Rutherford Regional Medical Center

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 39307 Based on policy and procedure review, medical record review, grievance file review, and staff interview, the hospital staff failed to respond to a grievance according to policy for 1 of 3 grievance files reviewed (Patients #4). Findings included: Review of the Complaint and Grievance Resolution policy, Number 20447334 last revised 06/2026 revealed “...Grievance ...The Patient Grievance Form will be forwarded to the appropriate Department Director and/or persons involved who can provide resolution to the grievance within (8) hours if possible. The Department Director and/or persons involved must provide a response to the grievance to the patient or patient’s representative within five (5) days. The response must provide the results of the investigation, including steps taken to resolve the grievance on behalf of the patient, if necessary. This information will be used by Administration to form a letter of resolution to the complainant .... Resolution: A letter of resolution will be sent to the complainant by day seven (7) of receiving the grievance. The letter of resolution will include the steps taken to resolve the grievance on behalf of the patient, the Department Leader completing the investigation, date of completion and the name and phone number of the person sending the resolution letter ...” Closed medical record review of Patient #4, on 06/02/2026 revealed the patient presented to the Emergency Department (ED) on 01/30/2026 after involved in a Motor Vehicle Crash as a restrained driver. Record review revealed the patient was assessed, evaluated and discharged on 01/30/2026 from the ED. On 02/05/2026 an initial complaint was received by the Assistant Director of Nursing about Patient #4 who had noted inaccurate documentation of vaccination status and inaccurate weight in the medical record. The ED Nurse Manager #7 spoke with the guardian of the patient and provided information on the process of medical record amendments. On 06/04/2026 (approximately 107 days later) a letter was provided to the complainant of the information. Review revealed the hospital failed to follow the necessary procedure of Complaint/Grievance Resolution for Patient #4 as per policy. Interview on 06/04/2026 at 1320 with the ED Nurse Manager #7 revealed the follow-through was missed for the procedure of Complaint/Grievance Resolution. It was the expectation to forward a Resolution letter to the complainant with explanation of the steps taken to correct the concern within 7 days of receipt of the complaint. Interview revealed that the hospital failed to forward a Resolution Letter to the complainant.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 41946 Based on policy review, incident report review, medical record review, and staff interview, the facility failed to complete incident reports per policy for 2 of 3 records reviewed. [Patient #2, Patient #10] the findings included: Review on 06/04/2026 of the facility policy, RL Solutions Reporting Involving Patients, Visitors, and Employees, H-05-03, last approved 03/2026 revealed, “... to ensure variances are tracked, reviewed and reported in a non-punitive manner. This process will also allow for the monitoring of appropriateness of care and aggregating and identifying opportunities for improvement. All employees and those who supply services to [named facility] should be aware of what constitutes a variance so that they are in the position to detect and report in RL Solutions when they occur. DEFINITION: Variance: any event or circumstance not consistent with the standard routine operations or the routine care of a patient. ... PROCEDURE: ...Examples are: ... errors in practice/procedure, ...Adverse reaction to professional care and/treatment...Patient: ... 4. Enter Variance into RL solutions, using SBAR [situation, background, assessment, and recommendation] format. ...” Request for incident reports revealed they were unavailable for Patient #3 and Patient #10. 1. Closed medical record review on 06/02/2026 revealed Patient #3, a 55-year-old female patient who arrived to the emergency department [ED] on 03/27/2026 at 1217 by emergency medical services [EMS] with complaints of a possible urinary tract infection, cough and congestion. Patient #3 was accompanied by a caretaker [assigned custodian by the guardian (department of social services)]. The patient was seen by the ED Nurse Practitioner [NP] #11 at 1223 for medical screening exam. The patient had a chronic foley catheter, was non-ambulatory, limited verbal skills, and a history of an intellectual disability. Patient #3 was evaluated in the ED and discharged by ED NP #11 on 03/27/2026 at 1500 and was awaiting transportation services. Record review revealed an additional ED Provider Note dated 03/27/2026 at 2345 by ED Medical Doctor [MD] #8 “...has been assessed earlier in the shift and written up to be discharged. She was awaiting transport. Caregiver then came and expressed concern that the patient did not look well [sic]. She was placed back on the monitor, noted to be tachycardic with a heart rate round 105 beats per minute, hypotensive with a blood pressure around 80/40, borderline febrile. Given additional IV fluid bolus in his [sic] dose of ketorolac [non-narcotic anti-inflammatory used for short-term treatment of pain] for her fever. On my evaluation, sleeping, she does appear acutely ill, dry mucous membranes. ... she does appear septic from urinary tract infection. I do feel admission it [sic] was appropriate at this time. I spoke with [named hospitalist] service ...” An ED disposition plan to admit to the hospital was ordered. The History and Physical on 