Cox Medical Centers

“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: 41865 Based on policy review, the hospital failed to accept one patient (#7) from another hospital out of 22 Emergency Department (ED) records reviewed from 10/19/25 through 04/19/26. These failed practices had the potential to cause harm to all patients needing care for an emergency medical condition (EMC). The hospital’s ED average monthly census over the past six months was 6,323. Findings Included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” reviewed 04/20/26, showed: - Capability was defined as the physical space, equipment, supplies and specialized services that the hospital provided. Capabilities of the staff of a facility meant the level of care that the personnel of the hospital could provide within the training and scope of their professional licenses. That included coverage available through the hospital’s on-call roster. The capabilities of CoxHealth were measured by the full scope of services normally provided by each hospital. - Capacity was defined as the ability of each hospital to accommodate the individual requesting examination, or to treat the presenting or transferred individual. Capacity encompassed such things as numbers and availability of qualified staff, beds and equipment and the hospital’s past practices of accommodating additional patients in excess of its occupancy limits. - Accepting and denying transfers was defined as the receipt of an individual in need of specialty services not available at the transferring facility. These transfers would be accepted if Cox Health had the capability and capacity to treat the individual. That determination would be based on, but not limited to, availability of qualified staff, beds, and equipment. Provider to provider communication was required for all ED transfer requests that were denied by the receiving provider. Please refer to A-2411 for further details.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to accept one patient (#7) from another hospital out of 22 Emergency Department (ED) records reviewed from 10/19/25 through 04/19/26. These failed practices had the potential to cause harm to all patients needing care for an emergency medical condition (EMC). The hospital’s ED average monthly census over the past six months was 6,323. Findings Included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” reviewed 04/20/26, showed: - Capability was defined as the physical space, equipment, supplies and specialized services that the hospital provided. Capabilities of the staff of a facility meant the level of care that the personnel of the hospital could provide within the training and scope of their professional licenses. That included coverage available through the hospital’s on-call roster. The capabilities of Cox Health were measured by the full scope of services normally provided by each hospital. - Capacity was defined as the ability of each hospital to accommodate the individual requesting examination, or to treat the presenting or transferred individual. Capacity encompassed such things as numbers and availability of qualified staff, beds and equipment and the hospital’s past practices of accommodating additional patients in excess of its occupancy limits. - Accepting and denying transfers was defined as the receipt of an individual in need of specialty services not available at the transferring facility. These transfers would be accepted if Cox Health had the capability and capacity to treat the individual. That determination would be based on, but not limited to, availability of qualified staff, beds, and equipment. Provider to provider communication was required for all ED transfer requests that were denied by the receiving provider. Review of the hospital’s On-call Schedule showed on 04/03/26, Staff F, Cardiothoracic (relating to the heart and chest) Surgeon, and Staff G, Vascular (relating to or containing blood vessels) Surgeon, were on-call. Review of Patient #7’s Hospital B ED Record, dated 04/03/26, showed: - At 5:46 PM, a 53-year-old male presented for new onset pain in the middle back area, right groin pain and numbness in his leg. - At 6:45 PM, a computed tomography angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of substance to produce detailed images of blood vessels and tissues in the body) of the chest, abdomen and pelvis with runoff was ordered. - At 8:21 PM, the patient was accepted to Cox South Medical Center, by Staff K, ED Physician, for an ED-to-ED transfer. - At 8:22 PM, the CTA was obtained. - At 8:51 PM, a CTA report showed an abdominal aortic dissection (a tear in the inner layer of the large blood vessel branching off the heart) extending into the bilateral proximal common iliac arteries (the two main blood vessels, at the very beginning of the pathway, that carry blood from the heart to the pelvis and legs). The dissection also extended into the mid superior mesenteric artery (SMA, provides oxygenated blood and nutrients to the intestines), celiac artery (critical, distinct branch of the abdominal aorta that supply blood to the stomach, liver, spleen and parts of the pancreas) and inferior mesenteric artery (major artery that supplies blood to the last third of the colon and rectum). The right common iliac artery was occluded. The right external iliac artery was occluded. Flow returned in the distal right external iliac artery. The right anterior tibial (vessel that carries blood to the muscles in the front of the shin and the top of the foot), posterior tibial and peroneal arteries (primary blood supply to the lower leg and foot) were not opacified (dense cloudy areas) but could be occluded. The right dorsalis pedis artery (main blood supply on the top of the foot) was not seen but could be occluded. The distal left anterior tibial, posterior tibial, peroneal arteries are not seen but could be occluded. The left dorsalis pedis artery was not seen but could be occluded. There was some limitation to the imaging study that may warrant repeat imaging at the receiving facility. The patient’s current condition was critical but stable and the most appropriate and indicated disposition at that time was emergent transfer to Cox South Medical Center for immediate vascular surgery evaluation and management. The patient required immediate transfer to a tertiary care facility with vascular surgery capabilities due to the life-threatening and limb-threatening nature of aortic dissection with compromised lower extremity perfusion. Vascular surgery at Cox South Medical Center was contacted emergently, and the patient was accepted for transfer. A cardiothoracic surgery consultation was also obtained, who recommended admission for a vascular surgery evaluation as there did not appear to be an aortic arch component requiring cardiothoracic intervention. - At 9:22 PM, a vascular surgeon from Cox South Medical Center called to review the CTA and stated the hospital did not have the capability to take care of that severe of a dissection and recommended a transfer to a higher level of care, such as St. Louis. - At 9:26 PM, a hospital in St. Louis accepted that patient for transfer. - At 10:44 PM, there was no air transport available for transfer to St. Louis. Due to concern for limb ischemia and significant delays due to ground transport