Chi Health Bergan Mercy

“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: 48575 Based on policy, procedure and protocol review, medical record review, observation and staff interviews, the facility failed to follow the pressure ulcer prevention protocol for 2 (Patient 2, and 11) out of 13 sampled inpatients with Hospital-Acquired Pressure Injury (HAPI)(a pressure injury that developed during the patient’s hospital stay). This failed practice has the potential to cause prolonged treatment for any admitted patient. The facility census on entrance was 331. See citation A0813, that also resulted in A0398 standard to be not met. Findings include: A. Review of facility policy, Core Nursing Standard of Practice, last revised 1/2025 revealed nursing interventions for patient activity and positioning is to be documented at a minimum of every 4 hours. Review of the facility Nursing Services Pressure Ulcer Prevention protocol, last revised 5/2024 revealed bed bound patients at risk with a Braden score (nursing tool used to identify patients at risk for skin breakdown) of 18 or less should be repositioned at least every 2 hours, even if on a pressure-reducing mattress. Review of facility organizational plan for the provision of patient care services, last revised 2/24/2025 revealed the staffing process is developed to ensure adequate numbers of qualified staff are available at all times to provide quality patient care, coordinate and supervise the provision of care, and meet the established standards of care. Review of facility policy, Skin Assessment - Wounds, Ostomy, and HAPI, last revised 11/2025 revealed to start prevention strategies for patients identified to be at risk for pressure injury development based on risk factors and the risk assessment tool. Interventions included to avoid the use of air cushions (waffle) placed on top of specialty foam or air surfaces. Verify support surfaces are appropriately functioning and offloading the patient from direct contact with the bed frame. B. Review of Patient 2’s medical record revealed the patient admitted to the acute care facility on 11/4/2025 via ambulance for a ground level fall. Patient 2 was admitted at 1:27PM for a C4-5 compression fracture (broken neck bone). The past medical history revealed post-polio (nerve virus with long term effects to muscles, and joints), chronic back pain, kyphosis (curvature of the spine) and was previously lived at an assisted living facility independent (doesn’t require assistance). On 11/5/2025 the patient was unable to be positioned and the surgeon stopped surgery. Patient 2’s American Spinal Injury Association (ASIA) revealed ASIA C (incomplete spinal cord injury with limited motor function below the level of the neck injury). Patient 2 was ordered bedrest (cannot get out of bed). The facility completed a 2-nurse skin check on admission per policy, no indication of skin abnormalities to the bottom area. Braden score of 13. Height was 5 feet 1 inch and weighed 132 pounds. Pressure ulcer prevention documentation revealed to turn the patient, and relieve pressure points every 2 hours. The first 27-hour timeframe Patient 2 was documented as repositioned 4 out of 13 times as evidenced by: 11/4/2025 at 8PM. 11/5/2025 at 6AM. 11/5/2025 at 12PM. 11/6/2025 at 4AM. [Calculations include Patient 2 admission time of 11/4/2025 at 1:27PM until 11/6/2025 at 4:00AM= 27 hours] [Every 2 hour reposition per protocol= 27 hours/2 hours=13 times that the patient should have been repositioned]. On 11/10/2025 at 8:00PM [6 days after admission] nursing documented a red non-blanchable area to the coccyx/buttock (tailbone). The wound care team was consulted and determined Patient 2 had a suspected deep tissue injury (DTI) (long periods of pressure with lack of blood flow to the muscle and tissue that causes the skin to turn purple or maroon approximately 2-4 days after injury). On 11/11/2025 at 6:03AM Patient 2 DTI measured 6.0 centimeters by 7 centimeters (6.0 cm x 7.0 cm x ?) (width, length and depth measurements). Patient 2’s medical record lacked evidence of any other measurements, or the wound nurse reassessment per plan prior to discharge on 11/17/2025 at 10:02AM, confirmed by RN-F. Review of Patient 11’s medical record revealed the patient admitted to the acute care facility on 1/7/2026 for critical care and treatment. Patient 11’s pressure injury was first discovered on 1/21/2026 (day 14), wound care was consulted. On 1/23/2026 at 10:27AM (day 16) the wound nurse measured the sacrum pressure injury at 1.2cm x 1.5cm x 0.1cm. On 1/29/2026 at 9:59AM (day 22) the wound nurse measured the sacrum pressure injury at 4.2cm x 2.2cm x 0.1cm (increased in size by 3cm x 0.7cm x same). C. During an observation on 1/29/2026 at 9:59AM of Patient 11’s wound care by Registered Nurse (RN-C) revealed: RN-C entered room, Patient 11’s was found lying in bed with both heels, and buttocks directly on the plastic waffle, no Medline heel boots on feet, plastic tubes under the left leg, and incontinent pad under shoulders. Patient 11’s coccyx wound boarders revealed dry rolled up skin, not intact, confirmed by RN-C. D. Interview with RN-C on 1/29/2026 at 10:22AM revealed there are 6 wound care nurses to cover 5 entities who work Monday through Friday. Four full-time, 1 part-time and a manager. RN-C confirmed the rolled-up skin on Patient 11’s coccyx wound boarders were from friction and shear (rubbing that occurs when skin drags across a surface). RN-C confirmed Patient 11’s coccyx pressure injury increased by 3cm in 6 days. Interview with RN-D on 1/29/2026 at 1:29PM revealed some days staffing lacks to provide ADL (activities of daily living) for dependent (can’t do themselves) patients. Leaders are expected to help with patient rounding and check in with the charge nurse as an extra hand. Interview with RN-E on 1/29/2026 at 2:04PM revealed the volume dependent staffing is generally 7 RNs and 1 Charge Nurse for an 18-bed intensive care unit (ICU) with an average daily census of 14 with 10-12 ICU level patients. Approximately 4 out of 7 days are not staffed for the true number the ICU qualifies for and struggle. RN-E revealed staffing used to include nursing assistants, but it was an organization wide decision not around a year or so ago.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. 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 include wound care and treatment that pertained to the patients current course of illness in the discharge paperwork for 2 (Patient 2 and 7) out of 13 sampled inpatients. This failed practice has the potential to affect all inpatients continuum of care. The facility census on entrance was 331. See citation A0398, that also resulted in A0813 standard to not be met. Findings Include: A. Review of the Care Coordination Discharge Planning Clinical policy, last revised 4/8/2025 revealed the bedside nurse is responsible for completion of the discharge instructions that include post-acute follow up. Review of the Virtually Integrated Care (VIC) - Nursing Transformation policy, last revised 8/2023 revealed the VIC Registered Nurse RN) role is defined as a care model with a goal to reduce the workload burden from the bedside nurse. Responsibilities include but are not limited to the patient admission and discharge coordination. B. Review of Patient 2’s medical record revealed the patient arrived at the acute care facility on 11/4/2025 via ambulance for a ground level fall and was admitted at 1:27PM for a C4-5 compression fracture (broken neck bone). Patient 2 was ordered bedrest (cannot get out of bed). The facility completed a 2-nurse skin check on admission per policy with no indication of a red area to the coccyx (tailbone) or buttock. According to Patient 2 medical record nursing documentation, the first 27-hour timeframe Patient 2 was repositioned 4 out of 13 times. On 11/10/2025 at 8:00PM [6 days after admission] nursing documented a red non-blanchable area to Patient 2 coccyx/buttock. The wound care team was consulted and determined Patient 2 had a suspected deep tissue injury (DTI) (long periods of pressure with lack of blood flow to the muscle and tissue that causes the skin to turn purple or maroon approximately 2-4 days after injury). On 11/17/2025 at 10:02AM Patient 2 was discharged to an inpatient rehabilitation facility for continued care and treatment of the new spinal cord injury. Patient 2’s continuum of care and after visit summary (AVS) (discharge paperwork) lacked evidence of wound care and treatment for the coccyx/buttock to the receiving facility on discharge. Review of Patient 7’s medical record revealed the patient was admitted to the acute care facility on 11/21/2025 for a cervical stenosis of the spinal canal (c-spine neck problem). Patient 7 had an anterior cervical discectomy and fusion (ACDF) of C6-7 (neck surgery). On 12/1/2025 nursing documentation revealed a DTI to the left buttock with measurements of 3 centimeters by 6 centimeters (3cm x 6cm x?) (length, width and depth measurements). On 12/30/2025 Patient 7’s left buttock measurements revealed 1.8cm x 1.3cm x 0.1cm. Patient 7 was discharged on 12/31/2025 to a facility for continued care and treatment. Patient 7’s Patient 2’s continuum of care and AVS lacked evidence of wound care and treatment for the left buttock to the receiving facility on discharge. C. Interview with a Discharge Planner on 1/28/2026 at 2:43PM revealed the virtual nurse sends the continuum of care and AVS to the receiving facility on discharge. Patient 2’s final discharge plan was in place 11/14/2025 and discharged 11/17/2025 at 10AM. Interview with RN-A on 1/28/2026 at 12:43PM revealed the first interaction with Patient 2 was the day of discharge on 11/17/2025.”

