Washington County Memorial Hospital

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 50151 Based on observation, interview, record review and policy review, staff failed to follow the hospital’s policy to ensure: - Staff verified medications prior to administration for all patients cared for in the Emergency Department (ED). - The safe administration of high alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) for one current patient (#1) of one patient who received a high alert medication. - ED nurses administered medications after the medication order was reviewed and approved by the pharmacist for two current patients (#9 and #16) of two current patients observed. The hospital census was 12, including swing beds. These failed practices resulted in a systemic failure and noncompliance with 42 CFR Subpar F 485.635 Condition of Participation (CoP): Provision of Services. Please refer to C-1049.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 50151 Based on observation, interview, record review and policy review, staff failed to follow the hospital’s policy to ensure: - Staff verified medications prior to administration for all patients cared for in the Emergency Department (ED). - The safe administration of high alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) for one current patient (#1) of one patient who received a high alert medication. - ED nurses administered medications after the medication order was reviewed and approved by the pharmacist for two current patients (#9 and #16) of two current patients observed. Findings included: Review of the hospital’s undated policy, “Medication Safety High-Alert Medications,” showed: - High risk or high alert medications were drugs involved in a high percentage of medication errors. - High risk drugs were to be stored separately from each other to avoid errors in drug selection. Different brands of insulin (a hormone that regulates the amount of sugar in the blood) would be stored separately. - Hospital committees developed strategies designed to promote the safe and effective use of high alert drugs. - A double check system should be implemented for the nursing service for preparing a dose of insulin. Review of the hospital’s undated policy, “Insulin Administration,” showed: - Prior to a dose of insulin being administered, a separate independent double check must be performed by two nurses. - The two nurses who performed the independent double check, must individually confirm/verify all components of the rights of medication administration. - The rights of medication administration included right patient; right drug; right dose; right route; and right time. - Each nurse independently reviewed the prescribed insulin order and calculations, used to determine the dose of insulin to be administered. - The two nurses’ findings were to be compared to the other’s, prior to the insulin dose being administered. - The insulin dose could be administered if both nurse’s finding matched. - The process was stopped and any identified issues resolved, prior to the insulin dose being administered. Review of the hospital’s policy, “Drug Preparation/ Dispensing,” dated 03/08/25, showed: - Drug preparation and dispensing was restricted to a licensed pharmacist or a designee under the direct supervision of a pharmacist. - The pharmacist was to review the appropriateness of all medication orders for drugs to be dispensed in the hospital. That included removal of medications from floor stock or from an automated medication storage distribution machine. - A pharmacist or authorized personnel under the direction of the pharmacist will fill and label containers from which drugs are to be distributed or dispensed. - In rare clinical situations such as an emergency when time does not permit a pharmacist’s review, a nurse may telephone the pharmacist for a new order and approval to administer a drug. - When an order was written when the pharmacy was closed and in the absence of a pharmacist, a healthcare professional determined to be qualified by the hospital will review the medication order. Observation with concurrent interview, on the medical-surgical floor, on 10/27/25 at 12:40 PM, showed: - Patient #1’s blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s normal range for a patient with diabetes [a disease that affects how the body produces or uses blood sugar and can cause poor healing] is 80 to 180) was 353. That blood glucose value required 12 units of Novolog (a rapid-acting blood glucose lowering medication) per the physician’s orders. - Staff G, Registered Nurse (RN), drew up 12 units of Novolog from a multi-dose vial. - Staff G checked Patient’s #1’s medical record in the patient’s room and verified the correct patient and correct dose. The patient and the medication were not scanned prior to administration. - There was no second nurse verification prior to the high alert medication being administered. - Staff G stated that insulin was unable to be scanned and she usually had a second nurse verify the dose prior to administering it, but the electronic medical record (EMR) did not require a witness to verify the medication administered and insulin could not be scanned prior to being administered. Observation with concurrent interviews on 10/28/25 at 9:40 AM, showed: - Staff U, RN, drew up and administered 15 units of Lantus (a long-acting blood glucose lowering medication) from a multi-dose vial in the medication room for Patient #1. - The medication was not scanned nor was a witness obtained to verify the order, medication or dose administered. - Staff U stated that she looked at the patient’s orders before she entered the medication room and remembered that 15 units were ordered and typed that amount into the automated medication storage distribution machine. Insulin was not a medication that was set up to be scanned and she triple checked it because it made her nervous. During an interview on 10/29/25 at 3:27 PM, Staff L, Pharmacy Director, stated that he didn’t believe insulin was a medication which required a witness to verify the dose administered prior to administration. The hospital had a high alert medication list that they would be reviewing to ensure a process would be set-up for high alert medication to require a barcode scan and witness verification prior to the dose being administered. Observation and concurrent interview, in the ED, on 10/28/25 at 1:25 PM, showed: - Staff W, RN, received a verbal order from the physician to administer a dose of Meclizine (a medication used to treat motion sickness and vertigo [dizziness or lightheadedness]) and lorazepam (a medication used to treat anxiety or sleep difficulty) to Patient #9. - Immediately after the verbal order was received, Staff W removed the oral medication from the automated medication storage distribution machine and administered it to Patient #9. - The patient’s name and date of birth were verified verbally but neither the patient nor medication was scanned. - Staff W stated that she was unsure if the order had been placed into the electronic health record yet. Both physicians and nurses entered verbal orders. There was no way for staff to scan patient medications in the ED. Observation in the ED on 10/29/25 at 11:50 AM, showed: - Staff Y, Charge Nurse, received a verbal order from the physician for Patient #16 to receive a dose of aspirin (blood thinner that can also treat pain, fever, headache and inflammation). - Immediately after the verbal order was received, Staff Y removed the medication from the automated medication storage distribution machine. The medication was not reviewed or approved by a pharmacist. - Staff Y administered the medication to Patient #16, then entered the verbal order and charted the medication as administered. During an interview on 10/28/25 at 3:00 PM, Staff A, ED and Medical-Surgical Nurse Manger, stated that: - ED patients did not have a patient specific medication profile, as ordered by the ED provider, set-up within their automated medication storage distribution machine. - When an ED nurse removed medications for an ED patient, every medication stocked in the medication storage distribution machine could be removed. - She expected the ED nurses to enter a verbal medication order into the computer prior to the medication being removed and administered. - Medications should not be removed and administered without an order being placed in the computer, unless it was an emergency. - They currently were unable to scan medication in the ED. During an interview on 10/29/25 at 4:22 PM, Staff O, Chief Nursing Officer (CNO), stated that she expected all staff to follow the hospital’s policies and procedures, at all times. 