The University Hospital

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 50613 Based on staff interviews, personnel file review, and facility document review, it was determined that the facility failed to ensure that endoscopy staff maintain the required credentials as outlined in the job description for the Senior Endoscopy Technician position. Findings include: On 07/14/2025 at 1:32 PM, during a review of Staff (S)15’s personnel file, a job description for the position of Senior Endoscopy technician was present in the file. The job description stated, “ ... Job Requirements ...Two (2) years of Endoscopy or related experience required. Certificate for Endoscopy Technician required, or one (1) year of additional related experience under the supervision of a Professional Nurse may be substituted for the certificate ...Credential required: ... Endoscopy Certificate ...” At 1:32 PM, S15’s certification in endoscopy reprocessing was requested. The certification document that the facility provided expired on 11/30/2022. There was no updated certification available in the employee’s file. The employee was not present on the day of the visit, S10 stated that he/she likely has a current certification, but no documentation was provided to confirm this. At 1:45 PM, upon interview, S7 confirmed that the documentation provided was an expired certificate, and certification was listed as a required credential.”

“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: 50613 Based on staff interviews, personnel file review, and facility document review, it was determined that the facility failed to ensure that 1) the assessment of endoscopy staff during orientation is implemented and documented, and 2) annual department specific competencies are conducted for all endoscopy technicians, in accordance with facility policy and Society of Gastroenterology Nurses and Associates (SGNA) guidelines. Findings include: Reference: SGNA Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes, 2023 stated, “ ... Personnel. Ensuring consistently effective endoscope reprocessing and safety is a multidisciplinary effort involving clinical and reprocessing staff, infection prevention personnel, and management. SGNA recommends that reprocessing personnel accomplish the following: Understand the rationale and importance of each step in reprocessing; Complete all endoscope reprocessing steps meticulously and efficiently, maintaining strict adherence to the reprocessing protocol; Readily access the manufacturer’s instructions for use (IFU); Demonstrate model-specific competency for all steps of endoscope reprocessing as outlined by the manufacturer, including proper use of validated automatic endoscope reprocessing systems and other equipment upon hire, at least annually, anytime a breach is identified, and when updated techniques or new endoscope or reprocessing accessories are introduced ... Complete additional training, updated evaluation and documentation of competency whenever a change in reprocessing guidance is received from the manufacturers’ IFUs, regulatory agencies, or guidance from professional organizations ... Complete reprocessing training with documented competency for new models of endoscopes, accessories, valves, and automatic endoscope reprocessors as soon as they are introduced in the facility ... Temporary personnel should not be allowed to clean or disinfect endoscopes in either a manual or an automated reprocessing system until competency has been established and verified ...” Facility policy titled, “Reprocessing Immersible Flexible Endoscopes With Automated Endoscopic Reprocessor (AER) (last reviewed July 2024) stated, “ ... Policy: Endoscope reprocessing shall be performed by staff members who are fully aware of the endoscope’s design and the dangers associated with inadequate cleaning and disinfection ...” 1. On 07/14/2025 at 10:09 AM, Staff (S)7 confirmed that the facility follows the Society of Gastroenterology Nurses and Associates (SGNA) Guidelines. At 10:15 AM, in the Reprocessing room, S13, an endoscopy technician, was observed manually cleaning a contaminated endoscope. Upon interview, S13 stated that he/she has worked in the endoscopy department for over 20 years, however he/she was not certified. S13 stated that they frequently precept new employees, and is currently precepting S12. When asked about the orientation process, S13 explained that he/she provides verbal feedback to S10 regarding the performance of the employee that is being precepted. S13 stated that in his/her opinion, S12 required additional supervision, and this was communicated to S10, which led to an extension of S12’s probationary period. S13 described S12 as receptive to instruction but since S12 has no experience, he/she would benefit from additional training. Upon interview, S13 stated that there was no checklist used during the training that outlines the steps and skills related to the decontamination and high-level disinfection of endoscopes. At 10:26 AM, upon interview, S12 stated that he/she had been a facility employee for three years and had the role of Patient Services Associate and Transporter. He/she began working as an endoscopy technician four months ago. S12 stated that he/she felt like the orientation process was progressing well, his/her preceptors have been providing “good feedback,” but stated that the probationary period has been extended. During the interview, S12 was asked if he/she had been instructed to follow the manufacturer’s instructions for use (IFU) when reprocessing endoscopes. S12 replied, “IFUs? I’m not sure what that is.” When asked how S12 knows the steps for reprocessing, he/she stated that there is a poster in the decontamination room outlining the steps, and that S13 instructed him/her to follow the poster. On 7/14/25 at 12:08 PM, a review of personnel files for S12, a newly hired endoscopy technician who had been in the position for two months, and S14, an agency employee who had been assigned to the facility for three months, revealed a lack of documented evidence of a standardized orientation specific to endoscope reprocessing. Upon request, S7 was unable to provide a specific endoscope reprocessing orientation document. S7 stated that while an employee was on orientation, verbal feedback was received from the preceptor, and a decision was made as to the employee’s competency, while using that verbal feedback. When asked how agency staff are evaluated, S7 stated that the agency provides documentation verifying the competency level and relevant experience. Upon request at 12:15 PM, S7 was not able to provide department specific orientation and training information for S14. At 12:20 PM, S10 confirmed that a standardized tool that contains the specific steps required for endoscopy reprocessing was not used for employee orientation. 