Putnam County Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41474 Based on policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) and ensure that an emergency medical condition (EMC) was stabilized for one patient (#13) of 24 Emergency Department (ED) records reviewed from 10/01/25 through 04/06/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Patient Transfer (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfer of individuals with an EMC)/Consolidated Omnibus Budget Reconciliation (COBRA, term used interchangeably with EMTALA) Definitions Policy,” dated 10/10/00, showed: - A MSE was a documented, ongoing process in which the physician or nurse practitioner determines with reasonable clinical confidence whether a emergency medical condition does or does not exist for an individual. - The MSE may be simple or complex and may involve ancillary services. - Documentation must reflect continued monitoring according to the patients’ needs and monitoring must continue until the patient is stabilized or appropriately transferred by the physician or nurse practitioner. - An EMC was defined as manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious harm, serious impairment of any bodily function, serious dysfunction of any bodily organ or part. - Capabilities of a medical facility mean that there are physical space, equipment, supplies, and services that the hospital provides. Hospital resources and staff available to inpatients at the hospital for emergency services must likewise be available to individuals coming to the hospital for examination and treatment of EMC’s because these resources are within the capability of the hospital. - To stabilize was defined with respect to an EMC, to either provide such medical treatment of the condition necessary to assure, within reasonable medical probability, no deterioration of the condition is likely to result from, or occur during, the transfer of individual from a facility. - A patient will be deemed stabilized if the treating physician or nurse practitioner in consultation with the physician attending to the patient in the ED of the hospital has determined, within reasonable clinical confidence, that the EMC has been resolved. - For patients whose EMC has not been resolved, determination of whether they are medically stable may occur for purposes of transferring a patient from a facility to a second facility or for purposes of discharging a patient other than for the purpose of transferring from one facility to another facility. Review of the hospital’s policy titled, “EMTALA/Cobra Amendment,” reviewed 03/27/17, showed that due to the lack of intensive care services, or certain specialties being available in the rural area, the ED physician may elect in the best interest of the patient to transfer an unstable patient to services that are equipped to deal with such emergencies and to try to prevent further deterioration of his or her condition due to lack of appropriate services available. The ED physician/nurse practitioner will first stabilize the patient’s condition to the best of their abilities and available resources according to law. Review of the hospital’s policy titled, “EMTALA Anti-Dumping/COBRA,” dated 05/23/17, showed responsibilities in emergency cases included providing for an appropriate MSE, provide necessary stabilizing treatment for EMCs, and provide for an appropriate transfer of the individual when the hospital does not have the capability or capacity to provide treatment necessary to remove the emergency condition. For an appropriate transfer the hospital will provide medical treatment within its capacity to minimize the risks. Review of the hospital’s policy titled, “Emergency Room Stabilization and Transfer,” dated 05/13/00, showed all EMC’s must be stabilized. When the hospital has exhausted all of its capabilities in attempting to remove the EMC, it must affect an appropriate transfer. Please refer to 2406 and 2407 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 41474 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) of 24 Emergency Department (ED) records reviewed from 10/01/25 through 04/06/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 82. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Patient Transfer (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfer of individuals with an EMC)/Consolidated Omnibus Budget Reconciliation (COBRA, term used interchangeably with EMTALA) Definitions Policy,” dated 10/10/00, showed: - A MSE was a documented, ongoing process in which the physician or nurse practitioner determines with reasonable clinical confidence whether a medical emergency condition does or does not exist for an individual. - The MSE may be simple or complex and may involve ancillary services. - Documentation must reflect continued monitoring according to the patients’ needs and monitoring must continue until the patient is stabilized or appropriately transferred by the physician or nurse practitioner. - An EMC was defined as manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious harm, serious impairment of any bodily function, serious dysfunction of any bodily organ or part. - Capabilities of a medical facility mean that there are physical space, equipment, supplies, and services that the hospital provides. Hospital resources and staff available to inpatients at the hospital for emergency services must likewise be available to individuals coming to the hospital for examination and treatment of EMC’s because these resources are within the