Edward W Sparrow Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 53475 Based on interview and record review, the facility failed to evaluate the patient’s need for home oxygen prior to discharge for 1 (P-1) of 1 patients reviewed for home oxygen, placing the patient at risk for respiratory compromise and adverse health outcomes. See Tag 0807”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to document wound prevention interventions for 2 (P-2, P-6) of 3 patients reviewed with wounds, resulting in the potential for wound evolution and poor patient outcomes. Findings include: P-2 is a 70-year-old with a history of sacral decubitus ulcer, tracheostomy with ventilator support, and tube feeding. P-2 was admitted to the facility on 5/16/26 with an unstageable wound to the coccyx measuring 10 cm x 10 cm x 1.5 cm. P-2 underwent wound debridement on 5/18/26 and 6/9/26. On 6/18/26, the coccyx wound measurements were documented as 14 cm x 12 cm x 3 cm x 4 cm. On admission, P-2 was ordered daily wound care, wound care team consultation, dietary consultation, and pressure reduction interventions which included: low air loss mattress, boots and/or bridge heels while in bed, turn patient every 2 hours, and head of bead up no more than 30 degrees while in bed except while eating or if contraindicated, i.e., breathing issues/ventilated. During record review on 6/23/26 at 1325, a seven-day sample of P-2’s “patient position” flowsheets were reviewed which indicated the following gaps: 6/15/26; no turning/repositioning documented from 1506-2025 (5 hours) 6/16/26; 0600-1929 (13.5 hours) 6/17/26; 0400-2000 (16 hours) 6/18/26; 0400-2000 (16 hours) 6/21/26; 0600-1700 (11 hours) 6/22/26; 0400-2028 (16.5 hours) P-6 is a 73-year-old with severe anoxic brain injury, tracheostomy/ventilator dependent, and “large deep sacral wound.” Patient position flowsheet indicated gaps in every 2-hour turning as follows: 6/21/26; 0900-2000 (11 hours) These findings were reviewed and acknowledged by the Chief Nursing Officer (Staff C) at time of discovery. Policies related to pressure injury prevention were requested. The Regional Director of Accreditation and Clinical Improvement (Staff A) stated, “none are available at this time and are currently in draft form” during an interview on 6/23/26 at 1630.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to ensure appropriate discharge planning. The facility did not follow its established process to evaluate the patient’s need for home oxygen prior to discharge for 1 (P-1) of 1 patients reviewed, placing the patient at risk for respiratory compromise and adverse health outcomes. Findings include: P-1, a 73-year-old female with a past medical history of chronic urinary tract infections (UTIs), gastroesophageal reflux disease (GERD), and kidney stones with stent placements on 05/04/2026 at 1635, experienced breathing difficulties related to sepsis during her second hospital admission from 05/14/2026 through 05/29/2026. P-1 required oxygen support for the majority of the admission and was evaluated for discharge needs on 05/28/2026. On 06/24/2026 at 0832, Hospitalist Staff MM was asked about P-1’s need for oxygen during the hospital stay from 05/14/2026 through 05/29/2026, as well as the patient’s discharge needs. Staff MM stated that on 05/28/2026 at 1143 and on 05/29/2026 at 0800 the provision of oxygen and oxygen equipment in the home setting would have improved P-1’s condition, noting that P-1 continued to require 1 Liter (L) of oxygen and nighttime oxygen support. Additionally, Staff MM confirmed that on 05/29/2026 at 0950 in the Discharge Summary Note P-1 had at times required up to 15 L of oxygen. Staff MM also confirmed that P-1’s atelectasis (collapse of lung tissue) had improved with aggressive chest physiotherapy using AccuPAP (such as percussion, vibration, and positioning to mobilize mucus and enhance ventilation and gas exchange) in combination with steroid and antibiotic therapy. Staff MM explained that home oxygen had been denied by the insurance provider due to a failed Overnight Pulse Oximetry Study conducted on 05/28/2026. On 06/24/2026 at 1032, the Director of Pulmonary and Neuroscience, Staff OO, who oversaw the respiratory team, was queried regarding P-1’s discharge and home oxygen needs. Staff OO explained that home oxygen requirements were evaluated using two methods and reviewed the studies with the surveyor: 1. Bedside Functional Assessment: Nursing staff monitored the patient’s oxygen saturation at rest, while sitting, standing, and ambulating to determine whether oxygen was needed during activity. The medical record reflected that P-1 had routine oxygen saturation checks throughout the hospitalization. 