St Mary’s General Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 41646 Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure grievances are documented in accordance with facility policy. Findings include: Facility policy titled “Verge Incident and Occurrence [sic] Reporting,” reviewed on 03/2023, stated, “...Incident or Occurrence: Any unplanned occurrence, or “near miss” which may include: ...Assault to patient... Anything that occurs that is out of the ordinary or requires attention for prevention of similar occurrences should be documented. ...” Facility policy titled “Grievance/Complaint Process,” reviewed 02/1025, stated, “Purpose: 1. To describe the process for the prompt resolution of a patient grievance regarding an alleged violation of patient rights as mandated by the Center for Medicare/Medicaid Services (CMS). ...Definitions: ...2. Patient Grievance is defined as a written or verbal concern...by a patient, or the patient’s representative, regarding the patient’s care, abuse, or neglect... 2.4 All verbal or written complaints regarding abuse, neglect, patient harm, ...are considered grievances for the purposes of these requirements. ... Procedure for a Patient to Submit a Grievance: ...4. If the grievance is applicable to this policy, then the patient will be provided with a ‘Grievance Form.’ The patient has the option of putting the grievance in writing or simply verbalizing the grievance. Should the patient wish to verbalize the grievance, the Department Director (or designee) will document a summary of the patient’s verbal complaints on the form. 5. The Department Director (or designee) will submit the “Grievance Form” to the Risk Management Department for further investigation as needed and response. ...” On 12/03/25 at 11:11 AM, on the inpatient Behavioral Health Unit, an interview was conducted with Staff (S)4 regarding patient (P)1. S4 stated that P1 is on the unit, on CEPP (conditional extension pending placement) status, meaning that the judge won’t release the patient until he/she has a place to go after discharge. S4 confirmed that the DDD (Department of Developmental Disabilities) is applying for guardianship of P1, and that P1 does not have a court appointed guardian. S4 stated that P1 had been living with his/her parents, and has a history of “mutism, autism, and anxiety.” At 11:40 AM, S4 stated that P1’s mother has made frequent complaints about P1’s care, which include the way that staff wash P1’s hair with his/her dandruff issues, staff use of shampoo on the patient’s hair, and insistence that the patient be forced to shower even when he/she refuses. S4 stated that due to all P1’s mother’s complaints, two staff members are now required to assist with P1’s showers. At 12:42 PM, during an interview, S6 stated that P1’s mother had complained last week that someone hit P1 in the head. S6 had asked P1 to write down the name of who hit him/her, but P1 will only smile and will not write down or say a name. S6 stated, “I brought the patient into the cafeteria. I asked, ‘Did someone hit you?’ [He/she] laughed, shrugged, smiled like [he/she] was playing.” At 12:58 PM, S4, in the presence of S3, stated that last Wednesday, 11/26/25, P1’s mother came to visit and asked to take the patient home. S4 explained again about the upcoming court date where guardianship will be determined. P1’s mother then reported that a staff member [S8] hit P1 on the head while washing his/her hair in the shower. S4 stated that he/she spoke with S8, and “[S8] said [he/she] was rubbing [his/her] head hard because [he/she] had dandruff and [his/her] hair was dirty.” S4 “spoke to the mom and let her know,” notified the psychiatrist, who also interviewed the patient, and “I let my supervisor know [S3].” S4 stated that from now on, two staff members are required to be present when washing P1’s hair, and that staff were all notified. A request was made to review the incident report documenting this investigation. At 1:20 PM, an interview was conducted with S8. S8 stated that when he/she had given P1 his/her shower on 11/26/25, P1 had a lot of dandruff and “I shampooed and conditioned it.” S8 stated he/she was happy that the patient’s hair looked clean, but that a few days later, P1’s mom had complained that the patient’s head was hit in the shower, and “now two people have to be there when [his/her] hair is shampooed.” S8 stated that P1’s mother does not want staff using shampoo when washing the patient’s hair. Review of P1’s medical record revealed the following: On 10/14/25 at 21:49 [9:49 PM], P1 was brought into the emergency department (ED) by emergency medical services (EMS). Documented in the ED Course, following medical clearance, P1 was evaluated by S6 and accepted for inpatient involuntary psychiatric admission. S6 documented in the “consults” notes: “Spoke with Mom. She reports that she and pt [patient] have been living in Dad’s car. Pt has non-verbal autism and cognitive delay. At a drug store, Mom went into the store to get pt to hurry up and she pulled pt’s hair... So, when [he/she] came to the car, Pt wanted Mom to sit in front with [him/her] but Mom was too upset and frustrated to do that ...Pt got out, pulled Mom’s hair, then pushed her and started punching her in the