Boone Hospital Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure patient safety when sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) were unsecured and accessible to patients, visitors and unauthorized individuals on six units of 15 units observed; (A-0144) - Ensure a patient on BiPap (a noninvasive device that helps with breathing) was not inappropriately restrained (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for one patient (#33) of two patients on BiPap observed; (A-0144) - Ensure that staff checked the crash cart daily according to policy on seven units of 15 units observed; (A-0144) - Ensure supplies in an emergency pediatric (pertaining to children) airway box were not expired for one of two pediatric airway boxes observed; (A-0144) - Ensure nursing staff recognized a change of condition for one discharged patient (#26) of one patient reviewed; (A-0145) - Ensure hospital staff completed appropriate code stroke documentation for one discharged patient (#26) of one stroke patient reviewed; (A-0145) - Ensure hospital staff recognized the need to review and educate staff appropriately following patient safety events for two discharged patients (#26 and #46) of four patients with serious safety events that resulted in a delay in care or treatment reviewed. (A-0145) - Follow their policy to ensure all patients placed in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) had a provider order for four discharged patients (#26, #28, #29 and #30) of five restraint patient records reviewed; (A-0168) - Ensure appropriate ongoing monitoring and nursing documentation during the use of restraints for five discharged patients (#6, #28, #29, #30 and #33) of five restraint patient records reviewed; and (A-0175) - Ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) evaluation within one hour of violent restraints application for three discharged patients (#26, #28 and #29) of three patient records reviewed with a violent restraint order. (A-0178) Please refer to A-0144, A-0145, A-0168, A-0175 and A-0178.”

“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: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure staff followed the fall prevention policy when six current patients (#1, #2, #3, #4, #6 and #66) of 11 current patients who were identified as a high or moderate fall risk had appropriate fall prevention measures in place; (A-0395) - Label intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and intravenous (IV, in the vein) tubing for 10 current patients (#1, #2, #5, #15, #24, #25, #38, #39, #40 and #65) of 17 current patients observed; (A-0395) - Complete pain assessments or reassessments for one current patient (#31) and one discharged patient (#32) of three patient records reviewed; (A-0395) - Turn two current patients (#1 and #40) and one discharged patient (#26) of four patient records reviewed who required assistance to turn; (A-0395) - Label fluid found in fluid warmers on two of two units with fluid warmers observed; (A-0395) - Store shower caps in the designated shower cap warmer on one of two units with shower caps observed; (A-0395) - Document the use of an incentive spirometer (IS, a hand-held breathing device in which the patient is instructed to take slow deep breaths through the device’s mouthpiece) for two current patients (#60 and #61) of two patient records with an order for an incentive spirometer reviewed; (A-0395) - Safely secure medications in appropriate locked areas for four current patients (#12, #20, #27 and #39) and two discharged patients (#14 and #21) of 12 patients observed and on three units of 15 units observed; (A-0405) - Discard three unlabeled insulin (medication that regulates the amount of sugar in the blood) vials stored in locked patient medicine drawers; (A-0405) - Administer medications at the time they were documented as administered for seven current patients (#3, #4, #24, #25, #39, #60 and #61) of 12 medication administrations observed; and (A-0405) - Administer medications according to policy for two current patients (#24 and #39) of seven observed medication administration by intravenous push (to manually administer a dose of medication through a tube into a vein) or gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach). (A-0405) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395 and A-0405.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure patient safety when sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) were unsecured and accessible to patients, visitors and unauthorized individuals on six units of 15 units observed; - Ensure a patient on BiPap (a noninvasive device that helps with breathing) was not inappropriately restrained (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for one patient (#33) of two patients on BiPap observed; - Ensure that staff checked the crash cart daily according to policy on seven units of 15 units observed; and - Ensure supplies in an emergency pediatric (pertaining to children) airway box were not expired for one of two pediatric airway boxes observed. Findings included: Although requested, the hospital failed to provide a sharps storage policy related to unsecured sharp access to patients, visitors and unauthorized individuals. Observation with concurrent interview on 06/23/26 at 3:00 PM, on the Surgical Specialties Unit, showed an unlocked medication cart in the hallway with two insulin (medication that regulates the amount of sugar in the blood) vials that belonged to Patient #14 and several packaged needles. There was a sticker on the medication cart that read, “no lock.” Staff J, Surgical Specialties Unit Manager, stated that Patient #14 had been discharged and that medications should not be left in unlocked medication carts. Observation with concurrent interview on 06/24/26 at 9:03 AM, in the Orthopedic (medical specialty dealing with bones) Clinic, showed an unlocked supply room. Within the unlocked supply room, there was an unlocked cabinet with several packaged needles stored inside. A patient assessment room was directly across from the supply room. Two nurses’ stations were at either end of the hallway on either side of the supply room. There was no visibility to the supply room from either nurse’s station. The cabinet had a lock but Staff GG, Group Administrator, stated that the cabinet was not routinely locked. She was unsure where the key was. Patients were not continuously monitored in patient assessment rooms. Staff DD, Patient Care Coordinator, told staff GG that all sharps must be locked. Staff GG then located the key to the cabinet and locked the cabinet door that contained the sharps. Observation on 06/24/26 at 10:30 AM, on the Surgical Specialties Unit, showed that the unlockable medication cart observed on 06/23/26 at 3:00 PM, remained in the hallway and had unsecured needles inside. Observation on 06/24/26 at 10:45 AM, in the Emergency Department (ED), showed an unsecured combined medication room and supply room which contained medications, needles and intravenous (IV, in the vein) fluids. There were two separate unsecured doors that lead into the area, and it was accessible to patients and visitors. Outside of a patient room there was an unsecured rolling suture (a strand or thread used to sew skin and other body tissues together to close up a surgical incision or a tear) cart that contained several boxes of sutures with attached surgical needles. One box of sutures expired on 02/28/26. Observation with concurrent interview on 06/24/26 at 1:16 PM, in the Pain Management Clinic, showed a supply room with an unlocked door. Sharps were stored and unsecured in the supply room. Patient assessment rooms were adjacent to the supply room. There was a nurse’s station directly across from the supply room with one staff member present. There was a separate area with no visibility to the supply room or nurses’ station that contained three patient observation rooms separated by curtains. Staff HH, RN, agreed that if there was an emergency that required all staff attention in the observation area, such as a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing), there was an opportunity for a patient to enter the supply room to obtain sharps from the patient assessment rooms. She could not guarantee that there was no access to the supply room. Observation with concurrent interview on 06/24/26 at 1:32 PM, in Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) zone III, showed there was a supply room door with a number pad lock that was ajar. There were sharps stored in the supply room. Staff DD, Patient Care Coordinator, left the area to find Staff II, Manager, and the survey team was left unattended with no MRI personnel present. Patient #34 approached the survey team from a restroom in MRI zone III in a hospital gown. There were no MRI personnel present. Staff DD located Patient #34’s MRI technician, who was in a separate room behind a closed door. Staff II stated that the supply room door was not routinely locked and was not currently locked because patients were not supposed to be unattended in MRI zone III. Observation on 06/25/26 at 9:00 AM, in the Preoperative Unit, showed a 15-bed unit. In each patient room there was an unsecured cabinet with IV start kits that contained needles that were accessible to patients and visitors. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that sharps should be secured in all areas that could be accessible to patients or the public. That included clinic areas. Sharps should be stored in a locked cabinet or behind a locked door unless they were in an area where patients were not unattended. During an interview on 06/24/26 at 10:50 AM, Staff U, ED Clinical Supervisor, stated that a staff member always sat outside of the supply room doors and would notice if a patient or visitor tried to go inside. There was no one assigned to monitor access to the supply room/medication room. Review of the hospital’s undated policy titled, “Non-invasive Assisted Ventilation,” showed a restraint should not be placed on a patient receiving non-invasive assisted ventilation. Review of the hospital’s undated policy titled, “Use of Restraint,” showed mittens (restrictive mitt that hinders picking and tube pulling) are considered a restraint. Review of Patient #33’s medical record, dated 04/11/26, showed: - He was a 77-year-old admitted to the hospital for heart failure and difficulty breathing. - On 04/14/26 at 9:40 PM, he was placed on BiPap. - At 10:59 PM, he was placed in bilateral mittens. A one-to-one (1:1, continuous visual contact with close physical proximity) observer was provided and documented every 15 minutes. - On 04/15/26 at 6:06 PM, a 1:1 observer documented an every 15-minute check for the last time. He remained on BiPap and in restraints. - At 8:00 PM, his restraints were removed. He remained on BiPap without a documented 1:1 for one hour and 56 minutes. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated that if a patient were on BiPap, they should not be restrained. It was not acceptable for Patient #33 to be restrained without an observer while on BiPap. During an interview on 06/22/26 at 2:50 PM, Staff LL, RN, stated that patients on BiPap were not restrained at the hospital and should not ever be restrained. Review of the hospital’s undated policy titled, “Crash Cart,” showed: - A crash cart is a cart containing equipment/medications needed for patient care in an emergency/code situation. - Each patient care unit or area has access to a crash cart sealed with a numbered lock. The nursing or designated departmental staff, in patient care areas, assume responsibility for maintaining the daily checklist, equipment and supplies on the cart, patency of locks and weekly defibrillator testing. - Battery operated equipment is to be plugged in at all times when not in use. - Check the crash cart daily by using the crash cart daily and weekly checklist, verify the following once every 24 hours: oxygen tank is present on the crash cart with greater than 1,000 pressure per square inch (psi); numbered seal/lock is intact; lock number on cart matches the last number entered on the crash cart checklist; if separate airway box/bag is used, numbered seal/red lock is intact; defibrillator (a device that controls the heart beat by applying an electric current to the chest wall or heart) is functioning properly, is plugged in, battery charge indicator light is lit, hands free defibrillator pads are present; electrocardiogram (ECG, test that records the electrical signal from the heart to check for different heart conditions) paper is present; packs of electrodes are on the crash cart and are not expired; appropriate size artificial manual breathing unit (AMBU bag, a hand held device used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) and face mask are present; suction (to remove thick mucus and secretions from the airway, that a person is not able to clear by coughing) machine is plugged in and functional; and date/initial checklist at the bottom when check is complete/accurate. - Materials and equipment applicable to the policy included pediatric bags. If a separate airway box or bag is used, the numbered seal/red lock should be checked daily to ensure it is intact. - Central services will round on every crash cart in the hospital in the last week of each month. Any crash cart that has an item that will expire in the next 30 days will be exchanged, the entire cart will be checked for expired supplies, restocked and put back into service. Observation and review of the Daily and Weekly Crash Cart Checklist for the Progressive Care Unit on 06/22/26 at 3:00 PM, showed from 03/01/26 through 06/23/26, a crash cart check was not completed on three days. Observation and review of the Daily and Weekly Crash Cart Checklist for the Surgical Specialties Unit on 06/23/26 at 2:50 PM, showed from 03/01/26 through 06/23/26, a crash cart check was not completed on 27 days. Observation and review of the Daily and Weekly Crash Cart Checklist for the Postpartum (hospital unit where healthy mothers and babies are transferred after delivery on an inpatient labor, delivery, and recovery unit where they stay until they are discharged) unit on 06/23/26 at 2:55 PM, showed from 03/01/26 through 06/23/26, a crash cart check was not completed on 38 days because the unit was closed. From 05/07/26 through 05/20/26, the weekly portion of the checklist was not completed, though the unit was open from 05/12/26 through 05/20/26. From 06/20/26 through 06/23/26, a crash cart check was not completed due to unit closure; however, patients were present on the unit. On 06/24/26 at 1:34 PM, when the crash cart log was provided to the survey team, a crash cart check was completed on 06/23/26 as a second entry for the day. Observation and review of the Daily and Weekly Crash Cart Checklist for the Neonatal Intensive Care Unit (NICU, unit for premature and ill newborns) on 06/23/26 at 3:15 PM, showed there was not a defibrillator located on the crash cart, nor was there a space to document that a defibrillator was checked on the crash cart checklist. Observation on 06/24/26 at 11:15 AM, in the Emergency Department (ED), showed the last check-off for the Pediatric Cart was dated 01/26/24. There were multiple supplies that expired for dates ranging from 09/23/23 through 06/08/26. Observation and review of the Daily and Weekly Crash Cart Checklist for the ED One Crash Cart on 06/24/26 at 11:40 AM, showed from 03/01/26 through 06/24/26, a crash cart check was not completed on four days. Observation and review of the Daily and Weekly Crash Cart Checklist for the Pain Management Clinic Crash Cart on 06/24/26 at 1:07 PM, showed from 03/01/26 through 06/23/26, a crash cart check was not completed on two days. The defibrillator was not plugged in. Observation and review of the Daily and Weekly Crash Cart Checklist for the MRI area Crash Cart on 06/24/26 at 1:35 PM, showed from 03/01/26 through 06/23/26, a crash cart check was not completed on four days. The defibrillator was not plugged in. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated that she expected the crash cart checklist to be completed per policy. If the NICU used the postpartum unit defibrillator, it should be checked daily, per policy, even if that unit was closed. Defibrillators should be plugged in when not in use. Decentralized supplies, such as the pediatric airway box in the ED, should be checked according to policy. It was not acceptable for the supplies in the pediatric airway box to be expired. During an interview on 06/23/26 at 3:00 PM, Staff J, Surgical Specialties Unit Manager, stated that the crash cart should be checked daily and documented. During an interview on 06/23/26 at 3:15 PM, Staff EE, RN, stated that the NICU crash cart did not have a defibrillator. If they needed to use a defibrillator, they would go to the postpartum unit and use that one. There was one locked door between the NICU and the postpartum unit. During an interview on 06/24/26 at 9:30 AM and 1:07 PM, Staff DD, Patient Care Coordinator, stated that she agreed that because the NICU used the defibrillator on the postpartum unit, it should be checked daily, even when the postpartum unit was closed. Defibrillators should be left plugged in when not in use. During an interview on 06/23/26 at 2:55 PM, Staff AA, Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Director, Staff CC, OB Nurse Supervisor, and Staff BB, OB Nurse Manager, stated the postpartum unit had been open for one hour, with patients admitted, without a crash cart check. 39562 47504”

