Presbyterian Hospital

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 53173 Based on interviews and observation, the facility failed to ensure any medical staff providers (Medical Doctors, Doctors of Osteopathy, Nurse Practitioners, Physician Assistants, etc.) had adequate training on how to set-up and adjust ventilators (a machine that helps a patient breathe or breathes for them), bi-pap (non-invasive ventilation that helps a patient breathe), or high-flow machines (heated humidified air delivered at high pressure through nasal prongs) to provide care to meet patient needs. This deficient practice could lead to delays in care and potential patient harm because medical staff cannot operate medical equipment. A. During an interview on 09/03/25 at 2:15 pm with S(Staff)14, non-clinical and S(Staff)15, non-clinical, it was confirmed that competency training on respiratory equipment such as ventilators, bi-pap, and high-flow machines was not required by the facility for medical staff personnel. B. During an interview on 09/02/25 at 3:15 pm with S(Staff)8, clinical, it was stated “I am not trained to set up a machine [referring to a ventilator].” C. During an interview on 09/02/25 at 4:36 pm with S14, non-clinical, it was reported that only one employee from the facility attended the seminar titled “Current Concepts in Mechanical Ventilation”, presented on July 25, 2025. The employee is a respiratory therapist, not a medical provider. D. During an observation on 9/4/25 at 2:00 pm, the facility was unable to produce competency validation checklists or other education documentation pertaining to ventilators, bi-pap, or high-flow machines for any medical provider on staff.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 53173 Based on observation and record review, the facility failed to ensure that 2 out of 2 ventilators (machines which help patients breathe or breathes for them) and 1 out of 1 bronchoscope (a thin tube used in a bronchoscopy procedure used to examine an airway) were inspected, tested, and maintained within their scheduled time periods to ensure performance, quality, and safety. This deficiency can lead to delays in care and potential patient and staff harm from potentially improperly functioning equipment. A. During observation on 09/02/25 at 2:53 pm, the ventilator in the supply closet was found to be without a biomed sticker (a mandatory safety and inspection label for medical equipment). B. During observation on 09/02/25 at 2:55 pm, the ventilator in the patient care area had an expired biomed sticker dated February, 2025. C. During observation on 09/02/25 at 2:57 pm, the single available bronchoscope in the facility had an expired biomed sticker dated August, 2025. D. Record review of the facility’s policy 02/22/25 “PHS Medical Equipment Management Plan 10” states: a. “The Hospital identifies high risk medical equipment on the inventory for which there is risk of serious injury or death to a patient or staff member should equipment fail.” (page 3). b. identifies ventilators as an example of High Risk equipment (page 3).”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 53173 Based on record review, the facility failed to ensure staff roles and responsibilities are specified in writing, either through job descriptions or policy, when supporting patient respiratory needs via ventilator (a machine that helps a patient breathe or breathes for them), bi-pap (non-invasive ventilation that helps a patient breathe), or high-flow machines (heated humidified air delivered at high pressure through nasal prongs). This can lead to delays in care and potential patient harm because staff cannot operate medical equipment. A. Record review of facility’s policy 10/27/23 “ED.PDS.016 Registered Respiratory Therapist Guidelines for Care in the Emergency and Urgent Care Department” does not specify respiratory therapist responsibility for ventilator, bi-pap, or high-flow machines. B. Record review of facility’s policy 12/20/22 “PUL.PDS.106 Ventilator Management” under “Therapist Responsibility,” it only specifies documentation responsibilities. It does not designate a responsibility to set up, monitor, or adjust ventilator settings. C. Record review of facility’s policy 04/25/25 “PC.PDS.288 Paramedic Guidelines for Care in The Emergency and Urgent Care Department” refers to “CPAP/BIPAP Monitoring” in Addendum B. The policy does not delineate paramedic responsibility to set up ventilators, bi-pap, or high-flow machines or to monitor a ventilator or high-flow machine. D. Record review of facility’s policy 04/21/25 “NSG.PDS.138 Emergency Department Nursing Guidelines for Care” does not delineate any nursing responsibility for either set up or monitoring of ventilators, bi-pap, or high-flow machines. E. Record review of the facility’s job description for a respiratory therapist describes ventilator management only. It does not specify ventilator setup, or setup/monitoring of bi-pap and high-flow machines. F. Record review of the facility’s job descriptions for EMT-P (emergency medical technician-paramedic), charge registered nurse, registered nurse, and licensed practical nurse do not delineate responsibilities to setup or monitor ventilators, bi-pap, or high-flow machines.”

“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: 47302 Based on record review and interview the facility failed to ensure patient’s received care in a safe setting for 3 (P[Patient] 5, P6, P10) out of 6 patients (P5-P7, and P10-P12) reviewed for receiving services at the hospital when staff failed to: 1. Monitor vital signs and pain for patient seeking care in the emergency department for P10. 2. Bathe P5 and P6. These deficient practices could lead to patients not receiving the care they need at the hospital such as hygiene services and vital sign monitoring. The findings are: Facility failed to monitor patients A. Record review of the facility’s policy titled, “Emergency Department Nursing Guidelines for Care” dated 09/17/2024 on page 3 under “Vital Signs” it stated, “Vital Signs frequency is based on the ESI [Emergency Severity Index, system used to triage patients] score assigned, or more frequently as patient condition warrants. This includes patients in the lobby. 3.1.1. ESI 1: frequency based on the severity of patient’s condition 3.1.2. ESI 2: every 1 - 2 hours 3.1.3. ESI 3: every 2 - 3 hours 3.1.4. ESI 4 and 5: every 3 - 4 hours 3.1.5. Within 30 minutes of discharge/transfer from the ED [Emergency Department]”. B. Record review of P10’s electronic medical record for the visit date 08/12/2024 revealed the following: 1. Vital sign flowsheets dated 08/12/2024, indicated P10’s vital signs were checked at 11:16 AM. Pain assessment with a rating of 0 (no pain) was charted at 11:16 AM and at 8:34 PM. The medical record contained only one set of vital signs and one pain assessment completed while patient was in the emergency department. 