Our Lady of Lourdes Memorial Hospital, Inc.

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46619 Based on medical record (MR) review, document review, and interview, in 1 of 10 MRs, the facility failed to ensure a registered nurse (RN) adequately supervised and evaluated the treatment of Patient #1. Specifically, there was no documented RN involvement in the discharge process, which included patient education, for a pediatric patient who was being discharged with a new medication to be administered via nebulizer. Findings include: -- Per MR review Patient #1 presented to the ED on 1/1/2026 at 2:34 pm with complaints of upper respiratory congestion and cough for 2-3 days. Oral intake was somewhat decreased. They were voiding normally and having bowel movements. Patient #1 was triaged on 1/1/2026 at 2:34 pm and was assigned an Emergency Severity Index (ESI) level of 3 (on a scale of 1 -5, [1 being resuscitation and 5 non-urgent]). A registered nurse (RN) at triage documented vital signs were temperature (T) 102.7 degrees Fahrenheit (elevated, normal is 98.6 degrees Fahrenheit), heart rate (P) 173 (elevated, normal is 80 - 130), respirations (R) 32 (normal is 20 - 40), oxygen saturation (SpO2) 98% (normal in 95% - 100%). There was no documentation in the MR indicating that there was RN involvement following the triage assessment. On 1/1/2026 at 4:08 pm a licensed practical nurse (LPN) documented that Patient #1 had vital signs repeated: T was 101.8 degrees Fahrenheit (lower, but remained elevated), P 180 (remained elevated), R 32 breaths/minute, SpO2 99% on room air. (There was no documentation to indicate that the abnormal vital signs were reported to the RN and/or the provider.) On 1/1/2026 at 4:13 pm an LPN documented the departure condition was good, the patient left being carried by parents. Discharge instructions were reviewed. Patient teaching provided and medications were discussed. Guardian verbalized understanding. Discharge papers were signed by patient’s guardian and LPN that certified that family participated in the discharge planning and have read and fully understand the discharge instructions and have had the opportunity to ask all questions. Printed education about RSV and when to seek additional medical care were provided upon discharge. -- Per review of the facility’s policy and procedure (P&P) “Standard of Care: The Nursing Process,” revised 3/26/2026, “Nursing performs patient assessment and then implements the nursing Process for care planning, patient education, and discharge ... Initial education and assessment of understanding is completed by the RN. Reinforcement of education can be completed by the RN or LPN. The P&P refers to Lippincott Solutions for Discharge. Per Lippincott’s guidance document, “Discharge,” revised 8/3/2026, “Although discharge from a health care facility is usually routine, effective discharge requires careful planning and continual assessment of the patient’s needs during hospitalization. The transition of care that occurs during discharge sometimes places patients at risk for medical errors ... The nurse should review procedures that the patient, family, or caregiver will have to perform at home.” -- Per interview of Staff A on 8/10/26 at 3:52 pm, they stated LPNs are allowed to go over the discharge instructions and obtain discharge signatures. Staff A noted for some patients with specific medication needs, such as a pediatric patient with a new medication via nebulizer, it would be expected that an RN would complete the discharge process including patient/family education. Staff A acknowledged the above findings.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 36617 Based on document review, medical record (MR) review, and interview, the hospital did not ensure an individual (Visitor #1) acting in a capacity (i.e., assisting on surgical cases) was qualified to do so and Visitor #1 was not onboarded through the hospital’s Medical Staff /Employee Health/ Human Resources Departments. Specifically, Visitor #1 verbally identified as a “surgical technologist in training” was assisting a surgeon in the hospital’s operating room (OR) during surgical procedures. In the MR they were identifed as a visitor. There was no file available to review and verify this person’s qualifications. There was no file available to review this person’s onboarding. There was no documented health assessment, vaccine status, personal information, reference checks or documentation of completion of hospital orientation or competencies for Visitor #1 Please See Tag A-0945 - Surgical Services §482.51(a)(4)”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46619 Based on document review and interview, in one of one 1 adverse event reviewed, the facility’s Quality Assessment Performance Improvement (QAPI) Program corrective actions to address concerns identified during its investigation were not adequate. Findings include: -- Per review of an adverse events documented by the hospital’s QAPI Program, a patient had a retained surgical sponge after a surgical procedure. The facility identified corrective improvement actions, however, at the time surveyors presented, their plan did not include follow up measures to ensure that the staff education and plan implementation was effective. -- During interview of Staff A, Non-Clinical staff, on 12/29/2025 at 1:30 pm, they acknowledged the above findings.”

