Woodhull Medical & Mental Health Center

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48940 Based on medical record review, document review, and interview, in one of eleven medical records reviewed, the facility failed to ensure all patients were free from all forms of abuse, neglect and harassment when staff failed to report an allegation of abuse (Patient #1). Findings: Review of the policy and procedure titled, “Patient Assault and Abuse,” (last revised 01/02/2026), revealed “1. Any allegation is to be reported immediately to the Department Supervisor. The primary nurse will assess the patient, provide emotional support and privacy until the Provider/Nursing Supervisor arrives ... 4. The Provider responsible for the patient’s care will complete a physical exam within a timely manner and document the findings in the patient’s chart. The Provider will determine whether additional medical consultations are necessary as part of the examination. 5. The Department Leadership/Director of Nursing ensures that an incident in VOICE is generated and notified the Administrator on Duty, Senior Leadership (CMO, CNO or COO), Risk Management after the patient and incident have been stabilized or as soon as feasible. Patient Relations will be notified if the patient wishes to file a complaint. In addition, incidents occurring in the Department of Psychiatry should be reported to the Chief of Psychiatry, Incident Review Committee Coordinator, Director of Nursing for Psychiatry and Risk Management/Behavioral Health. Senior leadership (CMO, CNO, or COO) will notify the Chief Executive Director.” Review of policy and procedure titled, “Notification and Investigation of Adverse Events,” (last revised 04/30/2025), revealed, under section “A. Who reports?... staff (e.g. departmental chairpersons, clinical directors, department heads, supervisors, nurses, physicians, physician assistants, nurse practitioners, managers, administrators and any other staff member of the hospital) are required to report incidents/occurrences and adverse events to the Risk Management Department ... E. What to Report?... sexual abuse/assault of any patient while receiving care, treatment, and services while on site at the facility or while under the care or supervision of the facility ...” Review of Patient #1’s medical record revealed that at 1:23 PM, Staff H (Nurse Practitioner) wrote a Psychiatric Emergency Services Assessment - Full which revealed, “... [They] briefly claimed [they] were raped by different people including security staff and the PA from the medical ED. When I attempt to clarify this, [they] replied again that [they] do not need psychiatric services and ultimately says that it did not happen.” Review of the facility’s adverse event reports from 05/01/2026 to present revealed no evidence that Patient #1’s allegation of abuse was reported. During interview with Staff H (Nurse Practitioner) on 08/04/2026 at 2:08 PM, Staff H stated that they recalled this patient briefly mentioning that they had been sexually assaulted by the PA or security in the ED. Staff H recalled that when they attempted to get more details from the patient, the patient was not able to answer questions or provide more information and then eventually stated that the incident did not occur. Staff H stated that they then did a medical record review for the patient and discovered that Patient #1 had prior visits where they had made similar allegations and felt that these types of allegations could be attributed to the patient’s chronic delusions associated with their diagnosis of schizophrenia. Staff H stated that the patient was evaluated a second time with the attending and the patient did not bring up the allegations again. Staff H felt that there was not a need at that time to pursue the allegations further as they were evidence in the patient’s medical record and the patient’s history of hypersexual statements that were more delusional in nature. When asked why they did not file an incident report, Staff H stated that their rationale was that the patient eventually denied an incident of sexual assault occurring during the same conversation. During interview with Staff N (Administrator) on 08/05/2026 at 4:57 PM, Staff N stated that they were familiar with the patient because this patient had called the Justice Center [Governmental agency tasked to protect people with special needs] (JC) many times during their admission. Once they were made aware of the case, Staff N stated that they began interviewing staff, reviewing video surveillance, and gathering notes from the medical record. Staff N stated that based on their preliminary review of the patient’s case, they could not determine that the patient’s allegations were substantiated. After the initial submission to the Justice Center, the case would go to the internal review committee which would then do an in-depth review of the case. When asked if there was an incident report filed for Patient #1’s allegations on 07/16/2026, Staff N confirmed that no incident report was filed. When asked if they would expect to receive an incident report for this patient, they stated that because the patient made this type of allegation, it would have been best for the provider to file an incident report. On 08/05/2026 at 5:45 PM, Staff L (Administrator) acknowledged these findings.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48939 Based on document review and interview, the facility’s Quality Assessment and Performance Improvement Program did not ensure all incidents were fully investigated and reviewed or identified gaps in patient care and implement appropriate corrective actions to improve patient care and prevent adverse outcomes (Patient #1, Patient #27). Findings: Review of the facility incidents and occurrences reports identified that the facility’s quality assessment review of patient incidents, a) failed to identify and implement appropriate corrective actions for a patient’s death from obstetric complications, b) failed to Identify gaps in patient care and implement appropriate corrective actions for a patient found pulseless on the floor while on a cardiac monitor. in the Emergency Department. (Patient #1, Patient #27) See Tag A-0283”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 37527 Based on medical record review, document review and interview, and one (1) of 24 medical records reviewed, the facility failed to, a) develop and implement detailed protocols that identify