2. Overnight Pulse Oximetry Study: Conducted over approximately 2-4 hours (or as ordered) to assess for nocturnal (night) desaturation. A cumulative oxygen saturation below 88% for at least 5 minutes, per CMS guidelines, would indicate the need for supplemental oxygen, based on the patient’s overall clinical condition and applicable qualification criteria. An Overnight Pulse Oximetry study was conducted to determine P-1’s eligibility for home oxygen: 1. Pulse Oximeter Analysis (based on machine recorded oxygen saturation values) 2. Overnight Oximeter Tracking Sheet (based on bedside visual observation) On 06/24/2026 at 1040, the following Overnight Pulse Oximetry Study results were reviewed with Staff OO: Overnight Pulse Oximetry Study - Retest on 05/28/2026 (0028 to 0510 on 05/29/2026): P-1’s oxygen saturation was below 88% for a cumulative 3.5 minutes. Based solely on the Pulse Oximeter Analysis, P-1 did not qualify for home oxygen. However, review of the Overnight Oximeter Tracking Sheet showed that the study was conducted improperly. Although the documented study window was 0028-0510, P-1 was tested without oxygen for only 4 minutes (0028-0032) and the oxygen saturation was 85%. From 0033 to 0354, P-1 was on 1 L of oxygen with an oxygen saturation of 90%, and beginning at 0355, P-1 was “found” on 2L of oxygen with an oxygen saturation of 94% for the remainder of the study until 0510. Prior to discharge, on 05/28/2026, P-1 had an oxygen saturation of 87% on room air and on 05/27/2026 at 2350 an oxygen saturation of 86% on room air. On 06/24/2026 at 1057, the Director of Pulmonary and Neuroscience Staff OO acknowledged that the results from the 05/28/2026 Overnight Oximeter Tracking Sheet had been interpreted incorrectly and should have resulted in a prescription for home oxygen. On 6/24/2026 at 1119, Director of Case Management and Utilization Review Staff NN reviewed both Overnight Pulse Oximetry Studies and stated that only the Pulse Oximeter Analysis was forwarded to the insurance company to seek portable oxygen coverage in the home setting. P-1’s home oxygen request was denied based on the results of the Pulse Oximeter Analysis from 05/28/2026. When queried about the Overnight Oximeter Tracking Sheet dated 05/28/2026, Staff NN acknowledged that the Overnight Tracking Sheet validated that P-1 was not able to sleep without oxygen; an indicator that P-1 should have been discharged with home oxygen. P-1 was discharged on 05/29/2026 at 1116 with home health services but no home oxygen. P-1 returned to the Emergency Department (ED) on 05/30/2026 at 1300 and stated as Chief Complaint “Shortness of Breath” with reported oxygen saturations decreasing to 79% throughout the day. P-1 was readmitted on 05/30/2026 at 2117 to Facility B and with an admitting diagnosis of nephrolithiasis (kidney stone), pulmonary embolism (blot clot in lungs), and difficulty breathing. P-1 was discharged from this facility with home oxygen. Review of the Policy “Discharge Planning” (no date) replacing the Discharge Planning policy from 2019, it states that “1.0 Purpose: Discharge planning is a multidisciplinary approach process which includes identifying resource needs based on the unique goals, preferences, and needs of the patient. This guideline is to ensure appropriate and safe transitions of care are developed with the patient and/or designee in accordance with CMS Regulations for Conditions of Participation for Discharge Planning while ensuring delivery of high-quality care ... RN/SW Case Manager to follow Guardianship Standard Operating Procedure. The discharge plan assessment includes the following components:1. Admitting diagnosis or reason for hospitalization hospital services 2. Relevant comorbidities 3. Pertinent medical and surgical history 4. Home assessment to include number of levels, stairs, entry way 5. Current Durable Medical Equipment 6. Services received prior to hospitalization (i.e home health agency, palliative care agency, DME vendor for supplies, and other communicated based vendors) 7. Prior to admission level of function 8. Anticipated resource needs post discharge 9. Readmission Risk 10. Psychosocial history/social support systems.