University Hospital S U N Y Health Science Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 21072 Based on document review and interview, the facility did not ensure that all staff who participate and monitor patients in restraint or seclusion receive training in first aid. In 2 of 2 clinical staff personnel files (Staff I and Staff J) reviewed, both lacked evidence of training in first aid. Findings include: -- Per review of Staff I’s personnel file and Staff J’s personnel file, neither employee file had documentation of first aid training. -- Per interview of Staff K, Clinical Staff on 4/8/2026 at 1:35 pm, they verified that these staff did not have first aid training and it was not currently required for this staff title.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 46869 Based on document review and interview, 21 months after the facility’s development of an After-Action Report (AAR) for a 7/2024 downtime event, the facility had not implemented a downtime procedures training program that was specified in the AAR’s improvement plan. Findings include: -- Review of the facility’s AAR for the 2024 Worldwide CrowdStrike Incident, undated, revealed that an area for improvement realized during the event was that “a majority [of] staff are always surprised to know the institution has downtime procedures. Several units had to do downtime “just in time” training for staff to be able to operate the unit, and also for remote work staff.” An improvement plan was established in the AAR to implement the following: “After the process for downtime procedures, and updating of downtime forms, there needs to be a training program created for all staff who will be impacted during downtime. Some training will need to be department or task specific.” -- Per interview of Staff A, Clinical Staff, on 4/6/2026 at 10:57 am and on 4/7/2026 at 2:42 pm, when asked about computer downtime procedures, Staff A indicated they have not experienced any downtime while working. If a downtime did occur, they would use paper forms and fax orders to the pharmacy, radiology, and laboratory. They did not recall education related to downtime procedures. -- Per interview of Staff B, Clinical Staff, on 4/7/2026 at 2:30 pm, Staff B is comfortable with downtime procedures. Staff B has experienced downtime at different facilities and here. The downtime here was hectic. Most staff did not know what to do. At other facilities, a paper packet is available as soon as a patient comes in. The packet follows the patient throughout their ED stay. This ensures all information goes with the patient. -- Per interview of Staff C, Clinical Staff, on 4/6/2026 at 4:10 pm, Staff C has only experienced downtime once. The charge nurse had helped them navigate the downtime. During that time, Staff C tried to do busy work, such as keeping the rooms stocked and changing IV tubing. Staff C stated that they would document later, after the downtime was over. -- Per interview of Staff D, Clinical Staff, on 4/6/2026 at 3:05 pm, Staff D stated during network and/or electronic medical record (EMR) downtime they paper chart everything. Staff D stated that they did not know where downtime procedures were kept, either physically printed or electronic. Staff D stated they had never seen a facility policy or procedure for downtime. Staff D stated the computers with red keyboards are business continuity access (BCA) computers that should work during downtime. Staff D stated they had never received formal training on downtime procedures specific to their unit. -- Per interview of Staff E, Clinical Staff, on 4/6/2026 at 3:33 pm, Staff E stated they had been trained on scheduled network and/or EMR downtime; however, when there is a scheduled downtime, they would delay any documenting until after the downtime was over. Staff E stated that during one of the unscheduled downtime events, every computer shutdown, including the business continuity access (BCA) computers on their unit. -- Per interview of Staff F, Clinical Staff, on 4/7/2026 at 9:20 am, Staff F stated that if there is a downtime event that affected their unit, there would be paper documents available to be used. They would need to print the Medication Administration Records (MARs) for their patients using their unit’s dedicated downtime computer. Staff F stated that there is a red phone and BCA computer in the nurses’ station. They were not certain where their unit’s downtime procedures were, either electronic or written, but was certain that their supervisor would know where it was. -- Per interview of Staff G, Clinical Staff, on 4/7/2026 at 9:30 am, Staff G stated that during downtime that affects their unit, they would have to print out physical forms for use in treatment, depending on the duration of the downtime. There is a OneDrive cloud system that can pull copies of their forms to print out, they do not have already printed documents for immediate use. Staff G stated that they have not been trained on downtime procedures when they went through orientation or since then. Staff G was not aware of the facility’s policy & procedure for downtime procedures. -- Per interview of Staff H, Non-clinical Staff, on 4/6/2026 at 2:00 pm and 4/8/2026 at 10:45 am, they detailed the facility’s development of a “super user” training program to train and reeducate unit nurse managers on downtime procedures, who can then in turn teach other unit staff. Staff H acknowledged the above findings and stated that the “super user” training program has not been implemented yet.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46869 Based on observation and document review, the facility did not ensure that patients received care in a safe setting. Specifically, two corridor doors on the first level of the Children’s Pavilion inpatient psychiatric facility were held open (with door holders) and posed a ligature risk for patients. Findings include: -- Per observation of the facility’s Children’s Pavilion inpatient psychiatric facility, on 5/5/2025 at 10:38 am and 10:40 am, two corridor doors were held open using door holders on the first-floor level of the facility, posing a ligature risk to patients. -- Per interview of Staff B, Assistant Director of Operations, on 5/5/2025 at 10:20 am, the two corridor doors on the first-floor level were held open as staff had to use a physical key to open them, and it was more convenient for staff to have them held open until badge access is enabled for the doors. -- During interview of Staff C, Deputy Director of Nursing for Inpatient Psychiatry, on 5/5/2025 at 1:20 pm, they acknowledged the above findings.