SSM Health Saint Louis University Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41865 Based on interview, record review, policy and document review, the hospital failed to within its capability and capacity, stabilize an Emergency Medical Condition (EMC) for one patient (#7) of 24 Emergency Department (ED) medical records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s 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),” revised 12/13/23, showed a MSE must be provided within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exist. Triage (process of determining the priority of a patient’s treatment based on the severity of their condition) was not an MSE. The patient must continue to be monitored according to the individual’s needs, and the medical record must reflect continued monitoring until it is determined whether or not the individual has an EMC and, if he/she does, until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer. All ministries shall provide necessary stabilizing treatment within the capabilities and capacity of the staff and facilities available. Review of the hospital’s policy titled, “Telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) Monitoring,” revised 03/19/26, showed patients would be assessed for appropriateness of telemetry monitoring and be removed from telemetry as their condition warranted. Review of the hospital’s document titled, “Attachment F- Required Elements of Daily Assessment (REDA)/ED,” revised 02/2026, showed: - Fragile care/geriatric patients would be assessed and documented upon arrival to the treatment area by the primary nurse, and at the time of handoff by the oncoming nurse. - Vital signs (VS, measurements of the body’s most basic functions) would be obtained and documented at the time of triage and then at a minimum of every two hours on medical patients with an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) of one through three. - More frequent VS or frequent assessments were appropriate if the patient’s condition warranted. - Assessment frequencies were based on the patient’s diagnosis and chief complaint. Review of the hospital’s policy titled, “Critical Values Communication,” reviewed 11/11/19, showed: - When non-radiologic critical values (as outlines in attached critical value lists) were obtained, within 15 minutes, the department Performing the test would communicate the value to a “Responsible Licensed Caregiver.” - If initial contact was unsuccessful, additional attempts must be made, including contacting the assigned nurse, charge nurse and nursing supervisor as needed. - Documentation was required at the time of the notification, including the name and credentials of the person notified, and verification of the critical value (read-back). - Once notified, the Responsible Licensed Caregiver was expected to assess the patient and initiate appropriate medical decision making and interventions. - The policy outlined specific escalation steps if the provider did not respond or address the critical value in a timely manner. Review of the hospital’s undated document titled, “Critical Values List,” showed that ventricular dysrhythmias (an abnormal electrical signal in the heart’s lower chambers that causes it to beat too fast, chaotically or ineffectively) were identified as critical values. As such, hospital staff were required to follow the hospital’s, “Critical Values Communication” to ensure timely, safe patient care. Review of the hospital’s undated document titled, “Sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) Mortality Reduction Guide,” showed: - Early and appropriate antibiotics were vitally important to reducing sepsis-related mortality. - Phase I was the determination of clinical time zero and updated sepsis best practice advisory (BPA). Focus on blood culture collection prior to appropriate antibiotic administration within 60 minutes of clinical time zero. - Phase II was to reduce ED arrival to antibiotic administration time to less than 120 minutes by implementation and utilization of an ED triage sepsis screening tool: National Early Warning Score (NEWS2, a standardized track-and-trigger tool to assess the severity of illness and identify clinical deterioration in adult patients). - A NEWS2 score of greater than five identified at risk patients. - The Sepsis Response Team would determine appropriate diagnostics and treatment. Please refer to A-2407 for further details.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to ensure that an Emergency Medical Condition (EMC) was stabilized for one patient (#7) of 24 Emergency Department (ED) medical records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s 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),” revised 12/13/23, showed a MSE must be provided within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exist. Triage was not a MSE. The patient must continue to be monitored according to the individual’s needs, and the medical record must reflect continued monitoring until it is determined whether or not the individual has an EMC and, if he/she does, until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer. Review of the hospital’s policy titled, “Telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) Monitoring,” revised 03/19/26, showed patients would be assessed for appropriateness of telemetry monitoring, with telemetry being removed as their condition warranted. Review of the hospital’s document titled, “Attachment F- Required Elements of Daily Assessment (REDA)/ED,” revised 02/2026, showed: - Fragile care/geriatric patients would be assessed and documented upon arrival to the treatment area, by the primary nurse, and at the time of handoff by the oncoming nurse. - Vital signs (VS, measurements of the body’s most basic functions) would be obtained and documented at the time of triage and then at a minimum of every two hours on medical patients with an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) of one through three. - More frequent VS or frequent assessments were appropriate if the patient’s condition warranted them. - Assessment frequencies were based on the patient’s diagnosis and chief complaint. Review of the hospital’s policy titled, “Critical Values Communication,” reviewed 11/11/19, showed: - When non-radiologic critical values (as outlines in attached critical value lists) were obtained, the department performing the test would communicate the value to a “Responsible Licensed Caregiver” within 15 minutes. - If initial contact was unsuccessful, additional attempts must be made, including contacting the assigned nurse, charge nurse and nursing supervisor as needed. - Documentation was required at the time of the notification, the name and credentials of the person notified, and verification of the critical value (read-back). - Once notified, the Responsible Licensed Caregiver was expected to assess the patient and initiate appropriate medical decision making and interventions. - The policy outlined specific escalation steps if the provider did not respond or address the critical value in a timely manner. Review of the hospital’s undated document titled, “Critical Values List,” showed that ventricular dysrhythmias (an abnormal electrical signal in the heart’s lower chambers that causes it to beat too fast, chaotically or ineffectively) were identified as critical values. As such, hospital staff were required to follow the hospital’s, “Critical Values Communication” policy to ensure timely and safe patient care. Review of the hospital’s undated document titled, “Sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) Mortality Reduction Guide,” showed: - Early and appropriate antibiotics were vitally important to reducing sepsis-related mortality. - Phase I, was the determination of clinical time zero and updated sepsis best practice advisory (BPA). Focus on blood culture collection prior to appropriate antibiotic administration within 60 minutes of clinical time zero. - Phase II, was to reduce ED arrival to antibiotic administration time to less than 120 minutes by implementation and utilization of an ED triage sepsis screening tool: “National Early Warning Score (NEWS2, a standardized track-and-trigger tool to assess the severity of illness and identify clinical deterioration in adult patients).” - A NEWS2 score of greater than five identified at risk patients. - The Sepsis Response Team would determine appropriate diagnostics and treatment. Review of Patient #7s medical record dated 01/09/26, showed: - He was a 91-year-old who presented to the ED at 6:04 PM with generalized weakness, congestion and shortness of breath, but no chest pressure. - His past medical and surgical history included coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), 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), atherosclerosis (the narrowing of the heart’s arteries due to a buildup of fatty plaque), pacemaker (small device that’s placed in the chest or abdomen to help control abnormal heart rhythms), an implantable cardioverter-defibrillator (ICD, battery-powered device placed under the skin, that continuously monitors heart rhythm and automatically delivers electrical pulses or shocks to correct life-threatening arrhythmias), 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), Transcatheter Aortic Valve Replacement (TAVR, minimally invasive procedure that replaces a diseased aortic valve with a biological tissue valve), and a left atrial appendage (LAA, a procedure that blocks or closes the opening to the LAA to keep blood clots from leaving entering into the bloodstream). - At 6:22 PM, a triage (process of determining the priority of a patient’s treatment based on the severity of their condition) note showed the patient’s daughter reported the patient was “wheezy” when she picked him up. He had a productive cough, decreased appetite, and occasional nausea when attempting to eat or drink. - At 6:20 PM, his VS included a blood pressure (BP, normal between 90/60 and 120/80) of 