North Memorial Health Hospital

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 43080 Based on interview and document review, the hospital failed to ensure inpatients were promptly asked after admission whom (family member or representative, and primary medical provider) should be notified of their admission to the hospital, and that such a conversation was documented in the patient’s medical record for 10 of 10 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10). This had the potential to affect all inpatients of the facility. Findings include: During the survey’s abbreviated medical record review process of 10 hospital inpatients, the following information was identified: -P10: Admitted on 8/6/25 and discharged 8/9/25. Contact information indicated two people (son and daughter). The admission notification sections for these contacts were unmarked. The record lacked a primary clinic/provider designation. The record lacked documentation P10, or a designated representative, was questioned on their desire for admission status notifications related to this admission, or that additional inquiries were made into a primary provider, and/or clinic, for notification of admission processes. -P9: Admitted 9/12/25 and discharged on 9/23/25. Contact information indicated four people (two sons, daughter, and a grandson). The admission notification sections for these contacts identified a “Yes” for one son; however, the other three were unmarked. The provider admission notification section indicated a “Yes” response. The record lacked documentation P9, or a designated representative, was questioned on their desire for admission status notifications related to this admission, or when the Yes responses were entered. -P2: Admitted on 9/18/25 and discharged on 9/20/25. Contact information indicated one person (mother). The admission notification for this contact was unmarked. The physician admission notification section identified a “No” designation. The record lacked documentation P2, or a designated representative, was questioned on their desire for admission status notification(s) related to this admission, or when the No response was entered. -P1: Admitted on 10/13/25 and discharged on 10/21/25. Contact information indicated three people (brother, friend, friend). The admission notification sections for these contacts identified a “No” designation for the brother and one friend, and the second friend was unmarked. P1’s record lacked a primary clinic/provider designation. The record lacked documentation P1, or a designated representative, was questioned on their desire for admission status notifications related to this admission, or when the No responses were entered. -P5: Admitted on 10/14/25 and discharged on 11/5/25. Contact information indicated one person (brother). The admission notification for this contact was “Yes.” The record lacked a primary clinic/provider designation. The record lacked documentation P5 was questioned on his desire for admission status notifications related to this admission, or when the Yes response was entered. Additionally, the record lacked documentation that additional inquiries were made into a primary provider, and/or clinic, for notification of admission processes. -P7: Admitted 10/26/25. Contact information indicated two people (spouse and sister). The admission notification sections for these contacts were unmarked. The record lacked a primary clinic/provider designation. The record lacked documentation P7, or a designated representative, was questioned on their desire for admission status notifications related to this admission, or that additional inquiries were made into a primary provider, and/or clinic, for notification of admission processes. -P6: Admitted 10/27/25. Contact information indicated one person (mother). The admission notification section for this contact was unmarked. The physician admission notification section identified a “Yes.” The record lacked documentation P6 was questioned on his desire for admission status notifications related to this admission, or when the Yes response was entered. -P8: Admitted 10/27/25. Contact information indicated one person (significant other). The admission notification section for this contact was unmarked. The provider admission notification section indicated a “No” response. The record lacked documentation P8, or a designated representative, was questioned on their desire for admission status notifications related to this admission, or when the No response was entered. -P3: Admission 11/2/15 and discharged on 11/4/25. Contact information indicated one person (guardian). The admission notification section identified “Yes” for admission notification. The provider notification section identified a “No” response. The record lacked documentation P3, or the guardian, was questioned on their desire for admission status notifications related to this admission, or when the Yes and No responses were entered. -P4: Admitted 11/2/25 and discharged 11/5/25. Contact information indicated one person (wife). The admission notification sections for both the wife and the physician identified “Yes” for admission notifications. The record lacked documentation P4 was questioned on his desire for admission status notifications related to this admission, or when the Yes responses were entered. When interviewed on 11/5/25, at 4:28 p.m., the quality manager (QM)-A stated she had heard staff inquired about admission notifications; however, this process was not documented for each admission. During a follow-up interview on 11/6/25, at 1:32 p.m., QM-A stated the facility did not have a consistent workflow for the admission notification process, nor did the facility have a policy related to such a process. She identified this was “a gap and a good gap to close.” When interviewed on 11/6/25, at 1:42 p.m., registration specialist (RS)-A stated she verified emergency contact information when a patient was registered; however, overall, she did not inquire into the admission notification questions or document such questions if asked during the registration process. During an interview on 11/6/25, at 1:51 p.m., RS-B stated she verified emergency contact and provider information when a patient was registered but she did not inquire into the admission notification question for the emergency contact(s). Despite this, she did ask if the patient wanted the primary provider updated and if so, she documented that in the hospital account notes. When interviewed on 11/6/25, at 1:59 p.m., during review of P1-P10’s registration/account notes sections of the medical record, the patient registration manager (RM)-A identified she was newer to the roll within the past two months and was unsure what the process was for representative and provider admission notifications. Later in the review process, after she inquired to other colleagues about the provider notification box, identified this box was not checked by registration staff but was checked by clinic staff. When interviewed on 11/6/25, at 3:04 p.m., the director of patient financial services stated “to a certain level” she was aware of the questions that surrounded admission notifications; however, was not aware of the details that surrounded this process. During an interview on 11/6/25, at 3:49 p.m., registered nurse (RN)-A identified he was a nurse manager and stated there was not a section within the nursing admission process where the nurses asked the patients about admission status notifications. A policy on admission notification was requested; however, a policy was not provided.