2. On 07/14/2025 at 12:32 PM, during a review of personnel files for S13, S15, and S16, it was revealed that the 2024 annual department specific competency and evaluation was not conducted for three out of three staff members. The personnel files of S13 and S16 contained the job description for the position of “Endoscopy Technician.” The job description stated, “Essential Duties and Responsibilities ...15. Maintains competency in performing Endoscopy Technician duties safely and effectively ...” The personnel file for S15 contained the job description for the position of “Sr. [Senior] Endoscopy Technician.” The job description stated, “9 ...maintains competency in performing MSP/Endoscopy duties safely and effectively ...” At 12:30 PM, S10 confirmed that an annual staff evaluation that includes unit specific competencies have not been completed for 2024.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 41646 Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure: 1.) patient transfer documentation is completed in accordance with facility policy (A1104); 2.) patients in the emergency department waiting room receive continued monitoring in accordance with facility policy, in one out of two medical records reviewed of patients with an acuity level of “2” (Patient (P)5) (A1104); 3.) a pain assessment is completed during triage in accordance with facility policy, in four out of six medical records reviewed (P7, P8, P11, and P19) (A1104); 4.) a pain reassessment is completed after pain medication administration per facility policy (A1104). Cross Reference: 482.55 (a)(3) Emergency Services: Emergency Services Policies”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 49174 Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure: 1.) patient transfer documentation is completed in accordance with facility policy; 2.) patients in the emergency department waiting room receive continued monitoring in accordance with facility policy, in one out of two medical records reviewed of patients with an acuity level of “2” (Patient (P)5); 3.) a pain assessment is completed during triage in accordance with facility policy, in four out of six medical records reviewed (P7, P8, P11, and P19); 4.) a pain reassessment is completed after pain medication administration per facility policy. Findings include: 1. Facility policy titled, “Patient Transfer Process From [Facility Name] to Other Hospitals” last reviewed 06/10/22, stated, “ ...Transfer Process. 2.) ...For patients [error - stable] for transfer, either the patient’s request for and consent to the transfer, or the physician’s certification outlining the risk and benefits of the transfer. ...” On 06/10/25 at 10:46 AM, Patient (P) 5’s medical record was reviewed and revealed the following: On 02/08/25 at 5:20 PM, P5 arrived at the Emergency Department (ED) via ambulance, with a chief complaint of drug overdose. At 5:25 PM, P5 was triaged, vital signs were obtained, and a Columbia Suicide Severity Rating Scale was conducted. At 5:36 PM, P5 had a medical screening examination (MSE) by Staff (S)49. S49 documented in the “ED Provider Note” that P5’s plan was for labwork, a psychiatric consultation, and a two to one observation of P5. S49 documented, “... MRI brain negative for acute stroke. Pt is now medically cleared pending psych eval ...” Review of P5’s medical record “Consult Notes” dated 02/08/25 at 10:28 PM, S50 documented “ ...Plan is for voluntary admission ...” Review of P5’s medical record “ED Note” dated 02/09/25 at 7:17 PM, S50 documented, “...[P5] believes [he/she] could benefit from psychiatric admission and has signed for voluntary admission ...” Review of P5’s medical record “ED Turnover Note,” dated 02/10/25 at 03:30 AM, S51 documented, “... Previously medically cleared incl [including] med [medical] tox [toxicology] consult, neuro consult. Pending vol [voluntary] admission ...” Review of P5’s medical record “ED Note,” dated 02/10/25 at 9:01 AM, S52 documented, “... Plan is for psychiatric voluntary admission ...” Review of P5’s medical record “ED Note,” dated 02/10/25 at 3:04 PM, S53 documented, “... “Pt taken to [facility name] via [name of transport company] with all belongings and paperwork.” The facility was unable to provide documentation of a transfer order or certification from the physician with the risk and benefits of the transfer. On 06/10/25 at 1:18 PM, S24 confirmed the above findings. On 06/11/25 at 10:40 AM, an interview with S10 was conducted. S10 explained the process of transferring a psychiatric patient to a facility. S10 stated that the ED physician medically clears the patient, a psychiatric evaluation and Crisis evaluation is completed, and the disposition of the patient is decided. The screeners will work on finding a bed for the patient. The ED physician will re-evaluate the patient, discuss the risks and benefits with the patient, sign the Transfer Form, and write a transfer order. S10 stated, “you have to put in a transfer order that contains why the patient is being transferred and where the patient is going.” S10 explained that by signing the Transfer form, the physician is attesting that he/she has discussed the risks and benefits with the patient. On 06/11/25 at 11:30 PM, S24 stated that the facility reached out to the accepting facility for clarification on P5’s disposition. On 06/11/25 at 12:35 PM, S55 was interviewed to provide clarification on P5’s discharge disposition. S55 explained that the Crisis screeners use two systems: the facility Electronic Medical Record (EMR) and a Crisis EMR. S55 had documented in the Crisis EMR on 02/10/25 at 09:45 AM - “Screener saw and spoke to patient, the process was explained and explained the process of a bed search. The patient reported that if [he/she] is accepted at an outside hospital patient will sign [himself/herself] out because all [his/her] services are at [facility]. 9:50 am: Spoke to [psychiatrist] patient to be converted to involuntary....” The facility was unable to provide documentation of the patient’s involuntary status in the facility EMR. The facility was also unable to provide documentation of an update to the primary medical team from psychiatry on the conversion of P5 to involuntary status. These findings were confirmed with S4 (Director of Regulatory) and S24. 