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 46869 Based on observation, interview, and document review, the facility did not ensure that all areas of the hospital were in compliance with National Fire Protection Association (NFPA) 99 (2012 ed.) section 9.3.1, which requires the facility to maintain compliance with American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170. Specifically, (1) the facility did not ensure that Upstate University Hospital at Community General’s sterile processing department was maintained within required temperature ranges specified in ASHRAE Standard 170; (2) the facility did not ensure that Upstate University Hospital at Community General’s pathology department was maintained within required temperature ranges specified in ASHRAE Standard 170 and did not maintain a negative pressure relationship between the pathology laboratory and the outside corridor. Findings regarding (1) include: -- Per observation at Upstate University Hospital at Community General’s sterile processing department on 12/30/2024 at 9:15 am, the ambient room temperature inside the main clean workroom was 79 degrees Fahrenheit (F). -- During interview of Staff F, on 12/30/2024 at 9:15 am, they acknowledged the above finding. -- During interview of Staff L, on 12/30/2024 at 10:00 am, they stated that it was a constant struggle to maintain correct temperature within the sterile processing department. The temperatures had been consistently elevated and made it difficult to work in. They kept putting in work orders to the facility’s Physical Plant department, but the issue was not being resolved. -- During interview of Staff M, on 12/30/2024 at 3:10 pm, they stated that temperature was a constant issue in the sterile processing department. Staff had to wear cooling vests and a portable air conditioning unit had been brought in to bring the heat down. Temperatures had reached, at maximum, 83 degrees F. The facility’s Physical Plant department had told them that the temperature issue was not fixable. -- Review of the facility’s temperature and humidity logs for Upstate University Hospital at Community General’s sterile processing department’s clean workroom, between 10/1/2024 - 12/27/2024, revealed that the sterile processing department had elevated temperatures above 76 degrees F, for at least an hour, on 55 out of 87 days. ASHRAE Standard 170 requires that temperatures inside a sterile processing department’s clean workroom be maintained between 68 degrees F - 73 degrees F. -- Review of the facility’s work orders submitted for Upstate University Hospital at Community General’s sterile processing department, between 4/1/2024 - 12/30/2024, revealed that sterile processing department staff submitted 5 different work orders complaining of excessive heat. All 5 work orders were closed, but the corrective action taken for each was not noted. Findings regarding (2) include: -- Per observation at Upstate University Hospital at Community General’s pathology laboratory on 12/30/2024 at 11:15 am, the visual indicator manometer installed above the pathology laboratory’s main entrance doors was indicating that the pathology laboratory’s air had a positive pressure relationship to the outside corridor. The door to the pathology laboratory was also left open to the corridor, although the manometer still indicated the same positive pressure condition when the door was closed. ASHRAE Standard 170 requires that a negative air pressure relationship be maintained between a pathology laboratory space and all adjacent rooms. -- During interview of Staff N, on 12/30/2024 at 11:15 am, they acknowledged the above findings. -- Review of the facility’s temperature and humidity logs for Upstate University Hospital at Community General’s pathology laboratory, between 1/1/2023 - 12/30/2024, revealed that in spring 2023 and spring 2024, the laboratory experienced temperatures above 75 degrees F for a total of 76 days, with temperatures reaching a maximum of 82.5 degrees F. ASHRAE Standard 170 requires that temperatures inside a pathology laboratory been maintained between 70 - 75 degrees F. -- During interview of Staff O, on 12/30/2024 at 2:45 pm, they stated that the temperatures within the pathology laboratory are only manageable due to 2 portable air conditioning units that the facility’s Physical Plant department brought in due to the consistent heat. They also stated that in the springtime, they have had laboratory analyzers shut down due to the excessive heat, as they can only run analyzer tests within normal temperature parameters. -- During interview of Staff P, on 12/31/2024 at 9:50 am, they stated that whenever the outside temperature reaches 50 degrees F, it gets excessively warm inside the pathology laboratory. If the temperature becomes excessively warm, above 80 degrees F, laboratory analyzers will shut down and not restart until the temperature has stabilized.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 46869 Based on document review and interview, the facility did not annually test all Line Isolation Monitors (LIMs) as of the start of the survey on 12/10/2024, as required per National Fire Protection Association (NFPA) 99 (2012 ed.) 6.3.4. Findings include: -- Review of the facility’s annual LIM tests, from 1/2024 - 12/2024, revealed that the annual tests for the following LIMs at Upstate Hospital SUNY Health Science Center were not completed at the start of the survey on 12/10/2024: - LIM B02 - UH East Wing 3rd Floor - Task due date 7/1/2024. - LIM B03 - UH East Wing 3rd Floor - Task due date 7/1/2024. - LIM B04 - UH East Wing 3rd Floor - Task due date 7/1/2024. - LIM B05 - UH East Wing 3rd Floor - Task due date 7/1/2024. - LIM A09 - UH East Wing 3rd Floor - Task due date 7/1/2024. - LIM B011 - UH East Wing 2nd floor - Task due date 10/31/2024. - LIM B06 - UH East Wing 3rd floor - Task due date 10/31/2024. - LIM A01 - UH East Wing 3rd floor - Task due date 10/31/2024. - LIM A02 - UH East Wing 3rd floor - Task due date 10/31/2024. - LIM Test 5 East OR 9 - UH East Wing 5th Floor - Task due date 1/31/2024. - LIM Test 5 East OR 11 - UH East Wing 5th Floor - Task due date 3/2/2024. - LIM Test 5 East OR 1 - UH East Wing 5th Floor - Task due date 5/1/2024. - LIM Test 