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 43080 Based on observation, interview, and document review, the hospital was found to be not in compliance with the Condition of Participation for Surgical Services (CFR 482.51) due to failure to ensure OR (operating room) suites underwent appropriate terminal (floor to ceiling) cleaning after all surgical cases were completed for the day. This resulted in the observation of dust accumulation in 1 of 3 OR suite (#5). This deficient practice had the potential to impact all patients where OR suites were not terminally cleaned appropriately. Findings include: An OR Readiness Rounds (environmental tour) report, dated 5/7/25, completed by infection preventionist (IP)-A, indicated a checklist category “Areas Are Free From Visible Dust.” The report lacked indication of what areas were visualized. The report identified an adjacent column with “Yes (Compliant)” as the chosen option. Operating room aide (ORA)-B’s employee orientation file identified the following information: -An Individual Action Plan (IAP), dated 4/28/25, identified ORA-B was assigned an OR Turnover & Terminal Cleaning HealthStream module. -A Continuing Education Earned (HealthStream) transcript, generated 8/21/25, identified ORA-B lacked information he completed the Operating Room Turnover and Terminal Cleaning module learning module. -A New Team Member Onboarding Checklist, dated 5/6/25, indicated ORA-B started the onboarding process. -A Competency Validation Checklist for Terminal Cleaning in the Operating Room, dated 7/1/25, identified ORA-B demonstrated the following competent cleaning tasks: demonstrate cleaning top to bottom, wet to dry, clean to dirty; Damp Dust High Surfaces; Clean Following Surfaces: Light Arm/ Surfaces/Handle/Boom and Spot Clean Walls & Other Visibly Soiled Surfaces. ORA-A’s employee orientation file identified the following information: -A Continuing Education Earned (HealthStream) transcript, generated 8/21/25, identified that on 5/13/25, ORA-C completed the computerized learning module Operating Room Turnover and Terminal Cleaning module. -A New Team Member Onboarding Checklist, dated 5/14/25, indicated ORA-C started the onboarding process. -A Competency Validation Checklist for Terminal Cleaning in the Operating Room, dated 5/25/25, identified ORA-C demonstrated the following competent cleaning tasks: demonstrate cleaning top to bottom, wet to dry, clean to dirty; Damp Dust High Surfaces; Clean Following Surfaces: Light Arm/ Surfaces/Handle/Boom and Spot Clean Walls & Other Visibly Soiled Surfaces. A provided email, dated 6/5/25, at 1:04 p.m., indicated registered nurse (RN)-E, who was identified as the infection prevention manager, sent an email to RN-A (the OR nurse manager) and RN-B (OR nurse educator), along with IP-A that communicated RN-E observed “a significant amount of dust” on the equipment in OR suite 6. Photos were provided in the email which showed visible dust [based on the email’s identification] accumulation on a boom arm (unidentified) and on the side of what appeared to be flexible metal conduit (housing that covers electrical wiring - unidentified location in the OR suite). The email identified staff thought the suite was used the day prior “which means it was this dusty when a patient was in the room,” and that RN-A was brought into the conversation surrounding this finding. Many topics were questioned for follow-up discussions which included, but not limited to, training and onboarding of the ORAs and their competency, and if the ORAs completed a checklist during turnover (suite cleaning between surgical cases) and terminal (end of the day) cleaning processes. The email included RN-E’s, or IP-A’s, offered assistance to help support the ORA work. An OR Register report, provided 8/19/15, identified a total of 60 scheduled surgeries for 8/19/25 and 8/20/25, which encompassed the services of oral surgery, plastics, general, orthopedic, urology, gynecology, ophthalmology, colon/rectal, cardiothoracic, pulmonary medicine, PCC Procedure, and neurosurgery. An All Surgeries and Invasive Procedures report, dated 8/21/25, identified the following information from 7/22/25, through 8/21/25: -OR Suite 5 was utilized 64 times for procedures related to the following services: oral surgery, plastics, general, orthopedic, urology, gynecology, ophthalmology, colon/rectal, cardiothoracic, and pulmonary medicine. -From 8/14/25, through 8/20/25, OR Suite 5 was utilized 13 times for the following services: gynecology, oral surgery, plastics, colon/rectal, and pulmonary medicine. -OR Suite 11 was utilized 80 times for the following services: oral surgery, plastics, general, orthopedic, urology, gynecology, ophthalmology, colon/rectal, cardiothoracic, pulmonary medicine, gastroenterology, and neurosurgery. -From 8/14/25, through 8/20/25, OR Suite 11 was utilized 19 times for the following services: general, podiatry, oral surgery, plastics, orthopedic, and neurosurgery. During a continuous observation on 8/20/25, that began at 12:13 p.m., an unidentified patient was wheeled out of OR Suite 5 by staff after the completion of an unidentified surgical procedure. After, ORA-A and ORA-D entered the suite and initiated turnover cleaning processes in preparation for the next surgical case. While ORA-A wiped down the surfaces of tables and ORA-D wiped down anesthesia equipment, RN-C entered and cleaned the surgical bed and top and bottoms of the surgical lights, which were mounted to the ceiling via movable arms. An unidentified staff member entered and began to set up anesthesia equipment while ORA-D inventoried anesthesia supplies in the anesthesia cart. ORA-A mopped the floor. RN-C did not clean the movable arms. Additionally, no staff cleaned the movable arm that held a monitor where the arm was over the surgical supply setup table, nor did staff clean the arms located above the anesthesia area. No OR staff brought a step stool and/or a duster into the OR suite. At 12:32 p.m., a coating of a whitish fluffy substance was visible on the top edges of an arm that was attached to a cube of electrical ports and outlets, located between the surgical bed and the wall. RN-A was called into the room and identified this arm as a boom. She identified the whitish substance on the movable boom and attached cube was dust. RN-A identified she expected the top surfaces of the boom arms to be cleaned and dusted every day with the terminal cleaning process and stated it obviously did not look like it was getting done. Shortly after, ORA-A was interviewed and stated she had performed her normal turnover cleaning in OR Suite 5 in prep for the next case and explained that boom cleaning was required to be done with the terminal cleaning process during the evening shift or when dust was observed during the turnover process. ORA-A stated she expected the suite to be free of dust after a terminal clean and verbalized if staff observed dust after the cleaning process, any initiated surgery setup was to be stopped, and any opened supplies were to be removed. During the interview, ORA-A also identified the whitish substance was dust. Further observation in the suite with RN-A, identified dust accumulation on the top of a boom arm and attached monitor that were located by the surgical supply setup table which was confirmed by RN-A. RN-A stated this dust could potentially fall into the sterile field of this area and any visible dust that fell onto this area would make the supplies unusable, but then stated not all dust was visible. Continued observation identified dust accumulation on top of a boom arm above the anesthesia area. RN-A described this as “peach fuzz.” After the surveyor wiped four fingers along the top of the boom arm, all four fingers, from tip to base, were covered with clumps of dust. In response, RN-A stated it looked as if the boom was not cleaned for awhile. RN-A proceeded to run her finger across the top of another monitor’s back edge, in which the top pad of her finger was covered with dust. RN-A stated the facility had not been dusting well. When interviewed on 8/20/25, at 3:59 p.m., ORA-B identified his duties included turnover and terminal OR suite cleaning processes. During the turnover process, he was expected to wipe down “everything touchable,” remove the trash, and mop the floors. For terminal cleaning, he was expected to clean everything in the room from floor to ceiling. ORA-B stated he often worked with another ORA where they either worked on this cleaning together or they cleaned the suites themselves. In addition, he identified there were no set schedules for who cleaned which suite, just an expectation all suites were to all be verified to be terminally cleaned by the end of the shift. ORA-B indicated there