capability of the hospital. Review of Patient #13’s first ED medical record dated, 02/14/26, showed: - He was a 27-year-old who presented to the ED for a headache. He reported pain in the left temporal region and rated it a nine on the pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). He described the pain as aching and pressure. Exacerbating factors included coughing, deep breathing, loud noises, bright lights and bending over. He reported having been sick for several days, coughing up clear sputum, sinus congestion with copious amounts of green mucous, chills, sweats and a persistent headache. Initially his entire head hurt, but over the past two days the pain increased and was isolated to the left temporal region. - His vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [P] 60 to100 per minute; respiratory rate [RR] normal 12 to 22 breaths per minute; and body temperature [T] normal 97.8 to 99 degrees) were T 99.1, BP 140/86, P 85 and R 20. His oxygen saturation (SpO2, measure of how much oxygen is in the blood. A normal is between 95% and 100%) was 96%. - Past medical history included low back pain, strain of back muscles, hard of hearing (reads lips), asthma (a chronic lung disease which makes breathing difficult), anxiety, depression (extreme sadness that doesn’t go away), chronic (ongoing) back pain, upper respiratory infection (URI, irritation and swelling of the upper airways with associated cough and nasal congestion), bronchitis, otitis media (inflammation or infection of the middle ear), sinusitis, aortic valve repair (repair of the heart’s aortic valve), otitis externa (inflammation of the outer ear) of the left ear and hernia’s (when part of the intestine bulges through the opening of abdominal muscles). - Past surgical history included revision of tympanoplasty (a surgical procedure to repair a perforated or ruptured eardrum). - A review of systems showed he was not feeling well, had depression and anxiety, nasal congestion, was hearing ok and had a mild sore throat. A physical exam showed he was in moderate distress, had mildly reduced breath sounds and his eyes, ears, nose and throat (EENT) examination was positive for nasal congestion. - Laboratory testing included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), swabs for influenza (highly contagious condition affecting the respiratory system) A, B, respiratory syncytial virus (RSV, common respiratory virus that usually causes mild, cold-like symptoms) and Covid-19 (highly contagious, and sometimes fatal, virus). - He was given Toradol (a nonsteroidal anti-inflammatory drug [NSAID] that is used to treat moderately severe pain and inflammation) and methylprednisolone acetate (depo Medrol, corticosteroid used to treat severe inflammation, allergies, and arthritis by reducing the immune system’s response) intramuscularly (IM, in the muscle). - He was diagnosed with influenza A and prescribed Tamiflu (treats and prevents influenza A and B by inhibiting the virus from spreading in the body), azithromycin (antibiotic), an albuterol inhaler, tramadol (narcotic-like pain reliever used to treat moderate to severe pain) and tessalon perles (prescription strength, non-narcotic medication used to relieve coughs caused by colds, bronchitis and pneumonia). - He rated his pain a one on the pain scale assessment and was discharged home at 3:45 PM. Review of Patient #13’s second ED medical record dated, 02/22/26, showed: - He was a 27-year-old who presented to the ED at 1:33 PM, for a severe headache. - A computed tomography (CT, a combination of x-rays[tests that creates pictures of the structures inside the body-particularly nones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of the head showed right parietal (an area near the center of the brain that processes sensory information it receives from the outside world, mainly relating to touch, taste and temperature) encephalomalacia (localized softening of the substance of the brain due to bleeding or inflammation) changes, chronic paranasal sinus disease and trace amounts of fluid in the left mastoid air cells (a honeycomb-like network of air filled, mucosa-lined cavities in the bony prominence behind and below the ear canal). - At 7:15 PM, he was transferred by Facility C, Air Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), to Hospital C, Acute Care Hospital. Review of Patients #13’s Hospital B (General Acute Care Hospital) medical record, dated 02/22/26, showed: - He was transferred from Hospital A for acute encephalopathy (damage or disease that affects the brain) concurring for acute meningitis (inflammation of the tissues surrounding the brain and spinal cord). -His diagnosis included acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) requiring invasive mechanical ventilation (process of where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own), altered mental status (AMS, mental functioning ranging from slight confusion to coma), severe sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs), possible meningitis and streptococcus pneumoniae (a bacterial infection that can cause pneumonia, meningitis or a blood stream infection) infection. - He was treated then discharged on 03/04/26 with plans to follow up with Ear, Nose and Throat (ENT, a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck). During an interview on 04/14/26 at 2:30 PM, Staff K, Physician, stated that he treated Patient #13 on 02/14/26 in the ED. He did not recall specifically if he looked in the patient’s ears, but typically he did. He usually started at the top and worked his way down. As a general rule they document anything abnormal. As he recalled, the patient did not look significantly ill and he was not a nine out of 10 for pain. Pain was subjective, different people had different thresholds. If an examination of his ear had issues, he may not have ordered imaging because it wouldn’t show anything related to the internal tissues of the ear.”

