Maria Parham Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 34065 Based on policy review, medical record reviews and staff interviews, hospital nursing staff failed to assess a patient for pain prior to and response after administration of pain medications in 1 of 5 records reviewed for pain (Pt #11). The findings include: Review of a policy titled “Pain Assessment and Management--General Principles” with revision date of 05/2022, revealed “....ASSESSMENT: The RN (Registered Nurse), physician or other health care professional shall perform an initial assessment of pain on all patients including Emergency Department (ED)....Conduct initial pain assessment: a. Select appropriate pain intensity scale for present pain. b. Obtain characterization of present pain and document. Review pain history for all relevant pain problems. For....ED: Assess: With initial assessment/contact. Assess patient every four hours. REASSESSMENT OF PAIN MANAGEMENT INTERVENTIONS: Medication effects on patients are continually monitored. Each patient’s response to his or her medication is monitored according to the clinical needs of the patient and addresses the patient’s response to the prescribed medication and actual or potential medication-related problems. Therapeutic response to pain medications should be evaluated within 4 hours of administration.... The hospital reassesses and responds to the patient’s pain through the following: evaluation and documentation of response(s) to pain interventions. Progress toward pain management goals including functional ability (i.e.ability to take a deep breath, turn in bed. Side effects of treatment. Risk factors for adverse events caused by the treatment.....” Medical record review on 04/21/2026 revealed Patient #11 was an 89 year old female, documented as weight of 155 lbs (pounds), who presented to the ED on 03/15/2025 at 0931 via EMS (ambulance) with complaints of a fall with complaints of left hip pain. Patient #11 reported she attempted to get up from bed but was laying at the edge of the bed, fell and hit the dresser. Patient #11 was noted to have a bruise on her back. Review of CT scan (computed tomography - type of imaging) dated 03/15/2025 at 1125 revealed “acute mildly displaced fractures of the left anterosuperior acetabulum (hip fracture) and superior and inferior pubic rami (pubic bones).” Record review revealed EMS administered a 1 liter bolus (1000 ml intravenous fluids) and 5 mg (milligrams) Morphine (narcotic pain medication) en route. Review of medications administered to Patient #11 in the ED included: Morphine 4 mg IV and Zofran (antiemetic) on 03/15/2025 at 1046. Morphine 4 mg IV was given again at 1443 (approximately 4 hours after previous dose); and a Hydrocodone-Acetaminophen 5/325 (Norco--opioid medication used to treat moderate to severe pain) mg tablet at 1443 on 03/15/2025. Review of Patient #11’s medical record revealed pain assessments were documented at 1151 as “pain assessment.” At 1614, documentation was “asleep after meds.” Review of a pain med assessment at 1914 revealed “lethargic.” Review revealed no further details documented with the pain assessments or pain scale. A physician note by MD #2 dated 03/15/2025 at 1850 revealed “....6:50 pm (1850) I was called to the bedside because patient was very somnolent (sleepy; drowsy) and with a decreased respiratory drive......Pupils were pinpoint. She is breathing 8 times per minute. We gave Narcan (opioid reversal agent) and she became more responsive.” Review of RN #3’s note dated 03/15/2025 at 1914 revealed “Transport at bedside to transfer pt to (local hospital). Pt not arousal to stimuli due to narcotics administered for pain. Pt family concerned. MD made aware. MD ordered Naloxone (Narcan) to be administered. Naloxone administered. Pt awake responding to stimuli....” Interview on 04/22/2026 at 1122 with MD #4 revealed Patient #11 received Narcan due to being too sedated prior to being transferred. Interview on 04/22/2026 at 1205 with RN #3 revealed Patient #11 was brought in to the ED after a fall. Family was at the bedside and wanted pain medications. Interview revealed Patient #11 was moaning in pain when she was awake. Interview revealed no documentation of pain assessments before or after pain medications were administered. Interview revealed the policy was not followed. Interview revealed the assignment was “busy.” Interview on 04/23/2026 at 1530 with CNO #1 revealed best nursing practice was to assess the patient and document before and after pain medication administration. The documentation should have included pain scale. Interview revealed the policy was not followed. NC00235356, NC00236535, and NC00236412”

“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 policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to provide an appropriate ongoing Medical Screening Examination (MSE) within the capability of the hospital’s DED to determine whether an Emergency Medical Condition (EMC) existed for one (1) of 26 sampled DED patients (Patient #7). ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.”

“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: 40299 Based on policy review, ambulance trip reports, review of the dedicated emergency department (DED) log and staff interviews, the hospital failed to accurately document on its DED central log all patients that presented to the hospital’s DED for treatment for four (4) of 26 records reviewed (Patients #6, #27, #13, and #16). The findings included: Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective date 09/2023, revealed “...CENTRAL LOG: To identify and document each individual who either comes to the Dedicated Emergency Department seeking treatment for any medical condition or presents on Hospital Property or Premises seeking care for an emergency medical condition. Each hospital that has a Dedicated Emergency Department will maintain a central log to include information on each individual who comes to the Hospital Property or Premises requesting treatment....The log must contain....the name of the individual who comes to the emergency department seeking assistance; and.... whether the individual: ...refused treatment ....was refused treatment .... was transferred ....was discharged. ...” Review of the EMTALA log for 09/07/2023 (date of the alleged violation) revealed the name of Patient #27 was not listed on the log. Review of the Emergency Medical Services (EMS) CALL LOG for 09/07/2023 revealed “EMS Unit: (EMS #1); Age: 56; M (male) [circled]; Visit ID: 13 ... Home ... Abd (abdomen) pain x (times) 30 mins (thirty minutes) sharp to back Dialysis pt (patient) ...” 1. Review of the Emergency Medical Services (EMS #1) Report dated 09/07/2023 revealed Patient #27 was transported to Hospital A Campus A’s DED arriving at 1718 and call completed at 1758. Review revealed “dispatched to residence ... to a 56-year-old male with breathing problems ... sudden onset of severe abdominal pain that radiates to his back. Patient is in obvious distress due to the pain ... Due to patient being Dialysis ... On arrival at (Hospital A Campus A), patient remained on stretcher without registration, triage or seen by any staff at (Hospital A Campus A) for approximately 45 mins (minutes). Patient noted staff appeared very rude and decided he wanted to leave facility and go elsewhere. EMS advised staff member of same and (CN #3), charge nurse states ‘That will be the best thing for him.’ Patient then refuses, EMS D/C (discontinues) IV (intravenous) and assisted patient to waiting are with wife ...” A search on 06/04/2024 in the hospital’s electronic medical record system for the name of Patient #27 revealed there was not an electronic medical record for the patient on 09/07/2023. Interview on 06/04/2024 at 1047 with the Manager of House Supervisors (HS #2) revealed he remembered the incident. When HS#2 arrived to the ED the charge nurse (CN #3) was speaking with the EMS personnel. The EMS personnel seemed upset and the patient decided to leave. The patient felt he would not have to wait if he went to another hospital in the area. Telephone interview on 06/05/2024 at 1400 with EMS #4 revealed he remembered the incident. Interview revealed toward the end of the afternoon EMS #1 picked up a patient in need of dialysis and a comorbidity was renal failure. The crew arrived onsite at (Campus A) where the charge nurse told them they needed to wait as they (Campus A ED) could not take anymore pts. EMS #4 stated the hospital staff were internally discussing the possibility of going on diversion however they were not on diversion when the EMS crew arrived to hospital (Campus A). The computers in the EMS trucks did not show the hospital was on diversion at the time either. Interview revealed after arriving to the hospital (Campus A) the charge nurse was not pleasant with the team and instructed the hospital registration staff to “not” register the patient. The EMS crew escalated this to leadership. EMS leadership spoke with the CN at (Campus A) to explain the problem with being on the property, the need to register the patient, and transfer the care of the patient to the ED staff and of the medical provider deemed it necessary, then transfer the patient to another facility. The EMS crew cannot leave with the patient once they have arrived on site at a hospital ED. EMS #4 was asked to speak to the ED Director, which he did and explained the same information to them as he had to the CN. The ED Director was in agreement, however stated she was being overruled by the House Supervisor (HS #2). EMS #4 attempted to contact HS #2 to try to resolve this issue. Interview revealed after about thirty minutes, the patient decided he was going to leave and go somewhere else. Telephone interview on 06/05/2024 at 1436 with Paramedic #5 revealed they were called to a resident for a patient with side pain similar to kidney stone on a dialysis patient. The patient was transported to Campus A. Upon arrival the nurse told the registration personnel not to register the patient. Paramedic #5 notified her supervisor, who in turn contacted the hospital supervisor (HS #2). The patient got “fed up” because all this was taking place in front of him, and he decided he wanted to leave. We (EMS crew) removed the monitor and IV and walked with the patient out the door. Telephone interview on 06/06/2024 at 1027 with Charge Nurse (CN #3) revealed the hospital was on diversion, there were patients in every room and in hallway beds. CN #3 acknowledged she told registration to not register the patient when they came in because they would be on the tracker board and it would look like they have not been triaged. HS #2 came to the ED, he said it was not an EMTALA violation, EMS crew said it was. The patient decided he wanted to leave. Interview on 06/10/2024 at 1319 with Information and Technology personnel (IT #7) revealed she reviewed the account. It appears “short registration was not used.” Short registration would have triggered a task for registration to complete once the MSE (medical screening examination) was completed. By not using this it did not put the patient in a pre-registration status and did not put the patient on the ED log. The medical record was created days after the event and still should have followed the normal process to ensure it was captured on the log. Telephone interview on 06/10/2024 at 1448 with Paramedic #6 revealed they were dispatched to pick up a patient from dialysis. The patient had a complaint of abdominal pain and was a dialysis patient. Arrived at Campus A’s ED and they were told they would have to wait. While waiting with the patient they went to register the patient up front. The registration staff would not register the patient as they were told by the CN to not register the patient. We contacted our supervisor about being told had to wait and the hospital staff not allowing the patient to be registered. During this time the hospital’s house supervisor came to the ED and he reiterated what the CN had said about having to wait. In summary, Patient #27 was brought into the DED via EMS, the patient was not registered as the registration staff was told not to register him in the computer. The patient decided to leave. As of date of survey, 06/04/2024, the patient was not on the EMTALA log. Review of the EMTALA log for 09/07/2023 (date of the alleged violation) revealed there were no “John Doe” patients listed on the log. 2. Review of the medical record created on 09/09/2024 for “John Doe” patient (Patient #6) revealed a 60-year-old male patient admitted to Campus A’s DED (dedicated emergency department) 09/07/2023 at 1740. Review of the Patient Profile revealed “ ... Patient Details; Admit Complaint: toe pain/missed dialysis ... Service: Emergency Room ... Discharge Date: 09/07/2024 ... Visit Status: Against Medical Advice ...” Review of the Progress Notes Report revealed an entry “Assessment Date; 09/11/2023 1032 This RN (Registered Nurse) arrived in ED at 1734 on 09/07/2023 to find this pt (patient) lying (sic) in an EMS (emergency medical system) stretcher with (EMS #1) present. The ED Charge RN was explaining to the pt and EMS that every room in the ED was currently full and they would need to wait in the hallway until staff was available to evaluate the patient and get him a room. The pt did not want to wait in the hallway and verbalized that he would like to leave. This RN explained to the pt that we would still like to evaluate him, but he was adamant that he would like to leave and be seen at another healthcare facility. Per pt request (EMS #1) then discontinued the pt’s IV (intravenous) and disconnected him from oxygen. EMS then walked the pt to the lobby where he was met by his wife. The pt and his wife left in a personal vehicle.” Interview on 06/04/2024 at 1047 with the Manager of House Supervisors (HS #2) revealed he remembered the incident. When HS#2 arrived to the ED the charge nurse (CN #3) was speaking with the EMS personnel. The EMS personnel seemed upset and the patient decided to leave. The patient felt he would not have to wait if he went to another hospital in the area. HS#2 reported he notified the patient they would be happy to see him and would get him in a room as soon as one became available. Interview revealed the patient did not want to wait for a room to become available and to be seen. Telephone interview on 06/05/2024 at 1400 with EMS #4 revealed he remembered the incident. Interview revealed toward the end of the afternoon EMS #1 picked up a patient in need of dialysis and a comorbidity was renal failure. The crew arrived onsite at (Campus A) where the charge nurse told them they needed to wait as they (Campus A ED) could not take anymore pts. EMS #4 stated the hospital staff were internally discussing the possibility of going on diversion however they were not on diversion when the EMS crew arrived to hospital (Campus A). The computers in the EMS trucks did not show the hospital was on diversion at the time either. Interview revealed after arriving to the hospital (Campus A) the charge nurse was not pleasant with the team and instructed the hospital registration staff to “not” register the patient. The EMS crew escalated this to leadership. EMS leadership spoke with the CN at (Campus A) to explain the problem with being on the property, the need to register the patient, and transfer the care of the patient to the ED staff and of the medical provider deemed it necessary, then transfer the patient to another facility. The EMS crew cannot leave with the patient on they have arrived on site at a hospital ED. EMS #4 was asked to speak to the ED Director, which he did and explained the same information to them as he had to the CN. The ED Director was in agreeance, however stated she was being overruled by the House Supervisor (HS #2). EMS #4 attempted to contact HS #2 to try to resolve this issue. Interview revealed after about thirty minutes, the patient decided he was going to leave and go somewhere else. Telephone interview on 06/05/2024 at 1436 with Paramedic #5 revealed they were called to a residence for a patient with side pain similar to kidney stone on a dialysis patient. The patient was transported to Campus A. Upon arrival the nurse told the registration personnel not to register the patient. Paramedic #5 notified her supervisor, who in turn contacted the hospital supervisor (HS #2). The patient got “fed up” because all this was taking place in front of him, and he decided he