Centerpoint Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 46856 Based on observation, interview, video review, medical record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. These failures had the potential to affect safety of all patients. The hospital failed to: - Ensure the CEO was responsible for management of the entire hospital; (A-0057) - Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility) of one current patient (#68) of one current patient record reviewed and three discharged patients (#14, #39, and #68) of three discharged patient records reviewed; (A-0144) - Ensure patients determined to be at risk for suicide (to cause one’s own death) were re-assessed per the hospital’s policy for one current (#5) patient of one current patient record reviewed and two discharged patients (#14 and #28) of two discharged patient records reviewed; (A-0144) - Ensure patients who required one to one (1:1, continuous visual contact with close physical proximity) sitters were appropriately observed per the hospital’s policy for one current patient (#5) of one current patient record reviewed and one discharged patient (#28) of one discharged patient record reviewed; (A-0144) - Ensure staff appropriately assessed, implemented and documented fall prevention interventions for four current patients (#1, #12, #64, and #65) of eight current patient records reviewed and one discharged patient (#13) of one discharged patient record reviewed; (A-0144) - Ensure staff followed provider orders and assessed for alcohol withdrawal symptoms on one current patient (#12) of one current patient record reviewed; (A-0144) and - Ensure appropriate monitoring and nursing documentation during the use of restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) for two discharged patients (#53 and #55) of four discharged patients records reviewed for restraints. (A-0175) These failed practices resulted in a systemic failure and non-compliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body. Please refer to the 2567 for further details.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50151 Based on observation, interview, video review, medical record review and policy review, the hospital failed to: - Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility) of one current patient (#68) of one current patient record reviewed and three discharged patients (#14, #39, and #68) of three discharged patient records reviewed; (A-0144) - Ensure patients determined to be at risk for suicide (to cause one’s own death) were re-assessed per the hospital’s policy for one current (#5) patient of one current patient record reviewed and one discharged patients (#14) of two discharged patient records reviewed; (A-0144) - Ensure patients who required one to one (1:1, continuous visual contact with close physical proximity) sitters were appropriately observed per the hospital’s policy and for one current patient (#5) of one current patient record reviewed and one discharged patient (#28) of one discharged patient record reviewed; (A-0144) - Ensure staff appropriately assessed, implemented and documented fall prevention interventions for four current patients (#1, #12, #64, and #65) of eight current patient records reviewed and one discharged patient (#13) of one discharged patient record reviewed; (A-0144) - Ensure staff followed provider orders and assessed for alcohol withdrawal symptoms on one current patient (#12) of one current patient record reviewed; and (A-0144) - Ensure appropriate monitoring and nursing documentation during the use of restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) for two discharged patients (#53 and #55) of four discharged patient records reviewed for restraints. (A-0175) The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 12/10/25, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on behavioral emergency response team (BERT, team members respond to a call to assist a patient in behavioral crisis) and missing person code activation. All remaining staff were provided education prior to the start of their next shift. These failed practices resulted in a systemic failure and non-compliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 46856 Based on observation, interview, video review, medical record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation: Patient’s Rights. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s untitled document, dated 12/10/25, showed that all administrative leaders reported to Staff QQQ, CEO. During a telephone interview on 12/31/25 at 10:30 AM, Staff QQQ, CEO, stated that he was “responsible for every aspect of what we do” at Centerpoint Medical Center.”

“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: 46856 Based on observation, interview, video review, record review, and policy review, the hospital failed to: - Prevent the elopement for one current patient (#68) of one current patient record reviewed and three discharged patients (#14, #28, and #39) of three discharged patient records reviewed for elopement; - Ensure patients determined to be at risk for suicide (to cause one’s own death) were re-assessed per the hospital’s policy for one current patient (#5) of one current patient record reviewed and one discharged patients (#14) of two discharged patient records reviewed for re-assessment; - Ensure patients who required one to one (1:1, continuous visual contact with close physical proximity) sitters were appropriately observed per the hospital’s policy for one current patient (#5) of one current patient record reviewed and one discharged patient (#28) of one discharged patient record reviewed for 1:1 observation; - Ensure staff assessed, implemented and documented fall prevention interventions for four current patients (#1, #12, #64, and #65) of eight current patient records reviewed and one discharged patient (#13) of one discharged record reviewed for fall assessment and interventions; and - Ensure staff followed provider orders and assessed for alcohol withdrawal symptoms on one current patient (#12) of one current patient record reviewed for alcohol withdrawal. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of hospital policy titled, “Patient Elopement,” reviewed 08/18/25 showed the hospital must provide a safe and secure environment for all patients. Special consideration must be given to patients who are not able to competently and safely care for themselves. Elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) will be enacted on those patients who have been determined to be an elopement risk. An elopement risk refers to a patient who leaves unsupervised, does not have the mental capacity or legal authority to leave the hospital against medical advice (AMA), is incapable of adequately protecting themselves and poses a safety risk to themselves or to others if left unattended. These patients should not leave the facility without proper discharge and a safety plan. All reasonable measures shall be taken to prevent patient elopement. EPs are interventions taken by staff to reduce the risk of patients with a known safety risk from wandering off or leaving the facility. Interventions include the use of a 1:1 sitter and bed alarm with frequent rounding. Patients should be in a hospital gown or paper scrubs, in a room away from the area exits, have their shoes and personal belongings removed. EPs do not require a physician order or affidavit (a written statement confirmed by oath, for use as evidence in court) and may be initiated by a RN for the protection and safety of the patient. Elopement risk factors include patients with decreased mental capacity, a previous elopement attempt, or a tendency to wander. They should be evaluated for a 1:1 observation or need for a sitter, and all personal belongings including cellphones should be removed from the room. When staff recognize the elopement of a patient, the staff member that initially detects the elopement will call the operator and request an overhead page for a missing person. The eloped patient should be returned to the unit, staff should notify the physician and charge nurse. An incident report should be completed, and the circumstances of the elopement will be reviewed through the serious event analysis process including the identification of the root cause, prevention and additional action steps. This should be reported to the patient safety committee. Review of Patient #14’s medical record, dated 11/14/25, showed: - A 46-year old male with a past psychiatric (relating to mental illness) history which included schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly) and bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) was admitted to the fourth floor for evaluation and treatment of abdominal pain, nausea, vomiting and diarrhea. While in the Emergency Department (ED), he provided conflicting information on the symptoms he had been having at home. He wasn’t able to provide much of a medical history and reported he would do whatever he needed to do to have surgery. A general surgeon was consulted and determined he did not require any surgical intervention. - On 11/17/25 at 12:47 PM, a telehealth psychiatric provider re-evaluated the patient. During the re-evaluation, he expressed suicidal ideations (SI, thoughts of causing one’s own death) and auditory hallucinations (hearing things that are not heard by others, imaginary) that told him to attempt suicide and hurt others. Based on his Suicide Risk Detail Assessment he was now considered as a high risk. The psychiatric provider recommended medication adjustments; transfer to an inpatient psychiatric hospital when medically cleared; a surrogate decision maker due to his lack of capacity to make informed treatment decisions; and that he not be allowed to leave AMA. Delirium (an abrupt change in the brain that causes confusion), EPs, suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm), and self-harm (behavior that is harmful or potentially harmful to oneself) precautions were recommended to be added to his treatment plan, along with the initiation of a 1:1 sitter for safety. - On 11/21/25, a follow-up telehealth psychiatric evaluation was performed. Nursing staff reported Patient #14 made suicidal statements, refused to take his medications, had continued agitation, made delusional (false ideas about what is taking place or who one is) statements and exhibited disorganized behaviors. - On 11/22/25, nursing assessed him to be oriented to person and place. His 1:1 sitter activated the Behavioral Emergency Response Team (BERT, a group of individuals with special training that respond to behavioral health emergencies) after Patient #14 laid on the floor and would not get up. Once he returned to his room he continued to yell and curse at himself. Medication for agitation was administered. After lunch, another BERT was paged overhead for the fourth floor. A nurse and a patient care technician (PCT) responded to Patient #14’s room but he was not there. They ran down the hall to a set of elevators where Patient #14’s 1:1 sitter informed them he had gotten into the elevator. The nurse proceeded to go down the stairs attempting to locate him. They exited the stairs on the first floor, but he was not there. Security officers arrived and they all proceeded to the first-floor lobby. Several staff members were in the stairwell looking down to the ground level. Patient #14 was located laying on the floor, bleeding badly. Two nurses were with him. Review of Patient #14’s trauma medical record, dated 11/22/25, showed: - At 1:57 PM, he was taken to the ED as a traumatic cardiac arrest (when the heart suddenly and unexpectedly stops pumping). He had suffered a fall of greater than 30 feet when he went over a first-floor railing and landed on the ground floor. - His head and right arm were bleeding. He had no purposeful movement and was not responsive. - Upon arrival to the ED he was pulseless. Saff initiated Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) and provided continuous life-saving measures but they were unable to revive him. - At 2:37 PM, life-saving measures were stopped, and the patient was pronounced deceased. Review of the hospital’s video footage titled, “Timeline-2025-11-22 09.30.11.450,” showed Patient #14 walking in the hall of the fourth floor. He was wearing blue scrub pants, no shirt and yellow hospital socks. His 1:1 sitter was walking approximately five feet behind him. He stopped in front of the elevators before going out of the frame. He reappeared, then got onto the elevator and his sitter was observed speaking to him. The elevator doors closed, and the sitter attempted to re-open them. The patient managed to get the elevators doors closed and the 1:1 sitter was observed trying to get them to open. Two minutes into the video, the 1:1 sitter was observed running down the hall and the elevator doors remained closed (the times on the video do not reflect the appropriate time). Review of the hospital’s video footage titled, “Time-line-2025-11-22 04.59.33 135,” showed Patient #14 exiting the elevator onto the fourth floor. He was wearing blue scrubs, no shirt and yellow hospital socks.” Review of the hospital’s video footage titled, “Timeline-2025-11-22 04.36.27.935,” showed Patient #14 walking toward the lobby on the first floor. There were no staff members around or following the patient. He arrived at a glass railing that over-looked the ground floor. He looked over the railing then attempted to swing his leg over the railing. He used a larger planter to step-up on as he attempted to go over the railing Review of the hospital’s video footage titled, “Timeline-2025-11-22 04.54.06.809,” showed the patient fall over the first-floor railing onto the ground floor below. The patient landed on his right shoulder and the right side of his head. He did not move after the fall. Review of the hospital’s document titled, “Incident Report #4638528,” dated 11/22/25, showed: - At 1:49 PM, a BERT was announced to the fourth floor. Three security officers responded and upon arrival were informed Patient #14 left the floor via an elevator. At the same time, the patient exited the elevators on the first floor and proceeded to the main lobby. The security team left the fourth floor using the same elevators the patient had used and went to the first floor. - At 1:50 PM, the patient climbed over the glass railing and fell to the ground floor. - When the security officers got to the first floor, one headed toward the ED and two headed toward the main entrance. Upon arrival at the main entrance, they observed several staff members surrounding Patient #14, who was laying on the ground floor unconscious. - At 1:53 PM, a security officer called a rapid response (a changing situation that requires more staff to address the current needs of the patient) for Patient #14. - At 1:54 PM, a missing person alert was announced over-head for a 46-year-old male from room 424. - At 1:56 PM, the patient was placed on a bed and transported to the ED. - Despite life-saving measures, the patient succumbed from his injuries he sustained during the fall. During an interview on 12/03/25 at 2:35 PM. Staff O, Chief Nursing Officer (CNO), stated that after patient #14’s elopement which resulted in his death, administration responded to the hospital to ensure all other “high-risk” patients were safe. The hospital implemented multidisciplinary daily safety huddles to ensure that high risk patients were having their needs addressed. Education was provided to all hospital staff regarding BERT activations as an elopement prevention measure. There was currently no elopement assessment tool in the electronic medical record (EMR) nor was there an order for EPs. The providers assumed the responsibility to assess if a patient was an elopement risk. During an interview on 12/04/25 at 3:15 PM, Staff Q, Security Guard, stated that he noticed that staff waited too long to press their panic buttons. As a result, security responded to the area where the BERT was activated, and the patient was already off the unit. For Patient #14, a BERT should have been activated when his 1:1 sitter could not get him to return his room, before he got into an elevator. This was a preventable event that resulted in the patient’s death. During a telephone interview on 12/15/25 at 11:35 AM, Staff FF, Telepsychiatry Physician, stated that when they consulted for patients, they provided recommendations only. The attending physician was responsible for implementing those recommendations into the patient’s treatment plan. He was consulted for Patient #14 due to agitation and psychosis (mental illness characterized by defective or lost contact with reality). The patient had disorganized and non-rational thoughts. There was no physical aggression, risk of flight or suicide identified. He needed inpatient psychiatric care when medically cleared and was appropriate to be considered as involuntary status (a legal process through which a person is hospitalized and treated for mental health disorders without their consent). Patient #14 lacked the mental capacity to be his own medical decision maker, and he recommended a surrogate decision maker be appointed. During an interview on 12/10/25 at 8:55 AM, Staff Z, House Supervisor, stated when a patient takes off, it should be called as an elopement. Most of the time staff called a BERT and the patient was already on the run. Security responded to the area of the incident then a missing person was called. Staff members should yell when elopements occur so other staff members on the floor can assist. The patient should not reach the elevators. 