University of Missouri Health Care

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Follow their policy for prompt resolution of grievances when they failed to enter a complaint into the event report (a staff report of an unexpected occurrence) system for one discharged patient (#50) of one discharged patient complaint reviewed; (A-0118) - Provide care in a safe setting when they failed to ensure safe patient monitoring for three patients (#35, #52, and #61) of five patients who received a blood transfusion (to administer blood into a vein); (A-0144) - Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a licensed practitioner (LP) responsible for the care of one discharged patient (#60) of two discharged restrained, physically held or secluded patient records reviewed; (A-0168) - Ensure the discontinuation of restraints, physical holds and seclusion were documented for one discharged Emergency Department (ED) patient (#58) out of two ED patients reviewed and one discharged in-patient (#60) of two inpatient medical records reviewed; (A-0175) - Ensure appropriate ongoing monitoring and nursing documentation during the use of violent restraints for one discharged ED patient (#58) of two discharged ED patients and two discharged in-patient patients (#57 and #60) out of two patients reviewed; (A-0175) - Follow their policy and ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) evaluation for one discharged patient (Patient #58) of two ED patients reviewed. (A-0178) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0118, A-0144, A-0168, A-0175 and A-0178. 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: 47504 Based on observation, interview, record review and policy review, the hospital failed to administer HumaLog (a rapid-acting blood-glucose-lowering medication) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for four current patients (#24, #53, #54, and #64) of four patients reviewed. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0405. 48359”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to provide a discharge plan that ensured safe, appropriate arrangements for post-hospital care for one incapacitated discharged patient (#31) of one incapacitated patient reviewed. This failed practice had the potential to cause poor health outcomes for all discharged patients. The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation (CoP): Discharge Planning. Please refer to A-0807.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. 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 prompt resolution of grievances when they failed to enter a complaint into the event report (a staff report of an unexpected occurrence) system for one discharged patient (#50) of one discharged patient complaint reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Patient’s Rights-Response to Patient Complaints Policy,” approved 03/09/26, showed complaints and concerns, received anywhere in the institution are to be entered by the receiving staff member into the event reports (a staff report of an unexpected occurrence) system as an event. Review of the hospital’s document titled, “Grievance Log,” dated 2025, showed Patient #50’s sister’s complaint was not logged into the event reporting system. Although requested, the hospital failed to provide a log of the grievance filed regarding Patient #50, the grievance was not logged. Review of the State Office document titled, “ACTS Complaint/Incident Investigation Report MO00258862,” dated 10/13/25, showed the complainant called patient experience twice regarding Patient #50, spoke with Staff PPP, Patient Experience Specialist and Staff QQQ, Patient Experience Specialist, and was assured management would contact the complainant. The complainant never received a follow-up phone call. During an interview on 03/18/26 at 9:43 AM, Staff EEE, Patient Experience Manager, stated that when a complaint was filed by anyone other than the patient the hospital logged the complaint and attempted to contact the patient to determine if information could be shared with the complainant and/or if the patient wanted follow-up communication regarding an investigation. If the hospital was unable to contact the patient or the patient did not request an investigation, the complaint was not investigated. Staff EEE, did not recall an investigation in relation to Patient #50. Staff EEE, did confirm that Staff PPP, Patient Experience Specialist and Staff QQQ, Patient Experience Specialist, were employed at the hospital at the time of the alleged complaint. During an interview on 03/19/26 at 1:50 PM, Staff AAAA, Chief Nursing Executive (CNE) and Staff YYY, Chief Nursing Officer (CNO), stated that they expected staff to follow all policies and procedures. All complaints were to be logged.”

“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: 51292 Based on observation, interview, record review, and policy review, the hospital failed to provide care in a safe setting when they failed to ensure safe patient monitoring for three (#35, #52, and #61) of five patients who received a blood transfusion (to administer blood into a vein). These failures had the potential to affect the quality of care and safety of all patients. Findings Include: Review of the hospital’s policy titled, “Nursing Services - Blood Product Transfusion - Clinical Guidelines,” dated 03/06/25, stated that required documentation for blood transfusions and administration should: - Include documentation of the initial assessment, any changes in assessment or history of prior transfusion reactions; - Include documentation of vital signs (VS, measurements of the body’s most basic functions) for pre-transfusion, 15 minutes after started and at the completion; - Include the time initiated and completed; - Begin as soon as possible after issue from blood bank (the area of the laboratory used for collecting blood, separating blood into components and storing of the blood) and be completed within four hours; - Not be placed in a unit refrigerator; and - Not be infused with any other solution or medications other than normal saline. Review of Patient #35’s medical record showed: - On 03/18/26 at 5:59 AM, a blood transfusion was initiated. - At 6:16 AM, VS were documented. - At 7:51 AM, VS were documented. - There was no documentation for the completion of the first unit with a complete set of VS’s. - At 9:19 AM, VS were documented. - At 9:21 AM, a second unit of blood was initiated. Review of Patient #52’s medical record showed: - On 11/20/25 at 4:59 AM, her hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body) was 6.8 grams per deciliter (g/dL, unit of measure). A blood transfusion was ordered. - At 8:22 AM, vital signs were taken. - At 8:26 AM, the transfusion was initiated. - At 8:41 AM, VS were documented. - At 8:44 AM, vancomycin (antibiotic) was started intravenously (IV, in the vein) with the blood. - At 8:56 AM, the nurse documented the daughter’s request to stop the vancomycin until the blood was finished. The antibiotic was stopped after five minutes and the blood continued to infuse. No further documentation provided when the vancomycin was restarted or completed. - At 4:00 PM, the VS were documented. There was no documentation recorded for the completion of the blood transfusion with a complete set VS at the end of transfusion. Observation on 03/18/26 at 10:00 AM, showed Staff CCCC, RN, put a unit of blood into a refrigerator located in the medication room, while Patient #61 was off the floor. Review of Patient #61’s medical record showed, at 10:47 AM, the blood was initiated 47 minutes after the blood was observed placed in the medication room refrigerator. During an interview on 03/18/26 at 3:26 PM, Staff BBBB, Nurse Manager, stated that she did not expect nursing to give IV medications with blood administration. She would expect the nurse to call the physician when both were due and obtain an order to hold the medication until the blood transfusion was completed. During an interview on 03/18/26 at 11:30 AM, Staff CCCC, RN, stated she did not know the policy for putting blood in the unit refrigerator, but didn’t know what else to do with it when she found out Patient #61 was not on the floor. During an interview 03/18/26 at 11:35 AM, Staff PP, Nurse Manager, stated she expected blood to be administered within 10-15 minutes of arriving to the floor, or have the blood returned to the blood bank. During an interview on 03/19/26 at 1:50 PM, Staff AAAA, Chief Nursing Executive (CNE) and Staff YYY, Chief Nursing Officer (CNO), stated that they expected staff to follow all hospital policies and procedures. Staff were expected to document the completion time of a blood transfusion. Blood was to be initiated within 30 minutes of the time the blood was retrieved from the blood bank and blood was not to be stored in the medication refrigerator. Blood was to be administered alone; no other medications were to be infused through the same IV site or tubing.”

“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: 47504 Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a licensed practitioner (LP) responsible for the care of one discharged (#60) of two discharged restrained, physically held or secluded patient records reviewed. Findings included: Review of the hospital policy titled, “Patient Safety-Violent Behavior Restraint and Seclusion,” dated 01/17/24, showed an order must be obtained from a LP before a restraint is applied. If the emergency application of a restraint is required, a Registered Nurse (RN) may apply the restraint and notify the LP within 15 minutes, if the attending physician is not present. Review of an undated hospital document titled, “WBT200-26 Restraint and Seclusion v2,” showed that a physical hold was defined as when a patient was physically restrained by a staff member for a temporary period of time. All restraints including manual/physical holds required a written order. During concurrent interview with Staff ZZZ, Risk and Regulatory, and review of Patient #60’s medical record dated 1/19/26 showed, he was placed in manual hold for an attempt to harm self or others prior to being placed in seclusion. There was no medical hold order from a LP. Staff ZZZ stated that all patients placed in a manual hold must have a LP order. She stated there was no manual hold order for Patient #60.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review the hospital failed to follow their policy to ensure the discontinuation of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head etc) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were documented for one discharged Emergency Department (ED) patient (#58) out of two ED patients reviewed, and one discharged in-patient (#60) of two inpatient medical records reviewed. The hospital failed to ensure appropriate ongoing monitoring and nursing documentation during the use of violent restraints for one discharged ED patient (#58) out of two discharged ED patients and for two discharged in-patient patients (#57 and #60) of two patients reviewed. Findings included: Review of the hospital policy titled, “Patient Safety - Violent Behavior Restraint and Seclusion,” dated 01/17/24 showed: - Restraints and Seclusion was to protect the patient from harm or injury and promote medical healing. - Nurses are to observe and document on the patient at least every hour for patients placed in restraints and seclusion. - Nursing assessments are necessary to assess for the continued safety, well-being, comfort and well-being of the patient. - The nurse should assess vital signs, level of distress and agitation, mental status, cognitive functioning, hydration, elimination needs, circulation, skin integrity, movement and sensation, and offer an appropriate range of motion, hydration, toileting and other relevant care as indicated by the patient’s needs. - The date and time of the restraint or seclusion discontinuation should be documented for every occurrence. Although requested, a policy for chemical restraints was not provided. During an interview on 03/18/26, Staff HHH, Director of Risk, stated that they did not have a policy for chemical restraints. They did not allow chemical restraints. During concurrent interview on 03/18/26 at 10:30 AM, Staff ZZZ, Risk and Regulatory, and review of Patient #58’s medical record dated 02/12/26 showed: - He was a 40-year-old with a history of polysubstance (multiple drugs) use disorder who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) for an evaluation after he was found unresponsive. - He was given Narcan (a medication used to counter the effects of narcotic overdose) and regained consciousness by EMS prior to arrival. - At 6:01 PM, he presented to the ED and was agitated and threatening to staff members. - At 6:47 PM, Vital signs (VS, measurements of the body’s most basic functions: blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degrees) were BP 126/78, P 107, R 18, and oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 95%. - At 8:00 PM, VS were BP 126/76, P 110, R 21 and SAO2 was 99%. - At 8:02 PM, the physician placed the order to initiate restraints for violent behavior and he was placed in four-point nylon violent restraints. - At 8:37 PM, he was given Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) two milligrams (mg) intravenous (IV, in the vein) to calm him down. - At 10:07 PM, VS were BP 128/79, P 101, R 21 and SaO2 93%. - At 10:54 PM, VS were P 91 and SAO2 91% - At 11:06 PM, the physician performed an initial face-to-face assessment. - There was no documentation of the discontinuation of the violent restraints. - Staff ZZZ, Risk and Regulatory, stated that all violent restraints should have a discontinuation time documented. - There were no hourly nursing assessments following the application of four-point violent restraints and no nursing assessments following the administration of Versed. - Staff ZZZ stated that all patients placed in a four-point violent restraint should have hourly nursing assessments from the time of the initiation of the restraint and until they were discontinued. During concurrent interview on 03/18/26 at 10:30 AM, Staff ZZZ, Risk and Regulatory, and review of Patient #57’s medical record dated 12/05/25 showed: - He was admitted as in-patient on 12/04/25. - On 12/05/25 at 3:15 PM, he was placed in four-point nylon violent restraints at 3:15 PM due to an attempt to harm others. - Nursing assessments were completed hourly from 3:15 PM through 7:10 PM. - At 8:29 PM the next nursing assessment was completed which was outside of the required hourly documentation. - At 9:53 PM the next nursing assessment was completed which was outside of the required hourly documentation. - At 10:50 PM the restraints were discontinued. - Staff ZZZ stated that all patients who were placed in violent restraints should have hourly nursing documentation from the initiation of violent restraints through the discontinuation of violent restraints. During concurrent interview on 03/18/26 at 10:30 AM, with Staff ZZZ, Risk and Regulatory and review of Patient #60’s medical record dated 01/19/26 showed: - On 01/19/26 at 9:45 PM, Patient #60 was placed in seclusion for an attempt to harm self and others and refusal of forced medications. She was on a 21-day commitment and could not refuse medications. - There was no nursing documentation until 11:28 PM. - There was no documentation of the time the seclusion was discontinued. - Staff ZZZ stated that all patients who were placed in seclusion should have hourly nursing assessments completed. She stated this restraint had been reviewed by Regulatory and was “flagged due to the lack of documentation.” Although requested, Patient # 60’s medical record was not received. The hospital submitted screenshots of documentation dated 12/05/25. During an interview on 03/19/26 at 1:30 PM, Staff YYY, Chief Nursing Officer (CNO) and Staff AAAA, Chief Nursing Executive (CNE), stated that nursing should perform assessments within one hour of the initiation and continue hourly assessments until the restraints were removed. They would expect a nurse to document every 15 minutes following the administration of an intramuscular (IM, within the muscle) medication given to a restrained patient to include versed. All restraints should have a discontinuation order when the restraint was removed.”