51509”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49404 Based on interview, record review and policy review the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#3) and ensure that an emergency medical condition (EMC) was stabilized for two patients (#3 and #24) of 24 Emergency Department (ED) records reviewed from 10/01/24 through 06/16/25. 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, “EMTALA Guidelines,” revised 03/05/24, showed: - All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists. - A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient’s chief complaint. An appropriate examination including the presenting complaint, potentially affected systems and known chronic conditions should also be included. - The results of any diagnostic tests and the resulting diagnosis must be assessed and validated. - Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines “stabilized” as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient. - The hospital must not transfer or discharge patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. Review of the hospital’s policy titled, “Guidelines Regarding MSEs,” reviewed 02/28/24, showed: - The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC. - Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE. - Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist. - Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient’s status at any given time while the patient is being evaluated and treated. - When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital. 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: 49404 Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#3) of 24 Emergency Department (ED) records reviewed from 10/01/24 through 06/16/25. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “EMTALA Guidelines,” revised 03/05/24, showed: - All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists. - A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient’s chief complaint. An appropriate examination including the presenting complaint, potentially affected systems, and known chronic conditions should be included. - The results of any diagnostic tests and the resulting diagnosis must be assessed and validated. - Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines “stabilized” as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient. - The hospital must not transfer or discharge patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. Review of the hospital’s policy titled, “Guidelines Regarding MSEs,” reviewed 02/28/24, showed: - The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC. - Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE. - Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist. - Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient’s status at any given time while the patient is being evaluated and treated. - When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital. Review of Patient #3’s medical record, dated 12/08/24, showed: - On 12/07/24 at 10:37 PM, a 21-year-old presented to the ED with a chief complaint of a cough, vomiting, and “feeling like passing out.” - His past medical history included polycythemia rubra vera (a rare, chronic blood cancer where the bone marrow produces too many red blood cells. This overproduction thickens the blood, potentially leading to complications like blood clots, stroke, or heart attack). - He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). - His skin color was ashen and jaundiced (yellowing of the skin or whites of the eyes that may occur if the liver can’t efficiently process red blood cells as they break down). - He reported that he became short of breath with exertion, had slight chest pain, and described his cough as mild. - Laboratory tests were ordered. - His examination showed crackles (irregular clicking, popping or rattling lung sounds) in his right lung. - At 10:48 PM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 113/73. - On 12/08/24 at 12:10 AM, his BP was 87/46, and he received one liter of intravenous (IV, in the vein) fluid. - At 12:11 AM, his oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) dropped below 90%, and supplemental oxygen was administered. - At 1:05 AM, a chest 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 moderate diffuse body wall edema (swelling) and a small amount of free fluid in the abdomen/pelvis that were evidence for fluid overload. - At 1:12 AM, his BP was 108/71 and his oxygen saturation was 94%. His blood tests showed his cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) were elevated. - At 1:36 AM, he received one liter of IV fluids. - At 1:42 AM, his BP was 90/44 and his oxygen saturation was 94%. - At 4:54 AM, Hospital B (an acute care hospital) was contacted regarding his transfer. - At 5:44 AM, he was accepted for transfer by Hospital B. - At 6:12 AM, his BP was 78/60. - At 6:22 AM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed. It showed a heart rate of 117, an incomplete right bundle branch block (condition caused by a blocked electrical pathway in the heart), right atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected), and right ventricular hypertrophy (a condition where the walls of one or both ventricles of the heart become thicker than normal). - At 6:33 AM, he received 500 milliliters of IV fluids. - At 6:42 AM, his BP was 105/39 and his oxygen saturation was 93%. - At 7:11 AM, his BP was 99/63 and his oxygen saturation was 94%. - At 7:14 AM, he departed via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to Hospital B with a diagnosis of polycythemia rubra vera and fluid overload. Review of Patient #3’s EMS report, dated 12/08/24, showed: - At 7:17 AM, EMS picked up the patient from the ED for transport to Hospital B. His BP was 104/73, his oxygen saturation was 93% and he was receiving supplemental oxygen. He was A&O X 3 and had no complaints of pain or distress. - At 8:01 AM, EMS arrived at the ED entrance of Hospital B. The patient stated that he was having trouble breathing and became unresponsive. He aroused and spoke to EMS, then became unresponsive again. He briefly responded to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response). - At 8:05 AM, EMS brough the patient into the ED and notified staff that the patient was deteriorating. He began agonal breathing (gasping, labored breathing) and his pulse could not be detected. - EMS and Hospital B staff initiated cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped). - At 8:21 AM, the patient expired. Review of Patient #3’s Hospital B medical record, dated 12/08/24, showed Patient #3 arrived at 8:05 AM breathless, unresponsive and pulseless with CPR in progress. He expired at 8:21 AM. During an interview on 06/17/25 at 3:00 PM, Staff H, Physician, stated that Patient #3 was a complicated case. Initial concerns based on blood tests, including elevated cardiac enzymes, was that the patient was dehydrated, and IV fluid administration was the best approach. Patient #3 began having low BPs, which responded to the IV fluids. He had crackles upon admission and his chest CT scan showed evidence of fluid overload, but Staff H canceled the order for a diuretic (medication that promotes the production and excretion of urine) due to Patient #3’s low BP. The CT scan did not show evidence of pulmonary edema (an abnormal buildup of fluid in the lungs). Patient #3 appeared to be stable and ready for transport to Hospital B. No other interventions were used to manage this BP. Staff H evaluated the ECG when it was performed, he did not know why and ECG was not done upon Patient #3’s arrival and prior to the administration of IV fluids. During an interview on 06/17/25 at 4:50 PM, Staff M, Medical Director, stated that the hospital did not have a cardiologist (a physician that specializes in the care of your heart and blood vessels) on call. ED staff would attempt to reach a patient’s cardiologist if they had one or reach out to other hospitals to discuss a transfer if there was a need.