1:1 sitters needed additional education for their important role. They often did not know how to respond appropriately. During a telephone interview on 12/15/25 at 4:15 PM, Staff W, Patient Safety Assistant, stated that she was hired into the sitter role in 10/2025. On 11/22/25, she was assigned to sit with Patient #14. That was her first time caring for the patient. When she started her shift, the previous 1:1 sitter informed her Patient #14 was psychotic. She was afraid of him, but he didn’t try to hit her. He usually stayed in his room. When he went into the hall, she attempted to re-direct him, but he walked away from her, and she didn’t request assistance soon enough. Review of Patient #28’s medical record, dated 10/05/25, showed: - A 19-year-old male presented to the ED for a mental health assessment. Over the last couple of days, he had begun leaving his home, wandering. He has an intellectual disability and was missing for two days when his father found him. He suffered blisters on his feet and required admission and treatment for rhabdomyolysis (breakdown of damaged skeletal muscle releasing harmful substances like myoglobin [iron containing protein in muscles that store and transport oxygen] in the blood which can lead to kidney failure). - He received a psychiatric evaluation on 10/06/25, with the recommendation for inpatient psychiatric admission once medically stabilized. During his evaluation Patient #28 exhibited delusional and paranoid (excessive suspiciousness without adequate cause) behaviors and was having auditory hallucinations. He became increasingly anxious with the questioning related to his psychotic symptoms. A medical hold was recommended. - 1:1 observation was initiated upon admission. - On 10/09/25, he was placed on EP. His patient observation tool did not show any 1:1 visual safety check entered from 1:30 PM through 6:45 PM, and from 7:00 PM through 11:30 PM. Review of an undated hospital document titled, “Finalized Approved Incident #4536692,” showed security received a call on 10/09/25 at 7:45 PM from the sixth-floor nursing staff regarding a SI patient who attempted to elope. Patient #28 exited his room and proceeded to run down the stairwell, clearing floors six through one. The patient then exited the side door of the hospital. He was located approximately five minutes later by nursing staff and was escorted back into the hospital. He received medication, the situation resolved, and security left the sixth floor. During a concurrent interview and review of incident #9592 with Staff M, Director Patient Safety, on 12/03/25 at 9:00 AM, showed Patient #28 was on the sixth floor and had a chair alarm on the date of event. A Code BERT was called as Patient #28 exited the stairway. Two RNs followed him and called security from the stairwell. Patient #28 exited the hospital to the parking lot when the two RNs and security found him. He was brought back into the hospital and escorted back to the sixth floor. The incident was substantiated, Patient #28 did elope, he did have a chair alarm in place. A missing person alert was not announced over the intercom. There was no 1:1 sitter at the time of the elopement and per documentation there was no 1:1 sitter documentation until 11:30 PM, immediately following the elopement. “Per policy there was a high risk of elopement with this patient, and he should have had a 1:1 Patient Safety Assistant (PSA, sitter).” There were no actions made by the hospital in response to this elopement. Review of Patient #39’s medical record, dated 10/16/25, showed: - A 74-year-old female was admitted to the hospital for confusion. Her family reported they were concerned about her being more forgetful. She was diagnosed with metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood). - On 10/19/25, a 1:1 sitter was placed with the patient for safety. - On 10/21/25, telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) psychiatric consult was performed due to psychosis and agitation. Recommendations included, a 1:1 sitter and assault precautions (AP, measures to alert staff of a patient’s potential to become violent with others). - On 10/23/25, she was re-evaluated by psychiatry. At the time of the evaluation, she was confused with disorganized ideas and had difficulty following redirections. She repeatedly requested to be discharged. However, she was unable to participate in safe discharge planning. Recommendations included transfer to an inpatient psychiatric hospital for stabilization when medically cleared. - On 10/24/25 at 4:00 PM, the patient’s 1:1 sitter was discontinued due to her improved condition. - On 10/26/25, physician documentation indicated that she was paranoid and thought she was going to be sent to a Russian prison. The patient was gravely disabled, unable to toilet herself or complete simple tasks. Recommendations included, reconsulting telehealth psychiatry for re-evaluation and guidance on her need to be admitted to an inpatient psychiatric unit on an involuntary status. - On 10/27/25, prior to her telehealth psychiatry re-evaluation, the patient and her friend presented to the nurse’s station and the friend demanded discharge paperwork because the Patient #39 was leaving the hospital. Her nurse was not at the desk and the patient’s friend pulled her into an elevator and they left the hospital. During a telephone interview on 12/10/25 at 5:15 PM, Staff CC, Case Manager, stated that if psychiatry recommended an inpatient psychiatric admission when medically cleared, they would need to say if the patient was allowed to leave AMA or not. The patient should have been held until they were able to be re-evaluated by psychiatry. During an interview on 12/11/25 at 10:15 AM, Staff M, Patient Safety Director, stated that Patient #39 and her family supported her going to an inpatient psychiatric hospital when medically cleared but something changed. When the patient left the hospital, the local area police department found her at home with her ex-husband. She refused to return to the hospital. After her elopement, the hospital identified an opportunity for improved collaboration with the hospitalist and the telehealth psychiatric providers. They expected the psychiatric providers to clearly state if a patient needed to be an involuntary status admission. The hospital implemented a Behavioral Health Management work group to provide leadership oversight to ensure patients had everything they needed put into place. During a telephone interview on 12/15/25 at 10:20 AM, Staff LL, Unit Secretary, stated that Patient #39 and her friend came up to the desk and demanded discharge paperwork. She was unsure if she was allowed to leave and asked them to wait for her to find the patient’s nurse. Since the patient’s Patient 1:1 sitter had been discontinued a few days prior, she was unaware if the patient could leave or not. They did not want to wait and entered the elevator as soon as it opened. She was not allowed to physically stop anyone, but she did activate a missing person alert. During a telephone interview on 12/16/25 at 1:25 PM, Staff MM, Physician, stated that they re-consulted telehealth psychiatry so Patient #39 could be evaluated to determine if she needed to be placed on involuntary status. When patients lacked mental capacity to be their own medical decision maker, two physicians were required to evaluate them to determine their mental capacity. Ideally, one of the physicians would be a psychiatric provider. That was why she re-consulted telehealth psychiatry to have Patient #39 re-evaluated. Every provider on Patient #39’s care team agreed, she was acutely psychotic and was not allowed to leave AMA. Review of Patient #68’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 12/19/25, showed: - At 6:14 PM, EMS responded to the fire department where Patient #68 walked out of the fire station. - The fire department reported that Patient #68 was hallucinating and had a history of schizophrenia. - He complained of pain and stated that he wanted a refill on his medication which was stolen a week ago. He denied SI, homicidal ideations (HI, thoughts or attempts to cause another’s death) or hallucinations. - He was transported to Centerpoint Medical Center’s ED. Review of Patient #68’s medical record, dated 12/19/25, showed: - At 6:40 PM, a 49-year-old male, with a past history of schizophrenia and substance abuse (a complex condition where there is uncontrolled use of a substance despite harmful consequence) presented to the ED via EMS. His chief complaint was left shoulder pain, and he requested a medication refill. - At 6:43 PM, the triage documentation indicated his suicide screening risk level was no risk. - At 7:53 PM, a behavioral health consult was ordered. - At 7:58 PM, Staff UUU, NP, documented that Patient #68 reported all over body pain. He was out of his prescribed pain and psychiatric medications. He stated his medications had been stolen from him and was asking for a new prescription. He had attempted to refill his medications, but the refill was denied by insurance as being too early for refill. Staff UUU attempted to get a list of medications from him, to which he stated that he was just going to go out and “kill somebody because no one was giving him the help that he needed.” Staff UUU attempted to explain to explain that she was trying to help him. He stated that “it no longer mattered because he would kill somebody and then he would get the help that he needed.” He had no current plan. Staff UUU discussed the situation with the charge nurse and requested to move Patient #68 to the psychiatric area and completed an affidavit. Staff UUU was notified that the patient eloped from the ED. - The affidavit included Patient #68’s statement of “I’m going to go out and kill someone. I need help and no one will listen to me.” Along with his refusal to provide a medication list, and a second statement that “it no longer mattered because he would kill somebody and then he would get the help that he needed,” was included. - At 8:09 PM, a missing person alert was called. Staff UUU was notified that Patient #68 had eloped and his disposition was listed as “left AMA, eloped.” Review of the hospital’s undated report titled, “Risk Management Investigation,” showed: - On 12/19/25 at 7:48 PM, Staff UUU, NP, entered Patient #68’s room to evaluate him. - At 7:52 PM, Staff UUU exited Patient #68’s room and informed the charge nurse that the patient required a psychiatric evaluation. - At 7:53 PM, Staff UUU entered orders for a behavioral health consult, laboratory orders for medical clearance, and a behavioral health affidavit. - At 7:57 PM, Patient #68 exited his room and went to the bathroom. - From 8:00 PM through 8:02 PM, Patient #68 had exited the bathroom, and a staff member attempted to direct him back to his room. - At 8:06 PM, Patient #68 exited his room wearing a coat, stocking hat, and carrying a bag. - At 8:09 PM, a missing person code was called overhead. - At 8:10 PM, per video review, Patient #68 was seen exiting the front entrance of the main hospital. Security searched the parking lot and was unable to locate him. Law enforcement was immediately notified. - At 8:19 PM, security cleared the missing person code after video review showed Patient #68 had exited the main entrance. - At 8:25 PM, staff attempted to call Patient #68’s phone number with no answer. His next of kin were notified and stated that they no longer spoke with the patient. - Law enforcement responded to the hospital and a police report was initiated. The house supervisor notified the Administrator on Call (AOC) and the Emergency Preparedness Coordinator. - On 12/20/25, interviews were conducted with the provider, primary RN, receiving RN, and charge nurse. - On 12/22/25, a team meeting was held to review the event. Review of the hospital’s video footage titled, “Timeline-2025-12-29 01.41.47.967 PM,” showed Patient #68 exiting his patient room in the ED, walking down the hallway and exiting from camera view. He was wearing a jacket and hat, carrying an over-the-shoulder bag. Several staff members were observed sitting in the nursing station, but none appeared to notice Patient #68’s exit. Review of the hospital’s video footage titled, “Timeline-2025-12-29 02.10.54.437 PM,” showed a view of the main hospital lobby. Patient #68 walked to a chair in the lobby, sat down and picked up a landline phone. He appeared to dial the phone several times. Two minutes after he sat down, he hung up the phone, got up, grabbed his shoulder bag, and then briskly walked toward the main hospital entrance. Two individuals sitting in the lobby looked around, then got up and started walking toward Patient #68. Review of the hospital’s video footage titled, “Timeline-2025-12-29 02.01.34.566 PM,” showed an interior view of the main hospital entrance. Patient #68 walked briskly out the main hospital entrance. Four seconds later, a staff member walked into camera view and looked toward the door. Two seconds later, another staff member walked into camera view. The staff members appeared to briefly speak and then continued on toward the door. The first staff member walked out of camera view. During a telephone interview on 12/30/25 at 12:00 PM, Staff SSS, RN, stated that Patient #68 came in with a complaint of shoulder pain and tried to get new medications, because his other medications had been stolen. He denied SI or HI. Staff UUU, NP, went in to evaluate him and that was when he made HI statements. Staff UUU reported this to the charge nurse, who then informed Staff SSS of the statements. Staff were going to move Patient #68 to the psychiatric area, but his newly assigned room was not clean. Staff SSS tried to watch Patient #68, but did not have an assigned1:1sitter at that time. When Patient #68 went to the bathroom, Staff SSS went to check on another patient. When Staff SSS returned got, Patient #68 was gone. He thought the patient had been moved to the psychiatric area, but he wasn’t there. Staff SSS then notified the charge nurse, and a missing person alert was called overhead. All of the staff were busy. They should have discussed who was going to watch Patient #68, so he didn’t elope, but they didn’t. When a patient made SI or HI statements, they should immediately change into paper scrubs and they needed a 1:1. Someone always needed to keep their eyes on the patient, and the patient should be moved to the psychiatric area. During a telephone interview on 12/30/25 at 7:56 AM, Staff KK, RN, stated Patient #68 came in via EMS with a chief complaint of shoulder pain. He was placed in a regular room, his nurse got him settled in, and he denied SI or HI. Prior to being made a psychiatric patient, Patient #68 had been up, walking around the ED. The provider assessed the