face and head. ...Mom is now afraid to live with pt in the car ...pt has not been able to bathe in 2 months and has not eaten in 2 days ...She does not have POA (power of attorney) ...Mom does admit that both she and Dad have been abusive towards [him/her], usually out of frustration. ... [Named] from DDD is working on expeditinh [sic] [him/her] to an intensive case manager ...This is the 3rd time [he/she] has come through DDD and they want pt to get services.” On 11/26/25, there was no documentation of any occurrences during P1’s shower. On 11/27/25 at 3:17 PM, S11 documented in the “Nursing Note” that “Pt was assisted with shower by 2 staff.” On 12/01/25 at 3:05 PM, S10 documented in the physician “Progress Notes” the following: “Patient reported by writing on paper that [he/she] was being ‘hit’ while in unit. However upon further questioning patient denied it. ...During interview today ... Patient was asked if [he/she] was hurt and ‘hit’ while in the unit and [he/she] smiled and denied. ...” At 2:23 PM, S1, S3, and S4 confirmed that P1’s mother’s allegations were not documented as a written grievance for submission to the Risk Management Director. At 2:30 PM, S1 confirmed that there was no documented incident report of the allegation, and that the facility’s action in response to the allegation (patient and staff interview, verbal notification to the complainant, staff education) were not documented. These findings were reviewed at 3:03 PM during exit conference with S1, S2, S3, S4, and S12.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49075 Based on review of medical records (MR), review of facility documents and interview with staff, it was determined that the facility failed to ensure patients in the progressive care unit (PCU) that are placed on telemetry monitoring [a method used to continously monitor the electrical activity of a patients heart] is monitored to detect abnormal heart rhythms and that a process is in place to notify nursing staff, when patients are monitored remotely (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. The IJ was identified on 5/13/2025 at 12:40 PM. The IJ template was provided to the facility on 5/13/25 at 4:56 PM and an acceptable IJ removal plan was recieved on 5/14/25 at 11:35 AM. The facility implemented the following: the house supervisor will on a shift by shift basis, inform the monitor technicians of their assignment to include all units of responsibility, both house supervisors and monitor technicians were educated on this process, monitor technicians were educated on the notification process and the steps to be taken in the event an arrythmia is detected, monitoring of telemetry PCU patients will be done by the 5 East 24/7, the bedside monitoring system was re-installed and put into working order on 5/13/24 allowing for bedside monitoring of all PCU patients (including the ability to monitor remotely). On 5/14/25 at 12:25 PM the surveyors verified full implementation and the IJ was removed. Verification of implementation was completed through a facility tour of the PCU and 5 East unit, review of staff education and signed attestations of education, and staff interviews.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49075 Based on observation, medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure patients in the progressive care unit (PCU) that are placed on telemetry monitoring [a method used to continuously monitor the electrical activity of a patient’s heart] is monitored to detect abnormal heart rhythms and that a process is in place to notify nursing staff, when patients are monitored remotely. Findings include: On 05/12/25 at 10:26 AM, during a tour of the PCU, Staff (S)6 (Registered Nurse [RN]) stated that in the PCU patient cardiac rhythms are monitored [telemetry monitoring] and are displayed on a monitor which can only be seen behind the nurse’s station on the PCU, or on the 5th Floor telemetry unit. S6 stated that on the PCU, they frequently do not have a monitor technician assigned to watch the telemetry monitor, or a staff member at the nurse’s station to answer phones if a monitor technician from the 5th floor called to report an arrythmia [irregularities in the heartbeat]. S6 stated that they do not have the ability to view the telemetry monitors from the patient’s bedside, and do not carry telephones to receive calls directly from monitor technicians. S6 further stated that until November 2024, the PCU had a dedicated monitor technician on day shift, 7:00 AM-3:00 PM, until the monitor tech [technician] went out on medical leave.” Once [he/she] left, we were completely reliant on the monitor tech upstairs [5th floor telemetry unit].” During an interview, S6 revealed that on 05/07/25, after dayshift began, a patient in the PCU was found unresponsive while nursing staff were performing patient care in other rooms. S6 stated that the nurse had not been notified that the patient had a change on the cardiac monitor. A code blue (a hospital code used to refer to a life-threatening medical emergency) was called on the patient (patient (P)1), who was transferred to the Intensive Care Unit (ICU), and expired that day. At 10:58 AM, during a tour of the PCU, the cardiac monitor was observed behind the nurse’s