Trinity Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41652 Based on interview, record review, and policy review, the facility failed to comply with the conditions of participation outlined in 42 CFR §489.20 and related requirements at §489.24: (refer to Appendix V). The facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 2 (#s 7 and 12) of 20 sampled patients who presented to the ED for emergency care. Findings include: 1. Patient #7 presented to the ED on 5/6/25 for medical clearance prior to incarceration. Patient #7 was identified as a high suicide risk. The on-call provider was not consulted prior to discharge. [See C-2406] Patient #12 presented to the ED on 6/10/25 for medical clearance prior to incarceration. Patient #12’s heart rate was outside the range indicated on the facility policy. The on-call provider was not consulted prior to discharge. [See C-2406] Review of a facility policy titled, “Nursing Medical Screening Examination (MSE) Policy for Incarcerated Patients,” dated 3/15/25, showed: - “1. Purpose To establish guidelines for nurses performing medical screening examinations (MSEs) for incarcerated patients presenting to the Emergency Department (ED) for clearance before jail admission...” and - “3. Criteria for Nursing Medical Clearance for Incarcerated Patients A nurse may medically clear an incarcerated patient without provider evalulation only if all of the following criteria are met: ...3. Vital Sign Criteria for Clearance ...Heart Rate (HR): 50 - 120 bpm... Temperature: 36.1 - 38.0°C (97.0 - 100.4°F) ...4. When to Escalate to a Provider ... Vital signs outside the specified ranges. ...” [See C-2406] The facility policy did not contain criteria for patients presenting with suicidal ideation or a high suicide risk score.. During an interview on 8/20/25 at 10:35 a.m., staff member B stated the facility had developed a policy regarding nursing staff performing the MSE for patients brought to the ED by law enforcement prior to incarceration. She stated the policy provided criteria for when the on-call provider was to be notified so the patient could receive an MSE from ED provider. The original policy was discussed with the medical staff in March and April of 2025, with an effective date of 5/1/25. The policy did not address the presence of an elevated suicide risk score. During an interview on 8/21/25 at 8:20 a.m., staff member B stated she reviewed the ED medical clearance for patient #7, and determine the patient should have been seen by an ED provider. She contacted the ED provider group to discuss necessary changes needed to the facility policy associated with the situation involving nursing MSE criteria. Further clarificiation was obtained on 12/22/25. Staff member B provided the following timeline for the implementation of the policy for MSEs for incarcerated patients: - Medical Staff Rules and Regulations, dated 10/18/22, showed, “Licensed nursing staff will be allowed to complete a medical screening examination to evaluate and triage Emergency Room patients in regards to whether they are emergent in nature ...If the RN begins the emergency medical screening and determines that the nature of the individual’s condition is outside his/her scope of practice, the on-call provider must be contacted ...” - A policy regarding the nursing MSE for incarcerated patients brought to the Emergency Department was discussed with the medical staff in March and April of 2025. The effective date of the original policy was 5/1/25. The handwritten date on the original policy was 3/15/25. This was not accurate.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 41652 Based on observation and interview, the facility failed to post signs in the dedicated ED (emergency department) specifying the hospital participates in the Medicaid program. Findings include: During an observation and interview with staff member C, on 8/21/25 at 7:57 a.m., the ED entrance and patient flow path were observed. One EMTALA sign was observed on the wall to the right of the patient flow path near the registration desk. The sign was partially obscured by a printer which was on the counter below where the sign was hung. It was not possible to clearly see the bottom portion of the sign due to the placement of the printer. The sign lacked clear language indicating whether or not the facility participated in Medicaid. The sign contained the following language, “The facility [empty check box] does [empty check box] does not participate in Medicaid.” Staff member C stated the sign had been in the same location for several years and she had never noticed the empty check boxes.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41652 Based on interview, record review, and policy review, the facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 2 (#s 7 and 12) of 20 sampled patients who presented to the ED for emergency care. Findings include: 1. Review of patient #7’s EHR, dated 5/6/25, showed the patient was a high suicide risk. The CSSRS (Columbia-Suicide Severity Rating Scale), completed by the ED nurse showed the patient answered the following questions with a Yes answer: - 1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? - 2. In the past month, have you actually had thoughts about killing yourself? - 3. In the past month, have you been thinking about how you might kill yourself? - 4. In the past month, have you had these thoughts and had some intention of acting on them? - 5. In the past month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? - 6a. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life? - 6b. If yes, was this within the past three months? Review of patient #7’s EHR, dated 5/6/25, showed patient #7’s MSE, provided by a nurse, resulted in a high CSSRS score. The EHR failed to show any further documentation related to evaluation by a pactitioner or suicide precautions. Review of patient #7’s discharge report, dated 5/6/25, showed, “Pt (patient) presents for medical screening exam prior to incarceration. Provider did not see this pt. No c/o (complaints of) pain/illness/injury at this time. Pt departs facility ambulatory, gait steady and tolerating activity well, to the care of law enforcement @ (at) 0138 (1:38 a.m.).” During an interview on 8/28/25 at 7:50 a.m., staff member I stated when local law enforcement arrested an individual, they were brought to the ED for a medical screening examination prior to being incarcerated. Staff member I stated this practice occured multiple times a day. Staff member I stated the facility implemented a process where an RN was able to perform the MSE and discharge the patient without notifying the ED provider. Staff member I stated this process involved checking the patient’s vital signs, and performing a head-to-toe physical assessment. If no abnormalities were found, the patient was discharged in the care of law enforcement to be taken to the jail. Although staff member I was the nurse who performed the MSE on patient #7, stated she did not specifically remember patient #7’s ED visit or the results of the suicide severity scale. Staff member I stated if a patient had suicidal ideation, she should have notified the ED provider prior to discharge. Staff member I could not explain why she did not notify the ED provider prior to discharging patient #7. 2. Review of patient #12’s EHR, dated 6/10/25, showed the patient presented to the ED at 00:23 a.m. for medical clearance prior to being incarcerated. The patient was brought in by a member of law enforcement. The patient’s heart rate was documented as 125 bpm (normal range as per facility policy was 50 - 120 bpm). The EHR failed to show an ED provider was notified the patient’s heart rate was outside the range identified in the facility’s policy, effective date of 5/1/25. During an interview on 8/20/25 at 10:35 a.m., staff member B stated the ED providers developed a policy which contained the criteria for nursing staff to complete the MSE for incarcerated patients being brought to the ED for medical clearance prior to going to jail. Staff member B stated the policy did not originally contain any language regarding psychiatric complaints, including suicidal ideations or a high risk score on the C-SSRS. Staff member B stated after reviewing patient #7’s EHR, she felt the criteria from the policy did not address patients with psychiatric issues and requested the policy be revised. Staff member B stated the nursing staff received additional education regarding the parameters for appropriate MSEs being done by nursing staff. Review of the facility’s policy titled, “Nursing Medical Screening Examination (MSE) Policy for Incarcerated Patients, effective date of 5/1/25, showed the criteria which must be met for nursing to perform and document the patient’s MSE. The policy showed a nurse may medically clear an incarcerated patient without provider evaluation only if all of the criteria are met. The criteria listed for medical clearance of incarcerated patients included age greater than 18 years, alert and oriented to person, place, time, and situation, GCS must be 15, ambulatory without assistance, absence of acute medical complaints (pain, shortness of breath, dizziness, psychiatric complaints, new or worsening neurological complaints, active bleeding, vomiting or diarrhea), all vital signs within the ranges specified, and the absence of red flag conditions (no visible trauma, no signs of substance withdrawal requiring treatment, no acute psychiatric crisis requiring medical or psychiatric evaluation, and no acute infectious disease concerns). If any single criteria was not met, the patient was to be evaluated by an ED provider before discharge. Further clarificiation was obtained on 12/22/25. Staff member B provided the following timeline for the implementation of the policy for MSEs for incarcerated patients: - Medical Staff Rules and Regulations, dated 10/18/22, showed, “Licensed nursing staff will be allowed to complete a medical screening examination to evaluate and triage Emergency Room patients in regards to whether they are emergent in nature ...If the RN begins to the emergency medical screening and determines that the nature of the individual’s condition is outside his/her scope of practice, the on-call provider must be contacted ...” - A policy regarding the nursing MSE for incarcerated patients brought to the Emergency Department was discussed with the medical staff in March and April of 2025. The effective date of the original policy was 5/1/25. The handwritten date on the original policy was 3/15/25. This was not accurate. - Revisions to the policy for MSEs for incarcerated patients in the ED are ongoing. These revisions have not been finalized or approved by the medical staff.”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was performed on 9/17/24. 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 of NFPA 101. The building construction type was found to be Type II (111) for the original building. No new construction has been done since the last survey on 8/27/19. The facility does not meet the prescriptive requirements of the applicable Life Safety Code or its referenced Codes that require two exits be available from each floor of the building (K241). The Fire Safety Evaluation System (FSES) based on NFPA 101A, Guide on Alternative Approaches to Life Safety 2001 Edition, has been utilized to determine if a level of safety is provided which is equivalent to the Life Safety Code. The FSES conducted during this survey indicates that an equivalent level of safety will be provided with the correction of the following deficiencies: K255, K321, K341, K353, K355, K911. These requirements were not met as evidenced by the following deficiencies:”