were no task checklists specific to the cleaning tasks for each suite, only a checklist to identify which OR suites were terminally cleaned. He explained he did not require such as checklist as he knew what needed to be cleaned. ORA-B stated that during his training, his trainers talked about boom arm cleaning but never explained the required process. He explained he had thought of the need to clean such surfaces; however, when he asked the trainers about it, they “basically said we do it here and there.” ORA-B stated the cleaning carts lacked dusters to clean the boom arms, or any surface(s) closer to the ceiling and thus he only cleaned surfaces he could reach with a rag while he stood on the floor. Since he started in May 2025, ORA-B had never witnessed the boom arms being cleaned by his co-workers, which included during his approximate month-long orientation, nor had he cleaned them himself. Since he completed orientation, he stated no one had audited his work for competency. ORA-B identified he, a trainee, and ORA-C terminally cleaned OR Suite 5 the evening of 8/19/25. He identified this OR suite’s boom arms were not cleaned that evening. ORA-B explained when he arrived at work earlier that day, management pulled him aside and questioned him about his cleaning processes, especially higher surface cleaning with the duster. After that conversation, he used a duster in OR Suite 11 and observed “dusty bunnies” on the boom arm sides which were located on the anesthesia side of the OR suite. ORA-B stated he was embarrassed by this dust and would not want family to bring their loved ones there for surgical procedures. During an interview on 8/20/25, at 4:29 p.m., ORA-C stated she started in May 2025, and her main duties surrounded turnover and terminal cleaning of the OR suites. During the terminal cleaning process, she was expected to ensure every single thing from floor to ceiling in the suite was cleaned but she explained that during her orientation, which was during the day shift hours when turnovers were overall completed, with minimal terminal cleaning, she was taught to clean from the lights down. She identified, due to her height stature, some OR suites she could barely clean the top of the lights. She had access to dusters; however, she usually did not utilize these as she was so small, and the duster was not long enough for her. Additionally, she explained she was not taught what to do it she could not reach something; however, she stated she had witnessed her co-workers cleaned the booms at times, but they were taller than her. ORA-C identified if the duster was longer; she could use it. She identified she had not talked with anyone about this and/or her inability to clean the boom arms. ORA-C identified she had only cleaned the boom arms once herself since hire, possibly in June of 2025, as there was a ladder in the suite that remained after construction. ORA-C stated no one had audited her work since her orientation and she did not have specific task checklists to use when cleaning: she just went off “muscle memory”. ORA-C indicated she assisted to clean OR Suite 5 yesterday with ORA-B and a trainee and identified the boom arms were not cleaned. During an interview on 8/20/25, at 10:06 a.m., RN-D stated she was a circulating nurse. RN-D indicated terminal cleaning was currently not completed per her standards based on how they were cleaned prior to a transition in who performed such tasks. She identified the cleaning role had recently switched to operating room aides from a prior combination of anesthesia aides and environmental services which she felt contributed to her concerns. She explained, previously, when she was part of the cleaning process, before her circulating role, they used to move everything into the center of the room during cleaning, washed the walls, checked the ceiling, and cleaned the anesthesia machine. The anesthesia machines were currently not cleaned thoroughly, and they were only being surface cleaned. During an interview on 8/20/25, at 9:40 a.m., circulating nurse and operating room nurse educator, RN-B, stated as an operating room circulator nurse she was the patient advocate and made sure all the rules were followed for aseptic and sterile techniques. She explained, the ORA role started in February 2025; it combined anesthesia aides and housekeeping into a new role, and the transition had been “bumpy”. RN-B stated the ORAs were ultimately responsible for the turnover and terminal cleaning processes, but everyone, including nurses and surgical technicians, were checked off on turnover competencies. She identified there were initial concerns when the ORA role first rolled out which continued to be present within the last 30 days. RN-B explained she thought they were still missing terminal cleans which she expected to be done by the evening ORAs. She identified there were times when the day shift staff noticed terminal cleaning was missed and ORA staff had to be instructed to terminal clean the rooms before the first case of the day. When interviewed, via telephone, on 8/21/25, at 1:01 p.m., RN-A stated she was super disappointed and upset related to the observations of dust from 8/20/25, especially as all staff had access to a step stool and longer dusters, and there had been rounding completed in June 2025, when opportunities for improvement were observed. Back in June 2025, after she was updated on the findings of dust in OR Suite 6, which she felt was not that bad but very concerning, she performed an entire OR suite audit. During this, she observed a little bit of dust in OR Suite 5 and in room two just a very light dusting, mainly on lights that appeared to not have been dusted in at least a week or so. At that time, she used a duster only to check for dust but did not utilize a ladder to visualize the tops of higher surfaces such as the booms. RN-A reported she did not document this audit, nor did she document the ORA huddle verbal education that she provided for about a week, as no one had questions, and they appeared to understand the information. She did not think ORA-B and ORA-C were involved in these huddles due to the timing of their employment/orientation. Additionally, she did not review any of the ORA’s education and/or competencies around cleaning processes, did not perform any additional audits, nor did she involve IP in any additional follow-up, as she did not receive any Safety First (concern) event reports after this, as she had received previously when staff identified concerns. RN-A explained she spoke to ORA-B and ORA-C on 8/20/25, when they arrived for work, and she was informed they both thought they were only to clean from the lights down. Due to this, she verbalized the dust findings on 8/20/25, made sense to her and in response she reviewed the ORA turnover and terminal cleaning training in Health Stream (computerized training modules) which educated cleaning from top to bottom. She felt she needed to work with the preceptors, and this training needed to be updated with additional details related to boom surface cleaning as this concerned and alarmed her. Additionally, she stated she needed to talk to the whole team as they should have noted the dust buildup during their own cleaning processes. Going forward, continued opportunities for improvements would continue which included documentation and competency audits. During a joint interview on 8/21/25, at 10:26 a.m., IP-B stated OR infection prevention rounds were performed at random intervals unofficially and every six months officially. During this process, OR suites, that did not have active surgical cases were evaluated. IP-B was unsure how the rounding frequency was determined. Results of every six months rounding was documented; however, the ad hoc rounds may not have been. Findings from the ad hoc rounds were communicated via email or verbally to the nurse manager. IP-A stated awareness of OR dust concerns that originated around May 2025, where the boom areas really stuck out to him. He identified the email sent on 6/7/25, by RN-E and he explained ORAs were identified to be competent after the dust was found; however, he was unable to verbalize