Highland Hospital

“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: 52113 Based on policy review, medical record review, and interview, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) in one of four psychiatric patient medical records reviewed, the physician failed to provide a complete medical screening examination to determine whether an emergency medical condition existed; and emergency department staff did not explain the risk/benefits and potential consequences of not being transferred to another hospital for a psychiatric evaluation.. Reference: Tag #2406- 489.24(a) & 459.24(c): Medical Screening. Tag #2407- 489.24(d)(1-3): Stabilizing Treatment.”

“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: 52113 Based on policy review, document review, medical record review, and interview, in one of four psychiatric patient medical records reviewed, the physician failed to provide a complete medical screening examination to determine whether an emergency medical condition existed. Specifically, a suicide screening assessment was performed by the physician but information related to a suicide attempt by Patient #1 the previous day was not utilized to determine the severity of the suicide risk. Findings include: Review of the policy “Identification and Care of the Suicidal Patient in the Emergency Department,” effective September 2025, revealed all patients greater than or equal to age nine will be screened for risk of suicide during their evaluation in the Emergency Department (ED). A patient presenting to the ED after demonstrating or threatening suicidal behavior, depression, and/or has made a suicidal gesture or attempt, requires rapid evaluation and initiation of safety measures which shall be triaged an Emergency Services Index, Level 2 (EMERGENT), high-risk situation, severe pain/distress, or altered mental status that must be seen quickly but not immediately life-threatening). These patients should not be placed in the waiting room. If it is discovered a patient is suicidal after triage or when C-SSRS (Columbia Suicide Severity Rating Scale- used to screen for suicide risk) or ASQ (Ask Suicide-Screening Questions- used to screen for suicide risk) screening occurs, a patient screens high risk and is not already in an appropriate care area, or safety measures are not implemented, they will be moved to an appropriate care area (e.g. removed from the waiting room) and safety measures will be enacted. Safety Measures: Modify patient care environment to the safest possible way to prevent self-harm, Utilized the Suicide Precautions Safety Checklist, ED staff must accompany the patient when leaving the evaluation area. The covering team is responsible for evaluating risk of suicide when a patient expresses suicidal ideation, exhibits suicidal behaviors, or if the patient has a history of suicide attempt. Social work is available to collaborate with the covering physician, nursing staff, and/or psychiatric consultant, in preparation with the patient and family prior to formal consultation and also in subsequent disposition planning. ED to Discharge: Once a patient is medically cleared and their risk for suicide remains low, the provider may determine the patient is safe for discharge. The discharge instructions must be accompanied by a documented safety plan. The safety plan may include the following: PCP (primary care physician) follow-up, mobile crisis, outpatient mental health referral, home safety plan, and/or other behavioral health resources. Review of the Centers for Medicare and Medicaid Services (CMS) website “C-SSRS (Columbia Suicide Severity Rating Scale) Screen Version pdf,” dated 2008, indicated the C-SSRS is a tool to assess suicide risk and severity in the past month. It consists of six questions with yes or no answers and risk level classification. The following questions and risk levels are listed: 1. Have you wished you were dead or could go to sleep and not wake up? Yes, it is low risk 2. Have you actually had any thoughts of killing yourself? Yes, it is low risk. If you answer yes, answer questions 3, 4, 5, and 6. If you answered no, go directly to question 6. 3. Have you been thinking about how you might do this? Yes it is moderate risk. 4. Have you had these thoughts and some intention on acting on them? Yes it is high risk. 5. Have you started to work out or worked out the details of how to kill yourself? Yes it is high risk. 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Answering Yes is high risk; No is moderate risk. (The hospital does not have a policy listing the questions and risk levels confirmed by Staff (A), Director of Quality). Review of the ED medical record for Patient #1 at Hospital #1 dated 01/31/26 revealed the following: -At 08:14 AM, Patient #1 arrived at the ED with a chief complaint of a mental health crisis. -From 08:16 AM to 08:19 AM, an ED triage note and assessment by Staff (S), Registered Nurse, revealed Patient #1 presented with a complaint of mental health crisis and reported severe depression, anxiety (feelings of worry, nervousness, unease), and psychosis (a mental state characterized by a loss of contact with reality). Their symptoms have worsened in the last three weeks. Patient #1 reported suicidal ideation, however, denied plan or access to means to end life. Patient #1 reported delusions (false belief, judgement, or perception) and denied hallucinations. An acuity/emergency severity index (ESI) of Level 2 or “Emergent (requires prompt evaluation and intervention)” was assigned and Patient #1 was given “bed K” (a hallway location within the ED). -At 08:47 AM, Staff (R), Registered Nurse, documented Patient #1 presented to the ED with a mental health crisis and stated they attempted to unalive themselves by suffocation the day prior but stopped. Patient #1 denied homicidal ideation but has periods of suicidal ideation. -At 09:29 AM, Staff (R), Registered Nurse, documented a suicide assessment (CSSRS - Columbia Suicide Severity Rating Scale Brief- tool to identify suicidal thought and behaviors). During the past month Patient #1 wished they were dead or wished they could go to sleep and not wake up; had thoughts of killing themselves, how they would do this, and had some intention of acting on them; and started to work out the details of how to kill themselves and intent to carry out this plan. Patient #1 answered that they have done something, started to do something, or prepared to do something to end their life. (The assessment does not document what risk level Patient #1 was for suicide. According to C-SSRS criteria in the attached policy, Patient #1 would be considered high risk with these answers). -At 09:31 AM, Staff (R), Registered Nurse, documented 1:1 (dedicated staff to provide constant observation) staff was in place, an initial room and patient search was performed and explained to Patient #1. Patient #1 did not have a current suicide plan but attempted suicide yesterday. No visitors were present. Patient #1 verbalized ideation spontaneously. 