Bryan Medical Center

“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: 48575 Based on policy and procedure review, medical record review, and staff interviews, the facility failed to identify a discrepancy in the nutrition screening policy regarding timeframe of completion for 2 (Patient 3 and 10) out of 10 sampled patients. This failed practice has the potential to cause a delay in nutrition interventions for all patients at the hospital. The facility census on entrance was 400. See citation A0630, that also resulted in A0286 to not be met. Findings include: A. Review of facility policy titled, Nutrition Screen and Rescreen, effective 7/1/2025 revealed a nutrition screening is defined as the process of using characteristics known to be associated with nutrition problems, to determine if individuals are malnourished or at risk for malnutrition. The nurse performs the initial (first) nutrition screen within 12 hours of admission and documents the findings in the electronic medical record using a validated malnutrition screening tool (MST). The staff then use a number guided tool to consult the clinical registered dietitian if the MST is 2 or greater for nutritional interventions. B. Review of Patient 3’s medical record revealed, the patient presented to the facility emergency department (ED) via ambulance on 12/17/2025 at 6:18 PM with a chief complaint of fatigue, confusion and a ground level fall with a pertinent past medical history of Alzheimer’s (progressive neurological disease that leads to confusion, and eventually unable to perform daily tasks), Parkinsonism (progressive neuromuscular-brain disease that affects movement, often shaking, and slow motions), and Anemia (low blood oxygen level count - can cause weakness). Patient 3 was previously ordered a dysphagia diet that was changed to a regular diet prior to 12/16/2025 discharge to a Skilled Nursing Facility for rehabilitation. Patient 3 was transferred via ambulance and admitted under observation status on 12/18/2025 at 12:17AM. Patient 3’s medical record revealed the initial nutrition screen was completed 12/19/2025 at 12:51 PM. Patient 3’s medical record lacked evidence of an initial nurse screening completed within 12 hours per policy, confirmed by Registered Nurse (RN)-D on 2/24/2025 at 1:29PM. -Review of Patient 10’s medical record revealed that the patient admitted to the facility on 2/17/2026 at 2:03PM for Cirrhosis (long term liver damage) management. Patient 10’s medical record review revealed the initial nutrition screening was completed 2/19/2026 at 7:28PM. Patient 3’s medical record lacked evidence of an initial nurse nutrition screening completed within 12 hours per policy, confirmed by Registered Nurse (RN)-D on 2/24/2025 at 1:29PM. C. An interview with RN-D on 2/24/2025 at 1:29PM revealed the electronic medical record for Patient 3 in observation status indicated the nutrition screening was due in 48 hours, and Patient 10 inpatient status was due in 24 hours versus the facility policy expectation due in 12 hours. -An interview with the Director of Quality on 2/25/2026 at 8:21AM confirmed the nutrition screen and rescreen policy and procedure discrepancy versus the organizational practice was not identified prior to surveyor findings on 2/24/2026.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 48575 Based on policy and procedure review, medical record review, staff interviews, and medical staff interviews, the facility failed to identify a patients ability to safely swallow prior to diet order per policy for 1 (Patient 3) out of 10 sampled patients. The facility also failed to provide follow-up action to prevent future occurrences prior to entrance. This failed practice has the potential to cause negative safety outcomes for all patients at the hospital. The facility census on entrance was 400. See citation A0286, that also resulted in A0630 to not be met. Findings include: A. Review of facility policy titled, Swallow/Screen Evaluation, effective 12/3/2025 revealed patients at risk for dysphagia (difficulty swallowing - a symptom that can cause coughing, choking or get food stuck in the throat or chest) who are not NPO (nothing by mouth), will be assessed with a bedside swallow screen before receiving food, fluids and medicine by mouth. If a patient fails the bedside swallow screen, then the patient is kept NPO and reassessed in a minimum of 2 hours. If a patient fails a 2nd bedside swallow screen, then the patient is kept NPO and the provider (Physician or Advanced Practice Provider) is notified. Once oral intake is started the patient at risk should be closely monitored for dysphagic signs and symptoms and referred to speech therapy if significant change of condition is seen. B. Review of Patient 3’s medical record revealed, the patient presented to the facility emergency department (ED) via ambulance on 12/17/2025 at 6:18 PM with a chief complaint of fatigue, confusion and a ground level fall with a pertinent past medical history of Alzheimer’s (progressive neurological disease that leads to confusion, and eventually unable to perform daily tasks), Parkinsonism (progressive neuromuscular-brain disease that affects movement, often shaking, and slow motions), and Anemia (low blood oxygen level count - can cause weakness). Patient 3 was previously ordered a dysphagia diet that was changed to a regular diet prior to 12/16/2025 discharge to a Skilled Nursing Facility for rehabilitation. Patient 3 was transferred via ambulance in observation status on 12/18/2025 at 12:17AM. On 12/17/2025 at 8:28 PM Patient 3 failed the first bedside swallow screen readiness. On 12/17/2025 at 10:06PM Patient 3 was ordered a regular consistency diet. Patient 3’s medical record lacked evidence of a second swallow screen readiness completed prior to diet order on 12/17/2025 at 10:06 PM or anytime on 12/18/2025 per policy, confirmed with Registered Nurse-C (RN-C). On 12/19/2025 at 8:15PM Patient 3s medical record revealed a nursing notification to the provider, “Evaluate: patient has pot roast stuck in throat I think, o2 is fine at 92% (oxygen level), but wondering about SLP (Speech Language Pathologist - can assess, diagnose and create patient specific treatment plans for swallowing disorders) consult and NPO.” On 12/19/2025 at 10:39PM Patient 3 was ordered a strict NPO diet by the provider. Patient 3s medical record lacked evidence of a note by the provider after notification of change in patient condition, confirmed by Physician-A. On 12/20/2025 at 9:28 AM Patient 3s progress note plan revealed, “Patient refusing/struggling to swallow pills overnight will consult SLP. Overnight patient became more confused and was having problems with swallowing pills. Was made NPO overnight and is awaiting speech to evaluate. Patient is drowsy this morning denies any pain.” Patient 3s medical record lacked evidence of the physician addressing or being aware of the 12/19/2025 nursing notification to the provider of potential pot roast stuck in the throat, confirmed by Physician-A. On 12/20/2025 at 1:16PM SLP-A instructed Patient 3s assigned nurse to give the Parkinson medication in attempt to help the patients ability to safely swallow before the clinical swallow evaluation. Per SLP-A note, Patient 3 appeared unable to clear material despite several attempts and required help to remove the applesauce from the back of the throat used to give the medication [while patient was NPO.] SLP updated the provider and nursing of findings and held clinical swallow evaluation due to patient safety factors. Patient 3s medical record lacked evidence of the SLP being aware of potential pot roast stuck in the throat from 12/19/2025 evening meal. On 12/21/2025 at 3:48PM SLP-A note revealed Patient 3 was seated upright and alert upon arrival, more alert and interactive. SLP-A swallow assessment and observations revealed, patient 3 displayed moderate oral dysphagia and suspected pharyngeal dysphagia (trouble starting the process of swallowing). Patient 3 coughed up liquid green-yellow material into an emesis bag, and no further trials were assessed due to the patient safety factor. Patient’s wife pointed out that patient had been coughing up similar green-yellow liquid throughout the day which started after patient consumed regular-consistency roast beef on Friday 12/19/2025. SLP discussed findings with the provider who planned for a modified barium swallow (MBS - video picture that shows how a person chews, drinks and swallows) study 12/22/2025. SLP-A recommended patient to remain NPO until MBS completed. On 12/22/2025 at 10:36AM SLP-A note revealed the MBS at 8:45AM was completed and recommended further evaluation of the esophagus (muscle tube in the chest that transports food and liquids from the throat to the stomach) per hospitalist discretion. On 12/22/2025 at 11:44AM the hospitalist ordered a gastrointestinal (GI) (specialist provider who focuses on the digestive system) consulted due to new dysphagia, regurgitation (swallowed food or stomach contents come back up through the throat) and abnormal MBS. On 12/22/2025 at 12:20PM Patient 3’s GI evaluation revealed possible food impaction with the patient’s swallow difficulties started after eating roast beef on 12/19/2025 and tolerated a general diet prior. The GI plan revealed to further evaluate acute dysphagia with an esophagogastroduodenoscopy (EGD) (a diagnostic test that the provider uses a tube with a camera that is passed through the mouth to examine the throat, stomach and first part of the small bowel). On 12/22/2025 at 2:01PM Patient 3 underwent an EGD procedure. Pre procedure diagnosis was acute dysphagia, Parkinson’s, Alzheimer’s. Post procedure diagnosis was food impaction. The GI procedure note revealed “ ...Immediately upon entering the esophagus, thick white fluid present and suctioned approximately 300mL. The mid-distal esophagus evidence of brown meat consistent with known roast beef. Able to push the food bolus into the stomach without any difficulty. Continued to clean up esophagus with a few other bits of meat stuck to the esophageal wall. After clearance of the esophagus, clear evidence of dilation and dysmotility.” The GI provider recommended dysphagia diet, soft foods, sit upright after eating, and possible walking after eating. C. An interview on 2/23/2026 at 2:24PM with RN-A revealed was the assigned nurse for Patient 3 on 12/19/2025 6:45PM-7:15AM. During bedside shift report on 12/19/2025 RN-B told RN-A that Patient 3 had been chewing for a while. RN-A noticed Patient 13 was pocketing (food in mouth located in the cheek areas), not safe for a regular diet and RN-B took the tray away. RN-A revealed that Patient 13 was clearing their throat a lot, coughing and contacted the provider to report a change in patient condition and ask for an NPO order with swallowing concerns. RN-A received the order and kept Patient 3 NPO. An interview on 2/24/2026 at 9:29AM with SLP-A revealed was consulted for Patient 3 on 12/20/2025 and recalled patient mentation as groggy, trouble with secretions and was pocketing medicine. Patient 3 was non-verbal at baseline (can’t speak) and did not recall if the patient power of attorney (POA) was present. SLP-A revealed concern of patient aspiration (upper swallowing problem that can go to the patients lungs) versus impaction (lower problem in the throat past the patient airway) at that time. SLP-A can recommend specialty consults but cannot order them. Specialty consults are ordered by the provider per discretion. An interview on 2/24/2026 at 1:14PM with RN-B revealed was the assigned nurse for Patient 3 on 12/19/2025 6:45AM-7:15PM. RN-B did not recall if Patient 3’s POA asked for the evening meal to be cut up before leaving on 12/19/2025. An interview on 2/24/2026 at 1:32PM with RN-C confirmed Patient 3 did not receive a second swallow screen per policy before 12/18/2025 midnight. An interview on 2/24/2026 at 2:01PM with Physician-A revealed upon chart review the first day of concern was on 12/20/2025 when Patient 3 could not take pills. GI can be consulted at any time. An interview on 2/25/2026 at 8:21AM with the Director of Quality revealed the grievance committee will be meeting 2/26/2026 [after SA exit] to discuss Patient 3’s internal investigation findings. No process changes have been made related to Patient 3 grievance that was received by the facility on 1/17/2026.