time to St. Louis, Hospital C in Springfield, MO, was contacted and accepted patient. - At 11:02 PM, the patient was transferred to Hospital C. Review of Patient 7’s Hospital C ED Medical Record, dated 04/03/26, showed: - At 11:47 PM, the patient arrived in the ED. - At 12:17 AM, the patient was admitted to the ICU. - At 1:39 AM, a critical care History & Physical (H&P) showed the plan was to proceed to the OR for emergent operative intervention for aortic dissection with limb-threatening ischemia. - An operative report showed the patient underwent a thoracic endovascular aortic repair (TEVAR, placement of a covered stent [tiny tube placed into an artery or vein to hold the structure open] into the weakened area of the artery) and a left femoral artery cutdown (a surgical procedure to expose the common femoral artery [main blood vessel that delivers blood to the entire leg] in the groin for direct vascular access during complex endovascular interventions), right common iliac artery stenting, right external iliac artery stent grafting (small metal coil or mesh tube placed inside an artery), and right lower extremity four-compartment fasciotomy (an emergency surgery to relieve dangerous pressure in the lower leg by cutting through fascia [tough connective tissue] surrounding all four muscle bundles), which resulted in restoration of right femoral pulse and patency of the right iliac system. Review of the hospital’s recorded Transfer Center (TC) phone call, dated 04/03/26, at 8:16 PM, showed: Staff H, Capacity Management & Access Coordinator: stated hello and introduced herself. Staff E, Hospital B ED Physician: Hey, we’ve got an ER to ER with a life threat in bed 26. With a dissection, the aortic arch all the way down to his iliacs. Staff H: Ok, have you talked to any specialists yet? Staff E- Nope. Staff H: I’ll get you down there, they may want to talk to you, but I’ll get you down there. Staff E: Ok sure. Review of the hospital’s recorded TC phone call, dated 04/03/26, at 8:25 PM, showed: Staff H: answered call. Staff F, Cardiothoracic (CT) Surgeon: Stated hello and introduces himself. “Is there a dissection coming? I haven’t heard anything.” Staff H: That’s why I paged you. Did you see the chat that I sent you? Staff F: No. Staff H: I was going to give you a couple minutes if you didn’t see it I was going to page you through the exchange, but yeah Branson just called, about a patient in the ER down there. Staff F: Can they send him someplace else? Staff H: Well, I supposed they could. That’s why I’m calling you to make sure it’s appropriate to bring him here. Staff F: Can they send him someplace else honestly? Staff H: Well, I mean I suppose they could but is that not something that we would take care of? Staff F: Well, my ICU is full. I’ve got two people that need CABGs. I don’t have a lot of people who can move out. I have three hearts on Monday. I have another guy upstairs who needs to be done. Staff H: He acted like it was pretty bad. I didn’t get a whole lot of info from him, but I don’t know if he has time to go elsewhere. Staff F: But why is no one calling me? Staff H: No, that was me calling you. Staff F: So, you guys are making decisions about dissections coming without talking to me or do I still have a say? Staff H: No, you still have a say. Staff F: So why are you, why are you, if I am telling you I don’t think they should come isn’t that the answer? Staff H: Ok, I can let them know, what reason should I give them? That we don’t have an appropriate ICU bed for him? Staff F: Yes Please. Staff H: Ok I can let the ER know and I can let Dr. (Staff E, ED Physician) in Branson know. Staff F: Why don’t you connect me to him and let me talk to him. Staff H: Oh yes. Hold on, let me get him for you. Staff H: Introduces physicians. Staff F: Why don’t you tell me what you’ve got? Staff E, ED Physician Hospital B: This gentleman, he is 53-years-old. Basically, comes in otherwise previously healthy doesn’t take any regular medications. He has a little bit of back pain the last day or so and then he was on the toilet like two hours before he came here and just said he had severe sudden onset right groin pain, some numbness to his right lower extremity and some low back pain. That was his primary complaint. He was super tender in the right groin, I couldn’t really feel a pulse in the left foot, it wasn’t super cold and cyanotic, but it was somewhat cooler. Anyways, I did order a CTA, it did take some time there was an issue with the lab but ultimately got the CTA back and I’m just now looking at the images. I don’t know if you’ve looked at it, but it looks like he’s got a dissection all the way up to the arch, I think it’s up to the arch, and then he’s dissected off his right common femoral, or right iliac, it looks like his right iliac is kind of dissected off. Staff F: So, it might go all the way around? Anytime this happens like this I worry about the arch. Is he stable? Staff E: He was pretty hypertensive when he initially got here like 240-250 systolic. I gave him a dose of Labetalol (medication used to treat high blood pressure) he came down to 200 and they’re starting a Esmolol (fast acting medication used for rapid heartbeats and high blood pressure) drip now. His heart rate is in the 60’s. He’s awake and alert. Staff F: So, you don’t have pulses in the femoral? Staff E: So, I thought I could feel a right femoral pulse honestly, but he was super tender, he almost jumped off the bed if I pushed on it too much, so I didn’t keep torturing him, but I definitely couldn’t get one on his pedal pulses. I could get a Doppler. Staff F: Didn’t you say that the CTA said it’s knocked off. Staff E: Well, it looks like it to me, but I don’t have a report. It literally just came across like five minutes ago, but it looks like to goes dark. It looks to me like it goes out. It goes down and pretty much right there at the iliac, he gets a little bit of flow, but I don’t think I’m feeling any pulses, based on the picture of it. He had a little bit of reconstitution at some point. Staff F: That’s probably knocked off. I mean you’re probably right he probably knocked off his right femoral. As we are talking, I am pulling this up. The problem is that we can’t cannulate his one femoral, which then raises problems about needing other access if we can’t get into the left. I am more worried about his arch. Staff E: It’s right there around the arch. Staff F: It has to. If it’s knocked off its iliac it has to go around. I mean it has to. If it went through, if it knocked his iliac off it would’ve had to go to his arch. Staff E: Alright, I can’t find the study of the chest with contrast that goes all the way up to the arch. Staff F: Ok I’ve got a CTA of the aorta with the iliac femoral run off; I see the dissection hold on. Staff E: Wouldn’t they get the contrast all the way up to the arch or did they just not get it up there? Staff F: Ok I guess I’m confused because he doesn’t have contrast. Does he have contrast? What am I missing here? Staff E: He does have one with contrast but that’s why I’m confused because and she called me and said, “so I went back and ran a non-contrast of his chest” and I was confused on why she went back and redid a non-constant of his chest, wouldn’t that angiogram aorta get that chest typically? Staff F: So, I