Benefis Hospitals Inc.

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to properly obtain informed consent for a procedure for 1 (#2) of 12 sampled patients. This deficient practice had the potential to affect all patients requiring informed consent for procedures. Findings include: Review of patient #2’s electronic medical record showed patient #2 was brought to the facility via ambulance after being found down, and unresponsive at home. After being assessed in the ED (emergency department), patient #2 was found to have a Glasgow Coma Scale score of 6 (moderate to severe level of impairment in a patient’s neurological function) and was intubated. Patient #2 was admitted to the ICU (intensive care unit) on 5/29/25 in diabetic ketoacidosis with a coma and probable aspiration. After medical management in the ICU, patient # 2 was extubated and downgraded to a lower level of care. On 6/7/25, patient #2 developed altered mental status and declined, requiring reintubation and transfer back to the ICU. An MRI (magnetic resonance image) of the brain was completed on 6/7/25 and showed, “No evidence of hemorrhage, acute infarction, mass or pathologic enhancement. General cerebral volume loss.” Review of a procedure note dated 6/8/25 at 9:34 am, showed: “Lumbar puncture. -consent obtained: Verbal -consent given by: [Family Member] via phone” ... Review of patient #2’s electronic medical record showed there was no consent form on file, signed by the physician or nursing staff. During an interview on 8/13/25 at 1:45 p.m., staff member A stated if a procedure was needed for a patient, the provider would place an order in the patient’s medical record. Staff member A stated the provider is the one who goes over the risks and benefits with the patient or the patient’s representative. Staff member A stated verbal consent can be received for procedures, but the process required two signatures on the form to verify that the risks and benefits were discussed prior to the procedure. Staff member A stated the expectation was for the policy to be followed in obtaining informed consent. Review of a facility policy titled, “Informed Consent,” with an approved date of 9/2024, showed: “ ... I. Provider: ... B. Obtains informed consent according to Medical Staff Rules and Regulations Section A: Surgery and Procedures: Article v, and documents in the patient’s chart ... II. Nurse or Respective Department Personnel A. Completes the information required on the Authorization for Surgery or Special Procedures form. B. Witnesses the patient’s or next of kin/legal representative’s signature ... ... 2. In the event the patient is unable to give consent and the legal representative or next of kin is not immediately available, consent may be received via phone with a second witness verifying their agreement.” Review of a Facility document titled, “Medical Staff Rules and Regulations, showed: “ ... 5. Informed consent: There shall be documentation within the medical record that the Hospital’s policy pertaining to informed consent has been followed by documenting the process.””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to adhere to infection prevention standards by not performing proper hand hygiene; not donning gloves prior to performing patient care or doffing gloves after performing patient care going from a dirty area to a clean area, for 2 (#s 6 and 11); and failed to clean medical equipment prior to entering or exiting a patient room for 2 (#’s 6 and 9) of 12 sampled patients. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include: 1. Review of patient #11’s electronic medical record showed, patient #11 was admitted to the facility on 7/29/25 with diagnoses of acute respiratory failure, acute on chronic encephalopathy, and hyponatremia. Patient #11 required admission to the ICU (intensive care unit) and mechanical ventilation. A bronchoscopy was completed, and on 8/6/25 it was determined patient #11 had acquired MSSA (Methicillin Susceptible Staphylococcus Aureus) from ventilator use. During an observation and interview on 8/12/25 at 8:40 a.m., patient #11 was lying in bed. Patient #11 was attached to a mechanical ventilator, had an indwelling foley catheter, a nasogastric tube, and an intravenous line with multiple secondary lines inserted in the left antecubital area. Patient #11 appeared agitated and restless. Staff member K stated patient #11 was agitated because she had tried to wean patient #11 off the mechanical ventilator and patient #11 had become tachycardic and could not maintain respirations on her own. Staff member K stated patient #11 had failed the trial. During an observation on 8/12/25 at 8:45 a.m., staff member K doffed a pair of gloves and walked over to the computer located next to patient #11’s bed and began to document in patient #11’s chart. At 8:47 a.m., staff member K turned away from the computer and walked over to the right side of patient #11’s bed. Staff member K leaned over the rail of the bed and touched the mechanical ventilator tubing, which was close to patient #11’s mouth, with her hands. No hand hygiene was performed after touching the computer or prior to touching the mechanical ventilator tubing, and staff member K did not don a pair of gloves prior to touching the mechanical ventilator tubing. At 8:49 a.m., staff member K walked back to the computer located at the bedside of patient #11 and began to document. No hand hygiene was performed. At 8:52 a.m., staff member K stopped documenting, walked about ten feet, and grabbed a pair of gloves from the container on the wall. Staff member K donned the gloves. No hand hygiene was performed prior to donning the gloves. Staff member K walked back to the right side of patient #11’s bed and began to touch the mechanical ventilator tubing again. Staff member K stated, “I was just checking the placement of the endotracheal tube by looking at the centimeters.” During an interview on 8/12/25 at 8:56 a.m., staff member K stated, “Hands should be sanitized or washed with soap and water before and after patient care is performed, and before and after donning and doffing gloves. Staff member K stated she had been educated on infection prevention policies, including hand hygiene and donning and doffing gloves. Staff member K stated, “I should not have touched the ventilator tubing without doing hand hygiene or wearing gloves.” Staff member K stated she understood how not performing hand hygiene and touching the mechanical ventilator without gloves could increase the risk of infection. 2. Review of patient # 6’s electronic medical record showed he was admitted to the facility on 8/8/25 with diagnoses of exacerbation of congestive heart failure, atrial fibrillation, and rheumatoid arthritis. On 8/10/25, two days after admission, patient #6 was transferred to the ICU with a new diagnosis of metabolic encephalopathy (a condition where brain function is impaired due to a chemical or metabolic imbalance in the body) and was placed on mechanical ventilation. During an observation on 8/12/25 at 9:06 a.m., patient #6 was lying in bed. Patient # 6 had an indwelling foley catheter, a nasogastric tube hooked up to suction, was on a mechanical ventilator, and had an intravenous line in the left antecubital area, with multiple secondary lines attached. During an observation and interview on 8/12/25 at 9:10 a.m., staff member L was standing at a computer located next to the right side of patient #6’s bed, and had documented a conversation with NF1, who was present in patient #6’s room. Staff member L stated she was getting ready to do her nursing assessment and provide care to patient #6. Staff member L donned a pair of gloves. No hand hygiene was completed after touching the computer or before donning gloves. Staff member L walked over to the right side of patient #6’s bed and placed her gloved hands on the side rail of the bed. As staff member L was standing next to the right side of patient #6’s bed, she dropped a piece of paper on the floor. Staff member L stepped back from the bed, bent over, touched the floor with her glove, picked up the piece of paper, placed it back into the pocket of her scrub top, and placed her hands back on the side rail of the bed. Staff member L did not doff her gloves or perform hand hygiene after the gloves became contaminated. At 9:13 a.m., staff member L reached into the pocket of her scrub top and grabbed the Rover (handheld device) used for charting and documentation. Staff member L turned on the flashlight on the device and proceeded to do a neurological exam on patient #6. Staff member L completed the neurological exam with the handheld device and placed it back into her pocket. Staff member L did not clean the device prior to use or after use. Staff member L did not perform hand hygiene or doff her gloves after using the unclean, handheld device. Staff member L walked over to patient #6’s intravenous lines and touched the intravenous access area near the left antecubital site. No hand hygiene or clean gloves were used prior to touching the intravenous lines. Staff member L then touched the nasogastric tube and unhooked it from suction. Staff member L placed her gloved thumb over the end of the suction tube, checked the suction, and then reconnected the suction tube to the nasogastric tube. The suction tube was not cleaned prior to reattaching it to the nasogastric tube. Gloves were not doffed, and no hand hygiene was completed after touching the end of the suction tube. With the same dirty gloves, staff member L began to touch patient #6’s arms, hands, legs, and feet to check for edema. Staff member L picked up the indwelling foley catheter tubing to assess patency. Staff member L put the indwelling catheter tubing down and touched the dorsal aspect of patient #6’s right foot to check for a pedal pulse. Gloves were not doffed when going from a dirty area to a clean area, and hand hygiene was not performed. Staff member L doffed her gloves, walked over to the computer at the right side of patient #6’s bed, and began to document. No hand hygiene was completed after doffing her gloves or prior to touching the computer. At 9:24 a.m., staff member L left patient #6’s room. No hand hygiene was completed. During an interview on 8/12/25 at 9:25 a.m., staff member L stated hand hygiene was to be completed prior to entering and exiting a patient room, before and after touching a patient, and when going from a dirty area to a clean area. Staff member L stated, “I am just so used to touching the patient all the time for assessments and to provide care, that I did not pay attention to hand hygiene or putting on clean gloves, and I did not think about cleaning the Rover (handheld device).” Staff member L stated she had been educated on infection prevention practices, hand hygiene, and donning and doffing personal protective equipment. 