03/27/2026 at 2355 by Hospitalist NP #14 was completed. The admitting diagnosis of sepsis and urinary tract infection. Patient #3 was admitted on 03/28/2026 at 0255 to an inpatient floor. Review revealed Patient #3 was admitted to the inpatient unit, with a stage II decubitus ulcer on her coccyx [triangular bone at the very base of the human spine area] that was pre-existing. Review of the Registered Nurse [RN] assessment flowsheet on 03/28/2026 at 0815 by Unit RN #21, revealed 2 wounds present at the initial nursing skin assessment to the medical unit, an abrasion to bilateral lower legs, and coccyx, stage II that were present. Review of the Nursing Skin Flowsheet on 03/30/2026 at 0800 by Unit RN #17 revealed, a new 3rd wound described “...Right lower buttock, pressure injury. Warm and dry. ...” Review on 03/30/2026 at 2000 of the Nursing Skin Flowsheet by Unit RN #18 revealed the right lower buttock wound with note, “... dressing changed, aquacell [soft gel dressing that contains moisture for wound healing] - 4X4 applied. ...” Patient #3 had a new wound to the right lower buttock. Patient #3 remained on the medical unit until 04/03/2026 at 1630 and was discharged home with home health services. In summary, a new pressure injury was documented on 03/30/2026 to the right buttock by RN #17. On request a facility incident report was unavailable for review. Telephone interview on 06/04/2026 at 1235 with RN #21 revealed, “... never had one to bad enough worth reporting. I would pass it on in report, and report to our supervisor [named], our acting wound care nurse [named], at night our access is limited. ...” The interview revealed, RN #21 had not completed an incident report per policy. Interview on 06/04/2026 at 1455 with Chief Nursing Officer, #22 revealed the expectation for incident reporting was to follow the policy. The interview revealed, if a new hospital acquired pressure injury was identified, an incident report should be completed by the nurse. 2. Closed medical record review on 06/03/2026 revealed Patient #10, a 47-year-old female patient who arrived to the emergency department [ED] on 12/26/2025 at 1505 with shortness of breath. A medical screening exam was completed by ED Nurse Practitioner [NP] #1 at 12/26/2026 at 1535. The ED disposition to admit was placed at 1658. A History and Physical was completed in the ED on 12/26/2025 at 2029 by Hospitalist NP #18 with an admitting diagnosis to include acute kidney injury, chronic kidney disease, hypertension [high blood pressure], and diastolic congestive heart failure [progressive condition in which the heart muscle becomes too weak to pump efficiently]. An order to transfuse one unit of red packed blood cells [RBCs]was placed on 12/27/2025 at 1555 by Hospitalist NP #19 for a hemoglobin of 7.2 [ref range 12 - 16]. The RBCs started on 12/27/2025 at 1550. Review of the RBC Monitor Flowsheet revealed pre-blood vital signs at 1548 were blood pressure 112/81, heart rate 81, temperature at 98.0, and oxygen saturation level of 96% on room air. The RBC transfusion began at 1550. The next vital signs at 1610 were blood pressure 133/93, heart rate 73, and temperature 98.2. At 1825, Patient #10’s vital signs were documented as blood pressure 155/113, heart rate 77, and temperature 99.1. The RBC transfusion was stopped by RN #20 at 1825. Review of the Nurse’s Note by Unit RN #20 at 1900 revealed, “...suspected reaction - HTN [high blood pressure]. ...” Record review revealed, the lab and physician were notified at 1825 by RN #20. Patient #10 was boarded in the ED through 12/28/2025 at 1606, when she was admitted to the medical unit. Patient #10 was discharged home from the medical unit on 12/30/2025 at 1430 with self-care. In summary, a blood transfusion reaction was reported on 12/27/2025 for Patient #10. On request a facility incident report was unavailable for review. Request to interview RN #20 revealed they were unavailable for interview. Interview on 06/04/2026 at 1455 with Chief Nursing Officer, #22 revealed the expectation for incident reporting was to follow the policy. The interview revealed that a blood transfusion reaction would be an adverse event, and an incident report should be completed by the nurse.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 53710 Based on policy review, guardian appointment review, elopement training review, medical record review, video surveillance review [Patient #2], incident report review, EMS document review, and staff interview, the facility failed to provide ED nursing supervision for 2 of 15 emergency department [ED] records reviewed. [Patient #2, Patient #3] and failed to provide discharge vital signs for 1 of 7 ED medical records reviewed. [Patient #4] The findings included: Review on 06/02/2026 of the facility policy, ED Assessment/Reassessment, last approved 01/2025 revealed “...PROCEDURE ...H. Emergency Department [ED] patients are monitored and reassessed at regular intervals as patient condition indicates based on response to care, significant change in condition, diagnosis, test results, and information from various assessments of the patient. ... I. Patient reassessments will be done in a time frame appropriate for the patient’s condition. Reassess body systems as indicated per patient condition and severity. ...1. Note ... treatments, diagnostics and any other pertinent data changed from last assessment. Minimally, nursing reassessment will be done according to hospital policy: ...” Review on 06/03/2026 of the Guardian Appointment Letter for Patient #2 revealed, “State of North Carolina” [named] Patient #2 an “incompetent person” and a ward of the state. A review of post Elopement Staff Training revealed the ED training was conducted on 4/30/2026 at 0730 by the ED Nurse Manager #7, reminding staff to call a missing person overhead alert. Obtained signatures from 28 of 37 ED staff. 