118/45; a pulse/heartbeats (HR, normal 60 to 100 per minute) of 63; a respiration rate (RR, normal 12 to 20 breaths per minute[bpm]) of 18; and a body temperature (T, normal 97.8o to 99o Fahrenheit [F]) of 99.5o F. His oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower.) was 95% on room air. - No other VS or assessment were documented after the initial triage. - At 6:23 PM, his NEWS2 score was a four. - At 6:59 PM, Staff N, Physician Assistant (PA), documented a MSE. She noted his respirations were even and unlabored with bilateral lower lobe crackles (irregular clicking, popping or rattling lung sounds). His HR was regular rate and rhythm. He was alert and oriented times three (A&O x 4, a person is oriented to person, place, time, and situation). Documentation indicated “a complete physical examination was limited due to patient sitting in upright position in chair. Based on the MSE performed and diagnostic tests at this time, further evaluation is indicated and will be performed. Patient will be transferred to a main ED room when one is available, and care will be transferred to ED provider.” - At 7:03 PM, bloodwork, respiratory testing, urinalysis (a laboratory examination of a person’s urine), a chest x-ray (test that creates pictures of the structures inside the body-particularly bones), an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), lactated ringers (IV fluid that contains electrolytes), an albuterol inhaler (bronchodilator medication used to relax muscles in the airways and increase airflow to the lungs) and Mucinex (medication used to thin and loosen mucus in the chest) were ordered and/or administered. - Bloodwork showed he was positive for influenza (highly contagious condition affecting the respiratory system). His potassium (mineral in the blood or body fluid, normal range 3.5 to 4.5 mmol/L) was 4.8, his creatinine (blood test that shows how the kidney is functioning, normal range 0.71 - 1.16 mg/dL) was 1.33, his estimated glomerular filtration rate (eGFR, calculation that measures how kidneys are filtering waste products, greater than 90 mL/min/1.73 m2 is normal) was 50 and his platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal range was 150 - 420 x10E9/L) were 85,and he was mildly anemic (low amounts of oxygen rich blood, causes paleness and weakness). - At 7:51 PM, the EKG results were ventricular-paced rhythm (an implanted pacemaker is electrically stimulating the lower ventricles [heart chamber] to beat) with occasional premature ventricular complexes (PVCs, isolated, extra beats that originate in the ventricles and disrupt the normal rhythm, often felt as a palpitation or a skipped beat). Abnormal EKG when compared with EKG of 10/25/24. Electronic ventricular pacemaker has replaced sinus rhythm. On 01/24/26, (14 days after the patient’s death) a provider confirmed “no significant change found.” - At 8:00 PM, it was documented that Staff M, ED Physician, was notified of the patient’s EKG results. - No telemetry orders were documented. - At 8:13 PM, his troponin (a type of blood test that measures whether a person is experiencing a heart attack, normal is less than 0.01) resulted at 95 ng/L (unit of measurement). - At 10:23 PM, his Troponin I High Sensitivity (a blood test that measures whether a person is experiencing a heart attack, normal result was less 35 ng/L) resulted at 85 ng/L. - At 12:47 AM, Staff E, ED Physician, noted he was called to evaluate the patient as he had been found unresponsive in the waiting room. Upon evaluation, patient was pulseless and apneic (temporary and involuntary pause in breathing) with Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) in progress. He learned from nursing and other bystanders that patient had been awake and talking and then was found slumped over. Patient was asystole (absence of activity of the heart) throughout Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient’s heartbeat or breathing stops) protocol at each rhythm check with no return of spontaneous circulation. - The patient was declared dead at 1:04 AM. During a telephone interview on 05/12/26, at 2:35 PM, Staff P, Patient Care Technician (PCT) stated that when PCTs were assigned to the waiting room their duties were to do rounds and get VS. Golden patients were supposed to get VS every hour, and regular patients, every two hours. VS were supposed to be put in the chart when they were taken, not later, and that was to ensure that they were accurate and on time. If a patient had any change, even a slight change, they shared that with the nurses, and they could refer to the older VS for comparison. “However, a lot of times, the waiting room gets so busy, especially with ambulances, that we get really backed up and VS and reassessments don’t get done. If the VS aren’t in a patient’s medical record it’s because they didn’t get taken, unfortunately that happens a lot.” The nurses did not do waiting room VS, they relied on the PCTs for that information. During a telephone interview on 05/12/26 at 2:05 PM, Staff F, RN, stated she performed the triage of Patient #7. He was with his daughter, and his chief complaint was general weakness and flu-like symptoms. He stated that he just wasn’t feeling good. His daughter said that he was more altered and confused than he usually was. She thought that she had assigned him an ESI of two, but when she was reviewing the chart, she noticed it was a three. His VS were stable at the time of triage, he was able to answer yes or no questions, but he was confused on exactly why he was in the ED. He saw the PA, who performed the MSE and then he was put in the waiting room with the rest of the patients. “He was given a gold color and slid over onto the board, which meant he was supposed to be in the “go next” section. This is basically a slot for patients that we’re actively concerned about, and if a room opens up, those were our priority patients.” When asked how often patients were to be rounded on and reassessed in the waiting room she responded, “in a perfect world, where we are staffed and have all of our resources, if there’s a patient that we are concerned about, it is the expectation that they have rounding, and VS done every one to two hours.” PCTs were assigned to the waiting room to do repeat VS and if they noted deterioration in a patient, they would alert the triage nurse. If a doctor needed to be notified it was expected that was done “sooner rather than later,” as well as appropriate documentation that the physician was notified. “At this hospital there is a significant delay before patients can make it back into a room to be with a provider. On that specific day there was quite a delay in patients being able to make it back to rooms. When I arrived, there were less than 15 patients in the waiting room and from 7:00 PM to midnight I believe that it grew to over 40 patients. There were several traumas activated, several medical resuscitations and we were very short staffed that night. When that happens and it’s the perfect storm it is not at all uncommon for things to unfortunately just kind of slip through the cracks because there are more resources strained than what we’re able to meet with the staff that we have.” During an interview on 05/12/26, at 3:40 PM, Staff E, ED Physician/Emergency Services Division Director, stated that on 01/09/26, he came on at 11:00 PM and he knew “we were boarded up badly. I knew we had a lot of patients that we needed to get back to rooms that we couldn’t get back. When that happens, we identify patients who need a room first by changing the color they are on the list. Our highest priority are gold patients. We place them in a dedicated area of the ED to keep a closer eye on them, and they are roomed before lower acuity patients. This patient had a positive flu, and he had been identified as needing room, but his initial VS had been stable. He had upper respiratory infection (URI, irritation and swelling of the upper airways with associated cough and nasal congestion) symptoms and a very mildly elevated troponin, but we had sicker people who were in the back.” He was involved in an RCA after this event and the main concerns identified were “being able to get patients who are a higher acuity back to rooms sooner. The problem wasn’t that we hadn’t identified this patient was potentially sick and should be back in a room, the problem really was our capacity, we just didn’t have the room.” He acknowledged that some of the issues were hospital capacity, inpatient boarding, ED boarding and some of it was nurse staffing. “This was a night where we were doing our best to follow our waiting room practice and doing our best to do our processes. If we had a reasonable throughput in the back, or reasonable nursing staffing, I think we would have been able to get this guy back.” Since the event, the hospital had done a lot to address the structural problems; “we are clearing the waiting room more effectively, improving waiting room safety practices, such as rounding. We are really pushing for proper full 24/7 nurse staffing in our ED, it’s a Level 1 Trauma Center, it’s a tertiary care center, it always needs to be fully staffed. We have to make sure that our beds are going to tertiary patients and so we’ve been working with our partner ministries to take capacity transfers. Our average hospital admission stay is 6 ½ days. In March, we sent out 120 patients to other ministry hospitals, so that’s 720 days of hospitalization that isn’t boarding in the ED. I have some confidence in that program in terms of just decompressing us and I think it’s a good solution because we need to be able to take the tertiary care patients as there’s no other places in the system to care for them.” Interviews with Staff N, PA, who performed the MSE and ordered initial treatment, and Staff M, ED Physician, who was notified of the patient’s EKG results, were requested but not completed. Staff N no longer works for the organization and Staff M was out on medical leave.”