patient and then informed him, Staff KK, that Patient #68 needed to be moved to a psychiatric room. Staff KK updated the nurse that was going to care for Patient #68 after he was moved. It was very busy, during change of shift. That was when Patient #68’s primary nurse informed him that the patient wasn’t in his room. A missing person alert was called overhead. Security was able to pull up video footage and observed Patient #68 leaving the building. Staff KK assumed that once the provider stated that Patient #68 had been made a psychiatric patient, he automatically thought that Patient #68 was SI or HI. Patient #68 “should not have been left alone.” During a telephone interview on 12/30/25 at 8:11 AM, Staff TTT, RN, stated that he was going to receive Patient #68 after he had made homicidal statements. He saw Patient #68 up and walking around the ED. His primary nurse directed him back to his room, and Staff TTT went to prepare his new room. When he returned, Patient #68’s primary nurse informed him that the patient was gone. A missing person alert was called overhead. If a patient reported SI or HI, he would assess them, notify the charge nurse and the provider, make sure someone was watching the patient, and then move the patient to the psychiatric area. Once moved, he would proceed with the hospital’s SI and HI safety protocol. During a telephone interview on 12/30/25 at 8:33 AM, Staff UUU, NP, stated that Patient #68’s psychiatric medications had been stolen, and insurance denied an early refill. She attempted to explain to him that if insurance had denied his prescription, she could write him a new one, but he would likely not be able to get it filled for the same reason. Patient #68 became upset and said no one was helping him. She explained to him that she was not involved with insurance approval but could give him a dose of his medications while he was in the ED. Patient #68 then stated that he was “going to kill someone to get the help that he needed.” Staff UUU told the patient that he would have to stay and walked to the doorway of the room. The charge nurse was just across the hallway, and she told him that Patient #68 had made a HI statement. His primary nurse entered the room and Staff UUU left the room to put in orders and fill out an affidavit. She “never left the patient alone.” She was told later that Patient #68 had eloped from the ED. During a telephone interview on 12/30/25 at 9:45 AM, Staff M, Patient Safety Director, stated that when they investigated Patient #68’s elopement, they found Staff SSS, RN, had not followed protocol and there was a delay in initiating safety precautions (changing the patient into paper scrubs, removing his belongings, 1:1 not being implemented, etc.). Staff were supposed to stay with the patient, secure the patient’s belongings, and get the patient to a monitored area. Patient #68 was able to go to the bathroom unattended and Staff SSS then directed the patient back to his room. Patient #68 entered his room, put on his coat and hat, and walked out of the ED to the main hospital lobby. A missing person alert was called overhead. Patient#68 heard it and walked out the main hospital entrance. Law enforcement was notified. The patient was known to be homeless. Staff called the patient several times but were unable to reach him. They contacted his next of kin to notify them of his status. His family indicated that they had not been in contact with Patient #68. He had “a few dozen ED visits over the past few months” for similar complaints of his medications being stolen but he had never escalated to making HI statements. Staff’s familiarity with Patient #68 “seemed to decrease risk awareness.” There had been a delay in Patient #68’s new room being cleaned and the garage door needed to be closed prior to Patient #68 being taken to the room. During an interview on 12/09/25 at 9:05 AM, Staff R, RN, stated that if a patient on EPs ran, he would call a BERT and the charge nurse to help. Patients could become violent if staff tried to prevent them from leaving. If a patient started running down the stairwell, he “would call a BERT.” During an interview on 12/09/25 at 9:50 AM, Staff T, RN, stated that if a patient was on EPs and left their room, she would try to get the patient back in their room and to keep them calm. If she could not stop the patient, she would “call a BERT team,” close the doors in the hallway and have people watch the stairwell. If a patient made it off the unit, she would call a missing person alert. Review of hospital policy titled, “Suicide prevention,” dated 12/2025, showed the hospital ensured a safe environment for the provision of care to patients at risk for suicide. Patients in non-psychiatric areas (ED and non-BH inpatient units), ages 12 years and older, who were evaluated or treated for behavioral health conditions as their primary reason for care, should be screened using the Columbia Suicide Severity Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life.). The at-risk patient was to be monitored and reassessed, with daily documentation. The nursing assessment included current, recent, and past thoughts of suicide, plans, means and/or intent, as well as recent or past history of suicide attempts within their lifetime. Any patient with a positive, “at-risk” C-SSRS screening (i.e., low, moderate or high risk) required a secondary level suicide detailed risk assessment to identify activating events, protective factors, and contributing clinical factors to risk of suicide. Those assessments were to be completed by a licensed or credentialed physician or practitioner who reassessed at-risk patients daily and as needed with a change in patient condition. High-risk patients were to have 1:1 PSA observation. Moderate-risk patients were to have a virtual PSA or were kept in continuous line of sight (LOS, continuous visual contact with the patient). Review of an undated hospital document titled, “On-going Environmental Safety Check List,” showed this form must be completed every shift and signed by the sitter and RN. Staff were to remove all of the patient’s clothing, shoes, jewelry, and phone, place them in paper scrubs, and search and remove all patient belongings. Curtains should be removed, and doors should be open at all times. Notify dietary to serve a “safety tray” finger foods with no utensils if possible. If utensils are necessary, they must be plastic, and a disposable tray used. Sitters accompanied patients to the bathroom, always maintain LOS, and carry safety pendants and phones with them at all times. Ligature risks were to be removed from the environment including tubing, wires, strings, or cords. Trash cans, side tables, drawers, chairs or any moveable furniture except the bed should be removed or secured. Any item that could be used as a weapon or for self-harm should be removed. Review of Patient #5’s medical record, dated 11/30/25, showed: - A 41-year-old female was admitted to the seventh floor for shortness of breath and fatigue. She was diagnosed with pneumonia. - She reported that she had taken 100 or more tablets of alprazolam (a sedative used to treat anxiety that can impair judgement, memory and coordination) and clonazepam (medication used to treat anxiety). She was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) and a 1:1 sitter was initiated. Her C-SSRS suicide risk level was documented as high risk. - On 12/01/25, a Suicide Risk Detail Assessment listed her overall risk level for suicide as high risk. She posed a high imminent risk of danger to self. Recommendations included 1:1 sitter, EPs, self-harm/suicide precautions, and to transfer her to inpatient psychiatric treatment when medically stable. - On 12/02/25, there was no Suicide Risk Detail Assessment documented. - On 12/03/25, 15-minute rounds were completed at 12:15 PM and 1:00 PM, with 45 minutes between rounding. Review of Patient #14’s medical record showed: - On 11/15/25 at 7:48 PM, his Suicide Risk Level was low. - On 11/16/25, a Suicide Risk Detail Assessment was not documented. - On 11/17/25 at 12:47 PM, a telehealth psychiatric provider re-evaluated him. He reported SI and auditory hallucinations that told him to attempt suicide and hurt others. His Suicide Risk Detail Assessment indicated he was now at high risk. The provider recommended some medication adjustments, transfer to an inpatient psychiatric hospital when medically cleared, the appointment of a surrogate decision maker since he lacked capacity to make informed treatment decisions, and that Patient #14 could not leave AMA. Delirium, EP, SP, and self-harm precautions were recommended to be added to his treatment plan and a 1:1 sitter should be initiated for safety. - At 2:15 PM, a 1:1 sitter was provided for the patient. - On 11/18/25, a Suicide Risk Detail Assessment was not documented. - On 11/19/25, a Suicide Risk Detail Assessment was not documented. - On 11/20/25, a Suicide Risk Detail Assessment was not documented. - On 11/22/25, review of the 1:1 Protective Observation tool showed Patient #14 was in his room from 7:00 AM to 1:45 PM, except for at 8:15 AM when he was in the hallway. At 1:51 PM, a BERT was activated when he eloped from the fourth floor. Per video footage, Patient #14 had been up walking in the hallway for approximately 15 minutes prior to the BERT being called and getting into the elevator twice. - No Suicide Risk Detail Assessment was not documented on 11/22/25. During an interview on 12/10/25 at 8:55 AM, Staff Z, House Supervisor, stated an overall risk assessment of all psychiatric patients should be updated every 24 hours by the attending physician. During an interview on 12/22/25 at 1:05 PM, Staff UU, RN, stated that nursing completed an initial suicide assessment and notified the provider if the patient screened positive for SI. The provider performed an assessment and determined the overall risk level (ORL) for the patient. The provider did a daily suicide risk assessment and behavioral assessment. When Staff UU spoke with some of the providers, they were not aware that they were supposed to be performing the daily suicide risk assessments for patients. During a telephone interview on 12/18/25 at 9:30 AM, Staff QQ, Manager, stated that nursing was expected to complete a C-SSRS every shift. Hospitalists assessed suicide risk daily or deferred the assessment to psychiatry. Review of Patient #28’s observation tool documentation showed: - On 10/05/25, from 6:00 AM until 6:45 AM, there was no documentation of 15-minute checks. He was on a 1:1 with PSA, no special safety precautions or visual safety checks were documented. - On 10/05/25, night shift, he was on a 1:1 with PSA, no special safety precautions or visual safety check were documented. - On 10/06/25, day shift, a mental status change was documented by the PSA. There was no documentation of notification made to the RN or physician. He was on a 1:1 with PSA, no special safety precautions or visual safety checks were documented. - On 10/06/25, night shift, no special safety precautions, type of patient observation, or visual safety checks were documented. - On 10/07/25, day shift, he was on a 1:1 with a PSA, no special safety precautions or visual safety checks were documented. - On 10/07/25, night shift, there were no visual safety checks documented. - On 10/08/25, day shift, no special safety precautions, type of patient observation or visual safety checks were documented. - On 10/08/25, night shift, documentation showed his door was closed from 7:30 PM through 2:15 AM, and closed again, from 3:00 AM through 3:15 AM. No special safety precautions or visual safety checks were documented. - On 10/09/25, his patient observation tool did not have a shift notated. There was no documentation on this form from 1:30 through 6:45 of 15-minute checks and no visual safety checks were documented. It is unclear if this was day or night shift. - On 10/09/25, night shift, he was on EP but no type of 1:1 observation was documented. There were no 15-minute safety checks documented from 7:00 PM through 11:30 PM or visual safety checks documented. - On 10/10/25, day shift, there was no documentation of 15-minute safety checks from 9:00 AM through 9:30 AM and 12:45 PM through 1:45 PM. He was on EPs and 1:1 with a PSA, with no visual safety checks documented. PSA documentation showed that at 1:59 PM, Patient #28 attempted to wrap a phone charger around his neck. The nurse was notified. There was no documentation by the RN of this incident. Neither the attending physician nor the psychiatrist were notified of the incident. Suicide precautions were not initiated, and no incident report was completed. A CSSR was not completed following the change in patient condition and there was no documentation of the removal of his personal belongings. - On 10/10/25, night shift, he was on EPs but no type of 1:1 was documented. His door was closed from 7:00 PM through 7:30 PM and 7:45 PM through 8:15 PM. No visual safety checks documented. - On 10/11/25, day shift, he was on EPs and had a virtual safety attendant. No 15-minute checks were completed from 1:15 PM through 2:00 PM. His door was closed 11:00 AM through 11:15 AM. There was no documentation of a 1:1 PSA from 1:30 PM through 2:00 PM and no visual safety checks were documented. - On 10/11/25, night shift, he was on EPs but no type of 1:1 was documented. His door was closed from 7:15 PM through 7:30 PM, and 7:45 PM through 9:00 PM. No visual safety checks were documented. - On 10/12/25, his patient observation tool did not have a shift notated. His door was closed from 7:00 through 8:30 and from 12:45 through 6:45. It is unclear if this was day or night shift. The PSA documented that Patient #28 attempted to leave at 8:30. No notification to the RN was documented and no visual safety checks were documented. - On 10/12/25, night shift, no visual safety checks were documented. - On 10/13/25, day shift, no visual safety checks were documented. - On 10/13/25 PM shift, he was on EPs, the type of 1:1 nor the visual safety checks were documented. - On 10/14/25, day shift, no special safety precautions, no type of 1:1 were documented, no visual safety checks were documented, and his door was closed from 8:00 AM through 8:30 AM. - On 10/14/25, night shift, no special safety precautions, no type of 1:1, or visual safety checks were documented. - On 10/15/25, day shift, no special safety precautions, no type of 1:1, no visual safety checks were documented, and his door was closed from 3:30 PM through 5:00 PM. - On 10/15/25, night shift, no special safety precautions, no visual safety checks were documented, and his door was closed from 7:45 PM through 8:15 PM. - On 10/16/25, day shift, his door was closed from 9:15 AM through 9:30 AM and no visual safety checks were documented. - Documentation was inconsistent related to visual safety checks and safety precautions. No On-going Environmental Safety Check Lists were completed. During an interview on 12/16/25 at3:15 PM, Staff X, PSA, stated she was often assigned to sit for two or three patients at a time. She usually sat in the hallway to attempt to watch the patients, but there were times she did not have continuous eyes on some patients since she was assigned more than one. At times, patients would shut their doors, and she would remain in the hallway. She would ask the patients to open the door, but they did not always do so. She would document the door as closed and did not have continuous line of sight. She was not sure what she was supposed to do when this occurred. She felt that the hospital did not do the 1:1 observations as they should have been and that this left the patients in unsafe situations. She had not been completing the visual safety checks on the patients. She was assigned as Patient #28’s 1:1 PSA, but she remained outside in the hallway. During an interview on 12/16/25 at 2:45 PM, Staff BBB, PSA, stated she was often assigned two to three patients to observe at one time. Most PSA’s sit in the hallway. Patients did shut their doors, even when they were on a continuous 1:1observation. Some PSAs just let them keep the door shut. She filled out the safety environmental sheets at times, but not with every patient. No