“Number of Exits - Story and Compartment CFR(s): NFPA 101 Number of Exits - Story and Compartment Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment. 18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to provide for two exits from the basement of the Critical Access Hospital in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 19.2.4.2. Findings include: 1. During an observation on 9/17/24 at 10:00 a.m., the basement was inspected. The basement is being used as a large storage area and includes a couple of seperate rooms. There is only one exit out of the basement. Code requires two exits from every story.”

“Suite Separation, Hazardous Content, and Subd CFR(s): NFPA 101 Suite Separation, Hazardous Content, and Subdivision All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction. 18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 This Standard is not met as evidenced by: 32381 Based on observation, suite separation was not being maintained because the gap between the double doors closing off the suite from the corridor was too large, per NFPA 101, 2012 Edition, Section 19.2.5.7.1.2. Findings include: 1. During an observation on 9/17/24 at 10:16 a.m., the cross-corridor smoke barrier doors on each end of the OB suite were found to have gaps exceeding the maximum allowable gap of 1/8” between the doors.”

“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 an observation, the facility failed to assure hazardous rooms/areas 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, 19.3.2.1.3 and 19.3.2.1.5 (7) (7). Findings include: 1. During an observation on 9/17/24 at 9:48 a.m., the purchasing area was inspected. The room exceeds 50 square feet, and contained a large amount of combustible supplies for the hospital. The corridor door did not have the required self-closer attached. 2. During an observation on 9/17/24 at 10:28 a.m., room 114 was found to be used to store equipment. The room exceeds 50 square feet and lacked the required self-closing device.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4. Findings include: 1. During an observation on 9/17/24 at 10:10 a.m., the fire alarm control panel (FACP) was inspected. The location of the electrical panel and breaker serving the FACP were not identified on the FACP. The Surveyor was unable to locate the panel and breaker serving the FACP.”