“SURGICAL PRIVILEGES CFR(s): 482.51(a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. This Standard is not met as evidenced by: 36617 Based on document review, medical record (MR) review, and interview, the hospital did not ensure an individual acting in a capacity (i.e., assisting on surgical cases) was qualified to do so and the individual was not onboarded through the hospital’s Medical Staff /Employee Health/ Human Resources Departments. Specifically, Visitor #1 verbally identified as a “surgical technologist in training” was assisting a surgeon in the hospital’s operating room (OR) during surgical procedures. There was no file to review to verify Visitor #1’s qualifications or onboarding. There was no documentation of delineation of privileges with competencies for the Visitor #1 Findings include: -- Review of the facility’s policy and procedure (P&P) titled “Academic Guests,” revised 10/2025, indicated the Medical Education Department is responsible for medical student clerkship and electives, Allied Health students, on-boarding and immunization and health records for nursing students. Clinical agencies desiring to utilize the Guthrie Clinic for hospital locations will develop an affiliation agreement with the organization. Medical Education monitors all contracts with affiliating agencies. -- Per MR review, Patient #1 presented to the hospital on 9/17/2025 for a left total hip arthroplasty (total hip replacement, includes removing damaged sections of hip joint and replaces them with an artificial joint). At 8:33 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #2 presented to the hospital on 9/17/2025 for a left total hip arthroplasty. At 9:55 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #3 presented to the hospital on 9/17/2025 for a left knee arthroplasty (total knee replacement, includes removing damaged sections of knee joint and replaces them with an artificial joint). At 9:44 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #4 presented to the hospital on 9/18/2025 for a revision right total knee. At 9:34 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #5 presented to the hospital on 10/1/2025 for a left total hip arthroplasty. At 8:22 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #6 presented to the hospital on 10/1/2025 for a left total hip arthroplasty. At 9:45 am the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #7 presented to the hospital on 10/1/2025 for a left total hip arthroplasty. At 12:09 pm the intraoperative report revealed Visitor #1 was present for the surgery. There were no comments documented. -- Per MR review, Patient #8 presented to the hospital on 10/2/2025 for a revision right total knee. At 7:55 am the intraoperative report revealed Visitor #1 was present for the surgery. Visitor comments, “surg tech training.” -- During interview of Staff B, Clinical Staff on 12/29/2025 at 12:55 pm and 12/30/2025 at 12:40 pm, they indicated they spend time orienting new staff including students from affiliated schools. Students work with a preceptor. They make sure staff are appropriately trained to scrub in for a surgical procedures. Visitor #1 had completed the education for surgical technologist and was at the hospital for clinicals. There had been emails regarding Visitor 1’s onboarding process. Then Staff B was asked to set up clinicals for Visitor #1. Visitor #1 stated all the paperwork was completed. Staff B reviewed the P&P with them and watched them scrub in for surgery. Visitor #1 reviewed instruments at the table with the surgical technologist. Staff B thought Visitor #1 was observing in the OR. After Visitor #1 had been in the OR a number of times, Staff B received a call from the orthopedic office( where Visitor #1’s parent worked) asking them to assist Visitor #1 in getting scrub access. That is when Staff B reached out to the education onboarding staff and found out they never received the affiliation agreement with the school in order for Visitor #1 to do clinicals at the hospital. Visitor #1 was then told not to return until affiliation and onboarding process was completed. Visitor #1 did not return to the hospital. -- During interview of Staff C, Non-clinical Staff on 12/30/2025 at 4:00 pm, they indicated if a school reaches out to request a student do their clinical rotation, staff verifies they have documentation of all required vaccines. They never received any information from the school that Visitor #1 had received their surgical technologist education. -- During interview of Staff D, Non-clinical Staff on 12/30/2025 at 4:10 pm, they indicated being asked by a surgeon to reach out to the hospital regarding a clinical rotation for their child. Visitor #1 had a certificate of course completion of a surgical technologist program through an online