UNC Health Care Wayne

“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: 16369 Based on policy review, closed medical record review, and physician and staff interviews, the hospital failed to comply with 42 CFR §489.24. The findings include: The hospital failed to provide timely stabilizing treatment within the capability of the hospital’s Dedicated Emergency Department for one (1) of 23 sampled patients (Patient #23) that presented to the hospital’s Dedicated Emergency Department (DED) with an emergency medical condition. ~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A2407.”

“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: 50318 Based on review of hospital policy, closed medical record review, and physician and staff interviews, the hospital failed to provide timely stabilizing treatment within its capability and capacity for one (1) of 23 sampled patients (Patient #23) that presented to the hospital’s Dedicated Emergency Department (DED) with an emergency medical condition. The findings include: Review of the facility policy, “EMTALA (Emergency Medical Treatment and Labor Act): Medical Screening Exam, Stabilization, and Refusal of Treatment,” effective date 12/2023, revealed, “ ... Procedure Outlining the Stabilization Process. Steps ... 2. If an Emergency Medical Condition exists, medical treatment, within the capabilities of the staff and facilities routinely available (“Capacity”), will be provided to stabilize the individual prior to consideration of discharge, admission, or transfer. 3. Stabilized for Transfer means: For individuals with an Emergency Medical Condition ...it shall mean that 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... Key Points... 2. Resources routinely available for patient diagnosis and treatment at Facility A continue to be available for stabilizing the patient for admission, discharge or transfer. 3. Stabilizing for Transfer means that the treating physician has determined, within reasonable medical probability, that the patient will be received at the receiving facility with no material deterioration in medical condition and that the receiving facility has the capability to manage the patient’s medical condition and any reasonably foreseeable complication of that condition... “ Review of the facility policy, “EMTALA: Transfers, To Other Medical Facilities,” effective date 11/2023, revealed, “... F. The occasion for transfer from Facility A to another medical facility must be for the following reasons: 1. Patient requires specialized treatment that is beyond the scope of services provided within Facility A; 2. Patient’s condition may deteriorate further if the specialized care is not available ... G. A stable or unstable patient may be transferred from Facility A to another medical facility when the following guidelines have been met: 1. The Receiving Facility has available space and Qualified Medical Personnel for the treatment of the patient and has agreed to accept the transfer and provide treatment ... “ Closed medical record review for Patient #23 revealed a 61-year-old patient who presented to the DED on 06/14/2025 at 0602 for abdominal pain. The patient’s vital signs at 0607 were pulse of 81, BP (blood pressure) of 131/65, respirations of 22 with SpO2 (oxygen saturation, a measurement of the percentage of oxygen in the blood) of 100% on room air. Triage started at 0612. ED Triage Note at 0613 revealed, “Pt (patient) c/o (complained of) sudden onset mid abdominal pain since 0200 am radiating to back. Intermittent pain with cramping. Took 3 gasX w/o (without) relief. + nausea. Vomited x2. Denies painful urination.” A CT scan (computed tomography scan, specialized x-ray to produce cross-sectional images of the body) of the abdomen and pelvis was ordered at 0644 for abdominal pain, vomiting, history of gastric bypass (a type of bariatric, or weight loss, surgery), and recent abdominal plastic surgery. ED Provider Note dated 06/14/2025 at 0651 revealed the patient appeared uncomfortable with right upper quadrant pain on palpitation and mild distention. The patient had CMP (comprehensive metabolic panel) labs drawn, which resulted at 0655. The patient’s potassium was 2.7 (reference range 3.5-5.1); the ED Provider was notified of this result as a “critical lab value” at 0656. The patient’s pain was assessed at 0709 as 10 out of 10 acute pain in the back and abdomen, and the patient was given Fentanyl (a pain medication) IV (intravenous) 50 mcg (micrograms) at 0709. The CT scan started at 0809 