St Dominic-Jackson Memorial Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48927 Based on review of the facility’s complaint investigation, staff interview and policy and procedure review the facility failed to ensure that an allegation of sexual abuse was immediately reported and investigated in accordance with Federal requirements and facility policy for one (1) of three (3) days of survey. Findings Include: An interview with the Chief Medical Officer (CMO) on 04/21/2026 at 1:56 p.m. confirmed the alleged assault was reported to Physician #1 on 02/02/2026 during an outpatient appointment and Physician #1 failed to report the allegation to the facility. Review of the facility’s policy, “Abuse, Neglect, and Exploitation of Vulnerable Persons: Identification and Reporting”, original effective date: 02/22/2024, last attestation campaign date: 11/17/2025, confirmed, “ ...Purpose: To provide staff with instruction in identifying, reporting and caring for suspected victims of abuse, neglect and exploitation ...Disclosure of abuse or neglect by victims, family or other parties should be taken seriously and promptly reported ...the facility must investigate suspected violations, take corrective action, and prevent recurrence of incidents to ensure patient safety ...Communication: All staff members receive training on this policy upon employment and during regular training updates ...”. Review of the facililty’s, “Compliant Investigation,” revealed the facility received an in-person complaint from Patient #1 on 03/25/2026. However, during the facility’s investigation on 03/31/2026 it was discovered Patient #1 reported the alleged assault to Physician #1 during an outpatient appointment on 02/02/2026 and Physician #1 failed to report the allegation resulting in video footage of Patient #1’s care area being deleted after 36 days and 22 hours, per policy. During the exit conference on 04/23/2026 at 3:00 p.m. with Performance Improvement Analyst, Administrative Fellow, Human Resources Director, Director of Regulatory, Chief Nursing Officer and Chief Medical Officer survey findings were discussed, and no further documentation was submitted for review.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48927 Based on staff interview and medical record review the facility failed to ensure that nursing staff performed an invasive procedure with a valid physician order for Patient #1 on three (3) of three (3) days of survey. Findings Include: An interview with the Director of Regulatory on 04/23/2026 at 12:36 p.m. confirmed there is no Physician order in Patient #1 medical record to obtain a urine specimen via In and Out catheterization. Review of the medical record titled, “Urine Culture” for Patient #1 revealed, Physician #1 order for Urinalysis: Urine Clean Catch stat on 01/16/2026 at 8:39 p.m. Further medical record review reveals RN #1 collected urine culture on 01/16/2026 8:38 p.m. by inserting an In and Out urine straight cath. Review of R.N. #1 job description titled “Registered Nurse 2 WOW” revealed, “ ...Accurately and promptly implements physician’s orders ...”. During the exit conference on 04/23/2026 at 3:00 p.m. with Performance Improvement Analyst, Administrative Fellow, Human Resources Director, Director of Regulatory, Chief Nursing Officer and Chief Medical Officer survey findings were discussed, and no further documentation was submitted for review.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48927 Based on observations, patient and staff interviews, medical record reviews, review of the facility’s policy and procedures, the facility failed to follow their policy and procedures for the prevention of Hospital Acquired Pressure Injury (HAPI) and the treatment for deep tissue injuries violating the patients right to receive care in a safe setting with staff following standard of practice for one (1) of three (3) patient medical records reviewed, Patient #1 Findings Include: An interview with Registered Nurse (RN) #1 on 04/07/2026 at 10:45 a.m. confirmed she is the Charge Nurse and doesn ’ t take patients. Interview further confirms patients are turned every two (2) to three (3) hours and also said there is not a strict turning schedule but there are turning clocks in every room. An interview with Nursing Assistant #1 on 04/07/2026 at 11:00 a.m. confirmed patients are turned every two (2) hours, daily baths are provided and turning clocks are in the room. An interview with RN #3, wound care nurse, on 04/08/2026 at 10:27 a.m. confirmed a consultation was placed for wound care nurse on 11/29/2025. Consult was performed on 12/01/2025 with a documented Braden score of 12 and pressure prevention protocol was