company. Staff D received required paperwork from the hospital and sent Visitor #1 the information packet. The surgeon again asked about clinicals. Staff D reached out to the school and sent the paperwork needed to initiate an affiliation agreement. Staff D never heard back from the school. Then there was one more contact made and the school indicated they were forwarding the paperwork to their lawyer prior to releasing. As of 10/30/2025 there was no response from the school and they stopped pursing the issue. -- During interview of Staff E, Clinical Staff on 12/30/2025 at 4:20 pm, they indicated that Visitor #1 took an online course for surgical technology and was training to be a surgical technologist. Staff E was told to train them. Visitor #1 scrubbed in and handed instruments to the surgeon during procedures. -- During interview of Staff F, Clinical Staff on 12/30/2025 at 4:30 pm they indicated they were told by someone that Visitor #1 had gone through all the training. -- During interview of Staff G, Non-clinical Staff on 12/31/2025 at 8:15 am they indicated conversations with Visitor #1 started in February 2025. Student coordinators are responsible for the onboarding of students and ensuring an agreement is in place. Because they never received an affiliation agreement, no other paperwork was sent. They did reach out to the school a few times but never received a signed agreement. Visitor #1 was told the hospital did not have an approved affiliation with the school and could not proceed. Staff G indicated Visitor #1 presented themselves as being all set to train. It could have been related to the fact that it was a surgeon’s child. Visitor #1 had no badge and no medical clearance. When a staff member was asked about accessing scrubs for Visitor #1, that is when they found out Visitor #1 had not been approved to be there. There was discussion that the surgeon threatened staff if they didn’t let Visitor #1 do clinicals. The situation was never escalated to administration. There has been no further contact with Visitor#1. -- During interview of Staff H, Clinical Staff on 12/31/2025 at 9:00 am they indicated Visitor #1 scrubbed in for cases (total knees and hip replacements). They assisted by holding retractors and handing instruments to the surgeon. Staff H documented them as a visitor in the OR. Staff H didn’t know what their role was. Visitor #1 was young and they only saw them a few times. -- During interview of Staff I, Clinical Staff on 12/31/2025 at 9:10 am, they believed that Visitor #1 had taken an online course for surgical technology and was approved for clinicals. Visitor #1 handed the surgeon some instruments and held retractors. Later in the interview Staff I indicated they were not in the room prior to closing but saw the visitor scrub in, and hand some instruments to the surgeon. -- During interview of Staff J, Non-clinical Staff on 1/5/2026 at 11;25 am they indicated being looped in on emails pertaining to Visitor #1 requesting clinicals at two of their hospitals. The first step is to have an affiliation with the school. They would need an affiliation amendment to add the program. Several emails went back and forth. Eventually they were able to put in a request to the school. They never heard back, so the amendment was never completed. They would not onboard a student until all required documents were received. If the affiliation went through, the student would have been notified and onboarded appropriately. -- During the exit conference on 1/5/2026 at 2:45 pm, Staff K, Non-clinical Staff acknowledged the above findings.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 36617 Based document review, medical record (MR) review and interview, in 2 of 10 MRs reviewed for patients receiving anesthesia services (Patient #_(Wendy Hurley) and Patient #_ (Francis Coleman), the MRs lacked documentation that a post-anesthesia evaluation was performed. Additionally, the hospital’s policy and procedure (P&P) did not address all the required elements for a post-anesthesia evaluation. Findings include: -- Review of the hospital’s P&P titled, “Documentation of Anesthesia Care,” reviewed 9/29/2023, indicated post-anesthesia should include the following: A. Patient evaluation on admission and discharge from the post anesthesia care unit. B. A time based record of vital signs and level of consciousness. C. A time based record of drugs administered, their dose and route of administration. D. Type and amount of intravenous fluids administered, including blood and blood products. E. Any unusual events including post-anesthesia or post-procedural complications. F. Post anesthesia visits. The P&P did not instruct anesthesia staff to document respiratory function, including respiratory rate, airway patency, and oxygen