“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: 47504 Based on interview, record review and policy review, the hospital failed to follow their policy and ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others]) evaluation for one discharged patient (Patient #58) of two Emergency Department (ED) patients reviewed. Findings included: Review of hospital policy titled, “Patient Safety-Violent Behavior Restraint and Seclusion,” dated 01/17/24 showed: - Restraints for violent behaviors include nylon four-point restraints. - The licensed provider must see and evaluate the patient within one hour of initial restraint/seclusion application and document the patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. - The licensed provider will indicate they type of restraint and how it is to be applied. - The licensed provider will indicate the minimum criteria for restraint discontinuation. Review of Patient #58’s medical record dated 02/12/26 showed: - He was a 40-year-old with a history of polysubstance (the consumption of more than one drug at once) use disorder who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) for an evaluation after he was found unresponsive. - He was given Narcan (a medication used to counter the effects of narcotic overdose) by EMS and regained consciousness prior to arrival. - At 6:01 PM, he presented to the ED and was agitated and threatening to staff members. - At 8:02 PM, the physician placed the order to initiate restraints for violent behavior and he was placed in four-point nylon violent restraints. - At 8:37 PM, he was given Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) two milligrams (mg, unit of measure) intravenously (IV, in the vein) to calm him down. - At 11:06 PM, the physician performed an initial face-to-face, three hours after the initiation of the four-point nylon violent restraints. During an interview on 03/18/26 at 10:30 AM, with Staff ZZZ, Risk and Regulatory Professional, stated that the medical record had been reviewed and there was no face-to-face documented within one hour per policy and was an on-going problem. During an interview on 03/19/26 at 1:50 PM, Staff YYY, Chief Nursing Officer (CNO) and Staff AAAA, Chief Nursing Executive (CNO), stated that a face-to-face should be completed within one hour of applying violent restraints per policy.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the hospital failed to administer HumaLog (a rapid-acting blood-glucose-lowering medication) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for four current patients (#24, #53, #54, and #64) of four patients reviewed. Findings included: Review of the hospital’s policy titled, “Endocrinology Services-Adult Subcutaneous Insulin Ordering and Administration-Guideline,” last approved 02/03/23, showed HumaLog’s blood sugar lowering effect started in 10-20 minutes and peaked at 1.5 to 2.5 hours. No guidance was given for timing between obtaining a blood glucose result and the administration of insulin. Although requested, there was no policy provided to show the appropriate time between a blood glucose measurement and administration of HumaLog. Review of Patient #24’s medical record, dated 03/04/26, showed on 03/17/26 at 10:17 AM, she was given one unit of HumaLog. Although requested, laboratory blood glucose measurements were not provided for Patient #24. Observation and concurrent interview on 03/17/26 at 10:17 AM, Staff GG, RN, stated that Patient #24’s insulin administration was based on a blood glucose measurement of 187 at 07:24 AM, almost three hours prior. Review of Patient #53’s medical record dated 03/13/26 showed: - On 03/15/26 at 6:05 AM, she had a blood glucose measurement of 185. - At 8:17 AM, two hours and twelve minutes later, she received three units of HumaLog. - There was no documentation of the glucose level being re-checked. Review of Patient #54’s medical record dated 03/14/26 showed: - On 03/17/26 at 8:16 AM, she had a blood glucose measurement of 175. - At 10:07 AM, one hour and 51 minutes later, she received one unit of HumaLog. - There was no documentation of the glucose level being re-checked. - On 03/18/26 at 8:49 AM, she had a blood glucose measurement of 205. - At 10:07 AM, one hour and 18 minutes later, she received one unit of HumaLog. - There was no documentation of the glucose level being re-checked. Review of Patient #64’s medical record, dated 03/02/26, showed: - On 03/16/26 at 6:40 AM, she had a blood glucose measurement of 315. - At 8:44 AM, two hours and four minutes later, she received 10 units of HumaLog. - There was no documentation of the glucose level being re-checked. During concurrent record review and interview on 03/19/26 at 1:50 PM, Staff AAAA, CNE, stated that she expected HumaLog administration to be within an hour of a blood glucose measurement. Staff YYY, CNO, stated that she expected HumaLog to be administered in conjunction with a physician’s directive. They would refer to a policy. During an interview on 03/17/26 at 10:53 AM, Staff EE, Clinical Educator, stated that she expected blood glucose measurements to be taken less than one and a half hours prior to HumaLog administration. During an interview on 03/18/26 at 3:45 PM, Staff OOO, Nurse Manager, stated that blood glucose measurements were typically taken before meals. Mealtimes were predictable but sometimes fluctuated. He expected blood glucose measurements to be taken less than an hour prior to HumaLog administration. 51264”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review, the hospital failed to provide a discharge plan that ensured safe, appropriate arrangements for post-hospital care for one incapacitated discharged patient (#31) of one incapacitated patient reviewed. This failed practice had the potential to cause poor health outcomes for all discharged patients. Findings included: Review of the hospital’s policy titled, “Discharge Planning and Care Coordination - Discharge Planning,” dated 11/14/23, showed: - The policy was to facilitate identification of the patient’s unique physical, emotional, social, spiritual and cultural needs, and to ensure interdisciplinary coordination of discharge services and to facilitate the provision of comprehensive post hospitalization services. - The discharge plan will be developed by a registered nurse (RN), Case Manager (CM) or other appropriately qualified personnel that develop or supervise the discharge evaluation in collaboration with appropriate staff involved. - If a patient has a guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) the case manager will work with the patient and guardian on the discharge plan. - Provides the patient/family/guardian with a list of post-hospital service options. If patient/family/guardian has a stated preference for a post-acute facility (skilled nursing facility, inpatient rehabilitation facility), home health agency, or hospice agency, case manager will initiate the referral to preferred facility/agency. If patient/family/ guardian do not have a preference, the case manager will provide the patient/family/guardian with a list of facilities in the geographic region of the hospital or the geographic region of the patient’s residence whichever is preferred. If home health services are indicated, they will provide a list of home health agencies that serve patient’s residence. - The patient is ready for patient transfer or discharge when the health situation and needs have been assessed, and the patient and/or family have identified a destination which is best suited to meet patient level of care and safety needs. Review of the hospital’s document titled, “Patient Safety At Risk Patients,” dated 11/14/23, showed the hospital should identify patients who are at risk for wandering or elopement, present a likelihood of harm to themselves or others, or are identified as being at risk for suicide (to cause one’s own death) or homicide (to cause another’s death). At Risk Patients are identified as one who is deemed to be at risk of wandering or elopement based on incapacitation or incompetence. Review of the hospital’s undated document titled, “Patient Rights - Guardianship and Conservatorship for Patients Lacking Decisional Capacity,” showed: - To provide guidelines to protect patients when the patient cannot make decisions regarding his/her health care and other needs. - A guardianship was identified as a legal process of a court appointing an appropriate person to have the care and custody, including the legal authority to make treatment decisions, of a person (patient) who is determined to be incapacitated. - An incapacitated person was identified one who was unable by reason of any physical, mental, or cognitive condition to receive and evaluate information or to communicate decisions to such an extent that the person, even with appropriate services and assistive technology, lacks the capacity to manage the person’s essential requirements for food, clothing, shelter, safety, or other care such that serious physical injury, illness, or disease is likely to occur. - The care coordinator will identify any existing family members and other interested persons and their involvement, if any, in patient’s care. - The care coordinator will then verify whether these family members and other interested persons are ready, willing, and/or able to file a petition for Guardianship and/or Conservatorship with the appropriate court. Reluctance to hire counsel or file the petition due to financial hardship should not be a disqualification for any person. - If there is no family or other interested person available, willing, or able to file a petition and the care coordinator believes a guardian or conservator is a necessity for the patient, the care coordinator will forward the worksheet, and other such additional information as may be requested to the Office of General Counsel. - The Office of the General Counsel will evaluate the documentation, consult with the care coordination team, and timely communicate its guidance to the care coordinator. - If the Office of General Counsel approves the filing of a petition for Guardianship and/or Conservatorship, care coordination leadership will work with designated legal counsel to provide necessary documentation and support for the filing of a petition for Guardianship and/or Conservatorship in the appropriate court. - When guardianship or conservatorship is being sought, the attending physician will be requested to complete an affidavit attesting to the physical, mental, and cognitive capacity of the patient to receive and evaluate information and communicate health care and other decisions. - The attending physician, primary care coordinator, and/or a secondary care coordinator may be required to testify before the Court and may have to attend more than one court hearing. - Care coordination will discuss care alternatives with the health care team as the guardianship and/or conservatorship proceedings progress in court. Review of Patient #31’s medical record showed: - She was a 38-year-old with a history of multiple psychiatric (relating to mental illness) disorders that included Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy) with amphetamine (an addictive mood altering drug) use. She had a recent admission for an altered mental status (any change in a person’s mood, behavior, psychomotor skills, and/or cognition) but was deemed functional. Her urine drug screen was positive for methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) and was diagnosed with a methamphetamine induced psychosis (a serious mental illness characterized by defective or lost contact with reality). - A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of the head was normal. - She was admitted on 01/27/26 with a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others.) - On 01/27/26, psychiatry was consulted. Staff VVV, Physician Assistant (PA), evaluated her and on examination she appeared somnolent (abnormally drowsy) and was oriented only to person. She was dysarthric (slurred or slow speech that can be difficult to understand), not appropriately responding to questions and unable to report past psychiatric history or current symptoms. He was unable to thoroughly assess the patient for competency. - On 01/28/26, Staff VVV documented “based on my above evaluation, that Patient #31 did not currently have decision making capacity. She did not understand the relevant medical information necessary to make a choice, could not appreciate the risk involved, and did not demonstrate proper reasoning skills. Given the patient’s documented history of long-term polysubstance use and sexual assault there was concern for an underlying neurocognitive disorder (decreased mental function either in language, learning, memory, or socially; and loss of ability to do daily tasks) that may be rooted in multiple etiologies such as substance-induced versus traumatic brain injury (TBI, an injury in how the brain works). This coupled with an established pattern of the patient’s presenting to the hospital for acute deterioration shortly after discharge from a controlled environment over the past five months increased suspicion that patient may be at cognitive baseline and struggles to appropriately manage her own care needs, thus is unlikely to regain decision making capacity (DMC.)” - On 01/30/26, Staff DDDD, Case Manager (CM), documented she continued to lack DMC on rounds. CM attended rounds and would work on guardianship and plans. Patient #31 had been at a skilled nursing facility prior to admission and stated she would like to go back there. She spoke with the facility, and they would accept the patient back if she had guardianship. - On 02/02/26 at 7:29 PM, Staff DDDD documented she contacted the patient’s sister, and she wanted the hospital to file for guardianship and would like a court appointed guardian. She did not want to be the guardian but would like to be involved in patient care. - On 02/03/26 psychiatry was reconsulted due to the patient having increasingly erratic behavior. Nursing noted the patient would have intermittent bouts of irritability/screaming as well as sexually inappropriate behaviors such as leaving her room without pants and attempting to lay in the common areas. On exam, the patient did not appear acutely manic (elevated or excited mood or behavior) or psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), patient’s behaviors could be secondary to underlying neurocognitive disorder versus personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving.) She was still deemed to lack DMC. - On 02/06/26 Staff DDDD spoke with legal counsel to further discuss if the patient could be discharged even though she was deemed to not have DMC, but otherwise medically stable for discharge. After further discussion and review with legal counsel it was advised that the patient could be discharged and if family wanted to pursue guardianship or appoint a public administrator as guardian, they could proceed to do so outside of the hospital setting and a medical affidavit (a written statement confirmed by oath, for use as evidence in court) could be provided to family to proceed forward. - On 02/10/26 Patient #31 was deemed medically stable for discharge. Staff DDDD spoke with the patient’s sister to inform her that the patient would likely discharge later that day or the next and if she wished to file for guardianship, she could do that outside of the hospital setting. - On 02/11/26 at 12:01 PM, Staff DDDD documented that she was medically cleared to discharge. CM was at the bedside and the patient stated she would go to a family friend’s house. CM inquired if that was a safe place and that there were no illegal drugs there. Patient #31 stated that it was safe and there were no illegal drugs there. She requested a Medicaid ride. - On 02/11/26 at 12:38 PM, documentation showed that discharge instructions were reviewed with the patient. She verbalized understanding of new medications, continue home meds, home care, urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) prevention, home safety and how to contact the physician. She was dressed and had all her belongings and was waiting on a Medicaid ride. She was discharged at 12:22 PM. - Patient #31, who had been declared not to have DMC, was discharged from the hospital. She was allowed to make the decision on where she was going to live following discharge. During an interview on 03/18/26 at 1:00 PM, Staff EEEE, CM, stated that the psychiatric team had been consulted for Patient #31, and she was declared not able to make decisions on her own. She stated she communicated with her sister regularly regarding guardianship. The sister could not afford to file the legal guardianship paperwork with the court system and asked the hospital to file it for her. She had been medically cleared for discharge, and that was sent to the legal department. The legal department determined she could be discharged, and they would give the sister an affidavit to file for guardianship and that the hospital was not going to do that. The sister did not want to be the legal guardian. The skilled nursing facility would not accept her without guardianship being established. She was previously admitted there and would leave whenever she wanted. When asked how someone could decide where to live if they lacked DMC she stated, “Legal told us we could.” When asked if it was a safe discharge, she stated, “It was cleared by the legal department, and we followed their instructions.” During an interview on 03/18/26 at 1:45 PM, Staff III, CM, stated that they had discussed the legal guardianship with Patient 31’s sister. She stated that the legal department had cleared the patient for discharge. She stated that she had been medically cleared for discharge and that she was going to a friend’s house. When she notified the sister she did not offer to pick her up, she was not happy or opposed to the discharge. Medicaid transport picked the patient up when she was discharged. She stated she was a frequent flyer, and they could not fix the outcome of drug abuse. When asked if she was capable of making a decision on where to go when she was discharged, she stated “Legal had approved everything and they were following that recommendation. She was medically stable.” During an interview on 03/19/26 at 9:25 AM, Staff VVV, Psychiatry Nurse Practitioner (NP), stated that he had provided care for Patient #31 in the past. He had been consulted on 01/27/26, but he was not able to perform the proper assessment needed to evaluate a patient for DMC. On 01/28/26 he did complete a full evaluation and stated that she was not capable of making any decisions for herself and unable to properly take care of herself. He stated she had an in-depth medical history and had been rescued by the police in a trailer with no power or heat. She had been forced to do drugs and perform sexual acts. He stated that when a male would start talking to her, she would have extreme anxiety and wet herself. He stated she suffered from PTSD as well as some underlying neurological problems related to the trauma she endured. She was a danger to herself. He stated he was very upset she was discharged without having legal guardianship. He stated that was left out of all the decisions regarding discharge. She was not able to make any decisions for herself and should not have been allowed to decide she was being discharged and to a friend’s house. He stated, “That was an unsafe discharge and should have never happened.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening exam (MSE) within the available capabilities of the hospital, sufficient to determine whether or not an emergency medical condition (EMC) existed for two patients (#10 and #26) of 27 Emergency Department (ED) records reviewed. Findings included: Review of the hospital’s document titled, “EMTALA - Emergency Medical Treatment and Active Labor Act - Compliance,” dated 12/16/25, showed: - When an individual presented or was brought to the hospital requesting treatment of a medical or mental health condition, a physician or advanced practice provider would provide a MSE within the capabilities of the facility for the purposes of determining the presence or absence of an EMC. - An EMC was a medical condition manifesting acute (a sudden onset) symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy, serious impairment to any bodily functions, or serious dysfunction of any bodily organ or part. - A MSE was the initial and on-going evaluation of the presenting patient conducted by a physician, advanced practice professional, or by a RN acting under medically approved guidelines and/or algorithm. - In the event that a patient either declined to be seen for a MSE or was unable to be located after a reasonable search of the ED waiting area, staff should complete the “Patient Request to Leave Prior to Medical Screening Exam/Left Without Being Seen” form and send a copy of the signed form to medical records. Please refer to A-2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening exam (MSE) within the available capabilities of the hospital, sufficient to determine whether or not an emergency medical condition (EMC) existed for two patients (#10 and #26) of 27 Emergency Department (ED) records reviewed. Findings included: Review of the hospital’s document titled, “EMTALA - Emergency Medical Treatment and Active Labor Act - Compliance,” dated 12/16/25, showed: - When an individual presented or was brought to the hospital requesting treatment of a medical or mental health condition, a physician or advanced practice provider would provide a MSE within the capabilities of the facility for the purposes of determining the presence or absence of an EMC. - An EMC was a medical condition manifesting acute (a sudden onset) symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy, serious impairment to any bodily functions, or serious dysfunction of any bodily organ or part. - A MSE was the initial and on-going evaluation of the presenting patient conducted by a physician, advanced practice professional, or by a RN acting under medically approved guidelines and/or algorithm. - In the event that a patient either declined to be seen for a MSE or was unable to be located after a reasonable search of the ED waiting area, staff should complete the “Patient Request to Leave Prior to Medical Screening Exam (MSE)/Left Without Being Seen (LWBS)” form and send a copy of the signed form to medical records. Review of the hospital’s undated patient transfer form showed the hospital was required by law to provide any presenting patient with a MSE to determine whether an EMC existed and to provide stabilizing care within its capabilities for EMCs. There were seven sections, to include patient condition, reason for transfer, hospital acceptance, risk of transfer, benefits of transfer, mode of transportation and patient consent to transfer. Review of Patient #10’s medical record, dated 11/16/25, showed: - At 1:18 PM, a 20-year-old female arrived at the hospital hyperventilating (breathe at an abnormally rapid rate, so increasing the rate of loss of carbon dioxide) after reportedly using her albuterol inhaler (bronchodilator medication used to relax muscles in the airways and increase airflow to the lungs) 10 times with no effect and a new or worsening cough. - Nursing documentation showed she was immediately taken to a triage (process of determining the priority of a patient’s treatment based on the severity of their condition) chair. Her significant other interrupted the registration process and told Staff M, RN, to “hurry up.” He was told to “knock it off.” Staff M attempted to listen to Patient #10’s lungs, but the patient would not lean forward until asked a fourth time, when she then “flopped” forward and stated, “I can’t hold myself up.” Patient #10’s significant other began to yell at Staff M, who asked the significant other to leave. Staff M attempted to redirect Patient #10 as her oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%) was 100%. Staff M applied supplemental oxygen. Initially, Patient #10’s labored breathing improved, however, when that was pointed out, she began to hyperventilate (breathe at an abnormally rapid rate, so increasing the rate of loss of carbon dioxide) again. Patient #10 asked, “is this all that’s going to be done, if so, I’m going to leave,” while she argued with Staff M. Staff M advised her that she needed to complete a triage assessment while treating her symptoms as there were no available rooms. Patient #10 then jumped up and left. - At 1:25 PM, a “Patient Request to Leave Prior to MSE/LWBS” form was signed by Staff M, however, the boxes for “patient/health care surrogate refused to sign form,” and/or “unable to locate after reasonable search” were not checked. Patient #10 did not sign the form. Review of Patient #26’s medical record, dated 12/07/25, showed: - A 62-year-old female presented to the ED with law enforcement for a sexual assault nurse exam (SANE, a registered nurse or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams). - A SANE provider was not available. She declined the need for an MSE. Hospital B was contacted and had a SANE provider available. Patient #26 was to present at Hospital B with a friend for the SANE exam. Hospital B was aware. - At 1:55 AM, a “Patient Request to Leave Prior to MSE/LWBS” form was signed by a staff member, however, the boxes for “patient/health care surrogate refused to sign form,” and/or “unable to locate after reasonable search” were not checked. Patient #26 did not sign the form. - An untitled form showed a SANE provider was not available and that the patient was transferred to another facility, Hospital B, for a SANE exam. The form was signed by a Nurse. The form was not a patient transfer form. During an interview on 12/30/25 at 2:16 PM, Staff J, ED Nurse Manager, stated that she expected the LWBS form to be completed properly by checking the boxes at the bottom if the patient did not sign the form. If a patient left prior to seeing a provider, they were not considered to have left AMA. Patient #10 left before she saw a provider. If a patient presented to the hospital for a SANE exam and a SANE provider was not available, they would transfer the patient just like all other patients. If the patient LWBS, the same process was followed. During an interview on 12/30/25 at 12:24 PM, Staff P, SANE Director, stated that when a SANE provider was not available for an exam, the patient would be medically cleared and then offered a transfer to another hospital. Patients were often transferred to Hospital B or other local hospitals. She was unsure if a refusal to transfer would be treated as a leaving AMA because the patient would have been medically cleared. She was unsure if the policy stated an AMA form was required. During a telephone interview on 12/30/25 at 4:08 PM, Staff M, RN, stated that she recalled Patient #10. She presented with shortness of breath with her inhaler. She immediately took Patient #10 to the triage room and sat her in a chair. She attempted to get vital signs (VS, measurements of the body’s most basic functions). Patient #10 continued to hyperventilate and attempted to lay on the floor. Staff M attempted to stop her from doing so and explained the care she was to receive. After arguing, Patient #10 asked to leave. Staff M told her she was free to go and was not being held against her will. Staff M did not have a discussion with Patient #10 about the risks of leaving prior to a MSE. She did not feel it would be appropriate to check the “unable to locate patient after reasonable search” because she knew where the patient was. She had left the hospital on purpose. She did not have time to present the form to Patient #10 before she left. During an interview on 12/29/25 at 9:46 AM, Staff I, RN, stated that if a patient had the appropriate mental capacity to leave prior to the completion of a MSE, she would attempt to speak with a provider. If a provider was not available before the patient left, she would explain the risks and benefits of leaving to the patient and complete the appropriate form. If the patient refused to sign, she would check the box in the medical record to indicate the form was provided to the patient, but they refused to sign it.”

“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: 38236 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure intravenous (IV) sites and tubing were labeled; (A-0749) - Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing patient care; (A-0749) - Prepare a sterile field for the removal of sutures or staples; (A-0749) - Prepare a clean work surface or barrier prior to patient care; (A-0749) - Date opened sterile water for patient care; (A-0749) - Date infusing medication; (A-749) - Label supplies with an open date and remove expired supplies; (A-0749) - Remove personal food items and discharged patients’ food from the patient nutrition rooms; (A-0749) - Ensure expired food was not available for patient use; (A-0749) - Ensure food was dated in patient nutrition rooms and in the kitchen; (A-0749) - Clean the kitchen dishes thoroughly prior to placement in the clean dish rack; (A-0750) - Clean all surfaces and equipment in the patient rooms during terminal cleaning; (A-0750) - Clean the microwave, refrigerators, ice machines in the patient nutrition rooms; (A-0750) - Clean floors, sinks, hoppers and supply bins in supply rooms, clean utility rooms and dirty utility rooms; (A-0750) and - Maintain a clean and sanitary environment. (A-0750) These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. The hospital census was 356. 40189 51292”

“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: 38236 Based on observation, interview and policy review, the hospital failed to: - Label the intravenous (IV, in the vein) site for 10 patients (#6, #12, #13, #36, #37, #41, #44, #45, #46 and #60), observed and label the IV tubing for five patients (#5, #25, #26, #38 and #44) of 22 patients observed. - Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for three patients (#17, #26 and #39) of 19 patients observed. - Prepare a sterile field for the removal of sutures or staples for one patient (#39) of one patient observed. - Prepare a clean work surface or barrier prior to performing patient care of 12 patients (#6, #24, #25, #26, #27, #35, #36, #37, #39, #40, #45 and #60) of 15 patients observed. - Date an opened sterile water bottle in one patient (#29) of one patient room observed. - Date an infusing medication for one patient (#5) of one patient room observed. - Label supplies with an open date and remove expired supplies from storage areas. - Remove expired food, label food when opened or with the expiration date in patient nutrition rooms and the kitchen. These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. Findings included: Review of the hospital’s policy titled, “Vascular Access (IV) - Clinical Guidelines,” dated 08/20/24, showed all IV dressings and lines should be labeled with the date and time they were changed. Observation on 08/04/25 at 3:10 PM, showed no label on the IV dressing for Patient #6. Observation on 08/04/25 at 2:50 PM, showed no label on the IV dressing for Patient #12. Observation on 08/05/25 at 8:35 PM, showed no label on the IV dressing for Patient #13. Observation on 08/05/25 at 8:55 AM, showed no label on the IV dressing for Patient #36. Observation on 08/05/25 at 9:19 AM, showed no label on the IV dressing for Patient #37. Observation on 08/05/25 at 10:50 AM, showed no label on the IV dressing for Patient #41. Observation on 08/05/25 at 10:50 AM, showed no label on the IV dressing for Patient #44. Observation on 08/05/25 at 9:05 AM, showed no label on the IV dressing for Patient #45. Observation on 08/05/25 at 9:20 AM, showed no label on the IV dressing for Patient #46. Observation on 08/06/25 at 9:50 AM, showed no label on the IV dressing for Patient #60. Observation on 08/04/25 at 2:55 PM, showed Patient #5 had unlabeled IV tubing. Observation on 08/05/25 at 9:30 AM, showed Patient #25 had unlabeled IV tubing. Observation on 08/05/25 at 9:30 AM, showed Patient #26 had unlabeled IV tubing. Observation on 08/05/25 at 9:31 AM, showed Patient #38 had unlabeled IV tubing. Observation on 08/05/25 at 10:50 AM, showed Patient #44 had unlabeled IV tubing. During an interview on 08/06/25 at 9:55 AM, Staff HHH, Registered Nurse (RN), stated that IV sites were to be dated and timed when started. Review of the hospital’s policy titled, “Infection Control Manual,” dated 10/24/24, showed: - Gloves should be worn as an additional measure, not as a substitute for hand hygiene. - Hand Hygiene should be performed before and after any patient contact. - Hand Hygiene should be performed prior to applying gloves and immediately after glove use. Observation on 08/05/25 at 9:40 AM, showed Staff LL, RN, performed hand hygiene and donned gloves prior to providing care for Patient #39. She logged into the computer and confirmed the patient’s identification. She then removed her right glove, held it in her left, used her right hand to scan the patient’s armband and then placed the glove back on her right hand. She proceeded to prepare the patient’s medications. She spiked the IV bag, primed the IV tubing, then removed her right glove, held the glove in her left hand, with the IV bag and tubing in her left hand, and scanned all the medications with her right hand. She then placed the glove back on her right hand. She used a saline flush to check the patency of the patient’s IV catheter, then removed her right glove, held it in her left hand and used her right hand to hang the IV bag on the IV pole. She placed the glove back her right hand and started the IV pump. She then proceeded to place all the patient’s medication in a cup. After placing the medications in the cup, she removed her right glove to pour water into the patient’s cup. At that time, she dropped the glove she had removed from her right hand and stated, “oh I guess I will have to get a new glove now.” She did not perform hand hygiene prior to donning the new glove. Observation on 08/05/25 at 9:00 AM, showed Staff GG, RN, placed her hand in her pocket, answered the phone and failed to perform hand hygiene prior to donning gloves. She then prepared medications and handed Patient #17 his inhaler. Staff GG removed the dirty gloves and failed to perform hand hygiene prior to donning a second pair of gloves. She proceeded to prepare and administered additional medication by mouth. Staff GG then placed her hand in her pocket and answered the phone, placed the phone back in her pocket with gloved hands. She continued to prepare and scan medications with the same gloves. Staff GG then reached into her pocket and removed alcohol swabs. She removed the dirty gloves, failed to perform hand hygiene and donned a third pair of gloves. She proceeded to administer a subcutaneous (under the skin) medication. Staff GG then removed her gloves and threw away dirty trash with bare hands. Staff GG missed three opportunities for hand hygiene between glove changes during medication administration. Observation on 08/05/25 at 9:40 AM, showed Staff V, RN, picked up a dropped transdermal patch (a medical device, typically an adhesive patch, that delivers medication through the skin and into the bloodstream) off the floor and did not perform hand hygiene and glove change before applying it to Patient #26’s arm. During an interview on 08/05/25 at 9:20 AM, Staff GG, RN, stated that she changed her gloves when dirty things were touched, but would have performed hand hygiene between glove changes only if she left the room and returned. She stated that it was not a problem to place gloved hands in pockets. Staff GG stated she should have possibly performed hand hygiene after she touched objects in the room. Review of the hospital’s undated, untitled, procedure for removing sutures or staples showed that a sterile field would be set up for both staple extractor and sterile suture removal kits. Observation on 08/05/25 at 9:31 AM, showed Staff KK, RN, removed staples and sutures from Patient #39’s surgical site. Neither the staple extractor kit, nor the sterile suture removal kit, were set up on a sterile field. Both items were placed directly on the patient’s bedside table with his food, cell phone and spit cup. Review of the hospital’s policy titled, “Infection Control Manual,” dated 10/24/24, showed: - Physical separation between clean and contaminated supplies; - Prepare medications in areas physically separated from those with potential blood/body fluid contamination; and - Barriers were to be used to protect surfaces from blood contamination during blood sampling. Observation on 08/04/25 at 3:10 PM, showed Staff O, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #6. Observation on 08/05/25 at 9:05 AM, showed Staff U, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #24. Observation on 08/05/25 at 9:30 AM, showed Staff W, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #25. Observation on 08/05/25 at 9:40 AM, showed Staff V, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #26. Observation on 08/05/25 at 11:10 AM, showed Staff Z, Patient Care Technician (PCT) entered the isolation room of Patient #27 with a supply kit for performing a blood glucose test. The PCT placed the kit on a bedside table without a barrier, touched the patient with gloved hands, used the soiled gloves to take supplies out of the kit, and then removed all the supplies from the patient room. The supplies were then taken out of the room to be used for all other blood glucose tests on the unit. Observation on 08/05/25 at 10:10 AM, showed Staff EE, RN, placed IV start supplies directly on Patient #35’s lap and bed. Observation on 08/05/25 at 8:55 AM, showed Staff KK, RN, placed all supplies and medication in Patient #36’s windowsill. Observation on 08/05/25 at 9:19 AM, showed Staff OO, RN, placed Patient #37’s medication on top of the dirty linen cart lid. Observation on 08/05/25 at 9:40 AM, showed Staff LL, RN, placed Patient #39’s medications on a stack of papers she brought into the room and placed IV supplies on the patient’s counter. Observation on 08/05/25 at 10:08 AM, showed Staff NN, RN, placed drain care supplies directly on Patient #40’s lap and bed. Observation on 08/05/25 at 9:05 AM, showed Staff SS, RN, failed to create a clean work surface or use a barrier for medication administration for Patient #45. Observation on 08/06/25 at 9:50 AM, showed Staff HHH, RN, placed blood draw supplies directly on Patient #60’s bed. During an interview on 08/06/25 at 9:55 AM, Staff HHH, RN, stated that the bed was considered dirty and a clean work surface should have been used. Observation with concurrent interview on 08/05/25 at 9:35 AM, showed in Patient #29’s room, a bottle of sterile water opened and undated. Staff S, Nurse Manager, stated that bottles of sterile water were to be dated when opened. Observation on 08/04/25 at 2:30 PM, showed no start date recorded on a bag of normal saline for Patient #5. Review of the hospital’s policy titled, “Patient Transport-Restocking of Supplies-Guidelines,” dated 07/22/25, showed the Care Team Associates-Support will supplement clinical staff with restocking of supplies within an assigned work area and are to inspect all items for expiration dates and remove any expired products. Observation on 08/04/25 at 2:05 PM, on the medical unit, at the nurse’s station, showed two blood glucose strip vials with no opened date. Observation with concurrent interview on 08/04/25 at 2:50 PM, in the Integrated Medical Unit storage room, showed a rectal tube that expired on 06/30/25. Staff I, Charge RN, stated that Distribution was responsible for the removal of outdated supplies. Observation with concurrent interview on 08/04/25 at 3:40 PM, in the Medical Intensive Care Unit (ICU, a unit where critically ill patients are cared for) storage room, showed 24 lubricated gauze packages that expired on 08/2022, one tubing connector that expired on 03/31/25, one wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) connectors that expired on 06/30/23, four that expired on 07/31/23 and one that expired on 03/31/25. Staff L, Acute Care Nurse Educator, stated that Distribution was responsible for the removal of outdated supplies. Review of the hospital’s policy titled, “Dietary Services-Dining & Nutrition-Floor Stock-Guideline,” dated 06/12/23, showed patient refrigerators were for patient food items only. Staff were responsible for discarding expired food and beverages. Observation on 08/05/25 at 9:20 AM, on the medical/surgical unit, showed the patient nutrition refrigerator contained two food items labeled with discharged patient’s names and an expired milk. Observation on 08/05/25 at 9:35 AM, on the medical/surgical unit, a patient refrigerator and freezer contained personal food items. Observation with concurrent interview on 08/05/25 at 9:35 AM, on the medical/surgical unit, a patient refrigerator contained expired yogurt and the freezer contained a personal food item. Staff SSS, Infection Prevention, stated that removing expired food was everyone’s responsibility and personal food should not be in patient refrigerators. Observation on 08/05/25 at 12:45 AM, in the kitchen, showed three bags of pasta and a milk container with no opened date. Observation on 08/05/25 at 10:20 AM, in the kitchen, showed approximately 20 small cup containers of granola filled from a bulk supply bin with no label or date showing expiration. Observation with concurrent interview on 08/05/25 at 12:45 AM, in the kitchen, showed expired cornmeal stuffing. Staff XX, Nutrition Director, stated that expired food should be discarded and open food should have a date label. During an interview on 08/06/25 at 2:00 PM, Staff NNN, Infection Control Manager, stated that IV sites and tubing were to be dated. Hand hygiene was expected before any care was given to a patient and between glove changes. Gloves were to be changed, and hand hygiene performed, after touching contaminated inanimate objects (areas or equipment that was not clean) in the room or placing a hand in a pocket. A patient’s room was considered contaminated. She expected that a clean work surface or barrier was used when medications were prepped or a procedure was performed. Sterile water bottles were to be dated when opened. Oldest supplies were placed in the front, so they were used first, and she expected that a designated person check for outdates one time a month. Staff food should not be stored in patient refrigerators. She expected no expired food or beverages in the patient nutrition areas. During an interview on 08/06/25 at 3:30 PM, Staff RRR, Chief Nursing Officer Executive (CNE), stated that IV sites and tubing were to be dated. She expected hand hygiene was performed between glove changes and before patient care was given. When inanimate objects were touched, staff were to remove gloves and perform hand hygiene. A clean work surface or barrier was to be used when a procedure or dressing change was performed. Sterile water bottles were to be dated when opened. It was everyone’s responsibility to check for outdated food and supplies. 40189 41865 50151 51292”