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 48575 Based on review of the latest evidence-based research guidance , review of policy and procedure, observations, and staff interviews the facility failed to monitor 2 (Patient 13 and Patient 14) of 3 patients who received blood within the first 15 minutes of administration for signs and symptoms of a blood transfusion reaction and vital signs. This failed practice has the potential to cause harm to any patient experiencing a blood transfusion reaction. The facility inpatient census on entrance was 499. Findings are: A. Review of the Lippincott Nursing Procedures (9th edition, 2023), revealed the “latest evidence-based research guidance” for the transfusion of blood and blood products implementation reads, “Remain near the patient during the first 15 minutes to monitor for signs and symptoms of a transfusion reaction, because if a major incompatibility exists, or a severe allergic reaction such as anaphylaxis occurs, signs and symptoms usually appear before the first 50 mL (milliliters, amount of blood product that enters the patients blood stream) of the unit have been transfused.” B. Review of the policy titled, Blood and Blood Components: Administration and Documentation (effective 6/5/2025) revealed “to document the patient’s 15-minute vital signs (Start of the transfusion + 15 minutes), and evaluate for possible transfusion reaction.” C. During observation of blood administration by Registered Nurse B (RN-B) on 7/22/2025 revealed the following: -Patient 13, on neutropenic precautions (body’s defenses are weak, high risk for infection), was ordered to receive a transfusion of blood, and had never received blood products before. Observation of RN-B at 10:47AM revealed the patient was prepped for the administration of blood that started at 11:02AM via peripheral intravenous (IV) (a tube that goes into a vein). RN-B left the room and closed the door. At 11:19AM an RN entered Patient 13’s room [17 minutes after the blood transfusion started], confirmed by Patient Safety RN. -Patient 14 was ordered to receive a transfusion of blood. Observation of RN-B at 12:19PM revealed the patient was prepped for the administration of blood that started at 12:28PM via peripheral IV. RN-B left Patient 14’s room at 12:30PM. RN-B entered Patient 14’s room at 12:50PM [22 minutes after the blood transfusion started.], confirmed by RN-A. D. Interview with the Patient Safety RN (7/22/2025 at 11:20AM and 12:51PM) confirmed RN-B did not monitor or recheck Patient 13 or Patient 14 for signs and symptoms of a transfusion reaction or obtain vital signs within the first 15 minutes of the blood transfusion start time.”

“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: 48575 Based on medical record review, policy review, and staff interviews the facility failed to ensure 1 (Patient 8) of 1 sampled patients with documented aggressive behaviors received a comprehensive behavioral care plan to protect the staff and patients per hospital policy. This failed practice has the potential to cause harm or negative outcomes to all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 489. 16132 Findings are: A. Medical Record review on (12/16/2024 at 1:48PM) revealed, 62-year-old, Patient 8 (Pt 8) was brought to the hospital on 10/15/2024 for persistent cough despite outpatient treatment by the patients physician. The patient was found to have pneumonia in the left lower lobe, and a history of non-small cell lung cancer. The patient was discharged on 10/17/2024. Review of Pt 8’s medical record identified: -On 10/15/2024 at 8:39 PM the nursing note by RN-C revealed, “Patient refused lab draw for lactate at 2000 (8 PM). Patient educated on the importance of getting lab draw. Patient stated does not want to be poked until tomorrow morning. (Dr) notified.” -On 10/15/2024 at 11:01 PM the nursing note by RN-C revealed, “This RN entered patient’s (room) due to complaining of pain.” The patient received pain medication earlier in the shift and was educated that “it was too soon to give another one. Offered to reach out to (Dr) to get another order for a pain medication. Patient’s voice escalated at this RN, the patients voice continued to escalate and started to swear at this RN. Pt started to throw blankets off and get out of bed. A Security assist was called. (A page is made that notifies Hospital Security and/or Armed Security to assist with any event at any time for assist with managing or controlling violent or aggressive behavior.) Security assist team helped deescalate the situation. Patient is now calm and resting in bed.” -On 10/15/2024 at 1:10 AM the nursing note by RN-C revealed, “This RN went to answer patient’s call light. As this RN entered the room, the patient stated, “I don’t want you. Get the (swear word) out.” This RN left the room and notified charge nurse. Cares transferred to Charge Nurse.” -On 10/16/2024 at 7:02 PM the nursing note by RN D revealed, “This RN went into patient’s room to administer a medication. Patient was willing to take (medication). Patient also expressed having pain with the infusion of the antibiotic and it’s leaking. This RN assessed IV, no swelling or redness noted at IV site, but leaking was noted from IV dressing. Antibiotic infusion paused at this time. Patient continued to fixate on the IV. Patient’s tone of voice escalated. RN reassured that IV would be addressed in that, RN would need to grab necessary supplied outside of the room. Patient started yelling. RN left room and patient escalated more by yelling at RN and staff. Security assist called.” -On 10/17/2024 at 11:56 AM the nursing note by RN-E revealed, “Pt left with shirt, pants, shoes, jacket, hat, cell phone and tub full of personal items including clothing. All discharge education complete and all questions answered.” Review of the Flowsheet charting for “History of Assaultive Behavior” identified: -10/15/2024 at 2320 (11:20 PM), “Aggressive episode” -10/16/2024 at 1830 (6:30 PM), “Aggressive episode” -10/17/2024 at 1150 (11:50 AM), “Aggressive episode” Review of Physician/Provider notes identified: -On 10/16/2024 at 11:22 AM, the Pulmonary service note revealed, “Pt is evaluated in bed. Awake and alert, reports feeling tired today. Overnight, became agitated, threatened to leave AMA, refused lab draws.” -On 10/17/2024 at 11:46 AM, the Pulmonary Service Discharge Summary revealed, “Patient seen at bedside. Multiple security assists called overnight due to patient’s agitation/anger. Is very anxious to discharge home today. Respiratory status remains stable on room air.” B. Review of the policy titled Caring for the Patient with Assaultive Behavior (effective 6/12/2023) revealed: -“Assaultive behavior during current hospitalization:” If an incident occurs, staff should complete the Assaultive Behavior documentation in the Care/Safety Flowsheet which will place the ‘history of Assaultive Behavior’ banner in the record. The Assaultive Behavior FYI Flag should also be added with the approval of nursing leadership. Notify the clinical manager. Consider interventions techniques listed below. Document the incident in a B-Safe. -“Request assistance from other available staff or contact Security:” Re-assess plan of care interventions at shift change; adjust as needed. If other intervention efforts have failed, consider convening a care conference to review options to prevent or manage future abusive, aggressive, or violent events. -“Initiate a Care Conference to address patterns of assaultive behavior and develop an individualized care plan.” A behavior treatment plan (behavior contract) may result fro the Care Conference for patients with capacity for understanding. Interventions resulting from the Care Conference should be documented by the Nurse Manager in the Assaultive Behavior documentation in the Care/Safety flowsheet and B-Safe. -“Documentation:” Document plan of care in the electronic medical record. Complete the Assaultive Behavior documentation in the Care/Safety flowsheet. C. Interview with RN-F on 12/18/2024 at 1:30 PM verified that Pt 8’s 10/15/2024-10/17/2024 medical record lacked a care plan related to Aggressive Behavior. RN-F revealed, it is not in Epic (electronic medical record) Library, and would expect a care plan due to pneumonia, discharge plan, knowledge deficit, pain, fall, the medical things. When inquired from RN-F if could add an aggressive behavior care plan, stated “No it isn’t in the Epic Library for this patient due to not having a psychiatric diagnosis. When inquired from RN-F that if having assaultive behavioral issues with a patient, would it not be beneficial for the nursing staff to have a care plan to guide the staff with this kind of behaviors? RN-F, stated, it was not part of this patients Epic Library for care plans. When inquired if the facility had the option to run the call light system for Pt 8 from 10/15-10/17/2024, RN-F said yes, will get it. [On 12/19/2024 at 9:15 AM, this surveyor was notified that the facility could only run ‘Hourly Round Report’ for that room in that time period and was unable to run the call light report related to the patient turning on the light and when it was answered. Per facility Pt 8’s room was identified as the only room that would not be able to produce a call light report for the requested dates for an unknown reason to staff.] D. Interview with Director of Safety and Security on 12/18/2024 at 8:49 AM stated, “I had been notified by the Nurse Manager (RN-F) on 10/15/2024 in the evening related to a patient with volatility and assaultive behavior, requiring Security support staff and to increase the Security rounding on this area. It was decided per the Caring for the Patient with Assaultive Behavior Policy that (Patient 8) would be presented a “Patient Cooperation Agreement” that would refer to the patient’s rights and the staff rights to allow for the treatment plan goals to be met. We (Director of Safety & Security and RN-F) entered the patient’s room with the Patient Cooperation Agreement Contract on 10/17/2024, at which time the patient was calm. As I read the contract to the patient, the patient became agitated and refused to sign the contract and would not leave AMA or leave until discharged by the doctor. We explained to the patient that if discharge by provider, refused to sign contract, and would not leave, the process would be to call LPD (Lincoln Police Department) to have the patient removed. The hospitalist gave the order already to discharge and were waiting on Pulmonary Services to round and discharge. The orders were received and the patient received the discharge instructions and left without further incident.””