saturation, temperature, pain, nausea and vomiting, and postoperative hydration in thier post anesthesia evaluation. -- Review of Patient #9’s MR, revealed on 12/9/2025 at 1:42 pm they underwent an exploratory laparotomy (open abdominal surgery) and right hemicolectomy (surgery to remove right side of colon) while receiving general anesthesia. Patient 9’s MR lacked a post anesthesia evaluation prior to their discharge. -- Review of Patient #10’s (Francis Coleman) MR, revealed on 12/23/2025 at 8:31 am they underwent a robotic left nephrectomy (removing all or parts of a kidney) while receiving general anesthesia. Patient 10’s MR lacked a post anesthesia evaluation prior to their discharge. -- During interview of Staff L, Non-clinical staff on 12/30/2025 at 10:15 am, they acknowledged the above findings.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 46869 Based on interview and document review, the facility did not ensure that surgical services were provided in accordance with acceptable standards of practice. Specifically, the facility did not ensure that there were policies and procedures developed, in accordance with standards of practice, for maintaining, monitoring, and addressing, in an emergency situation, the temperature and humidity levels in the facility’s operating rooms (ORs). The lack of these policies and procedures does not ensure the health and safety of patients undergoing surgery. See Findings in Tag A0951.”

“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: 46869 Based on interview and document review, the facility did not ensure that their policies and procedures pertaining to temperature and humidity to be monitored and maintained within the operating room (OR) environment, emergency response in the case of an abnormal temperature/humidity increase within the OR environment, and immediate use steam sterilization (IUSS) and the IUSS of implants, were developed in accordance with acceptable standards of practice. Findings include: -- Review of the facility’s after action report (AAR), titled “OR & SPD Humidity Incident,” dated 9/26/2024, revealed there was elevated humidity, above 60 percent (%) relative humidity, in the facility’s ORs and sterile processing department (SPD) on 9/26/2024 for approximately 2 and a half hours, before surgical cases had started that day. This compromised the sterility of almost all of the clean sterile supplies stored in those areas, which were then disposed of by facility staff. The AAR also revealed that there was confusion on what standards to follow for maintaining and monitoring temperature and humidity in the ORs and SPD. The date set for reviewing and implementing new facility policies and procedures concerning this incident was 3/1/2025 and the status stated “ongoing.” -- Review of the facility’s policy and procedure titled, “Installing & Maintaining Protected Environments,” effective date 7/1/2022, revealed that it lacked information on a specified temperature or humidity range that the ORs had to be maintained at, how the temperature and humidity levels would be monitored, or an acceptable standard of practice that the policy and procedure referenced. Also, there wasn’t a specific policy or procedure for emergency response in the case of abnormal temperature/humidity increase within the OR environment, or reference to an acceptable standard of practice. -- Per interview of Staff N, OR Staff, on 3/10/2025 at 3:00 pm, they are not aware of a facility policy and procedure in place for emergency response in the case of abnormal temperature/humidity increase within the OR environment. -- Per interview of Staff K, OR Staff, on 3/10/2025 at 10:35 am, during the facility’s OR and SPD humidity incident on 9/26/2024, there was a lot of confusion and none of the staff knew what to do. -- Per interview of Staff J, OR Staff, on 3/10/2025 at 10:00 am, Staff J recalled the humidity being elevated on 9/26/2024. Staff J felt the staff did not know what to do. They started to re-sterilize the OR trays because the filters inside the trays were wrinkled. Over 4000 trays had to be redone. -- Per interview of Staff L, OR Staff, on 3/10/2025 at 11:25 am, Staff L recalled there was an issue with the chiller in September in the middle of the night. It was almost foggy in the OR. Staff L went to the facility to assist staff. They were opening trays in the core and finding them compromised. Surgeries had started, but there was a lot of mixed messaging on how to proceed. Many surgeries were cancelled that day. The staff was upset and voiced their concerns. Staff didn’t know what to do. There was an issue with the leadership in SPD at that time. -- Per interview of Staff G, SPD Staff, on 3/10/2025 at 9:45 am and 3/11/2025 at 1:15 pm, they stated that the facility utilized One Tray Sealed