“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: 41474 Based on interview, record review and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#13) of 24 Emergency Department (ED) records reviewed from 10/01/25 through 04/06/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Patient Transfer (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfer of individuals with an EMC)/Consolidated Omnibus Budget Reconciliation (COBRA, term used interchangeably with EMTALA) Definitions Policy,” dated 10/10/00, showed: - An EMC was defined as manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious harm, serious impairment of any bodily function, serious dysfunction of any bodily organ or part. - Capabilities of a medical facility mean that there are physical space, equipment, supplies, and services that the hospital provides. Hospital resources and staff available to inpatients at the hospital for emergency services must likewise be available to individuals coming to the hospital for examination and treatment of EMC’s because these resources are within the capability of the hospital. - To stabilize was defined with respect to an EMC, to either provide such medical treatment of the condition necessary to assure, within reasonable medical probability, no deterioration of the condition is likely to result from, or occur during, the transfer of individual from a facility. - A patient will be deemed stabilized if the treating physician or nurse practitioner in consultation with the physician attending to the patient in the ED of the hospital has determined, within reasonable clinical confidence, that the EMC has been resolved. - For patients whose EMC has not been resolved, determination of whether they are medically stable may occur for purposes of transferring a patient from a facility to a second facility or for purposes of discharging a patient other than for the purpose of transferring from one facility to another facility. Review of the hospital’s policy titled, “EMTALA/Cobra Amendment,” reviewed 03/27/17, showed that due to the lack of intensive care services, or certain specialties being available in the rural area, the ED physician may elect in the best interest of the patient to transfer an unstable patient to services that are equipped to deal with such emergencies and to try to prevent further deterioration of his or her condition due to lack of appropriate services available. The ED physician/nurse practitioner will first stabilize the patient’s condition to the best of their abilities and available resources according to law. Review of the hospital’s policy titled, “EMTALA Anti-Dumping/COBRA,” dated 05/23/17, showed responsibilities in emergency cases included providing for an appropriate MSE, providing necessary stabilizing treatment for EMCs, and providing for an appropriate transfer of the individual when the hospital does not have the capability or capacity to provide treatment necessary to remove the emergency condition. For an appropriate transfer the hospital will provide medical treatment within its capacity to minimize the risks. Review of the hospital’s policy titled, “Emergency Room Stabilization and Transfer,” dated 05/13/00, showed all EMC’s must be stabilized. When the hospital has exhausted all its capabilities in attempting to remove the EMC, it must affect an appropriate transfer. Review of Patient #13’s ED medical record dated, 02/22/26, showed: - He was a 27-year-old who presented at 1:33 PM, for a severe headache. - At 1:36 PM, nursing documentation showed he had been diagnosed with influenza A (highly contagious condition affecting the respiratory system) a week prior. He was prescribed Tamiflu (treats and prevents influenza A and B by inhibiting the virus from spreading in the body) and an antibiotic and completed that course. He reported nausea and vomiting for over a week and had not been able to keep anything down for the past 24 hours. He had a low-grade fever off and on, but no high-grade fever. His headache was rated a 10 on the pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). He described the pain as intense pressure in both temples. Exacerbating factors included lying flat. His “eyes were open notably wide,” and he answered questions appropriately. His pupils were equal, round, reactive to light and accommodating (PERRLA). - Past medical history included aortic and mitral valve replacement (repair of the heart’s aortic and mitral valve). - Past surgical history included revision of tympanoplasty (a surgical procedure to repair a perforated or ruptured eardrum). - At 1:37 PM, vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [P] 60 to100 per minute; respiratory rate [RR] normal 12 to 22 breaths per minute; and body temperature [T] normal 97.8 to 99 degrees) were T 98.3, BP 139/80, P 89 and R 15. His oxygen saturation (SpO2, measure of how much oxygen is in the blood. A normal is between 95% and 100%) was 97%. - At 1:46 PM, VS showed a BP of 120/56 and P 88. - At 2:15 PM, VS showed a BP of 143/96 and P 91. - Laboratory testing included swabs for influenza (highly contagious condition affecting the