1:1 was maintained, and Patient #1 behaviors were calm, no unusual thoughts, and was able to engage. No 1:1 suicide intervention was needed. -At 10:02 AM, Staff (W), Physician, documented a suicide assessment (CSSRS) screening indicating during the past month, Patient #1 wished they were dead or wished they could get to sleep and not wake up. Patient #1 had thoughts of killing themselves. Patient #1 did not have a plan how they would do this and had no intention of acting on them; and did not work out the details of how to kill themselves and intent to carry out this plan. Patient #1 answered that they have not done something, have not started to do something, or have not prepared to do something to end their life in their lifetime. (There is no documentation in the medical record indicating if Patient #1 was at high, moderate, or low risk for suicide. (The assessment does not address/consider the RN notes and/or the C-SSR assessment at 09:29 AM documenting the suicide attempt the prior day. The assessment does not document the risk level. According to C-SSRS criteria in the attached policy, Patient #1 would be considered low risk with these answers). -At 10:04 AM, an order was placed by Staff (W), Physician, for outpatient referral to Adult Psychiatry for suicidal ideation. Patient #1 reports psychosis/mania but has no plan for suicide and has no symptoms of psychosis/mania at the time of the ED evaluation. Patient #1 was not in agreement for a voluntary CPEP evaluation. -At 10:40 AM, the documented departure condition for Patient #1 was stable condition, ambulatory, belongings were returned, and Patient #1 was in appropriate clothing. -At 10:42 AM, Staff (R), Registered Nurse, documented that discharge papers and crisis support information were given to Patient #1. Patient #1 verbalized understanding and stated their spouse was picking them up. Follow up care was discussed with Patient #1 who was calm, cooperative, and obeyed commands. -On 02/01/26 at 09:52 PM, a late entry note was entered by Staff (W), Physician (verified by Staff (A), Director of Quality) indicated Patient #1 presented to the ED seeking a psychiatric/mental health evaluation. Patient #1 stated they had been dealing with severe depression (mood disorder that causes persistent feelings of sadness and loss of interest in things) for many months which has now exacerbated with a loss of a job, health insurance, and hormone therapy. Patient #1 also reported episodes of psychosis (mental health condition characterized by a disconnection from reality) with hallucinations (perception of something not present), and a complete lack of sleep over the past two weeks that ended when they were able to sleep prior to presenting to the ED. Patient #1 described having suicidal ideation without a plan and reported a resolution to their auditory and visual hallucinations when they woke up. Patient #1 has called multiple places for outpatient treatment, however the soonest is not available for six weeks and would like evaluation and treatment sooner. Patient #1 stated they are not willing to go to another facility with CPEP (Comprehensive Psychiatric Emergency Program- 24/7 psychiatric emergency services) voluntarily believing it would be more traumatic and not beneficial. Patient #1 did not display any signs of psychosis. Based on Patient #1’s presentation, Staff (W) believed Patient #1 still had capacity and because they had capacity, Staff (W) did not have the ability to compel them to go voluntarily to the other facility’s CPEP. Staff (W) placed an urgent psychiatric referral from the ED for outpatient treatment. Patient #1 was also provided with multiple options for mobile health crisis from two different hospital systems. ED Course and Disposition: Patient #1 was provided with resources as above. Patient #1 stated they feel their mental health is getting worse and if they change their mind regarding CPEP, they will call. All questions and concerns were addressed. The most recent set of vitals were reviewed. Patient #1 was discharged in stable condition. (The assessment does not address/consider the RN C-SSR assessment at 09:29 AM and the suicide attempt the prior day). Interview on 03/10/26 at 02:34 PM with Staff (R), Registered Nurse, revealed Patient #1 presented with suicidal ideation and revealed they had made attempts the day prior. Patient #1 was alert and oriented and stated they were having an increase in stress having to deal with medical insurance problems. Interview on 03/10/26 at 02:55 PM with Staff (S), Registered Nurse, revealed Patient #1 expressed suicidal ideation but did not recall them having a specific plan. Patient #1 was depressed for approximately three weeks. Discharge disposition is directed by physician order. Typically, psychiatric patients who are not safe for discharge are seen for treatment at this hospital and are transferred to the CPEP within the same health care system. Interview on 03/11/26 at 07:09 AM with Staff (W), Physician, revealed psychiatric patients are not normally seen in the ED due to not having psychiatry services. Patient #1 was not acutely suicidal and there were no concerns they lacked decision making capacity. Patient #1 described a manic state in the weeks leading to their ED presentation. Patient #1 was able to sleep and was no longer having any hallucinations in the two days prior to presenting to the ED. Staff (W) does review nursing notes prior to assessment of a patient, however, did not see the note written by Staff (R), Registered Nurse, regarding Patient #1’s attempt at self-strangulation the day prior. Patient #1 did not report self-strangulation during their medical screening examination. Had Staff (W) seen the note, it would have changed the way that they asked questions of Patient #1, but it would have not necessarily have changed the treatment or disposition of Patient #1. There was no observation of any concerning psychiatric symptoms, such as hallucinations. Staff (W) completed an additional CSSRS screen with Patient #1 who scored moderate risk for suicide. Moderate risk does indicate that outpatient follow up is appropriate. Patient #1 was safe to discharge; they had capacity and expressed no plan or intent for suicide. Interview on 03/11/26 at 02:33 PM with Staff (V), Chief of ED/Physician, revealed based on their review of Patient #1’s ED presentation the standard of care was met and EMTALA regulations were followed. Patient #1 was not having an acute psychiatric event, did have suicide ideation but did not endorse a current suicide plan. Patient #1 was offered further evaluation at the local CPEP hospital and declined. The current policy “Identification and Care of the Suicidal Patient in the Emergency Department” has opportunities for improvement to further detail the care and discharge of a low or moderate risk scored patient. The policy only shows guidance for high-risk patients requiring one-to-one observation. Interview on 03/12/26 at 10:00 AM with Staff (A), Director of Quality, revealed there was no other policy that delineates the care of the psychiatric patient in the ED who scores a low or moderate risk on the CSSRS assessment. Additionally, there was no further policy guidance on what staff members (nursing or provider) were required to complete the CSSRS assessment.”