Sterilization Containers for IUSS instead of having sterilizers for IUSS in the clean sterile core of the ORs. They also stated they were unsure whether there was a facility policy and procedure concerning IUSS, the IUSS of implants, or the One Tray Sealed Sterilization Containers. -- Review of the facility’s sterilization and disinfection policies and procedures on 3/11/2025 revealed that there wasn’t a policy and procedure for IUSS, the IUSS of implants, or the One Tray Sealed Sterilization Containers, based on an acceptable standard of practice. -- During interview of Staff C, Physical Plant Director, on 3/4/2025 at 11:45 am, they confirmed that a new policy and procedure has not been reviewed and implemented yet for the monitoring of temperature/humidity levels in the ORs and SPD or for emergency response in the case of abnormal temperature/humidity increase within the OR environment.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 36617 Based on document review, medical record (MR) review, and interview, 1) in 10 of 10 MRs (Patient #1 - Patient #10), the anesthesia consent forms lacked the name of the specific provider performing the anesthesia service and the signature of the anesthesiologist was not legible. Additionally, the hospital’s policy and procedure lacked instruction to staff to document the name of the provider administering anesthesia on the consent. 2) In 4 of 10 MRs (Patient #1, Patient #2, Patient #3, and Patient #9) the surgical and/or the anesthesia consent forms lacked documentation of date and/or time the patients signed the consent. 3) In 1 of 10 MRs (Patient #4) the surgical consent form contained abbreviations. 4) In 1 of 10 MRs (Patient #5) the surgical consent contained a word that had been crossed out. This lack of documentation does not portray the actual care provided to the patient. Findings regarding (1) include: -- Review of Patient #1’s MR revealed, their anesthesia consent form dated 9/26/2024 at 8:16 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #2’s MR revealed, their anesthesia consent form dated 3/6/2025 at 10:38 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #3’s MR revealed, their anesthesia consent form dated 2/14/2025 at 12:17 pm, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #4’s MR revealed, their anesthesia consent form dated 2/25/2025 at 7:11 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #5’s MR revealed, their anesthesia consent form dated 1/10/2025 at 9:25 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #6’s MR revealed, their anesthesia consent form dated 2/28/2025 at 7:08 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #7’s MR revealed, their anesthesia consent form dated 2/24/2025 at 10:28 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #8’s MR revealed, their anesthesia consent form dated 3/10/2025 at 9:40 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #9’s MR revealed, their anesthesia consent form dated 9/26/2024 at 12:10 pm, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of Patient #10’s MR revealed, their anesthesia consent form dated 9/26/2024 at 7:39 am, lacked documentation of the name of the specific provider that provided anesthesia services to the patient and the anesthesia provider’s signature was not legible. -- Review of the facility’s policy and procedure titled “Procedure, Site, Location, & Patient Identification Verification,” revised 10/2023, lacked instruction to staff to identify the provider who would be providing the anesthesia to the patient during their procedure. Findings regarding (2) include: -- Review of the facility’s facility’s policy and procedure titled “Procedure, Site, Location, & Patient Identification Verification,” revised 10/2023, indicated consent documentation must include the patient, witness, and licensed practioner’s signature, date, and time the consent was obtained. -- Review of Patient #1’s MR revealed the surgical consent, dated 9/26/2024, lacked the time the patient signed the consent. The anesthesia consent, dated 9/26/2024, lacked the date and time the patient signed the consent. -- Review of Patient #2’s MR revealed the anesthesia consent, date 3/6/2025, lacked the date and time the patient signed the consent. -- Review of Patient #3’s MR revealed the anesthesia consent, dated 2/14/2025, lacked the date and time the patient signed the consent. -- Review of Patient #9’s MR revealed the anesthesia consent, dated 9/26/2024, lacked the date and time the patient signed the consent. Findings regarding (3) include: -- Review of the facility’s facility’s policy and procedure titled “Procedure, Site, Location, & Patient Identification Verification,” revised 10/2023, indicated consent documentation should have no acronyms or abbreviations, except spinal levels. -- Review of