wanted to leave. We (EMS crew) removed the monitor and IV and walked with the patient out the door. No risks and benefits were explained to the patient prior to leaving. Telephone interview on 06/06/2024 at 1027 with Charge Nurse (CN #3) revealed the hospital was on diversion, there were patients in every room and in hallway beds. CN #3 acknowledged she told registration to not register the patient when they came in because they would be on the tracker board and it would look like they have not been triaged. HS #2 came to the ED, he said it was not an EMTALA violation, EMS crew said it was. The patient decided he wanted to leave. CN #3 thinks HS #2 spoke with the patient prior to the patient leaving. CN #3 stated since the incident there has been re-education about EMTALA and she paid for a class about EMTALA outside of what the hospital provided. Interview on 06/10/2024 at 1319 with Information and Technology personnel (IT #7) revealed she reviewed the account. It appears “short registration was not used.” Short registration would have triggered a task for registration to complete once the MSE (medical screening examination) was completed. By not using this it did not put the patient in a pre-registration status and did not put the patient on the ED log. The medical record was created days after the event and still should have followed the normal process to ensure it was captured on the log. Telephone interview on 06/10/2024 at 1448 with Paramedic #6 revealed they were dispatched to pick up a patient from dialysis. The patient had a complaint of abdominal pain and was a dialysis patient. Arrived at Campus A’s ED and they were told they would have to wait. While waiting with the patient they went to register the patient up front. The registration staff would not register the patient as they were told by the CN to not register the patient. We contacted our supervisor about being told had to wait and the hospital staff not allowing the patient to be registered. During this time the hospital’s house supervisor came to the ED and he reiterated what the CN had said about having to wait. These conversations took place in front of the patient. The patient got upset decided he would leave and go somewhere else. No one explained the risks and benefits to the patient and EMS staff walked the patient out of the ED. In summary, Patient #6 was brought into the DED via EMS, the patient was not registered as the registration staff was told not to register him in the computer. The patient decided to leave. As of date of survey, 06/04/2024, the patient was not on the EMTALA log. Review revealed no evidence or documentation of risks and benefits prior to the patient leaving. 33790 3. Review of the Emergency Department log revealed Patient #13, a 44 year-old, arrived to the DED on 06/03/2024 at 1946 with a complaint of “Flank Pain” and had a discharge time recorded as 2000 for a length of stay of 14 minutes. Further review of the log revealed a visit status documented as “Canceled NoShow.” Documentation, received on 06/10/2024, related to Patient #13’s 06/03/2024 DED visit revealed two documents: an “ED Summary Report” and “Patient Details”. There were no notes to indicate Patient #13 was triaged or received any medical screening and no documentation to show if the patient was seen leaving the facility. A complaint of flank pain was entered on both documents and Patient #13 was noted to have departed the DED at 2000. Interview on 06/10/2024 at 1600 with Registration Staff #19 revealed the canceled no show documentation would be entered on the log if a patient had been initially entered incorrectly, for example if the patient arrived as an outpatient, not an ED patient, or if a patient came up and said they did not want to be seen. Follow-up interview on 06/11/2024 at 1620 revealed Patient #13 arrived to the DED, not as a planned outpatient. Registration Staff #19 stated that if a patient came up to registration before triage and stated they were leaving, Registration Staff would call it a cancel, no show to take the patient off the board. Interview revealed nursing entered the LWBS (left before being seen) or AMA (against medical advice), that Registration was taught to use the canceled no show. 4. Review of the Emergency Department log revealed Patient #16, a 38 year-old, arrived to the DED on 04/04/2024 at 1005 with a complaint of “Abdominal Pain.” The patient had a recorded discharge time on the log of 1019 for a length of stay of 14 minutes. The status noted on the DED log was “Canceled NoShow.” Documentation, received on 06/10/2024, related to Patient #16’s 04/04/2024 visit revealed an “ED Summary Report”, “Patient Details”, Demographics, and an “Event Log.” Review of the documents did not provide any notes to indicate Patient #16 was triaged, received any medical screening, nor any evidence whether the patient was seen leaving the facility. A complaint of abdominal pain was documented and the patient was noted to depart the DED at 1019. Interview on 06/10/2024 at 1600 with Registration Staff #19 revealed the canceled no show documentation would be entered on the log if a patient had been initially entered incorrectly, for example if the patient arrived as an outpatient, not an ED patient, or if a patient came up and said they did not want to be seen. Follow-up interview on 06/11/2024 at 1620 revealed Patient #16 arrived to the DED, not as a planned outpatient. Registration Staff #19 stated that if a patient came up before triage and stated they were leaving, Registration Staff would call it a cancel, no show to take the patient off the board. Interview revealed nursing entered the LWBS (left before being seen) or AMA (against medical advice), that Registration was taught to use the canceled no show.”

“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, medical record review and physician interviews, the hospital’s Dedicated Emergency Department (DED) failed to provide an appropriate ongoing Medical Screening Examination (MSE) within the capability of the hospital’s DED to determine whether an Emergency Medical Condition (EMC) existed for 1 of 26 sampled DED patients (Pt #7). The findings included: Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, titled “EMTALA: Medical Screening and Transfer of Patients...PC 103”, approved 09/2023, revealed “...L. Medical Screening Examination is the process required to reach with reasonable clinical confidence....whether or not an emergency medical condition exists....The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred. ...” Review of the Dedicated Emergency Department record revealed Patient #7 arrived to the DED on 11/29/2023 at 1452 by EMS. Review of the Triage Note revealed an acuity of 2 was assigned. A Glasgow Coma Scale (GCS) completed at 11/29/2023 at 1531 revealed a total score of 15 out of 15, noting Patient #7 was alert and oriented to person, place, time and situation and had clear speech. Review of an “ED Provider Scribe Template” date of service 11/29/2023 at 1507, revealed “...Chief Complaint/ HPI .... This is a 74-year-old male with a past medical history of hypertension, diabetes mellitus, and hyperlipidemia brought in by EMS who presents for nausea and vomiting. EMS reported the patient is complaining of nausea/a blood pressure in the 250s/120s and blood sugar level of 234. The patient states he’s had nausea and vomiting associated with diarrhea and stomach pain since 1 pm. He notes no appetite for the past two days. Patient denies fever, shortness of breath, extremity weakness, chest pain, dysuria, polyuria or any other associated symptoms. ...” Review revealed a central line was placed for hemodynamic monitoring and IV access (per nursing note this was done at 1746). Review of the “ED Provider Scribe Template” further revealed “...1850 we are at capacity in terms of PC and ICU (Progressive and Intensive Care) beds. Will attempt to transfer the patient to hospital with capacity. - I contacted (outside Hospital E)....is at capacity for ICU beds in step-down.... Condition: stable....Patient will be signed out to (MD #3) Final Diagnosis .... DKA (Diabetic Ketoacidosis) [space] Hypertensive Urgency. ...” Review of physician documentation did not reveal any notes made by the oncoming physician (MD #3) at hand-off to show the patient’s condition. On 11/29/2023 at 1949, a Nurse Note indicated Patient #7 got up out of bed and pulled out the central line, the physician (MD #3) was made aware and replaced the line. Blood glucose at that time was noted as 289. At 2011, Patient #7 was noted by nursing to have vomited “coffee-ground emesis.” At 2100 (documented at 2333), a RN Neurological Assessment noted that Patient #7 was “Confused” and “Nonverbal”. On 11/20/2023 at 0338, Patient #7 was documented to have complained of abdominal pain at a level of 10:10. At 0500, Patient #7 was again noted to be “Nonverbal” but was stated to be alert and oriented. Review did not reveal any physician documentation throughout the night to show if a physician evaluated Patient #7 or noted any change in condition. DED record review revealed an “ED Assumption of Care Note”, dated 11/30/2023 at 0630, that stated “...This patient was signed out to me by the outgoing physician. Please see their initial documentation for further details regarding initial H&P....The patient is currently boarding in the emergency department as there are no beds available for transfer and no ICU beds currently at this facility .... Of note, I consulted GI regarding concern for upper GI bleed. ...” Review of the physician’s note did not reveal information on the patient’s mental status or pain. Review of a GI Consult Note, dated 11/30/2023 at 1354, indicated “ ...Reason for consult....Coffee Ground emesis ....History of Present Illness: Reviewed; HPI details: 74-year-old male admitted with a hypertensive crisis, DKA with GI being consulted form coffee-ground emesis. Patient is awake but is not conversive, he moves around, does not appear in any distress, but does not answer any questions. As per patient’s nurse today, he is not alert and oriented...” Further review of the “ED Assumption of Care Note” revealed “...The patient is a (Hospital G) patient. I reached out to the (hospital G) to request transfer given no ICU bed availability here. The patient has been accepted for transfer to the (Hospital G). ...” Review of the note failed to reveal if any change in mental status was observed compared to when Patient #7 arrived. Review of a Nursing Assessment Note on 11/30/2023 at 1610 revealed Patient #7 was being Transferred Out and noted the patient’s condition at that time was “Stable” and “Fair” and the LOC was “Responds to painful stimuli.” Another note by the same RN, at 1620, indicated the patient was transferred at 1620 and was “...awake, not verbally responsive.” Review of the Transfer Form revealed it was signed by DO #18 and indicated the patient was stable for transfer at 1620. The form was dated and timed at the top of the form but the date/time beside the MD signature was left blank. There were no orders marked on the form to indicate the mode of transport or support orders during transport, however nursing documentation indicated Patient #7 was transferred out by (Hospital E ALS Transport) and remained on Nicardipine, Insulin and Protonix drips. No other notes were found by DO #18 to determine if the physician evaluated Patient #7’s mental status and overall condition. Telephone interview on 06/05/2024 at 1605 with MD #2, the physician who did the initial medical screening on Patient #7, revealed MD #2 did not recall the patient. Interview revealed MD #2’s documentation of the medical screening showed that Patient #7 was alert and oriented and talking with the physician at the time of the examination. Interview revealed MD #2 signed off to MD #3 at the end of the shift and did not have further interactions with Patient #7. Request for interview with MD #3, the ED physician to whom MD #2 signed over Patient #7, revealed that while MD #3 remained on staff, MD #3 had not worked at the hospital recently, had not responded to calls and thus was not available for interview. Requests to interview two nurses who documented change in mental status and nonverbal status revealed the nurses no longer worked at the hospital and were not available for interview. Telephone interview on 06/06/2024 at 1640 with DO #18, the physician who signed and certified the benefits exceeded the risks of transfer for Patient #7, revealed DO #18 did not write a note in Patient #7’s record, just signed the transfer form. Interview revealed the standard process before signing off a transfer form was to make a quick round on a patient to evaluate him/her before signing out the patient for transfer. Interview revealed DO #18 “almost certainly” saw and evaluated Patient #7. Interview revealed writing a note “probably should have happened.” DO #18 stated “ ...think I checked and was going to write and probably got called (away).” Telephone interview on 06/06/2024 at 1658 with MD #4, the day shift ED physician on 11/30/2024, revealed the providers round and see patients during report and sign off bed by bed; they discuss what has been done and how the patient appears. Interview revealed MD #4 would have checked the patient’s baseline for that shift and to see if there was a baseline change. Interview revealed the goal was to have everything written down and MD #4 could not say why more was not documented. Interview revealed providers check patients waiting for a bed at the beginning and end of the shift, then throughout the shift would check if requested. MD #4 stated the goal was to continue to treat and stabilize a patient waiting for a bed, and that ideally the patient would have been in an ICU bed. Interview revealed if there had been a substantial change in Patient #7’s condition that warranted imaging, there would have been a note. In regards to concern for a stroke, the physician indicated there would be focal deficits. If MD #4 had been concerned for a stroke, interview revealed, a code stroke would have been activated. The MD stated a change in mental status with no laterality was more suggestive of encephalopathy as opposed to a stroke. Interview on 06/07/2024 at 1030, with MD #13, ED Medical Director, revealed MD #13 had been briefed on Patient #7’s case. Interview revealed the expectation for documentation by ED providers was a shift to shift verbal sign-out, with the oncoming physician writing an assumption of care note, and at disposition the provider writing a summary or progress note. Interview revealed if a patient appeared well, a provider might just write “stable” but if there was a change, there should be a note of the change. Interview further revealed all patients in the ED were active ED patients, not boarder patients. Related to this patient, interview revealed, there should have been assumption of care notes from all ED providers when they assumed care and notes with condition changes to show what happened and when.