one did the environmental safety checks. She had never seen a nurse come in and do one on her shift. She had been assigned as Patient #28’s 1:1 observer and she remained in the hallway. PSA’s were allowed to bring personal belongings into the patient rooms when they were assigned to sit in a patient room. Most of the time they were assigned several 1:1 patients and stayed in the hall. She brought her backpack with snacks and drinks for the day and kept them in the patient rooms. “We were told to put them away by 8:00 AM last week because surveyors would be here.” During a telephone interview on 12/18/25 at 9:30 AM, Staff QQ, Manager, stated that there should be no gaps in every 15-minute rounds documentation. During an interview on 12/29/25 at 1:38 PM, Staff XX, PSA, stated that she was told that morning staff could no longer take their belongings into the patient rooms with them. Review of the hospital’s policy titled, “Fall Prevention Guidelines,” revised 06/2022, showed all patients were to be evaluated for fall risk during the admission assessment process, the initial and daily nursing assessments, at minimum of once per shift, following a change in medical condition and/or level of care, and post fall. Nursing interventions were to be initiated based on the level of fall risk. Review of Patient #1’s medical record, dated 11/26/25, showed: - An 80-year-old female was admitted for possible infection in her hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) line. She was assessed by nursing as a high fall risk. - On 11/29/25, there was no fall risk assessment documented for day shift. - On 12/03/25 at 8:00 AM, documentation indicated she was a high fall risk, and her fall prevention interventions included a low bed. A fall risk band was not included in the interventions. - On 12/03/25, there was no fall risk assessment documented for night shift. - On 12/07/25 at 9:45 AM, nursing documentation indicated that she was a high fall risk. No fall prevention interventions were documented. Observation on 12/03/25 at 9:00 AM on the fifth floor, showed Patient #1’s bed was not in the lowest position. She did not have a fall risk band on. Review of Patient #12’s medical record, dated 12/02/25, showed: - A 54-year-old female was admitted to the fifth floor for alcohol withdrawal (symptoms that occur when the intake of a substance such as alcohol or drugs is reduced or stopped). Her nursing admission assessment showed that she had weakness and an unsteady gait. A fall risk assessment indicated she was a high fall risk. - On 12/03/25, at 8:00 AM, a nursing assessment showed that she had weakness and an unsteady gait. Her fall risk assessment indicated she was a high fall risk and her fall prevention interventions included a low bed. - On 12/04/25, there was no fall risk assessment documented for day shift. Observation on 12/03/25 at 11:15 AM, on the fifth floor, showed Patient #12’s bed was not in the lowest position. During a telephone interview on 12/16/25 at 12:12 PM, Staff PP, RN, stated that beds should always be in the lowest position. Review of Patient #13’s medical record, dated 10/24/25, showed: - A 61-year-old male was admitted to the fifth floor for dizziness, nausea, new lung mass, and new cerebellum (part of the brain that controls balance for walking, standing, and other complex motor functions) stroke. - On 10/25/25, Occupational Therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) documented that he demonstrated deficits with activities of daily living (ADL, daily self-care activities, such as bathing, dressing and eating) performance, activity tolerance, functional mobility, safety, balance, and strength. Physical Therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) was unable to evaluate the patient due to his heart ultrasound (a test that uses sound waves to create images of structures within the body). - At 10:25 PM, documentation indicated he was a moderate fall risk. His fall interventions included a bed alarm, low bed, slow position changes, supervised/assisted walking, and supervised toileting. He was a stand-by assist for walking and had bathroom privileges. - On 10/26/25 at 12:30 AM, nursing documentation indicated that Patient #13 had an unwitnessed fall in the bathroom. Patient #13 stated after having a bowel movement, he stood up and tried to reach for something to grab. He tried to grab the shower curtain and ended up falling into the shower. He stood up, rang the bathroom call light and went back to bed. Staff went to the room and found him on his bed, holding his right shoulder. He informed them that he had fallen. His vital signs (VS, measurements of the body’s most basic functions) were stable, and his blood sugar was within normal limits. The provider was notified, and imaging was ordered. - There was no documentation that Patient #13’s bed alarm was on or had alarmed at the time of his fall. - On 10/29/25, there was no fall risk assessment documented for day shift. During a telephone interview on 12/16/25 at 8:50 AM, Staff OO, RN, stated that he received report that Patient #13 was getting around “pretty good.” He was in bed and denied dizziness. He did not observe him walking. When Patient #13 fell, Staff OO was in another patient room. Patient #13 reported that he had thought the shower curtain was the wall and fell into the shower. He pulled the bathroom call light and was able to get himself back to bed, where the charge nurse found him. After the fall, Staff OO’s unit, the fifth floor, received education on the Morse Fall Scale (a method of assessing a patient’s likelihood of falling). Patients who were a moderate or high fall risk had basically the same fall interventions, except a high fall risk patient had to have someone at bedside when they got out of bed. Review of Patient #64’s medical record, dated 12/25/25, showed: - A 60-year-old female who was admitted for worsening hallucinations and altered mental status (mental functioning ranging from slight confusion to coma). - On 12/26/25 at 1:55 AM and 8:00 AM, nursing documented that she was a high fall risk. - At 8:00 AM, her fall interventions included assistive devices, bed/chair alarm, diversion techniques, gait belt, supervised/assisted walking, supervised toileting, floor pads and a 1:1 sitter at bedside. - At 10:22 AM, she was attempting to climb out of bed and was being uncooperative. Her provider was notified and ordered medication to be administered. - At 5:25 PM, Patient #64 fell in her room. She was immediately assessed and had no injuries. - At 5:29 PM, her provider was notified of the fall. - At 5:40 PM, a post fall assessment was completed. - There was no fall risk assessment or fall interventions documented for night shift. - On 12/27/25 at 8:00 AM, nursing documented that she was a high fall risk and had a 1:1 sitter at bedside. - There was no fall risk assessment or fall interventions documented for night shift. During a telephone interview on 12/30/25 at 9:45 AM, Staff M, Patient Safety Director, stated that Patient #64 had been identified as a high fall risk, and had appropriate fall interventions in place, including a 1:1 sitter. The patient was from a residential facility and was confused and hallucinating. She had set off her bed alarm multiple times on 12/26/25, and per a bed exit alarm report, between 7:00 AM and 2:00 PM that day, she had 46 bed exits. Her physician had been notified and updated multiple times about the patient and was waiting on psychiatry recommendations prior to giving any new orders. When nursing was interviewed after the patient’s fall, they reported that the sitter told them that the patient bolted out of bed toward the bathroom and fell. The sitter had verbally redirected the patient back to bed. At the time of this interview, the sitter’s manager had not put in notes regarding the sitter’s statement. Staff M stated that they had 15 business days to complete an investigation, and that they were still investigating this fall. Review of Patient #65’s medical record, dated 12/25/25, showed: - A 67-year-old male was admitted for shortness of breath and high blood pressure. - On 12/28/25 at 7:50 AM, nursing documented that he was a moderate fall risk. - There was no fall risk assessment or fall interventions documented for night shift. During a telephone interview on 12/31/25 at 8:30 AM, Staff L, Assistant Chief Nursing Officer (ACNO), stated that fall risk assessments were done at least once per shift and with a change in status. She expected staff to document fall risk assessments. Review of Patient #12’s medical record, dated 12/02/25, showed: - A 54-year-old female was admitted to the fifth floor for alcohol withdrawal (symptoms that occur when the intake of a substance such as alcohol or drugs is reduced or stopped). - At 2:38 PM, she scored a 10 on a Clinical Institute Withdrawal Assessment (CIWA, a 10-item scale used in the assessment and management of alcohol withdrawal). - At 3:14 PM, a provider ordered CIWA assessments. If the patient scored less than eight, reassessments were performed every four hours. A score of eight to 15 required treatment and reassessment every two hours. A score of over 15 required treatment and reassessment every hour. - At 9:46 PM, Patient #12 scored a nine on a CIWA assessment (five hours and eight minutes late; seven hours and eight minutes after the last CIWA assessment). - On 12/03/25 at 2:11 AM, Patient #12 scored a nine on a CIWA assessment (two hours and 25 minutes late; four hours and 25 minutes after the last CIWA assessment). - At 6:16 AM, Patient #12 scored an eight on a CIWA assessment (two hours and five minutes late; four hours and five minutes after the last CIWA assessment). - At 8:36 AM, Patient #12 scored an eight on a CIWA assessment (20 minutes late; two hours and 20 minutes after the last CIWA assessment). - At 12:17 PM, Patient #12 scored a seven on a CIWA assessment (one hour and 41 minutes late; three hours and 41 minutes after the last CIWA assessment). - At 4:16 PM, Patient #12 scored a 14 on a CIWA assessment. - At 10:02 PM, Patient #12 scored an 11 on a CIWA assessment (three hours and 46 minutes late; five hours and 46 minutes after the last CIWA assessment). - On 12/04/25 at 2:00 AM, Patient #12 scored a seven on a CIWA assessment (one hour and 58 minutes late; three hours and 58 minutes after the last CIWA assessment). - At 5:20 AM, Patient #12 scored a nine on a CIWA assessment. - At 8:05 AM, Patient #12 scored a 10 on a CIWA assessment (45 minutes late; two hours and 45 minutes after the last CIWA assessment). - At 9:40 AM, Patient #12 scored an eight on a CIWA assessment. - At 12:00 PM Patient #12 scored a 10 on a CIWA assessment (two hours and 20 minutes after the last CIWA assessment). - At 3:30 PM, Patient #12 scored a seven on a CIWA assessment (one hour and 30 minutes late; three hours and 30 minutes after the last CIWA assessment). - At 7:52 PM, Patient #12 scored a one on a CIWA assessment (two hours and 22 minutes late; four hours and 22 minutes after the last CIWA assessment). - At 10:44 PM, Patient #12 scored a 12 on a CIWA assessment. - On 12/05/25 at 1:29 AM, Patient #12 scored a three on a CIWA assessment (45 minutes late; two hours and 45 minutes after the last CIWA assessment). - At 4:06 AM, Patient #12 scored a 11 on a CIWA assessment. - At 6:09 AM, Patient #12 scored a six on a CIWA assessment (two hours and three minutes after the last CIWA assessment). - At 11:36 AM, Patient #12 scored a 13 on a CIWA assessment. - At 3:00 PM, Patient #12 scored a zero on a CIWA assessment (one hour and 24 minutes late; three hours and 24 minutes after the last CIWA assessment). - At 8:05 PM, Patient #12 scored a zero on a CIWA assessment (one hour and five minutes late; five hours and five minutes after the last CIWA assessment). - A total of 15 out of 29 CIWA assessments were late. During a telephone interview on 12/22/25 at 1:05 PM, Staff UU, RN, stated that CIWA assessments were per the provider order. Patients were generally assessed every four hours unless the patient required medication or there was a visible change in the patient’s condition. During a telephone interview on 12/31/25 at 8:30 AM, Staff L, ACNO, stated that staff were expected to follow the CIWA order set. 50151”

“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: 46856 Based on interview, record review and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) for two discharged patients (#53 and #55) of four patients reviewed with restraints. This failure created an unsafe environment and had the potential to cause poor outcomes for all patients placed in violent restraints. Review of the hospital’s policy titled, “Patient Restraint/Seclusion,” dated 11/2024, showed that patients are assessed by a Registered Nurse (RN) at least every two hours. The assessment will include where appropriate: signs of injury associated with restraint, including circulation of affected extremities; respiratory and cardiac status; psychological status; needs for range of motion (ROM, how far you can move or stretch a part of your body, such as a joint or a muscle), exercise of limbs and systematic release of restrained limbs; hydration/nutritional needs; hygiene, toileting/elimination needs; maintenance of the patient’s rights, dignity, and safety; the patient’s understanding of reasons for restraint and criteria for release from restraint, and consideration of less restrictive alternatives to restraints. A trained staff member monitors each patient in restraint at least three times an hour for safety, and to confirm that the patient’s rights and dignity are maintained. This check will be documented in either electronic record or on paper. Review of Patient #53’s medical record, dated 11/18/25, showed: - A 19-year-old female presented to the Emergency Department (ED) with a chief complaint of alcohol intoxication and an altercation. - At 3:50 AM, she was placed in violent restraints for physical aggression. - At 3:51 AM and 3:52 AM, nursing completed a second-tier review and a face-to-face evaluation for the restraints. - At 4:00 AM, an unknown staff member documented on a paper form that Patient #53 was in violent restraints. There was no documentation of alternatives attempted, Patient #53’s behavior, skin integrity, respirations, circulation, range of motion/exercise of limbs, hydration/nutritional needs, hygiene/elimination needs, signs of injury, and safety/rights and dignity maintained every 15 minutes. There was no signature page for the paper form. - At 4:15 AM, her restraints were discontinued. Review of Patient #55’s medical record, dated 07/14/25, showed: - S 52-year-old male who presented to the ED for evaluation of agitation and aggression. - At 3:15 AM, he was placed in violent restraints for combative and destructive behaviors. Patient safety/rights/dignity were verified at that time. - At 3:16 AM and 3:17 AM, nursing completed a second-tier review and a face-to-face evaluation for the restraints. - At 4:40 AM, his restraints were discontinued. - There was no electronic or paper documentation that his rights and dignity were maintained while he was in restraints from 3:17 AM to 4:40 AM (one hour and 23-minute gap). - At 5:00 PM, he was placed in violent restraints for physical aggression and combative and destructive behaviors. Patient safety/rights/dignity were verified at that time. - At 5:01 AM and 5:02 AM, nursing completed a second-tier review and a face-to-face evaluation for the restraints. - There was no electronic or paper documentation that his rights and dignity were maintained while he was in restraints from 5:02 AM to 7:30 AM (two hours and 28-minute gap). - At 7:30 AM, his restraints were discontinued. During a telephone interview on 12/18/25 at 9:55 AM, Staff RR, ED Director, stated that in the ED, when a patient was placed in violent restraints, a tech would monitor the patient as a one to one (1:1, continuous visual contact with close physical proximity) and would document every 15 minutes on the paper documentation. There should have been a signature and initials on the paper documentation. Nurses charted every two hours, either on the paper documentation or in the electronic record.”