“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: 52113 Based on policy review, document review, medical record review, and interview, in one of four psychiatric patient medical records reviewed, emergency department staff did not explain the risk/benefits and potential consequences of not being transferred to another hospital for a psychiatric evaluation and did not obtain a signed “Informed Consent to Refuse” form from the patient and/or ED staff. Findings include: Review of the policy “Emergency Medical Treatment, Screening, Stabilization and Transfer (EMTALA),” effective August 2025, revealed a patient who has an emergency medical condition that has been stabilized may be transferred if the patient/legally responsible person requests or consents to transfer and has been informed of the risks and benefits involved in transfer. If a person refuses to consent to examination, treatment, or transfer deemed medically appropriate, the hospital must inform the patient/legal representative of the risks and benefits of the decision to refuse. If the patient refuses to sign the informed consent to refuse, it must be documented in the medical record. Review of the form “Adult Patient Certification of Release/Leaving Against Medical Advice (AMA)-SH 53 MR,” revised April 2023, indicated the form is not used in a psychiatric setting or for patients under the age of 18. The form documented the patient was being discharged at their request against the medical advice of the attending/emergency physician, and the provider has explained the following: the diagnosis/medical condition; what the treatment/plan was being refused; the risks or complications of not following medical advice; and the reason the patient was leaving against medical advice. There was an acknowledgment the patient was leaving at their own insistence and against medical advice; have been informed of the dangers/risk of leaving and understand the risks; release the hospital and persons involved with care from all and potential liability, claims, or actions related to the patient leaving against medical advice. There was an area for the patient and a witness to sign, date, and time the document. There was an attestation indicating the provider believes the patient is capable of understanding the risks with leaving against medical advice and has communicated to the patient this form will be retained as part of the medical record even if the patient/relative refuses to sign. There was an area for the providers printed name and signature with the date and time. There was an area for the attending physicians’ name and if they were notified. The last area indicated whether a copy (yellow) was given to the patient or if they refused. Review of the email dated 03/31/26 at 08:02 AM from Staff (A), Director of Quality, indicates “we would like to clarify the clinical circumstances surrounding this patients’ emergency department visit and subsequent discharge. Our ED AMA practice has been to engage patients in shared decision making and to utilize the AMA discharge process only when the team is unable to identify a medically appropriate disposition.” An email at 09:14 AM indicated the form used to discuss safety issues for AMA patients is SH 53 “Informed Consent to Refuse.” Review of the medical record for Patient #1 dated 01/31/26 from 08:14 AM to 10:44 AM revealed a full psychiatric evaluation was not performed at this hospital. No evidence was found in the medical record to indicate staff explained the risk/benefits and potential consequences of not being transferred to another hospital for a psychiatric evaluation or obtained documentation of the refusal on the “Informed Consent to Refuse” form by the patient and/or ED staff) Interview on 03/10/26 at 02:34 PM with Staff (R), Registered Nurse, revealed Patient #1 presented with suicidal ideation and revealed they had made attempts the day prior. Patient #1 was alert and oriented and stated they were having an increase in stress having to deal with medical insurance problems. Patient #1 refused further evaluation at the CPEP (Comprehensive Psychiatric Emergency Program- hospital that provides emergency psychiatric services) within the same health care system (transfer to another hospital). Interview on 03/10/26 at 02:55 PM with Staff (S), Registered Nurse, revealed Patient #1 expressed suicidal ideation but did not recall them having a specific plan. Patient #1 was depressed for approximately three weeks. Typically, psychiatric patients who are not safe for discharge are seen for treatment at this hospital and are transferred to the CPEP within the same health care system. Interview on 03/11/26 at 07:09 AM with Staff (W), Physician, revealed psychiatric patients are not normally seen in the ED due to not having psychiatry services. Patient #1 was not acutely suicidal and there were no concerns they lacked decision making capacity. Patient #1 did not want to be seen at the health system related CPEP hospital due to a previous traumatic experience. Patient #1 asked if there was any other place to go if they needed to in the future and a list of resources was provided including another hospital other than the health system related CPEP. Patient #1 did not indicate they were going to another hospital after discharge. Staff (W) stated that they would not have done anything different with the knowledge that Patient #1 was going to directly present to another facility because it would be considered a second opinion. Patient #1 was safe to discharge; they had capacity and expressed no plan or intent for suicide. A referral to psychiatry was ordered to help assist Patient #1 with obtaining a sooner outpatient appointment.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 49205 Based on policy review, medical record review, document review, and interview, in 1 of 13 medical records reviewed, the facility failed to ensure policies and procedures governing medical care provided in the emergency department are established by and are a continuing responsibility of the medical staff. Specifically, there is no policy that defines patient conditions for which the triage nurse would need to notify a provider. On 06/24/25, the triage nursing staff failed to notify a provider of Patient #3’s clinical presentation and placed Patient #3 in an emergency department (ED) hallway bed. Patient #3 experienced a medical emergency requiring cardiopulmonary resuscitation (CPR- chest compressions and rescue breaths to keep oxygenated blood flowing when the heart stops beating) and subsequently expired. Findings include: Review of “Emergency Department Documentation Standards”, effective July 2022, revealed vital signs reassessment and documentation for patients assigned an acuity level 2 (range: 1-immediate life-saving intervention, 2-emergent, 3-urgent, 4-less urgent, 5-non-urgent) will be every one hour and acuity levels 3-5 will be every two hours. Any change in patient condition, the Registered Nurse (RN) must make appropriate changes to acuity and collaborate with the charge nurse. This policy does not define patient conditions that would warrant immediate provider notification. Review of the “Emergency Severity Index Handbook Fifth Edition,” dated 2023, revealed the purpose of triage is to rapidly sort patients presenting for emergency department care, prioritizing those who are in more immediate need of care. Vital sign assessment can be critically important to correctly identifying these high-risk patients. Specifically, abnormal respiratory rate and high pulse rate have been found to be independent predictors of adverse events or deterioration. Unrecognized or unmanaged abnormalities of these vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation) is significantly associated with higher