Cape Fear Valley Medical Center

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 47421 Based on hospital policy, review of medical records, and staff interviews, the facility staff failed to initiate a timely discharge planning evaluation per the facility policy in 1 of 7 medical records reviewed. (Patient #1) The findings include: Review of hospital policy titled “Care of Coordination” effective 05/16/2025 revealed, “ ...1. Direct Service: ...a. Assessment of Needs: Patient assessment to identify area of need that may impact recovery, discharge, or transition to the next level of care ... COC (care of coordination) will evaluate the situation, discuss it with patient, family, POA (power of attorney), and provide appropriate agency referrals within 48 hours of the consultation. Documentation recorded in (named EMR) in patient’s chart. Information is shared as appropriate with the health care team to assist with the treatment plan and the discharge plan ... 5. Discharge Planning: ...c. The individual patient’s discharge planning process will continue to be refined during the hospitalization ... to include updating discharge planning progress notes at a minimum of every three days ... Holiday Coverage/Weekend Coverage ...I. Coordination of Care staff is considered essential; therefore, the department is to be staffed with minimum coverage during Holidays and weekends...” Closed medical record review on 01/21/2026 revealed, Patient #1 was a 90-year-old male that presented to the emergency department and was admitted on 12/22/2025 for urinary retention. On 12/23/2025 a rapid response was called due to tachycardia (increased heart rate) and hypotension (low blood pressure); the patient was transferred to the ICU (Intensive Care Unit). Review revealed the patient was in the ICU from 12/23/2025 through 12/26/2025 and then transferred to a medical unit on 12/26/2025 through 01/06/2026. Review of a Provider Note on 12/29/2025 at 0816 revealed, “Discussed with patient’s wife, updating clinical status and plan of care. She and her daughters are in agreement for hospice if no clinical improvement ...” Review of a COC Note on 12/29/2025 at 1703 (7 days later) revealed, “Pnd (pending) clinical impression, UTI (urinary tract infection) improving, family meeting for hospice tomorrow, dispo (disposition) plan pending ...COC will continue to follow, assist, and update.” Review of a COC Note on 12/30/2025 at 1653 (8 days later) revealed, “ ...Discharge planning assessment was completed with patient’s spouse, at bedside ...COC to follow.” On 01/06/2026 the patient was discharged home with arranged hospice service. Record review failed to reveal a discharge evaluation within 48 hours, or a progress note within three days following that. Interview on 01/21/2026 at 1453 with COC #1 revealed, the COC staff should see a patient within 24-48 hours after being admitted. Interview revealed that a COC staff member was scheduled to work every weekend and every holiday. Interview on 01/22/2026 at 1045 with COC #2 that saw the patient on 12/29/2025 revealed, the patient was seen by the COC on the unit after transferring out of ICU. The COC was assigned to the medical unit and not the ICU. Interview revealed that the COC was not aware of a discharge plan being initiated while the patient was in the ICU. Interview on 01/22/2026 at 1100 with Director of Discharge Planning #3 revealed that an initial discharge evaluation should be completed within 48 hours. Interview revealed that the ICU and medical unit had assigned COC staff. Interview revealed that when patients were in the ICU the COC staff assigned to the ICU would sometimes pend the discharge initiation and forget to go back. The Director was aware of this and informed the COC staff not to pend the evaluations. Interview revealed that the discharge planning should have been initiated in the ICU and a COC note should be documented every 3 days. Interview revealed that the Director of Discharge Planning reviewed the record and did not see that a discharge plan was started within 48 hours. NC00233781, NC00234732, NC00234914, NC00235285.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 38766 Based on policy and procedure review, medical record review, and staff interview, the facility staff failed to ensure medical records contained informed consent forms for procedures performed on 1 (one) of 4 sampled patients that received procedures requiring informed consent (Patient #2). The findings include: A review on 08/29/2025 of the hospital policy titled “Consent,” with a current effective date of 05/24/2022, revealed, “...VIII. Documentation: ... F. The nurse is responsible for assessing that the consent form is completed and that the patient or person authorized to sign for the patient communicates an understanding of the procedure/treatment. G. A copy of the executed consent form is placed in the patient’s medical record...” A closed medical record review, on 08/26/2025, of Patient #2 revealed the patient was transferred from an outside facility for worsening diffuse abdominal pain associated with poor appetite. The review indicated the patient had a vascular catheter (a temporary dialysis catheter) placed on 06/19/2024 at 1914 and initiated SHIFT therapy (continuous dialysis for slower ammonia removal) on 06/20/2024 at 0133. The record review showed that the providers obtained informed consents, but the medical record did not include the consent forms. An interview with Administrative Staff # 1 on 08/29/2025 at 1254 revealed that the consent forms for the vascular catheter and the shift therapy could not be located. A follow-up interview with Administrative Staff # 1 on 08/29/2025 at 1325 revealed that consent should have been obtained and documented on a consent form.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 26622 Based on policy review, medical record review, video review and interview, the Emergency Department staff failed to document a patient reassessment per policy for 1 of 11 sampled Emergency Department medical records (Patient #1). The findings include: Review on 08/28/2025 of the hospital policy titled “Adult Patient Reassessment” effective date October 18, 2024, revealed “... Procedural Guidelines: ... Patient Reassessment (Waiting Room) The frequency of reassessment is based on the patient’s acuity, condition, history, and complaint. ESI (Emergency Severity Index - triage system) level two (2) patients will be reassessed every two (2) hours. ... Reassessment includes vital signs and pain level. Physical assessments will be completed as needed. RN (Registered Nurse) or EMT-P (Emergency Medical Technician - Paramedic) may complete reassessments. ...” Review of the Emergency Department record for Patient #1 on 08/26/2025 revealed a 29-year-old female presented to the Emergency Department on 08/04/2025 at 1226 via ambulance, with a chief complaint of sickle cell crisis and weakness. Patient #1 was triaged by RN #2 at 1236 and reported chest pain level of 1 out of 10 (0 being no pain, 10 being worst pain). Patient #1 was assigned an ESI level (acuity level) of “2” during triage assessment. Vital signs at 1239 were Temperature (T) 98.7, Heart Rate (HR) 78, Respiratory Rate (RR) 18, Blood Pressure (BP) 101/73 and Oxygen Saturation (SpO2) was 97% on Room Air (RA). Review of record revealed documentation at 1240 by RN #2 that Patient #1 reported intermittent, squeezing chest pain rated at “4”. A medical screening exam (MSE) was