“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: 47504 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 (#17) of 31 Emergency Department (ED) records reviewed from 02/25/25 through 08/25/25. The hospital’s average monthly census was 4,990. Findings included: Review of the hospital’s 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) - Medical Screening Examination and Stabilization Policy,” dated 07/18/24, showed: - An EMTALA obligation is triggered when an individual comes to a dedicated ED and the individual, or a representative acting on their behalf, requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. - The hospital must provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the dedicated ED, to determine whether or not an EMC exists. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility, or an appropriate transfer as defined and required by EMTALA. - If a law enforcement officer (LEO) brings a person who is exhibiting behavior that suggests that he or she is intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) to the ED and asks for an MSE, or if a prudent layperson observer would believe that the individual needed examination or treatment for a possible EMC, then a MSE must be performed. This is required because some medical conditions could present behaviors similar to those of an intoxicated individual. - A MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - If a physician or qualified medical personnel (QMP) has begun the MSE or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment, or refuses any further care and is determined to leave against medical advice (AMA), after being informed of the risks and benefits and the hospital’s obligations under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or AMA form. The medical record must contain a description of the screening and the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. Review of the hospital’s policy titled, “Emergency Room Assessment and Reassessment,” revised 06/2019, showed: - Vital signs (VS, measurements of the body’s most basic functions) should not be the only indicator of whether a patient is unstable or stable. They are to be used in conjunction with a complete patient assessment, diagnostic testing, and the patient’s report of associated signs and symptoms. - Reassessment is the periodic re-evaluation based on the patient’s chief complaint, acuity, condition and symptoms or treatments. - All patients will be reassessed a minimum of hourly and as warranted by the patient’s condition. The ED physician is notified of all changes in the patient’s status. - VS frequency is warranted by the patient’s condition or physician order. - All assessments must be documented. Any critical findings should be verbally conveyed to the physician. - It is the responsibility of the physician to determine stability for discharge; therefore, any abnormal VS obtained on discharge must be brought to the attention of the physician prior to the patient’s disposition and actions are documented. - Those who may be released with abnormal VS include patients with a history of high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) and non-compliance with medical management who have no physical complaints. If any of these conditions are present or a nursing intervention has been done, VS must be documented within 15 minutes of discharge. Please refer to A-2406 for further details. 51264”

“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: 47504 Based on interview, record review and 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 (#17) of 31 Emergency Department (ED) records reviewed from 02/25/25 through 08/25/25. 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 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)- Medical Screening Examination and Stabilization Policy,” dated 07/18/24, showed: - An EMTALA obligation is triggered when an individual comes to a dedicated ED and the individual, or a representative acting on their behalf, requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. - The hospital must provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the dedicated ED, to determine whether or not an EMC exists. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility, or an appropriate transfer as defined and required by EMTALA, - If a law enforcement officer (LEO) brings a person who is exhibiting behavior that suggests that he or she is intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) to the ED and asks for a MSE, or if a prudent layperson observer would believe that the individual needed examination or treatment for a possible EMC, then a MSE must be performed. This is required because some medical conditions could present behaviors similar to those of an intoxicated individual. - A MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - If a physician or qualified medical personnel (QMP) has begun the MSE or any stabilizing treatment and an individual refuses to consent to a test, examination, or treatment, or refuses any further care and is determined to leave against medical advice (AMA), after being informed of the risks and benefits and the hospital’s obligations under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or AMA form. The medical record must contain a description of the screening and the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. Review of the hospital’s policy titled, “Emergency Room Assessment and Reassessment,” revised 06/2019, showed: - Vital signs (VS, measurements of the body’s most basic functions) should not be the only indicator of whether a patient is unstable or stable. They are to be used in conjunction with a complete patient assessment, diagnostic testing, and the patient’s report of associated signs and symptoms. - Reassessment is the periodic re-evaluation based on the patient’s chief complaint, acuity, condition and symptoms or treatments. - All patients will be reassessed a minimum of hourly and as warranted by the patient’s condition. The ED physician is notified of all changes in the patient’s status. - VS frequency is warranted by the patient’s condition or physician order. - All assessments must be documented. Any critical findings should be verbally conveyed to the physician. - It is the responsibility of the physician to determine stability for discharge; therefore, any abnormal VS obtained on discharge must be brought to the attention of the physician prior to the patient’s disposition and actions are documented. - Those who may be released with abnormal VS include patients with a history of high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) and non-compliance with medical management who have no physical complaints. If any of these conditions are present or a nursing intervention has been done, VS must be documented within 15 minutes of discharge. Review of Patient #17’s first medical record dated 07/01/25, showed: - At 4:17 AM, he presented to the ED by ambulance complaining of chest pain and alcohol intoxication. - He was alert and oriented times four (A&O x4, a person is oriented to person, place, time, and situation), breathing normally, he was shaking his right leg, and his skin was pink, warm, and dry. His pain was four on the pain scale (pain rating on a scale of zero to ten, zero means no pain and 10 means the worst possible pain). He appeared intoxicated. - His pulse was 80, temperature 99.1, respiratory rate (RR, normal breaths per minute for an adult at rest ranges from 12 to 20) was 30, oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%) was 99%, and his blood pressure was 153/92. - Nursing notes showed he called 911 because he thought he was having an atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) attack. He had multiple abrasions (an area of skin damaged by scraping) on the left knee, right wrist and left forehead from a fall a few days prior. He had a history of high blood pressure, A-fib, congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), alcohol abuse, and stomach ulcers. - At 4:20 AM, doctors ordered a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), complete metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), magnesium level, Troponin I High Sensitivity (a blood test that measures whether or not a person is experiencing a heart attack), electrocardiogram (ECG, test that records the electrical signal from the heart to check for different heart conditions), pulse oximeter (a machine that monitors the percentage of oxygen in the bloodstream, a normal reading was 95 to 100 percent), two intravenous (IV, in the vein) sites, 0.5 mg of Ativan (a medication used to treat anxiety or sleep difficulty), and 1000ml normal saline (solution made of salt and water). - At 4:35 AM, he had a chest x-ray (test that creates pictures of the structures inside the body-particularly bones) that showed no acute heart or lung problems. - At 4:37 AM, laboratory results showed some abnormal findings; he was slightly hypokalemic (low potassium level in the blood), his aspartate aminotransferase (AST, an enzyme that is found mostly in the liver where normal was 10-45 U/L) was 61, Total Alkaline Phosphatase (an enzyme responsible for bone growth and repair, normal is 45 to 132 U/L) was 136. Results also showed his red blood cell count (RBC) was 3.76 (where low was 4.10), white blood cell count (WBC, the number of white blood cells [infection-fighting cells] in the blood, normal was 4.1-11.1) was 14.1, Hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal was 13.5-16.5) was 11.8, and hematocrit (Hct, a measure of the percentage of red blood cells in the total volume of blood, normal was 38.4-50.8) was 33.8. - His Troponin I High Sensitivity (where less than 78ng/L was normal) was 23 and later 26. - At 4:45 AM, the heart monitor showed intermittent A-fib with normal sinus rhythm. - From 5:00 AM to 8:00 AM, the heart monitor showed normal sinus rhythm, no distress or breathing problems and vital signs (VS, measurements of the body’s most basic functions) were stable. - At 8:26 AM, his condition was “improved”, and he was being discharged. His VS were within normal limits (WNL) except his blood pressure, 163/91. - Physician notes showed his cardiac workup did not indicate any cardiac emergency and his vital signs had been stable. He was encouraged to follow up with his primary care physician and avoid consuming alcohol. Review of Patient #17’s second medical record dated 07/01/25, showed: - At 11:03 AM, he was a 43-year-old who presented for the second time that day, related to alcohol withdrawal. He had been discharged at 8:26 AM. - At 11:04 AM, triage notes showed he returned to the ED due to increased heart rate, tremors and nausea. He had an elevated BP of 173/100. His history included high BP, A-fib, CHF, alcohol abuse, stomach ulcers, and medical noncompliance. - Home medications included metoprolol (a medication used to treat high BP pressure and chest pain), gabapentin (medication used to treat nerve pain or seizures), mirtazapine (antidepressant, medication to reduce the constant feeling of sadness or hopelessness), and magnesium oxide. - At 11:08 AM, his monitored heart rhythm showed normal sinus rhythm (NSR, rhythm of a healthy heart). His cardiovascular assessment showed no physical findings. - At 11:09 AM, an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) was placed. - At 11:32 AM, laboratory orders included levels for magnesium and alcohol, a CMP, CBC, and a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications). He received 50 milligrams (mg) of Librium (medication used to treat anxiety, alcohol withdrawal symptoms, and tremors). - At 12:09 PM, his potassium (a mineral in the blood or body fluid) level was 3.2; he was given 40 milliequivalent (mEq) tablets of potassium chloride (medication used to treat and prevent low levels of potassium). His magnesium level was 1.47; he was given two grams (gm)/50 milliliter (ml) IV. - His CBC results showed his WBC count was 12.4, RBC count was 3.72, Hgb was 11.6 and his Hct was 33.5. - At 12:47 PM, his BP was 195/105. - At 2:24 PM, his pain score was two, using the pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). - At 2:42 PM, physician notes showed he was in no acute distress and was better after being given Librium. He was not sweaty, tremulous or tachycardic (abnormally rapid heart rate, greater than 100 beats per minute). The patient denied any thoughts of harm. His magnesium and potassium levels were replaced, and he was stable for discharge. His primary impression was alcohol withdrawal with a secondary impression of low potassium and magnesium. - At 3:06 PM, he was discharged home. Instructions included a referral to follow up with a local addiction recovery program and a primary care provider for high BP. - No VS reassessments were documented at discharge. Review of Patient #17’s third medical record dated 07/01/25, showed: - At 3:20 PM, he presented for a third time that day related to alcohol withdrawal. His chief complaint was anxiety. The initial assessment showed he was seen twice that day, and once the day before. Nursing assessments were normal. He reported no pain. His blood pressure was 198/114. - At 3:32 PM, laboratory orders included a CBC, CMP, magnesium level, and alcohol level. - At 3:45 PM, he was given a 2mg tablet of lorazepam (a medication used to treat anxiety or sleep difficulty). - Physician notes showed he was anxious related to alcohol withdrawal. He was previously admitted to the hospital for alcohol detoxification and was discharged a week ago. He was an alcoholic who got “extremely intoxicated last night.” He denied any thoughts of harm to self or others. - He received a complete review of systems that showed no abnormalities except he was tearful and anxious. - At 4:41 PM, he was discharged with a primary impression of alcoholism with secondary anxiety. He was given discharge instructions and another referral for alcohol withdrawal. - No VS reassessments were documented at discharge. Review of Patient #17’s fourth medical record dated 07/01/25, showed: - At 5:52 PM, he presented for the fourth time that day in the ED complaining of alcohol abuse and withdrawal, ingestion, and anxiety. He was sent by ambulance from a substance abuse center. - At 6:00 PM, nurse’s notes showed he needed help with alcohol withdrawal. He had been experiencing weakness in his legs. He denied shortness of breath. He had tremors and appeared anxious and clammy. All VS were stable except his BP was 184/104 and his heart rate was 112. - At 6:22 PM, laboratory results showed he had low potassium, low magnesium, high AST and total Alkaline Phosphatase. Blood results showed he had low RBCs, Hgb, and Hct. His alcohol level was still high. - At 6:42 PM, his heart monitor showed A-fib. He had high BP, his legs were weak, his heart rate was high, he was clammy, and he had a headache. - At 7:00 PM, his heart rate was 109, his BP was 168/85. - At 9:00 PM, his heart rate was 105, his BP was 187/98. - At 9:19 PM, he was admitted to the hospital as an inpatient. - Medications administered during this visit included Thiamine, IV fluids, magnesium sulfate, diazepam (a medication used to treat anxiety, muscle spasms and alcohol withdrawal symptoms), prenatal vitamins, folic acid, magnesium oxide, haloperidol (a medication used to treat mental disorders by decreasing excitement of the brain), ondansetron (medication used to treat nausea), promethazine, a nicotine patch, pantoprazole sodium, amlodipine besylate (a medication used to treat high blood pressure and chest pain), metoprolol tartrate, naltrexone, gabapentin (medication used to treat nerve pain or seizures), and mirtazapine (antidepressant, medication to reduce the constant feeling of sadness or hopelessness). During an interview on 08/28/25 at 10:03 AM, Staff T, stated that Patient #17 was in the ED often. Recommendations for patients with asymptomatic high BP in the ED were to not treat it in the emergency setting. BPs were reassessed but did not always get documented. The ED recently changed their model for patient care to decrease wait times. Staff tried to give good care while satisfying tracked time measures set forth by the new model. During an interview on 08/28/25 at 1:45 PM, Staff C, stated that reassessments were hard to do when they had to get patients seen and treated quickly. A high census of high acuity patients with few providers made it difficult to keep up. During an interview on 08/28/25 at 1:37 PM, Staff U, stated that reassessments for VS were being missed. It was very hard to do reassessments and document them when staff felt rushed “pushing numbers.” 51264”

“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: 46856 Based on observation, interview, record review, and policy review, the hospital failed to: - Discard expired tube feed (TF) and change tubing for two current patients (#18 and #24); - Follow physician orders for free water flushes for one current patient (#18); - Ensure a physician order was present prior to nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) insertion for one current patient (#33); - Date TF supplies for two current patients (#18 and #24); - Document TF and free water flushes on two current patients (#24 and #33); - Check residual aspirate for TF on three current patients (#18, #24, and #33); - Ensure staff were not scanning patient identification bands that were not attached to the patient for two current patients (#14 and #18); and - Ensure venous access device (VAD) dressings were labeled per policy for 16 current patients (#1, #2, #5, #6, #7, #9, #10, #12, #13, #14, #17, #20, #21, #22, #24, and #26). These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395.”