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 33790 Based on policy and procedure review, Medical Staff Bylaws Rules and Regulations review, medical record reviews, observations, incident report summary reviews, hospital documents, job description review, snack ingredient list, and staff and physician interviews, the governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient’s rights for a safe environment; an organized and effective quality assessment and performance improvement program for patient safety; an organized nursing service for supervision of nursing care; and an effective food and dietetic services for oversight of snacks to behavioral health patients. The findings included: 1. A medical provider failed to evaluate a patient following a fall for 1 of 2 sampled behavioral health patients who experienced a fall (Patient #2). ~cross refer to 482.12 Medical Staff Accountability Standard: Tag 0049 2. Hospital staff failed to notify a patient’s family after patient falls on the behavioral health unit for 2 of 2 sampled behavioral health patients who experienced a fall (Patients #2 and #15). ~Cross refer to 482.13 Patient Rights Informed Consent Standard: Tag 0131 3. Hospital staff failed to provide care in a safe setting by failing to utilize emergency medical equipment during resuscitation of a patient on the behavioral health unit for 1 of 1 sampled behavioral health patients that required resuscitation (Patient #3). ~ Cross refer to 482.13 Patient Rights Care in a Safe Setting Standard: Tag 0144 4. Hospital staff failed to analyze adverse events, identify opportunities for improvement, and implement preventative actions for 2 of 2 sampled patients with adverse events (Patient #3, Patient #2). ~ Cross refer to Patient Safety Standard: Tag 0286 5. Nursing staff failed to supervise the distribution of snacks to a patient with a known food allergy for 1 of 2 patients with food allergies (Pt #3). The patient received snacks containing the allergen, subsequently appeared to choke and then became unresponsive. Nursing staff failed to follow a provider’s order for neuro checks for 1 of 2 sampled behavioral health patients (Pt #2) who experienced a fall. ~ Cross refer to Nursing Supervision of Nursing Care Standard: Tag 0395 6. The hospital dietitian failed to provide supervision and oversight of diet and allergy appropriate snacks for 1 of 2 sampled patients that had food allergies (Pt#3). The patient received snacks containing the allergen, then after a snack the patient appeared to choke and became unresponsive. ~ Cross refer to Qualified Dietician Standard: Tag 0621”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33790 Based on policy review, medical record reviews, event report summary reviews, internal document reviews and staff interviews, the hospital staff failed to protect and promote each patient’s rights to care in a safe setting and involvement in care. The findings included: 1. The hospital staff failed to notify a patient’s family after a patient’s fall on the behavioral health unit for 2 of 2 sampled behavioral health patients who experienced a fall (Patients #2 and #15). ~Cross refer to 482.13 Patient Rights Informed Consent Standard: Tag 0131 2. The hospital staff failed to provide care in a safe setting by failing to utilize emergency medical equipment during resuscitation of a patient on the behavioral health unit for 1 of 1 sampled behavioral health patients that required resuscitation (Patient #3). ~ Cross refer to 482.13 Patient Rights Care in a Safe Setting Standard: Tag 0144”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 33790 Based on policy review, medical record reviews, internal document reviews, snack ingredient review and staff and physician interviews, hospital leadership failed to maintain an effective quality assessment and performance improvement program for identifying and investigating adverse events to identify opportunities for improvement and implement action plans. The findings included: Hospital staff failed to analyze adverse events, identify opportunities for improvement, and implement preventative actions for 2 of 2 patients with adverse events reviewed (Patient #3, Patient #2) ~ Cross refer to Patient Safety Standard: Tag 0286”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 33790 Based on policy review, observations, medical record reviews, Event Report Summary Form review, snack ingredient review and staff interviews, the hospital’s nursing staff failed to supervise and provide oversight of care for behavioral health patients. The findings included: Nursing staff failed to supervise the distribution of snacks to a patient with a known food allergy for 1 of 2 patients with food allergies (Pt #3). The patient received snacks containing the allergen, after a snack appeared to choke and then became unresponsive. Nursing staff failed to follow a provider’s order for neuro checks for 1 of 2 sampled behavioral health patients (Pt #2) who experienced a fall. ~ Cross refer to Nursing Supervision of Nursing Care Standard: Tag 0395”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 33790 Based on observations, medical record reviews, review of job descriptions and staff interviews the hospital failed to have a organized food and dietetic service to oversee snacks for patients with food allergies. The findings included: Based on observations, medical record reviews, review of job description, snack ingredient list and interviews with staff, the dietitian failed to provide supervision and oversight of diet and allergy appropriate snacks for 1 of 2 sampled patients that had food allergies (Pt#3). The patient received snacks containing the allergen, then after a snack the patient appeared to choke and became unresponsive. ~ Cross refer to Qualified Dietician Standard: Tag 0621”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 50318 Based on the hospital’s medical staff rules and regulations review, closed medical record review, event report summary review, and staff interviews, the hospital provider failed to evaluate a patient following a fall in 1 of 2 sampled behavioral health patients who experienced a fall (Patient #2). The findings include: Review on 06/11/2024 of the hospital’s Medical Staff Rules and Regulations, effective 10/2019, revealed...”Article II. Medical Records...2.4 Progress Notes. During hospitalization, progress notes will be recorded daily by primary attending and/or designee on all patients, to record significant changes in the patient’s condition and to describe the effects of the treatment. Progress notes will be recorded, dated and authenticated by primary attending and/or designee at the time of the observation of the patient. The PA, NP, and Nurse Midwife may enter progress notes and may make rounds.” Review of the hospital’s policy “Patient Assessment and Reassessment, PC-41,” effective 09/2020 through 09/2023, revealed, “... 3. Assessments are performed by each discipline within its scope of practice, state licensure laws, applicable regulations or certification... 5. Care decisions will be based upon data and information gathered in assessments and reassessments. This data will be utilized in prioritizing patient care needs and selecting appropriate interventions ...” Closed medical record review on 06/04/2024 of Patient #2 revealed a 70 year old patient was admitted to Campus B, Unit C on 01/05/2022 at 2308 for suicidal ideations with a plan to overdose. Patient #2 had a medical history of bipolar and 4 (four) previous suicide attempts by overdose. Patient #2’s Fall Risk Assessment on 01/05/2022 at 2000 was noted as a score of 4, with a score of 0-6 being low risk, and a falls risk comment noted “not a falls risk.” The Nurse’s Note dated 01/23/2022 at 0102 revealed “At approx (approximately) 2050 patient was running backwards in the hallway when she slipped and fell on the floor. She landed on her bottom and then hit her head. She was unable to verbalize a numerical pain score as she doesn’t currently respond to questions, but stated ‘hurt’. Vitals were taken; BP (blood pressure) 108/69, pulse 93. Her head was assessed and there was no visible evidence of lacerations or bumps. She laid down for a few minutes and then stood up and began walking in the hallway again. Prior to this incident, pt (patient) was taking her clothing off and running in the halls, despite staff prompts. On-Call provider was called and ordered q2hr (every 2 hour) neuro checks (neurological checks that assess a patient’s neurological functions, motor and sensory response, and level of consciousness). Program director was also called and made aware. Pt continued to run and attempt to strip her clothing in the hallway afterwards.” A verbal order for neuro checks q2hr was entered by RN#3 with NP#5 as the ordering provider, which started on 01/22/2022 at 2100 for 12 hours (a total of 6 neuro checks), followed by neuro checks q4hr (every 4 hours) on 01/23/2022 at 1300 for 12 hours (a total of 3 neuro checks). NP#5 Daily Progress Note dated 01/23/2022 at 1545 revealed, Interval Hx (history) 1/22/22: Staff reported that pt presents as somewhat delirious yet has been compliant with regimen. Interval Hx 1/23/22: Staff reported that patient continues to present as delirious. Laboratories results came back concerning and indicate that the current antibiotic regimen was not helping at all (for patient’s urinary tract infection) ... poor emotional range and insight at this time. Patient #2’s mental status exam revealed her thought process was incoherent with compulsions, and she was alert and oriented to person and place but was not oriented to time or situation. NP#5’s Clinical Update revealed, “Case discussed with nursing staff. Patient seen during rounding. Pt presents as though she may have delirium... Pt has been incoherent, unable to form meaningful dialogues, and intermittently confused. On 1.23.22 (sic), pt presents as confused. Continue current regimen ... with new antibiotic.” Record review revealed Provider’s assessment did not address Patient #’s 2 fall on 01/22/2022 and revealed no radiology was ordered following Patient #2’s fall on 01/22/2022. Review on 06/05/2024 of the Event Report Summary Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, related to Patient #2’s fall on 01/22/2022 revealed, “Brief, objective description of the event: Pt fell while running backwards in the hallway. No injuries noted. Provider notified q2° (every two hours) neuro checks ordered. Brief summary of interview findings: No injuries noted; provider notified. Summary of the improvements or response plan indicated and/or under evaluation: Protocol followed.” Review of Event Report Summary revealed no documentation regarding further follow-up related to Patient #2’s fall or the lack of provider assessment following Patient #2’s fall. Telephone interview on 06/06/2024 at 1051 with RN#3 revealed RN#3 did not recall Patient #2 and did not recall Patient #2’s fall. RN#3 revealed if a patient was found on the floor due to a fall, the patient would remain on the floor, with vital signs performed, then the patient would be assisted to a bed or chair, and the provider would be notified. RN#3 revealed it would be up to the provider for any x-rays or CT scans (computed tomography scan, specialized x-ray to produce cross-sectional images). RN#3 revealed the staff would follow the provider’s orders. Telephone interview on 06/06/2024 at 1247 with NP #5 revealed NP #5 did not recall Patient #2. NP #5 revealed he was probably on call for medical needs/consultations on 01/22/2022, and the staff called “pretty much every time” a patient fell. NP#5 verified the call history on his cell phone that he called Campus B on 01/22/2022, and Campus B called him three times on 01/22/2022, but the time stamps were no longer available to verify what times those calls were received. NP#5 revealed he would have ordered a head CT for a fall with a hit to the head or a lower back x-ray for a fall on the bottom. NP#5 acknowledged there was no mention of a fall in his progress notes for Patient #2. In summary, Patient #2 fell on 01/22/2022, NP#5 was notified and ordered neuro checks, but did not indicate an evaluation after the fall in any of the provider notes.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50318 Based on hospital policy review, closed medical record review, event report summary review, and patient and staff interviews, the hospital staff failed to notify a patient’s family after a patient’s fall on the behavioral health unit for 2 of 2 sampled behavioral health patients who experienced a fall (Patients #2 and #15). The findings include: Review on 06/05/2024 of the hospital’s policy “Falls Prevention Plan - Inpatient, PC-86,” effective 11/2021 through 11/2024, revealed...”G. Post Fall Management...7. Notify patient’s family/emergency contact.” 1. Closed medical record review on 06/04/2024 of Patient #2 revealed a 70 year old patient that was transferred from Hospital F and admitted to Campus B, Unit C on 01/05/2022 at 2308 for suicidal ideations with a plan to overdose. Patient #2’s demographic sheet listed her spouse as the person to notify in case of emergency. The Nurse Admission Assessment dated 01/05/2022 at 2000 revealed Patient #2 had no memory impairment, thought logically with coherent speech (speech that is clear, consistent, logical, and meaningful), and had a stable gait with a firm grip. Patient #2’s Fall Risk Assessment dated 01/05/2022 at 2000 was noted as a score of 4, with a score of 0-6 being low risk, and a falls risk comment noted “not a falls risk.” The Nurses’s Note dated 01/23/2022 at 0102 revealed “At approx (approximately) 2050 patient was running backwards in the hallway when she slipped and fell on the floor. She landed on her bottom and then hit her head. She was unable to verbalize a numerical pain score as she doesn’t currently respond to questions, but stated ‘hurt’. Vitals were taken; BP (blood pressure) 108/69, pulse 93. Her head was assessed and there was no visible evidence of lacerations or bumps. She laid down for a few minutes and then stood up and began walking in the hallway again. Prior to this incident, pt (patient) was taking her clothing off and running in the halls, despite staff prompts. On-Call provider was called and ordered q2hr (every 2 hour) neuro checks (neurological checks that assess a patient’s neurological functions, motor and sensory response, and level of consciousness). Program director was also called and made aware. Pt continued to run and attempt to strip her clothing in the hallway afterwards.” The Nurse’s Note dated 01/23/2022 at 0614 revealed, “During the evening the pt was behaving bizarrely, attempting to undress in public areas; ran from her room without clothing, and as previously noted, pt fell, the pt spent the majority of the evening and early night running from one door to the other in attempt to elope, the pt then sat on the floor of the hallway near the nurses station (sic)...” Record review revealed no documentation regarding family communication following Patient #2’s fall on 01/22/2022. Review on 06/05/2024 of the Event Report Summary Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, related to Patient #2’s fall on 01/22/2022 revealed, Brief, objective description of the event: Pt fell while running backwards in the hallway. No injuries noted. Provider notified q2° (every 2 hours) neuro checks ordered. Review of Event Report Summary revealed no documentation regarding family communication following Patient #2’s fall. Interview on 06/05/2024 at 1022 with a current patient at Campus B, Unit C revealed the patient’s family was not really updated, and it was expected for the patient to provide updates. Telephone interview on 06/06/2024 at 1051 with RN#3 revealed RN#3 did not recall Patient #2. RN#3 revealed the family would not always be notified of a patient’s fall, but if the patient’s chart indicated a family member’s involvement (on the face sheet or report sheet), they should be contacted right away, and family notification should be documented. RN#3 revealed the RNs should notify a patient’s family of any change in condition. Telephone interview on 06/06/2024 at 1247 with NP #5 revealed NP #5 did not recall Patient #2. NP #5 revealed he was probably on call for medical needs/consults on 01/22/2022, and the staff called “pretty much every time” a patient fell. NP#5 revealed the RNs should call the patient’s family if a patient fell, along with the Provider notification. Interview on 06/06/2024 at 1440 with the Facility Stroke Coordinator revealed she was unable to find any specific documentation in Patient #2’s medical record regarding family communication following Patient #2’s fall on 01/22/2022. 