don’t see this in his ascending. So, his aorta is big, but I see the dissection in the descending. Staff E: Right well that’s what I was telling you, but I also don’t find one with contrast right there. Do you see one with contrast of the ascending? Staff F: Okay, so I am confused. Do you think this is ascending or a descending? Staff E: It is clearly descending. I don’t have a report, that’s kind of why I’m calling you. They told me that it kind of looked like it went to the arch, and I’m seeing it right there at the cusp of the arch. I don’t see an ascending portion of it, but I also don’t see a contrasted study where I catch that. Staff F: I was given that this is an ascending and what you’re saying is ... Staff E: I am saying it looks like it went up to the arch. I called them (Transfer Center) before I had even been able to see the images because they called me from CT. So, the images came across about three minutes ago. I was scanning through as I’m talking to you. They called me from CT and said he had a dissection that goes all the way down to the iliacs and it looked like it goes up to the arch and CT said they went and did a non-contrast in his chest to get a better picture of that. Staff F: So, I think he started after the arch. I don’t even see it at the arch. I think he is starting just distal to the arch. Staff E: Yeah, I can buy that. Staff F: I guess I’m confused by the way they did these studies. Did they give him contrast and they just didn’t give him a lot of contrast, is that what they did? Staff E: If you look at the 2.5 millimeter (mm) slices he’s got good contrast on that one. That’s the best one. The problem is it doesn’t start until it’s already on the descending portion. So, I don’t know how it looks on yours but it’s the fourth block of scans. That’s the best one. I can see clear as day with good contrast load, then you can see it goes out the iliacs, but the problem is it’s like they started the scan too late, and they didn’t get the ascending portion of it. I’m guessing that’s what happened is they missed that so then they went back and said, “Oh crap, we need to go get higher up.” Staff F: Do they have to restudy him to make sure? If you ask me now, I will tell you with what I have I do not see an ascending component. I don’t even see an arch component. Staff E: If you go to the non-contrast I can see it, like you said, it starts right there at, mor just distal to the arch. That’s the one that I see. It’s like slice 26. Slice 25 you start seeing it. It’s right there where it starts on the descending portion of the arch. Staff F: The only thing I can see is his ascending aorta is large. I look at the ascending, I see the branches of the arch, and I don’t see anything. I see it going all the way back to the valve and on the scan, it looks ok. So, I think it’s one of two things, I think if you’re asking me now, I would say with the available studies we have, he does not have an ascending or an arch, he has a descending that goes down to the femoral. If we’re not comfortable with the studies we’ve got to reshoot them and have them get the ascending aorta with contrast. Staff E: I mean probably but he’s going to be coming up there either way, right? Staff F: Yeah, I guess he is. I think he’s a Type B dissection. That’s what you have. That’s going to go to the vascular surgeons. Ok. So let me talk to the transfer center and let them know. Staff E: He is going to go ED to ED and then they can call vascular when he gets there. If you all want to repeat the study when he gets there with another contrast load, I don’t think that would be unreasonable. Staff F: They can do that. Let me talk to the transfer center. Okay, all right, thank you. Staff E: Thank you, sir. Staff H: All right, I heard all of that. So, do you want me to let vascular know he’s coming or call to make sure they are agreeable to that? Staff E: He may have hung up on you but that sounds fair to me. Staff H: He might call me back. Staff E: I’m going to get him transferred either way if you’re good with that. Staff H: Uh yeah, well, I was going to make sure with comms (communications), hold on just a second, okay? Staff E: Ok. I think ED accepted, so he should be accepted. Staff H: Alright, I’ll call you back if there’s an issue. Review of the hospital’s recorded TC phone call, dated 04/03/26, at 9:01 PM, showed: Staff H: Hi, what Dr (Staff F) says is it’s a Type B dissection in Branson that they wanted to send this way. They just told me aortic dissection, so I called him first. Staff G, Vascular Surgeon: I just need to talk to them. I mean do they have the symptoms? What does it involve? And all of those types of things because sometimes they need to go to St. Louis. Staff H: Stated she would get Staff E for him. Staff G: They would be admitted to the Hospitalist anyway. I don’t think I can actually look at the films on my phone. Staff H: Do you just want to talk to Dr (Staff E, ED Physician)? Staff G: Yeah sure. Staff H: They were wanting to send him to the ED anyway so just a second and let me get him. Staff E: Hi, I’ve got a 53-year-old male here who comes in with some low back pain, right groin pain and decreased pulse in his right leg that started acutely tonight, while he was sitting on the toilet about an or two before he got here. Staff G: So where does the dissection go? Staff E: So, it says there is an abdominal aortic dissection extending into the bilateral proximal iliac arteries, extends into the mid SMA, no ruptured aneurysm, right common iliac is occluded, right external iliac artery is occluded. Staff G: Yeah, usually the things, these complex type B things go to St. Louis. Staff E: Do what? Staff G: These complex Type B dissections go to St. Louis. Staff E: Ok, so do you want me to stop them, don’t have them leave? Staff G: Don’t send him here. Because he’s just going to go to St. Louis then. Because we don’t have the ability to really fix it, to deal with it, this is a St. Louis advanced thing. Staff E: Ok I’ll stop them. During a telephone interview on 04/22/26 at 3:20PM, Staff E, Hospital B ED Physician, stated Patient#7 had an aortic dissection and no pulse in the right lower extremity. There was obvious concern for ischemia to the right lower extremity and worsening of his condition. He contacted Cox South Medical Center and spoke with Staff F, Cardiothoracic Surgeon. They reviewed the CTA at the same time because he was told it was a dissection before the radiology report had even come across. He initiated the transfer prior to reading the CTA report so he did not have time to review the images before he and Staff F talked. Staff F determined that the patient would need vascular surgery because his condition was descending and didn’t have an ascending component. At that point, he already had acceptance, or initial acceptance, from the ED Transfer Center. He stated the Transfer Center paged Staff G, Vascular Surgeon, who called him back about the time the patient was transporting out of the department. It was conveyed to him that the patient needed to go to a higher level of care as Staff G did not feel they had the capability to treat the patient adequately. “What specific procedure the other facility could do that they couldn’t; I do not remember, or recall, being given a reason for that. I don’t know if