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 48575 Based on policy review, medical record review and staff interviews the facility failed to ensure 1 (Patient 3) of 3 sampled patients diagnosed with malnutrition were ordered tube feeding recommended by the Registered Dietitian (RD), and the medical nutrition treatment plan of care was followed to monitor supplemental intake for effectiveness per hospital policy. This failed practice has the potential to cause negative outcomes for all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 489. Findings are: A. Review of the policy titled Medical Nutrition Therapy (effective 3/30/2023) revealed: 1. A diagnostic driven medical nutrition treatment plan of care is developed and reassessed at regular intervals to evaluate outcomes or effectiveness of interventions by an RD. 2. Patients identified at nutritional risk for malnutrition, through the nutrition screen receive a comprehensive nutritional assessment and a diagnostic driven medical nutrition treatment plan of care by a RD or Licensed Medical Nutrition Therapist (LMNT) with 48 hours of notification and procedure for nutrition screen/rescreen. 3. Planning of the patient’s care involves: individualized appropriate to age specific patient needs, inclusion of family, and interdisciplinary input. 4. The RD or LMNT write orders for tube feeding (TF) (liquid nutrition that either goes through a tube in the nose to the stomach or intestines, or abdomen to the stomach or intestines to provide life sustaining nutrition for a patient), or parenteral nutrition (PN) (liquid nutrition that goes through an intravenous (IV) line to provide life sustaining nutrition for a patient) in the physician’s orders when a physician writes for or gives a verbal order for the RD to: start TF or PN per RD, or RD to see and write orders for TF or PN, or start TF per RD recommendations, or RD to adjust and order TF. B. Review of the medical record (12/17/2024 at 7:51 AM) revealed Patient 3 was admitted to the hospital 9/29/2024 at 7:52 PM for shortness of breath, poor appetite, difficulty swallowing and extreme fatigue. Patient 3’s past medical history included but not limited to Lupus with failed kidney transplant requiring hemodialysis (treatment that filters waste and extra water from the blood), and sepsis (infection). Patient 3’s nutrition care plan from 9/30/2024 revealed: -Nutritional needs goal of eating greater than or equal to 75%. -Encourage adequate protein at meals and snacks to aid in the maintenance of lean body mass. -Supplement therapy interventions of send Ensure Clear (supplement) twice daily, and a protein shake in the afternoon for snack daily. -Monitor by mouth intake, weight and diet tolerance. Patients 3’s medical record by mouth intake (meal) documentation confirmed by RD-A revealed: -9/30/2024: 10% of meals (goal of 75%) -10/1/2024: 10% of meals (goal of 75%) -10/2/2024: lacked evidence of meal documentation. -10/3/2024: 25% and 0% of meals (goal of 75%) -10/4/2024: lacked evidence of meal documentation. -10/5/2024: 10% of meals (goal of 75%) -10/6/2024: 10% of meals (goal of 75%) -10/7/2024: 10% of meals (goal of 75%) -10/8/2024: 10% of meals (goal of 75%) -10/9/2024: 0% of meals (goal of 75%) -10/10/2024: 0% of meals (goal of 75%) -10/11/2024: lacked evidence of meal documentation (Patient 3 discharged at 3:45 PM). Patient 3’s medical record lacked evidence of supplement intake documentation three times per day on 9/30/2024, 10/1/2024, and 10/4/2024 through 10/11/2024, confirmed by RD-A. Patient 3’s medical record revealed documentation on 10/3/2024 at 11:45 AM of vomiting, “pink from drinking berry ensure and strawberry yogurt,” confirmed by Staff-A. Patient 3’s nutrition goals documented on 10/3/2024 at 2:56 PM revealed: -maintain weight, goal not met, continue. -weight down to 47.2 kilograms(kg) from admit weight of 53.1 kg. -meet nutritional needs greater than or equal to 75%, goal not met, continue. -by mouth intake of 0-25% at meals. -vitamin/mineral intake goal not met, continue. -intervention of continue three times per day supplements with meals and monitor by mouth intake and weight. Patient 3’s medical record revealed a documented nutrition assessment on 10/8/2024 at 2:00 PM that included: -patient continues to eat minimally, 0-10% of meals (goal of 75%), threw up after breakfast. -noted GI concern for achalasia (patient is unable to get food to the stomach) with plans for outpatient work up. -weight down approximately 6 kg since admit. -by mouth intake average of 11% of last 9 meals documented. -Enteral Nutrition Recommendations revealed patient, “is severely malnourished.....previously okay with short-term TF but didn’t want G-tube (a tube that requires surgery, and goes into the stomach) placed, may need to consider feeding tube placement (short term is a tube that goes through the nose into the stomach or intestines per a physician order) until patient is able to eat more by mouth and/or get work up for achalasia. TF recommendations: Osmolite 1.2, start at 20 milliliters per hour, advance 10 milliliters per hour every 8 hours with a goal of 60 milliliters per hour....TF regimen provides 1584 kcalories, 73 gram of protein.” RD-A confirmed Patient 3’s medical record lacked evidence of an order for the RD to start TF or PN on 10/8/2024 per hospital policy. Patient 3’s care plan documented on 10/8/2024 at 3:03PM revealed malnutrition interventions that included recommendations to monitor, adjust tube feedings, and parenteral nutrition based on nutritional status and assessed needs.” RD-B confirmed Patient 3 did not receive any TF or PN from 9/29/2024 - 10/11/2024. C. Interview (12/17/2024 at 1:03 PM) with RD-B revealed that a malnutrition score of 2 or greater from the nursing admit nutrition screen consults the RD to follow the patient. RD-B recalled Patient 3 had a malnutrition score of 3 on admit. RD-B recalled patient 3’s initial assessment on 9/30/2024 with a conversation of the patient willingness for short term tube feeding, and parenteral nutrition was not discussed due to infection concerns. The RD can diagnose malnutrition and then the physician can agree or disagree and address in the progress note. RD-B revealed the RD recommendations are automatically sent via the electronic medical record to the physician to address in the progress note. The RD stated they utilized a secure chat that is not a part of the medical record to communicate patient 3’s nutritional recommendations to the physician. The secure chat is no longer available to be viewed after 7 days. [The facility was unable to produce evidence of the physician being aware or addressing the RD tube feeding recommendation on 10/8/2024 in Patient 3’s entire medical record, confirmed by RD-A.]”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 16132 Based on record review, staff interview and review of policy and procedures the facility failed to ensure the staff provided 3 (Patient 3, Patient 10 and Patient 12) of 7 sampled patients requiring physical restraints to protect staff and the patients were ordered appropriately per the hospital policy. This had the potential to affect all patients in the facility requiring physical restraints. The facility identified 224 patients with restraint orders in the last 60 days. Findings are: A. Review of the policy titled Restraint/Seclusion Guidelines (effective date 5/31/23) under Procedures/Requirements stated the following: -“Non-Violent/Non-Self Destructive Restraint- Restraint application (wrists or ankles) for the physical safety of the patient to support medical healing (pulling lines, tubes, removal of dressings or equipment). The documentation of Non-Violent/Non-Self Destructive Restraint is every 2 hours. The order can continue with a daily review by the practitioner.” -“Violent/Self Destructive Restraint-Restraint application (soft wrist and ankle, leather wrist and ankle restraint,chest or thoracic strap) for the protection of the patient against injury to self or others because of an emotional or behavioral disorder. The physician order for Violent/Self Destructive Restraints application time limits for the protection of the patient or others against injury due to an emotional or behavioral disorder requires; if the patient is; Under 9 years -1 hour; Age 9-17 -2 hours; Adult 18 & up -4 hours, the patient must be reassessed by a RN prior to time limit and if continuation is necessary a renewal order must be obtained from the practitioner.; A face to face assessment by a practitioner or specially trained RN must see the patient within 1 hour of initiation of the restraint/seclusion; The practitioner responsible for the patient’s care will perform an in person evaluation within 24 hours of initiation of restraint/seclusion ands will document in the record. Continuous 1:1 is required for patients being physically restrained or secluded for violent/self-destructive behaviors.” B. Review of the medical record for 56 year old, Patient 3 (Pt 3) identified that the patient was brought to the hospital on 7/25/24 for acute alcohol withdrawal and a history of schizophrenia which was not being treated. Patient 3 was discharged home on 8/14/24. On admission the patient was experiencing tremors, was alert and oriented. The patient developed anxiety, restlessness, combativeness and delirium on 7/27/24. The patient was admitted and started on IV medication to assist the patient with acute alcohol withdrawal symptoms, and to continually assess the progress of withdrawal. The tool Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA) measures the level of withdrawal. A score of 8-10 indicates minimal to mild withdrawal; scores of 8-15 indicate Moderated withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal (impending delirium tremens). The tool assists the physician and nursing to provide medications related to the severity of withdrawal. The total score can range from 0 (no symptoms) to a maximum of 67. Review of the Pt 3’s medical record flowsheets identified: -CIWA flowsheet indicated on 7/25/24 at 3:42 upon admission had a CIWA score of 16, indicating severe withdrawal. The CIWA scores during the inpatient stay fluctuated with the scores ranging from 16 on admission to 19 on 7/26/24; 27 on 7/27/24; 20 on 7/28/24; intubated on 7/29/24; extubated on 