2. Facility policy titled, “Vital Signs,” last reviewed 04/22/2025, stated, “... Procedure ... B. Patients who are in a waiting area of the ED shall have vital signs reassessed a minimum of every 4 hours. C. Vital signs shall be reassessed during the ED visit as indicated by the clinical acuity outlined below. Clinical acuity is determined by the Emergency Severity Index (ESI) during the triage process...ii. ESI 2: Every hour until stabilized and then a minimum of every 4 hours...” On 06/10/25 at 10:03 AM, P6’s medical record was reviewed and revealed the following: On 02/01/25 at 2:43 PM, P6 arrived at the facility via ambulance with complaints of drug overdose. At 2:44 PM, P6 was triaged, had vital signs taken, and was assigned an acuity level of “2.” At 2:51 PM, P6 had his/her blood sugar taken and returned to the waiting room. At 9:14 PM, 6 and a half hours after triage, P6 had a second set of vital signs taken. At 9:41 PM, the triage nurse wrote a note stating, “pt [patient] now aao [awake, alert, and oriented], ambulated to the bathroom, given sandwich to eat, left ed, gait steady.” At 9:42 PM, P6’s Emergency Department (ED) Disposition was set to “Left without being seen.” The facility was unable to provide documentation of additional vital sign reassessments or a medical screening examination for P6. On 06/10/25 at 1:10 PM, S24 reviewed P’6s chart and confirmed the above findings. S24 explained that per policy, a patient with an acuity level of “2” would have his/her vital signs taken every hour until stable and then every four hours after. 51555 3. Facility policy titled, “Triage,” last reviewed on 04/14/2023, stated, “ ... IV Procedure ... 3. A complete set of vital signs, pain assessment, and height and weight should be taken and documented in the EHR [Electronic Health Record] of all patients during triage.” Facility policy titled, “Nursing documentation: Assessment and Reassessment in the Emergency Department/ Emergency Department Observation Unit,” last reviewed on 06/06/2023, stated, “ ... IV. Procedure: Triage Assessment ... 2. Documentation in the EHR should include: ... f. Pain assessment ...” A review of P7’s Medical Record (MR) was conducted and revealed the following: On 05/01/2025 at 11:27 AM, P7 arrived at the ED with complaints of arm pain. At 11:44 AM, a set of vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) were completed by an ED staff member. Review of P7’s “Chief Complaints Updated” note at 11:48 AM, S36 documented, “Arm pain (c/o R [right] forearm pain, back pain s/p MVA [motor vehicle accident] last Saturday).” At 11:50 AM, S36 documented, “Triage completed” and an acuity of 4 was assigned. There was no evidence of a pain assessment during triage in P7’s MR. The above findings were confirmed with S24 on 06/10/2025 at 1:04 PM. A review of P8’s MR was conducted and revealed the following: On 05/01/2025 at 6:49 PM, P8 arrived at the ED with complaints of blurred vision, chest pain, headache, and shortness of breath. At 6:54 PM, S36 documented triage vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) and a triage acuity level of 3 was assigned. At 6:58 PM, S36 documented, “Triage Completed.” There was no evidence of a triage pain assessment in P8’s MR. The above findings were confirmed with S24 on 06/10/2025 at 1:05 PM. A review of P11’s MR was conducted and revealed the following: On 05/05/2025 at 9:49 AM, P11 arrived at the ED with complaints of seizures. P11’s child reported that the patient had two episodes of seizure like activity at home. P11 has a history of cerebral aneurysms. At 10:00 AM, S19 documented a set of vital signs (blood pressure, pulse, respirations, temperature, and pulse ox), S19 documented, “Triage Completed” and an acuity level of 3 was assigned. There was no evidence of a triage pain assessment in P11’s MR. The above findings were confirmed with S24 on 06/10/2025 at 12:56 PM. A review of P19’s MR was conducted and revealed the following: On 03/14/2025 at 6:58 AM, P19 arrived at the ED with complaints of CVA (cerebral vascular accident - stroke) symptoms. At 7:13 AM, S47 documented triage vital signs (blood pressure, pulse, respirations, temperature, and pulse ox) and a triage acuity level of 2 was assigned. At 7:14 AM, S47 documented, “Triage Completed.” There was no evidence of a triage pain assessment in P19’s MR. The above findings were confirmed with S24 on 06/10/2025 at 1:38 PM. 4. Facility policy titled, “Nursing documentation: Assessment and Reassessment in the Emergency Department/ Emergency Department Observation Unit,” last reviewed on 06/06/2023, stated, “ ... 2. Pain assessment and reassessments must be completed as per the Pain Assessment and Management policy.” Facility policy titled, “Pain Assessment and Management,” last reviewed on 02/2023, stated, “...V. Procedure:... 6. Pain reassessment should occur within two (2) hours from the time a patient is treated with a pharmacological or non-pharmacological intervention based on the actions of the medication and route of administration.” A review of P13’s MR was completed and revealed the following: On 05/17/2025 at 5:30 AM, P13 arrived at the ED with complaints of mid-sternal chest pain for six days. At 6:30 AM, S45 administered ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID] used to relieve pain, reduce inflammation, and lower fever) 600 mg (milligrams) orally. At 8:54 AM, S56 documented a pain assessment that states, “Pain Assessment: No/denies pain.” The pain reassessment was not completed within two hours after medication administration as per facility policy. This finding was confirmed by S24 on 6/10/2025 at 12:53 PM. A review of P12’s MR was conducted and revealed the following: On 05/29/2025 at 8:42 AM, P12 arrived at the ED with complaints of seizures. At 2:12 PM, a pain assessment documented by S36 stated, “Pain Assessment: Pain Score 10.” At 2:12 PM, S36 administered acetaminophen (a pain reliever/fever reducer medication) 650 mg orally and ketorolac (an NSAID used to treat moderate to severe pain) injection 15 mg IV (intravenous). At 5:47 PM, a pain assessment documented by S44 stated, “Pain Assessment:... Pain Score: 4.” The pain reassessment was not completed within two hours after medication administration as per facility policy. On 06/10/2025 at 12:55 PM, an interview was conducted with S24. When asked what the process is for pain reassessment after medication administration, S24 stated, “pain should be reassessed one hour after meds