“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: 47504 Based on interview, record review and policy review, the hospital failed to ensure staff recognized a change of condition for one discharged patient (#26), completed appropriate code stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) documentation for one discharged patient (#26), and to recognize the need to review and educate staff appropriately following patient safety events for two discharged patients (#26 and #46) of four patients with serious safety events which resulted in a delay in care or treatment. Findings included: Review of the hospital’s undated policy titled, “ Critical Care Assessment/Adult-Emergency Department (ED),” showed: - Stroke symptoms can be identified with the BE FAST BEFAST (a tool used to help individuals identify the warning signs of a stroke [a medical emergency that occurs when the blood supply of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients]) stroke tool and may include any of the following symptoms: altered level of consciousness (the state of being fully alert, aware, oriented, and responsive to the environment), altered mental status (mental functioning ranging from slight confusion to coma), confusion, delirium (an abrupt change in the brain that causes confusion), aphasia (an impairment in the understanding or verbalizing ideas by language, such as reading, writing, or speaking; due to injury or disorders of the brain), dysarthric speech (slurred or slow speech that can be difficult to understand), focal weakness (impairments in nerve, spinal cord, or brain function that affect a highly specific area or function), paralysis or numbness of an arm, leg or face, visual disturbance, dizziness, headache with no known cause and an unstable gait. - Staff should initiate stroke center utilization for patients currently in a room with a symptom onset of less than 24 hours. - Team members designated in the stroke center utilization policy will converge and utilize a team approach with the licensed provider to conduct a brief evaluation including the latest set of vital signs (VS, measurements of the body’s most basic functions), goal discussion and identify potential complications. - Begin documentation on the ED stroke documentation section of the electronic medical record (EMR) or on the stroke timeline form to include last known well time, time of stroke team activation, the time of departure to 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),time returned from CT, the time the licensed provider was at the bedside, VS, glucose level (sugar level in the blood stream), creatine level (blood test that shows how the kidney is functioning), weight, National Institute of Health Stroke Scale (NIHSS, a tool used by healthcare providers to quickly assess the severity of a stroke experienced by a patient) score, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions), CT interpretation resulted or called to the provider and documentation to include the plan of treatment. Review of the hospital’s undated policy titled, “Rapid Response Team (RRT, a team used to identify and appropriately respond to a patient demonstrating signs or symptoms of clinical deterioration, with the goal of preventing further decline in the patient’s condition and reducing the risk of adverse outcomes or death.),” showed: - A RRT can be initiated by any team member and should be initiated for changes in mental status or neurological (neuro, relating to or affecting the nervous system) assessment or any concern for patient condition in order to obtain additional assessment and plan of care assistance. - The switchboard will be notified and will page the RRT. The STAT neuro nurse will respond immediately to the location and assist with patient assessment and stabilization. If indicated, they will initiate a code stroke and enter the RRT standing orders, using applicable algorithms, forms and tracking tools as designed to capture required documentation. - The team member initiating RRT is responsible for documenting patient assessments, interventions, notifications and the disposition within EMR. Review of the hospital’s undated policy titled, “Sentinel (actual events that could or did cause patient harm) and Serious Safety Events,” showed: - A sentinel event is a patient safety event that reached a patient and results in death, permanent harm, or severe temporary harm. Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition or additional major surgery, procedure or treatment. - Sentinel events shall be understood to include delays in treatment resulting in serious harm or death, whether such occurrences result in death, serious injury or loss of bodily function of a patient. - When a sentinel event occurs a comprehensive systematic analysis (CSA) is completed to identify the causal and contributory factors. The most common form used to identify the underling factors is Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause), which provides a structured approach focusing on systems and processes. The product of this analysis includes an action plan that addresses the following: actions to be taken; responsibility for implementation; timeliness; strategies for evaluating the effectiveness of the actions; and strategies for sustaining the change. Review of the hospital’s undated policy titled, “Behavioral Health and Suicide (to cause one’s own death) Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm),” showed: - SP may be initiated by a nurse based on patient verbalization or demonstration of suicidal statements or behaviors. The provider should be notified immediately, including a request for consideration of psychiatric (relating to mental illness) and social work consultations. - Patients determined at moderate or high risk of suicide are to be continuously monitored using direct visualization until the SP order is discontinued by the provider. The observer must remain close enough to the patient to intervene when needed. The patient observer must be a hospital employee. - A suicide risk assessment will be conducted by a provider using an evidenced based risk assessment tool, Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life), and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T, an evaluation used to identify risk and protective factors related to a patient’s suicidal thoughts to decide the best course of action) tool on any patient screened positive for suicidal ideation (SI, thoughts of causing one’s own death) risk assessment by nursing. Interventions for the safety of the patient will be implemented based on the risk level determined by the provider and the patient’s risk assessment. - A reassessment will be conducted by the provider using an evidenced-based risk assessment tool, C-SSRS and SAFE-T suicide risk assessment with a change in patient status. Reassessment will include the risk level of a patient with SI. Review of Patient #26’s incident report, dated 03/07/26 at 3:00 PM, showed that the family made a complaint. The family stated, on 03/07/26 at about 3:00 pm, they were walking down the hallway on the 5th floor towards Patient #26’s room behind a nurse and a student nurse. As they got closer to her room, they overheard the nurse say, “we need to go and check on crazy lady in room five. I think we are waiting for her to die.” They realized the nurse was talking about Patient #26. Family told the nurse to get out of the patient’s room and requested to speak with a supervisor or head nurse in charge immediately. After that, the patient’s granddaughter told Patient #26’s daughter that something was terribly wrong with the patient. When she went over to check on her mother, she noticed that Patient #26 was staring off, not focusing on them. She was unable to respond to questions, speak or move. She was locked in a bed enclosure (a tent-like mesh or nylon canopy that fits completely over a hospital bed that is zipped closed for patient safety), lying down without a bed sheet or a blanket and half naked. Family was confused about her wearing an adult diaper because the evening before she was getting her up to the bathroom. Family was unaware of any changes that required placing an adult diaper on Patient #26. When a nurse technician entered the room, Patient #26’s daughter voiced her concerns regarding the state her mother was in and asked for an update and to speak with a head nurse or supervisor immediately. Family stated something was terribly wrong with Patient #26 and someone needed to check on her. Staff showed no urgency whatsoever. Family presented to the nursing station and again requested a head nurse or supervisor immediately. Patient #26’s daughter was very upset she had declined so rapidly, and no one was able to tell her what was going on and how long she had been in that state. She wanted to know the last time staff had checked on her and why her food was untouched. Why was Patient #26 placed in an adult diaper? Why was it hanging off of her? Why had the diaper not been changed? Staff were unable to tell her anything or to provide her with an update. She wanted answers and to be told why her mother was in this state, completely opposite from the previous evening. Family was concerned that no one attempted to help her mother or seemed concerned about the changes in her status. A Clinical Nurse responded and proceeded to apologize for the delay, stating that staff were busy with other patients. Family felt that Patient #26 was not the staff’s priority, telling them that it was unacceptable and something was terribly wrong with her. The patient’s daughter insisted they check her. When the assessment was completed and they determined that she needed a CT scan to see if she was having a stroke or a seizure (sudden, uncontrolled electrical disturbance in the brain which causes changes in behavior, movements and/or in levels of consciousness). The Director of Nursing (DON) called the patient’s family in response to the letter and discussed the issues she had. Staff VV, Registered Nurse (RN), was counseled and staff were coached on being disrespectful and unresponsive to changes in patient conditions. Record review of Patient # 26’s medical record, dated 03/05/26, showed: - She was a 79-year-old who was admitted to the hospital for worsening confusion, a recent fall and dementia (a loss of thinking abilities and memory). - She had a past medical history of multiple strokes, high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), Type 2 Diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and a seizure disorder. - She was awake, alert and oriented to person only. She could follow instructions appropriately and move all extremities. - On 03/06/26 at 1:36 PM, physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) documentation showed she was responsive, alert and able to participate in her care. - On 03/07/26 at 7:51 AM, documentation showed she refused to be repositioned, was able to move in the bed, her gown and linens were changed, and her BP was 176/62. - At 9:02 AM, documentation showed she ate 10 percent of her breakfast, and she required a standby assist (a level of care where a caregiver remains within arm’s reach of the patient to assist a patient who may need verbal cues or assistance with performing an activity) for mobility. - At 11:00 AM, documentation showed she was asleep. - At 12:00 PM, Staff WW, RN, documented she was asleep. - At 12:49 PM, Staff WW documented she was unable to respond. - At 2:00 PM, Staff WW documented she was asleep. - At 2:47 PM, Staff WW documented she was asleep. - At 3:30 PM, Staff TT, RN, documented that there was an unexpected change in nursing assignments and she assumed care as her nurse. She had not received report from the off-going nurse, Staff WW, when family requested to speak with someone in charge to make a complaint. The House Supervisor (HS) was notified and sent Staff UU, STAT RN (A nurse who responds to emergency situations)/HS, to speak to Patient #26’s family. - On 03/08/26 at 00:48 AM, Staff UU documented that at approximately 3:00 PM, Patient #26’s family stated that there was a change in her status compared to the prior evening. The Primary Care Technician (PCT) relayed that she walked into the room behind the family and noticed a change in condition. - Assessment showed she had right sided facial drooping (when facial muscles are not working properly), right sided pursed-lip breathing (inhaling deeply through your nose, then exhaling slowly through pursed lips), was unresponsive, with a right sided gaze. She was unable to move her left arm or bilateral lower extremities. A Code Stroke was initiated. Staff XX, Neurology Nurse Practitioner (NP, a nurse with advanced clinical education and training), arrived and ordered a head CT. Upon arrival at CT, her right-hand twitch worsened. Staff XX determined that to be seizure activity. One milligram (mg) of intramuscular (IM) lorazepam (a medication used to treat anxiety or sleep difficulty) was given as Patient #26 had no intravenous (IV, in the vein) access. She was then intubated (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) due to an oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower.) of 78 percent on room air (not receiving supplemental oxygen). An additional two mg of lorazepam was ordered. Her BP was 251/101 and she was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). - On 03/08/26, an Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body.) showed there was left occipital lobe diffusion restriction (water molecules in the left-back part of your brain are temporarily trapped) and they could not exclude an acute (a sudden onset) cortical infarction (death of brain tissue in the brain’s outer layer). - There was no documentation to show Staff VV notified the physician, or that Patient #26 had been unresponsive at 12:49 PM. - There was no documentation to show the RRT was initiated. - There was no documentation to show what time the Code Stroke was initiated. - There was no additional documentation by nursing of the events that followed the initiation of the code stroke or documentation on a stroke timeline form per policy. The STAT nurse made an entry with only the approximate time she entered the room. - On 03/13/26 at 3:12 AM, Patient #26 passed away. Review of Patient #46’s incident report, dated 04/25/26, showed: - At 12:45 PM, therapy reported to nursing staff that Patient #46 reported a history of depression and recurrent SI. Nursing staff further inquired about his SI and asked if he had a plan. He informed them, “I was going to gas myself in the garage yesterday but knew my daughter would hear me, so I had her bring me to the hospital.” He endorsed that he was suicidal and would stick with his current plan. His family reported that it was an ongoing struggle for him, and that he had multiple previous inpatient psychiatric admissions. When the nurse reviewed emergency department (ED) physician documentation, they found that Patient #46 had informed staff about his SI and plan, but he was not placed on SP in the ED or at any time prior to when he reported his SI at 12:45 PM. Once the nurse identified the SI with plan, SP were appropriately initiated. - On 05/03/26 at 3:08 PM, Staff OO, ED Medical Director, stated that he spoke with the ED physician about the lack of SP. The ED physician’s impression was that it was “situational depression” and more passive SI, such as someone saying that their pain is so bad they might as well die. That physician indicated he did not typically consult psychiatry (the study and treatment of mental illness) for situational depression, nor would he initiate SP. He should have been more explicit in his note. - No house wide education was provided for a failure to initiate SP for a patient who reported SI with a plan and intent. Review of Patient #46’s medical record, dated 04/24/26, showed: - He was an 80-year-old with a chief complaint of lower back pain. - At 3:09 PM, he reported to the physician that, “the previous night, his pain was so severe that he told his daughter that he was going to go into the garage and turn the car on to kill himself.” There was no psychiatric consultation, additional questions about the suicidal statement or a risk assessment. SP were not initiated. - At 8:04 PM, he was documented as having a low suicidal risk based on the C-SSRS. The assessment was not completed by the physician he reported SI to. No additional C-SSRS assessments were completed during his admission. - On 04/25/26 at 12:05 PM, therapy documentation showed he reported depression and recent SI. That was relayed to nursing staff who stated they would call the provider. He was left with family present in his room. No SP were initiated, and he was not observed by a hospital employee. - At 12:45 PM, nursing staff informed the medical team that he had active SI with a plan. Psychiatry was consulted, and SP were initiated. His daughter reported that he had a history of recurrent SI and inpatient psychiatric admissions. - At 12:59 PM, one to one (1:1, continuous visual contact with close physical proximity) observer documentation was initiated. - On 04/26/26, he reported that he struggled with SI his entire life and outpatient psychiatric treatment was discussed. - On 04/28/26, a psychiatric evaluation (observes and measures a patient’s behaviors, thoughts, and emotions to determine a diagnosis and appropriate treatment plan) was completed and showed he felt helpless and hopeless in relation to his chronic (long-term, ongoing) pain and that he had been depressed after his wife passed a year prior. At the time of the evaluation, he no longer had SI and did not plan to hurt or kill himself. He was referred for follow up care outpatient and his psychiatric medication was adjusted. During a telephone interview on 06/30/26 at 2:00 PM, Staff WW, RN, stated that on 03/06/26, she had been assigned as Patient #26’s primary nurse. When she arrived for bedside report, she was unhappy as the patient had not been changed and was sitting in feces. She immediately assisted Patient #26 up to the shower. She was able to stand and pivot into the shower chair at that time. Patient #26 then sat up in the chair most of the day. She was able to follow commands but was confused. During a telephone interview on 06/30/26 at 10:00 AM, Staff VV, RN, stated that on 03/07/26, she was assigned as the primary nurse for Patient #26. She was removed from Patient #26’s care team at approximately 2:00 PM. She had walked down the hall and told a student nurse that, “it was time to go check on the crazy lady.” She did not realize the family was behind her and overheard her comment. When she went into Patient #26’s room the family ordered her out of the room. She immediately went to the Charge Nurse and told him about the situation. She was removed as the primary nurse, and she did not give report to the oncoming nurse. She did hear the code stroke but stayed away as the family did not want her present. She admitted that did not document that Patient #26 had been unable to respond, but then changed her statement and said, “If I did chart that I did not mean it like she was unresponsive; she was sleeping all morning.” She was unable to recall the last time Patient #26 was able to communicate. She was “lethargic (weak, sluggish), which was how she was all morning.” Staff VV stated that she was counseled for her behavior in relation to the comment overheard in the hallway. During a telephone interview on 06/30/26 at 3:00 PM, Staff TT, RN, stated that on 03/07/26 at approximately 3:00 PM, she was told she was assigned as the primary nurse for Patient #26. She was told that the assigned nurse had made some comments about the patient, the family had overheard the comments and did not want her in the room. She had to go find the nurse to get report. She had not received report when she was immediately called into Patient #26’s room for the initiation of the code stroke. Patient #26’s initial nurse did not relay the actual condition of the patient, and Staff TT was upset that she walked into that situation. She was told that Patient #26 had been lethargic and slept most of the day. She was unsure how long the patient had been unresponsive, but the family stated they had been trying to get the nurse to come and assess her all afternoon as they had noticed a change in her condition. She was not aware that Staff WW had documented that Patient #26 was unable to respond earlier in the day. During a telephone interview on 06/30/26 at 4:30 PM, Staff UU, STAT RN/HS, stated on 03/07/26, she was the backup HS. She was told to go and speak to Patient #26’s family because a nurse had made a comment about the “crazy lady.” The family had overheard the comment and were upset. The HS had been busy and unable to speak with the family. That happened about an hour prior, which would have been at approximately 2:30 PM. She arrived to Patient #26’s room at approximately 3:30 PM, and two PCT’s were present to clean the patient. The patient’s family met her at the door and immediately told her that something was wrong because that was not how she was the previous night. She went to assess her and immediately called a code stroke as Patient #26 had facial drooping on the right side and was unresponsive with a fixed stare. She attempted a sternal rub (an emergency medical technique used to test an unconscious person’s responsiveness) to arouse her but there was no response. The neurology NP came into the room and ordered a head CT, and Patient #26 was eventually transferred to the ICU. She stated that the PCT told her that the patient’s change of condition had just occurred. She did not speak with Staff VV as the charge nurse had removed her as the primary nurse for Patient #26. The family overheard Staff VV commenting to a student nurse that it was, “time to check on the crazy lady.” Staff UU did not review any other documentation prior to the event and did discuss appropriate behavior with Staff VV. She was not aware of the documentation that showed that patient was unresponsive earlier that day. Although requested, the PCT assigned to Patient #26 on 03/07/26, was not available for an interview. Although requested, the Charge Nurse for the 5th floor on 03/07/26, was not available for an interview. During an interview on 06/24/26 at 10:03 AM, Staff OO, ED Medical Director, stated that after Patient #46’s incident report was reviewed, he only spoke with the initial provider regarding the failure to initiate SP. No other staff members were educated. The ED physician was a newer provider who felt the patient made a passive statement that did not require further follow up. He was educated to be more thorough and detailed in his documentation. During an interview on 06/23 at 2:48 PM, Staff MM, RN, stated that if a patient reported SI, they should not be left alone for any amount of time. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that she became involved with Patient #26 in late May when her daughter sent a letter to the hospital. She reviewed the patient’s medical course and gathered information before she spoke with her daughter. They had a lengthy discussion, and Staff FF assured her that staff had just been in Patient #26’s room before her RRT was called. They came to an understanding and resolved the complaint. Additionally, she began to escalate her concern about a lack of compassion and caring communication with family members. She felt there were opportunities to handle the situation differently, and got ethics involved. She did not conclude that staff failed to escalate a change in condition. After a review of the PT note documented on 03/06/26, that showed the patient had been responsive, alert and able to participate in her care, she agreed that Patient #26’s condition was not the same on 03/07/26. She was not aware a nurse documented at 12:49 PM that Patient #26 was unable to respond when staff rounded on her. Nor was she aware the same nurse told an oncoming nurse during report at 3:00 PM that Patient #26 was minimally responsive and was, “just like that.” She agreed that the original nurse should have provided additional information to the RRT as she had more involvement and knowledge of Patient #26’s care at the time, even if the family had requested that she not return to her room. Staff FF agreed that leadership should have reviewed the medical record when the event was initially reported and the staff involved should have received education. She was not aware of any education provided to staff, other than in relation to the inappropriate comment made by a nurse. Neurovascular checks involved every 15-minute checks for the first hour of initiation. When the RRT was called, the rapid response RN was to document a “free text” note. The “stroke team,” which consisted of Staff XX, NP, was responsible for code stroke documentation and she was not sure what documentation was required. If a patient made a suicidal statement to a member of staff, an observer must be obtained to ensure the patient’s safety. All staff had a responsibility to report and escalate SI. All staff should have been educated after a staff member failed to address a documented suicidal statement made by a patient. 50321”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to follow their policy to ensure all patients placed in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) had a provider order for four discharged patients (#26, #28, #29 and #30) of five patient records reviewed. Findings included: Review of the hospital’s undated policy titled, “Use of Restraints,” showed: - An order by the physician or approved Licensed Independent Practitioner (LIP) responsible for the management and care of the patient is required for each restraint episode. - Additionally, an order is required if the medical reason, behavior, type of restraint or location changes from the current order. - Mittens (restrictive mitt that hinders picking and tube pulling) are considered to be a restraint when placed to prevent the patient from pulling out a tube, pulling off a dressing or scratching a wound, itch or other skin lesions (an abnormal area of tissue inside or outside the body). - Non-violent or non-self-destructive restraint orders must be renewed every calendar day. - Violent or self-destructive restraint (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) orders must be renewed every four hours for patients over the age of 18. Continuous one to one (1:1, continuous visual contact with close physical proximity) observation of the patient’s behavior is required while violent restraints are in use. - Intermittent use of a restraint is only acceptable for bed enclosures (a tent-like mesh or nylon canopy that fits completely over a hospital bed that is zipped closed and locked with quick-release buckles, requiring a caregiver on the outside to open it) because it is understood to be intermittent as the patient moves in and out of bed. In these situations, it is understood the restraint may be removed and replaced multiple times through the applicable time of the order. In these situations, the time must be documented for each intermittent placement and removal. - All restraint orders must be entered into the electronic medical record (EMR). - Available restraints at the hospital included soft wrist and ankle restraints, mittens and bed enclosures. Review of Patient #26’s medical record, dated 03/06/26, showed: - She was a 79-year-old who was admitted to the hospital after a fall. - At 1:24 AM, an order for a violent restraint was placed to start at 1:25 AM that was to be re-written every four hours. - At 1:25 AM, violent restraint documentation showed she was placed in a bed enclosure. - At 6:57 AM, an order for a non-violent restraint was placed to start at 1:30 AM that was to be renewed every calendar day. The order status showed it was canceled. - On 03/11/26 at 5:00 AM, the restraint was discontinued. - There were no additional restraint orders placed. Review of Patient #26’s incident report, dated 03/07/26, showed on 03/06/26 at 5:45 PM, Patient #26’s daughter arrived at her room and found her alone in a bed enclosure that was locked, indicating the bed enclosure was in use despite the lack of a restraint order. Review of Patient #28’s medical record, dated 06/07/26, showed: - He was a 72-year-old who arrived at the emergency department (ED) after he was found unresponsive at his nursing home (NH). - At 6:31 PM, violent restraint documentation showed he was in bilateral wrist restraints. - At 8:38 PM, non-violent restraint documentation showed he was in bilateral wrist restraints. - On 06/09/26 at 1:36 AM, an order for a violent restraint was placed to start at 1:36 AM that was to be re-written every four hours. - At 8:00 AM, violent restraint documentation showed he was in bilateral wrist restraints. - On 06/10/26 at 10:00 AM, the restraints were discontinued. - There were no additional restraint orders placed. Review of Patient #29’s medical record, dated 06/16/26, showed: - He was a 68-year-old admitted to the hospital after a fall. - On 06/21/26 at 6:07 PM, non-violent restraint documentation showed he was in bilateral wrist restraints. - At 8:00 PM, non-violent restraint documentation showed bilateral mittens were applied in addition to the wrist restraints. - On 06/23/26 at 11:11 AM, non-violent restraint documentation showed a left ankle restraint was applied in addition to the wrist restraint and mittens. - At 4:00 PM, the mittens and left ankle restraint were discontinued. The bilateral wrist restraints remained in place. - At 4:04 PM, an order for a violent restraint was placed to start at 4:04 PM that was to be re-written every four hours. - On 06/24/26 at 8:44 AM, the right wrist restraint was removed. - At 8:47 AM, the left wrist restraint was removed. - There were no additional restraint orders placed. Review of Patient #30’s medical record, dated 06/07/26, showed: - He was a 60-year-old admitted to the hospital for stroke-like symptoms. - On 06/08/26 at 7:37 AM, an order for a non-violent restraint was placed to start at 7:38 AM that was to be renewed every calendar day. - On 06/09/26 at 8:00 AM, non-violent restraint documentation showed he was in a restraint with an unknown type or location. - At 8:00 PM, the restraint was documented as a left wrist restraint. - At 12:00 PM, non-violent restraint documentation showed a left ankle restraint was continued. No application time was recorded. - At 2:09 PM, an order to discontinue restraints was placed. The order was canceled on 06/15/26 at 10:22 AM, however the restraints were not removed. - On 06/14/26 at 7:16 AM, an order for a non-violent restraint was placed to start at 7:15 AM that was to be renewed every calendar day. The order was canceled on 06/15/26 at 10:22 AM. - At 3:00 PM, the restraints were discontinued. - There were no additional restraint orders placed. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that an order should be obtained when restraints were applied, and a new order must be obtained if a new restraint type was initiated. It was not acceptable for restraints to be in use without an order. An order for violent restraints should only be placed when violent restraints were indicated. It was not acceptable for staff to place an order for violent restraints when non-violent restraints were indicated. During an interview on 06/24/26 at 1:48 PM, Staff RR, Patient Care Coordinator, stated that there had only been a couple of actual violent restraints applied at the hospital in 2026. She was aware staff mistakenly placed violent restraint orders when non-violent restraints were in use. If a patient were truly in a violent restraint, staff should document hourly, and the patient should be observed continuously. Violent restraint orders were to be renewed every four hours.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to ensure appropriate ongoing monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for five discharged patients (#26, #28, #29, #30 and #33) of five restrained patient records reviewed. Findings included: Review of the hospital’s undated policy titled, “Use of Restraints,” showed: - Required documentation in the medical record for all non-violent or non-self-destructive restraints includes an assessment at least every two hours. - Required documentation in the medical record for all violent or self-destructive restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) includes an assessment at least every hour. - Intermittent use of a restraint is only acceptable for bed enclosures (a tent-like mesh or nylon canopy that fits completely over a hospital bed that is zipped closed and locked with quick-release buckles, requiring a caregiver on the outside to open it) because it is understood to be intermittent as the patient moves in and out of bed, In these situations, it is understood the restraint may be removed and replaced multiple times through the applicable time of the order. In these situations, the time must be documented for each intermittent placement and removal. - Available restraints at the hospital included soft wrist and ankle restraints, mittens (restrictive mitt that hinders picking and tube pulling) and bed enclosures. Review of Patient #26’s medical record, dated 03/06/26, showed: - She was a 79-year-old who was admitted to the hospital after a fall. - On 03/06/26 at 1:24 AM, an order for a violent restraint was placed to start at 1:25 AM that was to be re-written every four hours. - At 1:25 AM, violent restraint documentation showed she was placed in a bed enclosure. - From 1:25 AM through 3:00 AM, restraint documentation was not completed. - At 6:57 AM, an order for a non-violent restraint was placed to start at 1:30 AM that was to be renewed every calendar day. The order status showed it was canceled. - From 03/06/26 at 5:54 AM through 03/11/26 at 5:00 AM, there was no restraint documentation. - On 03/11/26 at 5:00 AM, the restraint was discontinued. Review of Patient #26’s incident report, dated 03/07/26, showed on 03/06/26 at 5:45 PM, Patient #26’s daughter arrived at her room and found her in a bed enclosure that was locked, indicating the bed enclosure was in use despite a lack of nursing documentation in the medical record. Review of Patient #28’s medical record, dated 06/07/26, showed: - He was a 72-year-old who arrived at the ED after he was found unresponsive at his nursing home. - At 6:31 PM, violent restraint documentation showed he was in bilateral wrist restraints. - At 8:38 PM, non-violent restraint documentation showed he was in bilateral wrist restraints. - On 06/09/26 at 1:36 AM, an order for a violent restraint was placed to start at 1:36 AM that was to be re-written every four hours. - At 8:00 AM, violent restraint documentation showed he was in bilateral wrist restraints. - From 8:00 AM through 8:00 PM, there was no restraint documentation. - On 06/10/26 at 10:00 AM, the restraints were discontinued. - At 10:31 AM, an order for a non-violent restraint was placed to start at 10:31 AM that was to be renewed every calendar day. - At 10:52 AM, non-violent restraint documentation showed he was in bilateral mittens. - From 6:30 PM through 10:29 PM, there was no restraint documentation. - On 06/11/26 at 8:30 AM, the restraints were discontinued. Review of Patient #29’s medical record, dated 06/16/26, showed: - He was a 68-year-old admitted to the hospital after a fall. - On 06/21/26 at 6:07 PM, non-violent restraint documentation showed he was placed in bilateral wrist restraints. - At 8:00 PM, non-violent restraint documentation showed bilateral mittens were applied in addition to the wrist restraints. - On 06/23/26 at 11:11 AM, non-violent restraint documentation showed a left ankle restraint was applied in addition to the wrist restraints and mittens. - At 4:00 PM, the mittens and left ankle restraint were discontinued. The bilateral wrist restraints remained in place. - At 4:04 PM, an order for a violent restraint was placed to start at 4:04 PM that was to be re-written every four hours. There was no associated violent restraint documentation. - On 06/24/26 at 8:44 AM, the right wrist restraint was removed. - At 8:47 AM, the left wrist restraint was removed. Review of Patient #30’s medical record, dated 06/07/26, showed: - He was a 60-year-old admitted to the hospital for stroke-like symptoms. - On 06/08/26 at 7:37 AM, an order for a non-violent restraint was placed to start at 7:38 AM, it was to be renewed every calendar day. - On 06/09/26 at 8:00 AM, non-violent restraint documentation showed he was in a restraint with an unknown type or location. - At 8:00 PM, the restraint was documented as a left wrist restraint. - From 06/10/26 at 6:00 AM through 12:00 PM, there was no restraint documentation. - At 12:00 PM, non-violent restraint documentation showed a left ankle restraint was continued. No start time was recorded. - From 12:00 PM through 8:00 PM, there was no restraint documentation. - At 2:09 PM, an order to discontinue restraints was placed. The order was canceled on 06/15/26 at 10:22 AM. There was no documented removal of restraints. - From 06/11/26 at 3:00 PM through 8:00 PM, there was no restraint documentation. - From 06/12/26 at 6:45 PM through 06/13/26 at 12:00 AM, there was no restraint documentation. - From 06/13/26 at 6:00 PM through 06/14/26 at 8:00 AM, there was no restraint documentation. - On 06/14/26 at 7:16 AM, an order for a non-violent restraint was placed to start at 7:15 AM that was to be renewed every calendar day. The order was canceled on 06/15/26 at 10:22 AM. - At 3:00 PM, the restraints were discontinued. Review of Patient #33’s medical record, dated 04/11/26, showed: - He was a 77-year-old admitted to the hospital for difficulty breathing. - On 04/14/26 at 10:56 PM, non-violent restraint documentation showed he was in a restraint with an unknown type or location. An order for a non-violent restraint was placed to start at 10:56 PM that was to be renewed every calendar day. - On 04/15/26 at 8:00 AM, non-violent restraint documentation showed he was in bilateral mittens. - From 10:00 AM through 8:00 PM, there was no restraint documentation. - At 8:00 PM, restraints were discontinued. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that restraint documentation should be completed either hourly for violent restraints, or every two hours for non-violent restraints, per policy. A time of discontinuation must be documented when restraints were removed. During an interview on 06/24/26 at 1:48 PM, Staff RR, Patient Care Coordinator, stated that the type and location of the restraint should be documented. Staff should document the date and time a restraint is applied or discontinued.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to follow their policy to ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) evaluation within one hour of violent restraints application for three discharged patients (#26, #28 and #29) of three patient records reviewed with a violent restraint order. Findings included: Review of the hospital’s undated policy titled, “Use of Restraints,” showed: - Violent or self-destructive restraints require that the physician, licensed independent practitioner (LIP) designee or a specific registered nurse (RN) must see the patient within one hour. - At the hospital, there are no RNs trained to complete face-to-face evaluations. - A face-to-face evaluation conducted by the physician or LIP is required within one hour after the initiation of the restraint. - Available restraints at the hospital included soft wrist and ankle restraints, mittens (restrictive mitt that hinders picking and tube pulling) and bed enclosures (a tent-like mesh or nylon canopy that fits completely over a hospital bed that is zipped closed and locked with quick-release buckles, requiring a caregiver on the outside to open it). Review of Patient #26’s medical record, dated 03/06/26, showed: - She was a 79-year-old who was admitted to the hospital after a fall. - On 03/06/26 at 1:24 AM, an order for a violent restraint was placed to start at 1:25 AM that was to be re-written every four hours. - At 1:25 AM, violent restraint documentation showed she was placed in a bed enclosure. - On 03/11/26 at 5:00 AM, the restraint was discontinued. - There were no face-to-face evaluations for violent restraint episodes included in the medical record. Review of Patient #28’s medical record, dated 06/07/26, showed: - He was a 72-year-old who arrived at the ED after he was found unresponsive at his nursing home. - At 6:31 PM, violent restraint documentation showed he was in bilateral wrist restraints. - At 8:38 PM, non-violent restraint documentation showed he was in bilateral wrist restraints. - On 06/09/26 at 1:36 AM, an order for a violent restraint was placed to start at 1:36 AM that was to be re-written every four hours. - At 8:00 AM, violent restraint documentation showed he was in bilateral wrist restraints. - On 06/10/26 at 10:00 AM, the restraints were discontinued. - There were no face-to-face evaluations for violent restraint episodes included in the medical record. Review of Patient #29’s medical record, dated 06/16/26, showed: - He was a 68-year-old admitted to the hospital after a fall. - On 06/21/26 at 6:07 PM, non-violent restraint documentation showed he was placed in bilateral wrist restraints. - At 8:00 PM, non-violent restraint documentation showed bilateral mittens (restrictive mitt that hinders picking and tube pulling) were applied in addition to the wrist restraints. - On 06/23/26 at 11:11 AM, non-violent restraint documentation showed a left ankle restraint was started in addition to the wrist restraint and mittens. - At 12:00 PM, a face-to-face evaluation for violent restraints was completed. - At 4:00 PM, the mittens and left ankle restraint were discontinued. The bilateral wrist restraints remained in place. - At 4:04 PM, an order for a violent restraint was placed to start at 4:04 PM that was to be re-written every four hours. - On 06/24/26 at 8:44 AM, the right wrist restraint was removed. - At 8:47 AM, the left wrist restraint was removed. - There were no additional face-to-face evaluations for violent restraint episodes included in the medical record. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that if violent restraints were ordered, a face-to-face evaluation must be completed according to policy. It was not acceptable for a face-to-face evaluation to be completed several hours before the application of violent restraints.”