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure a face-to-face evaluation was performed after a patient was placed in violent restraints for 1 (P-2) of 3 patients reviewed for restraint monitoring resulting in the increased likelihood of negative outcomes and loss of patient rights for the patient. Findings include: On 11/7/2025 at 1320, P-2’s medical record was reviewed with Nursing Director Staff E. On 9/6/2025 at 1845, P-2 had an order for violent, four point soft restraints for danger to self. There was no documentation that a face-to face evaluation was performed following the initiation of the restraints. Staff E confirmed the findings at the time of discovery. According to the facility’s policy, “Restraint,” dated 7/8/2025, “A face-to-face evaluation includes both a physical and behavioral assessment of the patient that must be conducted by a qualified practitioner within the scope of their practice; Documentation must include, The patient’s immediate situation, The patient’s reaction to the intervention, The patient’s medical and behavioral condition, The need to continue or terminate restraint.” The policy also revealed that for “Violent/Self-Destructive Behavior Restraint, A face-to-face assessment by the Attending Physician or the LP must be obtained within 1 hour after the patient is restrained; A telephone call or telemedicine methodology is not permitted. (a) If the patient’s violent or self-destructive behavior resolves and the restraint intervention is discontinued before the practitioner arrives to perform the 1-hour face-to-face evaluation, the practitioner is still required to see the patient face-to face and conduct the evaluation within 1 hour after the initiation of this intervention. (b) If the Attending Physician or the LP of record is unavailable, responsibility for the patient must be delegated to another LP, who would then be considered the LP of record.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to assess a patient following the administration of a pain medication for 1 (P-7) of 3 patients reviewed for pain reassessment resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 11/17/2025 at 1330, P-7’s medical record was reviewed with Nursing Director Staff E. On 11/16/2025 at 0722 and at 0900, P-7 had a documented pain score of 9. On 11/16/2025 at 0844, P-7 had a one-time only order for hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet to be given once. On 11/16/2025 at 0901 P-7 medication administration record revealed P-7 received a dose of hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet by Nurse Staff X. After administering the dose, P-7’s medical record revealed there was no pain score documented to determine whether the pain medication had an impact on P-7’s pain. On 11/16/2025 at 1416, P-7 had an order for hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet, every 6 hours as needed for anticipated pain. On 11/16/2025 at 2331, P-7 had a documented pain score of 9. On 11/16/2025 at 2331, P-7 received one dose of hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet. There was no documented pain score following the administration of the pain medication to determine whether the pain medication had any impact on P-7’s pain. The next documented pain score for P-7 was on 11/17/2025 at 0748 and P-7 had a documented pain score of 9. On 11/17/2025 at 0810, P-7 received one dose hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet. There was no documented pain score following the administration of the pain medication to determine whether the pain medication had any impact on P-7’s pain and P-7’s next documented pain score was on 11/17/2025 at 1623 with a pain score of 9. Nursing Director Staff E confirmed the findings at the time of discovery. According to the facility’s policy, “Pain Management,” dated 8/25/2025, “Pain will be reassessed following PRN and one-time (i.e. ONCE) dose pain medication administration and as needed. 1. Reassess pain once sufficient time has elapsed to evaluate the effectiveness of intervention(s) 2. A pain reassessment includes, at minimum, the use of an appropriate pain assessment tool (the same tool used previously, unless patient’s condition now warrants use of a different tool) a. If the intervention was the administration of an opioid, include a sedation assessment at time of reassessment 3. Compare reassessment findings to previous assessment and patient’s pain management goal(s) to evaluate effectiveness of intervention.