2. Medications administered on 08/12/2024 revealed that patient was given lorazepam (medication given for anxiety) 2 milligrams at 11:57 AM, fentanyl (medication given for pain) 25 micrograms at 11:53 AM, fentanyl 25 micrograms at 12:33 PM, and naloxone (medication given to reverse pain medication) 2 sprays at 1:00 PM. 3. Patient was transferred out of the emergency department at 6:50 PM and admitted to the hospital. C. During an interview on 11/06/2024 at 3:30 PM with S (staff) 18, non-clinical, it was explained that vital signs are monitored regularly based on the patient’s condition. S18 explained that pain assessments should be done before and after pain medications. Facility failed to ensure patients were bathed: D. Record review of the facility’s policy titled, “Nursing Guidelines’s for Care - Adult Medicine/Surgical” dated 04/29/2024 on page 3 under “Dependent Care Related Measures” stated, “Assistance with complete bath or shower is offered and documented in the patient’s EMR [electronic medical record] at least once every 24 hours.” E. Record review of P5’s medical record for the hospital stay from 08/06/2024 through 08/12/2024 in the daily care flowsheets, staff did not document that a bath or shower was provided. F. Record review of P6’s medical record for the hospital stay from 08/06/2024 through 08/12/2024 in the daily care flowsheets, staff did not document that a bath or shower was provided. G. During an interview on 11/5/2024 at 3:00 PM S(Staff)5 confirmed there were no baths documented for P5 and P6.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47302 Based on observation, record review, and interview the facility failed to ensure staff were following the hospital’s policies and procedures to provide patients baths and monitoring patient’s pain and vital signs while in the hospital for 5 (P[Patient] 5, P6, P10, P13, and P14) out of 8 patients (P5-P7, and P10-P14) reviewed for receiving services at the hospital. This deficient practice could lead to an increased risk for skin breakdown, increased infection rate, lack of basic hygiene and lack of monitoring for all admitted patient in the facility. The findings are: A. Record review of the facility’s policy titled “Nursing Guidelines for Care” effective date 04/29/2024, under the heading “Hospitals,” number 4. “Dependent Care Related Measures,” section 4.1 and section 4.2 stated the following: 1. Section 4.1 “Assistance with complete bath of shower is offered and documented in the patient’s EMR [electronic medical record] least once every 24 hours.” 2. Section 4.2 “A partial bath is administered and/or offered as appropriate to the patient or situation (e.g. incontinence, semi-independent patient) and documented in the patient’s EMRa lease once every 24 hours.” B. Refer to Tag A-144 C. During an observation on the adult inpatient unit on 11/05/24 at 1:52 pm, P13 laid in bed with uncombed hair and a hospital gown that appeared unclean. D. During an observation on the adult inpatient unit on 11/05/24 at 2:07 pm, P14 laid in bed appearing disheveled with uncombed hair. E. Record review of a bath log was found at the nurse’s station on a clip board was noted not to have any patient showers or baths entered as completed for the day. F. During an interview on 11/05/24 at 1:52 pm with P13, patient stated he/she had not received or had been offered a bath or shower for several days. G. During an interview on 11/05/24 at 2:07 pm with P14, patient stated he/she had not been offered bath or shower for five days. H. During an interview with S(staff)11, clinical on an adult inpatient unit on 11/05/24 at 1:17 pm, S11 stated that patients are offered a shower or bath every shift with documentation of this hygiene entered into the patient’s EMR as well as documented on a bath log sheet which is kept at the nurses’ station on a clip board. 50656”

“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: 47302 Based on observations, record review and interview the facility failed to meet the Statutory Requirements to conspicuously post appropriate EMTALA (Emergency Medical Treatment and Labor Act) signs, failed to have an on-call list that covered all services that may be needed, failed to provide appropriate medical screenings, failed to provide stabilizing treatment and failed to obtain informed consent for transfer. The deficient practice could possibly lead to patients not receiving necessary medical care and not understanding the risks of refusing medical care. The findings are: A. Failed to provide a medical screening exam for patients presenting to the hospital for behavioral health concerns. Refer to tag 2406. B. Failed to provide stabilizing treatment and did not explain risks of refusing treatment. Refer to tag 2407.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 47302 Based on observation and interview the facility failed to post signage informing patients of their rights presenting to the emergency department through the ambulance bay. This deficient practice can lead to patients not being aware of their rights as a patient in the emergency department. The findings are: A. During an observation on 08/20/2024 at 12:00 PM in the ambulance bay where patients are brought into the emergency department a sign was not posted that informed patients of their right to be seen for any emergency condition per EMTALA (Emergency Medical Treatment and Labor Act) regulations. B. During an interview on 08/20/2024 at 12:00 PM with S(Staff)2, non-clinical, confirmed that there should be a sign posted in the ambulance bay.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to have a process in place to cover necessary services when an on-call provider is not available for 1 (P[patient]1) out of 20 (P1-P20) patients that presented to the emergency department seeking medical care. This deficient practice could possibly lead to patients not receiving the care they need when presenting to the emergency department. The findings are: A. Record review of the facility’s document titled, “On-Call Assignments” for the date range 02/21/2024-08/26/2024 revealed that a psychiatric provider was not on call from 08/06/2024 at 5:00 PM to 08/07/2024 at 8:00 AM. B. Record review of P1’s “ED [emergency department] Provider Note” for visit date 08/06/2024 revealed P1 presented to the emergency department with a psychiatric complaint of being homicidal and reported that he was suicidal to the provider. The medical record did not contain any evidence that a psychiatric provider was consulted. C. During an interview on 08/21/2024 at 11:00 AM with S(Staff)3, clinical, it was explained that psychiatric providers are not available to the emergency department at night and patients would have to wait until the next day to get services. D. During an interview on 08/21/2024 at 4:28 PM with S4, clinical, it was explained that a psychiatric provider should be available to consult with the emergency department physician at night.”