2. Closed medical record review on 06/07/2024 of Patient #15 revealed a 57 year old patient that was involuntarily committed (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) to Campus B, Unit C on 04/23/2024 for suicidal ideations with a plan of shooting himself and was abusing substances. Patient #15’s demographic sheet listed his spouse as the person to notify in case of emergency. Patient #15’s History and Physical dated 04/24/2024 at 0920 revealed he had a medical history of chronic pain, back surgery, multiple stents, and a graft replacement. Patient #15’s coordination revealed slow steady gait, but otherwise within normal limits. Patient #15’s Fall Risk Assessment on 04/23/2024 was noted as 55 on the Edmonson Psychiatric Fall Risk Assessment, with a score of greater than 90 considered a falls risk. The Nurse’s Note dated 04/28/2024 at 1344 revealed, “On making rounds patient made tech aware that he fallen (sic). he (sic) was sitting on the toilet when he made that statement and stated that he fell in the BR (bathroom) and hit his head on the toilet. Noted abraded (sic), raised area to forehead another red tender area to the right upper portion of head, he also has a skin tear to his left index finger. he (sic) was assessed by nurse and VS (vital signs) obtained. Noted a low BP, he has a h/o (history of) dizziness. Notified (NP#8), will obtin (sic) orthostatic vs (vital signs taken while the patient is lying down, then again while standing) and head CT (computed tomography scan, specialized x-ray to produce cross-sectional images). He is awake and alert, answering questions appropriately ...” The Nurse’s Note dated 04/28/2024 at 1359 revealed, “Notified (NP#8) of low orthostatic v.s. ... send to ED (Emergency Department) for evaluation of hypotension (low blood pressure), off unit to ED @ 1400.” The Nurse’s Note dated 04/28/2024 at 1451 revealed, “Fall at 1214, sent to ED at 1400 for hypotension. Head CT negative.” Record review revealed no documentation of family notification following Patient #15’s fall on 04/28/2024. Interview on 06/05/2024 at 1022 with a current patient on the behavioral health unit at Campus B, Unit C revealed the patient’s family was not really updated, and it was expected for the patient to provide updates. Interview on 06/07/2024 at 1550 with the Director #26 revealed the facility was unable to find any information in Patient #15’s medical record regarding family notification following Patient #15’s fall on 04/28/2024. Telephone interview on 06/10/2024 at 1615 with RN#9 revealed RN#9 vaguely remembered Patient #15. RN#9 revealed Patient #15’s fall was not witnessed, and Patient #15 was assessed and had a spot on his head. RN#9 spoke to the provider, who ordered a CT scan, and Patient #15 was sent quickly for the scan. RN#9 was not aware of any communication with Patient #15’s family regarding the fall and revealed there are numerous permissions in behavioral health to communicate with the family. RN#9 revealed typically the Provider or Social Worker will follow-up with the patient’s family.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50111 Based on policy review, observation, closed medical record review, internal document reviews and staff interviews, the hospital staff failed to provide care in a safe setting by failing to utilize emergency medical equipment during resuscitation of a patient on the behavioral health unit for 1 of 1 sampled behavioral health patients that required resuscitation (Patient #3). The findings include: Review of hospital policy “Code Blue (The initiation of resuscitative efforts in a cardiac or respiratory arrest)- (Hospital A, Campus B) - PC 200,” effective 08/2022, revealed, “... The initiation of resuscitative efforts in a cardiac or respiratory arrest will follow BLS (Basic Life Support)/ ACLS (Advanced Cardiac Life Support) / PALS (Pediatric Advanced Life Support) guidelines... Each member of the code team must be familiar with the crash code (sic) and its contents. ... PROCEDURE: ... C. Follow BCLS (Basic Cardiac Life Support) guidelines until code team members arrive. D. The Code Blue team must follow necessary ACLS/PALS guidelines. E. Code documentation will be completed by an identified clinical team member. ...” Observation at Campus B of Unit C on 06/05/2024 at 0940 revealed the presence of a Code Cart (a mobile unit that contains the necessary equipment and medications to respond to a respiratory or cardiac arrest), located in a hallway behind a locked nurses’ station. Observation revealed the contents of the Code Cart included a cardiac monitor, suction equipment, defibrillator pads (pads used for delivering a shock of electricity that can restore normal heart rhythm), an oxygen tank, and blank Code Blue Sheets (a form used to document procedures that occur during resuscitation). Observation revealed the Code Cart drawers were secured with plastic, breakable lock. Closed medical record review on 06/04/2024 for Patient #3 (Pt#3) revealed a 65 year-old female that was admitted to Unit C on 09/11/2023 at 1647 with Involuntary Commitment paperwork (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) and was admitted with a chief complaint of psychosis (a mental disorder characterized by a disconnection from reality). Review of the Daily Focus Assessment Report revealed, “Assessment Date 09/18/2023 21:00 Category Note: transfered (sic) to (Campus B) ED (Emergency Department) via Hospital bed... Refer to Following Paper Documentation... Code Blue Sheet.” Review failed to reveal evidence of a Code Blue Sheet or any notes documented from Unit C to indicate what happened with Pt#3, actions such as Heimlich maneuver or CPR (cardiopulmonary resuscitation), if a crash cart was obtained or used, if the patient was suctioned, placed on a monitor and/or received any medications prior to transport to the ED. On 09/18/2023 at 2114, Pt#3 arrived in the ED (Emergency Department). Review of the ED Daily Focus Assessment Report revealed “pt unresponsive, CPR in progress” and Pt#3 was intubated (a tube is inserted through the mouth or nose and into the airway to allow air to the enter the lungs) at 2114. Review of the Code Blue Sheet, started in the ED at 2115, revealed comments that stated, “Pt received from (Unit C) CPR in progress, asystole (no electrical activity or movement in the heart muscle), cont (continue) CPR, intubated... 2122 ROSC (return of spontaneous circulation is the resumption of a sustained heart rhythm after cardiac arrest)...” Review of the Code Blue Sheet failed to reveal documentation for the time the Code Blue was announced, the time CPR started, the time of MD (Medical Doctor) arrival, or the time the Code Blue was completed. Review revealed an electrocardiogram was performed in the ED at 2124 and revealed “ACUTE MI (myocardial infarction: heart attack).” The Triage Report at 2142 revealed, “ptover (sic) from (Unit C) with CPR in progrss (sic), reportedly was eating and then started choking, heilich (sic) was performed, pt became unresponsive CPR was started.” The ED Provider Note, documented at 2204 by PA#15, revealed, “... per nursing staff choked on a peanut butter sandwich. Had a sudden collapse loss of consciousness. They checked pulse, no pulse, Code Blue was called. Our free-standing ER is on the other side of the hospital. We respond, there was no pulse. CPR was continued as well as we bag the patient. On the 2nd pulse check patient had a pulse, she was continued to be bagged, she was transported to the emergency department... Patient was immediately intubated without any medications. IVs (intravenous catheters) were established. Patient did receive 2 rounds of epinephrine (a medication used to reverse cardiac arrest) and calcium (a medication used for regulating muscle contractility). At 2nd pulse check patient had bounding carotid pulse. (Pt#3) was placed on monitor... The patient will need ongoing evaluation, treatment, and transfer... Final Diagnosis: cardiac arrest, STEMI (ST- elevation myocardial infarction: a type of heart attack).” Pt#3 was transferred to Hospital E at 2245. Review on 06/07/2024 of the Admin Report for (7900 [number for Code Blue calls]) revealed the Code Blue was called on 09/18/2023 at 2104. Review on 06/07/2024 of Unit C’s Crash Cart Check Sheet, dated September 2023, revealed the Code Cart “Key Number” remained the same from 09/17/2023 through 09/19/2023, indicating that Code Cart drawers were not opened during resuscitation efforts for Pt#3 on 09/18/2023. Review on 06/05/2024 of the Event Summary Report Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, revealed, “... description of the event: Code called after patient noted to be choking. Heimlich maneuver attempted without success. CPR initiated and taken to ED where (Pt#3) was later transferred. Family notified, provider notified, director notified... summary of interview findings: Pt noted to be choking by 1:1 (one to one observation) tech (technician); charge nurse called, heimlich maneuver attempted, pt became unresponsive, code blue called overhead; staff from ED and (Unit D) responded, CPR started, taken to ED... Summary of the improvements or response plan indicated and/or under evaluation: Protocol followed...” Interview on 06/05/2024 at 1645 with the Physician Assistant (PA#15) revealed the PA was a member of the ED Code Blue team that responded to the overhead Code Blue called on 09/18/2023 for Pt#3. Interview revealed the ED Code Blue Team responded to the Code Blue with a transfer chair and bag valve mask (a mask with a self-inflating bag for manual resuscitation). PA#15 revealed that upon arrival to Unit C, “only chest compressions were occurring” and stated there was no equipment present. PA#15 stated that upon arrival to Unit C, only 1 RN was performing CPR and no one else was assisting with the Code Blue. PA#15 stated, “there was no Crash Cart (Code Cart) on the floor to my knowledge.” Interview revealed PA#15 asked for the Crash Cart and stated, “nothing came.” PA#15 stated he did not wait around or ask again and got the patient on the bed to move to the ED. Interview revealed there was difficulty moving the bed for transfer. Interview revealed CPR and “bagging” occurred during the entire transfer from Unit C to the ED. Interview on 06/06/2024 at 1215 with a Registered Nurse (RN#16), who responded to the Code Blue from Unit D on 09/18/2023, revealed RN#16 recalled Pt#3 “appeared to rouse at some point” during compressions, produced a sound “like the patient was going to vomit,” the patient was turned to the side and only “drool” came from the patient’s mouth. Interview revealed RN#16 did not recall suction being used during resuscitative efforts. Interview revealed RN#16 did not recall the Code Cart being “cracked” on Unit C during resuscitation. Interview on 06/05/2024 at 1505 with RN#29 revealed Pt#3 arrived in the ED with CPR in progress. Interview revealed IV access was obtained and intubation occurred upon arrival to the ED. Interview revealed RN#29 did not know when CPR was started on Unit C. Interview on 06/06/2024 at 1245 with Manager#24 revealed Manager#24 was not aware of missing documentation on Unit C related to the Code Blue or PA#15’s concerns regarding the lack of equipment on Unit C during the Code Blue event. Interview on 06/07/2024 at 1105 with Director#26 and Director#27 revealed the hospital “tries to do post Code Blue reviews” but could not confirm the review was done for Pt#3 because there was no “Post Code Huddle Sheet” for Pt#3. Interview revealed Director#26 and Director#27 were not aware of PA#15’s concerns regarding lack of equipment on Unit C during the Code Blue event. Interview revealed no investigation was completed on Pt#3’s Code Blue because there was no negative feedback from hospital staff at the time of the event and Pt#3’s evaluation showed the presence of a STEMI. RN#17, RN#18, and RN#19, RNs that participated in the Code Blue on 09/18/2023, were not available for interview. In summary, review failed to reveal evidence that hospital staff utilized the Code Cart, suctioning equipment, a heart rate monitor or an Automated External Defibrillator, or medications during the resuscitation of Pt#3 on Unit C. Review revealed that suctioning, intubation, and IV access occurred after Pt#3 was transferred to the ED. Review of the Event Report Summary Report revealed an Incident Report was completed and stated “Protocol followed.” However, the investigation revealed there was no evidence of the time the Code Blue occurred, the use of emergency medical equipment during the Code Blue, or procedures that were performed on Unit C to rescuscitate Pt#3.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50111 Based on policy reviews, medical record reviews, internal document reviews, snack ingredient review, and staff interviews, hospital staff failed to analyze adverse events, identify opportunities for improvement, and implement preventative actions for 2 of 2 sampled patients with adverse events (Patient #3, Patient #2). The findings include: Review of hospital policy “Confidential Incident Report, ORG-138,” effective 09/2021, revealed, “ ...Incident: Any actions, circumstances or events which might reasonably be expected to result in a claim or legal action against the organization for damages... RESPONSIBILITY: ... Department Manager - complete Confidential Investigation reports as assigned... Risk Management - Review, investigate and report Confidential Incident reports to committees as appropriate... 1. Confidential Incident reports will be reported to hospital committee(s) as appropriate ... Confidential Incident Report - This list is for examples... Policy or procedure violation... Fall... Sentinel Events (a patient safety event that is not primarily related to the natural course of the patient’s illness and results in death, permanent harm, or severe temporary harm and intervention is required to sustain life) ...” 1. Review of hospital policy “2023 Performance Improvement Plan - Patient Safety & Clinical Quality,” effective 02/2023, revealed, “... The following data sources may be considered during the quality planning process: ... Sentinel Events/Root Cause Analysis (identification of the breakdown in processes and systems that contributed to an event that resulted in an undesired outcome and develop corrective actions)... Data collection beyond the Balanced Scorecard (‘a tool used by leadership to measure progress toward the key performance metrics’) includes, but is not limited to, the following processes or outcomes: ... Patient safety events, error reports... Analyses of clinical processes that include hazardous conditions, process malfunctions, and how errors occurred... The results of resuscitation... Intense analysis includes conducting a thorough and credible comprehensive systematic analysis, for example Root Cause Analysis, in response to sentinel events... Consideration will be taken to analyze processes related to work flow, competency assessment, credentialing, supervision of staff, as well as orientation, training and education...” Review of hospital policy “Code Blue (The initiation of resuscitative efforts in a cardiac or respiratory arrest) - (Hospital A, Campus B) - PC 200,” effective 08/2022, revealed, “... G. The Code Blue response and outcomes will be followed up by The Critical Care committee with the findings reported to the Patient Safety Clinical Quality Committee quarterly.” Closed medical record review on 06/04/2024 for Patient #3 (Pt#3) revealed a 65 year-old female that was admitted to Unit C on 09/11/2023 at 1647 with Involuntary Commitment paperwork (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) and was admitted with a chief complaint of psychosis (a mental disorder characterized by a disconnection from reality). Review of the Patient Profile revealed Pt#3’s allergies were verified on 09/11/2023 at 1820. The list of allergies included the following food allergies: gluten, carrot, corn, and rice starch. Review failed to reveal documentation for “Reaction” or “Sensitivity” under each listed allergy. “Severity: Unknown” was documented for all allergies. Review of the Medical History and Physical (H&P), documented on 09/12/2023 at 1134 revealed a history of bipolar disorder (a disorder associated with episodes of mood swings ranging lows to highs) and schizophrenia (a psychiatric disorder that affects a person’s ability to think, feel, and behave normally). Review of the H&P revealed, “Food Allergy: Carrot: (SEVERITY UNKNOWN) Corn: (SEVERITY UNKNOWN) Gluten: (SEVERITY UNKNOWN) Rice Starch (SEVERITY UNKNOWN).” Review of the Patient Observation Rounds, documented on 09/18/2023, revealed Pt#3’s monitoring level was “line of sight” and Pt#3 was “Awake/Alert” and located in “Patient Room” at 2100. Review of the Daily Focus Assessment Report revealed, “Assessment Date 09/18/2023 21:00 Category Note: transfered (sic) to (Campus B) ED (Emergency Department) via Hospital bed... Refer to Following Paper Documentation... Code Blue Sheet.” Review failed to reveal evidence of a Code Blue Sheet completed on Unit C. On 09/18/2023 at 2114, Pt#3 arrived in ED (Emergency Department). Review of the ED Daily Focus Assessment Report revealed “pt unresponsive, CPR (cardiopulmonary resuscitation) in progress” and Pt#3 was intubated (a tube is inserted through the mouth or nose and into the airway to allow air to the enter the lungs) at 2114. Review of the Code Blue Sheet, started in the ED at 2115, revealed comments that stated, “Pt received from (Unit C) CPR in progress, asystole (no electrical activity or movement in the heart muscle), cont (continue) CPR, intubated... 