University of Cincinnati Medical Center, LLC

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 42492 Based on medical record review, observation, staff interviews, local health department interview, review of the Centers for Disease Control Legionella Assessment Form, review of the Legionella mitigation plan, review of electronic mail correspondence, review of the water pathogen management policy, review of the water management program guidelines, and review of the routine water testing results, the facility failed to ensure water supplies were free from Legionella and failed to respond timely to concerns for a Legionella outbreak. See A 0750.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 42492 Based on medical record review, observation, staff interviews, local health department interview, review of the Centers for Disease Control Legionella Assessment Form, review of the Legionella mitigation plan, review of electronic mail correspondence, review of the water pathogen management policy, review of the water management program guidelines, and review of the routine water testing results, the facility failed to ensure water supplies were free from Legionella and failed to respond timely to concerns for a Legionella outbreak. This affected four (Patients #1, #2, #11, and #12) of twelve patients sampled for infection control. The facility census was 540. Findings include: 1. Review of the medical record revealed Patient #1 was directly admitted to the hospital on 05/24/26 with diagnoses including sigmoid colon resection and colostomy. During the admission, Patient #1 received an exploratory laparotomy in Operating Room (OR) 2, stayed in the Surgical Intensive Care Unit (SICU) room 24, and was placed on the ninth floor of the Critical Care Pavilion (CCP) in room 9021. She was discharged on 06/03/26 in fair condition to an inpatient rehabilitation facility. Patient #1 returned to the ED on 06/04/26 complaining of shortness of breath and tested positive for Legionella antigen in her urine later that day. Patient #1 was discharged to a skilled nursing facility on 06/15/26. 2. Review of the medical record revealed Patient #2 was admitted to the hospital on 04/20/26 with diagnoses including acute kidney injury and fever. He had no respiratory symptoms. During this admission Patient #2 visited locations including OR 33 and eighth floor CCP room 8024. Patient #2 was discharged home with Home Health Services (HHS) on 05/01/26. Patient #2 was directly readmitted on 05/06/26 with severe chest pain, combined shock, multifactorial pneumonia, and acute hypoxic respiratory failure with a positive Legionella antigen test. Patient #2 was discharged home on 05/21/26 with HHS. 3. Review of the medical record revealed Patient #11 was admitted to the hospital on 03/09/26 with diagnoses including right acetabular fracture secondary to a mechanical fall, acute respiratory failure with hypoxia and hypercapnia, and Latent Autoimmune Diabetes in Adults (LADA). During this admission, Patient #11 visited locations including the emergency department (ED), shock resuscitation unit (SRU), and eighth CCP room 8015. Patient #11 was discharged home with HHS on 03/12/26. Patient #11 had no Legionella testing performed during this admission. 4. Review of the medical record revealed Patient #12 was admitted to the hospital on 02/19/26 and discharged on 03/07/26 with diagnoses of acute hypoxic respiratory failure with past medical history significant for stage IV Non-Small Cell Lung Cancer (NSCLC). During this admission. Patient #12 visited locations including the ED (Triage 03, Triage 01, and SRU 08), 2nd floor Peri-OP, and medical intensive care unit (MICU) room 16. During this admission Patient #13 had one negative urine antigen test and two bronchoscopies showing ongoing malignancy with no infection. Patient #13 was discharged home with assistance on 03/07/26 and was readmitted on 03/11/26 with Legionella pneumonia, volume overload, bilateral pleural effusions, and worsening signs of malignancy. Patient #13 had a cardiac arrest and expired on 03/21/26. Review of the facility water testing dated 06/25/25 revealed positive test results were identified in the Emergency Department Surgical Inflow (EDSI), the ED Tower, first floor, room 1841, B-11 sink, had a test result of 1.0 colony forming units (CFU) for Legionella. Also, on 06/25/25, the ED Tower, 1st floor, room 1705, sink, with a test result of 0.20 CFU for Legionella. The ED Tower was retested on 09/18/25, and all Legionella levels were below detectable limits (BDL). The 1st floor, room 1841, B-11 sink was not retested. Additionally, on 03/03/26, a positive test result was