“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: 47302 Based on record review and interview the facility failed to provide an appropriate medical screening exam for 1 (P[patient]1) out of 20 (P1-P20) patients reviewed for seeking emergency care. This deficient practice could possibly lead to patient’s medical conditions being untreated, resulting in harm. The findings are: A. Record review of the facility’s policy titled, “Medical Screening Exam EMTALA [Emergency Medical Treatment and Labor Act]” dated 03/05/2021 under “Policy” stated, “Any patient who comes to the hospital requesting emergency services is entitled to and will receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists.” On page 3, under, “D. How to Provide the Medical Screening Examination” stated, “. . . 4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient’s chief complaint, with the intent to determine the presence or absence of an emergency medical condition. 5. A hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the hospital for examination and treatment. . . . 10. If the Medical Screening Examination indicates that the individual has an Emergency Medical Condition, he or she must be given such further examination and treatment as required to stabilize the medical condition within the staff and facility capabilities available in the hospital or appropriately transfer the individual. On page 7 under “Definitions” stated “Emergency Medical Condition means: (i) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (A) Placing the health of the individual. . . in serious jeopardy. . .” B. Record review of the facility’s policy titled, “Patient Suicide Risk Prevention” dated 06/26/2023 under, “Purpose” stated, “This policy enhances patient safety by establishing guidelines to ensure that patients who are being seen with a primary diagnosis or complaint of an emotional or behavioral disorder are managed safely.” On page 2, under “Procedure” stated, “. . .2.5.2. Risk Level Minimal [low]: 2.5.2.1. Provider monitors and re-assesses as clinically indicated and treat as usual. 2.5.2.2. Consider safety precautions if indicated by professional judgement and on-going assessment. . .2.5.4. Risk Level High: 2.5.4.1. Ensure the patient is monitored and environment is safe. 2.5.4.2. Patient placed on 1:1 observation. 2.5.4.3. Complete room safety checklist. 2.5.4.4. Implement Safety Interventions in section 5. 2.5.4.5. The nurse or clinical designee who has initial contact with the patient ensures that the patient’s immediate environmental safety needs are addressed...” On page 4 under “Provider Assessment” stated, “The provider determines and documents the appropriate risk for the patient and may choose to escalate or deescalate suicide precautions by adding or removing orders as needed for the safety of the patient. 3.3. The provider assessment is accomplished by the use of a validated tool or validated process. . . 3.4. The assessment includes directly asking about: 3.4.1. Suicidal ideation 3.4.2. Plan 3.4.3. Intent 3.4.4. Suicidal or self-harm behavior (i.e.: eating/swallowing non-food Items) 3.4.5. Risk Factors 3.4.6. Protective Factors” On page 5 under “Discharge Planning” it stated, “6.1. Prior to discharge, the physician, the physician’s designee, or discharge planners meet with the patient to identify the patient’s post-discharge plan of care. The post discharge plan of care includes informing the patient, the patient’s family members, and/or significant others (as appropriate) about how to deal with crisis situations. The patient, patient’s family members, and/or significant others (as appropriate) are given the phone number to the National Suicide Prevention Lifeline hotline, at 1-800273-TALK, as well as other local resources they should use, as determined by the patient’s physician. 6.2. Patients are scheduled for follow-up visits with their Primary Care Physician, and/or a Behavioral Health clinic/professional.” C. Record review of facility’s policy titled, “Detaining Criminal Suspects” dated 2/15/2023 under “Responsibilities” it is stated, “. . . A Security Officer will remain with subject until the appropriate law enforcement agency arrives and never lose visual observation of the detainee. . . A subject may only be detained for a reasonable amount of time. If the detention period exceeds 2 hours, a hospital manager or security on-call manager will be contacted to determine if immediate release is appropriate, or if extenuating circumstances will warrant an extension of time. If law enforcement does not arrive within the two-hour detention, the subject may be let go and this will be documented in the Security Officer’s report.” D. Record review of P1’s medical record for emergency department visit dated 08/06/2024, arrival time 10:19 PM, revealed the following: 1. Review of P1’s “ED [emergency department] Provider Note” for visit date 08/06/2024 revealed P1 presented to the emergency department with a psychiatric complaint of being homicidal and reported that he was suicidal to the provider. Under “Medical Decision Making” it stated, “. . . Prior to my evaluation of patient, he punched an EMS [emergency medical services] worker who was transferring another patient in the room next to him. . . [Patient] is reporting auditory and visual hallucinations. States that the voices are telling him violent things and that they will hurt him and steal his money. . . He would like to go back to jail because he states that he feels more safe there then out in public. He states that ‘if I am in public, I will kill myself.’ Patient will be discharged to [police] custody and I do recommend a [behavioral health] evaluation while in custody.” 2. P1 had a suicide screening done on 08/06/2024 at 10:41 PM and was scored as “Low Risk.” P1’s medical record did not contain any evidence that P1 received a psychiatric medical screening, after P1 reported suicidal ideations a suicide screening was not done. 3. P1’s discharge instructions stated, “[Patient] will be discharge to [Name of Police department] custody after hitting EMS worker. Please have behavioral health evaluate this while in custody.” Patient was discharged on 08/06/2024 at 11:41 PM. There was no psychiatric evaluation prior to discharge. There is no evidence that patient’s family was notified of discharge. E. Record review of facility incident log revealed an incident dated 08/06/2024 involving P1the comments stated, “. . . [P1] was escorted from [locked behavioral health unit] to [conference room] following the incident. [P1] remained in handcuffs while waiting for [police] to arrive to take patient into custody. . . [P1] stayed in security custody until the two-hour time limit approached. [P1] was escorted out the [conference] room to the edge of property. [P1] was released from custody and was advised he is free to go. [P1] stated he wanted to go to jail. [P1] was advised he is more than welcome to wait for [police] to arrive. [P1] walked back to the Emergency Department and used the phone in the lobby. [P1] hung up the phone and walked out the lobby. . .” F. Record review of police report narrative dated 08/07/2024 at 1:34 AM regarding P1 stated, “Upon arrival, I was advised by [name of paramedic] with [name of ambulance company] that the pedestrian involved was deceased [2:15 AM]. I spoke with the driver of vehicle one who stated he was traveling west on [street name]. . . As he was approaching [address and name of business near hospital] he observed the pedestrian approximately 15 feet in front of him. The pedestrian was halfway in the roadway before leaping in front of vehicle as it was about to pass. I then spoke with security who work at [hospital address and name] who advised me that the pedestrian involved in the traffic accident does have a history of behavioral health issues. . .” G. During an interview on 08/20/2024 at 10:45 AM with S(Staff)2, non-clinical, stated the current process for patients that are presenting with a psychiatric emergency is for the emergency department provider to make the call on whether to discharge and document their rationale. They are working on a new process since the incident with P1. S2 explained that if the patient needs to be discharged to law enforcement, then security will hold them for two hours. Facility was unable to show evidence of corrective actions. H. During an interview on 8/20/2024 at 2:30 PM with S6, non-clinical, S6 explained that patients who have been discharged to police custody will be detained for 2 hours and then released. S6 explained that since these patients are already discharged, they would not check in with hospital staff prior to releasing them. I. During an interview on 08/21/2024 at 4:30 PM with S5, clinical, confirmed that a patient stating they have suicidal ideations would be considered a high suicide risk. When asked about the use of a “psychiatric hold” (involuntary mental health hospitalization if a patient is a danger to themselves or others) for such patients, S5 explained that a “psychiatric hold” was not used in the emergency department. S5 was asked about the discharge of P1 prior to a psychiatric evaluation and S5 explained that P1 was to be detained by security until the cops arrived. S5 was not aware that patient would be released after two hours and was not alerted prior to security releasing P1.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to provide stabilizing treatment for patients that present to the emergency department with a behavioral health crisis for 1 (P[patient]P2) out of 20 (P1-P20) patients reviewed for presenting to the emergency department. These deficient practices could possible lead to patients in a behavioral health crisis not receiving the necessary care and could lead to patient harm and/or death. The findings are: A. Record review of the facility’s policy title, “EMTALA [Emergency Medical Treatment and Labor Act] Stabilization” dated 03/05/2021 stated, “Purpose: To ensure that all patients determined to have an emergency medical condition shall be stabilized as required under Emergency Medical Treatment and Active Labor Act (EMTALA). Policy: Patients being transferred or discharged will be stabilized as required under EMTALA. Procedure: . . . 