1. Closed medical review on 6/02/2026 revealed Patient #2, a 67-year-old who arrived at the ED on 04/27/2026 at 1519 by emergency medical services [EMS] with a chief complaint of seizure (a temporary condition in the brain that causes a brief glitch in how one thinks or moves). EMS services reported seizure activity that lasted less than 2-3 minutes as per witnessed statement. An exam by ED Provider #8, [Doctor of Osteopathic Medicine-DO] at 1522 revealed that Patient #2 was designated a high fall risk, and had noted a past medical history of stroke, seizures, addiction and suicide attempt. Review revealed, at 1655, ED Registered Nurse [RN] #6 rounded on Patient #2. At 1701 a pain assessment was completed by ED RN #6, of “no pain.” The medical record review revealed [14 minutes later] Patient #2 left the ED prior to the ED DO #8’s order for discharge. Review on 06/03/2026 of Video Surveillance footage for ED encounter #1 on 04/27/2026 revealed, video surveillance captured Patient #2 leaving from ED unit, room H-2. At 1714, the patient exited H-2, walked down the corridor, and left the Emergency Department. Surveillance footage from the same minute shows the patient turning left upon exiting the ED, traversing the main hospital corridor, making a subsequent left turn, and heading toward the ED lobby and exit doors. At 1715, the patient exited the facility through the ED entry/exit doors on the Intensive Outpatient Program entry side and proceeded toward the front of the building. By 1716, the patient was observed crossing the front visitor parking lot. At 1719, the patient was filmed walking through the front parking lot, crossing into the grass, and heading toward the traffic signal; at this time, facility staff, security personnel, and ED staff, tracked down the patient after approximately one minute. The incident concluded at 1727 when the patient was returned to the facility via golf cart through the ambulance bay. [12 minutes later] A review of the “Event Report Summary “ on 06/03/2026 revealed Patient #2 on 04/27/2026 was awaiting discharge in ED and had left without being immediately noticed. “Patient was located nearby and cooperated in return to ED with hospital team member. Noted that patient was seen by his nurse just prior to leaving the hospital. ... No missing person alert called overhead when patient found missing.” In summary, Patient #2 arrived at the ED at 1519 due to seizure activity. The ED RN #6 pain’s last contact was a pain assessment at 1701, and 14 minutes later, Patient #2 walked out of the ED prior to completion of treatment and discharge. Video Surveillance revealed, Patient #2 was returned by security staff to the ED at 1727. [26 minutes later.] Request to interview, ED DO #8 for 04/27/2026 revealed they were not available for interview. A telephone interview on 06/03/2026 at 1425 with Guardian #9 revealed Patient #2 had a history of strokes [a medical emergency that occurs when blood flow to part of the brain is interrupted or reduced causing a brain injury] which impairs his ability to speak fluently ... and that Patient #2 had to be reminded frequently to use a wheelchair as he was impaired on right side of his body due to previous stroke and had frequent falls. A telephone interview on 06/04/2026 at 0937 with Adult Protective Services (APS) Supervisor #4 revealed that Patient #2 had a history of mini-stokes [occurs when blood flow to the brain is briefly blocked] that affected his speech. The interview revealed that Patient #2 “...also exhibited confusion ...” An in-person interview on 04/06/2026 at 1214 with ED RN #6 revealed, they remembered the incident on 04/27/2026. The interview further revealed ED RN #6 was unaware Patient #2 had left the facility and was not involved in recovering Patient #2 back to the ED. An in-person interview on 06/04/2026 at 1320 with ED Registered Nurse Manager #7 revealed staff education was implemented after the 04/27/2026 elopement of Patient #2. The interview revealed staff education was provided/completed on 04/30/2026 covering ED Elopements and there were current measures in place for when an ED patient was missing. ...” The interview revealed, Patient #2 had left the ED prior to provider discharge. 2. Closed medical review on 6/02/2026 revealed Patient #2, a 67-year-old who arrived at the emergency department [ED] on 05/01/2026 at 1307 for complaints of seizure [a temporary condition in the brain that causes a brief glitch in how one thinks or moves]. A medical screening exam at 1345 by Nurse Practitioner (NP) #1 revealed Patient #2 was brought to the ED by EMS [emergency medical services] for a seizure at the assisted living facility where he resided and was treated with intranasal midazolam (a controlled drug used calm the brain during seizure) prior to arrival with no ongoing seizure activity on ED evaluation. Exam findings include Patient #2 alert and oriented with a past history of stroke. At 1500 Registered Nurse [RN] #3 documented, “elevated head of bed, call bell within reach... pain, potty, position.” At 1548 the ED NP #1, placed a discharge order for Patient #2 to return to his assisted living facility. Review of Nursing Note documented at 1817 [3 hours and 17 minutes later] by ED RN #3 revealed Patient #2 was found sitting off property “refusing to return” to facility. ED provider #10 [Doctor of Osteopathic Medicine-DO], at 1913 [54 minutes later] revealed Patient #2 now presented to ED with right arm pain. On review, discharge summary revealed that after being discharged while walking, Patient #2 reportedly fell, landing onto his