“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 facility policy and procedure review, medical record review, medical staff and staff interviews the facility failed to follow their EMTALA (Examination, Treatment, and Transfer of Individuals who come to the Emergency Department) policy and Triage policy in the Emergency Department (ED) for 1 (Patient 13A) of 20 sampled ED patients. This failed practice has the potential to cause negative outcomes for all patients who present to the ED for care and treatment. According to facility provided data the ED saw an average of 5338 patients per month for the past 6 months. See citation A2406, that also resulted in A2400 to not be met.”

“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 policy and procedure review, medical record review, medical staff interview, and staff interviews, the facility failed to ensure the Triage and EMTALA policies were followed for 1 (Patient 13A) out of 20 sampled emergency department (ED) patients who waited to be roomed for 6+ hours without a medical screening exam (MSE) to rule out an emergency medical condition (EMC) or reassessment of patient condition while in the ED lobby. This failed practice has the potential to cause a delay in care and treatment for any patient who presents to the ED for care. According to facility provided data the ED saw an average of 5338 patients per month for the past 6 months. See citation A2400, that also resulted in A2406 to not be met. Findings include: A. Review of facility policy titled, “Triage,” approved 9/2025 revealed the triage Registered Nurse (RN) will prioritize patients based on the Emergency Severity Index (ESI) Triage Algorithm. Appropriate reassessments will be documented on the medical record. The need and frequency of the reassessments will be guided by medical conditions which have the potential for change in clinical status. Review of facility policy, “Examination, Treatment, and Transfer of Individuals who come to the Emergency Department (EMTALA),” approved 2/2023 revealed that the act of a patient triage is not considered a medical screening exam. A Medical Screening Exam (MSE) is defined as the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted by physicians to determine whether an EMC exists. An Emergency Medical Condition (EMC) is defined as a medical condition manifesting itself by acute symptoms of sufficient severity. If an EMC is determined to exist, the hospital will provide the individual ...any necessary stabilizing treatment within the capabilities of the staff and the facilities available at the hospital. B. Review of Patient 13A electronic medical record (EMR) revealed, P13A presented to the acute care hospital ED on 11/17/2025 at 12:02PM via car, with a chief complaint of “left ear pain that started 2 weeks ago making the left side of the face numb that started last night.” P13A was triaged by a Registered Nurse (RN) is not a qualified medical professional (QMP) before being sent back to the lobby to wait for a room at 12:14PM. Review of the EMR revealed P13’s documented triage nursing assessment lacked evidence of the new onset of facial numbness notification to a QMP. P13 was in the ED lobby waiting for 6 hours before the patient left without being seen (LWBS) by a qualified medical professional (QMP) to conduct an MSE to rule out an EMC. Review of the EMR revealed RN-A documented on 11/17/2025 at 6:38PM Registered Nurse A (RN-A) the patient was not in the waiting area when called to be roomed. [6 hours and 23 minutes after arrival]. Review of the EMR revealed P13 was triaged by RN-A at 12:14 and no further assessments or vital signs were documented while P13 waited 6 hours and 23 minutes to be evaluated for an emergency medical condition (EMC). P13A medical record lacked evidence of a reassessment of patient condition, vital sign recheck within 2 hours of waiting in the lobby per facility ED expectations, confirmed by RN-B. C. During an interview on 1/7/2026 at 3:36PM, Physician-A confirmed P13A was not seen by a qualified medical professional (QMP - a person qualified to conduct a MSE) on 11/17/2025 ED visit prior to the patient leaving without being seen (LWBS) (the patient leaves the ED with or without notifying the facility before being seen by a QMP). The ED had identified the need to staff an advanced practice provider (APP) in triage with the capability to start an MSE, unfortunately the facility did not have enough medical staff to fill the triage APP position for that action plan on 11/17/2025. During an interview on 1/8/2026 at 1:01PM, RN-A revealed 11/17/2025 was one of the busiest days the ED has experienced with approximately 20-25 people waiting in the lobby. The charge nurse and manager came in to assist in Triage. The lobby tech is assigned to recheck vital signs every hour while the patient is waiting, but did not have one on 11/17/2025. RN-A recalled that the patient did not notify anyone they were leaving. During an interview on 1/8/2026 at 11:30AM, Registrar-A revealed the clinical staff monitors patients while waiting in the lobby and generally come round every hour, and recheck vital signs. Registrar-A revealed the procedure after registration is to notify the triage RN of patient arrival, and if any stroke like symptoms immediately.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48575 Based on medical record review, policy and procedure review, observations and staff interviews, the facility failed to provide adequate supervision by nursing to ensure the unlicensed personnel (nurse assistant) sanitized the glucometer machine between patients per facility policy for 6 (Patients 13, 14, 15, 16, 17, 18) out of 6 patients observed. This failed practice has the potential to spread infectious diseases to staff and patients. The inpatient census at the time of entrance was 303. Findings are: A. Review of Patient 13’s medical record revealed the patient was admitted to the facility on 6/26/2025 with a diagnosis of sepsis (blood infection). Review of Patient 14’s medical record revealed the patient was admitted to the facility on 9/29/2025 with a diagnosis of heart failure. Review of Patient 15’s medical record revealed the patient was admitted to the facility on 9/29/2025 for trauma evaluation after a ground level fall which resulted in a subdural hematoma (SDH-brain bleed). Review of Patient 16’s medical record revealed the patient was admitted to the facility on 9/25/2025 with a diagnosis of NSTEMI (non-ST elevation myocardial infarction - heart attack). Review of Patient 17’s medical record revealed the patient was admitted to the facility on 9/29/2025 with a diagnosis of pneumonia (infection in the lungs). Review of Patient 18’s medical record revealed the patient was admitted to the facility on 9/30/2025 with a diagnosis of a diabetic foot infection. Review of Patients 13, 14, 15, 16, 17, and 18 medical records revealed an order for a glucose POCT (point of care testing) four times per day before meals and bedtime (a test that measures the amount of sugar in a patient’s blood through a finger poke blood sample that goes on a test strip into the machine.) B. Review of facility policy titled, Point of Care - Nova StatStrip Glucometer, last revised 10/2024, revealed maintenance of the machine includes to clean the glucometer (a machine that measures the amount of sugar in a patient’s blood through a finger poke blood sample that goes on a test strip into the machine) by wiping the external surface of the glucometer thoroughly with a fresh bleach wipe after each patient. The policy defines the disinfectant procedure in 6 steps for the staff to follow with an expectation to perform between each patient use. Step four defines the dry time for the bleach wipe [4 minutes] and allow an additional one minute. Step six defines once the glucometer is dry, return to the docking station. C. During observation of glucose POCT by Certified Nursing Assistant (CNA-A) on 10/1/2025 revealed the following: At 11:06AM CNA-A entered Patient 13’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer per policy prior to entering Patient 14’s room at 11:10AM, 2 minutes later, confirmed by Registered Nurse (RN-D). At 11:10AM CNA-A entered Patient 14’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer prior to returning the machine to the docking station, confirmed by RN-D. During an observation of glucose POCT by Certified Nursing Assistant (CNA-B) on 10/2/2025 revealed the following: At 11:08AM CNA-B entered Patient 15’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer prior to entering