3. For patients whose emergency medical condition has not been resolved, the determination of whether they are medically stable may occur in one of the following two circumstances: a. Stable For Transfer - A patient is stable for transfer from one facility to a second facility if the treating physician has determined within reasonable clinical confidence that the patient is expected to leave the hospital and be received at the second facility with no material deterioration in his/her medical condition and the treating physician reasonably believes that the receiving facility has the capability to manage the patient’s medical condition and any reasonably foreseeable complication of that condition. i. For purposes of transferring a patient with a psychiatric condition between facilities, the patient is considered to be stable when he/she is protected and prevented from injuring himself/herself or others. b. Stable For Discharge - A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic workup and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. For purposes of discharging a patient with a psychiatric condition, the patient is considered to be stable when he/she is no longer considered to be a threat to him/herself or to others. . . .” B. Refer to tag 2406 for finding related to policy on medical screening. C. Record review of P2’s medical record for emergency department visit on 08/03/2024 revealed the following: 1. Review of P2’s “ED Provider Note” for visit date 08/03/2024 at 4:04 PM revealed that patient (P2) presented after a suicide attempt and was diagnosed with overdose and altered mental status. Under “Medical Decision Making” it stated “. . . Here there is concern for overdose. Patient is a poor historian, but has some statements that are concerning for intentional overdose. . . It sounds like she [P2] was seen yesterday for similar symptoms of polypharmacy [when a patient takes several medications a day that can cause harmful drug interactions and increased side effects such as sedation] and drug overdose, at that time they [the previous hospital] let her go home. . . I do have discussion with our clinical liaison with behavioral health who agrees that patient is a poor candidate for just psychiatric assessment, recommends medical admission for further management, treatment and assessing polypharmacy, and states that [staff name] can follow for further inpatient psychiatric assessment while admitted.” 2. On 08/04/2024 at 5:34 AM the note was updated with this statement, “Patient [P2] is verbally abusive to staff members. Patient would like to go home. She is alert and oriented x 3 [scale used to state patient know name, date of birth, and time]. No delirium [confusion] She has no suicidal or homicidal ideation. She lives with her daughter. Will call her daughter to pick her up.” There was no psychiatric evaluation or evidence that patient’s discharge was discussed with the behavioral health liaison. 3. The patient was discharged on 08/04/2024 at 5:35 AM. 4. The patients “After Visit Summary” for visit on 08/03/2024 stated, “Instructions Please avoid taking excessive amounts of benzodiazepines. Continued use can lead to serious bodily harm or even death. Follow-up with your primary care provider and return to the hospital with any concerns.” The After Visit Summary did not contain any evidence of medication adjustments based on identified concerns. D. During an interview on 08/21/2024 at 4:28 PM with S4, clinical, it was confirmed that a patient presenting with homicidal ideations, suicidal ideations or hallucinations would warrant a psych consult. E. During an interview on 08/22/2024 at 10:06 AM with S3, clinical, it was explained that the facility does not have a “psychiatric hold” (involuntary mental health hospitalization if a patient is a danger to themselves or others) if needed the behavioral health department and the emergency department would communicate that the patient is involuntary.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49844 Based on record reviews and interviews, the facility failed to obtain written consent for treatment for 1 patient (P[patient] 2) of 10 patients (P1-P10) being reviewed for appropriate consent. This failed practice can lead to a violation of patient rights due to the lack of informed consent for treatment from the patient or the patient’s legal guardian. These findings are: A. Record review of the facility’s policy titled “Patient Rights and Responsibilities” dated 02/02/2023 section I-A titled “RIGHTS OF ALL PATIENTS” stated “Patients, or their legally authorized representatives, must be informed of the patient’s right to:. . . . give informed consent prior to receiving treatment and after a clear explanation of the risks, benefits, medical consequences, including potential problems that might occur during recuperation, and alternative treatments.” B. Record review of P2’s electronic medical record revealed that P2 was treated in the Emergency department and admitted to the inpatient unit to receive treatment on 01/27/24 at 11:23 PM. Record review of the Emergency Department Providers note revealed that the patient was alert and oriented and able to provide her own history. The record did not contain a consent for treatment in the patient’s medical record. C. During an interview on 03/20/24 at 1:12 PM, Staff ( S)7, Clinical Accreditation and Regulatory director, S7 stated “There is no consent for treatment for [P2]”. D. During an interview on 03/20/24 at 1:45 PM, with S13, Director of Risk Management, S13 confirmed consent for treatment should be obtained for 100% of patients.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 49844 Based on record review and interview the facility failed to provide necessary stabilizing treatment for 1 (P (patient) 2) of 20 (P1-P20) patients reviewed for stabilizing treatment in the emergency department. This deficient practice of failing to provide stabilizing treatment for a suicidal patient led to the patients death. These findings are: A. Record review of facility’s policy titled “Patient Suicide Risk Prevention” dated 06/26/23 under section 2.5.4 titled “Risk level high” under 2.5.4.2 explained high risk suicide patients should be placed on 1:1 observation (1 observation attendant to one patient). Under section 5.5 it is stated the Patient Observation Attendant (individual providing 1 on 1 observation) “. . . must maintain direct line of sight with the patient at all times.” B. Record review of P2’s medical record revealed: 1. P2 arrived to the emergency department on 01/29/24, at 7:28 AM, and a Suicide Screen (screening to determine if an individual is suicidal) was completed on 01/29/24, at 7:43 AM. Stated under “risk of suicide” was marked “high risk” (patient is at high risk for attempting and/or committing suicide). 2. Under the section “Quick updates” at 4:20 PM stated “pt (patient) (P2) is medically cleared, BH consult placed, pt upset that he is here in ER [emergency room] wants to leave AMA, male charge RN [registered nurse] at pt bedside to explain BH process”. Indicating that P2 made facility staff aware that P2 wanted to leave. 3. P2 had a psychiatric evaluation and under the section “Risk level” states “High - Risk factors are highly prominent and need to be managed intensely”. Indicating that the patient is high risk and requiring management. 4. Under the section “Disposition” states “Unable to determine” under the section “Rationale for Disposition” states “As this CL [clinician] was consulting with the psychiatrist [Name of Dr], I was informed by the ED [emergency department] provider and the ED RN that the pt had eloped from the ED. No final disposition was able to be given” C. Record review of video footage of outside P2’s emergency department (ED) room and ED hallways on 01/29/24, at 6:09 PM, revealed S(staff)4, Patient Observation Attendant did not have the patient in their direct line of sight and was helping a different patient, in the room next to the patients assigned room. D. Record review of the facility’s incident log on 01/29/24, at 7:13 PM, revealed “Patient under suicide hold with sitter at bedside. Despite having sitter at bedside patient eloped from our emergency department” and “. . . the patient was struck by a motor vehicle while outside of the emergency department” E. During an interview with S6, Security manager, on 02/12/24, at 9:15 AM. S6 confirmed that P2 had been hit by a motor vehicle after elopement from the emergency department. F. During a confirmation interview with S5, Patient Observation Attendant, on 02/13/24, at 9:00 AM. S5 confirmed that eyes should be kept on the patient, “At all times.” G. During an interview with S2, Emergency Department Manager, on 02/14/24, at 9:10 AM. S2 confirmed that P2 was out of the direct line of sight of S4 (patient observation attendant) for 4 minutes and 55 seconds. S2 also confirmed that P2 eloped from the emergency department at 6:12 PM, on 01/29/24. S2 stated the expectation of the sitter is, “to be keeping an eye on the patient.” H. Record review of the patients medical record from the outside hospital revealed the patient had presented to the outside hospital Emergency Department on 01/29/24, at 7:31 PM. Under the section titled “History and Physical” explains the patient presented for “peds [pedestrian] vs auto [automobile]”. Under the section titled “History of Present Illness” stated “The patient was transported by EMS [Emergency Medical Services], to [name of outside hospital] where they arrived in critical condition.” Under the section titled “Discharge Summary “ stated the patient was pronounced deceased at 11:02 PM.”