and revealed a small bowel obstruction (a partial or complete blockage in the small intestine). ED Nurse Note at 0842 revealed the patient complained of pain in their abdomen, and the ED Provider was notified. Zofran (anti-nausea medication) 4 mg (milligrams) IV was administered at 0905, and Fentanyl 50 mcg IV was administered at 0908 for 10 out of 10 acute pain. Potassium 20 mEq (milliequivalents) IV was started at 0917. ED Provider Note update at 0954 revealed the CT showed a small bowel obstruction at the proximal small bowel anastomosis (surgical reconnection of the small bowel). The patient’s gastric bypass surgery was performed in 2005 at Hospital C. ED Provider Note update at 1038 revealed the Provider spoke with Hospital C bariatric services Provider and discussed the patient’s workup and findings. The patient was accepted to their services, and the ED Provider was “awaiting bed assignment and will proceed with transfer.” The patient’s disposition was listed as transfer to another facility at 1104. The ED Provider completed an EMTALA transfer form at 1105, which listed the specific benefits of transfer as, “Continuity and optimization of care for patient’s condition, access to specialty services, bariatric services.” The patient was accepted to Hospital C and (named Provider) at 1105. ED Attending Provider Note at 1108 revealed on exam, the patient was “hemodynamically stable, appears uncomfortable, but non toxic, diffuse abdominal pain, worse in RUQ (right upper quadrant) ...” Fentanyl 50 mcg IV was administered at 1121 for 10 out of 10 acute pain to the abdomen. ED Nurse Note at 1141 revealed, “Pt c/o pain and saying Fentanyl not helping much with pain. Notified (named ED Provider) to see if another med could be ordered every couple of hours.” Phenergan (a medication for nausea, vomiting, and pain relief) 12.5 mg IV was administered at 1156, and Morphine (a pain medication) 4 mg IV was administered at 1202. ED Provider Note update at 1247 revealed, “Called to patient’s bedside regarding voice concerns to primary RN (Registered Nurse) ...Concerned with the amount of time patient has been in the ED, and patient’s pain control. A detailed discussion of patient’s interventions thus far, and specific qualifications of need to transfer to Hospital C versus another medical facility was had with patient and patient’s visitors. Understanding was verbalized. Risks and benefits of insertion of an NG (nasogastric) tube was explained in thorough detail to patient. Shared decision making was implemented and patient opted for insertion of NG tube along with a KUB (abdominal x-ray) for confirmation. Additional pain medication ordered.” The patient’s vital signs at 1315 were pulse 95, BP 138/74, and respirations 34 with SpO2 of 96%. Dilaudid (a pain medication) 1 mg IV was administered at 1349 for 10 out of 10 acute pain to the abdomen. A NG tube was placed at 1400 for decompression and was placed to low intermittent suction. The patient’s pain was assessed at 1512 as a 5 out of 10 acute pain. ED Provider Continuation of Care Note at 1555 revealed a second ED Provider assumed care of the patient at change of shift, and the plan of care was to follow-up with NG tube and transfer to Hospital C for further management of the small bowel obstruction. The patient’s vital signs at 1600 were pulse 112, BP 138/111, and respirations 35 with SpO2 of 95%. ED Provider Note update at 1602 revealed the Provider checked on the transfer, and there were no beds at that time. ED Nurse Note at 1621 revealed, “Notified (named ED Provider) of pt’s high HR (heart rate) 115 and RR (respiratory rate) in 30s.” ED Provider Note update at 1653 revealed the patient was tachycardic (fast heartbeat), and their abdomen was distended and tender. The patient was still awaiting transfer. The patient’s vital signs at 1700 were pulse 117, BP 137/99, and respirations 25 with SpO2 of 98%. ED Nurse Note at 1723 revealed, “Pt c/o pain ...This Nurse notified (named ED Provider) for more pain meds.” ED Nurse Note at 1742 revealed, “Abdomen is becoming more distended than earlier. Notified (named ED Provider).” Morphine 8 mg IV was administered at 1750 for a pain of 8 out of 10. The patient’s vital signs at 1800 were pulse 112, BP 137/93, and respirations 35 with SpO2 of 94%. ED Provider Note update at 1815 revealed the Provider was troubleshooting the NG tube as there was no significant gastric content. ED Provider Note update at 1908 revealed, “NG tube with poor output which may be normal with patient’s