Patient #4’s MR revealed the surgical consent form indicated the procedure being performed was a robotic assisted laparoscopic right partial nephrectomy, possible right radical nephrectomy with TAP block. TAP was not spelled out (transversus abdominis plane - numbs the nerves of the anterior abdominal wall). Findings regarding (4) include: -- Review of the facility’s facility’s policy and procedure titled “Procedure, Site, Location, & Patient Identification Verification,” revised 10/2023, indicated if consent documentation is altered or illegible, it must be redone and re-signed by all parties. -- Review of Patient #5’s MR revealed the surgical consent contained a word that had been scribbled over. No new consent was obtained. -- During interview of Staff O, Regulatory Director, on 3/11/2025 at 3:30 pm, they acknowledged the above findings.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36617 Based on document review, medical record review and interview, in 3 of 5 (Patient #1, Patient #2, Patient #3), medical records reviewed, documention of pressure injuries was inadequate, i.e., it lacked description of skin breakdown appearance, measurements of pressure injury, treatment implemented, etc.) This lack could lead to difficulty in determining changes in pressure injuries. Findings include: -- Review of the facility’s policy and procedure titled, “Admission History and Assessment,” reviewed 7/2023, “Nurses should remove all dressings to accurately assess pressure injuries and document all findings. If a patient has an open wound the registered nurse should ensure a referral to the wound ostomy continence nurse is ordered. If patients have reddened areas, blisters, necrotic areas, pressure injuries, nonsurgical, surgical or vascular wounds, the nurse should identify initial plans of care (dressings, creams, etc.) by entering wound care orders within their scope of practice. The “Pressure Injury Flow Record” should be used to document all injuries identified. Once pressure injuries are documented, these form are maintained with the Care Path/Flow Record, facilitating ongoing documentation. ... Nurses should complete a full reassessment within the first half of the shift assigned. Registered nurses working 12 hour shifts are expected to complete a full assessment during the first half of the shift and a second assessment in the second half of the shift that includes all required assessments (for example, risk for falls, injury from falls, skin breakdown and pain) and a focused assessment for any changes. -- Review the education provided to nursing staff (registered nurses, licensed practical nurses and patient care technicians) in May 2023 titled, “Pressure Injury Prevention and Stages,” not dated, indicated wound documentation should include the following: type of wound and location, description of the wound in tissue color percentage, drainage amount, color, odor and periwound (area around the wound) appearance, wound measurement in length x width x depth upon admission and weekly (every Wednesday), interventions for wound treatment and healing plan, patient care activity; turning and position, pressure reducing devices, offloading heels etcetera, and patient and caregiver education. -- Review of Patient #1’s (80-year-old female) medical record revealed, she presented to the hospital on 6/21/2023 with a chief complaint of right hip pain. Past medical history included included hypertension (high blood pressure), dyslipidemia (high cholesterol), myocardial infarction (heart attack) and macular degeneration (condition that results in loss of central vision). -- The admission assessment on 6/22/2023 at 2:30 am indicated Patient #1 had erythema to the right lower leg and bruising to the right lower and upper leg. -- Skin assessment on 6/25/2023 at 6:54 pm indicated erythema to the right lower leg, bruising to the right lower and upper leg, and blisters to the midline coccyx region. (No description of wounds documented). -- Skin assessment on 6/27/2023 at 4:21 am indicated erythema to the right lower leg, bruising to the right lower and upper leg, and blisters to the midline coccyx region with Allyven (water and bacterial proof) dressing intact. (No description of wounds documented). -- Discharge assessment on 6/28/2023 at 3:00 pm indicated erythema to the right lower leg, bruising to the lower and upper leg, blisters to the midline coccyx region, and a 5 millimeter superficial skin breakage to the right dorsal pedalis (top of foot). (No description of wounds documented). -- Review of Patient #2’s (71-year-old male) medical record revealed, he presented to the hospital on 2/6/2024 with a chief complaint of increasing weakness and decreased oral intake for the last 3 days. Past medical history included tonsillar squamous cell carcinoma (throat cancer) treated with chemotherapy, atrial fibrillation (irregular and rapid heart rate), hypertension, chronic obstructive pulmonary disease (lung disease) and was diagnosed with lung cancer 6/2023. He had chemotherapy and radiation, he now has recurrence of lung cancer diagnosed 10/2023. The admission assessment on 2/6/2024 at 11:04 pm indicated Patient #2 had a Stage 2 pressure injury on his sacrum with scant serosanguinous (clear/bloody) drainage, surrounding tissue intact, foam adherent dressing applied. No measurements of the pressure injury were documented. On 2/7/2024 at 10:03 am a wound ostomy continence nurse received a referral automatically generated through the medical record system based on the patient’s skin assessment. Following the automatic referral, the wound ostomy continence nurse contacted Patient #2’s nurse and gave recommendations for treatment, Aquaphor to radiation burns on neck, thick moisture barrier paste to buttock, upgrade to Triad paste (indicated for the local management of partial-and full-thickness pressure and venous stasis ulcers, dermal lesions/injuries, and first and second-degree burns) if patient is incontinent and if paste is not holding or skin begins to breakdown. The nurse was instructed to place a new referral to the wound ostomy continence nurse, if further evaluation was needed or if the patient needed to be seen. On 2/10/2024 at 6:20 pm, nursing documented Stage 2 pressure injury sacrum, erythema, non blanchable, Mepilex dressing and turn and position every 2 hours (no additional information about the wound was documented). On 2/13/2024 at 4:57 pm, nursing documented Stage 2 pressure injury sacrum, erythema, non blanchable, surrounding tissue intact (no treatment or additional information about the pressure injury was documented). On 2/14/2024 at 4:47 pm, nursing documented Stage 2 pressure injury sacrum, boggy, erythema, non blanchable (no measurements, treatment, or additional information about the wound was documented). On 2/21/2024 at 11:22 am, the wound ostomy continence nurse documented inpatient provider requested wound consult. The nurse documented a Stage 2 pressure injury, bilateral sacrum, partial thickness, scant serosanguinous drainage and surrounding tissue fragile. Pressure injury present on admission, measurements length 11 centimeters, width 5 centimeters and depth 0.2 centimeters. Recommended continue current treatment orders and pressure relief specialty bed. Patient refused Triad paste to sacrum, requested only foam border dressing be used. Wound photos uploaded to chart. Reconsult if needed. From 2/21/2024 - 3/5/2024 Patient #2’s pressure injury to the sacrum continued to be monitored and treated. Patient #1 frequently refused turning and positioning and the use of Triad paste. No repeat measurements of the pressure injury were documented on Wednesdays. On 3/6/2024 at 12:45 am, nursing documented Stage 3 pressure injury, present on admission to coccyx and sacrum, bilateral midline. The wound progressed from a Stage 2 to a Stage 3 pressure injury. No other wound description was documented. (Patient was still an inpatient on 3/6/2024.) -- Review of Patient #3’s (79 year-old female) medical record revealed, she was admitted to the facility on 3/3/2024 with a chief complaint of weakness and pneumonia. The skin assessment on admission at 2:42 pm indicated the following: Wound 1 - skin tear on the left elbow edges separated, moderate amount of sanguineous drainage Wound 2 - Stage 2 pressure injury on buttock/sacrum bilateral, erythema, blanchable, no drainage, present on admission. There were no pressure injury measurements documented. On 3/4/2024 12:02 pm, nursing documented, Wound 1 - skin tear on the left elbow edges separated, present on admission, dressing clean, dry and intact. Wound 2 - Stage 2 pressure injury on buttock/sacrum bilateral, present on admission, turn and reposition every 2 hours, pillow placed to elevate right side. There was no pressure injury description documented. On 3/5/2024 9:48 am, nursing documented, Wound 1 - skin tear on the left elbow, present on admission, scabbed. Wound 2 - Stage 2 pressure injury, present on admission, black percentage 0-25%, purple percentage 26-50%, wound drainage none, surrounding tissue intact, Triad applied, dressing covering wound. (Patient was still an inpatient on 3/5/024.) -- Per interview of Staff A, Registered Nurse on 3/6/2024 at 10:45 am, pressure injuries that are a stage 1 or 2, may need a dressing or a zinc oxide based cream applied. Pressure injuries that are stage 3 or 4 trigger a wound care nurse consultation automatically. Each individual nurse is responsible for the skin assessment and management of their patients. Staff A discussed that there is currently one pressure injury