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 49404 Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#3 and #24) of 24 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “EMTALA Guidelines,” revised 03/05/24, showed: - All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists. - A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient’s chief complaint. An appropriate examination including the presenting complaint, potentially affected systems, and known chronic conditions should be included. - The results of any diagnostic tests and the resulting diagnosis must be assessed and validated. - Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines “stabilized” as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient. - The hospital must not transfer or discharge patients who are potentially unstable if the hospital has the capabilities to provide treatment and care to the patient. Review of the hospital’s policy titled, “Guidelines Regarding MSEs,” reviewed 02/28/24, showed: - The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC. - Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE. - Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist. - Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient’s status at any given time while the patient is being evaluated and treated. - When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital. Review of Patient #3’s medical record, dated 12/08/24, showed: - On 12/07/24 at 10:37 PM, a 21-year-old presented to the ED with a chief complaint of a cough, vomiting, and “feeling like passing out.” - His past medical history included polycythemia rubra vera (a rare, chronic blood cancer where the bone marrow produces too many red blood cells. This overproduction thickens the blood, potentially leading to complications like blood clots, stroke, or heart attack). - He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). - His skin color was ashen and jaundiced (yellowing of the skin or whites of the eyes that may occur if the liver can’t efficiently process red blood cells as they break down). - He reported that he became short of breath with exertion, had slight chest pain, and described his cough as mild. - Laboratory tests were ordered. - His examination showed crackles (irregular clicking, popping or rattling lung sounds) in his right lung. - At 10:48 PM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 113/73. - On 12/08/24 at 12:10 AM, his BP was 87/46, and he received one liter of intravenous (IV, in the vein) fluid. - At 12:11 AM, his oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) dropped below 90%, and supplemental oxygen was administered. - At 1:05 AM, a chest 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 moderate diffuse body wall edema (swelling) and a small amount of free fluid in the abdomen/pelvis that were evidence for fluid overload. - At 1:12 AM, his BP was 108/71 and his oxygen saturation was 94%. His blood tests showed his cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) were elevated. - At 1:36 AM, he received one liter of IV fluids. - At 1:42 AM, his BP was 90/44 and his oxygen saturation was 94%. - At 4:54 AM, Hospital B (an acute care hospital) was contacted regarding his transfer. - At 5:44 AM, he was accepted for transfer by Hospital B. - At 6:12 AM, his BP was 78/60. - At 6:22 AM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed. It showed a heart rate of 117, an incomplete right bundle branch block (condition caused by a blocked electrical pathway in the heart), right atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected), and right ventricular hypertrophy (a condition where the walls of one or both ventricles of the heart become thicker than normal). - At 6:33 AM, he received 500 milliliters of IV fluids. - At 6:42 AM, his BP was 105/39 and his oxygen saturation was 93%. - At 7:11 AM, his BP was 99/63 and his oxygen saturation was 94%. - At 7:14 AM, he departed via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to Hospital B with a diagnosis of polycythemia rubra vera and fluid overload. Review of Patient #3’s EMS report, dated 12/08/24, showed: - At 7:17 AM, EMS picked up the patient from the ED for transport to Hospital B. His BP was 104/73, his oxygen saturation was 93% and he was receiving supplemental oxygen. He was A&O X 3 and had no complaints of pain or distress. - At 8:01 AM, EMS arrived at the ED entrance of Hospital B. The patient stated that he was having trouble breathing and became unresponsive. He aroused and spoke to EMS, then became unresponsive again. He briefly responded to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response). - At 8:05 AM, EMS brough the patient into the ED and notified staff that the patient was deteriorating. He began agonal breathing (gasping, labored breathing) and his pulse could not be detected. - EMS and Hospital B staff initiated cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped). - At 8:21 AM, the patient expired. Review of Patient #3’s Hospital B medical record, dated 12/08/24, showed Patient #3 arrived at 8:05 AM breathless, unresponsive and pulseless with CPR in progress. He expired at 8:21 AM. During an interview on 06/17/25 at 3:00 PM, Staff H, Physician, stated that Patient #3 was a complicated case. Initial concerns based on blood tests, including elevated cardiac enzymes, was that the patient was dehydrated, and IV fluid administration was the best approach. Patient #3 began having low BPs, which responded to the IV fluids. He had crackles upon admission and his chest CT scan showed evidence of fluid overload, but Staff H canceled the order for a diuretic (medication that promotes the production and excretion of urine) due to Patient #3’s low BP. The CT scan did not show evidence of pulmonary edema (an abnormal buildup of fluid in the lungs). Patient #3 appeared to be stable and ready for transport to Hospital B. No other interventions were used to manage this BP. Staff H evaluated the ECG when it was performed, he did not know why and ECG was not done upon Patient #3’s arrival and prior to the administration of IV fluids. During an interview on 06/17/25 at 4:50 PM, Staff M, Medical Director, stated that the hospital did not have a cardiologist (a physician that specializes in the care of your heart and blood vessels) on call. ED staff would attempt to reach a patient’s cardiologist if they had one or reach out to other hospitals to discuss a transfer if there was a need. Review of Patient #24’s medical record, dated 05/15/25, showed: - She was a 68-year-old with a past medical history of an abdominal aortic aneurysm (an excessive localized enlargement of an artery caused by a weakening of the artery wall), high blood pressure, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), and pneumonia (infection in the lungs). - On 05/15/25 at 7:45 PM, she presented to the ED via EMS with a chief complaint of shortness of breath, possible fever and pneumonia. EMS was unable to obtain IV access. - At 7:48 PM, her BP was 45/29 and the physician was notified. - At 7:56 PM, an ECG was completed. - At 7:57 PM, her BP was 102/44. - At 7:58 PM, a peripheral venous catheter (a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg, or foot] or in a vein in the scalp) was inserted into her ankle. - At 8:05 PM, one liter of IV fluids was administered. - At 8:15 PM, her BP was 78/48. - At 8:27 PM, the physician was at bed side. - At 8:31 PM, blood tests were drawn including blood cultures (a laboratory test to check for bacteria or other germs in a blood sample), complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and troponin (a type of blood test that measures whether or not a person is experiencing a heart attack). - At 8:48 PM, her BP was 80/50, she was noted to be diaphoretic (excessive, abnormal sweating), and multiple attempts were made for additional IV access, without success. - At 8:54 PM, a chest x-ray was completed that showed no acute abnormality. - At 9:01 PM, the physician was notified of the Patient #24’s continued low BP. - At 9:15 PM, the patient’s white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) resulted as 16.3, the normal range was 4.5 to 10.5. - At 9:16 PM, her BP was 62/28. - At 9:20 PM, one liter of IV fluids was administered. - At 9:32 PM, her troponin resulted as 520.8, the normal range was 8.4 to 18.7. - At 9:49 PM, nursing staff began contacting other hospitals to arrange transfer to a higher level of care. - At 10:03 PM, Hospital B accepted Patient #24 for transfer. - At 10:15 PM, ceftriaxone (antibiotic) was administered. - At 10:16 PM, her BP was 75/39. - At 10:25 PM, report was called by the nurse to Hospital B. - At 10:36 PM, her BP was 82/41 and the physician was notified by the nurse of her continued low BP and single IV access. A 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) was suggested. - At 10:37 PM, family declined placement of a central line and the CT scan of her abdomen. - At 10:46 PM, her BP was 83/36. - At 10:40 PM, one liter of IV fluids was administered. - At 10:50 PM, the patient left the ED via EMS for transfer to Hospital B. Review of Patient #24’s medical record from Hospital B, dated 05/20/25, showed: - On 05/15/25 at 11:38 PM, she presented to the ED via EMS with a chief complaint of low blood pressure. Norepinephrine bitrate (medication used to treat patients with very low blood pressure) was infusing into her ankle IV. EMS had initiated the medication to support her blood pressure during transfer. - At 11:42 PM, her BP was 91/57 and the norepinephrine bitrate infusion continued. - Laboratory testing, an abdominal CT scan, head CT scan, chest x-ray, and antibiotics were ordered. - The abdominal CT scan indicated an abdominal aortic aneurism, an esophagus (a muscular tube that food travels through from the throat to reach the