Patient 16’s room at 11:14AM. At 11:14AM CNA-B entered Patient 16’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer prior to entering Patient 18’s room at 11:20AM. At 11:20AM CNA-B entered Patient 18’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer prior to entering Patient 17’s room at 11:28AM. At 11:28AM CNA-B entered Patient 17’s room, performed the glucose POCT per order, left the room and failed to sanitize the glucometer prior to returning the machine to the docking station, confirmed by RN-E. D. Interview with CNA-A on 10/1/2025 at 11:15AM revealed they went through training to perform the glucose POCT 5 months ago and generally wipes down the glucometer machine between patients but forgot this time and could not remember which wipe to use. Interview with RN-D on 10/1/2025 at 11:28AM confirmed CNA-A was trained and signed off to use the Nova StatStrip Glucometer on 5/15/2025, and should have sanitized the glucometer between patient 13, 14 and when returned to the docking station. Interview with CNA-B on 10/2/2025 at 11:32AM revealed they haven’t wiped down the glucometer machine between patients and was unaware of the need to. Interview with RN-E on 10/2/2025 at 11:33AM confirmed that the glucometer machine should be sanitized between patient use and stated the use of the purple top wipes for regular patients and orange top [bleach] wipes for the patients on precautions (infectious diseases). Interview with RN-F on 10/2/2025 at 12:08PM confirmed that CNA-B was trained and signed off to use the Nova StatStrip Glucometer on 5/19/2025, and should have sanitized the glucometer between patient use with the bleach wipe and when returned to the docking station per facility policy.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 16132 Based on medical record review, review of facility policies and procedures and staff interview, the facility failed to ensure adequate supervision by nursing to document complete meal consumption and assistance, ongoing nutrition assessment and notification of nutritional changes to dieticians for 1 (Patient 1) of 9 sampled patients at nutritional risk due to poor meal consumption, pressure ulcer on left elbow, and systemic bacterial infection noted by positive blood cultures. This failed practice has the potential to cause negative outcomes for all inpatients who present to the hospital for care at nutritional risk. The facility inpatient census at the time of entrance was 337. Findings are: A. Review of Patient 1’s medical record identified the patients weight documented on 3/29/25 at 6:28 PM was 218 lb 3.2 oz. The medical record lacked another weight documented since admission. Patients 1’s medical record by mouth intake (meal) documentation confirmed by RN-C on 5/22/25 at 2:00 PM revealed: - 03/29/25: no documentation of meal consumption (patient 1 admitted at 3:59 PM) - 03/30/25: 0% breakfast; 25% at lunch; no documentation for evening meal - 03/31/25: 20% breakfast; 25% at lunch and 25% evening meal - 04/01/25: 10% breakfast; 20% at lunch and 30% evening meal - 04/02/25: 50% breakfast; 50% at lunch and no documentation of evening meal - 04/03/25: 10% breakfast; no documentation of documentation of lunch meal (patient 1 dismissed 3:59 PM) Review of Patient 1’s consult and progress notes related to left elbow wound revealed: -3/31/25 3:47 PM - Wound Care Consult Note - “The wound is characteristic of skin tear located left elbow measures 5.0 cm (centimeter) x (by) 4.0 cm x 0.1 cm. This ulcer is considered Full-thickness. The ulcer bed is pink granular and red granular and exposed subcutaneous tissue. The skin flap not adhering, dry and intact and erythematous (redness). There is a minimal amount of serous exudate draining from ulcer.” “PLAN: The treatment plan is skin integrity, prevent skin breakdown, pressure prevention measures, improve overall patient well being.” -4/1/25 6:14 AM - Dr B progress note - “Wound care consulted. Wound care noticed some purulence and erythema on 4/1/25 during dressing change.” -4/2/25 6:09 AM - Dr B progress note - “Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue.” -4/3/25 12:41 PM Discharge Summary Note 1 - Dr B stated, “Cellulitis of left upper extremity, pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue.” B. Interview on 5/22/25 at 10:34 AM with Dietitian (RD-A) scheduled on the area that the patient was placed in the hospital. The RD-A stated that this patient was not referred for nutritional intervention. The patient on admission scored on the Malnutrition “At Risk Assessment” scored by nurses was scored as a 0. The policy is “If they score a 2 or greater, the dietitian has to see the pt within 2 days.” “If a patient has been here 7 days, they are to be seen by the dietitian.” “If a physician requests a nutrition consult.” “We do MDR (multidisciplinary rounds) daily and this patient did not come up.” Upon review of Pt 1’s medical record with RD-A, revealed, the patient appetite was poor, there was a skin tear wound on the left elbow with cellulitis extending to left upper arm that progressed to a pressure ulcer, no supplement provided and positive blood cultures and no repeat weight (which is not required due to the Malnutrition Score of 0). RD-A confirmed that someone should have notified the dietitian of the pt’s poor to limited intakes during their stay.” C. Interview on 5/22/25 at 11:36 AM with RN-D that was the nurse manager while Pt 1 was hospitalized 3/29/25-4/3/25. RN-D stated, “I rounded on this patient for leader rounding. The patient didn’t communicate, the (child) would tell me, (Pt 1) isn’t normally like this.” “The patients family was upset because IV was saline locked (IV hub remains in place, no intravenous fluids running), also didn’t think was getting enough help eating.” The review of the record showed that at that time the patient was eating some of meal. IV fluid was restarted. RN-D confirmed that the patient intake wasn’t consistently charted and that there was not a dietitian consult. “I knew the son wanted to take the patient to the other hospital. The doctor came and talked to the family.” D. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed: -INTAKE AND OUTPUT; a) Fluid intake and output is recorded every shift if patient condition warrants. b) Meal intake is recorded as a percentage when the patient completes each meal. c) Supplements are recorded according to type and volume when the patient consumes the supplement. -CARE DELIVERY; a)The registered nurse performs and /or oversees delivers care according to the patient’s need, orders and the plan of care to achieve identified outcomes. -REFERRALS AND CONSULTS; a) Engages members of the interprofessional team according to patient condition, identified outcomes and patients plan of care; referrals include, but are not limited to: Dietitian b) The registered nurse must collaborate with the licensed practitioner to order consults.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 16132 Based on record review, policy review and staff interview; the facility failed to develop a nursing care plan to meet the identified nutritional needs for 4 of 11 sampled patients (Patients 1, 4, 6 and 11). The facility census was 337. This deficient practice had the potential to affect all patients admitted to the facility at nutritional risk. Findings are: A. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed: “1)Plan of Care-“The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes; the registered nurse: --Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. --Integrates inter-professional team partners in implementation of the plan through collaboration and communication across the continuum of care. --Delegates according to the health, safety, and welfare of the patient and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations. Institution, and regulatory entities while maintaining accountability for the care. --Documents implementation, modifications and evaluation of goals; including changes or omission, of the identified plan. The plan of care is reviewed and updated at a minimum of every shift and PRN (and as needed).” B. A review of the medical record for Patient 1 (admitted 3/29/25 and left AMA 4/3/25) following a ground level fall, history of lewy body dementia, dehydration, infection, left arm wound, poor meal intake and poor oral intake. Patient 1’s Plan of Care lacked a nutrition plan of care. C. A review of the medical record for Patient 4 (admitted 5/4/25 and remains hospitalized as of 5/28/25) with a stroke, malnutrition, aphasia (inability to speak) and dysphasia (difficulty swallowing). The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 4’s Plan of Care lacked a nutrition plan of care. D. A review of the medical record for Patient 6 (admitted 5/9/25 and dismissed 5/21/25) with hepatic encephalopathy (a brain dysfunction due to liver dysfunction which can alter the level of consciousness), hyperammonia (high levels of ammonia in the blood that can be harmful to the nervous system), malnutrition and bacteremia (bloodstream infection). The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 6’s Plan of Care lacked a nutrition plan of care. E. A review of the medical record for Patient 11 (admitted 5/10/25 and remains hospitalized as of 5/28/25) with a history of ground level fall sustaining a fracture humerus (upper arm) and C4 (neck vertebrae), perforation of feeding tube resulting in abdominal surgery, moderate malnutrition, and an open abdominal wound with a wound vac. The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 11’s Plan of Care lacked a nutrition plan of care. F. Interview with the Director of Quality on 5/28/25 at 2:07 PM, verified that the patients at nutritional risk, should have a nutrition plan of care and patients 1, 4, 6 and 11 lack a nutrition plan of care. the”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 16132 Based on policy review, medical record review and staff interviews the facility failed to ensure 1 (Patient 1) of 9 sampled patients at nutritional risk following admission to the hospital lacked a nutrition assessment, consistent meal assistance with documentation and notification of nutritional changes to dieticians. 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 337. Findings are: A. Review of the medical record revealed Patient 1 was admitted to the hospital 3/29/25 at 3:59 PM from the Emergency Room (9:41 AM-3:59 PM)for a recent ground level fall, history of lewy body dementia (a progressive form of dementia that affects thinking, reasoning and information processing), hypertensive encephalopathy (a rapid and dramatic rise in blood pressure greater than 180/120), dehydration, leukocytosis (elevated white blood cell count indicating infection), left arm wound with cellulitis, systemic inflammatory response syndrome (an overwhelming inflammatory reaction throughout the body that can be triggered by infection and trauma) and positive blood cultures. Patient 1’s vital signs and weight assessment documented on admission and leaving AMA (against medical advice) revealed: -3/29/25 at 9:42 AM: blood pressure 204/127; pulse 72; temperature 97.3; respirations 16. Weight documented at 6:28 PM was 218 lb 3.2 oz -4/3/25 prior to leaving AMA at 319 PM: blood pressure 155/85; pulse 85; temperature 97.9; respirations 18. The medical record lacked another weight documented since admission. Patients 1’s medical record by mouth intake (meal) documentation confirmed by RN-C on 5/22/25 at 2:00 PM revealed: - 03/29/25: no documentation of meal consumption (patient 1 admitted at 3:59 PM) - 03/30/25: 0% breakfast; 25% at lunch; no documentation for evening meal - 03/31/25: 20% breakfast; 25% at lunch and 25% evening meal - 04/01/25: 10% breakfast; 20% at lunch and 30% evening meal - 04/02/25: 50% breakfast; 50% at lunch and no documentation of evening meal - 04/03/25: 10% breakfast; no documentation of documentation of lunch meal (patient 1 dismissed 3:59 PM) Review of Patient 1’s provider progress notes revealed: -3/31/25 11:03 AM -Dr C stated, “(Pt 1) states can eat and drink like normal, though noted that (gender) is unable to feed self.” “Discussed with RN (registered nurse) to assist patient with feeding as (gender) is unable.” -4/1/25 6:14 AM and 4/2/25 6:09 AM -Dr B stated, “Cellulitis of left upper extremity, Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue.” “Family reports increased alcohol intake and poor oral intake recently (alcohol screen negative on admission).” “Pt had difficulty swallowing liquids on exam.” “Discussed with RN to assist patient with feeding as is unable.” -4/3/25 12:41 PM Discharge Summary Note- Dr B stated, “Cellulitis of left upper extremity, pressure ulcer with full thickness skin loss involving damage or necrosis (dead tissue) of subcutaneous tissue.” “(Speech Therapy) recommended soft diet and bite sized solids, thin liquids.” “Patient was stable and planned for discharge to SNF (Skilled Nursing Facility). On the day of discharge, son had frustrations regarding patient’s care and wanted to take patient to (Hospital B-in town) ER (emergency room). After discussions regarding (pt) care, (child) took patient AGAINST MEDICAL ADVICE via personal transportation.” Review of Physical Therapy note 4/3/25 at 9:34 AM revealed, “(child) present at bedside. Voices frustrations with level of care patient is receiving; pt’s (child) states the patient will be unable to participate due to being too dehydrated and out of it.” Review of the Case Manager note 4/3/25 at 2:20 PM revealed, “Pt’s (child) called and asked me to come to pt room. Reported that had been talking to (pt’s) (PCP) primary care physician. Call the PCP while I was in the room and decided that (child) would take (pt) via private vehicle to (Hospital -B).” Review of the patient 1’s Malnutrition Screen completed on 3/29/25 4:00 PM by the nurse on admission was scored as 0. The questions included: Unplanned weight loss in the last 6 months-No - 0; Eating poorly because of a decreased appetite -No- 0; Malnutrition Score =0. Patient 1’s medical record lacked a nutrition assessment, nutrition care plan and nutritional supplement’s offered to the patient throughout this hospital stay. B. Interview on 5/22/25 at 10:34 AM with Dietitian (RD-A) scheduled on the area that the patient was placed in the hospital. The RD-A stated that this patient was not referred for nutritional intervention. The patient on admission scored on the Malnutrition “At Risk Assessment” scored by nurses was scored as a 0. The policy is “If they score a 2 or greater, the dietitian has to see the pt within 2 days.” “If a patient has been here 7 days, they are to be seen by the dietitian.” “If a physician requests a nutrition consult.” “We do MDR (multidisciplinary rounds) daily and this patient did not come up.” Upon review of Pt 1’s medical record with RD-A, revealed, the patient appetite was poor, there was a wound with cellulitis on the left elbow and left upper arm that progressed to a pressure ulcer, no supplement provided and positive blood cultures and no repeat weight (which is not required due to the Malnutrition Score of 0). RD-A confirmed that someone should have notified the dietitian of the pt’s poor to limited intakes during their stay.” C. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed: -Intake and Output; a) Fluid intake and output is recorded every shift if patient condition warrants. b) Meal intake is recorded as a percentage when the patient completes each meal. c) Supplements are recorded according to type and volume when the patient consumes the supplement. D. Review of Patient 1’s medical record from Hospital-B’s 4/3/25 3:14 PM admission to the emergency department. The Emergency Room doctor (Dr-X) examined the patient at 3:21 PM, “Family brought here from (Hospital-A), has been deteriorating in health since Sat (3/29/25). Family called (Primary Care Physician) and was told to come here. Arrives confused in hospital gown.” “(Family) reports that patient has continued to decompensate, comes more confused. “(Family) reports that patient is now receiving hydration and was not being fed due to mental status changes, unable to eat for self”. “(Family) reports specifically worried about dehydration, nutritional status as pt hot been eating or getting fluids. Pt does appear dry on exam.” Patient 1 admitted to an inpatient room on 4/3/25 at 6:18 PM. Patient 1’s weight on admission was 200 lb’s. (Down 18 lb 3.2 oz from admission wt of 218 lb 3.2 oz at Hospital-A on 3/29/25 at 6:28 PM.)”

“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 facility policy/protocol review, medical record review, staff and medical staff interviews the facility failed to follow their EMTALA policy and Initial Patient Care (IPC) Protocols in the ED for 1 (P8) of 20 sampled emergency department (ED) patients. This failed practice has the potential to cause negative outcomes for all patients who present to the ED for treatment. According to facility provided data the facilities ED saw an average of 5,803 patients per month for the past 6 months. See citation A2406 and A2407, that also resulted in A2400 to not be met.”