3. Review of patient #9’s electronic medical record showed she was admitted to the facility on 8/10/25 with pyelonephritis and a possible small bowel obstruction. During an observation and interview on 8/12/25 at 9:40 a.m., staff member N was in the medication room with staff member M. Staff member N took the Rover (handheld charting device) out of her pocket and placed it on the counter near a sink and walked over to the medication dispensing system and pulled up patient #9’s physician orders. Staff member N reviewed patient #9’s medication orders and pulled out five milligrams of baclofen and a vial of fentanyl. Staff member N stated she was going to give 50 micrograms of fentanyl and waste the remainder with staff member M. At 9:43 a.m., staff member N picked up the Rover (handheld device) and placed it in the front pocket of her scrub top. Staff member N walked down the hallway to patient #9’s room and entered the room. No hand hygiene was completed prior to entering patient #9’s room. Staff member N reached into her front scrub pocket and took out the Rover and placed it on a shelf near patient #9’s bed. The Rover was not cleaned after being removed from staff member N’s pocket. Staff member N donned a pair of gloves. No hand hygiene was performed prior to donning gloves. Staff member N picked up the Rover with her gloved hands and picked up patient #9’s left hand and scanned her identification bracelet. Staff member N placed the Rover on the shelf. Staff member N did not doff her gloves or perform hand hygiene after touching the dirty Rover. Staff member N took an alcohol wipe from her front scrub pocket, opened the alcohol wipe, and cleaned patient #9’s intravenous port. Clean gloves were not donned, and hand hygiene was not completed prior to touching patient #9’s intravenous port. Staff member N administered five milliliters of normal saline through the intravenous line, picked up the syringe of 50 micrograms of fentanyl, administered the fentanyl over two to three minutes, and flushed the intravenous line with the remaining five milliliters of normal saline. Staff member N doffed her gloves, picked up the Rover, and left the room. No hand hygiene was completed after doffing her gloves, picking up the dirty Rover, or upon exiting patient #9’s room. Staff member N did not clean the Rover after leaving patient #9’s room and placed the Rover in her pocket. During an interview on 8/12/25 at 8:48 a.m., staff member N stated she had been educated on infection prevention practices, but did not recall ever having education on cleaning the Rover after its use. During an interview on 8/13/25 at 10:00 a.m., staff members C and Q stated all staff were educated on infection prevention, including hand hygiene, donning and doffing personal protective equipment, and cleaning medical devices. Staff member Q stated when she performs infection prevention audits, she utilized the “in the moment teaching,” but did not document any of the findings as she found them to be punitive. Staff member Q stated she had not completed any recent education on infection prevention with staff. Staff member Q stated equipment that entered patient rooms was required to be cleaned prior to and after use, and the Rover was to be cleaned with purple-topped sani-wipes. Staff members C and Q stated if staff had any questions about infection prevention, they should look at the facility policies. Staff members C and Q stated infection prevention education was completed upon hire and with mandatory annual education. Review of a facility policy titled, “Hand Hygiene,” with an effective date of 6/2025, showed: ... “Hand hygiene is expected of all employees before and after all patient/resident contacts, after glove use, before any clean or sterile procedure ... when hands are visibly soiled ... Staff education is provided during new employee orientation and annually regarding proper hand hygiene techniques. Procedure: ... D. Decontaminate hands with alcohol based waterless antiseptic agent or with soap and water if intolerant of alcohol-based product: 1. Before having direct contact with patients 2. After contact with a patient’s intact skin (as in taking a pulse or blood pressure ...) 3. After removing gloves 4. After contact with body fluids or excretions, mucous membranes, non-intact skin ... 5. When moving from a contaminated body site to a clean body site during patient care. 6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 7. Before preparing/administering medications, manipulating IV’s or other equipment. VI. Other aspects of Hand Hygiene ... E. Change gloves during patient care if moving from a contaminated body site to a clean body site. Review of a facility policy titled, “Infection Prevention and Control Plan,” with an effective date of 6/2025, showed: ... “XIII. Employees-Are responsible for complying with corporate and department specific infection prevention policies and attending infection prevention education programs ...” [sic] Review of a facility document titled, “Learner Transcript,” showed, staff member K completed the mandatory annual education, which included infection prevention, on 6/24/25. Staff member L completed the mandatory annual education, which included infection prevention, on 7/29/25. Staff member N completed the mandatory annual education, which included infection prevention, on 7/29/25. Review of a facility policy titled, “Guidelines for Isolation Precautions,” with an effective date of 1/2025, showed: ... “D. Patient Care Equipment 1. Reusable equipment is not used for the care of another patient/resident until cleaned and appropriately reprocessed. 2. Reusable equipment must be cleaned before and after each encounter with a patient/resident.” Review of an email provided by the facility, sent by staff member Q on 5/21/25, showed: ... “The purple wipes will now be outside of patient rooms to clean equipment and surfaces ...” Review of a facility document titled, “NPC Notes,” dated 1/21/25, showed: ... “Rovers can be cleaned with purple wipes.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Patient Rights at 482.13. Based on interview, record review, and policy review, the facility failed to: -Inform patients or their patient representatives of the patient’s rights prior to providing or discontinuing services. (A0117) -Investigate and address a written concern about a patient’s care in an outpatient setting in which the facility provides oversight. (A118) -Provide a written notice of resolution following a complaint/grievance investigation, to the patient or patient representative. (A0123) -Obtain a consent to treat in the emergency room setting prior to providing or discontinuing care. (A0131) -Inform a patient of their right to formulate an advanced directive in an outpatient setting. (A0132) -Inform a patient of their rights for visitation. (A216)”

“OUTPATIENT SERVICES CFR(s): 482.54 If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Outpatient Services at 482.54. Based on interview, record review, and policy review, the facility failed to develop and implement policies and procedures for their outpatient setting, to include mechanisms for triaging, pain management interventions, constipation management, and provider notification for 1 (#1) of 3 post operative patients sampled. This failure resulted in patient #1 passing away from a possible bowel obstruction and fecal vomiting with possible aspiration to the airway and lungs. This deficient practice had the potential to affect all post operative patients in the outpatient setting. Findings include: During an interview on 6/3/25 at 11:25 a.m., NF1 stated patient #1 was admitted to the hospital for a surgical procedure on 4/29/25 and was discharged home on 5/1/25. NF1 stated patient #1 lived with him and he was able to help care for patient #1 after his discharge from the hospital. NF1 stated patient #1 was doing well his first few days home. NF1 stated patient #1’s pain was under control and there were no concerns at that time. NF1 stated patient #1 had a follow up appointment with his surgeon on 5/5/25 and everything had gone well at the appointment. NF1 stated later in the day, following his appointment, patient #1 started to complain of pain and told NF1 his pain was an 8 out of 10 on a scale of one to ten. NF1 stated patient #1 called his surgeons office and spoke to a nurse and the nurse told him to take some Tylenol or ibuprofen. The nurse instructed patient #1 to call back if he was still in pain or was unable to urinate. NF1 stated patient #1 called the surgeons office again on 5/6/25, spoke to different nurse and reported increased pain and heartburn. NF1 stated the nurse told patient #1 to hydrate, take some MiraLAX, and go to the ER if his pain got worse. NF1 stated patient #1 was never asked about how bad his pain was or to rate his pain, or the characteristics of his pain. NF1 stated patient #1 kept telling NF1 his pain was at an 8. NF1 stated he had asked patient #1 if he wanted to go to the emergency room and patient #1 told him no, as the (staff) told him not to go unless his pain got worse. NF1 stated patient #1’s pain never got worse, but it never got better. NF1 stated on the morning of 5/8/25, patient #1 wanted to take a warm bath to see if that would help with his pain and discomfort, so NF1 helped patient #1 get a bath ready. NF1 stated, “I left the bathroom for a quick moment to get a towel and when I walked back into the bathroom I saw him (patient #1) hit the floor. I ran over to him, and he was unresponsive and started to vomit a black substance that smelled like feces. NF1 stated he started CPR and called 911. He stated he continued to do CPR on patient #1 until the ambulance arrived and they took over and took him to [Facility Name]. NF1 stated when patient #1 arrived to the ER, they continued to work on him. NF1 stated the doctor in the ER asked him what patient #1’s wishes were, and he stated he was unsure. NF1 stated the ED doctor informed him patient #1 had been unconscious for too long and there was likely no brain activity, so they stopped working on him. NF1 stated he requested an autopsy and was told one would not be completed because the manner of death was not suspicious. NF1 stated, “I had an independent autopsy done because I want to know why he died. I feel betrayed by [Facility Name]. They took him (patient #1) from me. They did nothing to help him, even though he reached out to the doctor’s office, like is discharge papers told him to do. We trusted the nurses that he talked to at the doctor’s office, we trusted their guidance. We did everything we were supposed to do, and now he is dead.” Review of patient #1’s electronic medical record dated 4/29/25-5/8/25 showed, patient #1 was admitted to the facility on 4/29/25 for a surgical procedure. The surgical procedure note showed patient #1 had “significant abdominal adhesions” and “an intraoperative decision was made to not perform the left pelvic lymphadenectomy given the risk-benefit ratio of the adhesions ...” After the procedure was completed and patient #1 was stable, he was transferred to the surgical unit to be monitored until discharge. While patient #1 was on the surgical unit, pain assessments show patient #1’s pain was never higher than a 6 on a 1-10 pain rating scale.” On 5/2/25 patient #1 was discharged home with NF1. Patient #1’s pain at discharge was under control, with a pain rating of a 3-4 on a 1 to 10 pain rating scale. Review of a facility document titled, “After Visit Summary,” dated 5/1/25 at 1:27 p.m., showed: ... “Instructions: Call your provider if you experience pain not relieved by medication. Start taking: -cephalexin (an antibiotic) 500mg, take 2 capsules by mouth in the morning and 2 capsules at bedtime for 5 days. -meloxicam (non-narcotic pain medication) 7.5 mg. Take 1 tablet by mouth 2 times a day for moderate pain for up to 12 days. -oxybutynin (bladder relaxant) 5 mg. Take 1 tablet by mouth 3 times a day as needed for bladders spasms for up to 15 days.” ... When to call the doctor? -signs of infection such as a fever of 100.4 degrees Fahrenheit or higher, pain with passing urine, wound that will not heal, or pain. ... -not able to have a bowel movement ...” Review of Patient #1’s progress note titled, “Office Visit,” dated 5/6/25, showed: ... “Patient presented for catheter removal. He has done well since hospital discharge.” ... I will see him back in 3 months ...” Review of patient #1’s outpatient telephone nursing note dated, 5/5/25 at 2:58 p.m., written by staff member H, showed: “[Patient Name] (patient #1) called because he was in pain surrounding the time when he was doing his kegels. He stated the cold of his urine was pink and he had been holding off doing anything because of the pain. H stated he hasn’t taken any medication today. I let him know he could take some Tylenol or ibuprofen and if he is still in a lot of pain and/or hasn’t voided to call back.” [sic] Review of patient #1’s outpatient telephone nursing note dated, 5/6/35 at 2:04 p.m., written by staff member F, showed: “Patient called today with complaints of abdominal pain. Patient states it is upper abd pain and heartburn. Patient states he has been taking pepto bismol for heartburn pain with some relief. Asked patient when the last time he had a bowel movement was, patient states some time last week and it was diarrhea. Explained to patient that is most likely the cause of his abd pain. Encouraged hydration and Miralax daily until he has a bowel movement ... Patient is to go to the ER if the pain gets worse or he is unable to have a bowel movement ...” [sic] During an interview on 6/4/25 at 9:00 a.m., Staff member F stated she had talked to patient #1 on 5/6/25. Staff member F stated she knew he was a post-surgical patient. Staff member F could not verbalize the surgical complications that could accompany patient #1’s surgical procedure and stated, “I do not have