right arm. The medical screening exam findings revealed Patient #2 radiology impression of an arm x-ray on 05/01/2026 at 2046 revealed the right arm “...findings concerning for non-displaced supracondylar fracture” [small hidden crack in the bone right above the elbow, without the pieces out of place]. Patient #2 was treated and discharged to [named] assisted living facility at 2157 via facility transportation. A review on 06/03/2026 of Video Surveillance for ED Visit #2 on (05/01/2027) revealed Patient #2 leaving the emergency department at 1723. Patient #2 exited room ED 07 walked down the corridor and left the ED. Footage from the same minute shows patient #2 turning left after leaving the unit, walking down the main hospital corridor, making a subsequent left turn, and heading toward the ED lobby and exit doors. At 1727, Patient #2 walked out of the facility through the ED entry/exit doors on the Intensive Outpatient Program entry side and proceeded toward the front of the building. Surveillance at 1729 captured Patient #2 walking through the front parking lot, crossing into the grass, and walking toward the traffic signal. At 1803 ED RN #3 looked into Patient #2 room to discover he was missing. Patient #2 arrived back at the facility via Emergency Medical Services (EMS) at 1850, entering through the EMS ambulance bay where they were wheeled to the main ED by EMS personnel. The surveillance review concluded at 1856 when Patient #2 was pushed into ED by stretcher in room ED 06. Review revealed Patient #2 left the Facility ED at 1727 and was returned by EMS with right arm pain at 1856 [1 hour and 29 minutes later.] A review of “Event Report Summary” on 06/03/2026 revealed Patient #2 was discharged, and a discharge report had been called at 1548, by the ED RN #3. Review of ED Note at 1819 by ED RN #3 revealed “patient found to be missing and was brought back to ED by EMS after falling.” Review on (06/03/2026) of the EMS run sheet revealed a patient encounter had initiated on 05/01/2026 at 1825 [1 hour and 2 minutes after ED departure] at a nearby restaurant parking lot. The EMS departed the scene at 1845 and arrived at the Facility ED at 1849. In summary, Patient #2 arrived at ED at 1307, triaged at 1319 and had a medical screening exam at 1345 by ED [NP] #1. There was a discharge ordered by [NP] #1 at 1548, and ED RN #3 had called (named assisted living facility) report and requested transportation for Patient #2’s return. The next documentation by ED RN #3 was at 1817, that Patient #2 was found sitting off property, “refusing to return.” Video surveillance showed Patient #2 leaving the Emergency Department at 1723 [1 hour and 35 minutes after the discharge order]. The Video Surveillance footage revealed ED RN #3 entering Patient #2’s room at 1803 to discover he was missing. EMS contacts Patient #2 at 1825 a nearby parking lot and returned Patient #2 to the Facility ED at 1849. [from 1548 at last documented nursing supervision to 1803 when the ED RN #3 discovered Patient #2 missing was 3 hours and 3 minutes] without nursing supervision. Interview on 06/03/2026 at 1050 with ED RN #3 revealed, Patient #2 had been discharged, report had been called, and transportation had been requested. The interview revealed due to a Code Blue Emergency at approximately 1700, the ED Nurse Manager #7 was present rounding on ED patients, while ED RN’s attended the Code Blue emergency. The interview further revealed, when the Code Blue emergency was completed, ED RN #3 went to Patient #2’s room, to find he was not there an alerted security. The interview revealed nursing care should continue until an ED patient left the facility. A telephone interview on 06/03/2026 at 1425 with Guardian #9 revealed patient #2 has a history of strokes which impairs his ability to speak fluently ... patient has to be reminded frequently to use wheelchair as patient is impaired on right side of his body, due to previous stroke. A telephone interview on 06/04/2026 at 0937 with Adult Protective Services (APS) Supervisor #4 revealed that Patient #2 had a history of mini-stokes [occurs when blood flow to the brain is briefly blocked] that affected his speech. The interview revealed that Patient #2 “...also exhibited confusion ...” An in-person interview on 06/04/2026 at 1320 with ED Nurse Manager #7 revealed she was present on 05/01/2026 approximately 1700 to cover rounding on ED patients due to a Code Blue emergency in the ED, however, stated they did not round on the back hallway where Patient #2 was roomed in ED 07 and did not see them leave the ED. “... I remember him walking up to the nurse’s desk but returned to his room. ...” The interview revealed nursing care should continue until an ED patient left the facility. 41946 the findings included: 3. Closed medical record review on 06/02/2026 revealed Patient #3, a 55-year-old female patient who arrived to the emergency department [ED] on 03/27/2026 at 1217 by emergency medical services [EMS] with complaints of a possible urinary tract infection, cough and congestion. Patient #3 was accompanied by a caretaker [assigned custodian by the guardian (department of social services)]. The patient was seen by the ED Nurse Practitioner [NP] #11 at 1223. Review revealed triage vital signs at 1230 were documented as temperature 97.7, blood pressure 109/61, heart rate 69, and oxygen saturation of 94% by ED Registered Nurse [RN] #10. Patient #3 was given an emergency severity index [ESI- 5-level algorithm used by triage nurses and physicians to quickly categorize patients by the severity of their illness and the amount of hospital resources they will likely need.] score of 3-urgent by ED RN #10. The patient had a chronic foley catheter, was