Allina United Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48300 Based on record review and interview, the facility failed to ensure nursing staff appropriately monitored, reassessed, and escalated worsening conditions for 1 of 10 patients (P1) reviewed when P1 demonstrated signs of clinical deterioration. This resulted in an Immediate Jeopardy (IJ) situation when P1’s decreased blood pressure (BP) was not reassessed, a subsequent BP was not obtained after an attempted BP check failed nor was P1’s medical provider updated when her clinical status worsened in the Emergency Department (ED) required admission to the intensive care unit (ICU) and subsequent death. The deficient practice resulted in an immediate jeopardy. The hospital was found out of compliance with the Condition of Participation Nursing Services at 42 CFR 482.23. See A-0395 for additional information.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48300 Based on record review and interview, the facility failed to ensure nursing staff appropriately monitored, reassessed, and escalated worsening conditions for 1 of 10 (P1) patients reviewed when P1 demonstrated signs of clinical deterioration. This resulted in an Immediate Jeopardy (IJ) situation when P1’s decreased blood pressure (BP) was not reassessed, a subsequent BP was not obtained after an attempted BP check failed nor was P1’s medical provider updated when her clinical status worsened in the Emergency Department (ED) required admission to the intensive care unit (ICU) and subsequent death. The IJ began on 7/22/26, after P1 was assessed to have hypotension without reassessment and/or provider notification for potential changes in treatment. On 8/14/26 at 1:11 p.m., the president, the risk manager, the accreditation program specialist, and the system accreditation program manager were notified of the IJ. The IJ was removed effective 8/14/26 after verification of the removal plan on 8/17/26. The hospital remained out of compliance at the Condition level for the Condition of Participation: Nursing Services at 42 CFR 482.23. Findings include: P1 presented to the ED on 7/21/26 at 7:09 p.m. with abdominal pain and constipation. Following laboratory blood work and imaging, P1 was diagnosed with ascending cholangitis (a serious, life-threatening bacterial infection of the bile ducts that requires prompt medical care) and septic shock (life-threatening immune system reaction to an infection). Based on P1’s flow sheets, her BP on 7/21/26 at 7:43 p.m. was 139/81. Review of P1’s medical record indicated the following: On 7/21/26 at 11:00 p.m., P1’s BP was 103/68 with a MAP (Mean Arterial Pressure - average artery pressure reflective of how the blood flows in the organs based on a BP reading calculation) of 83 (normal range - adequate blood flow to vital organs) and heart rate of 96 (standard adult normal range equals 60 to 100) bpm. At 11:04 p.m., P1’s lactate (lactic acid) lab value was 3.7 (mildly elevated with a normal range of 0.5 to less than 2. Elevated levels indicate buildup when cells produce more energy without enough oxygen), decreased from 4.7 (severe elevation) at 8:51 p.m. On 7/22/26: -12:15 a.m. P1’s BP was 89/63 (hypotensive (low) with a MAP of 71 (normal range) and pulse of 99 bpm. The BP cuff size as an “Adult Large Long.” -12:22 a.m. a nursing note by registered nurse (RN)-A indicated P1’s BP was “lower” due to P1 laying on her side. The note lacked evidence to support P1’s BP was rechecked, and/or rechecked to ensure the cause was P1’s position, or that the provider was notified. -12:56 a.m., P1’s lactate lab result was 5.1 (severe elevation that requires treatment to reduce the lactic acid and raise the blood’s pH back to a normal level). The note, along with the medical record, lacked evidence that the provider was updated for any treatment determination(s). -2:03 a.m., a nursing note by RN-A indicated P1 had not tolerated a Magnetic Resonance Cholangiopancreatography (MRCP. A non-invasive type of Magnetic Resonance Imaging [MRI] scan that creates detailed pictures of the liver, gallbladder, bile ducts, and pancreas used to visualize gallstones, blocked ducts, tumors, and fluid in the organs) procedure due to vomiting. The note lacked indication of notifying a provider of the inability to perform the MRCP and/or of P1’s vomiting. -3:22 a.m. a nursing note by RN-A indicated P1 had requested ice chips and complained that her face felt “hot”. RN-A provided an ice pack. -3:30 a.m., flowsheets identified P1’s pulse as 110 bpm; however, the flowsheets lacked BP documentation. -3:45 a.m., a nursing note by RN-A indicated the BP cuff was not reading and RN-A was going to try a smaller cuff. However, no BP was recorded at that time. The note also indicated P1 was “flipping from side to side”. -5:53 a.m., a nursing note by RN-A indicated P1 was found with the head of her bed elevated, oxygen off, mottling (discoloration of the skin caused by uneven blood flow/constriction or partial blockage in the tiny vessels just beneath the skin) on her extremities, and was not responding to painful stimuli. In response, a rapid response was called and P1 was moved to a stabilization room. -6:21 a.m., a nursing note by RN-B indicated he responded to the rapid response at 4:49 a.m. P1 was unresponsive with eyes open and did not respond to painful stimuli. RN-B was unable to obtain a BP with the BP machine, but manual BP was around 70/30 [MAP of 43 based on BP MAP calculation - low suggestive that the pressure driving blood through the arteries