“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 observation, the facility failed to ensure sprinkler piping was free from 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.; and failed to maintain escutcheon plates around sprinkler heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.1.; and failed to replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2, Findings include: 1. During an observation on 9/17/24 at 9:42 a.m., the outside biohazard room was inspected. There was a cat 5 wire running to a security camera outside the room, the bundle of wire was secured to the sprinkler pipe in the room. 2. During an observation on 9/17/24 at 10:20 a.m., the ER trauma room was inspected. There was a sprinkler head in the room which looked like it had been displaced. It was not perpendicular to the floor and the escutcheon plate had fallen down, leaving an annular opening around the sprinkler pipe. 3. During an observation on 9/17/24 at 10:40 a.m., the standpipe was inspected. The gauge on the standpipe was found to have an installation date of 7/2019 written on it. Gauges are to be tested or replaced every 5 years.”

“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 install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. Findings include: 1. During an observation on 9/17/24 at 9:51 a.m., the portable extinguisher on the wall in the boiler room hall was inspected. The extinguisher was mounted 67 inches high. Maximum allowable height is 60 inches from floor to top of extinguisher.”

“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 observations, the facility failed to maintain electrical panels to be locked where the circuit breakers going to category 1 and 2 rooms may be accessed by unauthorized building occupants per NFPA 99 Health Care Facilities Code, 2012 Edition, Sections 1.3.2.3, and 6.3.2.2.1.3(A), and NFPA 70 National Electrical Code 2011, Section 110.26(F). Findings include: 1. During an observation on 9/17/24 at 10:24 a.m., circuit breaker panels with breakers identified to be supplying rooms in the ER were located in the corridor system. The panels were found to be unlocked and accessible by anyone in the facility.”

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 45448 Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Surgical Services. Based on observation, interview, and record review, the facility failed to: 1. Meet acceptable standards of practice for Endoscopy cleaning and record keeping. During an observation and interview on 9/10/24 at 9:47 a.m., staff member L was observed wiping down the colonoscope with water-soaked gauze sponges and sucking sterile water through the colonoscope. Staff member L then transported the colonoscope to the soiled utility and placed it into the sink. The leak test device was retrieved from a cardboard box on a shelf, attached to the colonoscope and a leak test was attempted. The testing device had a leak and would not hold pressure to test the scope. Staff member L then filled the sink with water and proceeded to clean the scope per manufacturer recommendations. Staff member L said for pre-cleaning, she wiped down the surface of the scope with sterile water and sucked the irrigation through the scope. She had not been told she should be using an enzymatic detergent. Staff member L said she had another leak test device but did not attempt to locate the device. During an observation and interview on 9/10/24 at 9:53 a.m., staff member L removed her soiled gloves, donned clean gloves, did not wash her hands or remove the soiled gown from the colonoscopy procedure, reached into the disinfectant solution and removed a clean colonoscope. The disinfectant solution was not marked with an expiration date. Staff member L rinsed the colonoscope and flushed the channels. The scope was placed on a hanger on the wall. Staff member L said the disinfectant solution should have been marked with an out date. Staff member L said she had tested the solution with a test strip to make sure it was still viable. Staff member L said the testing and tracking of endoscope cleaning was not recorded. The facility had ordered an aerated cabinet for storage but it had not arrived. Staff member L said the endoscopes were hung on the wall for storage. The endoscopes were not cleaned prior to use, after being stored. During an interview on 9/11/24 at 9:42 a.m., staff member R said the disinfectant should be labeled with an outdate. Staff member R stated there was not a log for tracking the cleaning of endoscopes. Review of manufacturer recommendations, “Pentax Cleaning Instruction Summary,” not dated, showed: “Bedside Pre-Cleaning: Immediately after completion of the procedure begin pre-cleaning in examination room ...1. Wipe insertion tube 3 times with enzymatic detergent soaked sponge ...4. ...Flush the channel with a. 15 ml detergent solution ...Leak Testing: ...3. Perform DRY leak test watching needle in gauge to detect any major leaks ...5. Move scope, with leak tester attached to basin of clear water 6. Angulate scope and look for Champagne like bubbles ...” 