Rex Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 22198 Based on record review, interview, and review of facility policy, the facility failed to ensure their pain management policy was followed for assessment and reassessment and response to patient pain for three of 39 (Patients (P)14, P15, and P18). The facility further failed to ensure their wound care policy was followed regarding wound care for P24. This had the potential for the patients to have unmet care needs. Findings include: 1. Review of the Emergency Department (ED) medical record for P14 revealed the patient presented to the ED on 08/19/23 at 11:17 AM for “severe right side pain.” P14 received triage at 11:43 AM with an emergency severity index score (ESI) of 3, and a pain score of “10.” Review of nurses notes and flow sheet revealed, no other vital signs or pain assessments were completed for P14. The “Medication Administration Record (MAR)” revealed at 1:36 PM, two hours and 15 minutes after presenting at the ED with “severe right side pain” P14 was administered pain relief. There was on other assessment completed to determine P14s pain level at the time of administration or a reassessment to determine in the pain medication helped decrease P14’s pain. 2. Review of the ED medical record for P15 revealed the patient presented to the ED on 04/28/24 at 9:11 PM for a chief complaint of “Chest Pain,” was triaged at 9:13 PM and assigned an ESI of 3 at 9:17 PM. The nurse documented a pain score of “8.” Nursing failed to reassess P15’s pain or document any non-medication intervention attempted to relieve P15’s pain. Pain medication was ordered at 10:54 PM, however no pain medication was given because P15 left 11 minutes later at 11:05 PM after the doctor provided the risks and benefits to leaving Against Medical Advice (AMA). During an interview on 02/04/26 at 10:17 AM Sepsis Coordinator (SC) and Supervision Clinical Nurse (SCN)4 confirmed that the pain management and completing vital signs and pain assessment and reassessment were not documented per policy and procedure. 3. Review of the inpatient medical record for P18 who was admitted on 06/11/24 in-patient to have a total right knee arthroplasty The physician orders were as follows: 07/03/24 at 5:32 PM Tylenol 650 milligrams (mg) 1-tab every 4 hours PRN (as needed) and q6 (every 6) hrs (hours) PRN. 07/04/24 at 11:09 AM Keflex (antibiotic) 500 mg q 6 hours scheduled. 07/03/24 at 5:32 PM Dilaudid 2 mg PO (by mouth) q4 PRN for severe pain. 07/03/024 at 5:32 PM Dilaudid 4mg PO q 4 hrs PRN if the 2 mg does not work give an additional 2mg for a max of 4mg of Dilaudid. 07/03/24 at 5:32 PM Morphine IV (intravenous) 4 mg q2 hrs for severe pain. 07/03/24 at 4:51 PM Oxycodone 10 mg PO q4 hrs PRN. 07/03/24 at 4:51 PM Oxycodone 5 mg PO q4* PRN if the pain is unrelieved give an additional 5 mg for a total of 10 mg. Review of the inpatient nursing notes for 07/03/24 as follows: At 5:28 PM no pain assessment was identified in the medical record when P18 returned to the floor at 5:28 PM after surgery on P18’s right knee arthroplasty. Review of the “MAR” for pain medication administration and pain assessment/reassessment and scoring timeline for 07/03/24: At 5:50 PM a scheduled Tylenol 650 mg PO was given At 5:47 PM P18 received 2 mg Morphine IV for a reported pain level of 10/10 A reassessment was completed at 6:46 PM and P18 reported a pain score of 10/10. Two (2) mg morphine was given IV at this time. A pain reassessment was completed at 7:40 PM and P18 reported a pain score of 7 out of 10, however, no pain medication was administered. P18’s pain level was not reassessed until 8:46 PM and was given oxycodone 10 mg PO for a pain score of 7 out of 10. At 9:30 PM P18 reported a pain level of 6 out of 10 no medication was given. At 11:38 PM P18 received a scheduled Tylenol 650 mg PO. Review of the Physical Therapy (PT) note on 07/03/24 revealed: At 6:12 PM (P18) complained of numbness in LE (lower extremity) and pain in right knee at a 10 out of 10. At 7:25 PM PT returned and completed their evaluation and P18 tolerated tx (treatment) well with moderate to severe pain with rest. During an interview on 02/06/26 at 9:30 AM Clinical Nurse Specialist (CNS)1 and SC confirmed that nursing staff did not follow the pain management policy and procedure (P&P) for P18. Review of the hospital’s pain management policy titled “Pain Management Guidelines” dated 01/31/26 revealed, “ The RN is responsible for initial and subsequent pain assessment, the initiation and implementation of non-pharmacological and pharmacological pain interventions and ... Ancillary and allied health staff working with patients should notify nursing anytime a patient complains of pain ... Self-report is the gold standard for pain assessment and whenever the patient is capable, is the preferred method of assessment. To standardize assessment one of the following pain scales will be used for self-report ... ii. 0-10 numeric rating scale (NRS) ... NRS (0-10) Mild Pain 1-4 Moderate Pain 5-7 Severe Pain 8-10. ... A complete pain assessment cycle includes pain assessment an intervention and reassessment. This process is repeated until the patient has minimal pain or reaches and maintains target pain goals. 1. All PRN and one-time orders for analgesia require assessment and reassessment. ... 4. Time of pain assessment must be documented as close to analgesia administration time as feasible. If > (greater) than 60 minutes a new pain assessment should be obtained. 5. Time of reassessment must be within 60 minutes of analgesia administration time NOT the time of assessment was documented. ... A. Document pain assessment including pain intensity ratings as appropriate for individualized care. B. Document patient’s pain goal as appropriate. C. Document interventions, reassessment, and response to interventions. D. Pain medication administration is documented on the MAR. ...” 