“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: 38236 Based on observation, interview and policy review, the hospital failed to: - Clean the kitchen dishes thoroughly prior to placement in the clean dish rack; - Clean all surfaces and patient equipment in a terminal cleaned (a thorough, deep-cleaning of a room to include the ceiling, walls and floors) patient room; - Clean the microwave, refrigerators, drawers, shelving, coffee/tea machines and ice machines in the kitchen and patient nutrition areas; - Clean floors, sinks, hoppers and supply bins in supply rooms, clean utility rooms and dirty utility rooms; and - Maintain a clean and sanitary environment. Findings included: Review of the hospital manual titled “Infection Control” dated 10/21/24, states that standard precautions are used for all patient care areas to provide a consistent approach in protecting healthcare providers and patients from infection, which includes the cleaning and disinfecting of patient care equipment and environmental surfaces. Observation on 08/04/25 at 3:00 PM, on the medical unit, showed a terminally cleaned patient room had a dirty floor with blood drops and sticky areas, trash on the floor, and visible dirt on a vital signs machine. Observation on 08/05/25 at 9:30 AM, on the cardiology unit, showed a patient nutrition area with visible dirt on the floor, a refrigerator with rust halfway up the right side and ice machine with hard water build up around the dispenser. Observation on 08/05/25 at 10:20 AM, showed a large tea canister with black crusty rings around the inside of the container being used to make tea in the patient kitchen. Observation on 08/05/25 at 10:20 AM, showed dirty pans with food residue present on the clean rack of the patient kitchen. During an interview on 08/05/25 at 10:30 AM, with Staff AA, Kitchen Manager, stated that the tea cannister should be cleaned daily and it didn’t look like it had been cleaned prior to use. He further added he did not expect the granola cups to be undated, nor for dirty dishes to be placed on the clean rack. Observation on 08/04/25 at 3:10 PM, showed a medication room on a medical unit had a dirty utility sink with unidentified brown and white crust accumulated around the top surface. The floor had several areas of accumulated dust and pieces of trash. Observation on 08/04/25 at 3:10 PM, showed a medication room on a medical unit had a dirty floor with accumulated dust, sticky areas and trash. Observation on 08/04/25 at 3:12 PM, showed a patient nutrition room on a medical unit with an overflowed trash can, an ice machine with hard water build up, a coffee machine with coffee splatters and accumulated dirt and the entire floor was sticky. Observation on 08/04/25 At 3:15 PM, showed the supply room floor of a medical unit was dirty and had pieces of trash present. Observation on 08/04/25 at 3:20 PM, showed a supply room on the medical unit with trash cans overflowed and the floor had spills, dust and pieces of trash. Observation on 08/05/25 at 9:25 AM, showed a medication room on the medical/surgical unit that had accumulated dust and sticky residue on the floor. Observation on 08/05/25 at 9:45 AM, showed a soiled utility room on the medical/surgical unit with a dirty hopper (a sink or receptacle for discarding clinical liquid waste) that held dark brown water. Observation on 08/05/25 at 3:10 PM, showed overflowing trash cans in Patient #6’s room on the Surgical Services unit. Observation on 08/05/25 at 9:50 AM, on the Oncology unit nutrition area showed dirty drawers with sticky residue on edges and inside drawers. The floor of the nutrition area had dirt present and was sticky to the touch. Observation on 08/05/25 at 0900 AM, showed the soiled utility room of the Bone Marrow Transplant unit with dirty linens not confined inside a bag, lying on the floor. The nutrition room on the same unit, had spills on and inside drawers. The freezer area of the refrigerator had a collection of brown dust and debris from opening boxes inside the freezer. Observation on 08/04/25 at 3:25 PM, showed a patient nutrition room on the medical unit with two overflowed trash cans, a microwave with multiple food splatters/chunks of food and an ice machine with accumulated hard water. Observation on 08/05/25 at 11:30 AM, in the Emergency Department (ED) showed spills on the outside and inside of the drawers in the nutrition area of unknown substance. Observation on 08/04/25 at 3:37 PM, in Patient #7’s room on a medical unit, showed a floor with dust accumulations and sticky residue. Patient #7 stated the room was very soiled when she arrived, her bedside table was sticky, and the bathroom toilet and sink had hair in it. She was concerned about wearing her socks while walking around the room, as she would track dirt into her bed. She further stated the room had not been mopped since she arrived seven days ago. During an interview on 08/04/25 at 3:20 PM, Staff N, Acute Care Educator, stated that the sink should be clean and the floor free of debris. During an interview on 08/06/25 at 2:55 PM, with Staff QQQ, EVS Manager, stated that the patient rooms should be mopped daily, trash removed daily and sinks to be cleaned as needed, in patient care areas. During an interview on 08/06/25 at 3:30 PM with Staff RRR, CNE, stated she expected nutrition areas and patient rooms to be cleaned daily and as needed. 51292”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48359 Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#1 and #22) of 30 Emergency Department (ED) and Labor and Delivery records reviewed. Findings included: Review of the hospital’s policy titled, “EMTALA,” reviewed 03/24/23, showed: All persons presenting to the ED are entitled to a MSE to determine whether or not an EMC exists. A MSE is the initial and on-going evaluation of a patient based on their presenting condition and is conducted by a qualified provider. The MSE includes the history, physical examination, appropriate testing, appropriate documentation, and evaluation of the patient. The evaluation must be within the capabilities of the hospital, utilizing facilities routinely available to the ED and the use of on-call physicians as appropriate, to determine whether a patient has an EMC. All patients shall be monitored, and their vital signs recorded based on their triage (process of determining the priority of a patient’s treatment based on the severity of their condition) category. Patients presenting with psychiatric (relating to mental illness) disturbances are considered to have an EMC and should receive a mental health (MH) screening in addition to their medical screening. The MH screening should be utilized to determine the risk of harm to self or others and the appropriate disposition and/or transfer based on the patient’s condition. Patients must be protected and prevented from injuring themselves or others during transfer. The time of triage, category of triage, time of arrival, time of placing in a treatment room, time of the provider’s MSE, along with the time of call to and the arrival of any on-call provider should be noted. Patients should receive appropriate and necessary medical care to remove the risk of deterioration of their condition prior to discharge or transfer. Review of the hospital’s policy titled, “ED - Initial Suicide (to cause one’s own death) Assessment and Observation,” revised 02/13/23, showed: - Patients presenting to the ED will be initially screened through ED triage (process of determining the priority of a patient’s treatment based on the severity of their condition). - Nursing will utilize the 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) short version tool to assess the patient for suicide risk. - Questions required for all patients include, have you wished you were dead or wished you could go to sleep and not wake up; have you had any thoughts of killing yourself; and have you ever done anything, started to do anything or prepared to do anything to end your life? - Upon assessment of the patient, providers will enter a communication order if their clinical judgement deems the suicide risk level to differ from the C-SSRS recommendations. - Nursing will implement an observation level based on the new order. Review of the hospital’s policy titled, “Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Procedure,” revised 04/08/19, directed staff to observe, follow or attempt to contain patients to the extent that the safety of all persons is maintained. In the event of an elopement notify the administrator on-call and complete an event report. 51292”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#1 and #22) of 30 Emergency Department (ED) records reviewed from 10/01/24 to 04/02/25. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of the hospital’s policy titled, “EMTALA,” reviewed 03/24/23, showed: All persons presenting to the ED are entitled to a MSE to determine whether or not an EMC exists. A MSE is the initial and on-going evaluation of a patient based on their presenting condition and is conducted by a qualified provider. The MSE includes the history, physical examination, appropriate testing, appropriate documentation, and evaluation of the patient. The evaluation must be within the capabilities of the hospital, utilizing facilities routinely available to the ED and the use of on-call physicians as appropriate, to determine whether a patient has an EMC. All patients shall be monitored, and their vital signs recorded based on their triage (process of determining the priority of a patient’s treatment based on the severity of their condition) category. Patients presenting with psychiatric (relating to mental illness) disturbances are considered to have an EMC and should receive a mental health (MH) screening in addition to their medical screening. The MH screening should be utilized to determine the risk of harm to self or others and the appropriate disposition and/or transfer based on the patient’s condition. Patients must be protected and prevented from injuring themselves or others during transfer. The time of triage, category of triage, time of arrival, time of placing in a treatment room, time of the provider’s MSE, along with the time of call to and the arrival of any on-call provider should be noted. Patients should receive appropriate and necessary medical care to remove the risk of deterioration of their condition prior to discharge or transfer. Review of the hospital’s document titled, “Medical Staff Bylaws,” revised 10/03/23, showed the provider must complete and document a medical history and physical examination for each patient. Appropriate, timely, and continuous care of the patient shall be provided, including a complete and accurate medical record. Review of the hospital’s policy titled, “ED - Initial Suicide (to cause one’s own death) Assessment and Observation,” revised 02/13/23, showed: - Patients presenting to the ED will be initially screened through ED triage (process of determining the priority of a patient’s treatment based on the severity of their condition). - Nursing will utilize the 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) short version tool to assess the patient for suicide risk. - Questions required for all patients include, have you wished you were dead or wished you could go to sleep and not wake up; have you had any thoughts of killing yourself; and have you ever done anything, started to do anything or prepared to do anything to end your life? - Upon assessment of the patient, providers will enter a communication order if their clinical judgement deems the suicide risk level to differ from the C-SSRS recommendations. - Nursing will implement an observation level based on the new order. Review of the hospital’s policy titled, “Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Procedure,” revised 04/08/19, directed staff to observe, follow or attempt to contain patients to the extent that the safety of all persons is maintained. In the event of an elopement notify the administrator on-call and complete an event report. Review of Patient #1’s “Police Report Arrest Number 8063217,” dated 04/07/25 at 8:32 PM, showed Patient #1 was placed under arrest while standing near the ambulance bay. She eloped a 96-hour hold. Review of Patient #1’s medical record showed: - On 10/04/24 at 6:00 PM, a 37-year-old female presented to the ED and requested medication refills, she was anxious, incoherent and rambling to herself. - Her past medical history included schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) abuse and substance induced mood disorder (a change in the way you think, feel, or act, caused by taking or stopping a drug). - With word salad (confused or unintelligible mixture of seemingly random words and phrases) and tangential speech (a type of speech disorder in which each of a series of thoughts seems less closely related to the original thought than the one before it), she requested clonazepam (medication used to treat anxiety) for her constant movements. - She had erratic body movements and very bizarre behavior; she constantly changed the subject. - Methamphetamine use/induced psychosis was suspected, and she was not safe to herself or the public. - She was at risk of deteriorating. - At 6:19 PM, she denied thoughts of harming herself in the last three months. Questions one, two and six of the C-SSRS were not completed. - At 7:40 PM, she refused to enter an ED room and stormed out of the ED. She was found by security on the street, the local police department was notified, and she was taken into police custody. - Due to concern that she was at risk of harming herself and others, 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) paperwork was sent to the Sheriff’s office. - The 96-hour hold paperwork showed she presented to the ED acting erratically with tangential speech. The ED provider believed she was having a psychotic episode and was unsafe to herself and the public. She needed a psychiatric evaluation and treatment. During an interview on 04/03/25 at 3:18 PM, Staff W, ED Medical Director, stated that he expected staff to follow their Crisis Prevention Institute (CPI, a type of training where staff learn to safely defusing violent behavior and safe physical holds to restrict a person’s movement) training and call the response team to prevent elopements. The response team consists of security and law enforcement. If a suicidal patient attempted to elope, he expected the staff to attempt to de-escalate the situation, but not to restrain the patient. If the patient was on hospital property, he expected security to place a hold on the patient. Staff should follow the hospital’s policies and procedures. During a telephone interview on 04/04/25 at 9:33 AM, Staff X, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), stated that when a patient was deemed unsafe to themselves or others, he expected staff to prevent the patient from eloping. To avoid injury from a combative patient, the staff could call security for support. He expected the triage nurse to complete the suicide assessment screening according to the hospital’s policy. All staff should follow the hospital’s policies and procedures. During an interview on 04/03/25 at 1:43 PM, Staff O, ED Manager, stated that he expected staff to do everything they could to prevent elopements without placing themselves in harm’s way. All staff received CPI training, though classes were only held “a couple of times a year” for new staff. If a patient was a suicide risk, a one-to-one (1:1, continuous visual contact with close physical proximity) sitter was to be placed. He expected the security officers to assist with de-escalation. Patient #1 was “difficult” but not physically assaultive. The security officer declining to place Patient #1 in a hold upon the charge nurse’s request did not meet his expectations. The security officers should assist when needed. He did not understand why law enforcement did not return the patient to the ED. Staff should follow the hospital’s policies and procedures. He was not notified of the elopement until the following day, not at the time of the incident. Suicidal patients should not be allowed to elope from the hospital. There was no follow up or additional education with staff in response to this event. During a telephone interview on 04/03/25 at 12:14 PM, Staff T, Registered Nurse (RN), stated that when a patient was determined to be a risk to themselves a 1:1 sitter was placed. When the triage nurse determined a patient needed a psychiatric evaluation, the patient was immediately taken to an ED room and evaluated by the provider. The C-SSRS determined the necessity for a 1:1 sitter. If the provider’s assessment differed from the C-SSRS an order was written for the appropriate level of observation. When Patient #1 eloped, security was notified and found the patient on the property near a busy intersection. She was taken to the patient by security and attempted to convince her to return to the ED. She wanted the patient out of the street due to the danger. Staff T asked security to assist with getting the patient inside, but the security officer refused to place the patient in a hold. Security called local law enforcement, and the patient was taken into custody. The hospital needed to ensure suicidal patients did not elope. Patient #1’s elopement could have been prevented. No follow-up or education was received from leadership in response to this event. During an interview on 04/03/25 at 2:00 PM, Staff DD, Quality and Patient Safety Director, stated that an event report was not completed in related to Patient #1’s elopement. Review of Patient #22’s medical record showed: - On 09/08/24 at 7:08 PM, a 59-year-old male presented at the ED with complaints of generalized fatigue (weakness or tiredness) and malaise (body weakness or discomfort). He complained of vomiting and diarrhea for the last week without abdominal pain. He had a mild productive cough and felt like he had increased shortness of breath over the last three days. He denied any fever. - His medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), atrial fibrillation (A-fib, an irregular, often rapid heartrate that commonly causes poor blood flow), chronic ( long-term, ongoing) pain, depression, high blood pressure, pleural effusions (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), peri-rectal (the rectal space which is the last part of the large intestines where stool is stored before leaving the body) abscesses (a collection or pocket of thick fluid cause by an infection),and sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs), along with multiple co-morbidities ( the presence of one or more medical diagnoses existing along with a primary condition). - At 7:16 PM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was obtained and indicated a septal infarct (suggests a possible heart attack affecting the septum [the wall separating the heart’s chambers] at an unknown time in the past, potentially requiring further testing for confirmation and to determine the extent of damage). - At 7:42 PM, his vital signs (VS, Vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [HR] normal 60 to 100 per minute; respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degrees) were documented as a BP of 142/97, with a mean arterial pressure (MAP, is a key indicator of organ perfusion, with a normal range typically between 70 and 100 mmHg) of 112, a RR of 23, and a HR of 91. - At 7:49 PM, the laboratory results showed a white blood cell (WBC, the number of white blood cells [infection fighting cells] in the blood, the normal range between 4.8-10.8) count of 17,600, and an elevated blood urea nitrogen (BUN, test that specifies kidney function, normal range between 9 and 23) of 39. - At 7:51 PM, the chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed hyperaerated lungs (a condition where the lungs expand beyond their normal size due to trapped air, often seen in people with COPD which leads to difficulty breathing). - At 8:30 PM, his VS were BP 149/67 with a MAP of 89, HR 87 and RR 52. - At 9:00 PM, his VS were BP 106/59 with a MAP 76, HR 87 and RR 32. - At 9:02 PM, COVID-19 (highly contagious, and sometimes fatal, virus) and influenza (highly contagious condition affecting the respiratory system) tests were negative. - At 9:30 PM, his VS were BP 105/57 with a MAP 72, RR 32 and HR 85. - At 10:32 PM, Staff U, ED Physician, documented the laboratory results were re-assuring, other than the elevated WBC’s. Based on Patient #22’s history of COPD antibiotics and steroids were ordered. - At 10:44 PM, his VS are BP 91/54 with a MAP 65, RR 24 and HR 90. - His temperature was never recorded. - At 11:38 PM, he was discharged home. Review of Patient #22’s medical record dated 09/14/24, showed: - At 11:05 AM, he presented at the ED with complaints of constipation and rectal abscess. - At 11:11 AM, his VS were BP 129/72, HR 115, RR 22, T 98.0 and SAO2 95%. - At 11:50 AM, an abdominal and pelvis computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed peri-rectal and perianal (situated in or affecting the area around the anus) abscesses. - At 1:29 PM, he was admitted to the hospital to the general surgery department. During an interview on 04/03/25 at 3:20 PM, Staff W, ED Medical Director, stated with a MAP greater than 65, he would have liked to know whether the patient had a fever or not. Additional assessment, including a C-reactive protein test (CRP, a test that measures the amount of CRP in the blood to detect inflammation either for acute conditions or to monitor chronic conditions) and calcitonin (a hormone that regulates the amount of calcium in the blood, an elevated level can indicate kidney problems) level would have been helpful. He did not care for Patient #22 and he could not comment. During an interview on 04/03/25 at 2:35 PM, Staff U, ED Physician, stated she typically did not order blood cultures based only on an elevated WBC count. The elevation could be related to inflammatory issues from COPD exacerbation (increase in symptoms). Patient #22 was alert and oriented. He stated that he felt better after the breathing treatments and steroids. In hindsight, she would have ordered intravenous fluids to replenish his fluid volume. During an interview on 04/03/25 at 1:45 PM, Staff O, ED Manager, stated the hospital does not have a standard sepsis protocol. Orders are often placed based on the nursing assessment. He expected nurses to report any change in condition to the physician. He was surprised that Patient #22’s decrease in BP was specifically documented in the medical record. With the drop in BP, he would have expected blood cultures or a lactic acid level. Nursing staff should document full sets of VS upon admission. During an interview on 09/07/25 at 4:51 PM, Staff V, ED Charge Nurse, stated that the temperature should have been taken and monitored. Nursing should documenta a complete assessment. Had she been aware of Patient #22’s decreasing BP, she would have advocated for additional testing and monitoring. 51292”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to: -Ensure safe patient monitoring for one patient (#73) of three who received a blood transfusion (to administer blood into a vein); (A-0144) - Ensure blanket warmers-maintained temperatures in a safe range; (A-0144) - Secure medications on three units of 26 units observed; (A-0144) - Ensure sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) were safely stored; (A-0144) - Thoroughly investigate an allegation of abuse and neglect related to two patients (#67 and #68); (A- 0145) - Safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) of patients; (A-0147) - Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a licensed practitioner (LP) responsible for the care of the patient for five patients (#55, #66, #70, #71 and #79) of six restraint patients reviewed; (A-0168) and - Ensure appropriate monitoring and nursing documentation during the use of restraints for four discharged patients (#55, #66, #70, and #79) of six restraint patients reviewed. (A-0175) These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. Refer to A-0144, A-0145, A-0147, A-0168 and A-0175.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure proper insertion of an ultrasound (a test that uses sound waves to create images of structures within the body) guided intravenous (IV, in the vein) catheter for one patient (#78) of one discharged patient reviewed; (A-0395) - Maintain an effective wound care prevention program that prevented new or worsening wounds from occurring for one patient (#78) of one discharged patient reviewed; (A-0395) - Ensure proper hygiene policy was implemented for one patient (#78) of one discharged patient reviewed; (A-0395) - Ensure that staff followed the hospital policies when they failed to perform pain reassessments in a timely manner after pain medication administration for two patients (#78 and #28) of two patients observed; (A-0405) and - Ensure safe patient monitoring and infusion rate for one patient (#73) of three patients who received a blood transfusion (to administer blood into a vein) reviewed. (A-0410) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. Please refer to A-0395, A-0405, and A-0410.”