is below the range needed for adequate organ perfusion]. P1’s flow sheets dated 7/22/26 identified the following: -5:42 a.m., P1’s BP was 59/42, obtained via an arterial line, with a MAP of 47 (low). -5:46 a.m., P1’s BP was 65/50, obtained via an arterial line, with a MAP of 55 (low). P1’s medical record lacked evidence that a BP was checked/rechecked after 12:15 a.m. to the BP taken during the rapid response event. Additionally, the medical record also lacked provider notification during this time range related to the high lactate level at 12:56 a.m., the inability to complete the MRCP, the vomiting, and/or the BP concerns. P1 was admitted to the ICU on 7/22/26 and ultimately passed away on 7/23/26 at 12:29 a.m. from “ascending cholangitis,” based on P1’s 7/23/26 Discharge Summary. Additional diagnoses/problems that contributed to her death, but which did not lead to the main cause were identified as septic shock, ischemic bowel (reduced blood supply to the bowels), necrotic bowel (tissue death from loss of intestinal blood supply), acute systolic congestive heart failure (CHF), acute respiratory failure, acute renal failure, and metabolic acidosis (too much acid in the body fluids, leading to an imbalance in the bloods pH). During an interview on 7/27/2026 at 9:09 a.m. RN-C stated a provider should be notified when a patient has a MAP of less than 65, However, if the patient had a diagnosis of sepsis and their blood pressure was trending down, she would alert a provider before the MAP was under 65. If RN-C could not obtain blood pressure with the machine she would attempt a manual blood pressure and notify a provider. RN-C also stated she would notify the provider if the patient’s lactate was increasing and would document provider communication in a nursing note. During an interview on 7/27/2026 at 9:33 a.m. RN-D stated if a patient had severe sepsis, she would be checking vital signs frequently and would notify a provider if the blood pressure was trending down. If RN-D couldn’t obtain a blood pressure, she would try for a manual blood pressure and would also ask another nurse to try. If the second nurse was also having trouble, RN-D would notify the provider. RN-D would also update a provider if a patient’s lactate was increasing. All communication with a provider should be documented in a provider notification note. During an interview on 7/24/2026 at 11:57 a.m., medical doctor (MD)-A stated ascending cholangitis is an infection in the biliary tree (liver, gallbladder and connecting bile ducts) usually caused by blockage and was considered a medical emergency requiring close monitoring. MD-A would expect a nurse to notify a provider right away when a patient with septic shock had an increase in lactate lab numbers with a decreasing blood pressure or MAP. The provider would then look at the bigger picture of the patient and order appropriate interventions. MD-A stated that notification at 12:15 a.m. with the blood pressure of 89/63 or when a BP could not be obtained at 3:45 a.m. would have allowed the provider to evaluate P1 and consider additional interventions including intravenous fluids (IV) with a fluid monitoring device (NICOM) or could have sent P1 to the intensive care unit (ICU) for IV blood pressure medications (pressors) which may have changed P1’s outcome. During an interview on 7/24/2026 at 12:39 p.m., MD-B stated the overnight on call gastroenterologist (GI) (physician with dedicated training management of diseases of the gastrointestinal tract and liver) had been contacted at approximately 9:30 p.m. on 7/21/26 and gave orders for fluids, antibiotics and a MRCP. MD-B stated if GI had been informed P1 had not tolerated the MRCP, they might have attempted an endoscopic retrograde cholangiopancreatography (ERCP. A specialized medical procedure that combines a long, flexible camera tube and X-rays to diagnose and treat problems in the bile ducts, pancreatic duct, liver, and pancreas like opening blocked or narrowed ducts). An ERCP was performed on 7/22/26 at 12:00 p.m. and revealed P1 did not have ascending cholangitis. If the ERCP had been completed prior to P1 becoming unresponsive the provider team would have learned P1 did not have ascending cholangitis and could have started looking for other causes of sepsis. During an interview on 7/24/2026 at 1:04 p.m., RN-B stated when he responded to the rapid response call for a patient who was unresponsive despite a sternal rub (rubbing knuckles of a tight fist on a patient’s breastbone causing pain that is difficult for the brain to ignore to test a patient’s level of consciousness). P1 had a weak pulse, was breathing and had a BP of 70/40 via a manual BP. P1 required the placement of an arterial line, intubation (tube to help with breathing) and was admitted to the ICU for pressors. RN-B stated any communication to a provider should be documented in a nursing note with information about why the provider was contacted and their response. During an interview on 7/24/2026 at 3:01 p.m. MD-C stated she had taken over care of P1 around midnight on 7/22/26. She was not notified of P1’s increasing lactate level, decreasing BP, inability to obtain a BP or P1’s intolerance of the MRCP scan. If she had been notified, she would have ordered more IV fluids and NICON monitoring to see if P1 was responding to the fluids. She would have notified GI about the MRCP not being completed. MD-C stated, “we couldn’t do anything because we didn’t know what was going on.” MD-C stated she would expect to be updated when a