mortality rates. Signs of respiratory distress can include tachypnea (rapid breaths), tachycardia (rapid heartrate), speaking in short, 2-to-3-word sentences; abnormal lung sound; or congestion. Patients with mild to moderate respiratory distress should be further evaluated for respiratory rate and pulse oximetry to determine whether they should be categorized as acuity level 2. Patients who require two or more resources are assigned level 3, those who require one resource are assigned level 4, and those who require no resources are assigned level 5. Review of the Emergency Department (ED) medical record for Patient #3, dated 06/24/25, revealed the following: At 12:09 PM, an ED triage note by Staff (I), Registered Nurse (RN), revealed Patient #3 arrived at the ED from a group home via ambulance for increased weakness. Staff reported that Patient #3 had slid out of a chair at the group home and staff could not get Patient #3 back up. Patient #3 is usually ambulatory at baseline. Emergency Medical Services (EMS) placed Patient #3 on oxygen at 4 liters/minute via nasal cannula (clear tube into the nostrils to deliver oxygen). Patient #3 does not use oxygen at baseline. At 12:12 PM, Staff (I), RN, documented an assigned acuity level of 3 or “urgent”. Vital signs were a temperature of 96.4 degrees, a heart rate of 83, respirations of 12, a blood pressure of 150/65 (normal range 120/80), an oxygen saturation of 94% while receiving oxygen at 4 liters/minute, and a weight of 260 pounds. At 12:13 PM, Patient #3 was moved to a hallway bed. At 02:02 PM, Staff (I), RN, documented Patient #3 had a heart rate of 132 beats/minute. No other vitals noted. A code (emergency condition was identified) was called. At 02:16 PM, Patient #3 had a heartrate of 107 beats/minute, respirations of 16 per minute, a blood pressure of 54/22 millimeters of mercury, and an oxygen level of 89 percent on a ventilator (machine that provides respirations). At 03:04 PM, Staff (EE), Physician, documented Patient #3 presented from their group home with weakness and lethargy. Patient #3 had a witnessed cardiac arrest while awaiting ED provider evaluation. The group home staff member noticed that Patient #3 slumped over and became unresponsive and called for help. ED staff immediately initiated CPR. Emergency Medical Services (EMS) reported that Patient #3 was hypoxic, but Staff (EE) was not notified of what Patient #3’s oxygen level was prior to arrival at the ED. Patient #3 had been intubated during CPR and had received multiple rounds of epinephrine (increases blood flow to vital organs) prior to regaining a pulse. Patient #3’s initial cardiac rhythm was sinus tachycardia (abnormally fast heart rate) and there were no acute findings on an electrocardiogram (a test to check the heartbeat). The initial chest x-ray showed an evolving pneumonia involving the left lower lobe. Patient #3 was admitted to the Intensive Care Unit (ICU) for continued management. Interview on 12/17/25 at 02:40 PM Staff (I), Registered Nurse, revealed recalling Patient #3 presenting to the ED (second visit) via EMS with a staff member from their group home where they lived. EMS reported Patient #3 was not at their baseline and EMS had placed Patient #3 on oxygen. Staff (I) recalled Patient #3 appeared to be stable in triage, having normal respiratory effort even though they were on supplemental oxygen to maintain oxygen levels in the mid 90’s. Staff (I) recalled that the patient was not appropriate for the waiting room, but did not believe that Patient #3 needed immediate intervention or treatment. Patient #3 was moved to hallway bed on oxygen from the wall unit, and on a portable monitor. The monitor does not transmit the information into the patient’s medical record but will alarm when vital signs fall out of parameters. Staff (I) did not notify the attending physician of Patient #3’s presentation or their increased oxygen demand. Staff (I) was alerted when Patient #3 decompensated and was wheeled into room 17/18 for a code after rapidly declining. Interview on 01/08/25 at 11:15 AM with Staff (C), Hospital Administrator, revealed there is no policy specific to when a nurse would have to report an abnormal vital sign to an attending physician. There is no current triage policy, the hospital is working on one (in draft). The “ED Documentation” policy is currently being used as their triage policy.”

“SUPERVISION OF EMERGENCY SERVICES CFR(s): 482.55(b)(1) The emergency services must be supervised by a qualified member of the medical staff. This Standard is not met as evidenced by: 49205 Based on document review, policy review, medical record review, and interview, in 2 of 13 medical records (Patient #1 and Patient #3) reviewed, the medical staff failed to establish criteria in accordance with State law and regulations and acceptable standards of practice delineating the qualifications and supervision required for physician assistants (PA) in the emergency department (ED). Specifically, the hospital has an evaluation process to review the care provided by a PA every six months, but does not have a process for “continuous supervision,” of PA care provided in the ED. Patient #1 and Patient #3 were re-admitted to a hospital within 24 hours of discharge by a PA. There is no evidence in the medical records to indicate continuous supervision of the care provided by the PAs was conducted. Review of the “NYS Education Law, Article 131-B, 6542: Physician Assistants (PA): Performance of Medical Services,” indicated a PA may perform medical services, but only when under the supervision of a physician and only when such acts and duties as are assigned to such PA are within the scope of practice of such supervising physician. Supervision shall be continuous but shall not be construed as necessarily requiring the physical presence of the supervising physician at the time and place where such services are performed. Review of the document “Office of Professional Medical Conduct (OPMC) and Physician Discipline (PA),” indicated in December 1970, the American Medical Association adopted the following definition for Physician Assistant: The PA is a skilled person qualified by academic and practical training to provide patient services under the supervision and direction of a licensed physician who is responsible for the performance of that physician assistant. A PA is considered a dependent practitioner working under the supervision of a licensed physician responsible for the actions of the physician assistant. The supervising physician may delegate to the PA any medical procedures or tasks for which the PA is appropriately trained and qualified to perform and that are routinely performed within the normal scope of the physician’s practice. A PA can: 1. Evaluation- initially approaching a patient of any age group in any setting to elicit a detailed and accurate history, perform an appropriate physical examination, delineate problems and record and present the data. 2. Monitoring- assisting the physician in conducting rounds in acute and long-term inpatient settings, providing care in office-based and other ambulatory care settings, developing and implementing patient management plans, and recording progress notes. 3. Diagnostics- performing and/or interpreting, at least to the point of recognizing deviations from the norm, common laboratory, radiologic, cardiographic, and other routine diagnostic procedures used to identify pathophysiologic processes. 4. Therapeutics- performing routine procedures such as injections, immunizations, suturing and wound care, managing simple conditions produced by infections or by trauma, assisting in the management of more complex illnesses and injuries, and taking initiative in performing the evaluation and therapeutic procedures in response to life threatening situations. 