5 East OR 4 - UH East Wing 5th Floor - Task due date 7/1/2024. - LIM Test 5 East OR 2 - UH East Wing 5th Floor - Task due date 7/1/2024. - LIM Test 6 West Endovascular - UH2 6th Floor - Task due date 10/31/2024. - LIM Test 6 West Cath Lab - UH2 6th floor - Task due date 10/31/2024. - LIM Test 2 East Treatment Room - UH East Wing 2nd Floor - Task due date 5/14/2024. - LIM Test 2 East Exam Room - UH East Wing 2nd Floor - Task due date 5/14/2024. -- Per correspondence with Staff A, on 12/30/2024 at 11:51 am, they acknowledged the above findings”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48296 Based on medical record, document review and interview, in 6 of 6 medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6), the facility failed to recognize medications ordered to sedate violent and aggressive patients, were chemical restraints. The facility’s restraint policy and procedure failed to provide direction to staff on monitoring patients that were chemically restrained. Findings regarding 1) include: -- Review of Patient #1’s, Patient #2’s, Patient #3’s, Patient #4’s, Patient #5’s and Patient #6’s medical records revealed they all exhibited violent and/or self-destructive behavior and were administered medications to manage their behavior e.g., Ketamine (a dissociative anesthetic used for induction and maintenance of anesthesia), Versed (a hypnotic-sedative drug used for anxiety with amnesic properties), Zyprexa (medication used to treat severe agitation), Benadryl (an antihistamine that can cause drowsiness), Haldol (an antipsychotic drug used to treat schizophrenia). These medications were used to sedate patients and were not identified as chemical restraints. -- Review of the facility’s policy and procedure revealed it failed to give direction to staff on monitoring patients that were chemically restrained. -- Per interview of staff, many failed to understand the use of chemical restraints and subsequent patient monitoring. See tag 0160”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 48296 Based on medical record, document review and interview, in 6 of 6 medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6), the facility failed to recognize medications ordered to sedate violent and aggressive patients, were chemical restraints. The facility’s restraint policy and procedure failed to provide direction to staff on monitoring patients that were chemically restrained. Findings include: -- Review of Patient #1’s medical record indicated, on 11/14/2023 at 1:39 am, he presented to the emergency department after a self-inflicted wound to an extremity. Patient #1 was noted to be belligerent, combative, and yelling throughout triage. Verbal de-escalation was attempted by nursing and security staff. At 1:55 pm, 6 security guards were required to hold Patient #1 for the administration of Ketamine (general anesthetic that causes sedation) 400 milligrams intramuscularly, in the triage bay. Patient #1 became apneic (not breathing) with an oxygen saturation of 54%, and was intubated (insertion of a tube into the airway to provide oxygen). There was no documentation in the medical record indicating this medication was used as a chemical restraint. --Per interview of Staff H, Registered Nurse, on 12/12/2023 at 8:00 am, Patient #1 was intoxicated and acting belligerent. Patient #1 attempted to hit police and leave the emergency department. A physician was notified about Patient #1’s behavior and 400 milligrams of intramuscular Ketamine was ordered. Staff H and another registered nurse administered the Ketamine to Patient #1 on the ambulance stretcher. Patient #1 was taken into an empty room where he began to desaturate and was eventually intubated. -- Review of Patient #2’s medical record indicated, on 10/31/2023 at 8:06 am, he presented to the emergency department for an evaluation of back pain, abdominal pain, and visual and auditory hallucinations. Patient #2 became agitated and attempted to leave the emergency department after he was deemed to be an involuntary admission to the psychiatric unit, following a psychiatric evaluation. Patient #2 was placed in four point Twice as Tough restraints (hard restraints that limits the movement of all 4 limbs) with assistance of security at 1:15 pm and was given Ketamine 200 milligrams intramuscularly at 1:30 pm. At 3:00 pm, Patient #2 was re-evaluated by nursing staff and was found to be sleeping comfortably. Twice as Tough restraints were then removed by nursing staff. Provider documentation revealed Patient #2 required Ketamine sedation and is more calm following administration of Ketamine. There is no documentation in the medical records indicating this medication was given as a chemical restraint. -- Review of Patient #3’s (15-year old) medical record indicated, on 12/5/2023 at 7:43 pm, she presented to the emergency department via emergency medical services after a suicide attempt. Patient #3 was agitated and hostile. When she was brought into the emergency department, chemical and physical restraints were applied, She was medicated with Zyprexa (medication used to treat severe agitation) 5 milligrams intramuscularly at 7:46 pm, Benadryl (medication used for mild agitation) 50 milligrams intramuscularly at 7:52 pm and Ketamine 300 milligrams intramuscularly at 7:56 pm. Following the administration of Ketamine, Patient #3 was sedated, nursing removed her restraints. There is no indication in the provider order that these medications were given as a chemical restraints. -- Review of Patient #4’s medical record indicated on 11/24/2023 at 3:44 am, he presented to the emergency room for direct transfer/admission after a cocaine-induced myocardial infarction (heart attack). Patient #4 was extremely agitated in route to the emergency department and received Versed (causes sedation) 5 milligrams intravenously by emergency medical services. Upon arrival to the emergency department, nursing documented the patient was fighting with staff in the back of ambulance. Security was able to restrain the patient. The patient was given Versed 10 milligrams intramuscularly by emergency medical services without effect. Patient #4 was then given Ketamine 300 milligrams intramuscularly in the emergency department. Patient #4 was sedated for severe agitation and intubated for airway protection. There is no indication in the provider order that these medications were given as a chemical restraints. -- Review of