a surgical background.” Staff member F stated, “Usually when patient calls in with constipation we encourage them to take something at home, and if it continues then go to the ER.” Staff member F stated she was not sure if there were any policies, procedures, or protocols for patients with constipation. Staff member F stated patient #1 told her he was having pain. Staff member F stated she did not assess patient #1’s pain level or assess the characteristics of his pain. Staff member H stated she was not sure if there was a policy, procedure, or protocol for assessing pain. Staff member F stated she did not notify the physician that patient #1 had called and complained of pain or constipation. Staff member F stated she did not look back into patient #1’s chart to see if there was any other documentation of the patient calling and complaining of pain or constipation and had not looked to see what patient’s current medications were. During an interview on 6/4/25 at 11:00 a.m., staff member H stated she had worked in the physician’s office for roughly three months. Staff member H stated she had talked to patient #1 when he called the office on 5/5/25. Staff member H stated, “When a patient calls into the office with pain or constipation I try to find out what could be the cause of the pain or constipation. I ask about pain location, and pain characteristics, I also try to have them rate their pain for me, and then I document it in the nursing note” Staff member H stated she did not ask patient #1 about his pain level or have him describe the type of pain he was having. Staff member H stated she knew what some of the surgical complications were for patient #1’s procedure, but not all. Staff member H stated the only education she received in the physician’s office was how to triage catheter patients and she had not received any type of education related to surgeries or surgical complications. Staff member H stated she had advised patient #1 he could take Tylenol or ibuprofen for his pain. Staff member K stated she did not look in the patient’s chart to see if he already had pain medication prescribed to him prior to advising him to take the Tylenol or ibuprofen. Staff member H stated she was not aware that ibuprofen was contraindicated in conjunction with meloxicam or surgical procedures. Staff member H stated she did not notify the physician of patient #1’s complaint of pain. Review of online drug information for Meloxicam showed, Meloxicam and Ibuprofen both belong to the same drug class of non-steroidal anti-inflammatories and should not be taken together. Taking meloxicam and ibuprofen together can cause stomach ulcers, bleeding, stomach perforation, kidney damage, and an increased risk for heart attack, stroke, or high blood pressure. (https://medlineplus.gov/druginfo/meds). During an interview on 6/4/25 at 11:40 a.m., staff member K stated he evaluated patient #1 on 5/5/25 at his post operative appointment. Staff member K stated patient #1 was recovering well. Staff member K recommended patient #1 come back for a follow up in three months. Staff member K stated he was not made aware of patient #1’s phone calls or complaints. Staff member K stated, “I expect the nursing staff to bring concerns to our (physician’s) attention. Pain and constipation are the two most calls the office gets post-surgery. They (staff) should know how to triage those calls and use nursing judgement accordingly.” Staff member K stated nursing staff should be notifying the physicians of any complications, know what surgical complications were, and how to handle them appropriately. During an interview on 6/4/25 at 12:40 p.m., staff member G stated outpatient nurses do not get any additional training other than shadowing and working with the other nurses and providers to learn the flow and how to triage patients. Staff member G stated, “There are not really any polices or procedures that are followed in the outpatient setting. They do not have anything like a phone tree, protocol, or algorithm to assist with triage or different situations that may come up.” During an interview on 6/5/25 staff member L stated, “The outpatient nurses did their normal process based on their clinical understanding of the patient. There are some areas that can be improved. We are doing an action plan for outpatient staff about pain or when a patient calls in. There has not been any education provided yet until we finalize our plan. The plan we have is very vague at this time, it’s just a starting point. We are trying to come up with some kind of algorithm. This is just one of those things you don’t think about until you have an incident. It is an awful situation.” Outpatient policies, to include triage, pain assessment, and post-operative complications were requested on 6/2/25 and 6/4/25. Specific policies were not received prior to the end of the survey. During an interview on 6/5/25 at 11:10 a.m., staff member A stated, “The policies in our clinics are generic, they are not really specific.” Review of a facility policy titled, “Provider Practices Documentation Requirements for Staff,” with a revision date of 7/2024, showed: ... “XIII. Phone Calls ... B. Send message to provider/nurse group if needing clarification or further action ...” Review of a document titled, “Verbal Visual Preliminary findings,” dated 5/15/25, showed: “1. Bowel obstruction with fecal vomiting 2. Leaked bowel causing Gastric contents into the abdominal cavity 3. Aspiration in the lungs 4. Hemorrhagic bowels adhered to wall ...” [sic] Review of a document titled, “Preliminary Autopsy,” showed: ... “evidence of fecal vomiting with possible aspiration to the airway and lungs ... ... “pending pathologist review for final diagnosis ...” [sic]”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to inform 1 (#7) of patient rights prior to providing or discontinuing care; and failed to provide IM (Important Message from Medicare) within two days of admission and two days prior to discharge for 4 (#s 1, 2, 9, and 10) of 10 sampled patients. This deficient practice had the potential to affect all patients who were provided care for inpatient or outpatient services. Findings include: 1. Review of patient #7’s electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not informed of her patient rights prior to being provided care or being discharged from the emergency department. During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no documentation the patient received her patient rights. Staff member B stated patient #7 was intoxicated when she presented to the emergency department for care, but she should have had her rights given to her upon discharge. Staff member B stated patients or patient representatives are given a handout about their patient rights when the care agreement is signed. Review of a facility policy titled, “Care Agreement Policy,” with an effective date of 7/2024, showed: “Policy: [Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ... ... I. The Care Agreement document is explained to the patient and/or representative by the A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services.” ... III. The patient and/or representative sign and date the document ...” 2. Review of patient #1’s electronic medical record, dated 4/29/25-5/8/25, showed patient #1 was admitted into the hospital for a surgical procedure on 4/29/25 and was discharged from the hospital on 5/1/25. There was no documentation showing patient #1 received the IM (Important Message from Medicare). Review of patient #2’s electronic medical record, dated 4/11/25-4/12/25, showed patient #2 was admitted to the hospital on 4/11/25 and discharged on 4/12/25. There was no documentation showing patient #2 received the IM (Important Message from Medicare). Review of patient #9’s electronic medical record, dated 5/14/25-5/15/25, showed patient #9 was admitted to the hospital for a surgical procedure on 5/14/25 and discharged on 5/15/25. There was no documentation showing patient #9 received the IM (Important Message from Medicare). Review of patient #10’s electronic medical record, dated 3/4/25-3/6/25, showed patient #10 was admitted to the hospital for a surgical procedure on 3/4/25 and discharged on 3/6/25. There was no documentation showing patient #10 received the IM (Important Message from Medicare). During an interview on 6/4/25 at 10:40 a.m., staff member A stated, “The Medicare letter could not be found in the patient charts and medical records could not locate them either, I am not sure where they are at this time. They should be in the charts.” Review of a facility policy titled, “Medicare Regulatory Notice Delivery Policy,” with an effective date of 11/2024, showed: - ...”It is important that Medicare beneficiaries are informed of their rights ... - ... All patients and their representatives shall have notices delivered ... - ... Scan the signed notice into the associated patient encounter.””

“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: 47752 Based on interview and record review, the facility failed to investigate and address a written concern about care received in an outpatient setting, in which the facility provides oversight, for 1 (#1) of 10 sampled patients. This deficient practice had the potential to affect all patients who received care in an outpatient setting. Findings include: NF1 stated patient #During an interview on 6/3/25 at 11:25 a.m., NF1 stated he had sent a written complaint to the facility about the care patient #1 received from staff at one of the physician’s offices. NF1 stated patient #1 had been an inpatient from 4/29/25-5/1/25, due to a surgical procedure. NF1 stated patient #1 was doing well the first few days he was home. NF1 stated on 5/5/25 patient #1 had a follow up appointment with a physician and had his foley catheter removed. NF1 stated later on in the day on 5/5/25, the patient had placed a call to the physician’s office and talked with staff member H. NF1 stated patient #1 told staff member H he was having pain in his abdomen and pelvis. NF1 stated staff member H did not assess his pain and recommended he take Tylenol or Ibuprofen, and to call back if he could not urinate or the pain was worse. 1 called back the next day and spoke with staff member F. NF1 stated patient #1 told staff member F he was having abdominal pain and acid reflux. NF1 stated staff member F told patient #1 to take a laxative and stop taking the antacid, and to go to the emergency room if the pain gets worse or he cannot have a bowel movement. NF1 stated staff member F never assessed patient #1’s pain. NF1 stated the staff never asked patient #1 to rate his pain, or to describe the pain to them. NF1 stated, “When I would ask him about his pain, I would ask him to give me a number and he would tell me his pain was at an 8 and it was constant, he was not getting relief. The nurses never did that, how can they (the nursing staff) give advice if they don’t assess the pain?” NF1 stated patient #1 was in a lot of pain on the morning of 5/8/25. NF1 stated patient #1 wanted to take a warm bath to see if that would help with his pain. NF2 stated he had left the bathroom to grab a couple things for patient #1 and he returned less than a minute later to find patient #1 unresponsive on the bathroom floor. NF1 stated he started CPR until the ambulance could get there. NF1 stated when he was doing CPR, patient #1 vomited a black, foul substance that smelled like feces. NF1 stated patient #1 was transferred back to the hospital via ambulance in cardiac arrest and was pronounced deceased in the ER. NF1 stated the hospital contacted him about the emergency room visit and let him know they were looking into the situation. NF1 stated that was round 5/14/25. NF1 stated he had a couple of conversations with different staff members about patient #1 and the visit to the emergency room. NF1 stated the main staff member he was communicating with over this incident was staff member C. NF1 stated staff member C called and let him know that a case review was done on patient #1 and it was determined that the facility did everything they could to try and save patient #1. NF1 stated they never addressed the complaint that I filed on the physician’s office. NF1 stated he never really had a concern with the care that was provided in the emergency room or the emergency room staff. NF1 stated, “The only thing that upset