stomach) mass, and a pelvic mass. - At 1:03 AM, a central line was placed for administration of norepinephrine bitrate and other medications. - At 4:34 AM, she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for treatment of sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs). Review of the hospital’s undated document titled, “SBAR review,” showed the hospital received a complaint from Patient #24’s daughter concerning her mother’s care. The concerns included inadequate venous access, lack of blood pressure support and lack of monitoring. Norepinephrine bitrate was not initiated by hospital staff. EMS initiated the medication during transport to Hospital B. The patient’s RN was interviewed, and she stated that she was concerned about the patient’s BP and only having a single IV in her ankle. The nursed notified the physician of her concerns and repeatedly updated him of the patient’s continued low BP and the need for a central line. During a telephone interview on 06/17/25 at 5:55 PM, Staff N, RN, stated that Patient #24’s BP and lack of IV access was an immediate concern and that she went to the physician multiple times about both issues. IV access for the patient was very difficult and she “felt lucky” to establish an IV in the patient’s ankle. She sought assistance from other staff, including calling in the Nurse Manager from home, but they were all unsuccessful. The physician was aware of the IV access issue upon Patient #24’s admission to the ED and eventually agreed to place a central line. The family refused the line placement because she was transferring out and they had lost confidence in the care she was receiving. During an interview on 06/17/25 at 1:40 PM, Staff A, RN Manager, stated that she was called in from home to assist with patient #24. She and other staff members attempted to place an additional IV but were unsuccessful. She discussed central line placement with the physician and set up supplies, but the patient’s family did not want to wait any longer and wanted her transferred as soon as possible. She did not know why IV access wasn’t addressed by the physician sooner. During a telephone interview on 06/17/25 at 3:55 PM, Staff K, Physician, stated that Patient #24’s BP was a concern but was “moving in the right direction” after she received fluids and antibiotics. He did not initiate any other medications for her blood pressure because she responded to the IV fluids and the antibiotics covered possible sepsis. Hospital B thought she was appropriate for transport. EMS had norepinephrine bitrate if it was needed during transport. In retrospect the patient should have had more access, and a central line would have been preferred.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 36473 Based on observation, interview, record review and nationally-recognized standards review, the hospital failed to perform fire-risk assessments for one current patient (#9) and five discharged patients (#4, #5, #6, #7 and #8) prior to surgical procedures. These failures placed all surgical patients and staff at an elevated fire-risk.The hospital census was five Acute Care Patients, three 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 two Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of 10. Findings Included: 1. Observation on 03/11/24 at 1:30 PM, in the Operating Room Suite, showed during Patient #9’s Esophagogastroduodenoscopy (EGD, a procedure that visualizes the oropharynx, esophagus, stomach and duodenum) with biopsies, the staff failed to perform a fire-risk assessment 2. During an interview on 03/12/24 at 3:45 PM, Staff A, Nurse Manager of Surgical Services, stated they were unaware of the need for fire-risk assessments and have no policy. 3.Review of Patient #4’s medical record, dated 11/02/24 for a left knee arthroscopy (a procedure to view the joint) with excision, showed no fire-risk assessment was performed. 4.Review of Patient #5’s medical record, dated 11/02/23 for a left carpal tunnel (irritation of the median nerve in the wrist) release and Guyon’s canal (distal portion of the ulnar nerve) release, showed no fire-risk assessment was performed. 5.Review of Patient #6’s medical record, dated 10/03/23 for a sebaceous cyst (a fluid filled, noncancerous lump beneath the skin) removal, showed no fire-risk assessment was performed. 6.Review of Patient #7’s medical record, dated 02/22/24 for an EGD with biopsies and colonoscopy (an exam of the large intestine and rectum) with biopsies, showed no fire-risk assessment was performed. 7.Review of Patient #8’s medical record, dated 11/27/23 for a colonoscopy, showed no fire-risk assessment was performed. 8. Review of the Association of PeriOperative Registered Nurses (AORN) “Guidelines for Fire Prevention Practices,” dated 2023, showed the direction for staff to: - Perform a fire-risk assessment as part of the preprocedural briefing process, to include ignition, fuel, and oxidizer sources present in the Operating Room (OR). - Include cognitive aids (eg, algorithms, checklists). - Collaborate on and implement interventions based on the fire-risk assessment. - Document the fire-risk and the actions taken to address them. - Prevent contact between fuel sources (eg, drapes, skin antisepsis agents) and ignition sources (eg, electrosurgical devices). - Prevent pooling of flammable skin antiseptic agents under, on, or near the patient. - Prevent the pooling of flammable antiseptic agents by: *Placing sterile or clean towels near the surgical preparation site to absorb excess solution from pooling; *Using sterile towels to absorb excess solution from the prepped site; *Removing materials (eg, sterile or clean towels) that become wet with the skin preparation solution before draping; *Moving flammable antiseptic soaked materials away from ignition sources and outside of the patient care vicinity (ie, at least 6 feet away); *Allow the skin antiseptic agent to dry before applying surgical drapes and follow the manufacturer’s IFU for dry time; *Use a water-soluble gel for the patient’s head and hair when performing procedures that involve the head of neck.; and *Use moistened radiopaque sponges near oxidizer and ignition sources during airway procedures. The operating room contains several elements of the fire triangle, including oxygen (oxidizer), lasers and electrosurgical devices (ignition sources), and alcohol-based skin antiseptics and surgical drapes (fuel). The perioperative team can help reduce the risk of fire by performing a fire-risk assessment and implementing interventions (eg, preventing contact between fuel sources and ignition sources) based on that assessment.”

“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: 36473 Based on policy review, review of the Missouri Food Code and nationally-recognized standards review, observation and interview, the hospital failed to ensure staff maintained a sanitary environment was preserved through maintenance and cleaning that would not harbor bacteria and transmit infections in the kitchen, surgical hallway and the Central Sterile areas. The facility also failed to ensure staff performed hand hygiene (washing hands with soap and water or use of appropriate hand sanitizer) when indicated, wore gloves when indicated, performed hand hygiene after glove removal, and performed hand hygiene before re-gloving during medication administration for four patients (#11, #12, #13, and #14) out of five medication administration observations made of staff administering medication to patients. These failures had the potential to expose patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was five Acute Care Patients, three 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 two Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of 10. Findings included: Kitchen 1. Review of the facility’s policy titled, “Infection Prevention and Control Program,” last revised 10/2021, showed the direction for the infection control nurse to conduct surveillance within the organization and in consultation with other departments to include indications for obtaining microbiological cultures from patients and the environment as indicated. 2. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated 06/03/13, chapter 6, showed surface characteristics of floors, walls and ceiling surfaces should be smooth, durable, and easily cleanable for areas where food establishment operations were conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in-refrigerators, washing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods. 3. Observation on 03/13/24 at 9:30 AM, in the kitchen, showed: - The wall next to the entrance had sticky tape and seven holes. - A window with a large crack. - Caulking around sink was cracked. - Under the garbage disposal sink was two missing floor tiles with exposed glue. - The steam table was unclean on the outside and inside the second warmer was discolored. - One cart with four rusted (reddish-brown oxidation of metal that can harbor bacteria) wheels. - On the right side of the stove was grease and discoloration up the wall to the ceiling. - Inside the ice machine lid was unclean tape with paper and the right corner of the lid was broken with particle board exposed. - A rusted vent above the dishwasher. - The salad bar hinges were unclean. - Two cracked and stained ceiling tiles in the dining area. 4. During an interview on 03/14/24 at 10:30 AM, Staff H, Manager of Food Services, stated they should have reported any repairs needed to maintenance and they followed the Missouri Food Code. Surgical Services 5. Review of the Association for Professionals in Infection Control and Prevention (APIC), “Infection Preventionists Guide to the Operating Room,” dated 2018, showed the operating room environment (surgical hallway and Central Sterile Areas) required surfaces that were smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions with no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways that create environmental reservoirs for microorganisms. 6. Observation on 03/12/24 at 9:00 AM, showed outside of the Operating Room, chipped paint around window frame and door frame. 7. Observation on 03/12/24 at 9:10 AM, showed inside the Central Sterile clean room, drywall damage with particle shedding. 8. Observation on 03/12/24 at 9:15 AM, showed inside the Endoscope Decontamination room, wall damage with particle shedding. 9. During an interview on 03/12/24 at 3:45 PM, Staff A, Nurse Manager of Surgical Services, stated they follow APIC National Standards and she hadn’t put any work orders in. 10. During an interview on 03/13/24 at 11:30 AM, Staff G, Registered Nurse (RN), Infection Preventionist, stated they hadn’t performed environmental rounds for approximately five years, they expected staff to report any maintenance issues to their managers and they round on the surgery and kitchen areas quarterly. They also stated they followed APIC. Hand Hygiene and Gloving 11. Review of the facility’s policy titled, “Handwashing Policy,” dated 03/2022, in part showed staff directives: Use alcohol-based hand sanitizer: - Immediately before touching a patient. - Before performing an aseptic task (i.e., placing an indwelling device) or handling invasive medical devices. - Before moving from work on a soiled body site to a clean body site on the same patient. - After touching a patient or the patient’s immediate environment. - Immediately after glove removal. Wash with soap and water: - When hands are visibly soiled. - After known or suspected exposure to spores. - After contact with blood, body fluids, or contaminated surfaces. There are five key moments that define when a healthcare worker should perform hand hygiene: Before and after patient contact; before aseptic technique (process that is maintained free of germs or bacteria); after body fluid exposure risk; and after contact with patient surroundings. 12. Review of the facility’s policy titled, “Standard Precautions,” dated 03/19/21, in part showed staff directives: - To provide guidelines for interactions between patients and healthcare providers to prevent the transmission of infections agents associated with healthcare delivery. Standard Precautions include: - Hand Hygiene - Gloves: - To be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, and other contaminated items (i.e., equipment). Gloves do NOT take the place of hand hygiene. Hands are to be washed after removing gloves. - Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Safe Injection Practices: - Use aseptic technique to avoid contamination of sterile injection equipment. Care of the Environment: - Surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (i.e., bed rails, over the bed tables) and frequently-touched surfaces in the patient care environment shall be cleaned and disinfected on a more frequent schedule compared to that for other surfaces. - Multi-use electronic equipment, including those items that are used by patients, items used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently shall be cleaned and disinfected on a daily basis. 13. Observation on 03/12/24 at 8:16 AM, showed Staff C, RN: - Prepared medications to administer to Patient #11. - Performed hand hygiene and gloved upon entry into the patient’s room. - Removed the barcode scanner from the computer workstation, touched/scanned the patient’s identification (ID) band, and wearing the same gloves, Staff C scanned the five individual packaged medication’s barcodes. - After Staff C scanned each medication barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient. - Wearing the same gloves, Staff C removed a medication patch from the patient’s back, discarded the old patch, and placed a new medication patch to the patient’s lower back. - Removed gloves, performed hand hygiene, re-gloved, cleansed the IV port with an alcohol pad, and administered medication per intravenous (IV - in a vein) push (IVP - to manually administer a dose of medication through a tube into a vein). - Wearing the same gloves to administer the IVP medication, Staff C prepared subcutaneous (SQ - under the skin) medication to administer to the patient’s lower abdomen. Wearing the same gloves, Staff C cleansed the patient’s lower abdomen with an alcohol pad and administered the SQ medication to the patient’s lower abdomen. - After Staff C administered the SQ medication to the patient’s lower abdomen, Staff C removed gloves, performed hand hygiene, re-gloved, scanned the patient’s ID band, scanned the barcode on the IV antibiotic medication fluid bag, attached the IV antibiotic medication bag to the IV tubing, connected the IV antibiotic medication fluid bag tubing to the IV pump, programmed the IV pump to administer the antibiotic at the ordered rate, and touched the IV pump start function to administer the medication. 14. Observation on 03/12/24 at 8:52 AM, showed Staff O, RN: - Prepared medication to administer to Patient #12. - Performed hand hygiene and gloved upon entry into the patient’s room. - Removed the barcode scanner from the computer workstation in the patient’s room, touched/scanned the patient’s ID band, and wearing the same gloves, Staff O scanned the four individual packaged medication’s barcodes. - Wearing the same gloves worn to scan the patient’s ID band and medication barcodes, Staff O typed on the computer keyboard, then removed each medication from the individual package, placed each medication into a plastic medication cup, handed the plastic medication cup to the patient, and then removed an old medication patch and placed a new one on the patient. - Removed gloves, performed hand hygiene, re-gloved, cleansed the patient’s abdomen with an alcohol pad and administered SQ medication to the patient’s lower abdomen. - Wearing the same gloves to administer the SQ medication, Staff O turned off the IV pump, cleansed the IV port with an alcohol pad, and administered IVP medication. - After Staff O administered the IVP medication, wearing the same gloves, Staff O turned on the IVP pump, programmed the pump, and restarted the IV infusion. - Removed gloves and performed hand hygiene and exited the patient’s room to retrieve requested pain medication from the pharmacy. - Performed hand hygiene upon entry into the patient’s room. - Without gloves, Staff O removed the barcode scanner from the computer workstation in the patient’s room and scanned the patient’s ID band, typed on the computer keyboard, and scanned the barcode on the pain medication. - Performed hand hygiene, gloved, cleansed the IV port with an alcohol pad and administered the IV pain medication. - Wearing the same gloves worn to administer the IV pain medication , Staff O removed the old IV tubing and replaced the old tubing with new tubing. 15. Observation on 03/13/24 at 8:17 AM, showed Staff C, RN: - Prepared medication to administer to Patient #13. - Performed hand hygiene and gloved upon entry into the patient’s room. - Removed the barcode scanner from the computer workstation, touched/scanned the patient’s ID band, and wearing the same gloves, Staff C scanned the seven individual packaged medication’s barcodes. - After Staff C scanned each medication’s barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient. - Wearing the same gloves, Staff C cleansed the IV port with an alcohol pad and administered IVP medication. - Wearing the same gloves, Staff C turned off the alarm on the IV pump. - Twice Staff C removed gloves but failed to perform hand hygiene after each glove removal or before re-gloving. 