7/30/24- CIWA 19 on 7/30/24; 15 on 7/31/24; 12 on 8/1/24; 11 on 8/2/24; 13 on 8/3/24; 10 on 8/4/24; 36 on 8/5/24; intubated on 8/6/24 and extubated on 8/7/24; 22 on 8/8/24; 17 on 8/9/24; and 10 on 8/10/24. -Restraint flowsheet indicated on 7/25/24 at 6:20 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless. The bilateral soft wrist restraints were continued daily with every 2 hour charting. On 7/30/24 at 10:45 AM the restraints were discontinued. On 7/31/24 at 11:55 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless, with every 2 hour charting through 8/3/24 at 5:21 PM when discontinued. On 8/4 at 1:06 PM bilateral soft wrists and bilateral soft ankles (non-violent) initiated. (Note documented due to interference with medical treatment/agitated/restless, additional documentation at 12:45 PM identified patient was aggressive, hitting, kicking and having assaultive behavior.) The every 2 hour documentation on 8/5 and 8/6 continues to show the patient as agitated, restless, aggressive, hallucinating, screaming foul language at staff and trying to swing at staff even in restraints. On 8/7/24 the (non-violent)bilateral ankle soft restraints were discontinued at 6:00 AM, the patient continued to have (non-violent) bilateral wrist restraints due to interference with medical treatment, restless and agitated through 8/8/24 at 11:10 PM. On 8/8/24 at 11:30 PM the patient was documented as agitated and restless and due to interference with medical treatment, bilateral (non-violent) soft wrist restraints were restarted. The every 2 hour documentation on 8/9 identified the bilateral soft wrist restraints continued until 8/9/24 at 7:00 PM. The bilateral (non-violent) soft wrist restraints were restarted on 8/9/24 at 11:02 PM due to interference with medical treatment, restless and agitated and discontinued 8/10/24 at 8:00 AM. C. Interview with MD-M (9/3/24 at 12:40 PM) revealed when reviewed Pt 3’s charting on 8/4/23 at 12:45 PM related to behaviors including interference with medical treatment/agitated/restless/aggressive, hitting, kicking and having assaultive behavior; then reviewed MD-M’s order on 8/4/24 at 1:04 PM ordered “Restraints Non-violent or non-self destructive soft wrist restraints” and 8/4/24 at 1:06 PM “Restraints Non-violent or non-self destructive soft ankle restraints”. MD-M stated, “The patient kicked a nurse so ordered the ankle restraints. That should have been ordered as a violent restraint.” D. Review of the medical record for 50 year old, Patient 10 (Pt 10) identified that the patient was brought to the hospital on 6/28/24 for acute alcohol withdrawal, alcohol encephalopathy and a history of paranoid schizophrenia with suicidal ideation’s. Patient 10 was discharged home with a friend on 7/8/24. The patient developed anxiety, restlessness, combativeness, cursing, threatening, verbally abusive and yelling on 6/30/24 at 1:20 PM. The physician ordered bilateral soft wrist and bilateral soft ankle (Violent) Restraints due to a danger to self and others. combativeness, cursing, threatening, verbally abusive and yelling. Review of the Pt 10’s medical record restraint flowsheets identified: -On 6/30/24 at 1:20 PM bilateral (Violent) soft wrist and bilateral soft ankle restraints were applied due to a danger to self and others. The documentation of the Violent Restraints showed every 15 minute charting. -On 6/30/24 at 3:51 PM an order to discontinue all 4 violent restraints. The physician than ordered bilateral (non-violent) soft wrist restraints on 6/30/24 at 3:51 PM. An order was obtained for bilateral (non-violent) soft ankle restraints on 6/30/24 at 4:23 PM. The documentation to justify the need for the restraints ordered at 3:51 PM and 4:23 PM was interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 7/1/24 at 3:37 AM. -On 7/1/24 at 9:08 AM the soft wrist restraints were discontinued and Non-Violent bilateral 2 point leather wrist restraints were applied. The leather ankle restraints and soft wrist restraints were discontinued on 7/2/24 at 5:44 AM. -On 7/4/24 at 10:11 AM an order for bilateral (non-violent) soft wrist and ankle restraints for interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 7/5/24 at 12:00 AM, the wrist restraints continued. -On 7/5/24 at 10:00 AM an order for bilateral (non-violent) soft ankle restraints for agitated and restlessness were added, the bilateral soft wrist restraint continued. -On 7/6/24 at 9:40 AM an order for the bilateral wrist and ankle restraints were discontinued. E. Review of the medical record for 51 year old, Patient 12 (Pt 12) identified that the patient was brought to the hospital on 8/10/24 for acute alcohol withdrawal, alcohol encephalopathy. The patient developed agitation and restlessness on 8/16/24 at 12:41 PM, an order for (non-violent) bilateral wrist and ankle restraints was obtained with the justification of interference with medical treatment. Review of the Pt 12’s medical record restraint flowsheets identified: -On 8/16/24 at 12:41 PM, an order for (non-violent) bilateral soft wrist and ankle restraints was obtained with the justification of interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 8/17/24 at 3:20 AM. The bilateral soft (non-violent) wrist restraints continued. -On 8/19/24 at 10:57 AM, an order to discontinue the bilateral wrist restraints was received. F. Interview with Behavioral Health Manager RN-C (9/4/24 at 3:10 PM) revealed when reviewing ankle restraint documentation for Pt 3, Pt 10, and Pt 12, verified that the use of ankle restraints for agitation/restlessness would be a Violent Restraint and not a Non-Violent Restraint.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 16132 Based on record review, staff interview, review of policy and procedures, and administrative record review, the facility failed to maintain a safe environment by ensuring staff were educated on the facility expectation following an allegation of staff to patient abuse in 1 (Patient 3) of 19 sampled patients. The facility failed to ensure the nursing staff provided adequate supervision of care related to the allegation of abuse until an facility investigation could occur. This failure had the potential to affect all patients receiving nursing care in the facility. The census at the time of the survey was 466. Findings are: A. Review of the policy titled Abuse, Neglect and Exploitation: Identification and Reporting (effective date 10/1/2023) under Identification and Screening stated the following: -“Situations of abuse/neglect suspected of having occurred within the hospital will result in immediate action to eliminate the possibility of further occurrences in collaboration with house supervisor. -The staff person who suspects abuse or received the report of abuse is mandated by law to report to the proper authorities. -For support staff, reporting will be completed under the supervision of a Social Worker, Therapist, or Registered Nurse.” B. Review of the policy titled Corrective Action and Termination (effective date 2/17/23) under Violations which may result in immediate suspension or termination stated the following:. -“Depending on the nature and severity of the performance issue, the organization reserves the right to skip any of the aforementioned steps and move directly to suspension or termination. The list below includes some of the violation that may be cause for immediate suspension and/or termination. This is not intended to be an exhaustive list. -Abuse, harassment, discrimination or inconsiderate treatment of patients, visitors, volunteers, or other employees.” C. Review of the Administration Liaisons follow up on a grievance reported to the facility of an alleged staff to patient abuse from 8/4/24 revealed the report was shared with the facility on 8/4/24 when a family member was told by the patient (Pt 3) that a staff member hit them. The family member also had other concerns regarding nursing and patient rights. D. Interview (9/3/24 at 11:05 PM) with Pt Liaison stated, “When a concern is received by us, the leaders (Nurse Managers, Physicians, or their designee) of each area of the concern looks into the concern and investigates the issues and it is brought back to the group and we send a letter to the complaintant when the investigation is completed within the appropriate time frames.” “The concern’s that (Pt 3) family called in on 8/5/24 have been sent to the specific manager, physician or designee’s to follow up and investigate. Many of the area’s are still being reviewed and in process.” E. Interviews completed regarding the allegation of staff to patient abuse included: -An interview with the House Supervisor (HS RN F) on 9/3/24 at 2:30 PM, identified that he was working at the time of the allegation of abuse and other nursing issues that the family of Pt 3 had questions about. When asked if the bedside nurse or charge nurse had notified him that the patient family alleged the patient had told the family that a nurse hit (gender). The HS RN F stated, “No, we were involved with a conversation about hospital policy related to the family using their phone for photos and taping of the pt and staff. The family also had a concern of (Pt 3’s) position in bed, the patient was in bilateral wrist and ankle restraints, had a tube feeding running and asleep at the time. The family member was escorted out of the hospital due to the filming, and disruptive loud behaviors.” -An interview on 9/4/24 at 1 PM with the Nurse Manager RN E (NM RN E) for the unit that Pt 3 was a patient on 8/4/24), when asked when did RN H notified her of the incident, “RN H called me that night after the shift, the nurse told me that the patient had outbursts punched 2 nurses. When family got there was upset and became loud and aggressive, was video taping and taking pictures, refused to stop so the HS RN F and security was contacted. The family told RN H that (Pt 3) wasn’t being treated correctly and was calling LPD.” “I don’t think anything was said about the allegation of the patient being hit in that call.” “I talked to RN H the next day (8/5/24), that day I was informed that the family said we weren’t feeding (the pt) and claimed the nurse hit him.” “I found out also that LPD came on 8/4 and the HS RN F accompanied them to the patient room. LPD said that a family member reported that the patient was