Missouri Delta Medical Center

“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 policy review the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (# 6), and failed to ensure an EMC was stabilized for one patient (#7) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED and L&D 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 emergency medical condition),” reviewed 02/2024, showed hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual. They must provide appropriate stabilization for the patient’s EMC. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” adopted 04/06/06, showed: - The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual’s appearance or behavior, the individual needs services for a medical condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part. - If an EMC is found to exist, the hospital will provide necessary stablizing treatment or an appropriate transfer. - Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital. Review of the hospital’s policy titled, “MSE,” reviewed 02/2024, showed any persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated. Please refer to A-2406 and A-2407 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49404 Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#6) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit 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 emergency medical condition),” reviewed 02/2024, showed, Hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” adopted 04/06/06, showed: - The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual’s appearance or behavior, the individual needs services for a medical condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part. - If an EMC is found to exist, the hospital will provide necessary stabilizing treatment or an appropriate transfer. Review of the hospital’s policy titled, “MSE,” reviewed 02/2024, showed any persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated. Review of Patient #6’s medical record, dated 08/19/25, showed: - She was a 36-year-old with no significant past medical history. - At 7:41 AM, she presented to the ED accompanied by her supervisor after being hit in the head by a four-pound box at work earlier that morning. She reported pain, dizziness and vomiting after the incident. There was no loss of consciousness. She did have mild discoloration noted to the right upper forehead. - Her vital signs (VS, measurements of the body’s most basic functions) were normal, and her assessment was negative except for complaints related to her injury. - At 8:04 AM, a triage pain assessment showed she reported head pain and rated it a seven on a one to 10 pain scale. There was no documentation of her pain being reassessed. - 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) showed no acute process. She reported a persistent headache. - There was no reassessment of nausea or dizziness documented in the medical record. - There was no documentation in the medical record related to her ability to walk or tolerated oral intake. - No medication was ordered or administered. - Her discharge diagnosis was a head contusion. - At 9:20 AM, she was discharged with instructions to follow up with her worker’s compensation physician. During an interview on 09/16/25 at 11:05 AM, Staff G, ED Medical Director, stated that she cared for Patient #6. The patient’s injury appeared minor, but she ordered a head CT because the patient reported dizziness and vomiting after the incident. She did not recall that the patient had any difficulty ambulating or complained of nausea or vomiting after she presented to the ED. Her headache was minor, and she deferred treating it because it was not acute, and the patient was to see her worker’s compensation physician after she was discharged. The pain would be treated with over-the-counter medication. She did not recall meeting with the patient’s husband. The patient seemed satisfied with her care, although she seemed disappointed when informed of the negative results of the CT scan. The only dissatisfaction she was aware of occurred after discharge when the patient was in an outpatient lab to provide a sample for a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) required by her employer, but she did not know the nature of it. She felt she provided an adequate MSE and determined an EMC was not evident. During an interview on 09/16/25 at 11:55 AM, Staff M, CT Technician, stated that she recalled conducting Patient #6’s CT scan but did not recall anything out of the ordinary. The patient did not vomit or appear to be in any distress. She arrived by wheelchair and was able to transfer herself onto the scanner. If the patient had difficulty transferring or reported any distress she would have contacted the ED nurse, but that was not necessary. She did not recall the husband being present. During a telephone interview on 09/16/25 at 12:00 PM, Staff N, RN, stated that she cared for Patient #6 during her ED encounter. The patient presented after a workplace injury and wanted a CT of her head, which was completed. She did not recall a nausea complaint, and she did not witness any vomiting. The patient complained of a headache, but it was not acute, and the patient did not appear to be in distress. The patient was accompanied by her supervisor, and she did not recall if her husband was present. The physician saw the patient multiple times before she was discharged. During a telephone interview on 09/6/25 at 3:40 PM, Staff O, RN, stated that he was in nursing orientation when he cared for Patient #6. He recalled her mentioning pain and nausea and thinks it was relayed to the physician, but no orders were received. The patient did not appear to be in distress or discomfort and mostly relaxed in bed. She was able to ambulate and transfer to and from the chair. He took the patient by wheelchair from the ED to the outpatient lab when she was discharged at the request of her husband, who did not think she should walk following a head injury. Staff O did not observe any vomiting during her stay.”

“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: 49404 Based on interview, record review and policy review the hospital failed to ensure an emergency medical condition (EMC) was stabilized for one patient (#7) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit 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 emergency medical condition),” reviewed 02/2024, showed, Hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual. They must provide appropriate stabilization for the patient’s EMC. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” adopted 04/06/06, showed: - The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual’s appearance or behavior, the individual needs services for a medical condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part. - If an EMC is found to exist, the hospital will provide necessary stabilizing treatment or an appropriate transfer. - Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital. Review of Patient #7’s medical record, dated 07/19/25, showed: - He was a 30-year-old with a past medical history of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly) and frequent ED visits with behavioral health complaints. - On 07/19/25 at 12:12 AM, he presented to the ED and stated that he needed to be admitted to a psychiatric (relating to mental illness) hospital because people were manipulating him, and he was seeing atypical colors. His initial exam indicated psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature). - He was agreeable to a voluntary admission for psychiatric care and was medically cleared for admission to a psychiatric facility. - At 3:50 AM, he received a psychiatric evaluation via telepsychiatry (telepsych, physician or health care provided psychiatric care through a camera and video monitor, while the health care provider is at a separate location) that found the patient had schizophrenia with evidence of psychiatric decompensation marked by resurgence of psychotic symptoms including paranoia (excessive suspiciousness without adequate cause), hallucinations (seeing or hearing things which are not there), delusions (false ideas about what is taking place or who one is) about his body, and functional decline. His condition appeared to worsen despite reported adherence to treatment, which rendered him unable to maintain safety or function independently. He posed no imminent danger to self or others but was gravely disabled due to the severity of his psychosis. He met the criteria for inpatient psychiatric admission. - At 8:00 AM, the ED physician reviewed the patient with a psychiatrist from telepsych, the patient himself did not have decision making capacity at the time. A formal psychiatric consultation was planned for an involuntary admission. - At 8:09 AM, the patient allowed to leave against medical advice (AMA). Review of Patient #7’s medical record, dated 07/20/25, showed: - At 2:06 AM, he returned to the ED accompanied by family and reported hearing voices and requested to be “checked in somewhere to get help.” - Documentation indicated this was his tenth visit that month. - A 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) was obtained. - At 8:00 AM, he was transferred to a psychiatric hospital for treatment. During a telephone interview on 09/16/25 at 11:40 AM, Staff K, Physician, stated that he treated Patient #7 after he presented to the ED on 07/19/25 until his shift ended at approximately 7:00 AM. The patient had agreed to a voluntary admission to a psychiatric hospital and was waiting for placement. He was not a threat to himself or others but could not take care of himself. He was in a room close to the nurses’ station but not on continuous observation. Patients are not typically on continuous observation unless they are a threat to themselves or others. The patient should have been reassessed before being allowed to leave AMA. During an interview on 09/16/25 at 11:50 AM, Staff L, Registered Nurse (RN), stated that at the time the patient left he was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), and did not express suicidal ideation (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death). She notified the physician and charge nurse of the patient’s intentions to leave AMA. Patient #7 refused to sign the AMA form. During a telephone interview on 09/16/25 at 4:20 PM, Staff P, Physician, stated that he assumed care of Patient #7 at approximately 7:00 AM. He contacted a telepsych psychiatrist when the patient began to leave and was unable to reevaluate him before he left. Patient #7 did not pose imminent harm to himself or others and wished to leave. While he met the criteria for inpatient admission, he was unsure if he met the standard for an involuntary hold. Staff P was in the process of seeking advice from the psychiatrist when the patient left. He did not feel comfortable physically or chemically restraining (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) Patient #7. During a telephone interview on 09/16/25 at 4:45 PM, Staff G, ED Medical Director, stated that it was the responsibility of the physician to reevaluate patients before they left AMA if there was a question about their capacity to make decisions or their safety. If the physician’s judgment determined it was unsafe for the patient to leave, Public Safety Officers could detain the patient, and a court ordered hold could be sought.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by:”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48359 Based on observation, record review, policy review and interview the hospital failed to: - Provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#21) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed from 03/01/-24 through 09/30/24. - To ensure that an emergency medical condition (EMC) was stabilized for one patient (#14) of 27 ED and L&D records reviewed. - Accurately document the patient’s name, age, sex, date, time, means of arrival, complaint, disposition of the patient and disposition time on the ED and L&D central logs reviewed from 03/01/24 through 09/30/24. - Conspicuously post signs in the ED and L&D departments specifying the rights of individuals with respect to examination and treatment for EMCs, and information indicating whether or not the hospital participated in the Medicaid program. These failed practices had the potential to cause harm to all patients who presented to the ED and L&D 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 emergency medical condition),” reviewed 02/2024, showed: - Medicare participating hospitals must meet the EMTALA statute. - EMTALA requires hospitals with EDs to provide a MSE to any individual who comes to the ED and requests an examination and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an EMC. - The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care. - The patient should receive a medical screening examination. - The appropriate means of stabilization for the patient condition must be implemented. Review of the hospital’s policy titled, “MSE,” reviewed 02/2024, showed: - Persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated. - Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint or condition. - Persons presenting to the ED or presenting to any area of the hospital and being brought to the ED and requesting treatment or examination should be provided a MSE in the ED. - In the case of the obstetrical (OB, relating to childbirth and the processes associated with it) patient who is 20 or more weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) with complications of pregnancy, the screening should be performed in the L&D department. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” approved 02/06/92, showed: - The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for persons on the hospital’s property requesting services, for whom services are requested, and if an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individuals appearance or behavior, the individual needs services for a medical condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part. - If an EMC is found to exist, the hospital will provide necessary stablizing treatment. - Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital. Review of the hospital’s policy titled, “Obstetrics (the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Policy and Procedure Management of Severe Hypertension (elevated blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80]) Preeclampsia (a disorder of pregnancy characterized by the onset of high BP and often a significant amount of protein in the urine which increases the risk of the mother and the baby),” reviewed 02/2024, showed: - The purpose of the policy was to define Missouri Delta Medical Center’s policy regarding the multidisciplinary team management of pregnant and postpartum (the time that begins right after a woman gives birth and lasts about six weeks) patients with severe hypertension. - This is an organization-wide policy. It applies to all services and settings that provide maternal (characteristics of a mother) care. - Preeclampsia is characterized by a new onset of hypertension and proteinuria (elevated protein in the urine) after 20 weeks of gestation in a previously normotensive (an individual with a normal BP) woman. - Hypertension is diagnosed with two BP readings of greater than or equal to a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) of 140 or a diastolic pressure (the pressure against the wall of the artery when the heart rests, between beats) of 90 at least four hours apart. - Proteinuria is a protein/creatinine (a measure of the protein and creatine [a waste product] in urine) ratio of 0.3 or greater. - Eclampsia (a new onset of seizures [sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness] or coma in a pregnant/postpartum woman with preeclampsia) up to six weeks postpartum. - Severe hypertension is a systolic BP of 160 or greater, a diastolic BP of 110 or greater or both in a woman in the postpartum period. - Standardized, evidence-based clinical guidelines will be implemented for the management of patients with severe hypertension, preeclampsia and eclampsia. - Women in the postpartum period with acute (sudden) onset, severe systolic hypertension, severe diastolic hypertension or both require urgent antihypertensive (medication used to reduce high blood pressure) therapy. - Prompt treatment within 30 to 60 minutes of detection is recommended. Control of severe hypertension is the first priority. - A systolic BP greater than 160 or a diastolic pressure of greater than 105 to 110 is treated with intravenous (in the vein) antihypertensive medications to protect the patient from a stroke. The goal is a diastolic pressure of 90-100 to maintain circulation. - Magnesium sulfate (a medication used to prevent seizures in pregnancy/postpartum) administration is a first line drug to prevent seizures in women who have preeclampsia with severe features (signs or symptoms of significant organ dysfunction). Starting magnesium sulfate should not be delayed in the setting of acute severe hypertension. It is recommended for women with severe hypertension with or without proteinuria, hypertension with neurologic (neuro, relating to or affecting the nervous system including headache) signs or symptoms or eclampsia. - A team debrief is conducted by at least the primary registered nurse (RN) and primary physician and input is obtained from all or as many participants as possible in the care and treatment of a patient with severe hypertension, preeclampsia and/or eclampsia occurrence, including the ED. - The team debrief provides an opportunity for teams to review and document the sequence of events, success and barriers to a swift and coordinated effort for severe hypertension, preeclampsia and eclampsia occurrence. - Staff education will be provided to all staff and providers who treat pregnant and postpartum patients about hypertension and preeclampsia procedures. Education will occur at orientation, whenever changes to the procedures occur and every two years. - Severe hypertension, preeclampsia and eclampsia drills will be conducted at least annually to determine system issues as part of the ongoing quality improvement efforts. Drills include representatives from each discipline who treats pregnant/postpartum patients and include a team debrief after the drill. - Severe hypertension, preeclampsia and eclampsia cases that meet criteria will be reviewed to evaluate the effectiveness of care, treatment and services provided. The outcomes of the review will be reported to the appropriate clinical, medical staff and organizational quality improvement committees and as described in the organizations Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program/plan. Review of the hospital’s policy titled, “Log Book-Control Register,” reviewed 02/2024, showed: - An electronic patient register containing pertinent information should be continuously maintained for individuals seeking medical care through the ED. - OB patients should be logged in a register maintained by the OB department. - Information contained in the log should include, patient name, age, sex, date, time, means of arrival, patient complaint, disposition of the patient and disposition time. Although requested, the hospital did not provide a policy for EMTALA signage. Please refer to 2402, 2405, 2406 and 2407 for further details.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 48359 Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery (L&D) and the Emergency Department (ED) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMCs), and information indicating whether or not the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the L&D unit and ED for emergency medical treatment. The hospital’s average monthly ED census over the past six months was 1,777. The hospital’s L&D average monthly triage (process of determining the priority of a patient’s treatment based on the severity of their condition) census over the past six months was 410. Findings included: Although requested, the hospital did not provide a policy for Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) signage. Observation on 09/30/24 at 11:20 AM, in the L&D unit, showed no EMTALA signage in the L&D triage room. Observation on 10/03/24 at 10:30 AM, in the ED, showed no EMTALA signage in the ED treatment rooms. During an interview on 09/30/24 at 11:20 AM, Staff I, L&D Manager, stated she agreed there was no EMTALA signage in the L&D triage room. During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated he agreed there was no EMTALA signage in the ED treatment rooms. During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated EMTALA signs should be in each L&D triage room and ED treatment room. During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated EMTALA signs should be in each L&D triage room and ED treatment room.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48359 Based on observation, policy review and interview the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) and Labor and Delivery (L&D) for care of central logs reviewed from 03/01/24 through 09/30/24. Findings included: Review of the hospital’s policy titled, “Log Book-Control Register,” reviewed 02/2024, showed: - An electronic patient register containing pertinent information should be continuously maintained for individuals seeking medical care through the ED. - Obstetrical (OB, relating to childbirth and the processes associated with it) patients should be logged in a register maintained by the L&D department. - Information contained in the log should include, patient name, age, sex, date, time, means of arrival, patient complaint, disposition of the patient and disposition time. Review of the hospital’s document titled, “Activity Log,” dated 03/01/24 through 09/30/24 showed 28 ED patients without complaints and 40 ED patients without disposition locations documented. Review of the hospital’s undated and untitled document showed: - 633 patients without a means of arrival; - 170 patients without a disposition time; - 159 patients without disposition locations; - 13 patients without complaints; - 13 patients without an age; - 13 patients without a time; - 11 patients without a date; and - Two patients without names. During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated it was unacceptable that the central logs were not completed. He expected the central logs to be completed per the hospital’s policy. During an interview on 09/30/24 at 11:20 AM and 10/02/24 at 2:42 PM, Staff G, Nursing VP, agreed the central logs were incomplete. She expected the central logs were completed per the hospital’s policy. During an interview on 10/02/24 at 11:50 AM, Staff E, ED Manager, stated he expected the central logs were completed per policy. During an interview on 09/30/24 at 11:21 AM, Staff I, L&D Manager, stated she was not aware the central logs were incomplete.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#21) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act” (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) reviewed 02/2024, showed: - Medicare participating hospitals must meet the EMTALA statute. - EMTALA requires hospitals with EDs to provide a MSE to any individual who comes to the ED and requests an examination and prohibits hospitals with EDs from refusing to examine or treat individuals with an EMC. - The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care. - The patient should receive a medical screening examination. Review of the hospital’s policy titled, “MSE,” reviewed 02/2024, showed: - Persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated. - Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint or condition. - Persons presenting to the ED or presenting to any area of the hospital and being brought to the ED and requesting treatment or examination should be provided a MSE in the ED. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” approved 02/06/92, showed the hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED for persons on the hospital’s property requesting services, for whom services are requested, and if an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individuals appearance or behavior, the individual needs services for a medical condition. Review of Patient #21’s Hospital B Medical Record dated 04/15/24, showed: - At 2:08 PM, he was a 50-year-old male who presented to the ED and stated he had a bowel movement, got weak and fell into his bathroom counter causing left rib pain. He verbalized diarrhea and feeling bad all over with generalized weakness. - His past medical history included kidney failure, dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), high blood pressure, seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). - At 7:08 PM, his potassium (mineral in the blood or body fluid, normal is 3.3 to 5.0) level was 5.4. A comment showed the potassium result may be elevated due to moderate hemolysis (the destruction of red blood cells). No treatment was given. - At 7:45 PM, a stat (immediately) potassium level was ordered. - At 8:47 PM, his potassium level was 2.7. A comment showed slight hemolysis. Any hemolysis had the potential to falsely elevate potassium levels. - At 9:03 PM, he was discharged home. Review of Patient #21’s medical record dated 04/16/24, showed: - At 12:16 AM, he presented to the ED with a complaint of involuntary movement. - He arrived via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) after he had just gotten home from Hospital B for the same complaint and called EMS. He had a history of twitching and was scheduled for a Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) and an electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity) that morning but transportation services did not pick him up. He fell and hit his left rib area. - At 1:36 AM, his vital signs (VS, measurements of the body’s most basic functions: include blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP 170/89, HR 86, RR 18 and T 98.1. - The ED fall assessment showed no falls in the last three months. - At 1:36 AM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was six for rib pain. - He lived at home independently. - He had diffuse sporadic jerking, more so when Staff Q, Physician, talked to him during the exam. Before the exam Staff Q walked around the room and did not see any jerking. - Laboratory tests from a previous hospital show a potassium of 5.4, otherwise unremarkable. - The impression was patient was given Kayexalate (a medication that helps the body get rid of extra potassium) and discharged home. There was no plan to repeat laboratory testing. He needed to go to dialysis the next day. - The discharge diagnosis was anxiety, hyperkalemia (high potassium level in the blood) and twitching. - At 1:52 AM, he was discharged home. During a telephone interview on 10/01/24 at 9:10 AM, Staff N, ED Medical Director, stated Patient #21’s care in the ED did not meet MSE expectations. A patient should never be treated based on an outside hospital’s laboratory results. The results should have been re-evaluated before he received treatment. She stated outside laboratory results “should never be trusted.” Kayexaleate administration was inappropraite for a potassium