“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: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure staff followed the fall prevention policy when six current patients (#1, #2, #3, #4, #6 and #66) of 11 current patients who were identified as a high or moderate fall risk had appropriate fall prevention measures in place; - Label intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and intravenous (IV, in the vein) tubing for 10 current patients (#1, #2, #5, #15, #24, #25, #38, #39, #40 and #65) of 17 current patients observed; - Complete pain assessments or reassessments for one current patient (#31) and one discharged patient (#32) of three patient records reviewed; - Turn two current patients (#1 and #40) and one discharged patient (#26) of four patient records reviewed who required assistance to turn; - Label fluid found in fluid warmers on two of two units with fluid warmers observed; - Store shower caps in the designated shower cap warmer on one of two units with shower caps observed; and - Document the use of an incentive spirometer (IS, a hand-held breathing device in which the patient is instructed to take slow deep breaths through the device’s mouthpiece) for two current patients (#60 and #61) of two patient records with an order for an incentive spirometer reviewed. Findings included: Review of the hospital’s undated policy titled, “Fall Prevention,” showed that moderate fall risk interventions included implementation of a bed alarm on moderate sensitivity setting and the high fall risk interventions included implementation of a bed alarm on the most sensitive setting. Update the bottom section of the mobility poster in each patient’s room to ensure accurate reference on how to safely move or ambulate the patient. Review of Patient #1’s medical record, dated 06/19/26, showed she was a 71-year-old admitted to the hospital for weakness. On 06/22/26, she was a high fall risk. Observation on 06/22/26 at 3:15 PM, on the Cardiovascular unit, showed Patient #1 was a high fall risk on the mobility poster located in her room. Patient #1 was in bed, and the bed alarm was not on. Review of Patient #2’s medical record, dated 06/14/26, showed she was a 75-year-old admitted to the hospital for difficulty breathing. On 06/22/26, she was a high fall risk. Observation on 06/22/26 at 3:30 PM, on the Cardiovascular unit, showed Patient #2 was a high fall risk on the mobility poster located in her room. Patient #2 was in bed, and the bed alarm was not on. Review of Patient #3’s medical record, dated 06/14/26, showed she was a 52-year-old admitted to the hospital for a left foot wound. On 06/23/26, she was a moderate fall risk. Observation on 06/23/26 at 9:00 AM, on the Medical Specialties unit, showed Patient #3 was a moderate fall risk on the mobility poster located in her room. Patient #3 was in bed, and the bed alarm was not on. Review of Patient #4’s medical record, dated 05/09/26, showed he was a 76-year-old admitted to the hospital for bleeding and lower extremity swelling. On 06/23/26, he was a moderate fall risk. Observation on 06/23/26 at 9:30 AM, on the Medical Specialties unit, showed Patient #4 was a high fall risk on the mobility poster located in his room. Patient #4 was in bed, and the bed alarm was not on. Review of Patient #6’s medical record, dated 06/15/26, showed he was a 76-year-old admitted to the hospital after a fall. On 06/23/26, he was a high fall risk. Observation on 06/23/26 at 10:30 AM, on the Medical Specialties unit, showed Patient #6 was a high fall risk on the mobility poster located in his room. Patient #6 was lying in bed, and the bed alarm was not on. Review of Patient #66’s medical record, dated 06/22/26, showed she was a 78-year-old admitted to the hospital for difficulty breathing. On 06/25/26, she was a high fall risk. Observation on 06/25/26 at 11:00 AM, on the Medical Specialties unit, showed Patient #66 was a high fall risk on the mobility poster located in her room. Patient #66 was in bed, and the bed alarm was not on. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that fall precautions, such as bed alarms, should be implemented for patients identified as a fall risk. During an interview on 06/25/26 at 10:45 AM, Staff A, Cardiovascular Unit Manager, stated that all moderate and high fall risk patients should have their bed alarm on. During an interview on 06/25/26 at 11:15 AM, Staff C, Medical Specialties Unit Manager, stated that high fall risk patients should have their bed alarm at the highest sensitivity and moderate fall risk patients should have their bed alarm set at moderate sensitivity. Her expectation of staff was to round and make sure bed alarms were on for high and moderate fall risk patients. Review of the hospital’s undated policy titled, “IV Line Care - Adult,” showed all adult venous access devices should be labeled with the date of insertion or the date the dressing was changed. IV tubing should be labeled with the day of the week it is to be changed. Observation on 06/22/26 at 3:30 PM, in the Cardiovascular unit, showed Patient #1’s IVC was not labeled. Observation on 06/22/26 at 3:15 PM, in the Cardiovascular unit, showed Patient #2’s IVC was not labeled. Observation on 06/23/26 at 10:30 AM, in the Medical Surgical unit, showed Patient #5’s IVC was not labeled. Observation on 06/24/26 at 9:28 AM, in the Labor and Delivery unit, showed Patient #15’s IVC was not labeled. Observation on 06/24/26 at 10:45 AM, in the Emergency Department (ED), showed Patient #24’s IVC was not labeled. Observation on 06/24/26 at 10:50 AM, in the ED, showed Patient #25’s IVC was not labeled. Observation on 06/23/26 at 9:37 AM, in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Patient #38’s IVC and IV tubing were not labeled. Observation on 06/23/26 at 9:04 AM, in the ICU, showed Patient #39’s IVC and IV tubing were not labeled. Observation on 06/22/26 at 2:38 PM, in the Progressive Care Unit (PCU, a telemetry [remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring), showed Patient #40’s IV tubing was not labeled. Observation on 06/25/26 at 11:30 AM, in the Medical Specialties unit, showed Patient #65’s IVC was not labeled. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated that IVCs should be labeled with a date of insertion. IV tubing should be labeled. Review of the hospital’s undated policy titled, “Pain Assessment and Management,” showed: - The nurse is responsible for reassessment after intervention to determine effectiveness and additional interventions, if needed. - Pain scores should be reported or obtained by using an applicable scale. - Staff should document the initial pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a 10 means worst pain possible) score and a reassessment pain score. Review of Patient #31’s medical record, dated 06/24/26, showed: - She was a 32-year-old admitted to the hospital for a cesarean section (C-section, surgical delivery of a baby through an incision made in the mother’s abdomen and uterus). - Three one-time dose pain medications were administered. - There were no pain scale reassessments for any one-time dose medications administered. Review of Patient #32’s medical record, dated 06/15/26, showed: - She was a 37-year-old admitted to the hospital with pregnancy complications. - Three as needed (PRN) pain medications were administered. - On 06/16/26, six PRN pain medications were administered. - On 06/17/26, seven PRN pain medications were administered. - There were no pain scale reassessments for any PRN medications administered. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated that pain reassessments should be documented. It was not acceptable for staff to ignore alerts from the electronic medical record (EMR) to complete a pain reassessment. During an interview on 06/23/26 at 2:48 PM, Staff MM, Registered Nurse (RN), stated that pain assessments and reassessments were completed often, but not always documented. It was common for her and her coworkers to ignore the “red alert” that the EMR provided to remind staff to document. The expectation was to complete a pain reassessment within 30 minutes of pain medication administration. Review of the hospital’s undated policy titled, “Immobility,” showed: - Complete bed rest requires a physician’s order when patient status does not mandate immobility. - Skin and areas at risk for breakdown should be assessed every shift. - Assist the patient to turn every two hours while in bed. Ensure proper positioning and body alignment; use pillows as needed to maintain position. - Consider the impact of immobility and the impending complications upon the Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers) score. Review of the hospital’s undated policy titled, “Wound In-Patient Assessment and Intervention,” showed: - Assigned staff RN should routinely assess and document skin integrity on admission, transfer and daily for wounds and pressure injuries. - Assigned staff RN should use the Braden scale to assess the risk for pressure injuries. - Turning and repositioning with offloading of pressure areas has the greatest impact in the prevention and management of pressure injuries. - For a Braden Scale score of 18 or lower, implement the pressure ulcer prevention guidelines in addition to universal skin care practices. - A patient is “at risk” for pressure injuries with a Braden Scale score of 18 or below. - All barriers to turning should be documented. - Turning and repositioning with offloading every two hours should be completed in the turn/reposition flowsheet in the EMR. - The standard of care should be all patients must be repositioned at regular intervals unless medically contraindicated. Review of Patient #1’s medical record, dated 06/19/26, showed: - She had areas on her sacrum (triangular shaped bone above the tailbone) that were unblanchable (paling or whitening of the skin when pressed, when skin does not become pale with pressure it is often an indication of injury to the tissue) with wound orders to include turning every two hours. - Her Braden Scale score was 18 or less. She was to be turned every two hours. - From 06/19/26 through 06/20/26 at 11:56 PM, she was not repositioned. - From 06/20/26 at 11:56 PM through 06/21/26 at 10:06 PM, she was not repositioned. - From 06/21/26 at 10:06 PM through 06/22/26 at 10:11 AM, she was not repositioned. - From 06/22/26 at 10:11 AM through 06/23/26 at 3:06 AM, she was not repositioned. - From 06/23/26 at 3:06 AM through 11:56 AM and 11:56 AM through 11:45 PM, she was not repositioned. - From 06/23/26 at 11:45 PM through 06/24/26 at 2:00 PM, when the medical record was reviewed, there was no additional turn or repositioning documentation. Review of Patient #40’s medical record, dated 06/15/26, showed: - She was a 68-year-old who was admitted to the hospital for difficulty breathing. - Her Braden Scale score was 18 or less. She was to be turned every two hours. - From 7:43 PM through 11:49 PM and from 11:49 PM though 06/16/26 at 2:00 AM, she was not repositioned. - From 06/16/26 at 8:00 AM through 6:00 PM, every two hours, documentation showed she was not repositioned because she had been “repositioned in the last hour,” though previous documentation from 2:00 AM through 8:00 AM showed she refused to turn. Her position in bed was not documented. - From 6:00 PM through 06/17/26 at 2:02 AM, she was not repositioned. - From 06/17/26 at 2:02 AM through 06/19/26 at 8:00 AM, she was not repositioned. - From 06/19/26 at 8:00 AM through 6:00 PM, she was not repositioned. - From 06/19/26 at 6:00 PM through 06/22/26 at 3:00 PM, when the medical record was reviewed, there was no additional turn or repositioning documentation. Review of Patient #26’s medical record, dated 03/05/26, showed: - She was a 79-year-old who was admitted to the hospital after a fall at home. She was alert and oriented to person only. - She had a past medical history of dementia (a loss of thinking abilities and memory) and previous stroke. - Her Braden Scale score was 18 or less. She was to be turned every two hours. - From 03/05/26 at 11:00 PM, she was not repositioned because she had been “repositioned in the last hour,” though previous documentation did not show what position she was in. - From 11:00 PM through 03/06/26 at 6:00 PM, she was not repositioned. - From 03/06/26 at 6:00 PM through 03/07/26 at 7:00 AM, she was not repositioned. - From 03/07/26 at 9:00 AM through 8:03 PM, she was not repositioned. - From 11:47 PM through 03/08/26 at 2:00 PM, she was not repositioned - From 03/08/26 at 6:00 PM through 03/09/26 at 10:00 AM, she was not repositioned. - From 03/09/26 at 11:02 AM through 2:00 PM, she was not repositioned - From 2:00 PM through 03/12/26 at 3:12 AM, when she expired, she was not repositioned. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated all patients with repositioning orders should be turned and repositioned every two hours as per ordered and document in the EMR. Review of the hospital’s undated policy titled, “Fluid Warmer Safety,” showed: - All fluids should be dated with the date the fluid should be removed from the warmer. - All unused fluids should be removed after 14 days in the warmer. - If the temperature has exceeded 104 degrees at any point, discard all contents and notify clinical engineering. Observation on 06/24/26 at 10:30 AM, in the ED, showed eight bags of IV fluids in the fluid warmer that were not labeled with a removal date. Observation on 06/24/26 at 9:27 AM, on the Labor and Delivery unit, showed 10 containers of fluid in the fluid warmer that were not labeled with a removal date. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated fluid stored in fluid warmers should be labeled to ensure it was not stored for greater than 14 days, per policy. During an interview on 06/24/26 at 10:30 AM, Staff T, ED Manager, stated that they did not monitor the IV warmer and that he thought clinical engineering did. Although requested, no temperature logs were provided. Review of the hospital’s undated policy titled, “General Safety,” showed: - Blanket warmers are not to exceed a maximum of 120 degrees and shelves are not to be overfilled. - Microwaves used in patient care areas are to be used to warm food and oral fluids only. No other usage is permitted. - Microwaves should not be used to warm wet towels for warm moist packs, warm shampoo caps, “bed buddies” or other patient personal property including IV fluids. Review of the material data sheet titled, “ReadyBath Cap (a disposable, pre-moistened shower cap lined with a rinse-free shampoo and conditioner),” dated 05/2022, showed: - ReadyBath Caps were for patients needing their hair washed but who are unable to use a shower or tub. - They are to be used at room temperature or warmed using a Sage warming system (A special warming device specifically used to for body cleansing wipes and readybath caps). - Warming in the microwave is not recommended due to inconsistent heating. Microwave wattage varies and heating times must be adjusted accordingly. - Microwaves are to be used only if a facility or unit policy allows. They should not be warmed for longer than 15 seconds. - Closely monitor heat level for skin sensitive individuals and use caution when determining heat level as gloves diminish sensitivity to heat. Observation on 06/23/26 at 2:45 PM, on the Surgical Specialties unit, the blanket warmer’s temperature was 121 degrees. There were four bags of ReadyBath Caps placed in the blanket warmer wedged between blankets. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated that shower caps should not be stored in blanket warmers, nor heated in microwaves intended for patient food. During an interview on 06/23/26 at 2:45 PM, Staff P, Supervisor, stated that the ReadyBath Caps should be placed in the blanket warmer. They were to be microwaved for 15 seconds. The microwave that was used to heat the ReadyBath Caps was the same microwave that was used to heat perishable food items for patients. The Sage warming system was turned off and not in use. Review of the hospital’s undated policy titled, “Nursing Documentation: Assessment and Re-Assessment,” showed all treatments should be documented once per shift or as ordered and require complete documentation of normal and abnormal findings. Review of the hospital’s undated policy titled, “Immobility,” showed that every two hours patients should be assisted with IS use. Review of Patient #60’s medical record, dated 06/19/26, showed: - He was a 53-year-old was admitted to the hospital for dizziness with a fall. - On 06/19/26 at 8:52 AM, an order was placed for IS use every two hours. - On 06/20/26 at 8:02 AM, IS was documented. - On 06/23/26 at 10:44 AM, IS was documented. - There was no other documented IS use. Review of Patient #61’s medical record, dated 06/18/26, showed: - She was a 87-year-old who was admitted to the hospital for surgical repair of a left arm fracture (a break in a bone). - On 06/19/26 at 4:28 PM, an order was placed for an IS every hour while awake. - On 06/19/26 at 9:00 PM, IS was documented. - On 06/23/26 at 8:45 AM, IS was documented. - There was no other documented IS use. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, CNE, stated staff should document IS use, per provider orders. 