station, facing inside so that it could only be visualized from behind the nurse’s station. S6 confirmed that there are alarms for each patient, but they could only be heard near the monitor. At 11:19 AM, during a tour of the 5th floor telemetry unit, the telemetry monitors, including a monitor for the PCU, were observed. S3 (monitor technician) stated that he/she was responsible for watching the monitor for the PCU “just in case the nurses are busy.” S3 provided a telemetry communication log, which he/she stated the monitor technicians use to document when they notify other units of arrythmias. There was no documentation of any notification from the 5th floor monitor tech to the PCU, on 05/07/2025 between 5:47 AM and 7:18 PM. At 1:56 PM, during a review of staffing, S10 was identified as the monitor technician working on the 5th floor telemetry unit on 05/07/25 during the dayshift. On 05/13/25 at 10:22 AM, on the 5th floor telemetry unit, during an interview, S10 (monitor technician) stated that the PCU usually has a monitor tech watching their telemetry monitors, but as of last Wednesday [05/07/25], he/she was told they had to watch the monitors for PCU. S10 stated that on 05/07/25, he/she was made aware that a patient on PCU had a cardiac arrythmia when “the nurse manager called up here and asked if I noticed. I said no, I didn’t notice, because I was paying attention to the other monitors. That morning, nobody told me that they didn’t have a tech.” S10 stated that he/she can tell when the PCU has a monitor tech, when seeing activity on the monitor screen from the PCU. On the screen, a modified view of a PCU patient’s cardiac rhythm was observed, and S10 stated, “see, they have someone today. They are looking at the monitor down there [PCU] right now. That’s how I know they have someone watching.” At 10:37 AM, an interview occurred with S11 (RN, PCU and ICU [intensive care unit]). S11 stated that on 05/07/25, there was no monitor technician or unit secretary working at the PCU nurse’s station. At approximately 8:23 AM, PCU staff called a code blue after one of his/her patients (P1) was found unresponsive by a resident and cardiologist. S11 stated that after the patient was transferred to the ICU, he/she checked the telemetry strips, and learned that at 8:10 AM, the patient’s heartrate was 38, and at 8:17 AM was showing PEA (pulseless electrical activity). S11 stated he/she never received a call from the monitor technician. On Friday, 05/09/25, S11 stated that a conversation with S4 (Emergency Department [ED] Director) revealed that “there was a miscommunication between the two floors [PCU and the 5th floor tele unit 5 East] and that nobody was watching the telemetry monitors. The floor [PCU] needs to inform the 5th floor when there is no monitor tech. After that incident, they started calling us. In two years, I’ve never gotten a call from them, and we haven’t had a full-time monitor tech since November.” At 11:20 AM, behind the PCU nursing station, a staff member was observed modifying the view of the cardiac monitors. S6 confirmed that PCU nurses can modify the view of each PCU patient’s cardiac rhythm while looking at the cardiac monitor; however, this does not confirm that a monitor technician is staffed at the PCU nurse’s station for the day. Facility policy titled, “Admission, Transfer, and Discharge Critical Care Unit,” revised on 01/09/2024, stated, “... 1. The Admission, Transfer and Discharge policy will be effective for Critical Care Units: Intensive Care Unit (ICU), Progressive Care Unit (PCU), and Open- Heart Recovery (OHR). ... Admission Criteria ... 1. Monitoring (at least every 1-2 hours for ICU and Every 4 hours for PCU) 1.1 Vital Signs: Temperature, Pulse, Respirations, Blood Pressure, and Pulse Oximetry 1.2 Cardiac Monitoring ...” At 12:23 PM, an interview occurred with S1 (Chief Nursing Officer), S4, and S12 (Manger of 5th Floor Telemetry Unit). S1, S4, and S12 all confirmed that there is no formal or written process for who is watching the PCU telemetry monitors when there is not a monitor technician in the PCU. S1 stated that the process “will be formalized.” S1, S4, and S12 all confirmed that they need to discuss how this process is going to be handled as a nursing group, and that no education has been documented providing the facility staff on who is primarily responsible for watching the PCU monitors and, if the 5 East monitor technicians are watching, what is the process if they are unable to reach someone via phone in the PCU to notify nurses of a patient cardiac event. P1’s medical record was reviewed, and the following was revealed: P1 arrived in the ED via ambulance with paramedics on 04/19/2025, for altered mental status. It is documented in the past medical history that P1 had a history of, including but not limited to, anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), anxiety (a state of uneasiness and apprehension), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar in the blood), end stage renal disease (ESRD, the last stage of chronic kidney disease) on dialysis (a treatment that filters waste and excess fluid from the blood) gastroesophageal reflux disease (a chronic condition where stomach acid frequently flows back into the esophagus), hypertension (high blood pressure), pneumonia (inflammation of the lungs) and seizures (a sudden burst of abnormal electrical activity in the brain that affects awareness and muscle control). A review of the ADT (Admission, Discharge, Transfer) log indicated that P1 was brought to the ED on 04/19/2025 and was admitted to the ICU. P1 was transferred to the 6E Medical Surgical Unit on 04/30/2025 and then transferred to the PCU on 05/06/2025. A progress note entered by S13 (Medical Resident) on 05/07/2025 at 6:44 AM, stated, “... Subjective ... 