history of Roux-en-Y (gastric bypass surgery). It was initially at 67 cm (centimeters), pulled back to 50 cm gave some gastric content, but no significant amount. Patient is distended clinically, tachycardic, will give further morphine for pain ...” Morphine 8 mg IV was administered at 1926 (no pain score listed). The patient’s vital signs at 2014 were pulse 142, BP 90/57, and respirations 32 with SpO2 of 95%. The patient’s lactate level (a chemical the body produces when cells break down carbohydrates for energy) was drawn and resulted at 2025 as 4.5 (reference range 0.5-2.0); the ED Provider was notified of this result as a “critical lab value” at 2026. General surgery was at the bedside at 2026. The patient’s vital signs at 2059 were pulse 143, BP 95/82, and respirations 24 with SpO2 of 86%. Fentanyl 100 mcg IV was administered at 2123 (no pain score listed). The patient was admitted to the pre-operative area at 2205 (approximately 16 hours after presenting to the DED) and underwent an exploratory laparotomy (a surgical procedure where the abdomen is opened to examine the organs and diagnose or treat underlying conditions), closure of remnant stomach anterior gastric wall perforation (a rupture of the bypassed stomach [remnant], a rare complication after gastric bypass), closure of jejunojejunostomy hernia site (an internal hernia that occurs in the space between two surgically connected loops after gastric bypass), and closure of Petersons defect (an internal hernia after gastric bypass). The patient was transferred to the ICU (Intensive Care Unit) on 06/15/2025 at 0130. The patient was transferred to Hospital C at 1150 (approximately 29 hours and 43 minutes after presenting to the DED). Review of an EMTALA Transfer Certification revealed the reason for transfer was qualified clinical personnel or service was unavailable, and the accepting facility had “availability of bariatric surgery subspecialty evaluation.” Hospital C accepted the patient on 06/15/2025 at 1021, and the certifying Physician signed off on 06/15/2025 at 1021 and recertified at 1120. Patient #23 was transferred to Hospital C’s surgical ICU (Intensive Care Unit) on 06/15/2025. Provider’s History and Physical (H&P) dated 06/15/2025 at 1310 revealed the patient was transferred for further evaluation due to increasing vasopressor (a medication that constricts blood vessels, raising blood pressure and improving blood flow to organs) requirements and lactic acidosis (a metabolic disorder characterized by an excessive accumulation of lactic acid in the bloodstream, leading to a drop in blood pH [acidosis]). The patient was tachycardic and hypotensive (low blood pressure) with a lactate level of 5.5. The patient underwent an exploratory laparotomy on 06/15/2025, which revealed bowel ischemia (blood supply to the intestines is reduced, leading to tissue damage), and 51 cm of the small bowel were resected (removed). The patient underwent a second exploratory laparotomy on 06/16/2025. Brief Operative Note dated 06/16/25 at 1300 revealed, “ ... upon entering the abdomen there was obvious and frankly necrotic (dead tissue) small bowel with foul odor. No perforation. We measured roughly 225 cm of small bowel that was necrotic in addition to the ascending and descending colon being frankly necrotic. The remnant stomach was also necrotic in appearance. Given these findings, this is not a survivable injury ...” The operating team discussed the findings with the patient’s family and recommended comfort measures, which was pursued on 06/17/2025 with a plan for compassionate extubation on 06/18/2025. However, the patient passed away on 06/17/2025 at 2000. Request for peer review related to Patient #23 on 10/30/2025 revealed Provider peer review was initiated on 07/09/2025 and was currently ongoing. Further details were not able to be provided. Interview on 10/29/2025 at 1501 with DO (Doctor of Osteopathic Medicine) #1 revealed DO #1 recalled Patient #23 and was the attending ED Physician on the morning of 06/14/2025. DO #1 revealed the unit secretary called different transfer centers, and Hospital C was called directly first as Patient #23 previously had surgery there. DO #1 revealed a bariatric Surgeon at Hospital C accepted the patient, and the transfer paperwork was completed. Interview revealed before the transfer was initiated, the patient was feeling better with no nausea or vomiting, normal vital signs, and tenderness to the abdomen. DO #1 revealed later on the patient was belching and was in