other(s), court order, law enforcement or community agencies. 5. SW and/or Provider assessment B. Suicide Risk screening: 1. The Columbia-Suicide Severity Rating Scale (C-SSRS)... will be completed on all patients, 10 years of age and older, who presents to the Emergency Department, Inpatient hospital, expresses suicidal thoughts, demonstrates suicidal behaviors and/or screens at risk... C. Caring for an at-risk patient: 1. Refer to the applicable appendixes to guide the screening, assessment, interventions, and care of a patient who has been identified at risk... Appendix C: Inpatient and Emergency Department... B. Social Work (SW) evaluation of at-risk patient: 1. SW receives consult and completes the suicide assessment utilizing an evidence-based tool including suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors and protective factors. 2. SW validates or assigns risk level. 3. SW then notifies bedside nurse and provider with outcome of assessment and assigned risk level. 4. SW facilitates collaboration with the Provider for initiation or adjustment of patient care orders as appropriate. Only the Provider may adjust or discontinue orders. 5. SW will collaborate as needed with psychiatry, especially with a high-risk patient and discharge disposition to an outpatient setting. 6. SW will collaborate with the interdisciplinary team to guide the plan of care for patient. Information such as individual patient triggers, approved items that are deemed safe to remain with the patient, and/or approved and/or restricted visitors will be included in the patient’s plan of care. Routine RN assessments are conducted according to the applicable nursing assessment policy... SW will be promptly notified by the RN with any concerns for change in patient behaviors that may indicate change in risk level.” Review of the medical record for P-13 revealed she was a 30 year-old female that presented to the facility on 7/21/2024 with a suicide attempt. Review of documentation revealed a note present by the MSW there was a petition and clinical certification that had been done on the patient; however, it was not found in the medical record. Manager of Clinical Case Management Staff FF stated on 8/20/2024 at 1444 the petition and clinical certifications were not scanned into the medical record, they are kept with CarePoint and if needed are printed and sent with the patient to the inpatient unit or in the transfer packet to another facility.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide services necessary to avoid physical harm or mental anguish for 3 (P-1, 3, 11) of 3 patients reviewed for tracheostomy assessments and care resulting in the potential for unmet patient needs and poor patient outcomes. Findings include: On 8/16/2024 at 1400, review of the medical record for P-1 revealed she was a 35 year-old female who had a tracheostomy placed on 8/1/2024. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times: 8/2/2024 0304 (gap of 7 hours, 22 minutes) 2059 (gap of 6 hours, 59 minutes) 8/3/2024 1030 (gap of 7 hours, 29 minutes) 8/4/2024 0259 (gap of 6 hours, 40 minutes) 8/5/2024 0303 (gap of 18 hours, 16 minutes) 1020 (gap of 7 hours, 17 minutes) 1655 (gap of 6 hours, 35 minutes) 8/7/2024 0301 (gap of 6 hours, 29 minutes) 0939 (gap of 6 hours, 38 minutes) 1641 (gap of 7 hours, 2 minutes) 8/8/2024 0343 (gap of 7 hours, 59 minutes) 1541 (gap of 6 hours, 48 minutes) 8/9/2024 0304 (gap of 11 hours, 23 minutes) 1745 (gap of 9 hours, 55 minutes) 8/10/2024 0020 (gap of 6 hours, 20 minutes) On 8/16/2024 at 1259, review of the medical record for P-3 revealed he was a 21 year-old male who had a tracheostomy placed shortly after birth. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times: 8/12/2024 1838 (gap of 7 hours, 23 minutes) 8/13/2024 0303 (gap of 7 hours, 30 minutes) 8/14/2024 0347 (gap of 7 hours, 7 minutes) 8/15/2024 1532 (gap of 6 hours, 46 minutes) 8/16/2024 0915 (gap of 10 hours, 45 minutes) On 8/16/2024 at 1330, review of the medical record for P-11 revealed he was a 60 year-old male who had a tracheostomy placed 8/14/2024. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times: 8/14/2024 1535 (initial after placement) 8/15/2024 0449 (gap of 7 hours, 27 minutes) 8/16/2024 0330 (gap of 7 hours, 30 minutes) On 8/19/2024 at 1201, RT Staff P stated the RT is responsible for performing assessments on patients with an artificial airway. Facility policy titled “Artificial Airway Assessment” effective 7/19/2024 states, “Purpose: To outline the process and steps for artificial airway assessments performed by the Licensed Respiratory Therapist... An artificial airway is a device inserted into the trachea via nare, mouth or stoma bypassing the upper airway anatomical structures, rendering them nonfunctional. Artificial airway is the generic term for endotracheal tubes (ETT), nasotracheal tubes, tracheostomy and LaryTubes... Required observations will be performed at least every six hours...””