non-ambulatory, limited verbal skills, and a history of an intellectual disability. Code Sepsis [a rapid response protocol activated when a patient shows signs of infection in the blood stream] was called by the ED NP #11 at 1236, subsequent lab work followed and included urinalysis, and chest x-ray had been ordered. Review of the ED Provider Note by ED NP #11 dated 03/27/2026 at 1418 revealed the patient was unable to communicate, a “caretaker” at the bedside, and noted a stage II decubitus ulcer [a partial thickness skin wound where the outer layer of skin and part of the underlying layer are damaged or lost] of the coccyx. Due to the chronic foley catheter, the caretaker was noted as being concerned Patient #3 was Septic. The urinalysis revealed an abnormal result with moderate growth of bacteria, and blood tests included, a white blood cell count [determines infection in the blood] of 11.93 [high] [reference range 6-11]. A Discharge Disposition was documented at 1419 to discharge home and follow - up with primary medical doctor as needed, “...indwelling foley will be changed,. Final treatment and disposition: ...discussion with patient and guardian were given detailed discharge instructions, including return instructions should symptoms worsen, persist or any questions arise and plan to follow-up without fail. ...Discharge Diagnosis (1) UTI (urinary tract infection) ... Condition: stable ...” by the ED NP #11. Record review revealed, the foley catheter was changed and Rocephin [broad-spectrum IV antibiotic given for infection] 1 gram intravenously [IV] was administered at 1418 and was completed at 1508. Documented rounding by ED nursing staff was recorded at 1220, 1320, 1400, 1500, and at 1700, a blood pressure by ED RN #10 at 1700 of 88/62 was recorded, with no indication of any nursing interventions for the low blood pressure. The medical record failed to reveal a review of discharge instructions was complted by the ED RN #10. There was no indication documented of when the caretaker with Patient #3 left the ED in the record on review. On 03/27/2026 at 2130 [4.5 hours later], a blood pressure was recorded of 87/45, heart rate 98, and oxygen saturation of 94% by ED RN #12, the evening RN assigned to Patient #3. At 2230 a respiration rate of 30 was documented by the ED RN #12. At 2250, an IV bolus of lactated ringers [volume expanding Iv fluids], 1000 milliliters was administered. Further review of the ED Provider Note dated 03/27/2026 at 2345 by ED Doctor of Osteopathic Medicine [DO] #8 revealed “...has been assessed earlier in the shift and written up to be discharged. She was awaiting transport. Caregiver then came and expressed concern that the patient did not look well [sic]. She was placed back on the monitor, noted to be tachycardic with a heart rate round 105 beats per minute, hypotensive with a blood pressure around 80/40, borderline febrile. Given additional IV fluid bolus in his [sic] dose of ketorolac [non-narcotic anti-inflammatory used for short-term treatment of pain] for her fever. On my evaluation, sleeping, she does appear acutely ill, dry mucous membranes. ... she does appear septic from urinary tract infection. I do feel admission it [sic] was appropriate at this time. I spoke with [named hospitalist] service ...” Repeat lab work was performed on 03/28/2026 at 0105, with a disposition plan to admit to the hospital. The History and Physical on 03/27/2026 at 2355 by Hospitalist NP #14 was completed and had an admitting diagnosis of Sepsis and Urinary Tract Infection. Patient #3 was admitted on 03/28/2026 at 0255 to an inpatient floor. In summary, Patient #3 was dispositioned to discharge on 03/27/2026 at 1419 by the ED NP #11 and completed IV Rocephin at 1508. Patient #3 was awaiting transportation to pick her up. ED RN #10 had charted a blood pressure of 88/62 at 1700, without indication of further care treatment or follow - up indicated. The evening shift ED RN #12 documented vital signs at 2130 [4.5 hours later], with a blood pressure of 87/45, and heart rate of 98. Review of the ED Provider Note, by ED DO #8 was added at 2345 [8 hours and 37 minutes after Rocephin completed], with reassessment and changed the ED disposition to admit due to Sepsis. Review of the record failed to reveal nursing supervision of Patient #3 from 1700 to 2130, [4.5 hours]. Patient #3 had a change in condition. Patient #3’s blood pressure had dropped; heart rate and respirations [30] had increased and developed a fever [101.0]. Patient #3’s disposition was changed, and she was admitted to the hospital for sepsis, and urinary tract infection on 03/28/2026 at 0255. Request to interview ED DO #8 revealed they were unavailable for interview. Interview on 06/03/2026 at 1225 with ED RN #10 revealed, “... the patient was discharged at 1500, the caregiver was the transport. We were super busy that day, had critical patients all at the same time. ... I was with a critically ill patient, and surgical team, was pulled to help in the ED. Everyone was pulled to help. ...” The interview revealed ED RN #10 did not recall a blood pressure of 88/62, or notifying the ED Provider. Patient #3 had been discharged, and transportation had been called to pick her up. The interview revealed an ESI 3-urgent ED patient should have nurse rounding every one hour. ...” The interview revealed due to critical care needs of other ED patients, Patient #3 was not reassessed per policy. Interview on 06/03/2026 at 1150 with ED RN #12 revealed that the home caregiver came out from the room, and asked ED RN #12 to check on Patient #3. “... the patient had an increased temperature, and I reported it to the provider. ...” The interview revealed, Patient #3, was re-evaluated by ED MD #8, and was then dispositioned to be admitted. The interview revealed ED RN #12 did not reassess Patient #3 after receiving report at 1900 due to other critically ill patients in the ED. Interview on 06/03/2026 at 1010, with ED Nurse Manager #7 revealed “...for ED patients, who are discharged and holding, 2 hour reassessments were the expectation. ...” The interview revealed nursing supervision, and reassessments for Patient #3, did not meet policy expectations. 