18947 4. Review of P24’s electronic medical record (EMR) revealed the patient was admitted to the hospital on 01/27/26. The patient’s diagnoses included Parkinson’s Disease and Acute Respiratory Failure with Hypoxia. Review of the record indicated P24 was discharged to home on 02/03/26. Review of P24’s “Initial Skin Assessment - RN (Registered Nurse)” found in the EMR and dated 01/27/26, revealed P1 had a stage 3 pressure sore to his coccyx upon admission to the hospital. Review of P24’s “Physician’s Orders,” found in the EMR and dated 01/27/26 through 01/28/26, indicated no orders for care of the patient’s stage 3 pressure sore on those dates. Review of P24’s “Patient Flow Sheets” (the portion of the record utilized for documentation of wound care treatment), found in the EMR and dated 01/27/26 and 01/28/26, revealed nothing to show consistent treatment had been initiated or provided related to P24’s stage 3 pressure sore on those dates. Review of P24’s “Progress Notes,” found in the EMR and dated 01/27/26 and 01/28/26, revealed nothing to show consistent treatment had been initiated or provided related to P24’s stage 3 pressure sore on those dates. Review of P24’s “Initial Wound Consult Note,” found in the EMR and dated 01/28/26 at 3:10 PM, revealed P24 was seen by the Wound Care Nurse (WCN) 1 on that date and the document indicated the wound measurements to P24’s coccyx were 2.0 centimeters (cm) height x 2.0 cm length x 0.3 cm depth, and indicated the wound appeared to be a stage 3 pressure sore, and indicated the recommended treatment to be apply Aquacel AG (an antimicrobial hydrofiber wound dressing) to coccyx wound bed, cover with dry gauze and secure with silicone bordered foam dressing 4 inches x 4 inches. Change MWF (Monday, Wednesday, and Friday) or as needed for soilage/drainage. Do not place tape on skin.” Review of P24’s Physician’s Orders and Patient Flow Sheets revealed the above 01/28/26 3:10 PM recommended wound treatment was ordered and applied as of that date and time. During an interview with Clinical Nurse Specialist (CNS)2 while reviewing P24’s EMR on 02/04/26 at 10:45 AM, she confirmed there was not documentation in P24’s clinical record to indicate consistent treatment was provided for the treatment of the patient’s stage 3 pressure sore on 01/27/26 or 01/28/26 prior to the wound consult being done. She stated she would expect wound care and treatment to be initiated immediately upon discovery of any wound and stated the treatment was expected to be documented in the patient’s Patient Flow Sheet throughout the patient’s hospital stay. CNS2 stated, “Some sort of dressing should have been ordered for this patient (prior to the WOCRN’s consult). During an interview on 02/06/26 at 11:13 AM WCN1 on 02/06/26 11:13 AM, confirmed he/she was not able to locate consistent documentation in P24’s record to indicate treatment was provided for the patient’s stage 3 pressure sore prior to his/her 01/28/26 wound care consult. He/She stated the hospital had a wound management policy/protocol in place and that policy/protocol was what nursing was expected to follow for initial wound care orders for any patient with a wound. He/She stated there were multiple options for wound care orders/treatment indicated in the protocol and stated those orders were to be followed until a wound consult could be done. Review of the hospital’s policy and procedure titled “Wound Care Management” last reviewed and revised on 08/12/25 revealed, “Staff Responsibilities: A. RN/LPN (Registered Nurse/Licensed Practical Nurse) is responsible for the observation and documentation of wound character; B. RN/LPN will activate treatment and dressings per guidelines and plan of care, unless otherwise specified by provider/order 1. There are guidelines for topical wound management based on products on the UNC (University of North Carolina) Rex formulary; C. WOC (Wound Ostomy and Continence) Nurse Consult should be placed when indicated, 1. A consult is indicated for Stage 3, 4 or Unstageable pressure injuries, Deep Tissue Injuries (DTI), ANY stage pressure injury that was not present on admission, Negative Pressure Wound Therapy or any complex and/or deteriorating wound;” and “Topical Dressing Guidelines for Pressure Injuries: These are guidelines for topical wound management based on products on formulary. Each wound must be assessed on an individual basis. Consult WOC Nurse for any possible hospital acquired pressure injury and for POA Stage 3, 4, DTI and unstageable pressure injuries. These recommended therapies can be instituted by nursing until the patient can be seen for assessment by the WOC Nurse.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 18947 Based on facility policy review, observation, interview, and review of the “DEA (Drug Enforcement Administration - Controlled Substances Act (CSA) - Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970,” the hospital failed to ensure secure transport of controlled medications from the inpatient pharmacy to inpatient unit storage areas with two of two observed transports. This failure created the potential for patients, the public, and unauthorized personnel to easily access the controlled medication and for the potential of diversion of controlled medication. The total number of patients reviewed in the sample was 39. Findings include: During an initial tour on 02/02/26 at 2:00 PM of the pharmacy, along with the Inpatient Pharmacy Director (WRI) and the Certified Pharmacy Technician (CPT)1 the Inpatient Pharmacy Director indicated batches of medication, including controlled medication, was pulled together and then put into a plastic bag and onto (an unsecured) cart for delivery to each unit by a CPT. The Inpatient Pharmacy Director stated controlled medication was put into each Pyxis (secured medication dispensing machine) on each unit first, and then the non-controlled medications were loaded into the machine next. He stated controlled medications were placed on a cart with all of the other medications and were not specifically secured in any way. During an interview on 02/03/26 at 10:45 AM with Registered Nurse (RN)10 stated he/she had concerns with the storage of secured medication in the hospital. He/She stated “There is no secure way to return (larger quantities of) narcotics to the pharmacy. He/She confirmed controlled medications could easily be taken by someone not authorized to access the medication during transport. He/She stated security of controlled medication on the nursing units and within the hospital had been a concern for at least a couple of years. During observations of medication transport from the pharmacy to inpatient units with CPT2 on 02/05/26 at 10:22 AM, CPT2 was observed to verify orders and remove controlled medication from the secured area of the pharmacy for delivery. Controlled and noncontrolled medications were placed into basins organized by unit on an unsecured open three shelf cart. CPT2 stated all medications were tucked into the basins so they were not lost during transport. The medication cart was first transported by CPT2 through