39562 47504”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Safely secure medications in appropriate locked areas for four current patients (#12, #20, #27 and #39) and two discharged patients (#14 and #21) of 12 patients observed and on three units of 15 units observed; - Discard three unlabeled insulin (medication that regulates the amount of sugar in the blood) vials stored in locked patient medication drawers; - Administer medications at their documented administration times for seven current patients (#3, #4, #24, #25, #39, #60 and #61) of 12 medication administrations observed; and - Administer medications according to policy for two current patients (#24 and #39) of seven observed medications administered by intravenous push (IVP, to manually administer a dose of medication through a tube into a vein) or gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach). Findings included: Review of the hospital’s undated policy titled, “Medication Management-General Information,” showed: - Labels are to be placed when a multi-use vial/container is opened and marked with an expiration date of 28 days. - Medications are to be securely stored at all times. - Medications are not to be left at the bedside or anywhere they are not secured from access. - Medication should always be scanned as they are administered to verify that they are correct. - Medications are to be administered in a timely manner and within the parameters prescribed by the physician. - G-tube medication administration requires a flush before and after each medication with water. The tube should be clamped for 30 minutes after medication administration. - When using a non-safety needle, discard it in a puncture resistant container immediately after use, do not recap. If the needle cannot be discarded immediately after use and must be recapped, use the “scoop” method to replace the cap on the needle. Review of manufacturer instructions for the administration of Guar Gum Nutrisource Fiber (a natural, soluble dietary fiber extracted from the seeds of the guar bean plant), dated 2025, showed tube feeding (a liquid form of nourishment, for those individuals who are not able to eat solid food, that is delivered to the body through a flexible tube) administration required that one packet of guar gum powder was to be mixed with 60-120 milliliters (mL) of water and must be flushed with 30 to 60 mL of water after administration. Review of the hospital’s undated document titled, “Medication Security in Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body),” showed: - Medications are considered secure in the MRI department, as this space is locked and only accessible via badge reader to authorized individuals. - MRI zone III is an area near the magnet room where fringe, gradient or magnetic fields (an invisible area of magnetic force surrounding a magnet or a moving electrical charge) are sufficiently strong enough to present a physical hazard to unsecured patients and personnel. - Zone III includes the patient preparation area, dressing rooms, the control room and patient restrooms. - All access to zone III is strictly restricted, with access controlled by, and entirely under the supervision of, MRI personnel. - Drugs must be controlled and distributed in accordance with applicable standards of practice. All drugs must be kept in a secure area and locked when appropriate. - The medication administration machine and contrast media storage are located within zone III of the MRI department. As this zone is restricted with access controlled by, and under the supervision of, MRI personnel, with physical restrictions from general access in the form of automatic locking doors equipped with identification badge locking systems, it is considered a secure location that meets CMS conditions of participation. Observation with concurrent interview on 06/23/26 at 9:13 AM, on the Intensive Care Unit, showed Staff JJ, RN, scanned a tube of calmoseptine ointment (a multi-purpose skin protectant) and stated that she had already applied the ointment earlier that shift, but scanned it now, “because it was due.” Staff JJ had retrieved the ointment from an unlocked cabinet in Patient #39’s room that also contained carboxymethylcellulose eye drops (artificial tears used to temporarily relieve burning, irritation, and discomfort caused by dry eyes). There was an open vial of acetylcysteine (a medication that thins and loosens thick, sticky mucus in the airways) on the supply cart in Patient #39’s room. Staff JJ stated the acetylcysteine was administered by respiratory therapy and should not have been left on the supply cart, unsecured. Staff JJ crushed a multivitamin and lansoprazole (used to treat ulcers and heartburn) tablet and mixed them in a graduated cylinder with a packet of guar gum and approximately 300 mL of water. Staff JJ withdrew the medication mixture from the graduated cylinder (a container used to measure the volume of a liquid) into a syringe, paused Patient #39’s tube feed machine and detached the tubing from her G-tube. Staff JJ then attached the syringe to the G-tube and stated there was not a clamp. After Staff JJ administered the medication mixture she detached the syringe from the G-tube, but failed to manually clamp the G-tube, resulting in a large amount of the medication mixture, that had just been administered, flowing out of the G-tube and onto Patient #39’s gown, sheet and blanket. Staff JJ then reattached the tube feed tubing to the G-tube and set the tube feed machine to administer a flush. Observation on 06/24/26 at 9:15 AM, on the Orthopedic Medical Unit, Staff QQ, RN, documented medications were given by mouth to Patient #60 prior to administration. Observation on 06/23/26 at 9:17 AM, on the Surgical Specialty Unit, Staff D, RN, documented medications were given by mouth to Patient #3 prior to administration. Observation on 06/23/26 at 9:25 AM, on the Surgical Specialty Unit, Staff E, RN, documented medications were given by mouth to Patient #4 prior to administration. During an interview on 06/23/26 at 9:51 AM, Staff KK, RN, stated that medications administered through a G-tube must be mixed with water and administered one at a time, with a flush in between. A flush should be administered via the syringe used to administer medications, not via the tube feed machine. Observation with concurrent interview on 06/23/26 at 11:20 AM, on the Cardiovascular Unit, showed a locked medication cart in the hallway outside of Patient #12’s room. Staff G, Registered Nurse (RN), opened the medication cart and inside were two unlabeled insulin vials with no patient identification. Staff G stated that the unlabeled vials should be returned to pharmacy, and she did not know why they were left in the medication cart. During an interview on 06/23/26 at 11:25 AM, Staff A, Cardiovascular Unit Manager, stated that he expected nursing staff to return any medication to the pharmacy that was not labeled with a patient name. Observation with concurrent interview on 06/23/26 at 3:00 PM, on the Surgical Specialties Unit, showed an unlocked medication cart in the hallway with two vials of insulin that belonged to Patient #14. There was a sticker on the medication cart that read, “no lock.” Staff J, Surgical Specialties Unit Manager, stated that Patient #14 had been discharged and that medications should not be left in unlocked medication carts. Observation with concurrent interview on 06/23/26 at 3:15 PM, on the Surgical Specialties Unit, showed an insulin vial was found unsecured in a medical cart that was labeled with Patient #27’s information. Staff K, RN stated that she kept the insulin in the medical cart as it was easier to grab it throughout the day. Observation with concurrent interview on 06/23/26 at 3:30 PM, on the Surgical Specialties Unit, Staff K, RN, stated that she forgot she had Patient #20’s insulin vial in her pocket and showed it to this surveyor. She then stated that she left Patient #21’s insulin vial at their bedside. Observation in Patient #21’s room showed the patient had discharged, and no insulin vial was found in the room. Staff K stated that after insulin was administered to a patient, it should be placed in a locked container in the patient’s room or placed in the patient’s bin in the medication room. Observation on 06/24/26 at 9:40 AM, on the Orthopedic Medical Unit, Staff QQ, RN, documented medications were given by mouth to Patient #61 prior to administration. Observation on 06/24/26 at 11:15 AM, in the ED, Staff RR, RN, documented medications were given intravenously (IV, into the vein) to Patient #24 prior to administration. Staff RR prepared medication for Patient #24 as she grabbed an empty syringe and uncapped the syringe with her mouth and withdrew 30 mg of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] that is used to treat moderately severe pain and inflammation) from a vial without gloves. She then took the syringe cap out of her mouth and recapped the syringe using both hands and failing to use the “scoop” method. She then administered Patient #24 the Toradol that was in the syringe intravenous push (IVP, to manually administer a dose of medication through a tube into a vein). Observation on 06/24/26 at 11:20 AM, in the ED, Staff SS, RN documented medications were given IV to Patient #25 prior to administration. Observation with concurrent interview on 06/24/26 at 1:32 PM, in MRI zone III, showed there was a supply room door with a number pad lock that was ajar. There were medications stored in the supply room on an open shelf. Staff DD, Patient Care Coordinator, left the area to find Staff II, Manager, and the survey team was left unattended with no MRI personnel present. Patient #34 approached the survey team from a restroom in MRI zone III in a hospital gown. There were no MRI personnel present. Staff DD returned and located Patient #34’s MRI technician, who was in a separate room behind a closed door. Staff II, MRI Manager, stated that the supply room door was not routinely locked and was not currently locked because patients were not supposed to be unattended in MRI zone III. During a telephone interview on 07/07/26 at 11:30 AM, Staff FF, Chief Nursing Executive (CNE), stated that medications should not be left unattended or unsecured. If medications were patient specific, they could be stored in a locked cabinet in their room, and the cabinet should remain locked. Patient specific medications, such as a multidose insulin vial intended for one patient, should be labeled with patient information. Medications should be administered at the time they were documented as administered. Medications administered through a G-tube should be administered one at a time and a flush should be administered between each medication. Staff should follow manufacture guidance for medication mixing instructions. It was never acceptable for a staff member to remove a needle cap with her mouth. That should never have happened. Uncapped needles should not be recapped, as that would not follow proper medication administration procedure. Medications should be administered when they are documented as administered. 39562 50321”

“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: 48359 Based on policy review the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#6) and failed to ensure that an EMC was stabilized for one patient (#6) of 30 Emergency Department (ED) records reviewed from 12/25/25 through 02/25/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. 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 transfer of individual with an EMC),” showed: - The purpose of this policy is to ensure that Boone Health meets the requirements set forth in the EMTALA and accompanying regulations, which govern the hospital’s responsibility to afford MSEs to certain individuals with EMC’s and to transfer or discharge these individuals only in accordance with the requirements of federal law. - An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of an individual in serious jeopardy, serious impairment to any bodily function(s) of an individual or serious dysfunction of any bodily organ or part of an individual. - A MSE will be conducted by a qualified individual to determine if the individual has an EMC. - If the individual is found to have an EMC, it will be determined if the hospital has the capability through its staff and facilities to provide treatment to stabilize the individual’s condition. - When an individual presents to the ED, if the hospital has the capability to do so, then the hospital will provide such further examination and treatment as is required to stabilize the individual’s EMC. - Stabilize means with respect to an EMC to provide such medical treatment as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to occur. - For patients whose medical conditions have been stabilized, but not entirely resolved, discharge may occur when the ED physician or other physician determines with reasonable clinical confidence that the patient’s continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or at a later time as an inpatient. For patients with psychiatric conditions, discharge may occur when the patient is no longer considered to be a threat to himself/herself or others. Please refer to A-2406 and 2407 for further details.”

“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: 48359 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#6) of 30 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED. 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 EMC)” showed: - The purpose of this policy is to ensure that Boone Health meets the requirements set forth in the EMTALA and accompanying regulations, which govern the hospital’s responsibility to afford MSEs to certain individuals with EMC’s and to transfer or discharge these individuals only in accordance with the requirements of federal law. - A MSE will be conducted by a qualified individual to determine if the individual has an EMC. - Appropriate examination means an examination beyond medical triage which is conducted by “qualified personnel” that is within the capability of the hospital including ancillary services routinely available, to determine whether an EMC exists. - EMC means a medical condition manifesting itself by acute symptoms of sufficient severity, including psychiatric (relating to mental illness) disturbances, such that the absence of immediate medical attention could reasonably be expected to result in placing the individuals health in serious jeopardy or serious impairment to any bodily functions of an individual or serious dysfunction of an bodily organ or part of an individual. - If the individual is found to have an EMC, it will be determined if the hospital has the capability through its staff and facilities to provide treatment to stabilize the individual’s condition. - For patients whose medical conditions have been stabilized, but not entirely resolved, discharge may occur when the ED physician or other physician determines with reasonable clinical confidence that; the patient’s continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or at a later time as an inpatient; for patients with psychiatric conditions, discharge may occur when the patient is no longer considered to be a threat to himself/herself or others. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” approved 12/23/24, showed emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Review of Patient #6’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report dated 02/03/26, showed: - At 12:22 PM, a call was received for the non-emergent transfer of Patient #6, who was a 71-year-old male that was “just sitting and won’t do anything.” - His past medical history included an abdominal aortic aneurysm (AAA, a weak, bulging spot in the abdominal aorta [the body’s main artery that carries blood from the heart to the rest of the body]), balance issues, depression, dysphasia (condition that affects your ability to produce and understand spoken language), encephalopathy (damage or disease that affects the brain), failure to thrive, high cholesterol, insomnia (difficulty falling asleep or staying asleep), glaucoma (a group of eye conditions that can cause blindness, the nerve connecting the eye to the brain is damaged, usually due to high eye pressure), high blood pressure, kidney failure and pulmonary embolism (PE, blood clot in the lung) . - His home medications included Tylenol (medication that treats minor pains and fever), amlodipine (a medication used to treat high blood pressure and chest pain), atorvastatin (reduces the amount of cholesterol in the blood, to reduce the risk of cardiac problems), Brimonidine (eye drops to treat glaucoma), bupropion (medication to reduce depression), vitamin D supplement, Dorzolamide (eye drops to treat glaucoma), Eliquis (a medication used as a blood thinner or to prevent blood clots from forming), losartan (a medication used to treat high blood pressure), MiraLAX (a laxative [a medication that treats constipation]), mirtazapine (antidepressant, medication to reduce the constant feeling of sadness or hopelessness), olanzapine (antipsychotic medication that affects chemicals in the brain), omeprazole (medication to treat frequent heartburn), tamsulosin (medication that relaxes the muscles in the prostate and bladder neck, making it easier to urinate), timolol (eye drops to treat glaucoma) and Trazadone (a medication used to treat depression). - At 12:30 PM, upon arrival, the patient’s home health nurse advised EMS the patient was discharged from Nursing Home B the day before “without warning” and the patient did not have his medications or tube feeding supplies. The home health nurse stated the patient was not safe to leave by himself and the patient’s wife planned to return to work the following day. - The patient ambulated, down the stairs, to the outside stretcher with the assistance of two persons. - At 12:35 PM, his mental status was somnolent (sleepy, drowsy). - At 12:42 PM, his vital signs (VS, measurements of the body’s most basic functions: Blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute and respiration rate (RR) normal 12 to 20 breaths per minute) were HR 64, RR 18 and BP 