39307 the findings included: Review of the hospital policy titled Dispostion From Emergency Department last revised 01/2025, revealed Statement of Purpose To ensure the safe and appropriate disposition for discharge from ED (Emergency Department)...Procedure ...II. Patients in the department greater than 2 hours and/or abnormal vital signs will be reassessed and vital signs obtained within 30 minutes of leaving the facility...” (Patient #4) 4. Closed medical record review on 06/02/2026 revealed Patient #4 presented to the hospital Emergency Department (ED) on 01/30/2026 at 2218 for a chief complaint of motor vehicle crash. At 2218 Patient #4 walked into the ED for assessment and evaluation. The patient had vital signs of temperature 98, pulse 108, respiration rate 18 and blood pressure of 128/106 (113 mean arterial pressure), pain score of 7 out of 10 (10 being the worst pain) obtained by the assigned Registered Nurse #23. The patient was evaluated by the assigned ED Medical Provider, DO #8 at 0003 (within 1 hour and 45 minutes of arrival). The assigned RN #24 reassessed the chief complaints of the patient at 2359, 0014, 0015 and 0032 the patient was provided discharge instructions. Review revealed the guardian of Patient #4 signed the Patient Signature Page on 01/31/2026 at 0027 for the receipt of Patient Visit Information. Record failed to reveal an assessment of the patient’s vital signs within 30 minutes prior to leaving the facility. Interview on 06/04/2026 at 1320 with ED Nurse Manager #7 revealed it was the expectation of the nursing staff to obtain vital signs within 30 minutes prior to discharge from the department. NC00236075 NC00236939 NC00237261”

“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: 41946 Based on policy review, medical record review, and staff and physician interview, the hospital failed to comply with 42 CFR 489.20 and 489.24. The medical screening exam was not completed by a hospital approved licensed provider. This had the potential to affect all patients and did impact Patient #15. The findings included: The hospital’s DED [dedicated emergency department] failed to ensure an appropriate Medical Screening Examination [MSE] within the capability of the hospital’s DED, including ancillary services available to the DED, to prevent the determination of an Emergency Medical Condition (EMC) for 1 of 5 sampled OB medical records reviewed, who presented to the hospital for evaluation and treatment. (Patient #15). Cross Refer to tag 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41946 Based on policy review, medical record review, physician and staff interviews, the hospital’s DED [dedicated emergency department] failed to ensure an appropriate Medical Screening Examination [MSE] within the capability of the hospital’s DED, including ancillary services available to the DED, was completed by a qualified licensed medical professional to determine if an Emergency Medical Condition (EMC) existed for 1 of 5 sampled OB medical records reviewed, who presented to the hospital for evaluation and treatment, (Patient #15). The findings included: Review on 02/11/2026 of the policy, “Medical Screening Exam in Obstetrics” D-50-OB-14, last approved 04/2025 revealed “ ...POLICY: Provide a medical screening exam to all patients presenting for unscheduled obstetrical evaluation, testing or services within the capability of the hospital in the Obstetrical Department, including the use of on-call providers. ...PROCESS - Assessment Parameters: Obstetrical RNs [registered nurses] with the above competencies and acting as a QMP [Qualified Medical Professional], may perform the following assessments for patients 35 weeks gestational age or greater ... 2. The RN is not a QMP for other medical or pregnancy related conditions beyond, rule out labor, assessment of membranes, or fetal heart monitoring. For all other conditions, the RN will contact the OB Provider on call to complete the Medical Screening Exam ...” Closed medical review on 02/11/2026 revealed Patient #15, a 24-year-old patient who arrived at the emergency department [ED] on 02/8/2026 at 2228 by private vehicle with significant other for complaints of “water broke.” Review of the ED Nurses Note at 2228, by DED Registered Nurse [RN] #1 revealed “ ...presented to hospital concerned that her water broke around 2140 after getting out of the bath and had some fluid come out on the floor. Patient said she wiped after and had come mucus discharge. Patient denied vaginal bleeding. Pt states she had some occasional Braxton Hix Contractions” [practice contractions by the uterus not associated with active labor]. Pt. reported no contractions after water broke, ... pt [patient] was a G2 P1 [patient was pregnant 2 times and reached pregnancy 20 or more weeks one time] was at 31 weeks pregnant ...escorted to OB exam room, and TOCO [tocodynamometer, device that measures contractions] and EFM [electronic fetal monitoring, device that measures fetus heart rate] was applied to patient at 2231, and patient was admitted to “exam” by OB RN #2. OB RN #2 at 2330 notes that OB Medical Doctor [MD] #3 was notified of patient’s arrival and complaints of water breaking. OB MD #3 was made aware of negative Actim Prom test with no other complaints or concerns. OB