the hospitals main hallways, to the West Main Elevators (accessible by staff, patients, and the public) and then to the Seventh Floor West Unit Pyxis machine. CPT2 transported the cart past seven unidentified staff members on the way to the seventh floor west nurse’s station where the Pyxis machine was located. Fourteen vials of Hydromorphone liquid syringes (a potent narcotic pain medication) were removed from a basin on the unsecured cart and placed in the secondary Pyxis machine on the unit. The non-controlled medication was placed in the seventh floor west secondary Pyxis machine and then at 11:30 AM the cart was transported by CPT2 into the public hallway and past one unidentified staff member, one patient, and one family member/visitor to the seventh floor west main Pyxis machine, where 21 hydromorphone syringes, five 2 milligram (MG) Hydromorphone oral tablets and 15 50 MG Tramadol (a potent controlled pain medication) oral tablets were removed from the unsecured cart and placed into the main Pyxis machine. During observations of medication transport from the pharmacy to inpatient units with CPT3 on 02/06/26 at 3:00 PM, CPT3 transported an open and unsecured three shelf cart with basins containing 12 Fentanyl (a potent narcotic pain medication) 50 mg vials, 32 Oxycodone (a potent narcotic pain medication) 5 MG tablets, two Lacosamide (a controlled medication used for seizure control) 200 MG/20 milliliter (ML), one Fentanyl 2MCG/ML (microgram per milliliter) patch, 20 Hydromorphone Injection 1MG/1ML syringes through the hospital public hallways and up a main public elevator to the hospital’s Medical Surgical Intensive Care Unit (MSISU). There were additional unidentified staff members on the elevator at the same time the medication was transported. The medication cart was transported to MSICU Pyxis #1 and the controlled medication was placed into the Pyxis machine. During the observations of the transportation of the controlled medications, five unidentified staff members and one visitor passed through the hallway by CPT3. CPT3 then transported the unsecured medication cart to MSICU Pyxis #2, where an additional two Fentanyl 2500 MCG/50 ML syringes, 18 Propofol (a potent fast acting sedative-hypnotic medication used to induce and maintain general anesthesia) 1000 MG/100 ML vials were loaded into the machine. During an interview on 02/06/25 at 4:15 PM with CPT2 confirmed there were no locked containers or carts in the hospital for the transport of controlled medication from the pharmacy to each unit and stated he/she always transported all medication, including controlled medication, on the unlocked cart observed by each surveyor during the investigation. He/She confirmed controlled medication was stored in the pharmacy in a separate locked area and on each unit securely in Pyxis machines (secured automated drug dispensing machines). During an interview on 02/06/26 at 4:45 PM with CPT3 stated he/she had been working for the hospital for the past seven years and the process for transporting controlled medication from the pharmacy to the nursing floors was to place the controlled medication on regular unsecured cart along with all of the other uncontrolled medications for transport and delivery. He/She stated controlled medication was stored in a separately secured area in the pharmacy itself and stored in a Pyxis machine (a secured automatic drug dispensing machine on each of the units. During an interview on 02/06/26 at 5:00 PM with the WRI on indicated the hospital’s process for the transportation of controlled medications from the pharmacy to the hospital floors was to hand deliver the medication to each floor. He/She stated that is how the hospital ensured the controlled medication was secure. Review of the “DEA (Drug Enforcement Administration - Controlled Substances Act (CSA) - Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970” located at “Congress.gov” and “DEA.gov” revealed, “The Controlled Substances Act (CSA) - Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 - is the federal U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and other chemicals deemed to have a risk of abuse and dependence;” and “Hospital medication transport requires strict security, utilizing locked containers, tamper-evident seals, real-time tracking, and documented chain-of-custody signatures to prevent theft, diversion, and contamination. Procedures must comply with regulations like the Controlled Substances Act, ensuring secure storage, authorized handling, and verified delivery. Here is a breakdown of key aspects for secure medication transport within a hospital: Key Security Measures & Protocols Physical Security: Medications must be transported in securely locked, substantially constructed containers or carts. Tamper Evidence: Use of breakaway tags with unique identification numbers helps monitor container integrity. Chain of Custody: A rigid documentation process is required, often demanding signatures upon dispatch and receipt to ensure accountability. Technology Integration: Advanced systems include smart storage, RFID tracking, and Wi-Fi platforms to monitor cart location, user activity, and lock status in real-time. Authorized Personnel Only: Only designated staff should handle, transport, and receive controlled substances.” Review of the hospital’s policy and procedure titled “Medication Storage and Security” last reviewed and revised on 11/15/24 revealed, “Medication storage and security standards are designed to assist in maintaining medication integrity, promote the timely availability of medication, minimize the risk of medication diversion, and reduce potential dispensing errors;” and “The Department of Pharmacy is responsible for ensuring that appropriate procedures are in place for safe storage and security of medications;” and “A. Storage Requirements 1. Medications both within and outside of the pharmacy shall be in secure and sanitary areas under controlled temperature, light, moisture, and ventilation as specified in either official compendium or the manufacturer’s information;” and “B. Security Requirements 4. Medications are stored under secure conditions and are only accessible to authorized personnel who have job-related need for access;” and “D. Transportation Requirements 1. Medications must be under the constant control of an appropriate health-care provider or hospital’s contracted delivery service during transport from one area to another, except during pneumatic tube station transport.””