210/111. His oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100) was 97%. - At 12:54 PM, his VS were BP 182/100, HR 64, RR 18 and SAO2 100%. - Report was provided to the hospital registered nurse (RN) and the social worker. Review of Patient #6’s medical record dated 02/03/26, showed: - At 1:05 PM, he presented to the ED with a request for a medication refill. The family reported he was “kicked out” of Nursing Home B the day before without tube feed and wound care supplies or medications. - Additional home medications included Vyzulta (eye drops to treat glaucoma) and Rhopressa (eye drops to treat glaucoma). Trazadone was not listed as a home medication. - His body mass index (BMI, measurement of body fat based on height and weight, normal is 18.5 to 24.9) was 21.3. - At 1:07 PM, his VS were body temperature (T, normal 97.8o to 99o Fahrenheit (F)) was 97.8o F and RR 16. A Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) showed he was not being treated for a behavioral health condition. His pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was zero. - From 1:07 PM to 2:00 PM, his VS were HR 64 to 68, RR 16, BP 186/94 to 181/97 and SAO2 99% to 100%. - The history of present history showed his medical history included depression, schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work and may experience hearing voices that are not real), failure to thrive, alcohol abuse and “a number of other age-related comorbidities.” His wife reported the home health nurse visited and stated that he needed to be in a 24-hour care facility. There was some issue of what medications he should take, but the nursing home reported they inadvertently kept his medications, and they were available to the patient. The patient’s wife stated she could take care of Patient #6 at home, but not during working hours. Social work spoke with the patient and ultimately his wife did think she could take care of him at home. He walked and participated normally, had good strength and had no specific complaints. - The physical exam showed he was alert and oriented, thin, had a flat affect (absence or near absence of emotional expression) and was withdrawn. He was neurologically (neuro, relating to or affecting the nervous system) “grossly intact.” He had no suicidal ideation (SI, thoughts of causing one’s own death), homicidal ideation (HI, thoughts or attempts to cause another’s death), flight of ideas (jumping from one topic to the next, common with mania), ruminations (habit of constantly replaying negative scenarios in your mind) or disorganized thoughts. His wife reported he hallucinated (seeing or hearing things which are not there). - There was no documented skin, wound or feeding tube site assessment. - The medical decision making showed his prior visits were reviewed and no needs were identified. It appeared his wife needed help during the day. It was discussed the wife was to contact the patient throughout the day to make sure he was safe. She was instructed to have food items he would eat available and have family/friends check on him throughout the day. The wife was agreeable. Social work provided resources for social and elder services. - There were no social work notes in the medical record. - At 2:11 PM, he was discharged via a private vehicle with a clinical impression of failure to thrive in an older adult, major depressive disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy) with psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) features and severe protein-calorie malnutrition. - The discharge instructions included directions to supplement oral feedings with tube feedings, take medications as prescribed and contact senior services to help navigate in-home services. - A prescription was sent to a local pharmacy for tube feedings. - He was instructed to follow up with a referring provider in two to three days. - No laboratory work was completed. - On 02/05/26, Patient #6 passed away. Review of the police report titled, “Case Number 2026-001070,” dated 02/05/26, showed: - On 02/04/26 at approximately 4:45 PM to 5:00 PM, Patient #6’s spouse reported him missing. - On 02/05/26 at 11:00 AM, Police responded to an unconscious and not breathing back male found on the roadside. - The black male was identified as Patient #6 and he was deceased. During a telephone interview on 02/26/26 at 4:30 PM, Staff N, Physician, stated that Patient #6 had poor oral intake and was supplemented with tube feedings. The patient was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), answered questions appropriately and had no delusions (a strongly held, false belief that persists despite clear, undeniable evidence to the contrary). He called the nursing home and was told the patient’s medications were available for the patient’s wife to pick up. He discussed the tube feeding with the patient’s wife and she had administered the feedings previously. He felt confident in her ability to administer the tube feedings and care for the patient. He offered to admit the patient, but the patient and his wife wanted to be discharged. He stated that social work was involved to assist in the identification of barriers and those were addressed. He was confident the patient was given adequate supplies and resources for a safe discharge to his home. During a telephone interview on 03/03/26 at 1:03 PM, Staff O, Social Worker, stated that she was at the patient’s bedside with the physician to gather facts. She was familiar with the patient and declined to answer if she believed the patient was safe to be alone. She stated that she believed the patient was more capable than he wanted to appear. After a long conversation with the patient, his spouse and the physician, it was determined the patient could keep himself “occupied” during the day and they had “other people” to offer support. From the spouse’s reaction to the conversation, she believed the spouse understood the logic of the patient discharging to home. She observed the spouse nod as she “digested” the physician’s education, and she understood the patient’s discharge plan. There was no emergent crisis. She felt the home health nurse “overreacted,” and the issue was more social between the patient and his spouse. She assessed the patient to be “sheepish” because he allowed the home health nurse to overreact. She believed the spouse knew how to administer the tube feedings. She wrote no notes on this interaction because she was there as a witness and there was no additional planning required of her. During a telephone interview on 03/04/26 at 10:30 AM, Staff M, RN, stated that she cared for Patient #6 many times and his chief complaint during the visit was not having his medications or tube feeds. He spoke, walked and dressed independently. His spouse “seemed to know” what was going on and appeared capable of administering the tube feeding. The spouse was informed she could pick up his medications from the nursing home. She had no concerns the patient was not safe at home. He was not impulsive or inappropriate. If she did not believe he would be safe at home, she would have spoken up. She would not have allowed him to discharge to the care of his wife if she did not believe his wife was capable of caring for him.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#6) of 30 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. 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 EMC)” showed: - When an individual presents to the ED, if the hospital has the capability to do so, then the hospital will provide such further examination and treatment as is required to stabilize the individual’s EMC. - An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of an individual in serious jeopardy, serious impairment to any bodily function(s) of an individual or serious dysfunction of any bodily organ or part of an individual. - Stabilize means with respect to an EMC to provide such medical treatment as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to occur. Review of Patient #6’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 02/03/26, showed: - At 12:22 PM, a call was received for the non-emergent transfer of Patient #6, who was a 71-year-old male that was “just sitting and won’t do anything.” - His past medical history included an abdominal aortic aneurysm (AAA, a weak, bulging spot in the abdominal aorta [the body’s main artery that carries blood from the heart to the rest of the body]), balance issues, depression, dysphasia (condition that affects your ability to produce and understand spoken language), encephalopathy (damage or disease that affects the brain), failure to thrive, high cholesterol, insomnia (difficulty falling asleep or staying asleep), glaucoma (a group of eye conditions that can cause blindness, the nerve connecting the eye to the brain is damaged, usually due to high eye pressure), high blood pressure, kidney failure and pulmonary embolism (PE, blood clot in the lung). - At 12:30 PM, upon arrival, the patient’s home health nurse advised EMS the patient was discharged from Nursing Home B the day before “without warning” and the patient did not have his medications or tube feeding supplies. The home health nurse stated the patient was not safe to leave by himself and the patient’s wife planned to return to work the following day. - At 12:35 PM, his mental status was somnolent (sleepy, drowsy). - At 12:42 PM, his vital signs (VS, measurements of the body’s most basic functions: Blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute and respiration rate (RR) normal 12 to 20 breaths per minute) were HR 64, RR 18 and BP 210/111. His oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100) was 97%. - At 12:54 PM, his VS were BP 182/100, HR 64, RR 18 and SpO2 100%. - Report was provided to the hospital registered nurse (RN) and the social worker. Review of Patient #6’s medical record, dated 02/03/26, showed: - At 1:05 PM, he presented to the ED with a request for a medication refill. The family reported he was “kicked out” of Nursing Home B the day before without tube feed, wound care supplies and medications. - From 1:07 PM to 2:00 PM, his VS were HR 64 to 68, RR 16, BP 186/94 to 181/97 and SpO2 99% to 100%. -The present history listed his medical problems as depression, schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work and may experience hearing voices that are not real), failure to thrive, alcohol abuse and “a number of other age-related comorbidities.” His wife reported that the home health nurse visited and stated that he needed to be in a 24-hour care facility. There were issues with what medications he should take. The nursing home reported they had inadvertently kept his medications, but they were available to the patient for pickup. The patient’s wife stated she could take care of Patient #6 at home, but not during working hours. Social work spoke with the patient and ultimately his wife did think she could take care of him at home. - The physical exam showed he was alert and oriented, thin, had a flat affect (absence or near absence of emotional expression) and was withdrawn. He was neurologically (neuro, relating to or affecting the nervous system) “grossly intact.” He had no suicidal ideation (SI, thoughts of causing one’s own death), homicidal ideation (HI, thoughts or attempts to cause another’s death), flight of ideas (jumping from one topic to the next, common with mania), ruminations (habit of constantly replaying negative scenarios in your mind) or disorganized thoughts. His wife reported he hallucinated (seeing or hearing things which are not there). - There was no documented skin, wound or feeding tube site assessment. - The medical decision making showed his prior visits were reviewed and no needs were identified. It appeared his wife needed help during the day. It was discussed for his wife to contact the patient throughout the day to make sure he was safe. She was instructed to have food items he would eat available and have family/friends check on him throughout the day. His wife was agreeable. Social work provided resources for social and elder services. - There were no social work notes in the medical record. - At 2:11 PM, he was discharged via a private vehicle with a clinical impression listed as failure to thrive in an older adult, major depressive disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy) with psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature) features and severe protein-calorie malnutrition. - The discharge instructions included directions to supplement oral feedings with tube feedings, take medications as prescribed and contact senior services to help navigate in-home services. - A prescription was sent to a local pharmacy for tube feedings. - He was instructed to follow up with a referring provider in two to three days. - No laboratory work was completed. - On 02/05/26, Patient #6 passed away. Review of the police report titled, “Case Number 2026-001070,” dated 02/05/26, showed: - On 02/04/26 at approximately 4:45 PM to 5:00 PM, Patient #6’s spouse reported him missing. - On 02/05/26 at 11:00 AM, Police responded to an unconscious and not breathing black male found on the roadside. - The black male was identified as Patient #6, and he was deceased. During a telephone interview on 02/26/26 at 4:30 PM, Staff N, Physician, stated that Patient #6 had poor oral intake and was supplemented with tube feedings. The patient was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), answered questions appropriately and had no delusions (a strongly held, false belief that persists despite clear, undeniable evidence to the contrary). Staff N called the nursing home and was told the patient’s medications were available for the patient’s wife to pick up. He discussed the tube feeding with the patient’s wife and she had administered the feedings previously. He felt confident in her ability to administer the tube feedings and care for the patient. He offered to admit the patient, but the patient and his wife wanted to be discharged. He stated that social work was involved to assist in the identification of barriers and those were addressed. He was confident the patient was given adequate supplies and resources for a safe discharge to his home. During a telephone interview on 03/03/26 at 1:03 PM, Staff O, Social Worker, stated that she was at the patient’s bedside with the physician to gather facts. She was familiar with the patient and declined to answer if she believed the patient was safe to be alone. She stated that she believed the patient was more capable than he wanted to appear. After a long conversation with the patient, his spouse and the physician, it was determined the patient could keep himself “occupied” during the day and they had “other people” to offer support. From the spouse’s reaction to the conversation, she believed the spouse understood the logic of the patient discharging to home. She observed the spouse nod as she “digested” the physician’s education, and she understood the patient’s discharge plan. There was no emergent crisis. She felt the home health nurse “overreacted,” and the issue was more social between the patient and his spouse. She assessed the patient to be “sheepish” because he allowed the home health nurse to overreact. She believed the spouse knew how to administer the tube feedings. She wrote no notes on this interaction because she was there as a witness and there was no additional planning required of her. During a telephone interview on 03/04/26 at 10:30 AM, Staff M, RN, stated that she cared for Patient #6 many times and his chief complaint during the visit was not having his medications or tube feeds. He spoke, walked and dressed independently. His spouse “seemed to know” what was going on and appeared capable of administering the tube feeding. The spouse was informed she could pick up his medications from the nursing home. She had no concerns that the patient was not safe at home. He was not impulsive or inappropriate. If she did not believe he would be safe at home, she would have spoken up. She would not have allowed him to discharge to the care of his wife if she did not believe his wife was capable of caring for him.”

“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: 50151 Based on observation, interview, record review and policy review, the hospital failed to: - Provide registered nurse (RN) supervision and evaluation of nursing care for one patient (#35) of one discharged patient who required an insulin (medication that regulates the amount of sugar in the blood) pump for management of insulin dependent diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). (A-0395) - Follow the hospital’s policy for insulin pump management after surgery for one patient (#35) of one discharged patient reviewed who required an insulin pump for management of insulin dependent diabetes. (A-0395) - Recognize, investigate and follow the hospital’s policies and procedures for insulin administration for a patient with insulin dependent diabetes. (A-0395) - Ensure physician notification, appropriate consults, and orders were obtained for one patient (#35) of one discharged patient reviewed who required an insulin pump for management of insulin dependent diabetes. (A-0395) The safety and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 09/25/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions. Those actions included education to all clinical nursing and medical staff, and the addition of questions to the preoperative checklist regarding diabetes diagnosis and insulin management. These failed practices resulted in a systemic failure and non-compliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please see A-0395 for further details. .”