punched by a nurse, LPD then asked the bedside nurse (RN H) if (gender) hit the patient and about the feeding. RN H responded “NO.” When asked the Nurse Manager RN E, if once the facility staff was notified of an alleged allegation of staff to patient abuse, was the staff member removed from patient care, or how did they protect this and other patients until the Administrative staff can investigate the allegation. NM RN E stated, “no the staff member wasn’t removed.” -An interview with the Director of Safety and Security (DSS) on 9/3/24 at 1:18 PM. When asked if as part of the job gets involved in allegations of abuse by staff. The DSS responded, “yes, I am involved with employee misconduct.” When asked if was aware of the 8/4/24 allegation of staff to nurse. DSS stated, “yes, I received a report placed by the Charge Nurse (CN G) on 8/4/24.” “Its my understanding that the family member told staff that they were reporting to the Lincoln Police Department (LPD) and Adult Protective Services (APS) on 8/4/24.” “Approximately 2 hours after the family was escorted out of the hospital, LPD came to the unit, the Officer informed staff that the family had called LPD with reports that (hospital) staff is abusing the patient. The Bedside RN (RN H), CN G and HS RN F all gave their statements, and the Officer informed staff that the family was planning on contacting APS.” When asked after an allegation of a particular staff to patient alleged abuse was received, how does the facility ensures all patients are safe while the facility looks into the allegation, do you reassign the staff person immediately to non patient area’s, or have them go home while the facility looks into the allegation? “No not necessarily.” When asked if there is guidance for how floor staff (ie.charge nurse, house supervisor) handles the incident in the policy? “Not specifically, but staff does make a report and gets up the chain of command.” F. Review of the Pt 3’s medical record flowsheets identified: -CIWA flowsheet indicated on 7/25/24 at 3:42 upon admission had a CIWA score of 16, indicating severe withdrawal. The CIWA scores during the inpatient stay fluctuated with the scores ranging from 16 on admission to 19 on 7/26/24; 27 on 7/27/24; 20 on 7/28/24; intubated on 7/29/24; extubated on 7/30/24- CIWA 19 on 7/30/24; 15 on 7/31/24; 12 on 8/1/24; 11 on 8/2/24; 13 on 8/3/24; 10 on 8/4/24; 36 on 8/5/24; intubated on 8/6/24 and extubated on 8/7/24; 22 on 8/8/24; 17 on 8/9/24; and 10 on 8/10/24. -Restraint flowsheet indicated on 7/25/24 at 6:20 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless. The bilateral soft wrist restraints were continued daily with every 2 hour charting. On 7/30/24 at 10:45 AM the restraints were discontinued. On 7/31/24 at 11:55 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless, with every 2 hour charting through 8/3/24 at 5:21 PM when discontinued. On 8/4 at 1:06 PM bilateral soft wrists and bilateral soft ankles (non-violent) initiated. (Note documented due to interference with medical treatment/agitated/restless, additional documentation at 12:45 PM identified patient was aggressive, hitting, kicking and having assaultive behavior.) The every 2 hour documentation on 8/5 and 8/6 continues to show the patient as agitated, restless, aggressive, hallucinating, screaming foul language at staff and trying to swing at staff even in restraints. On 8/7/24 the (non-violent)bilateral ankle soft restraints were discontinued at 6:00 AM, the patient continued to have (non-violent) bilateral wrist restraints due to interference with medical treatment, restless and agitated through 8/8/24 at 11:10 PM. On 8/8/24 at 11:30 PM the patient was documented as agitated and restless and due to interference with medical treatment, bilateral (non-violent) soft wrist restraints were restarted. The every 2 hour documentation on 8/9 identified the bilateral soft wrist restraints continued until 8/9/24 at 7:00 PM. The bilateral (non-violent) soft wrist restraints were restarted on 8/9/24 at 11:02 PM due to interference with medical treatment, restless and agitated and discontinued 8/10/24 at 8:00 AM. G. Interview with MD-M (9/3/24 at 12:40 PM) revealed when reviewed Pt 3’s charting on 8/4/23 at 12:45 PM related to behaviors including interference with medical treatment/agitated/restless/aggressive, hitting, kicking and having assaultive behavior; then reviewed MD-M’s order on 8/4/24 at 1:04 PM ordered “Restraints Non-violent or non-self destructive soft wrist restraints” and 8/4/24 at 1:06 PM “Restraints Non-violent or non-self destructive soft ankle restraints”. MD-M stated, “That should have been ordered as a violent restraint.” H. Review of Pt 3’s medical record revealed an entry on 8/4/24 at 3:14 PM from Case Management (CM B) stated, “Of note, (Family member) did visit today and was verbally aggressive toward staff, including the primary RN (RN H), CRN (CN G) and house supervisor (HS RN F) and was escorted out by security.””

“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: 16132 Based on medical record review, staff interviews, and review of policy and procedures; the facility failed to follow their policies related to informed consent. The facility staff failed to ensure consent was provided prior to performing testing for evaluation of an emergency medical condition for 1 (Patient 3) of 11 patients treated at the hospital. This had the potential to affect all patients brought to the facility for care and services, the facility saw in the Emergency Department for April 2024: 8,336 and the hospital admitted for April 2024: 3,729 for inpatient care. Findings are: A. Review of the medical record for 43 year old, Patient 3 (Pt 3) identified that the patient was brought to the Emergency Department for evaluation following a motor vehicle accident by local law enforcement (LLE), prior to going to jail. The patient arrived at 3:40 AM on 10/13/23 and was discharged at 4:50 AM on 10/13/23. Upon arrival the Patient Access Staff (person that gathers your information and obtains consent to treat) asked the Pt 3 for consent to treat. Pt 3 refused to provide informed consent to treat verbally and refused to sign the (electronic) consent form. Review of the medical record identified: -On 10/13/23 at 0340, the local law enforcement officer told the Patient Access Staff that the Pt 3 was brought there for the complaint of FFC (Fit For Confinement-[jail]). -Pt 3 verbally refused to provide informed consent to the Patient Access Staff. -Pt 3 was taken to a room at 0340 and the nurse performed triage (initial assessment of concern by nurse). Pt 3 again refused to sign or give verbal consent to treat. Review of the “ED Acuity/Triage Plan” revealed the patient denied complaint of pain, vital signs (VS) completed; Temp 97.9-pulse 112-blood pressure 204/112-respirations-oximetry 100%. The patient was identified as a Patient Acuity of 3-urgent. (Per the Emergency Severity Index (ESI) that identifies patient acuity as: ESI level 1-Patient requires immediate life-saving intervention; ESI level 2-Patient is in a high risk situation, is disoriented, in severe pain, or vitals are in danger zone; ESI level 3-If multiple resources are required to stabilize the patient, but vitals are not in the danger zone; ESI level 4-If one resource is required to stabilize the patient; ESI level 5-If patient does not require any resources to be stabilized. Review of the Emergency Department Physician (MD-A) examination of Pt 3 documented at 3:58 AM stated the following: “hit a street sign, the patient had no loss of consciousness, denies any pain or discomfort at this time, and alcohol on board.” Review of documented revealed, the “patient had no respiratory distress, heart rate normal, abdomen non-tender/non-distended, PERRL (pupils of eyes equal, round, reactive, light, and accommodation) neuro- alert, appropriate with no focal deficits.” MD-A placed an order for a CT (Computed Tomography) Scan of the head without contrast. CT Scan completed at 4:09-4:13 AM, , results impression identified, “No acute or post traumatic abnormalities of the brain or skull are detected.” MD-A documented, “Patient’s blood pressure has gone down without any intervention, last reading 143/66. CT head with no acute findings. (Pt 3) will be discharged in the care of law enforcement at this time.” B. Telephone interview with MD-A (5/15/24 at 1:00 PM) revealed, when asked if Pt 3 refused the CT Scan, does the police without an order override the patient refusal? MD-A stated, “My understanding a patient can refuse a medical work up as long as capable.” “I did not know (Pt 3) refused treatment.” C. Review of the policy titled Consent (effective 7/28/23) stated under Procedure/Requirements: -“3.1 For the purpose of consent, adult means an individual who is 19 years of age or older. -3.2 Informed consent shall mean consent to a procedure based on information that would ordinarily be provided to the patient under like circumstances by health care providers engaged in a similar practice in the locality or in similar practice in the locality or in similar localities. The failure to obtain informed consent includes failure to obtain any express or implied consent for any operation, treatment, or procedure in a case in which a reasonably prudent health care provider in the community or similar community would have obtained an express or implied consent for such operation, treatment, or procedure under similar circumstances. Surgeons and physicians are thus required to provide their patient with sufficient information to permit the patient to make a fully informed decision to agree upon or refuse the proposed course of treatment or surgery.” Review of the policy titled Inmate Patient Care (effective 11/01/23) stated under Procedure/Requirements: -“3.1 Medical care for inmate patients is provided in a manner consistent with approved procedures and standers for patient care. All patients, including inmates, have the right to request treatment that is medically appropriate or refuse treatment to the extent permitted by law.” D. Interview with the Director of Security (5/16/24 at 1:40 PM), stated, “It is my understanding that the facility has to have a court order unless the physician feels the issue is emergent.” The medical record for Pt 3 lacked a court order for treatment.”