initialed. Tortoise applied and Lower Air Loss mattress has been ordered. Wound care nurse recommended Triad ointment daily and PRN. It is not on the medical administration record due to it as a supply room staple. An Interview with Director of Regulatory on 04/08/2026 at 2:15 p.m. confirmed Patient #1 was not on the Hospital Acquired Pressure Injury (HAPI) list because the patient ’ s wound was not considered a deep tissue injury or staged pressure ulcer but related to friction and moisture. An interview with the Senior Director of Nursing on 04/09/2026 at 3:30 p.m. Confirmed, after photographic review of Patient #1 ’ s sacral wound pictures dated, 12/01/2025 at 10:46 a.m., Patient #1 did have a Deep Tissue Injury(DTI) and should have been reported on the Hospital Acquired Pressure Injury (HAPI) List. Review of Patient #1 ’ s medical record titled “Care Plan Details,” for Patient #1 revealed, Problem: Skin/Tissue Integrity Adult with Goal: Pressure Injury Prevention was initiated by RN #2 on 11/14/2025 at 10:57 p.m. Review of Patient #1 ’ s medical record titled “Turn Patient Order,” for Patient #1 revealed, order was written on 11/14/2025 at 3:55 p.m. to turn patient every two (2) hours. Review of Patient #1 ’ s medical record titled “Media Information,” revealed buttock pictures taken on 11/14/2025 at 4:01 p.m., 11/19/2025 at 4:00 a.m., 11/21/2025 at 4:08 p.m., 11/29/2025 at 2:08 p.m. and 12/01/2025 at 10:46 a.m. Continued review of the medical record revealed no other pictures in “Media Information” after 12/01/2025 at 10:46 a.m. Review of the facility’s policy, “Wound/skin Photo Policy-SDSD original effective date 06/01/2025 with revision date 11/18/2025 confirmed “ ... Standardized process for the photographic documentation of existing wounds and anatomical areas at high risk for skin breakdowns, specifically the sacral, coccygeal and heal localities ... Accurate assessment of skin integrity at critical points in the patient’s care, include admission, inter hospital transfers, and discharge ... Photographs must be taken of the sacral, coccygeal, and heal areas, as well as any existing pressure injuries or any additional anatomical sites identified as high risk for skin breakdown based on the patient’s condition ... Upon admission within 4 hours of the patient’s arrival to the unit to document existing wounds or confirmed skin integrity ... At discharge ... Upload all photographs directly into the patient’s electronic medical record within the media section ... Photographic documentation will be reviewed as part of case discussions during hospital acquired pressure injury (HAPI) Meetings for any patients, including in those reviews ...”. During the exit conference on 04/09/2026 at 4:00 p.m. with Director of Regulatory, Senior Director of Nursing, Regulatory and Accreditation Coordinator, Senior Director and Senior Director of Quality, survey findings were discussed, and no further documentation was submitted for review.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48927 Based on observations, patient and staff interviews, medical record reviews, review of the facility ’ s policy and procedures the facility failed ensure the nursing staff developed and kept current a nursing care plan that reflects the patient ’ s goals and nursing care to be provided to meet the needs of the patient that resulted in Hospital-Acquired Pressure Injury (HAPI) for one (1) of three (3) medical records reviewed, Patient #1. Findings Include: An interview with Registered Nurse (RN) #1 on 04/07/2026 at 10:45 a.m. confirmed she is the Charge Nurse and doesn ’ t take patients. Interview further confirms patients are turned every two (2) to three (3) hours and also said there is not a strict turning schedule but there are turning clocks in every room. An interview with Nursing Assistant #1 on 04/07/2026 at 11:00 a.m. confirmed patients are turned every two (2) hours, daily baths are provided and turning clocks are in the room. An interview with RN #3, wound care nurse, on 04/08/2026 at 10:27 a.m. confirmed a consultation was placed for wound care nurse on 11/29/2025. Consult was performed on 12/01/2025 with a documented Braden score of 12 and pressure prevention protocol was initialed. Tortoise applied and Lower Air Loss mattress has been ordered. Wound care nurse recommended Triad ointment daily and PRN. It is not on the medical administration record due to it as a supply room staple. An Interview with Director of Regulatory on 04/08/2026 at 2:15 p.m. confirmed Patient #1 was not on the Hospital Acquired Pressure Injury (HAPI) list because the patient ’ s wound was not considered a deep tissue injury or staged pressure ulcer but related to friction