“DISCHARGE PLANNING - PAC PROVIDER DATA CFR(s): The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use on measures. The hospital must ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient’s goals and treatment preferences. This Standard is not met as evidenced by: 28154 Based on observation, record review, interviews, and facility policy review, the facility failed to plan and/or provide a safe discharge for two of 39 patients (Patient (P) 1 and P12) reviewed for discharge. The facility’s failure to develop and implement adequate discharge planning had the potential to result in unsafe or ineffective transitions of care, placing patients at increased risk for medication errors, unmet post discharge needs, avoidable complications, and rehospitalization. Findings include: 1.Review of P12’s facility printed face sheet revealed an admission on 04/29/25 for diabetic wet gangrene of the left foot. Record review of P12’s medical record revealed he/she had a wound VAC [negative pressure wound dressing to promote healing) in place to the left foot upon discharge for treatment of a post-operative multi-digit removal. Provider orders dated 05/07/25 instructed continued negative pressure wound therapy and dressing changes by a trained wound care nurse on Mondays, Wednesdays, and Fridays. Discharge planning documentation revealed a referral was made to a Home Health Agency (HHA1). During an interview on 02/05/26 at 10:18 AM, the referral HHA Care Team Assistant stated the referral was out of their service area, so it was withdrawn. During an interview on 02/07/26 at 11:22 AM, Case Manager (CM) 4 stated she met with P12 on the day of discharge regarding HHA services and P12 advised he/she was going to another county but did not yet have an address. CM4 called a HHA in the identified county that verbally stated they accepted the insurance and did provide wound care with wound vacs. CM4 stated he/she wrote the HHA information on a sticky note and gave it to P12 before he/she left to contact when P12 had an address for service. CM4 remembered he/she had to call P12 to return as some of the wound vac supplies and case were left in the room. During an interview on 02/07/26 at 2:30 PM, the Administrator for the second HHA (HHA2) stated he/she would not have accepted anyone over the phone and would have required CM4 to fax the information regarding P12 with a phone number and they would have followed up to see if there was a service address. During an interview on 02/07/26 at 3:50 PM, the Regional Director of Case Management (RDCM) stated providing a patient with HHA information on a sticky note was “not an acceptable practice.” When queried if follow up after discharge in this situation would have been expected, the RDCM responded, “Yes, it would have been the standard operating procedure.” 18947 2.Review of P1’s electronic medical record (EMR) revealed the patient was admitted to the hospital on 12/08/23. The patient’s diagnoses included Acute on chronic heart failure and atrial fibrillation. Review of the record indicated P1 was discharged to home on 12/22/23. Review of P1’s “Initial History and Physical” found in the EMR and dated 12/08/23, revealed P1 had a history of difficulties with transportation to home upon discharge with prior hospitalization and indicated a referral to Case Management on that date to assist P1 with coordinating safe transportation upon discharge from the hospital. Review of P1’s “Physician’s Orders,” found in the EMR and dated 12/08/23, indicated an order for a Case Management Referral for P1. Review of P1’s “Encounter Notes,” found in the EMR and dated 12/08/23, indicated, “Care Manager reviewed the plan of the patient’s care with the Multidisciplinary Team. No discharge planning needs identified at this time. Care Manager will continue to manage plan and monitor patient’s progress with the team.” Review of P1’s “Encounter Notes,” found in the EMR and dated 12/09/23, indicated, “CM (Case Manager” acknowledging consult and will continue to follow and assess (barriers) prior to DC (discharge).” Review of P1’s “Encounter Notes,” found in the EMR and dated 12/15/23, indicated, “The patient was discussed in rounds and the patient is possible DC (discharge) on Monday per RN (Registered Nurse) with no needs.” Review of P1’s “Encounter Notes,” found in the EMR and dated 12/21/23, indicated “Current Discharge Plan: Home with Self Care. Coordination of Care and Care Progression Notes: PT (Physical Therapy) had no recommendations. Patient plans to return back home when discharged from the hospital and his family will provide transportation back home. No needs identified at this time.” There were no additional notes found in P1’s record to indicate assistance with plans for transportation home upon discharge from the hospital or to indicate there were any plans for the patient’s family to transport him home or to indicate the patient’s family had been contacted to transport P1 home. Review of P1’s “Progress Notes,” found in the EMR and dated 12/22/23, indicated, “Pt (patient) given and educated on discharge paperwork. Pts IVs (intravenous catheter line) C/D/I (clean, dry, intact) when removed. No discharge needs. Pt refused discharge due to not having a ride. Pt was educated on options as to how to get home. Pt was escorted to the bus stop by security.” Review of the Hospital’s “Original Summary (Grievance Summary)” dated 12/29/23 indicated P1 reported a grievance to the hospital related to his concerns regarding his discharge to the bus stop with security escort rather than being provided with assistance with transportation to home after discharge as per the 12/08/23 physician referral to case management services for that very reason. P1 was not able to be reached for interview. During an interview on 02/04/26 at 1:53 PM with Clinical Nurse Specialist (CNS)2 while reviewing P1’s EMR he/she confirmed she was not able to locate any documentation to indicate assistance was provided for P1 related to his transportation barriers upon discharge to home. She stated the hospital’s Case Managers would be the staff members to arrange transportation for patients and there were a variety of options to assist with transportation home upon discharge from the hospital. She stated staff should try to identify the patient’s specific support system and identify a person or persons who were able to assist the patient with transportation home and she confirmed no documentation could be located in P1’s record to indicate this had happened during his hospitalization. CNS2 confirmed the record indicated P1 was escorted to the bus stop by security upon discharge and after voicing his concerns about transportation home. She stated, “(P1) should not have been taken to a bus stop ...that was not in his best interest.” Review of the hospital’s policy and procedure titled “Discharge Planning for Acute Care Patients” last reviewed and revised on 05/14/23 revealed, “A discharge planning assessment and plan of care should be developed for patients who are identified as likely to need services/assistance at the time of discharge. The Care Manager/SW (Social Worker) should reassess throughout the admission based on changes in patient condition, changes in available support and/or changes in post-acute care requirements;” and “The assigned Care Manager or Social Worker is also accountable for documenting the service provider and service arranged on the discharge instructions in the electronic medical record.””