Patient #5’s medical record indicated on 11/18/2023 at 9:22 am, he presented with an overdose after being found on the ground with minimal respiratory effort (not breathing adequately) and was given Narcan (reverses an overdose) by emergency medical services. Upon arrival into the emergency department, Patient #5 was agitated and combative with staff and was an immediate threat to himself and others. At 9:30 am Patient #5 was placed in Twice as Tough restraints and given Ketamine 300 milligrams intramuscularly. At 10:00 am, Patient #5 continued to be agitated and was medicated with Zyprexa 10 milligrams intramuscularly. At 10:24 am, Patient #5 was medicated with Versed 2 milligrams intravenously. At 10:30 am, Patient #5 was medicated with Ativan (used for agitation) 2 milligrams intravenously. At 10:31 am, Patient #5 was given Benadryl 50 milligrams intravenously. At 10:40 am, Patient #5 was medicated with Haldol (antipsychotic medication used to treat agitation) 5 milligrams intravenously. At 11:16 am, Patient #5 was medicated with Valium (treats anxiety and agitation) 5 milligrams intravenously. At 12:06 pm, Patient #5 was given Precedex (sedative) via a continuous intravenous infusion. There is no indication in the provider order that these medications were given as a chemical restraints. -- Review of Patient #6’s medical record indicated on 10/7/2023 at 8:53 am, Patient #6 was hitting and scratching staff and was medicated with Zyprexa 5 milligrams intramuscularly. At 10:43 am, Patient #6 was medicated with Ketamine 200 milligrams intramuscularly. There is no indication in the provider order that these medications were given as a chemical restraints. -- Review of the facility’s policy and procedure titled “Restraint Standards for Non-Psychiatric Patient Care Units,” last revised 5/2023, indicated that a “drug or medication when used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition is considered a restraint”. The policy did not provide guidance on monitoring patients after the administration of chemical restraints. --Per interview of Staff F, Director of Risk Management, on 2/16/2024 at 3:04 pm, he/she/they indicated “Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience” dated 1/2020, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081852/ was used to develop the facility’s Ketamine policy and procedure titled “Ketamine Use in the Emergency Department,” reviewed 2/2022. This article indicated using dissosciative sedation Ketamine for severe agitation or excited delirium, patient monitoring should include “immediate availability of advanced airway equipment. Patients requiring dissosciative sedation Ketamine for severe agitation or delirium should have continuous direct patient observation for 15 minutes, continuous pulse oximetry, cardiac monitor, and end-tital carbon dioxide monitoring.” The facilty’s Ketamine policy and procedure did not describe patient monitoring requirements -- Per interview of Staff A, Registered Nurse, on 12/11/2023 at 10:45 am, providers order intramuscular medications as one-time orders for agitation but they do not indicate that the medication is a chemical restraint. --Per interview of Staff G, Physician on 12/11/2023 at 3:20 pm. intramuscular Ketamine doses range from 500 milligrams to 600 milligrams for severe agitation. Staff G would not expect a patient to require intubation following Ketamine administration. Staff G always prepares for the worst possible outcome when administering Ketamine and opines that patients should be monitored closely. Patients who are given Ketamine have their airway monitored. The choice to use Ketamine is provider specific. -- Per interview of Staff B, Physician, on 12/12/2023 at 9:07 am, chemical and physical restraints are utilized when a patient is physically violent. The medical record has an order set for physical restraints but not chemical restraints. Medications needed for violent patients are ordered as needed for agitation. Staff B may order clinical monitoring such as telemetry and oximetry for a patient receiving as needed medications. There is no standardized clinical monitoring for patients following chemical restraints. --Per interview of Staff J, Physician, on 12/12/2023 at 9:20 am. Ketamine is administered to patients intramuscularly by registered nurses and there is “perhaps a 1% chance” of it resulting in a patient requiring intubation. -- Per interview of Staff C, Charge Nurse, on 12/12/2023 at 2:10 pm, if a patient continues to be violent, they should be placed in soft wrist restraints or 4-point soft restraints. The patient may be given Haldol or Zyprexa to calm down the behavior. Staff C does not consider the medications to be a chemical restraint. The patients do not have frequent vital signs done after receiving the medication unless the provider orders them. -- Per interview of Staff D, Registered Nurse, on 12/12/2023 at 2:25 pm, a chemical restraint is any medication or sedative ordered to calm down a violent patient. Medications commonly used by the facility are Haldol and Zyprexa. When violent patients are placed in restraints and then medicated, within 15 - 20 minutes the restraints can usually be removed because the patient has calmed down. Patients are usually drowsy after being medicated but arousable. Staff D stated there is no policy that indicates staff need to obtain additional vitals signs after a patient receives a chemical restraint. -- Per interview of Staff E, Clinical Trainer, on 12/12/2023 at 2:25 pm. Staff E has not seen a chemical restraint order, but does see chemical restraints used as needed for some patients. -- Per interview of Staff DD, Registered Nurse, on 12/12/2023 at 2:30 pm. Staff DD has never seen documentation for chemical restraints. The provider may order medication such as Zyprexa as needed for agitation or violence. -- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48296 Based on document review and medical record review, in 1 of 1 (Patients #4) patients lacked a physician’s order to physically restrain (hold) the patient in order to administer the medication. Findings include: -- Per review of the facility’s policy and procedure titled “Restraint Standards for Non-Psychiatric Patient Care Units,” revised 5/2023, “the application of force to physically hold a patient in order to administer a medication against the patient’s wishes is considered a restraint. Each episode of restraint must be initiated