it was, they didn’t have the tools or just they didn’t feel they had the capability at all, he just said the patient needed to go to St. Louis for a higher level of care.” During a telephone interview on 04/22/26 at 6:04 PM, Staff F, Cardiothoracic Surgeon, stated he couldn’t remember everything about Patient #7’s case but he remembered that the ICU called him and said, “Hey there’s a dissection coming up and I said God I don’t know anything about it.” He called the Transfer Center, and they put him in touch with Staff E, Hospital B ED Physician. They went through the films, and as they talked, they determined the dissection wasn’t ascending and it was a descending. If dissections were ascending it was going to be a struggle for him as there were no CVICU beds. However, since they figured out the dissection started just distal to the arch and that it was a descending, it would be a vascular case. “In the surgery world it’s very clear cut that the ascending and the arch are cardiothoracic and the descending and below is vascular”. The call center would have been responsible for notifying Staff G, Vascular Surgeon, about the case. During a telephone interview on 04/23/26 at 11:30 AM, Staff G, Vascular Surgeon, stated that in some cases involving the iliacs and the mesenteric vessels they would send those to St. Louis. He stated he wasn’t aware until he viewed the patient’s medical record that he went to another hospital in town. He stated, “I didn’t want that to happen. I wanted him to go where they deal with these types of cases on a weekly or daily basis. If I had known I would have been like ok send him up here.” He stated the hospital did perform TEVAR procedures but the one thing the hospital didn’t do was fenestrations and it looked at least some of Patient 7’s dissection was involving some of the celiac and the superior mesenteric. He was concerned he wouldn’t be able to treat that. His case was “a pretty complex one that he didn’t have much experience with so he thought it would be best to go to place that did.””

“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: 50321 Based on policy review, the hospital failed to accept one patient (#23) from another hospital out of 23 Emergency Department (ED) records reviewed from 05/12/25 through 11/12/25. These failed practices had the potential to cause harm to all patient’s needing care for an emergency medical condition (EMC). The hospital’s ED average monthly census over the past six months was 6,547. Findings Included: Review of the hospital’s undated policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” showed the following conditions must be met in order for a transfer to be considered appropriate: the medical treatment has been provided within the transferring hospital’s capacity to minimize the risks to the individual’s health; the receiving facility has the available space and qualified personnel for the treatment of the individual; and the receiving hospital has agreed to accept the transfer of the individual and to provide appropriate medical treatment. Receipt of an individual in need of specialty services not available at the transferring facility will be accepted if Cox Health has the capability and capacity to treat the individual. This determination will be based on, but not limited to, availability of qualified staff, beds, and equipment. Please refer to A-2411 for further details.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to accept one patient (#23) from another hospital out of 23 Emergency Department (ED) records reviewed from 05/12/25 through 11/12/25. These failed practices had the potential to cause harm to all patient’s needing care for an Emergency medical condition (EMC). The hospital’s ED average monthly census over the past six months was 6,547. Findings Included: Review of the hospital’s undated policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” showed the following conditions must be met in order for a transfer to be considered appropriate: the medical treatment has been provided within the transferring hospital’s capacity to minimize the risks to the individual’s health; the receiving facility has the available space and qualified personnel for the treatment of the individual; and the receiving hospital has agreed to accept the transfer of the individual and to provide appropriate medical treatment. Receipt of an individual in need of specialty services not available at the transferring facility will be accepted if Cox Health has the capability and capacity to treat the individual. This determination will be based on, but not limited to, availability of qualified staff, beds, and equipment. Review of the hospital’s On-call Schedule showed on 09/22/25, Staff I, Vascular (relating to or containing blood vessels) Surgeon, and Staff O, Gastroenterologist (physician who specializes in the digestive system), were on-call. Review of the hospital’s recorded transfer center call titled, “9222025” showed: - At 00:04 (not actual time), Staff P, Capacity Management Access Supervisor, called Staff I, Vascular Surgeon, and stated, “hi, sorry to bother, I’ve got a Physician’s Assistant (PA) down at Hospital B that has a 74-year-old lady that they believe, she’s got a distended gallbladder, probably choledocholithiasis (the presence of one or more gallstones in the common bile duct [tiny canals that connect some of the organs in your digestive system]), and a common bile duct distention that they feel she probably needs an endoscopic retrograde cholangiopancreatography (ERCP, a procedure to diagnosis and treat problems in the digestive system). She does have a history of gastric banding (a type of weight-loss surgery) in 2009 over in Tuson, AZ, they said she is kind of a hefty girl so it was a little difficult to view her films. She’s 136 kilograms (kg).” - At 00:40, Staff I replied, “oof.” - At 00:42, Staff P, replied, “they did cloud her films, and we do have them. She’s never been seen here.” - At 00:51, Staff I replied, “what are her labs like that they think she needs something done?” - At 00:56, Staff P replied, “white blood cell count’s (WBC, the number of white cells [infection-fighting cells] in the blood, normal 3.29 to 11.43) 18.4, most everything else was within normal limits, alanine transaminase (ALT, an enzyme primarily found in the liver, normal 0 to 32) was 47, aspartate aminotransferase(AST, and enzyme found in the liver, heart and muscles, normal 0-33) was 77, and total bilirubin (yellowish pigment that is made during the breakdown of red blood cells, normal 0.15-1.2) was 1.2.” - At 01:15, Staff I replied, “do you know what her alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 45 to 117) was?” - At 01:17, Staff P replied, “no, she didn’t tell me that. It was that it was kind of difficult to get some stuff from her.” - At 01:22, Staff I replied, “gotcha. This sounds to me like a patient they just don’t want to deal with cause she’s big.” - At 01:30, Staff P replied, “probably.” - At 01:31, Staff I replied, “yeah, so I’m gonna say no, they can shop elsewhere.” Review of Patient #23’s medical record from Hospital B showed: - On 09/22/25, she was a 74-year-old with severe right upper abdominal and epigastric (the upper part of the abdomen just below the rib cage) pain that began two to three hours prior. - She