identified in the Main Hospital (MH) Upper, North, seventh floor, room 7420 shower, with a result of 1.0 CFU for Legionella. Also, on 03/03/26, a positive test result was identified in the MH South, fifth floor, room 5234 sink, with a result of 1.0 CFU for Legionella. On 03/05/26, a positive test result was identified in the Main Hospital (MH) Lower, Endoscopy, second floor, room 2416, recovery #11 sink, with a result of 1.0 CFU for Legionella. Review of an electronic mail (Email) correspondence between the Cincinnati Health Department (CHD) and the Director of Infection Prevention (DIP) E revealed on 04/14/26 and 05/12/26, the CHD requested Legionella water sampling completed since September 2025. Review of an Email correspondence dated 05/12/26 revealed the DIP E acknowledged the CHD requested water samples and stated that although the former Director of Plant Operations (DPO) had recently separated employment from the facility with no replacement, the DIP E worked to get the results as requested. Review of an Email correspondence dated 06/02/26 revealed the CHD informed the DIP E and the team that the most recent case was considered a presumptive Healthcare Associated (HCA) case and recommended the facility follow the Centers for Disease Control (CDC) guidelines for a full investigation. The CHD recommended steps including contacting a Legionella consultant to assist with installing filters, collecting samples, and conducting a facility assessment; restricting access to water throughout the facility and installing a 0.2 micron Point-of-Use (POU) filters graded for at least 60 days within two to three days (by 06/05/26) within locations determined in collaboration with the Legionella consultant; posting information about water restrictions and signage near each installed fixture to communicate to staff and patients to contact maintenance staff if a filter was damaged or removed; conducting and upon completion sending a new risk assessment of the facility (CDC Legionella Environment Assessment Form recommended) to the Ohio Department of Health (ODH) and the CHD; creating and sending a Legionella sampling plan (per CDC guidelines for samples collected during an investigation) to ODH with locations marked on a facility map prior to sample collection; remediating/treating the facility’s water system per consultant guidance; collecting post-remediation samples from the same locations previously sampled within 72-hours of remediation/treating and collecting additional samples every two weeks until the facility had two consecutive negative sample sets; and collaborating with a consultant to revise the facility’s water management plan based on ODH and the CHD recommendations. Additionally, the CHD requested the following information prior to calling the facility on 06/03/26 including the most recent version of the facility’s water management program; any environmental Legionella samples collected within a year; a floor plan of the facility; temperature and chlorine monitoring logs for the facility; any maintenance or monitoring logs of the facility’s secondary disinfection system if available; and maintenance and monitoring logs for any additional water features at the facility (such as cooling towers). Review of an Email correspondence dated 06/03/26 revealed the CHD informed the DIP E of opening an investigation of Legionella outbreak related to three cases of HCA Legionnaire’s disease in a twelve-month period. At this time the CHD requested specific locations including buildings, floors, units, and room numbers for each case identified during the time period noted. Additionally, the CHD recommended testing any patient, staff person, or visitor who developed cough with fever, chills, shortness of breath or pneumonia; all patients or staff who developed new onset of cough with fever, chills, shortness of breath or pneumonia who were hospitalized at the University of Cincinnati Medical Center (UCMC) since March 1, 2026, or who worked at UCMC since March 1, 2026, for any duration of time during the 14-day period before onset of symptoms; and to consider testing any staff, contractors, and/or students who might not have been in the patient care buildings of the UC, but who might have been in or around any of the UC buildings and cooling towers. Review of an Email correspondence dated 06/06/26 revealed the CHD confirmed receipt of a new case of Legionnaire’s disease diagnosed by UC on 06/04/26 and informed the DIP E this case was determined the second presumptive HCA confirmed case associated with the facility in the last 30 days. The CHD planned an onsite investigation the following week to view spaces where