me was the coroner approved not doing an autopsy because [Patient Name] did not die a suspicious death, so I paid to have an independent autopsy done. I feel like the nursing staff at the physician’s office contributed to his (patient #1’s) death, I feel like they just blew us off. We had concerns, we did what the discharge paperwork told us to do, and now I am am without [omit]. The facility has done nothing with my complaint. I filed that complaint on 5/20/25.” During an interview on 6/4/25 at 1:35 p.m., staff member C stated she had reached out to NF1 about patient #1 and the sequence of events that happened on 5/8/25 regarding patient #1’s cardiac arrest and death. Staff member C stated she had found out about this incident from the funeral home because they had called me and informed me NF1 had requested an autopsy and had requested a pending death certificate. Staff member C stated she informed the funeral home that she could not do that because she did not have a final cause of death. Staff member C stated that was when she first reached out to NF1. Staff member C stated she had let NF1 know a case review had been completed. Staff member C stated she and NF1 about the code and the situation in the emergency room. Staff member C stated NF1 started talking about the situation at the physician’s office. Staff member C stated, “I told him that I do not know much about the outpatient side of things but would pass on his concerns to the right people.” Staff member C stated she had let staff member J know about the concerns.” Staff member C stated when they were doing the case review, they also started to look into patient #1’s inpatient visit on 4/29/25-5/1/25, and noticed patient #1 had called the physician’s office and spoke to staff on a couple of different occasions prior to 5/8/25. Review of a facility document titled, “Patient Relations Worksheet,” showed: NF1 had submitted a written complaint via email, about the concerns with the outpatient physician’s office which was received by the facility on 5/20/25. On 5/21/25 at 10:21 a.m., the information was forwarded to staff members G and J. During an interview on 6/4/25 at 12:40 p.m., staff member G said she had not done any type of investigation and had not provided any education to staff after NF1’s complaint. During an interview on 6/4/25 at 3:20 p.m., staff member J stated NF1 had arrived at the outpatient clinic and was asking questions about patient #1’s death. Staff member J stated, “I placed a call to staff member L, and she asked me to go and talk with NF1, so I took NF1 into a private room where we could talk. I just basically listened to him. After I listened to NF1 I called staff member L back and I was told she or [Staff Name] would handle it from there. I did not do an investigation into the outpatient side. I really did not know there was a concern.” During an interview on 6/5/25 at 9:00 a.m., staff member L stated, “I had actually heard about the incident prior to the complaint being filed. We were already in the process of getting a case review scheduled. As a group we went over the case to see what could have been done differently or what we could have done better. We went thought the surgical notes, inpatient notes, notes from the outpatient visit, nursing notes.” Staff member L stated, “At this time no education has been provided to staff.” Staff member L stated, “[Staff member J] was supposed to address the nursing concerns with [Staff members F and H]. We are aware there are some changes that need to occur in our outpatient setting and [Staff member J] and I have talked about that and what we need to do, but we have not done anything at this time.” During an interview on 6/9/25 at 12:32 p.m., NF1 stated he was never notified the complaint was resolved. NF1 stated, “They have done nothing, the only thing they did was look into when [patient #1] came to the ER and that was not even my concern.” Review of a facility document titled, “Patient Relations Worksheet,” showed: “REVIEWER: [STAFF NAME] (staff member C) STATUS: RESOLVED DATE CLOSED: 5/22/25.” Review of a facility document titled, “Complaint/Grievance Procedure (Customer), with an effective date of 7/2024, showed: ... “IV. Grievance Investigation A. The grievance must be reviewed, investigated and resolved within a reasonable timeframe ...”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to provide a written resolution following a complaint/grievance investigation to the patient or patient representative for 1 (#1) of 10 sampled patients. This deficient practice had the potential to affect all patients or patient representatives that have filed complaints or grievances with the facility. Findings include: During an interview on 6/3/25 at 11:25 a.m., NF1 stated he file a complaint with the hospital on 5/20/25 and on 5/22/25 he stated he received a phone call from a staff member but could not remember who it was. NF1 stated, “She (staff member C) called and told me they (the hospital) had completed the case review, and it was determined they did all they could for patient #1. She did not even address the complaint I filed about the physician’s office.” During an interview on 6/4/25 at 1:25 a.m., staff member C stated she felt she had a good rapport with NF1, so she had called him and let him know the results case review. Staff member C stated she did not speak with him about the inpatient complaint because that is not her area, and she is not familiar with how outpatient complaints are handled. During an interview on 6/9/25 at 10:32 a.m., NF1 stated he had not had any type of communication from the hospital regarding the complaint. NF1 stated he had not received any type of verbal or written communication indicating anything was resolved. NF1 stated, “Nothing has been resolved, they have not done anything.” Review of a facility document titled, “Patient Relations Worksheet,” showed: “REVIEWER: [STAFF NAME] (staff member C) STATUS: RESOLVED DATE CLOSED: 5/22/25.” Review of a facility document titled, “Complaint/Grievance Procedure (Customer), with an effective date of 7/2024, showed: ... “Grievance Resolution A. A grievance is considered resolved when the complainant is satisfied with the actions taken on their behalf. ... C. Upon grievance resolution, except when filed anonymously, a written response to the complainant is required providing: 1. Name of [Facility Name] contact person; 2. The steps taken on behalf of the complainant to investigate the grievance; 3. The results of the grievance process; 4. The date of completion.” [sic]”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to obtain a consent to treat in the emergency room setting prior to providing or discontinuing care for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented to the emergency room for care. Findings include: Review of patient 7’s electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. An informed consent to treat was not completed by patient #7 prior to being provided care or being discharged from the emergency department. There was no care agreement located in patient #7’s electronic medical record. On 6/3/25 at 4:15 p.m., a request was made for patient #7’s signed consent to treat form. During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no consent to treat for patient #7. Staff member B stated patient #7 was intoxicated when she presented to the emergency department for care, but she should have signed the consent prior to discharge. Review of a facility document titled, “Care Agreement,” showed: “This agreement includes and is effective for all acute care admissions, emergency room services.... ...2. MEDICAL CONSENT: I understand I was ... under the care and supervision of my attending physician or my physician’s designee. ...I understand that it is the responsibility of [Facility Name] and its staff ...I consent to ...medical treatment ...” Review of a facility policy titled, “Care Agreement Policy,” with an effective date of 7/2024, showed: “Policy: [Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ... ... I. The Care Agreement document is explained to the patient and/or representative by the A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services.” II. The patient and/or representative agree to the following: A. Consent is given to the Hospital to provide appropriate nursing care B. The patient gives permission to the Hospital to administer the care directed by their physician or physician’s designee, ...” ... III. The patient and/or representative sign and date the document ...””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to inform a patient of their right to formulate an advanced directive in an outpatient setting for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented for care in an outpatient setting. Findings include: Review of patient 7’s electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not notified of her right to formulate an advanced directive. There was no care agreement or documentation of information provided to patient #7 about the right to formulate an advanced directive located in patient #7’s electronic medical record. On 6/3/25 at 4:15 p.m., a request was made for patient #7’s care agreement and documentation of notification of the right to formulate an advanced directive. No documentation was provided by the facility. During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no signed care agreement or documentation the patient received information on the right to formulate an advanced directive, which is part of the facilities care agreement. Review of a facility document titled, “Care Agreement,” showed: “This agreement includes and is effective for all acute care admissions, emergency room services.... ...13. ADVANCED DIRECTIVES: I have been informed Advanced Directive information is available to me from [Facility Name] at my request. Review of a facility policy titled, “Care Agreement Policy,” with an effective date of 7/2024, showed: “Policy: [Facility Name] strives to provide that each patient and/or their representative are informed about their rights and responsibilities for their care and treatment ... ... I. The Care Agreement document is explained to the patient and/or representative by the A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services.” ... R. The patient acknowledges that they have been informed about the availability of Advanced Directive documents.” ... III. The patient and/or representative sign and date the document ...””

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(1), (h)(2) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.] A hospital must meet the following requirements: (1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section. (2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to inform a patient of their visitation rights for 1 (#7) of 10 sampled patients. This deficient practice had the potential to affect all patients who presented for care within the facility. Findings include: Review of patient 7’s electronic medical record, dated 5/10/25 showed, patient #7 presented to the emergency department for alcohol intoxication, facial contusion, and polysubstance abuse. Patient #7 was not notified of visitation rights. There was no care agreement or documentation of information provided to patient #7 about visitation rights located in patient #7’s electronic medical record. On 6/3/25 at 4:15 p.m., a request was made for patient #7’s care agreement and documentation that patient #7 was notified of visitation rights. The facility did not provide this documentation. During an interview on 6/4/25 at 10:00 a.m., staff member B stated there was no signed care agreement or documentation showing patient #7 received information on visitation rights, which is part of the facilities care agreement. Staff member B stated visitation rights are on a pamphlet that are given to patients at the time they sign their care agreement. Review of a facility policy titled, “Care Agreement Policy,” with an effective date of 7/2024, showed: “Policy: for their care and treatment ... ... I. The Care Agreement document is explained to the patient and/or representative by the A. Registration staff member and signed by the patient and/or representative up on admission to the Hospital for inpatient or outpatient services. ... III. The patient and/or representative sign and date the document ...””