in accordance with the order of a Physician, Resident, Nurse Practitioner or Physician Assistant who is responsible for the care of the patient.” -- Review of Patient #4’s medical record indicated on 11/24/2023 at 3:44 am, he presented to the emergency room for direct transfer/admission after a cocaine-induced myocardial infarction. Upon arrival to the emergency department, nursing documented the patient was fighting with staff in the back of ambulance. Security was able to restrain (hold) the patient. The patient was given Versed (causes sedation) 10 milligrams intramuscularly by emergency medical services without effect. Patient #4 was then given Ketamine (general anesthetic that causes sedation) 300 milligrams intramuscularly in the emergency department. There is no documentation of a provider order for a physical hold of the patient to administer a chemical restraint. -- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48296 Based on document review, medical record review and interview, 1 of 6 (Patient #5) patients requiring the use of violent or self-destructive physical restraints, lacked documentation of a one hour face-to-face with a provider after the initiation of restraints. Findings include: -- Per review of policy and procedure titled “Restraints Standards for Non-psychiatric Patient Care Units,” last reviewed 5/2023, “the patient must be seen face-to-face by a Physician, Resident, Nurse Practitioner or Physician Assistant responsible for the care of the patient within 1 hour after initiation of the intervention, even if the restraint intervention is discontinued before the practitioner arrives to perform the 1 hour face-to-face evaluation. This evaluation must be documented in the electronic medical record and will include the following: The patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.” -- Review of Patient # 5’s medical record revealed a verbal order was obtained for four-point violent restraints on 11/18/2023 at 9:30 am. There was no documentation of the required face-to-face evaluation by the provider. -- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 32908 Based on document review, medical record review and interview, the facility failed to ensure compliance with the Condition of Participation of Emergency Services as evidenced by inadequate monitoring of an ED patient and a delay in provider notification when neurological assessment changes were noted. This finding places all patients at risk for harm. Findings include: -- Hospital staff failed to monitor a patient (Patient #1) who presented to the emergency department with a chief complaint of chest pain. See Tag A1104. -- Nursing staff did not timely notify a provider when a patient (Patient #2) had changes in their neurological status. See Tag A1112.”

“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: 36617 Based on medical record review, document review and interview, in 1 of 21 (Patient #1) medical records reviewed, the hospital failed to monitor a patient who presented to the emergency department with a chief complaint of chest pain. The facility lacked a policy and procedure identifying staff who are responsible to monitor and reassess patients that have arrived via emergency medical services prior to room assignment and medical screening exam. This lack of a medical screening exam and reassessment could result in a poor patient outcomes. Findings include: -- Review of Patient #1’s medical record revealed, a 63-year-old, presented to the emergency department via by emergency medical services on 10/25/2023 at 12:05 pm, after experiencing an episode of stabbing chest pain of 8 out of 10 (0 = no pain - 10 = severe pain), shortness of breath, diaphoresis, and dizziness. He/she/they believed this episode was related to anxiety. Patient #1 had a past medical history of aortic stenosis status post aortic valve replacement in 2019. During transport, the patient received Aspirin 324 milligrams and refused intravenous access. At 12:27 pm, Patient #1 was triaged by nursing as an Emergency Severity Index level 2 (on scale of level 1- resuscitation - level 5 - non urgent). Patient #1 reported during triage that the chest pain had subsided to a level 2 out of 10 and did not radiate. An electrocardiogram was ordered and showed sinus bradycardia. Initial vital signs were blood pressure 106/67, pulse 46, respirations 16, oxygen saturation on room air 98%, and oral temperature of 96.8 Fahrenheit. Following triage, the patient remained on the emergency medical services stretcher with emergency medical services staff in the hallway of the emergency department, until a room became available. Vital signs were reassessed by a care attendant at 2:53 pm, blood pressure 108/71, pulse 54, respirations 18, oxygen saturation 100% on room air, and oral temperature of 97.5 Fahrenheit. Pain level was zero. Patient #1 was moved into a room in the emergency department at 3:04 pm (3 hours after arrival) and placed on the telemetry monitor at 3:09 pm. A provider was assigned at 3:25 pm. There was no documentation in the medical record that the patient remained on the emergency medical services cardiac monitor or was reassessed by nursing staff prior to room assignment. Physician orders were entered at 4:35 pm (4.5 hours after arrival), intravenous access was initiated at 5:17 pm. The patient had multiple laboratory studies performed along with a chest x-ray. Lab work included serial troponin, complete blood count, magnesium, D-dimer, and basic metabolic panel. The serial troponins, chest x-ray, and all other laboratory studies resulted in normal findings. The patient was placed in observation status and transferred to the Upstate Community Campus via emergency medical services. On 10/26/23 at 10:40 am, Patient #1 was discharged home with instructions to follow up with his/her/their primary care physician. -- Review of the facility’s policy and procedure titled, “Arrival and Triage of Emergency Department Patients and Triage Training Process for Staff,” revised 10/2022, indicated the triage nurse is responsible for all triaged patients, until they are assigned a room/nurse. The policy and procedure does not address patients, on emergency medical services stretchers, awaiting a room. -- Per interview of Staff A, Charge Nurse on 11/14/2023 at 9:35 am, patients are placed in rooms according to their acuity. There is a nurse assigned to emergency medical services triage. Once