cases were located in the facility during the 14-days prior to onset of symptoms. The CHD referred the DIP E to review immediate infection prevention measures recommended in the email on 06/02/26 and notified intentions to verify while onsite that the facility had taken the recommended actions to prevent additional exposures. Review of an Email correspondence dated 06/12/26 revealed the CHD informed the DIP E and the team of building-specific recommendations including submitting a sampling plan according to standard investigation guidelines for CCP/OR to ODH and CHD prior to implementation with case rooms as priority sample locations; providing Legionella sampling results in the Barrett Cancer Center from the past 12 months; and both installing POU filters and developing a targeted sampling plan for ED/SI where at least three cases within the past year had potential exposure associated with single hot water loop shared between these units. Review of an Email correspondence dated 06/24/26 revealed the Division of Infectious Diseases Director L informed the DIP E, the UCMC team, the CHD and the ODH that the facility was deferring decisions on POU filters based on results of testing in the ED. Review of the “Legionella Mitigation Plan” revised 07/02/26 revealed on 07/02/26, the facility identified key stakeholders for escalation, review, and reporting of any Legionella positive water results to discuss immediate next steps; implemented temporary water use restrictions in the ED/SI building; reviewed every in-house pneumonia patients and tested two patients identified with HCA pneumonia; provided Legionella education to all nursing and respiratory therapy; and began water pressure and temperature testing. Plans for immediate remediation included installation of 0.2 micron POU filters to targeted faucets/sinks in the ED/SI building beginning 07/03/26 including signage for instructions to communicate to the maintenance team any missing or damaged filters with completion by 07/10/26. Review of the CDC Legionella Environmental Assessment Form (LEAF) completed on 07/06/26 revealed the document was not completed correctly. The form indicated the hospital did not have humidifiers or water softeners; however, the facility had both types of devices. The humidifiers were located in the operating rooms, as required to maintain humidity. Observations made during the initial tour on 07/01/26 revealed that no POU filters had been installed anywhere in the facility. There were no water restrictions in place, and no signage informing patients, staff, and visitors of any precautions or limitations. Observations on 07/07/26 from 9:40 A.M. to 9:55 A.M. revealed most sinks but not all sinks in the ED/SI building had filters installed in patient rooms, staff areas, and both public and private bathrooms. Some ice machines had been closed with appropriate signs posted due to incorrect filters being sent. Bottled water was available for staff, patient, and visitor use where water was restricted. During an interview on 07/02/26 at 9:06 A.M. Chief Clinical Officer (CCO) F stated the facility had two presumptive cases in March in which patients tested positive by urine antigen testing at another facility. Neither had pneumonia symptoms and they were not thought to be true Legionella cases. During an interview on 07/02/26 at 11:29 A.M. the DIP E did not mention the CHD recommendations for remedial actions on 06/03/26. The DIP E stated the hospital learned of Patient #2 from the CHD in mid-June. The DIP E stated Patient #2 tested positive for antigens in urine and had no pneumonia or negative imaging at UCMC. Patient #2 tested positive at another facility on 05/05/26. During concurrent interviews on 07/02/26 from 1:38 P.M. to 1:50 P.M. Mechanical Operations Manager (MOM) K stated for each positive test result they flushed the system. The DIP E confirmed the facility had not conducted prompt retesting as stated per the water management plan. They did not test again until the next regularly scheduled water sampling in six months. The DIP E and MOM K each stated that the facility had no formal records of flushing and other remediation efforts when a positive test result was identified in any area. The Director of Plant Operations (DPO) B verified the facility had not conducted any additional sampling. They had not planned to do so until ODH reviewed the submitted sampling plan and returned an approved plan. According to DPO B, this was what one of the facility’s water management consultants had recommended to avoid double-sampling and sampling unnecessary areas. During an interview on 07/02/26 at 1:52 P.M. Chief Nursing Officer (CNO) D