5. Counseling- instructing and counseling patients regarding compliance with prescribed therapeutic regimens, normal growth and development, family planning, emotional problems of daily living, and health maintenance. 6. Referral- facilitating the referral of patients to other health related practitioners and community health and social service agencies when appropriate. PA’s may be employed under the supervision of a designated physician, in all areas of the hospital setting, including inpatient, emergency room, surgery, ambulatory care clinics, employee health and community outreach programs. PA’s employed or extended privileges by a hospital may, if permissible under the bylaws, rules and regulations of the hospital, write medical orders for inpatients under the care of the physician responsible for the supervision of the PA. Countersignature of such orders may be required if deemed necessary and appropriate by the supervising physician or the hospital, but in no event shall countersignatures be required prior to execution. Review of the “Medical Staff Bylaws,” effective 01/06/25, revealed dependent allied health professionals (physician assistants) may practice only under the supervision of an attending staff member as provided by law or regulation, or policies of the hospital or department in which the supervising physician is credentialed and privileged. Review of “Focuses Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)- Advanced Practice Practitioners,” effective 11/2018, revealed the purpose of this policy is to define and maintain an ongoing and continuous professional evaluation process in addition to reappointment cycle evaluation and annual performance evaluation; to assure early identification of performance concerns; to support evidenced-based clinical privilege decisions; and to ensure that health care professionals are qualified to perform procedures for which they are privileged. The initial FPPE for Physician Assistants (PA) must be completed within three months of hire by the supervising physician. The supervising physician is responsible to convene a team conference including consulting physicians, peer PA’s, nursing and other personnel (as appropriate) to evaluate the PA’s performance. The findings are discussed with the PA and documented. The (OPPE) must be completed twice per year by the supervising physician, who is responsible for completing the review form and returning it to the PA. The PA is responsible for developing an action plan (when performance issues are identified), then submit the complete evaluation to the program administrator. Review of the signed documents “Emergency Department (ED) Physician Assistant (PA) Job Description,” for Staff (S), PA, dated 10/26/16 and for Staff (T), PA (no date), revealed the PA will work under the direct supervision of the ED Attending Physician. The PA will evaluate and treat the acute and non-acute medical, surgical, orthopedic, OB/GYN, pediatric, and psychiatric patients through appropriate history and physical, radiology, and laboratory data. The essential duties include obtaining a detailed, accurate medical history, performs physical examinations and writes orders for treatments, medications, and appropriate and cost-effective testing. The PA develops a differential and working diagnosis; coordinates test results, history and physical examination to assure proper patient disposition; discharges and admits patients, assuring the patient and family have a thorough understanding of the findings and necessary follow-up; documents all findings clearly in the medical record; obtains consultation from a specialist as needed; and maintains consistent ongoing communication with the ED Physician about the patient’s status. Review of “Physician Assistant (PA)-Emergency Medicine Delineation of Privileges” for Staff (S), PA, dated 04/16/25 and Staff (T), PA, dated 12/17/25, revealed “Base privileges are defined as those standard, usual and customary activities appropriate to the diagnosis and treatment of patients. Physician Assistant base privileges include the evaluation, performing history and physical examination, differential diagnosis, provision of treatment, appropriate medical record documentation, monitoring, communication with patients and family regarding treatment, counseling, referral, and execution of treatment within the scope of practice and licensure of supervising physician. Perform, order and interpret preventive and non-invasive diagnostic tests commonly associated with the medical specialty of the supervising physician. Prescribe/order pharmacologic and non-operative therapeutic interventions commonly associated with the medical specialty of the supervising physician.” Staff (S) signed off they were granted base privileges on 06/24/25. Staff (T) signed off they were granted base privileges from 11/01/24 to 10/31/26. Interview on 12/18/25 at 11:30 AM and 01/08/26 at 02:20 PM, with Staff (S), Physician Assistant (PA), revealed they are regularly in contact with their supervising physician and meets with them every six months for performance review. While working in the ED, there is always an attending working and will help Staff (S) with cases if needed. There is no requirement for a PA to report every case to an attending physician prior to discharging the patient. The decision making of involving a physician in the care of a patient is done on a case-by-case basis. Interview on 01/08/26 at 11:00 AM with Staff (W), Physician, revealed physician assistants (PA) are utilized in the ED but are not required to present every patient they see to a medical doctor. PA’s have an opportunity to have the medical doctors examine their patients if they have a question or concern. PA’s do not have to present their patients to attending physicians. There are supervising physicians over the PAs who review charts periodically every six months. Advanced practice providers pick which patients they see during their shift in the ED. PA patient’s charts are not all reviewed unless there is an indication or concern. There is no national standard for an attending physician to sign off on all charts of a PA. Interview on 01/08/26 at 01:00 PM with Staff (LL), Physician Assistant (PA), revealed the PA’s work under a supervisory agreement with a physician that is reviewed every six months. The review is sent out to the supervising physician to fill out, then to the lead advanced practice practitioner for review, and finally to the medical staffing office for record obtainment. The privileges for a physician assistant are granted by the supervising physician. PA’s work within the guidelines of those privileges. PA’s working in the ED are not required to discuss patients they are providing care for with an attending physician, unless the PA feels a patient is more complex than they are comfortable treating. Staff (LL) stated there is always an attending physician on duty in the ED for the PA to turn to for guidance if needed. There is no policy in place requiring PA’s to speak with a physician prior to discharging a patient from the ED. Interview on 01/08/26 at 02:00 PM with Staff (C), Hospital Administrator, revealed that there is no “scope of practice” policy regarding physician assistants (PA) working in the ED. PA’s work under the guidance of the medical by-laws, the physician assistant supervisory agreement, and the delineation of privileges. Staff (C) acknowleged that Physician Assistants are not required to discuss every patient they see with an attending Physician. Review of the ED medical record for Patient #1, dated 03/29/25, revealed the following: At 06:44 AM, Patient #1 arrived at the ED via ambulance. Staff (S), Physician Assistant (PA), documented Patient #1 