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 482.41(b), a life safety code survey was performed on 6/24/24 - 6/26/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type I. New construction has occurred since the last full survey of the facility on 8/14/19. The hospital census was 181 at the time of the survey. These requirements were not met as evidenced by the following deficiencies:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.1. Findings include: 1. During an observation on 6/26/24 at 10:18 a.m., the second-floor west campus southeast door near the nurse’s station was observed. The door was marked as an emergency exit. A table was observed, stored in front of the exit and blocking the means of egress.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2. Findings include: 1. During an observation on 6/26/24 at 10:27 a.m., the wound care clinic was inspected. There was an exit sign on a door outside wound care leading to the behavioral health, and the door the was found to be locked. Marked exits cannot be locked unless the door is equipped with a special locking feature such as delayed egress. 2. During an observation on 6/26/24 at 10:35 a.m., the pain clinic was inspected. There was a marked egress door leading to the old pediatric therapy area which was found to be magnetically locked. Occupants could not follow the marked exit path through the door.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8. Findings include: 1. During an observation on 6/25/24 at 8:43 a.m., the elevator vestibule door on the 2nd floor was inspected. The door was exercised twice and failed to close and latch under the power of the self-closing device.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 40068 Based on observations, the facility failed to ensure smoke-proof rated stairway enclosures were continuously maintained per NFPA 101 Life Safety Code, 2012 Edition, Section 7.2.3.3.1. Findings include: 1. During an observation on 6/26/24 at 9:55 a.m., the first floor west campus exit stairwell door, next to room G-105, was exercised. The exit stairwell door would not close and positively latch. 2. During an observation on 6/26/24 at 10:21 a.m., the second floor of west campus was inspected. The southeast exit stairwell door (210) would not close and positively latch when exercised.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 19.2.10 and 7.10. Findings include: 1. During an observation on 6/25/24 at 9:17 a.m., the north end vestibule between the lab and GI was was observed to be lacking an exit sign on the lab side. The path of egress was not obvious.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to ensure hazardous rooms or rooms being used as storage had doors which were able to close and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. Findings include: 1. During an observation on 6/25/24 at 8:36 a.m., the corridor door to the soiled side of the laundry was exercised. The door failed to close and latch under the power of the self-closer. 2. During an observation on 6/25/24 at 9:38 a.m., resident room 319 was inspected. The room is over 50 sq. ft. and was found to be used as a storage room. The room was lacking the required self-closing device on the corridor door. 3. During an observation on 6/25/24 at 9:39 a.m., resident rooms 321 and 322 were inspected. The rooms were over 50 sq. ft. and were found to be used as a storage rooms. The rooms were lacking the required self-closing devices on the corridor doors. 4. During an observation on 6/25/24 at 9:44 a.m., resident room 324 was inspected. The room is over 50 sq. ft. and was found to be used as a clothing storage room. The room was lacking the required self-closing device on the corridor door. 5. During an observation on 6/25/24 at 9:55 a.m., EVS rooms 385-389 and 360 were all found to be used as storage rooms, and lacked the required self-closing devices, as all the rooms were over 50 sq. ft. 40068 6. During an observation on 6/25/24 at 10:10 a.m., the seventh floor of the North Tower was inspected. The surgical storage room (715) was used to store various medical equipment and did not have a self-closer on the door. 7. During an observation on 6/25/24 at 10:20 a.m. the eighth floor of the North Tower was inspected. Room 815, a storage room, was used to store various medical equipment and did not have a self-closer on the door.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 6/25/24 at 10:38 a.m. the x-ray suite was inspected. There was an ABHR dispenser mounted too closely or over a light switch.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure pendant type sprinkler heads were mounted at proper distances under unobstructed construction per NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1. Findings include: 1. During an observation on 6/26/24 at 9:32 a.m., the chapel was inspected. There was a pendant-type sprinkler head found to be less than 1” from being level with the drop down ceiling. There was not enough clearance between the deflector and the ceiling.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to: a) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.; b)ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).; and c) maintain fire department access in accordance with NFPA 25 Water-Based Fore Protection 2011Edition, Section 6.1.3. Findings include: 1. During an observation on 6/25/24 at 8:33 a.m., the soiled side of the laundry was inspected. There was a hard pipe line suspended from the facility sprinkler pipe in the room. 2. During an observation on 6/25/24 at 9:42 a.m., the 3rd floor soiled utility room was inspected. There was a ceiling tile observed to be missing from the ceiling structure within the room. 40068 3. During an observation on 6/25/24 at 9:58 a.m., the fifth-floor North Tower housekeeping closet (549) was inspected. There was a penetration observed in the ceiling tile. 4. During an observation on 6/25/24 at 10:04 a.m., the fifth-floor North Tower was inspected. Near room 587, a cabinet was observed with signage which read, “Standpipe for Fire Department Use Only.” The door was painted shut and was not accessible. 5. During an observation on 6/25/24 at 10:30 a.m., the eighth floor North Tower data closet (803) was inspected. There were two ceiling tiles that had been removed.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to: a) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.; and b) install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.4 and 6.1.3.8.1. Findings include: 1. During an observation on 6/26/24 at 10:23 a.m., the ambulatory pharmacy was inspected. There was a portable fire extinguisher blocked from immediate access by a small cabinet stored directly in front of it. 40068 2. During an observation on 6/26/24 at 9:38 a.m., the west campus kitchen was inspected. The portable K-tank was mounted 65 inches from the ground.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 32381 Based on observations, the facility failed to: a) ensure corridor doors were resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Sections 19.3.6.3.1.; and b) maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10. Findings include: 1. During an observation on 6/25/24 at 10:02 a.m., third floor room 381 was found to be completely lacking a corridor door. 40068 2. During an observation on 6/25/24 at 10:06 a.m., the fifth floor of the North Tower was inspected. The dialysis supply room (560) door wasobserved being held open by a wedge.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1. Findings include: During an observation on 6/26/24 at 9:34 a.m., the west campus basement smoke doors near the cafeteria were exercised. The south leaf would not close and latch when exercised.”

“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: 32381 Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2. Findings include: 1. During a review of facility fire drills on 6/24/24 at 8:00 a.m., it was determined the facility had not completed a fire drill for the evening shift of the second quarter of 2023.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). Findings include: 1. During an observation on 6/25/24 at 9:40 a.m., the third floor clean utility room was inspected. There were items found to be stored in front of the electrical panel in the room.”

“CARE OF PATIENTS - PRACTITIONERS CFR(s): 482.12(c)(2) [ ...the governing body must ensure that the following requirements are met:] If a Medicare patient is admitted by a practitioner not specified in paragraph (c)(1) of this section, that patient is under the care of a doctor of medicine or osteopathy. This Standard is not met as evidenced by: 41951 Based on interview and record review, the facility failed to establish policies and bylaws to ensure patients admitted to the hospital by mid-level providers, were under the care of a doctor of medicine or osteopathy. Findings include: During an interview on 6/19/24 at 7:55 a.m., staff member D stated patients admitted by mid-level providers are also under the care of a physician. During an interview on 6/19/24 at 4:23 p.m., staff member A stated the facility had identified some gaps in their process for MD/DO oversight. Staff member A stated the facility’s policies needed to be clearer in regards to patients admitted by a mid-level provider and medical record documentation of the patients being under the care of an MD/DO. Review of the facility’s document titled, Professional Staff Rules and Regulations, last revised September 2016, did not include documentation to ensure patients admitted to the hospital by a mid-level provider were under the care of an MD/DO.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to adhere to infection prevention standards by not performing hand hygiene in the laboratory for 1 (#18) of 34 sampled patients. This deficient practice had the potential to affect all patients who received care in the laboratory. Findings include: During an observation on 6/18/24 at 10:20 a.m., patient #18 presented to the laboratory for a blood draw. Staff member O brought patient #18 into the blood draw area and donned a pair of blue nitrile gloves. Staff member O did not perform hand hygiene prior to donning his gloves. Staff member O proceeded with the blood draw. After an unsuccessful attempt, staff member O removed the venipuncture device and discarded it into the sharps container. Staff member O touched the sharps container twice. Staff member O proceeded to touch the counter, and the box containing tourniquets. Staff member O did not change his gloves or perform any hand hygiene prior to proceeding with the second venipuncture. Staff member O collected three vials of blood. Staff member O discarded the used venipuncture device and escorted patient #18 from the laboratory area. Staff member O doffed his gloves and discarded them in the trash. No hand hygiene was performed. During an interview on 6/18/24 at 10:30 a.m., staff member O could not verbalize what the facility hand hygiene policy stated. Staff member O stated, “I usually just wash my hands in between patients.” Review of a facility document titled, “Hand Hygiene,” with an effective date of 05/2024, showed: “... Hand hygiene is expected of all employees before and after all patient/resident contact, after glove use...””

“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: 44770 Based on interview, policy review, and record review, the facility failed to comply with the conditions of participation outlined in 489.20 and related requirements at 489.24:(refer to appendix V). The facility failed to 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 for six patients (#s 15, 16, 17, 22, 23, and 24); and the facility failed to provide stabilizing treatment for 1 (#16) of 24 sampled patients. Findings include: Review of a facility policy titled, EMTALA Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, “Any person who comes to Hospital or an off-campus provider-based department of Hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening examination (MSE) performed by a qualified medical person to determine whether an EMC exists ... If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capabilities of Hospital, or an appropriate transfer, as defined by and required by EMTALA. Stabilizing treatment must be provided in a non-discriminatory manner.” -Patients #s 15, 16, 17, 22, 23, and 24 did not receive complete MSEs after seeking care in the emergency department. (Refer to A-2406). -Patient #16 did not receive stabilizing treatment in the emergency department before being discharged. (Refer to A-2407).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44770 Based on interview and record review the facility failed to maintain an accurate ED log for 1 (#17) of 24 sampled patients. Findings include: Review of a facility policy titled EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, “ ... 