“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: 28042 Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for one (P-12) of 13 patients reviewed, resuling in the lack of assessment and monitoring for P-12 and the potential for poor outcomes. Findings include: Review of P-12’s medical record on 08/20/2024 at 1350 revealed P-12 was a 44-year-old female with past medical history of coronary artery disease, hyperlipidemia, nonischemic cardiomyopathy who presented to the Emergency Department on 07/04/2024 with chest pain. Review of ED physician noted dated 07/04/2024 revealed P-12 had a heart attack on 05/30/2024, was subsequently admitted to the hospital where she had a coronary artery dissection and V-Fib arrest. P-12 did require placement of an Impella device (temporary heart pump implanted into the heart to improve blood flow) and ECMO. P-12 reported that she had been doing well until 02:30 on 07/04/2024 when she developed pain at the site, chest pain, shortness of breath, and a mild cough. P-12 was admitted to 7 Meijer Heart Critical Care Unit with diagnosis of hematoma and chest wall abscess. Review of nursing documentation indicated P-12 was admitted after right chest washout in the OR. Operative note indicated P-12 had incision and debridement of infection done on 07/04/2024 down to the muscle layer. Review of physician’s orders for P-12 revealed on order dated 07/07/2024 at 2318 for Leave of Absence (LOA) for Pivotal Life Event. Review of nursing notes for P-12 revealed nursing note dated 07/08/2024 at 0445 “Pt (patient) left hospital at 0145 via cab per leave of absence order to bring her 13-year-old daughter back home. Pt plans to return back via cab.” Nursing note dated 07/08/2024 at 0401 documented P-12 “arrived back on unit and is now in her room.” Assessment on 07/08/2024 at 0420 indicated P-12 had right, upper moderate chest pain/discomfort with pain medication given. Nursing note dated 07/08/2024 at 0533 indicated, “VSS (vital signs stable) on RA (room air). IV abx (antibiotics)continued. Pain controlled with oxy and Tylenol. Pts 13-year-old daughter was left here without a ride home. Hospital supervisors and provider made aware. Leave of absence order put in and pt left hospital at 0145 via cab with daughter per order to bring her home. Pt then arrived back in hospital at 0400.” The note did not reveal any documented assessment of P-12’s wound, or reason for admission. Review of entire medical record for P-12 for documented vital signs revealed the last vital signs completed on 07/08/2024 were at 2003. The next documented vital signs were 07/09/2024 at 0028. There were no vital signs documented prior to the LOA and upon return from the LOA for P-12. Review of facility grievance for P-12 on 08/20/2024 at 1220 revealed a grievance was filed for P-12 on 07/08/2024 by a staff member on 7 Meijer Heart Critical Care Unit. The grievance description indicated P-12 was upset she had to leave the hospital to take her 13-year-old home in the middle of the night. Felt the facility should have let her child stay until morning. Follow-up document included “we cannot be overnight babysitters” and “I knew this was coming”, “Yes we consulted with Risk who agreed options were that child present to ED so she could be cared for as a patient until morning (which would result in Peds having to contact CPS, per policy), patient could find a ride for her, or she could leave with her if doctor was willing to grant leave of absence”. Comment from Risk on the Grievance form was that they don’t like LOA’s because there is a lot of risk, but nursing had done this before calling Risk. Interview with P-12 on grievance revealed brother was coming to get 13-year-old but got pulled over. Father had taken his sleeping medication, other family not available, P-12 tried and explained this to everyone who came into her room. At 2:00am Supervisor came in her room. P-12 stated she felt harassed. Pulled her IV out, put her in a cab. The cab driver was going to leave her at her house. P-12 stated she had to talk to someone on the driver’s phone to get the driver to take her back to the hospital. The driver dropped her at the front door of the hospital which was locked. P-12 stated she had to walk around the entire hospital to get back into the hospital. She got 2 hours of sleep, was exhausted and cried all day the next day. P-12 stated there was zero reason for her to be treated this way. Review of facility “Inpatient Leave of Absence (LOA) policy, dated 04/21/224 revealed Purpose: This policy should not be used for non-time sensitive matters...” Examples of LOA would be for funeral of a close family member or a pivotal life event. I. If the patient is medically stable to have a LOA, consider if discharge is a safe option. II. LOA for inpatients will be managed and approved on a case-by-case basis. Prior to obtaining leave, approvals will be obtained from: medical, financial and administrative. Documentation: An inpatient LOA requires a physician’s order that is preferred to be written at least 24 hours in advance of the planned LOA that includes: date, duration of leave (no more than 4 hours), how patient may be transported, who must accompany the patient, equipment/medications to accompany patient and instructions for care. Physician’s progress note should include reason the LOA is required, summary of the patient’s current clinical status, discussion of the risks of the LOA. II. Nursing staff or physician: A. Date/time patient leaves the unit. B. Full patient assessment within 4 hours. C. Patient/family instructions were provided D. Notification of all approving bodies (medical, financial, and administrative representatives). III. Patient or legal representative should sign instructions as well as “Patient Convenience Leave Release without Discharge form”. IV. Upon return to nursing unit, staff will document the return date/time, full patient assessment, and record medication/treatments completed while on LOA. During the review of the medical record for P-12 on 08/20/2024 at 1350 with Staff A, a “Patient Convenience Leave Release without Discharge” form could not be located. Staff A reviewed the entire medical record, including scanned documents and stated the form was not in P-12’s medical record.