high-risk obstetric pregnancies and, b) respond timely to a patient’s emergent obstetric condition. (Patient #1) Findings: The facility failed to create and implement a protocol to define the high-risk obstetric patient and ensure that the medical staff identify and timely respond to the needs of a patient experiencing severe abdominal pain and fetal bradycardia. (Patient #1) See TAG A0347”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48939 Based on medical record review, document review, and interview, in one (1) of 24 medical records reviewed, the facility failed to ensure all nurses providing obstetrical (OB) care were trained to activate an “OB STAT” Team when they identify sudden change in the physiologic status of the obstetrical patient (Patient #1). Findings: Patient #1 developed increased abdominal pain and decreased fetal heart rate. The nurse notified the physician and there was a 15-minute delay in response to repeated calls to the attending physician. See Tag A-0395”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 37527 Based on medical record review, document review and interview, in one (1) of 24 medical records reviewed the facility failed to a) develop and implement detailed protocols to ensure appropriate classification and treatment of high-risk obstetric pregnancy, and b) respond timely to a patient’s emergent obstetric condition (Patient #1). Findings: Review of the medical record of Patient #1 revealed: this patient at 36 weeks and 3 days gestational age with an estimated date of delivery of 10/09/2024, presented to the Labor and Delivery (L&D) Triage on 09/14/2024 at 6:10 PM, with a chief complaint of vomiting since her discharge from Labor and Delivery (L&D) ED triage on 09/11/2024. The patient had a history of cesarean delivery in 2019 in setting of preterm labor at 32 weeks 1day, complicated by neonatal death one (1) hour after birth, preterm labor current pregnancy. The patient received Trial of Labor After Cesarean (TOLAC) counseling and consented on 08/14/2024. At 6:50 PM: RN Triage note documented the patient received a nursing assessment, Fetal Heart Rate was 150 beats per minute (BPM), the patient reported lower abdominal pain, back and pelvic pain scale 7-8 of 10 (normal range 0 -10). The patient was awaiting evaluation and disposition. At 7:07 PM: Certified Nurse Midwife (CNM) documented history and physical (signed at 11:20 PM) stated the patient complained of lower abdominal pain from hunger and lower back pain, and denied loss of fluid, or vaginal bleeding. The patient reported fetal movement. The patient was assigned a triage acuity level 3 (urgent). The patient’s family endorsed concerns for the patient’s continued vomiting and poor obstetric history. Between 8:33 PM and 11:00 PM, the medical record documented assessment by Certified Nurse Midwife (CNM) and RN for vomiting, fetal heart rate monitoring and administration of IV fluids, a medication for heartburn and upset stomach and Tylenol for pain. At 11:31 PM: Triage RN note documented the patient was transferred to the Mother Baby Unit (Antepartum) for observation and treatment. During a tour of the L&D Unit on 10/02/2024 at 11:49 AM, surveyor observed the Mother Baby Unit was a distance from the L&D Unit. Registered Nurses interviewed during the tour indicated they were not trained to manage antepartum emergencies and continuous fetal monitoring was not required. Per documentation by the Antepartum Unit RNs, on 09/15/2024 at 4:05 AM and 5:08 AM; the patient complained of lower abdominal pressure and pain 8 of 10 and 3 of 10 respectively (normal range 0 -10), feeling contractions, and physician was informed of the patient complaints. At 7:10 AM the patient reported intensifying anterior abdominal and back pain, the physician was again notified at 7:20 AM. At 7:35 AM, the physician was at the patient’s bedside and ordered the patient be transferred to the L&D Triage for further assessment. EFM showed fetal heart rate decreasing to 100-115. At 7:40 AM: The patient was transferred to L&D Triage room 110. At 8:11 AM: Triage RN note signed at 8:23 AM, documented receiving the patient at 7:38 AM for complaint of pain and pressure, fetal decelerations (heart rate decreasing) 95-100 bpm, fetal resuscitation measures began, and the patient was transferred to Labor and Birthing Room12. Per Labor and Delivery Attending Physician “Significant Event Note” signed on 09/16/24 at 7:49 AM documented, incision at 8:22 AM. Baby’s time of birth 8:25 AM, upon delivery, complete placenta abruption was noted. At 8:50 AM patient suddenly became bradycardic, 9:05 AM patient became pulseless, ACLS protocol initiated. The Code Team performed 2 hours of resuscitative measures without success. The patient was pronounced deceased at 11:05AM. There was no documented evidence of a provider assessment or consultation for another source of the patient’s pain. There was approximately a 15-minute delay from the time the attending physician was notified of the change in the patient’s condition to the time the physician evaluated the patient. There was an additional 45-minute delay in the attendings decision to move the patient to the operating room. During interview on 10/8/24 at 9:56 AM, Staff R, ED Triage RN who was involved in the patient’s care stated, the patient tolerated the oral challenge of water, and juice. However, the Staff V, Certified Nurse Midwife still wanted to admit the patient for observation. Staff W, Attending Physician covering L&D and Triage did not want to admit the patient and did not examine the patient. The Staff V, CNM, escalated and spoke to Staff O, another Attending Physician covering Mother Baby Unit who accepted the patient. Staff O came over from Mother Baby Unit, went in to speak with the patient but did not examine the patient. During interview on 10/08/2024 at 10:46 AM, Staff S, RN from the Antepartum Mother Baby Unit stated, at 4:05 AM, the patient complained of lower abdominal pressure scale eight 8 of 10, they placed the patient on the monitor. FHR was 145-150 BPM, no uterine contractions were noted. They informed Staff O, Ob/Gyn attending physician of the patient’s pain at 4:10 AM. No pain meds were ordered. During interview on 10/08/2024 at 11:03 AM, Staff T, RN on the Antepartum Unit stated they received report from the covering RN of the patient’s complaint of pain earlier and they informed Staff O, Ob/Gyn attending. Staff O, Ob/Gyn attending did not go to assess the