and moisture. An interview with the Senior Director of Nursing on 04/09/2026 at 3:30 p.m. Confirmed, after photographic review of Patient #1 ’ s sacral wound pictures dated, 12/01/2025 at 10:46 a.m., Patient #1 did have a Deep Tissue Injury (DTI) and should have been reported on the Hospital Acquired Pressure Injury (HAPI) List. Review of Patient #1 ’ s medical record titled “Care Plan Details,” for Patient #1 revealed, Problem: Skin/Tissue Integrity Adult with Goal: Pressure Injury Prevention was initiated by RN #2 on 11/14/2025 at 10:57 p.m. Review of Patient #1 ’ s medical record titled “Turn Patient Order,” for Patient #1 revealed, order was written on 11/14/2025 at 3:55 p.m. to turn patient every two (2) hours. Review of Patient #1 ’ s medical record titled “Flowsheets,” dated 11/14/2025 through 12/01/2025 revealed, 11/18/2025 through 11/23/2025 Braden Scale documented at 14. On 11/24/2025 at 1:26 p.m. Braden Scale was documented as 15, 11/25/2025 through 11/28/2025 Braden Scale documented as 14, 11/29/2025 Braden Scale documented as 13, 11/30/2025 Braden Scale documented as 12, and on 12/01/2025 Braden Scale was documented as 11. Review of the facility ’ s policy “Pressure Injury Prevention-SDSD,” original effective date 06/01/2025, revision date 11/18/2025 confirmed “ ...Hospital-Acquired Pressure Injury (HAPI): a pressure injury that develops during the course of hospitalization and was not present on admission ...all patients must undergo a skin assessment with a Braden scale evaluation: within four (4) hours of unit arrival, every shift, with any significant change in condition or transfer to another unit ...Patient ’ s with a Braden score of 18 or less should have the pressure ulcer prevention protocol added by the staff nurse ...”. Review of Patient #1 ’ s medical record titled “Media Information,” revealed buttock pictures taken on 11/14/2025 at 4:01 p.m., 11/19/2025 at 4:00 a.m., 11/21/2025 at 4:08 p.m., 11/29/2025 at 2:08 p.m. and 12/01/2025 at 10:46 a.m. Continued review of the medical record revealed no other pictures in “Media Information” after 12/01/2025 at 10:46 a.m. Review of the facility ’ s policy, “Wound/skin Photo Policy-SDSD original effective date 06/01/2025 with revision date 11/18/2025 confirmed “ ... Standardized process for the photographic documentation of existing wounds and anatomical areas at high risk for skin breakdowns, specifically the sacral, coccygeal and heal localities ... Accurate assessment of skin integrity at critical points in the patient’s care, include admission, inter hospital transfers, and discharge ... Photographs must be taken of the sacral, coccygeal, and heal areas, as well as any existing pressure injuries or any additional anatomical sites identified as high risk for skin breakdown based on the patient’s condition ... Upon admission within 4 hours of the patient’s arrival to the unit to document existing wounds or confirmed skin integrity ... At discharge ... Upload all photographs directly into the patient’s electronic medical record within the media section ... Photographic documentation will be reviewed as part of case discussions during hospital acquired pressure injury (HAPI) Meetings for any patients, including in those reviews ...”. During the exit conference on 04/09/2026 at 4:00 p.m. with Director of Regulatory, Senior Director of Nursing, Regulatory and Accreditation Coordinator, Senior Director and Senior Director of Quality, survey findings were discussed, and no further documentation was submitted for review.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 31935 Intakes: MS00027285 Based on staff interviews, family member interview, medical record reviews, review of facility policy and procedures the facility failed to ensure staff followed the facility’s policy and procedure for “Pain Management” resulting in an incomplete assessment and treatment for a patient presenting to the Emergency Department experiencing right shoulder and knee pain after a fall for one (1) of three (3) medical records reviewed. Patient #1. Findings Include: During an interview on 01/07/2024 at 1:48 p.m., with the facility’s Director of Quality (DOQ) it was revealed the facility received a complaint approximately one (1) month ago alleging the facility failed to assess and monitor a patient’s pain while in the emergency department (ED). The DOQ stated the complaint was investigated and findings revealed the ED nurses did not assess the Patient #1’s pain or report increased pain to the physician. In addition, failed to administer Acetaminophen (Tylenol) 650 milligrams as ordered, and fit and apply a shoulder sling to immobilize Patient #1’s fractured shoulder. During