patient who meets septic criteria had an increasing lactate or a decreasing blood pressure with a systolic (top number of a blood pressure reading) of less than 90. During an interview on 7/24/2026 at 1:32 p.m. emergency department (ED) nurse supervisor (RN-E) stated vital signs were obtained on admission to the ED. The frequency of additional vital signs was based on the patient’s ED stabilization score. P1’s score was three which instructed vital signs were to be obtained every two hours unless abnormal: “Which [P1’s] were.” Nursing judgment would determine how frequently vital signs should be completed if the numbers were abnormal. RN-E stated that an abnormal vital sign should be rechecked for accuracy and that the provider should be notified if the abnormal finding persisted. Any provider communication should be documented in a nursing note or a communication note. RN-E confirmed there was no documentation of blood pressure for P1 from 12:15 a.m. until 4:49 a.m. when the rapid response was called and there was no documentation the provider was notified before the rapid response was called. RN-E stated things started to go “downhill” after the nurse attempted to get a BP and was unsuccessful. RN-E stated no concerns about P1’s care had been brought forward and there were no “Risk Connects” associated with P1 for patient safety which either a nurse and/or a provider could initiate. RN-A’s time sheet indicated she worked 7/25/26 from 6:58 p.m. to 7/26/26 at 7:30 a.m., 7/26/26 from 6:58 p.m. to 7/27/26 at 7:26 a.m., and 7/30/26 from 6:58 p.m. to 7/31/26 at 7:58 a.m. When interviewed on 8/14/26, at 2:07 p.m., the patient care director of the ED (PCD) stated P1’s incident continued to be investigated and the facility continued to work on a root cause analysis which was still pending as the facility had to “tie up” the employee investigation before they could finish the analysis component. PCD reported this event was not as “global an issue” as they had initially thought and this appeared to be only a “gap” with RN-A’s work processes. During an interview on 8/14/2026 at 2:24 p.m., risk manager (RM) stated that on 7/22/26 at 10:49 a.m. an event was entered anonymously into the risk connect system regarding P1. P1 was in the ICU at that time. The investigation was started immediately, and the appropriate leaders were tagged in the event to review. During an interview on 8/14/2026 at 4:25 p.m., RN emergency department director (RN-F) stated RN-A had just returned from a personal leave of absence (LOA) and explained that if a nurse would like re-orientation shifts when returning from LOA, they must request the shifts. Following her shift on 7/21/26-7/22/26, RN-A requested re-orientation and received one re-orientation shift and worked two shifts on her own prior to being placed on administrative leave on 8/3/26 after RN-A expressed she had informed the charge nurse and the provider of P1’s deteriorating condition and it was later discovered that she had not escalated P1’s deteriorating condition to the charge nurse nor the provider. RN-F stated she was informed of the event on 7/22/26 and the investigation process started immediately, which involved assistance from RN-E. Education was started for all nurses in the emergency department on 7/24/26 regarding documentation and escalation expectations for boarding patients in the ED and all remaining staff were educated prior to their first shift following 7/24/26. RN-F considered P1’s situation a “reportable event ...a sentinel event,” and she considered RN-A’s lack of action as a failure to recognize change in condition and not following standard processes and standard work. An undated [ED] Registered Nurse Boarding Check-Off form identified the start of RN education related to ED Boarding Documentation began on 7/24/26, which continued through to 7/31/26. Despite RN-A working during this timeframe, the form lacked evidence RN-A was provided with this education. Another undated Registered Nurse Boarding/Care Check-Off form identified the start of RN education related to ED Standards of Care and ED Boarding Documentation began on 7/24/26, which continued through to 7/31/26. RN-A’s name was identified on the form; however, her name was highlighted red and the “Date” [for education] remained blank, along with 27 other RNs who had yet to complete this education. When subsequently interviewed on 8/17/26, RN-E identified P1’s event required a “full” investigation before removing a nurse, such as RN-A, from the schedule as this was their standard practice. RN-E stated she would not have thought to tell the surveyor on 7/24/26 about the education that was provided that day and that this situation was not a concern with the whole department, just basically an isolated issue with the one nurse. RN-E explained that RN-A was not added to the education forms as “she was no longer a concern because she wasn’t working. She would have had several opportunities to get the education in the huddles,” as the huddles are mandatory. Voice messages and texts were sent to RN-A requesting an interview on 7/27/26 at 7:03 a.m., 8:43 a.m., and 3:27 p.m. A text response was received that indicated availability for an interview on 7/31/26 at 10 a.m. A voice message and text were sent on 7/31/26 at 10:02 a.m. with no response. The Emergency Department Standards of Care of Medical Boarded Patients dated November 2025, instructed nursing staff to reassess, document, and notify the admitting team of any changes in condition. The nurse should maintain