completed by MD #3 at 1244. Review of the Emergency Department timeline revealed that Paramedic #4 documented the vital signs timer was reset/restarted at 1420 with no documentation of reassessment of vital signs or pain. Medical record review revealed that Patient #1 was reassessed by MD #3 after altercation with security at 1600. Nursing staff documented at 1602 that the Patient refused vital signs. Patient #1 was discharged to local police custody at 1627. Review on 08/29/2025 of video footage in the waiting room revealed that Patient #1 left the waiting room to go to X-ray department at 1335 and returned at 1340 to the same waiting room area behind the half-wall. Video review from 1340 to 1430 failed to reveal Paramedic #4 completing a reassessment of vital signs for Patient#1. Interview on 08/28/2025 at 1255 with Paramedic #4 revealed the paramedic role included reassessment of vital signs and pain based on ESI acuity level. Interview revealed that for an ESI level “2” acuity, the paramedic should have reassessed vital signs and pain level every two (2) hours. Paramedic #4 stated that a reassessment was not completed due to Patient #1 was not in the waiting room at the time the reassessment should have been completed. Interview on 08/29/2025 at 1015 with Director #5 revealed that Paramedic #4 failed to reassess Patient #1’s vital signs and pain while in the waiting room per hospital policy. Interview revealed the paramedic or nurse assigned in the waiting area were expected to reassess ESI level 2 patients every two (2) hours. NC00231099; NC00233242; NC00232476; NC00232752; NC00232052; NC00231956; and NC00233969”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 51294 Based on the review of facility policies and procedures, medical record reviews and staff interviews, facility staff failed to document application of a restraint and a fall while restrained for 2 of 8 sampled patients in restraints (Patient #2 and #22). The findings include: Review of policy titled “Restraints, Seclusion and Safety Devices” effective 09/23/2024 revealed, “...D. Monitoring for Non-Violent/ Non-Self Destructive and Violent/ Self Destructive restraints is individualized based on patient needs but at a minimum occurs once every 2 hours. E. Monitor and document the following every 2 hours: i. Type of restraint, ii. Restraint status (initiated, continued, discontinued), iii. Range of Motion exercises to restrained limbs, iv. Patient’s physical comfort, v. Nutrition/hydration, vi. Elimination, vii. Skin Integrity in area in direct contact with restraint, viii. Respiratory status, ix. Circulation to restrained limbs, x. Patient’s behavior/readiness for discontinuation of restraint, F. Assess if a less restrictive intervention may be appropriate.” Review of policy titled “Falls Reduction and Response- Adult” effective 09/05/2023 revealed, “Purpose: To prevent patient falls and falls with injury and to establish a uniform response method when a patient fall occurs...Audience: All hospital employees...Definitions: “A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g. a counter), on another person, or on an object (e.g. a trash can).”...In the event a fall occurs, provide immediate assistance and care as necessary, notify appropriate staff members, document, and report event, and reassess the individual for future falls...I. In the event a fall occurs, see Falls Response Plan below...Falls Response Plan...4. Documentation- The nurse is responsible for documenting the fall. Documentation may include but is not limited to: a. witnessed or unwitnessed by staff, b. location of the fall, c. nursing assessment post fall, d. treatment provided, e. notification of provider, f. Notification of family (if applicable)...6. Reporting...b. The staff member responsible for the individual at the time of the fall and/or charge or designee completes a post-fall huddle form and submit to manager for review. 7. The responsible PCM (Patient Care Manager) reviews all falls.” Review of policy titled “Documentation by Nursing Personnel” effective 05/30/2024 revealed, “Purpose: To provide guidelines for documentation by nursing personnel to reflect status of patient, assist in developing a plan of care, describe care given, and provide for continuity of care. Documentation in a patient’s medical record creates a valuable source of information for all members of the health care team...Definition: Health care documentation- a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a patient’s medical record. Policy: The patient’s medical record reflects care given, as well as presenting a picture of what is happening with the patient while at the hospital. Personnel document patient data and the care given according to established guidelines. Review of policy titled “Documentation in the Medical Record” effective 10/16/2020 revealed, “...Policy: Accurate and complete documentation is required in the medical record for creating a legal document that reflects the assessment, planning, and continuity of the patient’s medical treatment and care. The medical record contains an assessment of the patient’s condition, patient problem(s) and goal(s), action plan(s), the treatment and services provided, the evaluation of goal attainment and status and disposition of patient at the conclusion of treatment.” 1. Closed medical record review of Patient #2 on 04/08/2025 revealed an 88-year-old woman admitted on 10/25/2024 as a transfer from an outside hospital for a history of generalized weakness and decreased oral intake for one week. Patient #2 was diagnosed with Acute Unilateral (one-sided) Obstructive Uropathy (blockage of the urinary tract) and Urinary Tract Infection (UTI). Emergency Department (ED) Timeline primary assessment on 10/25/2024 at 0202 revealed, patient was “confused with aggression”. Doctor order for Restraints non-violent or non-self destructive: Restraint type: Vest was signed and released on 10/25/24 at 0719. Central supply request order for a “posey vest restraint size medium” was placed on 10/25/2024 at 0722. Restraint order for the vest was discontinued on 10/26/24 at 0253. Nursing note dated 10/25/2024 at 0737 revealed, “0600 Patient received from ED (Emergency Department) to room 509, confused, refused hospital gown, tele monitor leads placed with difficulty. IVF (Intravenous Fluid) started.” Nursing note dated 10/25/2024 at 0741 (and deleted/ stricken on 10/25/2024 at 0856) revealed, “Patient (#2) is confused, impulsive and refusing tele and IVF. Restraints were initiated at 0730 this morning.” Internal Medicine progress note dated 10/25/24 at 1353 revealed, “Patient (#2) was agitated upon arrival last night and received a dose of Haloperidol, soft restraints were also applied overnight. Patient is seen at bedside this morning with daughter at her side, she is resting comfortably.” Internal medicine progress note dated 10/26/24 at 1816 revealed, “Patient in a pleasant mood, off restraint today...Patient’s daughter at bedside who was updated in great detail about patient condition and our management plan...Hospital induced delirium- After admission patient was noted to have episode of agitation on 10/25/2024 requiring restraint and Haldol.” Discharge summary dated 10/27/2024 at 1109 revealed, “...Patient (#2) has a history of dementia, she had episode of agitation after admission requiring Haldol and restraints, restraints were discontinued and patient (#2) has been very cooperative for more than 24 hours.” No flow sheet documentation of restraints were found in the medical record. Review of incident report for Patient #2 dated 10/28/2024 (date of incident- 10/25/2025) revealed, “Restraint nursing issue: missing documentation. Vest restraint ordered 10/25 0719...