2. Meet acceptable standards of practice for labeling of medication drawn into a syringe, Maintenance of Emergency Crash Cart medications, and Malignant Hyperthermia management. During an observation on 9/10/24 at 9:17 a.m., staff member K was observed administering IV medications in unlabeled syringes during an outpatient procedure. During an interview on 9/10/24 at 10:10 a.m., staff member K said his syringes were not labeled with medications. Staff member K said “No one messes with my stuff, I get irate if they do.” Staff member K said staff knew better than to touch his medications. During an interview on 9/11/24 at 9:42 a.m., staff member K said all medications drawn up in a syringe should be labeled. During an observation and interview on 9/10/24 at 1:46 p.m., staff member L said the operating room did not have a full crash cart but had a crash cart “of sorts”. A cart was observed to be located behind the anesthesia area in a corner. Located on top of the cart was a defibrillator that was last checked on 5/9/24, anesthesia circuits, laryngeal mask airways (LMA) x 2, a bin of medication label stickers, and a cardboard box with a Germ away electrical device placed on top. Upon inspection, the first two drawers were empty, the third drawer contained 3 expired emergency IV medication kits: -Norepinephrine drip kit, Dextrose 5% 500 ml IV bag, expiration 3/2024, Norepinephrine ampoule 4ml, expiration 4/30/24 -Epinephrine drip kit, dextrose 5% 250 ml IV bag, expiration 7/2024, Epinephrine ampoule 1ml, expiration 8/2024 -Dobutamine drip kit, Dobutamine 250 ml pre-mix IV bag, expiration 6/2024 During an interview on 9/11/24 at 9:42 a.m., staff member R said the department had “kind of a crash cart,” and the crash cart was not complete because many of the items needed were in the anesthesia cart. Staff member R said the there was no check list for the cart and the defibrillator only required checking every 6 months. Staff member R said she was not aware the crash cart would fall under the facilities crash cart policies and procedures. Staff member R said the scrub tech was responsible for checking the cart for outdated medications. During an interview on 9/10/24 at 12:13 p.m., staff member B said crash carts are to be checked and documented each shift. Review of a facility policy titled, “Crash Cart,” with a last approved date of 2/2024, showed: “... The crash carts are to be checked every month for inventory and outdates. ...” During an observation on 9/10/24 at 1:55 p.m., the Malignant Hypothermia (Hyperthermia) container was observed to contain: [sic] -Dextrose 50% injection x2, expiration 3/24 with a note dated 8/15/24, “on backorder” -Dantrium 20mg vials x6, expiration 4/23 with a note dated 8/15/24, “shortage, on waiting list” -Dantrium 20 mg vials x 6, expiration dated 3/26 and one vial expiration dated 4/26. (insufficient quantity) Review of a facility document, “Malignant Hyperthermia,” revision dated 5/2021, showed: “... In the event of a real or suspected case of MH (Malignant Hyperthermia), [Facility Name] anesthesia, medical, surgical, and nursing staff will follow the guidelines set forth by the Malignant Hyperthermia Association of the United States. ...” Review of Malignant Hyperthermia Association of the United States guidelines (www.mhaus.org), dated 2024, showed: “...1. Dantrium/Revonto- 36 vials should be available in each institution where MH can occur ...” 3. Meet acceptable standards of practice for Sterile Processing of instruments and testing. During an observation and interview on 9/10/24 at 1:46 p.m., staff member L explained the process for decontamination and processing of instrument trays. Staff member L removed a cloth instrument wrap and demonstrated how an instrument tray was processed. Staff member L explained that instrument trays were wrapped in a cotton wrap. Staff member L said she was not aware of the Association of periOperative Registered Nurses’ (AORN) guidelines for single use, non-woven materials to be used for wrapping instruments. Staff member L then showed a cupboard with single use instrument wrap available for use. Staff member L said the biological indicators used for sterilization testing were read at 48 hours. Staff member L said she did not hold the instrumentation load for the full 48 hours, for the biological indicator to be read. She would distribute the instruments for use based on the steam indicator reading. Staff member L said she thought when the steam indicator changed and showed the instrument was sterile, the instrumentation was cleared for use. Staff member L said she had not been provided updated sterile processing recommendations since she was trained “many years ago”. During an interview on 9/11/24 at 9:42 a.m., staff member R said she had her CNOR (Certified Perioperative Nurse) certification. Staff member R said the facility follows AORN recommended standards. Staff member R said she was having a difficult time getting the single use wrap during COVID and thought the cloth wraps were acceptable. Staff member R said the instrument sterilization biological was to be read at 48 hours and the instruments were to be held until the load was cleared based on the biological. Staff member R said she had provided education to staff on “many topics” but was unable to produce any documentation of education provided. 4. Provide an updated history and physical and assess anesthesia risk for outpatient procedures. (See C1144) 5. Follow staff bylaws and provide anesthesia privileges. (See C1145)”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45448 Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Patient Rights. Based on interview, and record review, the facility failed to: - inform each patient receiving care within the emergency room and outpatient setting of their visitation rights. (See C1056) - inform patients and/or their representatives of their rights prior to providing or discontinuing care. (See C2502) - inform outpatients of their right to formulate individual advance directives. (See C2515) - provide patients with notification of their right to receive care in a safe setting, free from abuse or harassment prior to providing care in the ER or outpatient setting. (See C2525) 47752”