“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: 50151 Based on observation, interview, record review and policy review, the hospital failed to: - Provide registered nurse (RN) supervision and evaluation of nursing care for one patient (#35) of one discharged patient who required an insulin (medication that regulates the amount of sugar in the blood) pump for management of insulin dependent diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). - Follow the hospital’s policy for insulin pump management and blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal ranges are considered between 70 and 100. Normal range for a known diabetic is 80 to 180) checks after surgery for one patient (#35) of one discharged patient reviewed who required an insulin pump for blood glucose management. - Recognize, investigate and follow the hospital’s policies and procedures for insulin administration for a patient with insulin dependent diabetes. - Ensure physician notification, appropriate consults and orders were obtained for one patient (#35) of one discharged patient reviewed who required an insulin pump for management of insulin dependent diabetes. Findings included: Review of the hospital’s undated policy titled, “Insulin Pumps,” showed: - Patients were permitted to use their personal insulin pump while hospitalized when they were alert, physically capable, had the ability to properly work the pump functions and were willing to manage their pump. - Patients with an altered mental status, or with unstable level of consciousness, whose pump was disconnected for more than one hour, or if they were undergoing a test or procedure that would interfere with the pump’s operation, they must be managed with an alternative method of insulin administration. - Patients unable to use their insulin pump and require basal (long-acting insulin used to maintain stable blood sugar levels between meals and during sleep), mealtime (fast-acting or rapid-acting insulin taken at mealtimes to manage the rise in blood sugar that occurs after eating and correction (dose of rapid- or short-acting insulin given to lower blood sugar levels that are currently high) insulin doses. - The provider must be consulted for alterative insulin orders when an insulin dependent diabetic was unable to use their insulin pump for blood glucose management. - The nurse should contact the provider for basal, bolus and correction insulin orders, one to two hours prior to removing an insulin pump. Review of the hospital’s undated policy titled, “Medication Administration: Insulin,” showed, the provider should be notified for guidance when removing an insulin pump to request an alternative method of blood glucose management when a patient with an insulin pump has been scheduled for surgery and would not be able to manage their blood glucose with the insulin pump. Review of the hospital’s document, “Incident Report,” dated 06/25/25, showed: - An incident report was entered after a rapid response (a changing situation that requires more staff to address the current needs of the patient) team was activated for Patient #35. Her blood glucose was 501. - The nurse was unaware that Patient #35 was an insulin dependent diabetic with an insulin pump. - Staff WW, Physician, was present during the rapid response and reported she had expected a call for additional orders since Patient #35 was unable to operate her insulin pump. - On 06/26/25 at 10:23 AM, Staff E, Nurse Manager, documented the potential root causes for Patient #35 going into diabetic ketoacidosis (DKA, life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic) and the inadequate blood glucose management. Reasons included glucose checks were ordered per protocol, but the protocol was not listed; there were no further instructions or direction regarding glucose management; an order for an insulin pen was activated on her home medication list; the pharmacy entered the insulin pen to be restarted the following morning; and the recovery room admitting nurse did not contact the provider for clarification regarding insulin management orders or for blood glucose checks. The pharmacist working on 06/24/25, attempted to contact the nurse for clarification of the insulin orders but did not receive a response from the patient’s nurse. The start time for the insulin pen order was entered to start on the morning of 06/25/25, not immediately after surgery. - On 07/02/25, Staff ZZ, Chief Medical Officer, reviewed the incident report and indicated the development of a team to improve the process for insulin pump usage for hospitalized patients. - On 09/23/25 at 9:18 AM, Staff VV, Clinical Nutrition Manager, documented a multidisciplinary team was formed to improve the process for inpatient insulin pump usage and to identify patients wearing an insulin pump when admitted. - There were no additional action items or education provided as a response to the incident. Record review of Patient #35’s medical record showed: - On 06/23/25 at 1:06 PM, she was contacted by phone for a pre-operative assessment. Her home medications were reviewed, an entry for an insulin pen was activated, and an entry to deactivate insulin administration via her insulin pump was initiated. Patient #35 was instructed not to take any insulin the day of surgery. - On 06/24/25 at 6:44 AM, Patient #35, a 74-year-old female, presented to the hospital’s pre-admissions department for a scheduled sigmoid colon (S-shaped part of the large intestine just before the rectum) resection (to remove part of an organ). She did not wear her insulin pump to the hospital, as instructed. - Her belongings list did not show she had an insulin pump. - At 7:21 AM, blood glucose checks were ordered per protocol. - At 8:27 AM, she received a one-time dose of seven units of insulin in the operating room (OR). - At 12:11 PM, a post-operative assessment showed she was able to move all four extremities voluntarily and on demand; she was able to open her eyes to verbal commands. - At 12:19 PM, she received a one-time dose of five units of insulin in the recovery room. - At 1:43 PM, her blood glucose was 240. Anesthesia was notified and provided an order for a one-time dose of insulin. - At 1:56 PM, Patient #35 transferred to the surgical floor. - At 6:38 PM, her post-operative orders were initiated. The orders included correction insulin doses before meals and at bedtime, to start the morning of 06/25/25. No orders were listed for basal or meal-time insulin, or for the patient to utilize her insulin pump. - During the night, her blood glucose was never checked, she did not receive any insulin, and her insulin pumped was not resumed. - On 06/25/25 at 7:45 AM, nursing staff found her unresponsive to painful stimuli. A rapid response was activated, and her blood glucose was found to be 501. She was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with DKA and started on an insulin drip. - At 8:00 PM, her blood glucose levels had returned to the normal range along with her mental status. - On 06/26/25 at 11:48 AM, she received a dose of basal insulin and was transitioned off the insulin drip. Orders were initiated that indicated her blood glucose was to be managed with basal, mealtime and correction insulin doses. - At 6:41 PM, an endocrinologist (a physician who specialize in the endocrine system of glands that make hormones to control moods, growth and development, metabolism, organs, and reproduction) was consulted for blood glucose management. The endocrinologist noted Patient #35 went into DKA as a result of not resuming her insulin pump post surgery. The recommendation was to restart her insulin pump the next morning on 06/27/25. - On 06/28/25, her blood glucose values were being adequately managed with her insulin pump, and she was discharged home. During an interview on 09/24/25 at 11:00AM, Staff E, Nurse Manger, stated that she thought Patient #35’s family had brought her insulin pump to the hospital and had questioned her RN about allowing her to use the insulin pump. The nurse should have contacted the provider for insulin management orders when the family asked about the insulin pump. There were no orders for insulin management in her medical record. During an interview on 09/24/25 at 11:30 AM, Staff VV, Clinical Nutrition Manager, stated that, she was not involved with Patient #35’s care and was unaware of the incident until after it occurred. A committee was looking into hypoglycemic events and possible root causes for hypoglycemic episodes. The committee discussed Patient #35’s incident but that was not their focus. She was not aware of any action items being rolled out in response to the event but knew there was going to be work on the subject. During an interview on 09/24/25 at 12:00 PM, Staff WW, Physician, stated that she placed the orders for Patient #35’s insulin pump to be restarted after surgery. She was not notified by nursing staff that Patient #35’s insulin pump had not been restarted or contacted for alternative insulin management orders. She has not been contacted or received any communication related to Patient #35’s incident. She expected nursing staff to contact her when physician orders were unable to be followed. During an interview on 09/24/25 at 4:00 PM, Staff ZZ, Chief Medical Officer (CMO), stated that Patient #35 went into DKA because her insulin pump was not restarted after surgery. As a result of Patient #35’s incident, they formed a team to look at insulin pump management in the hospital. They were working on improving their order set and have added a few questions regarding diabetes and insulin pump usage to their preoperative checklist. They discovered that Patient #35 was called on 06/23/24 for her preoperative interview, the incorrect insulin order was activated and the order for insulin administration through her insulin pump was deactivated. She believed the hospital has put into place or was working on implementing interventions to prevent other patients from developing DKA as a result of insulin pumps not being restarted. During an interview on 09/25/25 at 11:15 AM, Staff CCC, RN, stated that she admitted Patient #35 to the floor from the recovery room. Another nurse resumed Patient #35’s care an hour later. When she arrived at the floor, a blood glucose was not checked because she had not been out of the OR for more than an hour. She released the physician’s postoperative orders but was unable to recall if those orders included insulin or not. When the pharmacy attempted to contact her regarding the insulin order, she was busy and declined the call. She never followed up with the pharmacy regarding the nature of their call. Patient #35’s sister was with present when she arrived on the floor. Her sister mentioned she had the patient’s pump but did not specify it was an insulin pump. She did not instruct the sister to take the insulin pump home. During an interview on 09/25/25 at 11:30 AM, Staff DDD, Chief Nursing Executive Officer, stated that she was not very involved with the incident but had been educated once the survey started. A Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) or Critical Incident Analysis should have occurred. The order for the insulin pen should have been caught and followed up on by the nurse. There should have been a hand-off between the recovery room and the floor nurse, which should have included a medical history. Staff were not provided education related to Patient #35’s incident. The hospital needed to work on the process of identifying patients who used insulin pumps and how they are to be used for insulin management with hospitalized patients.”

“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: 50151 Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#1) of 21 Emergency Department (ED) records reviewed from 11/01/24 through 08/25/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 3,139. Findings included: Review of the hospital’s undated policy titled, “EMTALA,” showed: - An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future. - A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility. - When the MSE indicated that a patient had an EMC, the hospital must provide stabilizing treatment within its capability and capacity or, if the hospital did not have the capacity or capability to provide stabilizing treatment, the hospital must provide a transfer to another hospital that had such capabilities. - To be stabilized means being provided medical treatment necessary to ensure no medical deterioration of the condition was likely to occur. Please refer to 2406 for further details.”

“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: 50151 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#1) of 21 Emergency Department (ED) records reviewed from 11/01/24 through 08/25/25. These failures had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s undated policy titled, “EMTALA,” showed: - An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future. - A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility. - When the MSE indicated that a patient had an EMC, the hospital must provide stabilizing treatment within its capability and capacity or, if the hospital did not have the capacity or capability to provide stabilizing treatment, the hospital must provide a transfer to another hospital that had such capabilities. - To be stabilized means being provided medical treatment necessary to ensure no medical deterioration of the condition was likely to occur. Review of Patient #1’s medical record, dated 11/20/24, showed: - At 1:21 PM, she was a 36-year-old who arrived at the ED with a chief complaint of heavy vaginal bleeding, abdominal pain and bloating, since having a colposcopy (a procedure used to examine the cervix [the lower, narrow end of the that forms a canal between the uterus and vagina] for any abnormalities) performed on 10/31/24. - She had a past medical history which included, depression (extreme sadness that won’t go away), attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and a recent abnormal pap smear (a screening procedure that examines cells from the cervix for abnormalities that may indicate cervical cancer). Her pap smear showed she had atypical squamous cells of undetermined significance (ASCUS, indicates there are abnormal cells on the cervix, but it is not clear if they are precancerous or cancerous) and was positive for human papillomavirus (HPV, a sexually transmitted infection of the virus that can cause genital warts and cervical cancer). A colposcopy was performed on 10/31/24, due to the abnormal pap smear. - She was triaged and her VS were taken. Her pulse was 96, BP 141/96, and temperature of 97.8 degrees. A pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) showed she rated her pain as a five out of ten. A sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) screening performed showed she was not at risk for developing sepsis. - At 1:28 PM, Staff L, Physician, ordered a complete blood count with differential (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 45 to 117), a C-reactive protein test (CRP, a test that measures the amount of CRP in the blood to detect inflammation either for acute conditions or to monitor chronic conditions) and urinalysis (a laboratory examination of a person’s urine). - At 2:41 PM, her pregnancy test was negative. Her CBC showed, her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) was 10.8, other laboratory results were normal. - At 2:52 PM, her pulse was 80 and BP 133/65. - At 3:00 PM, her pulse was 79 and BP 125/63. - At 2:59 PM, Staff L, Physician, documented Patient #1 was calm, cooperative and comfortable. She was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). - At 3:15 PM, her pulse was 74 and BP was 119/67. - At 3:57 PM, a transvaginal ultrasound showed, the uterus was normal size, contour and echotexture. The endometrium (mucous membrane lining the uterus) was not thickened, at eight millimeters (mm). There was no free fluid and the left ovary had a normal appearance. A transabdominal ultrasound was performed to assess the right ovary, which showed it had a normal appearance. - At 4:00 PM, her pulse was 74 and BP 116/66. - At 4:13 PM, Staff L documented that he re-evaluated the patient. He reviewed her laboratory and ultrasound (a test that uses sound waves to create images of structures within the body) results. He ordered a urine culture to be performed on the urine sample she provided, to rule out a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). The MSE provided to Patient #1, determined there was no evidence of cervicitis (inflammation of the cervix) as her inflammatory markers were not elevated. He determined she could be discharged home with instructions to follow-up with her OB/GYN within the next week. She was instructed to take over-the counter pain relievers and to return to the ED if she developed a fever or if her symptoms worsened. She was provided a follow-up referral to see a primary care provider, within two to three days. Discharge education provided included, education on vaginal bleeding and cervical biopsy (take a sample of tissue or cells for testing). - A pelvic exam was not performed as part of her MSE. - At 4:14 PM, she received a dose of Ketorolac (a nonsteroidal anti-inflammatory drug used to treat pain) intravenous (IV, in the vein) for pain. - At 4:45 PM, she was discharged home. During an interview on 08/27/25 at 12:15 PM, Staff L, Physician, stated that Patient #1’s lab work was within normal ranges. She didn’t need a pelvic exam because she had just had a colposcopy and a transvaginal ultrasound was performed while she was in the ED. He didn’t recall the patient pushing to have a pelvic exam performed. He thought she was set up to have an ultrasound repeated as an outpatient. When a patient presented to the ED with a complaint of vaginal bleeding, a MSE consisted of frequent vital sign checks, and checking their blood counts and urine to determine stability. The MSE was aimed at finding the cause of the bleeding and to determine how much blood they had lost or were actively losing. Patients were monitored in the ED for a few hours for evaluation and for active blood loss to be identified. Heavy blood loss was considered when a pad needed to be changed once or more per hour. When heavy bleeding occurred, blood counts would be rechecked a couple of hours after the first test was performed. The patient’s vital signs were checked every 15 minutes during the time they are being evaluated. The decision to transfer a patient would be made if their vital signs became unstable or blood counts showed acute blood loss that the hospital was unable to manage The hospital had full OB services and a patient would not be transferred to another hospital for a higher level of OB care. He did not recall Patient #1 voicing any concerns about being discharged. Prior to discharging a patient, he would go into the room to speak with the patient, ask them if they understood the precautions they were to be discharged with and ask if there was anything they needed prior to being discharged. He felt Patient #1 was stable from a bleeding standpoint and was not concerned with her slightly elevated WBC count. He instructed her to return to the ED if she developed a fever or if her bleeding increased. She was also instructed to follow-up with her primary care and OB/GYN providers. During an interview on 08/27/25 at 1:25 PM, Staff M, CMO, stated that a second peer review was completed for Patient #1’s ED visit on 11/20/24. It was determined she received a complete and thorough MSE, for her chief complaint. Her VS and blood counts were stable throughout her ED visit. A pelvic exam was not indicated since a transvaginal ultrasound was performed. She was instructed to follow up with her OB/GYN. The MSE determined she did not have an EMC, at that time. She had several things happen in the weeks and months following her ED visit. The issues, which occurred later , were not caused by the care she received in the ED. She followed-up at Hospital B’s OB/GYN clinic and her additional concerns were managed on an outpatient basis. In addition to the second peer review, Patient #1’s case was presented to the Professional Practice Committee who determined she received appropriate care based upon her chief complaint. A pelvic exam was not needed in every case of vaginal bleeding and not doing one didn’t mean she wasn’t provided a complete MSE. Patient #1’s WBC count was not elevated to the point they were concerned or considered an infection as a differential diagnosis. The patient never mentioned she had symptoms of bacterial vaginosis which was diagnosed at her follow-up OB/GYN visit. Her chief complaint did not include itching and vaginal discharge. Typically, bacterial vaginosis didn’t cause an elevated WBC count or an invasive infection. When she went to her OB/GYN appointment a week or so after her ED visit, and reported that since her ED visit, she noticed vaginal discharge. She was diagnosed with bacterial vaginosis and was provided a medication for treatment. Although requested, no interview was conducted with the physician who performed Patient #1’s colposcopy, on 10/31/24.”

“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: 39147 Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) and failed to follow their policy that addressed individuals who presented for treatment for one patient (#25) of 30 Emergency Department (ED) records reviewed from 04/01/23 through 10/30/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 2,728. Findings included: Review of the hospital’s undated policy titled, “EMTALA”, showed that if an individual presents to an “area of the hospital” other than the ED and seeks or appears to need treatment for an EMC, the following will occur: If the individual is within the main building of the hospital and it can be done safely, the individual will be escorted to the ED. If there is concern that this cannot be done safely, then a call will be made on 3501 to the ED or if the individual’s condition presents an imminent (code) situation, then a call will be made on 3333. If the individual is at another area of the hospital, Boone Health will provide an MSE to the extent that qualified personnel are available and can do so. These personnel who are present will function as first responders. “Area of the Hospital” for purposes of this policy means any part of the hospital building or grounds. Review of the hospital’s undated policy titled “Medical Staff Rules and Regulations - MSEs”, showed that individuals that present to the hospital seeking treatment or examination, should receive a MSE to rule out an EMC. Patient #25 was driven to the hospital by a friend and arrived at the main entrance of the hospital. The friend entered the main entrance and asked for immediate help but was directed by the front desk staff to drive to the ED entrance. Prior to arrival the patient complained of not feeling well, a sore throat, and a rash. During her transport to the hospital, she became unconscious. Review of Patient #25’s ED medical record, dated 04/13/23, showed: - She was a 29-year-old female who arrived at 2:19 PM. - Two hours prior to her arrival at the ED, she took a dose of an old prescription antibiotic and experienced an odd feeling of itching, and was overall, not feeling well. She took two antihistamine (a medication used to relieve allergy symptoms, such as hay fever, hives, and reactions to insect bites or stings) tablets. - At 2:20 PM, her blood pressure (BP, normal was approximately 90/60 to 120/80) was low, at 78/39 and she was assessed by an ED Physician. - At 2:24 PM, an intravenous (IV, in the vein) line was inserted. - At 2:25 PM, blood work was drawn. Her BP was 100/49. - At 2:27 PM, IV fluids were administered, along with IV steroids (drugs used to relieve swelling and inflammation). - At 2:29 PM, she received a dose of IV antihistamine. Her strep throat culture was negative. - At 2:30 PM, her BP was 121/66. - At 4:25 PM, her BP was 134/79. - At 7:15 PM, she was discharged home with diagnoses of anaphylaxis (severe, life threatening allergic reaction) and hypotension. The failure of the hospital staff to follow their internal policy related to a individual who presents to any area other than the hospital ED delayed emergency medical care to determine an emergency medical condition when Patient #25 was driven to the main hospital entrance seeking emergency care. The ED is located on the opposite side of the main entrance. Travel to the ED required leaving the hospital campus and traveling down side streets to arrive at the ED entrance, which had the potential to further delay emergency care. Review of Patient #14’s first medical record, dated 08/07/23 at 11:28 AM, showed that she was a 51-year-old female who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), due to alcohol intoxication. She reported that she consumes a fifth of vodka daily. She denied any drug use. During triage (process of determining the priority of a patient’s treatment based on the severity of their condition) she stated, “I just want to kill myself. I would use a knife.” She repeated that statement multiple times. She kept insisting that she needed to leave. At 11:49 AM, she left the ED, her disposition was left without being seen (LWBS). Law enforcement was alerted. Review of Patient #14’s second medical record, dated 08/07/23 at 2:58 PM, showed that she presented to the ED via EMS with complaints of alcohol intoxication and drunk in public. During triage she stated again that she was suicidal (thoughts of causing one’s own death). At 5:38 PM, Patient #14 left against medical advice (AMA). Authorities were alerted again. The police department found the patient and took her to Hospital B where she was placed on a 96-hour hold (court-ordered evaluation by behavior specialist to determine if a person is safe to themselves and others) and admitted for further care on 08/07/23. Please refer to 2406 for further details.”