(Nursing) note from 10/25 0741 was deleted. This note mentions initiation of a restraint. A secure chat was sent to the nurse seeking clarity if the vest restraint was applied. Per secure chat, “vest was applied but came off immediately as daughter was sitting at bedside”. No restraint flow sheet documentation.” Interview with Internal Medicine (IM) Physician #4 on 04/09/2025 at 1435 revealed, that they reviewed the case and it is difficult because this is referring to October of 2024. He stated that patient was already out of restraints by the time he saw patient. IM Physician #4 stated that patient possibly had wrist and vest restraints. IM Physician #4 stated that for geriatric (older adult) patients, we do not like to use restraints if there are other alternatives such as a if family can sit with the patient. Interview with Nurse Auditor Supervisor #3 on 04/10/2025 at 1110 revealed, “It is hard to say, there is nothing on the flow sheet, no documentation other than the stricken note” in regard to documentation of initiation of the restraint. The nurse that documented then deleted the note in regard to application of the restraint was not available for interview as they no longer work at the named facility. 2. Open medical record review of Patient #22 on 04/09/2025 revealed a 72-year-old male admitted on 03/31/2025 after an unwitnessed fall and was diagnosed with altered mental status likely due to metabolic encephalopathy (disruption of chemical processes that affect the brain). Patient #22 had a past medical history of hypertension (high blood pressure) and stroke. Secure messaging between Patient #22’s nurse and attending provider revealed, “Patient (#22) squirmed around in the bed and was able to get his feet on the floor. I am told this is technically a fall. The patient says he is not hurt and his vitals are unchanged. His BP (blood pressure) is a little high, but seems to be where it has been. (Provider asked) But his feet only touched the floor and he did not actually fall on the floor? Just making sure I don’t need to order anything. (Nurse responded) He was still attached to his restraints.” Review of Incident Report for Patient #22 dated 04/01/2025 revealed, “Patient attempted out of bed unassisted, bed alarm went off, when staff entered room, patient was still attached to bed via left wrist restraint on wall side but had 1 knee on the floor and the other foot on the floor. Patient did not complain of any pain. Assisted patient back to bed, resecured restraints. Vitals obtained; provider notified, bed alarm set more sensitive.” Interview with Quality Nurse #1 on 04/10/2025 at 1550 revealed, “the only documentation of a fall I see is the fall prior to admission.” Interview with Manager #2 on 04/10/2025 at 1705 revealed, “I did find a secure chat (the nurse) let the doctor know (about the fall) but I did not find a note (in the chart).” Manager #2 further stated that, “I would expect a note for a patient found on their knees on the floor.” No provider note or nursing note was found in regards to the fall. Manager #2 stated, “It should be documented as per policy with all elements, we will provide (the nurse) with the policy and have them sign that they have receive it.””

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 34065 Based on policy review, observations, and staff interviews, the hospital’s dietary staff failed to carry out duties in a competent manner to ensure correct concentration of the dishwashing soap in the dish water of the compartment sink; failed to document meal temperatures on the logs; and failed to secure beards in proper restraints for 1 of 1 kitchens toured. The findings include: A. Review of policy titled “Procedures: Pots & Pans/Cookware--Cleaning and Sanitizing--Manual Method: Procedure Steps: ...4. While pots and pans are soaking in Sink 1, fill Sink 2 (rinse sink) with hot water. Next fill Sink 3 (sanitizer sink) with a water and Sanitizer solution (Use 150 ppm-40pm for U.S.).....5. Use QT-40 Test Strips to ensure concentration of sanitizer in Sink 3 is within proper efficacy range. Note: Place a sample of solution from Sink 3 in a small container and allow to cool to room temperature. Dip test paper in container solution for 10 seconds. Remove and compare test paper color to the color chart on the test strip package.” Observation on 04/10/2025 at 1100 during tour of the kitchen revealed Dishwasher #1 was standing at the compartment sink. Dishwasher #1 demonstrated the technique for verifying the sanitizer strength of the dish water by allowing the test strip to stay submerged in the dish water more than 10 seconds. Dishwasher #1 then tore the test strip in half and again submerged the used test strip in the dish water. Dishwasher #1 did not use a time clock during the process. Interview on 04/10/2025 at 1115 with Kitchen staff #2 revealed the test strip should not have been torn and submerged in the water longer than 10 seconds. Interview revealed policy was not followed. B. Review of policy titled “Hot & Cold Food Serving Temperature Log” with revision date of 10/01/2021, revealed “Instructions: Use this log to record time/temperature controlled for safety food (TCS food--Time/Temperature Control for Safety) that is in cold and/or hot holding for service....Manager must review log within 7 days...(7) Starting Temp: Document the first temperature of the food at time of set up...” Review of Daily Temperature Logs for Pod 1 from 03/31/2025 through 04/09/2025 revealed no food temperatures recorded on 03/31/2025 for dinner; 04/01/2025 for dinner; 04/04/2025 at dinner; 04/06/2025 at dinner; 04/08/2025 at lunch or dinner; and 04/09/2025 at dinner. Review of Daily Temperature Logs for Pod 3 from 03/31/2025 through 04/09/2025 revealed no food temperatures recorded on 03/31/2025 at lunch or dinner; 04/01/2025 at breakfast or dinner; 04/02/2025 at breakfast or dinner; 04/03/2025 at dinner; 04/04/2025 at dinner; 04/05/2025 at breakfast or dinner; 04/06/2025 at lunch or dinner; 04/07/2025 at breakfast or dinner; and 04/09/2025 at lunch or dinner. In summary, there was no documentation of food temperatures for 7 of 30 meals in Pod 1 and 15 of 30 meals in Pod 3. Interview on 04/10/2025 at 1137 with Dipper #3 revealed the night staff “does not do temps.” Interview revealed “I tell the supervisor but nothing changes.” Interview on 04/10/2025 at 1140 with Kitchen staff #2 revealed the log temps should be done before each meal. C. Review of policy titled “Personal Appearance Food and Nutrition Employees” with effective date of 02/16/2024, revealed “...b. Facial Hair: Males are to be clean shaven or with neatly trimmed beards or mustaches. Beard guards are to be worn regardless of beard length....” Observation on 04/10/2025 at 1100 revealed Kitchen Staff #3 building trays on the food line. Observation revealed Kitchen staff #3 had facial hair. Observation revealed no beard guard covered the facial hair. Interview on 04/10/2025 at 1105 with Administrative staff #4 revealed all facial hair should be covered while in the kitchen. NC00228940; NC00223657; NC00228332; NC00225156; NC00227400; NC00227511; NC00227344; NC00226219; NC00226021; NC00227331; NC00224558; and NC00225340.”