MD #3 gave a verbal telephone order for Patient #15 to be discharged. At 2357 patient was given verbal and written discharge instructions and verbalized understanding. Patient #10 was discharged stable condition with significant other on 12/07/2025 at 2357. In summary, Patient #15 arrived at the ED, and was sent to the Labor and Delivery floor for evaluation at 31 weeks gestation for complaint of rupture of membranes on 02/08/2026 at 2231. A registered nurse [RN] #2, completed the MSE [Medical screening exam] on 02/08/2026 at 2327. Patient #15 was then discharged by OB RN#2 at 2357, after telephone consultation with medical doctor OB [MD]#3. Review revealed Patient #15 was not evaluated by a qualified licensed provider, according to hospital policy prior to discharge. A telephone interview with the OB Medical Director #6 on 2/10/2026 at 1210 revealed, the aforementioned case was an error in miscommunication. Nurses that are qualified are able rule out false labor. The interview revealed, no concerns were brought to his attention about this incident, “which does not happen very often.” The interview revealed, OB MD #6, acknowledged OB patients under 35 weeks should be medically screened by a licensed provider. A telephone interview with OB RN #2 on 02/11/2026 at 1030 and had knowledge of Patient #15 and circumstances. The interview revealed, “...shouldn’t have done the test...” that was performed on a patient of 31 weeks gestation per policy. Interview with OB MD #3 on 2/11/2026 at 1043 revealed Patient #15 was low risk and had no contractions with a negative Actim Prom test, ...was safe to discharge. OB MD #3 mentioned, “patients under 35 weeks gestation need to be seen by a licensed provider.” Interview on 02/11/2026 at 1055 with OB Unit Manager, OB RN #4 revealed, the expectation was for the OB patient to be greater than 35 weeks gestation, before the QMP RN could complete the MSE. The interview revealed, the MSE for Patient #10 did not follow hospital policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 35306 Based on hospital policy review, medical record review and staff interview, the hospital staff and failed to ensure the provider conducted a face-to-face evaluation within 1 hour after the initiation of restraint for the management of violent or self-destructive behavior that included all required elements for 2 of 2 patient records sampled (Patient #14 and #11). Findings included: Review on 12/12/2024 of the policy titled, “Restraint Management Program”, last revised 08/2024, revealed, “ ... RESTRAINT ORDERS AND RENEWAL ORDERS ... 7. A provider must perform a face-to-face assessment of the patient within one (1) hour of application of Violent (behavioral) restraints ... 8. The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion, for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others includes evaluation: *The patient’s immediate situation, *The patient’s reaction to intervention(s), *The patient’s medical/behavioral condition, *The need to continue or terminate the restraint or seclusion ...” 1. Closed medical record review for Patient #14 revealed a 69 year-old presented to the ED, via EMS on 11/11/2024 at 1601 with a chief complaint of diabetic toe wound and was admitted to the 4th floor surgical unit for continued treatment and stabilization. Review of a nursing progress note by RN #3, dated 11/18/2024 at 0600, revealed, “ ... At approx. [approximately] 2045 pt became confused, trying to get OOB [out of bed], taking clothes off and brief, yelling at staff, and pulling IV tubing. Staff attempted to re-orient pt to surroundings and situation. Called [name], pt. girlfriend, she was unable to calm pt. [Girlfriend name] states, ‘He gets like this at times at night ready to go fight people.’ Pt. became more agitated trying to stand and remove iv’s being a danger to himself. security [sic] and RRT [rapid response team: group of critical care health professionals called to patient bedside to assess and treat a patient showing signed of clinical deterioration] called. Security utilized handle with care [training for hospital staff on how to manage patient with challenging behaviors] hold from 2110-2120 due to pt. hitting, cussing, and spitting ...” Review of a “SECURITY INCIDENT REPORT” by Security Officer (SO) #1, dated 11/17/2024 at 2107, revealed, “ASSAULT OR VIOLENT ACT” was checked under “1. NATURE OF THE INCIDENT”. Further review of the report revealed, “... 2. DETAILS LEADING TO INCIDENT At or about 2107 security was called for 465 [patient room number]. Patient was confused and being combative with staff. We placed the patient in a Four Limb Hold (HWC) [Handle with Care] tactic 21:10 and a HWC (nose pull) at 21:20 after subject spit on me and kicked at staff. Hand restraints were put on the subject and he received an injection to help him deescalate ...” Review of the nurse practitioner (NP) progress note by NP #1, dated 11/18/2024 at 0602 revealed, “Patient became very agitated and confused. Security at bedside, patient spit at security guard and became more agitated required [sic] sedation and restraints.” Review revealed no documentation of the one-hour face-to-face evaluation following initiation of physical restraint per policy. Interview on 12/12/2024 at 1730 with Director #1 revealed, upon review of the medical record for Patient #14, she was unable to verify if the one hour face-to-face assessment was conducted. Interview revealed there was no documentation of a face-to-face in the medical record. 