“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: 39147 Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) of 30 Emergency Department (ED) records reviewed from 04/01/23 through 10/30/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 2,728. Findings included: Review of the hospital’s undated policy titled “Medical Staff Rules and Regulations - MSEs”, showed that individuals that present to the hospital seeking treatment or examination, should receive a MSE to rule out an EMC. Review of Patient #14’s first ambulance report, dated 08/07/23 at 10:45 AM, showed that law enforcement located this female lying in a parking lot and was slow to respond to officers. She was initially unaware of Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) upon approach. She was slow to wake up with verbal prompts. Throughout EMS interaction, the patient refused to answer most questions, proving to EMS that she was alert and oriented only to self. After evaluation, the patient requested EMS transport to a hospital ED, but refused to inform EMS as to why she wished to be transported. Upon arrival to the ED, patient care was transferred to ED nursing staff and patient then informed nursing staff that she was suicidal (SI, thoughts of causing one’s own death). Review of Patient #14’s first ED medical record, dated 08/07/23, showed that: - She was a 51-year-old female who arrived in the ED via ambulance due to alcohol intoxication at 11:21 AM. - At 11:22 AM, her triage (process of determining the priority of a patient’s treatment based on the severity of their condition) assessment noted the patient presented for alcohol intoxication, confirmed she was homeless, reported drinking a fifth of vodka that day and denied any drug use. During her triage, she said “I just want to kill myself. I would use a knife.” multiple times and insisted she “needs to leave”. Multiple staff members tried to talk the patient into being evaluated. Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) showed her as high risk. The protocol orders listed in the triage note included one to one observation (1:1, continuous visual contact with close physical proximity), elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury), notify provider, prepare a psychiatric (relating to mental illness) safe room (a room that has been cleared of any objects a patient might use to harm themselves or others), paper scrubs, and to provide resources at discharge. - At 11:23 AM, her vital signs (VS, body temperature, blood pressure, heart rate, and breathing rate) were blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80), 115/87, temperature (T, degree of hotness or coldness of the body, normal is 98.6 °F) 97.7 degrees, heart rate (HR, the number of times the heart beats within a certain time period, usually a minute) 80, respiration rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) 16, and oxygen saturation (SPO2, measure of how much oxygen is in blood) 100%. - At 11:39 AM, she denied treatment, asked to leave, and left the ED. Disposition was charted as left without being seen (LWBS). - At 11:40 AM, Staff AA, ED Physician, noted that Patient #14 left prior to seeing her. A nurse called 911 due to the patient’s intoxication. - At 11:41 AM, Staff Y, ED Clinical Supervisor, noted that she insisted that she needed to leave and verbalized multiple times of SI. Multiple staff members tried to talk the patient into being evaluated. The patient ripped off the heart monitor and walked out of the ED. - At 11:45 AM, Staff BB, ED Social Worker (EDSW), noted that Patient #14 reported SI, but had no plan. She requested to leave, and EDSW tried to convince her to stay for mental health treatment. Patient #14 denied treatment, asked to leave, and left the department. EDSW contacted Boone County Joint Communications to report patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility). During a phone interview on 11/01/23 at 1:55 PM, Staff BB, EDSW, stated that she had been called to assist with the triage of Patient #14 during her first ED visit. She was pretty intoxicated. The patient had voiced to the triage nurse that she wanted to harm herself with a knife. When Staff BB spoke with her, she did not disclose any type of plan, but had stated repeatedly that she was, “tired of living,” and she just “wanted to die.” When Staff BB attempted to discuss a treatment plan, Patient #14 became agitated. She just kept repeating, “I’m tired of living,” and “I just want to die.” The next thing she knew, Patient #14 pulled the heart monitor wires and the blood pressure cuff off, got up and left the room. She stated that staff members attempted to get her to stay for treatment, but she just stated, “I want to leave.” When Patient #14 left the ED, she contacted local law enforcement out of concern, to notify them that the patient was intoxicated. During an interview on 11/01/23 at 11:20 am, Staff Y, ED Clinical Supervisor, stated that Patient #14 came in by EMS, and was uncooperative with staff and answering questions. She was highly intoxicated, got agitated, and wanted to leave. She started ripping everything off. Other staff and Staff BB were in the room. The protocol would be initiated if the patient’s C-SSRS evaluation score was moderate to high risk. The ED would start 1:1 observation, clear the room, and secure the patient’s belongings at the nurses’ station. 1:1 observers were to fill out a form and place in the patient’s chart. When asked what elopement was, Staff Y responded “That’s a great question,” its patients leaving the hospital not in their right mind and unable to make decisions for themselves. A disposition of elopement was not seen a lot. Staff could refer to the policy or ask the SW if they had questions regarding which disposition to use. During an interview on 11/01/23 at 2:20 PM, Staff Z, ED Manager, stated that he could not find any 1:1 observation documentation for either visit for Patient #14. During a concurrent interview with Staff CC, RN, and Staff Z, ED Manager, on 11/01/23 at 2:20 PM, they stated that ED staff were not allowed to hold patients in the ED per the hospital’s legal staff. During an interview on 11/01/23 at 1:30 PM, Staff AA, ED Physician, stated that Patient #14’s first visit, she arrived via EMS, and by the time she got to see her, the patient had walked out. Staff called 911. Review of Patient #14’s second ambulance report, dated 08/07/23 at 2:31 PM, showed EMS found her sitting on a curb by a building, and still had her hospital bracelet on. She was holding a gallon jug of vodka. She refused to answer questions. She had discharge paperwork for alcohol intoxication from her earlier ED visit, approximately three hours prior. When she stood up, she defecated on the Emergency Medical Technician (EMT). Review of Patient #14’s second ED medical record, dated 08/07/23, showed that: - At 2:58 PM, she arrived via ambulance, with a complaint of alcohol intoxication and drunk in public. - At 2:59 PM, she was assessed by an ED Physician. - At 2:59 PM, Staff CC, ED RN, triage assessment noted EMS was called again due to the patient sitting up against a wall of a gas station and appeared to be under the influence of alcohol with a large bottle of vodka sitting behind her. Patient refused to answer any questions, therefore EMS had to bring patient to the ED to be medically evaluated. During triage, the patient would intermittently respond to some questions but was not clear with responses due to slurred speech. BP was 125/75, C-SSRS risk level was high risk. Response protocol was initiated which included 1:1 observation, EP, notify provider, prepare a psychiatric safe room, paper scrubs, notify dietary, and provide resources at discharge. - At 3:16 PM, ethyl alcohol (ETOH, amount of alcohol in the blood. Normal range is less than 10) was elevated at 386, urinalysis (a laboratory examination of a person’s urine) returned positive for a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra), and she tested negative for illegal drugs. - At 3:41 PM, a Point-of-Care testing (POC, medical testing done at or near the point of care of patient) Arterial Blood Gas (ABG, a blood test that measures the amount of oxygen and carbon dioxide in the blood) test was completed, and abnormal findings include Partial Pressure of Oxygen (pO2, measures the pressure of oxygen dissolved in your blood. It helps show how well oxygen moves from your lungs to your bloodstream. Normal range is 74-108) was low at 47. - At 3:48 PM, Staff AA, ED Physician, noted Patient #14 had altered mental status, and appeared under the influence. Patient #14 was not talking at first, then had slurred speech when she did start talking to the RN. She admitted to SI, but had no plan. - At 3:55 PM, Staff CC, ED RN, noted she was disorientated, restless, alert to person only, slurred speech, resistive to care, alcohol intoxication, diarrhea, and urinary incontinent upon arrival. - At 4:09 PM, her care was transferred from Staff AA, ED Physician to Staff X, ED Physician Assistant (PA). - At 5:07 PM, her VS were BP 157/111, HR 129, and SPO2 99%. - At 5:10 PM, Staff CC, ED RN, rounding documentation noted Patient #14 was restless and stated “I need to go to the bathroom.” She told Patient #14 that she did have a female external urinary catheter in place, but the patient removed it from herself. She asked the patient to stand so they could place new clean linens on the bed while Staff BB, EDSW, was at bedside conversing with patient. Patient then began to say “I need to go. I need to go. Where’s my debit card? I need to go.” Which mimics the same statements and attitude patient exhibited earlier today upon her first visit, RN and EDSW attempted to inform the patient that they could help her feel better and get her the long-term help she was seeking, but if she left again, they would be legally forced to notify law enforcement of her against medical advice (AMA) status while she also claims to be SI. A few minutes later, patient started dressing herself and said “I need to go.” Staff X, ED PA, was notified. The patient walked to the bathroom and then shortly after wandered out to a side exit of the ED, became lost, needed a provider to buzz the patient back into the ED and then Staff CC asked patient if she was looking for the exit still and patient replied “Yeah.” Staff CC then showed the patient the direction to the exit. Law enforcement was notified by EDSW immediately. - At 5:38 PM, Staff CC, ED RN, documented she left AMA, dressed herself, walked to the bathroom, and then to the exit without assistance. - EDSW noted she was alerted to patient upon her arrival to the ED. Patient #14 arrived via EMS with reports of alcohol intoxication. Patient #14 endorsed SI thoughts at that time but denied a plan. She appeared altered and answered questions after they have been repeated several times. EDSW later spoke with patient who endorses SI again, denied a plan, and requested to leave at that time. EDSW attempted to work with patient to get her to stay to seek mental health treatment. Patient left the ED and EDSW contacted Boone County Joint Communications and updated them on the patient’s location and concerns for her safety. EDSW spoke with a law enforcement officer who came to the ED to follow up and obtain a description of patient. - Staff X, ED PA, noted she was seen walking the department and her VS remained stable. She did not speak with nursing staff, but spoke freely with EDSW. She was supposedly under arrest sometime today. She continued to wander the floors and at one point got stuck in the hallways behind our locked doors. She eventually eloped, and 911 was called, as she was considered a danger to herself. During a phone interview on 11/01/23 at 1:55 PM, Staff BB, EDSW, stated that during Patient #14’s second ED visit, she was returned by EMS. ED staff had prepared room two for her, since it had direct line of sight (LOS, continuous visual contact with the patient) for all staff members. When Staff BB spoke with the patient and asked about intent to harm herself, Patient #14 denied a plan. She had repeated multiple times that she, “wanted to die,” and she, “didn’t want to live anymore.” When they began discussing a treatment plan, she was kind of agreeable to receiving help. The second time Staff BB entered the room, Patient #14 stated that she did not want placement and did not want help. Staff CC, RN, and Staff BB, were both in the room when Patient #14 wanted to “find my debit card and leave.” She grabbed her clothes, got dressed, and left the room. Staff BB was present in the room when Patient #14 got dressed. Once the patient left, Staff BB, placed a call to local law enforcement. Staff BB stated that the plan had been to find placement for Patient #14 the entire time. She had not sent any referrals out yet, because the patient’s intoxication level was too high for placement. If a patient’s alcohol level was too high, they would need to sober up and would be held in the ED. She was unsure whether or not Patient #14 was safe. She had been able to answer questions, she seemed alert and orientated. She was able to walk, wasn’t stumbling, but wasn’t 100% steady. During an interview on 11/01/23 at 2:20 PM, Staff CC, RN, stated that she was the nurse assigned on the second ED visit. She had not been aware of the patient’s first visit. Patient #14 had been brought in to the ED by EMS. She was drunk and disorderly. It had been difficult to get through the triage process. Patient #14 had not been cooperative and would not respond to questions. She would just look around, or not answer, or only supply half answers. She had asked about SI, but had to ask several times. Patient #14 would answer, “Yeah.” She did not verbalize that she had a plan. By the end of the triage questions, she was very antsy. She seemed frantic, and kept searching for answers. The provider asked Patient #14 if she was SI and she would say, “No.” But when the EDSW asked if she was SI, then she would say, “Yes.” Patient #14 had been cooperative for the first couple of sets of VS, then all of the sudden she was pulling the cords off and the external urinary catheter. She was asking for her debit card. She would say she was, “ready to go.” She became frantic and kept asking about her debit card. Patient #14 stated she wanted her clothes, she then got dressed. She asked to use the bathroom and was showed the way. She was trapped in a back hallway and security had to open the door for her, and let her out. Staff called local law enforcement to report that Patient #14 had left the ED and was visibly intoxicated. She was definitely pretty intoxicated and did not want to cooperate. She had been with it enough to demand to leave. Staff CC stated that staff members tried to get Patient #14 to stay and to de-escalate her. She was a danger to herself, something could have happened, or she could injure herself. Staff contacted law enforcement because they were concerned for her safety, she was still saying she was SI. Staff cannot hold a patient against their will or physically hold them down for treatment. During an interview on 11/01/23 at 1:30 PM, Staff AA, ED Physician, stated that during Patient #14’s second visit, she was awake and alert, but she didn’t want to talk. She did take her clothes off and was given a paper gown. Patient #14 did eventually report SI. The mental health assessment was based on nursing documentation, and the provider evaluation. At the end of her shift, she signed Patient #14 over to Staff X, ED PA. During an interview on 11/01/23 at 11:05 AM, Staff X, ED PA, stated that Patient #14 was handed off to her at shift change and she needed to find her psychiatric placement. Staff X was shocked that the ED RN showed her out to the exit. She was not capable of making her own decisions, and she was still intoxicated. During an interview on 11/01/23 at 11:20 am, Staff Y, Clinical Supervisor, stated that during Patient #14’s second visit, she had a 1:1 observer. Patient #14 refused to talk. Her RN and physician did believe she was SI. If a SI patient walked out, we contacted Joint Communications and the Police Department, and gave a description. During an interview on 11/01/23 at 11:20 AM, Staff Z, ED Manager, stated that psychiatric patients should be 1:1 observation until they have been cleared or admitted to a mental health treatment facility. He would expect his staff to verbally convince a psychiatric patient to stay for treatment. Review of Police Department E’s document titled, “Reporting Officer Narrative - 2023-007248,” dated 08/07/23 at 6:31 PM, showed: - Law enforcement officers had been called for a female wandering around a parking lot, getting into random cars. - There had been two previous calls in relation to Patient #14. She had presented to Hospital A both times, stated she was SI, and then left the hospital before being treated. She was gone before law enforcement officers could arrive at Hospital A. - The officer located Patient #14. She was extremely intoxicated, and had appeared to have vomited on herself. She told the officer she wanted to “go to the hospital.” She stated that she was having SI thoughts. - Upon arrival at Hospital B, Patient #14 attempted to leave multiple times. She informed hospital staff that she was very drunk and SI, she wanted to kill herself using a knife. - 96-hour hold (court-ordered evaluation by behavioral specialist to determine if a person is safe to themselves or others) paperwork was completed. Review of Hospital B’s document titled, “Notice of Admission of Involuntary Patient,” dated 08/07/23, showed that Patient #14 was placed on a 96-hour hold for detention, evaluation and treatment due to reasonable cause that she was suffering from a mental disorder or alcohol and drug abuse, and presented a likelihood of serious physical harm to herself or others. Review of Hospital B’s document titled, “Application for 96 Hour Imminent Harm Admission,” dated 08/07/03 at 7:13 PM, showed that Patient #14 was highly intoxicated and was observed going into other persons vehicles and drinking from bottles she found inside of the vehicles. She had previously presented to Hospital A twice that day, stating that she wanted to kill herself. Review of Patient #14’s Hospital B ED medical record, dated 08/07/23, showed that: - At 7:07 PM, she arrived at the hospital very intoxicated, reporting that she was SI and would use a knife to stab herself. - She was being admitted on a 96-hour hold. - She reported drinking one pint of vodka per day, but recently as much as a gallon per day for the last few days. - She had been experiencing auditory and visual hallucinations (hearing and seeing things that are not heard by others, imaginary). - She was discharged from medical on 08/14/23, and admitted to psychiatry. Ultimately being discharged from the hospital on 08/17/23, 10 days after admission to the ED.”