level of 5.4 without the presence of EKG changes. She expected Patient #21 would have been admitted to the hospital with an order for a neurology (a branch of medical science that is concerned with disorders and disease of the nervous system) consultation. The hospital was capable of providing a telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) neurology consultation. An ED visit did not provide sufficient time to evaluate Patient #21’s electrolytes (minerals in the blood and other body fluids that carry an electric charge) imbalance and symptoms, considering he had two ED visits. During an interview on 10/01/24 at 4:00 PM, Staff L, Chief of Staff, stated he could “argue either way” Patient #21 received a completed MSE. The completed history and physical assessment documentation qualified as a completed MSE. He stated that retrospectively the MSE was not “the best” and was not a completed evaluation. Next time, “for goodness sakes, the provider should do more. If he were in Staff Q’s, Physician, shoes, he would have ordered more laboratory testing.” During a telephone interview on 10/01/24 at 11:28 AM, Staff Q, Physician, stated he received a report for Patient #21 from the patient, EMS, nursing staff and a “stack of papers.” He was unfamiliar with the electronic medical record (EMR) system for the outside hospital but “did his best” to look at the paperwork. He did not see any indication that the report he received was “wrong.” He decided to treat Patient #21 based on the outside hospital’s laboratory results, the results were “only a few hours” old. He did not repeat the laboratory tests because he was “conscious of expenses.” He did not see that any treatment was given at Hospital B and the patient’s potassium level “drastically” dropped to 2.7 before he ordered the Kayexalate administration. His orders were based on “what he saw.” He learned his lesson and will double-triple check in the future. It was not an intentional mistake and should not have happened. He did not consider ordering a neurology consult, the patient was not “convulsing, spoke in complete sentences and he followed the EMS and nursing story.” The patient looked “anxious.” He believed the patient’s activity level in the ED was equal to the patient’s “baseline and he needed extensive help to get from one place to another.” During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated he expected a complete MSE as indicated to meet the patient’s needs. Outside medical records could be used on an “adjunct basis.” He expected new laboratory work to be completed in the ED. If the outside medical records were used in the care of a patient, those records were scanned into the patient’s medical record. “All information needed to be in the medical record.” During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated a complete MSE included the imaging, laboratory work, consultations, etc., needed to determine the presence or absence of an EMC. The care Patient #21 received in the ED did not meet her expectations and Patient #21 did not receive a complete MSE. Staff Q, Physician, was decredentialed after the event with Patient #21. Laboratory results from an outside hospital could be used to assist with an assessment to “identify trends,” but were not to be the basis for ED treatment. Those records were to be scanned into the medical record if used in the assessment of the patient. In addition to the expectation that new blood work was completed prior to medication administration for hyperkalemia, she expected a patient’s potassium level was evaluated after treatment was given prior to the patient’s discharge home. She stated the patient required an admission for further observation and assessment. During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated his epectations were not met when Patient #21 received treatment based on laboratory results from Hospital B. If laboratory results from another hospital were included in the assessment of a patient, those records were to be scanned into the patient’s medical record. The ED had the capability to obtain an emergent MRI and EEG. He agreed Patient #21 did not receive a complete MSE. If the patient fell during transfer to his car after his discharge from the ED, the patient should have been re-evaluated for a possible unsafe discharge. During an interview on 10/02/24 at 3:09 PM, Staff T, RN, stated she “kind of remembered a stack of papers” with Patient #21. She stated that “normally” the labs were obtained at the hospital. She did not recall if the patient fell. “A technician assisted Patient #21 to his car.” If he fell, she expected the technician to bring the patient back into the ED for further assessment. She expected a telehealth neurology consult for Patient #21. If neurology recommended admission, the patient was admitted to the hospital.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#14) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit 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 emergency medical condition), reviewed 02/2024, showed: - Medicare participating hospitals must meet the EMTALA statute. - EMTALA prohibits hospitals with emergency departments from refusing to examine or treat individuals with an EMC. - The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care. - The appropriate means of stabilization for the patient condition must be implemented. Review of the hospital’s policy titled, “Medical Screening Examination (MSE),” reviewed 02/2024, showed in the case of the obstetrical (relating to childbirth and the processes associated with it) patient who is 20 or more weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days), with complications of pregnancy, the OB screening should be performed in the L&D department. Review of the hospital’s document titled, “Missouri Delta Medical Center Medical Staff - Rules and Regulations,” approved 02/06/92, showed: - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part. - If an EMC is found to exist, the hospital will provide necessary stablizing treatment. - Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital. Review of the hospital’s policy titled, “OB Policy and Procedure Management of Severe Hypertension (elevated blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80]) Preeclampsia (a disorder of pregnancy characterized by the onset of high BP and often a significant amount of protein in the urine which increases the risk of the mother and the baby),” reviewed 02/2024, showed: - The purpose of the policy was to define Missouri Delta Medical Center’s policy regarding the multidisciplinary team management of pregnant and postpartum (the time that begins right after a woman gives birth and lasts about six weeks) patients with severe hypertension. - This is an organization-wide policy. It applies to all services and setting that provide maternal (characteristics of a mother) care. - Preeclampsia is characterized by a new onset of hypertension and proteinuria (elevated protein in the urine) after 20 weeks of gestation in a previously normotensive (an individual with a normal BP) woman. - Hypertension is diagnosed with two BP readings of greater than or equal to a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) of 140 or a diastolic pressure (the pressure against the wall of the artery when the heart rests, between beats) of 90 at least four hours apart. - Proteinuria is a protein/creatinine (a measure of the protein and creatine [a waste product] in urine) ratio of 0.3 or greater. - Eclampsia is a new onset of seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness or coma) in a pregnant/postpartum woman with preeclampsia up to six weeks postpartum. - Severe hypertension is a systolic BP of 160 or greater, a diastolic BP of 110 or greater or both in a woman in the postpartum period. - Standardized, evidence-based clinical guidelines will be implemented for the management of patients with severe hypertension, preeclampsia and eclampsia. - Women in the postpartum period with acute (sudden) onset, severe systolic hypertension, severe diastolic hypertension or both require urgent antihypertensive (medication used to reduce high blood pressure) therapy. - Prompt treatment within 30 to 60 minutes of detection is recommended. Control of severe hypertension is the first priority. - A systolic BP greater than 160 or a diastolic pressure of greater than 105 to 110 is treated with intravenous (in the vein) antihypertensive medications to protect the patient from a stroke. The goal is a diastolic pressure of 90-100 to maintain circulation. - Magnesium sulfate (a medication used to prevent seizures in pregnancy/postpartum) administration is a first line drug to prevent seizures in women who have preeclampsia with severe features (signs or symptoms of significant organ dysfunction). Starting magnesium sulfate should not be delayed in the setting of acute severe hypertension. It is recommended for women with severe hypertension with or without proteinuria, hypertension with neurologic (neuro, relating to or affecting the nervous system including headache) signs or symptoms or eclampsia. - A team debrief is conducted by at least the primary registered nurse (RN) and primary physician and input is obtained from all or as many participants as possible in the care and treatment of a patient with severe hypertension, preeclampsia and/or eclampsia occurrence, including the ED. - The team debrief provides the team an opportunity for teams to review and document the sequence of events, success and barriers to a swift and coordinated effort to severe hypertension, preeclampsia and eclampsia occurrence. - Staff education will be provided to all staff and providers who treat pregnant and postpartum patients about hypertension and preeclampsia procedures. Education will occur at orientation, whenever changes to the procedures occur and every two years. - Severe hypertension, preeclampsia and eclampsia drills will be conducted at least annually to determine system issues as part of the ongoing quality improvement efforts. Drills include representatives from each discipline who treats pregnant/postpartum patients and include a team debrief after the drill. - Severe hypertension, preeclampsia and eclampsia cases that meet criteria will be reviewed to evaluate the effectiveness of care, treatment and services provided. The outcomes of the review will be reported to the appropriate clinical, medical staff and organizational quality improvement committees and as described in the organizations Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program/plan. Review of Patient #14’s medical record dated 07/26/24 showed: - At 4:23 PM, she was an 18-year-old female who presented to the L&D triage unit via a wheelchair and complained of a headache since 11:00 AM, her BP was high, and her feet were still swollen. - Her past medical history included epilepsy (a neurological disorder that can cause unpredictable seizures). - At 4:34 PM, her BP was 157/102. - At 4:45 PM, blood work was obtained. She verbalized occasional blurred vision, denied seeing spots and epigastric (the upper part of the abdomen just below the rib cage) pain. She verbalized taking ibuprofen (a medication that is used for treating pain, fever, and inflammation) for the headache without improvement. Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was five to six in the front of her head and behind her eyes. She had mild generalized edema (swelling); deep tendon reflexes (the strength of a reflex, two plus is normal) were three plus in her left knee and two plus in her right knee. - At 4:52 PM, her urine protein-creatinine ratio was 0.59. Her platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding) were 461. - At 5:03 PM, her BP was 136/86. - At 5:06 PM, her BP was 165/96. - At 5:15 PM, her BP was 151/89. - At 5:30 PM, her BP was 150/91. - At 5:38 PM, Staff Y, Physician, was notified of the patient’s BPs and laboratory results. - At 5:40 PM, her BP was 135/91. - At 5:50 PM, her BP was 132/92. An oral antihypertensive medication was administered. The patient was instructed to try Tylenol for the treatment of her headache. - At 6:03 PM, her BP was 130/91. - At 6:20 PM, her BP was 131/92. She was discharged with instructions to alternate ibuprofen and Tylenol (medication that treats minor pains and fever) for a headache, to take the antihypertensive medication twice daily as prescribed and postpartum hypertension education was provided. Review of Patient #14’s medical record dated 07/27/24, showed: - At 1:37 PM, she presented to the ED and stated her BP was 150/108, she had a baby a week ago and was at the hospital the day before. - At 1:41 PM, her BP was 146/95. - At 2:22 PM, her BP was 145/87. The history of present illness showed she presented to the ED with a chief complaint of elevated BP at home and a headache. She stated her BP at home was 180/110. She was nine days postpartum. She took the antihypertensive medication and ibuprofen. Her headache started the day before and was a four on the pain assessment scale. When she stood that morning, she felt dizzy and thought she might pass out. No deep tendon reflex assessment was performed. - At 2:32 an EKG showed a normal HR and rhythm. - At 2:50 PM, 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) showed no abnormality. - At 2:54 PM, her BP was 148/106. - At 3:04 PM, her platelets were 479, urine protein was one plus and urine white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) count was 30.1. - At 3:58 PM, her BP was 161/96. - At 4:02 PM, she was given IV antibiotics. - At 5:03 PM, her BP was 160/105. - At 5:41 PM, her BP was 169/106. - At 5:50 PM, she was