respiratory system) A, B, respiratory syncytial virus (RSV, common respiratory virus that usually causes mild, cold-like symptoms) and Covid-19 (highly contagious, and sometimes fatal, virus). - At 3:04 PM, a computed tomography (CT, a combination of x-rays [tests 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 completed. Findings included right parietal (an area near the center of the brain that processes sensory information it receives from the outside world, mainly relating to touch, taste and temperature) encephalomalacia (localized softening of the substance of the brain due to bleeding or inflammation) changes, chronic paranasal sinus disease and trace amounts of fluid in the left mastoid air cells (a honeycomb-like network of air filled, mucosa-lined cavities in the bony prominence behind and below the ear canal). - At 3:48 PM, laboratory tests showed his white blood cell count (WBC, the number of white cells [infection fight cells] in the blood) was 11.4, sodium (a mineral in the blood or body fluid) 132, glucose (sugar) 150, total protein 8.9, globulin (a group of proteins produced by the liver and immune system that play critical roles in liver function, blood clotting and fighting infections) 4.2 and lactic acid (an acid produced in muscle tissues during strenuous exercise) 2.0. - At 4:02 PM, VS showed a BP of 134/75 and P 92. - At 4:57 PM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed and showed abnormal EKG, borderline right axis deviation (the right side of the heart is overriding the left), sinus rhythm with first degree atrioventricular block (The heart’s electrical signals are delayed as they travel from the atria [upper chambers of the heart] to the ventricles [lower chambers of the heart]; the mildest form of heart block). - At 5:14 PM, nursing documentation showed he was having difficulty concentrating, fatigue, headache, light sensitivity, nausea, sleep disturbance and vomiting. He appeared ill, toxic and was in moderate distress. His skin was pale and his PERRL showed brisk. His left and right radial pulses were bounding. - At 5:16 PM, VS showed a BP of 168/91, P 103 and SpO2 of 94%. - At 5:39 PM, nursing documentation showed he was unable to maintain his balance, was drowsy, disoriented, nonverbal and incoherent. - Physician documentation showed, “the patients T was 102.8, he appeared to be somewhat ill in no acute distress initially, but his overall status did deteriorate rather notably during his stay in the ED, which was approximately four to five hours, he became confused, then failed to follow commands and then became nonverbal.” - At 7:05 PM, nursing documentation showed, “prior to going to CT the patient’s level of consciousness declined to drowsy, then declined to confused and he was no longer following commands well. He was still able to maintain his balance when standing. An EKG was obtained after he returned from CT and then he became non-verbal. He opened his eyes, but he was no longer answering questions. Additional blood was drawn and an intravenous catheter (IV, in the vein) was placed, the patient seemed unaware of what was happening. The patient declined to a Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) of six. An accepting physician was located at Hospital B (Acute Care Hospital) for transfer. IV antibiotics were given and the patient began dry heaving. IV nausea medication was administered. Facility C, Air Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), was contacted for the transfer and their response time was 22 minutes. The patient was still opening his eyes spontaneously and at times he thrashed on the bed for a few seconds. Otherwise, he was not responding. Facility C arrived at approximately 5:55 PM, and the crew sedated and intubated (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) the patient prior to transporting him to Hospital B. - He was discharged at 7:15 PM. Review of Patient #13’s Facility C (Air EMS) medical record, dated 02/22/26, showed they were called at 4:58 PM for interfacility transfer from Hospital A to Hospital B. The patient was diagnosed with influenza A on 02/13/26 and had a worsening headache. He drove himself to the hospital. He was walking, able to give a medical history and follow commands. He became confused with a GCS of 13, a head CT was obtained. While he was walking back to the ED room, he became more confused and unsteady on his feet. He was no longer able to follow commands, was rolling around in bed, combative at times and stopped talking to staff. Upon Air EMS’s arrival, the patient was rolling around in the bed, non-verbal, eyes open and unable to follow commands. He was responsive to pain. He was connected to their monitors, the crew elected to intubate for airway protection and safety. He was given medications to sedate him and he became more calm. Intubation supplies were set up and he was given medications to intubate. He was loaded and taken to Hospital B with no unexpected events. Review of Patients #13’s Hospital B medical record, dated 02/22/26, showed: - He was transferred from Hospital A for acute encephalopathy (damage or disease that affects the brain) concurring for acute meningitis (inflammation of the tissues surrounding the brain and spinal cord). - According to the patient’s family he had generalized weakness and fevers starting on 02/13/26. He presented to Hospital A, where he was diagnosed with influenza A and managed with Tamiflu and antibiotics. The patient finished his medications but continued to have worsening bi-temporal