are given.” The above findings were confirmed with S24 on 06/10/2025 at 12:55 PM. 49077 A review of P14’s MR was conducted and revealed the following: On 01/22/25 at 2:09 PM, P14 arrived at the ED with a complaint of back pain. At 2:19 PM, P14’s pain was documented as 10/10 on a pain scale. At 4:51 PM, P14 received 975 mg of acetaminophen orally, 15 mg of ketorolac intravenously, and 15 mg of morphine orally for pain relief. P14’s medical record does not display another pain assessment until 01/23/25 at 6:31 AM, 4/10 on a pain scale. The pain reassessment was not completed within two hours after medication administration as per facility policy. This finding was reviewed upon exit conference on 06/11/25 at 2:04 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51555 Based on review of medical records, review of facility documents, and interview with staff, it was determined that the facility failed to ensure safety measures are in place for a patient that demonstrated aggressive and violent behavior multiple times during his/her admission as evidenced by a staff member obtaining serious harm, injury, and impairment after being attacked by a patient (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing serious risk of harm to staff. Findings include: On February 25, 2025 at 11:36 AM, an IJ was identified for the facility’s failure to have a process in place to ensure staff and patient safety when caring for an aggressive and violent patient (A0144). On February 25, 2025 at 2:35 PM, the IJ Template was presented to Administration and a removal plan was requested. On February 26, 2025 at 12:16 PM, an acceptable removal plan was received. Verification of the IJ removal plan was conducted and included the following: review of updated policies, staff education, sign-in sheets, and staff interviews regarding policy and process changes when caring for a patient with a history of violent or aggressive behavior. Process changes included: Admission Criteria policy updated to include any patient with a history of violence or aggression will be placed on a 1:1 (one-to-one) until evaluated by attending physician/resident, increase in patient safety measures (i.e. use of quiet room, timeout, diversionary activities, 1:1 monitoring), Code Yellow/CRT debriefing with review and updating patient treatment plans, alternative medications added to admission order set for violent/aggressive patients, enhanced communication and awareness to staff of patients with a history of violence and aggression, requiring nursing staff to use panic buttons, and requiring staff to work in teams when caring for these patients. The IJ was removed on February 26, 2025 at 12:26 PM, after the State Survey Agency verified the full implementation of the removal plan. Cross Reference: 482.13(c)(2) Patient Rights: Care in a Safe Setting”

“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: 47131 Based on staff interviews, review of one of three medical records (MR 1) of patients exhibiting violent behavior, and facility document review, it was determined that the facility failed to ensure safety measures are implemented for a patient that exhibited aggressive and violent behavior multiple times during [his/her] admission. Findings include: Facility policy titled, “Patient Observation//Safety Watch” (Revised 7/2024) states, “...IV. Policy: ...3. Patients at risk for harm to themselves or others will be assessed for underlying cause and treated accordingly per the UH Safety Watch Assessment & Treatment Algorithm... 4. Alternative interventions to promote patient safety will be implemented as appropriate. ... .” An entrance conference was conducted on 02/24/25 at 10:24 AM, in the presence of Staff (S)1, S2, S3, S4, S5, S6, S7, and S8. During the entrance conference, it was confirmed that the BHU (Behavioral Health Unit) uses the “Broset” (a tool used to assess the risk of violence.) The Broset Violence Checklist (BVC) is a short-term violence prediction tool that assesses behaviors including confusion, irritability, and verbal threats to assess a patient’s risk of violence. The BVC is completed and documented by nursing staff each shift (12 hours) and as needed. On 02/24/25 at 11:05 AM, a tour of the ‘G-Yellow’ BHU was conducted in the presence of S1. Upon interview with S9 at 11:10 AM, he/she explained that ‘panic buttons’ for staff to wear are available but not required to be worn because “sometimes the patients get paranoid about the buttons. [The patients] will sometimes think it [the panic button] is a camera and the patient is being recorded.” Upon interview with S12 conducted on 02/24/25 at 12:10 PM, he/she explained that nurses complete a BVC each shift and as needed. S12 stated, “If there is a change in behavior, or the patient becomes more agitated, we report the change to all of the staff working on the unit and to the on-call physician. All staff are alerted. We discuss ‘high risk’ patients during shift report.” When asked what safety measures are implemented for patients that are agitated or demonstrate aggressive behavior, S12 stated, “We would attempt to verbally deescalate the patient. If that does not work, I’d get an order from the physician to administer medication.” S12 confirmed that he/she attends weekly safety drills on the unit. S12 was not observed to be wearing a Panic Button. During an interview conducted with S11 on 02/24/25 at 1:22 PM, he/she confirmed that on 02/15/25 at 10:30 AM, a nurse was assaulted by Patient (P) 1 and sustained a brain injury, broken tooth, and two subdural hematomas from the attack, which required the nurse to be admitted to the Trauma ICU (Intensive Care Unit). On 02/24/25 at 1:45 PM, the medical record (MR) for P1 was reviewed and the following was revealed: P1 arrived at the ED (Emergency Department) via ambulance on 02/06/25 at 20:08 (8:08 PM) with complaints of “Hallucinations (Hearing voices), denies SI [suicidal ideations]/HI [homicidal ideations.] Headache x1wk [week].” A CSSRS (Columbia Suicide Severity Rating Scale) and Homicide Risk Assessment were completed at 20:25 (8:25 PM). No risk of harm to self or others was identified upon the patient’s arrival to the ED. An ED Physician Note dated 02/06/25 at 23:47 (11:47 PM) states, “...Reevaluations: 11:32 PM Upon my arrival patient is standing on bed screaming. Refusing lab [laboratory] work, in the setting of active hallucinations telling [him/her] to hurt [him/her] self, will medication [sic].” A ED Note dated 02/06/25 at 11:47 states, “Pt [patient] in tx [treatment] area