given 500 milliliters of IV fluids. - At 6:31 PM, an IV antihypertensive medication was administered. - At 6:41 PM, her BP was 162/106. - At 7:14 PM, she was diagnosed with postpartum hypertension and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). - At 7:32 PM, her BP was 163/108. - No Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women’s health and delivering babies) consult was completed. - At 7:33 PM, she was discharged home with a prescription for oral antibiotics and UTI education. Review of Patient #14’s medical record dated 07/28/24, showed: - At 4:36 AM, she presented to the ED with seizures. - At 4:43 PM, the history of present illness showed the seizure onset was just prior to her arrival at the ED. She was lying in bed and began having seizure like activity. She had two episodes lasting two to three minutes each. - At 4:44 AM, IV levetiracetam (antiseizure medication) was administered. - At 4:55 AM, she was admitted to the L&D unit. - At 5:02 AM, IV magnesium sulfate was administered. - On 07/30/24 at 8:55 AM, she was discharged home. During an interview on 10/01/24 at 1:15 PM, Staff J, OB Medical Director, stated during Patient #14’s visits she had BP’s greater than 160/110 with severe features of a headache and a protein-creatinine ratio of 0.59, which was diagnostic for severe postpartum hypertension. The care Patient #14 received did not meet her expectations, she was not stabilized. At a minimum she expected Patient #14 to be monitored for at least four hours to observe her BP’s four hours apart. Staff J attempted to speak to Staff P, Nurse Practitioner (NP, a nurse with advanced clinical education and training) and she became “defensive.” Patient #14 should have been evaluated in the L&D triage (process of determining the priority of a patient’s treatment based on the severity of their condition) unit, she did not understand why Patient #14 remained in the ED. She expected, at a minimum, Patient #14 would have been admitted to the hospital, started on the hypertension in pregnancy protocol and IV magnesium sulfate. She agreed the staff needed increased awareness of hypertension in pregnancy/postpartum. She was unsure if any hypertension in pregnancy education was given to the ED providers. She requested the OB/GYN physician on call be contacted for every postpartum patient that presented to the ED. There was no debrief or case review completed for the events related to Patient #14. During an interview on 10/02/24 at 9:10 AM, Staff N, ED Medical Director, stated Patient #14’s ED visit was mismanaged, and the provider missed the diagnosis. She expected the hypertension in pregnancy protocol to be initiated. She expected a case review and team debrief be completed in relation to Patient #14 according to the hospital’s policy. She did not know why the case was not identified for a case review. Staff education needed to be provided for pregnancy related hypertension. She expected a face to face follow up with the provider and an entire team awareness about the care of hypertension in pregnancy. During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated she had “no idea” why patient #14 was prescribed oral antihypertensives and discharged from L&D triage. The patient had risk factors for hypertension in pregnancy, a headache, a BP of greater than or equal to 160/110 and recurrent BPs of greater than or equal to 140/90 with both visits. She expected Patient #14 to be admitted to the hospital and IV magnesium sulfate administered with both visits. Patient #14’s case was not reviewed; education was to be provided. NP’s saw the lesser acute patients in the ED, she was not able to state why Patient #14 was not recognized as a high-risk OB patient. The hospital failed to stabilize Patient #14; she should have been admitted to the hospital. During an interview on 10/01/24 at 1:45 PM and 10/02/24 at 10:00 AM, Staff I, L&D Manager, stated that there was “more than enough” reason to admit Patient #14 during her evaluation in the L&D triage unit and the ED. She expected the patient’s headache was treated and reassessed prior to discharge. An unrelieved headache was a severe feature for hypertension in pregnancy and demonstrated a potential for seizures. She expected a longer evaluation of at least four hours. She agreed the diagnosis and stabilization was missed during both visits. Patient #14’s BP in the ED and L&D triage was greater than 160/110 and she needed an admission to the hospital. The third time Patient #14 returned to the hospital with eclamptic seizures. The ED staff lacked experience with pregnancy related complications and needed to refer to the OB department. Patient #14 came to the hospital twice and asked for help. Staff I spoke with Staff E, ED Director, regarding the events with Patient #14 but was unsure of additional follow up. She expected the ED staff were given hypertension in pregnancy education. There was no debrief or case review for Patient #14. The L&D department performed hypertension in pregnancy drills annually, the ED staff were not included in the drills. During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated the ED was an “opportunity rich environment.” There was no hypertension in pregnancy education provided to the ED staff as a response to Patient #14’s events. He was not aware of any hypertension in pregnancy education given to the ED staff within the previous two years. He speculated the registration staff failed to recognize Patient #14’s hypertension was pregnancy related and failed to request the patient be seen in the L&D unit. He believed the ED nurse felt the patient was in a hypertensive crisis, she did not consider the patient was postpartum and this was a pregnancy related hypertension. He expected the ED staff to “look deeper” into patient’s that presented with pregnancy related hypertension. There was no team debrief or case review completed for the events related to Patient #14. During an interview on 10/02/24 at 10:45 AM, Staff P, NP, stated she frequently used “references” to ensure she understood the expectations for patient care. She consulted the OB/GYN provider and was told to discharge the patient. She “normally documented the consult and conversation in the medical record.” She agreed the diagnosis was missed and the patient was not stabilized. She was not debriefed or provided education in response to Patient #14’s events. She was expected to follow the hospital’s policies. She agreed a deep tendon reflex assessment and urine protein-creatinine ratio testing was appropriate. BPs of greater than or equal to 140/90 required further observation which was not given to Patient #14. During an interview on 10/02/24 at 12:23 PM, Staff R, RN, stated she rechecked Patient #14’s BP immediately after the reading of 165/96 and it was 151/89. Typically, a patient that presented with the symptoms like Patient #14 exhibited was observed for 30 minutes, a urine sample was obtained, BPs were monitored every 15 minutes and the OB/GYN provider was consulted. She agreed Patient #14 should have been assessed for four hours to assess her BPs for severe hypertension. When a patient complained of a headache, the headache was treated and reassessed prior to discharge. Patient #14’s headache was not treated or reassessed. The doctors calculate the patient’s urine protein-creatinine ratio, she was not aware of what result was diagnostic for preeclampsia. Leadership did not follow up with her in regard to Patient #14 for a debrief. During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated he expected Patient #14’s events to be peer reviewed and escalated to the quality department. During an interview on 10/02/24 at 12:35 PM, Staff S, Laboratory Director, stated the calculated protein-creatinine ratio for Patient #14 was 0.59. During an interview on 10/01/24 at 4:00 PM, Staff L, Chief of Staff, stated he was not aware of the events related to Patient #14. Although requested, the hospital did not provide an interview with Staff X, RN, the RN who cared for Patient #14 in the ED on 07/27/24, she was on medical leave. Although requested, the hospital did not provide an interview with Staff Y, Physician, the OB/GYN provider who consulted on Patient #14, she had passed away.”

“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 interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient’s Rights and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship. The hospital failed to: - Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital. (A-0057) - Ensure the Nursing Vice President (VP) was responsible for nursing staff who provided patient care. (A-0395) - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients; - Ensure staff followed the suicide (to cause one’s own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed; and - Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one Emergency Department (ED) suicidal patient (#47) of three ED left without treatment record reviews. (A-0144) - Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient’s room for one current patient (#22) of one insulin medication observed. (A-0405) - Follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged ED patient (#62) of two ED records reviewed. (A-0168) - Follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged ED patients (#47, #62 and #63) of three discharged ED patients reviewed. (A-0178) - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, and #45) of nine patients observed; - Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care; - Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room; - Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed; - Cleanse a medication vial for two patients (#16 and #22) of two patients observed; - Remove expired food on four patient care units and in the kitchen; - Remove expired supplies on one unit; - Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient); - Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication); and - Follow their Infection Prevention Plan to maintain a sanitary environment. (A-0749) - Clean the anesthesia storage room; - Clean the table in the decontamination room; - Clean the kitchen floor in the dishwasher area; - Clean the equipment in the kitchen area; - Clean the microwave on one patient care unit; and - Follow their Infection Prevention Plan to maintain a sanitary environment. (A-750) These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. Please refer to A-0057, A-0144, A-0168, A-0178, A-0395, A-0405, A-0749 and A-0750”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39840 Based on observation, interview, record review, policy review and video review, the hospital failed to: - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients. (A-0144) - Ensure staff followed the suicide (to cause one’s own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed. (A-0144) - Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one ED suicidal patient (#47) of three ED left without treatment record reviews. (A-0144) - Follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged Emergency Department (ED) patient (#62) of two ED records reviewed. (A-0168) - Follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged Emergency Department (ED) patients (#47, #62 and #63) of three discharged ED patients reviewed. (A-0178) These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 08/27/24, the hospital provided an immediate action plan sufficient to remove IJ #one when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on continuous telemetry monitoring. All remaining staff were education prior to the start of their next shift. As of 08/28/24, the hospital provided an immediate action plan sufficient to remove IJ #three when the hospital staff implemented corrective actions that included educating all current and oncoming nursing staff on elopement and suicide precautions. 48359”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure that the Nursing Vice President (VP) provided adequate oversight and supervision of nursing personnel when the staff failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient’s room for one current patient (#22) of one insulin medication observed. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 08/27/24, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on medication administration verification. All remaining staff were education prior to the start of their next shift. Please refer to A-0405.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 39840 Based on observation, interview and policy review, the hospital failed to: - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, #29 and #45) of nine patients observed; - Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care; - Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room; - Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed; - Cleanse a medication vial for two patients (#16 and #22) of two patients observed; - Remove expired food on four patient care units and in the kitchen; - Remove expired supplies on one unit; - Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient); - Clean a medication scanner for one patient (#22) when entering and exiting the room of five patients observed; - Clean a stethoscope for one patient (#22) after performing a physical assessment on one patient observed; - Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication); - Clean the anesthesia storage room; - Clean the table in the decontamination room; - Clean the kitchen floor in the dishwasher area; - Clean the equipment in the kitchen area; - Clean the microwave on one patient care unit; and - Follow their Infection Prevention Plan to maintain a sanitary environment.”