appropriate monitoring as ordered or indicated as able. If the patient deteriorates, nursing staff should contact the hospitalist and communicate a higher level of care is needed. The IJ, which began on 7/22/26 at 12:15 a.m., was removed effective 8/14/26 after verification of the removal plan on 8/17/26, which, based on interviews and document review, demonstrated immediate ED-specific safeguards were implemented related to reassessing worsening clinical changes, provider notification(s), and provider communication (if such communication were to occur). The plan included: Review of the following policies with no change deemed necessary: -Standards of Care of Medical Boarded Patients dated November 2025 -Emergency Department Standards of Care dated November 2025 -Critical Test Results dated July 2025. RN-A was suspended on 8/3/26 pending investigation. The ED nurses were re-educated on Standards of Care of Medical Boarded Patients specifically process for recognizing changes in condition, notifying providers and documenting provider communication in which any nurses not yet educated, due to not having yet worked, were to be educated prior to their next shift.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure a comprehensive medical screening examination (MSE) was completed to determine if an emergency medical condition was present for 1 of 20 patients (P1) reviewed. P1 presented to the ED with symptoms of shortness of breath, however, had a persistent elevated heart rate which was not addressed in the record. See A-2406 for additional information.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure the emergency department (ED) central log was accurately maintained to demonstrate separate episodes of care for 1 of 20 patients (P1) reviewed. P1 presented to the ED for care, was treated, then physically discharged from the ED. P1 then returned a short time later for further care; however, these encounters were not separately recorded on the ED log. Findings include: P1’s hospital record, dated 5/11/26, identified the following: - P1 presented to the ED via EMS from an attached nursing care center on 5/11/26 at 12:53 a.m. with a chief complaint of shortness of breath. P1 had a history of stroke, and EMS found him to have oxygen levels of 97% (Sp02) on room air upon their arrival to the nursing care center. - A series of laboratory tests and chest x-ray were done. P1’s vital signs were recorded in the record. - P1 status was changed at 3:05 a.m. to, “Ready for Discharge,” and his disposition was set to discharge back to the care center. P1’s discharge instructions were printed off. P1’s ED Nursing Discharge Note, dated 5/11/26, identified P1 was being discharged back to the care center and a hospital patient care technician (PCT) pushed him back down to the care center from the ED. P1 had verbalized understanding of his discharge instructions and was given a copy of them. Report was given to the care center nurse. P1’s subsequent Note, dated 5/11/26 at 5:12 a.m., identified P1 was taken to the care center but the nurse there “sent him back” due to abnormal breathing and concern for low oxygen levels. The note identified, “Patient returned at 0340 [3:40 a.m.].” P1’s oxygen saturation was 96% on room air in the ED and he was not in distress. Registered nurse (RN)-A authored the note. P1’s (ED) Discharge Summary, dated 5/11/26 at 12:31 a.m., identified P1 was seen by medical doctor (MD)-A and had been brought over from the attached care center due to concerns of appearing short of breath. EMS arrived and his saturations were over 95% on room air. Lab results showed P1 was negative for COVID/RSV, and a chest x-ray showed mild basilar opacities which, “ ... could be atelectastic or less likely infectious.” P1 was discharged and brought back to the nursing care center, however, they declined to take him back due to concern for his respiratory status. As a result, P1 was returned to the ED, and hospitalist was contacted for potential admission. The ED central log, provided by the hospital and dated 5/10/26 to 5/12/26, identified P1 with a recorded date of time of 5/11/26 at 12:53 a.m. P1’s disposition was listed as, “Observation.” The log did not identify a separate visit for each encounter for care despite P1 being physically discharged from the ED and returning for care on the same date. When interviewed on 6/9/26 at 1:56 p.m., registered nurse (RN)-A stated when a patient is brought into the ED by EMS, then the nurse working enters them into the system for registration and starts their assessment process. The ED log is then pulled using electronic data complied into the system later. RN-A recalled P1’s case on 5/11/26 and stated MD-A assessed P1 and felt he was clinically stable to discharge back to the care center. The ED PCT then pushed P1 back to the care center but the nurse there refused to accept him back due to a slightly elevated respiratory rate. P1 was then brought back to the ED after “maybe 15-20 minutes” and MD-A assessed him again still finding few, if any, reasons to admit him to the hospital. RN-A stated when a situation like that happens, the nurses will ask the MD what they would like to do regarding starting a new encounter on the log or just re-opening the previous encounter. However, RN-A stated they did not know how the decision to re-open the encounter for P1 was made on 5/11/26, as they were not involved with the conversation. RN-A reiterated the MD will make the decision on that but added those situations like with P1 did not happen