some pain, and Morphine seemed to help with the pain. Interview revealed the patient’s family had requested an evaluation by the Provider, so DO #1 and NP (Nurse Practitioner) #2 spoke with the patient and family at the bedside about the plan of care. DO #1 re-examined the patient at that time, and the patient was stable. Interview revealed one of the family members asked about an NG tube, and DO #1 called a bariatric surgeon at Hospital C to discuss NG tube placement. Interview revealed NG tubes were not typically indicated for bariatric patients unless the symptoms (such as nausea or vomiting) were severe. DO #1 revealed the bariatric surgeon thought an NG tube could be tried for Patient #23 to help their symptoms (belching). Interview revealed per the CT, the patient had some contents in her stomach, but the DO’s shift ended prior to the NG tube being placed. Interview revealed the patient did not specifically request an NG tube but was agreeable to the plan, and the patient did not request for a transfer to another facility after the transfer was arranged with Hospital C. DO #1 revealed the patient seemed comfortable with the plan at that time and was not pushing for interventions. Interview revealed the patient’s family asked specifically about transfer to Hospital B, and DO #1 discussed that Hospital B did not have bariatric services. DO #1 did not see a reason why a GI (Gastrointestinal) Specialist would have been consulted as the patient’s small bowel obstruction was the reason for the transfer, and “they would handle it from there” at Hospital C. DO #1 revealed as the situation changed with Patient #23, the patient was evaluated and treated. DO #1 revealed there was a delay in transferring the patient and “wished we got her to (Hospital C) faster” but did not know if anything would have changed if the patient got there sooner. Interview on 10/29/2025 at 1531 with NP #2 revealed NP #2 recalled Patient #23 and cared for her on the morning shift on 06/14/2025. NP #2 revealed Patient #23 was uncomfortable with pain and tenderness to the right upper quadrant of the abdomen, and her abdomen was soft and mildly distended. The patient was not vomiting but was very nauseated. Interview revealed the patient’s CT scan showed a small bowel obstruction. NP #2 spoke with General Surgery at the facility, who recommended further management at Hospital C as they had bariatric services, and the patient previously had Roux-en-Y surgery there. NP #2 discussed Patient #23 with a bariatric surgeon at Hospital C, who recommended medications, including Zofran, but did not recommend an NG tube at that time, as the patient was not vomiting. Interview revealed at Hospital C there was not bed availability, but “beds were coming available,” and the bariatric Surgeon accepted the patient for transfer. NP #2 revealed the patient had a stable presentation at that time. NP #2 revealed Nursing had informed the Providers that the family was upset, so NP #2 and DO #1 went to the bedside. Interview revealed a close friend was there, who was concerned that Patient #23 was still in pain, uncomfortable, and had not been transferred. NP #2 explained the best recommendation was to transfer to Hospital C with their bariatric services and continue to monitor the patient, who appeared comfortable at that time but did have some discomfort. Interview revealed DO #1 offered to insert a NG tube and offered more pain medication, which the patient was agreeable to try to help her feel better. NP #2 revealed a KUB confirmed placement of the NG tube, and no other significant changes were noted. NP #2 discussed with the family that a CT was a better diagnostic, but there were no significant changes in vital signs, and the patient did not appear septic (a life-threatening condition that occurs when the body’s immune system overreacts to an infection, leading to widespread inflammation and organ damage). NP #2 then signed out to an oncoming Provider, and they were still awaiting bed availability at Hospital C. Interview revealed no other transfer requests were made at that time; other facilities were considered, but they did not reach out to any other facility. NP #2 did not recall if they had GI Specialists that day and stated it depended on the day with their on-call schedule if there was GI coverage. Telephone Interview on 10/29/2025 at 1608 with PA (Physician’s Assistant) #3 revealed they recalled Patient #23 and took over her care at 1500 on 06/14/2025. PA #3 revealed the patient appeared