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to protect the rights to receive care in a safe setting for 1 (P-4) of the 4 pediatric patients reviewed. On 8/19/2023 a grievance was filed by P-4’s parent that revealed concerns for a delay in surgical repair of the hernia and that the “surgical staff made the decision that P-4’s hernia was urgent, but not emergent”. On 2/22/2024 at 1430 in an interview was conducted with Manager of Patient Relations (Staff MM) and Lead Patient Relation Specialist (Staff NN), to review the grievance that was filed by P-4’s father on 8/21/2023. This grievance revealed a note by the Associated Medical Director of the Emergency Department (ED) from 8/22/2023 which included “Much of this complaint has to go to the surgical service to review as the ED doesn’t make the determination about taking kids to the operating room (OR) or not. So perceived delay is something I cannot comment on. However, with limited blood flow to the ovary, this usually would be considered emergent rather than urgent.” Staff NN stated the Grievance was forwarded to the Surgery Physician Leader. Upon further review of the grievance revealed a response by the Surgery Physician Leader from 8/22/2023 which included, “I am a bit concerned in reviewing this case that the patient was not taken to the operating room at the time of admission if the hernia could not be reduced. It seems like the decision making there is not quite sound (why even try to reduce the hernia if it wasn’t an emergency and it was going to be done until the next day?) I am also a little concerned that the patient was seen at 10 am and not operated on until 4 pm with subsequent findings of an ischemic ovary. I think that this case should be referred to MSPC (Medical Staff Performance Committee) for further evaluation and provider attribution.” On 2/22/2024 at 1415 during an interview with Staff KK, the Pediatric General Surgeon that was consulted to evaluate P-4 by the ED, Staff KK stated he did remember P-4 and the circumstances around this case. Staff KK stated he spoke with the surgical resident regarding the case and did not evaluate the patient personally. He reported the patient had a lump in the groin and ultrasound showed ovary incarceration and the surgical resident in the ED felt he was “partially able to reduce” the hernia. The plan was to admit the patient and perform surgery in the morning. Staff KK stated he read the ultrasound report, looked at the images and was “not concerned about blood flow”, which was noted by the radiologist that reviewed the study because “ultrasound is not a reliable test for blood flow”. When queried what Staff KK thought was a reliable way to assess a hernia in a pediatric patient he stated, “physical exam and this is the standard of care” and “I don’t think an ultrasound is indicated” for treatment of a hernia and surgery is the only treatment. When queried whether P-4 should have been taken to the operating room sooner, Staff KK stated “yes, after physician JJ told me what happened in the OR” When queried how often surgical patients are typically evaluated while waiting for surgery, Staff KK stated he rounds in the morning, the nurses round every few hours and a resident may be asked to evaluate a patient again, but this would not be typical for this type of problem. On 2/22/2024 at 1255 in an interview with the Pediatric Surgeon (Staff JJ) who performed the surgery for P-4 revealed he “remembered the patient very, very well”. Stated that he was not on call when P-4 presented to the ED and care was handed off to him the following morning by Staff KK. Staff JJ stated he was told the patient had an incarcerated hernia and it had been reduced but the patient needed to be taken to the operating room. Staff JJ stated the physical exam of the hernia was revealed it had been slight reduced and surgery was scheduled. Staff JJ stated there was a delay taking the patient to the operating room because of the busy schedule. Stated he reviewed the ultrasound and was “very concerned”. Staff JJ stated while operating he found the hernia was “markedly worse than before” but during the procedure he was able to get the ovary and fallopian tube to “pink up”. When queried if he has the ability to “bump” a case in the operating room for an emergent case, he stated “yes, I am able to do that”. Staff JJ stated the case was discussed at the MSPC in October and the committee felt P-4 should have been taken to the operating room sooner. Staff JJ stated “If I had been on call that night, I would have taken her to OR that night” but I may have an outcome bias and I learned a lot from this case. When queried whether any changes in procedures were made following the MSPC meeting, Staff JJ stated “no new policies” were initiated.