“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: 33790 Based on hospital policy review, medical record review, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: The hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for one of one postpartum patients who arrived to OB Triage area seeking care (Patient #3). ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 33790 Based on policy review, Emergency Medical Treatment and Labor Act (EMTALA) log reviews, medical record review, documented electronic medical record events and staff and physician interviews, the hospital failed to have an accurate and complete EMTALA log for one of one postpartum patients who arrived to the obstetrical triage area seeking care (Patient #3). The findings included: Review of the “Obstetrical Medical Screening, Examination, and Admissions/Disposition from L&D.... LDR and Emergency Department” policy, dated 12/28/2023, revealed “...RN or designee enters patient information into the triage log. ...” Review of the OB EMTALA log revealed Patient #3, a 21-year-old, arrived on 07/30/2024 at 1825. Medical record review revealed Patient #3 arrived to the “Waiting Room” at 1813 and was moved into Labor and Delivery (L&D) triage at 1825, noting that the patient was sent from the office for pre-eclampsia labs. Review revealed Patient #3 was admitted and delivered on 08/01/2024 at 0454. A Progress Note on 08/03/2024 at 1012 documented “...blood pressures are a bit elevated but not in the severe range....Principal Problem: Preeclampsia, third trimester....Overall doing well. Home today....Continue....labetalol along with routine postpartum meds. ...” The last noted vital signs at 1050 revealed a blood pressure of 148/88. Patient #3 was discharged home on labetalol 400 mg twice a day. Review of the EMTALA logs did not reveal Patient #3 listed on either the ED or OB EMTALA logs on 08/14/2024. Review of entries on Patient #3’s list of encounters revealed an entry, dated 08/14/2024 which stated “Admission (Canceled)... “ Review of “Event Management....Admission Details (Canceled)...” revealed an encounter was created for Patient #3 on 08/14/2024 at 1447, which documented the patient arrived to the Labor and Delivery Waiting Room at 1447 and was listed as “Pending Admission”, then also at 1447, and entry that stated “Confirmed Admission.” At 1510, an entry was documented that indicated “Canceled Admission [space] Entered in Error.” Requests on 04/10/2025 to interview the two staff members who entered the 08/14/2024 events on Patient #3 revealed neither staff member worked at the hospital now and thus were not available for interviews. Interview with MD #6, on 04/10/2025 at 1325, revealed the MD understood Patient #3 may have come to L&D for triage at some point after discharge. Interview revealed if a postpartum (after delivery) patient arrived to L&D the patient should be registered. Registration staff were not allowed to send a patient off the floor, they were to get a nurse, more often than not the Charge Nurse, who would speak to the patient and then call the physician. Interview revealed MD #6 was not aware of being contacted about Patient #3 as a postpartum arrival. Interview on 04/10/2025 at 1430 with Supervisor #8, Patient Access Manager, revealed that when information was pulled on Patient #3’s 08/14/2024 event no account notes were written but should have been. Interview revealed there was a consent form signed but nothing to indicate if a nurse was called or what happened with Patient #3 during the encounter. Supervisor #8 stated she attempted to pull footage, but none was available, video footage was only kept for 60 days. Interview further revealed staff should have documented all information they had on what occurred during the visit. If an encounter was canceled, notes should have indicated why it was canceled. Supervisor #8 stated the two staff members involved no longer worked at the hospital so there was no way to determine if there was a deviation in their practice and what it was. Interview on 4/10/2025 at 1550 with an OB Charge Nurse, RN #10, revealed if a patient needed to be sent to the ED from the OB triage area, the Charge Nurse designated someone to take the patient down. Interview revealed RN #10 would not generally write a note about the encounter and stated that patients taken down to the ED prior to triage would not appear on the OB log. Interview revealed patients were not placed on the log until they moved into triage. In summary, there was evidence Patient #3 returned to the obstetrical triage area on 08/14/2024 since a event for the patient was entered into the computer system. Patient #3’s name did not appear on the EMTALA log on 08/14/2024. An OB Charge Nurse stated arriving patients would not appear on the log until the patient was placed into triage. Pt #3 was documented on the entry as in the waiting room “Pending Admission” and the event was then canceled.”