“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: 48575 Based on review of policies and procedures, medical record review, staff and provider interviews the Acute Care Facility (ACF) failed to follow their policies and procedures for 3 (P3A, P3B, and P11) of 20 sampled patient medical records to ensure complete medical screening exams (MSE) were provided to rule out the presence of an emergency medical condition (EMC) prior to discharge. This failed practice has the potential to cause harm or death due to delayed treatment or transfer of all patients that present to the ACF Emergency Department (ED). According to facility provided information the ED treats an average of 7, 936 patients per month. See A2406 and 2407 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met. Findings include: A. Review of the facility policy, “Mental Health Evaluation-Emergency Services,” effective 11/11/2022 revealed, “Medical staff documentation includes all of the elements of the medical screening examination including observations and the diagnostic test results supporting a conclusion that an emergency medical condition does or does not exist.” -“Emergency Department and Mental Health staff will collaboratively assure appropriate treatment, admission/discharge and transfer procedures are implemented.” B. Review of the facility policy, “EMTALA,” effective 6/2/2023 revealed: -Emergency medical condition (EMC): “A condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, intoxicated individuals, and individuals expressing suicidal or homicidal thoughts or gestures such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or that may pose a threat to the health and safety of the woman or unborn child.” -Medical screening examination (MSE): “Process required to reach, with reasonable clinical confidence and not on the basis of an individual’s source of payment or ability to pay, the point at which it can be determined whether a medical emergency does or does not exist.” .” ..... “A medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the person’s needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer.” -“The following are always considered emergency medical conditions (EMC) and must be screened and treated.” ... ...Psychiatric disturbances, Symptoms of substance abuse, and Intoxication. -Medical Screens will include: “Appropriate physical examination, including vital signs, the presenting complaint, potentially affected systems, known chronic conditions, and appropriate psychosocial information.” “Supportive diagnostic evaluation according to presenting medical complaint.” C. Review of the facility policy, “Medical Staff Rules & Regulations Excerpts pertaining to EMTALA & QMP,” approved by the Board of Trustees on 1/23/2023 revealed, “Any patient determined to have a psychiatric disorder (i.e., a clinically significant disturbance in the individuals cognition, emotion regulation, or heavier that reflects a dysfunction in the psychosocial, biological, or developmental processes underlying the individual’s mental functioning may be admitted to the psychiatric area of the Medical Center when medical conditions permit, as determined by the Admitting Practitioner. If there are no accommodations available in this area, the patient shall be transferred, if possible, to another institution where suitable facilities are available in accordance with EMTALA procedures.” D. Review of Patient 3A (P3A)’s medical record (1/2/2024 at 9:12 AM) revealed P3A presented to the ACF ED on 11/18/2023 at 9:44 PM via ambulance after being found stumbling down the street intoxicated. According to the facility policy, “EMTALA,” effective 6/2/2023, “The following are always considered emergency medical conditions (EMC) and must be screened and treated ....Psychiatric disturbances, Symptoms of substance abuse, and Intoxication.” The Physician Assistant-A (PA-A) Emergency Department (ED) provider note titled physical exam lacked documentation of mental health screening, labs, drug or alcohol screening, consults, or imaging prior to disposition of discharge. A review of P3A’s entire medical record lacked evidence of documentation of discharge criteria set by PA-A prior to P3A discharge, confirmed by Registered Nurse-A (RN-A) during an interview on 1/2/2024 at 3:25PM. -Review of Patient 3B (P3B)’s medical record (12/28/2023 at 12:21PM) revealed P3B presented to the ACF ED on 11/20/2023 at 9:14PM for a mental health evaluation. The Advanced Practice Registered Nurse (APRN) ED provider note lacked evidence of labs, drug or alcohol screening, or imaging. P3B 11/20/2023 Mental Health Emergency Department (MHED) medical record lacked evidence of RN-D, RN-E, APRN, or PA-B collaboratively assuring appropriate treatment, admission/discharge and transfer procedures were implemented prior to discharge. The documentation from APRN and PA-B lacked evidence of supportive diagnostic evaluation according to presenting medical complaint of, “mental health problem-pt (patient) states is here for a mental health eval. Intoxicated and aggressive in triage. ED security present.” The APRN ED course & medical decision-making documentation revealed, “Unfortunately, [Detox Center A] does not have any beds at this time. [3B] was evaluated by the psychiatry team. Mother is going to try at [Detox Center B]. [3B] was given 1 dose of Zyprexa (antipsychotic medication, helps regulate mood, behavior and thoughts). Discharge with provisional diagnosis of alcohol use disorder.” P3B 11/20/2023 ED medical record lacked evidence of, “If there are no accommodations available in this area, the patient shall be transferred, if possible, to another institution where suitable facilities are available in accordance with EMTALA procedures.” E. During an interview on 1/3/2024 at 7:27AM RN-D revealed that RN-D’s interactions with P3B were prior to RN-E assessments, and RN-D was not the primary nurse assigned to P3B. RN-D recalled that P3B was coming to the nurses’ station, “agitated, wanting to leave, unwilling to stay in an area, and attempted to redirect P3B back to MHED room [security was called to assist].” P3B medical record from 11/20/2023 lacked notification documentation of communication between RN-D and RN-E, or RN-D and APRN or PA-B regarding the 10:01PM behavioral event by P3B; RN-D did not recall communicating P3B’s behavioral event to RN-E, APRN or PA-B. -During an interview on 1/3/2024 at 10:02AM APRN revealed the APRN consulted psychiatry [PA-B] and did not recall speaking to RN-E or PA-B regarding P3B. The APRN stated the Qualified Medical Professional (QMP) has access to the medical record and collaborates with psychiatry who makes the final decision on the disposition (decision to discharge, transfer or admit the patient) of the patient. -During an interview on 1/3/2024 at 8:14AM with PA-B revealed PA-B was consulted by APRN, PA-B did not see P3B in person, and did not access P3B’s medical record at the time of consult. PA-B communicated with RN-E via one telephone call regarding P3B. PA-B did not recall if RN-E reported P3B’s 10:01PM behavioral event that resulted in security involvement. -During an interview on 1/3/2024 at 10:33AM with RN-E revealed RN-E was the assigned QMP for P3B and did not recall if RN-D reported P3B’s 10:01PM behavioral event that resulted in security involvement. RN-E unaware of security involvement with P3B and did not report to PA-B during the psychiatric consult phone call to determine patient disposition (decision to discharge, transfer or admit the patient). RN-E confirmed no lab, drug or alcohol screen were ordered by APRN or PA-B during P3B’s entire 11/20/2023 ED visit. 46123 F. Review of Patient 11 (P11)’s medical record review revealed an admission blood pressure of 102/71 at 10:23PM on 9/8/23. While in the ED P11 received 2 liters of IV fluids with partial vitals that included pulse, blood pressure, MAP and oxygen saturation being checked at irregular intervals. P11’s blood pressure and Mean Arterial Pressure (MAP) continued to be low. The medical record lacks evidence of an evaluation prior to discharge as part of the ongoing process of the medical screening examination according to the facilities policy EMTALA effective 6/2/23. G. During an interview on 1/3/24 at 1:00PM, Medical Doctor-A (MD-A) revealed that he did not remember P11. MD-A was able to review P11’s medical record for the 9/8/23 visit prior to interview. MD-A stated that his shift was 3PM-12AM that day and he would have reported off to the oncoming provider (MD-B). The medical record lacks documentation that a handoff of providers was completed or that MD-B evaluated P11 prior to discharging.”

“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: 48575 Based on hospital policy and procedure review, medical record reviews, medical staff and staff interviews the Acute Care Facility (ACF) failed to ensure that 2 (P3B, and P11) of 20 sampled patients medical records received a complete Medical Screening Examination (MSE) to determine the presence of an emergency medical condition (EMC) prior to discharge. This failed practice has the potential to cause harm or death due to delayed treatment to all patients that present to the ACF Emergency Department (ED). According to facility provided information the ED treats an average of 7, 936 patients per month. See A2400 and A2407 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met. Findings Include: A. Review of the facility policy, “Mental Health Evaluation-Emergency Services,” effective 11/11/2022 revealed, “ ... ...the physician is responsible for the conclusion of the medical screening examination and the determination of whether the patient has an emergency medical condition. When an EMC is determined to exist, continued stabilizing and evaluative care will be rendered within the capabilities of the Medical Center.” -“In addition to those conditions described in the EMTALA procedure, all patients presenting with psychiatric disturbances presenting at an Emergency Department are declared by law to be emergencies requiring a medical screen, to exclude organic causes and additional psychiatric assessment of the patient’s condition, to provide for stabilization within the capabilities of the institution.” ..... “The following conditions are examples of Unstable Psychiatric Conditions, as defined by CMS ... ...Danger to self or others .....Change in mental status (must rule out organic causes, intoxication, masked conditions.” -“Emergency Department and Mental Health staff will collaboratively assure appropriate treatment, admission/discharge and transfer procedures are implemented.” “Medical staff documentation includes all of the elements of the medical screening examination including observations and the diagnostic test results supporting a conclusion that an emergency medical condition does or does not exist.” B. Review of the facility policy, “EMTALA,” effective 6/2/2023 revealed: -Emergency medical condition (EMC): “A condition manifesting itself by acute symptoms of sufficient severity (including .....psychiatric disturbances, symptoms of substance abuse, intoxicated individuals ... ....the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health ... ...in serious jeopardy.” -Medical screening examination (MSE): “Process required to reach, with reasonable clinical confidence and not on the basis of an individual’s source of payment or ability to pay, the point at which it can be determined whether a medical emergency does or does not exist.” -“A medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the person’s needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer.” -“The following are always considered emergency medical conditions (EMC) and must be screened and treated.” ... ...Psychiatric disturbances, Symptoms of substance abuse, and Intoxication. -Medical Screens will include: “Appropriate physical examination, including vital signs, the presenting complaint, potentially affected systems, known chronic conditions, and appropriate psychosocial information.” “Supportive diagnostic evaluation according to presenting medical complaint.” C. Review of Patient 3B (P3B)’s medical record (12/28/2023 at 12:21PM) revealed P3B presented to the ACF ED on 11/20/2023 at 9:14PM for a mental health evaluation. The APRN ED provider note revealed P3B was a return visit within 24 hours [P3A was discharged 11/19/2023 at 2:07AM]. The APRN ED provider note revealed P3B a past medical history (PMH) of alcohol abuse, anxiety, bipolar, depression, drug abuse, and psychosis. P3B history of present illness (HPI) documented by the APRN revealed, “ ...