6. Central Log is a record maintained of all individuals who come to a department seeking emergency care. The log shall be kept for five years and shall contain specific patient information including: a. Patient identification b. Medical record and encounter number c. Presentation time d. Triage time e. MSE time f. Discharge time g. Disposition ... The purpose of the Central Log is to track the care provided to each individual who comes to Hospital seeking emergency medical care...” During an interview on 12/6/23 at 1:31 p.m., staff member F stated she was a Registration Clerk for the facility ED. She stated, “If the hospital is on internal disaster status, there is a form that staff can read to patients to tell them how long the wait will be.” Staff member F said in some cases it can take up to twelve hours to be seen in the ED. She stated the registration clerks are permitted to give patients options of where they can go to be seen more quickly. Staff member F stated, “If a patient decides to leave, we ask the patient to sign a form saying they are choosing to leave.” She said some patients will sign the form and others do not. Staff member F stated some patients choose to leave right away after they are told how long the wait will be; these patients choose not to stay and do not get registered or placed on the ED log. During an interview on 12/11/23 at 10:00 a.m., patient #17 stated he went to Benefis Hospital on 12/4/23 because he was having abdominal pain and thought he might be having another pancreatitis attack. He stated he could not remember the exact time he went to the ED. Patient #17 said the registration clerk at the ED told him there was going to be an 8-12 hour wait to be seen by a physician. Patient #17 told the registration clerk he was also vomiting blood and didn’t think he could wait that long. He stated the registration clerk told him he could try going to the other hospital in town. Patient #17 said he did not know there was another hospital in town, so the registration clerk told him how to get there. Patient #17 said the registration clerk did not take his name or register him in the computer. He stated he did not go to triage, and he did not receive a patient name band. During a phone interview on 12/8/23 at 9:45 p.m., NF4 stated he was an ED physician at another local hospital. He stated he had a patient (#17) that came to his facility on 12/4/23 to be seen in his emergency department. NF4 stated the patient had recently been admitted and discharged from Benefis Hospital for pancreatitis. NF4 said he asked the patient why he had not gone back to Benefis, as he had been treated there previously. He stated the patient (#17) told him he was told by the registration clerk he would be waiting 8-12 hours and he was afraid that since he was vomiting blood, he could not wait that long. NF4 stated patient #17 told him he was unaware there was even another hospital in the area, so the registration staff had to give him directions to get to the other location. Review of Benefis Hospital ED logs failed to show patient #17 presented to the facility ED on 12/4/23.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44770 Based on interview and record review the facility failed to provide an MSE for 6 (#s 15, 16, 17, 22, 23, and 24) of 24 sampled patients. This deficient practiced caused five of the six patients to seek care at another hospital, and all required inpatient admissions. One patient was discharged home and was pronounced dead the following day. Findings include: Review of a facility policy titled EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, “ ...Hospital must provide an appropriate MSE within the capability of Hospital’s Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an EMC exists: (a) to any individual, including a pregnant woman having contractions, who requests such an examination; (b) to any individual who has such a request made on his or her behalf; and (c) to any individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE ...Triage is not equivalent to an MSE.” During an interview on 12/6/23 at 1:31 p.m., staff member F stated she was a Registration Clerk for Benefis ED. She stated, “If the hospital is on internal disaster status, there is a form that staff can read to patients to tell them how long the wait will be.” Staff member F said in some cases it can take up to twelve hours to be seen in the ED. She stated the registration clerks are permitted to give patients options of where they can go to be seen more quickly. Staff member F stated, “If a patient decides to leave, we ask the patient to sign a form saying they are choosing to leave.” She said some patients will sign the form and others do not. Staff member F stated some patients choose to leave right away after they are told how long the wait will be; these patients choose not to stay and do not get registered. 1) Review of patient #15’s EMR on 10/10/23 showed patient #15 presented to Benefis Hospital ED at 7:21 a.m. The patient went to triage at 7:33 a.m., and left without being seen at 7:34 a.m. There were no triage vital signs or assessments documented in the patient’s medical chart. During a telephone interview on 12/11/23 at 12:45 p.m., patient #15 stated, “They [Benefis ED] said there would be a very long time to wait. The lady at the front desk suggested we try the other hospital, [Other Hospital Name].” Patient #15 stated she did not see a nurse while at the ED and she did not have her vital signs taken. Patient #15 said the facility staff had her sign a form so she could go somewhere else due to the extended wait time. She stated she did not know what the form was for, and no one explained the risks of leaving the hospital to seek care elsewhere. Review of patient #15’s medical record from the other local hospital showed the patient presented to their emergency department on 10/10/23. The patient was complaining of a right lower quadrant pain which had worsened over the last 2 days. The patient had CT imaging and diagnostic laboratory testing conducted which indicated she was having appendicitis. The patient required admission to the facility for surgical management of her appendicitis. 2) Review of Benefis ED log for 11/15/23, showed, patient #16 presented to the Emergency Department at 3:00 p.m. for alcohol detoxification. During the patient’s ED visit, patient #16 reported to facility staff that she was having thoughts of suicide in addition to her withdrawal from alcohol. The facility failed to provide an appropriate MSE for the patient. Patient #16 was discharged to home at 6:51 p.m., and the patient was pronounced dead the next day. Review of patient #16’s medical record showed: “32-year-old female nontoxic in appearance although visibly intoxicated presents today requesting admission for detox .... I have very low suspicion for current alcohol withdrawal. A conversation was had with the patient advising her that we do not admit patients for detox especially when they are still currently intoxicated. Patient subsequently became upset. Verbal de-escalation did ensue with subsequent consultation with social worker who came and personally evaluated the patient with advisement of having her follow-up in the outpatient setting ... Patient was discharged shortly afterwards.” Review of patient #16’s ED behavioral health notes showed, “patient states she was referred to Benefis by [medical provider name]. ‘I am trying to detox without killing myself.’ ... Patient states she had about three fourths of a pint of vodka earlier today. Her last drink was around noon .... She states she was recently diagnosed with early cirrhosis of the liver. She has never been to treatment before but is agreeable to going and has been accepted to [detox center]. She states she is afraid to detox ...” Review of a facility report titled, “Severity Measure for Depression Adult”, adapted from the PHQ-9, dated 11/15/23, showed patient #16 scored 27 of 27, indicating the highest score possible for depression. During an interview on 12/8/23 at 3:51 p.m. NF2 stated he and patient #16 went to [health provider name] seeking substance abuse assistance for patient #16. NF2 stated they saw NF3 at [health provider name] because patient #16 wanted to stop her addiction to alcohol. NF2 said NF3 did an assessment and felt that patient #16 should be detoxed under medical supervision because of the extent of her alcohol use, and the patient had a history of having seizures from withdrawing from alcohol. NF2 stated he and patient #16 received some paperwork from NF3’s office, and they went straight to Benefis ED as they were instructed to do by NF3. NF2 stated patient #16 checked in at the Benefis ED, they sat in the waiting room for a very long time. NF2 stated he and patient #16 were taken back into the emergency department. They were not placed in a patient room. NF2 said they were instructed to sit in a chair next to the nurse’s station. When the doctor (staff member G) approached them, NF2 stated he handed the doctor the paperwork from NF3’s office. NF2 stated the doctor looked at the paperwork, rolled his eyes, and stated, “They are going to have to stop doing this,” and he walked away. When he came back, the doctor told NF2 and patient #16 that [health provider name] needed to stop sending people to be admitted, it was his decision to admit people, and he was not going to admit patient #16 to detox under medical supervision. NF2 stated patient #16 started crying and begged the physician to reconsider. NF2 said, “She was begging for her life. She told him he was going to kill her if she didn’t get help in the hospital.” NF2 said after patient #16 begged the doctor to help her, the doctor said he would have the counselor come to talk with her to arrange for help on an outpatient basis. NF2 said the hospital did not do any blood work on the patient, they just had her blow into a breathalyzer. Patient #16 blew a 0.4 (normal 0). NF2 stated a counselor (staff member H) came to talk to them and completed some assessments. NF2 said patient #16 told staff member H she was ready to get sober and told her about some of the things that happened in her life. By the time staff member H was done talking to them, NF2 said all of them were crying, including staff member H. NF2 said staff member H felt patient #16 should be admitted because she was also suicidal. NF2 said staff member H walked over to staff member G. He could not hear what was said, but he saw staff member H lower her head and walk away. NF2 stated staff member H looked “frustrated.” Shortly after staff member H talked to the doctor (staff member G), the doctor came over to NF2 and patient #16 and told them he, “absolutely” was not going to admit patient #16 because she was still drunk. NF2 said, “She absolutely looked like she was in withdrawal to me. With her, it didn’t take very much because she always drank so much. She was shaking and sweating. Since he told us he was not going to admit her no matter what, we just decided to leave. Some nurse said she had discharge instructions for us, but we didn’t get them.” NF2 stated, “(Patient #16) was determined to go to rehab which had been prearranged, but she had to be sober to get into the rehab facility”. NF2 stated patient #16 did not consume alcohol after she left the hospital, she ate, and went to bed. NF 2 stated that when patient #16 woke the next morning, she was nauseated, unable to eat, shaking, and didn’t look very good, but did not return to the ED because of how they were treated the day before. Patient #16 went back to bed, and when NF2 went to check on her, she was not breathing. NF2 initiated CPR and called 911. NF2 stated the sheriff showed up and took over CPR until the ambulance came to get patient #16. NF2 stated the ambulance arrived and took over patient #16’s care. He stated, “That was the last time I saw her.” During an interview on 12/8/23 at 12:04, staff member H said she remembered patient #16. Staff member H stated she assessed patient #16 for suicidal ideation and homicidal ideations. Staff member H said patient #16 said, “If someone were to give me a handful of pills, I would take them.” Staff member H said patient #16 scored 27 of 27 on the PHQ-9 (an assessment for a patient’s suicidal thoughts. 27 is the highest possible). Staff member H said she was aware patient #16 had seizures with withdrawal in the past. Staff member H said she did not get to finish her evaluation. During an interview on 12/8/23 at 10:45 a.m., staff member G said he remembered patient #16 presenting at the ED. Staff member G stated patient #16 came in requesting detoxification from alcohol. Staff member G stated he was not aware patient #16 had scored a 27 of 27 on the PHQ-9 assessment and said he was not sure what that was, but stated he was not aware that patient #16 was suicidal. Staff member G stated he normally asks all patients seeking detoxification from alcohol if they are suicidal, and it would not be typical to discharge a patient who had suicidal thoughts. Patient #16 had two EMC’s (emergency medical conditions); alcohol intoxication with concern for potential alcohol withdrawal and seizures, as well as suicide ideation with a history of prior suicide attempts. Patient #16’s emergency department record for 11/15/23 showed one set of vital signs were obtained at 3:01 p.m., and a point of care breathalyzer test result of 0.4 was documented. No laboratory or diagnostic tests were ordered. Patient #16 did not receive a psychiatric evaluation, despite her reporting to staff that she was suicidal. 