“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: 48359 Based on interview, policy review and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient’s Rights and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship. 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, “Organizational Chart,” dated 01/2024, showed that all administrative leaders reported to Staff DDD, CEO. During an interview on 08/29/24 at 9:49 AM, Staff DDD, CEO, stated that he had full oversight of the hospital.”

“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: 39840 Based on observation, interview, record review, policy review and video review, the hospital failed to: - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients; - Ensure staff followed the suicide (to cause one’s own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed; and - Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one ED suicidal patient (#47) of three ED left without treatment record reviews. Findings included: 1. Although requested, the hospital failed to provide a policy that directed staff to provide continuous observation of the telemetry monitor located at the nurse’s station. Observation on 08/26/24 at 4:15 PM, on the medical/surgical floor, showed seven patients (#12, #15, #16, #29, #30, #31 and #32) on the telemetry monitor with no staff present to observe the monitor. Observation on 08/27/24 at 8:37 AM, on the medical/surgical floor, showed eight patients (#12, #15, #16, #21, #29, #30, #31, and #32) on the telemetry monitor with no staff present to observe the monitor. Observation on 08/27/24 at 9:27 AM, on the telemetry floor, showed 16 patients (#17, #18, #19, #25, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) on the telemetry monitor with no staff present to observe the monitor. During an interview on 08/26/24 at 4:15 PM, Staff O, Registered Nurse (RN), stated that nurses at the desk were to watch the patients on the telemetry monitor. During an interview on 08/27/24 at 9:27 AM, Staff P, Nurse Manager, stated that no one constantly watched the telemetry monitors. During an interview on 08/27/24 at 2:03 PM, Staff V, Nursing Vice President (VP), stated that the telemetry monitors should be monitored at all times. 2. Review of the hospital’s policy titled, “Close Observation/Suicide Assessment,” reviewed 02/2024, directed staff to assess and document the patient’s level of suicidality each shift. Review of Patient #28’s medical record, dated 06/22/24, showed: - She was a 16-year-old female admitted to the Adolescent Behavior Health Unit (BHU) with Suicide Ideations (SI, thoughts of causing one’s own death). - Her initial suicide risk assessment screen showed she was a high risk for suicide. - There was no time documented on the assessment. - At 4:01 PM, a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) showed she wished she was dead and had actual thoughts of killing herself. -There were no additional suicide assessment screens completed. - On 06/27/24 at 10:47 AM, she was discharged to home. During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected staff to complete suicide risk assessment screens according to the policy. During an interview on 08/26/24 at 3:35 PM, Staff E, BHU Director, stated that the C-SSRS was completed upon admission and every shift. 3. Review of the hospital’s policy titled, “Close Observation/Suicide Assessment,” reviewed 02/2024 showed: - Close observation is the provision of a member of the hospital’s staff to be in constant attendance and in close proximity to the patient, even during bathroom use. The staff member must have a clear and unobstructed view of the patient at all times. - All patients assessed by the RN to be at risk for suicide or self-harm will have continuous one to one (1:1, continuous visual contact with close physical proximity) monitoring. - Close monitoring is maintained until discontinued by the appropriate provider. - A handoff of all pertinent information will occur, including information on stored personal belongings and level of risk. - Patient clothing is to be removed and stored and patient placed in hospital attire. Review of the hospital’s Policy titled, “Post Elopement,” reviewed 02/2024, showed: - In the event of a patient elopement, the staff attempts to find the patient and notifies all concerned parties. - Available staff looks throughout the unit as soon as the elopement is confirmed. - The Charge Nurse or the patient’s nurse immediately notifies security. - The Charge Nurse or patient’s nurse notifies the patient’s family or responsible party as indicated on the Release of Information/Telephone Vising Consent form of the elopement unless the Physician chooses to talk with the family. - The Charge Nurse or patient’s nurse notifies the Program Director and Nurse Manager of the elopement within 30 minutes or as soon as possible. - The Charge Nurse or patient’s nurse accurately records the calls. - The Charge Nurse or patient’s nurse completes an Incident Report. - 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) should be conducted. - Document the time the absence was confirmed. - List the individuals who were notified. - Document efforts to locate the patient. - Record the plan. - If the patient does not return, document continuing effort to locate. Review of the hospital’s document titled, “Quality of Care Concern,” dated 07/03/24, showed: - The event was an ED elopement on a court ordered psychiatric (relating to mental illness) patient awaiting transfer to an inpatient facility. - The problem statement was the patient was found not to be in room five. He was awaiting Department of Protective Services (DPS) transportation to Hospital B’s psychiatric facility. - There was a failure to maintain 1:1 observation. - The sitter left her observation post for approximately two to three minutes and the patient was unsupervised. - The patient was allowed to have his personal belongings by the sitter who thought the patient needed them for transfer. - The Charge Nurse notified DPS but did not notify leadership of the elopement. - The root cause was the ED Technician, who was assigned to the 1:1, left her observation post, leaving the patient unsupervised. The ED Technician who was assigned the 1:1 observation allowed the patient his personal belongings and a gap in observation allowed the patient time to elope. - The corrective action plan was coaching completed with the ED Technician and Charge Nurse and department staff education on the proper process for 1:1 observation. Review of the hospital’s document titled, “Current Summary,” dated 07/03/24, showed: - Staff CCC, SW, reported that SW was notified via an electronic message (e-mail) from a Public Safety Officer that officers presented to transport Patient #47 to Hospital B at 8:45 PM and were notified Patient #47 “walked off premises”. - SW obtained a court order earlier in the day for Patient #47’s SI and self-mutilating behavior. - There was no documentation in the medical record regarding the elopement. - The ED Manager was not notified. - SW was unaware of how long Patient #47 was outside of the hospital. - The patient’s mother was contacted by police to assist with the search for Patient #47. - Hospital B was not notified of Patient #47’s elopement. Review of the hospital’s document titled, “Department Updates,” dated 07/03/24 and 07/24/24, showed staff education was isolated to ED RN’s, Paramedics and ED Technicians. Review of Patient #47’s medical record dated 07/01/24 showed: - He was a 31-year-old male who presented to the ED with self-inflicted cuts to his left hand and wrist and auditory hallucination (hearing things that are not heard by others, imaginary). He stated he was suicidal and wanted back on his psychiatric medications. - His past medical history included schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression and anxiety. - His symptoms were acute (sudden onset) and severe. - His plan was admission to an inpatient BHU. - A sitter was at his bedside. Security was required at times to redirect the patient to stay in his room. - At 7:30 PM through 07/02/24 at 8:00 PM, Patient #47 was provided 1:1 observation. He eloped from the ED on 07/02/24 after 8:00 PM. - At 7:42 PM, a C-SSRS placed him at a high risk for suicide. Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were ordered. - On 07/02/24 at 1:07 AM, he was given Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) intramuscularly (IM, in the muscle). - At 1:15 AM, Patient #47 attempted to run through an open door at the entrance of the ED and was stopped by nurses. The police were notified. He was gently led back to his room and became upset that he was not able to see his girlfriend. The provider was notified. - At 12:19 PM, a SW note showed a judge granted a court order which was faxed to hospital B. - At 3:13 PM, a SW note showed transfer was accepted at Hospital B and was delayed until 6:30 PM. - At 6:13 PM, DPS was contacted and planned to transport Patient #47 to Hospital B at 8:30 PM. - At 9:30 PM, the Provider was notified, DPS presented to transport Patient #47. The patient was not in his room, it was assumed Patient #47 left the ED. DPS was searching for the patient. He had a saline lock (a thin flexible tube placed into a vein used for fluid or medication or nutrition administration) in place. - On 07/03/24, Staff W, RN, entered a late nurse progress note that showed DPS was made aware Patient #47 eloped from the ED. Two addresses were given to the officers to assist with locating the patient. On 07/02/24 at 9:53 PM, DPS was notified Patient #47 had an intravenous (IV, in the vein) catheter in his left forearm. DPS reported no updates. - On 07/04/24, Staff GGG, RN, entered a late nurse progress note that showed on 07/02/24 at 8:20 PM, she noticed the ED technicians were cleaning Patient #47’s room, she assumed the patient was transported to Hospital B. The officers were initially scheduled to pick up the patient at approximately 8:30 PM. Later police officers arrived to pick up Patient #47. The police officers were informed the patient left one hour prior and were asked if different officers transported the patient. The nursing staff were notified that police officers did not transport Patient #47 to Hospital B. Staff W, RN, informed the officers of two addresses to assist with locating the patient. He was court ordered for an involuntary admission. - There was no notification to Security, the Program Director or the Nurse Manager. - There was no documentation of notification of the patient’s family. - The incident reports were not completed until the following day. - There was no clear documentation of when the absence was confirmed. - There was no documented plan or continued efforts to locate Patient #47. During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected staff to follow all hospital policies. She expected notification to leadership, including the Administrator On-Call (AOC), DPS, to ensure “diligence” in the patient search and security, to search the entire hospital inside and out. She expected the operator to make an overhead announcement. The ED Director was to call the Chief of Police. This was a serious event; the patient had a court order for an involuntary admission. Officers went to his address and later he was found at his “girlfriends house.” During an interview on 08/29/24 at 9:49 AM, Staff DDD, President, stated that he expected staff to follow all hospital polices. He expected leadership to be notified of an elopement. During an interview on 08/27/24 at 10:30 PM, Staff A, ED Director, stated that Patient #47 had a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) and was waiting for DPS to transport him to Hospital B. Staff ZZ, ED Technician, placed Patient #47’s clothing in his room, she believed he needed them for transfer. Staff ZZ went to the back hallway for an unknown reason. Staff A believed it was to make a personal phone call. Staff ZZ’s behavior did not meet his expectations. Staff GGG, RN, who was Patient #47’s primary nurse, transferred a patient out of the ED, upon her return she discovered Patient #47 was not in his room. Staff GGG informed Staff W, Charge Nurse, and Staff W believed Patient #47 was with DPS. Later, Staff ZZ returned to the patient’s room and discovered he was gone, and she informed Staff FFF, Phlebotomist, his