“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 facility policy/protocol review, medical record review, staff and medical staff interviews the facility failed to follow the chest pain protocol in triage, and failed to room a patient to be seen with a chief complaint of chest pain within 3 hours of presentation to conduct an medical screening exam (MSE) to rule out an emergency medical condition (EMC) for 1 (P8) of 1 left without being seen after triage ED sampled patients. This failed practice has the potential to cause harm or death to patients who present to the emergency department (ED) with an EMC. According to facility provided data the ED saw an average of 5,803 patients per month for the past 6 months. See citation A2400 and A2406, that also resulted in A2407 to not be met. Findings include: A. Review of facility policy, “Examination, Treatment, and Transfer of Individuals who come to the Emergency Department (EMTALA),” approved 3/2023 revealed: 1. A Medical Screening Exam (MSE) is defined as, “the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted by physicians to determine whether an EMC exists. 2. An Emergency Medical Condition (EMC) is defined as, “a medical condition manifesting itself by acute symptoms of sufficient severity.” Review of facility policy, “Triage,” approved 2/2023 revealed criteria for a designated triage nurse is a Registered Nurse (RN) must have the approval of director or designee and completed Emergency Severity Index (ESI) training and competency. Appropriate reassessments will be documented on the medical record. Review of facility policy, “Initial Patient Care (IPC) Protocols in the ED,” approved 6/2023 revealed IPC protocols are pre-approved physician orders for commonly seen symptoms in the ED. The RN will use the symptom-based IPC protocols as written and will not substitute, eliminate, or extend treatment beyond what is specified in the IPC protocol. The use of an IPC protocol is not a substitute for physician involvement and will never alter/delay interaction between the physician and the patient. B. Review of P8’s medical record revealed, P8 presented to the acute care hospital ED on 10/16/2024 at 2:55 PM via car, with a chief complaint of chest pain, the facility IPC ED chest pain protocol was initiated by the triage Registered Nurse (RN) at 2:59 PM. P8’s medical record lacked evidence of the facility following the IPC ED chest pain protocol orders, confirmed with RN-A on 12/10/2024 at 2:48PM as evidenced by: -No documentation of Aspirin given. -No documentation of an intravenous IV being placed -No documentation of continuous telemetry (monitor the heart to rule out an emergency). -No documentation of a repeat an EKG every 5 minutes (12 leads are placed on the patient’s chest to take a picture of the heart to rule out an emergency, requires a physician to decide). -No documentation of P8’s triage 232/148 blood pressure being communicated to a physician. -No documentation of the IPC ED chest pain protocol order being discontinued by a physician prior to P8 being placed in the lobby on wait room status at 3:28PM. -No documentation of P8’s blood pressure being rechecked before P8 was called to be roomed at 6:10 PM [3 hours after P8 presented to the ED with a chief complaint of chest pain.] C. During an interview on 12/11/2024 at 10:24AM, Physician-A confirmed that P8’s medical record lacked evidence of triage nurse and physician communication regarding P8’s 232/148 blood pressure. Physician-A confirmed P8’s medical record lacked evidence of P8 being seen for a chief complaint of chest pain by a QMP to rule out an EMC on 10/16/2024 before the patient was discovered to have LWBS (the patient left the facility without being seen by a qualified medical professional) after triage at 6:10 PM with a presentation time of 2:55PM. [3 hours and 21 minutes later]. Physician-A confirmed P8’s medical record lacked evidence of the nurse following the IPC ED chest pain protocol, and no IPC ED chest pain protocol discontinue order by a physician prior to P8 being placed in the lobby on wait room status at 3:28PM.”

“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: 48575 Based on EMTALA policy review, medical record review, staff and medical staff interviews the facility failed to rule out an emergency medical condition (EMC) within 3 hours of patient presentation with a chief complaint of chest pain for 1 (P8) of 1 sampled left without being seen (LWBS) (the patient left the facility without being seen by a qualified medical professional) after triage emergency department (ED) patients. This failed practice has the potential to cause a delay in stabilizing treatment to all patients who present to the ED with an EMC. According to facility provided data the ED saw an average of 5,803 patients per month for the past 6 months. See citation A2400 and A2406, that also resulted in A2407 to not be met. Findings include: A. Review of facility policy, “Examination, Treatment, and Transfer of Individuals who come to the Emergency Department (EMTALA),” approved 3/2023 revealed: 1. A Medical Screening Exam (MSE) is defined as, “the process required to determine with reasonable clinical confidence whether an EMC does or does not exist. Screening is to be conducted by physicians to determine whether an EMC exists. 2. An Emergency Medical Condition (EMC) is defined as, “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain).” 3. If an EMC is determined to exist, the hospital will provide the individual ...any necessary stabilizing treatment within the capabilities of the staff and the facilities available at the hospital.” B. Review of P8’s medical record revealed, P8 presented to the acute care hospital ED on 10/16/2024 at 2:55 PM via car, with a chief complaint of chest pain. P8’s medical record lacked evidence of a qualified medical professional (QMP) ruling out an EMC prior to being placed in the lobby on waiting to room status for 3 hours and 21 minutes, confirmed by Physician-A on 12/11/2024 at 10:24AM. C. During an interview on 12/11/2024 at 10:24AM, Physician-A confirmed that P8’s medical record lacked evidence of triage nurse and physician communication regarding P8’s 232/148 blood pressure. Physician-A confirmed P8’s medical record lacked evidence of P8 being seen for a chief complaint of chest pain by a QMP to rule out an EMC on 10/16/2024 before the patient was discovered to have LWBS (the patient left the facility without being seen by a QMP) after triage at 6:10 PM with a presentation time of 2:55PM.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 46123 Based on record review, staff interviews and review of facility policy and procedure the Acute Care Hospital (ACF) failed to ensure that 4 of 7 restrained patients (Patient’s 3,4,6 and 14) reviewed had appropriate orders and documentation of restraint use. This failed practice has the potential to cause harm or even death to all patients in the facility. On day of admission the facility census was 319 patients including the offsite facility. Findings include: A. Review of Patient (P) 3’s medical record revealed that P3 was admitted on 5/7/24 at 5:39 PM with a diagnosis of altered mental status. On 5/7/24 at 6:14PM bilateral mitts to hands were ordered due to P3 pulling at lines and other interventions not effective. Bilateral mitts were placed. In restraint documentation it is documented that the mitts were removed on 5/8/24 at 8:00AM. The order for the restraints was not discontinued for this restraint episode. The order was automatically discontinued on patient discharge on 5/20/24 at 4:26PM. B. Review of P4’s medical record revealed, P4 was admitted on 6/21/24 for encephalopathy. On 6/24/24 at 1:20AM an order for nonviolent restraints was placed for bilateral mitts to hands. The medical record lacks documentation of mitt restraints being used. The order for bilateral mitts was discontinued on 6/29/24 at 3:01AM. On 6/27/24 at 10:13AM an order was placed for violent or self-destructive restraints; restraint type is entered as personal/physical hold. The medical record lacks documentation of a physical hold being done. On 6/27/24 at 9:06PM an order for non-violent restraints was placed. Restraints ordered were 4-point soft restraints. The medical record lacks documentation of restraint use on 6/27/24 at 9:06PM. Order for restraints to be discontinued was entered on 6/29/24 at 10:53AM. C. On 6/21/24 at 3:05PM P6 was admitted for a heart attack and cardiac arrest. The medical record revealed documentation of bilateral soft wrist restraints being initiated on 6/21/24 at 4:00PM and continuing through 7/2/24. The medical record lacks an order for the nonviolent restraints until 6/27/24 at 8:17AM being placed as a late order. D. On 5/31/24 at 10:57AM P14 was admitted for septic shock (a serious condition that occurs when a body-wide infection leads to dangerously low blood pressures). On 6/1/24 at 11:49AM an order for nonviolent restraint was placed for 4-point soft restraints. P14 had an amputation above the left knee and only has 3 limbs. The medical record has documentation from 6/1/24 at 12:00PM for bilateral soft wrist restraints being used. Documentation in the medical record continues until 6/10/24 at 2:30PM when bilateral soft restraints were stopped. A discontinue order for the restraints was entered into the system on 6/14/24 at 7:16AM. E. Review of facility policy Restraint management in Acute Care (Approved 3/2024) revealed for nonviolent, non-self-destructive restraint order: - must be ordered with each episode of restraint initiation. - The registered nurse (RN) will terminate the restraints when the clinical justification is no longer present. F. Interview with the Director of Quality and Patient Safety (7/2/24 at 10:15AM) confirmed that the order for restraints should be discontinued in the system by nursing when restraints are discontinued.