patient. At 7:09 AM, the patient’s call bell was going off. “I went to the room. The kind of pain the patient was in I’ve never seen that before...They called for help and their charge nurse and colleagues came. They called Staff O, Ob/Gyn attending. I called both phones. Both went to voicemail. The attending called back. I told them what happened, they said give me five (5) minutes, I’m in the shower. I went back to the room...No physician really did anything. Then we started to hear this slowdown in heartrate. It went down to 110 and 100. Staff O, Ob/Gyn attending not there yet, they made a second phone call to Staff O It was about 7:20, 7:30 AM, Staff O came about two (2) minutes after...” During interview on 10/09/2024 at 1:36 PM, Staff C, Chief of OB/GYN stated there was no policy specific to the identification and treatment of high-risk pregnancies, the facility adopted the ACOG guidelines. The surveyor was provided with copied pages from an article in The American College of Obstetricians and Gynecologists Vol. 134, NO.2, August 2019, which described various levels of care for pregnant patients. Staff C also stated that an intrapartum patient with one (1) previous c-section would not be considered a high-risk patient. Staff C also stated: “ ...There was a delay. I would’ve liked patient to get to the OR sooner. There seem to be a 16-minute gap between leaving the triage and getting to the labor floor. Nobody knew patient was coming but it is a bit long to me. I don’t know why the delay happened ...” Per review of the ACOG guidelines presented by the facility, the guidelines did not provide guidance for identifying a high-risk OB patient. During interview on 10/10/2024 at 10:58 AM Staff A, Chief Medical Officer stated the ability to manage the patient safely is based on their comorbidities, and risk is a clinical decision guided by Maternal Fetal Medicine as well as service leadership and Regional Perinatal Centers colleagues. “We try not to be overly picky about that.” During interview on 10/11/2024 at 11:00 AM, Staff B-1, Attending Physician stated, during morning sign out on 09/15/2024 at 8:05 AM, they looked at the screen and saw a deceleration. “It was clear there was a deceleration. I asked who the patient was, I was given a quick debrief and went to the room. The patient was by themself. I arrived in the room. The patient was in acute distress screaming, jumping all over the bed, in great distress. It was as if someone was cutting them open. I saw baby’s heart rate was down. The patient was in severe pain ...I took the patient emergently to the OR ...” An Immediate Jeopardy (IJ) situation was identified on 10/16/2024 at 5:29 PM, due to the facility’s failure to, a) develop and implement protocols to ensure appropriate identification and treatment of high-risk maternal patients and, b) failure to respond timely to a patient’s emergent obstetric condition. The facility provided an IJ Removal Plan to survey staff on 10/21/2024 at 2:50 PM. The plan included a newly created policy titled: Identification and Management of High-Risk Patients in the Prenatal/Antepartum/Intrapartum Setting, and to provide education to pertinent staff on the newly created policy. The chief of OB/GYN would be responsible to ensure all pertinent staff get trained with a goal of 100% completion of training by 10/31/2024. The IJ Removal Plan was accepted on 10/22/2024 at 12:33 PM. The IJ was removed on 10/23/2024 at 5:50 PM, based on onsite verification of the facility’s implementation of the IJ Removal Plan. Surveyors verified the policy was created, and training of pertinent staff had begun.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48939 Based on medical record review, document review, and interview, in one (1) of 24 medical records reviewed, the facility failed to ensure all nurses providing obstetrical (OB) care were trained to activate an “OB STAT Team” when they identify sudden change in the physiologic status of the obstetrical patient (Patient #1). Findings: The facility Policy and Procedure titled, “OB STAT Team,” Effective 11/20/2023, states on Page 3: “PURPOSE: 1. The American College of Obstetricians and Gynecologists, the Institute for Healthcare Improvement and the American Medical Association has endorsed the rapid response system approach which has applicability to inpatient obstetric care, where there is not one patient, but two, and where the status of both mother and baby can change dramatically from one moment to the next. Unique to the obstetric setting is the fact that the status of one patient (either the mother or the baby) can profoundly affect the outcome of the other. 2. Approximately 1 to 2 percent of pregnancies are complicated by an obstetrical emergency, and in extreme obstetrical emergencies, minutes are crucial to perinatal outcome. Therefore, the timing of the delivery and the ability to quickly assemble all necessary personnel and equipment is critical. 3. The purpose of the OB STAT Team is to provide rapid, organized, efficient response to obstetrical emergencies and improve maternal and neonatal outcomes. Policy 1: Any clinical staff member that identifies an obstetrical patient is experiencing a sudden change in physiologic status or feels uncomfortable with a patient condition/situation and desires additional help, can activate the OB STAT Team.” Review of the Medical Record (MR) for Patient #1 revealed: patient presented to the Labor and Delivery (L&D) Triage on 09/14/2024 at 6:10 PM, with a chief complaint of vomiting. The patient was pregnant at 36 weeks and 3 days gestational age with an estimated delivery date of 10/09/2024. The patient also endorsed lower abdominal pain from hunger and lower back pain, The patient was assigned a triage acuity of Level 3 (urgent). On 9/15/24 at 7:24 AM, Staff T, Registered Nurse (RN) documented, “0710 AM Patient called to report intensifying anterior abdominal and back pain. Pain rated 10/10 pain... Staff O, nightshift Mother Baby Attending Physician, made aware of patient’s complaints. 0735 AM Staff O, nightshift Mother Baby Attending Physician at patient’s bedside. As per MD’s order, patient can be transferred to Triage for further assessment. EFM [External Fetal Monitor] showed fetal heart rate decreasing to 100-115 [normal 110-160]. 