4/21 Code blue during HD [hemodialysis, a procedure for removing metabolic waste products or toxic substances from the bloodstream by dialysis] (cardiac and resp [respiratory] arrest) ROSC [Return of Spontaneous Circulation] achieved after 2 minutes.” The “plan” section of the progress note stated, “... CV [cardiovascular] ... Plan Cardiac monitoring, pulse ox [pulse oximetry], vital signs ...” Facility provided Electrocardiograms (ECG, a test to record the electrical signals in the heart) were reviewed. An ECG dated 05/07/2025 at 8:10 AM stated, “... HR (ECG): [37] BPM [Beats Per Minute] ... Event: Asystole ...” A second ECG dated 05/07/2025 at 8:17 AM stated, “HR (ECG) 68 BPM ... Event: Asystole ... “ The “Significant Event Addendum” note entered by S11 on 05/07/2025 at 10:45 AM, stated, “Patient Vitals taken and assessed at 7:30 am. Patient was talking in Spanish and sleeping/resting. Alert but confused. Not oriented. [His/her] HR [heart rate] was 62 NSR [normal sinus rhythm], BP [blood pressure] 100/41, SPO2 [oxygen saturation] 97%. ... As per night shift, Patient was coughing phlegm and every time he wanted to drink, he was coughing more. I did not give the patient [his/her] breakfast to prevent any aspiration. 08:23 [8:23 AM] patient found unresponsive, no pulse Code blue was initiated, with ACLS [Advanced Cardiac Life Support] protocol. Intubated by anesthesia, no complications noted. Patient got total of 2 doses of epi [Epinephrine, ], 1 D50 [Dextrose] and pulse + at 08:32 ROSC achieved at 08:32 am Code blue documentation done on [name of electronic medical record system]. Patient was safely transported to ICU with monitor on.” The “Code Documentation” entered by a Pulmonology Resident, dated 05/07/2025 at 9:12 AM, stated, “... Pt [patient] with multiple comorbidities including Insulin-dependent T2DM [type two diabetes], ESRD, on HD, HTN [hypertension], Seizures, Anxiety and MDD [Major Depressive Disorder], Septic Shock [a condition of physiologic shock caused by an overwhelming infection) secondary to infected dialysis catheter on 04/19, Cardiac arrest during HD on 04/21, Subacute parenchymal pontine hemorrhage [bleeding in the brain] on 04/27, persistent thrombocytopenia [low blood platelet count] with multiple cryoprecipitate [a blood product] transfusions that coded 2 times during this hospital course. This morning pt coded with ROSC at 8 minutes. Pt was intubated during the event by anesthesia. Family was extensively explained about event, prognosis and was inquired about code status. After discussion with patient’s mother, and daughter, wife [name], decided to change code status to DNR/DNI [ Do not resuscitate/Do not Intubate]. Decision was made to keep patient intubated and to continue current management, if pt decompensates again, family does not want to pursue with chest compressions or re-intubation if needed. ... “ A nursing note entered on 05/07/2025 at 9:45 AM, by an RN, stated, “Patient’s heart rate dropped to the 40’s on monitor with agonal rhythm. ICU team made aware and at bedside immediately to assess. No Pulses palpable. Patient was pronounced at 9:45 AM by [Physician’s name]. Family at bedside.” A “Death Note” entered on 05/07/2025 at 11:50 AM, by a Critical Care Resident, stated, “Called by RN for no palpable pulses Pt’s code status is DNR/DNI. On exam, the patient was unresponsive, pupils dilated, fixed & non reactive to light. No response to verbal and tactile stimuli. Heart sounds absent. BP was un recordable. EKG showed no electrical activity. ... Pronounced dead at [sic] 05/07/25, at 9:45am by [Physician’s name].””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 51038 Based on staff interview, review of facility documents, and review of medical records, it was determined the facility failed to ensure comprehensive pain assessments and reassessments are completed, in accordance with facility policy. Findings include: Facility policy titled “Nursing Assessment Documentation”, last reviewed, 9/6/24, states, “ ...Policy: The Registered Nurse (RN) in the ED will utilize the Emergency Department Nursing Assessment Record (EHR) to document nursing assessment and interventions related to the care of the patient. ...Procedure: ...The Emergency Department RN will document on the Emergency Department Assessment Record (EHR) the following guidelines: ...Vital Signs, Pain, ...”. Facility policy titled “Pain Assessment- All Ages”, last reviewed 10/21/24, states, “ ...Responsibility: Emergency Department RN Policy: It is policy of [facility name] that all patients have a right to pain assessment and management. ...Procedure: 1. All patients will be assessed for the presence/absence of pain. ... 