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 22198 Based on observation, record review, interview, and policy review, the facility failed to ensure for two of four surgical observations (wound closure and operating room (OR) break down and cleaning) staff followed appropriate policy and procedures for hand hygiene, failed to ensure an item that was used was cleaned before placing it back to its original location, and failed to ensure one of one patient (Patient (P)17) reviewed received a “call back” from the OR nursing staff within the hospital’s defined time frames to ensure patient safety. This had the potential to affect all patients receiving services from the hospital. Findings include: 1. a. During an observation on 02/03/26 at 11:58 AM of wound closure for P33, the Circulator Registered Nurse (RN) 9 was observed to touch uncleaned surgical instruments and bloody surgical laparotomy sponges hanging over the kick bucket, left the OR suite to obtain additional equipment for the wound closure, without removing his/her gloves. RN9 grabbed the door handle and opened it and entered the “Sterile Core” (a centrally located sterile equipment and instruments easily located between the four ORs). RN9 was observed removing the gloves while in the Sterile Core and placed them in his/her surgical scrubs pocket without performing hand hygiene. During an interview on 02/03/26 at 11:58 AM RN9 confirmed he/she should have removed and discarded the gloves in the OR prior to leaving and should have performed hand hygiene. RN9 confirmed he/she knew he/she should not have placed the dirty gloves in his/her pocket. During an interview on 02/03/26 at 12:02 PM RN Surgical Services Manager (SSM) confirmed dirty gloves are to be removed and hand hygiene performed immediately after removing the gloves. RN SSM confirmed dirty gloves are to be discarded and not placed in the nurse’s scrub pocket. b. During an observation on 02/03/26 at 12:07 PM during room turn over and cleaning, Surgical Technician (ST) 1 was observed removing gloves after assisting with the OR case closure without hand hygiene, before donning a new pair of gloves and moving to another task. c. During an observation on 02/03/26 at 12:10 PM of the breakdown of the back surgical table and organizing and placing contaminated surgical instruments in the transportation cart ST1 was observed removing a can of spray from the top of the hand sanitizer dispenser, spraying foam from the can onto the instruments in each tray. Once the transportation cart was filled the cart was closed. ST1 placed the can of foam spray back on top of the hand sanitizer dispenser without cleaning the can. During an interview on 02/03/26 at 12:10 PM ST1stated the can of foam spray was an enzymatic foam spray which initiated the decontamination process of surgical instruments at the point of use to reduce biofilm formation, reduces manual scrubbing, and ensure the instruments would last longer. During an interview on 02/03/26 at 12:15 PM RN SSM confirmed on top of a hand sanitizer dispenser was not a good place to store the Enzymatic Foam Spray, and ST1 should have wiped that off prior to returning it to a clean hand sanitizer dispenser. RN SSM did not think the Surgical Services Infection Prevention policy addressed the Enzymatic foam spray, stating “we did not think about that.” Review of the hospital’s policy titled, “Surgical Services Infection Prevention” dated 01/20/26 revealed, “Hand Decontamination: A. If hands are not visibly soiled use an alcohol based handrub in the following situations: ... 2. After contact with body fluids, secretions, excretions, mucous membranes, and non-intact skin. 3. After contact with inanimate objects in the immediate vicinity of the patient. 4. When moving from a contaminated to a clean body site. 5. After removing gloves. B. Apply product to one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. ... Standard precautions (access via the Rex web standard Precautions) are designed to reduce the risk of transmission of organisms from recognized and unrecognized sources and must be applied to all patients regardless of diagnosis or presumed infection status. Standard Precautions must be practiced when in contact with blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes and include the following. 1. Hand hygiene. ... 4. Handling of patient care equipment. 5. Environmental surface cleaning. ...” The policy did not include the Enzymatic foam spray stored in each OR and used on the post-surgical contaminated instruments. 2. During an interview on 02/02/26 at 2:49 PM P17 stated that he/she attempted to call the doctor (Medical Doctor (MD) 6 and Physician’s Assistant (PA) 3) about the post-surgical concerns of increased pain and redness at the incision site, however no one returned his/her call and P17 did not received a post operative call from the hospital. Review of P17’s surgical record from 01/08/24 surgical Left Rotator Cuff Repair revealed a nurse from Surgical Services did not document a call back post operatively for P17. During an interview on 02/06/26 at 11:00 AM Clinical Nurse Specialist (CNS) 1 confirmed there was not a post-surgical follow-up call documented. During an interview on 02/03/26 at 11:00 AM RN SSM confirmed that their Quality Specialist has been tracking post-surgical “call backs” and they realized surgical staff were not consistent, and there was room for improvement. RN SSM confirmed that if a post-surgical call back occurred and it would be documented in the patient’s medical record. A request for the OR P&P for post-surgical call backs was requested, and RN SSM stated the OR did not have a defined policy and/or procedure for OR post-surgical call backs. RN SSM was asked how to you track data when you have no P&P to ensure staff know within what time frame to call, or what critical information needs to be obtained during the call back or what to do with that call back information if there were concerns, RN SSM stated “your point is noted.” Review of the Quality data being collected on the OR post-surgical call backs titled “Completed Call backs” for the past 12 months of tracking data on the OR post-surgical call back process as follows: From February 2025 through August 2025 completed post-surgical call backs ranged from 12% with one month reaching 73% compliance with a seven-month average of 32.9% compliance. The graph had a had a typed in arrow showing “call back process started” with the arrow toward the line above September. From September 2025 when the OR implemented the “call back process” and in September the OR was at 58% compliance, October was 60%, November was 30%, December was 83% and January 2026 was 51% with a five-month average of 56.4% compliance.”