an interview on 01/08/2025 at 11:15 a.m., The Director of Nursing (DON) confirmed an order for Acetaminophen (Tylenol) 650 milligrams for Patient #1 was recorded by ED Physician #1 however, the medical record reveals no documented evidence Patient #1’s pain was assessed or reassessed or that the medication (Acetaminophen) was administered. During an interview on 01/08/2025 at 11:45 a.m., the facility’s Pharmacist confirmed an order for Acetaminophen (Tylenol) 650 milligrams was written and somehow “pinned” by the physician while the patient went to the radiology department for a Computerized Tomography (CT) scan. The pharmacist further reported it does not appear the medication (Acetaminophen) was administered. During an interview on 01/08/2025 at 12:51 p.m., Family Member #1 revealed his mother, Patient #1, has dementia and was clearly in pain when the staff picked her up from the stretcher and placed her in a wheelchair. The family member confirmed he did not ask the emergency room staff for pain medication for his mother, and the staff did not ask if she was in pain. He further confirmed he was sent home with a physician’s name and phone number to set up an appointment with and was given written instructions for care and to give Tylenol for pain. Review of Patient #1’s medical record “Patient Care Timeline” (date 06/18/2024) revealed no documented evidence of a pain assessment or reassessment performed, no documented evidence of the administration of Acetaminophen (Tylenol) 650 milligrams ordered for pain, or documentation the patient was fitted with an arm sling for a “mildly impacted fracture of the humeral head neck,” while in the E.D from 07:39 a.m. and 11:03 a.m. Review of facility policy entitled “Pain Management” (effective date (12/20/2023) revealed “in acute care areas pain assessment shall be addressed with each scheduled patient body assessment, at least every shift, and as indicated by patients’ complaint of pain. All other patient care areas shall utilize an established process to assess, reassess, document and report unrelieved pain as appropriate to their specific setting ...pain shall be reassessed within one (1) hour after administration of oral analgesic and within 30 minutes after IV analgesics ...The patients healthcare provider is notified of the patients’ pain when treatment fails to reduce pain to a level acceptable to the patient.” The Exit conference was held on 01/08/2024 at 1:42 p.m. with the Director of Quality, Senior Director of Quality and Regulation, Senior Director of Emergency Services, and the Regulatory and Accreditation Coordinator. No additional documents were presented by the facility.”

“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: 45467 This standard is not met based on staff interview, review of facility’s documents “Account Receivable Form” and “Standard Operating Procedure Emergency Department Registration,” and policy and procedure review. The facility failed comply with the Emergency Medical Treatment and Labor Act (EMTALA) regulations by requesting payment before providing a test (computed tomography (CT) scan) ordered by the physician to determine if an emergent medical condition (EMC) existed on one (1) of 20 medical records reviewed, (Patient #1). Findings Include: Review of the medical record for Patient #1 revealed he arrived at the Emergency Department (ED) via private vehicle on 09/26/2024 at 8:45 p.m. with a complaint of syncope (fainting) and falling, hitting the back of his head on a door. Patient #1 reports he was unconscious for fifteen (15) minutes and now has pain at the base of his skull and nausea. During the medical screening examination, the provider ordered a CT scan of the cervical spine and head without contrast at 8:57 p.m. Review of the facility’s document, “Account Receivable Form,” reveals on 09/26/2024 at 9:06 p.m. the facility documented collection of $642.38 from Patient #1 before a CT scan was performed at 9:17 p.m. and the medical screening exam (MSE) was completed. An interview on 10/17/2024 at 10:45 a.m. with the Director of Patient Access, confirms the “Account Receivable Form” is correct and $642.38 was received from Patient #1 by Patient Access Registration (PAR) Staff #2 at 9:06 p.m. on 09/26/2024 before the MSE was completed. Cross Refer to 2408 for additional findings.