actions taken by OR leadership after RN-E sent the email. Additionally, he reported IP had not completed any OR environmental rounds, or audits, since the one in May 2025. Currently, the IP team worked on re-implementing cleaning audits for the OR, but these had yet to be started. IP-B stated dust was horrible, unacceptable, and the risk was huge, and she explained any speck of dust that fell, depending on what it was, could cause infections with organisms such as aspergillus or staphylococcus. When IP-A and IP-B were updated on what was found in the OR, IP-B stated that type of dust accumulation happened over a cumulative period of time, not overnight. IP-A indicated cleaning expectations, and cleaning checklists, related to turnover and terminal cleaning were outlined in facility policies; however, the checklists were not required documentation but were more for staff reference. During a subsequent interview on 8/21/25, at 12:45 p.m., IP-B clarified the every six-month rounding was completed on all non-patient OR areas and only in the OR suites not occupied by a current surgical case. They did not go back at a later date to evaluate all of the OR suites. The rounding in May 2025, only encompassed two OR suites: one in between cases and one with a patient expected to arrive soon, thus the evaluation was done quickly. IP-B explained during these rounds; she used her hand as a wipe to check the tops of surfaces that she was able to reach with her five-foot four inches stature. She identified she did not utilize a ladder to inspect surfaces higher then that. IP-B stated if there were dust concerns, she expected OR terminal cleaning audits, to ensure proper cleaning processes and then as needed just in time education. She confirmed IP had not completed such audits. Both IPs stated their infection tracking and monitoring lacked any identified concerns potentially associated with dust accumulation. During an interview on 8/21/25, at 9:34 a.m., the system director of perioperative services stated she expected OR terminal cleaning to include cleaning from ceilings to floors and under and on top of things. If an ORA could not reach something to clean it or did not have the appropriate equipment to do so, she expected staff to update leadership. She would not expect to see dust in OR suites and stated the dust seen by surveyors was unacceptable and presented infection risks; however, she was not made aware of the dust location(s). During an interview on 8/21/25, at approximately 1:40 p.m., medical doctor (MD)-A, identified he was the vice president of medical affairs and was also a practicing facility OBGYN (obstetrics and gynecology) surgeon. As a surgeon, he expected all floor to ceiling surfaces in the OR suites to be free of any debris or potential infectious sources such as dirt, blood, and dust to ensure a sterile environment. If this expectation was not maintained, there were increased risks for such things as surgical site infections. The level of risk was dependent on case specifics such as a laparoscopic procedure versus an open abdomen surgery, open joint, or head or neck surgery; debris location(s) such as on the top of the booms over the patient, the attached monitors, or anesthesia area located near the head of the patient; and intubation status. MD-A stated the monitors were placed at different areas in the OR suite and were surgeon and case dependent, but despite this, he still expected the whole OR suite to be as sterile as possible. MD-A was unaware of dust concerns within the OR suites as this was not a part of the perioperative executive committee (PEC) meetings. MD-A stated he would like to see resolution of the dust as the surgeon in him expected clean booms whenever surgery was provided and the administrative part of him expected this concern to be measured and subsequently validated to ensure implemented changes were sustained. An EVS Procedural Room Terminal Clean Checklist and Guide protocol, dated 12/22/2020, identified it applied to specific facility locations which included the OR suites. An embedded table, titled Procedural Room Terminal End of Day Cleaning Checklist, directed staff to “dust high surfaces,” and clean surfaces inclusive of: “light arm/boom” and “any other visibly soiled surface.” An Infection Prevention Program policy and procedure, dated 3/20/2023, indicated its purpose was to identify and reduce the risk of transmission of infections associated with the provision of patient care, performance of medical procedures, and the use of medical equipment, devices, and supplies. The policy directed three components for direct observation and environmental audits under Program Implementation that included the following: environment inspections by the IP team performed bi-annually of patient care units; direct observation of infection prevention best practice and compliance with policies and procedures may be monitored as part of ongoing surveillance or targeted process improvement work; audits for infection prevention measures are completed using standardized criteria developed by staff trained in infection prevention. An Infection Prevention: Environment of Care policy, dated 9/26/2023, identified its purpose included, “contaminants including dust, soil, and infectious agents are present on environmental surfaces in healthcare settings. These agents are a potential source for healthcare-acquired infection transmission. This policy and procedure outlines methods for maintaining a safe and sanitary environment of care.” The policy directed all horizontal surfaces, high touch surfaces and equipment used for procedures was to be cleaned after each patient procedure [turnover] and the last case of the day (terminal cleaning) with the use of a sporicidal disinfectant and microfiber cloth [not just a duster]. Additionally, the policy directed staff who performed cleaning and disinfecting procedures were to be educated on these cleaning procedure expectations, along with performance competencies to measure effectiveness of its cleaning program.”

“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: 34083 Based on observation, interview and document review the facility failed to follow facility policy and procedure for appropriate disinfection of the Nova Biomedical Stat Strip Glucose Hospital Meter System following use during 1 of 1 observation for a patient (P43). Findings include: Observation on 7/23/25 at 12:06 p.m., with nursing assistant (NA)-A as she retrieved a Stat Strip glucose meter from the docking station at the nursing station, obtained her supplies and proceeded to P43’s room. She explained the procedure to the patient, obtained a blood glucose sample, disposed of the used lancet and blood glucose strip, and returned to the nursing station with the meter. NA-A was observed taking a purple top Sani cloth wipe from the container and wiped over the surface of the meter for 10 seconds, before returning it to the charger and identifying it was ready for the next glucose test. Interview on 7/23/25 at 12:15 p.m. with NA-A identified she reported wiping off the meter with the Sani cloth wipe disinfected the meter. She was unaware of the manufacture’s package instruction for a surface to remain wet for 2 minutes to provide disinfection and thought wiping off the surface of the meter and replacing it in the wall charger was adequate. Interview on 7/ 23/25 at 12:20 p.m. with registered nurse (RN)-A identified the manufacture’s instructions required the surface to remain wet for 2 minutes to allow for appropriate disinfection. RN-A was not aware staff were not adequately disinfecting the glucose meters. Interview on 7/23/25 at 12:33 p.m., with RN-B identified she demonstrated the procedure for cleaning the Stat Strip Glucose meter. She was aware of the 2-minute dry time for disinfection, but identified she was not aware the surface needed to remain wet for 2 minutes. She remarked she would only wipe the surface of the meter and would not ensure it remained wet for the identified contact time. She had not been trained or instructed that she needed to ensure the surface remained wet to ensure disinfection. Observation and interview on 7/23/25 