2. Pain will be assessed at the point of triage using an appropriate pain assessment scale based upon chronological or developmental age. ...6. Reassessment: Evaluate response to medication at the appropriate interval, in reducing pain to a level that is acceptable to the patient. Suggested time intervals include: - 1 hour for PO [oral] analgesia, sub-cutaneous, or IM [intramuscular] analgesia -15 minutes for intravenous analgesia -1-2 hours after all non-pharmacological interventions (heat, cold, position changes, relaxation, etc.) ...”. On 11/14/24, medical record review revealed the following: Patient (P)6 presented to the Emergency Department (ED) on 11/11/24 at 3:44 PM, with a chief complaint of ankle sprain. P6 was triaged at 3:56 PM, and had a pain score of 7/10. At 7:05 PM, P6’s pain score was 7/10, and oral Percocet 5-325 mg (milligrams) was administered. P6’s medical record lacked documentation that a pain intervention was implemented upon triage and that a pain reassessment was completed one (1) hour after the administration of pain medication. P7 presented to the ED on 1/9/24 at 3:49 PM, with a chief complaint of abdominal pain and vomiting. P7 was triaged at 9:21 PM with a pain score of 8/10. At 2:06 AM, P7’s pain was reassessed with a pain score of 4/10 and oral Tylenol 650 mg was administered. P7 was discharged at 2:13 AM. P7’s medical record lacked documentation that a pain intervention or reassessment was completed after triage. P8 presented to the ED on 1/20/24 at 12:32 PM with a chief complaint of wrist pain and laceration. P8 was triaged at 1:36 PM. His/her medical record lacked documentation of an initial pain assessment. At 2:02 PM, P8’s pain score was a 10/10. At 2:17 PM, 4 mg Morphine IV (intravenous) was ordered, but not administered. At 4:50 PM, P8’s pain reassessment was 7/10. P8 was discharged at 4:56 PM. P8’s medical record lacked documentation that pain medication was administered, or that a pain intervention was implemented. P9 presented to the ED on 2/29/24 at 9:26 AM with a chief complaint of left hip pain status post fall. P9 was triaged at 9:44 AM. His/her medical record lacked documentation of an initial pain assessment. At 11:30 AM, P9’s pain score was 9/10. At 11:30 AM, Morphine 4 mg IV was administered. P9 was transferred to another facility at 3:43 PM. P9’s medical record lacked documentation that a pain reassessment was completed (1) hour after the administration of pain medication. P10 presented to the ED on 10/2/24 at 12:44 PM for evaluation status post fall. P10 was triaged at 2:12 PM. His/her medical record lacked documentation of an initial pain assessment. At 5:53 PM, P10’s pain score was 3/10 and oral Ibuprofen 600 mg was administered. P10 was discharged at 7:10 PM. P10’s medical record lacked documentation that a pain reassessment was completed one (1) hour after pain medication administration. P11 presented to the ED on 3/6/24 at 12:00 AM with a chief complaint of abdominal pain and vomiting. P11 was triaged at 12:13 AM. P11’s medical record indicated P11 was “dismissed” at 1:05 AM. P11’s medical record lacked documentation that a pain assessment was completed upon triage. P12 presented to the ED on 10/13/24 at 3:46 PM with a chief complaint of ankle pain status post fall. At 3:55 PM, P12 was triaged with a pain score of 9/10. P12 received intramuscular Toradol 30 mg for pain at 4:28 PM. At 7:12 PM, P12’s pain reassessment score was 6/10 and oral Tylenol 1000 mg was administered. P12 was discharged at 7:30 PM. P12’s medical record lacked evidence that a pain reassessment was documented within one (1) hour of pain medication administration. On 11/15/24 at 2:00 PM, an interview was conducted with Staff (S) 4, ED Director. S4 stated that pain should be assessed during the initial nursing triage and reassessed within one hour after pain medication administration. The above findings were confirmed with S4.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48414 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to implement policies and procedure for the care of suicidal patients presenting to the Emergency Department. Findings include: Facility policy titled, “Nursing Assessment Documentation,” reviewed, 9/6/24, states, “ ...Policy: The Registered Nurse (RN) in the ED will utilize the Emergency Department Nursing Assessment Record (EHR) to document nursing assessment and interventions related to the care of the patient. ...Procedure: ...The Emergency Department RN will document on the Emergency Department Assessment Record (EHR) the following guidelines: Initial Nursing/Triage Assessment...Suicide Assessment... .” Facility policy titled, “Suicide Precautions”, reviewed 10/21/24, states, “ ...PURPOSE: To ensure a safe environment for potentially self-destructive patients and to establish guidelines for staff observation of these patients. RESPONSIBILITY: Emergency Department Staff POLICY: Each patient triaged will be screened for suicidal and homicidal ideations. If a patients answer is yes to having suicidal ideations, constant observation (1:1) will be triggered. PROCEDURE: 1. Suicide precautions will be ordered by the physician, but nursing staff will implement suicide precautions while awaiting the order. 