[P3B] Patient admits to acute alcohol intoxication. States that he also uses methamphetamines and weed. Mother is concerned as he has a history of schizophrenia and is not taking any of his medications at this time. The APRN ED provider note physical exam documentation revealed, “Mother and family member at bedside, patient is only wearing pants, no shoes or socks, no shirt, disheveled, walking around the room, comes close to my face multiple times, intrusive.” [Danger to others]. The ED APRN medically cleared P3B for the Mental Health ED (MHED) and consulted psychiatry to complete the MSE on 11/20/2023 at 9:56PM. -P3B was transferred from the ED to the MHED within the ACF. RN-D documented, “Pt [patient] became agitated and was unable/unwilling to listen to redirection from MHED staff, ED security called to assist with pt [patient],” on 11/20/2023 at 10:01PM. A review of RN-E mental health assessment revealed RN-E documented P3B’s admission type as voluntary, for “alcohol sucks,” ... mental status behavior characteristics as, “unwilling to participate, hyperactive, intrusive, guarded, resistant to care;” ... “concentration, insight, and judgement as impaired,” ... decreased appetite, disturbed/interrupted sleep on 11/20/2023 at 10:48PM. [Danger to others]. -The 11/20/2023 MHED medical record for P3B lacked evidence that a physician from the psychiatry team directly evaluated P3B to complete the MSE per policy, and no documentation or acknowledgement/signature from PA-B the consulted psychiatry regarding decision making of P3B disposition prior to discharge or thereafter. -RN-E designated as the (qualified medical professional) QMP documented the Mental Health Emergency Department (MHED) plan after assessment naming psych consulted as PA-B which revealed a plan of discharge with alcohol use disorder as the diagnosis that was co-signed by a psychiatric MD on 11/21/2023 at 7:26PM. [19 hours and 56 minutes after P3B was discharged from the MHED on 11/20/2023 at 11:30PM]. D. During an interview on 1/3/2024 at 7:27AM RN-D revealed that RN-D’s interactions with P3B were prior to RN-E assessments, and RN-D was not the primary nurse assigned to P3B. RN-D recalled that P3B was coming to the nurses’ station, “agitated, wanting to leave, unwilling to stay in an area, and attempted to redirect P3B back to MHED room [security was called to assist].” P3B medical record from 11/20/2023 lacked notification documentation of communication between RN-D and RN-E, or RN-D and APRN or PA-B regarding the 10:01PM behavioral event by P3B; RN-D did not recall communicating P3B’s behavioral event to RN-E, APRN or PA-B. -During an interview on 1/3/2024 at 10:02AM APRN revealed the APRN consulted psychiatry [PA-B] and did not recall speaking to RN-E or PA-B regarding P3B. The APRN stated the QMP has access to the medical record and collaborates with psychiatry who makes the final decision on the disposition (decision to discharge, transfer or admit the patient) of the patient. -During an interview on 1/3/2024 at 8:14AM PA-B revealed PA-B was consulted by APRN, PA-B did not see P3B in person, and did not access P3B’s medical record at the time of consult. PA-B communicated with RN-E via one telephone call regarding P3B. PA-B did not recall if RN-E reported P3B’s 10:01PM behavioral event that resulted in security involvement. -During an interview on 1/3/2024 at 10:33AM RN-E revealed RN-E was the assigned QMP for P3B and did not recall if RN-D reported P3B’s 10:01PM behavioral event that resulted in security involvement. RN-E unaware of security involvement with P3B and did not report to PA-B during the psychiatric consult phone call to determine patient disposition (decision to discharge, transfer or admit the patient). RN-E confirmed no lab, drug or alcohol screen were ordered by APRN or PA-B during P3B’s entire 11/20/2023 ED visit. 46123 E. Review of Patient 11’s (P11) medical record from Facility -A revealed on 9/8/2023 at 10:23PM P11 presented to the ED at Facility A via ambulance. P11 is an 18-year-old who lives at the dorm. P11 had complaints of nausea, vomiting, cough and almost passing out at the dorm. The RN (Registered Nurse) at the dorm called 911. Upon admission to the ED P11’s vitals were Temp (T) 99.5 F, Pulse (P) high at 135 (normal average 60-100 ), Respirations (R) 18, blood pressure (BP) 102/71 oxygen saturation (SPO2) 96%. MD-A evaluated P11. The assessment revealed that P11’s lungs were clear in all lung fields no abnormal lung sounds heard, bowel sounds were positive and abdomen was soft, nontender and nondistended, skin was warm and dry. Orders included, CBC (complete blood count a test that provides information about the cells in a person’s blood), BMP (basic metabolic panel is a blood test that measures glucose (sugar) electrolytes and how well the kidneys are working), COVID nasal swab, IV (intravenous) fluids, IV Zofran (medication to treat nausea and vomiting) and an EKG (electrocardiogram a recording of the heart’s electrical activity) were ordered. Abnormal lab results include potassium (a blood chemical that if low can cause fatigue, muscle cramps and abnormal heart rhythm) low at 3.2 (normal range 3.5-5.3) Creatinine (a waste product produced by your body that is filtered out by the kidneys. A high level can be a sign of a possible kidney problem.) high at 1.93 (normal range 0.50-1.40) white blood cells (part of the blood to help fight infection) low at 3.22 (normal range 4-10) platelet count (part of the blood that forms clots and stops or prevents bleeding) low at 79 (normal range 150-400) band neutrophils % (elevated concentration is the result of infection or inflammation) high at 60.2% (normal range 0.0-20.0%) lymphocytes, absolute (low levels can place the patient at higher risk of infection) low at 0.22 (normal range 0.80-3.30) vacuolated neutrophils (often indicators of an infection such as sepsis) abnormal with cells present (normal results cells absent). The COVID nasal swab was negative. The EKG was interpreted as sinus tachycardia (fast heart rate) with no acute ischemic changes (no reduction of oxygen rich blood flow to the heart - causes a change to the hearts electrical activity). While in the ED P11 was receiving IV fluids. During this time P11’s P, SPO2, BP and MAP (Mean Arterial Pressure- the average arterial pressure throughout one cardiac cycle. Normal range is 70-100. If below 60 there is a concern that there won’t be enough pressure to perfuse vital organs) are documented in the medical record. Documented vital signs include 9/8/23 at 11:30PM: P 122, SPO2 97%, BP 90/35, MAP 50 (P and BP marked as abnormal) 9/9/23 at 12:17AM: P 121, SPO2 100%, BP 85/54 MAP 64 (P marked as abnormal) 9/9/23 at 12:30AM: P 115, SPO2 98%, BP 85/45, MAP 58 (P and BP marked as abnormal) 9/9/23 at 12:45AM: P 115, SPO2 99%, BP 93/42, MAP 57 (P and BP marked as abnormal) 9/9/23 at 1:30AM: P 109, SPO2 95%, BP 91/47, MAP 59 (BP marked as abnormal) The medical record lacks evidence of MD-A or MD-B being notified of abnormal vital sign results during P11’s ED visit. At 12:03 AM on 9/9/23 MD-A set P11’s disposition to discharge home in the electronic medical record (EMR) and sent an order for Zofran (medication to treat nausea and vomiting) to the pharmacy. At 1:48AM MD-B changed the patient status in the EMR to “Patient Ready to Go.” The medical record lacks documentation that MD-B continued the ongoing process of the MSE with an evaluation of P11 prior to discharge to determine if the EMC had been resolved. RN-F was the discharging nurse that reviewed the after-visit summary (AVS) with P11 and family. The medical record lacks evidence of a full set of vitals (a full set of vitals includes temperature, pulse, respirations, blood pressure, oxygen saturation) prior to discharge. P11 was discharged home with parents at 2:00AM on 9/9/23. F. Review of medical record from Facility-B reveals that P11 presented to the ED on 9/9/23 at 4:00PM (14 hours after discharge from Facility-A). P11 chief complaint included not feeling well for the past couple of days, headache, body aches, abdominal pain, dizziness, nausea, and fevers. Triage vital signs were T 97.9 oral, P 104, R 20, BP 94/39, MAP 57, SPO2 100% on room air and pain rating of 4 out of 10 in the upper abdomen. P11 also admitted to new onset diarrhea with 7 episodes on 9/9/23. Assessment was completed. Labs, radiology and IV fluid bolus were ordered. Abnormal labs included WBC (white blood count- can indicate an infection) high at 18 (normal range 4-10), Platelets (help with clotting) low at 96 (Normal range 150-450), Glucose (sugar) high at 114 (normal range 70-99), Sodium (low sodium can cause nausea, vomiting, loss of energy and confusion) low at 131 (Normal range 136-145), BUN (a product in the body removed by the kidneys elevated levels can indicate the kidneys aren’t working well) high at 30 (Normal Range 6-22), Creatinine (a waste product produced by your body that is filtered out by the kidneys. An elevated level can be a sign of a possible kidney problem.) high at 2.51 (Normal range 0.50-1.40), AST (an elevated level can indicate liver disease) high at 65 (Normal range 0-41), high sensitivity CRP (c-reactive protein high levels can indicate a serious infection) high at greater than 300 (Normal range 0.0-5.0), Lactate (an elevated level can indicate organs are not functioning properly) high at 3.3 (Normal range 0.7-2.1) Procalcitonin (a substance the body produces in response to bacterial infection, elevated levels can indicate a serious infection or sepsis) high at greater than 100 (Normal range less than 0.08). While in the ED at Facility-B P11 received 5 liters of IV fluid, IV Zosyn (antibiotic), IV Vancomycin (antibiotic) and a Levaquin tablet (antibiotic). P11 was also started on a levophed (an IV medication used to treat low blood pressure ) infusion. P11 was transferred to Facility-C via Advanced Life Support (ALS) ambulance at 8:50PM. Vital signs prior to transfer were T 98.6, P 91, R 30, BP 102/47 MAP 