“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: 48359 Based on observation, interview, record review, video review and policy review, the Governing Body failed to: - Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital; (A-0057) - Follow the hospital’s policy for the delivery of the Important Message from Medicare (IM, information about a patient’s right to appeal discharge) upon inpatient admission and prior to discharge for five (#8, #12, #17, #23 and #25) of eight medical records reviewed; (A-0117) - Provide house-wide staff education following serious safety events for two hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) patients (#49 and #50) of two hemodialysis patient event reports reviewed; (A-0144) - Ensure the safe discharge for one incapacitated patient (#12), when she was inappropriately discharged alone to a motel; (A-0144) - Ensure oxygen tanks were properly stored; (A-0144) - Follow the hospital’s policy for refrigerator and freezer temperature monitoring on six of six units observed; (A-0144) - Properly monitor and maintain one blanket warmer; (A-0144) - Use the least restrictive method for one patient (#12) of two restrained patients reviewed; (A-0164) - Ensure the use of restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were in accordance with the order of a licensed practitioner (LP) for one current patient (#1) and one discharged patient (#9) of three restrained patients reviewed; (A-0168) - Ensure appropriate monitoring and nursing documentation during the use of restraints and seclusion for one current patient (#1) and two discharged patients (#12 and #34) of four restrained patients reviewed; (A-0175) - To assess/re-evaluate the appropriateness of discharge and post-hospital plan for follow-up care, for one patient (#12) of one incapacitated discharged patient reviewed; (A-0802) - Establish an appropriate discharge evaluation and review the evaluation with the patient’s representative, for one patient (#12) of one incapacitated discharged patient reviewed; and (A-0808) - Transfer or refer the patient, along with all necessary medical information pertaining to the current course of illness and treatment, post-discharge goals of care and treatment preferences at the time of discharge to the appropriate post-acute care service providers, for one patient (#12) of one incapacitated discharged patient reviewed. (A-0813) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body. Please refer to A-0057, A-0-117, A-0144, A-0164, A-0168, A-0175, A-0802, A-0808 and A-0813.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review, video review and policy review, the Governing Body failed to: - Follow the hospital’s policy for the delivery of the Important Message from Medicare (IM, information about a patient’s right to appeal discharge) upon inpatient admission and prior to discharge for five (#8, #12, #17, #23 and #25) of eight medical records reviewed; (A-0117) - Ensure oxygen tanks were properly stored; (A-0144) - Follow the hospital’s policy for refrigerator and freezer temperature monitoring in six of six units observed; (A-0144) - Properly monitor and maintain one blanket warmer; (A-0144) - Provide house-wide staff education following serious safety events for two hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) patients (#49 and #50) of two hemodialysis patient event reports reviewed; (A-0144) - Ensure the safe discharge for one incapacitated patient (#12), when she was inappropriately discharged alone to a motel; (A-0144) - Use the least restrictive method for one patient (#12) of two restrained (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) patients reviewed; (A-0164) - Ensure the use of restraint or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were in accordance with the order of a licensed practitioner (LP) for one current patient (#1) and one discharged patient (#9) of three restrained patients reviewed; and (A-0168) - Ensure appropriate monitoring and nursing documentation during the use of restraints and seclusion for one current patient (#1) and two discharged patients (#12 and #34) of four restrained patients reviewed. (A-0175) The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety also known as Immediate Jeopardy (IJ). As of 12/17/25, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and on coming staff education on safe discharge planning and dialysis connection devices. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0117, A-0144, A-0164, A-0168 and A-0175.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to: - Assess/re-evaluate the appropriateness of discharge and post-hospital plan for follow-up care, for one patient (#12) of one incapacitated discharged patient reviewed; (A-0802) - Establish an appropriate discharge evaluation and review the evaluation with the patient’s representative, for one patient (#12) of one incapacitated discharged patient reviewed; and (A-0808) - Transfer or refer the patient, along with all necessary medical information pertaining to the current course of illness and treatment, post-discharge goals of care and treatment preferences at the time of discharge to the appropriate post-acute care service providers, for one patient (#12) of one incapacitated discharged patient reviewed. (A-0813) These failed practices had the potential for adverse health consequences, medical errors during transitions of care and negative impacts on vulnerable populations upon discharge. The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation (CoP): Discharge Planning. Please refer to A-0802, A-0808 and A-0813.”

“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: 38236 Based on observation, interview and policy review, the Governing Body failed to ensure the Chief Executive Officer 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 and 42 CFR 482.43 CoP: Discharge Planning. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Saint Louis University Hospital Organization Chart,” revised 09/22/25, showed all administrative leaders reported to Staff SS, President. During an interview on 12/29/25 at 1:30 PM, Staff SS, President, stated she was appointed by the Governing Body, and she was responsible for managing the hospital. 48359”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38236 Based on interview, record review and policy review, the hospital failed to follow their policy for the delivery of the Important Message from Medicare (IM, information about a patient’s right to appeal discharge) upon inpatient admission and prior to discharge for five (#8, #12, #17, #23 and #25) of eight medical records reviewed. Findings included: Review of the hospital’s policy titled, “Medicare Important Message (IM) and Medicare Outpatient Observation Notice (MOON) Corporate Policy,” dated 01/04/23, showed: - Hospitals are required to deliver the IM to all Medicare beneficiaries who are hospital inpatients. - The Sisters of St. Mary (SSM) must issue the initial IM within two days of admission and must obtain the signature of the beneficiary or their representative. - SSM must also deliver a copy of the signed notice to each beneficiary not more than two days before the day of discharge. - The facility must document delivery of the notice in order to demonstrate compliance with this requirement. - When a beneficiary is unable to understand the notice, the hospital may have the beneficiary’s representatives receive and sign the notice. - If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary’s rights. - If the representative is not available for in person delivery, the notice may be made by telephone, but not by voicemail, with a copy of the notice mailed or faxed that same day. - If a representative agrees, notice may be electronically mailed (email) following the telephone call. - If the hospital is unable to reach the representative by telephone, the notice may be sent by certified mail/return receipt. Review of the hospital’s undated document titled, “Case Manager Audits,” showed 10 discharged Medicare patients were audited for IM given within two days to four hours prior to discharge. Four of the 10 audits showed no IM was given. Review of Patient #12’s medical record, dated 06/27/24 through 10/21/25, showed: - The admission IM, dated 06/28/24, was not signed by the patient’s representative. - The signature box showed, “discharge rights given verbally by PV”, written in cursive by an unknown person. - On 10/21/25 at 5:00 PM, Staff KK, Social Worker (SW), documented an IM was emailed to the patient’s guardian at 1:00 PM, with instructions on how to appeal the discharge. The IM was never signed or acknowledged prior to discharge. During an interview on 12/23/25 at 3:00 PM, Staff NN, Physician, stated that the comment and initials in the signature box dated 06/28/24 were not his. He had never seen the patient prior to 10/21/25. Review of Patient #8’s medical record showed she was admitted as an inpatient on 12/10/25. Her IM was signed on 12/13/25, three days after her admission. Review of Patient #17’s medical record, dated 10/29/25 through 11/05/25, showed her IM was signed on 11/02/25, four days after her admission. Review of Patient #23’s medical record showed she was admitted as an inpatient on 10/03/25. There was no documentation of the IM delivery notice prior to her discharge on 10/14/25. Review of Patient #25’s medical record showed he was admitted as an inpatient on 08/15/25. His IM was signed on 08/21/25, six days after his admission. During a telephone interview on 12/30/25 at 12:00 PM, Staff WW, Patient Access Manager, stated that her team had two midnights to obtain the IM for inpatient Medicare patients. Her Emergency Department (ED) team members reviewed a cue every hour for admission orders to identify patients in need of the IM document. If the ED team members were unable to provide the patient with the document, the morning team reviewed a daily report and worked to provide the document to patients already admitted to the units. She stated that there was “a lot of need for the number of available staff.” Her team also worked with the case managers and social workers to ensure communication regarding patient’s needs for the IM. Her team attempted to reach out to families as needed to ensure the IM was completed. Her team “just kept on until the patient was discharged,” in an effort to complete the IM as required. During a telephone interview on 12/30/25 at 1:00 PM, Staff KK, Case Management Manager, stated that the discharge IM was to be provided to the patient within four to 48 hours of discharge. Case Management was responsible for the discharge IM, Social Work provided support as well. He performed random monthly audits on every staff member and had identified issues with the completion of the IMs at discharge. The Case Managers attended Multiple Discipline Rounds (MDRs) every weekday to identify patient’s discharge plans. There was no process on the weekends in place to identify discharging patients who were not identified for discharge on Friday, to ensure the IM was provided within four hours. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO) and Staff EEE, CNO, stated that they were not aware of the details for how Patient #12’s representative was provided the IM prior to her discharge. They expected staff to follow the IM policy. 48359”