“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: 33790 Based on policy review, Obstetrics (OB) Emergency Medical Treatment and Labor Act (EMTALA) log review, event review, medical record review and staff and physician interviews, the hospital failed to provide a medical screening examination on one of one postpartum patients reviewed who arrived to the OB triage area (Patient #3). The findings included: Review of the “Obstetrical Medical Screening, Examination, and Admissions/Disposition from L&D.... LDR and Emergency Department” policy, dated 12/28/2023, revealed “...In compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) law, [Hospital Name] ....L&D provides a medical screening examination to individuals requesting care and if it is determined an emergency medical condition exists, provides treatment to stabilize the condition... .” Although the policy mentioned maternal hypertension, review of the policy did not reveal how postpartum patients would be managed if they arrived to OB triage seeking care. Medical record review for Patient #3 revealed the patient was admitted on 07/30/2024, delivered, and was discharged 08/03/2024. Review of the EMTALA logs for 08/14/2024 did not reveal Pt #3’s name appeared on either the ED or the OB log, however, there were entries noted in the electronic medical record on Patient #3’s list of encounters. An entry, dated 08/14/2024 noted “Admission (Canceled)... “ Review of “Event Management....Admission Details (Canceled)...” revealed an encounter was created for Patient #3 on 08/14/2024 at 1447, which documented the patient arrived to the Labor and Delivery Waiting Room at 1447 and was listed as “Pending Admission”, then also at 1447, a note indicated “Confirmed Admission.” At 1510, an entry was made that documented “Canceled Admission [space] Entered in Error.” Interview with MD #6, an Obstetrician, on 04/10/2025 at 1325, revealed the physician was on call for the group on 08/14/2024. Interview revealed MD #6 remembered Pt #3. Interview revealed MD #6 understood Patient #3 may have come in to L&D for triage postpartum (after delivery) on 08/14/2024 and possibly went to the ED. Interview revealed if a postpartum patient arrived to L&D the patient should be registered. Registration staff were not to send patients off the floor, they were to get a nurse who would speak to the patient and then call the physician. Interview revealed MD #6 was not aware of being contacted about Patient #3 on 08/14/2024. Interview on 04/10/2025 at 1430 with Supervisor #8, Patient Access Manager, revealed that when information was pulled on Patient #3’s 08/14/2024 event no account notes were written but there should have been an explanation of what occurred. Interview revealed a consent form was signed by the patient but nothing to indicate if a nurse was called or what happened during the encounter. Interview revealed staff should have documented all information they received to explain the event note. If an encounter was canceled, interview revealed, notes should have indicated why it was canceled. Interview on 4/10/2025 at 1550 with an OB Charge Nurse, RN #10, revealed patients were not placed on the OB log until they moved into OB triage. Interview revealed RN #10 generally did not write a note about an encounter when a patient arrived to the OB triage and was sent to ED for care. Interview with MD #12 on 04/10/2025 at 1730 revealed MD #6 was a solo practice and was on call for the practice every day. In summary, there was evidence that Patient #3 returned to the obstetrical triage area on 08/14/2024. An event was entered into the system to indicate a possible admission. The patient was not on an EMTALA log on 08/14/2024. An OB Charge Nurse stated OB patients would not appear on the OB log until they went brought into triage. Pt #3 was noted to be in the waiting room not in triage. The event was canceled without explanation of the reason for the “Entered in Error” note. There is documentation that Patient #3 arrived to the hospital OB triage waiting area seeking care but there was no evidence Patient #3 was offered or received a medical screening examination.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 17281 Based on record review, interview, and policy review, the hospital failed to ensure the supervisor investigated and made an attempt to resolve one patient’s grievance (Patient (P) 3) of three patients who requested to file a grievance. This failure had the potential to affect all patients who request to the file a grievance at the facility. Findings include: Review of the policy titled, “Patient Grievance” effective date 10/06/22, revealed, “ ...Concerns that cannot be resolved by staff present at the time the complaint is made are considered grievances and are referred to the Supervisor, Charge Resource Nurse, or Manager for investigation and attempts at resolution. When an employee receives a concern that constitutes a grievance, he/she addresses the issue promptly and notifies the next person in chain of command.” Review of P3’s electronic medical record (EMR) revealed P3 arrived at the emergency department (ED) on 06/11/24 at 1:56 PM with a chief complaint of “general checkup.” Reveal of the triage nurse note located in P3’s EMR dated 06/11/24 at 2:11 PM revealed, “ ...Pt arrived to [sic] triage with co [complaint] of needs total checkup, requesting CT [Computerized Tomography] scan of body. Pt states have chronic pain /Pt uses cane for ambulation at all times Pt states central area chronic chest pain and abdominal pain for one year. Pt complaints of generalized body aches, lower back pain, wearing sling on right arm ...Pt denies any SOB, nausea, vomiting or dizziness at this time ...Pt states taking Advil and pain is not well controlled at this time. Pt with edema on bilateral legs at this time HX [history] of BP[ high blood pressure], diabetes, elevated cholesterol.” Review of P3’s EMR dated 06/11/24 at 2:20 PM revealed, “Acuity/Destination Patient Acuity: 3 Triage Complete.” Review of the “ED Quick Updates” dated 06/11/24 at 8:50 PM located in P3’s EMR revealed, “Patient came up to RN [Registered Nurse] asking why the wait is so long. RN explains to patient that everyone is waiting for a room in the back to see a doctor. Patient states she has not eaten all day and needs something to eat. RN provided patient crackers and water.” Review of the “ED Quick Updates” dated 06/11/24 at 9:30 PM located in P3’s EMR revealed, “Patient’s spouse came up to front desk asking, ‘what is taking so long’. RN explained to escort that the patient is waiting for a room in the back to talk with the doctor about [his/her] results from lab work and imaging. Escort asks RN ‘How do we make this go faster.’ RN explained that it is a process and is based on the acuity of the patient and how critical everyone is. RN [not] able to provide an exact time to escort.” Review of the “ED Quick Update” dated 06/11/24 at 11:24 PM located in P3’s EMR revealed, “ ...Patient came up to the front window yelling at triage nurse. Patient screams “I need a form to make a complaint!” [name] RN explains to patient that we do not have a form but gave the number to patient relations to have the patient call that number ...RN explains that we [hospital] do not have a form system, and you have to call this number to file complaint. Patient is upset and states that she wants to see an administrator ... called lead charge to have her come up. ...” Review of P3’s EMR did not reveal a Supervisor, Charge Resource Nurse, or Manager responded to P3’s request to speak to someone concerning his/her complaint of a long wait time to be seen. During an interview on 11/19/24 at 8:00 AM, the Corporate Director of Emergency Services (CDED) stated, “grievances go to me or the lead charge nurse.” CDED confirmed P3’s EMR did not include documentation the Lead RN spoke to the patient on 06/11/24 or that a grievance was filed. During an interview on 11/19/24 at 11:00 AM, Registered Nurse (RN) 2, who was the Lead RN on duty on 06/11/24, stated he/she did not recall any notification from RN5 that P3 complained about a long wait time in the ED and wanted to speak to someone in administration. RN 2 stated if notified, documentation in the medical record would include that the patient was seen and Patient Relations notified to either meet face to face with the patient or open a grievance.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 17281 Based on record review, observation, interview, and policy review, the hospital failed to ensure an adequate basis for the use of a restraint and failed to ensure the least restrictive intervention was implemented for one (Patient (P) 25) of three patients reviewed for use of a restraint. This failure had the potential to affect all patients who may require the use of a restraint at the facility. Findings include: Review of the facility policy titled, “Restraint Seclusion and Safety Devices” effective 09/23/24 revealed, “Alternatives and Preventive Strategies to Use of Restraints: A. Alternatives are considered before using restraints on any patient and particularly ...vulnerable patients, such as emergency, pediatric, or cognitively and/or physically limited patients. B. Alternatives may include but are not limited to the following methods: direct observation, family/friend attends/sits with, verbal interventions/de-escalation/re-direction, environmental measures, (relaxing music, lighting, decrease stimulation, place near nurse’s station) use of bed check alarm, comfort measures (pain management, positioning), Medical nutrition (discontinue unnecessary lines), Structure/limit setting activities, noise control, and diversional activities ...A restraint is only used if needed to improve the patient’s well-being and less restrictive interventions have been ineffective to protect the patient or others from harm ...Restraints are not a routine part of a fall prevention program ....” Review of the facility policy titled, Special Observation: Safety Attendant, Patient Observer and Virtual Sitter Roles” Effective Date: 07/11/24 revealed, “ ...4. Order Virtual Sitter when a patient requires remote continuous monitoring. Place patient in a room equipped with video surveillance capability. Circumstances for virtual sitter may include, but are not limited to: A. Risk for falls B. Confusion C. Unilateral weakness D. Patient safety E. Patient with substance use disorder After the order is placed, the patient’s name appears on the worklist to initiate monitoring. ...” Review of P25’s electronic medial record (EMR) revealed P25 was admitted to the facility on 06/17/24 with diagnoses of dementia with behaviors, hypernatremia, diabetes mellitus, risk for falls, and depression. Review of the “Morse Fall Risk Assessment” dated 11/05/24, located in P25’s EMR revealed a score of 65 which indicated P25 was a high risk for falls. Review of the “Morse Fall Risk Assessment” dated 11/06/24 through 11/18/24 revealed P25 was a high risk for falls. Review of the “Care Plan” dated 11/05/24 located in P25’s EMR revealed risk for falls with interventions to provide environmental measures (relaxing music, lighting), use of bed check alarm, chair alarm, direct observation, verbal intervention, and comfort measures (pain management and positioning). Review of the “Shift Report” dated 11/05/24 at 6:56 PM located in P25’s EMR revealed, “ ... patient fairly cooperative during the morning and early afternoon but had increased behaviors as the day went on. Yelling constantly for help, trying to get up without assistance, becoming more agitated and defiant with certain staff members, and minimally redirectable ....” Review of the “Assessment” dated 11/05/24 at 7:04 PM located in P25’s EMR revealed, “aggressive, agitated and repeated attempts to get oob/chair.” Review of the “Nurse’s Note” dated 11/05/24 at 7:40 PM located in P25’s EMR revealed, “ ...received report from day RN patient attempts to get out of chair with alarm on. Vest restraint placed on pt [patient] for safety. Safety measures in place with chair alarm on including vest ...Provider notified.” Review of the “Orders” dated 11/05/24 through 11/18/24 located in P25’s EMR revealed, “ ...Restraint nonviolent or non-self-destructive: Restraint type: Vest ... Continuous up to 1 calendar day ...Remove restraint at the earliest possible opportunity ...Restraint reason: interferes with necessary treatment, is unable to follow directions to avoid self-injury ....” Review of the Nurse Practitioner note “Summary Restraints” dated 11/05/24 at 7:04 PM located in P25’s EMR revealed, “ ...patient has a history of dementia, TBI (Traumatic Brain Injury/2003) ...The nurse reported that the patient has had multiple attempts to get out of bed, not following instructions, unable to keep patient in the chair, and is high risk for falls. Patient placed in posey vest for patient safety ...Face to face completed. Patient is alert and oriented x 3 and pleasant. Nursing instructed to removed posey vest as soon as its safely possible and have safety measures in place. Patient sitting in reclining chair with posey vest in place at the entrance to his room. We will monitor behavior closely, try to remove posey vest ASAP and adjust treatment plan as indicated ....” Observation on 11/18/24 at 1:30 PM revealed P25 was in a private room, in bed with the bed in a position that was not in view from the door. P25 was observed with a vest restraint on over a johnnie gown. An overbed table was in front of the patient. The television in the room was not turned on. There wasn’t any diversional activity equipment observed in the room. Review of the nurse “Assessments” located in P25’s EMR revealed every two hour assessments were conducted by nursing while P25 had the vest restraint in use. Review revealed “television” was the only alternate intervention identified as being used. Review of the “Provider Notes” located in P25’s EMR revealed a “Face to Face” was conducted by a provider every 24 hours during the use of the vest restraint. During an interview on 11/20/24 at 10:00 AM, the Corporate Director of Critical Services (CDCS) stated that per hospital policy, before nonviolent restraints are used because a patient cannot follow direction, alternate measures are implemented. Measures can include busy blanket, recreation therapy, being near the nurses station, television, and chair/bed alarms. CDCS confirmed that because a patient was a fall risk is not a reason to initiate a restraint. Extra watching/surveillance can used and any interventions I mentioned. CDCS stated P25 had the “virtual sitter” as an intervention in the past and could not explain why the intervention or others were not attempted before the use of the vest restraint on 11/05/24.”