0740 AM: Patient transferred to Triage room 110.” On 9/15/24 at 8:15 AM, note from Staff B-1, the dayshift L&D Attending indicated: “I arrived at the hospital and assumed day shift at 8:05 AM ...I immediately looked at the screen with all fetal tracings and noted that the EFM was abnormal with decelerations (decrease in the fetal heart rate below the fetal baseline heart rate 110 to 160 beats per minute), and fetal bradycardia (slow heart rate). I asked for rapid debrief about the patient, and then ran out of “sign out” to go assess patient at the bedside ... patient was in active distress, complaining of acute abdominal pain, writhing in pain, jumping up in the bed and fetal heart rate was 89 bpm. I saw that there had been several minutes of intermittent bradycardia prior to my arrival ...I recommended STAT cesarean section.” Staff B-1, day shift L&D Attending documented the following timeline in their operative report including: 8:22 AM: Incision 8:24 AM: Uterine incision 8:25 AM: Baby’s time of birth, upon delivery, complete placenta abruption was noted. (Signs and symptoms of placental abruption includes abdominal pain, back pain, uterine tenderness and contractions. Vaginal bleeding may or may not occur). Per interview with Staff T, RN on 10/8/2024 at 11:03 AM, they stated, “At 7:10 AM I went into the patient’s room... I’ve never seen anyone in pain like that before ...with the way she was screaming, it was like a continuous contraction with no rest phase ...I called the other nurses to help, and when they came in, I made the phone call to Staff O, Mother Baby Attending Physician. I called his personal phone and pager. He called back and said he would be there in five (5) minutes. I went back in the room and tried to help the patient change positions, and then we heard the sound of the fetal heart rate dropping into the low 100s on the monitor ...the charge nurse called Staff O, Mother Baby Attending Physician again around 7:20 AM and told them to come right away ...I wish there was a way to call for an antepartum emergency outside of a code green or code blue.” Per interview with the Staff C, OBGYN Chief on 10/9/24 at 4:11 PM, they stated, “I think the OB STAT would be helpful to do more education with the mom/baby nurses.” Per interview with the Staff A, Chief Medical Officer on 10/10/24 at 10:57 AM, they stated, “If a nurse wasn’t getting assistance from a physician, they could have called an OB STAT to expedite the process.” Per follow-up interview with the Staff T, RN on 10/11/24 at 12:38 PM, when asked if they were trained on the OB STAT policy, they stated, “I never had the opportunity to be trained on OB STAT before this happened.” An immediate jeopardy situation was identified on 10/16/24 at 5:27 PM due to the facility’s failure to ensure nursing staff caring for obstetrical patients were educated on the OB STAT policy. The facility provided an IJ Removal Plan to survey staff on 10/21/2024 at 2:50 PM. The IJ Removal Plan included educating nursing staff on the OB STAT policy before the start of their shift on the Mother-Baby Unit, L&D Unit, Pediatrics, and Neonatal Intensive Care Unit (NICU). The IJ Removal Plan was accepted on 10/22/2024 at 12:33 PM. The IJ was removed on 10/23/2024 at 5:50 PM, 2024 based on onsite verification, including interviews and document review, that the facility had implemented their Plan.”

“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: 47318 Based on document review, medical record review, and interview, in one (1) of 23 medical records reviewed, the facility failed to provide an appropriate medical screening examination.(Patient #1) Findings include: Review of the Medical Record for Patient #1 identified: a 36W0D (weeks/days) pregnant patient who presented to the Emergency Department (ED) on 9/11/2024 at 10:25 AM for vomiting. The patient was then escorted to the Obstetrics Department Triage Unit on 9/11/2024 at 10:27 AM. Patient reported 5 episodes of emesis (vomiting) since discharge yesterday and was observed for emesis in Triage. The Patient reported No vaginal bleeding. The patient reviewed their obstetrical history with a Nurse Midwife. Patient had a history of Pulmonary Tuberculosis, asthma, multiple pregnancies, and neonatal death with fetal malformation. The patient’s vital signs were Blood pressure 118/69 (normal range 90/60 - 120/80), Pulse 112 (normal range 60-100 beats per minute), Respirations 20 (normal range 12-18 breaths per minute), Temperature 97.9 degrees (normal range 97.8- 99.1 degrees Fahrenheit), and Sp02 (blood oxygen) 100% on room air (normal range: 95 - 100). There was no documented evidence of a physical exam in the patient’s medical record. The patient remained in the ED and received assessment and treatment to include administration of intravenous fluids, pelvic exam, Fetal Heart Monitoring, and medication to stop the vomiting. On 9/11/2024 at 3:53 PM, the patient was discharged home with a prescription for Reglan 10mg tablets, to be taken as needed for nausea and vomiting at home. On 9/11/2024, at 3:52 PM nursing noted written by Staff A (Staff Nurse) “Patient seen by Certified Nurse Midwife (CNM) and being discharged in stable condition. Discharge instructions given and educated to return to triage if any pain, decreased fetal movement, vaginal bleeding, or loss of fluids. The Patient verbalized understanding.” On 9/11/2024, Discharge Summary, no time indicated on document, written by Staff B, Certified Nurse Midwife, (DNP), “Being observed for emesis. Patient reports feeling better and is ready to go home. Patient stated they were able to eat fruit and keep it down. Patient discharged on oral Reglan once daily as needed (PRN). Patient verbalizes understanding of how and when to take medication.” There was no documented evidence in the medical record that the patient received a medical screening exam on 9/11/2024. Interview on 10/18/2024, at 12:21PM with Staff B, Certified Nurse Midwife, (DNP), stated “every patient receives a physical exam when they come to triage, I did the exam, but I forgot to document it.” The facility Operating Procedure titled, “Emergency Medical Treatment and Labor Act (EMTALA),” last reviewed 6/8/2018, stated “Every individual that comes to the Emergency Department of a System facility - whether it is in a (DED) Dedicated Emergency Department or on Hospital Property - must be provided a Medical Screening Examination within the capability of the facility’s emergency department to determine whether an EMC or Emergency Medical Condition exists ...” This finding was confirmed with Staff E, Chief of Emergency Services, on date 10/17/2024 at 4:02 PM.”