“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: 46856 Based on observation, interview, record review, and policy review, the hospital failed to: - Discard expired tube feed (TF) and change tubing for two current patients (#18 and #24) of four observed; - Follow physician orders for free water flushes for one current patient (#18) of four observed; - Ensure a physician order was present prior to nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) insertion for one current patient (#33) of four observed; - Date TF supplies for two current patients (#18 and #24); - Document TF and free water flushes on two current patients (#24 and #33) of four observed; - Check residual aspirate for TF on three current patients (#18, #24, and #33) of four observed; - Ensure staff were not scanning patient identification bands that were not attached to the patient for two current patients (#14 and #18); and - Ensure venous access device (VAD) dressings were labeled per policy for 16 current patients (#1, #2, #5, #6, #7, #9, #10, #12, #13, #14, #17, #20, #21, #22, #24, and #26) of 24 observed. Findings included: Review of the hospital’s policy titled, “Enteral Nutrition Feeding,” revised 02/2022, showed enteral feeding tubes must be labeled prior to infusion and staff were to: - Assess the patient every shift and as needed. - Change tubing and discard unused enteral feeding after 24 hours when a closed system was used. - Change tubing and discard unused enteral feeding after eight hours when an open system was used. - Measure and document TF residual every four hours in critical care areas and every eight hours on general medical floor units. - Document the assessment, patient’s tolerance/response to feeding, type and amount of feedings, presence or absence of complications, the character and amount of residual aspirate and whether it was returned or discarded. Review of Patient #18’s medical record, dated 07/12/25, showed a 60-year-old female with a past medical history of gastro-esophageal reflux disease (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining), depression, and insomnia (difficulty falling asleep or staying asleep) presented to the Emergency Department (ED) after suffering a cardiac arrest (when the heart suddenly and unexpectedly stops pumping). She underwent ten minutes of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped), was intubated (a 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) and a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) and angioplasty (a procedure to repair or unblock a blood vessel) were performed. An orogastric tube (OG, small tubes placed through the mouth and end with the tip in the stomach) was placed for suctioning and the administration of medications and TF. - On 07/15/25 at 4:22 PM, a physician’s order showed TF with a goal of 50 milliliters (mL) per hour and a water flush of 50 mL every six hours. The TF would be managed by a dietician. - On 07/16/25, a total of 131 mL of TF and 50 mL of water were administered. The dietician’s note indicated Patient #18 was tolerating the TF at 40 mL per hour. - On 07/17/25, a total of 403 mL of TF and 100 mL of water were administered. - On 07/18/25, a total of 1015 mL of TF and 150 mL of water were administered. The dietician’s note indicated Patient #18 was tolerating the TF at 45 mL per hour. - On 07/19/25, a total 445 mL of TF and 100 mL of water were administered. - On 07/20/25, a total 619 mL of TF and 100 mL of water were administered. - On 07/21/25, a total 1413 mL of TF and 193 mL of water were administered. The dietician’s note indicated Patient #18 was tolerating the TF. She was extubated (removal of breathing tube) and an NG tube was placed. - From 07/22/25 through 07/26/25, there was no documentation of TF or water being administered. - On 07/22/25, the dietician’s note indicated the TF was off but would be resumed that day. - On 07/23/25, the dietician’s note indicated the TF was running at 25 mL per hour but would be held for a swallow study. - On 07/24/25, the dietician’s note indicated Patient #18’s TF goal remained the same, at 50 mL per hour. - On 07/25/25, the dietician’s note indicated that Patient #18’s husband reported the TF had been on hold since 7:00 PM the night before due to increased secretions and coughing. A gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) consult was ordered for possible percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tube placement. - On 07/26/25, nursing documentation indicated the TF was running at 10 mL per hour. - On 07/27/25, a total of 181 mL of TF and 100 mL of water were administered. - On 07/28/25, a total of 111 mL of TF and 100 mL of water were administered. - On 07/29/25, a total 150 mL of TF and no water were administered. - On 07/30/25, Patient #18 had a PEG tube placed, and TF were scheduled to resume the following day. - From 07/15/25 through 07/30/25, there was no documentation of residual assessments. During concurrent observation and interview on 07/29/25 at 9:35 AM, with Staff U, Registered Nurse (RN), showed: - Two undated, clear plastic cups and an undated, open large volume syringe were stored on paper towels at the sink and were used to administer medications through Patient #18’s NG tube. Staff U stated that some staff members dated the supplies but she just changed them out every few days. She was unsure when those specific supplies were opened but “they looked clean”. - A bottle of TF, dated 07/26/25 at 6:20 PM, was administered Patient #18 through a TF pump. Staff U stated that the date on the bottle was the opened date and that it was good for 24 hours. She indicated that Patient #18 had not been able to tolerate the TF and had not been getting it at the rate ordered. It was okay to continue using the bottle, until it ran out. - The tubing and a full bag of water connected to the TF system were not dated. Staff U indicated the water was hung at the same time as the bottle of TF. - The TF pump was set to deliver a water flush of 150 mL every six hours. Staff U indicated the rate was incorrect and changed it to administer 50 mL every six hours. During concurrent observation and interview on 07/29/25 at 10:30 AM, Patient #18’s husband stated that: - Patient #18 was doing good and was well cared for until 07/22/25 when she transferred to 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). Overnight, she was laid too far back in the bed and coughed incessantly. He voiced concerns to the staff, but nothing was done. Some staff told him she needed to suction herself and other staff told him she just needed to cough it out. - A speech therapist informed him that Patient #18 required suctioning because her epiglottis (a flap just above the voice box that prevents food and drink from entering the lungs) was not working properly. - The charge nurse told him they were short staffed, and the nurse manager told him that patients in Intensive Care Unit (ICU, a unit where critically ill patients are cared for) did not have a dedicated nurse to suction them whenever they required it. - Patient #18 was too weak to suction herself and the coughing only made her weakness worse. She was not able to get the suction tube in her mouth correctly and it would get stuck to the NG tube in the back of her throat. He suctioned her when it was needed, and he was worried she had aspirated (inhaled foreign material into the lungs). - He pointed out a cannister on the wall and said, “look it’s still there. That is what I suctioned out of her, and it looks just like her TF.” The cannister contained 150 mL of a creamy brown liquid mixed with a little mucus. Half of it was a watery liquid. - He had to insist multiple times for the TF to be turned off. - Someone was staying with her around the clock to help suction and monitor her. He was afraid that staff would just let her die. - Only one staff member checked the TF residual. - The free water flush bag and bottle of TF, dated 07/26/25, had both been hanging in the room and connected to the pump since that date. On occasion, staff restarted the TF but the water had never been touched. He never observed water being administered through the NG tube. - Patient #18 was very dehydrated (excessive loss of water from the body) and staff struggled to draw blood for laboratory testing. Her fingers, hands, arms and stomach had various shades of bruising with obvious puncture marks in the center. - Patient #18 was finally doing better, after he insisted, they stop giving her TF at night. - He was afraid to say too much to management for fear his wife would not be treated properly. During an interview on 07/31/25 at 8:15 AM, Staff T, PCU Manager, stated that: - She was unsure what an open system versus a closed TF system were and would have to reference the policy. - TF was to be dated when hung and was only good for 24 hours regardless of how long it had been running or if it had been on hold. - The free water flush bag was considered dated the same as the tubing and was only good for 24 hours. - TF intake was to be documented once per shift. - Free water flushes during medication administration were to be documented with each administration. - Residuals were to be checked when the TF was initiated or when there were signs or symptoms of intolerance. - She was unsure how long open bolus TF containers were kept and would have to reference the policy. - TF supplies included plastic cups and large volume syringes. They were expected to be dated when opened and discarded after 24 hours. Review of Patient #24’s medical record, dated 07/13/25, showed she was a 63-year-old female with past history of high blood pressure and alcohol abuse. She presented to the ED with right facial droop, hemiparesis (partial paralysis affecting only one side of the body) and 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). - On 07/23/25 at 11:18, AM a physician order showed TF Jevity (caloric, fiber-fortified liquid nutrition) 1.5 carton (356 mL) four times a day and 25 mL of water before/after the TF bolus (large amount). - From 07/23/25 through 07/26/25, there was no documentation of TF assessment, type, amount or residual. - On 07/27/25 at 12:00 PM and 4:00 PM, a total of 380 mL of TF and 60 mL of water were administered. - From 07/28/25 through 07/29/25, at 12:00 PM and 4:00 PM, a total of 380 mL of TF was administered. - On 07/29/25 at 9:55 PM, a total of 356 mL of TF and 100 mL of water were administered. - On 07/30/25 at 12:30 AM, documentation indicated a bolus was administered with a residual of ten mL. The TF was intermittent. - 07/30/25 at 4:35 PM, a physician’s order indicated to hold the PEG TF until cleared by GI, due to vomiting. During concurrent observation and interview on 07/29/25 at 2:00 PM, with Staff FF, RN, in Patient #24’s room showed: - Three bottles of Jevity TF on paper towels near the sink along with an opened, undated, wet, large volume syringe. - One bottle of TF was open with no date. Staff FF stated that he opened the bottle today. He should have put an open date on the bottle, and it was good for six hours. - He stated Patient #24 was on intermittent TF, 380 mLs of Jevity per jejunostomy tube (J-tube, soft, flexible tube placed through the skin of the abdomen into the midsection of the small intestine) four times per day, at 6:00 AM, 11:00 AM, 4:00 PM and 10:00 PM. During an interview on 07/29/25 at 2:15 PM, Staff GG, Nurse Manager, stated the open bottle of Jevity should have an open date and she was unsure how long the open bottle was good for. Review of Patient #33’s medical record, dated 07/19/25, showed she was a 38-year-old female admitted through the ED after being found unresponsive. She had a history of severe alcohol abuse and was placed on a ventilator (a machine that supports breathing). - On 7/22/25 at 1:26 PM, a physician ordered Vital AF (caloric, fiber-fortified liquid nutrition) TF, with a goal of 55 mL per hour, a 30 mL flush of water every eight hours and the dietician was to manage the TF. And OG tube was to be used for administering TF and Patient #33 was nothing by mouth. - From 07/22/25 through 07/30/25, documentation showed missing and inconsistent types, amounts, residuals and whether the TF was being tolerated or on hold. - From 07/24/25 through 07/27/25, there were no nutritional assessment completed by a dietician. - On 07/28/25 at 1:34 PM, a nutritional assessment indicated Patient #33’s TF was on hold and had been since 07/27/25. - On 07/30/25 at 12:00 PM, an NG tube was placed without a physician order. During an interview on 07/31/25 at 9:50 AM, Staff M, RN Quality, stated that there should have been an order for the NG tube placement. Staff KKK, RN Educator, had reported the TF policy did not state when to document information regarding the TF, but the standard of practice was to document every shift. During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that staff were expected to follow the hospital policy for TF. They were unsure what an open system versus a closed system was. The TF container, tubing and supplies were to be dated when opened and changed every 24 hours for both, intermittent or continuous TF. They considered the free water flush bag a part of the tubing and did not expect to see a separate date from the tubing. Residuals were to be checked upon administering TF or water flushes, and any time a patient showed signs of intolerance. Review of the hospital’s policy titled, “Medication Administration (eMAR),” revised 06/2025, showed that it was against policy to scan anything other than the armband attached to the patient in order to verify the patient’s identity. Staff members found violating this policy were subject to disciplinary action. Observation on 07/29/25 at 9:35 AM, showed Patient #18 was not wearing an identification (ID) band, but one was taped to the computer. Staff U, RN, scanned the ID band on the computer when medication was administered. Observation on 07/29/25 at 9:10 AM, showed Staff X, Patient Care Technician (PCT), attempted to scan Patient #14’s ID band. When the scanner did not work, she attempted to scan an extra ID band in the room. After multiple attempts at scanning Patient #14’s ID band and the extra ID band, Staff X was able to scan the ID band on Patient #14’s arm. During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that patient ID bands were to be on the patient and scanned prior to medication administration. Review of the hospital’s policy titled, “Venous Access Device Insertion, Maintenance and Removal,” revised 03/2024, showed venous access device (VAD) dressings were to be: - Changed every two days for non-transparent or gauze dressings; - Changed every seven days for transparent dressings; - Changed as soon as possible if the dressing was compromised; and - VAD dressings were to be dated and initialed. Observation on 07/28/25 at 3:00 PM, showed Patient #1’s VAD dressing was not dated or initialed. Observation on 07/28/25 at 3:15 PM, showed Patient #2’s VAD dressing was not dated or initialed. Observation on 07/28/25 at 2:15 PM, showed that Patient #5’s VAD dressing was not dated or initialed. Observation on 7/28/25 at 2:30 PM, showed that Patient #6’s VAD dressing was not dated or initialed. Observation on 07/28/25 at 2:45 PM, showed that Patient #7’s VAD dressing was not initialed. Observation on 07/28/25 at 2:50 PM, showed that Patient #9’s VAD dressing was not dated or initialed. Observation on 07/28/25 at 3:30 PM, showed that Patient #10’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 8:40 AM, showed that Patient #12’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 8:55 AM, showed that Patient #13’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 9:10 AM, showed that Patient #14’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 8:46 AM, showed that Patient #17’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 9:00 AM, showed that Patient #20’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 9:20 PM, showed that Patient #21’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 1:00 PM, showed that Patient #22’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 2:00 PM, showed that Patient #24’s VAD dressing was not dated or initialed. Observation on 07/29/25 at 1:30 PM, showed that Patient #26 had two VAD dressings that were not dated or initialed. During an interview on 07/29/25 at 10:40 AM, Staff DD, RN, stated that VAD dressings should be dated and initialed. During an interview on 07/31/25 at 9:40 AM, Staff N, Chief Nursing Officer (CNO) and Staff D, Assistant CNO, stated that they were unsure if all VADs should be dated and initialed but expected staff to follow the hospital policy. 51509”

“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: 40189 Based on observation, interview, record review, and policy review, the hospital failed to: - Implement and document seizure precautions (precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure) for one current patient (#9) out of one reviewed; - Prevent and manage wounds appropriately for four current patients (#4, #25, #27, and #40) of eleven reviewed, and one discharged patient (#51) of one reviewed; - Adequately document assessments for five current patients (#2, #3, #4, #22, and #40) of eleven reviewed, and three discharged patients (#49, #50 and #51) of four reviewed; and - Ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed. These failures had the potential to lead to poor outcomes, increased risk of harm, impaired skin integrity, and overall increased risk of health status deterioration for every patient admitted to the hospital.”