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50585 Based on observation, interview and record review, the facility failed to follow national standards and policy in safely preparing medication for 1 (P-6) of 2 patients reviewed resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 11/18/2025 at 1010, during observation of Nurse Staff O preparing a medication for administration to P-6, Staff O obtained a vial of hydromorphone 2 mg /milliliter for injection. Staff O removed the flip cap and proceeded to withdraw the medication into a syringe. After administering the dose, Staff O was queried whether they should have wiped the vial top with an alcohol pad prior to removing the medication into a syringe, Staff O revealed they did not have to wipe with alcohol since the vial has a “cap.” On 11/18/2025 at 1340, CNO Staff B confirmed that Nurse Staff O should have used an alcohol swab to wipe the vial prior to removing the medication contents. According to the facility’s policy, “Safe Injection Practices,” dated 6/5/2025, for “Injections: Septum on all medication vials, whether unopened or previously accessed, is disinfected with alcohol prior to piercing.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 15195 Based on interview and record review, the facility failed to provided written notice of the investigative findings and completion of a grievance for 1 (P-8) of 3 grievances reviewed, resulting in unmet patient rights for written communication response. Findings include: Medical record review revealed that P-8 was a 45-year-old female who had a total abdominal hysterectomy, bilateral salpingo-oophorectomy (removal of uterus, fallopian tubes, and ovaries) and lysis of adhesions. This surgery was performed last year on 5/8/24 due to an abdominal mass. The patient was discharged on 5/11/24 with a scheduled post-operative follow-up on 5/15/24. The patient presented to the emergency department due to increased vaginal bleeding on 5/19/24 and had surgery to close the vaginal cuff. The patient was discharged on 5/21/24. The patient had post-operative follow-up visits on 6/5/24, then on 8/20/24. Record review revealed that on the 8/20/24 post-operative visit, the patient complained to the surgeon and the office manager that she had been penetrated by something after the first surgery on 5/8/24. The patient believed she was assaulted. On 3/24/25 at approximately 1300, interview with the Regional Director Accreditation (Staff B) revealed that the Departments of Risk Management and/or Public Safety/Security handle allegations of possible abuse. Staff B also stated that the Department of Patient Relations handled (minor) complaints, not allegations of abuse. Interview with Security Officer/Investigator (Staff O), on 3/24/25 at approximately 1400, revealed that he had done the investigation and could not substantiate the allegation. Staff O also stated that he reported his findings to his manager, but was not responsible for sending findings to the complainant. Staff O had his written report available to review. On 3/24/25 at approximately 1430, interview with the Risk Manager (Staff K) and Risk Management Director (Staff L) revealed that a letter of investigative findings had not been sent to the patient. Staff L stated that the process had changed and the informational findings letter to the patient was errantly missed. Interview with the Office Manager (Staff M), on 3/24/25 at approximately 1530 revealed that she had reported the allegation to the hospital Risk Manager and entered the allegation in the facility incident reporting system. Staff M stated that she received a call from Risk Management staff informing her that the process had changed and that the Security Office/Department of Public Safety would handle the investigation. Review of the facility policy titled “Complaint and Grievance Management, revised 3/20/25 (previous edition dated 1/5/22)” documented, “Investigation and Conclusion... However, in all cases Patient Relations & Clinical Risk must provide a written notice (response) to each patient grievance(s). This had not been done.”