“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: 49835 Based on observation and interview the facility failed to meet the Condition of Participation to maintain a physical environment in a manner that ensures the safety and well-being of patients. This deficient practice could result in the inability for ambulances to access the patients that need transportation in an emergency. The findings are: The facility failed to maintain a physical environment by having the ambulance bay locked and blocked with supplies. Refer to tag A-0701”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49835 Based on record review the facility failed to provide an informed consent for private vehicle transfer for a higher level of care needed for 1 (P (patient)18) out of 13 (P3, P6, P8, P9, P10, P11, P12, P13, P14, P15, P16, P18, and P20) patients being reviewed for informed transfer consent in privately owned vehicles. This deficient practice could possibly lead to the patient transferring to another hospital without having any knowledge of all of the risks involved in the transfer. A. Record review of the facility’s policy titled Patient Rights and Responsibilities dated 02/02/23 stated “Except in emergencies, or when otherwise permitted by law, (patients) give informed consent prior to receiving treatment and after a clear explanation of the risks, benefits, medical consequences, including potential problems that might occur during recuperation, and alternative treatments” B. Record review of P18’s medical record revealed the following: - Section titled “Physician Certification written on 11/25/2023 at 7:18 pm “the risks of transfer included “Deterioration; discomfort; MVA [Motor Vehicle accident] [S.I.C]” -Section titled “Patient Request/Refusal Consent to Transfer” dated 11/26/2023 at 7:40 pm, P18 gave consent to transfer in POV (privately owned vehicle) with the only risk mentioned on the consent form was MVA (motor Vehicle Accident). This transfer form failed to inform the patient of all the risks of a POV transfer.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 46375 Based on record review, interviews, and observations, the facility failed maintain the personal privacy of patients. The Protected Health Information (PHI) for 62 (P (Patient) 22 - P84) of 62 (P22-P84) patients. This deficient practice is likely to lead to a breach in an increased risk of misuse in patient confidentiality and privacy. The findings are: A. Record review of facility’s policy titled “HIPPA: Administrative, Technical and Physical Safeguards for PHI [Protected Health Information]”, dated 01/09/2024, stated “POLICY: 2. Physical Safeguards [bolded in policy] a. Securing the Physical Environment x. Password protected [facility name] approved screen savers should be utilized (where available) on computer workstations located in public areas. xi. Workforce should close electronic records containing PHI when not in use, log off computer applications when not actively using and log off computer workstations at the end of each shift.” B. During an observation on 01/23/2024, at 11:41 am of an open area nursing station the following PHI was visible on computer workstations: 1. Workstation 1 showed the following PHI of P22: patient name, date of birth, age, sex, location, suicide screen, vaccine status, drug allergies, chief complaint, temperature, pulse, respiratory level, weight, blood work results and medical record number. 2. Workstation 2 showed the following PHI of P23: patient name, date of birth, age, location, suicide screen, vaccine status, drug allergies, chief complaint, temperature, pulse, respiratory level, blood pressure, sex, and medical record number. 3. Workstation 3 showed the following PHI for P22, P24, P25, P26, P27, P28, P29, P30, P31, P32, P33: location, patient name, chief complaint, acuity level, sepsis level, comments, time spent in room and age. 4. Workstation 4 showed the following PHI for P24, P25, P26, P27, P28, P29, P30 - P49: patient name, location, acuity level, chief complaint, sepsis level, blood pressure, pulse, oxygen level, respiratory level, temperature, age and length of stay. 5. Workstation 5 showed the following PHI for P22 - P49: patient name, age, location, blood pressure, chief complaint, acuity level, early sepsis screening, comments, and length of stay. C. During an observation on 01/25/2024, at 11:39 am, of an open area nursing station the following PHI was visible on computer workstations: 1. Workstation 1 showed the following PHI for P50 - P71: location, patient name, age, sex, chief complaint, acuity level, early sepsis screening, disposition, comments, and length of stay. D. During an observation on 01/25/2024, at 1:07 pm, of Workstation on Wheels (WOW) showed the following PHI for P72: location, patient name, sex, age, date of birth, medical record number, suicide screen, vaccine status, allergies, blood type, chief complaint with comments, blood pressure, temperature, pulse, respiratory rate, oxygen level, weight, emergency department vitals, physical exam with comments, and emergency department provider note. E. During an observation on 01/25/2024, at 4:56 pm, of open nursing area station the following PHI was visible on computer workstation: 1. Workstation 1 showed the following PHI for P73: patient name, location, sex, age, date of birth, medical record number, suicide screen, allergies, blood type, vaccine status, chief complaint, blood pressure, temperature, pulse, respiratory rate, oxygen level, weight, event log, medications, doctor orders and results. 2. Workstation 2 showed the following PHI for P74 - P84: location, patient name, age, sex, complaint, sepsis screen, and length of stay. 3. Workstation 2 showed specific PHI for P81: patient picture, patient name, sex, age, date of birth, vitals, blood pressure, temperature, pulse, and oxygen level. F. During an interview on 01/30/2024, at 12:30 pm, with Staff (S)1, Charge nurse when asked what the policy is on workstation HIPPA, S1 explained when an employee walks away, we’re supposed to be locking the screen. When asked if an employee should ever leave a workstation screen open, S1 answered “No, we should be locking them.” G. During an observation in the waiting room on 01/24/2024, at 12:00 pm, surveyor was able to hear the triage of a patient complaining of an earache and sore throat. Triage nurse stated, “well you don’t have a fever.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49835 Based on record review and interview the facility failed to ensure staff followed policies for 21 (P (Patient) 1-21) of 21 patients reviewed. 1. Obtain a full set of vital signs every two hours on P1-21 patients. 2. Follow the procedure on obtaining a urine specimen (urine sent for testing) from foley (a tube inserted in bladder for drainage of urine) for P7. These deficient practices are likely to lead to serious injury, harm or death to all patients presenting to the emergency room. The findings are: Facility failed to obtain full set of vital signs: A. Record review of facility’s policy titled “Triage in the Emergency Department” dated 06/20/2022, on page 2 number 5 stated, “Triage should include a full set of vital signs to include blood pressure, temperature, pulse, respirations, pulse oximetry (measure the amount of oxygen in the body) and pain level.” B. During an interview on 02/05/2024, at 2:43 pm, with Staff (S)13, Emergency Room Manager confirmed that Emergency room nurses should obtain a full set of vital signs every two hours. C. Record review of P1 through P21’s medical records did not have a full set of vital signs every two hours while in the emergency room. Facility failed to obtain a full set of vital signs and did not follow procedure on obtaining a urine specimen: D. Record review of document named “The Quick Sheet” how to perform a procedure: this procedure is how to collect a urine specimen from a foley. On the top of this page it was stated “Alert: Do not collect a urine specimen for culture from a urine drainage bag.” E. During record review for P7’s medical record revealed: 1. “Arrived at facility on 12/09/2023, at 3:01 pm, there was no temperature obtained during triage or during the emergency room visit. This patient was discharged with a urinary tract infection.” 