prevention certified licensed practical nurse on the unit. There is also a wound care nurse available to consult within the hospital. Staff A discussed that he/she/they rely on the wound care nurse for accurate staging of pressure injuries. -- Per interview of Staff B, Registered Nurse on 3/6/2023 at 11:00 am, he/she/they discussed pressure injury prevention measures include using protective dressings, frequent repositioning and keeping the patient’s heels elevated. There is a wound care nurse in the hospital that helps with more complex pressure injuries/wounds. Each nurse is responsible to document a head to toe skin assessment and the management of pressure injuries. A wound care nurse consultation is triggered for stage 3 and 4 pressure injuries. There are no in person competencies provided to staff on staging pressure injuries. Staff use a pressure injury reference binder available at the front desk, but usually call the wound care nurse to stage all wounds. -- Per interview of Staff C, Nurse Manager of Wound Care on 3/6/2024 at 9:25 am, there is not a specific policy and procedure pertaining to pressure ulcers and the required documentation. There are binders on each unit to help staff identify and stage pressure injuries along with treatment recommendations. When staging a pressure wound, it is expected that all nursing staff will document measurements of the wound. Staff C acknowledged the above findings.”

“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: 36617 Based on medical record (MR) review, document review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, in 2 of 5 (Patient #9 and #16) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the benefits and risks of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer and untoward patient outcomes. Please reference findings at Tag 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36617 Based on medical record review, document review and interview, in 2 of 5 (Patient #9 and #16) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the benefits and risks of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer. Findings include: -- Per review of Patient #9’s medical record, he presented to the emergency department on 10/29/2023 at 5:35 pm with a chief complaint of a fall from a roof. The provider determined Patient #9 needed to be transferred to a higher level of care for a trauma due to multiple fractures, bilateral fracture of pubic rami, left acetabular fracture, closed fracture of one rib and closed fracture of lumbar vertebra. The transfer form titled “Consent for Transfer to Hospital,” dated 9/9/2016, under the section titled “Risks” contained the following preprinted statement: “All transfers have the inherent risks of unexpected worsening of medical condition, traffic delays, accidents during transport, inclement weather, rough terrain and the limitations of equipment and personnel present in the vehicle. Other ____” (left blank). The section titled “Benefits” contained the following preprinted statement: “higher level of care at receiving facility” (initialed by provider). There was no documentation regarding the specific risks and benefits of transfer related to the patient’s condition. -- Per review of Patient #16’s medical record, she was a three week old infant who was brought to the emergency department on 1/24/2024 at 3:02 pm. The provider determined Patient #16 needed to be transferred to a higher level of care for pediatric specialty care to rule out sepsis, obtain laboratory studies and possible lumbar puncture. The transfer form titled “Consent for Transfer to Hospital,” dated 6/12/2019, under the section titled “Risks” contained the following preprinted statement: “All transfers have the inherent risks of unexpected worsening of medical condition, traffic delays, accidents during transport, inclement weather, rough terrain and the limitations of equipment and personnel present in the vehicle. Other ____ “ (left blank). The section titled “Benefits” contained the following preprinted statement: “higher level of care at receiving facility” (initialed by provider). There was no documentation regarding the specific risks of transfer related to the patient’s condition. -- Review of the hospital’s policy and procedure titled “Cobra/EMTALA,” revised 5/2022, indicated prior to transfer of a patient the Consent for Hospital Transfer form detailing the risks and benefits of transfer must be completed. -- Per interview of Staff E, Education Coordinator, on 1/24/2024 at 2:00 pm, transfer documentation should include risks and benefits that are specific to each patient’s condition. -- During interview of Staff A, Emergency Department Director, on 1/24/2024 at 3:30 pm, and other times during the survey, he/she/they acknowledged the above findings.”