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 48575 Based on TEAMNET record review, work order review, administrative record review, asset snapshot review, policy and procedure review, observation, and staff interview the facility failed to have reliable safe equipment for 2 machines used in surgery, 1 operating room (OR) Anesthesia machine serial DRUL-0062 failed 5 times since 12/31/2023, and the nerve monitoring system (NIM) machine had failed twice during surgery. The facility failed to have a cleanable surface for OR 10 fixed table base. This failed practice caused patients preventable prolonged anesthesia time and has the potential to cause harm or death to all patients who present to the facility for surgery. The facility census was 340 on entrance. The Standard cited A0951 also resulted in the Condition of Participation for Surgical Services to be not met. The Condition is not met as evidenced by: A. Review of TEAMNET (incident/equipment) request 570618 from 12/31/2023 revealed the Anesthesia machine (life sustaining equipment used in surgery) in OR 9, “not reading End Tidal Carbon Dioxide (ETCO2) and end tidal gas capabilities,” (monitors gas exchange in the lungs while the patient is asleep in surgery) that required biomed (certified engineers) to call Drager [manufacturer] for machine malfunction assistance during the case while a patient was connected to the machine on 12/31/2023 at 11:53AM. See work order 61-1876894. Review of TEAMNET request 571504 from 1/4/2024 revealed the Anesthesia machine in OR 9, “not reading ETCO2 and end tidal gas capabilities,” that required biomed to call Drager [manufacturer] for assistance. See work order 61-18782297. Review of TEAMNET request 577858 from 2/6/2024 at 8:00AM revealed the Anesthesia machine in OR 9, “The multi gas analyzer has been intermittently failing and gives no values but corrects itself ....but still needs to be inspected as it has failed critically and abruptly many times in the past.” See work order 61-18967579. Review of TEAMNET request 583282 from 3/4/2024 revealed the Anesthesia machine in OR 9, “The ventilator (life sustaining machine that provides breathing for the patient while they are asleep for surgery) will not pass a leak test. All disposables (circuits, soda lines, tan hose, etc.) were changed out several times and the machine passed the compliance and systems test, but not the ventilator.” See work order 61-19029928. B. Review of work order 61-18776894 from 12/31/2023 revealed the Scio four oxi plus (a part on the anesthesia machine that measures gas concentrations in the breathing circuit to help avoid under or overdosage of medicine used to put the patient to sleep during surgery) serial ASBA-0013 was replaced on the OR 9 Anesthesia machine on 12/31/2023. Review of work order 61-18782297 from 1/5/2024 revealed the Anesthesia machine was pulled from OR 9 and put into storage on 2/14/2024 at 12:15PM [1 month and 9 days after submitted]. Review of work order 61-108059 from 1/18/2024 revealed the Vapor 2000 Sevoflurane (a part on the anesthesia machine that delivers an accurate, adjustable concentration of inhaled medicine used to put the patient to sleep during surgery) serial ASMA-0283 was not tested by Drager [manufacturer] until 3/1/2024 for Anesthesia machine in OR 9. Review of work order 61-18967579 revealed on 2/9/2024 the data cable was replaced by Tech-A who noticed the network cable for the dock station was frayed in several places and taped, which was replaced for Anesthesia machine in OR 9. Review of work order 61-19029928 revealed on 3/5/2024 Tech-B replaced a hose on the Anesthesia machine in OR 9 ventilator serial DRUL-0062, leak test on ventilator passed (test to determine if the machine is functioning properly). C. Review of administrative record revealed OR 9 Anesthesia machine CO2 analyzer failed 2/5/2024 and 2/6/2024, removed from service 2/6/2024 after a meeting was held and determined the manufacturer Tech-C would evaluate anesthesia machines 1, 6, 9, 10, 11 and 12 for a second opinion. OR 9 Anesthesia machine was cleared for use by Tech-D and senior leadership and put back into service 3/1/2024 at 8:53AM. D. Review of Asset Snapshot NIM machine (allows surgeons to identify, confirm and monitor motor nerve function to reduce the risk of nerve damage during surgery) Serial #1NN3-0392 revealed 1/10/2024 the NIM machine was not working, Tech-G called manufacturer about the issue, repaired. On 2/12/2024 the NIM machine monitor was not working. Tech-G set up the return to the manufacturer on 3/5/2024. E. Review of policy, “Environmental Cleaning in Operating Rooms, Sterile Processing Departments, and Procedural Areas (Last approved 4/2023),” revealed, “Clean: The absence of visible dust, soil, debris, blood, or other potentially infectious material.” F. During observation of Operating Room (OR) number 10 on 3/7/2024 at 10:23AM with RN-A revealed the fixed urology table base and lining was rusted and appeared to be painted over, not a cleanable surface. Confirmed by RN-A. Photograph obtained and attached. G. During an interview with Tech-E and Tech-F 3/6/2024 at 2:45PM revealed Biomedical staff are certified engineers, and complete annual competencies by a manager who is credentialed in clinical engineering (CE). Only certified Drager CE techs work on Drager equipment. If equipment issues cannot be resolved by the CE tech assigned, the CE tech will reach out to other facility CE techs to service internal. If another CE tech cannot resolve the issue, then they call the manufacturer to service the equipment. During an interview on 3/7/2024 at 12:59PM, the Chief Medical Officer (CMO) confirmed was aware of OR 10 fixed table requires replacement, on the list and the national team is completing an onsite equipment assessment next week. During an interview on 3/7/2024 at 12:59PM RN-C could not recall if aware of OR 10 fixed table rust, and not a cleanable surface. During an interview on 3/7/2024 at 1:21PM with RN-A and RN-B, both confirmed OR 9 Anesthesia machine serial DRUL-0062 Co2 analyzer had failed four times, and the ventilator once since December 2023. Surgical equipment issues are a daily occurrence that require perioperative staff to search for equipment that works to get them through the day. The NIM machine failed twice when doctors needed in surgery and required staff to go to the Ambulatory Surgical Center (ASC) to get a new NIM machine, plug it in and recalibrate prior to use for the patient, which caused the patient to be under anesthesia longer. The NIM machine was sent twice to manufacture, and the facility currently has a loaner. RN-A and RN-B revealed aware of OR 10 fixed urology table rust, not a cleanable surface and had quotes for construction and new table. RN-B was told must prioritize equipment replacement needs due to budget restraints.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 48575 Based on TEAMNET record review, work order review, administrative record review, asset snapshot review, policy and procedure review, observation, and staff interview the facility failed to have reliable safe equipment for 2 machines used in surgery, 1 operating room (OR) Anesthesia machine serial DRUL-0062 failed 5 times since 12/31/2023, and the nerve monitoring system (NIM) machine had failed twice during surgery. The facility failed to have a cleanable surface for OR 10 fixed table base. This failed practice caused patients preventable prolonged anesthesia time and has the potential to cause harm or death to all patients who present to the facility for surgery. The facility census was 340 on entrance. The condition cited A0940 also resulted in the Condition of Participation for Surgical Services to be not met. Findings Include: A. Review of TEAMNET (incident/equipment) request 570618 from 12/31/2023 revealed the Anesthesia machine (life sustaining equipment used in surgery) in OR 9, “not reading End Tidal Carbon Dioxide (ETCO2) and end tidal gas capabilities,” (monitors gas exchange in the lungs while the patient is asleep in surgery) that required biomed (certified engineers) to call Drager [manufacturer] for machine malfunction assistance during the case while a patient was connected to the machine on 12/31/2023 at 11:53AM. See work order 61-1876894. Review of TEAMNET request 571504 from 1/4/2024 revealed the Anesthesia machine in OR 9, “not reading ETCO2 and end tidal gas capabilities,” that required biomed to call Drager [manufacturer] for assistance. See work order 61-18782297. Review of TEAMNET request 577858 from 2/6/2024 at 8:00AM revealed the Anesthesia machine in OR 9, “The multi gas analyzer has been intermittently failing and gives no values but corrects itself ....but still needs to be inspected as it has failed critically and abruptly many times in the past.” See work order 61-18967579. Review of TEAMNET request 583282 from 3/4/2024 revealed the Anesthesia machine in OR 9, “The ventilator (life sustaining machine that provides breathing for the patient while they are asleep for surgery) will not pass a leak test. All disposables (circuits, soda lines, tan hose, etc.) were changed out several times and the machine passed the compliance and systems test, but not the ventilator.” See work order 61-19029928. B. Review of work order 61-18776894 from 12/31/2023 revealed the Scio four oxi plus (a part on the anesthesia machine that measures gas concentrations in the breathing circuit to help avoid under or overdosage of medicine used to put the patient to sleep during surgery) serial ASBA-0013 was replaced on the OR 9 Anesthesia machine on 12/31/2023. Review of work order 61-18782297 from 1/5/2024 revealed the Anesthesia machine was pulled from OR 9 and put into storage on 2/14/2024 at 12:15PM [1 month and 9 days after submitted]. Review of work order 61-108059 