2. “Foley was changed on 12/05/2023 per caregiver.” On 12/09/2023 at 3:38 pm CNP (Certified Nurse Practitioner) ordered for urine to be collected, with instructions “If indwelling catheter has been placed > (more than) 48 hrs (hours), remove and insert new catheter”. F. During an interview on 01/25/2024, at 10:30 am, with S5, Registered Nurse confirmed that a full set of vital signs especially temperature should be taken at triage and through emergency department visit especially on patients with a diagnosis of an infection or receiving antibiotics. During interview when asked how the urine from a foley is obtained S5 confirmed the urine is obtained from the foley bag. G. During interview on 02/05/2024, at 2:43 pm, with S13, Emergency Room Manager confirmed, the foley is not changed, we get the urine from the foley bag, we fill a urine cup and take it to the lab.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 49835 Based on observation and interview, the facility failed to maintain a physical environment in a manner that ensures the safety and well-being of patients, by having the door to the ambulance bay locked and having the ambulance bay access blocked. This deficient could result in the inability for ambulances to access the patients that need transportation in an emergency. The findings are: A. During observation on 01/25/2024 at 12:43 pm an ambulance arrived and was unable to enter the emergency room due the inner ambulance bay door was locked, and a security guard was unable to open the ambulance bay doors and could not let the ambulance in. Then another staff member from the emergency room had to come and unlock the ambulance bay door and the ambulance entered the bay and picked up a patient to be transferred to a higher level of care. B. During an observation on 01/26/2024 at 8:57 am of the Emergency Department ambulance bay a delivery truck parked in the ambulance parking and unloaded biohazard medical waste containers into the ambulance bay doorway that blocked the entrance to the emergency room. The driver of the delivery truck drove away and left the boxes in the bay between the outer and inner doorway. C. During an observation on 01/26/2024 at 10:14 am of the Emergency Department a delivery truck in the ambulance bay unloaded linens. The delivery truck driver left the linen in the ambulance bay which blocked the entrance to the Emergency Room. D. During an observation on 01/26/2024 at 12:46 pm of the Emergency Department ambulance bay entrance an ambulance was parked, and a gas truck parked in front of the ambulance, which blocked the ambulance from exiting the facility. E. During an interview on 01/26/2024 at 9:05 am with S (staff) 9 (clinical) when asked about the ambulance bay being blocked and who would move the items being delivered S9 stated “I am unaware who has access to the ambulance bay door, and I don’t know who would remove the delivery items I don’t even know how to open doors when they are locked.” F. During an interview on 01/26/2024 at 11:29 am with S3 (non-clinical) confirmed, if the ambulance bay is blocked it could delay the care of a patient.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49835 Based on record review, observation and interviews the facility failed to provide a clean and sanitary environment. This deficient practice places all patients entering the emergency room at risk for infections. The findings are: A) Record review of the facility’s policy titled “Identification of Clean and Dirty Reusable Medical Equipment.”, dated 02/01/2019, stated: “Purpose: To provide guidance on identifying clean and soiled equipment to prevent the transmission of infection to staff, visitors, and patients. To define the type of cleaning, disinfection, and/or sterilization appropriate for reusable medical equipment. Policy: Ensuring that patients receive clean equipment is required to prevent the transmission of infectious pathogens (A germ that could cause infection). Patient care equipment needs to be appropriately identified as clean, soiled, or in use. Section 2.1 Once a patient is no longer using a piece of equipment, it is placed in the Soiled Utility Room for cleaning. After cleaning, the item is placed in the Clean Utility Room. 2.3 Any equipment that is not cleaned immediately after use is placed in the Soiled Utility Room. 3.2 Patient care equipment without clear definition of clean/soil status is assumed soiled and must be cleaned/disinfected before the next patient use.” B) Record review of mattress care: Manufacturer instruction “Cleaning the Mattress” stated, “Inspect mattress covers for tears, punctures, excessive wear, and misaligned zippers each time the covers are cleaned. If compromised, the mattress should be removed from service immediately and replaced to prevent cross-contamination.” C) During an observation on 01/26/2024, at 9:12 am, of the decontamination room (patient room) behind a curtain was five bedside commodes, a large trash can with other patient care items such as reacher’s, (equipment used by patients to grab items out of reach for them), foot rests used on wheelchairs to place the patients feet on while being transported, a plastic kiddie pool to be used for patients were in the decontamination room to wash them from the chemical exposure, a plastic bin with holes on the bottom of it on the floor with linen wrapped in plastic. D) During an interview on 01/26/2024, at 9:13 am, with Staff (S)9, Registered Nurse (RN) when asked if the decontamination room was an appropriate place to store supplies, S9 stated “I have no idea why there were supplies in the decontamination room behind the curtain.” E) During an interview on 01/26/2024, at 9:13 am, with S7 Charge Nurse when asked if the decontamination room was an appropriate place to store supplies S7 stated “JCAHO (Joint Commission on Accreditation of Healthcare Organization, independent organization develops standards and guidelines to improve the safety, effectiveness, and quality of health care and accredits medical providers and programs) doesn’t have a problem with it so we shouldn’t.” S7 confirmed that the linens shouldn’t be in there. F) During observation on 01/26/2024, at 9:12 am, of a trauma room being cleaned by S11 Tech, the mattress being cleaned had a patch on it covering a tear that had brown residue around the edges. G) During an interview on 01/26/2024, at 9:13 am, with S7 RN Charge Nurse regarding mattress care it was explained if there is a tear, they place a patch on it to prevent the tear from growing and to cover it.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49193 Based on record review, observations, and interview the facility failed to meet the Condition of Participation to protect patient’s rights: A. The facility failed to maintain the personal privacy of patients. Refer to tag A-0143. B. The facility failed to ensure that all patients remain free from neglect by failing to provide appropriate psychiatric care. Refer to tag A-0145. C. The facility failed to ensure patients have the right to be free from restraints. Refer to tag A-0154. D. The facility failed to ensure that restraint orders were not written on as an needed basis. Refer to tag A-0169. E. The facility failed to ensure that restraint orders had a duration (timeframe). Refer to tag A-0173”