16. Observation on 0313/24 at 8:40 AM, showed Staff C, RN: - Prepared medication to administer to Patient #14. - Performed hand hygiene and gloved upon entry into the patient’s room. - Removed the barcode scanner from the computer workstation, scanned the patient’s ID band, and wearing the same gloves, Staff C scanned the four individual packaged medication’s barcodes. - After Staff C scanned each medication’s barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient. 17. During an interview on 03/13/24 at 9:12 A, Staff D, RN, Director of Patient Care Services, stated staff was expected to perform hand hygiene when indicated, wear gloves and change gloves when indicated, and 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 “Hand Hygiene” policy and procedure. 18. During an interview on 03/13/24 at 9:13 AM, Staff N, RN, stated: - The facility provided infection control prevention during orientation and yearly. - Staff are expected to perform hand hygiene anytime staff touch something, between patient care/tasks, and when going from one patient’s body part to another part. - Before staff put on gloves, after glove removal, and before re-gloving. - After touching inanimate objects (barcode scanner, computer keyboard, mouse, bed rail, over-the bed table ...) in a patient’s room. 19. During an interview on 03/13/24 at 11:37 AM, Staff G, RN, Infection Preventionist, stated staff are expected to perform hand hygiene: - Upon entry/exit of patients’ rooms. - Before medication prep. - Before gloving, after glove removal and before re-gloving. - Anytime staff touch items in the patient’s room, for example, computer keyboard, computer mouse, barcode scanner, side rails, and over-the-bed table. - After staff use the barcode scanner to scan the patient’s ID band and medication barcodes. - Before staff remove medications from the individual packaging and place into the plastic medication cup. - After staff remove old medication patches and before placing a new patch onto the patient. - When going from one patient body part to another. - After and before staff administer medications of different routes, for example, after administering SQ medications and before staff administer IVP medications or hang IV antibiotic medications. Staff G stated staff was expected to follow the facility’s infection control policy’s related to hand hygiene and standard precautions. 18018”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 16639 Based on interview and policy review the facility failed to ensure a policy or procedure was developed to ensure adequate protection when the fire alarm or sprinkler system was impaired The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10. Findings included: 1. During an interview on 03/13/24 at 8:30 AM, Staff I, Maintenance Lead, stated the facility did not have a policy or procedure when the fire alarm system was out of service that stated to evacuate or implement a fire watch. 2. Review of the facility’s policies showed a fire watch policy but did not contain a policy on what to do when the fire alarm was out of service.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 16639 Based on interview and policy review the facility failed to ensure fire drill evaluations included simulations of actual fire conditions, documented the time of the drill, or evaluated the proficiency of staff participating in the drills. The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10. Findings included: 1. During an interview on 03/13/24 at 10:10 AM, Staff I, Maintenance Lead, stated there is no scenario for the drills for staff to respond to and there is not after action report to evaluate staff response to drills or if they reacted appropriately. The time of the drill was not documented. 2. Review of the drill reports showed staff participating were documented by signature. There was a date for the drill, but a time was not documented for the drill to indicate they had been done at various times of the day.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 16639 Based on interview and record review the facility failed to ensure the monthly generator test included all information required to be documented which would indicate it had been tested under load. The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10. Findings included: 1. During an interview on 03/13/24 at 10:10 AM, Staff I, Maintenance Lead, stated the monthly generator documentation did not include Hertz or Amps. 2. Review of the monthly generator sheets did not show Hertz or Amps indicated on the documents.”

“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 interview, record review and policy review, the hospital failed to: - Follow their internal policy to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#1 and #21) of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24; - Follow their internal policy that addressed discharge for one patient (#1); and - Identify within the hospital’s by-laws or rules and regulations who was a Qualified Medical Person (QMP) to perform a MSE. 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). Findings included: Review of the hospital’s undated 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) Guidelines for Emergency,” showed in the absence of an actual request for services, if a “prudent layperson” observer would believe, based on the individual’s appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies, and the person must be accepted and evaluated for treatment. MSEs should include at a minimum, an examination of known chronic conditions. Review of the hospital’s policy titled, “Guidelines for Discharge,” reviewed 09/2010, showed the purpose of the policy was to discharge patients from the hospital with all possible safety, considerations and courtesy. Nursing personnel should accompany patients to the door and remain with them until he/she has left the hospital. If at discharge or immediately after, a patient develops different symptoms or tells any staff member they have a complaint different than the one they presented with during the initial triage, the ED physician should do a second medical screening. If at any time, the Registered Nurse (RN) determines a patient is not safe for discharge, he/she should discuss their concerns with the ED physician. Review of the hospital’s document titled, “Medical Staff Bylaws,” revised 11/28/23, showed no definition of a QMP authorized to perform a MSE. Review of Patient #1’s medical record showed she was a 44-year-old female, presented to the ED with a chief complaint of headache. She was discharged to the waiting room. During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated that he expected a patient was discharged to a “reasonably safe situation.” He expected staff to speak to a nurse when there was a request for re-evaluation and the nurse would notify the physician. During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that a request for re-evaluation would require a second MSE. A City Police Officer (CPO) was asked to transport Patient #1. The CPO asked that the patient be re-evaluated. Nursing or Physician staff were not notified of the request for re-evaluation. Patient #1 was homeless and was kicked out of her family home. A County Deputy (CD) attempted to transport the patient to the address of which she was kicked out. The patient asked to be let out of the vehicle before she arrived at the address. The patient was later found dead. Review of the hospital’s untitled document, dated 08/14/23 at 3:30 PM, showed Patient #21 called the hospital with a complaint. She was not feeling well after her discharge, was evaluated at Hospital E and diagnosed with two deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that is deep under the skin). Review of Patient #21’s medical record showed she was a 70-year-old female, presented to the ED with a chief complaint of cough with spontaneous onset. She had a history or pulmonary embolism (PE, blood clot in the lung). An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed tachycardia (fast heartrate) of 102 beats per minute. She was discharged home. During an interview on 01/31/24 at 9:00 AM, Staff S, ED Medical Director, stated that a more thorough physical examination of Patient #21 would have revealed another pathway for diagnosis and treatment. A CT angiogram was appropriate, if the physician felt it would change the outcome, for a patient with tachycardia and a history of PE. A more thorough physical exam was the most important. Although requested, Patient #21’s Hospital E medical record was not provided, the hospital was unable to determine where she was evaluated. Please refer to 2406 and 2409 for 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: 48359 Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#1 and #21) of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24. 