“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: 49489 Based on observation, interview, record review, and policy review, the hospital failed to: - Implement and document seizure precautions (precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure) for one current patient (#9) out of one reviewed; - Prevent and manage wounds appropriately for four current patients (#4, #25, #27, and #40) of eleven reviewed, and one discharged patient (#51) of one reviewed; and - Adequately document assessments for five current patients (#2, #3, #4, #22, and #40) of eleven reviewed, and three discharged patients (#49, #50 and #51) of four reviewed. These failures had the potential to lead to poor outcomes, increased risk of harm, impaired skin integrity, and overall increased risk of health status deterioration for every patient admitted to the hospital. Review of the hospital’s undated document titled, “Initiating Seizure Precautions for Adults,” showed staff were to implement the following for patients with seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) related concerns: - Review the patient’s care plan, physician orders, and hospital policy for initiating and maintaining seizure precautions. - Review the patient’s medical history/medical record for indications for seizure precautions, relevant medical history, including the type of previous seizures, medications, pertinent laboratory values that could indicate potential for seizures, such as electrolyte imbalances, and any allergies the patient may have. - Ensure interventions such as padding around the headboard, foot board and side rails, the bed in the lowest position and signage has been placed, if the patient was at risk for seizures. Review of Patient #9’s medical record showed: - On 12/01/24, a 61-year-old woman with a past medical history of a seizure disorder was admitted to the medical-surgical unit after a fall. - On 12/01/2024 at 5:43 PM, seizure precautions were ordered. - On 12/03/24 at 1:04 PM, seizure precautions were discontinued upon patient’s transfer from the operating room (OR). Observation on 12/02/24 at 4:00 PM, showed Patient #9 was in a hospital bed with unpadded headboard, footboard, and side rails. Observation on 12/03/24 at 8:49 AM, showed Patient #9 was in a hospital bed with unpadded headboard, footboard, and side rails. During an interview on 12/02/24 at 4:00 PM, Staff K, RN, stated that patients on seizure precautions should have the hospital bed side rails padded. She had not had time to place the padding on Patient #9’s side rails during her shift. During an interview on 12/03/24 at 8:15 AM, Staff Q, Medical-Surgical Manager, stated that she expected seizure precautions to begin within one hour of admission for patients with known seizure history. Review of the hospital’s policy titled, “Prevention of Pressure Injuries (injury to the skin and/or underlying tissue, usually over a bony area),” dated 02/28/23, showed: - Pressure injuries were categorized into the following stages: stage one pressure injury was a non-blanchable erythema (redness of the skin) of intact skin; stage two was a partial-thickness skin loss with exposed dermis (middle layer of skin); stage three was a full-thickness skin loss; stage four was a full-thickness skin and tissue loss; unstageable pressure injuries were obscured, full-thickness skin and tissue loss; and deep tissue pressure injuries were persistent, non-blanchable deep red, maroon, or purple discoloration. - All patients would have a full skin assessment and be assessed for pressure injury risk level using a standardized, evidence-based, risk assessment tool upon admission, once per shift, following any change in medical condition and upon transfer. A score less than or equal to 18 was considered “at risk.” - The hospital’s skin risk assessment tool was modified from the Braden Scale (an assessment tool for predicting the risk of bedsores or pressure ulcers). - Patients who were determined to be not at risk would have ongoing skin assessments with their complete patient assessments. Patients found to be at-risk would have focused skin assessments every four hours or more frequently if ordered by a licensed practitioner. - Pressure injury interventions and an individualized plan of care, including education, would be implemented and documented for all at-risk patients. Review of the hospital’s policy titled, “Wound Assessment & Treatment (Non pressure ulcers),” dated 01/21/19, showed staff were to notify the wound nurse and physician for lower extremity and foot wounds for consultation prior to utilizing specific products, if there was deterioration of wounds, signs of wound or systemic infection, or a poor response to therapy. Patients and families were to be educated about the importance of high protein/carbohydrate foods and fluids to promote wound healing, the need to inspect skin daily, to keep the skin clean and dry and the use of available skin products. Review of the hospital’s policy titled, “Nursing Departments Standards of Care,” dated 05/2023, showed patients would be bathed with 2% chlorhexidine gluconate (CHG, a disinfectant and antiseptic used to bathe patients in order to kill bacteria and reduce the spread of infections) wipes on admission and daily. Perineal/perianal area would be cleansed and skin barriers applied as needed. Patients would be encouraged to walk or sit up in a chair as much as tolerated and per the physician orders. Patients on bedrest would be turned and repositioned every two hours and as needed. Skin integrity was assessed on admission, at each shift, and as needed. Universal skin care practices were used for all patients. Bony prominences were monitored and precautions would be taken to prevent pressure areas. Review of Patient #4’s medical record showed: - No skin assessment was documented on admission. - On 11/19/24, a nursing assessment noted he had a deep tissue injury on the tailbone. There was no wound description or measurement documented. - On 11/21/24, an orders for a wound consult and daily ointment were placed. - On 11/22/24, Staff V, Wound Nurse, described the wound as beefy red with slough present. He applied a dressing, but no wound measurements or staging for severity was documented. - On 11/25/24, 11/26/24, and 11/29/24, no wound care was documented. - Patient #4’s skin assessment rating scores were consistently below 18, indicating he was at risk for developing a pressure wound. Observation on 12/03/24 at 8:30 AM, showed Patient #4 had an open wound with a large area of redness. Staff Y, RN, provided wound care but failed to take any wound measurements at the time of the dressing change. During an interview on 12/03/24 at 8:30 AM, Patient #4 stated that he did not remember when his wound developed. He was only turned and repositioned by staff twice daily when they checked him for bowel movements. Observation and concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to place a clean barrier under Patient #25’s leg during a wound dressing change. He failed to use a barrier when assembling wound dressing supplies, placing them directly on the countertop adjacent to the sink. He stated he did not place a barrier under Patient #25’s leg during the dressing change as the wound was not “oozing.” Observation on 12/03/24 at 1:30 PM, showed Staff V, Wound Nurse, performed a dressing change and pressure injury assessment on Patient #27’s tailbone area. When the patient was turned, he was found to have soiled himself. Staff V removed the old dressing and cleaned the patient of incontinence. He then removed his gloves and donned new gloves without performing hand hygiene. The wound was not cleansed with saline or any other product. He then applied a new foam dressing and dated it. During an interview on 12/03/24 at 1:45 PM, Staff V, Wound Nurse, stated that Patient #27 did not have any physician orders specifying the wound treatment. It was usual practice for him to be consulted by the physician or nurse and for him to make recommendations on the wound treatment products and interventions. He demonstrated how he placed orders after his assessment and stated the physicians always sign them off. He stated he usually cleans wounds with saline or another wound cleansing product depending on the wound. Review of Patient #40’s medical record showed: - On 11/15/24, she was admitted for dizziness, confusion, weakness and frequent falls. - Her initial skin assessments showed no alterations other than a contusion to her face. - She had a history of diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), neuropathy (develops when nerves in the hands, feet or arms, are damaged), chronic kidney disease (CKD, ongoing, gradual loss of kidney function) and left leg arterial occlusions. - On 11/18/24, she was noted to have swelling to her left lower leg by PT. - On 11/22/24, an x-ray (test that creates pictures of the structures inside the body-particularly bones) was obtained of her left foot. Her morning assessment did not indicate any concerns related to that extremity. The afternoon reassessment indicated dark red discoloration or bruising. The foot wound was warm and closed, without any drainage. A dressing was applied. - On 11/22/24, she was discharged. The discharging physician did not reference a foot wound and her case management notes only addressed her dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) needs. - On 12/04/24, she patient was readmitted for surgery related to gangrenous (localized death of tissue resulting from either obstructed blood flow or infection) tissue and to have her 4th and 5th toes, on the left foot, amputated (removal of an injured or diseased body part). During an interview on 12/03/24 at 2:52 PM, Patient #40’s husband stated that during her hospitalization two weeks prior the staff neglected to notice wounds and discoloration that developed on her left foot. She was expected to go to surgery the next day to have toes amputated which could have been avoided if appropriate interventions had occurred sooner. On 12/02/24 at 2:40 PM, a review of Patient #2’s medical records showed inconsistent documentation of his skin and wound assessments. He was receiving ongoing treatment for wounds and the documented assessments failed to mention his wounds. On 12/02/24 at 2:45 PM, a review of Patient #3’s medical records showed inconsistent documentation of his skin and wound assessments. He was receiving ongoing treatment for wounds and the documented assessments failed to mention his wounds. Review of Patient #22’s medical record, dated 11/27/24 through 12/03/24, showed: - She was a 74-year-old woman with a past medical history of multiple sclerosis (MS, a disorder in which the immune system attacks the protective covering of the nerve cells). - She was admitted to the medical telemetry unit from home after 10 days of MS exacerbation (increase in symptoms) and generalized weakness. - She was bed bound. - At 4:00 AM, her skin risk assessment pressure injury risk score was 14. Her skin was warm and dry. - At 9:00 AM, her skin was warm and dry. - At 8:15 PM, her skin was warm and dry. - On 11/28/24 at 9:00 AM, her skin was warm and dry. - On 11/28/24 at 8:20 PM, her skin was warm and dry. - On 11/29/24 at 9:00 AM, her skin was warm and dry. - On 11/29/24 at 8:00 PM, her skin was warm and dry. - On 11/30/24 at 1:54 AM, she was repositioned. - At 8:00 AM, she was repositioned, six hours and six minutes later. Her skin was warm and dry. - At 8:00 PM, her skin risk assessment pressure injury risk score was 13. - On 12/01/24 at 5:03 AM, she was repositioned, 21 hours and three minutes later. - At 7:45 AM, she was repositioned, two hours and 42 minutes later. Her skin was warm and dry. - At 8:51 PM, she was repositioned, 13 hours and six minutes later. Her skin was warm and dry. - On 12/02/24 at 9:55 AM, she was repositioned, 13 hours and four minutes later. - At 11:07 AM, her skin was warm and dry. - At 8:00 PM, her skin was warm and dry. - On 12/03/24 at 8:30 AM, her skin was warm and dry. - At 9:25 AM, she was repositioned, 23 hours and 30 minutes later. Observation on 12/03/24 at 9:05 AM, Patient #22 was lying on a basic air mattress. During an interview on 12/05/24 at 8:15 AM and at 9:38 AM, Staff S, CN, stated that Patient #22 was on a basic air mattress and “possibly had a waffle underneath her.” Patients unable to turn themselves should be turned and repositioned every two hours. Review of Patient #49’s medical record showed: - He was a 39-year-old man with cerebral palsy (CP, caused by abnormal brain development before birth, is a group of disorders that affect a person’s ability to move and maintain balance and posture) and nonverbal. - On 05/22/24 at 11:58 PM, he was admitted to the emergency department for low blood pressure from a group home. - On 05/23/24 at 4:24 AM, he was admitted inpatient to the medical telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) unit. Dressing changes were completed for a stage two anterior sacral pressure injury and a stage one posterior right sided buttock pressure injury, both present on admission. - At 7:00 PM, he was repositioned. - On 05/24/24 at 10:45 PM, bilateral contractures to his hands and legs were documented and positioning aids in place. He was bed bound and non-ambulatory (not able to walk) with generalized weakness. - On 5/25/24 at 9:00 AM, he was repositioned. He had remained in the same position for 36 hours. He was placed on a low air loss specialty bed and required a two person assist. - On 5/26/24 at 9:00 AM, he was repositioned. He had remained in same position for 24 hours. - On 05/28/24 at 12:28 PM, nursing documented that a skin tear was present upon admission. Review of Patient #50’s medical record showed the following: - She was admitted on 10/20/24 with no skin alterations or wounds. - She had an initial skin risk score that suggested she was at risk for skin breakdown. - Nursing documentation of the Skin Risk Assessment tool on admission was 14 indicating the patient was at risk for pressure injury (injury to the skin and/or underlying tissue, usually over a bony area). - On 10/21/24 the nurse assessment showed the patient had a small area of redness measuring less than one centimeter (cm) with no depth or open areas, stating it was a Stage 1 pressure injury (intact skin with an area of redness that does not go away when pressure is applied) on