“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: 48359 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) and glove changes when providing care for 15 patients (#3, #4, #5, #6, #27, #28, #35, #36, #40, #47, #52, #62, #63, #72 and #73) of 38 patients observed; - Label intravenous (IV, in the vein) sites and tubing for nine (#1, #3, #4, #29, #31, #47, #50, #62 and #63) patients of 28 patients observed; - Follow asepsis technique for a sterile (completely clean and free from germs) procedure for one patient (#27) of one sterile procedure observed; - Prepare a clean work surface prior to performing patient care for 10 patients (#3, #4, #7, #25, #26, #27, #35, #40, #52 and #72) of 14 patients observed; - Scrub the rubber stopper of an injectable medication vial for two patients (#3 and #27) of 8 patients observed; - Remove expired food in five departments of 29 departments observed; - Remove expired supplies on five units of 26 units observed; - Remove wet blankets/towels from under the sink/counter in two patient nutrition rooms of 17 patient nutrition rooms observed; - Discard one used disposable gown and three dirty towels in the decontamination room of Sterile Processing; - Laminate paper hung on walls in patient care areas to create a cleanable surface on six units of six units observed; - Clean a microwave and refrigerator in two patient nutrition rooms of 17 patient nutrition rooms observed; - Remove a staff members personal item from a food dry storage area in one kitchen of three kitchens observed; - Follow policy related to soiled linen and storage of clean patient supplies on four units of 26 units observed; and - Follow their Infection Prevention Plan to maintain a sanitary environment. These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. Please refer to A-0749.”

“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: 41865 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure safe patient monitoring for one patient (#73) of three who received a blood transfusion (to administer blood into a vein); - Ensure blanket warmers-maintained temperatures in a safe range; - Secure medications on three units of 26 units observed; - Ensure sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) were safely stored. Findings included: 1. Review of the hospital’s policy titled, “Blood Product Transfusion,” dated 05/09/22, showed: Vital signs (VS, measurements of the body’s most basic functions) were to be recorded prior to the transfusion, 15 minutes after the transfusion started and at completion. Staff were to remain with or able to closely observe the patient for the first 15 minutes of the infusion to observe for adverse reactions. Review of Patient #73’s medical record, dated 10/30/24, showed a blood transfusion started at 12:15 PM and VS were recorded at that time. VS were next recorded at 2:26 PM when the transfusion ended. Observation on 10/30/24, showed Staff ZZZ, Registered Nurse (RN), obtain VS at 12:15 PM and started the blood transfusion for Patient #73 at 12:20 PM. He obtained VS at 12:30 PM, then left the patient’s room. During an interview on 10/31/24 at 2:25 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected patient observation and VS monitoring should follow hospital policy for all patient receiving blood transfusions. 2. Although requested a policy related to blanket warmer temperature monitoring was not provided. Observation on 10/30/24 at 12:49, in the Cardiovascular Unit, showed the blanket warmer located in the supply room had a temperature of 131 degrees. Observation on 10/29/24 at 10:15 AM, in the nursery, showed the blanket warmer temperature was 132 degrees. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated that she expected blanket warmers to be monitored and for there to be a policy to ensure monitoring was completed. During an interview on 10/30/24 at 2:29 PM, Staff HHHH, Facilities Director, stated that they were not able to monitor the temperatures of blanket warmers remotely and there was no system for monitoring the temperatures at all. Unit staff were expected to check the temperature and report any blanket warmers that were out of range. During an interview on 10/30/24 at 12:49 PM, Staff BBB, Service Line Specialist, stated that she generally checked the temperature on the blanket warmers periodically but did not have a log to indicate when or how often it was checked. The goal was for the temperature to be under 130 degrees. During an interview on 10/29/24 at 8:15 AM, Staff CC, Risk and Regulation Manager, stated that the blanket warmers were to be no warmer than 130 degrees Fahrenheit. Staff were expected to assess the blanket warmers temperature every shift, logs were not completed to confirm the temperature. During an interview on 10/30/24 at 2:29 PM, Staff JJJJ, Maintenance, stated that the newer blanket warmers would not alarm until the temperature reached 136 degrees. The older models would not alarm at all. During an interview on 10/30/24 at 9:58 AM, Staff FF, Women’s Services Manager, stated that the blanket warmers were centrally monitored by clinical engineering. During an interview on 10/29/24 at 9:55 AM, Staff EE, RN, stated that she did not know who was responsible to assess the warmer temperatures. 3. Review of the hospital’s policy titled, “Medication Management - Medication and Quality Assurance - Policy,” approved 06/08/21, showed: - To ensure patient safety and regulatory compliance, it is necessary that unusable medication be unavailable for patient use. - Medication storage areas will be kept clean, organized, temperature-controlled, secured, and with appropriate light, moisture and ventilation levels. - Any unusable medication will be removed from active stock. Observation on 10/29/24 at 11:10 AM, in the Labor and Delivery Unit anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) work area, showed 12 vials of injectable medication in an unsecured cabinet. Observation on 10/29/24 at 9:50 AM, in the Pediatric (pertaining to children) Unit, showed one partially used tube of medication in an empty patient room. Observation on 10/29/24 at 2:45 PM, in Hospital C’s medication room, showed one unsecured partially used medication vial and one opened package with one white tablet unsecured in a medicine cup in a patient’s medication bin. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected unsecured medications were discarded. She expected all medications to be secured. 4. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed: - All health care workers shall take precautions to prevent injuries caused by needles. - Prepare each injection in a designated clean area where blood and body fluid contamination are unlikely. - Inspect the syringe and needle package for breaks. - Discard syringe and needle if the package has been punctured, torn and/or damaged by exposure to moisture. Observation on 10/29/24 at 11:13 AM, on the Medical/Surgical unit of Hospital B, showed a computer workstation on wheels that was left unattended in the hallway. The workstation contained unlocked drawers with multiple insulin syringes. Observation on 10/29/24 at 11:13 AM, on the Progressive Care Unit (PCU) unit of Hospital B, showed a new packaged 18-gauge needle that was left on the patient’s bedside table. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated that she would not expect to see sharps anywhere outside of a locked drawer or sharps container. During an interview on 10/29/24 at 2:55 PM, Staff TTT, Hospital B Director of Nursing, stated that she expected staff members to lock up the insulin syringes when they walked away from their workstations. 46554 48359 49404 50321”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 41865 Based on interview, record review, video review and policy review, the hospital failed to thoroughly investigate an allegation of abuse and neglect related to two patients (#67 and #68). They failed to determine whether abuse had occurred, failed to notify the patient’s guardians and failed to provide education to all staff. These failed practices placed all patients admitted to the hospital at increased risk for their safety. Findings Included: Review of the hospital’s policy titled, “Abuse and Neglect Prevention,” dated 03/27/19, showed: - Employees who observe acts of possible sexual misconduct by a patient or against a patient, should immediately report the incident to the direct supervisor. - Contact security to have them meet with the patient and set expectations of appropriate behavior, if applicable. - Document patient’s misconduct in the Electronic Medical Record (EMR). - A trained investigator with Missouri University Health Care (MUHC) Security will initiate a fair, impartial and reliable investigation of the allegations. - Investigative efforts may include instituting interim remedies for the safety and security of all patients, visitors and employees at MUHC. - Interview direct witnesses of the alleged conduct and other relevant witnesses, if available. - Collect relevant evidence; security footage, emails/text messages/photos, documentation of related prior conduct, etc. - Allow the accused party to tell their side of the story. - At the completion of the investigation, a summary of the investigation will be submitted to the MUHC Title IX (a federal law that prohibits sex-based discrimination in educational programs and activities that receive federal financial assistance) Coordinator’s designee and any necessary stakeholder. - If the MUHC Title IX Coordinator makes a determination that there was a violation of the Collected Rules & Regulations (CRR) 600.020 Sexual Discrimination, Harassment or Misconduct in Education/Employment Policy, then a committee comprised of the Manager of Regulatory Affairs, the Manager of Risk Management and the MUHC Title IX Coordinator or Deputy Title IX Coordinator, or designee, and other stakeholders as needed, will recommend appropriate sanctions or remedial actions, if applicable. - If supported by the evidence sanctions may include a Behavioral Intervention Plan which outlines expectations and possible consequences for the patient’s failure to adhere to the Behavioral Intervention Plan. Risk Management will only approve and/or recommend a Behavioral Intervention Plan if the evidence supports it. - Termination of the patient, area specific, or system wide. Review of the hospital’s policy titled, “Discharge Planning & Care Coordination - Guardian Notification of Important Clinical Events,” dated 12/08/20, showed that the purpose of the policy was to establish guidelines for contacting guardians after important clinical events, however, the policy does not address the notification of a minor’s parent or guardian after any type of verbal, physical or sexual allegation. Review of the hospital provided document titled, “Incident Number 922494,” dated 03/28/24, showed Patient #77 reported to a Mental Health Technician (MHT) she did not want to be in the room she was currently located in. When the MHT asked her why she said that Patient #68 came into the room and had sex with her roommate, Patient #67, while staff were not present. The patient then showed the MHT a bed sheet that she had kept that the “patient had put his semen on”. Patient #77 stated that she was waiting for her roommate to be discharged before reporting because she did not want her to get in trouble. Review of Patient #67’s medical record showed: - She was a 17-year-old female admitted to the adolescent psychiatric (relating to mental illness) unit on 03/22/24. - Progress Notes dated 03/23/24 through 03/26/24, showed no documentation of any inappropriate sexual behaviors or encounters. - Nursing Narrative Reviews dated 03/22/24 through 03/26/24, showed no documentation of any inappropriate sexual behaviors or encounters. - There was no documentation in the EMR of parental notification after the alleged sexual encounter between Patient #67 and Patient #68. - She was discharged on 03/27/24. Review of Patient #68’s medical record showed: - He was a 16-year-old male admitted to the adolescent psychiatric unit on 02/15/24. - Progress Notes, dated 03/23/24 through 03/28/24, showed no documentation of any inappropriate sexual behaviors or encounters. - Nursing Narrative Reviews, dated 03/22/24 through 03/27/24, showed no documentation of an inappropriate sexual behaviors or encounters. - A Nursing Narrative Review dated 03/28/24, showed the patient, “keeps asking to go back to 3 South, doesn’t want to be on Pediatric Assessment Unit (PAU).” - A Progress Note dated 03/29/24, showed the patient, “did not like the fact that he was moved from the inpatient unit and wants to go back to the other side. Patient did not mention anything regarding why he was moved yesterday.” -A Social Work Narrative Review dated 03/28/24, showed Staff EEEE, Licensed Master Social Worker (LMSW), received a call from the patient’s guardian (the person/ appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) who “mentioned that the patient talked about going into a female’s room for two to five minutes.” Staff EEEE confirmed to the guardian that the patient was in a female patient’s room for about three minutes, but the patient denied doing anything physical or sexual with the other patient. - He was discharged on 04/01/24. Review of video surveillance from the West Corridor, West Dining Room and the West Television Room on 03/26/24, showed: - At 09:06:48 PM, an unidentified MHT was observed sitting at a dining room table with view of the patient hallway. - At 09:07:02 PM, the MHT was observed walking out of camera view, leaving the patient hallway unmonitored. The hallway was not visible from the nurse’s station. - At 09:07:35 PM, Patient #68 exited the room and proceeded down the hallway to Patient #67’s room. - At 09:07:41 PM, Patient #68 entered Patient #67’s room and closed the door. - At 09:11:21 PM, Patient #68 exited Patient 67’s room. Review of the hospital provided document titled, “Case Report #2024-000428,” submitted 04/06/24, showed: - On 03/28/24 at 8:33 AM, security was dispatched to the Pediatric Psychiatric Unit. Upon arrival, security was informed that Patient #77 reported that Patient #67 and Patient #68 had, what was believed to be, consensual sexual contact on 03/26/24 around 9:00 PM. Patient #77 reported that she was present in the room at the time of the event and witnessed the encounter. She also reported she “still had the sheet the two were on while having sex.” The sheet had since been placed in a bag. - Patient #67 had been discharged on 03/27/24. Patient #68 and Patient #77 were still present on the unit but had been separated from having contact with each other. - At 8:38 AM, security dispatch was informed that an investigator needed to be assigned for further follow-up as the incident would be considered a Title IX Investigation. Review of the hospital provided document titled, “Follow-Up 2024-00428,” submitted 04/01/24, showed: - On 03/28/24 at 9:58 AM, Patient #77 was interviewed and reported that it was “around bedtime” when Patient #67 and Patient #68 had sex. Patient #68 entered Patient #67’s room between staff room checks and was in the room for approximately five minutes. When asked to describe what she saw Patient #77 only mentioned the two patients undressing. She reported that they did not speak and “they just started fucking.” Patient #77 reported that Patient #67, “spit cum on the ground” and then helped Patient #68 “clean up using the sheet”, which Patient #77 later provided to staff. Patient #77 stated she did not report the incident sooner as she “didn’t want to get anyone in trouble” and that she was afraid Patient #67 and Patient #68 “would do it again.” - On 03/28/24 at 12:40 PM, Patient #68 was interviewed, and he admitted to going into Patient #67’s room but said that they were “only talking.” He claimed he “could not remember the girl’s name nor could he remember what they talked about because it was a long time ago.” He denied having any sexual contact with Patient #67. When it was explained to him that there was a bed sheet that allegedly had semen on it, and if he had an explanation, he claimed to not know what semen was. - Security collected the “bed sheet that was inside a large bag that had been stapled closed across the top.” The bag was sealed with evidence tape and locked the bag inside a cabinet. - Video footage from the evening of 03/26/24 was reviewed. Patient #68 was observed entering Patient #67 and Patient #77’s room at 9:07 PM. Patient #68 was in the room for three minutes and 37 seconds. There were no staff in view of the patient rooms when Patient #68 entered. - After Patient #68’s interview a team meeting was held, and “interim remedies” were discussed for the patients. Patient #67 had already been discharged and the decision was made to move Patient #68 to a different unit for closer observation. The topic of patients’ guardians came up and staff were advised “to follow their policies and/or standard procedures that covered providing notifications to guardians.” - On 03/28/24, a copy of the report was sent to Staff MMMM, Title IX Coordinator, and Staff CC Risk/Regulatory Affairs Manager for review and further action. - On 04/02/24 at 3:59 PM, the determination was made that the case was “dismissed pursuant to Title IX policies because the allegations do not describe a possible violation of the Title IX and circumstances prevented the gathering evidence sufficient to reach a determination as to whether the respondent is responsible for a possible policy violation.” - The matter was referred back to Risk & Regulatory Affairs. Although requested the Risk & Regulatory Affairs department failed to provide evidence that Patient #67 was interviewed, that either patient’s parent/guardian were notified or that education was provided to hospital staff after the incident. During an interview on at 10/30/24 at 10:25 AM, Staff EEEE, LMSW, stated that when there was an allegation, or sexual offense of some kind, a Title IX request and an incident form would be completed. The only role that hospital staff played would be separating the patients, notifying the parent or guardian and making a note regarding the incident in the patient’s nursing progress notes. During an interview on at 10/31/24 at 1:10 PM, Staff MMMM, Title IX Coordinator, stated that if there was an allegation of abuse, security had a team that would investigate. Any abuse or neglect allegation was potentially a Title IX allegation as well. Security would conduct the investigations and report their findings to both the Title IX department and the hospital’s Risk/Regulatory department. Title IX standards were different than the hospital’s regulatory standards. If an allegation of abuse had a sexual misconduct component the Title IX investigators would investigate and make a determination. “If the determination was made that an allegation did not meet Title IX standards, that would not mean anything as to whether or not there was abuse or neglect related to a hospital patient. The Title IX team would not have the authority to make that determination, which is why the Risk & Regulatory department should be doing their own parallel investigation. This was how the process used to be, but recently there had not been two different parallel decision-making processes.” During an interview on at 10/31/24 at 2:00 PM, Staff IIIII, Hospital Security Captain, stated that the hospital was required to follow Title IX standards as they were a University that accepted federal funds. The hospital had a Title IX Coordinator who oversaw and understood all of the regulations. When there was an allegation, his team would be asked to go and find “the facts”. Security would notify the Title IX Coordination as well as Risk and Regulatory and let them know the allegation they received. They would then review video, speak with staff members and patients involved to find all the details of that event. They would then report their findings to the Title IX Coordinator who would make a determination as to whether or not the allegation fell under Title IX standards. If it did not, the investigation would be referred back to Risk and Regulatory. Any further involvement from the security department would only be if Risk and Regulatory requested their assistance. For this particular investigation, Patient #67 was not interviewed as security does not have any authority outside of the organization and the patient had already discharged. The hospital should have policies for investigative processes and notification of parents or guardians and the hospital staff would need to follow those policies. During an interview on at 10/31/24 at 3:03 PM, Staff CC, Risk/Regulatory Affairs Manager, stated that typically the Risk and Regulatory department started an abuse and neglect investigation regardless of the Title IX investigation/outcome. This allegation was sent to Title IX for investigation and Risk/Regulatory made a behavioral plan for the patient. “After getting it back from Title IX we assumed they would take care of it, so I take full responsibility for this one not getting done.” Going forward there would be a new process to ensure that if an allegation did not fall under Title IX, that on the hospital’s end there would be a full and complete investigation, including interviewing all parties involved, notifying all parents, and guardian if that applied, and then determining whether the allegation was substantiated or unsubstantiated.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 41865 Based on observation, interview and policy review, the hospital failed to safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) of patients. This failure had the potential to affect the confidentiality of all patients in the hospital. Findings included: Review of the hospital’s policy title, “Medical Record Service - Confidentiality of Medical Record Information - Policy,” approved 05/14/24, showed patient protected health information (PHI) shall be maintained in a confidential and controlled environment, regardless of whether it is stored in paper or electronic form. Observation on 10/29/24 at 10:25 AM, on the Progressive Care Unit (PCU) of Hospital B, showed a manila folder, on the ledge of the nurse’s station, with papers turned sideways and facing outward. On the paper was the list of room numbers and patient first and last names on that unit. The patient information was visible to anyone that would approach the nurse’s station. Observation on 10/29/24 at 11:13 AM, on the Medical/Surgical Unit of Hospital B, showed a computer workstation on wheels that was left unattended in the hallway. The patient information was visible to anyone walking in the hallway. During an interview on 10/29/24 at 2:55 PM, Staff TTT, Director of Nursing at Hospital B, stated that she expected staff members to shut down their computer screens when they walked away from their workstations to protect patient’s privacy. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected all staff to protect PHI. 46554”

“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 ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a licensed practitioner (LP) responsible for the care of the patient for five patients (#55, #66, #70, #71 and #79) of six restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. Findings included: Review of the hospital’s policy titled, “Patient Safety - Nonviolent Behavior Restraint Policy,” approved 01/17/24, showed an order must be obtained from the LP before a restraint is applied. If emergency application of a restraint is required, a registered nurse (RN) may apply, or delegate application to permissible professionals and then shall request an order immediately. Review of Patient #55’s medical record dated 09/18/24, showed: - On 09/18/24 at 6:00 PM, nonviolent restraints were applied. - At 8:00 PM, an order was written for nonviolent restraints, two hours after the restraints were applied. - On 09/19/24 at 4:00 AM, an order was written to continue nonviolent restraints. - On 09/22/24 at 4:00 AM, an order was written to continue nonviolent restraints. - Patient #55 remained in nonviolent restraints on 09/20/24 and 09/21/24 without a restraint order. Review of Patient #66’s medical record dated 10/19/24, showed: - On 10/20/24 at 6:00 PM, an order was written to initiate nonviolent restraints. - On 10/22/24 at 4:00 AM, an order was written to continue nonviolent restraints. - Patient #66 remained in restraints on 10/21/24 without a written restraint order. Review of Patient #70’s medical record dated 09/26/24, showed: - On 09/27/24 at 8:00 PM, nonviolent restraints were applied. - On 09/28/24 at 12:00 AM, an order was written for nonviolent restraints, four hours after the restraints were applied. - On 09/29/24 at 12:00 AM, an order was written to continue nonviolent restraints. - On 10/01/24 at 12:00 AM, an order was written to continue nonviolent restraints. - Patient #70 remained in restraints on 09/30/24 without a restraint order. Review of Patient #71’s medical record dated 10/06/24, showed: On 10/11/24 at 8:00 PM, nonviolent restraints were applied. At 10:00 PM, an order was written for nonviolent restraints, two hours after the restraints were applied. Review of Patient #79’s medical record dated 10/06/24, showed on 04/22/24 at 8:00 PM, violent restraints were applied. At 10:44 PM, an order was written to initiate violent restraints, two hours and 44 minutes after the restraints were applied. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected all restraints had a provider order written within one hour of the restraint application. Delays in obtaining restraint orders did not meet her expectations.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for four discharged patients (#55, #66, #70, and #79) of six restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. Findings included: Review of the hospital’s policy titled, “Patient Safety - Nonviolent Behavior Restraint Policy,” approved 01/17/24, showed the nurse is to observe and document on the patient at least every two hours. Review of Patient #55’s medical record dated 09/18/24, showed on 09/23/24 at 4:01 AM, a restraint observation was documented. At 8:00 AM, a restraint observation was documented. There were three hours and 59 minutes between restraint observations. Review of Patient #66’s medical record dated 10/19/24, showed on 10/23/24 at 6:00 AM, a restraint observation was documented. At 8:46 AM, a restraint observation was documented. There were two hours and 46 minutes between restraint observations. Review of Patient #70’s medical record dated 09/26/24, showed on 10/03/24 at 6:00 PM, a restraint observation was documented. At 8:58 PM, a restraint observation was documented. There were two hours and 58 minutes between restraint observations. Review of Patient #79’s medical record dated 10/06/24, showed on 04/21/24 at 5:00 AM, a violent restraint observation was documented. At 7:00 AM, a violent restraint observation was documented. There were two hours between violent restraint observations. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected nursing observations were completed and documented as required by the hospital’s policy.”