2122 ROSC (return of spontaneous circulation is the resumption of a sustained heart rhythm after cardiac arrest)...” Review of the Code Blue Sheet failed to reveal documentation for the time the Code Blue was announced, the time CPR started, the time of MD (Medical Doctor) arrival, or the time the Code Blue was completed. Review revealed an electrocardiogram was performed at 2124 and revealed “ACUTE MI (myocardial infarction: heart attack).” The Triage Report at 2142 revealed, “ptover (sic) from (Unit C) with CPR in progrss (sic), reportedly was eating and then started choking, heilich (sic) was performed, pt became unresponsive CPR was started.” The Ed Provider Note, documented at 2204 by PA#15, revealed, “... per nursing staff choked on a peanut butter sandwich. Had a sudden collapse loss of consciousness. They checked pulse, no pulse, Code Blue was called. Our free-standing ER is on the other side of the hospital. We respond, there was no pulse. CPR was continued as well as we bag the patient. On the 2nd pulse check patient had a pulse, she was continued to be bagged, she was transported to the emergency department... Patient was immediately intubated without any medications. IVs (intravenous catheters) were established. Patient did receive 2 rounds of epinephrine (a medication used to reverse cardiac arrest) and calcium (a medication used for regulating muscle contractility). At 2nd pulse check patient had bounding carotid pulse. (Pt#3) was placed on monitor... The patient will need ongoing evaluation, treatment, and transfer... Final Diagnosis: cardiac arrest, STEMI (ST- elevation myocardial infarction: a type of heart attack).” Pt#3 was transferred to Hospital E at 2245. Review on 06/07/2024 of the Admin Report for (7900 [number for Code Blue calls]) revealed the Code Blue was called on 09/18/2023 at 2104. Review on 06/07/2024 of Unit C’s Crash Cart Check Sheet, dated September 2023, revealed the Code Cart “Key Number” remained the same from 09/17/2023 through 09/19/2023, indicating that Code Cart drawers were not opened during resuscitation efforts for Pt#3 on 09/18/2023. Review on 06/11/2024 of the ingredient list for the peanut butter and jelly sandwiches provided on Unit C revealed the sandwiches contained wheat gluten. Review on 06/05/2024 of the Event Summary Report Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, revealed, “... description of the event: Code called after patient noted to be choking. Heimlich maneuver attempted without success. CPR initiated and taken to ED where (Pt#3) was later transferred. Family notified, provider notified, director notified... summary of interview findings: Pt noted to be choking by 1:1 (one to one observation) tech (technician); charge nurse called, heimlich maneuver attempted, pt became unresponsive, code blue called overhead; staff from ED and (Unit D) responded, CPR started, taken to ED.” . Summary of improvements or response plan indicated and/or under evaluation: Protocol followed ...” Review failed to reveal documentation that Pt#3 ingested a known food allergen. Review failed to reveal evidence of analysis of the Code Blue event, identified opportunities for improvement, or actions taken by the hospital. Review on 06/07/2024 of the Critical Care Committee Meeting minutes, dated 04/23/2024, revealed Code Blue data was reviewed for September 2023 through March 2024. Review of the meeting minutes failed to reveal evidence of review of Code Blue response and outcomes related to Pt#3. Review revealed “Scheduling mock codes” was listed under “Open Issues.” Interview on 06/05/2024 at 1540 with Dietitian#1 revealed Patient #3 “should not have received the peanut butter and jelly sandwich. It was not an appropriate snack for that patient with a gluten allergy.” Interview on 06/06/2024 at 1030 with MD#25 revealed P#3 should not have received any food containing gluten. Interview revealed Pt#3 “should not have received anything that was listed as an allergy.” Interview on 06/05/2024 at 1645 with the Physician Assistant (PA#15) revealed the PA was a member of the ED Code Blue team that responded to overhead Code Blue called on 09/18/2023 for Pt#3. Interview revealed the ED Code Blue Team responded to the Code Blue with a transfer chair and bag valve mask (a mask with a self-inflating bag for manual resuscitation). PA#15 revealed that upon arrival to Unit C, “only chest compressions were occurring” and stated was no equipment present. PA#15 stated that upon arrival to Unit C, only 1 RN was performing CPR and no one else was assisting with the Code Blue. PA#15 stated, “there was no Crash Cart (Code Cart) on the floor to my knowledge.” Interview revealed PA#15 asked for the Crash Cart and stated, “nothing came.” PA#15 stated he did not wait around or ask again and got the patient on the bed to move to the ED. Interview revealed there was difficulty moving the bed for transfer. Interview revealed CPR and “bagging” occurred during the entire transfer from Unit C to the ED. Interview on 06/06/2024 at 1245 with Manager#24 revealed Manager#24 was not aware that Pt#3 had received food containing a known food allergen immediately prior to the patient’s Code Blue event. Interview revealed Manager#24 was not aware of missing documentation on Unit C related to the Code Blue or PA#15’s concerns regarding the lack of equipment on Unit C during the Code Blue event. Interview revealed Unit C staff were “upset and crying” after Pt#3’s Code Blue and that staff had been informed that Code Blue mock drills would be provided to the staff following the event on 09/18/2023. Interview revealed no Code Blue mock codes had been performed on Unit C since the event on 09/18/2023 and there were no mock codes scheduled as of 06/06/2024. Interview on 06/06/2024 at 1020 with RN#21, an RN on Unit C, revealed RN#21 had not received education about Code Blues. Interview revealed that leadership had discussed providing mock Code Blue training, but no mock Code Blue had occurred as of 06/06/2024. Interview revealed RN#21 recalled that Pt#3 had received multiple peanut butter and jelly sandwiches during Pt#3’s stay on Unit C. Interview on 06/05/2024 at 1630 with Director#27 revealed there was no documentation of corrective actions or staff coaching that occurred on Unit C after Pt#3’s Code Blue event on 09/18/2023. Interview on 06/07/2024 at 0910 with Director#26 revealed no Root Cause Analysis had been performed for Pt#3’s Code Blue event. Interview on 06/07/2024 at 1105 with Director#26 and Director#27 revealed the hospital “tries to do post Code Blue reviews” but could not confirm the review was done for Pt#3 because there was no “Post Code Huddle Sheet” for Pt#3. Interview revealed no Code Blue mock code had been completed since 09/18/2023 and it was an issue “to work out with (Campus B).” Interview revealed Director#26 and Director#27 were not aware of PA#15’s concerns regarding lack of equipment on Unit C during the Code Blue event. Interview revealed there was a Critical Care Committee that reviewed Code Blue data, but the committee did not review response and outcomes specific to Pt#3’s Code Blue event. Interview revealed no investigation was completed on Pt#3’s Code Blue because there was no negative feedback from hospital staff at the time of the event and Pt#3’s evaluation showed the presence of a STEMI. In summary, review revealed an Incident Report was completed and the Event Report Summary Report and stated “Protocol followed.” However, the investigation revealed hospital staff failed to analyze Pt#3’s Code Blue event and identify that there was no Code Blue documentation on Unit C, there was no evidence that emergency medical equipment was used on Unit C during the Code Blue, or that Pt#3 had received a known food allergen on multiple occassions prior to the Code Blue event. The investigation revealed that leadership had informed staff that mock Code Blue training would occur after the event on 09/18/2023, but no training had occurred as of 06/11/2024. 50318 2. Review of the hospital’s policy “2021 Performance Improvement Plan - Patient Safety & Clinical Quality,” effective 12/2020 through 03/2022, revealed, “... Data collection includes, but is not limited to the following processes or outcomes ... Risk management activities including trending of reported variances/occurrences, Adverse Events/Near Misses, Analyses of clinical processes that include hazardous conditions, process malfunctions, and how the errors occurred ... Information from the analysis of data collection will be used to identify changes that will improve performance or reduce the risk of sentinel events ... System and process breakdown is the primary focus of any analysis ... When systems and process breakdowns have been identified, corrective actions will be evaluated for the strength of their effectiveness ... “ Closed medical record review on 06/04/2024 of Patient #2 revealed a 70 year old patient that was transferred from Hospital F and admitted to Campus B, Unit C on 01/05/2022 at 2308 for suicidal ideations with a plan to overdose. Patient #2 had a medical history of bipolar and 4 (four) previous suicide attempts by overdose. Patient #2’s demographic sheet listed her spouse as the person to notify in case of emergency. The Nurse Admission Assessment dated 01/05/2022 at 2000 revealed Patient #2 had no memory impairment, thought logically with coherent speech (speech that is clear, consistent, logical, and meaningful), and had a stable gait with a firm grip. Patient #2’s Fall Risk Assessment on 01/05/2022 at 2000 was noted as a score of 4, with a score of 0-6 being low risk, and a falls risk comment noted “not a falls risk.” The Nurse’s Note dated 01/23/2022 at 0102 revealed, “At approx (approximately) 2050 patient was running backwards in the hallway when she slipped and fell on the floor. She landed on her bottom and then hit her head. She was unable to verbalize a numerical pain score as she doesn’t currently respond to questions, but stated ‘hurt’. Vitals were taken; BP (blood pressure) 108/69, pulse 93. Her head was assessed and there was no visible evidence of lacerations or bumps. She laid down for a few minutes and then stood up and began walking in the hallway again. Prior to this incident, pt (patient) was taking her clothing off and running in the halls, despite staff prompts. On-Call provider was called and ordered q2hr (every 2 hour) neuro checks (neurological checks that assess a patient’s neurological functions, motor and sensory response, and level of consciousness). Program director was also called and made aware. Pt continued to run and attempt to strip her clothing in the hallway afterwards.” A verbal order for neuro checks q2hr was entered by RN#3 with NP#5 as the ordering provider, which started on 01/22/2022 at 2100 for 12 hours (a total of 6 neuro checks), followed by neuro checks q4hr (every 4 hours) on 01/23/2022 at 1300 for 12 hours (a total of 3 neuro checks). Neuro checks were performed using the Glasgow Coma Scale (a scale used to measure a person’s level of consciousness) for the first 8 (eight) hours, for a total of 4 (four) neuro checks. Record review revealed no other neuro checks were performed for the next 10 hours. A Psychosocial Assessment was performed on 01/23/2022 at 1324 which noted Patient #2’s cognition as oriented x1 (times one, with no specification on patient’s orientation), disoriented, and confused. Record review revealed no other neuro checks were performed until 01/25/2022 at 2119 (approximately 56 (fifty-six) hours after the Psychosocial Assessment). Review on 06/05/2024 of the Event Report Summary Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, related to Patient #2’s fall on 01/22/2022 revealed, Brief, objective description of the event: Pt fell while running backwards in the hallway. No injuries noted. Provider notified q2° (every 2 hours) neuro checks ordered. Brief summary of interview findings: No injuries noted; provider notified. Summary of the improvements or response plan indicated and/or under evaluation: Protocol followed. Summary of the monitoring and audit plan: Falls reported at PSCQC (Patient Safety and Clinical Quality Committee). Review of Event Report Summary revealed no documentation regarding further follow-up related to Patient #2’s fall, no documentation regarding family communication following Patient #2’s fall, no documentation that Patient #2’s neuro checks were not completed as ordered, and a lack of provider assessment following Patient #2’s fall. Interview request on 06/05/2024 at 1300 for Registered Nurse (RN # 30), who cared for Patient #2 on 01/23/2022, revealed the RN was no longer employed at the facility. Interview request on 06/06/2024 at 0959 for Registered Nurse (RN # 31), who documented regarding Patient #2’s fall on 01/22/2022, revealed the RN was no longer employed at the facility. Interview on 06/07/2024 at 1152 with Directors #26 and #27 revealed the incident report created for Patient #2’s fall on 01/22/2022 noted that prior to the fall, Patient #2 was running through the hall and taking her clothes off. Patient #2 fell on her bottom first, fell backwards, and then hit her head. The Program Director, Team Lead (RN#3), and NP#5 were notified. Directors #26 and #27 revealed they were unsure if the family had been notified. Directors #26 and #27 revealed nothing was written on the incident report that seemed to be a problem. Directors #26 and #27 revealed the Nurse Manager for the unit was responsible for a review of the incident report and to follow-up if there were concerns. Directors #26 and #27 revealed the unit Nurse Manager who would have reviewed this incident report and the Program Director were no longer working at the facility. Follow-up Interview on 06/10/2024 at 1312 with Director #26 revealed Patient #2’s fall was not considered a sentinel event (an unanticipated event that results in death or serious physical or psychological injury to a patient), therefore, no root cause analysis was performed, and the “typical review process” was utilized (the Nurse Manager reviewed the incident report and would follow up with any concerns). Director #26 revealed no issues or concerns were noted with the incident report regarding Patient #2’s fall on 01/22/2022.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50111 Based on policy review, observations, closed medical record review, Event Report Summary Form review, snack ingredient review and staff interviews, nursing staff failed to supervise the distribution of snacks to a patient with a known food allergy for 1 of 2 patients with food allergies (Pt #3). The patient received snacks containing the allergen, subsequently appeared to choke and then became unresponsive. Nursing staff failed to follow a provider’s order for neuro checks for 1 of 2 sampled behavioral health patients (Pt #2) who experienced a fall. The findings include: 1. Review of hospital policy “Patient Assessment and Reassessment, PC-41,” effective 09/2023 through 09/2026 , revealed, “... 3. Assessments are performed by each discipline within its scope of practice, state licensure laws, applicable regulations or certification. 