“GOVERNING BODY AND TELEMEDICINE SERVICES CFR(s): §485.616(c)(3) The governing body of the CAH must ensure that when telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the agreement is written and specifies that the distant-site telemedicine entity is a contractor of services to the CAH and as such, in accordance with §485.635(c)(4)(ii), furnishes the contracted services in a manner that enables the CAH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in this section with regard to its physicians and practitioners providing telemedicine services. §485.616(c)(4) When telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the CAH’s governing body or responsible individual may choose to rely upon the credentialing and privileging decisions made by the governing body of the distant-site telemedicine entity regarding individual distant-site physicians or practitioners. The CAH’s governing body or responsible individual must ensure, through its written agreement with the distant-site telemedicine entity, that the following provisions are met: (i) The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at (c)(1)(i) through (c)(1)(vii). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides a current list to the CAH of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH whose patients are receiving the telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the CAH whose patients are receiving the telemedicine services, the CAH has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such information for use in periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the CAH’s patients and all complaints the CAH has received about the distant-site physician or practitioner. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to ensure staff members employed as medical providers had current credentials and privileges to medically treat patients in the facility. This deficient practice had the potential to affected all patients who received medical care by these providers. Findings include: During an observation on 9/10/24 at 9:15 a.m., staff member K was providing anesthesia services for an outpatient colonoscopy procedure. During an interview on 9/10/24 at 10:10 a.m., staff member K said his last work day would be 9/11/24, as he would be retiring. During an interview on 9/11/24 at 12:50 p.m. staff member D stated he was responsible for reviewing the credentials for providers before requests were taken to the Governing Board. Staff member D stated all initial requests for privileges are provisional for 90 days and at the end of 90 days he would recommend privileges with out provisions. Staff member D stated providers are re-approved for privileges every two years, based on his recommendations. A review of staff member K’s credentialing file on 9/11/24, showed he was granted privileges to practice at the facility on 10/29/2019 and was valid through 6/30/2021. Staff member K’s credentials and privileges were not reviewed after 6/30/2021. Staff member K continued to provide care to patients in the operating room after his privileges had expired. Staff member K’s privileges had been expired for 1,169 days at the time of the survey. A review of staff member H’s credentialing file on 9/11/24, showed she was granted privileges to practice at the facility on 6/20/2022 and was valid through 6/30/2024. Staff member H’s credentials and privileges were not reviewed after 6/30/24. Staff member H continued to provide care to patients in the emergency room and hospital after her privileges had expired. Staff member H’s privileges had been expired for 73 days at the time of the survey. During an interview on 9/11/24 at 4:33 p.m., staff member A stated he was not sure what happened with the reappointment of privileges for the providers. Staff member A stated, “there is no excuse for this.” Review of a facility document titled, “[Facility Name] Medical Staff Bylaws,” dated 9/29/22, showed: “... Article V: Terms of Appointment and Reappointment: A. All appointments, reappointments, and delineation of privileges and assignments are at the discretion of the Board of Directors upon recommendations of the Medical Staff. ... C. Appointments shall be for a period of not more than two medical staff years. Medical Staff reappointments shall be made in even numbered years ...For the proposes of these By-Laws the medical staff year commences on the first day of July and ends on the thirtieth day of June ...”[sic]”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired medications were not accessible and removed from use in the emergency department. This deficient practice has the potential to affect all patients requiring medication in the emergency department. Findings include: During an observation on 9/11/24 at 9:33 a.m., staff member AA unlocked the medication crash carts located in the emergency room. The following medication was found to be past the expiration date: - Epinephrine Drip Kit -5% dextrose 250 ML, expiration date of 7/24, - 4 vials of dopamine Hcl 200mg/5ml (40mg/ml) expiration date of 4/1/24, and - 3 boxes of Atropine 0.5 mg/5ml (0.1mg-ml), expiration date of 4/24. During an interview on 9/11/24 at 10:10 a.m., staff member AA stated she was unsure who was responsible for checking the medications in the crash carts. During an interview on 9/11/24 at 4:44 p.m., staff member B stated staff member L was the one that was checking the crash carts for outdated medications and supplies. Staff member B stated it was not being checked regularly. During an interview on 9/11/24 at 4:49 p.m., staff member L stated she had not been doing the outdate checks since March and she was not sure who was currently doing them, but at one time there was a “traveler” who was checking the crash carts. Review of a facility policy titled, “Crash Cart,” with a last approved date of 2/2024, showed: “... The crash carts are to be checked every month for inventory and outdates.” ...”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired supplies were replaced prior to the expiration date. This deficient practice had the potential to affect any patient requiring supplies in the emergency department. Findings include: During an observation on 9/11/24 at 9:33 a.m., staff member AA unlocked the crash carts located in the emergency room. The following supplies were found to be outdated: - one (1) Provent blood sampling kit with Heparin for gases and electrolytes, with an expiration date of 9/1/24, - two (2) Pediatric Colorimetric CO2 Detector 1-15 kg, with an expiration date of 8/14/24, - six (6) Illinois bone marrow aspiration/ interosseous infusion needle, with an expiration date of 8/3/24, - two (2) size 1 McGrath Mac disposable laryngoscope blades, with an expiration date of 8/7/24, - two (2) size 2 McGrath Mac disposable laryngoscope blades, with an expiration date of 8/7/24, - one (1) package of sterile surgical gloves, with an expiration date of 9/1/24, and - one (1) IV start kit, with an expiration date of 7/2023. During an interview on 9/11/24 at 10:10 a.m., staff member AA stated she was unsure who was responsible for checking the medications or supplies in the crash carts. During an interview on 9/11/24 at 4:44 p.m., staff member B stated staff member L was the one that was checking the crash carts for outdated medications and supplies. Staff member B stated it was not being checked regularly. During an interview on 9/11/24 at 4:49 p.m., staff member L stated she had not been doing the outdate checks since March and she was not sure who was currently doing them, but at one time there was a “traveler” who was checking the crash carts. Review of a facility policy titled, “Crash Cart,” with a last approved date of 2/2024, showed: “... The crash carts are to be checked every month for inventory and outdates.” ...”