uncomfortable when the PA examined her around 1530, and Nursing was having trouble with the NG tube. The patient’s abdomen was distended, which was not uncommon with a small bowel obstruction; the patient was also tachycardic and needed more fluids and pain medication. PA #3 revealed the patient’s presentation was changing, and they “ultimately pivoted to our surgeon intervening.” PA #3 did not recall Patient #23 specifically requesting to go to Hospital C, but the patient had a Roux-en-Y procedure done there “a long time ago.” Interview revealed it could be hard to get another facility to accept a patient with a small bowel obstruction. PA #3 revealed the patient “clearly perforated and was very sick.” PA #3 called the bariatric surgeon back at Hospital C to state the patient was really sick, and the patient got a bed at Hospital C. PA #3 then called the General Surgeon at Hospital A, and it was “clear to both the patient was very sick.” PA #3 was unsure if the Surgeon had seen the patient earlier in the day or if General Surgery or GI had been consulted previously. PA #3 was unsure if another facility had been contacted for transfer, as the patient was accepted at Hospital C, but there was no bed. Interview revealed the Surgeon at Hospital A agreed to the take the patient to the Operating Room as surgery needed to happen. PA #3 revealed the patient was “okay to wait on a bed transfer” as the patient was previously hemodynamically stable with “fairly normal vital signs.” Interview revealed that the patient’s abdominal exam changed, and the Surgeon accepted her urgently as there was a perforation. Interview on 10/30/2025 at 0943 with Surgeon #4 revealed that the Surgeon had been called the morning of 06/14/2025 to provide feedback on Patient #23 but had not seen her at that time. Patient #23 had previously had gastric bypass surgery, and Surgeon #4 recommended sending the patient to Hospital C. Interview revealed when Surgeon #4 evaluated the patient in the evening of 06/14/2025, the patient was in distress, tachycardic, diaphoretic (excessive sweating), in pain, “needed an operation, and could not wait any longer.” Surgeon #4 revealed after the patient’s surgery, she was transferred to the ICU and then to Hospital C after that (on 06/15/2025). Interview revealed Surgeon #4 was not involved in the transfer conversations regarding Patient #23. Interview on 10/30/2025 at 1019 with Director #6 revealed peer review was initiated related to Patient #23’s care on 07/09/2025 as part of the facility’s patient safety evaluation process. Director #6 revealed the peer review was currently ongoing, and they were following their internal processes for the review. In summary, Patient #23, a 61-year-old, presented to the DED on 06/14/2025 at 0602 for abdominal pain, which was assessed as 10 out of 10 pain at 0709. The patient’s CT scan at 0809 revealed a small bowel obstruction. The patient was accepted by a bariatric Provider for transfer to Hospital C at 1104, but there were no beds available at that time. The patient remained in the DED until she was taken to the OR for an exploratory laparotomy (approximately 16 hours after presenting to the DED), which revealed remnant stomach gastric wall perforation and contamination of the peritoneal cavity with small bowel contents. The patient was transferred to the ICU on 06/15/2025 at 0130 with severe sepsis/septic shock and acute hypoxemic respiratory failure. The patient was transferred to Hospital C at 1150 (approximately 29 hours and 43 minutes after presenting to the DED). The patient expired at Hospital C on 06/17/2025 at 2000. The hospital failed to provide stabilizing treatment within its capability and capacity for a patient with a small bowel obstruction.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 34065 Based on review of policies, medical records, and interviews with staff, the facility failed to provide a face to face within 1 hour after a violent restraint intervention for 1 of 1 patient with violent restraints. (Patient #22) The findings include: Review on 12/12/2024 of policy titled “Restraints, Violent or Self-Destructive” with revision date of 07/2023, revealed “Purpose: To provide guidelines regarding the utilization of restraints for patient behavioral emergencies. Policy: A. Physical restraints may be imposed when there is imminent risk of a patient physically harming him/her-self or others and/or when patients are severely aggressive or display destructive behavior...M. Provider visits for Physical Restraints: 1. The provider must see the patient face-to-face within 1 hour after the intervention of physical restraints (either physical restraints or physical hold). a. If the patient’s behavior resolves prior to the arrival of the provider performing the 1-hour face-to-face evaluation, the provider is still required to see the patient face-to-face within the hour. b. The evaluation must include: 1. Patient’s immediate situation 2. Patient’s reaction to the intervention. 