at 12:45 p.m. with NA-B identified her usual practice was to wipe off the surface of the meter with a purple top Sani cloth before taking it to the patient room to “make certain” it was clean. She demonstrated the cleaning and disinfection process by obtaining a wipe from the Sani-cloth container. She then wiped the surface of the meter and laid it on the counter for 2 minutes. NA-B failed to ensure the wet contact time was maintained for 2 minutes. She was unaware the surface of the meter needed to remain wet for 2 minutes to ensure disinfection. Interview on 7/23/25 at 12:59 p.m., with RN-C from a second nursing unit identified it was her expectation for staff to follow manufacturer’s recommendations for disinfection on the glucose meters. Interview on 7/23/25 at 2:22 p.m. with the manager of infection prevention, identified she confirmed her expectation was for staff to follow facility policy and ensure the meter would remain wet for the required 2 minutes to ensure disinfection. Review of the 9/26/23 policy Infection Prevention: Environment of Care identified re-usable patient care equipment was to be cleaned by wiping the surface with a single use disinfectant wipe and disinfected by application of the wipe for the wet contact time specified on the manufacturer’s instructions.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 43080 Based on observation, interview, and document review, the hospital failed to ensure signage pertaining to the Emergency Medical Treatment and Active Labor Act (EMTALA) was posted in all areas likely to be noticed by patients entering the Emergency Department (ED). This had the potential to affect all patients presenting to the ED seeking care and treatment. Findings include: On 7/21/25, at 12:40 p.m., a tour of the ED was conducted with the ED nursing director (EDND) and the ED nursing manager (EDNM). During the tour, both identified the main ED entrance patients passed through before they entered the ED lobby, where they then presented to the registration desk. Both the main ED entrance area, and the registration lobby desk, lacked evidence of EMTALA signage. Additionally, due to the placement of an EMTALA sign in a corridor, that was adjacent to the waiting room and led to the triage rooms, this sign was not visible to all patients who entered the ED and waited in the waiting room. The EDND and EDNM acknowledged there was no signage posted in the ED entrance, and the only EMTALA signage were the posting in the corridor that led to triage and in the ambulance bay. An Emergency Medical Treatment & Active Labor Act (EMTALA) policy, dated 10/18/24, stated its purpose was to set forth the requirements for compliance related to EMTALA, and identified a section labeled Signs. EMTALA Signage was to be posted in “all Dedicated Emergency Departments.” The policy lacked additional directions to identify specific locations required”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49618 Based on interview and record review, the facility failed to ensure a patient was free from physical abuse when a security guard used his weapon to restrain a patient during de-escalation resulting in risk of serious injury, harm, impairment, or death to one of ten patient (P1) reviewed for patient rights. P1 became verbally aggressive and had clenched fists when security guard (SG)-A used his TASER. SG-A unholstered his TASER and pointed it at P1, then holstered it, then pointed and deployed the TASER. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. An immediate jeopardy was issued at A0154. See A0154 for additional information.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to ensure a patient was free from physical abuse when a security guard used his weapon to restrain a patient during de-escalation resulting in risk of serious injury, harm, impairment, or death to one of ten patient (P1) reviewed for patient rights. P1 became verbally aggressive and had clenched fists when security guard (SG)-A used his TASER. SG-A unholstered his TASER and pointed it at P1, then holstered it, then pointed and deployed the TASER. The immediate jeopardy began on 4/26/25 when SG-A tased P1 when attempting to restrain P1 and was identified on 5/13/25. The Quality Systems Director, Chief Compliance Officer, and Director of Security and Emergency Department were notified of the immediate jeopardy on 5/13/25 at 4:42 p.m. The immediate jeopardy was removed on 5/14/25 but noncompliance remained at a condition level. Findings include: Video footage dated 04/26/25 of security guard (SG)-A tasing P1 was reviewed on 5/8/25 at 1:03 p.m. with security captain (SC) and security director (SD)-A. The video footage did not have audio. The video identified on 4/26/25 at 11:18:11 a.m., P1 was exiting his room and walking towards the elevators. Between 11:18:11 and 11:19:46 medical staff were talking with P1 while walking in the hall and P1 was attempting to get on the elevator. At 11:21:00, SG-A and SG-B were seen by the elevator. P1 was in the corner of the elevator, shaking his head, but not moving his arms. At 11:23:24, SG-C was seen approaching the elevator. At 11:25:03, P1 took off his shirt. At 11:25:13, P1 threw his hands up near his face, SG-A drew his TASER and pointed the taser at P1’s right upper thigh and right side of abdomen near his naval. The TASER laser was on P1 until SG-A took the TASER off him at 11:28:14. At 11:31:22, P1 was seen leaning his head back against the wall while looking up at the ceiling. At 11:38:02, SG-A turned his TASER laser back on and pointing the TASER on P1’s right upper thigh and right side of abdomen near his naval. At 11:38:14, SG-A was seen deploying his TASER. At 11:38:18, P1 was seen falling to the floor in the elevator and P1 ripped out a TASER probe from his thigh and abdomen. Security was seen moving into the elevator to attempt to hold P1. Between 11:38:18 and 11:39:21, SG-A, SG-B, and SG-C were seen escorting P1 back to his room. SG-A was on P1’s left side of body with P1’s left arm behind his back. SG-B was on P1’s right side holding his right arm behind P1’s back. SG-C was following behind the patient and SG-A and SG-B. P1 resisting the hold escort by thrashing his arms during the hold and P1 would stop walking, digging his heels into the floor. At 11:39:21, P1 is seen entering his room. There was no video into P1’s room. P1’s medical records indicated P1 was admitted to the hospital on 4/25/25 for an intentional overdose. P1 arrived at the hospital via ambulance from home. P1 was 6 feet and 5 inches tall and weighed two-hundred fifteen pounds. The hospital did not have any prior diagnoses listed. P1’s Violence Risk Assessment dated 4/25/25 indicated P1 did not have a history of violence towards others. P1’s provider progress note dated 4/26/25 at 10:00 a.m. indicated medical director (MD)-A met with P1 advising him he was recommending P1 go to an inpatient psychiatric unit given his depressive thoughts and recent overdose. P1 was adamant that he did not want to be in the hospital, and that he would try to leave the hospital to attend a basketball game. MD-A attempted to discuss with P1 about his 72-hour hold. MD-A indicated that he was later informed of P1 attempting to elope, a code green was called, and P1 was tasered in the elevator. MD-A stated given the situation, P1 would need a high acuity bed, in which the hospital did not currently have room, so P1 would need to go to another hospital. P1’s provider progress note dated 4/26/25 at 12:04 p.m. indicated MD-B stated he was called to the code green involving P1. MD-B stated P1 continued to escalate threats towards the SG’s while standing in the elevator. SG’s attempted to talk to P1 for “approximately 15 minutes”. P1 was told by SG’s that he would be tased if he continued to threaten violence. SG’s tased P1 and escorted him back to his room where he was given emergency medications and was placed in restraints. P1’s incident report dated 4/26/25 written by SG-A indicated SG-A responded to a code green on 4/26/25 at 11:22 a.m. to 3-west elevators. P1 was attempting to elope while being on a 72-hour medical hold. P1 presented agitated and verbally aggressive. P1 