“PA, NP, & CLINICAL SPEC RESPONSIBILITIES CFR(s): Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, a doctor of medicine or osteopathy on the staff of the CAH is notified of the admission. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to have a process in place to ensure Nurse Practitioners and Physicians Assistants notified a Doctor of Medicine or Osteopathy when an inpatient admission occurred for 2 (#s 4 and 17) of 23 sampled patients. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. Findings include: Review of the following medical records failed to show the Nurse Practitioner, or the Physician Assistant notified the physician, of the admission to inpatient status: - Patient #4, admitted on 9/6/24, discharged on 9/10/24, and - Patient #17, admitted on 7/16/24, discharged on 7/19/24. During an interview on 9/10/24 at 3:00 p.m., staff member E stated if he was notified of an admission electronically though the medical record he could sign off the required documentation quickly, but if he was not notified though the medical record it took longer to review and sign off on the documentation. Staff member E did not recall having been notified of the admission for patient #4 or patient #17.”

“PATIENT VISITATION RIGHTS CFR(s): §485.635(f) Standard: Patient visitation rights. A CAH 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 CAH may need to place on such rights and the reasons for the clinical restriction or limitation. A CAH 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, in advance of furnishing patient care whenever possible. (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: 45448 Based on interview and record review, the facility failed to inform each patient receiving care within the emergency room and outpatient setting of their visitation rights for 17 (#s 1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice has the potential to affect all patients receiving services in the emergency room and as an outpatient. Findings include: Record review of patient #1’s EMR with an admission date of 9/1/24, failed to contain a notification of visitation rights. Record review of patient #3’s EMR with an admission date of 8/13/24, failed to contain a notification of visitation rights. Record review of patient #5’s EMR with an admission date of 9/6/24, failed to contain a notification of visitation rights. Record review of patient #6’s EMR with an admission date of 9/8/24, failed to contain a notification of visitation rights. Record review of patient #7’s EMR with an admission date of 9/9/24, failed to contain a notification of visitation rights. Record review of patient #10’s EMR with an admission date of 9/5/24, failed to contain a notification of visitation rights. Record review of patient #11’s EMR with an admission date of 4/27/24, failed to contain a notification of visitation rights. Record review of patient #12’s EMR with an admission date of 5/12/24, failed to contain a notification of visitation rights. Record review of patient #13’s EMR with an admission date of 6/6/24, failed to contain a notification of visitation rights. Record review of patient #14’s EMR with an admission date of 7/1/24, failed to contain a notification of visitation rights. Record review of patient #15’s EMR with an admission date of 8/28/24, failed to contain a notification of visitation rights. Record review of patient #16’s EMR with an admission date of 8/5/24, failed to contain a notification of visitation rights. Record review of patient #18’s EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights. Record review of patient #19’s EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights. Record review of patient #20’s EMR with an admission date of 9/11/24, failed to contain a notification of visitation rights. Record review of patient #21’s EMR with an admission date of 8/22/24, failed to contain a notification of visitation rights. Record review of patient #23’s EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights. During an interview on 9/11/24 at 2:06 p.m., staff member W said the facility did not provide ER patients and outpatients with a notification of patient rights. During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient settings. 47752”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure there was a process in place to verify the completeness of medical records for 7 (#s 2, 3, 4, 7, 8, 13, and 17) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include: Review of patient #2’s electronic medical record, with an admission date of 7/30/24, failed to show a comprehensive assessment within 14 days of admission. Review of patient #3’s electronic medical record, with an admission date of 8/13/24, failed to show a co-signature of the history and physical by a physician. Review of patient #4’s electronic medical record, with an admission date of 9/6/24, failed to show notification of a physician for admission, and co-signature of the history and physical by a physician. Review of patient #7’s electronic medical record, with a treatment date of 9/6/24, failed to show a signed consent to treat. Review of patient #8’s electronic medical record, with an admission date of 4/10/24 , failed to show a discharge plan. Review of patient #13’s electronic medical record, with a treatment date of 6/6/24, failed to show a signed consent to treat. Review of patient #17’s electronic medical record, with an admission date of 7/16/24, failed to show notification of a physician for admission and a co-signature of the history and physical by a physician. During an interview on 9/11/24 at 3:33 p.m. staff member W stated, “Ultimately it is my responsibility to make sure the medical records are complete. I do not have anything in place to make sure this occurs. I know it needs to happen though. Currently, I do not have a policy or procedure in place.””

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 2 (#s 3 and 17) of 23 sampled patients. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include: Review of patient #3’s EMR, dated 8/13/24 to 8/28/24, showed patient #3 was admitted to inpatient status on 8/13/24 by staff member CC. No physician co-signature was noted on the admisssion history and physical. Review of patient #17’s EMR, dated 7/16/24 to 7/19/24, showed patient #17 was admitted to inpatient status on 7/16/24 by staff member H. No physician co-signature was noted on the admission history and physical. During an interview on 9/10/24 at 3:00 p.m., staff member E stated he was responsible for co-signing inpatient history and physicals and providing oversight to the mid-level providers in the hospital. Staff member E stated if he was notified of an admission electronically though the medical record, he could sign off the required documentation quickly, but if he was not notified though the medical record it took longer to review and sign off on the documentation. Staff member E stated he had 30 days to complete the co-signature for the history and physicals, but at times get behind. Staff member E could not recall co-signing the history and physical note for patient #3 or patient #17. During an interview on 9/11/24 at 3:30 p.m., staff member W stated, “It does not look like staff member E was notified of admission and the history and physical was not sent to him for review and co-signature.” Review of a facility document titled, “[Facility Name] APP Practice Guidelines,” undated, showed: “... 3. Required physician consultation and/or notification of a physician under the following circumstances: ... 3.3. Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, the Facility Medical Director (FMD) is notified of the admission through the EMR. 3.4. Physician chart co-signature for all admissions by a nurse practitioner, physician assistant, or clinical nurse specialist to be completed within 30 days.””

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to assess anesthesia risk for outpatient procedures for 1 (#22) of 3 sampled surgical records; and failed to include a history and physical the day of the procedure, to include a heart and lung evaluation for 3 (#19, 22, and 23) of 3 sampled surgical records. This deficient practice had the potential to affect all patients having outpatient procedures performed. Findings include: Review of patient #19’s electronic medical record, failed to contain an updated history and physical for the procedure dated 9/10/24, by staff member D. Review of patient #22’s electronic medical record, failed to contain an updated history and physical and anesthesia risk assessment for the procedure dated 8/22/24, by staff member Y. Review or patient #23’s electronic medical record, failed to contain and updated history and physical for the procedure dated 9/10/24, by staff member D. During an interview on 9/11/24 at 9:42 a.m., staff member R said an anesthesia risk assessment is not performed for outpatient procedures, and she was not aware it was a requirement. Staff member R said patients were referred to the facility for pain injections and a history and physical or update was not performed for those procedures. Staff member R said the provider was to update the history and physicial for outpatient procedures the day of the scheduled procedure. Review of a facility document, “Interventional Pain Management Program,” with a revision date of November 2022, showed: “...Evaluation for appropriate treatment is done by the CRNA prior to performing the procedure. This includes: ...4. Perform a limited, focused physical assessment pertinent to the patient/client’s condition. ...” Review of a facility document, “Risk Classification of Anesthesia Patients,” with a revision date of May 2021, showed: “ ...Policy: ...only patients classified as class I, II or III will be electively scheduled for anesthesia-related procedures at the hospital. All patients who are classified in other physical status categories will be evaluated on an individual basis for surgery. Procedure: A. Upon admission to the preoperative area, all patients will be evaluated by a Certified Registered Nurse Anesthetist (CRNA). One of the components of this evaluation will include an assignment of a “Physical Status” (PS) classification ...””