headaches, so he went back to Hospital B. - He had been intubated en-route to the hospital. He was extubated (removal of breathing tube) on 02/25/26. - Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) showed probably cholesteatoma (a noncancerous, skin lined cyst that develops in the middle ear or mastoid bone, often behind the eardrum, usually resulting from chronic infections) and left tegmen dehiscence (a rare bony defect in the skill base where the thin roof of the middle ear or mastoid erodes or becomes absent, this creates a hole separating the brain cavity from the middle ear) with suspected secondary meningitis/labyrinthitis (inner ear infection or inflammation affecting the membranous labyrinth [a system of fluid filled tubes responsible for balance and hearing]). -His diagnosis included acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) requiring invasive mechanical ventilation (process of where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own), altered mental status (AMS, mental functioning ranging from slight confusion to coma), severe sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs), possible meningitis and streptococcus pneumoniae (a bacterial infection that can cause pneumonia, meningitis or a blood stream infection) infection. -He was admitted to the medical intensive care unit (MICU, a unit where critically ill patients are cared for) and remained there until 02/27/26, when he was transferred to the medical floor. - He was discharged on 03/04/26 with plans to follow up with an Ear, Nose and Throat (ENT, a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck) provider to address the ear tegmen dehiscence. During a telephone interview on 04/10/26 at 8:30 AM, Staff E, Physician, stated that when Patient #13 got to the ED he had a normal GCS that rapidly changed to a six or seven. He had a history of influenza A, but no fever. He, “didn’t necessarily dismiss him when he got there, but his level of concern for him was very low. He took longer to respond to questions and his speech became confused and not always appropriate.” Toward the end he would resist movements to reposition him. He “knew he needed to intubate him but waited for the Facility C crew to arrive for assistance. There weren’t very many hands-on deck so we waited for them. If the patient had gone to the ED a few hours earlier in the day they probably would not have done a full work-up, he seemed ok.” During a telephone interview on 04/13/26 at 8:58 AM, Staff J, Licensed Practical Nurse (LPN), stated that she was the ED nurse working when Patient #13 arrived. He complained of a severe headache in his temple, his eyes were “odd and he did not look well, his eyes were just wide open and that was it.” He declined quickly and it was very busy that day. Since it was the second time the patient went to the ED for a headache, they did a CT. He was ok when he went to CT, but after they were done staff told her, “He was not acting right, something was very wrong.” He couldn’t speak appropriately or maintain his balance. She got a urine sample and did a UDS. The patient was not maintaining an airway, and the Facility C crew intubated him. He had been thrashing around and not able to follow commands. Although requested neither of Facility C’s, Air EMS, staff were available for interviews.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 18018 Based on policy review, observation, interview and document review, the facility failed to ensure staff followed infection control policies/procedures and infection prevention standards when staff failed to: - Provide a sterile field to place dressing supplies on for one of one dressing change observed; - Perform hand hygiene after removal of gloves and before re-gloving; and - Follow aseptic technique (a process free of germs or bacteria) during sterile compounding of immediate-use medication. These failed infection control practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. Review of the facility’s policy titled, “Dressing Change,” revised 07/28/2015, showed staff directive: Prepare sterile field (free from germs). Observation on 11/07/23 at 8:52 AM, showed Staff I, Registered Nurse (RN), prepared Patient #1 for a dressing change of the patient’s left lower abdominal wound. Staff I placed the dressing supplies on top of the patient’s bed linens without a barrier. During an interview on 11/07/23 at 8:52 AM, Staff I acknowledged that she failed to place a barrier on the patient’s bed linen before she placed the wound dressing supplies on the bed linens. Staff’s failure to place a barrier on top of the patient’s bed linen prior to placing dressing supplies on the bed linens increased the risk for the dressing supplies to become contaminated from contact with the bed linen. During an interview on 11/08/23 at 3:31 PM, Staff D, RN, Infection Control Preventionists (ICP), Quality Assureance (QA), stated staff was expected to place a barrier on the bed before staff placed supplies on top of patient’s bed linens. 