the patients are triaged, the nurse discusses the patient with Staff A to determine placement. Emergency medical services staff stays with the patient until a bed is available. The goal is to offload emergency medical services patients within 1 hour. There are 11 hall beds in the unit and if the patient is stable enough and a bed is available, they will be placed there. If they don’t meet the criteria, they should stay on the emergency medical services stretcher and monitor until a room is available. Rarely have patients had to stay on an emergency medical services stretcher for 2 or more hours. It is expected that emergency medical services staff will monitor the patient and alert staff to any changes in condition. There is no documentation in the medical record that emergency medical services are monitoring the patient. -- Per interview of Staff B, Registered Nurse on 11/14/2023 at 9:40 am, when emergency medical services arrives, the initial intake starts with the triage process to evaluate the patient’s acuity level, vital signs, height, weight, and reason for visit. Some patients can be placed in the waiting room if they are stable. If they are not stable and there are no rooms available, the patient would stay on the emergency medical services stretcher in view of the nurse. Emergency medical services continues to monitor them and should let the nurse know if there are any changes in the patient’s condition. -- Per interview of Staff C, Nurse Manager on 11/14/2023 at 1:10 pm, he/she/they keeps track of the emergency medical services offload time frames. When there is 80+ patients in the emergency department the offload times increase. The emergency medical services triage nurse, charge nurse, and emergency medical services staff primarily monitor the patient. The triage nurse assesses the patient to determine their triage level, does vital signs and electrocardiogram when necessary. It is rare that a physician will start orders on a patient before the patient is placed in a room unless the patient is more unstable and requires the provider to see them sooner. The emergency department is stretched thin with the high acuity of patients that present. -- Per interview of Staff D, Registered Nurse on 11/14/2023 at 3:10 pm, when a patient presents via emergency medical services, he/she/they receives report from emergency medical services and triages the patient. He/she/they keeps an eye on the patient until a bed is assigned. Staff D is not clear who is in charge of monitoring patients on the emergency medical services stretcher. The physicians wait to place orders until the patient is roomed. Staff D also assists with traumas and cardiac arrests and is not always able to visualize the patients waiting on the emergency medical services stretchers. -- Per interview of Staff E, Emergency Department Director, on 11/27/2023 at 9:00 am, emergency medical services triage nurse takes report from emergency medical services, does the patient’s vital signs and patient assessment. The triage nurse would notify the charge nurse of a patients’ Emergency Severity Index level and ask where the patient should be placed. There are many patients that present with chest pain. If those patients are stable and have a normal electrocardiogram, they will be a priority but do not necessarily require a room immediately. The triage nurse and charge nurse are responsible for the patients on the emergency medical services stretchers. Emergency medical services is not responsible for the patients once they arrive in the emergency department. It has been a practice in the emergency department not to start care on a patient prior to rooming. Once roomed the patient would be seen by the resident. The triage nurse will also assist with other emergent patients (e.g., trauma, stroke, or cardiac arrest) and will not always be able to see the patients on emergency medical services stretchers. Starting orders is difficult until the patient is placed in a room. The patients become the hospitals responsibility once they cross the threshold. The goal is to start care and orders as soon as possible to get the emergency medical services personnel back on the street. -- Per interview of Staff F, Registered Nurse, on 11/27/2023 at 9:15 am, when a patient presents via emergency medical services, he/she/they will triage them as quickly as possible. Staff F would notify the charge nurse if a patient looked bad and needed a room immediately. Emergency medical services notifies staff if a patient looks like they need immediate attention. There is no nurse assigned to monitor when the patients are on the emergency medical services stretcher. Orders are not initiated until the patient is in a room or assigned a hallway stretcher. Staff F indicated there is a risk to patients when they have to wait to be roomed. Also there is no documentation in the medical record on their condition. If a trauma patient presents to the emergency department Staff F would leave the triage area to assist. -- Per interview of Staff G, Physician, on 11/27/2023 at 9:35 am, patients are assigned rooms based on illness presentation. Staff G always looks at the Emergency Severity Index level of the patient and will see the higher acuity patients first. Patients that need providers assigned show up on the registration board in red. Once assigned to a provider the patient name on the registration board changes to pink. (The registration log is used to track patients’ statuses and ensure all patients are seen by a provider timely and according to their ESI level.) Staff G can’t perform a medical screening exam on a stretcher, but providers will walk around the emergency department including the emergency medical services bay to observe patient status. Staff G cannot write orders until a patient is roomed because there will not be a nurse assigned to those patients. When patients are on an emergency medical services stretcher, they are emergency medical services responsibility. -- Per interview of Staff H, Physician, on 11/27/203 at 10:00 am, medical screening exam cannot be delayed. The hospital is responsible for the patients as soon as they come into the emergency department. Staff H indicated providers should complete an medical screening exam on the emergency medical services stretcher and have an nurse monitor patients waiting in the emergency medical services hallway. The systemic problem is the number of boarders