“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: 38236 Based on interview, record review and policy review, the hospital failed to provide care in a safe setting when they failed to: - Provide house-wide staff education following serious safety events for two hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) patients (#49 and #50) of two hemodialysis patient event reports reviewed; - Ensure the safe discharge for one incapacitated patient (#12), when she was inappropriately discharged alone to a motel; - Ensure oxygen tanks were properly stored; - Follow the hospital’s policy for refrigerator and freezer temperature monitoring in six of six units observed; and - Properly monitor and maintain one blanket warmer. Findings included: Review of the hospital’s undated policy titled, “Care of the Dialysis Patient,” directed staff to observe for bleeding from the access site. Review of the hospital’s document titled, “Event Summary with Action Plan,” dated 08/31/25, showed: - Education was provided for all staff on hemaclips (safety devices used to secure tubes during dialysis) and maintaining good visibility of the dialysis access during treatment, including utilizing gauze under the connection for better visualization of blood; - The action item was due for completion on 11/30/25 and completed on 12/10/25; - Criteria was formulated with guidelines for dialysis to be done in the dialysis unit versus the bedside; and - The action item was due for completion on 11/30/25 and completed on 12/15/25. This action item was a duplicate from Patient #50’s event on 12/09/24. Review of the hospital’s undated document titled, “10R Machine Log,” showed the dialysis machine was not quality checked prior to Patient #49’s dialysis treatment. Review of Patient #49’s medical record dated 08/25/25 through 08/31/25, showed: - She was a 61-year-old admitted to the hospital with chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), obstructive sleep apnea (a sleep-related breathing problem that involves a decrease or blockage in airflow despite an ongoing effort to breathe), high blood pressure, acute (sudden onset) on chronic (long-term, ongoing) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and heart failure (a chronic condition in which the heart cannot pump or fill adequately). - Her past medical history included kidney failure that required dialysis. - On 08/25/25 at 8:41 PM, an order was written by Staff AAA, Physician, for telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen). The order showed the patient did not require telemetry monitoring while off the nursing unit. - On 08/26/25 at 3:35 PM, a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called for oxygen desaturation (a decrease in oxygen saturation in the blood) as low as 60%. - On 08/30/25 at 9:41 AM, she was on heated and humidified oxygen at 15 liters per minute via a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen). - At 11:11 AM, she arrived in the dialysis unit. - At 12:40 PM, a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called for cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and a large amount of blood was found near her dialysis line. - At 1:20 PM, the patient was declared expired. During a telephone interview on 12/18/25 at 11:00 AM, Staff YY, Dialysis RN, stated that when she received report, she was told the patient was on 15 liters of oxygen. She stated that other hospitals she worked at did not take high flow oxygen patients in the dialysis unit. The dialysis for those patients was typically completed at their bedside. The patient was not escorted by a respiratory therapist and wall oxygen was not available which caused the patient to remain on a portable oxygen tank. She asked the charge nurse to call maintenance after the patient depleted two portable oxygen tanks because she had a high flow rate. She reminded the charge nurse again to call for the respiratory therapist. Hemaclips were typically placed on the venous (blood that is low in oxygen content and is carried through blood vessels from the body back to the heart) side, but she placed two hemaclips because the patient was “fidgety.” Staff YY went to check on her other patient and when she returned the patient had turned to her right side with her knee’s bent and her left arm over the bed rail. The dialysis catheter was on her right side. There was no visible blood at that time and the machine did not alarm because the tubing was still connected. She observed the patient’s oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) declined to 89% to 90% from her usual 93%. She was concerned because the patient had already depleted two portable oxygen tanks. A respiratory therapist went to the room and the patient was turned off of her side. Blood was visible on her pillow under her breast. The leurlock (a standardized, threaded fitting used in medical devices for secure, leak-free connections) was loose. She estimated a blood loss of 1,000 milliliters. When she saw the blood, she asked the charge nurse to call a code blue. She had heard of a leurlock coming loose and that was why the hemaclips were in place to prevent loosening of the connections. She never experienced a similar event. The machine log was not completed because she normally documented the log about 45 minutes into the dialysis session, she was told to go home after the code blue. During an interview on 12/15/25 at 10:15 AM, Staff HH, Dialysis Manager, stated that the nurse was going back and forth between two patients and both hemaclips were in place. The patient kept moving. The patient was found on her side, when she was rolled over, pooled blood was found and the leurlock was loose on the venous side. A code blue was called. The patient was on a portable oxygen tank because the wall oxygen was not working. During an interview on 12/18/25 at 1:15 PM, Staff AAA, Physician, stated that he expected dialysis patients had continuous telemetry monitoring. He expected a patient with a high demand for oxygen and episodes of desaturations to be monitored with continuously telemetry. He believed “the does not require telemetry monitoring while off nursing division” applied to the patient walking in the hallways, otherwise a patient with a telemetry order should be continuously monitored. During an interview on 12/18/25 at 11:30 AM, Staff ZZ, Patient Safety Specialist, stated that she received Patient #49’s event report, reported to leadership and a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) was indicated. Opportunities were identified and a plan was initiated. She stated that her perception of the wall oxygen issue was user error, which was not identified as a cause of the event. There was no house-wide oxygen administration education provided. She stated that she would look for patterns with the wall oxygen. She did not delve into the oxygen issue because that was not the cause of harm to the patient. Education was provided that included a double check of the hemaclips and that the hemaclips did not replace the leurlocks. The Patient Safety Committee planned to meet the following Monday to approve the guidelines for dialysis to be done in unit versus the bedside. She stated that there were no other near misses or events in the dialysis unit. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO), and Staff EEE, CNO, stated that they initially believed the cause for Patient #49’s event was related to the hemaclips, not the leurlock. Education was provided to the dialysis staff during the survey to ensure the leurlocks were properly visible and secure. They believed the hospital had an opportunity to educate providers on the telemetry orders to clarify their expectations. Review of the hospital’s document titled, “Event Report (a staff report of an unexpected occurrence) for Patient #50,” dated 12/09/24, showed the report was submitted by an anonymous individual. The patient had severe emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) and received oxygen therapy. She was in the dialysis unit and received oxygen via an oxygen tank. The patient went into cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and the reporter was notified (not documented anywhere in the chart) the oxygen tank was empty, the patient was not receiving oxygen, which likely led to her hypoxic respiratory arrest (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system). Review of the hospital’s document titled, “M.D. Action Plan,” dated 12/10/24, showed: - A short-term action item was to assess the current state of report between the floor nurse and dialysis nurse prior to the patient coming to dialysis for: - Time of report (should be within one hour); - Criteria established for establishing if patient is stable to come to dialysis; - Instability should be escalated to primary team and nephrology (the branch of medicine that deals with the kidneys, especially their functions or diseases) provider prior to going to dialysis. - This action item was due for completion on 03/10/25, completion was 05/01/25. - A short-term action item was once the new state of report between the floor nurse and the dialysis nurse was developed, it would be presented to the ministry directors and rolled out to nursing staff, and all providers. - This action was due for completion on 03/28/25, completion was on 05/01/25. Review of the hospital’s document titled, “Oxygen Work Orders-Year to Date,” dated 01/01/25 to 12/30/25, showed nine work orders related to the wall oxygen not working throughout the hospital. Review of the hospital’s electronic mail (email) dated 12/30/25, showed that a quick review of most of the issues related to the wall oxygen work orders were user error and the flow meters needed to be pushed hard into the port for flow to initiate or the port in the wall needed replacement. Real time education was given to the individual who entered the work order. No house-wide education was provided. Although requested, the hospital failed to provide an Oxygen Management policy. Although requested the hospital failed to provide an interview with Staff BBB, Previous Dialysis Manager, she was on leave and unavailable. Although requested the hospital failed to provide an interview with Staff CCC, Rapid Response RN, she was on leave and unavailable. Review of Patient #50’s medical record dated 11/13/25 through 12/15/25, showed: - She