had a surgical history of an appendectomy (a surgical procedure that removes the appendix [a small tube-shaped part that is joined to the intestines on the right side of the intestines]) and gastric binding. The gastric banding was reversed at Hospital B more than five years prior. - At 7:31 PM, lab work was completed and showed a WBC of 18.37, AST of 77, ALT of 44, Total Bilirubin of 1.2, and an alkaline phosphatase of 84. - An abdomen and pelvis computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed a distended gallbladder with acute (a sudden onset) cholecystitis (inflammation of the gallbladder), biliary ductal dilation with distal choledocholithiasis, and hepatomegaly (an enlarged or swollen liver). Further evaluation with ERCP was recommended. - An abdominal ultrasound (US, a test that uses sound waves to create images of structures within the body) showed distention of the gall bladder with acute cholecystitis not excluded. Biliary ductal dilation and further work up was recommended as the above obstructive process at the common bile duct was not excluded, with possible correlation related to her alkaline phosphatase values. - Physician documentation showed Hospital A was contacted for transfer and the surgeon refused without explanation. A second request to transfer was made and the transfer center supervisor advised that Staff I, Vascular Surgeon, refused to accept the patient and to check other hospitals. - A local surgeon on call was contacted and confirmed a transfer was necessary given the CT and US results indicated choledocholithiasis. Services to treat the condition, such as ERCP, was not available at Hospital B. - Hospital C, Acute Care Hospital, transfer center was contacted and agreed to accept Patient #23 when bed space was available the next day to complete a Magnetic Resonance Cholangiopancreatography (MRCP, a type of scan used to create detailed images of the bile and pancreatic ducts). - Medical decision-making documentation showed bilirubin was likely not yet high because her pain had begun only two to three hours prior, on arrival. Alkaline phosphatase had not yet risen either. The best outcome for her was to transfer to a tertiary level of care. - On 09/23/25, she was transferred to Hospital C. Review of Patient #23’s medical record from Hospital C showed: - On 09/23/25, she was admitted to the hospital for management of acute cholecystitis and common bile duct dilation. Gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) was consulted and an MRCP was likely to occur the next day. - On 09/24/25, an MRCP was performed and showed the common bile duct was moderately dilated, choledocholithiasis was present and removed. Surgical removal of the gallbladder was recommended. - On 09/25/25, a cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) was performed. - On 09/27/25, she was discharged. During a telephone interview on 11/12/25 at 10:02 AM, Staff I, Vascular Surgeon, stated that on 09/22/25, he was working nights and was on call. He would have decided whether to admit patients from other hospitals. When another hospital called to transfer a patient, he had to ensure there was available space and appropriate services to accept a transfer. Hospital A had a GI group, but not all physicians on the GI team were capable of performing an ERCP. He would have needed to check to see who was on call to see if there would be availability of a provider who could do the procedure, but he did not have the time, so he did not check. He had been “burned” in the past when he admitted patient’s he thought the hospital could care for, only to find out they could not, and a second transfer was needed. On 09/22/25, he recalled the conversation about the potential transfer of Patient #23. He would only have accepted the transfer if the ERCP was emergent, which he did not agree to be the case. The dilation of the common bile duct was very mild. She was not septic (life threatening condition when the body’s response to infection injures its own tissues and organs), and her lab work was not concerning. Based on how the patient was presented to him, he was not concerned for sepsis or cholangitis (an infection and inflammation of the bile ducts), which would have been the only reason to emergently transfer the patient. He felt Hospital B only wanted to transfer the patient because she was obese. During an interview on 11/12/25 at 3:25 PM, Staff J, Transfer Center Nurse Manager, stated that the hospital might not have accepted the transfer due to GI or surgery availability. During a telephone interview on 11/13/25 at 1:00 PM, Staff O, Gastroenterologist, stated that on 09/22/25, he was on call. When he was on call, he may receive a request for consultation. If his services were needed for a patient from an outside hospital he would assess their need for intervention, but he would need to be consulted first. Staff I, Vascular Surgeon, did not consult him about Patient #23. It was always appropriate to accept a patient from an outside hospital, but the goal would always be to keep a patient local, if possible. Indications for an ERCP would include elevated liver enzymes paired with right upper abdominal pain and other abnormalities. Elevated liver enzymes alone would not be enough to confirm the necessity for an ERCP. After review of the information Staff P, Capacity Manager Access Supervisor, gathered from Hospital B, he noted that she did not present with pressure in the hepatic duct (a tube that carries bile from the liver to aid in digestion), she was obese and her total bilirubin made him weary of the necessity of performing an ERCP as it was barely past the threshold. The US obtained would not reliably indicate the necessity of an ERCP for an obese patient. CT imaging would not be able to distinguish between potential duct overlap, which could incorrectly identify dilation. Patient #23 would require an MRCP, not an ERCP, and she would be at the threshold for their equipment due to her size, so he would need to know definitively if dilation was present. Had he been consulted for this patient; he would have required Hospital B to obtain lab work the following morning prior to accepting the transfer. Patient #23 could also have been admitted locally to Hospital B with medical management before she might potentially need a transfer. He felt that some smaller hospitals would focus on getting patient’s out of their ED as fast as possible to make sure they had space for other potential patients, especially at night, but that caused unnecessary transfers.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to follow their policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one patient (#50) and immediately remove two staff members from patient care after allegations of abuse were reported for two discharged patients (#50 and #105) of two allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety. These failed practices resulted in noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0145 41474”