3. Patient’s medical and behavioral condition. 4. The need to continue or terminate the restraint.” Review on 12/12/2024 of a closed medical record of Patient #22 revealed a 27 year-old female that presented to the Emergency Room on 09/06/2024 with Altered mental status. Patient #22’s prior medical history revealed a history of asthma and bipolar disorder. Review of the physician’s orders revealed an order for a therapeutic hold restraint dated 09/07/2024 at 1430. Review revealed Patient #22 was placed in a therapeutic hold from 1439-1441. Review of the documentation revealed no provider face-to-face evaluation within 1 hour of the restraint. An interview with the provider was not obtained. The provider was not available. Interview on 12/12/2024 at 1400 with Manager #9 revealed no face-to-face documentation by a provider. Interview on 12/12/2024 at 1635 with Manager #8 revealed no face-to-face documentation by a provider. The interview revealed the policy was not followed.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 50111 Based on policy review, observation, personnel file review, staff schedule review, and staff interviews, the hospital failed to ensure current certification was maintained in Pediatric Advanced Life Support (PALS) for 1 of 3 Unit A Registered Nurse (RN) personnel files reviewed requiring PALS certification according to hospital policy (RN #4). The findings include: Review on 12/12/2024 of hospital policy “Education, Orientation, and Training,” effective 03/24/2024, revealed, “... H. Pediatric Advanced Life Support (PALS) ... This certification is mandatory for nurses in ... [Unit A] ... 1. All teammates are required to meet established mandatory requirements according to policies ... These mandatory requirements include, but are not limited to, certifications (i.e. ... PALS ...) ... Teammates whose certifications ... have expired may not work beginning at midnight on the date of expiration ...” Observation on 12/10/2024 at 1023 revealed RN #4 was working on Unit A. Review on 12/12/2024 of RN #4’s personnel file revealed RN #4’s PALS certification expired on 10/31/2024. Review failed to reveal evidence of PALS certification renewal after 10/31/2024. Review on 12/12/2024 of RN #4’s schedule revealed RN #4 worked the following dates: 11/01/2024, 11/06/2024, 11/07/2024, 11/08/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/29/2024, 11/30/2024, 12/01/2024, 12/05/2024, 12/06/2024, 12/09/2024, 12/10/2024, and 12/11/2024 (20 of 42 days since PALS certification expired). Interview on 12/10/2024 at 1025 with RN #4, while on tour of Unit A, revealed the RNs on Unit A maintained PALS certification because the unit occasionally received surgical pediatric patients. Interview on 12/12/2024 at 1419 with Training Specialist #2 revealed PALS certification was required for RN #4 and the certification was expired. Training Specialist #2 revealed RN #4 was enrolled in a certification renewal class prior to the expiration date but cancelled the enrollment. Interview revealed RN #4 was enrolled in a PALS renewal class on 01/23/2025 (84 days after expiration). Training Specialist #2 revealed staff should not work with an expired certification per hospital policy. Training Specialist #2 stated a monthly report with staff certification expiration dates was sent to unit leaders. Interview revealed unit leaders were responsible for following up with staff members. Interview on 12/12/2024 at 1520 with the Chief Nursing Officer (CNO #1) revealed RN #4 should have renewed the PALS certification prior to the expiration date. CNO #1 stated the expired PALS certification would not prevent RN #4 from working because there were other PALS certified staff members available for emergency situations. Interview revealed CNO #1 would follow up with the Director for Unit A (Director #3) regarding a plan for RN #4’s expired PALS certification and appropriate assignments on Unit A. Director #3 was unavailable for interview. NC00185397; NC00186155; NC00186953; NC00193569; NC00199004; NC00200550”