“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 observation, interview and record review, the facility failed to provide a safe environment for 1 (P-2) of 10 patients when hygiene care was not provided during the period of time in which the patient was hospitalized in the Emergency Department resulting in the potential for the loss of emotional and physical well being. Findings include: On 05/07/2024 at 1045 a tour of the Emergency Department (ED) revealed a busy 69-bed unit with 4 trauma bays, which is a Level 1 Trauma Center. Observations of the triage process, provider in triage area and patient care area including bedside care, medication administration and patient interviews were completed during the tour. At the time of the tour the ED was “holding” 40 patients awaiting bed placement in the facility, while continuing to care for new ED arrival patients. On 5/7/2024 at 1142 an interview was conducted with ED Patient Care Tech (Staff P). Staff P revealed patients in the unit are rounded on the half hour to hourly and are monitored to make sure they are clean and dry, call lights are within reach, meal trays are provided. When queried whether they document hygiene interventions in the medical record, Staff P responded, “we try to”. On 5/7/2024 at 1150 an interview with P-6 revealed she had been in the ED approximately 16 hours. P-6 stated the care “has been very good, despite how busy they have been”. When queried whether she has received a timely response to her call light, request for food, medication and hygiene assistance during her stay in the ED, P-6 stated “yes”. On 5/8/2024 at 1530 during review of policy “RISK-Investigation of Patient Reports of Abuse & Neglectful Behavior Occurring within the Inpatient Setting”, dated 4/25/2023, under Section 3.0 Definitions: Neglect “The absence of the minimal services or resources required to meet basic needs. Neglect includes withholding or inadequately providing medical care and, consistent with the usual care, treatment, or services, food and hydration...clothing, or good hygiene.” On 5/7/2024 at 1446 record review of P-2’s chart revealed no documented entries for hygiene care from 1/22/2024 through the time of discharge of 1/25/2024. On 5/7/2024 at 1515 an interview with the ED Director (Staff G) and ED Manager (Staff H) was conducted. Staff G and Staff H revealed it is an expectation that patients being “held” in the ED awaiting bed placement should be provided adequate assistance with hygiene during their stay and these interventions should be documented in the medical record. Staff H confirmed there were no entries of hygiene interventions throughout P-2’s admission.”

“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: 45245 Based on interview and document review, the facility failed to maintain an accurate medical record for one (P-1) of ten patients sampled, resulting in the potential for poor outcomes. Findings include: Document review revealed P-1 was a 50-year-old female who presented to the facility on 04/04/2022 for an elective surgery. Interview with P-1 on 12/11/2023 at 1025 revealed that after surgery, she noticed incorrect medications in her chart and her insurance coverage had changed, leading to billing errors. P-1 stated her primary insurance provider has been and is currently with Medicare/Medicaid. P-1 submitted a grievance on 04/21/22. Review of grievance report dated 04/25/2022 revealed the facility addressed the issue and corrected the error. However, further review of documents revealed ongoing issues. Document titled ‘biller’ notes printed by Staff K, dated 07/11/23 at 1518 states, “Went over this patient with supervisor during 1 on 1 yesterday. The Blue Cross/Blue Shield (BCBS) coverage does not belong to this patient. It is the same name and DOB (date of birth), but not her per the patient. Medicaid did remove it and claims were resubmitted and paid but they just recently put it back on again and are taking back payments and denying for COB (coverage of benefits/payment).” On 12/11/23 at approximately 1100, an interview and chart review were conducted with Supervisor of Patient Access, Staff K. Staff K was queried to demonstrate P-1’s current primary insurance provider. Staff K demonstrated that BCBS was primary insurer at the time of survey. Staff K was questioned if that was correct? Staff K stated that it was an ’ error, ’ according to the multiple biller notes present, and that it would need to be corrected by the complainant. Staff K then entered a ’ billing note ’ into the record, stating [Do not add BCBS]. Staff K stated that the coverage will again be terminated (when the biller sees the note) and demonstrated multiple ’ biller notes ’ present, that call for the termination of BC/BS due to error.”