“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: 41474 Based on interview, record review and policy review, the hospital failed to follow their policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one patient (#50). Immediately remove two staff members from patient care after allegations of abuse were reported for two discharged patients (#50 and #105) of two allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety. Findings included: Review of the hospital’s policy titled, “Allegation of Abuse, Neglect or Harassment,” last revised 12/30/22, showed: - Patients have the right to be free from abuse or neglect (as a form of abuse) and harassment. - All forms of abuse, neglect, or harassment whether from staff, practitioners, other patients or visitors are prohibited. - Allegations or information indicating that abuse, neglect, or harassment may have occurred will be thoroughly and promptly investigated with appropriate follow-up action. - Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, pain or mental anguish. - Abuse is a willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. - Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to the patient or their families within their hearing distance. Examples include tone of voice, such as yelling, screaming or arguing; harassment, threats of harm; saying things to intentionally frighten the patient. - Employees who provide care to patients will receive abuse, neglect, and harassment mandatory training at the time of orientation and re-orientation annually. Training includes prevention, intervention, detection and related reporting requirements. - When an allegation of abuse or neglect was received the department supervisor, or nursing supervisor would initiate the triage process immediately which included; interviewing the patient as appropriate; assessing the patient for evidence of injury, harm or mental distress; obtain written statements from the person making the allegation, any witnesses and the accused individual; then complete the assessment and notify the Administrator in charge of the patient care area to make a determination. - If the allegation was considered credible or required further investigation, Human Resources would be notified immediately. - As soon as the identity of the accused individual was known, the accused individual would be removed from all patient care immediately. - The accused individual may not care for, or have any in-person contact, with any patients while the triage process and/or investigation was ongoing, and a determination was pending. Review of the hospital’s document titled, “Current Summary Multiple Issues Feedback (336625),” dated 02/07/24, showed the following: - On 02/07/24, a grievance was submitted through e-mail by Patient #50’s wife regarding several concerns. A patient advocate went to the patient room and the spouse reported all written concerns in the email were resolved. - The email received from Patient #50’s wife on 02/07/24, stated that the patient originally was admitted with renal (pertaining to the kidneys) failure, severe colitis (inflammation of the inner lining of the colon) and alcohol withdraw (symptoms that occur when someone stops using alcohol after a period of heavy drinking). During his stay in room 429, she arrived at the hospital to find him naked with only a pure wick (an external device that uses suction and a soft, flexible wick to draw urine away from the body into a sealed collection canister) attachment on, his bed pushed up against a very cold window and no bed linens within reach to cover himself. She understood that he was taking off his gown, however that was during a time when the outside temperature was below zero. She asked staff several times to move his bed away from the window. Those requests were not acknowledged until she arrived to find him naked and shivering in front of the window again. She became angry and expressed her frustration to the Nurse Assistant (NA) in the room. The NA moved him immediately and got him sheets and blankets. Patient #50 was supposed to be under constant supervision with a live sitter or a tele-sitter (caregivers that watch at-risk patients via monitor and report to the primary caregiver). On the afternoon of 01/26/24, she was not able to stay the full day and left around noon. When she left, the patient was in his recliner with a live sitter. A short time later the live sitter left and the tele-sitter was either not active or not paying attention. The patient attempted to stand on his own and suffered a hard fall to the floor, injuring his left hip/leg/ankle. Patient #50 was moved to room 214 and the quality of his care dropped again. He had been more confused and had an increase in hallucinations (seeing or hearing things which are not there). He had issues with his oxygen and carbon dioxide (CO2, a gas produced by exhaling) levels being off. He was not given his continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while a person sleeps) to wear at night and his oxygen was not on. The morning of 02/06/24, she arrived at the hospital and heard his overnight nurse telling him that she would refuse to be his nurse again that night due to his behavior. The wife explained to the nurse the patient’s need for oxygen, his CPAP at night and that he had increased confusion. The nurse reported to her that none of that information had been passed along to her. The night nurse explained that staff had just had to clean the patient up because he had a bowel movement in his shorts without telling anyone. After the nurse left the room, Patient #50’s wife attempted to turn on the patient’s television and found his call button/remote was hanging on the wall behind him and unplugged from the wall. It was not accidental as it would set off an immediate alarm that would need to be silenced. Patient #50 was left with no way to reach out for assistance when he needed to use the bed pan and had obviously sat in his stool for a long period of time because he developed a rash on his bottom and scrotum. - Nurse management notes showed that she met with Patient #50’s wife and discussed her concerns. She assured the wife that she would look into her concerns. She then spoke with the patient’s Registered Nurse (RN) and NA about increasing the frequency of rounding. - A second grievance email was sent from Patient #50’s wife on 02/10/24, and showed the same concerns as the prior email with the addition of arriving that morning to find the patient naked, in a puddle of urine, with both bed rails down and half of his body hanging off the bed. Photographs were sent with the email. She moved the patient up onto the bed and called for the nurse. She felt that if she hadn’t arrived, he would have again fallen onto the floor and suffered additional injuries. There was also a photograph of moldy strawberries that were included in his breakfast that morning. She stated in the email that the type of care Patient #50 received reflected negligence in addition to neglect. - Staff VVVVV, Patient Advocate, made a note about meeting with Patient #50’s spouse and reporting to her that the investigation was under review through the grievance process. Concerns and comments had been tasked to new leadership. - Notes on 02/14/24 by Staff WWWWWW, Clinical Risk Manager, showed that there were no elements of permanent harm that made the complaint of poor nursing and negligent care a risk management liability concern. It was, however, by the email report from the spouse and pictures, very concerning for allegations of neglect. The grievance was appropriate to be reviewed and addressed