“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: 22198 Based on interview, policy review, and record review, the facility failed to ensure staff documented intravenous (IV) insertion per policy for one of seven emergency department (ED) patients (Patient (P)19) reviewed and failed to remove the catheter from P19’s vein prior to the patient leaving the ED, additionally the facility gave P19 an extra blood tube to hold on to while waiting in the ED. This had the potential for the patient to have complications due to the hospital’s failure. Findings include: Review of P19’s ED medical record dated 11/27/24 revealed the following: Nowhere in P19’s medical record was an IV insertion documented. Nowhere in P19’s medical record was a practitioner’s order found for an IV insertion. The Physician’s Assistant (PA)1 documented on 11/27/24 at 7:58 PM in a final note ... “ When I went to talk to the patient discussed discharge, he/she was very short and anxious. Continually cutting me off saying just take the IV out and discharge me. ... Furthermore, I offered to correct/address whatever has made him/her upset and might have caused a disconnect during his/her visit and address any concerns he/she has had he/she just repeats please take the IV out and discharged me. ...” During an interview on 02/02/26 at 3:09 PM, P19 stated that while in the ED on 11/27/24, they were asked to hold onto an extra unlabeled tube of his/her blood just in case they needed it. P19 also stated he/she had asked numerous times to have his/her IV catheter removed because P19 wanted to leave, however no one ever removed the IV catheter and P19 left the ED. P19 confirmed no one called P19 about the IV catheter left in P19’s arm to see if P19 was ok. During an interview on 02/05/26 at 1:30 PM Interim Director of Centralized Nursing Support (IDCNS) and Director of Nursing and Clinical Operations - Holy Springs Campus (DNCO-HS) confirmed the hospital was aware that P19 was asked to hold onto an extra tube of blood and left the ED with an IV catheter still inserted because P19 complained to the hospital. IDCNS and DNCO-HS confirmed that should not have happened and stated we do not ask our patients to hold onto extra tubes of blood. IDCNS and DNCO-HS confirmed that PA1 did not write and order for an IV insertion however the RN did insert an IV catheter but failed to document it in P19’s medical record and that was most likely the reason the nurse forgot to remove the IV catheter. IDCNS and DNCO-HS stated that no one called to check on P19 to see if P19 had removed the catheter or would come back to the ED to have it removed, because it was not documented as inserted by the Nurse. IDCNS and DNCO-HS stated that education for IV documentation, lab tube labeling, checking the patients prior to discharge and the staff needs to follow the procedure for extra blood tube drawn or the blood tube needs to be discarded. Review of the hospital’s policy titled “Specimen Collection by Venipuncture” dated 11/21/25 revealed, ...”Each specimen container must be labeled (one label per container, whenever possible) in the presence of the patient and according to established specimen labeling procedures ... Ensure that the correct specimen label is placed on the appropriate colored tube. ... Deliver specimen(s) to the laboratory. ...” Review of the hospital’s policy titled “Intravenous and Vascular Access Therapy - Adult (13 years and older)” dated 12/11/25 revealed “Insertion of a peripheral catheter requires a physician order.””

“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: 40299 Based on policy review, medical record review, Lift ticket (outside transport service) review and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: 1. The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 30 sampled Emergency Department (ED) patients (Patient #12). ~ Cross refer to Medical Screening Exam - Tag A2406.”

“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: 40299 Based on policy review, medical record review, Lift ticket (outside transportation services) review, and staff interviews, the hospital failed to perform an appropriate medical screening examination within its capacity to determine if a patient that presented to the hospital’s Dedicated Emergency Department (DED) with a chief complaint of “Psych Eval - feels off” had a medical emergency for one of 30 sampled patients, (Patient #12). The findings included: Review of the hospital’s policy, “EMTALA (Emergency Medical Treatment and Labor Act): Treatment Of Patient’s With Emergency Medical Conditions” revealed “... It is the policy ... that all of the following individuals presenting to a dedicated emergency department ..., including women in labor, be given an appropriate medical screening examination by a qualified medical person ... to determine if an emergency medical condition exists: *Individuals who request, or on whose behalf a request is made for, examination or treatment for a medical condition, or *If no such request is made, present with appearance or behavior sufficient to cause a prudent layperson observer to believe that the individual needs examination or treatment for a medical condition ... Procedure; A. Medical Screening Examination; 1. All individuals presenting to a dedicated emergency department ... of (Hospital Name) for examination or treatment, including minors without a parent and women in labor, shall be given an appropriate medical screening examination to determine if an emergency medical condition exists. The medical screening examination may include laboratory tests, radiology studies, or consultations, as appropriate ...” Review of a closed DED medial record on 02/13/2024 for Patient #12 (Campus B) revealed a 66 -year-old female that presented to the DED on 07/28/2022 at 0251 with a chief complaint of “Psych Eval - feels off”. Review of the ED Triage note at 0256 revealed “Patient call non emergency (sic) 911 that she need help, (sic) scared to be alone and not feeling safe and not sure if she will be harm to other people, (sic) extreme guilt and afraid of dying..She’s (sic) feeling uneasy,hot flushes. (sic) Patient is seeing a psychiatrist in Monarch NC and she’s taking lithium and risperidone. Patient (sic) traumatized seeing her neighbor committing suicide (sic) last fall of 2021. Patient is complaining of abdominal and back pain.” The Nurses note at 0308 revealed “Patient is scared to die and no plan to self harm, feeling so confused.” Review of the ED Care Timeline at 0310 revealed a “Richmond Agitation Assessment Scale (RASS): Anxious, apprehensive, but not aggressive.” Patient #12 was assigned an acuity score of “2” (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Vital signs at 0310 revealed “... 