“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: 16362 Based on medical record review, document review, video surveillance review, and interview, the facility failed to meet the needs of patients in accordance with acceptable standards of practice. Findings: The facility failed to: (A) Identify a patient residing in a skilled nursing facility; (B) Provide return transportation for a patient residing in a skilled nursing facility; (C) Ensure consistent practice in reviewing the Ambulance Call Reports (ACR). (See Tag A-1104)”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48940 Based on medical record review, document review, and interview, in one (1) of seven (7) medical records, the facility failed to identify and analyze an opportunity for improvement. Findings: The facility’s policy and procedure titled, “Discharge from the Emergency Department,” last revised 2/2/2023, stated, “ ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence. The Emergency Department staff will discuss disposition and appropriate mode of transportation with the residence staff before transportation requests are made...” Review of Patient #1’s medical record identified this patient was brought to the emergency department via ambulance from a skilled nursing facility on 07/13/2024 at 9:24 PM. On 07/14/2024 at 12:19 AM, Patient #1 was discharged. There was no documented evidence that discharge disposition and mode of transportation were discussed with the skilled nursing facility staff, nor that return transportation from the emergency department to the skilled nursing facility was provided, as per facility policy. On 07/15/2024 at 2:53 PM, Patient #1 returned to the emergency department via ambulance from a skilled nursing facility. At 3:11 PM, Patient #1 completed triage and was moved to the EZ-Care Area. There was no documented evidence that Patient #1 was identified to have arrived from a skilled nursing facility and would require return-transportation. Video surveillance footage, dated 07/15/2024 from 3:07 PM, identified that Patient #1 left the EZ-Care Waiting Area without being seen on 07/15/2024 at 4:02 PM. On 07/16/2024 at 4:24 PM, Patient #1 returned to the emergency department, accompanied by their daughter, who requested a psychiatric evaluation for Patient #1. A Physician Progress Note written by Staff K (Chief of Emergency Services) on 07/16/2024 at 6:10 PM, stated “FYI [for your information] this patient resides at the [skilled nursing facility] and should not be discharged on his own, as he has tendency to wander and get lost. Please call [administrator at skilled nursing facility] if patient being discharged.” During interview of Staff L (Associate Executive Director, Emergency Services) on 07/29/2024 at 12:55 PM, Staff L stated that they became aware of an incident regarding Patient #1 when they met the administrator of Patient #1’s skilled nursing facility during the patient’s visit on 7/16/2024. Staff L stated that the administrator informed them Patient #1 had recent visits to the emergency department, that they wander around the skilled nursing facility, and that they wanted to have the patient evaluated for decisional capacity. Staff L stated they spoke with [Staff K] to relay the information they had received. During interview of Staff K (Chief of Emergency Services) on 07/30/2024 at 11:50 AM, Staff K stated they spoke with the administrator of the skilled nursing facility and were informed that “the patient never made it back” to the skilled nursing facility after their 07/15/2024 emergency department visit, and that the patient had a tendency to wander. Staff K stated they reviewed this medical record to determine if the medical standard of care had been met. Staff K confirmed that no concerns were identified nor was the incident escalated for further investigation. During interview of Staff J (Director of Regulatory Department) on 7/26/24 at 2:14 PM, when asked whether the facility had any reports regarding Patient #1, Staff J confirmed no VOICE reports [incidents/occurrences] were filed for this patient. The facility’s policy and procedure titled, “Notification and Investigation of Adverse Events,” revised date 03/05/2024, stated, “ ...[Purpose] Early identification and reporting of events to Risk Management ...to reduce the probability of such an event occurring in the future...[Objectives of the Event Investigation] Assisting in the prevention of similar incidents in the future through thorough analysis of data and the human and systemic factors that contributed to the incident ...[How and When to Report] Immediately by telephone, or within 24 hours, but as soon as practical, the staff member should enter the report electronically in VOICE ...All incidents and occurrences are to be entered in the Voicing Our Incidents, Concerns, and Encounter (Voice Report) within 24 hours ...” During interview of Staff M (Director of Risk Management/Clinical Services) on 07/29/2024 at 12:20 PM, Staff M stated that the facility has an internal incident reporting system called “Voice.” Staff M confirmed no “Voices” were received by the Emergency Department for this incident, and that this was the first they had been informed of this event.”