“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: 17281 Based on record review, interview, and policy review, the hospital failed to complete a medical screening exam (MSE) for one patient (Patient (P) 4) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 06/11/24 seeking emergency care. This failure had the potential to harm all patients who present to the ED seeking emergency care. Findings include: Review of P4’s electronic medical record (EMR) revealed P4 arrived at the emergency department (ED) on 06/11/24 at 1:56 PM with a chief complaint of “general checkup.” Review of the “ED Triage Note” dated 6/11/2024 at 2:11 PM documented by the Registered Nurse (RN) revealed, “Pt arrived in {sic} triage with co [complaint] of needs {sic} total checkup, requesting CT [Computerized Tomography that is a scan of the body]. Pt states [he/she] moved from New York to Fayetteville one year ago and states [he/she] got assaulted and beat up in New York one year ago, causing [him/her] to have chronic pain / Pt uses cane for ambulation at all times. Pt states central area chronic chest pain and abdominal pain for one year Pt complaints of generalized body aches, lower back pain, wearing sling on right arm. Pt states is painful to raise bilateral arms up x [times] one year. Pt denies any SOB [shortness of breath], nausea, vomiting or dizziness at this time ...Pt ambulatory AXOX4 [alert and oriented times 4]. Pt denies any problems urinating or moving bowels at this time. Pt states taking Advil and pain is not well controlled at this time. Pt with edema on bilateral legs at this time HX [history] of BP [hypertension], diabetes, elevated cholesterol.” Review of P4’s EMR dated 06/11/24 at 2:20 PM revealed, “Acuity/Destination Patient Acuity: 3 Triage Complete.” Review of the note documented by ED/Doctor of Osteopathy (ED DO) on 06/11/24 at 2:23 PM located in P4’s EMR revealed, “MSE: 68-year-old [sex] presents with generalized pain for over a year after being assaulted in New York. [He/she] is requesting a total checkup and a body scan for this. [He/she] also is complaining of chest pain however this appears to be chronic as well. Protocol orders placed. Nursing in triage, to be further evaluated when [he/she] is roomed.” Review of the “Orders” dated 06/11/24 located in P4’s EMR revealed to obtain a CBC (complete blood count) with differential, CMP (basic metabolic panel), Lipase, High Sensitivity baseline Troponin level, electrocardiogram (ECG), and chest x-ray. Review of the “Orders” dated 06/11/24 located in P4’s EMR revealed to administer aspirin chewable tablet 324 milligrams (mg). Review of the EMR revealed aspirin 324mg was administered at 2:24 PM. Review of the CMP collected on 06/11/24 at 2:41 PM revealed the results were within normal limits except for the random glucose that was 276 mg/dL (milligrams per deciliter) [Reference Range: 74 - 109 mg/dL]. Review of the “ED Quick Updates” dated 06/11/24 at 8:50 PM located in P4’s EMR revealed, “Patient came up to RN asking why the wait is so long. RN explains to patient that everyone is waiting for a room in the back to see a doctor. Patient states he/she has not eaten all day and needs something to eat. RN provided patient crackers and water.” Review of the “ED Quick Updates” dated 06/11/24 at 9:30 PM located in P4’s EMR revealed, “Patient’s [escort] came up to front desk asking, ‘what is taking so long’. RN explained to escort that the patient is waiting for a room in the back to talk with the doctor about [his/her] results from lab work and imaging. Escort asks RN ‘How do we make this go faster.’ RN explained that it is a process and is based on the acuity of the patient and how critical everyone is. RN [not] able to provide an exact time to escort.” Review of the “ED Quick Updates” dated 06/11/24 at 9:54 PM located in P4’s EMR revealed, “Patient came up to the front window asking, ‘I have been here all day, why are people going back before me.’ RN explained that the wait was not based on how long a person has been here but how critically ill based on vitals, lab work, and imaging. Patient states, ‘well I am done.’ RN explains that the patient is not being held here and was free to go at any point if he/she wants too. Patient leaves front window and has a seat back out in the lobby.” Review of the “ED Quick Update” dated 06/11/24 at 11:24 PM located in P4’s EMR revealed, “ ...Patient came up to the front window yelling at triage nurse. Patient screams “I need a form to make a complaint!” [name] RN explains to patient that we do not have a form but gave the number to patient relations to have the patient call that number ...RN explains that we [hospital] do not have a form system, and you have to call this number to file complaint. Patient is upset and states that she wants to see an administrator ... called lead charge to have her come up. ...” Review of P4’s EMR revealed, “Disposition- ED Dismiss -Left Before Treatment Complete.” Review of P4’s EMR dated 06/12/24 at 12:10 AM, “Patient dismissed.” During an interview on 11/20/24 at 11:00 AM, ED DO stated he/she was the provider scheduled in the triage area when P4 presented to the ED on 06/11/24. ED DO stated he/she evaluated the patient and started the MSE. ED DO stated orders were placed for bloodwork and other tests to determine if immediate placement was necessary. ED DO stated he/she did not complete the MSE because his/her shift ended at 7:00 PM on 06/11/24 and the patient remained in the waiting area and had not been brought back into a room. ED DO stated he/she reviewed the blood work results and the ECG and chest x-ray and did not have any concerns that would expedite moving P4 to a room. During an interview on 11/20/24 at 11:15 AM, Chief Clinical Officer (CCO) stated the MSE was initiated in the triage area by the assigned provider. The provider assigned was responsible for the patient until they are moved into a room in the back. When a patient is brought back into a room, a different provider is responsible for the patient’s care and that provider completes the MSE to determine whether an EMC exists and determine disposition. CCO stated long waits are not the goal of the hospital and if the front line nurses tell the provider the patient complains and states, “That’s it I’m going” the provider will speak to the patient and explain the risks/ benefits of leaving without waiting for treatment to be completed. CCO stated although RN5 told the patient he/she is not being held here (hospital) and was free to go at any point if he/she wanted to, he/she felt that was misinterpreted. CCO confirmed the patient left before the MSE was completed and the provider was not notified the patient stated, “Well I am done” so the patient was not seen. Hospital policy titled, “Refusal to Consent to Treatment or Transfer - Elopement/Walk Out/AMA”, effective 08/14/23, defines “Against Medical Advice (AMA): A situation whereby the patient/guardian expresses a desire to refuse further treatment, procedures, transfer from or admission to CFVHS.” The policy stated, “Prior to Completion of Medical Screening Examination 1. Staff discusses the situation with the patient/guardian and attempts to dissuade the departure. 