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). Findings included: Review of the hospital’s undated 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) Guidelines for Emergency,” showed in the absence of an actual request for services, if a “prudent layperson” observer would believe, based on the individual’s appearance or behavior, the individual needs an examination or treatment for a medical condition, EMTALA still applies, and the person must be accepted and evaluated for treatment. MSE’s should include at a minimum, an examination of known chronic conditions. Review of the hospital’s policy titled, “Guideline Regarding the MSE for Mental Health Patients in the ED,” reviewed 10/2010, showed it is the hospital guideline to provide a MSE to all patients presenting with mental health needs within the capabilities of the hospital. Review of the hospital’s policy titled, “Guidelines for Discharge,” reviewed 09/2010, showed if at discharge or immediately after, a patient develops different symptoms or tells any staff member they have a complaint different than the one they presented with during the initial triage, the ED physician should do a second medical screening. Review of Patient #1’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 01/08/24, showed: - The man on the scene stated that he wanted Patient #1 to have a mental health evaluation (MHE). - The man stated that Patient #1 had recently been treated at Hospital B and was treated for a drug overdose. She denied this allegation. - Patient #1 stated she fell the day before; did not believe she struck her head. - Patient #1 was alert and oriented to person, place, city, event, recent holiday and the President. She was unsure of the year. Review of Patient #1’s medical record showed: - On 01/08/24, she was a 44-year-old female. - Her medical history was congenital hydrocephalus (a condition when CSF builds up in the brain and spinal cord), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pneumonia (infection in the lungs), anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn’t go away) and Post Traumatic Stress Disorder (PTSD, a mental health problem you may develop after experiencing traumatic events). - Her surgical history was a ventriculoperitoneal (VP) shunt (a narrow plastic tube that drains excess CSF from the brain into the abdomen) was placed three weeks prior, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and a total hysterectomy (surgical removal of the hollow, pear-shaped organ that is located in a woman’s lower abdomen between the bladder and the rectum). - Her current visit assessment showed Patient #1 had no recent surgery and had not been hospitalized within the last 30 days. - She was homeless. - She denied falling unexpectedly or frequently. Her Morse Fall Risk Screening (a method of assessing a patient’s likelihood of falling) showed she had no history of falls within the last three months. - At 3:40 PM, her pain scale (a score of 0 means no pain, and 10 means the worst pain you have ever felt) assessment was seven out of ten. - No MHE was performed. - At 5:51 PM, the nursing discharge documentation showed the patient’s pain was eight out of ten. Smoking cessation information was not given. The patient left the facility by walking. During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated that he was not informed the boyfriend had requested a MHE. He expected staff to speak to a nurse with a request for re-evaluation and the nurse would then notify the physician. During an interview on 01/29/24 at 10:05 AM, Staff C, ED Manager, stated that she was not aware the police officer had requested a second assessment of the patient. The support staff were to report patient needs to the nurse. During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that a request for re-evaluation would require a second MSE. During an interview on 01/30/24 at 4:15 PM, Staff B, Quality and Risk Director, stated that a request for a re-evaluation would require a second MSE. During an interview on 01/29/24 at 10:40 AM, and a telephone interview on 01/31/24 at 11:00 AM, Staff J, Registered Nurse (RN), stated that she received a verbal report from the Emergency Medical Technician (EMT), she was not informed the boyfriend requested a MHE. During an interview on 02/01/24 at 10:50 AM, Staff U, EMT, stated that she was on the crew that transported Patient #1 to the hospital. The man on the scene stated that he wanted the patient to have a MHE. During an interview on 01/30/24 at 6:25 PM, Staff R, Registration Clerk, stated that Staff W, CPO, came into the ED for an unrelated patient, and was asked to give the patient a ride. Staff W, spoke with the patient. He came back to the registration desk and said, “she’s kind of out of it. Can anyone check on her?” Staff R stated that he needed to talk to a nurse. Staff W then went to speak with Staff N, Emergency Room Technician (ERT), who spoke with the patient and confirmed the address for transport. No staff informed a nurse or physician of the deputy’s request for re-evaluation. Review of the hospital’s untitled document, dated 08/14/23 at 3:30 PM, showed Patient #21 called the hospital and reported a complaint. She was not feeling well after her ED discharge on 07/31/23, was seen at Hospital E and diagnosed with two deep vein thrombosis (DVT, the formation of a blood clot in a blood vessel that is deep under the skin). Review of Patient #21’s medical record showed: - On 07/31/23 at 4:45 PM, she was a 70-year-old female who presented to the ED with a chief complaint of cough with spontaneous onset. - She had a past medical history of coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), asthma (a condition in which the airways narrow and swell making it difficult to breathe), COPD and pulmonary embolism (PE, blood clot in the lung). - At 4:49 PM, her vital signs (body temperature [T, degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [HR, the number of times the heart beats within a certain time period, usually a minute], and breathing rate) were BP-131/73, T-97.4 F, HR-110, pulse oximetry (the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent) was 96%. - Her review of systems showed cough, shortness of breath and dyspnea on exertion (shortness of breath with activity). - She had been on antibiotics (medications that destroy or slow down the growth of bacteria) for 12 days. - A chest x-ray (test that creates pictures of the structures inside the body- particularly bones) showed no acute abnormality with her heart or lungs. - An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed tachycardia (fast heartrate) of 102 beats per minute. - Laboratory testing and CT angiography (a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body) were not performed. During an interview on 01/31/24 at 9:00 AM, Staff S, ED Medical Director, stated that a more thorough physical examination of Patient #21 would have revealed another pathway for diagnosis and treatment. A CT angiogram was appropriate, if the physician felt it would change the outcome, for a patient with tachycardia and a history of PE. A more thorough physical exam was most important.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#1), out of 21 Emergency Department (ED) records reviewed from 07/31/23 through 01/29/24. This failed practice had the potential to cause harm to all patients who presented seeking care at the ED. Findings included: Review of the hospital’s policy titled, “Guidelines for Discharge,” reviewed 09/2010, showed the purpose of the policy was to discharge patients from the hospital with all possible safety, considerations and courtesy. Nursing personnel should accompany patients to the door and remain with them until he/she has left the hospital. If at any time, the Registered Nurse (RN) determines a patient is not safe for discharge, he/she should discuss their concerns with the ED physician. Review of the hospital’s policy titled, “ED Standards of Care,” revised 05/01/10, showed appropriate discharge planning included information on available community resources. Review of the hospital’s undated policy titled, “After Hours Social Service Manual,” showed the hospital has a contract with Southeast Missouri Transport Services (SMTS) for patients who have absolutely no transportation. In the event of an after-hours discharge, staff can call one of the cell phone numbers of the employees responsible for SMTS transportation. Review of the hospital’s undated document titled, “Daily ED Log from 01/08/24 12:00 AM to 01/09/24 11:59 PM,” showed during the time Patient #1 was in the waiting room there were two to five patients receiving care in the ED. Review of the hospital’s undated document titled, “Homeless Shelters,” showed the location and contact information for five shelters. Review of the hospital’s undated document titled, “Women’s Domestic Shelters and Resources,” showed the location and contact information for six shelters. Review of the hospital’s undated documented titled, “Community Resources,” showed the location