2. Patients shall be placed in one of the safer rooms located in bed #20, or #FT 2 3. The “Safer Room” Checklist will be complete by the primary RN (see attached). 4. 1:1 Observation will be initiated following guidelines of the 1:1 Policy ... .” Facility policy titled, “One to One (1:1) Observation/Close Observation (CO),” revised 12/21, states, “ ...Procedure: ...2. 1:1 Observation: The patient shall be observed on a 1:1 staff/patient ratio when clinical assessment indicates immediate or impulsive behavior that may be harmful to self or others. ...Documentation: 1. An order for a One to One Constant Observation will be written in the medical record by the MD/APN [medical doctor/advance practice nurse] only. ...2. The Frequent Observation Flow Sheet must be started as soon as the patient is placed on one to one (1:1). An entry must be made every 15 minutes. ...3. Safe Environment Documentation: A. Emergency Room staff will complete The Emergency Room Safe Environment Risk Assessment Tool prior to patient placement in a treatment area. ... .” On 11/15/24 medical record review revealed the following: Patient (P)1 presented to the Emergency Department (ED) on 5/18/24 at 6:42 AM with an arrival complaint of Suicidal Ideation. P1 was assigned to Room 05 in the ED. At 6:56 AM, the Chief Complaint Updated states, “Suicidal (Brought by EMS from [facility name] nursing home, reported pt [patient] verbalizing wants to kill self, that [he/she] does not want to stay in that nursing home, reported that staff noted pt tried to used [sic] belt to hurt [himself/herself]).” At 6:58 AM, P1’s Columbia Suicide Severity Rating Scale (C-SSRS) score was “High Risk,” and P1 answered “yes” to suicidal thoughts. At 7:12 AM, P1’s belongings were taken to the utility room. At 9:12 AM, P1 was transferred to Room 06. At 9:19 AM, P1’s C-SSRS score was “Moderate Risk.” At 9:37 AM, the ED Provider Note stated, “ ...Psychiatric/Behavioral: Positive for behavioral problems and suicidal ideations. ...Comments: Suicidal Ideation - “I will hurt myself if I have to return to the nursing home” ...Patient medically cleared for psychiatric evaluation ... .” At 10:35 AM, the Psychiatric Consultation Note, states, “ ...On evaluation this morning at the ED, ... [He/she] stated that [he/she] hung up [his/her] belt in anger and realized that it was wrong to do so. ...[He/she] reports a history of auditory hallucinations, hearing voces [sic] telling [him/her] to hit or attack anyone at times but [he/she] does not pay attention to them. ... “I love myself, I can never kill myself,” [he/she] stated. On assessment, [he/she] denied auditory and visual hallucinations, denied suicidal or homicidal thoughts or plans or actions. ...Plan: Patient psychiatrically cleared for discharge. ... .” P1 was discharged back to the nursing home at 12:54 PM. P1’s medical record lacked evidence of a physician’s order for 1:1 observation. P1’s medical record lacked documentation of the “Special Precautions/Observation Record,” which is used to document the 1:1 observation. P1’s medical record lacked evidence that an “Emergency Room Safe Environment Risk Assessment Tool” was completed. P1 was assigned to ED Room’s 05 and 06, which are not “safer rooms” that P1 should be assigned to, in accordance with facility policy. P1 presented to the ED again on 9/2/23 at 3:13 PM, with a chief complaint of Weakness. P1 was assigned to Room 15. At 3:55 PM, the Chief Complaint Updated, states, “Suicidal (Patient BIBA (brought in by ambulance) from [town]. EMS [Emergency medical services] from [town name]. EMS reports, patient was found wandering around lost. Patient states to RN [Registered Nurse] ‘I want to kill myself. I feel very depressed and do not want to live anymore.)’ ... .” At 4:54 PM, P1’s belongings were searched and placed into a locker/storage area. At 5:20 PM, P1 was medically cleared for psychiatry. On 9/2/24 at 10:19 PM, P1’s Psychiatric Consult Note stated, “ ...Patient states recently when [his/her] blood pressure is high and [he/she] gets angry [he/she] wants to kill [himself/herself] but does not really mean it and never has had a plan, nor has [he/she] ever attempted suicide. Patient currently denies suicidal ideations and has contracted for safety. ...Plan: ...Patient is cleared psychiatrically and does not need psychiatric hospitalization at this time. The [emergency room] to provide outpatient psychiatric follow up for this patient.” On 9/2/24 at 11:20 PM, P1 was assigned to Room 20. On 9/3/23 at 8:10 AM, P1’s C-SSRS score was low risk. On 9/3/24 at 9:24 AM, P1 was discharged. P1’s medical record, had a scanned in 1:1 observation document titled “Special Precautions/Observation Record,” dated 9/2/24, from 4:00 PM until 11:30 PM. P1’s medical record lacked evidence that a suicide screening was completed on the initial nursing/triage assessment when P1 presented to the ED on 9/2/23. P1’s medical record lacked evidence of a physician’s order for 1:1 observation and lacked evidence that an “Emergency Room Safe Environment Risk Assessment Tool” was completed. P1 was assigned to Room 15, which is not a “safer room” that P1 should be assigned to, in accordance with facility policy. P3 presented to the ED on 2/8/24 at 7:28 PM, with a chief complaint of alcohol intoxication and suicidal ideation. At 7:43 PM, the ED RN Note stated, “1:1 in place for safety. Pt changed into blue scrubs all belongings removed from patient.” On 2/9/24 at 2:53 PM, the Psychiatric Consult stated, “ ...Plan: ...Pt does not meet any inpt [inpatient] psychiatric commitment criteria at this time. ...Pt is psychiatrically cleared at this time... .” P3 was discharged on 9/3/24 at 4:38 AM. P3’s medical record lacked evidence of a physician’s order for 1:1 observation. P3’s medical record lacked documentation of the “Special Precautions/Observation Record” which is used to document 1:1 observation. On 11/18/24 at 12:00 PM, these findings were confirmed with S4 (ED Director).”