2. Closed medical record review for Patient #11 revealed a 21 year-old presented to the Emergency Department (ED), via Emergency Medical Services (EMS) on 11/24/2024 at 2054 with a chief complaint of overdose and alcohol intoxication. Review of the nursing assessment flowsheet revealed the patient was place in a four-point physical hold restraint on 11/24/2024 at 2115 for “Agitated/Hyperactive Demanding/Hostile Psychotic Behavior”. Review revealed the patient remained in restraints until 2120 (5 minutes). Review of a nursing progress note by RN #1, dated 11/24/2024 at 2152, revealed, “UPON ARRIVAL PT WAS COMBATIVE AND SECURITY HAS TO BE CALLED. PT HAD TO BE PHYSICALLY RESTRAINED IN A FOUR POINT HOLD BY SECURITY AND NURSES PRESENT. PROVIDER NOTIFIED AND RESTRAINT ORDER IN PLACE ...” Review of the restraint order details revealed a verbal order was received by RN #1 for “Violent Restraint” from MD #1 on 11/24/24 at 2155. Review of the ED provider notes revealed a “Reevaluation” was performed at 2115 with “Improved” noted by MD #1. Review did not reveal documentation of the patient’s immediate situation, reaction to intervention(s), medical/behavioral condition, or the need to continue or terminate the restraint per policy. Interview on 12/12/2024 at 1730 with Director #1 revealed, upon review of the “Reevaluation” by MD #1 at 2155 for Patient #11, she was unable to verify the required elements for the one hour face-to-face assessment was conducted.”

“PATIENT RIGHTS: INTERNAL DEATH REPORTING LOG CFR(s): 418.13(g)(2), (3)(ii), (4) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (2) When no seclusion has been used and when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-like materials, the hospital staff must record in an internal log or other system, the following information: (i) Any death that occurs while a patient is in such restraints. (ii) Any death that occurs within 24 hours after a patient has been removed from such restraints. (3) [The staff must document in the patient’s medical record the date and time the death was:] (i) Recorded in the internal log or other system for deaths described in paragraph (g)(2) of this section. (4) For deaths described in paragraph (g)(2) of this section, entries into the log or other system must be documented as follows: (i) Each entry must be made not later than seven days after the date of death of the patient. (ii) Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient medical record number, and primary diagnosis(es). (iii) The information must be made available in either written or electronic form to CMS immediately upon request. This Standard is not met as evidenced by: 35306 Based on policy review, internal death log review, medical record review and staff interview, hospital staff failed to document in a patient’s medical record the date and time an entry of the death was made into the internal death log for 2 of 2 death records sampled (Patient #13 and Patient #22). Findings included: Review on 12/12/2024 of the policy titled, “Restraint Management Program”, last revised 08/2024, revealed, “...FACILITY RESPONSIBILITIES... 4. Reporting of Deaths related to Restraints... F. When no seclusion has been used and when the only restraints used on the patient are wrist restraints composed solely of soft non-rigid, cloth-like material, the hospital does the following... 5. Records in a log or other system any death that occurs while a patient is in restraint... 9. Documents in the patient record the date and time that the death was recorded in the log or other system. ...” Review of the hospital’s internal death log, on 12/12/2024, revealed Patient #13 and Patient #22’s names were included. 1. Closed medical record review for Patient #13, on 12/11/2024, revealed the 66 year-old patient was admitted with diagnoses that included among others, acute hyponatremia (low sodium) and confusion, following a recent admission for colitis (inflammation of the colon) and failure to thrive. Review revealed the patient was placed in non-violent medical restraints on 11/07/2024. Review revealed the last documentation of monitoring of restraints was on 11/09/2024 at 1000, indicating that soft limb restraints were discontinued. Further review revealed Patient #13 expired on 11/09/2024 at 1307. Review did not reveal any documentation in the medical record that the death was recorded on the internal death log. Interview on 12/12/2024 at 1535 with Director #1 revealed deaths in restraints or within 24 hours of restraint were recorded on an internal log. Further review revealed, “This is an area of opportunity for us. I cannot find documentation of the date and time the death was recorded in the log in either of the medical records.” Interview revealed, “We will get on this.” 2. Closed medical record review for Patient #22, on 12/12/2024, revealed the 80 year-old patient was admitted with diagnoses that included among others, electrolyte imbalance (levels of electrolytes are too high or too low), chronic kidney disease, hypertension, and coronary artery disease. Review revealed the patient was placed in non-violent medical restraints on 11/02/2024. Review revealed the last documentation of monitoring of restraints was on 11/04/2024 at 1829, indicating that soft limb restraints were discontinued. Further review revealed Patient #22 expired on 11/04/2024 at 1829. Review did not reveal any documentation in the medical record that the death was recorded on the internal death log. Interview on 12/12/2024 at 1535 with Director #1 revealed deaths in restraints or within 24 hours of restraint were recorded on an internal log. Further review revealed, “This is an area of opportunity for us. I cannot find documentation of the date and time the death was recorded in the log in either of the medical records.” Interview revealed, “We will get on this.” NC00194149, NC00206053, NC00206097, NC00206851, NC00214727, NC00215997, NC00220012, and NC00220308”