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to ensure nursing standards of practice were followed for PEWS (Pediatric Early Warning Score) assessments for 1 (P-4) of the 4 pediatric patients reviewed which resulted in delayed medical intervention. Review of grievance dated 8/19/2023 sent by P-4’s parent revealed she was not monitored while waiting for surgery and “vitals were only taken at 3:30 am, 7:40 am, and no one came in to check on her before surgery at 4 pm to see if there was any progression”. On 2/22/2024 at 1430 during an interview with the Manager of Patient Relations (Staff MM) and the Patient Relations Specialist (Staff NN) it was revealed the facility received a complaint from P-4’s father on 8/21/2023. Staff NN stated P-4’s father had several concerns with their daughter’s care and felt she was not monitored properly during the admission to the 5th floor. Staff NN stated this concern was sent to Staff AA for review and received a response on 8/25/2023 which stated that “my night shift supervisor reviewed this chart...The only thing that looks odd is that she did not get vitals at noon”. On 2/21/2024 at 1430 review of Nursing documentation reveals P-4 was admitted to the 5th floor and transferred to that unit at 0300. Review of Nursing Orders dated 6/27/2023 at 0224 reveals vital signs were ordered “Routine Per policy 6/27/2023 0730-Until Specified” with orders to Notify Provider - Vital Signs (VS) if “Temperature greater than: 38.5 (Celsius), Systolic Blood Pressure (BP) less than: 75, Diastolic BP greater than: 75, Heart Rate greater than: 170, Heart Rate less than: 70, Respiratory Rate greater than: 55, Respiratory Rate less than: 16, measurement of oxygen saturation (Sp02) less than: 90” and “Frequency: Routine Until discontinued 6/27/23 0730-Until Specified”. Record reviews reveals report was given to the nurse on the 5th floor at 0259 on 6/27/2023. Vital signs were completed at 0246 in the ED, prior to transfer. Assessment and vital signs were completed on the 5th floor at 0743 and included a temperature of 37 (Celsius), pulse 114, respiratory rate 34, blood pressure 81/56 and Sp02 96% room air. There are no documented assessments after 0743 and vital signs were not repeated until P-4 was taken to the operating room (OR) at 1610 in the OR and continued throughout surgery. Pediatric Early Warning Score (PEWS) assessments were documented on 06/27/2023 at 0247, 0326, 0745 and were all zero. There were no new PEWS scores documented until 1954 which was 2, following surgical procedure. During an interview on 2/21/2024 at 1330 with a charge nurse (Staff BB) for the 5th floor it was revealed, “all patients get vital signs every four hours”, unless the patient requires closer monitoring. Staff BB stated they use the “PEWS” assessment to determine frequency. Staff BB stated a PEWS score of 0-2 is green which requires vital signs every four hours, PEWS score of 3-4 is yellow and requires vital signs every 2 hours and a PEWS score greater than or equal to 5 is red and requires every one-hour vital signs, unless they are needed more frequently. Staff BB stated staff uses a PEWS assessment guide to help them determine a score and this assessment should be documented in the medical record and the PEWS score should be updated with each assessment. On 2/22/2024 at 0957 an interview with the registered nurse on the 5th floor (Staff GG) that was assigned to provide care for P-4 on 6/27/2023 from 0700 until she was taken to the operating room at 1600. Staff GG stated she did not remember P-4 and did not have the opportunity to review the medical record. Staff GG stated if she was caring for a patient that was scheduled for surgery, she would continue to monitor the patient and complete an assessment every 4 hours, unless the patient requires more frequent monitoring and this includes vital signs, oxygen requirement, skin and capillary refill. Staff GG stated she could not remember P-4 and could not think of a reason why the PEWS assessment and vital signs were not completed for P-4 from 0743 until 1610. On 2/22/2024 at 1046 an interview with the Nurse Manager for the 5th floor (Staff AA) it was revealed, that the standard of care on the unit is that nurses assess PEWS and vital signs every 4 hours or sooner if needed, which aligns with hospital policy. Staff AA stated there are times when the PEWS assessment and vital signs may not be able to be completed if a patient is off the unit for a procedure or if a patient is asleep, however this would be documented in the medical record. Staff AA stated audits are not completed to ensure timely PEWS assessments and vital signs are completed. Documentation review revealed no explanation for missing PEWS assessment and vital signs for P-4. On 2/22/2024 at 1630 review of policy titled Assessment Standards for Nursing: Pediatric Inpatient, reference #21418, effective 7/25/2023 under “6. Focused Assessment, 6.1 Frequency, 6.1.1 Non-ICU: Every 4 hours. 6.2. The focused assessment will be documented, as needed, as changes are identified”. On 2/22/2024 at 1630 review of policy titled Vital Signs and I&O Monitoring, reference #21728, effective 1/12/2023 under “3. Pediatric Routine Vitals Frequencies unless otherwise ordered by a provider...d. Increase monitoring according to PEWS scoring system and clinical picture.””