her sacrum (triangular shaped bone above the tailbone). The wound was covered with a dressing. No orders were put into the chart for wound care. - On 10/25/24, the wound was noted to be red with purple center. The dressing was changed with no measurements, description of wound, no plan of care update, and no provider notification was documented. - On 10/26/24 and 10/27/24 the dressing was noted to be intact. There was no wound description noted. - On 10/28/24 a dressing change was performed with no description of the dressing, no wound description, no wound measurements, no update to the plan of care, and no provider notification. - On 10/30/24, dressing was noted intact, no documentation of wound measurements, description of wound, plan of care updates or provider notification. - For 10/31/24 and 11/01/24 there was no wound or dressing assessment. - Skin risk assessment tool rated Patient #50 a 17 at the time of discharge on 11/01/24 to a long-term acute care (LTAC, facilities that specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis). Review of Patient #51’s medical record showed: - On 04/22/24, he was admitted with no skin alterations or wounds. - His initial skin risk score indicated he was not at risk for skin breakdown. - Subsequent risk scores indicated his risk had increased over the course of his hospitalization. - He was placed on a specialty low air loss mattress (LAL mattress, a pressure reducing mattress used to prevent and treat pressure ulcers) and had frequent hygiene interventions documented. - On 05/23/24, a stage two pressure injury was noted and treated. Wound and Physical Therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) consultations were ordered at that time. - The patient was discharged to a long-term acute care (LTAC, facilities that specialize in the treatment of patients with serious medical conditions that require care on an ongoing basis) hospital the following day. During an interview on 12/03/24 at 3:35 PM, Staff KKK, RN, stated that patients who were bed-bound were at risk for pressure injuries and were to be turned and repositioned every two hours. Skin assessments were to be completed every shift and turns were to be documented in the medical record. During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated that having only one wound care nurse for a hospital their size was probably insufficient and wound care was an opportunity for improvement. Her expectation was that a bedside nurse should be able to manage a stage one or stage two pressure injury and a wound consultation would be requested if the wound worsened. Nurses should turn immobile patients every two hours and assist patients who weren’t entirely immobile as needed. She stated that she expected a patient with seizure precautions ordered would have those interventions implemented soon after admission. Clean barriers should be placed under the area of a patient’s wound during dressing changes. 50496”

“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: 51292 Based on observation, interview and policy review, the hospital failed to ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed. This had the potential to place all patients admitted to the hospital at risk for their safety. Findings included: Review of hospital’s policy titled, “Administering a Subcutaneous Injection to Adults Procedure,” showed: -Nurses must create a general aseptic field by cleaning off and disinfecting the work surface (or tray). They should allow the surface dry before using, perform hand hygiene and apply gloves. -If using a needle and syringe, nurses must cleanse the top of the vial with an antiseptic swab prior to inserting a filter needle, blunt tip needle or regular needle into the stopper of medication vial or ampule in order to withdraw the medication from the vial. -After withdrawing the prescribed amount of medication, staff should detach the filter or blunt tip needle, dispose of it appropriately and attach a new needle to the syringe. Review of the policy titled, “Medication Administration (MAR),” dated 07/2024, showed nurses are to review and acknowledge all medication orders prior to administration. Administrative or disciplinary action may be taken in situations of disregard for policy or for patient safety. Observation on 12/04/24 at 8:45 AM, showed Staff Z, RN, failed to clean the rubber stopper of an IV medication, famotidine (a medication that treats excess stomach acid or heartburn), prior to the insertion of the needle for withdrawal, while administering medications to Patient #27. She then attempted to dilute an IV medication, piperacillin/tazobactam (an antibiotic), by injecting the medication to be diluted into the open needle hub of a syringe filled with normal saline, causing some of the medication to splash out of the open tip. Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean the rubber stopper of an IV medication, cephazolin (an antibiotic), prior to the insertion of the needle for withdrawal. She then administered the IV medication to Patient #45 in less than 30 seconds. The administration instructions for Cephazolin on the MAR indicated that the medication was to administered over three to five minutes. During an interview on 12/03/24 at 2:10 PM, Staff Z, RN, stated she should have used a blunt tip to withdraw medication from the vial into the syringe with the normal saline. During an interview on 12/03/24 Staff E, Vice President of Quality, (VPQ), stated she would expect nurses to clean the top of a vial prior to the withdrawal of medications. During an interview on /12/05/24 with Staff B, Chief Nursing Officer, stated she expected nurses to follow administration instructions as indicated on the MAR and to follow hospital policies.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50496 Based on observation, interview and policy review, the hospital failed to: - Prepare a clean work surface prior to performing patient care for nine current patients (#4, #22, #23, #25, #27, #29, #31, #32, and #45) of 18 patients observed. - Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) during patient care for five current patients (#23, #25, #27, #45 and #48) of 43 patients observed; - Perform glove changes for three current patients (#4, #5 and#25) of 37 patients observed; and - Ensure staff followed intravenous (IV, in the vein) medication administration guidance for two current patients (#27 and #45) of six patients observed. Findings included: Although requested, the hospital failed to provide a policies regarding the use of a clean work surface, use of barriers or glove changes while providing patient care. Review of hospital’s policy titled, “Hand Hygiene,” dated 10/03/24, showed: - The purpose of hand hygiene is to prevent the transmission of healthcare associated pathogens on the hands of healthcare personnel to reduce the incidence of healthcare-associated infections (HAIs). - All healthcare personnel shall adhere to the Centers for Disease Control and Prevention (CDC, the nation’s health protection agency that saves lives and protects people from health threats) guidelines on hand hygiene as specified in this policy. - Alcohol-based products and/or soap and water may be used for standard hand hygiene. - Hand hygiene should be completed at the following instances: before and after direct contact with patients; before donning sterile gloves; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient); after contact with body fluids, excretions, mucous membranes, nonintact skin, and during dressing changes; if moving from a contaminated-body site to a clean-body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; or after removing gloves. Review of hospital’s undated policy titled, “Administering a Subcutaneous Injection to Adults Procedure,” showed nurses must create a general aseptic (free from harmful bacteria, viruses, or other microorganisms) field by cleaning off and disinfecting working surfaces (or tray). Staff should allow the surface to dry before using, then perform hand hygiene and apply gloves. If using a needle and syringe, nurses must clean top of the vial with antiseptic swab prior to inserting a filter, blunt tip or regular needle into the stopper of a medication vial or ampule to withdraw medication. Observation on 12/03/24 at 8:30 AM, showed Staff Y, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #4. Observation on 12/03/24 at 9:05 AM, showed that Staff R, RN, failed to clean her work surface or place a barrier prior to medication preparation and administration for Patient #22. Observation on 12/03/24 at 9:15 AM, showed that Staff S, CN, failed to place a barrier under Patient #23’s arm prior to placing an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream). Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to place a clean barrier under Patient #25’s leg during a wound dressing change. He failed to use a barrier, placing the wound dressing supplies on the countertop adjacent to the sink. He stated that he did not us a barrier under Patient #25’s leg because the wound was not “oozing.” Observation on 12/03/24 at 8:45 AM, showed Staff Z, RN, did not clean surface or use barrier prior to preparing medications for administration for Patient #27. Observation on 12/03/24 at 9:45 AM, showed Staff CC, RN, prepared oral meds for administration without cleaning the work surface or using a barrier for Patient #29. Observation on 12/03/24 at 3:20 PM, showed Staff J, RN, failed to clean a work surface or use a barrier when preparing medications for Patient #31. Observation on 12/03/24 at 10:10 AM, showed Staff DD, RN, did not clean the work surface or use a barrier when preparing medication for Patient #32. Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean a work surface prior to preparing medications for administration at the nursing desk. She then placed the medications on the uncleaned and cluttered patient tray table without using a barrier, then administered Patient #45’s IV medications. During an interview on 12/04/24 at 8:50 AM, Staff H, Nurse Manager, stated she expected nursing staff to clean surface prior to medication preparation and administration. During an interview on 12/04/24 at 8:50 AM, Staff D, Assistant Chief Nursing Officer, (ACNO), stated that she expected nursing staff to clean surfaces prior to medication preparation and administration. During an interview on 12/05/24 at 12:05 PM, Staff B, CNO, stated that she expected a clean barriers to be placed beneath medications before medication administration, under wound dressing supplies, and under the area of a patient’s wound during dressing changes. Observation on 12/03/24 at 8:30 AM, showed Staff Y, RN, grabbed her badge with soiled gloves while performing wound care on Patient #4, continue with patient care without changing gloves. During an interview on 12/03/24 at 2:15 PM, Staff Y, RN, stated she should have removed her gloves and performed hand hygiene prior to touching her badge. Observation on 12/04/24 at 10:05 AM, showed Staff XX, RN, while replacing a dressing, reached in her pocket with gloved hand to answer her phone, then put her phone back in her pocket and continued with patient care for Patient #5. During an interview on 12/04/24 at 10:40 AM, Staff XX, RN, stated she should have removed her gloves and performed hand hygiene prior to answering her phone and then again prior to continuing patient care. Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to change gloves after picking up trash on the floor and touching the trash can during a wound dressing change on Patient #25. He stated he should have changed his gloves after touching the trash on the floor and the trash can, before touching the clean dressing supplies and the patient. Observation on 12/03/24 at 9:15 AM, showed Staff S, CN, failed to perform hand hygiene after touching the patient, removing gloves and donning gloves while preparing supplies during an IV insertion for Patient #23. Observation with concurrent interview on 12/03/24 at 10:00 AM, showed Staff V, Wound Nurse, failed to perform hand hygiene prior to entering the patient’s room and donning gloves, after touching a trash can and after removing gloves while performing a wound dressing change on Patient #25. Staff V stated he should have performed hand hygiene before entering a patient’s room, before putting on gloves, after removing dirty gloves and putting on new gloves. He should have performed hand hygiene after touching the trash on the floor and the trash can before touching the clean wound supplies and applying them to the patient. Observation on 12/03/24 at 1:30 PM, showed Staff V, Wound Nurse, performed a dressing change and pressure injury assessment on Patient #27’s tailbone area. When the patient was turned, he was found to have soiled himself. Staff V removed the old dressing and cleaned the patient of incontinence. He removed his gloves and donned new gloves without performing hand hygiene. Observation on 12/04/24 at 8:30 AM, showed Staff D, RN, failed to perform hand hygiene after picking up trash off the floor for Patient #45. Observation on 12/04/24 at 11:10 AM, showed Staff V, Wound Nurse, failed to perform hand hygiene after removing gloves, touching a dirty wound dressing and donning clean gloves while performing a wound dressing change for Patient #48. During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated she would expect nursing staff to complete hand hygiene before donning and doffing gloves, before entering and after exiting a patient’s room and moving from a contaminated area to a clean area of the patient’s body. Observation on 12/04/24 at 8:45 AM, showed Staff Z, RN, failed to clean the rubber stopper of an IV medication prior to the insertion of the needle for medication withdrawal for Patient #27. Observation on 12/04/24 at 8:30 AM, showed Staff WW, RN, failed to clean the rubber stopper of an IV medication prior to the insertion of the needle for medication withdrawal, then administered the IV medication to Patient #45. During an interview on 12/05/24 at 12:20 PM, Staff B, CNO, stated she would expect nursing to clean the rubber topper of a medication vial with alcohol after “flipping off” the cap and withdrawing medication with a needle. During an interview on 12/03/24 at 3:15 PM, Staff E, VPQ, stated she expected staff to clean the top of the vial of medication prior to withdrawal. 49489”