“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 observation, interview, record review and policy review, the hospital failed to: - Ensure proper insertion of an ultrasound (a test that uses sound waves to create images of structures within the body) guided intravenous (IV, in the vein) catheter for one patient (#78) of one discharged patient reviewed; - Maintain an effective wound care prevention program that prevented new or worsening wounds from occurring for one patient (#78) of one discharged patient reviewed; and - Ensure proper hygiene policy was implemented for one (#78) of one discharged patient reviewed. Findings included: 1. Review of Patient #78’s medical record, dated 11/06/23 through 11/18/23, showed: - On 11/06/23, she was a 90-year-old who was admitted for an obstructed left arteriovenous fistula (AVF, an abnormal connection between an artery and a vein). - On 11/07/23, a right antecubital (AC, inner elbow) IV was inserted via ultrasound guidance by Staff DDDDD, Registered Nurse (RN). - On 11/11/23, a nursing note stated that she had reported that her IV was painful. The RN removed the IV and it bled profusely. After 15 minutes of holding pressure at the insertion site, the RN called a physician to the bedside who then consulted vascular surgery (surgery that can be used to treat a wide range of heart and blood flow issues). The vascular team placed a pressure dressing and the bleeding subsided. - A second nursing note documented that a type and screen (a laboratory test that identifies a person’s blood type and screens for unexpected antibodies in the blood that may react with transfused blood products) was obtained in case she needed blood related to the bleeding at the IV insertion site. - A physician’s note documented that they received a page at 4:39 PM after an IV was removed due to pain and continued to bleed. Bleeding was contained while pressure was held but pulsated when released. Vascular surgery was then consulted. A computed tomography angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of substance to produce detailed images of blood vessels and tissues in the body) was obtained to rule out a thrombus (blood clot formation in a deep vein in an arm or leg). Anticoagulants (drugs used to prevent blood clots) were then held for two days. Informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained in case she required a blood transfusion (to administer blood into a vein). - A vascular surgery note documented that an IV had been placed in the right brachial artery (the major blood vessel supplying blood to your upper arm, elbow, forearm and hand). - On 11/12/23, a vascular surgery note documented that she had some associated numbness and tingling. A CTA showed no arterial injury or hematoma (collection of blood below the surface of the skin). During an interview on 11/04/24 at 4:43 PM, Staff CCCCC, Vascular Surgeon, stated that he had been consulted to assess Patient #78 for a vascular injury after the removal of a line. He stated that typically this would be related to an incorrectly placed arterial line (thin, flexible tube placed into an artery). He was not aware that line was an ultrasound guided peripheral IV. During an interview on 10/31/24 at 9:11 AM, Staff UUUU, Registered Nurse (RN), stated that she had been called into a room by Patient #78’s primary RN. She observed that the patient was bleeding and proceeded to hold pressure so the primary RN could call the physician to the bedside. Vascular surgery was consulted and came to the bedside. She was not aware the IV had been inserted in an artery but did recall that the primary RN had been “squirted in the face” by the blood. During an interview on 10/29/24 at 11:36 AM, Staff AAAAA, RN, stated that she did not insert this IV, but she was on the vascular access team (VAT) and was qualified to insert such IVs. If an IV had been inserted in an artery she would expect to observe pulsatile blood flow (the rhythmic, intermittent movement of blood through blood vessels) and it would be harder to stop any associated bleeding. Although requested Staff DDDDD, RN, who placed the IV was not available for interview. 2. Review of the hospital’s document titled, “Skin and Wound Care - Skin Impairment Potential for Adolescent/Adult - Clinical Guidelines,” dated 03/13/23, showed: - On admission and each shift a nurse should assess the color and condition of all bony prominences (a part of the body where a bone is close to the skin’s surface) and for moisture and incontinence (inability to control urination or bowel movements). - Mobility was assessed each shift. If the patient was chair bound (unable to get out of a chair), and a moderate or high-risk, sitting time should be limited to no more than one to two hours. Patients who were unable to reposition themselves would receive assistance, and those who were cognitively impaired (the loss of intellectual abilities such as: memory loss and reasoning that interfere with daily living) would receive verbal cues with observation by staff. Bed bound patients would be turned every two hours. - Interventions was based on a Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers) subscale score. The subcategories were mobility, activity, sensory perception, moisture, friction and shear and nutrition. If a subscale score was below four in mobility, sensory perception or friction and shear they would require a turn schedule or assistive device to prevent injury. Review of the hospital’s undated document titled, “Hospital Acquired Pressure Injury Prevention Bundle,” showed: - The bundle applied to all patients. - The patient should be turned and repositioned at least every two hours. - A Braden Scale score should be calculated every shift and as needed for changes with the patient. Review of the hospital’s document titled, “Skin and Wound Care - Four Eyes in Four Hours - Guideline,” dated 08/15/23, showed: - The four eyes in four hours skin assessment was used to identify skin issues within the first four hours of admission. - Two staff members were to assess a patient’s skin for impairments within four hours of arrival to their unit. - Staff were to look at the patient’s skin from head to toe and confirm the assessment and charting were correct. Review of Patient #78’s undated document titled, “Admission Skin Assessment - Four Eyes in Four Hours,” showed: - A skin assessment was verified by a second staff member. - The sacrum (triangular shaped bone above the tailbone) was assessed and intact. - Imaging did not reveal tissue injury presence. Review of Patient #78’s medical record, dated 10/01/23 through 10/13/23, showed: - On 10/01/23, she was admitted for abdominal pain. - On 10/03/23 at 2:27 AM, a nursing care plan for “skin/wound high risk” was initiated. The outcome was for the patient to remain free of skin breakdown or further impairment. The expectation was noted to be met. - Her care plan interventions included “turn schedule established” from 10/11/23 at 9:51 AM through 10/13/23 at 9:00 AM; “education regarding pressure injury prevention” from 10/03/23 at 7:54 AM; and “disposable incontinence pad in use” from 10/03/23 at 9:00 PM through 10/13/23 at 9:00 AM. - Her total Braden Scale score was documented as 18 or below from 10/02/23 at 10:00 PM through 10/13/23 at 8:00 AM. - There were 35 instances in which no repositioning was charted at the ordered every two-hour interval. There were eight instances where the same position was charted consecutively for four or more hours. There were three instances where a refusal to turn was charted. - On 10/03/23, 10/09/23, 10/10/23 and 10/12/23, physical therapy notes documented that she required assistance for all bed mobility, transfers and ambulation. - On 10/06/23 and 10/12/23, a nutrition note documented that skin was noted to be intact per nursing. She had been identified as moderately malnourished with mild muscle wasting and protruding clavicles. - On 10/13/23 at 3:50 PM, she was discharged to Facility B. Review of Patient #78’s medical record from Facility B, dated 10/13/23, showed: - On 10/13/23 at 6:22 PM, she was admitted to the facility for rehabilitation (the action of restoring someone to health or normal life through training and therapy). - Her Braden Scale subcategory total for sensory perception, mobility and friction and shear all scored less than four. - Her skin assessment showed a Stage two pressure injury (a shallow opening in the skin with red or pink tissue or may present as a fluid filled blister) was present on her intergluteal cleft (the groove that runs between the buttocks, from the sacrum to the perineum) on admission. It measured 2.9 centimeters (cm) by 0.7 cm. Review of Patient #78’s medical record, dated 10/24/23 through 10/31/23, showed: - On 10/24/23, she was admitted for uncontrolled pain. - On 10/25/23 at 1:08 AM, a skin team consult was submitted for a pressure injury. - On 10/25/23 at 5:17 PM, a right gluteal stage three pressure injury was identified. It measured 4.0 cm by 3.0 cm by 0.1 cm. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected staff to turn patients and complete thorough skin assessments. During an interview on 10/30/24 at 12:31 PM, Staff ZZZZ, Inpatient Nursing Director, stated that she expected staff to follow protocol and turn patients every two hours. The gaps in repositioning could have contributed to the skin breakdown Patient #78 experienced. During a telephone interview on 11/04/24 at 10:30 AM, Staff BBBBB, RN, stated that if a patient’s Braden Scale total score was 18 or less the expectation was to ensure they were turned every two hours. Patient care technicians shared that responsibility, but ultimately the nurse was responsible. If a patient were to refuse a turn, she had many ways to document that. She felt the expectations on her unit were very high and turns may not have been one of her priorities. During an interview on 10/30/24 at 2:54 PM, Staff WWWW, RN, stated that she would consider Patient #78 to be at high risk of developing a pressure injury. The wound did not look new when she observed it during her second admission. She would expect nursing staff to thoroughly assess for skin injuries. During an interview on 10/31/24 at 10:37 AM, Staff SSSS, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), stated that Patient #78 was at a high risk for developing pressure injuries. She would expect staff to implement preventative measures such as frequent turns and thorough skin assessments. During an interview on 10/31/24 at 12:40 PM, Staff OOOO, Regulatory Affairs, stated that Patient #78 had a Braden Scale subcategory score of less than four for mobility, sensory perception or friction and shear for all total scores of 18 or less. This indicated that nursing staff should have turned her at least every two hours. The document titled, “Admission Skin Assessment - Four Eyes in Four Hours,” was the only assessment she could find for Patient #78’s first admission and it was completed on 10/01/23. 3. Review of the hospital’s document titled, “Skin and Wound Care - Skin Impairment Potential for Adolescent/Adult - Clinical Guidelines,” dated 03/13/23, showed elderly and/or patients with fragile skin should receive a daily bath. Review of Patient #78’s medical record, dated 10/01/23 through 10/13/23, showed she was bathed on three of 12 days. There were no documented instances of a refusal to bathe. Review of Patient #78’s medical record, dated 10/24/23 through 10/31/23, showed she was bathed on five of seven days, one of which was noted to have been completed by her family. She refused a bath once. Review of Patient #78’s medical record, dated 11/06/23 through 11/18/23, showed she was bathed on eight of 12 days. She refused a bath on one day. Review of Patient #78’s medical record, dated 11/25/23 through 12/29/23, showed she was bathed on 21 of 34 days. There were no documented instances of a refusal to bathe. During an interview on 10/30/24 at 12:31 PM, Staff ZZZZ, Inpatient Nursing Director, stated that she expected staff to offer every patient assistance with bathing daily. If a patient were to refuse it should be documented. 50321”

“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 interview, record review and policy review, the hospital failed to ensure that staff followed the hospital policies when they failed to perform pain reassessments in a timely manner after pain medication administration for two patients (#78 and #28) of two patients observed. Findings include: Review of the hospital’s document titled, “Pain Management - Policy,” dated 10/09/23, showed: - Pain would be assessed and managed by screening patients for the presence and absence of pain, assessing and reassessing for pain and measuring pain levels by using standardized tools. - Pain would be reassessed before and after each as needed pharmacologic intervention. If a pain medication was scheduled routinely a pain assessment would be completed with vital signs (VS, measurements of the body’s most basic functions). - A pain assessment would be documented prior to and after each as needed medication administration. Intravenous (IV, in the vein) medications required an assessment within 30 minutes of administration, and oral or intramuscular (IM, within the muscle) required an assessment within 60 minutes after administration. Review of Patient #78’s medical record, dated 10/01/23 through 10/31/23, showed: - On 10/01/23, IV pain medications were administered at 9:00 AM and 10:29 AM. A pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was not completed within 30 minutes after administration. - On 10/02/23, an IV pain medication was administered at 9:17 AM. A pain scale assessment was not completed within 30 minutes after administration. - On 10/12/23, an IV pain medication was administered at 9:18 PM. A pain scale assessment was not completed within 30 minutes after administration. Review of Patient #78’s medical record, dated 10/24/23 through 10/31/23, showed: - On 10/25/23, an oral pain medication was administered at 8:53 AM. A pain scale assessment was not completed within 60 minutes after administration. A pain scale assessment score of 0 was recorded before administration of pain medication at 8:53 AM - On 10/26/23, an oral pain medication was administered at 5:18 PM. A pain scale assessment was not completed within 60 minutes after administration. - On 10/30/23, an oral pain medication was administered at 11:26 PM. A pain scale assessment was not completed within 60 minutes after administration. Review of Patient #78’s medical record, dated 11/06/23 through 11/18/23, showed: - On 11/09/23, oral pain medications were administered at 9:57 AM and 8:24 PM. A pain scale assessment was not completed between 3:44 PM and 11/10/23 at 9:00 PM. - On 11/13/23, an oral pain medication was administered at 1:48 AM. A pain scale assessment was not completed within 60 minutes after administration. - On 11/15/23, an oral pain medication was administered at 11:01 PM. A pain scale assessment was not completed within 60 minutes after administration. Review of Patient #78’s medical record, dated 11/25/23 through 12/29/23, showed: - On 11/30/23, an oral pain medication was administered at 1:39 AM. A pain scale assessment was not completed within 60 minutes after administration. - On 12/02/23, an oral pain medication was administered at 11:52 PM. A pain scale assessment was not completed within 60 minutes after administration. - On 12/04/23, an oral pain medication was administered at 3:51 AM. A pain scale assessment was not completed within 60 minutes after administration. - On 12/29/23, oral pain medications were administered at 12:49 AM and 3:33 AM. A pain scale assessment was not completed within 60 minutes after administrations. Review of Patient #28’s medical record, dated 10/27/24, showed on 10/28/24 at 6:49 AM, oral pain medication was administered. A pain scale assessment was not completed within 60 minutes after administration. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected staff to follow the pain assessment and reassessment policy. During an interview on 10/29/24 at 11:00 AM, Staff FF, Women’s Services Manager, stated that a pain reassessment was required within one hour of oral pain medication administration. During an interview on 10/31/24 at 9:11 AM, Staff UUUU, Registered Nurse (RN), stated that pain assessments should be completed with vital signs and before administration of pain medication. Vital signs were scheduled every four hours for patients, typically. Pain should be reassessed within 30 minutes if a medication was given IV and within 60 minutes if given orally. 50321”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 49404 Based on observation, interview and policy review, the hospital failed to ensure safe patient monitoring and infusion rate for one patient (#73) of three patients who received a blood transfusion (to administer blood into a vein) reviewed. Findings included: Review of the hospital’s policy titled, “Blood Product Transfusion,” dated 05/09/22, showed: - Vital signs (VS, measurements of the body’s most basic functions) were to be recorded prior to the transfusion, 15 minutes after the transfusion started and at completion. - Blood transfusions were to start at a rate of approximately 2 milliliters (ml) per minute (120 ml per hour) for the first 15 minutes. - Staff were to remain with or able to closely observe the patient for the first 15 minutes of the infusion to observe for adverse reactions. Review of Patient #73’s medical record, dated 10/30/24, showed a blood transfusion started at 12:15 PM and VS were recorded at that time. VS were next recorded at 2:26 PM when the transfusion ended. Observation on 10/30/24 showed Staff ZZZ, Registered Nurse (RN), obtain VS at 12:15 PM and started the blood transfusion for Patient #73 at 12:20 PM. He obtained VS at 12:30 PM, then left the patient’s room. The transfusion was initiated at a rate of 175 ml per hour. During an interview on 10/31/24 at 2:25 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected blood transfusion rates, patient observation and VS monitoring should follow hospital policy for all patient receiving blood transfusions.”