previous sitter. Staff A’s expectations for an elopement were DPS, the House Manager and the AOC were notified. The notifications were not done. The following morning, he obtained a statement from Staff ZZ and provided coaching. She verbalized an understanding of the patient’s belongings and blue scrub process to identify suicidal patients. He provided coaching to Staff WW regarding the communication escalation expectations for an elopement. The management of Patient #47’s elopement did not meet his expectations. He sent two emails to the ED staff on 07/03/24 and 07/24/24 and provided education at the August ED staff meeting to discuss SI/homicidal ideation (HI, thoughts or attempts to cause another’s death) and sitter precaution expectations. The time on the video footage was “off, because of daylights saving time.” During an interview on 08/27/24 at 2:07 PM, Staff Z, SW Director, stated that she was notified of the elopement by Staff CCC, SW, who was contacted by DPS via an email the morning after the patient eloped. Staff A, ED Director, was not aware of the patient’s elopement. He believed the patient was at Hospital B. She contacted Risk Management and the AOC. She was involved in the RCA. The hospital planned to provide education related to the miscommunication between the sitters, personal belongings for SI patients and 1:1 sitter expectation. Staff A provided the staff education. During an interview on 08/27/24 at 2:32 PM, Staff CCC, SW, stated that she met Patient #47 in the ED and completed the 96-hour hold application. He was expected to transfer to Hospital B. The next morning, she received an email from DPS stating that Patient #47 was not at Hospital B. He was not at the ED when DPS arrived for transport. She reviewed the medical record and informed Staff Z, SW Director, of the event because “nothing made sense.” She was “nauseated and very upset,” he eloped from the ED with a 96-hour hold court order in place. He was located approximately 24-hours later at his father’s home after he eloped. He was taken to Hospital B. No leadership staff were aware the patient eloped prior to the email she received from DPS. Patient #47 was a risk of harm to himself. She completed an incident report. She could not remember if she was questioned during the RCA or if any house-wide education was provided. The hospital’s psychiatric protocols were “not strong.” Staff ZZ was not given report. Staff A, ED Director, stated that he was not aware of the elopement. During an interview on 08/28/24 at 9:14 AM, Staff FFF, Phlebotomist (a health worker trained in drawing venous blood for testing or donation), stated that he provided 1:1 observation for Patient #47 for most of the day. Patient #47 was irritated. Staff FFF was called away for a blood draw and asked Staff ZZ, ED Technician, to watch Patient #47. He told Staff ZZ Patient #47 was expecting transport, was a suicide risk and “really wanted to leave.” Staff ZZ sat down outside of room eight. Staff ZZ placed Patient #47’s clothing in his room, she did not want him to leave them behind. He returned 15 to 20 minutes later, the patient was gone, and Staff ZZ was “freaking out.” Staff W, Charge Nurse, was notified and believed Patient #47 was picked up by DPS, he started to clean the room. Staff A, ED Director, called him the following day. The ED staff were aware of the elopement approximately an hour after Patient #47 left the ED. When providing 1:1 observation, continuous line of sight was expected as well as documentation of every 15-minute observations. During a telephone interview on 08/27/24 at 1:30 PM, Staff ZZ, ED Technician, stated that she did not have any interaction with Patient #47 she expected him to be transferred five minutes after she was asked to sit with him. Staff FFF, Phlebotomist, was asked to draw labs on another patient, he asked her to watch Patient #47. She set his belongings inside his door and “walked around the corner.” She spoke with Staff A, ED Director, regarding protocols, SI belongings, every 15-minute observations and not leaving her post when assigned 1:1 observation. She was not aware Patient #47 was on SP, she did not receive report from Staff FFF. One-to-one observation required her to sit in a patient’s room, within walking distance and maintain the patient in her line of sight. 48359”

“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: 48359 Based on interview, record review and policy review, the hospital failed to follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged Emergency Department (ED) patient (#62) of two ED records reviewed. Review of the hospital’s policy titled, “Restraints,” revised 05/2024 showed: - A restraint is the use of a manual method, physical or mechanical device, medication, material or equipment attached or adjacent to the patient’s body that he/she cannot easily remove, that restricts freedom of movement or normal access to one’s body. - Drugs used as restraints are medication used in addition to or in replacement of the patient’s regular medication regimen to control extreme behavior or restrict patient movement in an emergency and is not part of standard treatment for the patient’s medical or psychiatric condition. - Initiation of restraints requires the order of a provider. Review of Patient #62’s medical record dated 06/28/23, showed: - At 10:12 PM, he was an 18-year-old male who presented to the ED with agitated or violent behavior and altered mental status (any change in a person’s mood, behavior, psychomotor skills, and/or cognition). - The patient was brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) escorted by a police officer due to the EMS request for assistance in transporting the patient. - At 11:46 PM, he left his room and would not come back, he disturbed other patients and was redirected to his room. - On 06/29/24 at 12:10 AM, he refused “the shot,” became very distressed, grabbed a chair, jumped on the bed and threatened staff. The Police Department (PD) were called, he ripped his shirt and wrapped it around his fist. He threatened to harm staff if they entered his room. He was physically restrained, Zyprexa (medication used to treat mental disorders), Haldol (a medication used to treat mental disorders by decreasing excitement of the brain), Diphenhydramine (medication used to treat itching, insomnia, allergic reactions and decrease excitement in the brain) and Ativan (a medication used to treat anxiety or sleep difficulty) were given intramuscularly (IM, in the muscle). - At 12:55 AM, the restraints were removed, and he was able to move all extremities. - No order was written for restraints. - At 2:09 AM, the juvenile officer left without telling anyone. - He was discharged to an inpatient Behavioral Health Unit. During a telephone interview on 09/03/24 at 8:33 AM, Staff CC, ED Manager, stated that he expected an order was written for all restraints. He was unable to determine if the patient was placed in handcuffs or violent restraints. No order was written for restraints for Patient #62. During a telephone interview on 09/03/24 at 9:03 AM, Staff V, Nursing Vice President VP), stated that she expected orders to be written for violent restraints. The police were called for Patient #62 because he was violent. It was unclear if he was placed in violent restraints or handcuffs. He was not in the custody of the police. During a telephone interview on 09/03/24 at 2:20 PM, Staff HHH, RN, stated that Patient #62 arrived with a police officer. The officer left the ED, and the patient became violent. The PD were called because he jumped on the bed, grabbed a chair and threatened to hurt the staff. He was not certain if the patient was placed in handcuffs or violent restraints. He could not recall if the police officer was present during the patient’s entire restraint episode. The patient was also chemically restrained.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged Emergency Department (ED) patients (#47, #62 and #63) of three discharged ED patients reviewed. Findings included: Review of the hospital’s policy titled, “Restraints,” revised 05/2024 showed: - When restraint or seclusion is used to manage violent or self-destructive behavior, a Provider, Registered Nurse (RN) or Physician Assistant (PA) must see the patient face-to-face within one hour after the initiation of the intervention. - This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behavior. - Drugs used as restraints are medication used in addition to or in replacement of the patient’s regular medication regimen to control extreme behavior or restrict patient movement in an emergency and is not part of standard treatment for the patient’s medical or psychiatric condition. - When the one-hour face-to-face evaluation is conducted by a qualified RN or PA, they must consult the attending provider or other provider who is responsible for the patient’s care as soon as possible after completing the one-hour evaluation. If a patient who is restrained for aggressiveness or violence quality recovers and restraints are removed, a face¿to-face assessment must still occur. 1. Review of Patient #47’s medical record, dated 07/01/24 showed: - He was a 31-year-old male who presented to the ED with self-inflicted cuts to his left hand and wrist and auditory hallucination (hearing things that are not heard by others, imaginary). He stated he was suicidal (thoughts of causing one’s own death) and wanted back on his psychiatric (relating to mental illness) medications. - Security was required at times to redirect the patient to stay in his room. - On 07/02/24 at 1:07 AM, he was given Haldol IM. - At 1:15 AM, Patient #47 attempted to run through an open door at the entrance of the ED and was stopped by nurses. The police were notified. He was gently led back to his room and became upset that he was not able to see his girlfriend. The provider was notified. - No face-to-face assessment was performed. 2. Review of Patient #62’s medical record, dated 06/28/23, showed: - At 10:12 PM, he was an 18-year-old male who presented to the ED with agitated or violent behavior and altered mental status (any change in a person’s mood, behavior, psychomotor skills, and/or cognition). - The patient was brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.). - On 06/29/24 at 12:10 AM, he refused “the shot,” became very distressed, grabbed a chair, jumped on the bed and threatened staff. The Police Department (PD) were called, he ripped his shirt and wrapped it around his fist. He threatened to harm staff if they entered his room. He was physically restrained, Zyprexa (medication used to treat mental disorders), Haldol (a medication used to treat mental disorders by decreasing excitement of the brain), Diphenhydramine (medication used to treat itching, insomnia, allergic reactions and decrease excitement in the brain) and Ativan (a medication used to treat anxiety or sleep difficulty) were given intramuscularly (IM, in the muscle). - At 12:55 AM, the restraints were removed, and he was able to move all extremities. - No face-to-face assessment was performed. During a telephone interview on 09/03/24 at 2:20 PM, Staff HHH, RN, stated that Patient #62 arrived with a police officer. The officer left the ED, and the patient became violent. The PD were called because he jumped on the bed, grabbed a chair and threatened to hurt the staff. He was not certain if the patient was placed in handcuffs or violent restraints. He could not recall if the police officer was present during the patient’s entire restraint episode. The patient was also chemically restrained. He “hoped” he completed the face-to-face assessment. 3. Review of Patient #63’s medical record, dated 06/13/23 showed: - She was a 39-year-old female who presented to the ED via EMS. - At 10:30 AM, she attempted to fight and bite staff, was verbally aggressive, and an order was written for, and she was placed in violent restraints. - No face-to-face assessment was performed. During a telephone interview on 09/03/24 at 9:03 AM, Staff V, Nursing Vice President (VP), stated that medication given for behavior management were chemical restraints and she expected a face-to-face assessment was completed. She expected a face-to-face assessment was completed for all violent restraints. During an interview on 08/29/24 at 10:20 AM, Staff C, ED Manager, stated that he expected a face-to-face assessment for violent restraints. Providers were expected to complete the face-to-face assessment. The failed face-to-face assessments did not meet his expectations.