threatened to punch and fight any SG’s who would attempt to stop him from eloping. While P1 was standing in a defensive stance with his fist “bald up” and standing in the corner of the elevator, SG-A pulled out his TASER and pointed it at P1 while continuing to de-escalate the situation. SG-A and other SG’s attempted to plea with P1 for over 25-30 minutes to walk off the elevator and walk back to his room. Due to P1 being bigger in size and taller than most of the staff members involved, SG-A made the decision for the safety of all hospital staff involved to deploy his TASER and “fire” at P1. The TASER strike hit P1 in the upper stomach and high. P1 dropped to the floor inside the elevator. SG-A, SG-B, and SG-C assisted medical staff by escorting P1 back to his room, assisted with delivering medications, and put P1 in restraints. P1’s incident report dated 4/26/25 written by SG-B indicated SG-B responded to a code green involving P1 who was trying to elope. SG-B and SG-C were the first on the scene. SG-B attempted to empathize with P1 for over 30-40 minutes to start complying with the SG’s and medical staff’s request, but P1 was adamant about wanting to leave the hospital. P1 was observed getting agitated and was “in deep thought and looking down the whole time, making eye contact a few times”. SG-B changed the tactic and began getting more assertive to start “getting the patient to comply”. P1 stated “come on, I’m ready to take all y’all on”. SG-A withdrew his TASER, activated it, and pointed the lasers at P1, continuing to plea with P1 to comply, and holstered his TASER. SG-A informed P1 that if he was going to holster his TASER, P1 needed to cooperate. A few minutes later, SG-A and SG-C discussed and realized that P1 was not going to cooperate, and if the SG’s were to go “hands on” it would most likely lead to one of the SG’s getting hurt. P1 was 6’6” and 240 pounds. SG-A drew his TASER, activated the TASER, and discharged. The TASER was deployed and struck P1 in the abdomen area and thigh. After a successful deployment, P1 ripped the TASER probe that struck in the thigh area and P1 dropped to the ground right away. SG-B entered the elevator and positioned himself behind P1, placing his hands under P1’s arms, while SG-A and SG-C each grabbed one of P1’s legs and transported P1 back to his room. After getting P1 back to his room, P1 was placed in 4-point restraint and continued to resist. P1’s incident report dated 4/26/25 written by SG-C indicated SG-A and SG-B responded to a call from dispatch while P1 was in the elevator. A few minutes later, a code green was called and that is when SG-C responded to the scene. P1 was standing in the elevator, and SG-A and SG-B were asking P1 to leave the elevator and go back to his room, but he refused to do so; P1 was agitated and refusing to go back to his room. P1 was in a fighting posture. P1 kept saying he wanted to go home and that nobody could stop him. SG-C explained to P1 that he was on a hold and that he could not go home. P1 threated to fight any SG. SG-A pulled out his TASER and pointed it at P1. P1 was warned and was saying “tase me, tase me”. P1 kept threatening SG’s verbally and P1 did not show any will at this time. At that point SG-A decided to tase P1 and as soon as P1 was tased, SG-B and SG-C rushed into the elevator to hold P1’s arms while SG-A held both of his legs as they escorted P1 back to his room, put him on his bed, and put him into restraints. P1’s medical records dated 4/26/25 at 12:00 p.m. indicated P1 was assessed after the incident. The assessment included observation and vital signs. No injuries were noted. A hospital report titled Vulnerable Adult Investigation Report dated 4/28/25 indicated the risk management team was alerted that a TASER deployment occurred involving P1. The use of force review was being scheduled by the security department in accordance with the policy. Risk management confirmed with human resources (HR) that SG-A was placed on administrative leave pending the investigation. The report named SG-A as the alleged perpetrator who had been employed at the hospital since 5/31/22. SG-A served as a SG, field training officer, and shift lead. SG-A was the lead SG on the code green call. In conclusion, P1 met the statutory requirements of a vulnerable adult. After reviewing the event, it gave the risk management team reason to believe maltreatment may have occurred and the state agency was notified of the event. A hospital report titled Alleged Abuse/Neglect of Patient report dated 4/28/25 indicated the event was reviewed and it was determined that this event would benefit from a multi-disciplinary adverse health event review with the clinical care team involved in P1’s hospitalization. The determination meeting was scheduled for 5/6/25 to organize next steps. Email correspondence dated 5/13/25 at 10:19 a.m. indicated QSD-A received an email on 5/5/25 form SG-D stating SG-B was invited to a scenario-based use of force training on 5/31/25 and 6/7/25. SG-D’s email stated this use of force training was mandatory. This email did not include SG-C. Email correspondence on 5/14/25 at 11:45 a.m., QSD-A stated she was unable to send the surveyor an electronic copy of the vulnerable adult investigation report or the alleged abuse/neglect of patient report stating they were peer review protected. Security schedule dated 5/25/25 through 5/14/25 indicated SG-A worked 4 shifts during this time, SG-B worked 11 shifts during this time, and SG-C worked 12 shifts during this period. SG-A’s personnel file indicated he was hired at the hospital as a SG on 5/31/22. A team member performance discussion dated 5/29/24 indicated SG-D’s goal for SG-A was to find a more regulated demeanor when situations arise causing concern; SG-A’s heightened emotion had an impact on the security team as they looked to SG-A for guidance. On 3/1/24, SG-A signed a memo stating he understand and read the use of force policy. On 9/5/24, SG-A had an incident of excessive use of force when he responded to a call about an agitated patient and SG-A entered the room rapidly and aggressively and shoved the patient onto the bed. SG-A proceeded to grab the patient’s scrub top and pinned him to the bed and placed his forearm on the patient’s neck. The corrosive action was effectively immediate, SG-A was expected to improve and sustain his performance following the appropriate procedures and policies set forth by the hospital. Failure to comply with any process or procedure set forth by the hospital could have resulted in continuation of the performance improvement process up to and including termination of employment. SG-A signed this performance improvement review on 11/6/24. SG-A had completed his Workplace Violence online training on 2/2/25, Emergency Response & Equipment Safety online training on 1/30/25, Patient Care & Safety online training on 1/30/25, and Security Use of Force policy review on 4/17/24. SG-B’s personnel file indicated SG-B was hired at the hospital as a SG on 2/17/25. SG-B received his TASER certification on 2/24/25. On 2/17/25, SG-B was trained on code green per his orientation packet on 4/2/25. SG-B completed his Emergency Response & Equipment online training on 2/18/25 and Patient Care & Safety online training on 2/18/15. SG-B did not have any incidents of excessive use of force on file. SG-C’s personnel file indicated SG-C was hired at the hospital as a SG on 1/2/23. SG-C received his TASER certification on 11/5/24. SG-C completed his Workplace Violence online training on 1/8/25, Patient Care & Safety online training on 12/30/24, Emergency Response & Equipment Safety online training on 12/11/24, and Security Use of Force policy review on 3/16/24. SG-C did not have any incidents of excessive use of force on file. During an interview at on 5/8/25 at 2:26 p.m. SG-A stated he had talked with P1 in the elevator for about 20-30 minutes. Later in the interview SG-A stated he had talked to P1 in the elevator for 25-40 minutes. P1 threatened to punch and “swing” at the SG’s if they escorted P1 out of the elevator. That is when it was decided SG-A would tase P1 and escort him back to his room. P1 continued to say that he