in the emergency department which is constantly being addressed. -- Per interview of Staff I, Emergency Department Medical Director, on 11/27/2023 at 1:40 pm, emergency medical services is not responsible to watch the patients once they arrive to the emergency department. Emergency medical services patients should be treated as the waiting room patients who arrive by car. An emergency medical services stretcher is not the appropriate place to perform a medical screening exam. Staff I indicated that having a second nurse assigned to assist with the emergency medical services patient reassessment and performing vital signs would be useful. -- Per interview of Staff J, Division Chief of Emergency Services,on 11/27/2023 at 2:35 pm, when patients come to the emergency department via emergency medical services, they are no longer emergency medical services responsibility. There is no nurse assigned to these patients to complete the orders before a patient is roomed. It is not appropriate for patients to remain on an emergency medical services stretchers for extended periods of time. Staff J wants to offload patients quickly to get emergency medical services back out in the community. -- During interview of Staff K, Director of Risk Management, on 11/27/2023 at 3:00 pm, he/she/they acknowledged the above findings.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 32908 Based on document review, medical record review and interview, in 1 (Patient #2) of 10 medical records, staff assessed and documented changes in the patient’s neurological status. Staff failed to timely report these changes to a provider. This lack of timely provider notification could lead to untoward patient outcomes. Findings include: -- Review of the facility’s policy and procedure titled “Care of the Stroke Patient (ischemic or hemorrhagic),” revised 11/2022, indicated patients presenting to the Comprehensive Stroke Center at University Hospital State University of New York Health Science Center “with actual or potential stroke will receive timely recognition and treatment based on the most current evidence-based practice guidelines.” -- Review of the facility’s policy and procedure titled “Nursing Assessment and Documentation,” revised 10/2023, indicated “documentation of nursing care shall be pertinent, concise and shall reflect the patient’s status and response to interventions. Nursing care documentation should be recorded promptly at the time of observation or completion of any tasks to ensure that accurate and timely information is reflected in the medical record. The needs of the patient (including interpreter needs) shall be initially assessed upon admission/presentation for services and reassessed when there is a change in the patient’s general status or after any diagnostic, operative, or invasive procedure. Assessment will be documented in the patient’s medical record.” -- Review of Patient #2’s medical record revealed he arrived to the Emergency Department (a designated Comprehensive Stroke Center) on 5/26/2023 at 1:21 am with stroke symptoms. Chief complaints were left facial droop, left upper extremity weakness, and aphasia (trouble with speaking, writing, and understanding speech) after falling from a chair at home at approximately 11:00 pm on 5/25/2023. Past medical history included diabetes mellitus and deep vein thrombosis which was being treated with Eliquis (medication used to treat and prevent blood clots as well as strokes). A Stroke Code (a multidisciplinary clinical team experienced and dedicated to the management of patients with stroke) was activated prior to Patient #2’s arrival to the emergency department on 5/26/2023. Computerized tomography angiogram of head and neck was done and revealed: 1. Region of hypoattenuation in the right frontal lobe which could represent age-indeterminate infarct. No acute intracranial hematoma. 2. Major intracranial arteries and arteries of the neck are patent. 3. Patent main arteries of the circle of Willis. Addendum by attending: Additional old infarcts are present in the left cerebellar hemisphere, occipital poles bilaterally as well as right posterior parietal lobe. At 1:30 am - Emergency Department provider documented left facial droop, left upper extremity weakness, and aphasia. National Institutes of Health stroke scale total score 3 (National Institutes of Health stroke scale is a standardized tool that measures and records the level of impairment caused by a stroke. Higher the number equals greater severity of stroke symptoms). He is on Eliquis. After computerized tomography angiogram of head and neck, patient does not appear to have any intracranial bleed at this time. Of note, patient was not a candidate for thrombolysis because of Eliquis use at this time. Impression: Acute cerebral vascular accident. At 1:43 am - Registered Nurse documented neurological assessment; right lower extremity decreased sensation and left upper extremity weakness. At 1:46 am - Registered Nurse documented patient complained of left upper extremity weakness, mild left facial droop which has since resolved, expressive aphasia, intermittent right lower extremity loss of sensation. At 3:31 am - Neurology resident examined Patient #2 with family member present. Documented right upper extremity had mild pronation with no drift, muscle strength of 5 out of 5 throughout, and expressive aphasia improved significantly with patient’s family member agreeing speech was very close to baseline. National Institutes of Health stroke scale total score 2. Patient #2 was admitted to stroke (neurology) inpatient service. Patient #2 remained in the Emergency Department as a “boarder patient” pending bed availability in the inpatient unit. At 3:44 am - Neurology resident documented a history and physical (in part) that on initial encounter, patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. National Institutes of Health stroke scale = 3. Diagnosis: Acute ischemic stroke; small vessel, Left Middle Cerebral artery. Etiology: most likely small vessel disease. Plan: admit, start on home medication, monitor blood pressures until sure cerebrovasculature is patent, full stroke work up including Magnetic Resonance Imaging. Swallow evaluation to be performed, if patient passes will start on regular diet, physical therapy and occupational therapy, and speech evaluations. Order for neurological checks every 4 hours. At 4:00 am - (oncoming) Registered Nurse