“ADMINISTRATION OF ANESTHESIA CFR(s): The CAH designates the person who is allowed to administer anesthesia to CAH patients in accordance with its approved policies and procedures and with State scope-of-practice laws. (1) Anesthesia must be administered by only-- (i) A qualified anesthesiologist; (ii) A doctor of medicine or osteopathy other than an anesthesiologist; including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (iii) A doctor of dental surgery or dental medicine; (iv) A doctor of podiatric medicine; (v) A certified registered nurse anesthetist (CRNA), as defined in Sec. 410.69(b) of this chapter; (vi) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter; or (vii) A supervised trainee in an approved educational program, as described in §§ 413.85 or 413.86 of this chapter. This Standard is not met as evidenced by: 45448 Based on observation, interview, and record review, the facility failed to follow staff bylaws and provide anesthesia privileges for 1 (#K) of 8 sampled providers. This deficient practice had the potential to affect all patients receiving anesthesia services from provider K. Findings include: During an observation on 9/10/24 at 9:15 a.m., staff member K was providing anesthesia services for outpatient colonoscopy procedures. During an interview on 9/10/24 at 10:10 a.m., staff member K said his last workday would be 9/11/24, as he would be retiring. During an interview on 9/11/24 at 12:50 p.m., staff member D stated he was responsible for reviewing the credentials for providers before requests were taken to the Governing Board. Staff member D stated all initial requests for privileges are provisional for 90 days and at the end of 90 days he would recommend privileges without provisions. Staff member D stated providers are re-approved for privileges every two years, based on his recommendations. A review of staff member K’s credentialing file on 9/11/24, showed he was granted privileges to practice at the facility on 10/29/2019 and was valid through 6/30/2021. Staff member K’s credentials and privileges were not reviewed after 6/30/2021. Staff member K continued to provide care to patients in the operating room after his privileges had expired. Staff member K’s privileges had been expired for 1,169 days at the time of the survey. Review of a facility document, “Responsibilities of Anesthesia Services,” revision dated 5/2021, showed: “... The Anesthesia staff is responsible to the [Facility Name] and it’s Board of Directors for the day-to-day provision of safe and appropriate anesthesia care for all patients receiving ansthesia services. ...Procedure: A. To maintain a staff of one highly qualified associate, 24 hours per day, who is priileged by the medical staff to provide services. ...” Review of a facility document titled, “[Facility Name] Medical Staff Bylaws,” dated 9/29/22, showed: “... Article V: Terms of Appointment and Reappointment: A. All appointments, reappointments, and delineation of privileges and assignments are at the discretion of the Board of Directors upon recommendations of the Medical Staff. ... C. Appointments shall be for a period of not more than two medical staff years. Medical Staff reappointments shall be made in even numbered years ...For the proposes of these By-Laws the medical staff year commences on the first day of July and ends on the thirtieth day of June ...” [sic]”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include: During an interview on 9/10/24 at 2:03 p.m., staff member P stated she had started her Infection Prevention training, but had only completed a few modules. Staff member P stated she knew the education was to be completed within 30 days. Staff member P stated she started the Infection Control Training in August. Staff member P stated she was appointed by the Governing Board in May 2024. Record review of the facilities personnel file for staff member P showed the Infection Prevention Education was started in August 2024 but had not been completed.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to provide education to all staff related to infection prevention and control practices in the facility. This deficient practice had the potential to affect all staff providing care at the facility and all patients receiving care at the facility. Findings include: During an interview on 9/10/24 at 2:03 p.m., staff member P stated she and staff member Z had not provided any staff education regarding infection prevention. A review of a facility document titled, “Infection Control Program,” with an approval date of August 2023, showed: “... Program Goals ... Provide education and other services that are designed to change the attitudes and behaviors of employees when indicated, in order to facilitate the creation of an environment in which consistent optimal standards of care can be achieved.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAHs, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This deficient practice had the potential to affect all patients receiving care and all staff providing care in the facility. Findings include: During an interview on 9/10/23 at 2:03 p.m., staff member P stated she had not done any kind of education with staff or providers on antibiotic stewardship guidelines, policies, or procedures. Staff member E stated staff member Z handles the antibiotic stewardship program. Staff member E stated she had never spoken with the medical staff or any staff about any type of antibiotic stewardship guidelines. Staff member P stated, “Staff member Z had not done any training with staff or providers at this time, but it is something we want to do.” Staff member Z was not available for interview prior to the end of the survey. Review of a facility policy titled, “Antibiotic Stewardship [Facility Name] Policy and Procedure,” with a last approval date of May 2023, showed: “... Procedure: ... 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. 3. Training and education will include emphasis on the relationship between antibiotic use and: a. Gastrointestinal disorders b. Opportunistic infections (e.g. C. difficile, candida albicans, etc.) c. Medication interactions; and d. The evolution of drug-resistant pathogens.”[sic]”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to complete a comprehensive assessment on a swing bed patient within 14 days of admission for 1 (#2) of 23 sampled patients. This deficient practice had the potential to affect all patients admitted for swing bed services. A review of patient #2’s EMR, dated 7/30/24, showed admission to swing bed. No comprehensive assessment was completed within 14 days of admission. A review of patient #2’s paper swing bed chart, dated 7/30/24, showed no comprehensive assessment had been completed within 14 days of admission. During an interview on 9/11/24 at 3:30 p.m., staff member W stated, “it does not look like the comprehensive assessment was completed. If the assessment is not in the EMR or the paper chart, then I don’t think it was done.” During an interview on 9/11/24 at 4:40 p.m., staff member B stated the comprehensive assessment for patient #2 should have been completed by nursing staff. Review of a facility document titled, “Swing Bed Comprehensive Assessment and Care Planning, undated, showed: ... “2. The assessment process will include direct observation and communication with the resident ... A. With in 14 calendar days after admission ... B. Not less often than once every 12 months. ... 4. The comprehensive assessment will be completed by the charge nurse and reviewed and signed by the Director of Nursing.””