2. Review of the facility’s policy titled, “Hand Hygiene - CDC Guidelines,” revised 04/23/2018, in part showed staff directives: - To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections. - Before applying gloves and inserting indwelling catheters, peripheral vascular catheters, other invasive devices that do not require a surgical procedure. - After coming in contact with patient’s intact skin, for example, taking a patient’s blood pressure, pulse, lifting/moving the patient. - After coming in contact with bodily fluids, dressings, and mucous membranes. - After contact with medical equipment/supplies in patient areas. - Always after removing gloves or facemasks. - Always follow Standard Precautions. Observation on 11/07/23 at 9:41 AM, showed Staff J, RN, prepared Patient #2 for an intravenous (IV - in a vein) infusion. Staff J removed gloves, however, Staff J failed to perform hand hygiene before re-gloving to administer pre-infusion medications. After Staff J administered medication to the patient, Staff J removed gloves, however, Staff J failed to perform hand hygiene after glove removal and before typing on the computer keyboard. Staff J applied patient identification stickers to two blood collection tubes that contained the patient’s blood and transported the two blood collection tubes with blood to the laboratory. Staff J handled the two blood collection tubes without gloves and transported the two tubes with blood to the laboratory without being contained in a bio-hazard bag. Staff’s failure to wear gloves to place patient identification stickers on the two tubes that contained the patient’s blood increased Staff J’s risk of being exposed to the patient’s blood. Staff’s failure to place the two tubes with blood into a bio-hazard bag to transport to the laboratory increased the risk of blood exposure to everyone Staff J passed on the way to the laboratory. Observation on 11/07/23 at 10:37 AM, showed Staff J, RN, administered Patient #2’s IV infusion. After Staff J administered IV medication, Staff J removed gloves, however, Staff J failed to perform hand hygiene after removal of gloves. After Staff J removed gloves, Staff J took the patient’s vital signs (blood pressure, pulse and temperature) and at the completion of obtaining the patient’s vital signs, Staff J failed to perform hand hygiene. Observation on 11/07/23 at 11:10 AM, showed Staff J, RN, administered intramuscularly (IM - within the muscle) medications to Patient #3. After Staff J prepared the IM medications, Staff J removed gloves, however, Staff J failed to perform hand hygiene before re-gloving to administer the IM medications to the patient. Observation on 11/08/23 at 9:33 AM, showed Staff J, RN, prepared Patient #5 for medication administration per the patient’s port (port - a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) access. During the procedure of cleaning, accessing and administrating medication per the patient’s port access, Staff J removed gloves four times, however, Staff J failed to perform hand hygiene after each removal of gloves and before re-gloving. Staff’s failure to perform hand hygiene after removal of gloves increased the risk of the gloves becoming contaminated from failure to perform hand hygiene after removal and before re-gloving. During an interview on 11/08/23 at 12:56 PM, Staff J, RN, stated the infusion clinic did not provide containers to dispense hand sanitizer in each of the patient care stations, which increased her difficulty in following infection control practices when she provided various cares, treatments and administration of medications for patients. Staff J stated because of the lack of hand sanitizing dispensers it was difficult for her to perform the various task needed for patients when they received care in the patient care stations. Staff J stated when she removed gloves, she always ensured she re-gloved between task due to the inaccessibility to perform hand hygiene after glove removal and before re-gloving in the patient care stations. Staff J stated she at least removed gloves after task that required gloves to be changed between tasks. Staff J stated she received infection control training/education and staff was expected to perform hand hygiene before gloving, after glove removal and after any contact made with a patient. Observations made of the infusion clinic on 11/07/23 and 11/08/23 showed no hand sanitizer dispensers located in any of the patient care stations for either staff or patients to perform hand hygiene when needed/required. The lack of the infusion clinic to provide hand sanitizing dispensers located in each patient care station increased the risk for cross-contamination and infections to patients, visitors and staff. During an interview on 11/8/23 at 3:31 PM, Staff D, RN, ICP, QA, stated staff was expected to perform hand hygiene before gloving, after removal of gloves and before re-gloving. Staff D stated staff was expected to follow the facility’s policy related to hand hygiene and glove use. 3. Review of the facility’s policy titled, “Sterile Compounding/IV Admixture,” revised 04/11/23, in part showed staff directives: Compounding in the Mobile Isolation Chamber (MIC) - Assemble all materials (medications, diluents, IV solutions, syringes, needles, sterile wipes, security seals) needed for the complete preparation of the final product. - Perform hand washing and don personal protective equipment if required. - Place the assembled non-paper items into a plastic try (that has been previously sanitized). Remove the outer wrap of any IV solutions. Mist or wipe with the designated sanitizing agent before introduction into the MIC. - Verify the inner airlock door is closed. Place the tray(s) into the outer chamber and close and latch the outer airlock door. - Enter the MIC through the glove/sleeve ports. Verify the outer airlock door is closed. - Open the interior airlock door and transfer the tray into the MIC. - Begin the sterile compounding preparation using proper procedures and aseptic technique. - Verify that the