“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: 48940 Based on medical record review, document review, video surveillance review, and interview, in one (1) of four (4) medical records, the facility failed to: (A) Identify a patient residing in a skilled nursing facility; (B) Provide return transportation for a patient residing in a skilled nursing facility; (C) Ensure consistent practice in reviewing the Ambulance Call Reports (ACR). The failure to identify patients residing in skilled nursing facilities potentially placed patients at risk for inappropriate provision and coordination of care. Findings: Review of Patient #1’s medical record identified this patient presented to the emergency department on three separate occasions: On 07/13/2024 at 9:24 PM, Patient #1 was brought in by ambulance from a skilled nursing facility with a chief complaint of dental pain. The Ambulance Call Report (ACR - a pre-hospital care report completed by ambulance staff that details a patient’s care/treatment during emergency transportation), dated 07/13/2024 at 9:20 PM, indicated that Patient #1 was brought into the hospital from a “nursing home.” At 9:28 PM, Patient #1 completed triage and was moved to the EZ-Care Area (Fast-track: area in the emergency department designated to provide care to patients presenting with non-urgent complaints). Patient #1 was evaluated and was discharged on 07/14/2024 at 12:19AM. On 07/15/2024 at 2:53 PM, Patient #1 returned to the emergency department via ambulance from a skilled nursing facility with a chief complaint of dental pain. The Ambulance Call Report, dated 07/15/2024 at 3:31 PM, indicated that Patient #1 was brought into the hospital from a “nursing home.” At 3:11 PM, Patient #1 had completed triage and was moved to the EZ-Care Area. Patient #1’s name was called to be seen and evaluated, once at 5:40 PM and twice at 6:01 PM, without response. Patient #1 was documented as left without being seen (LWBS) and was “discharged” from the electronic medical record (EMR) system. On 07/16/2024 at 4:24 PM, Patient #1 walked into the emergency department accompanied by their daughter, who requested a psychiatric evaluation for Patient #1. Patient #1 remained admitted in the inpatient unit at the time of this survey. Findings for (A): The facility’s policy and procedure titled, “Discharge from the Emergency Department,” last revised 2/2/2023, stated, “ ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence ...” Review of Patient #1’s medical record identified there was no documented evidence on 07/13/2024 nor 07/15/2024, that Patient #1 was identified to have arrived from a skilled nursing facility and would require return-transportation. During interview of Staff E (Emergency Department Registered Nurse) on 07/26/2024 at 10:51 AM, Staff E confirmed they triaged Patient #1 on 7/15/2024, but could not specifically recall this encounter. Staff E stated that information about the patient arriving from a skilled nursing facility would typically be given in the verbal report from the ambulance staff, and that ambulance staff would hand the triage nurse any paperwork from the skilled nursing facility. Staff E stated that the triage nurse would “type a note in the Chief Complaint section of the Triage Note” to indicate that the patient is from a skilled nursing facility. During interview of Staff F (Emergency Department Staff Registered Nurse) on 07/26/2024 at 11:32 AM, Staff F confirmed they triaged Patient #1 on 07/13/2024, but could not specifically recall this encounter. When asked to describe the process of receiving a patient from a skilled nursing facility from ambulance staff, Staff F stated that they would write a note in the Chief Complaint section indicating the patient was from a skilled nursing facility. Staff F added that ambulance staff does not always verbalize that patients are from a skilled nursing facility, but that “it is very rare that a patient will come to the facility without paperwork from the nursing home.” During interview of Staff K (Chief of Emergency Services) on 07/29/2024 at 11:57 AM, Staff K stated that they reviewed Patient #1’s medical record when they were made aware of the incident involving Patient #1. Staff K stated that based on their review, it appeared that the triage nurse was not aware that Patient #1 had arrived from a skilled nursing facility, and that it is “common practice to ask where the patient came from.” During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, Staff N stated that it is the expectation that the triage nurse would ask ambulance staff where the patient was from and would communicate this information to the care team. When asked how this information would be communicated, Staff N stated that the facility has a process for triage nurses to document in the electronic medical record from where the patient arrived. Staff N stated that staff would select a location from a preselected list of choices within the Triage Note. When asked to provide a policy which delineated these expectations, Staff N stated they were unable to provide a policy. There was no documented evidence that the emergency department staff identified that Patient #1 arrived from a skilled nursing facility, although the ambulance care reports indicated Patient #1 was picked up from a “nursing home.” There were discrepancies between staff’s practice and administration’s expectations for how to verify and where to document that patients arrived from skilled nursing facilities. The facility policy and procedure lacked guidance directing emergency department staff to verify from where patients arrived with ambulance personnel, and where to document this information for return transportation to be arranged. Findings for (B): The facility’s policy and procedure titled, “Discharge from the Emergency Department,” last revised 2/2/2023, stated that it was the responsibility of the medical and nursing staff to: “Collaborate with social work to address any social needs the patient has prior to discharge ...Any patient who resides in supportive housing with coordination of care (i.e. medical/psychiatric services) will be dispositioned as a discharge, but transportation from the Emergency Department will be provided back to their residence. The Emergency Department staff will discuss disposition and appropriate mode of transportation with the residence staff before transportation requests are made...” Review of Patient #1’s medical record identified that on 7/13/2024, there was no documented evidence of the location to which Patient #1 was discharged, nor of Patient #1’s mode of transportation upon discharge. On 7/15/2024, video surveillance footage (dated 07/15/2024 from 3:07 PM) identified that Patient #1 left the EZ-Care Waiting Area without being seen on 07/15/2024 at 4:02 PM. In addition, there was no documented evidence of collaboration with social work services, the arrangement or provision of return-transportation to Patient #1’s skilled nursing facility, nor that Patient #1’s disposition and appropriate mode of transportation was discussed with skilled nursing facility staff, as per facility policy. The facility’s policy also lacked guidance directing staff of the details to be documented during patients’ emergency department discharge. During interview of Staff K (Chief of Emergency