presented to the ED with lower back pain which has been worsening over the past week. Patient #1 reported their pain was significantly worse overnight. They took medications and applied heat to alleviate the pain, with no significant improvement. Patient #1 reported their pain is mostly in the lower right back but radiates down their right leg with some tingling noted in their right foot, which had been intermittently present over the past year. Patient #1 denied any true numbness or changes in bladder/bowel function. Patient #1 was seen by their spinal specialist the previous day, was started on a Medrol dose pack (pre-packaged steroid medication typically prescribed for a six-day course to help reduce inflammation), and a Magnetic Resonance Imaging (MRI-uses magnets/radio waves to create detailed pictures within the body) was ordered and scheduled for 04/04/25. At 06:47 AM, Staff (Y), Registered Nurse (RN), documented a triage note indicating Patient #1 arrived in the ED with “sharp/stabbing” right leg pain with a history of sciatica (pain, numbness, tingling, or weakness radiating from the lower back down the leg). At 06:48 AM, triage vital signs were normal except a pain level of 10/10 (0-no pain, 10-worst pain). Patient #1 was assigned an acuity level of 4 or “less urgent.” At 06:58 AM, a falls assessment indicated Patient #1 was a medium risk. Gait and transferring were documented as “normal/bedrest/wheelchair.” At 07:00 AM, an assessment by Staff (R), RN, revealed back pain was present starting in the lower lumbar area and radiated down the right leg. Patient #1 had full range of motion in all extremities and strong strength in both arms and the left leg. The right leg assessment did not specify strength, only indicating Patient #1 had a history of sciatica that started in the lower back radiating down the right leg. At 07:15 AM, Staff (R), RN, documented Patient #1’s right leg had full strength with “slight numbness to inside of the right foot”. At 07:33 AM, Patient #1 received 1,000mg Tylenol (relieve minor aches and pains) orally, 5 mg Cyclobenzaprine (short term muscle relaxant) orally, 15mg Ketorolac (non-opioid nonsteroidal anti-inflammatory drug used short-term for moderate to severe acute pain) intramuscular (in the muscle), and a Lidocaine 4% patch (topical anesthetic to provide temporary relief for minor muscle/joint pain) was applied to the lower right back. At 08:14 AM, Staff (R), RN, documented Patient #1 reported their pain level was 6/10 with pain shooting down their right leg. At 08:49 AM, Patient #1 received 5 mg Cyclobenzaprine orally. At 09:14 AM, Staff (S), Physician Assistant, documented Patient #1 had 5/5 strength (full) in both lower extremities with sensation grossly intact (normal). There were no red flags noted such as changes in bowel/bladder function, fever/chills, or recent trauma/injury. Patient #1 was treated for their pain with improvement noted. Patient #1 had been able to ambulate independently while in the ED. Staff (S) recommended Patient #1 start taking Tylenol 1,000mg three times a day, apply one Lidocaine patch daily, continue taking the Medrol Pack as prescribed by their spinal specialist, and advised Patient #1 they could utilize Cyclobenzaprine and Gabapentin previously prescribed for them. A note was provided to Patient #1 excusing them from work until the date of their scheduled MRI. Staff (S) had a detailed discussion with Patient #1 regarding their exam and explained there was no indication for further emergent intervention of inpatient treatment. Patient #1 was advised to follow-up with their primary care provider, their spinal specialist, and to return to the ED for any worsening or persisting symptoms. Patient #1 verbalized an understanding of diagnosis, plan, and follow-up. At 10:05 AM, Staff (R), RN, documented the departure condition of Patient #1 as stable, with mobility listed as “wheelchair.” Discharge instructions, follow-up care, medications given, and pain management were all discussed or reviewed with Patient #1, who verbalized an understanding. Patient #1 was discharged via wheelchair to home in stable condition. (There was no evidence of attending physician documentation found in the medical record). Review of the medical record for Patient #1 (from the 2nd hospital), dated from 03/30/25 to 04/01/25, revealed Patient #1 was seen in the ED with severe back pain after being discharged home from another hospital the previous day. Overnight, the pain further intensified, and they had two episodes of urinary incontinence. Patient #1 reported feeling some weakness of the right leg and their right leg felt “cold.” There was tenderness present in the lower lumbar region into the sciatica area. The neurological exam revealed a sensory deficit present. Patient #1 reported decreased sensation of the right outer leg from the knee to ankle and at the top of the foot. Patient had an MRI of the left spine, and Ortho/Spine consult, and underwent surgery for a undergo L4-5 discectomy (surgery to remove part of a damaged spinal disc that’s pressing on a nerve), and disc repair the following day. Review of the ED medical record for Patient #3 (1st visit), revealed the following: On 06/23/25: At 02:05 PM, Staff (T), Physician Assistant, documented Patient #3 presented to the ED with lethargy, abdominal pain and a cough. Group home staff reported Patient #3 had been more lethargic over the past two days, was having difficulty getting out of bed today, and had a cough for a little over a month like others at the group home. Patient #3 was not ill-appearing and exhibited no signs of acute distress; had a normal heart rate; and had normal beath sounds, with normal effort of breathing. Patient #3’s abdomen was flat, soft, non-tender, and had normal bowel sounds. At 02:07 PM, vital signs were a temperature of 97.2 degrees (normal range 96-99 degrees) Fahrenheit, a heart rate of 101 (normal range 60-100) beats per minute, respirations of 18 (normal range 12-20) breaths per minute, a blood pressure of 151/96 (normal range 90-140/60-90) millimeters of mercury, an oxygen saturation of 92 (normal range 93-100) percent, and a weight of 256 pounds. At 02:10 PM, an ED triage note revealed group home staff report Patient #3 was lethargic, having abdominal pain, and was pointing to their groin indicating they were in pain. An acuity level of 3 or “urgent” was assigned. At 05:58 PM, bloodwork results revealed a white blood cell count of 11.4 thousand per microliter (normal level 4-11), mean corpuscular volume 103 femtoliters (a measurement of the average size of red blood cells, normal level 80-100), neutrophils 7.8 thousand per microliter (type of white blood cell that fight infection normal level 1.8-7.7). At 06:01 PM, the “Sepsis Predictive Model Score” for Patient #3 was 1 (over 6 is treated as sepsis). At 06:24 PM, blood work results revealed a sodium of 133 millimoles per liter (electrolyte in blood that helps control water balance, normal level 135-145), chloride 97 milliequivalents per liter (an electrolyte in blood that regulates acid/base balance, normal level 98-107), and carbon dioxide 22 millimoles per liter (a waste product in blood that the body naturally eliminates through breathing, normal level 22-30). At 07:35 PM to 07:38 PM, Staff (U), RN, documented Patient #3 had 4/10 (0-no pain, 10-worst pain ever) abdominal pain. Patient #3 was lethargic, but arousable to verbal stimuli. Patient #3 was non-verbal but was able to nod appropriately. Patient #3 had hypoactive (slower than normal) bowel sounds and their abdomen was distended. Patient #3 had regular, easy respirations, clear lung sounds and a cough present. Patient #3 had a 4 out of 10 pain level (0-no pain, 10-worst pain). Temperature was 96.3 degrees, a heart rate of 87, respirations