3) During an interview on 12/11/23 at 10:00 a.m., patient #17 stated he presented to Benefis Hospital ED on 12/4/23. He said he was worried he was having problems with pancreatitis again. The patient could not remember exactly what time it was when he arrived. Patient #17 said he went to the front desk and asked to be seen by a physician. The registration person told the patient it was very busy, and it would take 8-12 hours before he could be seen in the ED. When patient #17 told the staff member he was also vomiting blood and did not think he could wait that long, the staff member told him he could try going to the other hospital in town. The staff member gave the patient the name of the hospital and gave him directions to get there because he was unaware there was another hospital, and he did not know where it was located. Patient #17 stated, “She didn’t even check me in or get my insurance information.” He stated they did not take his vital signs and no one other than the registration clerk spoke to him during his time at the ED. Review of Benefis ED log failed to show patient #17 presented in the ED on 12/4/23. Review of patient #17’s medical record from the other hospital showed, “labs are obtained and show evidence of acute pancreatitis. His lipase is significantly elevated ...” The ED physician who examined the patient contacted the on-call hospitalist and she agreed to admit the patient to the hospital for further observation and treatment. During a telephone interview on 12/8/23 at 9:45 a.m., NF4 stated he was the ED physician who examined patient #17 in his ED on 12/4/23. NF4 stated patient #17 told him he was sent to his hospital from Benefis ED because they were very busy and had extreme wait times. NF4 stated he was worried because patient #17 had told Benefis ED staff that he was vomiting blood, and they sent him away. NF4 stated he felt the actions of the Benefis ED could be dangerous because patient #17 would not be monitored when he left and could have suffered negative consequences. NF4 stated he has had several patients present at his ED stating they were sent over by Benefis, and others come there on their own because the wait times are so long at Benefis. NF4 stated he called to speak to the registration clerks at the Benefis ED on a few occasions to inform them it was not acceptable for the facility to send patients to other places to receive care. NF4 stated some of the registration clerks at Benefis ED would argue with him, and one even told him, “We tell patients that our wait time is 11 hours, there is another ER in town, so if they chose to go there, that’s on them.” NF4 stated on 9/26/23 he had three patients tell him they had been sent over to his hospital from Benefis ED, so he called and talked to the charge nurse who was on duty. The charge nurse informed NF4 that Benefis ED staff had been instructed by hospital administration that the facility was on disaster status and staff were instructed to inform patients they were going to have a very long wait time before they could be seen in the ED. NF4 stated the charge nurse told him they were also sending patients home, and the facility would call them to come back when they were available to examine them. Review of a facility document titled, ED Operations During an Internal Disaster, not dated, showed: “ ...scripting for patients ... We have declared an internal disaster as a result of a large patient population needing care today. During this time, we change how we triage to a nationally accepted triage method that is color coded and right now you meet the green criteria and can expect a wait time from 8-12 hours to get into the ED. You are more than welcome to wait or to try walk-in, same day orthopedics, or your primary care. We know you need to be seen; we are just letting you know a realistic time to expect ....” 4) During an interview on 12/12/23 at 11:55 a.m., patient #22 stated he presented to Benefis Hospital ED on 10/23/23 because he was having chest pain. He stated the chest pain caused him to get very sweaty. Patient #22 stated, “I wasn’t feeling too good. I felt like I was going to pass out.” Patient #22 said the facility registration clerk checked him in and then told him he would be waiting 6-12 hours to be seen in the emergency room. Patient #22 stated he sat down in the lobby for a few minutes and then started feeling like he was going to pass out. He stated he went back up to talk to the registration clerk and he explained to her that he had a history of heart problems, and he was afraid he was having an emergency. Patient #22 stated the registration clerk told him again there would be a very long wait before he could be seen. Patient #22 stated, “She told me I should go to [the other hospital] if I felt I was having an emergency. They basically turned me away.” Patient #22 stated he went to the other hospital because he was scared. He said when he got there, the other hospital checked him in right away and took him to a room. Patient #22 stated his blood sugar was very high and his troponin was elevated and kept increasing. Patient #22 said he was admitted to the hospital for monitoring and treatment. Review of Benefis ED log showed patient #22 was registered on 10/23/23 at 7:36 p.m. Patient #22 was not triaged and left without being seen at 7:49 p.m. Review of patient #22’s medical record from the other hospital showed, “At 7 p.m. this evening, the patient developed 8/10 intensity pressure-like chest pain radiating to his left should/left upper extremity/left upper back associated with diaphoresis, shortness of breath, nausea; but completely resolved after 1 hour ... troponins (lab test indicating cardiac muscle damage) have increased from 0.108 at 9:00 p.m. to 0.12 (normal <0.04) at 11 p.m. ... Initial lactic acidosis with lactic acid level 4.4 (normal 0.5-2.2, lactic acid increases when the bodies tissues are deprived of oxygen, it can also be elevated if the liver or kidneys aren’t able to metabolize it efficiently) ... elevated blood sugar 565 (normal is 80-130 for patients with type II diabetes) ... The patient is being admitted for myocardial injury/NSTEMI ... chest pain, nonketotic hyperglycemia, lactic acidosis, CAD ... uncontrolled diabetes mellitus ... hypertension, obesity.” 5) During an interview on 12/14/23 10:06 a.m., Patient #23 stated he presented at Benefis ED and asked to be seen because he was not feeling well. Patient #23 stated he had diabetes, and he thought his blood sugar was off. He stated, “They refused to do anything for me, I sat there for about an hour throwing up and they were not helping me. They didn’t even register me for a long time. Then, when they were going to triage me, the first thing they said was the wait time was going to be very long. They didn’t even check my vital signs or check my blood sugar. My meter wasn’t working so I didn’t even know how high my blood sugar was and they would not check it either. They told me it would be at least 12 hours before a doctor would see me. It is not the first time they have done that either. DKA(Diabetic ketoacidosis, a life-threatening complication of type 1 diabetes) is very dangerous, and they just didn’t seem to understand that it was dangerous. I am a drug addict and I have relapsed in the past. I think the reason they treated me that way is because they thought I was just seeking drugs or that I was on drugs, and they just didn’t care. They don’t treat people with drug or alcohol problems very well there.” During an interview on 12/14/23 at 9:46 a.m., NF6 stated she was with patient #23 on 10/6/23 when he went to Benefis for emergency care. She stated, “They said the doctor wouldn’t be able to see him for like 12 hours or something like that. That upset him because he has type 1 diabetes and when he has ketoacidosis it is very dangerous for him. That can kill him. They wouldn’t even just check his sugar for him. His meter wasn’t working but he knew by the way he felt he had a serious problem, and they were not taking him seriously at all.” Review of patient #23’s medical record from Benefis Hospital showed patient #23 presented to Benefis ED on 10/6/23. The patients ED notes did not show vital signs were recorded or blood glucose testing. There was one nursing note that showed, “Patient was acting hostile toward staff. Pt walked out of triage stating ‘take me to [other facility name]’ to Mother and staff, patient walked out of the waiting room door ...” Review of Benefis ED log for 10/6/23 showed patient #23 presented to the ED at 9:47 p.m. Patient #23 left at 10:07 p.m. There was no triage level or presenting complaint listed on the log. Review of patient #23’s medical record from the other hospital showed, on 10/6/23 at 10:15 p.m., patient #23 presented to be seen in their emergency department. The patient had a 30-year history of type one diabetes. Patient #23 went to the ED because he thought he was in DKA. He told the doctor in the ED he could usually tell when he was in DKA, and he began vomiting and feeling poorly that day. Patient #23 thought he must not have gotten the needle for his insulin pump properly inserted into his skin, causing the insulin not to be pumped into his body correctly. Patient #23’s blood glucose was elevated to 688 (normal for type 1 diabetes is 80-130), his pH was 7.27 (normal is between 7.35 and 7.45) indicating acidosis, and his anion gap was 37.5 (normal is 3-11) indicating he was in Diabetic Keto-acidosis. Patient #23 was admitted to the hospital to correct his blood sugar with an IV (intravenous) insulin infusion and for medical monitoring. 6) During an interview on 12/12/23 at 12:52 p.m., NF1 said she takes care of patient #24 and his mother. Patient #24 has a history of advanced, rapidly progressive Parkinson’s disease/dementia/severe neurocognitive deficits/wheelchair and bedbound and had urinary retention requiring the use of a Foley catheter (indwelling catheter to drain urine). NF1 said patient #24 had been residing at a local care facility because his care needs had been more than his mom could handle at home. NF1 and her employees had been taking care of patient #24’s mother and had been taking her back and forth to see patient #24 at the care facility where he resides. On 9/21/23 one of NF1’s employees and patient #24’s mother went to the care facility to see patient #24 and they were told that he had been sent to Benefis ED. When they arrived at Benefis ED they found patient #24 sitting in the waiting area, alone. Patient #24 did not have anyone with him, and he was unable to communicate. NF1 stated her staff called her to inform her of the situation. NF1 stated she went directly to Benefis ED to see what was transpiring. NF1 stated when she arrived at Benefis ED, she saw patient #24 sitting in a wheelchair, slumped over, and drooling on himself. She stated patient #24 had been sitting in the waiting area for roughly three hours. NF1 stated she was very concerned when she saw the condition patient #24 was in. NF1 stated she asked the registration person what was happening. NF1 stated she was told the ED was very busy and there would be a very long wait for him to be seen by the doctor. NF1 said, “I am convinced that if I had not shown up when I did, he would have died. I felt like we needed to save his life and the registration person just did not care. She said we could take him elsewhere if we felt he was having an emergency.” NF1 said she didn’t even talk to the nurses, at that point, she just took him to her car. NF1 said, “I was focused on getting him the hell out of there.” NF1 said it took three people to get patient #24 in the car. She took the patient directly to the other hospital in town. NF1 stated the other hospital took him straight back to a room in the ED. She said the nurses and doctors worked quickly because patient #24 was so sick. NF1 stated they took patient #24’s temperature, and it was 103.1 F. NF1 stated they inserted a foley catheter, and during insertion, all that came out was puss. NF1 stated the doctor told her he was not sure patient #24 was going to survive. Review of Benefis ED log showed, patient #24 arrived via ambulance on 9/21/23 at 6:26 p.m. with a complaint of a “fall” and left without treatment at 9:59 p.m. Review of patient #24’s ambulance report showed, on 9/21/23 at 6:25 p.m., the ambulance service transferred care of patient #24 to Benefis Hospital. The ambulance report showed the patient was transported to Benefis because he had fallen and hit his head at the care center where he resided. The Ambulance report showed the patient had a temperature of 100.2 F (Normal is 98.6) and his heart rate was elevated at 104 (normal is 60-100). The ambulance reported the patient had slurred/incomprehensible speech. Review of patient #24’s medical record from Benefis Hospital showed, on 9/21/23 at 6:26 p.m. the patient was registered to the emergency department. Initial vital signs were recorded. Patient #24’s temperature was 100.3, heart rate 104, respirations 14, blood pressure was 104/62, and his oxygen saturation was 95%. No doctor was assigned to patient #24. Review of patient #24’s medical chart showed there were no other assessments, vital signs, or notes for patient #24. The chart read, “ELOPED” at 9:59 p.m. Review of patient #24’s medical record from the other hospital showed patient #24 presented to their emergency department at 10:00 p.m. on 9/21/23. The physician notes showed, “In the emergency department, the patient was found to be severely septic/dehydrated/almost unresponsive/confused/disoriented on top of dementia, fever 103.1 degrees (normal 98.5), tachycardic 102 (normal 60-100), tachypneic with respiratory rate 22 (normal 12-18) blood pressure 112/65 (normal 90/60-120/80) pulse oximetry 94% (normal >90%) on room air, purulent urine obtained with Foley catheter placement with urinalysis consistent with UTI, met sepsis criteria, cultures taken, antibiotics given, IV hydration ...HPI (history of present illness) 65 yo male presents to the emergency department after being brought from outside facilities waiting room. Patient apparently was taken to Benefis by ambulance from [assisted living facility name] where he resides on a long-term basis for end-stage Parkinson’s disease ...” Patient #24 was admitted to the hospital for severe sepsis (life threatening infection), acute UTI (urinary tract infection), toxic metabolic encephalopathy (brain disfunction due to metabolic issues, i.e. fever and infection), acute urinary retention, dehydration, severe protein-calorie malnutrition, abnormal weight loss and Parkinson disease.”