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure that the Nursing Vice President (VP) provided adequate oversight and supervision of nursing personnel when the staff failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient’s room for one current patient (#22) of one insulin medication observed. 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, “Organizational Chart,” dated 01/2024, showed that all nursing leaders reported to Staff V, Nursing VP. During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she had full oversight of the nursing staff.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient’s room for one current patient (#22) of one insulin medication observed. Findings included: Review of the hospital’s policy titled, “Medication Administration,” reviewed 02/2024, showed: - Medications are administered to diagnose, to prevent and assist in the cure of disease, and to heal the injured. Medications ordered by a physician may be administered by appropriately licensed Nurses, Certified Registered Nurse Anesthetists (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia), Paramedics, Respiratory Therapists and Radiology Technicians. - Take medicine to the patient’s bedside with any needed supplies, including the barcode scanner. - Verify the correct medication by scanning the medication package barcode. Review of the hospital’s policy titled, “Medication Storage,” reviewed 02/2024, showed all medications are stored in accordance with established standards. Observation on 07/27/24 at 11:10 AM, showed: - Staff U, Registered Nurse (RN), removed insulin from the medication dispensing machine, withdrew the insulin into a syringe and returned the insulin vial to the medication dispensing machine. - Staff U entered Patient #22’s room, scanned her identification bracelet, returned to the computer outside of the room, opened a locked drawer next to the computer and scanned a barcode taped inside of the drawer to complete the medication administration documentation. He did not scan the barcode on the insulin vial. - Five different types of insulin barcodes were taped inside the drawer next to the computer. Review of Patient # 22’s medical record, showed on 08/27/24 at 11:46 AM, Staff U, RN, administered two units of insulin.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 39840 Based on observation, interview and policy review, the hospital failed to: - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, #29, and #45) of nine patients observed; - Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care; - Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room; - Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed; - Cleanse a medication vial for two patients (#16 and #22) of two patients observed; - Remove expired food on four patient care units and in the kitchen; - Remove expired supplies on one unit; - Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient); - Clean a medication scanner for one patient (#22) when entering and exiting the room of five patients observed; - Clean a stethoscope for one patient (#22) after performing a physical assessment on one patient observed; - Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication); and - Follow their Infection Prevention Plan to maintain a sanitary environment. Findings included: 1. Review of the hospital’s policy titled, “Hand Hygiene, Hand and Nail Care,” dated 01/2024, showed staff were to perform hand hygiene before donning gloves and after removing gloves, before clean or aseptic procedures, before administering medication, after touching a patient, and after touching patient surroundings. Observation on 08/27/24 at 9:00 AM, showed Staff N, Registered Nurse (RN), failed to perform hand hygiene prior to putting on his gloves while administering medication to Patient #13. Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, failed to perform hand hygiene between glove changes while he performed a point of care blood sugar test on Patient #13. Observation on 08/27/24 at 8:42 AM, showed Staff O, RN, failed to perform hand hygiene between glove changes while administering medications to Patient #15. Observation on 08/27/24 at 11:05 AM, showed Staff O, RN, failed to perform hand hygiene after removing her gloves when she performed a point of care blood sugar test on Patient #15. Observation on 08/27/24 at 9:07 AM, showed Staff K, RN, failed to change her gloves after administering a subcutaneous medication and prior to administering a topical medication to Patient #16. She also failed to perform hand hygiene after removing her gloves. Observation on 08/27/24 at 9:50 AM, showed Staff R, Licensed Practical Nurse (LPN), failed to perform hand hygiene prior to putting on her gloves and after removing her gloves while administering medication to Patient #19. Observation on 08/27/24 at 9:50 AM, showed Staff S, RN, failed to perform hand hygiene after removing her gloves while administering medication to Patient #19. Observation on 08/27/24 at 11:09 AM, showed Staff O, RN, failed to remove her soiled gloves prior to reaching into her pocket after she performed a point of care blood sugar test on Patient #21. Observation on 08/27/24 at 11:15 AM, Showed Staff III, RN, failed to perform hand hygiene after removing her gloves while performing a physical assessment on Patient #22. Observation on 08/27/24 at 11:05 AM, showed Staff X, RN, failed to perform hand hygiene between gloves changes during insertion of a midline catheter (a catheter that is inserted into a vein near the bend of the arm and advanced three to 12 inches into the upper arm) for Patient #23. Observation on 08/27/24 at 1:50 PM, showed Staff O, RN, failed to perform hand hygiene prior to putting on her gloves and between glove changes. She also failed to remove her soiled gloves prior to reaching into her pocket after removing a catheter for Patient #29. Observation on 08/27/24 at 2:05 PM, showed Staff Y, RN, failed to perform hand hygiene prior to medication administration for Patient #45. During an interview on 08/29/24 at 1:40 PM, Staff S, Nursing Manager, stated that hand hygiene should be performed prior to putting on gloves, between glove changes, and after removing gloves. During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that all staff should follow the policy for hand hygiene. During an interview on 08/28/24 at 9:55 AM, Staff V, Nursing Vice President (VP), stated that staff should perform hand hygiene when entering and exiting a patient room, before and after medication administration, between glove changes, and when they touch anything that is unclean. 2. Review of the hospital’s policy titled, “Hand Hygiene, Hand and Nail Care,” dated 01/2024, showed all artificial nail enhancements, including but not limited to nail tips/extenders, artificial nails, nail jewelry or adornments, and wraps are prohibited for employees performing direct patient care. Observation on 08/26/24 at 4:15 PM, showed Staff K, RN, had red dipped nails and was assigned to patient care. Observation on 08/27/24 at 3:40 PM, showed Staff LL, RN, had pink dipped nails and was assigned to patient care. During an interview on 08/26/24 at 4:18 PM, Staff G, Nurse Manager, stated that patient care staff were not supposed to have artificial nails. During an interview on 08/29/24 at 10:18 PM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that staff should follow the policy on nails and should not be worn when providing patient care. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she would not expect patient care staff to have artificial nails or any nail art. 3. Review of the hospital’s policy titled, “Exposure Control Plan,” dated 01/2024, directed staff to wear eyewear during surgical procedures. Observation on 08/28/24 at 9:25 AM, in the operating room, showed Staff OO, Certified Registered Nurse Anesthetist (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia); Staff PP, CRNA; and Staff EEE, CRNA Student, failed to have protective eyewear in place during the 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) of surgical patients. During an interview on 08/28/24 at 9:27 AM, Staff C, Surgical Services Director, stated that all staff should have eye protection while in the operating room. During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected all operating room staff to wear eye protection when in the operating room providing patient care. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected operating room staff to wear eye protection during intubation. 4. Although requested, the hospital failed to provide a policy that addressed preparing a clean work surface prior to performing patient care. Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, placed medications on Patient #13’s bedside table prior to administering medications and failed clean the bedside table or place a barrier. Observation on 08/27/24 at 8:42 AM, showed Staff O, RN, placed medications on Patient #15’s bedside table prior to administering medication and failed to clean the bedside table or place a barrier. Observation on 08/27/24 at 11:01 AM, showed Staff K, RN, placed supplies in Patient #16’s bed prior to removing the intravenous (IV, in the vein) catheter and failed to place a barrier. Observation on 08/27/24 at 9:50 AM, showed Staff R, LPN, placed Patient #19’s medication on the bedside table prior to administration and failed to clean the bedside table or place a barrier. Observation on 08/27/24 at 11:09 AM, showed Staff O, RN, placed supplies in Patient #21’s bed before she performed a point of care blood sugar test and failed to place a barrier. Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, placed medications on Patient #22’s bed prior to administering medications and failed to place a barrier. Observation on 08/27/24 at 11:05 AM, showed Staff X, RN, failed to place a barrier or clean an area to place supplies prior to insertion of a midline catheter (a catheter that is inserted into a vein near the bend of the arm and advanced three to 12 inches into the upper arm) for Patient #23. Observation on 08/27/24 at 2:05 PM, showed Staff Y, RN, failed to clean the bedside table or place a barrier prior to medication administration for Patient #45. During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected staff to have a clean work surface prior to placing any supplies that were to be used on a patient but there was no specific policy. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that although there was no policy that specifically addressed using a barrier, she expected staff to have a clean work surface during patient care. 5. Although requested, the hospital failed to provide a policy that addressed cleaning of the medication vial prior to administration. Observation on 08/27/24 at 9:07 AM, showed Staff K, RN, failed to clean the medication vial prior to removing the solution when administering medications to Patient #16. Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, failed to clean the medication vial prior to removing the solution when administering medications to Patient #13. During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected staff to clean the hub of the medication vial prior to medication administration. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected staff to clean the medication vial prior to medication administration. 6. Review of the hospital’s policy titled, “Food and Supply Storage,” dated 01/2024, showed foods past the use by date should be discarded. Open packages should be covered, labeled and dated. Review of the hospital’s policy titled, “Expired Items, Disposal of Assets/Property and Other Items,” dated 02/2024, showed departments are to assure that no expired items or supplies are in use or available within their departments. Observation on 08/26/24 at 3:00 PM, showed one sandwich with an expiration date of 08/25/24, and 12 packages of coffee creamer in a bag with a placed date of 06/06/24 and no expiration date on the bag or on the product in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) nutrition area. Observation on 08/26/24 at 4:00 PM, showed a bowl of undated food in the refrigerator and 11 Chicken broth packets with an expiration date of 04/06/24 on unit Three F in the nutrition area. Observation on 08/27/24 at 8:30 AM, showed one opened bottle of barbeque sauce in the cabinet with no open date and no expiration date and eight single use bags of coffee grounds without expiration dates in the Emergency Department (ED) nutrition room. Observation on 08/27/24 at 8:50 AM, showed four single use pepper, five salt and seven ketchup packets without expiration dates in the Labor and Delivery Unit nutrition room. During an interview on 08/29/24 at 1:40 PM, Staff P, Nursing Manager, stated that all patient food in the refrigerators should be labeled with a patient sticker and an expiration date, and there should be no expired supplies in the nutrition area. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that dietary staff were responsible for the food items in the kitchen of patient care areas and no expired food items should be available for patients. Observation on 08/28/24 at 10:25 AM, showed, in cooler four in the kitchen: - Five packages of molded strawberries; - Two bags of spinach with an expiration date of 08/25/24; - Two opened bottles of barbeque sauce and one opened bottle of hot sauce with no open date and no expiration date; and - Two opened packages of shredded cheese with no open date and no expiration date. Observation on 08/28/24 at 10:45 AM, showed, in the dry storage area of the kitchen: - One opened package of quinoa with no expiration date; - One opened waffle mix with an expiration date of 03/19/24; - One opened bag of rice with no expiration date; - Two opened bags of pasta with no expiration date; - One container of liquid smooth with an expiration date of 12/18/23; - 47 packages of individual cookies with an expiration date of 06/15/24; and - 19 packages of individual cereal bars with an expiration date of 06/24/24. During an interview on 08/28/24 at 10:15 AM, Staff TT, Food Services Director, stated that expired food items were unacceptable and should not be available for staff or patients. During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that expired food items should not be available for patients. During an interview on 08/29/24 at 9:50 AM, Staff DDD, President, stated that dietary staff were responsible for the rotation of food and dating food items. 7. Review of the hospital’s policy titled, “Expired Items, Disposal of Assets/Property and Other Items,” dated 02/2024, showed departments are to assure that no expired items or supplies are in use or available within their departments. Observation on 08/28/24 at 9:20 AM, in the Labor and Delivery Operating Room, showed: - One expired bottle of open scrub soap with an open date of 03/12/23; - Three nasopharyngeal (the upper part of the throat behind the nose) suction tubes with expiration dates of 08/05/24; - One newborn endotracheal tube (a tube inserted through the mouth or nose, that extends into the lungs, to maintain an open passageway for oxygen) with an expiration date of 11/28/23; - One newborn umbilical artery catheterization (a thin, flexible tube that is placed in a blood vessel located in the stump of a newborn’s umbilical) kit with an expiration date of 07/2024; - One bag of Intravenous (IV, in the vein) fluids with an expiration date of 06/2024; - Two carbon dioxide (CO2, a gas produced by exhaling) detectors with expiration dates of 07/11/24; - One newborn laryngeal blade (a device used to visualize the vocal cords to assist with intubation [a process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) with an expiration date of 05/31/24; and - One uterine hemorrhage balloon (a device to control uterine [hollow, pear-shaped organ in a woman’s pelvis] hemorrhage [excessive bleeding]) with an expiration date of 07/29/24. During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected expired supplies were removed from patient care areas. The expired umbilical artery catheterization tray was significant and would become a Quality Assurance and Performance Improvement Program (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) item. 8. Although requested, the hospital failed to provide a policy related to the cleaning of the WOW. Observation on 08/27/24 at 8:37 AM, on unit Three F, showed four WOWs with dirty keyboards, dusty and dirty bases, and dirty wheels. Observation on 08/27/24 at 9:33 AM, on unit Two F, showed three WOWs with dirty keyboards, dusty and dirty bases, and dirty wheels. Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, failed to clean the WOW before entering and exiting Patient #13’s room. During an interview on 08/27/24 at 10:02 AM, Staff P, Nursing Manager, stated that the WOW was to be cleaned by nursing staff when they went in and out of patient rooms. He also stated that he was not sure who cleaned the wheels. During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected the WOWs to be cleaned by nursing staff before going into a patient’s room and after coming out of a patient’s room. He also stated that he expected the WOW to be free of dust and debris. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected nursing staff to keep the WOW clean. 9. Review of the hospital’s policy titled, “Cleaning and Disinfectant Policy,” reviewed 01/2024, showed the surfaces of non-critical patient-care equipment should be wiped with a cloth saturated, but not dripped, with a detergent-disinfectant. Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, failed to clean the medication scanner before entering and exiting Patient #22’s room. During an interview on 08/27/24 at 11:50 AM, Staff W, ICU Director, stated that she expected the medication scanners to be cleansed prior to entering and exiting a patient’s room. Observation on 08/27/24 at 11:15 AM, showed Staff III, RN, failed to clean her stethoscope prior to replacing it around her neck after performing a physical assessment on Patient #22. During an interview on 08/27/24 at 11:50 AM, Staff W, ICU Director, stated that she expected a stethoscope to be cleansed after each patient use. 10. Review of the hospital’s policy titled, “Cleaning and Disinfectant Policy,” dated 01/2024, directed staff to remove visible dust and disinfect surfaces for patient care items regularly. Observation on 08/28/24 at 9:45 AM, in the post anesthesia care unit, showed dust accumulation on the top of the crash cart. During an interview on 08/8/24 at 9:45 AM, Staff C, Surgical Services Director, stated that there should be no dust accumulation on the crash cart and nursing was responsible for cleaning the crash cart. During an interview on 08/28/24 at 9:47 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he would not expect to see dust accumulation on the top of the crash cart. During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected nursing staff to keep the top of the crash cart clean. 11. Review of the hospital’s document titled, “Infection Prevention Plan,” dated 03/18/24, showed infection prevention is an integral part of all services and prevention of infection is a primary responsibility of all healthcare workers. The hospital failed to follow their infection prevention plan which placed all patients at risk for infection. 48359”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 39840 Based on observation, interview and policy review, the hospital failed to ensure infection control policies were followed when they failed to: - Clean the anesthesia storage room; - Clean the table in the decontamination room; - Clean the kitchen floor in the dishwasher area; - Clean the equipment in the kitchen area; - Clean the microwave on one patient care unit; and - Follow their Infection Prevention Plan to maintain a sanitary environment. Findings included: 1. Review of the hospital’s policy titled, “Cleaning and Disinfectant Policy,” dated 01/2024, showed cleaning involves the removal of visible dust, soil and other foreign material. Responsible persons should be designated by the nurse manager for each nursing unit, or the Department Director of each patient care department. Observation on 08/28/24 at 9:30 AM, showed an anesthesia supply storage room with dusty shelves, dusty bins and numerous bins with sticker residue, not allowing for a smooth surface for cleaning. During an interview on 08/28/24 at 9:40 AM, Staff C, Surgical Services Director, stated that the shelves and bins should not be dusty, and the outside of the bins should be smooth and free of debris. During an interview on 08/28/24 at 9:42 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that there should not be dust in the bins or on the shelves and the bins should be cleanable and the labels smooth. 2. Although requested, the hospital failed to provide a policy that addressed when to clean the tables in the sterile processing department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment). Observation on 08/28/24 at 9:50 AM, showed a paper covered table in the decontamination area of SPD with frayed edges and tape present. During an interview on 08/28/24 at 9:50 AM, Staff SS, SPD Supervisor, stated that the table cover was changed weekly. During an interview on 08/28/24 at 9:50 AM, Staff C, Surgical Services Director, stated that she would not expect to see frayed edges or tape present on the table in SPD. She stated this would be difficult to clean. 3. Although requested, the hospital failed to provide a policy that addressed kitchen floor cleaning. Observation on 08/28/24 at 10:10 AM, showed a long piece of red fraying sticky tape on the floor marking a boundary area for the dishwashing area. During an interview on 08/28/24 at 10:10 AM, Staff TT, Food Services Director, stated that there should be a smooth surface on the floor and debris could get caught in the sticky area. During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that the kitchen floor should be a smooth surface for thorough cleaning. 4. Review of the hospital’s policy titled, “Cleaning of Food and Nonfood Contact Surfaces,” dated 06/2024, showed: - Food contact surfaces are in good condition and are easily cleanable; - To prevent cross-contamination, kitchenware and food contact surfaces of equipment shall be washed, rinsed and sanitized after each use; - The food contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil; and - Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. Observation on 08/28/24 at 10:35 AM, showed: - Muffin tins with a build up of food debris and were located on the clean cart; - Four bins that contained flour, sugar, corn meal and breadcrumbs with debris on the outside of the container; - Two ovens with grease build up on the interior racks; - Two drawers that contained cleaning gloves and sponges with debris present on the gloves, sponges and inside the drawer; - A tilt skillet with debris build-up on the back ledge and liquid contained inside the bin of the skillet; and - Dust on the ledge behind the fryers. During an interview on 08/28/24 at 10:45 AM, Staff TT, Food Services Director, stated that she expected all food containers, both inside and outside, to be clean and free of debris. She also stated that ovens, drawers and equipment should be free of dust and debris as well as grease build up. During an interview on 08/29/24 at 9:50 AM, Staff DDD, President, stated that he expected the kitchen area to be clean and was maintained by the contracted company. 5. Review of the hospital’s policy titled, “Cleaning and Disinfectant Policy,” dated 01/2024, showed cleaning involves the removal of visible dust, soil, and other foreign material. Responsible persons should be designated by the nurse manager for each nursing unit, or the Department Director of each patient care department. Observation on 08/26/24 at 4:00 PM, showed a dirty microwave in the nutrition area of unit Three F. During an interview on 08/26/24 at 4:00 PM, Staff G, Nursing Manager, stated that she was not sure who cleaned the microwave. During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that the microwave oven on the patient care units should be clean. 6. Review of the hospital’s document titled, “Infection Prevention Plan,” dated 03/18/24, showed infection prevention is an integral part of all services and prevention of infection is a primary responsibility of all healthcare workers. The hospital failed to follow their infection prevention plan which placed all patients at risk for infection.”