was a 68-year-old admitted to the hospital with a pulmonary embolism (PE, blood clot in the lung). - Her past medical history included kidney failure that required dialysis, COPD, high blood pressure and colon cancer. - On 12/09/25 at 6:49 PM, her oxygen saturation was 99%. An oxygen saturation was not documented again until 8:30 PM. - At 8:00 PM, a code blue was called in the dialysis unit. The patient was reportedly having a high oxygen demand prior to the code blue. - After 12 minutes of Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped), return of spontaneous circulation (ROSC, the resumption of a sustained heart rhythm after cardiac arrest) was achieved and she was transferred to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). - On 12/10/25 at 11:37 AM, a hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) note showed “yesterday she was receiving routine hemodialysis and by report she was found in cardiac arrest. By report, her oxygen tank was depleted, and the arrest was suspected to be hypoxia (not enough oxygen reaching the cells and tissues in the body) mediated. She underwent CPR with ROSC and is now in shock (a critical condition brought on by the sudden drop in blood flow through the body) in the ICU.” - On 12/15/25, she was discharged to hospice care (a program that provides specialized care to patients at or near end of life). During a telephone interview on 12/31/25 at 11:10 AM, Staff XX, Respiratory Care Manager, stated that the hospital building was new in 2020 and some of the oxygen ports took effort to push in the flowmeters. She stated there was a correct way to place the oxygen regulators in the wall and saw value in house-wide education. As the Respiratory Care Manager, she believed staff could be educated to do better as a whole. She believed education was an “excellent idea.” During a telephone interview on 12/30/25 at 5:00 PM, Staff HH, Dialysis Manager, stated that she knew a little bit about the event with Patient #50. She did not know why the patient was not placed on wall oxygen. She stated that education was given in reference to hand off to ensure patient were connected to wall oxygen by the receiving nurse. No education was given in regard to the management of oxygen administration. During a telephone interview on 12/30/25 at 12:27 PM, Staff VV, Respiratory Therapist, stated that Patient #50 was in ROSC when she arrived at the code. She was told by a “rapid response nurse” that the oxygen tank was empty which caused the patient’s arrest. She did not recall the nurse’s name. She stated that the oxygen flow meters pop out of the walls when they are bumped. Work orders have been placed throughout the hospital. There have been patient issues when patients were left on portable oxygen tanks instead of transferring them to wall oxygen. During a telephone interview on 12/30/25 at 12:30 PM, Staff UU, Rapid Response RN, stated that Patient #50 had multiple oxygen issues during her hospitalization, and it stood to reason that she had a quick respiratory decline when her portable tank was depleted. The patient had poor perfusion which caused poor monitoring of her oxygen saturations. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, ACNO, and Staff EEE, CNO, stated that oxygen management was discussed during general orientation. The hospital had a tier huddle process where charge nurses discussed incidents which led to educational opportunities. Oxygen administration and education needs were not previously discussed during the huddles. They stated that any identified opportunity for education created a safer environment. Education for oxygen administration was a “good opportunity.” They stated that their expectations for corrective action plans were to ensure timely education and provide education to staff prior to the start of the next shift for staff members on leave. Review of the hospital’s undated policy titled, “Standard Work for Discharge Planning Documentation,” showed, required documentation for all case managers (CM) and social workers (SW) included an initial assessment, updated progress notes every 72 hours and a Friday note. Review of the Judicial Court document titled, “Letters of Successor Guardianship of an Incapacitated Person,” dated 11/21/11, showed Patient #12 was legally incapacitated and was assigned a guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves). Review of Patient #12’s medical record, dated 06/27/24 through 10/21/25, showed: - She was a 47-year-old admitted for evaluation of septic arthritis (a serious joint infection in the synovial fluid and tissues, causing rapid pain, swelling, redness, and warmth, and can lead to permanent joint damage if not treated urgently with antibiotics), osteomyelitis (infection in the bone) around the left collarbone and breastbone joint from previously placed foreign objects under the skin. - She had a history of Borderline Personality Disorder (mental health disorder marked by unstable, intense emotions and mood), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail) which involved a compulsion (persistent and repetitive urge to perform an act) to eat/swallow non-food items with numerous ingestions, self-injurious behaviors (SIB, behaviors that result in physical injury to an individual’s own body), cutting behaviors, suicide attempts, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy), recurrent deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), morbid obesity and hyperthyroidism (overactive thyroid [a large gland in the neck that secretes hormones that regulate growth and development]). - She was legally incapacitated since age 18 and had a guardian. - She lived in a residential facility which provided 24-hour care prior to the hospital admission. She had required 24-hour care for over 20 years. - From 06/28/24 to 10/21/25, the patient swallowed non-food items approximately 13 times requiring numerous esophagogastroduodenoscopies (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) to remove them. The items included batteries, a metal shower hook, a piece of glass, plastic spoon, screws, plastic knife and a hair tie. - On 09/19/25, the patient swallowed three AA batteries, one of the batteries went into the patient’s windpipe which required an emergency bronchoscopy (procedure to insert a camera down the windpipe to visualize the inside of the windpipe or lungs) and intubation (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) for life support. - On 10/14/25 at 11:54 AM, Social Work (SW) documented the expected day of discharge was 10/20/25, and the patient swallowed a heparin lock the prior evening. Kidney, ureter, and bladder x-ray (KUB; assesses the structures of the urinary and/or gastrointestinal system) was ordered and a possible EGD. - From 10/15/25 to 10/20/25, there were no nursing, Case Management (CM) or SW notes regarding the discharge plan or documented attempts to discuss the discharge plan with the guardian/family. - On 10/21/25 at 5:00 PM, Staff KK, SW, documented an expected discharge date of 10/21/25. The patient was medically ready for discharge to the next level that day. A reservation was made at a Super 8 motel in Washington, MO. That was approved and paid for by the Sisters of St. Mary (SSM). The patient’s sister-in-law (SIL) lived near that area. She was willing to help the patient but could not let her live with her. SW attempted to contact the patient’s SIL but got no answer. The CM manager spoke with the patient and explained the plan that her room was paid for until Saturday and that she could reach out to her guardian for assistance with future residence needs or with her SIL. The patient was supplied with two bags of food from the breadbasket. That should provide four days of food. The hotel also had a free breakfast. The CM manager called and spoke with Staff RR, General Council. He was aware of the discharge and in agreement. - On 10/21/25 at 5:34 PM, she was discharged to a motel in a different city by herself via a public vehicle. Review of Patient #12’s Hospital B medical record, dated 10/23/25 through 10/27/25, showed: - At 9:28 PM, she was admitted through the emergency department (ED), with throat pain after she ingested two safety pins within the last hour. - She was located at the Super 8 motel, where SSM St. Louis University discharged her to. She called her SIL after she swallowed the safety pins. - At 10:35 PM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed one safety pin in the esophagus (a muscular tube that food travels through from the throat to reach the stomach), one in the stomach and one in the small bowel. - The patient had four EGDs during her hospitalization. - On 10/27/25, at 8:41 PM, she was discharged to a residential care facility (RCF, a nonmedical facility that provides a home-like environment for individuals who are unable to live independently, but do not require 24-hour nursing care). During an interview on 12/23/25 at 12:40 AM, Patient #12’s SIL, stated that she was not aware the patient was discharged until the patient called her from the motel on 10/22/25. She spoke to Staff OO, SW, sometime around 10/15/25. The hospital continued to push her into letting the patient live with her. She told them no, more than once. Staff OO did not tell her the patient was going to discharge or discharge to a motel. Instead, Staff OO told her they were going to look for a shelter to send her to. She told them the shelter would not be safe; the patient must have constant care. She could not take care of herself; she could not manage finding a place to live, her medications or her finances. During an interview on 12/18/25 at 12:00 PM, Staff NN, Physician, stated he was the practitioner who discharged Patient #12. He never saw the patient before 10/21/25. He was informed by Staff KK, CM Manager; Staff PP, Chief Medical Officer; and Staff RR, General Counsil, that the patient was cleared by all disciplines, the SIL was going to help take care of the patient and all documentation, including the guardian, was completed for a safe and appropriate discharge. He was not aware the patient was going to a motel and agreed a motel was not a safe discharge for that patient. During an interview on 12/17/25 at 2:16 PM, Staff KK, CM Manager, stated that the discharge of Patient #12, a legally incapacitated person, to a motel was safe. They paid for the motel for five days, gave her food for four days, she had all of her medications, she had money, and she had help from her SIL. Staff KK had no contact with the guardian or SIL in the seven days prior to discharge on 10/21/25. He was aware that a patient with a guardian could not be discharged without their consent but Staff RR, General Counsil, informed him everything that needed to be done was complete and all Staff KK needed to do was send the guardian the discharge Medicare Important Message (IM, information about a patient’s right to appeal discharge) within four hours of discharge. Staff KK emailed the IM to the guardian at 1:19 PM, with no response. The patient was discharged at 5:34 PM. During an interview on 12/29/25 at 1:30 PM, Staff SS, President, stated that she was aware of Patient #12’s discharge and felt it was a safe discharge based on the information she was provided. She was not aware the guardian had not given permission for the discharge and that there was no family member ready to help the patient post discharge. When asked again if that was a safe discharge, she did not reply. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO), and Staff EEE, CNO, stated that they were aware of Patient #12’s discharge and believed at the time was a safe discharge plan. They believed the patient’s family was going to care for her upon discharge to the hotel. They believed that after her prolonged hospitalization her assessment showed she was not a danger to herself. They were aware she had been under the guardianship of the state and resided in a mental health residential facility prior to her hospitalization. Finding placement for Patient #12 was challenging. They expected additional case management and/or social work prior to Patient #12’s discharge. Review of the hospital’s policy titled, “Medical Gas Cylinders,” reviewed 08/13/25, directed staff to always restrain gas cylinders in a rack or cylinder holder specifically designed for medical gas storage. Observation on 12/15/25 at 2:16 PM, on Bordley Seven North, showed two oxygen tanks stored outside of the storage rack on the floor. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, ACNO, and Staff EEE, CNO, stated that they expected oxygen tanks were stored according to the hospital’s policy. Review of the hospital’s policy titled, “Food Safety and Storage for Patient Care Areas,” Revised 08/25/22, showed: - All refrigerators containing patient food will be monitored daily or continuously for appropriate temperature by a designated individual(s) within the department containing the refrigerator. - Daily monitoring of refrigerator temperatures require daily documentation of the temperature of the refrigerator and freezer on a log sheet - The log sheet will be kept near the individual refrigerator. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Six North Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Freezer Temperature Log,” dated 12/2025, from the Bordley Six North Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Six South Unit, showed five of 15 days without recorded temperatures. Review of the hospital’s document titled, “Freezer Temperature Log,” dated 12/2025, from the Bordley Six South Unit, showed five of 15 days without recorded temperatures. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Seven North Unit, showed five of 15 days without recorded temperatures. Review of the hospital’s document titled, “Freezer Temperature Log,” dated 12/2025, from the Bordley Seven North Unit, showed five of 15 days without recorded temperatures. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Seven South Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Freezer Temperature Log,” dated 12/2025, from the Bordley Seven South Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Nine North Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Freezer Temperature Log,” dated 12/2025, from the Bordley Nine North Unit, showed four of 15 days without recorded temperatures. Review of the hospital’s document titled, “Refrigerator Temperature Log,” dated 12/2025, from the Bordley Nine South Unit, showed four of 15 days without recorded temperatures. There was no freezer temperature log. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, ACNO, and Staff EEE, CNO, stated that they expected refrigerator and freezer temperature logs were completed everyday as required per the hospital’s policy. Review of the hospital’s undated document titled, “Instructions for Use (IFU) Man_01_Rev_n_D_series_warming_cabinets_TOC,” showed: - The Association of Perioperative Registered Nurses (AORN) recommends the cabinet temperature should be routinely monitored and documented on a temperature log or on a record provided by an electronic recording system. - The display panel shows the current chamber temperature and the set point temperature. - Weekly checklist recommendations included a check that all control indicators (heat and alarm) were lit up. Review of the hospital’s documented titled, “Work Order for Blanket Warmer,” dated 12/15/25, showed at 5:34 PM, a work order was entered for a blanket warmer that did not display a temperature on the monitor and the machine felt over heated. Review of an email dated 12/30/25, showed the hospital did not keep temperature logs for the blanket warmers. They followed the instructions for use for maintenance and monitoring. Although requested, the hospital failed to provide a blanket warmer policy. Observation on 12/05/25 at 2:00 PM, in the Bordley Nine North Unit, showed the display panel on the blanket warmer did not show the current chamber or set point temperatures. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, ACNO, and Staff EEE, CNO, stated that the malfunctioning blanket warmer still in use did not meet their expectations. They stated that the hospital had an opportunity to develop a daily blanket warmer temperature log. 48359”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 46856 Based on record review and policy review, the hospital failed to use the least restrictive method for one patient (#12) of two patients placed in non-violent restraints (devices used to restrict movement of the arms, legs, body, hands, fingers or head to promote medical healing and/or diminish risk of suffering or physical harm). This failure had the potential to place all patients admitted to the hospital at risk for their right to be free from restraints used to impose coercion, discipline or convenience. Findings included: Review of the hospital’s policy titled, “Non-violent restraints and restraint alternatives,” revised 12/13/23, showed: - Patients will be protected from harm in the least restrictive environment possible with the intent to prevent, reduce and work towards the elimination of restraints use. - Patients will be restrained only when necessary to ensure safety and when the least restrictive interventions are determined ineffective. - Prior to the use of restraints, the following intervention, as appropriate, should be considered, including but not limited to offering companionship, such as family, friends, volunteers and staff. - Each episode of restraint use documentation includes circumstances leading to use, with failure of less restrictive alternatives. Review of Patient #12’s medical record showed the following: - On 06/26/24, she was a 46-year-old with a history of borderline personality disorder (mental health disorder marked by unstable, intense emotions and mood), multiple foreign body ingestions and self-harming behaviors. - On 09/20/25 at 5:10 PM, she was placed in non-violent restraints. Clinical justification was unable to contract for safety. Less restrictive alternatives included an alarm. The alternatives did not include companionship/sitter. - On 10/03/25 at 2:00 PM, restraints were discontinued. She was restrained for 12 days, 21 hours and 50 minutes without assessment for failure of companionship. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO), and Staff EEE, CNO, stated that restraints were to be used as a “last resort.” The hospital strived to be restraint free. They expected documentation of other interventions used to prevent Patient #12 from self-harm by swallowing inedible objects.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to ensure the use of restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) was in accordance with the order of a licensed practitioner (LP) for one current patient (#1) and one discharged patient (#9) of three restrained patients reviewed. Findings included: Review of the hospital’s policy titled, “Violent Restraint (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed the physician, or another licensed independent practitioner who is responsible for the care of the patient, who is permitted by the state to order seclusion or restraints, gives the order only when less restrictive measures have been found to be ineffective to protect the patient or others from harm. If the order is about to expire and the registered nurses (RN) assessment shows that the patient requires continuous restraint, the RN will contact the physician and request that the original order be renewed for another period of time. Review of Patient #1’s medical record showed the following: - On 12/07/25, he was a 36-year-old admitted to the Behavioral Health Unit (BHU). - On 12/10/25 at 1:59 AM, a physician order for seclusion expired. - At 2:00 AM through 2:15 AM, nursing documented that Patient #1 was in seclusion. - At 2:04 AM, a physician ordered seclusion. The start time for seclusion was 2:15 AM. - He was in seclusion with no order for 16 minutes. - At 3:17 AM, a physician discontinued the seclusion order and ordered a therapeutic hold. Seclusion was not reordered. - At 3:30 AM through 5:15 AM, nursing documented that Patient #1 was in seclusion. - At 5:25 AM, seclusion was discontinued. - He was in seclusion with no order for one hour and 55 minutes. - On 12/11/25 at 4:29 PM, nursing documented that Patient #1 was placed in a therapeutic hold. - At 4:30 PM, the therapeutic hold was discontinued. The hold lasted one minute. - There was no physician order for a therapeutic hold. - On 12/14/25 at 3:59 PM, a physician order for seclusion expired. - At 4:00 PM through 4:15 PM, nursing documented that Patient #1 was in seclusion. - At 4:24 PM, seclusion was discontinued. - He was in seclusion with no physician order for 24 minutes. Review of Patient #9’s medical record showed the following: - On 12/10/25, she was a 27-year-old in the Emergency Department (ED). - At 4:00 AM, the patient was unsuccessfully redirected, and security and the physician were called for emergent supervision with violent restraints. - The patient was held down by four security officers for an injection. - At 4:30 AM, the patient slipped out of the violent restraints due to extremely small wrists and was able to remove her ankle restraints. - The nursing note showed no order for restraints was required per the provider as they were removed within seconds after placement upon staff leaving the room. - Orders were not written for the therapeutic hold or violent restraints. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO), and Staff EEE, CNO, stated that they expected an order for each restraint episode regardless of how long the restraints were in place.”