did not want to be in the hospital. SG-A stated he tased and did not go “hands on” with P1 because P1 was a “strong individual”, and he did not want to risk anyone getting hurt. He did not think P1 was going to be disabled or die because the TASER was used but he was nervous that P1 was going to punch him. SG-A stated he was trained on use of force annually and was current on his use of force training. He was never re-educated on use of force after this incident or put on an administrative leave. SG-A stated he is no longer employed at the hospital because found another job, not because of this incident or being terminated. During an interview on 5/12/25 at 9:25 a.m., SG-B stated during the code green, he was the one that was mostly talking with P1. He attempted to de-escalate the situation but did not get a response from P1 other than he wanted to go home. P1 looked like he was in deep thought and was looking down with his hands clenched and his jaw was tight. SG-B attempted to de-escalate the situation for 25-40 minutes. He talked to SG-A and stated P1 was not cooperating and asked what else SG’s could do to de-escalate the situation. SG-B was still in training at the time. SG-B stated he wanted to try different tactics. P1 stated he was “going to take all of us out”. SG-A pulled out his TASER and tased P1. SG-B stated there was nothing he could do. He did not go “hands on” with P1 because SG’s believed one of them would get hurt in the process because P1 was taller and weighed more than them. SG-B stated “P1 really wanted to get tased. He said that he wanted it.” He did not feel threatened, but he thought SG-A felt threatened. After the incident, SG-B had a conversation with SG-D about the use of force policy. SG-B stated he started in his position on 2/28/25. During an interview on 5/12/25 at 9:48 a.m., SG-C stated the goal in a code green (aggressive patient call) is to de-escalate the situation without harming the patient, staff, or other patients. On 4/26/25 SG-C was on a different call when a code green was called for P1. When SG-C arrived at the scene P1 was in the elevator and SG-A and SG-B were “begging” him to come out of the elevator. P1 was clenching his fists and stating he wanted to go home. SG-A told P1 did not leave the elevator that he would have to tase him while pointing his TASER at him. P1 took his shift off and had “tense” posturing. At one point SG-A holstered his TASER and P1 calmed down “a little bit”. SG-C stated SG-A stated that SG’s should not go “hands on” with the patient because he did not want one of us getting hurt. SG’s did not continue talking to P1 while he was in the elevator because “everyone was scared”. SG-C stated SG’s did not have any other option other than to tase P1. SG-A tased P1 and P1 was escorted back to his room where SG’s and medical staff put P1 in restraints. During an interview on 5/12/25 at 11:14 a.m., SG-E stated if he were to respond to a code green, he would have continued to de-escalate the situation by verbally talking with the patient. If his verbal de-escalation were not working, he would use a hand technique called a blanket hold to escort the patient back to his room. If a patient were still resisting the SG’s, they would call the local police department to respond. SG-E stated if a patient started to physically fight SG’s, which is when he would deploy his TASER. In the situation regarding P1, he would not have used his TASER because P1 was not hurting anyone, and the SG’s did not verbally de-escalate the situation long enough to justify deploying the TASER. During an interview on 5/12/25 at 11:30 a.m., SG-F stated if he were responding to a code green and verbal de-escalation was not working, he would try to have another SG attempt to verbally de-escalate the situation to see if another SG’s verbal de-escalation would work. If medical personnel stated they were attempting to get the patient back to his room, SG-F would question why the patient needs to go back to his room. If a patient were on a hold in the hospital, they do not have to be in their room unless the medical personnel were attempting to give them emergent medications. SG-F stated if a patient had clenched fists, it does not necessarily mean that the patient was aggressive; maybe the patient could have a medical aliment that their fists hurt or could not move his fists. If the patient took off their shirt in an elevator, he would not see that as a threat and would not deploy his TASER. During an interview on 5/12/25 at 11:43 a.m., SG-G stated is she was in that situation and verbal de-escalation was not working with one SG, she would try switching SG’s to see if that would work. If that did not work with the patient, she would have let P1 sit in the elevator for a while. If P1 would not have come out after a while, she would have called the local police department. SG-G stated the use of a TASER should be the SG’s last resort. SG-A was the supervisor. SG-A continued to work the rest of his shirt. SG-A resigned from his position due to finding another job. After the incident, there was some conversations with SG-A, SG-B, and SG-C but she was not part of those conversations. During an interview on 5/12/25 at 12:00 p.m., security director (SD)-A stated the hospital has a policy where they have to review situations of weapon use within 3 days. SD-A stated he would have liked to see more de-escalation until there was an attack on a SG before TASER deployment. SG-A initially gave a two week notice of his resignation from his position, which was accepted himself and the administrative team. The resignation was effective immediately. Administration scheduled the use of force training for SG’s that needed their annual training. SD-A stated he did not interview SG-A about his thought process during the incident. SD-A stated SC-A was completing education for the security team. During an interview on 5/12/25 at 12:34 p.m., security captain (SC)-A stated after the incident involving the deployment of the TASER, he received a call from an unknown SG stating SG-A used his TASER on a patient. SC-A spoke with SG-D who confirmed SG-A deployed his TASER on P1. SC-A stated he did not know the extent of the situation until he came in on 4/28/25 and watched the video footage. The situation is not what the hospital trains the SG’s on. A review of the incident was done, and it was determined it was a performance issue by SG-A. SC-A stated the security team has a training on use of force in “about a week”. The education will be on how to use TASERs, when the SG’s use their TASERs, and scenario-based training. The training was scheduled prior to this incident on 4/26/25. SC-A stated he did not put SG-A on an administration leave because SG-A had turned in his two week’s notice and SC-A consulted with HR who stated SG-A’s resignation was approved, but for immediate resignation. SC-A stated he delegated training SG’s to SG-D about the use of TASERs. During an interview on 5/12/25 at 1:51 p.m., SG-D stated before this incident occurred, the security team already had a use of force training date set in place for 5/31/25 and 6/7/25. Following this use of force incident, SG-D spoke with SG-B about the incident and reviewed the use of force policy and training, as well as watched the video footage of the incident. The conversation included what situations a TASER should be deployed and when a TASER should not be deployed. SG-D stated SG-B would be attending the use of force training on 5/31/25 and 6/7/25. SG-D stated she had a conversation with SG-C about not “overstepping” the lead when making decisions on a call and that he should have “went hands on” with the patient following the TASER deployment. SG-D did not have a conversation with SG-C about TASER use because he was not the SG who deployed his TASER. SG-D stated the TASER deployment was an inappropriate use of force. During an interview on 5/12/25 at 2:27 p.m., administrative manager (AM)-A stated a patient’s nurse is medically responsible for the patient during a code green. During an interview on 5/12/25 at 3:54 p.m., MD-B stated when P1 was tased, he was concerned that P1 could have had cardiac arrythmias