documented neurological assessment; expressive aphasia with strong grip in both hands. At 4:01 am - Registered Nurse documented stroke dysphagia screen completed, patient “passed” the water trial instructions. At 4:41 am - Magnetic Resonance Imaging of brain findings were acute embolic type infarct in the left frontal lobe and the left parietal lobe, severe ischemic microvascular white matter disease, asymmetrical to the right. Addendum by attending: Acute cortical-based infarcts are present in the posterior left insular cortex and left postcentral gyrus while acute infarct is also seen in the left anterior centrum semiovale. All infarcts are in the left Left Middle Cerebral territory. At 8:00 am - (different oncoming) Registered Nurse documented neurological assessment; expressive aphasia and right upper extremity drift. (changes in neurological assessment) At 8:33 am - Registered Nurse documented vital signs. At 8:45 am - Registered Nurse noted physical therapy/occupational therapy were at Patient #2’s bedside. At 8:53 am - Registered Nurse administered Patient #2’s prescribed medications. At 9:10 am - Registered Nurse documented neurological assessment; right facial droop, expressive aphasia, drift and weakness in right upper extremity, and decreased sensation in right lower extremity. (changes in neurological assessment) At 9:10 am - occupational therapy documented (in part) response to evaluation (after assessment), the session was tolerated well. Demonstrates significant deficits in speech/language, coordination, balance, etc. On initial encounter patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. General observation: patient met semi-reclined on stretcher surface, awake and alert in no acute distress. Plan: restorative occupational therapy recommended for 7 times/week for 6 weeks. Physical therapy documented (in part) response to evaluation (after assessment), the session was tolerated fair as evidenced by patient reported fatigue. On initial encounter patient was severely aphasic, expressive type. He had right sided facial droop and right sided sensory loss mostly in the right lower extremity and sparse patchy in the right upper extremity. General observation: supine in bed with head of bed slightly elevated in no apparent distress. Strength: left and right upper extremity and lower extremity at least 3/5 grossly, decreased grip strength to right, decreased dorsiflexion strength on right. Pain unchanged, patient’s heels offloaded at end of session. Plan: restorative physical therapy is recommended for 7 times/week for 5 weeks. (changes in neurological assessment) At 10:56 am - Speech Language Pathology saw the patient for clinical swallow evaluation. History of present illness (in part) initial National Institutes of Health stroke scale score = 3 for facial palsy, sensory loss, and aphasia (although National Institutes of Health stroke scale score documented 7 minutes later also 3 but for facial palsy, sensory loss, and partial neglect (can the patient pay attention to stimuli on both sides at the same time). Overnight Registered Nurse swallow screen documented as “pass” and regular diet ordered. Registered Nurse reports attempting oral meds with sips and a few bites of breakfast tray earlier this morning and had immediate anterior loss and sputtering cough with liquids, significant difficulty manipulating solids so further oral held until Speech Language Pathology exam. Seen and examined at bedside. Awake and alert. Breathing comfortably on room air. Functionally nonverbal due to aphasia and apraxia (the loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them), able to indicate yes/no with approximate verbalization and head nod/shake. Response to evaluation (after assessment), the session was tolerated well. Plan: restorative Speech Language Pathology services recommended 4-5 times a week. At 11:09 am - Case Management screen and assessment; met with patient at the bedside; patient had difficulty communicating due to aphasia. Tried calling family member twice to discuss baseline assessment but no answer. Chart reviewed to complete screen. Physical therapy and occupational therapy recommendation is for short term rehabilitation, this was discussed with the patient. At 11:13 am - Registered Nurse paged physician due to Patient #2’s family identifying a change in patient’s ability to express speech. Requesting physician to come evaluate patient. At 11:30 am - Registered Nurse paged physician to evaluate Patient #2. At 11:45 am - Registered Nurse called stroke team to evaluate Patient #2. At 11:57 am - Physician was at bedside and called an acute stroke page at 11:58 am. At 12:00 pm - Registered Nurse documented neurological assessment; expressive aphasia, drift in right upper extremity and decreased sensation in right lower extremity. At 12:30 am - Neurology resident examined and documented patient was admitted to stroke service for left Middle Cerebral Artery embolic strokes. National Institutes of Health stroke scale total score increased to 10 (from previously documented score of 2). Family observed worsening aphasia and right sided hemiparesis (weakness). Magnetic Resonance Imaging brain without contrast. Impression: Acute embolic type infarct in the left frontal lobe and left parietal lobe. Severe ischemic microvascular white matter disease, asymmetrical to the right. At 4:00 pm - Registered Nurse documented neurological assessment; expressive aphasia, right upper extremity with drift, and right lower extremity with decreased sensation. At 5:51 pm - Vascular Neurology Attending documented diagnosis: Recurrent left Middle Cerebral Artery (most common artery involved in acute stroke) territory strokes. Etiology: Embolic, suspected cardio-embolic due to atrial fibrillation (a type of arrhythmia, or abnormal heartbeat). Daily updates: Patient’s exam worsened in the Emergency Department with worsening aphasia and right sided weakness, repeat Magnetic Resonance Imaging of brain showed new stroke in the left Middle Cerebral Artery territory. Echocardiogram did not show a clot. Patient was in atrial fibrillation during echocardiogram (confirmed with Cardiology attending). At 6:38 pm - Patient #2 was physically admitted inpatient and transferred to neuroscience critical care unit. -- During interview of Staff K, Director of Risk Management on 11/27/2023 at 3:00 pm (Exit Conference), he/she/they acknowledged the above findings.”