of 18, blood pressure of 143/102, and an oxygen saturation of 93 percent. At 07:52 PM, Staff (T), Physician Assistant, ordered Covid, influenza and Respiratory Syncytial Virus (RSV) (common lung illness) testing which were negative. At 09:11 PM, the computed tomography (CT scan- uses x-ray and computer to create an image of inside the body) of the abdomen and pelvis results revealed findings of patchy bands of consolidation in the lower lungs with may represent atelectasis, but superimposed pneumonia (a bacterial lung infection) could not be entirely excluded. At 11:19 PM, the chest x-ray results revealed findings of increased interstitial markings in both lungs. These findings may represent edema (fluid in the lungs) or atypical (caused by bacteria, viruses or fungi) infection. At 11:39 PM, Staff (T), Physician Assistant, documented Patient #3 was arousable when their name was called and was responding to questions. The laboratory was notable for mild leukocytosis (an increase in the number of white cells in the blood). Covid, influenza and RSV testing was negative. Thyroid testing was normal. Patient #3 did not have any infectious source at that time. The urinalysis was normal. The CT scan of Patient #3’s abdomen showed signs of constipation but no evidence of bowel obstruction. There were concerns for potential bands of consolidation (area in the lung where the air in the small airways has been replaced by a fluid or solid material). Patient #3 was sent for chest x-ray without evidence of focal consolidation (a localized area in the lung where the normally air-filled alveoli become filled with fluid, pus, blood, or other substances). Patient #3 was afebrile (no fever), had a normal heart rate, no tachypnea (abnormally rapid breathing) and normal oxygen levels, making pneumonia unlikely. These results were discussed with Patient #3 and the group home staff member at bedside who will be discharged home in stable conditions. At 11:47 PM, the discharge instructions indicated a diagnosis of weakness. Laboratory blood work and imaging results were “overall reassuring.” The CT scan did not show evidence of acute abnormalities. Vitals signs are a blood pressure of 143/100, pulse of 87, respirations of 18, temperature of 96.3, and an oxygen saturation of 93% (with no supplemental oxygen). Follow up with the primary care physician in one week. Return to the ED if your symptoms persist or worsen, especially if you experience chest pain or trouble breathing. No medications were ordered for discharge. On 06/24/25: At 12:03 AM, Staff (U), RN, documented they notified Staff (T), Physician Assistant of Patient #3’s vital signs and Staff (T), PA was present when Staff (U) rechecked Patient #3’s temperature. Patient #3 was able to stand at bedside, was assisted with getting dressed, and ambulated to a wheelchair. Group home staff member verbalized an understanding of the discharge plan. Vital signs were a temperature of 95.1, a heart rate of 89, respirations of 18, a blood pressure of 140/100, and an oxygen saturation of 96 percent. At 12:18 AM, Staff (U), RN, documented Patient #3 was in stable condition. (There was no evidence of attending physician documentation found in the medical record). Review of the ED medical record for Patient #3 (2nd visit), revealed on 06/24/25 at 12:06 PM, Patient #3 presented back to the ED via ambulance. At 12:12 PM, Staff (I), RN, documented vital signs with a temperature of 96.4 degrees, a heart rate of 83, respirations of 12, a blood pressure of 150/65, an oxygen saturation of 94 % while receiving oxygen at 4 liters/minute, and a weight of 260 pounds. At 02:02 PM, Patient #3 experienced a medical emergency requiring CPR. At 02:16 PM, Patient #3’s had a heartrate of 107 beats/minute, respirations of 16/minute, a blood pressure of 54/22 millimeters of mercury, and an oxygen level of 89 percent on a ventilator. At 02:20 PM, the chest x-ray results revealed findings of continued consolidation throughout most of the left lung. This may represent atelectasis or infection. Patient #3’s clinical condition worsened. On 07/06/25, Patient #3 was extubated while surrounded by family and passed peacefully at 03:14 PM.”

“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: 49420 Based on policy review, document review, medical record review, and interview, it was determined that the nursing staff failed to adhere to policies and procedures of the hospital for the following: 1) Nursing staff failed to notify a provider when the blood glucose results were outside of reference range per facility parameters for 1 of 13 medical records reviewed. (Patient #1) 2) Nursing staff failed to complete hourly in person one-to one observation documentation for 4 (Patient #1, #9, #10, and #11) out of 13 patient medical records reviewed and failed to document initiation and discontinuation of in person one-to one observations for 3 (Patient #9, #10, and #11) out of 13 patients. Review of the policy “Nursing Process and Documentation Guideline”, last revised February 2024, revealed that “Progress notes are utilized to address all variances from the desired outcomes of the plan of care and must reflect the status of the patient problem identified and should be written when information required is not easily documented in other areas of the medical record or the information is not easily synthesized. In general nursing documentation in the medical record is completed for a change in the patient condition or behavior, and notification of a provider including the time of notification and the corresponding nursing intervention.” Findings #1: Review of the medical record for Patient #1, dated 01/27/25 to 02/06/25, revealed the following: -On 01/28/25 at 01:03 AM, a Lispro insulin order by Staff (L), Nurse Practitioner, revealed the provider was to be notified if the fingerstick blood sugar was greater than 400. -On 01/28/25 at 05:18 PM, the fingerstick blood glucose result was 428 and there was no documentation found that the provider was notified of the blood glucose being greater than 400. -On 01/29/25 at 12:36 AM, the fingerstick blood glucose result was 443 and there was no documentation found that the provider was notified of the blood glucose being greater than 400. -On 01/29/25 at 05:54 AM, the lab blood glucose result was 446 and there was no documentation found that the provider was notified of the blood glucose being greater than 400. -On 02/03/25 at 01:07 AM, the lab blood glucose result was 591 and there was no documentation found that the provider was notified of the blood glucose being greater than 400. -On 02/03/25 at 06:24 AM, the fingerstick blood glucose result was 460 and there was no documentation found that the provider was notified of the blood glucose being greater than 400. Interview on 03/17/25 at 10:30 AM with Staff (F), Registered Nurse, revealed that if they are taking a fingerstick blood glucose and it reads out of expected range (less than 70 or greater than 120) they would recheck it and notify the provider. If the reading is “HI” (greater than 400), they would recheck and contact the provider. Interview on 03/17/25 at 02:40 PM with Staff (J), Registered Nurse, revealed that if a patient’s blood sugar in greater than 400 and the insulin parameters state to notify the provider, it would be documented in a progress note or in the medication administration record. Interview on 03/17/25 at 04:00 PM with Staff (E), Performance Improvement Coordinator, verified these findings. Findings #2: Review of the policy “Utilization of Staff and Staffing,” last revised February 2023, revealed “the initiation of a one-to-one observation for patients that have delirium, or behavioral conditions are assessed and categorized from tier one to five. Tiers one to three receive