0-10 Pain Scale: 5 (0 means no pain and 10 mean severe pain); ... Pain Type: Acute pain; Pain Location: Abdomen; Pain Frequency: Constant/continuous; Pain Onset: On-going” Review of the ED Care Timeline at 0326 revealed the “ED Disposition was set to Discharge.” Review of the Provider note filed at 0326 revealed “ ... 66 y.o. (year-old) female with past medical history anxiety, bipolar disorder, diabetes, hypertension, hyperlipidemia presenting to the emergency department brought in by law enforcement for evaluation after the patient called nonemergency 911 asking for help because she is scared to be alone at home. On initial presentation, patient well-appearing, awake alert oriented answering questions appropriately. Vital signs stable ... Overall, presentation consistent with an early cry for help. Patient does not meet IVC (involuntary commitment) criteria at this time. Based on my evaluation, no indication for emergent blood work or diagnostic imaging. Patient will need psychiatric crisis center. A Lyft ride was set up for the patient to go (Facility C). Patient verbalized understanding and agreement with the plan ... HPI (History Present Illness) ... Patient explains she is very anxious at home and is not feeling safe. Patient reports that she feels like something bad is going to happen to her because she has recently been masturbating and feels that that (sic) is a sin for which she is going to be punished for...Patient reports that she is had (sic) some intermittent lower abdominal and lower back pains that have been chronic in nature ...” Patient #12 was discharged from the DED at 0414. Review of the Lift Ticket revealed Patient #12 was picked up from Campus B’s ED on 07/28/2022 at 0414 and dropped off at the address of Facility C at 0425 (11 minutes after being picked up). Interview on 02/14/2024 at 1225 with Director #2 revealed he was the Associate Director at (Facility C) during the time Patient #12 presented there. Interview revealed Director #2 currently (as of date of interview 02/14/2024) works at Hospital A and B. Patient #12 was in the ED at Hospital B during the time of their initial opening of Hospital B. Interview revealed “the only way” a patient would be evaluated for psych concern in the initial opening of Hospital B is if they met IVC criteria. Interview on 02/14/2024 at 1649 with Medical Director #3 revealed Patient #12 went home from the ED and called her OBGYN Provider. Patient #12 reported a similar story about excessive masturbation at home. Then Patient #12 presented to (Facility C) via the Police. Interview revealed Patient #12 could understand instructions based on documentation. Interview revealed a Psych Consult would be ordered for a patient if it was determined or known someone was not safe, or if someone is actively suicidal, or the Provider cannot determine these. Less than 50% of patients who come in with a chief complaint of “Psych Eval” would see or get a consult” because they would not meet criteria when one would be ordered. Interview revealed Medical Director #3 had reviewed the medical record for Patient #12 and everything in the note says Patient #12 was “medically stable and Psychiatrically stable”. Interview revealed it “doesn’t make sense some of the documentation” and then to give a Lift ticket to (Facility C). Interview revealed like any patient you want immediate follow up so in this case, was expediting that follow up by providing her with a ride there. Request on 02/14/2024 to interview Provider #4 revealed he was not available. Complainant subject (Patient #12) Facility C visit: Review of the closed medical record for Patient #12 revealed Patient #12 presented to Facility C on 07/28/2022 at 1034. Review of the ED Care Timeline revealed at 1035 “Arrival Complaint: assessment.” Review of the Psychologist Provider note at 1045 revealed “The patient is a 66 y.o. female with a history of MDD (major depressive disorder), Bipolar Disorder I with Psychotic Features, and PTSD (post traumatic stress disorder), who presents voluntarily with (town initials) PD (police department). She called the crisis line this morning because she adamantly believes she has killed someone, despite the fact there is no evidence to support this belief (police have checked on neighbors, attempted to reassure her everyone is ok). Patient reports that she was at (Hospital B) last night for this but was discharged back to her provider, (Named). She reports having recent med (medication) change, from Abilify to Risperidone, however, she is very confused and can’t remember if she is taking her medication, taking too much, or not taking enough. Patient’s symptoms on presentation include: confusion, disorientation, tangential and illogical thinking, severe anxiety, mood lability, sleep and appetite disturbance. She is very tearful, explaining that she is having lots of difficulty with her memory lately. ... Clinical Summary: The patient is at acutely elevated risk of suicidal/dangerousness to others and further worsening of psychiatric condition. Plan/Disposition: Patient will be referred for an emergency psychiatric evaluation to determine appropriate level of care needed.” Review of the LCMHC (licensed clinical mental health counselor) note at 1230 revealed “ ... 66 y.o. ... female with a history of bipolar disorder with psychosis who presents to CAS (certified addiction specialist) due to concerns over psychiatric decompensation. Patient has been experiencing worsening mood symptoms of psychosis including believing that she will die if she closes her eyes. Also believes that everyone around her knows that she is dying but no one will be honest enough to tell her. Patient also reports that she has murdered someone but cannot explain why. She reports not sleeping for the last several days due to being preoccupied about death. She has been eating poorly. She has not been caring for herself including medical conditions. Patient presents as extremely distraught and cried through the assessment. Patient is currently experiencing symptoms of hypomania. She endorses compulsive sexual behaviors (masturbation). The patient is experiencing a decompensation of mood symptoms without a clear precipitant. This decompensation is likely to continue without immediate intervention. At this time, the patient presents as acutely dangerous to herself and requires inpatient hospitalization for safety and stabilization. The patient is in an acute elevated risk of suicide/dangerousness to others and further worsening of psychiatric condition ... patient does meet North Carolina involuntary commitment criteria at this time.” In summary, Rex Hospital failed to provide an appropriate evaluation of Patient #12 who presented to the Emergency Department with evidence of bizarre and delusional thought processes with report of pain.”