“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: 48965 Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility is not in compliance with §489.24 as evidenced by failure to ensure: 1.) all entries in the ED (Emergency Department) log are complete and accurate (A-2405); 2.) a medical screening exam (MSE) was completed by qualified medical personnel in one of five obstetric medical records reviewed (Patient (P) 19) (A-2406); 3.) the physician certification and consent forms were completed at the time of transfer for two of three transfer medical records reviewed (P7 and P16) (A-2409). Cross Reference: 489.20(r)(3) - Emergency Room Log 489.24(a)(1)(i) - Medical Screening Exam 489.24)e)(1)-(2) - Appropriate Transfer”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48414 Based on the review of four of 22 medical records (Patient (P)10, P12, P14, and P15), staff interviews, and review of facility documents, it was determined that the facility failed to ensure all entries in the ED (Emergency Department) log are complete and accurate. Findings include: Review of the facility policy titled, “Emergency Department (EHR)” revised 9/6/24, states, “ ...Policy: To maintain an accurate log of every patient presenting to the Emergency Department. Procedure: The Emergency Department log will record the following information on each patient. ...Disposition ...” On 11/13/24, a review of the ED Log for P10 indicated the patient’s disposition as “Eloped.” A review of the medical record revealed P10 presented to the facility’s ED on 11/1/24 at 3:07 PM, with a chief complaint of vomiting and abdominal pain. P10’s vital signs were obtained, and lab work completed. A CT [computed tomography] of the abdomen/pelvis was ordered, and P10 refused. The ED Nursing Note dated 11/1/24 at 4:41 AM, stated, “Pt [patient] and family member observed leaving, pt pulled out [his/her] own iv [intravenous] access does not want dressing to be applied, pt stated [he/she] does not want to have ct scan done, felt much better and [he/she] has to take care of [his/her] pets, [doctors name] notified pt leaving.” On 11/15/24 at 11:10 AM, the above findings were reviewed with S4, ED Director. S4 stated, P10’s discharge disposition should have been documented as “AMA [Against Medical Advice],” and if P10 refused to sign an AMA form, the nurse should have noted that the patient refused to sign. S4 indicated a disposition of elopement is used when a patient leaves the facility unwitnessed and without notifying facility staff. 48965 On 11/13/24, a review of the ED Log for P14 indicated the patient’s disposition as “Eloped.” A review of the medical record revealed P14 presented to the facility’s ED on 9/20/24 at 6:29 AM, with a chief complaint of a hand injury. The ED doctor suspected that P14’s injuries resulted from a gunshot wound, therefore, he/she notified the police. P14 no longer wanted to be treated once the police arrived. The ED doctor documented a conversation regarding the risks of P14 leaving without treatment. P14’s response was “I don’t care.” The ED doctor documented that P14 left AMA and he/she refused to sign the paperwork. The ED nurse documented P14 was discharged and the ED log lists P14 as eloped. On 11/15/24 at 11:00 AM, S4 confirmed that P14’s discharge disposition was inaccurate on the ED log. S4 explained that P14’s disposition should have been logged as left AMA. 51038 On 11/13/24, a review of P12’s medical record revealed P12 presented to the facility’s ED on 3/6/24 at 12:00 AM with a chief complaint of vomiting and abdominal pain. The Registered Nurse (RN) completed triage at 12:13 AM. At 1:05 AM, P12’s ED disposition was documented as “dismissed” in the medical record. A review of the ED log for P12 demonstrated a blank space in the patient disposition column. On 11/14/24, a review of P15’s medical record revealed P15 presented to the facility’s ED on 9/7/24 at 9:20 AM with a chief complaint of ankle pain. At 9:31 PM, P15’s ED disposition was documented as “dismissed” in the medical record. A review of the of the ED log for P15 demonstrated a blank space in the patient disposition column. On 11/15/24 at 10:00 AM, an interview was conducted with S17, Director of Patient Access. S17 does not fully understand when “dismissed” is used for disposition. He/she explained that registration staff reported being asked to enter “dismissed” when a patient leaves the waiting area without being treated. According to S17, this would be considered “Left without treatment.” S17 thinks patient “dismissed” would be used if a patient is registered for the ED in error instead of a different department, such as radiology. S17 indicated registration should not be entering discharge dispositions for patients. On 11/15/24 at 11:00 AM, an interview was conducted with S4, who confirmed he/she reviews the ED logs daily. P12 and P15 lacked a discharge disposition on the ED logs. S4 indicated he/she was unable to provide an explanation as to why P12 and P15 lacked a disposition on the log. In addition, S4 stated “dismissed” is not a discharge disposition that should be used within the facility and that there is no related policy. S4 indicated he/she was unaware that dismissed was being used as a discharge disposition.”