outer airlock door is closed. Place the finished preparation, the additive(s) and diluent(s) into the tray. Place into the airlock chamber. - Verify the inner airlock door is closed and remove the finished preparation. - Document the date and time compounded on the IV label and the IV compounding log next to the hood. Staff Training All personnel preparing sterile preparations in the MIC must review the MIC Annual Refresher Course provided by Containment Technologies Group prior to operating the MIC and annually thereafter. MIC operation competency will be assessed with a ten question quiz. Exam scores will be kept on file in the employee’s file in human resources. Observation on 11/07/23 at 10:14 AM showed Staff J, RN,: - Prepared Patient #2’s IV infusion medication for immediate-use per sterile compound method utilizing the MIC. - Failed to perform hand hygiene before she put on gloves and retrieved the plastic bin from the outer airlock chamber. - After removal of the plastic bin from the outer airlock chamber, Staff J placed the plastic bin on top of the medication dispensing system and retrieved supplies and medication needed to mix the medication for immediate-use. - Failed to disinfect the plastic bin and remove the outer wrappings from the supplies before Staff J placed the supplies into the plastic bin. - Placed the non-disinfected plastic bin and un-wrapped supplies into the outer airlock chamber. - Performed hand hygiene, placed her arms in the MIC sleeves, put on gloves inside the MIC and opened the inner airlock chamber, retrieved the plastic bin, placed it in the inner airlock chamber and closed the outer airlock chamber door. - Removed the supplies from the plastic bin and placed them on the surface of the inner airlock chamber shelf. - Removed the outer wrappings on the supplies (syringes, alcohol pads, needles) and placed the removed wrappings on the inner airlock chamber surface. - After mixing and adding the medication to the IV fluids, Staff J took a pen from the plastic bin and wrote on the IV label and placed it on the IV bag of fluids. Staff J affixed the IV label to the IV fluid bag while still inside the inner airlock chamber. Staff J, RN, failed to: - Perform hand hygiene before putting on gloves to retrieve the plastic bin from the outer airlock chamber and retrieving supplies and medication needed for the IV infusion. - Disinfect the plastic bin after removal from the outer airlock chamber, before placing supplies/medication into the plastic bin and before returning the bin into the outer airlock chamber. - Remove the outer wrappings from supplies before placing them into the plastic bin. - Sanitize the supplies and medication before placing the items into the plastic bin and before returning the plastic bin into the outer airlock chamber. - Write on the IV label and affix it to the IV fluid bag after it had been removed from the MIC. During an interview on 11/07/23 at 2:20 PM, Staff F, Licensed Practical Nurse, Certified Pharmacy Technician, stated when staff used the MIC unit staff was expected to: - Perform hand hygiene. - Retrieve the plastic bin from the outer chamber of the MIC and spray the bin with alcohol. - Gather needed supplies and medication needed for the immediate-use medication to be mixed, place into the plastic bin and spray the items with alcohol and return the plastic bin to the outer chamber. - Remove all jewelry, perform hand hygiene, place arms through the MIC sleeves and put on gloves placed inside the MIC’s main chamber. - If staff have sprayed the items in the plastic bin and the inside chamber with alcohol, staff are allowed to remove the items in the plastic bin and place them on the surface of the inner chamber. - After staff have completed mixing the immediate-use medication, staff are expected to remove the medication from the MIC and then affix the IV label to the IV fluid bag. Staff F stated staff was expected to follow the facility’s policy “Sterile Compounding/IV Admixture”. During an interview on 11/08/23 at 12:56 PM, Staff J, RN, stated: - She received education/training on sterile compounding for immediate-use medication using the MIC yearly during the hospital’s competency fair. - Staff was expected to perform hand hygiene before gloving, after removal of gloves and before re-gloving. - Acknowledged she missed a few steps during the process of sterile compounding for immediate-use medication for Patient #2 on 11/07/23. During an interview on 11/08/23 at 3:31 PM, Staff D, RN, ICP, QA, stated staff was expected to follow the facility’s policies and procedures for infection control. 4. Review of the facility’s document titled, “IV Testing Log 2023,” showed Staff J, RN, had completed sterile compounding media fill kit, gloved fingertip test and written exam on 05/01/23 and successfully passed all required testing.”