often. When interviewed on 6/9/26 at 2:59 p.m., MD-A stated they recalled assessing P1 on 5/11/26 and he “looked fine” so they cleared him to discharge back to the care center. However, the nurse there then sent him back to the ED. MD-A stated P1 had stable vital signs and was in stable condition upon discharge the first time he left the ED. MD-A stated the decision to re-open a previous encounter or begin a new one if someone returns is “not up to us [MD]” and would be someone from the registration staff to make that decision. MD-A stated that process was “more a housekeeping thing.” On 6/9/26 at 3:16 p.m., a group interview was held with the ED manager (EDM), ED supervisor (EDS), chief nursing officer (CNO), and patient access manager (PAM). EDM stated a patient is entered into the system and the log started by either registration staff or the nurses working in the ED, as who entered it depended on if they arrived by walk-in or EMS. If a patient left and returned within a short period, then there was usually a discussion between the MD and staff working on how to code that on the log with either a new encounter or just re-opening the previous one. EDM stated they often will just re-open the last encounter as it already has the work-up completed on the patient and helps reduce the billing to the patient. EDM stated if the second visit was for a totally unrelated complaint to the first visit, then it would automatically be a new encounter. However, there was no official policy or protocol for this to help staff determine when or how to make these decisions. PAM reviewed P1’s medical chart and stated their encounter history showed P1 had been set to discharge on 5/11/26 and then a subsequent entry listed it as, “Undone to confirm admission.” This was initially done by RN-A. EDM reiterated the decision to just re-open a previous encounter was done to help prevent the patient from getting two bills for care, but these situations did not happen often. The CNO stated it was important to keep an accurate ED log as it helped ensure the needed medical screening examinations (MSE) were done and treatment was provided to each patient. The hospital Emergency Medical Treatment and Labor Act (EMTALA) policy, dated 1/2024, identified the policy applied to all hospital campuses and any off-campus services that met the definition of an ED. The policy listed a section labeled, “Central Log,” which identified the hospital would maintain a log to record information about all individuals who presented to the hospital and requested an evaluation or treatment for a medical condition. The log would be maintained for, at minimum, six years and identified it would “ ... contain sufficient detail about disposition.” However, the policy lacked any information on when it was allowable to just re-open a previous encounter if a patient returned in a short period of time; nor did the policy have information on how this would be captured on the ED log.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure a comprehensive medical screening examination (MSE) was completed to determine if an emergency medical condition was present for 1 of 20 patients (P1) reviewed. P1 presented to the ED with symptoms of shortness of breath, however, had a persistent elevated heart rate which was not addressed in the record. Findings include: P1’s hospital record, dated 5/11/26, identified P1 presented to the ED via EMS from an attached nursing care center on 5/11/26 at 12:53 a.m. with a chief complaint of shortness of breath. P1 had a history of stroke, and EMS found him to have oxygen levels of 97% (Sp02) on room air upon their arrival to the nursing care center. P1’s Flowsheet(s), dated 5/11/26, identified P1’s collected and recorded vital signs in the ED. This included a section labeled, “HR [heart rate],” which recorded several heart rates including: - 5/11/26 at 12:58 a.m. - 91 beats per minute (BPM) - 5/11/26 at 1:00 a.m. - 100 BPM - 5/11/26 at 1:08 a.m. - 96 BPM - 5/11/26 at 1:16 a.m. - 100 BPM - 5/11/26 at 1:30 a.m. - 98 BPM - 5/11/26 at 1:45 a.m. - 116 BPM - 5/11/26 at 2:02 a.m. - 112 BPM - 5/11/26 at 2:21 a.m. - 104 BPM - 5/11/26 at 3:00 a.m. - 110 BPM In total, P1 had 26 recorded pulse rates in the ED record. Of these, all were over 90 BPM and eight (8) were recorded at or over 100 BPM until 3:05 a.m. when P1 was marked as, “Ready for Discharge.” Normal resting heart rate for an adult is between 60 and 100 beats per minute. P1 was discharged back to the care center at 3:18 a.m. with directions to follow-up with their primary care provider (PCP) in one week. P1’s corresponding After Visit Summary (AVS), dated 5/11/26, identified P1 was seen in the ED for shortness of breath. P1’s vital signs were listed as 103/77 (BP), 105 (P), and 99.5 (F). P1’s ED Nursing Discharge Note, dated 5/11/26, identified P1 was being discharged back to the care center and a hospital patient care technician (PCT) pushed him back down to the care center from the ED. P1 had verbalized understanding of his discharge instructions and was given a copy of them. Report was given to the care center nurse. P1’s subsequent Note, dated 5/11/26 at 5:12 a.m., identified P1 was taken to the care center but the nurse there “sent him back” due to abnormal breathing and concern for low oxygen levels. The note identified, “Patient returned at 0340 [3:40 a.m.].” P1’s oxygen saturation was 96% on room air in the ED and he was not in distress. Registered nurse (RN)-A authored the note. P1’s ED Provider Note, dated 5/11/26 at 4:25 a.m., identified