that could have led to P1 feeling dizzy, fainting, or increased anxiety. Attempts to contact registered nurse (RN)-A on 5/12/24 at 11:28 a.m. and 2:12 p.m. with no success. During an interview on 5/12/25 at 3:46 p.m., quality systems director (QSD)-A stated a determination meeting is pulling the stakeholders together following a report. This meeting needs to happen within 3 days of the incident. QSD-A stated a determination meeting is a “quick huddle” to determine the next steps in the review. The adverse health event review was scheduled for 6/6/25 to review the event. During an interview on 5/13/25 at 10:46 a.m., nursing assistant (NA)-A stated she was providing 1:1 support for P1 during the time of the incident. P1 started to get agitated after he had met with the behavioral health provider who stated P1 could not leave due to being on a hold and that P1 needed to go to an inpatient behavioral health unit at another hospital. When P1 started getting agitated, she had called RN-A into the room to assist in de-escalating the situation. NA-A and RN-A talked to P1 in his room for “less than 10 minutes” before P1 left the room. P1 continued to say that he did not want to hurt NA-A or RN-A but that he wanted to go home. Once P1 attempted to enter the elevators additional medical staff attempted to de-escalate the situation and once that was not working, they called a code green. NA-A does not remember who called the code green. Once the code green was called, security responded. P1 was not making eye contact and did not say anything besides him wanting to leave. Due to SG’s being in the doorway of the elevator, NA-A was unable to see when SG’s deployed their TASER or what happened prior to the deployment. NA-A stated she was behind the SG’s to one of the sides of the elevators during this incident. Attempts to contact RN-A on 5/13/24 at 7:29 p.m. and 7:58 p.m. with no success. The hospital’s TASER policy dated 12/22/17 indicated the use of a TASER against an individual is permitted only in situations as outlined in the Security Use of Force policy. The policy indicated SG’s must use their discretion in determining whether to draw or deploy a TASER against any individual. Use of a TASER in any situation must be in accordance with the policy, the Security Use of Force policy, and the SG’s training. Designated staff members are required to be certified in TASER instruction and re-certified every two years by a national TASER certification organization. Annual use of force training is required of all SG’s, which includes training on the use of the TASER. The use of a TASER is permitted only under in situations outlined by the Security Use of Force policy. Whenever possible and practical, prior to deploying the TASER, SG’s shall give a verbal warning to the aggressor that states who they are and what they want the aggressor to do. The hospital’s Code Green policy and procedure dated 2/9/21 indicated during a code green, interventions would be initiated in the least restrictive fashion and intensified to the level of intervention that is both necessary and reasonable to maintain, regain or control the situation for the purpose of preventing injuries to the patients, staff, and visitors. The hospital’s System Security Use of Force policy dated 2/28/24 indicated the policy provides guidelines to refuse the risk of violent behavior from any individuals of the hospital by outlining the continuum of actions necessary to maintain a violence free environment. The continuum of action is appropriate where the SG believes an emergency situation puts the hospital at risk for substantial or great bodily harm. The policy defines great bodily harm as a bodily injury which creates a high probability of death, or which causes serious permanent disfigurement, or which cause a permanent or protracted loss or impairment of the function of any bodily member or organ or other serious bodily harm. SG’s would use the minimal degree of force necessary to effectively bring the incident under control. SG’s must engage in reasonable use of force interventions when presented with circumstances such as assault, theft, damage to property, or disorderly conduct or violent attach. This includes using force when necessary to protect the welfare of the aggressor or others. The use of force is never used as a means to coercion, discipline, convenience, or retaliation against any person, including the patient. Weapons and handcuffs are security tool interventions and are not to be used on patients. Force would be administered to prevent and minimize physical harm and maximize safety. If a weapon is used by a SG on a person to protect people or the hospital property and community from imminent risk of substantial or great bodily harm, the SG would contact law enforcement, requesting a response to the emergency situation. The use of weapons would be solely in response to an emergency situation of imminent risk of substantial or great bodily harm with possible factors such as weather all avenues of de-escalation have reasonably been exhausted, the behavior of the person upon which force is to be used, actions or other people who may be present, physical odds against the SG, the feasible or availability of alternative actions, whether the patient armed or is able to become armed, the presence of other SG’s, and any variable listed in the use of force continuum. SG’s may choose to distance themselves and others from a dangerous person, calling for law enforcement support and/or other supporting team members as appropriate depending on totality of circumstances of the aggressive or violent person. The use of force interventions on a patient includes a continuum. The least level of force is physical presence of one or more SG’s. The next level is verbal de-escalation or verbal comments. The next level is soft handed control techniques such as therapeutic redirection, escorts, or join locks. The next level is restraint devices. The next level is security tools such as TASER, chemical agent, hard control techniques, or baton. This level requires an immediate emergency situation when the patient presents danger of substantial or great bodily harm to themselves or others. The next level is the local law enforcement. The immediate jeopardy that began on 4/26/25 was removed on 5/14/25 when the facility revised their System Use of Force policy and procedure on 5/14/25 to include a statement stating security tools would not be used as a restraint device and clarified steps to include SG’s would be placed on immediate administrative leave when security tools are used. The facility also had a one-to-one conversation with SG-B and SG-C about the incident and the expectations around the use of force. SG-B and SG-C attested their understanding of the use of force expectations. The facility updated the use of force education module on 5/14/25 to include policy review and attestation of expectations, as well as updated testing questions to include more robust scenarios to demonstrate competency. The facility completed a security meeting with the SG’s that were currently on shift about the changes to the System Use of Force policy and procedure as well as expectations on when to use a TASER and when not to use a TASER, the steps to take when responding to a code green, and the steps required after deployment of the TASER. The facility updated the electronic training module to be completed at the beginning of SG’s shift starting 5/14/25. The facility updated the Use of Force training modules to occur semiannually when it was previously scheduled annually. The facility would email a memo to all security and clinical staff regarding changes to the System Security Use of Force policy and use of force expectations on 5/15/25. The noncompliance remained at a lower scope and severity at level D because the System Use of Force policy did not include SG’s would not use security tools as a restraint device or that the SG would be relieved of their shift after use of security tools and placed on administration leave immediately. During interviews, SG-B and SG-C were unaware of the additional steps SG’s should take prior to TASER deployment.”