Services) on 07/26/2024 at 2:49 PM, Staff K confirmed that social work services was not contacted to arrange and coordinate return-transportation to the skilled nursing facility for Patient #1’s discharge on 07/14/2024 at 12:19 AM. During interview of Staff P (Emergency Department Physician Assistant) on 07/29/2024 at 11:33 AM, Staff P stated that when patients from a skilled nursing facility are being discharged to return to the skilled nursing facility, the provider contacts the social worker to arrange for transportation and to coordinate the discharge with the skilled nursing facility. During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, when asked about the expectations for discharge documentation, Staff N stated that documentation at the time of discharge typically includes if the patient is being picked up by ambulance, what the condition of the patient is at the time the patient leaves, and vital signs, depending on the acuity of the patient. Staff N explained that the registered nurse is not always the last staff member to interact with the patient, so they do not always document the patient’s final discharge, condition, or mode of departure. During interview of Staff K (Chief of Emergency Services) on 07/30/2024 at 11:50 AM, Staff K stated they spoke with the administrator of the skilled nursing facility and were informed that “the patient never made it back” to the skilled nursing facility after their 07/15/2024 emergency department visit, and that Patient #1 had a tendency to wander. Staff K stated that they reviewed this medical record to determine if the medical standard of care had been met. Staff K confirmed that no concerns were identified nor was the incident escalated for further investigation. Findings for (C): The facility’s policy and procedure titled, “Triage Policy,” last reviewed 01/24/2024, stated, “All EMS call reports [Ambulance Care Reports] will be reviewed by the triage provider and signed/timed once the ACR is completed.” Review of Patient #1’s medical record identified that the Ambulance Call Reports dated 07/13/2024 and 07/15/2024 noted Patient #1 to have arrived from a “nursing home,” but this information was not documented by the emergency department staff. During interview of Staff E (Emergency Department Registered Nurse) on 07/26/2024 at 10:51 AM, when asked to describe the process of receiving a patient from ambulance staff, Staff E stated that the triage nurse takes a verbal report from the ambulance staff and signs the tablet (the electronic device containing the Ambulance Care Report) after the verbal report is received. During interview of Staff H (Clerical Associate) on 07/26/2024 at 12:20 PM, Staff H stated that the Ambulance Call Report is sometimes faxed to an area separate from the triage areas that is not monitored for incoming faxes but is checked periodically for faxes that have been received. Staff H stated that clerical associates will write patients’ medical record numbers on the Ambulance Call Reports and place them in a location to be scanned into the medical records. During interview of Staff K (Chief of Emergency Services) on 07/29/2024 at 11:57 AM, Staff K stated that any provider can access the Ambulance Call Report online and do not rely on the faxed copies. Staff K explained that providers can only see what has been entered and uploaded by ambulance personnel at the time. Staff K stated that the reports are not routinely reviewed and are typically only looked at when questions arise. Staff K explained that the reports are not always completed at the time the verbal report between ambulance personnel and emergency department staff is given, and that reports are typically made available between 30 minutes to one (1) hour after the patient has been received. Staff K confirmed that patients may have completed and exited the triage area by that time. During interview of Staff N (Director of Nursing, Emergency Services) on 07/30/2024 at 11:08 AM, when asked about the expectations of the ambulance triage nurse with the Ambulance Care Report, Staff N stated that the triage nurse receives a verbal report from ambulance staff, reviews the ambulance staffs’ tablet for the digital Ambulance Call Report, and signs the tablet to confirm the transfer of care has occurred. The “Triage Policy,” which speaks to the signed/timed review of the completed Ambulance Call Report by the triage provider was shared and discussed with Staff N. Staff N acknowledged the Ambulance Call Report is not always completed when verbal report is given, the tablet is signed, and transfer of care occurs.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 37527 . Based on medical record review, document review and interview, the facility failed to: 1) Recognize the need for timely management and interventions of a patient who developed fetal decelerations during labor. (Patient #1); 2) Ensure the operative report for Patient #2 included documentation on intraoperative complications, and implement timely actions for the management of post-operative complications. These failures were identified in two (2) of six (6) medical records reviewed. Findings include: See Tags A0951 and A0959 .”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 10686 . Based on document review and staff interview, the hospital did not ensure that in its review of incidents/adverse events, proposed corrective actions were timely implemented. These findings were noted in two (2) of three (3) incidents reviewed. (Patient #1 and #2). Findings include: Review of the Incidents/Adverse Events Log from 10/01/2023 to 11/12/2023, documented two (2) incidents which resulted in the implementation of an improvement plan on 11/30/2024. A review of the implementation of corrective actions for both incidents revealed education to Obstetric (OB) staff had not been completed prior to the start date of the survey. There was no documented evidence that all applicable staff received education on OB STAT process (Activation of Maternal Team for maternal complications), Team strategies and tools to enhance performance and patient safety, Fetal Heart Rate Tracings, Implementation of Maternal Early Warning System (MEWS) to facilitate timely recognition, diagnosis, and treatment of Obstetrics/Gynecology; Care of OB Patients in the Post Anesthesia Care Unit (PACU), and OB mock codes. Review of staffing records revealed staff members who have not been educated to the improvement actions were on duty and others were scheduled to work. During interview with Staff O, Chief of OB/GYN on 12/13/2023 at 12:30 PM, Staff O acknowledged that education and training were on-going and has not been completed. .”