aggressive towards staff. CRT [Crisis Response Team] called. Pt medicated. Pt on 1:1 [one-to-one] monitoring. The patient was medicated with Midazolam [a sedative medication] 5mg [milligrams] IM [intramuscular] and Haldol [an antipsychotic medication] 5mg IM at 23:47 (11:47 PM).” The patient was transferred to the ED Crisis unit on 02/07/25 at 00:38 (12:38 AM). A behavioral health assessment completed on 02/07/25 at 10:00 AM, states, “...Thought process: ...Hallucination: Auditory, Command: ...Patient Behaviors: Aggressive verbally ... .” An ED Note addendum written at 11:42 AM, states, “Pt restless, pacing at desk, intrusive. Upon attempting to administer PRN [as needed] medication pt punched staff. PRN medications administered and restrained.” A nursing note written at 15:30 (3:30 PM) states, “Patient now calm, all restraints removed.” An ED Note dated 02/08/25 at 08:15 (8:15 AM) states, “The pt is in the hall standing by the exit door and arguing when staff asked [him/her] not to be by the door.” An ED Note written at 08:25 (8:25 AM) states, “The pt moved away from the exit and moved to stand near the other exit and again arguing with staff.” P1 was administered Ativan 2mg IM and Haldol 5mg IM at 08:32 (8:32 AM.) The medical record lacked documentation that any other alternative safety interventions were implemented in the patient’s plan of care per the facility’s “Patient Observation/Safety Watch” policy. An Emergency Psychiatry Consult Note written by S17 (Medical Director, Psychiatry) on 02/07/25 at 1021 (10:21 AM) states, “...Recommendations: Observation status: No need for 1:1 [one-to-one monitoring] while in crisis unit, however, if moved outside of crisis unit, (P1) will require 1:1 or 1:2 [one-to-two monitoring] for safety, elopement, unpredictable behavior. ... .” On 02/10/25 at 3:24 PM, P1 was admitted to “G-Yellow” BHU on an involuntary status. P1 was placed on “Close q15 [every 15] minutes” monitoring upon [his/her] admission to the inpatient unit. The “Initial Psychiatric Evaluation/Comprehensive Clinical Summary” completed on 02/11/25 at 1:09 PM, states, “... [Patient] is s 35-year-old [male/female] with hx [history of] schizophrenia and multiple prior [names of Psychiatric Forensic facilities] hospitalizations for aggravated assault, who presented to [facility] Crisis ER [emergency room] for headache and hallucinations for 1 week. On evaluation, patient is calm and cooperative. Endorses AH (auditory hallucinations) stating racial slurs. Collateral from [family member] expresses serious concern about [his/her] violent nature and warns [he/she] is an active threat to [him/her] self and others. At this time, patient is a danger to [him/her] self and others due to active AH, medication noncompliance, and current history of assaulting family members... . ...Plan: begin Zyprexa [an antipsychotic medication] 5mg daily at bedtime, utilize PRNs [medications] as needed for agitation and aggravated behavior, ... .” A nursing note dated 02/12/25 at 20:58 (8:58 PM) states, “... Patient walked up to staff [name] and threw water in [his/her] face in reference to snacks. Code yellow called. Patient escorted to [his/her] room, Ativan 2mg IM, Benadryl 50mg IM, and Haldol 50mg IM given, patient instructed to remain in [his/her] room. ... .” The medical record lacked documentation that any other alternative safety interventions were implemented in the patient’s plan of care per the facility’s “Patient Observation/Safety Watch” policy. A “Psychiatry Progress Note” dated 02/13/25, states, “... Subjective: Pt [patient] states [he/she] was frustrated when [he/she] did not get s sandwich, so [he/she] threw water at the nurse. Patient today counseled on impulse control and anger management. Patient endorses that [he/she] will speak to management instead of getting physical. Pt refused Zyprexa last night. ... Counseled on importance of taking [his/her] medications. Pt was given prn Ativan, Benadryl, Haldol to calm [him/her.] No other acute events overnight. As per chart/staff, patient has been compliant with medications as prescribed, without any acute behavioral issues/episodes. However, in the morning, patient refused morning medicines and requested Tylenol for a headache. ... .” A nursing note dated 02/14/25 at 0642 (6:42 AM), states, “Patient is irritable this morning, refused vitals check, refused scheduled Synthroid (medication used to treat hypothyroidism).” A nursing note written at 0824 (8:24 AM), states, “Received pacing at the hallway this morning. [He/She] is very irritable, angry, arguing with writer about [his/her] ‘water consumption’ ... [He/She] was later on asking the social worker if [he/she] can be transferred to another hospital. ... .” A “Psychiatric Progress Note” written at 11:29 AM, states, “...Subjective: ...Today, treatment team meeting was deferred as patient was aggressive and upset; [he/she] came in and screamed ’[expletive] you!’ with an aggressive posture & asked to leave the hospital ...Assessment: At this time, patient is actively aggressive towards staff throughout the day, cursing, aggressive and is a danger to [him/her] self and others. Treatment team deferred due to aggressive behavior. ...Plan: ...counsel patient to try and have [him/her] stop refusing the medicines, utilize prn’s (medications) as needed for agitation and aggravated behavior, patient encouraged to continue group/rec [recreational] therapy, milieu... .” The medical record lacked documentation that any other alternative safety interventions were implemented in the patient’s plan of care per the facility’s “Patient Observation/Safety Watch” policy. A note dated 02/14/25 at 1053 (10:53 AM) by a Social Worker, states, “Pt has significant hx of aggression, physical aggression. This morning around 10am as sw [social worker] walked by the pt, pt cursed at the sw, without any particular reason. SW informed RN.” A nursing note dated 02/14/25 at 1202 (12:02 PM), states, [Patient] “Continues to refuse [his/her] medication despite encouragement. [He/She] initially said [he/she] wants it after breakfast but refused again when writer went to offer it ...