“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: 49193 Based on record review and interview the facility failed to provide all patient’s or the patient’s representative with the correct phone number for filing a grievance with the State agency. This failed practice increases the likelihood of patients not being able to report grievances. The findings are: A. Record review of facility’s Patient Admission Packet, revised October 2018 had a phone number noted for Department of Health as 505-827-2613. The correct phone number is 1-800-752-8649. B. During an interview on 01/16/24 at 4:44 PM, with Staff (S) 2 Regulation and Accreditation Director confirmed the Patient Admission Packet that was provided to patients had the wrong number to file a complaint with the New Mexico Department of Health.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 49844 Based on record review, interviews and observations, the facility failed to maintain the personal privacy of patients. The Protected Health Information (PHI) for 25 (P (patient) 6, P11, P13, P19 - P40 ) of 40 (P1- P40) patients. This deficient practice is likely to lead to a breach in patient confidentiality and privacy. The findings are: A. Record review of the facility’s policy titled, “HIPPA [Health Insurance Portability and Accountability Act]: Protected Health Information (PHI) Minimum Necessary” with an effective date of 06/14/2023 under section 3 stated, “[Facility Name] shall maintain responsible administrative, technical, and physical safeguards to protect the privacy of PHI from any intentional or unintentional use or disclosure that is in violation of federal and state privacy law.” B. During an observation of the nursing station on 01/10/2024, at 9:46 AM, PHI for P6, including name, location in the hospital, date of birth, diagnosis, allergies, history and physical, language, vital signs, height and weight was displayed on an unattended computer screen. C. During an observation of a nursing station on 01/10/2024, at 9:49 AM, PHI for P16 and P17, including patient name gender, date of birth, MRN (medical record number), primary problem, allergies, code status, COVID-19 (strain 19 of coronavirus) diagnosis, and restraints status was displayed on an unattended computer screen. D. During an observation of a nursing station on 01/10/2024, at 9:55 AM, PHI for P18 including name, date of birth, location, allergies, vital signs, MRN, and nursing assessment was displayed on an unattended computer screen. E. During an interview on 01/12/2024, at 5:06 PM, with Staff (S)15, Registered Nurse (RN), when asked if computer screens should be left unattended with patient information showing, S15 stated “We usually don’t leave them [computers] open. We usually slide our badges across [the badge scanner] to lock them, but I guess it didn’t work.” F. During an interview on 01/17/2024, at 9:00 AM, with S14, Registered Nurse, when asked if it is standard practice for computers to be left open with patient information, S14 stated, “We always close our computers when we walk away. I slid my badge [ID card] [across the badge scanner] and it did not work.” G. During an observation of a nursing station on unit 3F on 01/17/2024, at 9:55 AM, revealed accessible patient information for 24 patients (P11,P13, P19-P40) on a document titled “3F Census 01.17.24” was sitting on top of the nursing station accessible to anyone. This document included the following: 1. Patient room number 2. Isolation LDA [lines, drains, and airways] [restraints] 3. Patient Name 4. Day RN 5. Night RN 6. MD (medical doctor) H. During an interview on 01/17/2024, at 2:22 PM, with S6, nursing director, confirmed that the census sheets are for nursing staff and are updated at the change of the shift and should not be available for anyone to grab from on top of the nursing station. S6 confirmed that patient information listed on the 3F Census did contain PHI.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49193 Based on record review and interview the facility failed to ensure that all patients remain free from neglect by failing to provide psychiatric care prior to discharge for 1 (P (Patient)1) of 15 (P1-P15) patients being reviewed for patients rights. This deficient practice is likely to lead to serious harm, serious injury, serious impairment, or death. The findings are: A. Record review of P1’s electronic medical record (EMR) revealed the following: 1. P1 was admitted on 08/06/2023 and discharged on 10/30/2023. 2. A document titled, “Discharge Summary” dated 10/30/2023 at 5:37 PM under “Brief HPI[history of present illness]/Hospital course” indicated the patient’s diagnosis was bipolar disorder and depression. This section stated, “Today Psychiatry was consulted again, patient with worsening behavior and trying to harm the personal [sic].” Under the “Physical Exam” section of the discharge summary stated the patient was “Alert not oriented [not aware of time place or situation].” Under “Brief HPI/Hospital Course” the provider indicated 911 was called on the patient and patient was discharged to police custody. 3. A document titled, “Progress Note” dated 10/30/23 at 11:54 AM stated: “Pt [patient] has been misbehaving” and “Pt with hallucinations.” Under the section “Hospital Issues” stated, “Psychiatry re-consulted 10/30 (10/30/23), pt may qualify for psychiatry admission.” 4. The record did not contain any documentation of a psychiatry consult being done on 10/30/2023. 5. A “Discharge order” dated 10/30/23, at 5:37 PM, placed by Staff (S) 17, Hospitalist, [inpatient medical provider] with a disposition [place of discharge] to a “Psychiatric Hospital or Psychiatric Unit of a Hospital.” B. Record review of the facility’s security report dated, 10/30/2023, revealed patients disposition was not a Psychiatric hospital or Psychiatric unit of a hospital and stated “At approximately 1730 hours [5:30 PM] [Name of Police Department] and nursing staff escorted [name of patient] off the unit and out to the lobby and placed her in custody and in the back of the police unit.” C. During an interview with the complainant on 01/08/2024, at 2:50 PM, it was explained that P1 was brought to the outside psychiatric facility on 10/31/2023 [sic] and admitted to psychiatry. D. During an interview on 01/10/2024, at 3:00 PM, with S7, Case Manager, it was asked if P1 was medically cleared for discharge. S7 stated “All I asked was for her to be arrested. I never asked to have her taken to [outside psychiatric facility]. I thought he [police officer] was going to take her to jail.””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49193 Based on interview, observations, and record review the facility failed to ensure all patients have the right to be free from restraints for 3 (P (Patient) 1, P11, and P12) of 15 (P1-P15) patients. This deficient practice of using restraints without a duration, an accurate indication, and discontinuation at the earliest possible time is likely to lead to serious harm, serious injury, serious impairment, or death. The findings are: A. Record review of facility’s policy titled, “Restraints Management” effective 02/28/2023 revealed: 1. Section 1 “[name of facility] uses restraint [sic] only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others.” 2. Section 1.3 stated, “Discontinuation of restraints at the earliest possible time regardless of the scheduled expiration of the order will be utilized.” 