“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 restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for one current patient (#1) and two discharged patients (#12 and #34) of four restrained patients reviewed. This failure created an unsafe environment and had the potential to cause poor outcomes for all patients placed in restraints or seclusion. Findings included: Review of the hospital’s policy titled, “Violent Restraint (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed: - On-going assessment and monitoring at regular intervals is to determine: physical and emotional well-being while in restraints; maintenance of patient’s rights, dignity, comfort and safety; changes in behavior or clinical condition that may indicate the removal of the restraint or change to less restrictive method’ and proper application of the restraint and that no harm is caused. - An assigned staff member must monitor the patient and document the findings at the initiation of restraint or seclusion and every 15 minutes thereafter. - The following will be monitored and documented every 15 minutes: signs of any injury associated with the application of restraint or seclusion; circulation in the restrained extremities; physical and psychological (relating to the mind or mental activity) status and comfort (including pain); maintenance of the head of the bed elevation of 30 degrees unless medically contraindicated; readiness for discontinuation of restraint or seclusion and suction equipment availability. Review of the hospital’s policy, titled, “Non-Violent Restraints and Restraint Alternatives,” revised 12/13/23, showed observation and monitoring are performed at last every two hours to include circulation and skin check of restrained extremities and patient comfort; release of restrained extremity and provision of range of motion (ROM, how far you can move or stretch a part of your body, such as a joint or a muscle); observe for signs of injury associated with application/release of restraint; offer nutrition, hydration and toileting while awake; repositioning as appropriate; maintenance of head of bed elevation of 30 degrees for patients restrained in supine (lying on the back with the face and torso facing upward) position, unless medically contraindicated; psychological status and readiness of discontinuation of restraint. Review of Patient #1’s medical record showed the following: - On 12/07/25, he was a 36-year-old admitted to the Behavioral Health Unit (BHU). - On 12/15/25 at 9:26 AM to 11:27 AM, nursing documented that the patient was in the seclusion/restraint room, who initiated the restraint and the restraint type. - At 11:33 AM, seclusion was discontinued. - For two hours and seven minutes, there was no documentation on signs of injury, circulation, physical and psychological status, release readiness assessment and suction equipment availability. Review of Patient #12’s medical record showed the following: - On 06/27/24, she was a 45-year-old admitted to the Eight North Unit. - On 12/18/24 at 3:45 PM to 12/19/24 at 7:25 PM, nursing documented that the patient was in nonviolent soft restraints to both wrists. - On 12/19/24 from 4:01 PM to 7:24 PM, there were no visual checks, circulation/skin checks, ROM, signs of injury observations, nutrition/hydration, elimination, head of bed elevation documented, repositioning, psychological status or readiness for discontinuation of restraints assessments. - On 09/20/25 at 5:10 PM to 10/03/25 at 2:00 PM, nursing documented that the patient was in nonviolent soft restraints to both wrists. - On 09/21/25 from 4:01 AM to 7:59 AM, 09/22/25 from 4:01 PM to 7:59 PM and 10/02/25 from 12:01 PM to 3:59 PM, there were no visual checks, circulation/skin checks, ROM, signs of injury observations, nutrition/hydration, elimination, head of bed elevation documented, repositioning, psychological status or readiness for discontinuation of restraints assessments. Review of Patient #34’s medical record showed the following: - On 08/23/25, she was a 79-year-old admitted to the Six South Unit. - On 08/24/25 at 6:32 AM to 08/26/25 at 4:43 PM, nursing documented that the patient was in nonviolent mitten restraints to both hands. - From 6:32 AM to 9:44 PM, there were no visual checks, circulation/skin checks, ROM, signs of injury observations, nutrition/hydration, elimination, head of bed elevation documented, repositioning, psychological status or readiness for discontinuation of restraints assessments. During a telephone interview on 01/05/26 at 9:00 AM, Staff DDD, Associate Chief Nursing Officer (ACNO), and Staff EEE, CNO, stated that they expected observations were performed and documented according to the hospital’s policy for violent and non-violent restraints.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 38236 Based on interview, record review and policy review, the hospital failed to assess/re-evaluate the appropriateness of discharge and post-hospital plan for follow-up care, for one patient (#12) of one incapacitated discharged patient reviewed. Findings included: Review of the hospital’s policy titled, “Discharge Planning,” dated 05/07/25, showed: - A Health Care Decision Maker includes a Legal Guardian (the person appointed by a judge to manage healthcare options, the property and rights of another person who is considered incapable of doing so themselves), Power of Attorney (POA, someone legally designated to make decisions about a patient’s healthcare options, who is not able to make decisions on their own), Health Care Proxy (a legal document naming a trusted person [agent] to make medical decisions for you if you can’t, ensuring your wishes are followed for care, treatments, and access to records when incapacitated) and Patient Representative. - The discharge planning process shall focus on patient goals and treatment preferences and include the patient and their caregivers support person(s) in the discharge planning for post-discharge care. There must be documentation in the patient’s medical record of the patient’s goals and treatment preferences. The documentation must include that the patient and their Health Care Decision Maker was included in the development of the goals. Documentation should be completed by social work, case management and discharge planners. - The discharge planning process and the discharge plan shall be consistent with the patient’s goals for care and their treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care and reduce the factors leading to a preventable hospital readmission. - The patient’s condition must be re-evaluated at least every seven days to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Review of the hospital’s undated policy titled, “Standard Work for Discharge Planning Documentation,” showed required documentation for all case managers (CM) and social workers (SW) included: - An initial assessment; - Updated progress notes every 72 hours; and - A Friday note. Review of the court document titled, “Letters of Successor Guardianship of an Incapacitated Person,” dated 11/21/11, showed Patient #12 was legally incapacitated and was assigned a guardian. Review of Patient #12’s medical record, dated 06/27/24 through 10/21/25, showed: - She was a 47-year-old admitted for evaluation of septic arthritis (a serious joint infection in the synovial fluid and tissues, causing rapid pain, swelling, redness, and warmth, and can lead to permanent joint damage if not treated urgently with antibiotics), osteomyelitis (infection in the bone) around the left collarbone and breastbone joint from previously placed foreign objects under the skin. - She had a history of Borderline Personality Disorder (mental health disorder marked by unstable, intense emotions and mood), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail) which involved a compulsion (persistent and repetitive urge to perform an act) to eat/swallow non-food items with numerous ingestions, self-injurious behaviors (SIB, behaviors that result in physical injury to an individual’s own body), cutting behaviors, suicide attempts, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy), recurrent deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), morbid obesity and hyperthyroidism (overactive thyroid [a large gland in the neck that secretes hormones that regulate growth and development]). - She lived in a residential facility which provided 24-hour care prior to presenting to the hospital. She had required 24-hour care for over 20 years. - On 10/13/25 at 12:28 PM, CM documented the patient was not medically ready for discharge. - From 10/14/25 to 10/21/25, there was no CM or SW assessment/re-evaluation of the patient to determine what was needed for a safe discharge. - On 10/21/25 at 5:34 PM, she was discharged to a motel in a different city by herself via a public vehicle. Review of Patient #12’s Hospital B medical record, dated 10/23/25 at 9:28 PM, showed she was admitted through the emergency department (ED), with throat pain after she ingested two safety pins. During an interview on 12/17/25 at 2:16 PM, Staff KK, CM Manager, stated that the discharge of Patient #12, a legally incapacitated person, to a motel was safe. He was not sure why there was no CM or SW documentation of a re-evaluation of the patient.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 38236 Based on interview, record review and policy review, the hospital failed to establish an appropriate discharge evaluation and review the evaluation with the patient’s representative, for one patient (#12) of one incapacitated discharged patient reviewed. Findings included: Review of the hospital’s policy titled, “Discharge Planning,” dated 05/07/25, showed: - A Health Care Decision Maker includes a Legal Guardian (the person appointed by a judge to manage healthcare options, the property and rights of another person who is considered incapable of doing so themselves), Power of Attorney (POA, someone legally designated to make decisions about a patient’s healthcare options, who is not able to make decisions on their own), Health Care Proxy (a legal document naming a trusted person [agent] to make medical decisions for you if you can’t, ensuring your wishes are followed for care, treatments, and access to records when incapacitated), and Patient Representative. - The documentation must include that the patient and their Health Care Decision Maker was included in the development of the goals. - Documentation should be completed by social work, case management and discharge planners. Review of the court document titled, “Letters of Successor Guardianship of an Incapacitated Person,” dated 11/21/11 showed Patient #12 was legally incapacitated and was assigned a guardian. Review of Patient #12’s medical record, dated 06/27/24 through 10/21/25, showed: - She was a 47-year-old admitted for evaluation of septic arthritis (a serious joint infection in the synovial fluid and tissues, causing rapid pain, swelling, redness, and warmth, and can lead to permanent joint damage if not treated urgently with antibiotics), osteomyelitis (infection in the bone) around the left collarbone and breastbone joint from previously placed foreign objects under the skin. - She had a history of Borderline Personality Disorder (mental health disorder marked by unstable, intense emotions and mood), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail) which involved a compulsion (persistent and repetitive urge to perform an act) to eat/swallow non-food items with numerous ingestions, self-injurious behaviors (SIB, behaviors that result in physical injury to an individual’s own body), cutting behaviors, suicide attempts, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy), recurrent deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), morbid obesity and hyperthyroidism (overactive thyroid [a large gland in the neck that secretes hormones that regulate growth and development]). - She lived in a residential facility which provided 24-hour care prior to the hospital admission. She required 24-hour care for over 20 years. - From 10/14/25 to 10/21/25, there were no Case Management (CM) or Social Work (SW) documentation of a discharge evaluation/plan review with the patient’s guardian. - On 10/21/25 at 5:34 PM, she was discharged to a motel in a different city by herself via a public vehicle. During an interview on 12/17/25 at 2:16 PM, Staff KK, CM Manager, stated there was no contact with the guardian in the seven days prior to discharge on 10/21/25.