and contact information for 14 resources. Review of the hospital’s undated document titled, “Do You Need a Warm Place to Stay When the Weather is Below Freezing,” showed the location and contact information for a warming station. Review of the hospital’s Self-Report to the Department of Health and Senior Services, dated 01/17/24, showed the patient was found deceased. Review of Patient #1’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 01/08/24, showed she was picked up by the ambulance at Cadet, MO 63630. The man on the scene stated Patient #1 was staying with him after her “family kicked her out.” Review of Patient #1’s medical record showed: - On 01/08/24, she was a 44-year-old female. - Her home address was Potosi, MO 63664 - Her medical history was congenital hydrocephalus (a condition when CSF builds up in the brain and spinal cord), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), pneumonia (infection in the lungs), anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn’t go away) and Post Traumatic Stress Disorder (PTSD, a mental health problem you may develop after experiencing traumatic events). - Her surgical history was a ventriculoperitoneal (VP) shunt (a narrow plastic tube that drains excess CSF from the brain into the abdomen) was placed three weeks prior, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and a total hysterectomy (surgical removal of the hollow, pear-shaped organ that is located in a woman’s lower abdomen between the bladder and the rectum). - At 5:41 the decision was made to discharge Patient #1. - At 5:51 PM, the nursing discharge documentation showed the patient left the facility by walking. During an interview on 01/30/24 at 4:00 PM, Staff E, Chief Nursing Officer (CNO), stated that staff would provide resources if they knew a patient was homeless. She expected discharged patients waiting for rides to be included in shift report. A social work consult could have been placed when the boyfriend refused to pick up the patient. It was “unusual” for a security officer to initiate a deputy transfer; it was not securities “place” to involve law enforcement. Nursing should have been involved; nursing was ultimately responsible for patient discharges. All discharge efforts were documented in the medical record. The patient could have stayed overnight in the ED. During an interview on 01/29/24 at 10:05 AM and 01/30/24 at 3:00 PM, Staff C, ED Manager, stated that she expected staff to ensure patients were clear and appropriate for discharge. Patients without rides would “hang out more times than not until daytime and a better plan was established.” If the ED was not busy, patients were allowed to stay in the ED rooms. There were 10 ED rooms and space to create three additional hallway bed. “The normal practice was for the patient to stay in the ED.” She did not know why Patient #1 was taken to the waiting room. She would not have expected a patient to be in the waiting room hoping for someone to call and check on her. Patients were only placed in the waiting room if they were attempting to call friends/family. When a patient did not have transportation, she expected a call was placed to every family and friend available to the patient, a social work consult and community resources were provided. She expected all efforts made for transportation were documented in the medical record. She expected staff to escalate to management when there was no “realistic” option for transportation. The maintenance department transported patients with a place to go, as a last resort, after hours. She did not expect law enforcement to transport patients. When a patient was in the waiting room after discharge, she expected the nurse to notify the registration clerk and security of the situation. She expected the registration clerk and/or security officer to inform the nurse of any patient needs. It was not an expectation of the support staff to find patient rides or make patient decisions. During an interview on 01/29/24 at 10:40 AM, and a telephone interview on 01/31/24 at 11:00 AM, Staff J, RN, stated that she was aware the patient was homeless, was kicked out of her family home and was staying with her boyfriend. She did not consult social work, provide community resources or call SMTS. She did not recall if the patient had a list of phone numbers and did not remember calling anyone for the patient. She reported to the waiting room staff the patient was discharged, was waiting for a ride and she was attempting to arrange a ride. The boyfriend had called to check on the patient before she arrived at the ED. She thought he would call again, be informed she was discharged and would pick her up. She did not inform the waiting room staff the patient was homeless and was kicked out of her family home. During an interview on 01/31/24 at 8:00 AM, Staff S, ED Medical Director, stated that “all people” should have been called for Patient #1’s transportation issue. She should have been provided community resources. Options should have been presented to the patient. The physician, nurse and social worker should have been involved in the discussion. During an interview on 01/31/24 at 2:10 PM, Staff T, ED Physician, stated he was aware the patient was homeless. She was staying with her boyfriend. He expected the patient to be given resources and options. He expected a patient was discharged to a “reasonably safe situation.” During an interview on 01/29/24 at 2:45 PM, Staff L, Security Officer, stated that on 01/08/24 at approximately 4:30 PM, the patient came up to his desk and said, “I want to go home.” He then went to speak with the nurse. Staff J, RN, told him she had left a message with a number on a piece of paper in the patient’s bag. He was not allowed to make phone calls for patients. At 7:00 PM, he asked Staff R, Registration Clerk, to “please help her get home.” The patient gave the clerk a piece of paper with the numbers. There were four to five mental health facility numbers and two other numbers. One of those numbers was her boyfriend and the other was a female. Staff R, called the boyfriend, he answered, and the phone was given to the patient. The patient began to cry and hung up the phone. Staff R asked the patient if he was coming to get her and the patient said “no, he isn’t coming to get me,” and sat down. He told the patient they would “try to figure something out.” One to two hours later Staff W, City Policy Officer (CPO) entered the ED for an unrelated patient. Staff L, asked Staff W, if he could “help give the patient a ride.” Staff W spoke with the patient, the patient would not provide an address. Staff N, Emergency Room Technician (ERT), spoke with the patient and was able to confirm the address with the medical record. The address was outside of the city limits, Staff W called Staff V, County Deputy (CD), to transport the patient. During an interview on 01/30/24 at 6:25 PM, Staff R, Registration Clerk, stated that she came to work on 01/08/24 at 7:00 PM. The patient was in the waiting room, waiting for a ride. The patient handed her a list of numbers and walked away. The numbers were to “facilities” and two other names. She called both “other” numbers; the boyfriend answered. After the patient spoke with the boyfriend she began to cry and said, “he’s not coming to get me.” The patient did not come back to the desk. Staff W, CPO, came into the ED for an unrelated patient, and he was asked to give the patient a ride. Staff W, spoke with the patient, the patient would not provide an address. Staff N, ERT, confirmed the address with the patient and the medical record. During an interview on 01/31/24 at 6:15 PM, Staff V, CD, stated that she heard the call through dispatch Patient #1 needed to be transported. She entered the hospital through the ambulance bay, spoke with the other officers and was given a slip of paper with an address. She was not aware the patient was homeless or was kicked out of her family home. She stated the address on Shirley School Road to Patient #1 and she agreed. The patient was concerned the deputy was going to “get into trouble” for taking her home and asked to be let out of the car. The location the patient was dropped off was not the address listed on the paper. During an interview on 01/29/24 at 2:15 PM, Staff Q, Social Services Director, stated that social work could be called after hours. A social worker could have been called for Patient #1. A maintenance worker could have taken her home during working hours. It was not safe to discharge the patient to the location from which she was kicked out. During an interview on 02/01/24 at 10:50 AM, Staff U, Emergency Medical Technician, (EMT), stated that she was on the crew that transported Patient #1 to the hospital. The man on the scene told Staff U the patient could not stay with him, and her family kicked her out.”