from 1/18/2024 revealed the Vapor 2000 Sevoflurane (a part on the anesthesia machine that delivers an accurate, adjustable concentration of inhaled medicine used to put the patient to sleep during surgery) serial ASMA-0283 was not tested by Drager [manufacturer] until 3/1/2024 for Anesthesia machine in OR 9. Review of work order 61-18967579 revealed on 2/9/2024 the data cable was replaced by Tech-A who noticed the network cable for the dock station was frayed in several places and taped, which was replaced for Anesthesia machine in OR 9. Review of work order 61-19029928 revealed on 3/5/2024 Tech-B replaced a hose on the Anesthesia machine in OR 9 ventilator serial DRUL-0062, leak test on ventilator passed (test to determine if the machine is functioning properly). C. Review of administrative record revealed OR 9 Anesthesia machine CO2 analyzer failed 2/5/2024 and 2/6/2024, removed from service 2/6/2024 after a meeting was held and determined the manufacturer Tech-C would evaluate anesthesia machines 1, 6, 9, 10, 11 and 12 for a second opinion. OR 9 Anesthesia machine was cleared for use by Tech-D and senior leadership and put back into service 3/1/2024 at 8:53AM. D. Review of Asset Snapshot NIM machine (allows surgeons to identify, confirm and monitor motor nerve function to reduce the risk of nerve damage during surgery) Serial #1NN3-0392 revealed 1/10/2024 the NIM machine was not working, Tech-G called manufacturer about the issue, repaired. On 2/12/2024 the NIM machine monitor was not working. Tech-G set up the return to the manufacturer on 3/5/2024. E. Review of policy, “Environmental Cleaning in Operating Rooms, Sterile Processing Departments, and Procedural Areas (Last approved 4/2023),” revealed, “Clean: The absence of visible dust, soil, debris, blood, or other potentially infectious material.” F. During observation of Operating Room (OR) number 10 on 3/7/2024 at 10:23AM with RN-A revealed the fixed urology table base and lining was rusted and appeared to be painted over, not a cleanable surface. Confirmed by RN-A. Photograph obtained and attached. G. During an interview with Tech-E and Tech-F 3/6/2024 at 2:45PM revealed Biomedical staff are certified engineers, and complete annual competencies by a manager who is credentialed in clinical engineering (CE). Only certified Drager CE techs work on Drager equipment. If equipment issues cannot be resolved by the CE tech assigned, the CE tech will reach out to other facility CE techs to service internal. If another CE tech cannot resolve the issue, then they call the manufacturer to service the equipment. During an interview on 3/7/2024 at 12:59PM, the Chief Medical Officer (CMO) confirmed was aware of OR 10 fixed table requires replacement, on the list and the national team is completing an onsite equipment assessment next week. During an interview on 3/7/2024 at 12:59PM RN-C could not recall if aware of OR 10 fixed table rust, and not a cleanable surface. During an interview on 3/7/2024 at 1:21PM with RN-A and RN-B, both confirmed OR 9 Anesthesia machine serial DRUL-0062 Co2 analyzer had failed four times, and the ventilator once since December 2023. Surgical equipment issues are a daily occurrence that require perioperative staff to search for equipment that works to get them through the day. The NIM machine failed twice when doctors needed in surgery and required staff to go to the Ambulatory Surgical Center (ASC) to get a new NIM machine, plug it in and recalibrate prior to use for the patient, which caused the patient to be under anesthesia longer. The NIM machine was sent twice to manufacture, and the facility currently has a loaner. RN-A and RN-B revealed aware of OR 10 fixed urology table rust, not a cleanable surface and had quotes for construction and new table. RN-B was told must prioritize equipment replacement needs due to budget restraints.”

“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: 46123 Based on record reviews and facility policy review the facility failed to follow its policies regarding Triage, Medical Screening Exams (MSE), Transfers and patient leaving prior to being seen for 4 (Patient (P)2, P11, P12, P16) of 20 sampled patient records. These failures have the potential to cause harm or death due to delay in care to all patients that present to the Emergency Department (ED). According to the facility provided information the 3 dedicated emergency departments (DED) see on average of 5,409 patients per month. Also see A2406 and A2409 Findings Include: A. Review of facility policy “Triage”, approved 2/2023 revealed, all patients seeking emergency care will have a triage assessment by an Registered Nurse (RN) promptly upon arrival in the ED. Appropriate reassessments will be documented on the medical record. B. Review of facility policy “Turn-Around Times and Delay of Testing Notification”, approved 2/2024 revealed, testing ordered STAT (to be done immediately) will be given special consideration due to the emergency condition of the patient. Response to the patient for collection is expected to be within 10 minutes of notification. With reporting to be done within 60 minutes of order. C. Review of facility policy “Patient Departure Prior to Dismissal (AMA)”, approved 11/2023 revealed, to leave without being seen is specific to patients who have not received a medical screening examination in a dedicated emergency department. - If the patient or legally recognized representative does not inform anyone prior to leaving: -Attempts will be made to locate the patient in the waiting area and restrooms. -If unable to locate, staff will note the same on “Refusal of Medical Screening Examination” form. -Documentation in the medical record should include the following: -Attempts made to inform patient or legally recognized representative of risks and/or attempts made to locate the patient. -Impression of patient’s mental and physical status, as able. -Notification of Qualified Medical Provider (QMP). - If a patient does not make the care team aware of the intent to leave (patient is found to be gone from care area) -Staff will immediately notify the provider. -Staff and/or provider will make reasonable attempt to locate or make contact with the patient to determine why they left and encourage them to return for completion of treatment. -If the patient is located and declines to return, the provider should make attempts to inform the patient of the risks and document the departure (see section A- Against Medical Advice) -If the patient is not located, this will be noted in the medical record. D. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)”, approved 2/2023 revealed, MSE is the process required to determine with reasonable clinical confidence whether an emergency medical condition (EMC) does or does not exist. Screening is to be conducted to the extent necessary, by physicians and/or other QMPs, as defined, to determine whether an EMC exists. The extent of the MSE may vary depending on the individual’s signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board. The MSE is an on-going process. The medical record will reflect an ongoing assessment of the individual’s condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the Hospital, is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital’s capabilities, is discharged, or expires. The MSE process must be documented in the medical record. The off-campus DED must develop protocols to effectuate an Appropriate Transfer. The DED at Lasting Hope Recover Center will provide all patients arriving at the Assessment Center with a MSE by a QMP. -The Behavioral nurse will notify the On-Call behavioral physician regarding the results of the assessment. -If during the MSE, it is determined that the patient needs additional medical screening, the patient will be transported to the medical Emergency Department for a medical evaluation and treatment as needed. E. The facility failed to follow their policy dated 2/2023 titled, Triage and did not provide P11 with a prompt triage assessment by a RN upon arrival to the ED. P11 presented to the ED on 1/23/24 at 5:33AM. P11 was taken to triage at 6:37AM (64minutes after presentation to the ED). The facility failed to follow their policy dated 2/2024 titled, “Turn-Around Times and Delay of Testing Notification” P11 had a STAT lab ordered at 6:43AM that was not drawn until 8:54AM (71 minutes after ordered). STAT medication was ordered at 8:53AM and was never given to P11 prior to P11 eloping from ED. Due to incomplete physical exam and delay in lab P11 did not have a complete MSE to determine with reasonable clinical confidence that an EMC did not exist. F. The facility failed to follow their policy dated 2/2024 titled, “Turn-Around Times and Delay of Testing Notification” MD-D placed a STAT order for hemoglobin (part of the red blood cell that carries oxygen from the lungs to tissues and organs) and hematocrit (the percentage by volume of red cells in your blood) at 10:26PM. P12 was discharged from the ED at 11:35PM without lab draw being completed as ordered nor a discontinue order documented for the lab. Due to ordered lab not being completed P12 did not have a complete MSE conducted to rule out an EMC prior to discharge. G. Review of Facility A’s medical record for P2 revealed, P2 presented to the ED on 5/21/23 at 3:54AM. P2 was taken to triage at 4:18AM and triage was marked complete at 4:22AM when P2 was also assigned an ED room. At 5:18AM documentation in the EMR reveals that P2’s disposition was marked as left without being seen (84 minutes after arrival). The medical record lacks documentation of attempts made to inform patient of risks and/or attempts made to locate the patient. Notification of the QMP. The medical record also lacks the “Refusal of Medical Screening Examination” form with staff note of being unable to locate patient.”