as soon as possible by upper clinical leadership with regulatory review, oversight and input. There was a request to escalate the complaint to the nursing director level for awareness and there was no further action warranted from the risk management department. - Notes on 02/15/24 by Staff VVVVV, Patient Advocate, indicated a grievance resolution letter was mailed to the patient. The complaint was substantiated and there indicated an issue with nursing care. Appropriate leadership reviewed the grievance, commented and it was closed. - A letter was sent to Patient #50’s wife on 02/15/24 apologizing for their experience and that they could not share information related to staff as it was confidential. - Photographs received in the grievance email were not included with the requested grievance. Review of Patient #50’s medical record dated 12/31/23 through 02/13/24, showed the following: - He was a 51-year-old male who presented to the Emergency Department (ED) with a chief complaint of dizziness, hallucinations, nausea, vomiting, lower leg weakness, bowel incontinence, and multiple falls where he hit his head. It was noted he took blood thinners. - Past medical history included a stroke, alcohol use, alcoholic hepatitis (inflammation of the liver. The various forms of viral hepatitis are named after different letters of the alphabet), chest pain, shortness of breath, swelling, high blood pressure, high cholesterol, lupus anticoagulant disorder (a rare autoimmune disorder [a disease in which the body’s immune system attacks healthy cells] that causes blood clots to form in various parts of the body and can be life threatening depending on the location of the clots), deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and Crohn’s disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract). - Nurse documentation on 02/06/24 at 5:05 AM, showed Patient #50 had a tele-sitter and his call light was within reach. Respiratory was called to check on the patient’s CPAP. Vital signs were checked by the NA at 4:30 AM, 6:05 AM, and 7:27 AM. At 7:15 AM he was lying on his bed alert but did not know the time. At 9:00 AM the patient had one bowel movement recorded for the shift. - RN and NA documentation for the night of 02/06/24 into the morning of 02/07/24 showed the patient was intermittently confused, but calm and cooperative with no significant events noted. - A discharge summary dated 02/13/24, showed Patient #50 was admitted to the hospital for colitis and alcohol detoxification (process of removing drugs or alcohol from the body). He was given medications and then developed symptoms of severe alcohol withdrawal with hallucinations and confusion. Though he was no longer experiencing symptoms of alcohol withdrawal, he had ongoing hallucinations and intermittent agitation (state of feeling irritated or restless). He was discharged to a rehabilitation facility. During an interview on 03/14/24 at 8:25 AM, Staff VVVVV, Patient Advocate, stated that she received an e-mailed grievance from Patient #50’s spouse that listed several concerns. She went to see the patient and his spouse who told her that all concerns were resolved. Another e-mail was received a few days later with additional concerns. All the concerns were shared with leadership. She spoke with the patient’s wife again and sent the grievance resolution letter. She was never able to identify what happened to the patient, but the Nurse Manager documented in the file all issues were addressed and staff had been spoken to. She did not know if any disciplinary action was given to staff. Her job was only to notify the appropriate staff and communicate with the patient. During an interview on 03/14/24 at 8:45 AM, Staff WWWWWW, Clinical Risk Manager, stated that she looked at the grievance from a liability standpoint and made leadership aware. Those type of issues were spearheaded by regulatory staff, patient safety staff and leadership staff. That was their job. She did not know the outcome of the grievance investigation. During an interview on 03/14/24 at 8:50 AM, Staff MMMMMM, RN, stated that she was the charge nurse for the 200 unit on 02/06/24 and 02/07/24. They had just finished up their night shift when the NA reported to her Patient #50’s wife was upset. The wife reported she found her husband hanging off the bed, naked, cold, with his call light tucked under the bed and unplugged from the wall. The wife showed her a picture on her phone of the situation Patient #50 was in when she arrived. She listened to the wife’s concerns and started an incident report. She reported the issues to Staff V, Nurse Manager, and the RN assigned to him that day. The decision was made to round more frequently on the patient. The night shift RN had already left for the day, so she did not speak with her. She felt the call light being unplugged from the wall had been an accident. During an interview on 03/14/24 at 9:05 AM, Staff V, Nurse Manager, stated that she was told about the incident with Patient #50 and that everything had been corrected. She looked into the concerns and no staff were aware of the call light being unplugged from the wall. Nursing staff were giving report to one another and the night nurse told the day nurse that she would be requesting a different team, but did not berate the patient. Patient #50’s wife must have overheard their conversation and become upset. Patient #50 was a handful and the nurses discussed that. She did not know how long the call light had been unplugged from the wall. All call lights flashed above the room and made an obnoxious noise when they were unplugged from the wall. During an interview on 03/14/24 at 9:20 AM, Staff I, Director of Nursing (DON) and Staff EEEEEE, Chief Nursing Officer (CNO), stated that Staff V, Nurse Manager, did the grievance investigation. Typically, if allegations contained a neglect or abuse element, they became a part of the investigation. The allegations did not go through the correct channels. Staff EEEEEE stated that there was a process problem because the grievance was not entered correctly from the beginning. The grievance investigation did not follow the abuse and neglect policy. Staff should have acted faster, and it was never brought to her attention. Staff I stated that she had been tasked several days after the grievance was submitted. She did see the call light had been unplugged, but felt it was accidental and not willful. Staff just forgot to plug it back in to the wall. She did not know how to turn off a call light alarm and did not know how long it had been unplugged from the wall. The whole story did not make sense. An investigation had been done but did not follow the abuse and neglect investigation protocol. During an interview on 03/14/24 at 10:20 AM, Staff LLLLLL, Administrative Director of Quality and Safety, stated that there was no way to determine how long Patient #50’s call light had been unplugged from the wall. During an interview on 03/14/24 at 2:00 PM, Staff AAAAA, RN, stated that she was the primary RN taking care of Patient #50 on the night shift of 02/06/24 into 02/07/24. Patient #50 was an alcoholic who transferred to their unit from another floor. The patient had been confused but remembered his medications well. He told her when he needed his pain medication and wanted it a certain