3. Section 2.2 states “Physician orders for non-violent restraints remains in effect until . . . [Section] 2.2.2 the indication for discontinuation of the restraint are met” 4. Section 4.2 “Monitoring occurs at least every two hours or more frequently as the patient condition warrants.” B. Record review of a staff education Tipsheet titled “PATIENT SAFETY ALERT #24-002” under background stated “Restraint use and long term use of restraints has the potential to lead to additional harm if not monitored frequently. This harm can lead to longer hospital stays.” C. Record review of P1’s electronic medical record revealed (EMR): 1. P1’s restraint order dated 08/20/2023, at 8:09 PM indicated the reason for restraint was for keeping in bed for safety and to prevent patient from wandering. 2. P1 had been restrained continuously from 08/25/2023 to 10/30/2023 for 66 days. The discontinuation of restraints is not charted. 3. P1 remained in restraints while documented as calm and cooperative on the restraint timeline for the following dates and times: a. On 09/20/2023 at 5:45 PM through 09/23/2023 at 9:45 AM (P1) was calm and cooperative. b. On 09/24/2023 at 7:45 AM, the patient (P1) was calm and cooperative and additional restraints were applied at this time. c. On 09/25/2023 at 7:45 AM to 11:00 AM. P1 was calm and cooperative. 5. The record did not contain any documentation of monitoring of restraints for the following dates and times: a. On 08/28/2023 from 7:00 AM to 7:00 PM b. On 09/08/2023 from 9:00 PM to 09/09/2023 at 7:00 AM c. On 09/19/2023 from 11:00 AM to 7:45 PM d. On 10/09/2023 from 6:45 PM to 10/10/23 at 8:10 AM D. During an interview on 01/12/2024 at 1:29 PM, Staff (S)4, Nursing Director, confirmed that there was no documented restraint charting for P1 during the times listed above. E. During an interview on 01/12/2024, at 5:07 PM, with S4, Nursing Director confirmed P1 had been restrained continuously from 08/25/2023 to 10/30/2023. F. Record review of P11’s admission “History and Physical” dated 08/06/2023 at 10:24 PM under physical exam revealed that P11 was “Alert, Oriented x (times) 4 [oriented to self, time, place, and situation].” G. Record review of P11’s discharge summary under physical exam revealed that at discharge patient is “alert not oriented” and patient had been hospitalized 86 days and had a cognitive decline (decrease in mental status). H. Record review of P11’s medical record revealed: 1. The restraint order dated 01/16/2024 was modified and indicated vest while sitting in a chair, and vail bed. This order did not have an end date and indicated “UNTIL DISCONTINUED”. 2. P11 was admitted on 07/17/2023 and remained hospitalized as of 01/30/2024. I. During an observation of P11’s room on 01/16/24, at 4:50 PM, P11 had a vest restraint applied while sitting in a chair and the order for the vail bed restraint remained in place. J. During an interview on 01/17/2024, at 9:00 AM, S12, Registered Nurse confirmed P11 had been restrained for over a month for the prevention of falls and wandering. When asked about the duration of P11s restraint S12 stated “this restraint order is a continuing order.” K. During an interview on 01/17/2024, at 4:50 PM, with S18, hospitalist, S18 confirmed the indication for P11’s restraint order of “interference with medical treatment” is from seven months ago when the order was placed and has not been updated. L. An observation on 01/17/2024, at 7:50 AM, revealed P12 was in a vail bed (netted in bed) restraint and the call light was placed outside of the vail bed where the patient could not access it. M. During an interview on 01/17/2024, at 7:55 AM, with S19, Registered nurse, when asked how the patient can use the call light S19 stated, “I don’t really know because I’m new to vail beds.” N. During an interview with S16 Charge Nurse, on 01/17/2024, at 8:00 AM, S16 stated, “There should always be a call light in the [vail] bed.” O. Record review of P1, P11, and P12’s restraint orders do not have an end date and are ordered “UNTIL DISCONTINUED”. P. During an interview on 01/12/2024, at 12:40 PM, with S4, Nursing Director, S4 confirmed that restraint orders do not have a duration (timeframe). S4 stated “restraints can be ordered until discontinued per policy they do not have to expire.” Q. Record review of the facility’s Clinical Performance Quality Committee meeting minutes from January 2023 to November 2023, revealed that restraints are not reviewed with leadership or the QAPI (Quality Assurance and Performance Improvement) committee. R. During an interview with S2, Accreditation Director on 01/16/2024, at 4:44 PM, S2 confirmed, restraints are not reviewed through the hospital QAPI program.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 49193 Based on an observation, interview, and record review, the facility failed to ensure that restraint orders were not written on an as needed basis for 1 (P (patient) P11) of 15 (P1-P15) patients. This deficient practice is likely to lead to poor patient outcomes or patient injury. The findings are: A. Record review of facility’s policy titled, “Restraint Management” effective date 02/28/2023 section 3 stated, Restraints are not written as a PRN (as needed) or standing order.” B. Record review of P11’s medical record, the provider ordered a Vail bed (netted in bed) restraint placed on 1/16/24, at 8:03 AM, and stated in the comment section “Vest while up in chair.” The restraint type on the order did not match the restraint type placed on patient and the vest was ordered on an as needed basis. C. During an observation of P11’s room on 01/16/24, at 4:50 PM, P11 had a vest restraint applied while sitting in a chair and the order for the vail bed restraint remained in place. D. During an interview with Staff (S)13, Nurse Executive on 01/17/2024, at 4:06 PM, S13 confirmed that when a restraint is removed from a patient, the order should be discontinued and reflect what is currently applied to the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 49193 Based on record review and interviews the facility failed to ensure that restraint orders had a duration (time frame) for 3 patients (P (patient)1, P11, and P13) of 18 (P1-P18) patients. This deficient practice is likely to lead to patients being restrained for extended periods of time. The findings are: A. Record review of the facility’s policy titled “Restraint Management,” effective date 02/28/2023, under “Central Delivery System,” section 2.2.2 indicated the duration of restraint orders remain in effect until the indication for discontinuation are met. Time frames for the renewal of orders for restraint of the non-violent non-self destructive patient is not addressed in the facility’s policy. B. Record review of P1’s medical record indicated the restraint order placed on 09/07/2023, at 5:25 PM, was discontinued on 10/3/2023, at 8:37 PM. The following restraint order was placed on 10/03/2023, at 8:37 PM, and was discontinued on 10/27/2023, at 12:26 PM. Both orders had no end date and stated “Until discontinued.” C. Record review of P13’s orders revealed a restraint order dated 01/15/2024, at 3: 30 PM, had no end date and indicated “UNTIL DISCONTINUED” D. Record review of P11’s medical record under the restraint order dated 01/16/2024, at 8:15 AM, did not have an end date and indicated “UNTIL DISCONTINUED” E. During an interview on 01/17/2024, at 9:00 AM, with Staff (S)12, Registered Nurse, confirmed that the restraint order for P11 is a continuing order. F. During an interview on 01/12/2024, at 12:40 PM, with S4, Nursing Director, confirmed “restraints can be ordered until discontinued per policy they do not have to expire.””