“QAPI CFR(s): (d) Standard: Program activities. For each of the areas listed in paragraph (b) of this section, the CAH must:] (2) Use the measures to analyze and track its performance. This Standard is not met as evidenced by: 16639 Based on record review and interview, the facility failed to use measurable data to develop plans to continuously analyze, correct, and track performance for problem prone areas. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings include: 1. Review of the facility’s document titled “1st quarter 2023-2024 Agenda” for the quality and performance improvement committee (QAPI), dated 11/08/23, under old business from the previous quarter showed quality assurance issues at less than 80% compliance. This included areas such as: - Medical Floor the sepsis protocol was started; - Centers for Medicare/Medicaid measures; - Dietary pantry temperatures; - Swing bed history and physical within 24 hours; and - Infection Control for four areas; Under new business for the category of the current quarter at less than 80% showed similar issues for: - CMS core measures; - Dietary pantry temperatures; and - Infection control with three issues. For areas identified the only comment was the issues were to be reported to the appropriate committee at the next meeting. 2. Review of the facility’s document titled, “Quality and Performance Improvement Plan,” dated 08/03/23, showed under plan organization and structure the QAPI committee was to report findings and improvements made to patient care services through implementation of the plan to the Board on a quarterly basis. Under the section Department Manager Responsibility showed they should report problem identification, identification of corrective actions, implementation of corrective actions, evaluation of corrective actions and measures to improve quality on a continual basis. 3. During an interview on 11/08/23 at 2:30 PM. Staff D, Quality Assurance, stated the areas in need of improvement discussed in the quality assurance committee did not have formal plans to correct identified issues. They track the current compliance or non-compliance during the meetings but don’t have a formal plan for each item to identify corrective actions needed or have a method to track progress from one meeting to the next. Items identified as less than 80% compliance should be improved.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 16639 Based on record review and interview the facility failed to ensure a disaster plan was developed using a hazard risk assessment to include natural and man made disasters. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. Review of the facility’s document titled, “Systems Risk Assessment Tool,” for 2023 and 2024 showed an assessment for each patient room and the risk from loss of utilities such as electrical, vacuum, and water. (note: the form did not include natural disasters such as tornado, severe weather, or man made disasters). 2. During an interview on 11/08/23 at 12:50 PM, Staff H, Maintenance Team Lead, stated they did not do a risk assessment for natural disasters and the level of risk to the facility to develop policies accordingly.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 16639 Based on observation, interview, and record review the facility failed to ensure the extinguishment system for the kitchen hood was inspected routinely and could be operated as designed when needed. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. Observation on 11/07/23 at 9:13 AM, the manual pull which activated the kitchen extinguishment system was blocked by a refrigerator. Interview upon observation with Staff G, Maintenance Team Lead Assistant, confirmed the pull could not be activated as it was blocked by the refrigerator. 2. During an interview on 11/08/23 at 10:15 AM, Staff H, Maintenance Team Lead, stated it was not clear if the most recent fire system inspection included the kitchen extinguishment system and the previous inspection before that was dated 06/01/21. 3. Review of the facility’s policy titled, “Kitchen Hood Automatic Fire Extinguisher System,” dated 05/23/17, showed the system was to be inspected every six months.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 16639 Based on interview and National Standards the facility failed to ensure a check of the fire alarm system was performed annually. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. During an interview on 11/07/23 at 9:30 AM, Staff G, Maintenance Team Lead Assistant, stated after a phone call with the fire alarm isnpection company the most recent inspection believed to have happened only checked the fire extinguishers and the fire alarm system was not checked. At 10:40 AM Staff G confirmed the most recent inspection would have been due on 08/04/23 and the last full inspection was done in 06/01/21. 2. Review of the National Fire Protection Association (NFPA) code 72, 2010 edition, showed fire alarm systems should be inspected in accordance with table 14.4.5. The table showed an annual inspection should be performed for the entire system annually.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 16639 Based on interview, record review, and observation the facility failed to ensure all fire doors were repaired and maintained in a fully functional manner. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six. Findings included: 1. During an interview on 11/07/23 at 8:30 AM, Staff G, Maintenance Team Lead Assistant, stated the fire doors had received an inspection earlier in the year and confirmed five doors were indicated on the report as being in need of repair and any needed repairs had not yet been done. 2. Review of the facility’s report of the most recent fire door inspection dated 04/17/23 showed five of 11 doors had repairs needed and listed these as three being critical and two being immediate. 3. Observation on 11/08/23 showed a set of double doors between the kitchen and the dining area to have a broken closer on one of the doors and a wedge of cardboard holding the door open. The set of double doors near the rehabilitation and administration area did not completely close when released from the magnetic hold opens and had an approximately one inch gap.”