4. A Registered Nurse assesses the patient’s need for nursing care in all settings where nursing care is provided. ...” Request for a policy regarding nursing oversight and delegation of tasks on 06/11/2024 revealed no policy existed. Observation at Hospital A, Campus B on 06/05/2024 at 0940 of the nourishment room on Unit C revealed a refrigerator containing patient snacks that included food industry labeled peanut butter and jelly sandwiches, yogurt, and milk. Observation revealed the refrigerator contained hospital prepared sandwiches that were wrapped in plastic, dated, and did not include a list of ingredients. Observation of the Shift Report Sheet, held by RN#32, revealed information for each patient including diet and allergies. Observation on 06/05/2024 at 1515 at Campus B revealed MHT#32 distributing snacks to patients. MHT#32 stood inside the door of the nourishment room and gave snacks to patients waiting at the door. A list of available snacks for patients on a diabetic diet was posted on the door. Observation revealed no list posted for other special diets or snacks containing common food allergens. Observation failed to reveal the presence of a registered nurse (RN) during distribution of snacks. Closed medical record review on 06/04/2024 for Patient #3 (Pt#3) revealed a 65 year-old female that was admitted to Unit C on 09/11/2023 at 1647 with Involuntary Commitment paperwork (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) and was admitted with a chief complaint of psychosis (a mental disorder characterized by a disconnection from reality). Review of the Patient Profile revealed Pt#3’s allergies were verified on 09/11/2023 at 1820. The list of allergies included the following food allergies: gluten, carrot, corn, and rice starch. Review failed to reveal documentation for “Reaction” or “Sensitivity” under each listed allergy. “Severity: Unknown” was documented for all allergies. Review of the Provider Orders revealed an order for “Low Fat, Low Cholesterol Diet” was placed by MD#25 on 09/11/2023 at 2218. Review of the Medical History and Physical (H&P), documented on 09/12/2023 at 1134 revealed a history of bipolar disorder (a disorder associated with episodes of mood swings ranging lows to highs) and schizophrenia (a psychiatric disorder that affects a person’s ability to think, feel, and behave normally). Review of the H&P revealed, “Food Allergy: Carrot: (SEVERITY UNKNOWN) Corn: (SEVERITY UNKNOWN) Gluten: (SEVERITY UNKNOWN) Rice Starch (SEVERITY UNKNOWN).” Review revealed Pt#3 was transferred to the Emergency Department (ED) on 09/18/2023 at 2114 for cardiac arrest. The Ed Provider Note, documented at 2204 by PA#15, revealed, “... per nursing staff choked on a peanut butter sandwich. Had a sudden collapse loss of consciousness.” Pt#3 was transferred to Hospital E at 2245. Review on 06/11/2024 of the ingredient list for the peanut butter and jelly sandwiches provided on Unit C revealed the sandwiches contained wheat gluten. Interview on 06/05/2024 at 1530 with the mental health technician (Tech#20) revealed Tech#20 was alone in the room with Pt#3 when Tech#20 gave the patient a peanut butter and jelly sandwich as an evening snack. Interview revealed the snack was brought into the room by another technician earlier in the evening. Interview revealed the patient appeared to choke while eating the sandwich, then became unresponsive and CPR was initiated. Interview revealed Tech#20 did not recall that Pt#3 had an allergy to gluten. Tech#20 stated mental health technicians had to determine if a patient could have a certain snack based on the patient’s allergies or had to ask the registered nurse (RN). Tech#20 stated, “patients will tell us if they can’t have certain foods.” Interview on 06/06/2024 at 1020 with a Registered Nurse (RN#21), who had taken care of Pt#3, revealed RN#21 would not have given Pt#3 a peanut butter and jelly sandwich based on the patient’s allergy to gluten. Interview revealed technicians typically distributed snacks to the patients. Interview revealed RN#21 was not sure if the technicians knew to check the ingredient label and compare the label to a patient’s allergy list. RN#21 revealed technicians did not normally ask the RNs if a snack is appropriate to give to a patient. Interview revealed RN#21 recalled that Pt#3 had received multiple peanut butter and jelly sandwiches during Pt#3’s stay on Unit C. Interview on 06/10/2024 at 1225 with Tech#23 revealed that mental health technicians were responsible for pulling snacks and distributing snacks to patients. Interview revealed Tech#23 used the Shift report Sheet to determine patient allergies and diet. Interview revealed that RNs were not involved in pulling snacks for patients. Interview on 06/10/2024 at 1310 with RN#22 revealed the RNs were responsible for monitoring the entire unit and did not “closely observe” the technicians’ distribution of snacks to patients. RN#22 revealed that RNs reported allergies to the technicians and the technicians “should know the allergies and appropriate snacks.” Interview revealed RN#22 has never had a technician ask if food was appropriate to give to a patient based on the patient’s allergies. Interview on 06/05/2024 at 1540 with Dietitian#1 revealed RNs on the unit are responsible for determining if a snack is appropriate for a patient. Interview revealed Pt#3 “should not have received the peanut butter and jelly sandwich. It was not an appropriate snack for that patient with a gluten allergy.” Interview on 06/06/2024 at 1030 with MD#25 revealed P#3 should not have received any food containing gluten. Interview revealed Pt#3 “should not have received anything that was listed as an allergy.” Interview on 06/06/2024 at 1245 with Manager#24 revealed technicians should not make the determination regarding what snack is appropriate for a patient. Interview revealed the RN was responsible for determining appropriate snacks and should be present when snacks were given. Interview on 06/06/2024 at 0940 with Director#26 revealed that it had been reported that Pt#3 had received multiple peanut butter and jelly sandwiches. In summary medical record review and interviews failed to reveal evidence that nursing staff supervised and monitored the distribution of snacks to Pt#3. The investigation revealed that Pt#3 received a snack with a known food allergen on multiple occassions. 50318 2. Review of the hospital’s policy “Falls Prevention Plan - Inpatient, PC-86,” effective 11/2021 through 11/2024, revealed, “...G. Post Fall Management 1. Assess for injury. If suspected neck or head injury notify physician before moving... 5. Monitor patient as condition warrants.” Review of the hospital’s policy “Patient Assessment and Reassessment, PC-41,” effective 09/2020 through 09/2023, revealed, “... 3. Assessments are performed by each discipline within its scope of practice, state licensure laws, applicable regulations or certification. 4. A Registered Nurse assesses the patient’s need for nursing care in all settings where nursing care is provided. ...” Request for a policy regarding nursing oversight and following physician’s orders on 06/11/2024 revealed the only policy was specific to medication orders. Closed medical record review on 06/04/2024 of Patient #2 revealed a 70 year old patient was transferred from Hospital F and admitted to Campus B, Unit C on 01/05/2022 at 2308 for suicidal ideations with a plan to overdose. Patient #2 had a medical history of bipolar disorder and 4 (four) previous suicide attempts by overdose. The Nurse Admission Assessment on 01/05/2022 at 2000 revealed Patient #2 had no memory impairment, thought logically with coherent speech (speech that is clear, consistent, logical, and meaningful), and had a stable gait with a firm grip. Patient #2’s Fall Risk Assessment on 01/05/2022 at 2000 was noted as a score of 4, with a score of 0-6 being low risk, and a falls risk comment noted “not a falls risk.” The Nurse’s Note dated 01/23/2022 at 0102 revealed “At approx (approximately) 2050 patient was running backwards in the hallway when she slipped and fell on the floor. She landed on her bottom and then hit her head. She was unable to verbalize a numerical pain score as she doesn’t currently respond to questions, but stated ‘hurt’. Vitals were taken; BP (blood pressure) 108/69, pulse 93. Her head was assessed and there was no visible evidence of lacerations or bumps. She laid down for a few minutes and then stood up and began walking in the hallway again. Prior to this incident, pt (patient) was taking her clothing off and running in the halls, despite staff prompts. On-Call provider was called and ordered q2hr (every 2 hour) neuro checks (neurological checks that assess a patient’s neurological functions, motor and sensory response, and level of consciousness). Program director was also called and made aware. Pt continued to run and attempt to strip her clothing in the hallway afterwards.” A verbal order for neuro checks q2hr was entered by RN#3 with NP#5 as the ordering provider, which started on 01/22/2022 at 2100 for 12 hours (a total of 6 neuro checks), followed by neuro checks q4hr (every 4 hours) on 01/23/2022 at 1300 for 12 hours (a total of 3 neuro checks). Neuro checks were performed using the Glasgow Coma Scale (a scale used to measure a person’s level of consciousness) for the first 8 (eight) hours, for a total of 4 (four) neuro checks. Record review revealed no other neuro checks were performed for the next 10 hours. A Psychosocial Assessment was performed on 01/23/2022 at 1324 which noted Patient #2’s cognition as oriented x1 (times one, with no specification on patient’s orientation), disoriented, and confused. Record review revealed no other neuro checks were performed until 01/25/2022 at 2119 (approximately 56 (fifty-six) hours after the Psychosocial Assessment). Review on 06/05/2024 of the Event Report Summary Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, related to Patient #2’s fall on 01/22/2022 revealed, Brief, objective description of the event: Pt fell while running backwards in the hallway. No injuries noted. Provider notified q2° (every 2 hours) neuro checks ordered. Brief summary of interview findings: No injuries noted; provider notified. Summary of the improvements or response plan indicated and/or under evaluation: Protocol followed. Summary of the monitoring and audit plan: Falls reported at PSCQC (Patient Safety and Clinical Quality Committee). Review of Event Report Summary revealed no documentation regarding further follow-up related to Patient #2’s fall, and no documentation that Patient #2’s neuro checks were not completed as ordered. Interview request on 06/05/2024 at 1300 for Registered Nurse (RN # 30), who cared for Patient #2 on 01/23/2022, revealed the RN was no longer employed at the facility. Interview request on 06/06/2024 at 0959 for Registered Nurse (RN # 31), who documented regarding Patient #2’s fall on 01/22/2022, revealed the RN was no longer employed at the facility. Telephone interview on 06/06/2024 at 1051 with RN#3 revealed RN#3 did not recall Patient #2 and did not recall Patient #2’s fall. RN#3 revealed if a patient was found on the floor due to a fall, the patient would remain on the floor, with vital signs performed, then the patient would be assisted to a bed or chair, and the provider would be notified. RN#3 revealed it would be up to the provider for any x-rays or CT scans (computed tomography scan, specialized x-ray to produce cross-sectional images). RN#3 revealed for neuro checks, the RNs assessed if the patient was alert, oriented, their pupils were equal, and any other abnormalities or changes in orientation. RN#3 revealed the staff would follow the provider’s orders. Interview on 06/07/2024 at 1152 with Directors #26 and #27 revealed the incident report created for Patient #2’s fall on 01/22/2022 noted that prior to the fall, Patient #2 was running through the hall and taking her clothes off. Patient #2 fell on her bottom first, fell backwards, and then hit her head. The Program Director, Team Lead (RN#3), and NP#5 were notified. Directors #26 and #27 revealed nothing was written in the incident report that seemed to be a problem. Directors #26 and #27 revealed the Nurse Manager for the unit was responsible for a review of the incident report and to follow-up if there were concerns. Directors #26 and #27 revealed the unit Nurse Manager, who would have reviewed this incident report, and the Program Director were no longer working at the facility. Follow-up Interview on 06/10/2024 at 1312 with Director #26 revealed Patient #2’s fall was not considered a sentinel event (an unanticipated event that results in death or serious physical or psychological injury to a patient); therefore, no root cause analysis was performed, and the “typical review process” was utilized (the Nurse Manager reviewed the incident report and would follow up with any concerns). Director #26 revealed no issues or concerns were noted in the incident report regarding Patient #2’s fall on 01/22/2022.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 50111 Based on policy review, observation, closed medical record review, internal document reviews and staff interviews, hospital staff failed to document resuscitation procedures on the behavioral health unit for 1 of 1 sampled behavioral health patients that required resuscitation (Patient #3). The findings include: Review of hospital policy “Documentation of Nursing Care,” effective 02/2023, revealed, “... 1. Documentation of Nursing Care includes: ... b. the nursing diagnosis and/or patient care needs/problems... c. the plan of patients care including interventions to address the diagnosis and/or need the nursing care provided... d. the effectiveness/outcomes of nursing interventions, including patient’s response... 5. All entries are to be recorded by the person providing the care/making the observation... Review of hospital policy “Code Blue (The initiation of resuscitative efforts in a cardiac or respiratory arrest) - (Hospital A, Campus B) - PC 200,” effective 08/2022, revealed, “... E. Code documentation will be completed by an identified clinical team member. ...” Observation at Campus B of Unit C at on 06/05/2024 at 0940 revealed the presence of a Code Cart (a mobile unit that contains the necessary equipment and medications to respond to a respiratory or cardiac arrest), located in a hallway behind a locked nurses’ station. Observation revealed the contents of the Code Cart included blank Code Blue Sheets (a form used to document procedures that occur during resuscitation). Closed medical record review on 06/04/2024 for Patient #3 (Pt#3) revealed a 65 year-old female that was admitted to Unit C on 09/11/2023 at 1647 with Involuntary Commitment paperwork (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) and was admitted with a chief complaint of psychosis (a mental disorder characterized by a disconnection from reality). Review of the Daily Focus Assessment Report revealed, “Assessment Date 09/18/2023 21:00 Category Note: transferred (sic) to (Campus B) ED (Emergency Department) via Hospital bed... Refer to Following Paper Documentation... Code Blue Sheet.” Review failed to reveal evidence of a Code Blue Sheet completed on Unit C. On 09/18/2023 at 2114, Pt#3 arrived in ED (Emergency Department). Review of the Code Blue Sheet, started in the ED at 2115, revealed comments that stated, “Pt received from (Unit C) CPR (cardiopulmonary resuscitation) in progress, asystole (no electrical activity or movement in the heart muscle), cont (continue) CPR, intubated... 2122 ROSC (return of spontaneous circulation is the resumption of a sustained heart rhythm after cardiac arrest)...” Review of the Code Blue Sheet failed to reveal documentation for the time the Code Blue was announced, the time CPR started, the time of MD (Medical Doctor) arrival, or the time the Code Blue was completed. Pt#3 was transferred to Hospital E at 2245. Review on 06/07/2024 of the Admin Report for (7900 [number for Code Blue calls]) revealed the Code Blue was called on 09/18/2023 at 2104. Review on 06/05/2024 of the Event Summary Report Form (a documented summary of the original incident report), completed on 06/05/2024 by Director#27, revealed, “... description of the event: Code called after patient noted to be choking. Heimlich maneuver attempted without success. CPR initiated and taken to ED where (Pt#3) was later transferred. Family notified, provider notified, director notified... summary of interview findings: Pt noted to be choking by 1:1 (one to one observation) tech (technician); charge nurse called, heimlich maneuver attempted, pt became unresponsive, code blue called overhead; staff from ED and (Unit D) responded, CPR started, taken to ED.” Interview on 06/05/2024 at 0940, during tour of Unit C, with a Registered Nurse (RN#32) revealed Code Blue documentation should occur on the Code Blue Sheet and in a Progress Note. Interview revealed Code Blue Sheets were stored on the Code Cart. Interview on 06/05/2024 at 1645 with the Physician Assistant (PA#15) revealed the PA was a member of the ED Code Blue Team that responded to overhead Code Blue called on 09/18/2023 for Pt#3. Interview revealed PA#15 “did not recall documentation on a Code Blue Sheet occuring on Unit C at the time of the Code Blue. Interview revealed the Code Blue Sheet was started in the ED after the patient was transferred to the ED for continued resuscitation. Interview on 06/06/2024 at 1020 with RN#21, who was present at the Code Blue, revealed it was the responsibility of the RN who responded to the Code Blue to document the event on the Code Blue Sheet or in a Progress Note. Interview on 06/06/2024 at 1215 with RN#16, who responded to the Code Blue from Unit D on 09/18/2023, revealed RN#16 did not recall documentation on a Code Blue Sheet occurring on Unit C at the time of the Code Blue. Interview on 06/04/2024 at 1600 with Manager#24 revealed the expectation that Code Blue documentation should occur on the Code Blue Sheet and in a Progress note. Medical record review failed to reveal documentation of resuscitative efforts during the resuscitation of Pt#3 on Unit C.