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 37527 Based on medical record review, document review, and staff interview, in one (1) of six (6) medical records reviewed, the medical provider failed to ensure Patient #1 who developed fetal complications of decreased heart rate during Trial of Labor After Cesarean (TOLAC) (attempting to have vaginal birth after a previous cesarian birth) was promptly managed. Findings include: Review of the triage nursing notes on 10/29/2023 at 11:45PM identified Patient #1, with a history of previous caesarean birth, presented to the Labor and Delivery (L&D) triage in labor and was admitted for TOLAC. Per nursing documentation on 10/30/2023 from 4:15AM to 8:40AM, the patient ‘s blood pressure ranged between 105/45 and 89/40 (Normal Blood Pressure range: 90/60 to 120/80). There was no documentation indicating the OB provider was notified. Nursing note on 10/30/2023 at 8:40AM revealed the patient received intravenous fluids and her blood pressure improved to 110/57. Per nursing documentation on flowsheet on 10/30/23, fetal heart rate measured every fifteen minutes from 8:00 AM to 11:30 AM, were between 62 to 84 beats per minute (bpm) (normal is between 110 and 160 beats per minute). There was no documentation indicating the OB provider was notified. Certified Nurse Midwife (CNM) on 10/30/2023 at 7:00 PM noted the fetus had an episode of decrease heart rate to 105 and at 10:51 PM, CNM documented the patient reported increased rectal pressure. FHR 145, contractions every 2-3 mins. The CNM note 10/31/2023 at 1:00 AM indicated that the fetus was not doing well for greater than one hour, and at this time the obstetric attending (OB) counseled the patient regarding the need for cesarian section. There was no documentation in the medical record that indicated the attending physician was notified of the abnormal fetal heart rate prior to CNM note on 10/31/2023 at 1:00 AM. The brief operative note by the OB Attending on 10/31/2023 initiated at 2:17 AM, revealed that the patient had an emergency cesarian section, and during the procedure was found to have a uterine wall tear, with the tear extending down to the bladder which resulted in a removal of the uterus and surgical repair of the bladder wall. The infant was delivered at 2:42AM and required resuscitation (efforts to restore a heartbeat and/or breathing). Resuscitation efforts were unsuccessful. During interview with Staff P (Chief Medical Officer) on 12/12/2023 at 11:19 AM, they stated, “There was a significant delay in recognizing abnormal fetal tracing, which led to delay in cesarian section.” An Immediate Jeopardy situation was identified on 12/18/2023 at 4:05 PM due to the facility’s failure to ensure Patient #1 was promptly managed. The facility provided an IJ Removal Plan to survey staff on 12/18/23 at 11:55 PM which included the following: -An OB Safety Plan highlighting improving response to interpretation and management of category 2 fetal heart tracings, management of Trial of Labor After C-section (TOLAC), collaboration of the obstetric team, improving obstetric emergency response time, and decision to incision time. -A new policy titled OB STAT delineates the roles of the various members of the OB team during an obstetrical emergency. - Revision of the TOLAC policy to indicate the OB doctors as primarily responsible for the care of the TOLAC patients. The IJ was removed on 12/19/2023 at 5:15 PM after an onsite verification of newly created and revised policies and procedures, interviews, and verification of staff education to the newly created and revised policies and procedures.”

“OPERATIVE REPORT CFR(s): 482.51(b)(6) An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. This Standard is not met as evidenced by: 37527 . Based on medical record review, document review, and interview, in one (1) of six (6) medical records reviewed, the provider failed to ensure operative report for Patient #2 included documentation of surgical complications and implement timely actions for the management of post-operative complications. Findings include: Review of the medical record of Patient #2 identified the following: Labor and Delivery triage note on 11/12/2023 at 5:52 AM indicate patient presented with a complaint of contractions since 11/11/23 at 11:00 PM. Midwife notes on 11/13/23 at 12:54 AM documented that on 11/12/2023 at 11:41 PM, the patient was taken to the Operating Room. The surgeon’s brief operative report on 11/13/23 at 2:29 AM (filed at 7:40 AM), indicated “no intraoperative surgical complications.” Late entry notes by Staff H on 11/13/2023 at 10:56 AM revealed the patient was in the recovery room at 1:09 AM with the anesthesiologist at the bedside. At 2:50 AM, the patient was visibly agitated, removing leads and pulling at intravenous access. The patient was evaluated by the anesthesiologist and a Rapid Response was called at 3:02 AM. Anesthesiologist’s notes on 11/13/2023 at 5:52 AM revealed the patient became pale and bluish with tachycardia in the range of 179 beats per minute and high respiratory rate with clenching jaws and lower pulse oximeter reading (indicating low oxygen levels in body tissues). The patient was intubated. Senior Medical Resident (PGY3) code documentation on 11/13/2023 at 8:57 PM indicated that due to fetal bradycardia (low fetal heartbeat) the patient underwent an emergent cesarian section at 11:41 PM. Rapid Response was called at 3:30 AM due to patient’s agitation. The patient’s Blood Pressure was 120/60 (normal is 120/80) heart rate 140 (normal is 60-100 beats per minute). At 3:36 AM, the patient rapidly became bradycardic (low heartbeat), and pulse was lost. The patient’s heartbeat returned during cardiopulmonary resuscitation (to get the heart to start beating again). During transfer of the patient to the Intensive Care Unit (ICU), the patient lost pulse again, resuscitation efforts were unsuccessful. The patient was pronounced dead at 4:41 AM. Review of the Medical Bylaws stated operative reports shall include a detailed account of the findings during surgery including complications. During interview on 12/11/2023 at 2:06 PM, Staff O, Chief of Obstetric Services stated that during discussion with the assisting surgeon, she learned an injury had occurred during the cesarean section. Post operative bleeding and resulting signs and symptoms of low oxygen in the body from this complication were not identified by the clinical staff. During interview on 12/12/2023 at 11:19 AM, Staff P, the Chief Medical Officer acknowledged there was no documentation in the operative report of a complication during the cesarian section and the injury was not reported to other members of the clinical team. An Immediate jeopardy situation was identified on 12/18/2023 at 4:05 PM due to the facility failure to document an intraoperative complication of Patient #2, and timely manage the patient postoperatively. The facility provided an IJ Removal Plan to survey staff on 12/18/2023 at 11:55 PM. The plan included: 1) A new policy titled “Obstetric Post Anesthesia Care Unit (PACU) describing nursing care documentation and monitoring for the OB post anesthesia patient. 2) A new policy titled “ OB STAT.” The policy delineates roles and responsibilities of various OB team members during an obstetric emergency. 3) A memo issued by the Chief Medical Officer to all surgeons detailing the need for prompt and complete documentation of the operative report. The IJ was removed on 12/19/2023 at 5:15 PM based on onsite verification of newly created and revised policies and procedures, interviews, and verification of staff education to revised policies and procedures. All the staff interviewed on 12/19/2023 verbalized knowledge and completion of the education and training regarding the IJ Removal Plan. Staff were not permitted to begin their shift without completion of the training. Staff members who have not been trained will not begin their shift until they have been trained on all new and revised policies.”