65. Facility-B documented the transferring diagnosis as Septic shock without obvious source. G. During an Interview on 1/3/23 at 2:30PM, RN-F revealed that in the ED the EMR is set up to run the sepsis screening in the background when criteria information is entered. In the ED the system runs the qSOFA (quick sequential organ failure assessment) screen. Criteria used for screening include altered mental status (AMS), respiratory rate greater than 22 and hypotension (low blood pressure) SBP (systolic blood pressure - the top number of blood pressure) less than 100. RN-F confirmed that since P11 did not have mental status and respiratory rate entered with documented vital signs the qSOFA screen did not run. RN-F stated that expectation for vital signs is hourly. The hourly vital signs expectation is to include temperature and respiratory rate. RN-F stated there was not a policy for vital signs only that they are a care expectation. RN-F confirmed that P11 was not screened by the EMR using the qSOFA screen due to no respirations or the altered mental status being addressed during the ED visit after the initial set of vitals. H. During an interview on 1/3/23 at 1:00PM, MD-A revealed that he does not remember P11 however he was able to review the medical record. MD-A states that looking at the chart P11 looked more viral sick than bacterial sick. P11s lung sounds were clear, and a chest x-ray was not indicated. MD-A felt that with an elevated creatinine and the increase in P11’s pulse that P11 was dehydrated. MD-A was asked if P11’s blood pressure was concerning, and MD-A replied that the blood pressure could have been due to the dehydration. When asked if MD-A thought P11’s lab should have been redrawn due to the EDTA-medicated platelet clumping (an anticoagulant used in blood collection tubes can cause the platelets to clump). MD-A responded that he did not feel that the lab needed to be redrawn. MD-A stated that he worked 3P-12A on 9/8/23 so he was not working when P11 was discharged. MD-A stated that he would have reported off to the oncoming medical provider at the end of his shift, but he does not recall P11 or reporting off.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 46123 Based on medical record review, staff interviews and policy review the facility failed to ensure that 1 (P11) of 20 sampled patient medical records received necessary stabilizing treatment for an EMC within the capabilities of the facility. This failed practice has the potential to cause harm or death due to delayed treatment to all patients that present to the ACF ED. According to facility provided information the ED treats on average 7,936 patients per month. See A2400 and 2406 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met. Findings include: A. Review of facility policy “EMTALA”, effective 6/2/2023 revealed, that the MSE is an ongoing process, and the record must reflect continued monitoring according to the person’s needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer. The MSE will include an appropriate physical examination including vital signs. B. Review of Patient 11’s (P11) medical record from Facility-A revealed on 9/8/2023 at 10:23PM P11 presented to the ED at Facility A via ambulance. P11 is an 18-year-old who lives at the dorm. P11 had complaints of nausea, vomiting, cough and almost passing out at the dorm. The RN (Registered Nurse) at the dorm called 911. Upon admission to the ED P11’s vitals were T 99.5 F, P high at 135 (normal average 60-100), R 18, BP 102/71 (normal range 100-139/50-89) and oxygen saturation (SpO2) 96% (normal range 90%-100%). MD-A evaluated P11. The assessment revealed that P11’s lungs were clear in all lung fields no abnormal lung sounds heard, bowel sounds were positive, and abdomen was soft, nontender and nondistended, skin was warm and dry. Orders included, CBC (complete blood count a test that provides information about the cells in a person’s blood), BMP (basic metabolic panel is a blood test that measures glucose (sugar) electrolytes and how well the kidneys are working), COVID nasal swab, IV (intravenous) fluids, IV Zofran (medication to stop nausea) and an EKG (electrocardiogram a recording of the heart’s electrical activity) were ordered. Abnormal lab results include potassium (a blood chemical that if low can cause fatigue, muscle cramps and abnormal heart rhythm) low at 3.2 (normal range 3.5-5.3) Creatinine (a waste product produced by your body that is filtered out by the kidneys. A high level can be a sign of a possible kidney problem.) high at 1.93 (normal range 0.50-1.40) white blood cells (part of the blood to help fight infection) low at 3.22 (normal range 4-10) platelet count (part of the blood that forms clots and stops or prevents bleeding) low at 79 (normal range 150-400) band neutrophils % (elevated concentration is the result of infection or inflammation) high at 60.2% (normal range 0.0-20.0%) lymphocytes, absolute (low levels can place the patient at higher risk of infection) low at 0.22 (normal range 0.80-3.30) vacuolated neutrophils (often indicators of an infection such as sepsis) abnormal with cells present (normal results cells absent). The COVID nasal swab was negative. The EKG was interpreted as sinus tachycardia (fast heart rate) with no acute ischemic changes (no reduction of oxygen rich blood flow to the heart - causes a change to the hearts electrical activity). While in the ED P11 was receiving IV fluids. During this time P11’s BP, MAP (Mean Arterial Pressure- the average arterial pressure throughout one cardiac cycle. Normal range is 70-100. If below 60 there is a concern that there won’t be enough pressure to perfuse vital organs) P, and SPO2 are documented in the medical record. Documented vital signs include 9/8/23 at 11:30PM: P 122, SPO2 97%, BP 90/35, MAP 50 (P and BP marked as abnormal) 9/9/23 at 12:17AM: P 121, SPO2 100%, BP 85/54 MAP 64 (P marked as abnormal) 9/9/23 at 12:30AM: P 115, SPO2 98%, BP 85/45, MAP 58 (P and BP marked as abnormal) 9/9/23 at 12:45AM: P 115, SPO2 99%, BP 93/42, MAP 57 (P and BP marked as abnormal) 9/9/23 at 1:30AM: P 109, SPO2 95%, BP 91/47, MAP 59 (BP marked as abnormal) The medical record lacks evidence of MD-A (shift from 3PM-12AM) or MD-B (shift started at 12AM on 9/9/23) being notified of abnormal vital sign results during P11’s ED visit. At 12:03 AM on 9/9/23 MD-A set P11’s disposition to discharge home in the electronic medical record (EMR) and sent an order for Zofran to the pharmacy. At 1:48AM MD-B changed the patient status in the EMR to “Patient Ready to Go.” The medical record lacks documentation that MD-B continued the ongoing process of the MSE with an evaluation of P11 prior to discharge to determine if the EMC had been resolved. RN-F was the discharging nurse that reviewed the after-visit summary (AVS) with P11 and family. The medical record lacks evidence of a full set of vitals prior to discharge. P11 was discharged home with parents at 2:00AM on 9/9/23. C. Review of medical record from Facility-B reveals that P11 presented to the ED on 9/9/23 at 4:00PM (14 hours after discharge from Facility-A ED). P11’s chief complaint included not feeling well for the past couple of days, headache, body aches, abdominal pain, dizziness, nausea, and fevers. Triage vital signs were T 97.9 oral, P 104, R 20, BP 94/39, MAP 57, SPO2 100% on room air and pain rating of 4 out of 10 in the upper abdomen. P11 also admitted to new onset diarrhea with 7 episodes on 9/9/23. Assessment was completed. Labs, radiology and IV fluid bolus were ordered. Abnormal lab results include WBC (white blood count- can indicate an infection) high at 18 (normal range 4-10), Platelets (help with clotting) low at 96 (Normal range 150-450), Glucose (sugar) high at 114 (normal range 70-99), Sodium (low sodium can cause nausea, vomiting, loss of energy and confusion) low at 131 (Normal range 136-145), BUN (a product in the body removed by the kidneys elevated levels can indicate the kidneys aren’t working well) high at 30 (Normal Range 6-22), Creatinine (a waste product produced by your body that is filtered out by the kidneys. An elevated level can be a sign of a possible kidney problem.) high at 2.51 (Normal range 0.50-1.40), AST (an elevated level can indicate liver disease) high at 65 (Normal range 0-41), high sensitivity CRP (c-reactive protein high levels can indicate a serious infection) high at greater than 300 (Normal range 0.0-5.0), Lactate (an elevated level can indicate organs are not functioning properly) high at 3.3 (Normal range 0.7-2.1) Procalcitonin (a substance the body produces in response to bacterial infection, elevated levels can indicate a serious infection or sepsis) high at greater than 100 (Normal range less than 0.08). While in the ED at Facility-B P11 received 5 liters of IV fluid, IV Zosyn (antibiotic), IV Vancomycin (antibiotic) and a Levaquin tablet (antibiotic). P11 was also started on a levophed (an IV medication used to treat low blood pressure ) infusion. P11 was transferred to Facility-C via Advanced Life Support (ALS) ambulance at 8:50PM. Vital signs prior to transfer were T 98.6, P 91, R 30, BP 102/47 MAP 65. Facility -B documented the transferring diagnosis as Septic shock without obvious source. D. During an interview on 1/3/23 at 1:00PM, MD-A revealed that he does not remember P11 however he was able to review the medical record. MD-A states that looking at the chart P11 looked more viral sick than bacterial sick. P11s lung sounds were clear, and a chest x-ray was not indicated. MD-A felt that with an elevated creatinine and the increase in P11’s pulse that P11 was dehydrated. MD-A was asked if P11’s blood pressure was concerning, and MD-A replied that the blood pressure could have been due to the dehydration. When asked if MD-A thought P11’s lab should have been redrawn due to the EDTA-medicated platelet clumping (an anticoagulant used in blood collection tubes can cause the platelets to clump). MD-A responded that he did not feel that the lab needed to be redrawn. MD-A stated that he worked 3P-12A on 9/8/23 so he was not working when P11 was discharged. MD-A stated that he would have reported off to the oncoming medical provider at the end of his shift, but he does not recall P11 or reporting off. E. During an Interview on 1/3/23 at 2:30PM, RN-F revealed that in the ED the EMR is set up to run the sepsis screening in the background when criteria information is entered. In the ED the system runs the qSOFA (quick sequential organ failure assessment) screen. Criteria used for screening include altered mental status (AMS), respiratory rate greater than 22 and hypotension (low blood pressure) SBP (systolic blood pressure - the top number of blood pressure) less than 100. RN-F confirmed that since P11 did not have mental status and respiratory rate entered with documented vital signs the qSOFA screen did not run. RN-F stated that expectation for vital signs is hourly. The hourly vital signs expectation is to include temperature and respiratory rate. RN-F stated there was not a policy for vital signs only that they are a care expectation. RN-F confirmed that P11 was not screened by the EMR using the qSOFA screen due to no respirations or the altered mental status being addressed during the ED visit after the initial set of vitals.”