[He/She] was increasingly agitated after breakfast, worse during community meeting where [he/she] was yelling and disrupting group. [He/She] was not responding to verbal redirection. Security was called. IM prn Ativan, Geodon (an antipsychotic), and Benadryl given at 1016 (10:16 AM) without physical hold though [he/she] was argumentative with staff and security. [He/She] is calmer now but monitored closely for aggression and impulsive behavior.” In a nursing note written at 1504 (3:04 PM) it states, “[He/She] woke up and was pacing, anxious, agitated, verbally abusive towards staff and [name of physician.] ... [He/She] later on asked for “PRN tablet.” [Name of physician] notified and order one time Ativan, Haldol, and Benadryl PO [by mouth]. [He/She] refused Haldol... .” The medical record lacked documentation that any other alternative safety interventions were implemented in the patient’s plan of care per the facility’s “Patient Observation/Safety Watch” policy. Review of P1’s Broset Violence Checklist flowsheet completed by nursing staff confirmed the risk assessment was completed every 12 hours and scores were documented as follows: “02/11/25 at 0500 (5:00 AM)=0; 02/11/25 at 1500 (3:00 PM)=0; 02/12/25 at 0500 (5:00 AM)=0; 02/12/25 at 1800 (6:00 PM)=2; 02/13/25 at 0500 (5:00 AM)=0; 02/13/25 at 1837 (6:37 PM)=1; 02/14/25 at 0600 (6:00 AM)=1; 02/14/25 at 1804 (6:04 PM)=3; 02/15/25 at 0500 (5:00 AM)=3.” The facility failed to provide a “Broset Violence Checklist policy” upon surveyor requests made on 02/24/25 at 10:40 AM, again at 2:30 PM and 02/25/25 at 10:00 AM. Reference: Broset Violence Checklist- Score = 0 The risk of violence is small; Score = 1-2 The risk of violence is moderate. Preventive measures should be taken; Score > 2 The risk of violence is very high. Preventive measures should be taken. In addition, a plan should be developed to manage the potential violence. A nursing note dated 2/15/25 at 1131 (11:31 AM), states, “...Refused AM [morning] medication ...All staff on board and security was called for assistance; patient was in social area, redirected [patient] to [his/her] room [and the patient] was medicated with Haldol, Ativan, and Benadryl IM. Few minutes after patient came out of the room and assaulted charge nurse, and [nurse] fell on the floor, and patient continue (sic) to hit [him/her] til [until] male staff intervened. Patient remains aggressive and agitated, started to fight male staff, [patient] was taken to quiet room and placed in restraint. Writer asked patient why [he/she] attacked staff, patient stated [he/she] revenged because [he/she] was forced to be medicated.” A provider note dated 02/15/25 at 1046 (10:46 AM), states, “Patient received PRN Haldol 5mg, Ativan 2mg, Diphenhydramine 50mg IM with help of security at 10:36 AM. During medication, [he/she] was actively yelling at nurses and threatening to fight. Patient came out of [his/her] room, ran in corridor, grabbed the nursing staff from [his/her] back and hit [him/her], punched [him/her] as per nursing staff. Nursing staff fell to the ground. Other nursing staff reached for help, found nursing staff bleeding from [his/her] nose. Security was called, Bandit (emergency response) team was called to secure bleeding. Nursing staff was taken to the ER. Patient posing a significant risk to the physical and psychological health, and safety of the individual and staff. Non-physical interventions were attempted. Due to imminent risk of the individual physically harming themselves or others, the patient was restrained. Patient restrained at 11:00 am using 4-point restraints for 4 hours. Patient to be reevaluated for the necessity of continued restraints every 30 minutes. ... .” A “Psychiatry Progress Note” dated 02/15/25 at 2:19 PM, states, “... Discharge to police custody today ... Pt to follow up with infirmary/psychiatrist in jail ...Discharge instructions for follow-up were provided as follows: [name of facility] walk in clinic upon discharge from police custody. ...” A “Clinical Note” dated 02/15/25 at 1:21 PM, states, “To Whom it May Concern: Re: Psychiatric Evaluation of [name of patient] ...This is to inform that the above patient was seen and evaluated at [name of hospital.] No need for inpatient psychiatric care at present time. Patient can follow up with mental health services in prison. Recommend to go to infirmary in jail. ... .” The patient was discharged to police custody on 02/15/25 at 2:14 PM. On 02/25/25 at 10:40 AM, the medical record was reviewed with S9, who confirmed that the P1 exhibited numerous acts of aggression towards staff including an assault on staff in the ED resulting in CRT and Code Yellow prior to the patient attacking a nurse on 02/15/25. S9 explained that CRT response and Code Yellow are “the same code depending on the hospital unit. Code Yellow is called on the BHU and CRT is for all of the other units including the ED.” When asked what interventions were implemented to manage the patient’s behavior before [he/she] became aggressive, S9 stated, “I am familiar with this patient. [He/She] was manipulative and demanding. I tried to get [him/her] what [he/she] wanted to appease [him/her.] I’d consider the patient a psychopath.” On 02/25/25 at 11:30 AM, S9 confirmed that the P1 exhibited numerous acts of aggression towards staff which included assaulting staff in the ED prior to the patient physically assaulting and injuring a nurse on 02/15/25. S9 confirmed that no additional safety measures were implemented to ensure the safety of patients and staff on the BHU despite documented acts of aggression towards staff while P1 was admitted on the BHU.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47131 Based on medical record review, staff interviews, and review of facility policy, it was determined the facility failed to ensure that all non-violent restraints are implemented in accordance with the physician’s order in one of four medical records reviewed (MR1). Findings include: On 01/28/25 during a review of Patient (P)1’s medical record, in the presence of Staff (S)4 (Patient Safety Manager), and S12 (Assistant Director of PCU [Progressive Care Unit]), the following was revealed: A nursing note written on 1/21/2025 by S28 (Registered Nurse [RN]) stated, “0745 (7:45 AM)-While receiving report, patient noted to be agitated pulling on chest leads ... [name, S28], RN bedside attempting to verbally de-escalate patient. ...patient began screaming not to touch [him/her] and became increasingly more agitated and aggressive. When asked if patient would return to bed, patient lunged at RN. Crisis called. Night RN and writer followed patient from a distance around unit, until meeting security in the elevator lobby. When security attempted to redirect patient, patient shoved security guard. Security physically restrained patient and escorted patient back to room. Patient placed back in bed and put in soft restraints. IM (intramuscular) Geodon (antipsychotic medication prescribed for symptoms of acute agitation) given as per MD (medical doctor) order. Patient placed back on central monitor, vitals noted to be stable.” The restraint order written by S26 (MD) on 1/21/25 at 0744 (7:44 AM), stated, “Restraints Non-Violent/Non-Self Destructive (Discontinued) ... Reason for Restraints: Pulling on Medical Devices; Response and Reaction of the Patient: Agitated; I have conducted a face to face assessment within 1 hour of initiation of restraint: Yes; Use of Restraints clinically appropriate: Yes; Less restrictive measures as indicated on restraint/seclusion flowsheet, attempted and unsuccessful: Yes; Type of Restraint: Non-Violent Restraint L (left) Wrist, Non-Violent Restraint R (right) ankle, Non-Violent Restraint R Wrist.” Review of the ‘Restraints Flowsheet’ in MR1 stated, “01/21/25 0800 (8:00 AM); Type of Order: 24 hours (Non-Violent); MD Notified: Yes; Order Obtained: Yes; Less Restrictive Alternative Prior to Restraint: Verbal De-Escalation; Clinical Justification: Danger to Others; Visual Check: Yes; Signs of Injury: No; Need for Continued Restraints: Yes; Non-Violent Restraint R Wrist: START; Non-Violent Restraint L Wrist: START.” The medical record lacked documentation in the restraint flowsheet that Non-Violent Restraint was applied to the patient’s right ankle per the order written by S26. Upon interview, when asked if P1’s right wrist, left wrist, and right ankle were placed in restraints on 01/21/25, S12 stated, “No, P1 was placed in 2-point non-violent restraints (right and left wrist only). We [PCU] do not allow anything more than that-there is no such thing as 3-point restraints (right wrist, left wrist, and right ankle). 4-point restraints (both wrists and both ankles) are considered ‘Violent Restraints’ which the unit does not permit. I do not know why S26 wrote the order for Non-Violent Restraints to be placed on the patient’s R ankle.” When asked if the restraint order should have been discontinued and an order for Non-Violent Restraints for the Right and Left wrist entered, S12 stated, “Yes.” On 01/28/25 at 1:05 PM, S4 and S12 confirmed that the orders in MR1 for Non-Violent Restraints to be placed on P1’s right wrist, left wrist, and right ankle on 01/21/25 was incorrect. S12 confirmed the medical record lacked an order for the patient to be placed in 2-point non-violent restraints. A review of the facility policy titled, “Use of Restraints and Seclusion” (Issued March 2023), the policy did not address the type of restraints to be applied to a patient’s extremities, for non-violent restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 47131 Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that a 1-hour face-to-face assessment is conducted and documented for patients placed on non-violent restraints in one of four medical records reviewed (MR1). Findings include: Facility policy titled, “Use of Restraints and Seclusion” (Issued March 2023) stated, “ ... Orders: A. Restraints and/or can be initiated as follows: 1. An individual written order by the LP (Licensed Practitioner); or 2. An RN (Registered Nurse) in response to an unanticipated or emergent situation a. The RN must immediately notify and consult with the LP after placing patient in restraints and/or seclusion. ... B. The LP will: 1. Conduct and document face-to-face assessment within one (1) hour of restraint placement ...” On 1/28/25, during the review of P1’s medical record, in the presence of Staff (S)4 (Patient Safety Manager) and S12 (Assistant Director of PCU [Progressive Care Unit]), the following was revealed: On 1/21/25 at 7:44 AM, S26 (Medical Doctor) order for restraint indicated, “Restraints Non-Violent/Non-Self Destructive ... Reason for Restraints: Pulling on Medical Devices; Response and Reaction of the Patient: Agitated; I have conducted a face to face assessment within 1 hour of initiation of restraint: Yes; Use of Restraints clinically appropriate: Yes; Less restrictive measures as indicated on restraint/seclusion flowsheet, attempted and unsuccessful: Yes; Type of Restraint: Non-Violent Restraint L (left) Wrist, Non-Violent Restraint R (right) ankle, Non-Violent Restraint R Wrist.” Upon interview, S12 confirmed that the restraint order written by S26 documented that a face-to-face assessment was completed, however the MR lacked any details of the face-to-face assessment or provider note. A CRT (Crisis Response Team) Note, documented by S26 on 1/21/25 at 7:54 AM, stated, “CRT with behavioral health doctor was called on this patient at approximately 7:33 am because patient was getting out of bed, taking [his/her] clothes off, and attempting to leave. When writer arrived to room, patient was being restrained. Patient was calm after restraints but did not answer questions appropriately. [He/She] did not appear to understand questions and was repeatedly speaking about [his/her] mother. Patient had difficult forming sentenced and repeated [himself/herself] several times. Primary team was not present, so writer ordered Geodon (an antipsychotic medication prescribed for symptoms of acute agitation) 10mg IM once for agitation. ...” The medical record for P1 lacked documentation that S26 completed the face-to-face assessment within one (1) hour after P1 was placed in restraints and medicated with Geodon at 7:44 AM. In accordance with the facility’s restraint policy, P1 should have received a face-to-face assessment from a provider by 8:44 AM on 01/21/25. The patient was next assessed at 11:09 AM by S27 (MD, Attending Physician, Neurology Department.) On 1/28/25 at 1:10 PM, upon interview, S4 and S12 confirmed MR1 lacked documentation that a provider completed a face-to-face assessment within one hour of restraint placement as per facility policy.