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 45467 This standard is not met based on facility staff interviews, record reviews, policy and procedure review, and review of facility documents “Standard Operating Procedure Emergency Department Registration”, and the facility’s “Account Receivable Form”, the facility failed to provide a computed tomography (CT) scan, before the medical screening exam (MSE) was completed, necessary for the diagnosis of an emergent medical condition (EMC) on an individual presenting to the Emergency Department with a complaint of a head injury after a fall resulting in the loss of consciousness before payment for the CT scan was received for one (1) of 20 medical records reviewed, Patient #1. Findings Include: Review of the medical record for Patient #1 revealed he arrived at the ED via private vehicle on 09/26/2024 at 8:45 p.m. with a complaint of syncope (fainting) and falling, hitting the back of his head on a door and was unconscious for fifteen (15) minutes and now has pain and tenderness at the base of his skull and nausea. Patient reported dining at a restaurant and consuming six (6) and a half (1/2) ounces of alcohol (whiskey) during the meal lasting approximately one and a half (1½) to two (2) hours. Patient #1 reported standing up after the meal, became lightheaded, had tunneling vision and fainted, striking his head on the door and ultimately the tile. Medical record reveals a medical screening examination was started at 8:47 p.m. Triage Acuity Level 2, emergent, high risk. Electrocardiography (EKG), lab work, chest X-ray, and a computed tomography (CT) scan were ordered. Review of the facility’s document, “Account Receivable Form,” reveals on 09/26/2024 at 9:06 p.m. the facility documented collection of $642.38 from Patient #1 before a CT scan was performed at 9:17 p.m. and the medical screening exam (MSE) was completed. An interview on 10/17/2024 at 10:45 a.m. with the Director of Patient Access, confirms the “Account Receivable Form” is correct and $642.38 was received from Patient #1 by Patient Access Registration (PARs) staff #2 at 9:06 p.m. on 09/26/2024 before the MSE was completed. An interview on 10/15/2024 at 4:17 p.m. with the Director of Patient Access confirms the Emergency Department (ED) Registration Clerks are not allowed to seek or ask for any payment or money at any time until a Medical Screening Exam (MSE) is completed, and the patient is stable. Review of the Facility’s document, “Standard Operating Procedures (SOP) ED Registration,” effective date 06/01/2021, reveals “ ...Quick Registration Process ...Full Registration Process ...This standard operating Procedure ...is intended to be used by the Patient Access Registration staff, hereon referred to as PARs(s), when working in the Emergency Department registration area ...expectations and processes that PARs are expected to adhere to when registering patients ...The Stat Reg ...process starts by obtaining and validating the patients information ...patients input their social security number using the keypad, verbally verify the correct spelling of their name and date of birth ...If this information is not gathered accurately, patient safety may be compromised...The full registration process starts after triage...Full registration process...the process below outlines the next steps to be used by PARs after a patient has already arrived, placed in a bed, triaged by a Nurse and medically screened by a Physician. This process is intended not only as a continuation of the STAT Reg process ...Patients will NOT be approached for money until a medical screening exam (MSE) has been conducted and the patient determined, by the physician or physician extender to be in stable condition ...if patients arrive to the ED via ambulance, the STAT Reg process is still utilized. If the patient’s condition requires them to bypass STAT Reg, PARs will be required to execute the Arrival as well as the Full Registration for patient at the point of contact ...when patients are fully registered, PARs will attempt to collect the entire amount owed from the patient at bedside ...”. Review of the Facility’s policy “EMTALA,” dated 12/01/2023, reviewed or revised 11/21/2023, “ ...The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient may be refused treatment or transferred from one hospital to another when he/she is in an unstable medical condition ...provide for an appropriate medical screening examination and necessary stabilizing treatment ...without regard of ...ability to pay for services ...will not engage in any action ...such as by demanding that emergency department patients pay before receiving treatment for emergency medical care ...No attempt at debt collection activities will be attempted until EMTALA ...requirements have been satisfied ...”. During exit conference on 10/18/2024 at 3:30 p.m. survey findings were discussed with Senior Director of Emergency Services, Regulatory and Accreditation, and Director of Accreditation. No further documentation was submitted for review.”