the highest priority for one to one-to-one coverage. Tier one is patients on suicide precautions, tier two is behavioral patients for substance abuse, tier three is for patients that are at risk for harming themselves or others, tier four is for patients that have a previous history of falls, and tier five is for patients that are at risk for falls. One-to-one coverage may be provided by a patient care technician or a companion observer. Documentation of observations for behaviors of the patient are made hourly by the staff observing the patients. The decision to discontinue the one-to-one coverage is made based on clinical judgement by the nurse however, if the one-to-one coverage was ordered by a provider, nursing must consult with the provider to determine if the patient is appropriate for discontinuation of the one-to-one observation.” Review of the medical record for Patient #1, dated 01/27/25 to 02/06/25, revealed on 01/27/25 at 11:56 PM, Patient #1 was admitted to the hospital for congestive heart failure. On 01/29/25 at 12:30 AM, Staff (P), Registered Nurse, documented Patient #1 was confused, impulsive, and attempting to get out of bed. Patient #1 fell out of bed after their bed alarm sounded sustaining multiple injuries. At 04:47 AM, Staff (N), Physician Assistant, ordered for a one-to-one bedside sitter for behavior after the fall. On 02/03/25 at 05:52 PM, Staff (EE), Physician Assistant, discontinued the order for a one-to-one bedside sitter. Review of the “One-to-one daily staffing assignment,” revealed Patient #1 was assigned to have a one-to-one sitter or virtual sitter from 01/29/25 to 02/03/25 for impulsiveness and was scored a tier four (previous history of falls). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/29/25 from 04:47 AM to 03:47 PM and from 06:20 PM to 12:00 AM; on 01/30/25 from 12:00 AM to 08:00 AM, 02:00 PM to 04:00 PM, and 07:00 PM to 12:00 AM; 01/31/25 for the entire day; on 02/01/25 from 12:00 AM to 11:00 AM and 07:25 PM to 12:00 AM; and on 02/02/25 at 12:00 AM to 02/03/25 at 05:52 PM. Review of the medical record for Patient #9, dated 02/01/25 to 02/14/25, revealed on 02/01/25, Patient #9 was admitted to the hospital for Right Internal Jugular Thrombosis (blood clot in vein in neck) and Cervical Lymphadenopathy (swollen lymph nodes in neck). On 02/02/25 at 01:16 PM, Staff (NN), Physician, progress note revealed that Patient #9 had a one-to-one bedside sitter due to aggression earlier that day. On 02/08/25 at 07:11 AM, Staff (OO), Physician, revealed that Patient #9 was on a one-to-one bedside sitter as they were more confused. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued. Review of the “One-to-one daily staffing assignment,” revealed Patient #9 was assigned to have a one-to-one sitter or virtual sitter from 02/02/25 to 02/04/25 for attempting to get out of bed and pulling at lines and was scored a tier three (at risk for harming themselves or others). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 02/02/25 from 12:00 AM to 10:00 AM and from 07:00 PM to 12:00 AM; and on 02/03/25 from 12:00 AM to 11:11 AM. Review of the medical record for Patient #10, dated 12/26/24 to 01/11/25, revealed on 12/26/24, Patient #10 was admitted to the hospital for orthostatic hypotension (sudden drop in blood pressure when you stand up). On 01/01/25 at 04:15 PM, Staff (PP), Physician Assistant, progress note revealed that Patient #10 had a one-to-one bedside sitter due to a witnessed fall and Patient #10 needed to continue to have the one-to-one bedside sitter. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued. Review of the “One-to-one daily staffing assignment,” revealed Patient #10 was assigned to have a one-to-one sitter or virtual sitter from 01/01/25 to 01/02/25 for attempting to get out of bed and pulling at lines and was scored a tier four (previous history of falls). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/01/25 from 12:00 AM to 03:00 PM and from 05:00 PM to 06:00 PM; and on 01/02/25 for the entire day. Review of the medical record for Patient #11, dated 12/26/24 to 01/27/25, revealed on 12/26/24, Patient #11 was admitted to the hospital for congestive heart failure exacerbation (worsening of heart failure symptoms). On 12/26/24 at 12:37 PM, Staff (QQ), Physician Assistant, ordered for a one-to-one bedside sitter for agitation and confusion. On 01/13/25 at 10:39 AM, Staff (RR), Physician Assistant, discontinued the order for a one-to-one bedside sitter. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued. Review of the “One-to-one daily staffing assignment,” that began on 01/01/25 revealed Patient #11 was assigned to have a one-to-one sitter or virtual sitter from 01/01/25 to 01/02/25 for fall risk and impulsiveness and was scored a tier three (at risk for harming themselves or others). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/01/25 from 12:00 AM to 10:00 AM and from 11:00 PM to 12:00 AM; and on 01/02/25 for the entire day. Interview on 03/17/25 at 10:30 AM with Staff (F), Registered Nurse, revealed that if they believed that a patient needed a one-to-one bedside sitter, they would have one of the patient care technicians stay with the patient while they contacted the patient ’ s provider and nursing supervisor to arrange for a sitter to be assigned to the patient. Sitters document on patient safety once an hour, or if there are any changes. This documentation is typically entered into the electronic medical record by the sitter, but there are instances where the sitter fills out a paper form which is latter scanned and uploaded into the electronic medical record. Interview on 03/17/25 at 02:40 PM with Staff (J), Registered Nurse, revealed that if a patient is impulsive, agitated, and a fall risk Staff (J) would either obtain an in person one-to-one sitter or a virtual sitter to attempt to keep the patient safe. If a patient is on a one-to-one sitter there would be documentation in the electronic medical record by the sitter and the nurse caring for the patient. Interview on 03/18/25 at 09:15 AM with Staff (DD), Patient Care Technician, revealed they were actively observing a patient who was currently on a one-to-one sitter for behavior from 03:00 AM to 09:15 AM. Staff (DD) was not aware they had to document in the electronic medical record behavioral observation flowsheet for patients on a one-to-one sitter for behavior until that morning at 08:00 AM. Interview on 03/18/25 at 01:30 PM with Staff (E), Performance Improvement Coordinator, revealed they were unable to locate any other one-to-one in person sitter paper documentation forms for Patient #1, #9, #10, and #11. Staff (E) verified that a one-to-one in person sitter for behavior is a nurse driven decision for safety and does not need an order to obtain. The nurse would communicate the need to their manager, or the nursing supervisor and the sitter assignments are kept on a staffing log and are evaluated every four hours to determine the continued need for the one-to-one sitter. Interview on 03/18/25 at 01:35 PM with Staff (T), Companion Observer, remembered Patient #1 and they were assigned on 01/29/25 to monitor Patient #1 who was on a one-to-one sitter for behavior after they fell. Staff (T) revealed that Patient #1 was confused, agitated, and they would not sit still. Staff (T) sat with Patient #1 and attempted to keep them calm, but Patient #1 continued to attempt to get out of bed. Staff (T) revealed documentation is completed every hour when a patient in on a one-to-one in person sitter for behavior but revealed that they did not complete the documentation per policy for Patient #1. Staff (T) obtains report from the sitter before their shift, the patient care technician, or the nurse before they begin to monitor the patient in person.”