P1 was seen by medical doctor (MD)-A. P1 was a 63-year-old male with a past medical history of stroke, pulmonary disease, prior respiratory failure, and high blood pressure. P1’s medications were reviewed and per EMS, P1 had stable oxygen saturations in the mid-90’s (%). EMS identified fluctuating blood pressures which were consistent with the paperwork history obtained. EMS reported clear lung sounds, and no treatments were provided en route to the ED. On evaluation, P1 reported feeling better and breathing without issue. P1 denied being in pain or feeling sick. The note outlined, “Initial bedside assessment described no respiratory distress and an unremarkable exam.” A later evaluation, around 1:40 a.m., found P1 still feeling good with normal oxygen saturation levels but tachycardic (high heart rate). A chest-x-ray was completed which resulted with “ ... questionable infiltrate.” P1’s temperature was 99.5 (F) and he indicated he could return to the care center before later saying he did not want to go back. P1’s attached imaging results identified the x-ray results showed mild basilar opacities which, “ ... could be atelectasis or less likely infectious.” The section labeled, “ED COURSE / MDM [medical decision making],” identified shortness of breath, now improved, tachycardia, possible pneumonia. MD-A recorded his physical examination of P1 showed no respiratory distress, no accessory muscle use with breathing, and clear lungs which lowered suspicion for ongoing acute bronchospasm or respiratory failure. However, the note then combined the findings from P1’s initial presentation and subsequent presentation back to the ED. The note recorded, “Given the chest X-ray with a questionable infiltrate and low-grade temperature (99.5 F) plus new tachycardia ... expanded evaluation was planned to assess for infection/sepsis physiology ... Earlier in the course, with reassuring exam and no distress, plan was for chest x-ray and no additional labs at that time; this decision was revisited after development of persistent tachycardia and equivocal imaging/temperature.” P1’s tachycardia was unresolved without intervention at time of discharge. When interviewed on 6/9/26 at 1:56 p.m., registered nurse (RN)-A recalled P1’s case on 5/11/26 and stated EMS had reported an increased heart rate but good oxygen saturation levels. RN-A stated they recalled P1’s vital signs in the ED as “kinda calmed down” and stable. P1 never complained of pain or being short of breath while in the ED, and MD-A assessed P1 and felt he was clinically stable to discharge back to the care center. The ED technician pushed P1 back to the care center but the nurse there refused to accept him back due to a slightly elevated respiratory rate. P1 was then brought back to the ED after “maybe 15-20 minutes” and MD-A assessed him again. RN-A stated they felt the elevated vital signs on return were just P1 being “kinda worked up.” When interviewed on 6/9/26 at 2:13 p.m., MD-B stated they got involved with the case for P1 when P1 returned to the ED the second time on 5/11/26, as the nursing home had declined to re-admit P1. The initial ED evaluation (done by MD-A) showed P1 was relatively stable, and the team then decided discharge was appropriate. MD-B stated he evaluated P1 using a tele-health monitor and not physically in-person but felt when he evaluated P1 on re-visit to the ED that P1 was stable. The x-ray showed “maybe a touch of pneumonia,” and MD-B explained it was important to consider the whole presentation of the patient to determine when to treat something. In this case, P1 did not feel sick and was not short of breath to support a pneumonia confirmation, so treating it or not the first time could “go both ways.” P1 had been in the ED for several hours and remained relatively stable, so that could easily be a reason not to act and treat with antibiotics. MD-B reiterated the x-ray results were “very questionable.” When interviewed on 6/9/26 at 2:59 p.m., MD-A stated they recalled assessing P1 on 5/11/26 and he “looked fine” so they cleared him to discharge back to the care center. However, the nurse there then sent him back to the ED. MD-A recalled ordering a chest x-ray but did not recall anything about pneumonia being present on it. MD-A stated they recalled not being very concerned with P1’s presentation and he had “reassuring vitals” during the first visit to the ED. MD-A stated they felt P1 was in stable condition and able to discharge otherwise he would have done more work up on him. The hospital Emergency Medical Treatment and Labor Act (EMTALA) policy, dated 1/2024, identified the policy applied to all hospital campuses and any off-campus services that met the definition of an ED. A MSE would be completed by a qualified medical person or physician, and the hospital would provide stabilizing treatment irrespective of the patient’s ability to pay. The definition of MSE was listed as, “An examination performed by a physician or Qualified Medical Person for the purpose of determining with reasonable clinical confidence whether a person who has come to the [ED] has an emergency medical condition.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47264 Based on interview and document review, the hospital failed to ensure patients were free from abuse for 2 of 10 patients (P1 and P2) reviewed for patient rights. P2 entered P1’s room, engaged in sexual activity, and exited when another patient alerted P1 and P2 staff were present on the milieu. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. See A-0145 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47264 Based on interview and document review, the hospital failed to ensure patients were free from abuse for 2 of 10 patients (P1 and P2) reviewed for patient rights. P2 entered P1’s room, engaged in sexual activity, and exited when another patient alerted P1 and P2 staff were present on the milieu. Findings include: P1 was a 34-year-old male with a relevant past medical history of bipolar disorder type I, autism spectrum disorder, post-traumatic stress disorder (PTSD), alcohol use disorder, and cannabis use disorder. P1 presented to the hospital on 1/27/26 at 4:32 p.m. as a direct transfer to the mental health inpatient unit from an outside hospital. A nursing admission note dated 1/27/25 at 5:30 p.m. indicated P1 was oriented to the unit and was cooperative with nursing staff. A provider note dated 1/28/28 at 3:43 p.m. indicated P1 presented from an outside hospital on 1/26/26 with concerns of insomnia and disorganization. The note indicated P1 had a history of commitment and obtained a stay of commitment in May of 2024. His history of hospitalization had been reviewed and did not contain any concerns with sexually inappropriate behaviors. The notes indicated P1 was disorganized and unable to answer mental health questions in a meaningful way. The note indicated P1 was at the hospital on a voluntary basis and met criteria to enact an emergency hold if necessary. A nursing note dated 1/31/26 at 4:35 a.m. indicated P1 was seen hugging P2 in the milieu. The note indicated the patients were redirected and boundaries were enforced. A nursing note dated 1/31/26 at 9:21 a.m. indicated P1 was transferred to a different unit at 9:15 a.m. for peer separation. An order dated 2/1/26 at 12:48 a.m. indicated sexual precautions were initiated for P1 due to alleged sexually inappropriate conduct on 1/30/26. P2 was a 35-year-old female with a relevant past medical history of bipolar disorder with psychotic features, attention deficit hyperactivity disorder, and PTSD. P2 presented to the hospital emergency department at 5:40 a.m. via ambulance for evaluation of mental health concerns. A provider note dated 1/30/26 at 6:54 a.m. indicated P2 had a history of mental illness that included a period of without medications for nine years. P2 endorsed paranoid delusions and auditory hallucinations. A nursing mental health admission notice indicated P2 was agitated during her orientation to the unit. The note indicated P2 was verbally abusive towards staff and peers and required redirection. A nursing note dated 1/31/26 at 12:46 a.m. indicated P2 was seen socializing with P1 in the milieu. The note indicated later P1 and P2 were seen holding hands. The note indicated both instances were redirected and informed patients need to maintain healthy boundaries while on the unit. A nursing note dated 1/31/26 at 4:12 p.m. indicated P2 reported earlier in the shift she had been coerced into sex while in P1’s room on 1/30/26. The note indicated P1 was transferred to another unit, P2 was moved to another unit, the on-call psychiatrist was informed, and a 1:1 attendant was initiated for both P1 and P2. A sexual assault team note dated 1/31/26 at 5:59 p.m. indicated the exam began at 2:23 p.m. for an assault that occurred on 1/30/26 at 9:00 p.m. The note indicated P2 was highly disorganized during the interview and examination and endorsed delusions. The note indicated P2 reported P1 ejaculated into her vagina. The note indicated P2 endorsed feeling tearful, labile, and “dead inside.” An order dated 2/1/26 at 12:43 a.m. indicated sexual precautions were initiated for P2 due to sexually inappropriate behavior with peers. On 2/4/26 at 2:09 p.m., video footage with no audio from 1/30/26 at 8:16 p.m. was reviewed with the director of risk, an accreditation program specialist, and the manager of the inpatient psychiatric unit. Footage showed P1 in the day space with a group of other patients as they all watched a movie. P2 exited her room, stood behind a structural pillar, and lifted her shirt towards P1. P1 got out of his chair and approached P2. They conversed, standing close to each other while behind the pillar. Staff were present in the nursing station, but based on the position of the pillar, were unable to see this interaction. Shortly afterwards, P2 and P1 separated and went to their own rooms. Shortly after, P2 reentered the day space and conversed with other patients. Another patient pointed to P1’s room, and P2 walked into P1’s room and closed the door. Staff could be seen sitting at the nursing station. A few moments later, a nurse exited another patient’s room and went directly to the nursing station. A few minutes later, the same nurse went back to that patient’s room and closed the door. Shortly afterwards, another staff member entered the nursing station with a clipboard. A patient noted this and began looking between P1’s room and the nursing station. While observing nursing staff, this patient stood up, knocked on P1’s door, and returned to his seat. P1 and P2 were in P1’s room while unmonitored between 8:20 p.m. and 8:26 p.m. P2 then exited P1’s room and ambulated in the kitchenette space for a bit before returning to her room. The staff with the clipboard then walked from the nursing station to the kitchenette and appeared to prepare snacks for the patients. P2 returned to the day space while staff distributed food to patients. Shortly afterwards, staff returned to the nursing station. In an email on 2/5/26 at 3:48 