“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: 46554 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) and glove changes when providing care for 15 patients (#3, #4, #5, #6, #27, #28, #35, #36, #40, #47, #52, #62, #63, #72 and #73) of 38 patients observed; - Label intravenous (IV, in the vein) sites and tubing for nine (#1, #3, #4, #29, #31, #47, #50, #62 and #63) patients of 28 patients observed; - Follow asepsis technique for a sterile (completely clean and free from germs) procedure for one patient (#27) of one sterile procedure observed; - Prepare a clean work surface prior to performing patient care for 10 patients (#3, #4, #7, #25, #26, #27, #35, #40, #52 and #72) of 14 patients observed; - Scrub the rubber stopper of an injectable medication vial for two patients (#3 and #27) of 8 patients observed; - Remove expired food in five departments of 29 departments observed; - Remove expired supplies on five units of 26 units observed; - Remove wet blankets/towels from under the sink/counter in two patient nutrition rooms of 17 patient nutrition rooms observed; - Discard one used disposable gown and three dirty towels in the decontamination room of Sterile Processing; - Laminate paper hung on walls in patient care areas to create a cleanable surface on six units of six units observed; - Clean a microwave and refrigerator in two patient nutrition rooms of 17 patient nutrition rooms observed; - Remove a staff members personal item from a food dry storage area in one kitchen of three kitchens observed; and - Follow their Infection Prevention Plan to maintain a sanitary environment. Findings included: 1. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, directed staff to: - Perform hand hygiene before and after any patient contact, prior to applying gloves and after glove use and after touching beds or bedside objects (patient equipment, computers, handrails, nightstands, phones, etc.); - Perform hand hygiene before performing a clean or invasive procedure, after handling body fluid, after touching the patient, environment, or objects involved in the patients’ care, after removing gloves and between glove changes. - Perform frequent hand hygiene. - Gloves shall be worn as an additional measure, not as substitute for hand hygiene. - Wear non-sterile, disposable, single-use gloves for direct contact with patient’s mucous membranes, blood, body fluids, moist body substances and non- intact skin. - Wear gloves for handling potentially infectious materials or in contact with contaminated items and/or surfaces. - Standard precautions are used for all patient care. Provides a consistent approach to managing patient body substances to protect healthcare providers from infection and prevention to prevent the spread of infection from patient to patient. Review of the hospital’s document titled, “Hand Hygiene Compliance,” dated 08/04/24 through 10/26/24, showed hand hygiene compliance ranged from 88.6 percent to 91.2 percent. Observation on 10/28/24 at 2:00 PM, of the Medical Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Staff C, RN, failed to perform hand hygiene between glove changes in Patient #5’s room. Staff C failed to change gloves and perform hand hygiene when she touched the patient then touched the IV tubing, bag and pump and then administered an IV medication. Observation on 10/28/24 at 2:10 PM, of the Surgical unit, showed Staff F, RN, failed to perform hand hygiene prior to entering Patient #3’s room and between glove changes. Staff F failed to change gloves and perform hand hygiene when she touched the patient then touched the keyboard and then administered a subcutaneous (under the skin) medication. Observation on 10/28/24 at 2:29 PM, of the ICU, showed Staff D, RN, failed to perform hand hygiene between glove changes in Patient #6’s room. Staff D failed to perform hand hygiene when she donned three pairs of clean gloves layered over each other to provide personal care following a bowel movement, she then removed each layer of gloves with each patient touch. She then failed to perform hand hygiene prior to reaching into the clean glove box and donning additional clean gloves and completing personal care to the patient. She touched the patient with gloved hands and entered a clean drawer with clean supplies without removing the gloves or performing hand hygiene. Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, failed to perform hand hygiene prior to donning gloves. Staff H failed to change gloves and perform hand hygiene when she picked up trash from the floor then retrieved supplies from a cart and placed a dressing on the Patient #4’s injection site. Observation on 10/29/24 at 10:00 AM, of the Progressive Care Unit (PCU) at Hospital B, showed Staff VV, RN, failed to perform hand hygiene before donning gloves when he provided care to Patient #40. Observation on 10/29/24 at 10:35 AM, of the nursery unit, showed Staff GG, Pediatric Resident (doctor in training), failed to perform hand hygiene prior to donning and removing gloves when she provided care to Patient #27. Observation on 10/29/24 at 10:50 AM, of the post-partum unit (hospital unit where healthy mothers and babies are transferred after delivery on an inpatient labor, delivery, and recovery unit where they stay until they are discharged), showed Staff FF, Women’s Services Manager, failed to perform hand hygiene prior to entering Patient #28’s room. Observation on 10/29/24 at 10:57 AM, of the Surgical unit at Hospital B, showed Staff XXX, patient care technician (PCT), failed to perform hand hygiene while performing Patient #62’s bedside blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health) testing. Staff XXX failed to change gloves and perform hand hygiene when she touched the patient to collect the patient’s vital signs, then touched the blood glucose tester to insert the testing strip. She then collected the fingertip blood sample. Observation on 10/29/24 at 11:01 AM, of the Integrated Medicine Unit, showed Staff YY, RN, failed perform hand hygiene before donning gloves, and proceeded to touch the patient scanner without a glove change when she provided care to Patient #36. Observation on 10/29/24 at 11:09 AM, of the Surgical unit at Hospital B, showed Staff XXX, patient care technician (PCT), failed to perform hand hygiene while performing Patient #63’s bedside blood glucose testing. Staff XXX failed to change gloves and perform hand hygiene when she touched the patient to collect the patient’s vital signs, then touched the blood glucose tester to insert the testing strip. She then collected the fingertip blood sample. Observation on 10/29/24 at 11:17 AM, of the Integrated Medicine Unit, showed Staff ZZ, RN, failed to perform hand hygiene before donning gloves when she provided care to Patient #35. Observation on 10/29/24 at 3:20 PM, of Hospital C, showed Staff MMM, Patient Care Technician, failed to perform hand hygiene prior to entering Patient #52’s room and before donning and after removing gloves. Staff LLL, failed to perform hand hygiene prior to entering Patient #52’s room. Observation on 10/29/24 at 12:00 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to perform hand hygiene before donning and after removing gloves when performing wound care for Patient #72. Observation on 10/29/25 at 12:10 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to perform hand hygiene before donning gloves and after removing gloves when providing care to Patient #73. Observation on 10/29/24 at 3:20 PM, of Hospital B, showed Staff GGG, RN, failed to apply gloves prior to priming tubing for a blood transfusion (to administer blood into a vein). Staff GGG also failed to perform hand hygiene between gloves changes four separate times when moving from a dirty area to a clean area when providing care to Patient #47. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated she expected staff to follow the hand hygiene policy. Staff were to change gloves and perform hand hygiene when moving from a dirty area to a clean area. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she expected staff to perform hand hygiene before entering a patient’s room, after touching a patient, when moving from a dirty area to a clean area and between glove changes. The patient environment was considered dirty. She expected clean hands when removing supplies from the patient’s supply carts. Triple gloving was not acceptable. 2. Review of the hospital’s policy titled, “Vascular Access (IV) - Clinical Guidelines” dated 08/20/24, showed that all IVs and lines should be labeled with the date and time they were changed. Observation on 10/28/24 at 11:18 AM, of Hospital C, showed Patient #50’s IV insertion site was not labeled with a date or time. Observation on 10/28/24 at 2:05 PM, of the Surgical Unit, showed Patient #1’s IV tubing was not labeled with a date or time. The IV tubing was looped and connecting to the side port. Observation on 10/28/24 at 2:10 PM, of the Surgical Unit, showed Patient #3’s IV insertion site was not labeled with a date or time. Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed two of Patient #4’s IV tubing were not labeled with a date or time. Observation on 10/29/24 at 10:35 AM, of Hospital C, showed Patient #47’s four different sets of IV tubing were not labeled with a date or time. Observation on 10/29/24 at 10:57 AM, of the Surgical Unit, showed Patient #62’s IV insertion site was not labeled with a date or time. Observation on 10/29/24 at 11:09 AM, of the Surgical Unit, showed Patient #63’s IV insertion site was not labeled with a date or time. Observation on 10/29/24 at 11:18 AM, of the Labor and Delivery Unit, showed Patient #29’s IV insertion site and two IV tubings were not labeled with a date or time. Observation on 10/29/24 at 1:00 PM, of the Cardiovascular Unit, showed Patient #31’s IV insertion site was not labeled with a date or time. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected IV tubing and sites to be labeled according to the hospital’ policy. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she expected all IV sites and tubing to labeled according to the hospital’s policy. She was not surprised the IV tubing and sites were not labeled. 3. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed: - Critical items are defined as items which enter sterile tissue, or the vascular system, and must be sterile. - If sterility is compromised prior to use, the item must be re-sterilized or discarded if it is a single use item. - If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible. Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Resident, placed a dirty diaper on the counter next to surgical supplies. She opened and donned sterile gloves next to the dirty diaper prior to performing a circumcision on Patient #27. Observation on 10/29/24 at 10:40 AM, of the Nursery Unit, showed Staff HH, Physician, placed an unopened instrument package on the sterile field. Staff GG, Pediatric Resident Physician opened the instrument package and failed to perform hand hygiene and a sterile glove change prior to completing a circumcision on Patient #27. During an interview on 10/29/24 at 10:35 AM, Staff HH, Physician, stated a circumcision was “not the most sterile procedure, but we did our best to keep it sterile.” During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected surgical instruments were not dropped on the sterile field in their packages. She expected surgical instruments to be opened using a sterile technique and diapers were to be discarded, not placed on the counter next to patient care supplies. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated a circumcision was a “clean procedure.” It was not acceptable to drop a dirty package on the sterile field. She expected a sterile glove change after the instrument package was opened prior to returning to the procedure. Clean and dirty items were to be separated. The dirty diaper was to be discarded, not placed on the counter next to the circumcision procedure supplies. 4. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed: - If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible. - Clean and disinfect patient care equipment and environmental surfaces. - Draw up all medications in a clean medication preparation area. - Prepare medications in areas physically separated from those with potential blood/body fluids contamination. - Use barriers to protect surfaces from blood contamination. Observation on 10/28/24 at 2:10 PM, of the Surgical Unit showed Staff F, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #3’s counter. Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #4’s counter. Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Resident, failed to provide a clean barrier for medication administration when she placed the medication on the treatment room counter for Patient #27. Observation on 10/29/24 at 10:00 AM, of the Family Medicine Unit, showed Staff VV, RN, failed to provide a clean barrier for medication administration when he prepared an IV medication on Patient #40’s computer workstation. Observation on 10/29/24 at 11:17 AM, of the Integrated Medicine Unit, showed Staff ZZ, RN, failed to provide a clean barrier for medication administration when he placed a medication on Patient #35’s counter. Observation on 10/29/24 at 11:35 AM, of Hospital C, showed Staff K, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #7’s blanket in his wheelchair. Observation on 10/29/24 at 3:10 AM, of Hospital C, showed Staff MMM, Patient Care Technician (PCT), failed to provide a clean barrier for blood sugar supplies for Patient #52. Observation on 10/29/24 at 11:10 AM, of the Post Anesthesia Care Unit (PACU), showed Staff Y, RN, failed to provide a clean barrier for patient supplies when removing an arterial line from Patient #25. Observation on 10/29/24 at 11:55 AM, of the Emergency Department (ED), showed Staff BB, RN, filed to provide a clean barrier for patient supplies when starting an IV on Patient #26. Observation on 10/30/24 at 12:00 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to provide a clean barrier for patient supplies when providing wound care for Patient #72. Observation on 10/29/24 at 12:10 PM, of the Medicine Unit, showed Staff ZZZZ, RN, grasped the sterile end of blood tubing with his gloved hand while providing care to Patient #72. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected a clean surface and/or barrier for patient care supplies and medications. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, she expected a clean surface and/or barrier was in place for patient care supplies and injectable medication administrations. It was unacceptable to place patient care supplies and/or medications on the patient blanket. 5. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, directed staff to disinfect medication vial by rubbing the diaphragm with alcohol. Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Pediatric Resident Physician, failed to scrub the rubber stopper of an injectable medication vial prior to withdrawing the medication for administration to Patient #27. Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, wiped Patient #3’s injection site with a used alcohol wipe that was on the patient’s blanket. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected staff to follow the policy for medication administration. 6. Review of the hospital’s policy titled, “Dietary Services - Dining & Nutrition - Food Receiving Storage and Labeling - Guideline,” dated 12/08/23, showed: - All items shall be stored in sealed, original containers or in Dining and Nutrition Services (DNS) approved containers with tight covers that have been labeled with content and dated. - All food items in refrigerators and freezers are properly dated, labeled and covered. - Canned food items and juices are not stored in open cans. After opening, the food is transferred to non-corrosive containers with tight fitting lids, dated and labeled. Review of the hospital’s policy titled, “Dietary Services - Dining & Nutrition - Floor Stock - Guideline” dated 06/12/23, showed the DNS assigned to an inpatient unit will be responsible for discarding expired food and beverage items. Observation on 10/28/24 at 2:35 PM, of the Surgical Unit, showed single serving cracker packages without expiration dates. Observation on 10/28/24 at 2:40 PM, of the Surgical ICU patient nutrition room, showed one bottle of multi-serving instant coffee grounds without an open date. Observation on 10/29/24 at 9:55 AM, of the Post-Partum Unit patient nutrition room, showed single serving packages of pepper, salt, cheese slices and cheese sticks without expiration dates. A nipple therapy pack, patient care supply, was in the nutrition freezer. Observation on 10/29/24 at 2:45 PM, of Hospital C’s patient nutrition room number one, showed two multi-serving creamer bottles without open dates. Packages of hot cocoa mix, sweetener, creamer, peanut butter, salt, pepper, honey, syrup, jelly, ketchup, cream of wheat, mayonnaise, broth, crackers, cheese sticks, cheese slice and butter without expiration dates. Observation on 10/29/24 at 3:10 PM, of Hospital C’s patient nutrition room number two, showed packages of creamer, tea bags, sweetener, mustard, honey, mayonnaise, ketchup, lemon juice, peanut butter, sugar, syrup, hot cocoa, oatmeal, butter, cheese sticks and cheese slices without expiration dates. Observation on 10/29/24 at 3:50 PM, of Hospital C’s kitchen, showed packages of creamer, jelly, peanut butter, mayonnaise, salad dressing, syrup, hot sauce, ketchup, mustard, croutons, salt, sweetener, pepper, hot cocoa and oatmeal without expiration dates. Single serve containers of granola, brown sugar, cinnamon and oil-vinegar without open or expiration dates. Observation on 10/29/24 at 4:00 PM, of Hospital C’s kitchen, showed one container of seasoning salt with an expiration date of 08/29/24. A second expiration sticker was placed on the container with an expiration date of 08/15/25. One can of vegetable spray, one box of salt, one bottle of soy sauce, one box of corn starch, one bottle of oyster sauce, one bottle of vanilla extract, one bag of seasoned salt, one bag of flour, two bags of brown sugar, one bag of pancake mix, on package of dry pasta, one bag of gravy mix and one bag of potato pearls without open or expiration dates. Observation on 10/29/24 at 4:00 PM, of Hospital C’s kitchen refrigerator, showed one container of whipped topping, six bags of pizza crust, 3 bags of dinner rolls, seven bags of English muffins, one jar of pickles and one bottle of salad dressing without open or expiration dates. Observation on 10/29/24 at 10:00 AM, of Hospital A’s kitchen refrigerator, showed undated grapes, raspberries, tomatoes, lettuce salads, and strawberries. Observation on 10/29/24 at 10:15 AM, of Hospital A’s kitchen freezer, showed an opened, undated bag of sausage links and an undated bag of hamburger patties. Observation on 10/29/24 at 10:35 AM, of Hospital A’s peri-op refrigerator, showed three sandwiches past their expiration dates. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected all food items to have visible expiration dates. When food items were opened, they were to be marked with open and expiration dates. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the dietary department stocked and rotated food in the patient nutrition areas. She expected all products to have expiration dates in the patient nutrition rooms and kitchens. Placing a new expiration date on an expired item was unacceptable. 7. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, directed staff to conduct period inspections of facilities and equipment which may contribute to infectious hazards. Observation on 10/28/24 at 2:30 PM, of the Pediatric (pertaining to children) ICU, showed 10 expired needle guide kits. Observation on 10/29/24 at 9:45 AM, of the PCU, showed 25 expired size six sterile gloves. Observation on 10/29/24 at 10:00 AM, of the Post-Partum Unit, showed 11 expired tubes of sterile water. One expired specimen swab, seven open cotton tipped vaginal swabs and four packages of expired sterile gloves. Observation on 10/29/24 at 2:45 PM, of Hospital C’s medication room, showed nine oral syringes not in packages and 22 expired needles. Observation on 10/29/24 at 10:55 AM, of the PACU, showed five expired IV catheters in a cart labeled “Airway Cart,” five expired blades used for intubation in a cart labeled “Intubation Cart,” and two expired sheaths in a cart labeled “Line Cart.” During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated it was every staff members responsibility to ensure expired supplies were not in patient care areas. The distribution team was responsible to rotate supply stock. Oral syringes and vaginal swabs were to be in sealed packages. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the distribution department was responsible for rotating and evaluating expiration dates for supplies. She was surprised expired supplies were in the patient care areas. 8. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed: - Only cleaning products and heavy-duty utility gloves may be stored under any sink within MUHC. - All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes. - Soiled linens that are lightly to moderately moist should be folded and/or rolled in such a way as to contain the moist area in the center of soiled linen; and - Soiled linens that are saturated with moisture should be placed in a plastic bag and tightly secured. Observation on 10/29/24 at 12:30 PM, of the Integrated Medicine Unit, showed a portable fan under a sink in the patient nutrition room. Observation on 10/29/24 at 12:49 PM, of the Cardiovascular Unit, showed a plastic basin holding a water filter under the sink in the patient nutrition room. Observation on 10/29/24 at 2:45 PM, of Hospital C’s patient nutrition room number one, showed a metal tank in a cabinet under the counter with blankets wrapped around the base of the tank. Three cases of soda were next to the tank and blankets. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected leaks to be repaired to ensure blankets and buckets were not under the counters collecting leaking water/condensation. Soda was not to be stored next to wet blankets. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated only cleaning supplies were to be stored under the sinks. It was “not good” that soda cans were in a cabinet with blankets wrapped around a tank to collect condensation. During an interview on 10/30/24 at 2:29 PM, Staff HHHH, Facilities Director, stated it was unacceptable for blankets to be in a cabinet wrapped around a tank to collect condensation. She expected the unit staff members to clean the microwaves and refrigerators. During an interview on 10/29/24 at 12:30 PM, Staff AAA, Service Line Specialist, stated it was her expectation for the area under the sink to remain clear. During an interview on 10/29/24 at 12:49 PM, Staff AAA, Service Line Specialist, stated the plastic bin had been placed in case the filter leaked. 9. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed after use, remove gown promptly and discard. All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes. Observation on 10/29/24 at 11:45 AM, of Sterile Processing, showed one used disposable gown placed on the decontamination sink, one dirty washcloth laying on the floor and two dirty washcloths on the shelf above the decontamination sink. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected disposable gowns to be discarded when removed, not left on the decontamination sink. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated disposable gowns used in the Sterile Processing Department were to be discarded when removed, not placed on the decontamination sinks. 10. Review of the undated Center for Disease Control and Prevention Best Practices for Environmental Cleaning in Healthcare Facilities Version Two showed wall surfaces should be washable. Observation on 10/29/24 at 9:55 AM, in the Post-Partum Unit, showed paper taped to the wall in the nutrition room, hallways and supply room. Observation on 10/29/24 at 10:15 AM, of the Nursery Unit, showed paper taped to the walls in the nurses’ station, treatment room and soiled utility room. Observation on 10/29/24 at 11:10 AM, of the Labor and Delivery Unit, showed paper taped to the wall in the anesthesia work area and nurses’ station. Observation on 10/29/24 at 11:30 AM, of the Neonatal Intensive Care Unit (NICU, unit for premature and ill newborns) showed paper taped to the hallway walls. Observation on 10/29/24 at 2:45 PM, of Hospital C showed paper taped to the hallway walls, two medication rooms and nutrition room number two walls. Observation on 10/29/24 at 3:50 PM, of Hospital C’s kitchen, showed paper taped to the walls. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated unlaminated paper was to be limited in patient care areas. Paper hanging on the walls was an infection prevention concern. Unlaminated paper and tape residue should not be in the areas of terminal cleaning. 11. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed items that are routinely shared shall be cleaned and disinfected. Procedures shall be established for assigning responsibility and accountability for routine cleaning. Review of the hospital’s policy titled, “Dietary Services - Dining & Nutrition - Floor Stock - Guideline” dated 06/12/23, showed the DNS assigned to an inpatient unit will be responsible for cleaning the refrigerator. Observation on 10/28/24 at 2:00 PM, of the Medical Specialties Unit, showed the refrigerators in the patient nutrition rooms on both the east and west end were dirty and appeared to have has a spill in both refrigerators that had dried. Popcorn, crackers, and visible grime were seen below the microwave on the west end. Observation on 10/29/24 at 2:45 PM, of Hospital C’s patient nutrition room number one, showed the microwave had a sticky red substance scattered on the inside. During an interview on 10/28/24 at 2:00 PM, Staff OO, RN Manager, stated he was responsible to ensure the patient nutrition rooms were clean, and he expected unit staff to clean all spills immediately. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the unit staff were responsible for cleaning the unit refrigerators and microwaves. She expected them to be clean. Environmental services cleaned the patient nutrition rooms every day. 12. Review of the hospital’s policy titled, “Dietary Services - Dining and Nutrition - Food Receiving Storage and Labeling - Guideline,” approved 12/08/23 showed: - Holding of food at optimal conditions to minimize bacterial growth until food is prepared for consumption. - Foods are stored in a manner to prevent contamination. - The storeroom is without contamination. Observation on 10/29/24 at 3:55 PM, of Hospital C’s kitchen, showed an ear pod case sitting on the shelf with spices and cooking sprays. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated ear pods were not to be stored near patient food. 13. Review of the hospital’s policy titled, “Infection Prevention and Control Program - 2024 Infection Control Manual,” approved 11/20/23, showed: - All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes; - Do not shake or place linen directly on the floor; - Soiled linens that are lightly to moderately moist should be folded and/or rolled in such a way as to contain the moist area in the center of soiled linen; and - Soiled linens that are saturated with moisture should be placed in a plastic bag and tightly secured. Observation on 10/28/24 at 2:29 PM, of the ICU, showed the foam repositioning pillow was on the floor in Patient #6’s room. Staff D, RN picked the pillow up from the floor and placed it on the ledge of the window to perform patient care. After completing care, she returned the pillow to Patient #6’s bed. Observation on 10/29/24 at 12:49 PM, of the Cardiovascular Unit, showed one bloody hand towel and one large towel on the floor under a sink in Patient #32’s room. The patient stated the towel had been present since the night before. Observation on 10/28/24 at 3:08 PM, of the Medical Specialties Unit, showed 1 sterile sponge and three sterile dressings had been stored on a ledge in the patient supply room. Observation on 10/29/24 at 9:45 AM, of the PCU, showed 26 abdominal pad dressings in a box and one purple disinfectant container stored on a vent in a patient supply room. During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected staff to ensure towels and bloody items were picked up. During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she would expect nursing staff to remove dirty or bloody linens and they should not be kept on the floor. Supplies should not be store on vents or ledges. During an interview on 10/29/24 at 9:45 AM, Staff TT, RN Manager, stated supplies should not be stored on ledges, vents, or counters. 14. Review of the hospital’s policy titled, “Environmental Services - Operating Room Terminal Clean - Guideline” dated 09/24/21, showed to completely clean and disinfect all ceilings, external wall vents, all walls, horizontal/vertical surfaces (including doors) as per wall washing instructions. Observation on 10/29/24 at 9:15 AM, of Hospital B’s Surgical Area showed Operating Rooms (OR) #5, #6, Obstetrics OR room and the surgical transport patient hallway had exposed sheet rock, paint peeling off the walls, multiple areas with adhesive residue from tape, paper logs taped on to the OR door, ceiling air vents were visibly dirty and the IV poles had visible rust present on the casters and legs. Observation on 10/29/24 at 2:00 PM, of Hospital B’s sterile processing area showed the autoclave (a strong heated container used for chemical reactions and other processes using high pressures and temperatures, e.g. steam sterilization) had discoloration and mineral build up. During an interview on 10/29/24 at 2:55 PM, Staff SSS, Infection Control Personal, stated there should not be peeling paint or exposed sheet rock in any area that is terminally cleaned and the autoclave should be cleaned regularly. He would not expect to see rust in an OR environment and the Autoclave should be cleaned to manufacture’s recommendation. During an interview on 10/31/24 at 3:32 PM, Staff LLLL, Infection Control Manager, stated there shouldn’t be paper or tape in areas that are terminally cleaned. 41865 48359 49404 50321”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44536 Based on interview, record review and policy review the hospital failed to: - Conspicuously post signs in the Labor and Delivery (L&D) Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), and information indicating whether the hospital participated in the Medicaid program (A2402); - Maintain an accurate Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) triage (process of determining the priority of a patient’s treatment based on the severity of their condition) log and failed to identify three patients (#17, #19, and #27) and incorrectly logged the disposition of one patient (#8) of eight L&D patient records reviewed. The hospital also failed to provide a complete Emergency Department (ED) log to the survey team in a timely manner. The complete ED log was provided 30 hours after requested (A2405); and - Provide stabilization treatment with an appropriate discharge including discharge instructions for follow-up care and outpatient treatment recommendations for one patient (#1) of 17 ED patient records reviewed (A2407). These failed practices had the potential to affect all patients who presented to the ED and OB for triage and treatment of EMCs. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)-Compliance,” dated 10/17/22, showed: - When an individual presented or was brought to the hospital requesting treatment of a medical or mental health condition, a physician or advanced practice provider (APP, a licensed medical professional who is not a doctor, but has specialized training to diagnose, treat, and manage many common medical conditions) provided a MSE within the capabilities of the hospital. - Patients with an EMC received examination and treatment within the capabilities of the staff and hospital to stabilize the EMC. - An EMC was a medical condition manifesting acute symptoms of sufficient severity that if immediate medical attention was not performed, the health of the person would be in serious jeopardy of a risk of serious impairment of bodily function. Special categories of EMCs included severe pain. - A patient was deemed stable when no material deterioration of their condition was likely to occur upon discharge or referral for outpatient follow-up. - Patients treated for an EMC that was resolved by treatment in the ED must have certification in the ED record by the attending physician, APP, or consulted medical specialist that the EMC no longer exists. - Discharge was defined as the release of a patient from the ED to their place of residence or other non-acute care healthcare facility. Review of hospital policy titled, “Facility Planning, Design, and Construction Signage,” dated 01/19/22, did not contain requirements or direction of EMTALA signage in triage areas. Although requested, a policy was not provided for EMTALA signage in triage areas. Review of the hospital’s document titled, “ED-Triage-Protocol,” dated 07/03/23, showed the following: - The policy applied to all patients presenting to University of Missouri Health Care (UMHC) ED for care. - The purpose of the policy was to determine acuity of patients presenting for care. - Registration of a patient presenting to triage was completed by any staff member by verifying the patient’s full name and date of birth. - Documentation included the patient’s chief complaint. - The policy did not reference maintaining a log of patients who presented to the ED. - The policy did not reference patients presenting to L&D for triage. Although requested, a policy on maintaining a log in the ED or L&D was not provided. Review of the hospital’s policy titled “Patient Rights-Patient Right to Refuse Care, Treatment, and Services Against Medical Advice (AMA)-Policy”, dated 07/17/23, showed when a patient chooses to leave the hospital AMA, a conversation with the patient regarding risks and benefits of medical care, treatment or services the patient needs in order to participate in health care decisions, the decision to refuse care and leave AMA, including the patient’s reason(s) for refusing care and leaving AMA, will be documented in the patient’s medical record. The patient will be asked to sign a “Patient Right to Refuse Care, Treatment and Services AMA Form.” If the patient refuses to sign the AMA form, a physician or nurse will sign and date the form, indicate the patient refused to sign on the form and placed the form in the patient’s medical record. Review of hospital policy titled, “ED-Department Specific Standards,” dated 07/31/23 showed discharge education shall be provided to patients and family prior to leaving the ED. The discharge education shall include a review of the patient’s diagnosis and self-care needs, skills and knowledge related to that diagnosis.”