“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: 40299 Based on medical record review and physician interview, Emergency Department (ED) staff failed to notify a patient of their final lab result post emergency department discharge for one of 14 patients discharged from the ED. The findings included: Review on 02/13/2024 of the closed medical record for Patient #11 revealed a 54-year-old male who presented to Campus B DED (Dedicated Emergency Department) on 05/11/2022 at 2154 with a chief complaint of “Blood in Stool.” Review of the Triage note dated 05/11/2022 at 2211 revealed “Blood in stool started today. Had CT (computed tomography - computerized x-ray images that make a series of detailed pictures of areas inside the body) this morning in Puerto Rico. Started in cipro (sic). Vital Signs at 2213 revealed “Temp (temperature): 36.4 ... Heart Rate: 93 ... Resp (respirations): 16; BP (blood pressure): 126/93 ... SpO2 (oxygen saturation) 97%; O2 (oxygen) Device: None (Room air) ...” Patient #11 was assigned a “Patient Acuity:3” at 2216. Review of the Complete Blood Count (CBC) with Differential at 2240 revealed an abnormal result with elevated white blood cells and elevated absolute neutrophils. Review of the Comprehensive metabolic panel (CMP) at 2255 resulted an abnormal result with low sodium, low chloride, low alkaline phosphatase, elevated creatinine and elevated ALT (alanine transaminase - enzyme found in liver released in blood when liver is damaged). Review of the Provider note at 2302 revealed “ ... male ... presents to the emergency department with blood in his stool. Patient was just in Puerto Rico for the last 2 weeks. Last night, he had some scant blood on the surface of his stools as well as loose stools. He went to the emergency department in Puerto Rico where CT of the abdomen and pelvis was performed that showed evidence of colitis, without diverticulitis, perforation or abscess formation. He has the CT report with him. He was given a dose of IV (intravenous) Decadron and started on oral ciprofloxacin as well as oral prednisone, with tramadol for breakthrough pain. Today he has had a few more episodes of where he has had some streaks of blood in his stool. He remains with diarrhea. He and his wife are concerned about ongoing blood in his stool which is what prompted him to come to the emergency department. He reports some generalized abdominal cramping but reports this feels significantly improved compared to last night. He denies any fever or chills. He denies any testicular or urinary discomfort. Denies any chest pain or shortness of breath. He denies any neurologic sequela including difficulty speaking, unilateral limb weakness or difficulty walking ... MEDICAL DECISION MAKING & ED COURSE ... Differential diagnosis includes, but is not limited to: Diverticulosis, lower GI (gastrointestinal) bleed, infectious colitis, constipation, gastroenteritis, enteritis. He does have a printout of the CT performed earlier this morning that showed diffuse colitis but without any evidence of diverticulitis, abscess formation or perforation. He has a benign abdominal exam without any focal tenderness to palpation and without any peritoneal signs. Given that he is not complaining of any abdominal pain now and is currently afebrile, ... Patient is well-appearing ... will proceed with a rectal exam to rule out any other source of bleeding or significant melena that may need evaluation with a colonoscopy. GI pathogen panel ordered and the patient was able to provide a stool sample. Will obtain a CBC and CMP as well. His wife is concerned because they were unable to cover for anaerobes given that he does have a Flagyl sensitivity, and requesting reevaluation of his current antibiotic therapy. Update: Patient’s rectal exam showed no evidence of gross blood, no melena, Hemoccult negative. He does not have any internal or external hemorrhoids or fissures ... He does have a mild white count of 13,700. His hemoglobin is normal ... and given the findings on his rectal exam it does not appear that he has any significant ongoing bleeding. Given that he was currently in Puerto Rico, do feel that antibiotics are currently still warranted as I suspect his colitis is infectious in nature. However he is afebrile and has no clinical findings of sepsis. His CMP was reviewed and is unremarkable. GI pathogen panel was sent. I do feel the patient is appropriate for outpatient management. His ciprofloxacin was changed to moxifloxacin to offer anaerobic coverage. He has no peritoneal signs and a nonsurgical abdomen and his vital signs are reassuring ... did encourage him to discontinue prednisone as I doubt this is inflammatory as he has no personal history of Crohn’s or ulcerative colitis ... did review that he is to follow-up with a GI physician for colonoscopy once his symptoms improve. His wife already has a GI, and will prefer to self refer, which I do feel is reasonable. He was given return precautions to return immediately to the ED for any new or concerning symptoms including high fever, any new or worsening abdominal pain, or any other concerns. He and his wife with (sic) verbalized understanding ... FINAL IMPRESSION: 1. Colitis; DISPOSITION: Discharged home in stable condition with return precautions provided. Review of the ABO/Rh (blood group type/positive or negative) at 2322 revealed “A POS (blood type A Positive)”. Review of the Provider Orders revealed a GI Pathogen Panel was ordered on 5/12/2022 at 0103 and collected at 0114. Review of the ED Care Timeline revealed at 0104 the “ED Disposition was set to Discharge.” Patient #11 was discharged from the ED at 0124. The GI Panel resulted on 05/12/2022 at 0302 positive for Shiga-like Toxin Producing E. coli PCR (polymerase chain reaction) and E-Coli (Escherichia coli - bacteria). Review of the Pharm D note on 05/12/2022 at 1235 revealed “Spoke with (MD #3) regarding patient’s culture and antibiotic regimen prescribed from previous ED visit. Per (MD #3), it is recommended to keep current antibiotic regimen and make no change. No need for follow-up.” Medical record review revealed no telephone call to Patient #11 after discharge with his GI Panel results. Telephone interview on 02/14/2024 at 1035 with RN #2 revealed she did not remember Patient #11. Interview revealed she could only read what she documented in the medical record for Patient #11. Telephone interview on 02/14/2024 at 1320 with MD #1 revealed Patient #11 was diagnosed with infectious colitis. The antibiotics Patient #11 was prescribed would take care of the symptoms of colitis, technically the patient should not have been on antibiotics. Interview revealed Patient #11 was given handwashing and transmission precautions to prevent the transmission of e-coli to others. NC00188683, NC00188849, NC00195463, NC00197271”