“NOTICE OF RIGHTS CFR(s): 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: 45448 Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care for 18 (#’s 1, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice has the potential to affect all patients receiving care in the facility to acknowledge their patient rights. Findings include: Review of patient #1’s EMR showed an admission date of 9/1/24. No acknowledgement of patient rights was in the medical record. Review of patient #3’s EMR showed an admission date of 8/13/24. No acknowledgement of patient rights was in the medical record. Review of patient #4’s EMR showed an admission date of 9/6/24. No acknowledgement of patient rights was in the medical record. Review of patient #5’s EMR showed an ER admission date of 9/6/24. No acknowledgement of patient rights was in the medical record. Review of patient #6’s EMR showed an ER admission date of 9/8/24. No acknowledgement of patient rights was in the medical record. Review of patient #7’s EMR showed an ER admission date of 9/9/24. No acknowledgement of patient rights was in the medical record. Review of patient #10’s EMR showed an ER admission date of 9/5/24. No acknowledgement of patient rights was in the medical record. Review of patient #11’s EMR showed an ER admission date of 4/27/24. No acknowledgement of patient rights was in the medical record. Review of patient #12’s EMR showed an ER admission date of 5/12/24. No acknowledgement of patient rights was in the medical record. Review of patient #13’s EMR showed an ER admission date of 6/6/24. No acknowledgement of patient rights was in the medical record. Review of patient #14’s EMR showed an ER admission date of 7/1/24. No acknowledgement of patient rights was in the medical record. Review of patient #15’s EMR showed an ER admission date of 8/28/24. No acknowledgement of patient rights was in the medical record. Review of patient #16’s EMR showed an ER admission date of 8/5/24. No acknowledgement of patient rights was in the medical record. Review of patient #18’s EMR showed an outpatient treatment date of 9/10/24. No acknowledgement of patient rights was in the medical record. Review of patient #19’s EMR showed an admission date of 9/10/24. No acknowledgement of patient rights was in the medical record. Review of patient #20’s EMR showed an outpatient treatment date of 9/11/24. No acknowledgement of patient rights was in the medical record. Review of patient #21’s EMR showed an admission date of 8/22/24. No acknowledgement of patient rights was in the medical record. Review of patient #23’s EMR showed an admission date of 9/10/22. No acknowledgement of patient rights was in the medical record. During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient setting. 47752”

“EXERCISE OF RIGHTS CFR(s): 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, 489.102, and 489.104 of this chapter. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to inform outpatients of their right to formulate individual advance directives for 5 (#s 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving outpatient care in the facility. Findings include: Review of patient #18’s EMR showed an outpatient date of 9/10/24. No acknowledgement of patient rights to formulate an advanced directive was in the medical record. Review of patient #19’s EMR showed an admission date of 9/10/24. No acknowledgement of patient rights to formulate an advance directive was in the medical record. Review of patient #20’s EMR showed an outpatient date of 9/11/24. No acknowledgement of patient rights to formulate an advanced directive was in the medical record. Review of patient #21’s EMR showed an admission date of 8/22/24. No acknowledgement of patient rights to formulate an advance directive was in the medical record. Review of patient #23’s EMR showed an admission date of 9/10/22. No acknowledgement of patient rights to formulate an advance directive was in the medical record. During an interview on 9/11/24 at 2:06 p.m., staff member W said the facility did not provide outpatients with a notification of patient rights to formulate an advance directive. 47752”

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide patients with notification of their right to receive care in a safe setting, free from abuse or harassment, prior to providing care in the ER or outpatient setting for 17 (#s 1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving care provided in the ER or as an outpatient. Findings include: Review of patient #1’s EMR showed an admission date of 9/1/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #3’s EMR showed an admission date of 8/13/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #5’s EMR showed an ER admission date of 9/6/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #6’s EMR showed an ER admission date of 9/8/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #7’s EMR showed an ER admission date of 9/9/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #10’s EMR showed an ER admission date of 9/5/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #11’s EMR showed an ER admission date of 4/27/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #12’s EMR showed an ER admission date of 5/12/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #13’s EMR showed an ER admission date of 6/6/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #14’s EMR showed an ER admission date of 7/1/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #15’s EMR showed an ER admission date of 8/28/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #16’s EMR showed an ER admission date of 8/5/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #18’s EMR showed an outpatient date of 9/10/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #19’s EMR showed an admission date of 9/9/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #20’s EMR showed an outpatient date of 9/11/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #21’s EMR showed an admission date of 8/22/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. Review of patient #23’s EMR showed an admission date of 9/10/22. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record. During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient setting. 47752”