“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: 47504 Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), and information indicating whether the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the Labor and Delivery (L&D) unit for emergency medical treatment. The average number of patients triaged (process of determining the priority of a patient’s treatment based on the severity of their condition) in the Women’s Health Department from 03/11/24 through 06/10/24 was 1,220 per month. The hospital provided an average L&D triage per month for 06/10/24 through 09/11/24 of 288 per month. Review of hospital policy titled, “Facility Planning, Design, and Construction Signage,” dated 01/19/22, did not contain requirements or direction of Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) signage in triage areas. Although requested, a policy was not provided for EMTALA signage in triage areas. Observation on 09/12/24 at 10:30 AM, in the Labor and Delivery Unit, showed no EMTALA signage at the registration desk, waiting room, or patient rooms. During an interview on 09/13/24, Staff D, Clinical Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Manager, stated that she was aware that they did not have the required EMTALA signage posted at the registration desk, waiting room or any of the patient rooms. She stated that the L&D unit had moved two months prior and the hospital was waiting on new signs from the printing company.”

“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: 44536 Based on observation, interview, record review, and policy review the hospital failed to maintain a complete log of Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients triaged (process of determining the priority of a patient’s treatment based on the severity of their condition) through the Women’s Health Unit. The log failed to identify three OB patients (#17, #19, and #27) of eight Women’s Health Unit patients records reviewed, was incomplete with date gaps and missing patients and one patient’s (#8) disposition was incorrectly identified. The inconsistency of the OB triage logs skewed the average number of OB patients triaged per month provided to the survey team. The hospital also failed to provide a complete Emergency Department (ED) log to the survey team in a timely manner. The log initially provided failed to identify two patients (#13 and #22) of 32 patient medical records reviewed who presented to the hospital ED seeking care from 03/11/24 through 09/11/24. The complete ED log was provided 30 hours after originally requested. This failure had the potential to affect all patients who presented to the ED and OB for treatment of emergency conditions. Findings included: Although requested, no policy on maintaining a log in the ED or OB triage patients was provided. Review of the hospital’s document titled, “ED - Triage - Protocol,” dated 07/03/23, showed the following: - The policy applied to all patients presenting to University of Missouri Health Care (UMHC) ED for care. - The purpose of the policy was to determine acuity of patients presenting for care. - Registration of a patient presenting to triage was completed by any staff member by verifying the patient’s full name and date of birth. - Documentation included the patient’s chief complaint. - The policy did not reference maintaining a log of patients who presented to the ED. - The policy did not reference OB patients presenting to the Women’s Health Unit for triage. Review of the hospital’s policy titled “Patient Rights - Patient Right to Refuse Care, Treatment, and Services AMA - Policy”, dated 07/17/23, showed when a patient chooses to leave the hospital AMA, a conversation with the patient regarding risks and benefits of medical care, treatment or services the patient needs in order to participate in health care decisions, the decision to refuse care and leave AMA, including the patient’s reason(s) for refusing care and leaving AMA, will be documented in the patient’s medical record along with the time of the patient’s departure. The patient will be asked to sign a “Patient Right to Refuse Care, Treatment and Services Against Medical Advice (AMA) Form.” If the patient refuses to sign the AMA form, a physician or nurse will sign and date the form, indicate the patient refused to sign on the form and placed the form in the patient’s EMR. Observation on 09/11/24 at 11:45 AM showed electronic logs with folders labeled “WH (Women’s Health) ED 2023”, “CRMC (Capital Region Medical Center) ED log 2024”, “UH (University Health Care) ED log 2023” and “UH ED log 2024” provided to the survey team for selection of a comprising sample of ED patients treated at the hospital. The folder labeled “WH ED 2023” contained two documents titled “WH 6-11-23 to 8-11-23” and “WH 3-11-24 to 6-10-24”. The survey team requested logs for every patient who received unscheduled assessments in the hospital from 06/11/23 through 08/11/23 and from 03/11/24 through 09/11/24. Review of the electronic log titled “WH 3-11-24 to 6-10-24” showed a total number of patients on the log as 3,660, which would average 1,220 per month for the three months. Patients listed on the electronic log showed numerous male patients and patients less than 12 years old. Review of the hospital document provided on 09/19/24 showed the hospital’s Women’s Health Unit reported they triaged an average of 288 OB patients per month from 06/10/24 through 09/11/24. During an observation and subsequent interview on 09/11/24 at 2:30 PM, Staff A, Manager of Risk and Regulatory, stated that the Women’s Health Unit moved from an off-campus location to the current location within the hospital in June of 2024. Their newer logs were maintained by a different computer system and providing the log to the survey staff would be delayed. Staff A provided hand-written logs with patient identification stickers obtained from the Women’s Health Unit and stated that they were the logs for OB patients triaged from 06/01/24 through 09/11/24. Review of the hand-written OB logs on 09/11/24 at 2:50 PM showed Patients #17, #19 and #27 were not included. The hand-written log for OB for 09/01/24 through 09/11/24 showed dates with no patient triages between 09/05/24 at 8:07 PM through 09/09/24 at 12:30 PM, indicating missing pages and missing patients within the log. There were 85 patients listed on the hand-written log, 22 patients did not have a disposition indicated. Review of Patient #17’s medical record dated 09/11/24 at 10:14 AM, showed she was a 31-year-old female at 37 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) who presented to OB triage for a labor check. She was discharged home on 09/11/24 at 11:40 AM. Review of Patient #19’s medical record dated 09/11/24 at 11:40 AM, showed she was 20-year-old female at 37 weeks gestation who presented to OB triage with abdominal pain. She was discharged home 09/11/24 at 4:40 PM. Review of Patient #27’s medical record dated 06/25/24 at 1:55 PM, showed she was 27-year-old female at 30 weeks gestation who presented to OB triage for a blood pressure evaluation. She was discharged home on 06/25/24 at 5:30 PM. During an observation and subsequent interview on 09/11/24 at 4:00 PM, Staff A, Manager of Risk and Regulatory, provided a computer-generated log from the hospital’s billing department to the survey team and reported it contained OB triage patients from 06/01/24 through 09/06/24. The computer-generated log did not identify patient names, date of birth, or chief complaint. The patient dispositions were listed. Staff A stated that the hospital met the 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) requirement with the hand-written logs with patient sticker identification. Review and comparison between the computer-generated log from the hospital’s billing department and the hand-written log for OB triage between the dates of 06/11/24 and 06/30/24 showed the log from the hospital’s billing department had entries of “OB Triage Facility Fee” for 52 patients with discharge dates the same as their admission date and not located on the hand-written logs, including one patient with a disposition of AMA and one with the disposition of Transferred to Another Facility. Review and comparison between the computer-generated log from the hospital’s billing department and the hand-written log for OB triage between the dates of 09/01/24 and 09/06/24 showed entries “OB Triage Facility Fee” for 15 patients with discharge dates the same as their admission date and not shown on the hand-written logs. Review of both the OB electronic triage log titled “WH 3-11-24 to 6-10-24” and the computer-generated log from the hospital’s billing department, showed Patient #8 was triaged in the Women’s Health Unit on 06/03/24 with a disposition of “Left AMA.” Patient #8 did not appear on the hand-written log. Review of Patient #8’s medical record dated 06/03/24 at 1:17 AM showed she was a 26-year-old female at 36 weeks gestation who presented to the Women’s Health Unit for OB triage with lower back pain and lower abdominal cramping. The medical record showed Patient #8 left the Women’s Health Unit without notifying nursing staff and before she was evaluated by the provider. Her disposition was recorded in the medical record as “Left Without Being Seen.” There was no documentation of review of risks and benefits and no “Patient Right to Refuse Care, Treatment, and Services AMA Form.” During an interview on 09/12/24 at 11:00 AM, Staff D, OB Clinical Manager, stated that the log of patients triaged in the Women’s Health Unit was the hand-written pages with patient stickers attached. She stated that she knew log pages were out of date order and staff had looked for missing pages. She stated that the unit moved from another building to their new location on the hospital campus a few months prior and had not kept up with maintenance of the log. Review of Patient #22’s medical record showed she had presented through the hospital’s ED on 09/05/24 and was transferred to the Women’s Health Unit for OB evaluation. During an interview on 09/12/24 at 1:30 PM, Staff S, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), stated that Patient #13 was triaged in the ED on 08/02/24 and transferred to the University of Missouri Psychiatric (relating to mental illness) Center (MUPC) for evaluation. Review of the original ED log provided to the survey team showed Patient #13 did not appear on the log for an ED visit on 08/02/24 and Patient #22 did not appear on the log for an ED visit on 9/05/24. Observation on 09/12/24 at 3:45 PM showed the hospital provided a second electronic ED log. The second log showed visits by Patient #13 on 08/02/24 and Patient #22 on 09/05/24. During an interview on 09/12/24 at 2:20 PM, Staff R, Service Line Specialist, stated that the electronic log for the ED originally provided to the survey team was generated with a filter that removed patients who were low-risk behavioral health and immediately moved to MUPC and those greater than 20 weeks gestation and immediately moved to the Women’s Health Unit for OB triage. The filter on the electronic log was not discovered until the survey team identified visits for Patients #13 and #22 did not appear on the electronic logs originally provided.”

“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: 47504 Based on interview, record review, and policy review, the hospital failed to provide discharged patients with discharge instructions identifying conditions stabilized and the plan for appropriate follow-up care for one emergency department (ED) patient (Patient #1) out of 17 patient records reviewed. This failure could affect all patients discharged from the ED. 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)-Compliance,” dated 10/17/22, showed: - Discharge was defined as the release of a patient from the ED to their place of residence or other non-acute care healthcare facility. - An EMC was a medical condition manifesting acute symptoms that the absence of immediate medical attention could reasonably be expected to result in placing the person in jeopardy, serious impairment of bodily function, or dysfunction of a bodily organ or part. - A special category under EMC was severe pain. - Stabilizing treatment included removing the risk of deteriorate to the patient’s medical condition prior to discharge. - A patient was deemed stable when no material deterioration was likely to occur from or during discharge. - Patients treated for an EMC that was resolved by treatment in the ED must have certification in the ED record by the attending physician, advanced practice professional, or consulted medical specialist, that the EMC no longer exists. Review of hospital policy titled, “ED -Department Specific Standards,” dated 07/31/23 showed: - Discharge education shall be provided to patients and family prior to leaving the ED. - Discharge education shall include a review of the patient’s diagnosis and self-care needs, skills and knowledge related to that diagnosis. - Signs and symptoms that require notification of a provider and who to call should be provided. - The hospital/provider call back numbers should be provided to the patient. Review of hospital policy titled, “Medical Record Service - Provider Content of the Medical Record: Document Information required based on visit type,” dated 8/29/22 showed all emergency visits should include the final disposition, condition of patient and instructions for follow-up. Review of Patient #1’s medical record showed: - He was a 49-year-old male who presented to the ED on 06/25/23 with a past medical history of a closed head injury and seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) who lived with caregivers in an assisted living facility (ALF). - He was brought to the ED via ambulance with right arm pain following a seizure and fall. - A physical assessment was completed showing he had swelling, limited range of motion, discomfort, and pain of the right arm. - A series of x-rays (tests that creates pictures of the structures inside the body-particularly bones) were performed showing a displaced fracture of the right humerus (a long bone in the arm that runs from the shoulder to the elbow) - Staff GG, Orthopedic (medical specialty dealing with bones) Physician, was consulted, and the treatment plan included a support sling for the arm and to follow up as an outpatient within the next few days. - Documentation showed he was educated verbally by Staff X, Registered Nurse (RN) on the treatment plan and follow up with family present. -The discharge instructions provided to the patient and the ALF included the recommended treatment plan for his seizure diagnosis. - Documentation failed to include documentation of the broken humerus, follow-up instructions, and pain management. The record did not show ED staff called the ALF staff and reported findings and recommendations during Patient #1’s ED visit. Review of Patient #1’s second medical record showed: - He was a 49-year-old male who presented to the ED on 06/27/23 with right arm pain after he slept on his arm “wrong” and had difficulty with his balance since a fall with right arm fracture. - He was evaluated in the ED on 06/25/23 for right arm pain and a fracture was identified. His right arm was placed in a support sling and he was discharged home with instructions to follow-up with orthopedics and neurology (neuro, relating to or affecting the nervous system) as an outpatient. - Patient #1 was admitted to the hospital on 06/27/23 for orthopedic and neurologic evaluation. Conservative management of his right arm fracture was followed until he underwent surgical correction on 07/19/23. - Patient #1 was discharged from the hospital on 08/02/23. During a telephone interview on 09/18/24 at 3:22 PM, Staff X, RN, stated that she could not recall if she had called report to anyone at the ALF. She stated that if a patient had a consult in the ED that required follow-up, but nothing was listed on the discharge instructions, she would have the provider enter the correct information. The nurses did not have the ability to change the discharge information.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41474 Based on observation, record review, interview and policy review the hospital failed to: - Ensure staff removed expired supplies from patient care areas on one Intensive Care Unit (ICU, a unit where critically ill patients are cared for) of five ICUs reviewed. (A-0144) - Ensure staff followed hospital policy for crash cart (mobile cart which contains emergency medical supplies and medication) checks for three out of five ICU crash cart logs reviewed. (A-0144) - Follow their policy when they placed one patient (#23) in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) when he attempted to get out of bed. (A-0161) - Develop care plans to include the use of restraints for three patients (#61, #66, and #67) out of three patients reviewed with restraints. (A-0166) - Ensure restraints were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for three patients (#26, #61 and #66) of eight restraint patients reviewed. (A-0168) - Ensure orders for restraints were not written as standing orders for four patients (#26, #61, #66 and #67) of eight patients with restraints reviewed. (A-0169) - Ensure appropriate monitoring and nursing documentation during the use of restraints for two patients (#66 and #67) of eight restraint patients reviewed. (A-0175) - Ensure staff had training and met requirements to perform a one-hour face-to-face evaluation for one patient (#26) of eight patients with restraints reviewed. (A-0178) These failures resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0144, A-0161, A-0166, A-0168, A-0169, A-0175 and A-0178”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 41474 Based on observation, interview, record review and policy review, the hospital failed to ensure licensed staff adhered to policies and procedures of the hospital when staff did not follow the hospital’s infection prevention policy while providing care to seven current patients (#7, #13, #14, #17, #27, #31 and #60) at three of the four hospitals that made up the system where patient care was observed. These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. Please refer to A-0395”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46856 Based on observation, interview, record review, and policy review, the hospital failed to ensure that staff removed expired supplies from patient care areas and staff followed hospital policy for crash cart (mobile cart which contains emergency medical supplies and medication) checks for three out of five Intensive Care Unit (ICU, a unit where critically ill patients are cared for) crash cart logs reviewed. Observation on 06/03/24 at 3:22 PM, on the Cardiac ICU (CICU), of a procedure cart showed the following: - Three expired arterial line (thin, flexible tube placed into an artery) pressure monitoring kits; one that expired on 08/08/19, one that expired on 08/26/21, and one that expired on 06/21/23. - One sterile (completely clean and free from germs) solution applicator that expired on 02/2024. - One hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) catheter that expired on 05/17/24. - Two central line/central venous catheter (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) monitoring catheters that expired on 03/23/24. - Four thoracic catheters (a catheter that is for effective drainage after thoracic [middle portion of the spine] surgery), one that expired on 01/04/19 and three that expired on 03/10/19. - One spring wire guide (a support for vascular access device [a flexible, sterile plastic tube inserted into a blood vessel to allow blood to be drawn from or medication to be delivered into a patient’s bloodstream] needs) that expired on 01/31/22. - One deluxe chest tube tray that expired on 04/30/21. During an interview on 06/03/24 at 3:53 PM, Staff H, Registered Nurse (RN) CICU Manager, stated that the procedure cart had always been on the unit. It was not assigned to anyone to be checked for expiration dates. The cart was not used a lot. She had no idea the items found were expired. Review of the hospital’s document titled, “Rapid Response - Crash Cart Maintenance and Exchange - Policy,” dated 01/09/23, showed daily unit nurse responsibilities included ensuring the emergency crash cart is sealed and locked, and then documented on the checklist. Review of the hospital’s document titled, “Crash Cart Verification Sheet,” dated 04/2024, showed one of two crash carts in the ICU at Capitol Region Medical Center (CRMC) was not checked on 04/07/24, and both crash carts in the ICU were not checked on 04/10/24; 04/13/24; 04/15/24; 04/16/24; 04/17/24; and 04/18/24. Review of the hospital’s document titled, “Crash Cart Verification Sheet,” dated 06/2024, showed both crash carts in the ICU at CRMC were not checked on 06/03/24; 06/06/24; 06/07/24; and 06/08/24. Review of the hospital’s document titled, “PICU - Crash Cart Log March to June 2024,” dated 06/12/24, showed that the Pediatric ICU crash cart at University Hospital was not checked on 03/02/24; 03/16/24; 04/21/24; and 05/24/24. 41474 39354”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 46856 Based on interview, record review, and policy review, the hospital failed to follow their policy when they placed one patient (#23) in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) when he attempted to get out of bed. Review of the hospital’s policy titled, “Patient Safety - Nonviolent Behavior Restraint - Policy,” dated 01/17/24, showed the objectives of the policy are to outline appropriate process for use of restraints for patients with non-violent behaviors in recognition of the rights of patients to be free from restraints that are not medically necessary or restraints that are imposed as a means of coercion, discipline, convenience, or retaliation. Review of Patient #23’s medical record showed he was a 50-year-old male admitted on 04/21/24. On 05/21/24, he was in cloth tied four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). The behavior requiring non-violent restraint was listed as attempting to get out of bed, and documentation showed he was in restraints for attempting to get out of bed from 8:00 AM to 12:00 PM. The physician order for restraints listed the reason for restraints was tampering with medical devices. During an interview on 06/06/24 at 1:40 PM, Staff JJJ, Surgical Specialties Registered Nurse (RN), stated that Patient #23 was a Traumatic Brain Injury (TBI, an injury in how the brain works) patient, who was oriented only to his name. He was in a sitter room and would try exiting out of the bed. He was in restraints for tampering with medical devices. When Staff JJJ cared for patients in restraints, her practice was to try to document a reason more specific to why they were in restraints. She documented the reason Patient #23 was in restraints was he was trying to get out of bed. He tried exiting forcefully out of the bottom of the bed. Staff tried turns and distractions, but nothing worked. Restraints were not to be used as an intervention for high fall risk patients. During an interview on 06/06/24 at 1:45 PM, Staff KKK, Manager of Surgical Specialties and Surgical Intensive Care Unit (Intensive Care Unit (ICU, a unit where critically ill patients are cared for), stated that Patient #23 would throw the lower half of his body out of bed. He did have a sitter and was not able to be redirected. It became a safety issue when Patient #23 started kicking at the sitter. As Patient #23 improved, they removed his restraints. Restraints were not to be used as a fall prevention intervention. During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that it would not be appropriate to place patients in restraints to keep them from getting out of bed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 46856 Based on interview, record review, and policy review, the hospital failed to develop care plans to include the use of restraints for three patients (#61, #66, and #67) out of three patients reviewed with restraints. This had the potential to affect the care of all patients in restraints. Findings included: Review of the hospital’s policy titled, “Restraint Use (All Ages),” dated 02/03/21, showed there was no requirement for nursing to document a written modification to the patient’s plan of care regarding the use of restraints. Review of the hospital’s policy titled, “Patient Safety - Nonviolent Behavior Restraint - Policy,” dated 01/17/24, showed the patient’s plan of care shall be updated to reflect the use of a restraint. The nurse will update the plan of care to reflect the trigger in patient behavior that requires restraint, the intervention taken, goal of removing the restraint and steps taken to prevent use of further restraint. Review of Patient #61’s medical record showed he was in restraints from 12:00 PM on 06/07/24 through 8:47 AM on 06/10/24. There was no restraint plan of care within his record. Review of Patient #66’s medical record showed he was in restraints from 8:00 PM on 05/13/24 through 4:00 PM on 05/23/24. There was no restraint plan of care within his record. Review of Patient #67’s medical records showed she was in restraints from 12:00 PM on 06/07/24 through 10:00 AM on 06/11/24. There was no restraint plan of care within her record. During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at Capitol Region Medical Center (CRMC), stated that there should have been plans of care for restraints for patients in restraints. During an interview on 06/11/24 at 4:15 PM, Staff OOOO, Director of Quality and Patient Safety at Capitol Region Medical Center, stated that plans of care for restraints were an “area of improvement,” and it made sense to have them. During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that she would expect care plans for restraints at all hospitals in the system would be completed per University of Missouri Health Care policy.”