“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: 44770 Based on interview and record review, the facility failed to provide stabilizing medical treatment before discharge for 1 (#16) of 24 sampled patients. Patient #16 expired the following day. Findings include: Review of a facility policy titled, EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, “Stabilizing Treatment Within Hospital Capability. The determination of whether an individual is stable is not based on the clinical outcome of the individual’s medical condition. An individual has been provided sufficient stabilizing treatment when, the physician treating the individual in the Emergency Department determines within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability, to result from, or occur during, the transfer of the individual from a facility ...or in the case of an individual with a psychiatric or behavioral condition, the individual is protected and prevented from injuring himself or herself or others ... Stable for discharge. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, the treating physician determines that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the Emergency Department must be resolved, but the underlying medical condition may persist ...” During an interview on 12/8/23 at 3:51 p.m. NF2 stated he and patient #16 went to [health provider name] seeking substance abuse assistance for patient #16. NF2 stated they saw NF3 at [health provider name] because patient #16 wanted to stop her addiction to alcohol. NF2 said NF3 did an assessment and felt that patient #16 should be detoxed under medical supervision because of the extent of her alcohol use, and the patient had a history of having seizures from withdrawing from alcohol. NF2 stated he and patient #16 received some paperwork from NF3’s office, and they went straight to Benefis ED as they were instructed to do by NF3. NF2 stated patient #16 checked in at the Benefis ED, they sat in the waiting room for a very long time. NF2 stated he and patient #16 were taken back into the emergency department. They were not placed in a patient room. NF2 said they were instructed to sit in a chair next to the nurse’s station. When the doctor (staff member G) approached them, NF2 stated he handed the doctor the paperwork from NF3’s office. NF2 stated the doctor looked at the paperwork, rolled his eyes, and stated, “They are going to have to stop doing this,” and he walked away. When he came back, the doctor told NF2 and patient #16 that [health provider name] needed to stop sending people to be admitted, it was his decision to admit people, and he was not going to admit patient #16 to detox under medical supervision. NF2 stated patient #16 started crying and begged the physician to reconsider. NF2 said, “She was begging for her life. She told him he was going to kill her if she didn’t get help in the hospital.” NF2 said after patient #16 begged the doctor to help her, the doctor said he would have the counselor come to talk with her to arrange for help on an outpatient basis. NF2 said the hospital did not do any blood work on the patient, they just had her blow into a breathalyzer. Patient #16 blew a 0.4 (normal 0). NF2 stated a counselor (staff member H) came to talk to them and completed some assessments. NF2 said patient #16 told staff member H she was ready to get sober and told her about some of the things that happened in her life. By the time staff member H was done talking to them, NF2 said all of them were crying, including staff member H. NF2 said staff member H felt patient #16 should be admitted because she was also suicidal. NF2 said staff member H walked over to staff member G. He could not hear what was said, but he saw staff member H lower her head and walk away. NF2 stated staff member H looked “frustrated.” Shortly after staff member H talked to the doctor (staff member G), the doctor came over to NF2 and patient #16 and told them he, “absolutely” was not going to admit patient #16 because she was still drunk, and to him, she did not seem to be having bad enough withdrawal symptoms to warrant being admitted. NF2 said, “She absolutely looked like she was in withdrawal to me. With her, it didn’t take very much because she always drank so much. I was so worried about her. We went there to get help and we were just turned away. She was shaking and sweating. Since he told us he was not going to admit her no matter what, we just decided to leave. Some nurse said she had discharge instructions for us, but we didn’t get them.” NF2 stated, “(Patient #16) was determined to go to rehab which had been prearranged, but she had to be sober to get into the rehab facility”. NF2 stated patient #16 did not consume alcohol after she left the hospital, she ate, and went to bed. NF 2 stated that when patient #16 woke the next morning, she was nauseated, unable to eat, shaking, and didn’t look very good, but did not return to the ED because of how they were treated the day before. Patient #16 went back to bed, and when NF2 went to check on her, she was not breathing. NF2 initiated CPR and called 911. NF2 stated the sheriff showed up and took over CPR until the ambulance came to get patient #16. NF2 stated the ambulance arrived and took over patient #16’s care. He stated, “That was the last time I saw her.” During an interview on 12/8/23 at 8:07 a.m., NF5 said she was on the phone with patient #16 off and on while she was in the emergency department on 11/15/23. NF5 said patient #16 was very scared to detox; she had tried a few times before and had seizures. NF5 said patient #16 told her she was afraid she was going to die before she could make it to the rehab center. NF5 said she saw patient #16 a few days before and she talked to her about getting help. She seemed very motivated to get well. NF5 said patient #16 came to her house a few times to try to detox and she had seizures and shakes. When patient #16 told her she was going to the hospital to detox she told NF5 she was very scared. NF5 said she did not know patient #16 had not been admitted to the hospital until she found out patient #16 was in the ambulance on her way back to the hospital. NF5 said she was devastated when she found out patient #16 was dead. NF5 stated, “I want to go up to that doctor (staff member G) with my granddaughter, stand her in front of him, and show him this beautiful little girl that is going to have to grow up without her mother because he didn’t care, and he didn’t listen to her about her past experiences or how scared she was.” During an interview on 12/7/23 at 10:44 a.m., NF 3 said she did a full chemical dependency workup on patient #16. Patient #16 told her she had seizures when she tried to detox on her own in the past. NF3 said patient #16 applied for an inpatient bed at a rehab facility in Butte Montana and she was accepted to their program, but she would have to be sober upon entrance to the facility. Because of her history, NF3 felt patient #16 should be monitored medically while she detoxed from alcohol. NF3 said, “I assured her that the hospital would take good care of her.” NF3 said after she heard patient #16 died the next day, she said she was devastated. NF3 stated she spoke to patient #16’s mother and husband and found out what happened. NF3 said, “I just could not let it go. I assured her that the hospital would take good care of her. The patient was so scared, and I sent her there for help. She was only 32 years old.” NF3 said patient #16’s husband told her Benefis Hospital refused to help his wife. During an interview on 12/6/23 at 1:50 p.m., staff member I stated if a patient comes to the hospital for alcohol detoxification and has a history of seizures, the patient can be admitted for medical management during their detoxification, and phenobarbital can be administered to minimize the patient’s risk of seizures. Staff member I stated the hospital had a progressive care unit where these patients can be cared for, or if they are very sick, they can be admitted to the intensive care unit where Precedex (a medication used for severe alcohol withdrawal syndrome) can be administered. During an interview on 12/7/23 at 9:16 p.m. staff member J stated the hospital could admit intoxicated patients, especially those with a history of alcohol withdrawal seizures, and manage the patient with the CIWA protocol (used to manage the symptoms of alcohol withdrawal to improve outcomes). During an interview on 12/8/23 at 12:04, staff member H said she remembered patient #16. Staff member H said the patient told her she had been accepted as a patient in a rehab facility and was seeking medical detox. She said patient #16 had never been to treatment before. Staff member H stated she assessed patient #16 for suicidal ideation and homicidal ideations. Staff member H said patient #16 said, “If someone were to give me a handful of pills, I would take them.” Staff member H said patient #16 scored 27 of 27 on the PHQ-9 (an assessment for a patient’s suicidal thoughts. 27 is the highest possible). Staff member H said she was aware patient #16 had seizures with withdrawal in the past. Staff member H said, “She (patient #16) was scared to go through a seizure.” Staff member H said she never told staff member G she did not recommend in-patient admission for patient #16. Staff member H said she went to talk to staff member G to explain her findings. Staff member H stated she then went to talk to the staff in behavioral health to formulate a plan. When she came back to talk to the patient, the patient was gone. Staff member H said she did not get to finish her evaluation and she did not have the opportunity to tell patient #16 she would be detoxed under medical supervision if it was determined she needed to be admitted to the behavioral health department. During an interview on 12/8/23 at 10:45 a.m., staff member G said he remembered patient #16 presenting at the ED. Staff member G stated patient #16 came in requesting detoxification from alcohol. Staff member G stated, “She got upset when I told her she was not going to be admitted.” Staff member G stated he was not aware patient #16 had scored a 27 of 27 on the PHQ-9 assessment and said he was not sure what that was, but stated he was not aware that patient #16 was suicidal. Staff member G stated he normally asks all patients seeking detoxification from alcohol if they are suicidal, and it would not be typical to discharge a patient who had suicidal thoughts. Staff member G stated detoxing from alcohol can be dangerous, but a patient needs to be exhibiting alcohol withdrawals before he would admit them to the hospital. Benefis ED log for 11/15/23, showed, patient #16 presented to the Emergency Department at 3:00 p.m. and was discharged to home at 6:51 p.m. Review of patient #16’s medical record showed: -Patient #16’s EMR showed she had a history of alcoholic pancreatitis with two hospital admissions. Her previous visit on 8/10/23, showed she was hypokalemic (low potassium level) and had EKG changes on her visit on 8/10/23. Patient #16 required IV fluids and potassium replacement. -On 11/15/23 at 3:00 p.m., patient #16 presented to Benefis Emergency Department, the ED physician’s notes showed, “32-year-old female nontoxic in appearance although visibly intoxicated presents today requesting admission for detox .... I have very low suspicion for current alcohol withdrawal. A conversation was had with the patient advising her that we do not admit patients for detox especially when they are still currently intoxicated. Patient subsequently became upset. Verbal de-escalation did ensue with subsequent consultation with social worker who came and personally evaluated the patient with advisement of having her follow-up in the outpatient setting ... Patient was discharged shortly afterwards.” ED behavioral health notes showed, “patient states she was referred to Benefis by [medical provider name]. ‘I am trying to detox without killing myself.’ ... Patient states she had about three fourths of a pint of vodka earlier today. Her last drink was around noon .... She states she was recently diagnosed with early cirrhosis of the liver. She has never been to treatment before but is agreeable to going and has been accepted to [detox center]. She states she is afraid to detox ...” A point of care breathalyzer test result of 0.4 was documented. A report titled, “Severity Measure for Depression Adult”, adapted from the PHQ-9, showed patient #16 scored 27 of 27, indicating the highest score possible for depression. -Patient #16 presented to Benefis Emergency Department on 11/16/23 at 2:21 p.m. via ambulance. The patient was unresponsive with CPR in progress. The emergency room report for 11/16/23 showed, “32-year-old female with history of alcohol abuse presents with ongoing CPR and an unwitnessed cardiac arrest. Unknown downtime ... Due to prolonged nature of the arrest and the persistent asystole (no cardiac electrical activity) both in the field and during our attempts in the emergency department, resuscitative efforts were terminated, and patient was pronounced dead at 1427. (2:27 p.m.).” Review of patient #16’s medical record showed the patient was mildly tachycardic. The patient required frequent monitoring for alcohol withdrawal symptoms, to include neurological checks and CIWA scores. Patient #16 required admission, as per the hospital policy for alcohol withdrawal, as the patient had a history of known alcohol withdrawal seizures. Additionally, patient #16 reported having suicidal ideation. The patient should have had a psychiatric consultation, been placed on an involuntary hold, and admitted to the hospital to ensure the patient had a safe environment and was provided with constant observation.”