“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: 46123 Based on record review, policy and procedure review and staff interviews the facility failed to provide 3 (P11, P12 and P16) of 20 sampled patient records a complete MSE to rule out an emergency medical condition (EMC) after presentation to the ED. This failed practice has the potential to cause harm or death to all patients that present to the ED. According to facility provided information the average number of patients seen per month is 5,409. Findings include: A. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)”, approved 2/2023 revealed, MSE is the process required to determine with reasonable clinical confidence whether an EMC does or does not exist, or with respect to a pregnant woman experiencing contractions whether or not she is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMPs, as defined, to determine whether an EMC exists. The extent of the MSE may vary depending on the individual’s signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board. With respect to an individual manifesting behavioral or psychiatric symptom, the MSE consist of both a medical and behavioral /psychiatric health screening. The act of patient triage is not considered an MSE. The MSE is an on-going process. The medical record will reflect an ongoing assessment of the individual’s condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the Hospital, is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital’s capabilities, is discharged, or expires. The MSE process must be documented in the medical record. B. Review of P11’s medical record revealed, P11 presented to the ED on 1/23/24 at 5:33AM. P11 was taken to triage at 6:37AM. Vitals on admit to triage were T 97.7, P104, R18, BP 157/98, SpO2 99% on room air. Pain rating of 8 on 0-10 pain scale. P11 was given an emergency severity index (ESI- an algorithm tool used in the ED to triage patients from 1-most urgent to 5-least urgent) of 3 at 6:38AM. P11’s chief complaint in triage was neck stiffness since 1/8, over the last week pain in neck has worsened, states “had meningitis last month.” Denies trauma. Nurse Practioner (NP)-C reviewed P11’s chart and noted P11 was hospitalized for sepsis and pneumonia last month not meningitis. NP-C placed STAT lab orders at 6:43AM. Lab orders included: salicylate level (a blood test that checks for overdose of aspirin), acetaminophen level ( a test to check level of acetaminophen or Tylenol for overdose), C-Reactive Protein (CRP - measures inflammation in the body), Comprehensive Metabolic Panel (CMP- test that checks electrolyte levels kidney and liver function), Complete blood count (CBC- measures the number of red and white blood cells and platelets ). At 8:49AM vitals were done P105, R16, BP145/108 SpO2 100% on room air, pain rating of 10 on a 0-10 pain scale. NP-C placed an order for Norflex (a muscle relaxer) 60mg intramuscular (IM) STAT at 8:53AM. Lab was not drawn until 8:54AM (2 hours and 11 minutes after STAT order placed). After lab was drawn P11 returned to the lobby. The medical record lacks documentation of ongoing assessment while P11 was in the lobby. Lab results were documented as unremarkable by NP-C. At 12:32PM a nurse went to lobby to call P11’s name and P11 was not in lobby. A nurse returned to the lobby at 1:10PM and again called P11’s name, P11 was not in lobby. At 1:11PM the nurse called P11’s name again and P11 was still not in lobby. P11 was marked as eloped at 1:11PM. P11 did not receive STAT medication ordered at 8:53AM when pain was documented as a 10 nor was P11 reassessed while in lobby. C. Review of P12’s medical record revealed, P12 presented to the ED on 11/27/23 at 10:12PM with complaints of a nosebleed for the past 3 hours. Medical Doctor (MD)-D provided initial exam at 10:26PM. MD-D placed a STAT order for hemoglobin (part of the red blood cell that carries oxygen from the lungs to tissues and organs) and hematocrit (the percentage by volume of red cells in your blood) at 10:26PM. At 11:35PM P12 was discharged to home. The medical record lacks documentation of completed lab as ordered. The medical record lacks documentation of order to discontinue lab. The EMR automatically discontinued lab after P12 was discharged. D. Review of P16’s medical record revealed, P16 presented to DED-C on 1/15/24 at 5:41PM with complaints of attempting to kill themselves by freezing to death but “didn’t know it was going to hurt so much.” P16 complains of having frostbite on fingers and tip of finger is black. The medical record lacks documentation of which fingertip is black and assessment for frost bite of other limbs. E. During an interview on 2/29/24 at 9:35AM, NP-C revealed if we (providers) give an order we would want that to be completed. When patients come into the ED and are evaluated if labs, tests, medications are ordered that is part of the MSE to make sure the patient is stable. It is part of the exam to evaluate if stable for discharge or if patient needs admission.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46123 Based on record review, policy and procedure review and staff interviews the facility failed to provide 1 (P16) of 5 sampled patient transfers an appropriate transfer from an off-campus DED. CHI Health Creighton University Medical Center-Bergan Mercy system has 3 Dedicated Emergency Department’s (DED); (DED A) is at the main campus, a level 1 trauma center capable of providing all levels of emergency care; (DED B) is an off campus facility which is a full service emergency department staffed with board-certified emergency physicians; and (DED C) is the Psychiatric Assessment Center (Lasting Hope Recovery Center -LHRC). The main campus (DED A) is 6 miles from LHRC (DED C) and DED B is 1.5 miles from LHRC. This failure places all emergency patients presenting to DED C at risk of harm due to an inappropriate transfer without the receiving hospital agreeing to accept transfer of the individual. According to facility provided information all 3 DED’s transfer an average of 96 patients per month. Findings include: A. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) - (CUMC-Bergan Mercy)”, approved 2/2023 revealed, the qualified medical provider (QMP) on duty at the off-campus DED will either arrange for movement of the individual to the hospital’s main campus DED or arrange for an appropriate transfer. The off-campus DED must develop protocols to effectuate an appropriate transfer. B. Review of facility Organization and Functions Manual last approved 10/8/21 revealed, that patients arriving in the Assessment Center at LHRC will have a MSE for the existence of an EMC performed by the LHRC QMP nurse. The examination will include a complete set of vitals, if it is determined that the patient needs additional medical screening based on initial presentation beyond the capability of Lasting Hope, the behavioral health nurse will complete an MSE within the facility’s capabilities and notify the on-call psychiatrist of the results and if necessary, obtain orders to transfer the patient to a medical facility. C. Review of P16’s medical record from DED-C revealed, P16 presented to DED C on 1/15/24 at 5:40PM an emergency encounter was created in the EMR. P16 walked into the lobby of DED-C. RN-E documented that P16 “triaged in lobby and is highly intoxicated and was attempting to kill herself by freezing to death but didn’t know it was going to hurt so much. Breathalyzer reads 0.287 (intoxication level is 0.08). Patient states she has frostbite on fingers. Tip of finger is black.” RN-E completed triage in the lobby at 5:44PM. RN-E documented P16 endorses having suicidal ideation. RN-E notified MD-F who gave order to send patient out from lobby via 911 at 5:52PM. At 5:52PM RN-E documented P16’s vital signs as T 98.5, P 103, R16, BP 138/85, SpO2 96% on room air, pain 0 on 0-10 pain scale. 911 ambulance and law enforcement responded to DED C and report given. RN-G called Hospital D ED (a full service main campus DED 1.8 miles away) for report. ED staff at Facility D aware police may place P16 in emergency police custody (EPC). 911 Ambulance will take P16 to Hospital-D as it is the closest facility to DED C. RN-E and RN-G both signed form refusal to permit to medical screening examination. Indicating that P16 left the hospital without signing the form. The medical record lacked documentation indicating DED C had explained the risks and benefits of the transfer, had confirmation from a representative at Hospital-D that Hospital-D had available space, qualified personnel to treat P16, Hospital-D agreed to accept transfer of P16 and provide appropriate medical treatment. The medical record lacked a transfer consent form. P16’s medical record indicates that P16 was transferred to ED at Facility D at 6:00PM. D. During an interview on 2/29/24 at 8:45AM, RN-E revealed, that there had been confusion with staff in the Assessment Center. Staff do what is considered “triage” in the lobby. Staff believed since the patient did not go through the doors and into the Assessment Center that was considered left without being seen. Education was recently sent out by Director of Nursing (D.O.N.). D.O.N. and supervisors are also talking to each staff member regarding transfers and difference of left without being seen before and after triage.”