“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: 41474 Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for three patients (#26, #61 and #66) of eight restraint patients reviewed. Findings included: Review of the hospital’s policy titled, “Patient Safety-Violent Behavior Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) Policy,” dated 01/17/24, showed the following: - A LP was any individual permitted by State law and organization policy to order restraints and seclusion for patients independently within the scope of the individual’s license and consistent with the individually granted clinical privileges. - An order must be obtained from an LP before a restraint is applied. - If the emergency application of a restrain is required, a Registered Nurse (RN) may apply, or delegate application to permissible professionals, the restraint and then shall request an order (written or verbal) immediately. - The patient’s attending physician shall be notified as soon as possible if the attending physician does not initiate the order. Review of the hospital’s policy titled, “Restraint Use (All Ages),” dated 02/03/21, showed a Physician, an Advance Practice Registered Nurse (APRN), or Physician Assistant may determine whether restraints are necessary for and order restraints for non-violent care or for violent reasons. The RN must have a provider order before applying restraints, except in life threatening situations which requires obtaining a physician order immediately after application. Orders for restraint will be renewed every calendar day. Review of Patient #26’s medical record, dated 06/03/24, showed the following: - He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma). - On 06/03/24 at 2:59 PM, Staff NN, RN, entered a standing order to initiate four point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM. - Patient #26 was in restraints beginning at 12:50 PM and he remained in restraints until 3:35 PM. - The standing order to initiate four-point restraints was not signed by Staff MM, Physician, until 06/08/24. During an interview on 06/04/24 at 3:30 PM, Staff A, Risk and Regulatory Director, stated that a nurse did put in the order for the restraint and the physician did not sign it until much later. Review of Patient #61’s medical record showed the following: - He was a 69-year-old male admitted to Capitol Region Medical Center (CRMC) on 06/05/24. - He was in cloth tied restraints for both arms from 12:00 PM on 06/07/24 through 06/10/24 at 8:47 AM. - He had no restraint orders on 06/07/24. Review of Patient #66’s medical record showed the following: - He was a 69-year-old male admitted to CRMC on 05/13/24. - He was in restraints from 08:00 PM on 05/13/24 through 4:00 PM on 05/23/24. - He had no order for restraint on 05/13/24; 05/15/24; or 05/16/24 During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to assess the patient for the appropriate type of restraints and behaviors and to reach out to the provider for a new order. Patients should not be in restraints without an active order. During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, CNO of University of Missouri Health Care, stated that there should be a physician order for each restraint episode and the order should not be a standing order. 46856”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 41474 Based on interview, record review and policy review, the hospital failed to ensure orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were not written as standing orders for four patients (#26, #61, #66 and #67) of eight patients with restraints reviewed. Findings included: Review of the hospital’s policy titled, “Patient Safety-Violent Behavior Restraint and Seclusion Policy,” dated 01/17/24, showed the following: - A Licensed Provider (LP) was any individual permitted by State law and organization policy to order restraints and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for patients independently within the scope of the individual’s license and consistent with the individually granted clinical privileges. - An order must be obtained from an LP before a restraint is applied. - If the emergency application of a restraint is required, a Registered Nurse (RN) may apply, or delegate application to permissible professionals, the restraint and then shall request an order (written or verbal) immediately. - The patient’s attending physician shall be notified as soon as possible if the attending physician does not initiate the order. - An as needed order (PRN) for restraints was not allowed. Review of the hospital’s policy titled, “Restraint Use (All Ages),” dated 02/03/21, showed the following: - A Physician, an Advance Practice Registered Nurse (APRN), or Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider) may determine whether restraints are necessary for and order restraints for non-violent care or for violent reasons. - The RN must have a provider order before applying restraints, except in life threatening situations which requires obtaining a physician order immediately after application. - PRN orders will not be permitted. Review of Patient #26’s medical record, dated 06/03/24, showed the following: - He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma). - On 06/03/024 at 2:59 PM, Staff NN, RN, entered a protocol/standing order to initiate four-point restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM. - The standing order to initiate four-point restraints was not signed by Staff MM, Physician, until 06/08/24. During an interview of 06/04/24 at 3:30 PM, Staff A, Director of Risk and Regulations, stated that restraints were never to be placed as standing orders. The standing order for restraints was a one off, and the nurse had put the order on the wrong form. Review of Patient #61’s medical record showed the following: - He was a 69-year-old male admitted to Capitol Region Medical Center (CRMC) on 06/05/24. - He was in cloth tied restraints for both arms from 12:00 PM on 06/07/24 through 8:47 AM on 06/10/24. - He had restraint orders for 06/08/24 at 12:40 AM and 06/09/24 at 11:36 PM. Both orders were listed as per protocol/standing order. Review of Patient #66’s medical record showed the following: - He was a 69-year-old male admitted to CRMC on 05/13/24. - He was in restraints from 08:00 PM on 05/13/24 through 4:00 PM on 05/23/24. - He had restraint orders on 05/14/24; 05/17/24; 05/18/24; 05/19/24; 05/20/24; 05/21/24; and 05/22/24. Four (05/17/24; 05/19/24; 05/21/24; and 05/22/24) out of seven restraint orders were listed as per protocol/standing order. Review of Patient #67’s medical record showed the following: - She was a 62-year-old female admitted to CRMC on 05/30/24. - She was in cloth tied restraints for both arms from 4:30 PM on 06/07/24 through 10:00 AM on 06/11/24. - She had restraint orders for 06/07/24; 06/08/24; 06/09/24; and 06/10/24. Three (06/08/24; 06/09/24; and 06/10/24) out of four restraint orders were listed as per protocol/standing order. During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to be familiar with the hospital’s restraint policy. Protocols and standing orders were not to be used for restraints. During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at CRMC, stated that they did not have protocols or standing orders for restraints. Restraint orders were not to be a “just in case” order. During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, CNO of University of Missouri Health Care, stated that restraints were never to be placed as standing orders. 46856”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 46856 Based on interview, record review, and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for two current patients (#66 and #67) of eight restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. Findings included: Review of the hospital’s policy titled, “Patient Safety - Nonviolent Behavior Restraint - Policy,” dated 01/17/24, showed the nurse is to observe and document on the patient at least every two hours. These observations are necessary to assess for the continued safety, well-being, comfort and dignity of the patient. Assess vital signs (measurements of the body’s most basic functions), level of distress and agitation, mental status, cognitive functioning, hydration, elimination needs, circulation, skin integrity (refers to skin health, to be free of wounds or irritation), movement, and sensation, and offer an appropriate range of motion, hydration, toileting, and other relevant care as indicated by the patient’s needs. Review of the hospital’s policy titled, “Restraint Use (All Ages),” dated 02/03/21, showed patients will be monitored at least every two hours for hydration, nutrition, elimination, skin condition, range of motion, circulation, and clinical condition. Nursing documentation for non-violent restraints included: type of restraint applied; date and time restraint applied; patient’s condition warranting restraint use; assessment every two hours; family and patient education regarding the need for restraints; interventions attempted for reducing use of restraint or seclusion of least restrictive restraint; signs of injury; and date and time of restraint removal. Review of Patient #66’s medical record showed the following: - He was a 69-year-old male admitted to Capital Regional Medical Center (CRMC) on 05/13/24. - He was in restraints during his hospitalization. - On 05/13/24, there were no nursing restraint assessments documented for five hours (missing restraint assessments at 4:00PM and 6:00 PM). - On 05/15/24, there were no nursing restraint assessments documented for seven hours (missing restraint assessments at 2:00 AM, 4:00 AM, and 6:00 AM). - On 05/16/24, there were no nursing restraint assessments documented for 11 hours (missing restraint assessments at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM). - On 05/21/24, there were no nursing restraint assessments documented at 10:00 AM and 2:00 PM. - On 05/23/24, there was no nursing restraint assessment documented at 2:00 AM. Review of Patient #67’s medical record showed the following: - She was a 62-year-old female admitted to CRMC on 05/30/24. - She was in restraints during her hospitalization. - On 06/08/24, there was no nursing restraint assessment documented at 6:00 PM. - On 06/09/24, there was no nursing restraint assessment documented at 6:00 PM. During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to be familiar with the hospital’s restraint policy. Staff were to follow policy on the frequency of assessments, monitoring, and documenting on restraints. During an interview on 06/11/24 at 4:15 PM, Staff OOOO, Director of Quality and Patient Safety at CRMC, stated that the hospital had room for improvement and better documentation with restraints. Patients needed to be assessed every two hours at minimum. During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at CRMC, stated that non-violent restraints were to be documented on every two hours or per policy. Elements included in the documentation were skin checks, range of motion, hydration and elimination needs, and assessing if the patient needed the restraint. She did not expect there to be gaps in nursing documentation.”

“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: 41474 Based on interview, record review and policy review, the hospital failed to ensure staff had training and met requirements to perform a one-hour face-to-face evaluation for one patient (#26) of eight patients with restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) reviewed. Findings included: Review of the hospital’s policy titled, “Patient Safety-Violent Behavior Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) Policy,” dated 01/17/24, showed that an order must be obtained from a licensed professional (LP) before a restraint is applied. An LP was defined as any individual permitted by state law and organization policy to order restraints and seclusion for patients independently within the scope of the individual’s license and consistent with the individually granted clinical privileges. The LP must see and evaluate the patient within one hour of initial restraint/seclusion application. Review of the hospital’s personnel records on 06/12/24 at 9:00 AM, showed that Staff KK, Registered Nurse (RN), did not receive training to perform a one-hour face-to-face assessment following the application of restraints. Review of Patient #26’s medical record, dated 06/03/24, showed the following: - He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma). - On 06/03/24 at 2:59 PM, Staff NN, RN, entered a standing order to initiate four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM. - On 06/03/24 at 1:01 PM, Staff XXXXX, ED Physician, documented an ED note but did not complete the one-hour face-to-face evaluation. - On 06/03/24 at 2:59 PM, Staff KK, RN, documented a one-hour face-to-face assessment had been completed at 12:50 PM. - Patient #26 was in restraints beginning at 12:50 PM and he remained in restraints until 3:35 PM. During an interview on 06/12/24 at 9:00 AM, Staff SSSSS, Director of Human Resources, stated that RNs did not receive training to complete a one-hour face-to-face assessment and typically LPs performed those assessments. One-hour face-to-face assessment training could be unit based, but she did not have those records. During an interview on 06/13/24 at 9:25 AM, Staff A, Director of Risk and Regulatory, stated that Staff KK, RN, did not meet training requirements to complete a one-hour face-to-face and he did not know why RNs were completing the assessments. During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that Physicians should complete the one-hour face-to-face assessment on patients in restraints.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40189 Based on observation, interview and policy review, the hospital failed to ensure licensed staff adhered to policies and procedures of the hospital when staff did not follow the hospital’s infection prevention policy while providing care to seven current patients (#7, #13, #14, #17, #27, #31 and #60) at three of the four hospitals that made up the system where patient care was observed. Findings included: Review of the hospital’s policy titled, “Infection Prevention and Control Program- 2024 Infection Control Manual,” dated 11/20/23, showed the following: - The infection Control Manual functions as the definitive policy and guideline reference for all facilities, settings and health care personnel at University Of Missouri Health Care. - Standard precautions (also known as universal precautions, avoiding contact with patients’ bodily fluids by means of wearing gloves, goggles and face shields) were used for all patient care and included frequent hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer), clean and disinfect patient care equipment and environmental surfaces. - Hand hygiene was to be performed before and after any patient contact, prior to applying gloves and after glove use and after touching beds or bedside objects (patient equipment, computers, handrails, nightstands, phone, etc.). - Gloves shall be worn as an additional measure, not as a substitute for hand hygiene. - Wear non-sterile, disposable, single-use gloves for direct contact with patient’s mucous membranes (membrane that lines various cavities [mouth, nose, etc.] in the body and covers the surface of internal organs), blood, body fluids, moist body substances and non-intact skin. - Wear gloves for handling potentially infectious materials or in contact with contaminated items and or surfaces. - Federal law requires that gloves must be worn for all intravascular (relating to or containing blood vessels) procedures such as blood draw or intravenous (IV, in the vein) start. - Critical items are defined as items which enter sterile tissue or vascular system (vessels that carry blood and lymph [fluid that removes waste products] through the body) and must be sterile. - If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible. Review of the hospital’s policy titled, “Infection Control Guidelines,” dated 01/24/23, showed infection control practices are critical to reduce the transmission of infections from one person to another, such as from a healthcare worker to a patient or vice versa. It is best practice to “foam in” upon entering the treatment area before touching patients and then to “foam out” upon completion of treating the patient. Observation on 06/04/24 at 10:00 AM, on the Medical Intensive Care Unit (MICU, a unit where critically ill patients are care for) three, showed Staff SS, Registered Nurse (RN), walked into Patient #31’s room with a mobile wound cart that contained new wound dressing supplies, a clip board and papers that listed other wound patients she had to see, and failed to perform hand hygiene. Staff SS put single use nonsterile gloves on and cleaned stool from the patient’s bottom and thighs. She then removed a soiled dressing from a wound on the patient’s back, picked up a phone and ruler from the wound cart, measured the patient’s wound and photographed it, without changing her gloves or performing hand hygiene. She then set the phone and ruler on the patient’s incontinence pad where it stayed until she used it to photograph a second open area on the patient’s right buttocks. After she photographed the second wound, she placed the phone and ruler on her mobile wound cart. She did not clean the phone used to photograph the wounds prior to placing it on her mobile wound cart. Patient #31 was turned and a third wound was assessed and the dressing was changed. Staff SS did not perform hand hygiene during the entire visit until she was ready to leave the room. She did not clean her phone that was on the patient’s dirty bed pad and had been handled with dirty gloves until just before she exited the patient’s room. During an interview on 06/05/24, Staff SS, RN, stated that she only needed to perform hand hygiene after entering a patient room and just before exiting the room. Supplies and her phone should not be placed on patients’ personal items and then placed onto the wound cart because she did take the cart into other patient rooms. During an interview on 06/05/24 at 1:55 PM, Staff XX, Clinical Manager for Nursing Support Services, stated that hand hygiene was to be performed upon entering a patient’s room, after touching a patient or equipment, before touching a patient, and between glove changes. Contaminated equipment and items should not be placed on the wound carts. The carts had clean supplies and were taken into several different patient rooms. There was a potential for infection to be spread to each room the cart was taken into. Observation on 06/03/24 at 3:53 PM, in the Emergency Department (ED), showed Staff TTTTT, X-ray (test that creates pictures of the structures inside the body-particularly bones) Technician walked into Patient #7’s room with gloved hands and failed to remove her dirty gloves, perform hand hygiene and don new gloves before providing care. When finished, Staff TTTTT, walked out of the room with the same gloved hands, failed to clean the x-ray machine or perform hand hygiene and pushed the machine into a trauma room where there was another patient. During an interview on 06/12/24 at 10:50 AM, Staff TTTTT, X-ray Technician, stated that she was to perform hand hygiene before she entered the patient’s room and put on gloves, and after she removed her gloves and exited the room. The x-ray machine was normally cleaned in the hall prior to entering another patient’s room, but the hallway was too crowded that day. Observation on 06/03/24 at 3:56 PM, in the ED, showed Staff QQ, RN, failed to perform hand hygiene, don gloves or clean Patient #7’s IV port with an alcohol swab before she flushed the line. She again failed to perform hand hygiene after she provided care. During an interview on 06/03/24 at 4:00 PM, Staff I, ED Service Line Specialist (Educator), stated that the process was to perform hand hygiene before placing gloves on and after removal. Gloves were not to have been placed on outside a patient’s room and before performing hand hygiene. The x-ray technician was to have removed her gloves prior to leaving a patient’s room and performed hand hygiene. He stated that he expected that the nurse performed hand hygiene, put on gloves and then used an alcohol swab before she flushed an IV. Observation on 06/04/24 at 10:50 AM, at the Missouri Orthopedic Institute (MOI), Staff T, RN, failed to perform hand hygiene and change gloves after touching the computer and before removal of a drain from Patient #13’s left knee. She then used the computer with the same gloves and took the drain out of the patient’s room without placing it in a biohazard bag. Staff T never performed hand hygiene before she left the patient’s room. During an interview on 06/04/24 at 11:05 AM, Staff T, RN, stated that she should have removed her gloves and performed hand hygiene after touching the computer and before removing the patient’s drain. She added that she did not realize that she needed a biohazard bag to take the drain out of the patient’s room. During an interview on 06/13/24 at 10:00 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that it was not appropriate to have worn gloves from the hallway into a patient’s room prior to performing hand hygiene. She expected hand hygiene was performed before and after gloves were worn. She expected the nurse to perform hand hygiene, wear gloves and clean an IV port with alcohol prior to the administration of anything into an IV line. Observation on 06/04/24 at 9:25 AM, on MICU three, showed Staff V, ICU RN, failed to perform hand hygiene between glove changes while performing tracheostomy (an opening created in the neck in order to place a tube into a person’s windpipe that allows air to enter the lungs) care on Patient #14. Observation on 06/04/24 at 10:15 AM, on MICU five, showed Staff X, ICU RN, discontinued a blood transfusion on Patient #17. Staff X did not wear gloves or place the used blood tubing in a biohazard bag prior to taking it out of Patient #17’s room. Observation on 06/05/24 at 9:00 AM, on the Cardiology floor, showed Staff NN, RN, failed to perform hand hygiene before putting on gloves. She moved two urinals off Patient #27’s bedside table to a chair, and did not change her gloves or perform hand hygiene prior to opening eight oral medication packages, dumping them in a pill cup, and handing the pill cup and a water cup to the patient, then administered subcutaneous insulin in the patient’s arm. Staff NN then changed her gloves, did not perform hand hygiene, and administered an inhaler medication to the patient. During an interview on 06/05/24 at 10:05 AM, Staff NN, RN, stated that hand hygiene was performed on entrance and exit from a patient’s room. She should have changed her gloves after moving the patient’s urinals off the bedside table. Observation on 06/06/24 at 9:10 AM, on MICU three, showed Staff ZZ, RN, assisting with a dressing change on Patient #31. At the end of the dressing change, Staff ZZ removed Patient #31’s old pad from underneath her back/buttocks, then boosted the patient up in bed and adjusted the patient’s head and pillow, all with the same gloves on and no hand hygiene. Observation on 06/10/24 at 11:40 AM, on the ICU at Capitol Region Medical Center (CRMC), showed Staff TTTT, RN, discontinued a blood transfusion on Patient #60. Staff TTTT placed the used blood tubing on Patient #60’s bedside table, then placed it in a biohazard bag prior to taking it out of Patient #60’s room. She did not clean the bedside table after removing the used blood tubing. During an interview on 06/10/24 at 12:00 PM, Staff TTTT, RN stated that she should have cleaned the patient’s bedside table after putting the used blood tubing on it. 41474”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41474 Based on observation, interview and policy review the hospital failed to provide care in a safe environment when hospital staff failed to ensure lock tags that secured crash carts (mobile cart which contains emergency medical supplies and medication), suture carts and drawers in patient rooms, which contained sharps (a term used for devices with sharp points or edges that can puncture or cut the skin), lab collection tubes, packaged syringes and sterile supplies, were secured and not accessible to patients, visitors or unauthorized personnel in the ED. These failures had the potential to place all patients in an unsafe environment. The failures resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights.”

“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: 41474 Based on observation, interview and policy review the hospital failed to provide care in a safe environment when hospital staff failed to ensure lock tags that secured crash carts (mobile cart which contains emergency medical supplies and medication), suture carts and drawers in patient rooms, which contained sharps (a term used for devices with sharp points or edges that can puncture or cut the skin), lab collection tubes, packaged syringes and sterile supplies, were secured and not accessible to patients, visitors or unauthorized personnel in the ED. These failures had the potential to place all patients in an unsafe environment. Findings included: Review of the hospital’s undated document titled, “Patient Rights and Responsibilities,” showed patients had the right to receive care in a safe environment. Review of the hospital’s policy titled, “Medication Management - Needle and Syringe Safety,” dated 10/18/19, showed all needles and syringes shall be secured in locked rooms, cabinets or carts to prevent access to patients, visitors and unauthorized staff unless located in a secured nursing unit. Review of the hospital’s policy titled, “Rapid Response - Crash Cart Maintenance and Exchange,” dated 01/09/23, showed daily unit nursing responsibilities included ensuring the emergency crash cart was sealed, locked, and documented on the checklist. During the restocking process, distribution staff will lock the cart (with the appropriate break away lock) and place a label on the cart with the date, item and item number of the nearest expiration item in the cart. Distribution staff will then document in SharePoint the cart number, cart’s location, and lock tag number. Observations on 01/30/24 at 9:00 AM, and 01/31/24 at 10:05 AM, on Pods A, B, C, E and P of the Emergency Department (ED), showed unsecured drawers inside patient rooms with numerous patient supplies which included needles for syringes, intravenous (IV, in the vein) needles, lab collection tubes, IV tubing, sterile supplies and packed syringes. During an interview on 01/30/24 at 9:15 AM, Staff QQ, ED Service Line Specialist, stated that the drawers in patient rooms should have been locked. Observations on 01/30/24 at 9:20 AM, and 01/31/24 at 10:15 AM, in ED hallway, showed a crash cart with red lock tags securing the drawers. On a cart beside the crash cart was an opened bag of red tags identical to the tags securing the crash cart. During an interview on 01/30/24 at 9:30 AM, Staff SS, Registered Nurse (RN), stated that red lock tags were to be kept in the supply room or the medication dispensing machine. Observations on 01/30/24 at 9:35 AM, and 01/31/24 at 10:25 AM, showed an unlocked suture cart that contained sharps in the hallway of the ED accessible to patients and visitors. During an interview on 01/30/24 at 9:35 AM, Staff OO, Interim Service Line Specialist, stated that she was not sure if the suture cart should have been locked, it had always been kept in the hallway and unlocked. During an interview on 01/30/24 at 9:40 AM, Staff P, ED Director, stated that the suture cart should have been locked. Observation on 01/31/24 at 10:30 AM, showed two unattended and unsecured supply carts in the hallway that contained numerous patient supplies, which included needles, IV needles, lab collection tubes, IV tubing, sterile supplies and packed syringes. Observation on 01/31/24 at 10:40 AM, showed three IV start kits, with 20-gauge needles inside, unsecured on top of a computer on wheels in the hallway of the ED accessible to patients and visitors. During an interview on 01/31/24 at 10:45 AM, Staff S, RN, stated that the IV start kits should have been removed from the computer on wheels and secured if not being used. The supply carts were in the hallway as the rooms were to be restocked that morning. She was unsure why the supply carts were unattended and stated, “they probably just stepped away for a minute.” During an interview on 02/01/24 at 2:20 PM, Staff C, Chief Nursing Officer (CNO), stated that red lock tags should be kept behind locked doors and accessible to employees only. Sharps should be stored in locked cabinets and drawers and not accessible to patients and visitors.”