way. Patient #50 whistled and yelled for her and then told her he didn’t need anything, he just wanted to make sure someone was there. The whole night went that way. She was giving report to the day shift nurse when they heard Patient #50’s bed alarm go off. They stopped report and went into his room. They found the patient trying to get out of bed and he had his legs looped through the bed rails. It took three staff members to reposition him and get him untangled. The patient was confused, tried to leave and kept telling her he wanted tequila. The wife entered the room and became upset. Staff AAAAA told the wife about the night they had and answered all of her questions. The call light was never unplugged from the wall. There was no way to unplug a call light without it making a loud, alarming sound. The call light would have only been unplugged from the wall in the case of an emergency. She never requested a different team or to not be Patient #50’s nurse. During an interview on 03/18/24 at 3:45 PM, Staff RRRRRR, NA, stated that she was assigned to Patient #50 for the night shift beginning on 02/06/24. She never had a conversation with his wife about his care. He was not a difficult patient and not very active. He pretty much just slept. She did not know anything about his call light being unplugged from the wall. During an interview on 03/14/24 at 10:50 AM, Staff X, RN, stated that she was Patient #50’s nurse the day of 02/07/24. She did not know anything about his call light being unplugged from the wall. Patient #50’s spouse had been upset that day and felt the night staff had not taken care of Patient #50. Patient #50’s spouse was very nice and very thankful for her husband’s care. No one from leadership interviewed her or asked her any questions about the incident. During an interview on 03/18/24 at 2:30 PM, Staff QQQQQQ, NA, stated that she had taken care of Patient #50 on the day of 02/07/24. She did not remember ever being told a call light had been unplugged from the wall. Patient #50’s wife never spoke to her or reported concerns during his stay. There was a way to silence the alarm when the call light was unplugged from the wall. Review of the hospital’s documents titled, “Current Summary 337628,” and “Current Summary 337637,” both dated, 02/23/24 showed the following: - On 02/22/24, Patient #105 made an allegation that Staff TTTTTT, Physician, touched her inappropriately. - On 02/22/24, at approximately 6:00 PM, Staff TTTTTT was notified of the allegation and told that the care of Patient #105 would be transferred to Staff UUUUUU, Physician. - On 02/23/24, at 7:30 AM, Staff TTTTTT was contacted by phone where he reported nothing inappropriate had occurred. He reported that the patient was upset about her upcoming discharge. - On 02/23/24, Staff UUUUUU was contacted “to discuss her impressions. Agree with her recount of the events as described.” - On 02/23/24, Staff GGGG, Customer Service Supervisor, documented that he and a Patient Advocate spoke with Patient #105 and she reported Staff TTTTTT was “feeling her on her thigh and progressed up” and that he was “on the bed with her rolling around.” The patient gave the impression that these events happened more than one time that week. - The patient was in a semi-private room with a roommate. - The patient reported that her two friends were in the room at the time of the alleged event. - Staff GGGG, Customer Service Supervisor, copied and pasted an excerpt from the patient’s medical record, documented by the Nurse Manager, that stated the patient was “intermittently confused and did not remember provider rounding” and that the nurse “reminded patient of provider round this morning when her daughter was present.” - On 03/06/24, the allegation was noted as unsubstantiated and a resolution letter was mailed to the patient. - There were no documented statements from the patient’s roommate, any possible witnesses, Staff UUUUUU, who took over care of the patient, or the accused individual Staff TTTTTT. - Staff TTTTTT was removed from Patient #105’s care but not removed from all patient care. Review of Patient #105’s medical record showed: - She was a 58-year-old, admitted on 02/18/24 for pneumonia (infection in the lungs) and difficulty breathing. - On 02/18/24, a History & Physical (H&P) showed she was alert, oriented and cooperative with an appropriate mood & affect. - On 02/22/24, a Progress Note showed she had no surviving relatives. She was alert, oriented and cooperative with an appropriate mood & affect. - On 02/23/24, a Discharge Summary showed she had no next of kin. She was alert, oriented and cooperative with no focal deficits. During an interview on 03/14/24 at 10:28 AM, Staff GGGG, Customer Services Supervisor, stated that his role in Patient #105’s reported allegation was to gather information for the incident report, interview the patient and notify the proper departments, which in that case was Regulatory and the Medical Director. “When there are allegations of abuse or neglect against a physician, due to the nature of the allegations, we step back and let the appropriate parties do their investigation.” During a telephone interview on 03/14/24 at 12:20 PM, Staff UUUUUU, Physician, stated that when an abuse or neglect allegation was made against a physician there would be an immediate investigation “within 24 hours.” An emergency meeting would need to be held “if there was a real concern that the abuse or neglect happened.” If there was an immediate concern, the physician would be suspended. She was unsure what the hospital’s abuse and neglect policy stated. Her “assumption would be that if it was needed, the physician in question would be taken off duty immediately, depending on the allegation.” In the case of Staff TTTTTT, he was removed from that patient’s care and the investigation was handled by his supervisor Staff OOOOOO. During an interview on 03/14/24 at 1:00 PM, Staff OOOOOO, Physician, stated that when he was notified of an allegation of abuse against a physician, he reviewed the complaint, met with the patient if they were still in the hospital, and had a one-to-one conversation with the physician in question. That conversation would be “documented and then it’s over.” He stated he kept notes to show when he had met with a physician after an allegation and he would refer to those notes to see if there were patterns of behavior. He stated he had “been doing this for 12-15 years, and as a Director, I have never removed anyone from patient care.” He discussed this specific allegation regarding Patient #105 verbally with Staff TTTTTT. Staff UUUUUU “and others were in agreement that no further intervention was needed.” When asked if the abuse and neglect policy that stated all staff accused of abuse or neglect would be removed from patient care until a determination was made, applied to physicians; he replied “blanket policies, like this, are preposterous.” He added that he knew Staff TTTTTT very well, and given a disability that the physician had, it would have been physically impossible for him to do what the patient alleged. During concurrent personnel file review and interview on 03/15/24 at 10:00 AM, Staff VVVVVV, Medical Staff Manager, stated that Staff TTTTTT, Physician, had not received training on abuse and neglect since 2017. 41865”