“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: 38289 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure a medical screening exam (MSE) was completed by qualified medical personnel in one of five obstetric medical records reviewed (Patient (P) 19). Findings include: Facility document titled, “[Facility] Medical/Dental Staff Bylaws”, approved and adopted on 3/21/2012, states, “... E. EMTALA/Medical Screening ... 3. Authorized qualified medical personnel are those authorized by the Medical/Dental Staff Bylaws and approved by the Board of Trustees. In addition to the Licensed Independent Practitioner, the following personnel are designated as qualified medical personnel and authorized to conduct medical screening examinations for individual who come to the Emergency Department or Labor and Delivery department requesting examination and treatment: Labor and Delivery Department - Level II Registered Nurse (RNC [Registered Nurse Certified] or NP [Nurse Practitioner]) ...” A review of P19’s medical records revealed that the patient presented to the facility’s Emergency Department on 7/19/24 at 4:53 AM with complaints of abdominal pain. P19 was quick triaged (time illegible), found to be over 20 weeks pregnant, and was transferred at 4:59 AM to the Maternal Child Health Unit for further triage and assessment. A nursing assessment was completed by Staff (S) 19, Registered Nurse (RN), at 5:37 AM. The communication/provider note by S19 identified a request for S18, an Obstetric Provider, to evaluate P19 in person. A telephone order was received by S19 from S18 on 7/19/24 at 6:32 AM to discharge P19 to home or self care. The medical record lacked evidence of an MSE for P19. On 11/15/24 at 9:50 AM, upon review of S19’s personnel file, it was revealed the personnel file lacked evidence that S19 was a Level II RN, RNC, or NP. Upon request, S1, Chief Nursing Officer, and S12, Director of Maternal Child Health Services, were unable to provide evidence of S19’s Level II, RNC, or NP certification. On 11/15/24 at 12:44 PM, S1 and S12 confirmed that S19 was not a Level II, RNC, or NP and that P19’s medical record did not have evidence of an MSE performed by a qualified provider.”

“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: 48414 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the physician certification and consent forms were completed at the time of transfer for two of three transfer medical records reviewed (Patients (P)7 and P16). Findings include: Review of the facility policy titled, “EMTALA/Medical Screening Evaluation”, last reviewed 9/6/24, “ ... If a patient is to be transferred for medical necessity, the following must be followed: ... A physician certification (located on the transfer sheet) that the risk of transferring the patient are outweighed by the potential health benefits. The individual risks and benefits must be documented and the patient’s medical record must support these. The receiving hospital must give acceptance in advance. The accepting physician’s name must be documented on the transfer sheet. The patient/representative give written consent for transfer (located on the transfer sheet). ...” Review of the facility policy titled, “Transfer of Patient to Another Facility” last reviewed 9/5/23, states, “ ... Policy: ... 2. If the provider determines, through the hospital policy that the patient should be transferred to another facility for further care, EMTALA standards must be followed. ... 5. Transfer paper will be completed with the following information included. -Physician Authorization for Transfer. -Patient Consent (or Refusal Signature) ...” On 11/14/24 at 10:20 AM, a review of medical records revealed the following: On 2/29/24 at 9:26 AM, Patient (P)7 arrived to the Emergency Department (ED) via ambulance, status post fall. The patient was transferred to another facility for a higher level of care at 3:43 PM. P7’s medical record lacked documentation that the “Certification of Transfer” and “Consent for Transfer” forms were completed. On 9/15/24 at 2:43 AM, P16 presented to the ED with a chief complaint of “Alcohol Intoxication and Assault Victim.” P16 was transferred to another facility for a higher level of care at 5:11 AM. P16’s medical record lacked documentation that the “Certification of Transfer” and “Consent for Transfer” forms were completed. On 11/15/24 at 2:20 PM, S2, Director of Quality, and S3, Performance Improvement Coordinator, were unable to provide evidence that the “Certification of Transfer” and “Consent for Transfer” forms for P7 and P16 were completed. 51038”