2. Staff requests a family member or significant other, when available, to try to convince the patient to stay. 3. If the patient continues to express desire to leave prior to receiving complete MSE, staff requests that the ‘Refusal to Consent to Medical Screening Examination/Treatment/Transfer’ form (FF#0162) be signed by the patient/guardian. 4. If the patient/guardian refuses to sign the ‘Refusal to Consent to Medical Screening Examination/Treatment/Transfer’ form, staff completes the form and documents the patient’s/guardian’s refusal to sign. Staff obtains the signature of two witnesses on the form. Staff offers to provide a copy of the form to the patient/guardian. If the patient ‘elopes or walks out’ without staff being aware, the nurse documents the medical record what occurred to the best of his/her knowledge. 5. Staff documents in the medical record the specifics as to what was occurring at the time of the patient’s refusal of care or departure against medical advice, including: a. Reasons why the patient is leaving. b. Condition of the patient at the time of departure. c. Instruction(s) provided to the patient. d. Care provided to the patient in preparation for leaving, e.g. removal of IV’s, discontinuation of monitoring, etc. e. Date and time the patient left the care area. 6. The ‘Refusal to Consent to Treatment/Transfer’ form remains in the patient’s medical record. 7. Staff immediately requests review of the above documentation by the Patient Care Manager or Nursing Supervisor.” There was no documentation in the medical record to show the hospital staff followed its own policy on “Refusal to Consent to Treatment or Transfer - Elopement/Walk Out/AMA”.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 47421 Based on review of hospital policy and a closed medical record review the hospital staff failed to follow the ED triage policy for 1 of 41 patients reviewed (Pt#11). The findings included: Review of hospital policy titled “Triage Policy for Adults” revealed an ESI (emergency severity index) triage algorithm. The algorithm revealed when a patient required immediate life-saving intervention they would get triaged as an ESI 1. When a patient presented with a high-risk situation, confused/lethargic/disoriented, or in severe pain/distress they would get triaged as an ESI 2. When patients do not fall into an ESI 1 or 2 level. The number of resources a patient required determined ESI levels 3-5. Two or more resources would get an ESI 3, one resource would get and ESI 4, and no resources would get an ESI 5. When a patient presents with dangerous vital signs, to include heart rate and respiration, further consideration should be made. For a patient 8 years and older a heart rate greater than 100, respirations greater than 20, and an SpO2 less than 92% could warrant an ESI 2. Closed dedicated emergency department (DED) medical record review of Patient #11 revealed an 83 year old female presented to the ED via EMS on 08/24/2022 at 1956 with neck pain after sneezing. Review of the ED triage note at 2002 revealed “ ...Pt (patient) reports that pain is now radiating to head and down arms. No neurological deficits noted, no blurred vision or light sensitivity.” Review of the ED vital signs at 2007 revealed temperature 97.8, heart rate 99, respiration 20, blood pressure (BP) 221/113, SpO2 94%, and a neck pain score of 10. At 2009 patient assigned acuity of 4. At 2012 Tylenol 650mg (milligrams) was given orally. Review of the ED nursing note revealed the patient was offered an ice pack and heating pack, the patient declined and stated, “it probably wont work.” Review of the triage note at 2104 revealed the patient became unresponsive in the waiting room. Glucose 222. BP 223/115. At 2107 patient assigned acuity 2. Review of the ED nursing note at 2110 revealed the physician assessed the patient at bedside. At 2112 the patient was roomed to ED38. At 2115 the patient status changed to Code Stroke. At 2116 labs, arterial blood gas, ECG, CT head neck angio, CT cervical, and a CT head were ordered. At 2118 an inpatient Neurology consult was placed. At 2128 a chest Xray was ordered. At 2142 NIH Stoke Scale: 27. At 2155 tele neurologist assessed the patient. At 2156 Neurosurgery consult was placed. At 2200 the patient was assigned acuity 1. At 2213 an Endotracheal tube was placed, 7.5mm (millimeter) cuffed. At 2216 ED disposition was set to transfer. At 2223 a CVC triple lumen catheter was placed in the right femoral. At 2248 Protime 10.6 seconds, INR 1.0, and aPTT 24.5 seconds. Review of ED vital signs at 2250 revealed temperature 96.8 bladder, heart rate 88, respiration 20, BP 156/81, and SpO2 94%. Review of a Physician note at 2312 revealed “ ...presented initially for neck pain but developed altered mental status ...patient was made a code stroke ... CT head shows large subarachnoid hemorrhage at the skull base, likely aneurysmal ... Neurosurgery recommended airway control and transfer emergently for intervention ...” At 2319 flight crew at bedside. At 2357 high sensitivity Troponin 191. On 08/25/2022 at 0000 the patient was discharged. Review of the grievance received on 09/12/2022 revealed a resolution letter was sent out on 10/26/2022. Review of the SIR event revealed it was entered on 09/29/2022 by risk management. NC00194349, NC00207728, NC00205597, NC00200341, NC00204911”