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 33557 Based on observation and staff interview conducted on 6/5/24, it was determined that the facility failed to ensure the hospital is maintained for the safety of patients in accordance with the 2012 edition of the National Fire Protection’s Life Safety Code (A0710). Findings include: Cross Reference 42 CFR 482.41(b)(1)(12)(3) - Life Safety from Fire”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 33557 Based on observations and staff interview conducted on 6/5/24, it was determined that the facility failed to ensure doors protecting corridors and hazardous areas are maintained to resist the transfer of smoke or fire in accordance with the 2012 edition of the National Fire Protection’s Life Safety Code. Findings include: Reference: National Fire Protection Association’s Life Safety Code, 2012 edition, 101:8.5.4.3 “Latching hardware shall be required on doors in smoke barriers . . .” Reference: National Fire Protection Association’s Standard for Fire Doors and Other Opening Protective’s, 2013 edition, 80:5.2.3.5.2 “(1) Labels are clearly visible and legible.” Reference: National Fire Protection Association’s Life Safety Code, 2012 edition, 101:8.5.4.1 “Doors in smoke barriers shall close the opening . . . “ Reference: National Fire Protection Association’s Life Safety Code, 2012 edition, 101:19.3.6.3.10 “Doors shall not be held open by devices other than those that release when the door is pushed or pulled.” During a tour of Floor-A on 6/5/24 at 11:30 AM in the presence of Staff (S)9, the Manager of Access Control, the 90-minute fire rated doors separating the Cargo Elevator Lobby from the Corridor was missing latching hardware. S9 confirmed this finding at the time of observation. During a tour of Floor-A at 11:57 AM in the presence of S9, the fire rated door outside room A132 does not self-close and latch. The fire rating for this door was unknown due to the label being painted over. S9 confirmed this finding at the time of observation. During a tour of Floor-C at 12:24 PM in the presence of S9, the ¾ hour smoke barrier doors near Room C234 did not close completely. S9 confirmed this finding at the time of observation. During a tour of Floor-C at 12:30 PM in the presence of S9, the ¾ hour fire rated door outside Room C360 is held open by a scrap piece of metal wedged between the bottom of the door and the floor. S9 confirmed this finding at the time of observation. During a tour of Floor-E at 12:48 PM in the presence of S9, the double doors separating the Operating Room Suite from the Corridor were splitting apart down the middle edge of the door and not fully closing. S9 confirmed this finding at the time of observation. During a tour of Floor-F at 12:56 PM in the presence of S9, the Cross-Corridor ¾ hour fire rated doors separating Inpatient Unit Blue from the Corridor did not close fully from the open position. S9 confirmed this finding at the time of observation. During a tour of Floor-F at 1:10 PM in the presence of S9, the two (2) ¾ hour fire rated door between the Corridor and FICN Unit were held open by air pressure from the air conditioner unit pushing air through the corridor creating wind which is preventing the cross-corridor doors from fully closing. S9 confirmed this finding at the time of observation. During a tour of Floor-H at 1:18 PM in the presence of S9, the ¾ hour fire rated door between inpatient unit Blue H and the public corridor near the elevators did not fully close and latch. S9 confirmed this finding at the time of observation. During a tour of Floor-A at 11:48 AM in the presence of S9, the Loading Dock doors separating the loading dock from the main hospital corridor do not close and positively latch. S9 confirmed this finding at the time of observation. During a tour of Floor-B at 12:02 PM in the presence of S9, the 90-minute fire rated door separating the Kitchen from the Corridor does not positively latch. S9 confirmed this finding at the time of observation.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 33557 Based on observation and staff interview on 6/5/24, it was determined that the facility failed to ensure hazardous areas are protected to resist the passage of smoke or fire. Findings include: During a tour of Floor-A at 11:48 AM in the presence of Staff (S)9, the Manager of Access Control, it was observed that the Loading Dock doors, separating the loading dock from the main hospital corridor, do not close and positively latch. S9 confirmed this finding at the time of observation. During a tour of Floor-B at 12:02 PM in the presence of S9, the 90-minute fire rated door separating the Kitchen from the Corridor does not positively latch. S9 confirmed this finding at the time of observation. During an interview at 12:33 PM, S9 stated, “I have the parts to fix most of these doors. I am just waiting on the go ahead to shut down areas to do the work.””

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 33557 Based on observations and staff Interview on 6/5/24, it was determined that the facility failed to ensure doors protecting corridors are maintained to resist the transfer of smoke or fire. Findings include: During a tour of Floor-A at 11:30 AM in the presence of Staff (S)9, the Manager of Access Control, the 90-minute fire rated doors separating the Cargo Elevator Lobby from the Corridor was missing latching hardware. S9 confirmed this finding at the time of observation. During a tour of Floor-A at 11:57 AM in the presence of S9, the fire rated door outside room A132 does not self-close and latch. The fire rating for this door is unknown due to the label being painted over. S9 confirmed this finding at the time of observation. During a tour of Floor-C at 12:24 PM in the presence of S9, the ¾ hour smoke barrier doors near Room C234 did not close completely. S9 confirmed this finding at the time of observation. During a tour of Floor-C at 12:30 PM in the presence of S9, the ¾ hour fire rated door outside Room C360 is held open by a scrap piece of metal wedged between the bottom of the door and the floor. S9 confirmed this finding at the time of observation. During a tour of Floor-E at 12:48 PM in the presence of S9, the double doors separating the Operating Room Suite from the Corridor were splitting apart down the middle edge of the door and not fully closing. S9 confirmed this finding at the time of observation. During a tour of Floor-F at 12:56 PM in the presence of S9, the Cross-Corridor ¾ hour fire rated doors separating Inpatient Unit Blue from the Corridor will not close fully from the open position. S9 confirmed this finding at the time of observation. During a tour of Floor-F at 1:10 PM in the presence of S9, the two (2) ¾ hour fire rated door between the Corridor and FICN Unit were held open by air pressure preventing these doors from resisting the passage of smoke. S9 confirmed this finding at the time of observation. During a tour of Floor-H at 1:18 PM in the presence of S9, the ¾ hour fire rated door between inpatient unit Blue H did not fully close and latch. S9 confirmed this finding at the time of observation. During an interview at 12:33 PM, S9 stated, “I have the parts to fix most of these doors. I am just waiting on the go ahead to shut down areas to do the work.””