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 50111 Based on observations, medical record reviews, review of job description, snack ingredient list and interviews with staff, the dietitian failed to provide supervision and oversight of diet and allergy appropriate snacks for 1 of 2 sampled patients that had food allergies (Pt#3). The patient received snacks containing the allergen, then after a snack the patient appeared to choke and became unresponsive. The findings included: A request for policies related to identifying correct nutritional snacks revealed no policies were available for distributing snacks to patients with food allergies. Observation at Hospital A, Campus B on 06/05/2024 at 0940 of the nourishment room on the behavioral health unit (Unit C) revealed a refrigerator containing patient snacks that included food industry labeled peanut butter and jelly sandwiches, yogurt, and milk. Observation revealed the refrigerator contained hospital prepared sandwiches that were wrapped in plastic, dated, and did not include a list of ingredients. Observation on 06/05/2024 at 1515 on Campus B revealed MHT #32 distributing snacks to patients. MHT #32 stood inside door of kitchen area and gave snacks to patients waiting at the door. A list of available snacks for diabetic diet was posted on the door. Observation revealed no list posted for other special diets or snacks containing common food allergens. Observation failed to reveal the presence of a registered nurse (RN) during distribution of snacks. Closed medical record review on 06/04/2024 for Patient #3 (Pt#3) revealed a 65 year-old female that was admitted to Unit C on 09/11/2023 at 1647 with Involuntary Commitment paperwork (a legal process by which a person is confined to a psychiatric hospital or unit when symptoms of a mental illness or disorder escalate and a person is considered a danger to themselves or others) and was admitted with a chief complaint of psychosis (a mental disorder characterized by a disconnection from reality). Review of the Patient Profile revealed Pt#3’s allergies were verified on 09/11/2023 at 1820. The list of allergies included the following food allergies: gluten, carrot, corn, and rice starch. Review failed to reveal documentation for “Reaction” or “Sensitivity” under each listed allergy. “Severity: Unknown” was documented for all allergies. Review of the Provider Orders revealed an order for “Low Fat, Low Cholesterol Diet” was placed by MD#25 on 09/11/2023 at 2218. Review of the Medical History and Physical (H&P), documented on 09/12/2023 at 1134 revealed a history of bipolar disorder (a disorder associated with episodes of mood swings ranging lows to highs) and schizophrenia (a psychiatric disorder that affects a person’s ability to think, feel, and behave normally). Review of the H&P revealed, “Food Allergy: Carrot: (SEVERITY UNKNOWN) Corn: (SEVERITY UNKNOWN) Gluten: (SEVERITY UNKNOWN) Rice Starch (SEVERITY UNKNOWN).” Review revealed Pt#3 was transferred to the Emergency Department (ED) on 09/18/2023 at 2114 for cardiac arrest. The Ed Provider Note, documented at 2204 by PA#15, revealed, “... per nursing staff choked on a peanut butter sandwich. Had a sudden collapse loss of consciousness.” Pt#3 was transferred to Hospital E at 2245. Review of job description for Dietitian #1 revealed “Educate patients and/or family members on nutritional needs...Inform nursing and/or family members on nutritional needs as indicates. Educate staff, nursing and food service employees on issues regarding special diets. Attend patient rounds on assigned floors. Inform nursing and physician of changes in the patient’s nutritional status....” Review on 06/11/2024 of the ingredient list for the peanut butter and jelly sandwiches provided on Unit C revealed the sandwiches contained wheat gluten. Interview on 06/05/2024 at 1530 with a mental health technician (MHT, Tech#20) revealed the MHT gave Pt#3 a peanut butter and jelly sandwich as an evening snack. Interview revealed the patient appeared to choke while eating the sandwich, then became unresponsive and CPR was initiated. Interview revealed Tech#20 did not recall that Pt#3 had an allergy to gluten. Interview revealed MHTs have to determine if a patient can have a certain snack based on the patient’s allergies or ask the registered nurse (RN). Interview on 06/06/2024 at 1420 with Dietician#1 revealed the dietary department was responsible for stocking snacks, delivered snacks to the unit, but was not responsible for oversight of the distribution of snacks to patients on the unit. Interview revealed staff referred to the medical record for patient allergies. Dietician#1 stated RNs on the unit are responsible for determining if a snack is appropriate for a patient. When asked how hospital staff could determine if a snack with no ingredient label contained a food allergen, Dietician#1 stated, “I have no answer for that”. Interview revealed that Dietician#1 provided no formal education to hospital nursing staff or technicians, but was available to answer questions as needed. Dietician #1 stated there had been no classes provided to the staff related appropriate sancks and no staff education regarding gluten free diet choices. Interview revealed Pt#3 should not have received the peanut butter and jelly sandwich based on the patient’s allergy to gluten. Dietician #1 stated there were interdisciplinary rounds on patients each morning. Interview on 06/06/2024 at 1645 with Director#28 revealed Dietician#1 should provide education to unit staff periodically and as needed. Interview revealed no formal education about snacks had been provided to staff. 34065 Interview on 06/05/2024 at 1515 with MHT #32 confirmed there was no list for appropriate snacks for patients with special dietary needs or allergies. Interview revealed the charge nurse would be asked if there was a question about the correct snack for the patient. Interview revealed no recall of classes or education received regarding appropriate snacks for special diets. Interview on 06/05/2024 at 1615 with LPN #34 revealed LPN #34 was unsure of the correct snack for a gluten free diet. Interview revealed there was not a list of appropriate snacks available for reference. Interview of LPN #34 revealed LPN #34 asked the surveyor if gluten was in bread. Interview revealed the gluten free snacks were fruit and pudding from the refrigerator. Interview on 06/05/2024 at 1625 with RN #33 revealed he was charge nurse of the day of the interview. RN #33 returned to surveyor with a list titled “Beverages, Snacks, & Condiments” found at the back of the file drawer. Interview revealed RN #33 had to look for the list for a few minutes, not easily available to the staff. Interview revealed there was no effective date on the diet list. Interview revealed the list did not include approved snacks for the gluten free diet. Interview on 06/07/2024 at 1430 with Administrator #35 revealed the dietary department reports to this administrator. Interview revealed the job description revealed the dietitian is responsible for teaching the staff about special diets and appropriate foods for the patients. The interview revealed there was no documentation of the dietitian providing education to the staff for special diets or appropriate foods for the patients.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 47421 Based on review of policies, medical staff rules and regulations, medical record reviews and staff and physician interviews, the Emergency Department physicians failed to take ownership of a patient and incorporate hospital resources to ensure a safe and appropriate disposition of a patient who presented to the hospital DED for 1 or 26 ED patients reviewed (Pt #1) and failed to provide documented evidence of physician assumption of care and ongoing reassessment results for 1 of 26 ED patients reviewed (Pt #7) The findings included: Review of the Medical Staff Bylaws dated 04/18/2023 revealed “...BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP Each member of the Medical Staff shall:...Provide his/her patients with continuous care at the generally recognized professional level of quality....Adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the Hospital ...” 1. Visit #1. Hospital A-Campus B. Closed dedicated emergency department (DED) medical record review of Patient #1 revealed a 57 year old male presented to (Hospital A-Campus B) ED on 03/09/2024 at 1348 after being released from prison via a private ambulance company. The chief complaint was listed as social problem. Past medical history included DM (diabetes mellitus) and right hemiparesis after a stroke 5 months ago. Review of nursing note at 1400 revealed the patient’s sisters refused the patient to be brought to their home. At 1410 the MSE (medical screen exam) was initiated. Review of a nursing note at 1410 revealed “APS (adult protective services) refused to take aps report for abandonment from (named prison) and family.” Review of a physician note at 1410 revealed “ ...Medical Decision Making: 57-year-old male who was discharged from (named prison) hospital. He was brought to our ER (emergency room) after his sister said she was unable to care for him at home. No arrangements were made ... He apparently is not able to ambulate without assistance. However there is no new medical problem that needs treatment today he was supposed to go home. Ambulance squad says they were insert [sic] to bring him to Lewis Berg [sic] because this is where he lives. the prison officers apparently despite knowing that there was a problem left the scene [sic] Multiple discussion phone calls with both the ambulance company (named) from (named ambulance company), our nurse manager (named), and the nursing supervisor and the CO [sic] (named). the [sic] ambulance company said they had talked to (named hospital-Hospital C) transfer center and were told that the patient was accepted at the ER. However this was discussed with the nurse manager from (named hospital-Hospital C, named manager) and also the ER doctor (named) neither of whom knew anything about an acceptance/transfer [sic] we [sic] were assured by (named CEO) that if we did an MSE and discharged the patient we would no be in violation of EMtala [sic]. MSE is documented patient does not have any acute problems requiring admission at this time. We are instructed to discharge the patient. The ambulance company will take him to (named hospital-Hospital C) although the ER is still unaware of any acceptance as per discussion with (named manager) again ... Incidentally patient can not be return to (named prison) because he is no longer prisoner and the prison officers left the scene ...” Review of a triage note at 1434 revealed “Patient brought by (named ambulance company) after being released by (named) prison. Ambulance passed by multiple hospitals to bring the patient to louisburg [sic].” Review of vital signs at 1434 revealed temperature 98.0, heart rate 66, respiration 21, SpO2 99%, blood pressure 123/74, pain score of 0, and glucose of 144. Review of a nursing note at 1436 revealed “Spoke with charge nurse of 5th floor at (named prison) about the patient and they were under the impression he was being taken to the sisters house.” Review of a nursing note at 1558 revealed “Pt (patient) had multiple family members show up to see the patient however none of them offered to take him to their home.” Review of a nursing note at 1558 revealed “Patient discharged to (named ambulance company) to be taken back to (named prison), which was his point of origin.” The patient was discharged at 1558. Visit #2. Hospital C. Closed dedicated emergency department (DED) medical record review of Patient #1 revealed a 57 year old male presented to (Hospital C) ED on 03/09/2024 at 1711 via a private ambulance company. Review of ED timeline chief complaint revealed “Weakness (Pt BIB (named ambulance company), unit 9, after being released from (named prison) earlier today. EMS (emergency medical services) called originally because pt is R (right) side paralysis d/t (due to) previous CVA (cerebrovascular accident-stroke). Pt altered LOC (level of consciousness) at baseline s/p (status post) CVA, poor historian. EMS took pt to (named hospital-Campus B), pt remained on stretcher for 3 hrs then sent out of ED. EMS team then continued on to this ED because they did not know what to do with pt. Pt w no new c/c (chief complaint) at this time. (Named hospital-Campus B) told EMS to take pt back to prison. EMS chief told team to bring here.” Review of a physician note at 1721 revealed “ ...Due to the patient’s prior strokes, he is nonambulatory. Per family, the plan was to provide the patient with a hospital bed at home and in-home nursing ... Family states that they were called to pick the patient up from present [sic] today, but that none of the home measures had been put into place yet, so they refused to bring him back home ...Family states that they would be willing to bring the patient home if proper measures to care for the patient were in place ... After a long discussion with family, we opted to keep the patient here pending case management/PT/OT (physical therapy/occupational therapy) evaluation to attempt to arrange for better resources for the patient outside of the hospital ... The patient he was taken by private ambulance service to (named hospital-Campus B) in Louisburg. According to staff here, a physician from (named hospital-Campus B) emergency department called this facility earlier today and requested that the patient be sent from the emergency department to our emergency department. Our staff here informed the other hospital that the patient would need an accepting physician and inpatient bed and could not be transferred ED to ED as this was not a higher level of care and there did not seem to be a medical reason for it. The other hospital was given the transfer center information and asked to arrange transfer. The charge nurse here states that she was then called back by (named hospital-Campus B) and was told that ‘the patient was being discharged and 911 was being called to bring him to this facility ...’ They arrived with a discharge sheet/aftercare instructions ...no other documentation was brought with he patient. There was no EMTALA form. The discharge form states the patient received a ‘medical screening exam.’ There are no laboratory results, imaging results, or prior medical records that were brought with the patient.” At 2137 ED disposition set to admit. Review of discharge summary revealed the patient was accepted to (named) rehab for long term care. Review revealed the patient was discharged on 04/08/2024 at 1422. Review of private ambulance care record revealed “Upon arrival at (named hospital-Campus B), ED staff informed Unit 9 that there [sic] were not aware of PT coming to their facility and that no beds were available. Unit 9 was informed that it would be a while before a bed would be made available. Once in the ED, Unit 9 was then informed by ED staff that they will not be accepting this patient. Unit 9 called dispatch to let them know about this situation. (Named prison) Correctional Officers left at 13:35. Dispatch said for Unit 9 to leave the hospital and take the PT to (named hospital-Hospital C) ED. Unit 9 informed (named hospital-Campus B) ED staff that we would be taking the pt to (named hospital-Hospital C) ED but they told Unit 9 that they will not be allowing Unit 9 to leave due to (named hospital-Campus B) ED staff being worried about getting a violation. (Named hospital-Campus B) ED staff told Unit 9 to keep the pt on the stretcher and that they will be discharging him immediately, because they will not have this pt ‘dumped’ at their ED. ED staff explained that they are a free-standing ER and do not have the capacity for this PT to stay for months. ED staff took PT vitals, glucose levels, and looked at pt’s back side before discharging. Pt remained on the stretcher in the hallway of the ED for over 3 hours, before Unit 9 signed the discharge paperwork. During the 3 hours at the ED, Unit 9 involved dispatch and the medical director to help aid this situation. (Named hospital-Campus B) refused to let Unit 9 leave their ED, but also refused to take the PT. (Named hospital-Campus B) ED staff refused to sign on behalf of the PT. Unit 9 then left (named hospital-Campus B) ED with the PT and headed to (named hospital-Hospital C) ED where the pt was accepted and care was transferred to ED staff, who signed for the PT.” Interview on 06/04/2024 at 1615 with CEO #38 revealed that the patient was discharged home by (named prison). The ambulance staff were then instructed to take the patient to the hospital in the patient’s county of residence after the sister refused to accept the patient at her home. Interview revealed the patient had no medical complaints. The MSE was done, and staff were told to instruct the ambulance company to send the patient back to his place of origin. Interview revealed the CEO spoke with administration from (named prison) and they were informed that the patient would be coming back to the prison and the patient needed to be safely discharged from the prison. Interview revealed “The patient was essentially dumped here. The patient had no medical need to be treated or transferred. It would have been inappropriate to transfer him with no acute medical need and the patient was at his baseline. The (named prison) should have handled his discharge appropriately.” Interview revealed had the patient had a medical need the hospital would have taken him, but no need was communicated to us. Interview revealed the CEO was unaware of the patient being taken to (Hospital C) or what the ambulance dispatch advised the ambulance crew to do. Interview revealed it was communicated to the ambulance crew to take the patient back to his place of origin after being discharged from (Campus B). Interview on 06/05/2024 at 0944 with RN #8 revealed the ambulance service stated they were taking the patient to (Hospital C) per their supervisor. Interview revealed that when the physician called (Hospital C) no one knew about the patient coming. Interview revealed (Campus B) only discharged the patient after getting an MSE, the patient was not transferred to (Hospital C). Interview revealed the ambulance company was told to take the patient back to (named prison). Interview on 06/05/2024 at 0950 with NM #12 revealed the call placed to (Hospital C) was only for courtesy, not because the patient was being transferred there. Interview revealed the patient was to go back to place of origin for them to provide a safe discharge. Interview revealed that patients have come into our ED in the past and were kept for placement, but in this case the patient did not have a medical complaint. Interview on 06/05/2024 at 1035 with MD #10 revealed that the ambulance staff stated their director informed them to take the patient to (Hospital C). Interview revealed that the physician called (Hospital C) as a courtesy and the staff were not aware of the patient being accepted there. Interview revealed that the physician called back to (Hospital C) after the patient was discharged to inform them that the patient was possibly on the way there. “(Hospital C) knew it was not a transfer.” Interview revealed calls were placed to administration staff and the ED physician and staff were told it was not a violation if an MSE was done. Interview revealed the patient needed rehab service and the (named prison) released him and would not take him back. Interview revealed it was not (campus B) idea for the patient to go to (Hospital C), the ambulance staff stated they were instructed to take him there. Interview revealed Hospital A-Campus B did not have any inpatient beds and the patient would have needed to be discharged to another facility regardless. Interview revealed the physician felt the discharge plan for the patient to be taken to Hospital C via private ambulance was a safe discharge plan. Interview on 06/05/2024 at 1600 with RN #11 revealed that the patient was not transferred to (Hospital C) because it was not appropriate to transfer a patient that did not have a need or the need for a higher level of care, “that would be dumping on (Hospital C) had we did that.” Interview revealed that the ambulance company should have taken the patient directly back to the place of origin once the sister refused care. Interview revealed the ambulance staff were informed to take the patient back to the place of origin and if dispatch then told their ambulance staff different that was not our decision. Interview revealed the physician and staff were given the final decision from higher up staff, but the physician had the final decision had she felt the patient had a medical need. Interview revealed the patient had no acute medical needs. Interview on 06/07/2024 at 1045 with MD #16 revealed the expectation should have been for the patient to be placed on an ED stretcher and he should have become our patient and responsibility to find placement and needed services. Interview on 06/11/2024 at 1624 with Dispatcher #14 revealed she was called by staff that day due to the ED not accepting the patient. Interview revealed the patient remained on our ambulance stretcher for 3 hours with our ambulance staff present due to the hospital not having any beds available and the ED staff would not sign for transfer of care of the patient. Interview revealed the patient could not go back to the prison since he had been released and (Hospital C) was the next closest facility, so ambulance crew was instructed by the dispatcher to take the patient there. The patient was stable but did require total care. Interview revealed the patient was accepted at (Hospital C) without any issue. 33790 2. Review of the Medical Staff Rules and Regulations, dated 04/18/2023, revealed under Article VI, responsibilities for emergency medical screening exams and stabilization. Review did not reveal any specific documentation requirements for ongoing screenings and re-evaluations of patients with extended visits. Review of the Emergency Department (ED) record, on 06/05/2024, revealed Patient #7 arrived to the ED on 11/29/2023 at 1452. Review of the Triage Note revealed an acuity of 2 was assigned (on a scale of 1-5 with 1 being most severe). Review of a Glasgow Coma Scale (GCS) completed at 11/29/2023 at 1531 revealed a total score of 15 out of 15, noting Patient #7 was alert and oriented to person, place, time and situation and had clear speech. Review of the “ED Provider Scribe Template” date of service 11/29/2023 at 1507, revealed “ ...Chief Complaint/HPI .... This is a 74-year-old male with a past medical history of hypertension (elevated blood pressure), diabetes mellitus, and hyperlipidemia (elevated lipids [fats] in the blood) brought in by EMS who presents for nausea and vomiting. EMS reported the patient is complaining of nausea/a blood pressure in the 250s/120s and blood sugar level of 234. The patient states he’s had nausea and vomiting associated with diarrhea and stomach pain since 1 pm. He notes no appetite for the past two days.... Review of Systems ....CVS (Cardiovascular): No chest pain [space] Respiratory: No dyspnea (difficulty breathing) GI (gastrointestinal): Positive nausea/ vomiting. Positive abdominal pain, Positive diarrhea. Physical Exam [space] General Appearance: Patient appears uncomfortable ....CARDIAC: .... Rhythm is regular. LUNGS: Clear to auscultation bilaterally.... Tachypneic (fast breathing) ABDOMEN: Diffuse tenderness to palpation. No rebound or guarding. No masses palpated. no localized tenderness to palpation. ...” Review revealed a central line was placed for monitoring and IV access (per nursing note this was done at 1746). Review revealed testing and treatment was begun. Further ED record review revealed “ ....1850 we are at capacity in terms of PC (progressive care) and ICU (intensive care) beds. Will attempt to transfer the patient to hospital with capacity. - I contacted (Hospital E) ....is at capacity for ICU beds in step-down .... Condition: stable ....Patient will be signed out to (MD #3). Final Diagnosis .... DKA (Diabetic Ketoacidosis, serious complication of diabetes) Hypertensive Urgency (very high blood pressure). ...” Review of the record failed to reveal any notes made by the oncoming physician (MD #3) throughout the night to show if Patient #7 was evaluated by a physician or if there was any noted any change in condition. At 11/29/2023 at 1949, a Nurse Note indicated Patient #7 got up out of bed and pulled out the central line. The Nurse Note indicated MD #3 was made aware and replaced the line. No note was found by MD #3. At 2011, Patient #7 was noted by nursing to have vomited “coffee-ground emesis.” At 2100, a RN Neurological Assessment noted that Patient #7 was “Confused” and “Nonverbal” but at 2200 was noted to have “Clear” speech. On 11/20/2023 at 0338, Patient #7 was documented to have complained of abdominal pain and at 0500, Patient #7 was again noted by nursing to be “Nonverbal”, but alert and oriented. No notes were found by MD #3 to indicate if the physician was aware of any changes. DED record review revealed an “ED Assumption of Care Note”, dated 11/30/2023 at 0630 by MD #16 that stated “ ...This patient was signed out to me by the outgoing physician (MD #3).... In brief this is a 74-year-old male with history of hypertension, insulin-dependent diabetes mellitus, polysubstance use disorder and medication noncompliance who presents for evaluation due to concerns for DKA and hypertensive crisis. Prior to transfer of care workup was initiated and he was started on insulin drip. Cardene drip and Protonix drip (medication IV drips).... The patient is currently boarding in the emergency department as there are no beds available for transfer and no ICU beds currently at this facility ....Of note, I consulted GI regarding concern for upper GI bleed. ...” Review of a GI Consult Note, dated 11/30/2023 at 1354, indicated “ ...Reason for consult ....Coffee Ground emesis ....History of Present Illness: Reviewed.... Patient is awake but is not conversive, he moves around, does not appear in any distress, but does not answer any questions. As per patient’s nurse today, he is not alert and oriented....” Further review of the “ED Assumption of Care Note” by MD #16 revealed “ ...The patient is a (Hospital G) patient. I reached out to the (Hospital G) to request transfer given no ICU bed availability here. The patient has been accepted for transfer ...” Review of the note failed to reveal any note by MD #16 related to change in mental status. A Head CT without contrast was completed on Patient #7 on 11/30/2023 at 1516 for a history of “Hypertensive Crisis”. No note was seen to indicate it was for a change in mental status or overall condition. The Head CT resulted at 1602 and revealed “ ...Impression: 1. No acute intracranial abnormality 2. Intracranial atherosclerosis. Chronic microvascular ischemic change. Right thalamic old lacunar infarction. ...” No additional notes related to Patient #7’s condition were note by MD #16. Review of a Nursing Assessment Note on 11/30/2023 at 1610 revealed Patient #7 was being Transferred Out and noted the patient’s condition at that time was “Stable” and “Fair” and the LOC “level of consciousness” was “Responds to painful stimuli.” Another note by the same RN, at 1620, indicated the patient was transferred at 1620 and was “ ...awake, not verbally responsive” with another note that there were “No non-verbal indications of pain noted. ...” Review of the Transfer Form revealed it was signed by DO #18 and indicated the patient was stable for transfer at 1620. In review of the record, no other notes were found by DO #18 to determine if the physician evaluated the patient, the patient’s mental status, or the patient’s overall condition. In summary, review of Patient #7’s medical record revealed the patient arrived with an extremely elevated blood pressure and elevated blood sugar. but was alert and oriented and answering questions on admission. There were no beds available for admission and request to transfer revealed the requested hospital had no ICU or stepdown beds available so Patient #7 remained in the ED receiving treatment. The MD who did the initial medical screening signed out the patient to MD #3, the overnight physician. No documented notes were found on the patient’s condition from MD #3. The oncoming day provider on 11/30/2024 noted Patient #7 was receiving treatment and was boarding in the ED. MD #16 arranged transfer to Hospital G but no notes were found from MD #16 to indicate if there was a change in mental status/ condition. A GI Consult note by MD #17 did state the patient was not answering questions and at 1610 nursing documentation indicated the level of consciousness was “Responds to painful stimuli.” Patient #7 was transferred out at 1620 on 11/30/2024. No notes were found by the transferring physician (DO #18) to indicate the patient’s mental status and overall condition at the time of transfer other the transfer form that noted Patient #7 was stable for transfer. Telephone interview on 06/05/2024 at 1605 with MD #2, who did the initial medical screening on Patient #7, revealed the physician did not recall the patient at all. Interview revealed MD #2’s documentation of the medical screening showed that Patient #7 was alert and oriented and talking with the physician at the time of the examination. Interview revealed MD #2 signed off to MD #3 at the end of the shift and did not have further interactions with Patient #7. Requests for interview with MD #3 revealed the physician while still considered prn had not worked at the hospital recently and was not available for interview. Telephone interview on 06/06/2024 at 1640 with DO #18, the physician who signed and certified the transfer, revealed DO #18 did not write a note in Patient #7’s record, just signed the transfer form. Interview revealed the standard process before signing off the transfer form was to make a quick round on a patient to evaluate him/her before signing out the patient for transfer. Interview revealed DO #18 “almost certainly” saw and evaluated Patient #7. Interview revealed writing a note “probably should have happened.” DO #18 stated “ ...think I checked and was going to write and probably got called (away).” Telephone interview on 06/06/2024 at 1658 with MD #4, the doctor assigned to Patient #7 on day shift 11/30/2024, revealed the providers see patients during report and sign off bed by bed to discuss what has been done for the patient and how the patient appears. Interview revealed MD #4 would have checked the patient’s baseline for that shift and for a baseline change. Interview revealed the goal was to have everything written down. MD #4 could not say why it was not documented that day. Interview revealed providers check on patients at the beginning and end of the shift, then during the shift would check if requested. MD #4 stated the goal was to continue to treat and stabilize a patient waiting for a bed, that ideally the patient would have been in an ICU bed. Interview revealed if there had been a substantial change in Patient #7’s condition that warranted imaging, there would have been a note. In regards to concern for a stroke, there would need to be focal deficits. If MD #4 had been concerned for a stroke, interview revealed, a code stroke would have been activated. The MD stated a change in mental status with no laterality was more suggestive of encephalopathy as opposed to a stroke. Requests to interview two nurses who documented a change in mental status and nonverbal status revealed the nurses, RN #36 and RN#37, no longer worked at the hospital and were not available for interview. Interview on 06/07/2024 at 1030, with MD #16, ED Medical Director, revealed MD #16 been briefed on Patient #7’s case. Interview revealed the physician expectations for documentation by ED providers was a shift to shift verbal sign-out with the oncoming physician writing an assumption of care note and at disposition writing a summary or progress note. Interview revealed if a patient appeared well, a provider might just write “stable” but if there was a change, there should be a note of the change. Interview further revealed all patients in the ED were active ED patients, not boarders. Related to this patient, interview revealed, there should have been assumption of care notes from subsequent ED providers when they assumed care and notes with condition changes to show what happened and when. NC00205693, NC00205871, NC00206407, NC00214672”