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 38236 Based on interview, record review and policy review, the hospital failed to transfer or refer the patient, along with all necessary medical information pertaining to the current course of illness and treatment, post-discharge goals of care and treatment preferences at the time of discharge to the appropriate post-acute care service providers, for one patient (#12) of one incapacitated discharged patient reviewed. Findings included: Review of the hospital’s policy titled, “Discharge Planning,” dated 05/07/25, showed: - A Health Care Decision Maker includes a Legal Guardian (the person appointed by a judge to manage healthcare options, the property and rights of another person who is considered incapable of doing so themselves), Power of Attorney (POA, someone legally designated to make decisions about a patient’s healthcare options, who is not able to make decisions on their own), Health Care Proxy (a legal document naming a trusted person (agent) to make medical decisions for you if you can’t, ensuring your wishes are followed for care, treatments, and access to records when incapacitated), and Patient Representative. - The discharge planning process shall focus on patient goals and treatment preferences and include the patient and their caregivers support person(s) in the discharge planning for post-discharge care. There must be documentation in the patient’s medical record of the patient’s goals and treatment preferences. The documentation must include that the patient and their Health Care Decision Maker was included in the development of the goals. Documentation should be completed by social work, case management and discharge planners. - A discharge planning evaluation shall include an evaluation of a patient’s likely need for appropriate post-hospital services and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. Review of the court document titled, “Letters of Successor Guardianship of an Incapacitated Person,” dated 11/21/11 showed Patient #12 was legally incapacitated and was assigned a guardian. Review of Patient #12’s medical record, dated 06/27/24 through 10/21/25, showed: - She was a 47-year-old admitted for evaluation of septic arthritis (a serious joint infection in the synovial fluid and tissues, causing rapid pain, swelling, redness, and warmth, and can lead to permanent joint damage if not treated urgently with antibiotics), osteomyelitis (infection in the bone) around the left collarbone and breastbone joint from previously placed foreign objects under the skin. - She had a history of Borderline Personality Disorder (mental health disorder marked by unstable, intense emotions and mood), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail) which involved a compulsion (persistent and repetitive urge to perform an act) to eat/swallow non-food items with numerous ingestions, self-injurious behaviors (SIB, behaviors that result in physical injury to an individual’s own body), cutting behaviors, suicide attempts, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy), recurrent deep vein thrombosis (DVT, is the formation of a blood clot in a blood vessel that is deep under the skin), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), morbid obesity and hyperthyroidism (overactive thyroid [a large gland in the neck that secretes hormones that regulate growth and development]). - She lived in a residential facility which provided 24-hour care prior to the hospital admission. She required 24-hour care for over 20 years. - On 10/13/2025 at 12:28 PM, Case Management (CM) documented the patient was not medically ready for discharge. - From 10/14/25 to 10/21/25, there were no CM or Social Work (SW) assessment/re-evaluation of the patient to determine what was needed for a safe discharge. - On 10/21/25 at 5:00 PM, Staff KK, SW, documented an expected discharge date of 10/21/25. The patient was medically ready for discharge to the next level that day. An Important Message from Medicare (IM, information about a patient’s right to appeal discharge) was emailed to the patient’s guardian at 1:00 PM, with instructions on how to appeal the discharge. A reservation was made at a Super 8 motel in Washington, MO. That was approved and paid for by the Sisters of Saint Mary (SSM). The patient’s sister-in-law (SIL) lived near that area. She was willing to help the patient but could not let her live with her. SW attempted to contact the patient’s SIL but got no answer. The CM manager spoke with the patient and explained the plan that her room was paid for until Saturday and that she could reach out to her guardian for assistance with future residence needs or with her SIL. The patient was supplied with two bags of food from the breadbasket. That should provide four days of food. The hotel had free breakfast. The CM manager called and spoke with Staff RR, General Council. He was aware of the discharge and in agreement. - On 10/21/25 at 5:34 PM, she was discharged to a motel in a different city by herself via a public vehicle. During an interview on 12/17/25 at 2:16 PM, Staff KK, CM Manager, stated that no medically necessary information was sent with the patient or to the guardian. An appointment with a medical clinic was made but transport to this appointment was not set up. The patient was informed to follow up with her guardian or the SIL for care.”

“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: 49404 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 (#5) of 22 Emergency Department (ED) records reviewed from 09/26/24 through 03/26/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 3,954. 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),” revised 12/13/23, showed: - A MSE shall be provided to any individual who presents to the ED and/or hospital and requested emergency care regardless of diagnosis, financial status, race, color, national origin, and/or disability. - A MSE is an examination which is sufficiently detailed to reveal whether an EMC exists and must include medically indicated screens, tests, mental status evaluations, and a history and physical examination within the capability of the hospital’s ED. - The MSE must be provided within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. If an EMC is determined to exist, all ministries shall provide any necessary stabilizing treatment. - The patient must continue to be monitored until it is determined whether or not the individual has an EMC, they are stabilized or appropriately transferred. Please refer to 2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49404 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 (#5) of 22 Emergency Department (ED) records reviewed from 09/26/24 through 03/26/25. 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),” revised 12/13/23, showed: - A MSE shall be provided to any individual who presents to the ED and/or hospital and requested emergency care regardless of diagnosis, financial status, race, color, national origin, and/or disability. - A MSE is an examination which is sufficiently detailed to reveal whether an EMC exists and must include medically indicated screens, tests, mental status evaluations, and a history and physical examination within the capability of the hospital’s ED. - The MSE must be provided within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. If an EMC is determined to exist, all ministries shall provide any necessary stabilizing treatment. - The patient must continue to be monitored until it is determined whether or not the individual has an EMC, they are stabilized or appropriately transferred. Review of Patient #5’s medical record, dated 03/22/25, showed: - At 8:33 AM, a 49-year-old male presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and law enforcement after having seizure-like (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) activity at the St. Louis City Justice Center, where he was in custody. He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time) upon arrival. - EMS reported that he was given Narcan (a medication used to counter the effects of narcotic overdose) prior to their arrival at 7:59 AM by jail staff. He was A&O X 3, stated he had heartburn for two weeks, and there were multiple emesis piles on the floor around him. - He did not have a significant past medical history. - At 8:40 AM, he was assessed by a physician. His vital signs (VS, measurements of the body’s most basic functions), blood and urine were obtained. His urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) and laboratory tests were within normal limits, no drugs were detected. - At 8:44 AM, a troponin-I high sensitive baseline (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 35) blood test was drawn, and the result was less than three. - At 9:23 AM, a troponin-I high sensitive plus one-hour blood test was drawn, and the result was four. - A head computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan, brain Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body), chest x-ray (test that creates pictures of the structures inside the body-particularly bones), and an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) were completed and were negative for a myocardial infarction (MI, heart attack). - A Neurology (a branch of medicine concerned with the study and treatment of disorders of the nervous system) consultation was ordered. They recommended an electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity) in addition to the MRI. - At 4:07 PM, report was called by the ED RN to inpatient unit 5N. He was admitted to unit 5N at 4:17 PM under the Neurology service. An admission assessment was charted at 4:30 PM. The EEG was performed and was negative. - The seizure like activity reported at the jail was not observed during the patient’s visit and he remained A&O x 3. - Patient #5 was not evaluated by a cardiologist (a physician that specializes in the care of your heart and blood vessels) or worked up further for chest pain. - At 7:16 PM, he was discharged from unit 5N to the custody of the St. Louis City Justice Center. Review of Patient #5’s Hospital B medical record, dated 03/23/25, showed: - At 4:45 AM, he presented to the ED via EMS and law enforcement from the St. Louis City Justice Center in cardiac arrest (when the heart suddenly and unexpectedly stops pumping) after he was found unresponsive by jail staff. - Jail staff initiated Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped). EMS continued CPR upon their arrival, which continued until they transferred care of the patient to ED staff. - The ED staff continued CPR and provided Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient’s heartbeat or breathing stops) measures until he expired at 5:00 AM. During a telephone interview on 03/27/25 at 10:30 AM, Staff N, Physician, stated that Patient #5 received treatment consistent with the signs and symptoms he presented with. He considered an electrolyte (minerals in the blood and other body fluids that carry an electric charge) imbalance or heart disease in addition to seizures as the cause of the patient’s symptoms. Imaging by CT and MRI, lab tests, and examination did not indicate the cause of the patient’s unresponsive episode. His VS were stable, and the patient did not exhibit any seizure like activity. He followed the neurologist’s recommendation and admitted the patient for additional tests including an electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity).”