p.m., the accreditation program specialist stated the Vulnerable Adult Maltreatment: Assessment and Reporting in Minnesota policy is used to guide reporting and response to abuse. The accreditation program specialist stated the department leaders are aware of their own abuse prevention practices. During an interview on 2/4/26 at 10:42 a.m., registered nurse (RN)-A stated when admitting a patient, they look through previous health records to determine if they have exhibited sexually inappropriate behavior prior to hospitalization. Patients may need additional monitoring, such as a 1:1 attendant. Every 15 minutes, staff note where each patient is and what they’re doing and record this information on a clipboard. If patients are not on a 1:1 and staff are not actively completing 15-minute rounds, they can observe the milieu from anywhere on the unit, including the nursing station. RN-A stated she was P2’s primary nurse on the morning of 1/31/26. At that time, P2 disclosed an allegation of sexual abuse to her, but could not verbalize with whom or when this occurred. RN-A told the on-call psychiatric provider and her charge nurse who alerted the administrative nurse supervisor. RN-A stated P1 was compliant with moving to another unit, both P1 and P2 were placed on 1:1s, and a sexual assault nurse examiner (SANE) evaluated P2. During an interview on 2/4/26 at 10:59 a.m., P2 stated she had inappropriate interactions with another patient. P2 stated she had a “rape kit” completed on her because of this incident. During an interview on 2/4/26 at 11:25 a.m., RN-B stated leadership had not spoken to them or provided any education about the incident between P1 and P2. She believed leadership would provide education for them that would likely be distributed in their morning meetings to continue watching patients. During an interview on 2/4/26 at 12:47 p.m., RN-C stated abuse is primarily prevented by the admitting nurse when they review a patient’s hospitalization history. They can also prevent abuse by interacting with patients when possible and providing them with patient-specific interventions to help calm them down. During an interview on 2/4/26 at 12:25 p.m., the director of risk management stated she had been contacted on the morning of 1/31/26 to assist with responding to the allegation of sexual abuse between P1 and P2. At the time of the allegation, security footage was reviewed, and SANE services were offered to both patients. A vulnerable adult report was completed because both patients were actively psychotic. The director of risk stated their quality team reviewed the incident on 2/2/26. During an interview on 2/4/26 at 1:08 p.m., P1 denied having any inappropriate interaction with P2. P1 stated on 1/30/26, he had been relaxing in the day space and then he went back to his room by himself. During an interview on 2/4/26 at 2:38 p.m., RN-D stated nursing typically prevents abuse by reviewing the patient’s medical record for history of abuse, and by watching the milieu as much as possible. RN-D stated this can be done from the nurse’s station. During an interview on 2/4/26 at 3:46 p.m., the sexual assault nurse examiner stated P2 disclosed she had engaged in penetrative intercourse with P1. The nurse examiner stated P2 had felt an overwhelming pressure from the universe to engage in these actions and believed this was how she had been coerced. During an interview on 2/5/26 at 8:33 a.m., RN-E stated abuse on the unit is prevented by interacting with patients on the unit, observing for behaviors, and providing intervention as needed. During an interview on 2/5/26 at 1:03 p.m., the patient care manager stated abuse is prevented through milieu engagement and visibility. They expected staff observing the milieu to be present and available to intervene as needed. Based on patient behaviors, nursing can implement 1:1 or other types of checks or precautions. The patient care manager stated they consistently encourage staff to be out in the patient milieu. This can be difficult depending on what is happening on the unit, such as group, admissions, medical emergencies, etc. They do not have a staff assigned to monitor the milieu. The patient care manager stated the nursing station is an appropriate place to monitor the milieu, as their unit does not have long hallways or corners, and the entire unit is visible from the desk. During an interview on 2/5/26 at 3:52 p.m., the director of inpatient mental health stated they prevent abuse by identifying previous history of abuse in hospitalization settings, determining which patients are appropriate for roommates, using interdisciplinary teams, and observing for concerning behaviors. Staff need to conduct ongoing assessments on patients that continue after admission to prevent abuse. Patient population management between units and 1:1 staff assignments are the primary strategies used to help monitor and mitigate inappropriate behavior. The director of inpatient mental health stated he was notified of the incident between P1 and P2 on 2/2/26. A root cause analysis was conducted with the senior leadership team. Their findings indicated staff followed their standard operating procedure, and staff conduct did not vary from their normal practice. The director of inpatient mental health stated their established practices were enough, and no changes needed to be made to prevent abuse. A policy dated August 2025 and titled “Vulnerable Adult Maltreatment: Assessment and Reporting in Minnesota,” did not provide guidance on preventing abuse.”