verified she and other members of the clinical administrative team were unaware of the CHD recommendations on 06/02/26 for remedial actions. CNO D stated she appreciated how Facilities and Infection Prevention “had a piece” but Operations needed to be included in the process. CNO D verified that Water Management Team Meeting Minutes for meetings held in March and June were absent of discussions of Legionella findings and did not follow the Water Management Program Guidelines. CNO D verified the facility had not begun testing patients with HCA pneumonia for Legionella per policy until 07/02/26. During an interview on 07/06/26 at 11:16 A.M. Interim DPO B stated she was unaware of the email the CHD sent on 06/03/26 with recommendations for remedial actions regarding Legionella including water restrictions, filters, and LEAF assessment. During a telephone interview on 07/06/26 at 2:20 P.M. the CHD Epidemiologist M confirmed the CHD team had been exchanging Emails with the DIP E and team for months regarding now four cases of Legionella traced back to UCMC. The Epidemiologist stated the CHD first requested water samples after learning about a suspected case in Indiana and one diagnosed at UCMC in March. Not long after, another case was reported from Kentucky. That was the first time the Director of Environmental Health sent an email to UCMC and recommended they use filters and other things. The CHD met DIP E on 06/03/26 on a conference call and opened an outbreak investigation in conjunction with the Bureau of Infectious Disease. The CHD asked for DIP E and team to report any new cases. There was another telephone meeting on 06/11/2026 between the CHD and DIP E and team which was unproductive. DIP E and team only wanted to argue the validity of the cases and said the patients arrived to the facility with the disease. Onsite visits, dates not specified, revealed none of the recommended preventive measures had been placed to keep staff, patients or visitors from being exposed, although staff were more cooperative with identifying the locations patients had been during the admissions. The CHD investigation revealed all four patients were admitted to the same unit, and three patients had exposure time in the ED/SI building. The last two patients, who were presumptive, both went to the Barrett’s Cancer Center during admission. Hospital staff said they do not even test for Legionella in that building because it was considered an outpatient services building. The ODH team recommended they get a baseline and test that building, too. The last follow-up meeting on 07/01/26 DIP E and team said they were not installing POU filters and would start testing on Monday, 07/06/26. During an interview on 07/06/26 at 2:40 P.M. CNO D verified LEAF assessment recommended by CHD on 06/03/26 was not completed until 07/06/26. Review of the guidelines titled “Water Management Program Guidelines”, dated 2019 revealed in the event of a positive Legionella case traced back to the facility, staff performed checks of hot water, cold water, and ice machine in locations dependent upon where the patient stayed in the facility. The team first held a meeting and discussed any positive results in hot or cold-water outlets and ice machines Depending upon the concentration and percent positivity, possible actionable steps included extended flushing for 30 minutes, performing online secondary disinfection, and/or installing point-of-use (POU) filters. Prompt re-testing was performed upon completion of the strategy to ensure the remediation strategy was effective. Review of the policy titled “Water Pathogen Management” dated 03/25/24 revealed in the event of Legionella outbreak, all patients at the hospital diagnosed with HCA pneumonia by a physician were tested for Legionella by urinary antigen testing. If a species other than Legionella pnuemophila was identified, all patients with HCA pneumonia were tested for Legionella by respiratory culture.”

“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: 28999 Based on record review, interview and policy review, the facility failed to ensure staff reported monitoring alarms to the proper staff and failed to ensure patients were turned and repositioned to prevent the development of pressure ulcers. This affected one (Patient #1) of 20 records reviewed. Findings include: 1a. Review of the medical record of Patient #1 revealed the patient presented to the hospital as a transfer from an outside hospital on 01/25/25 at 11:24 PM. The patient was initially admitted to the outside hospital for syncopal episodes suspected to be cardiac in nature. According to the attending physician’s history and physical, the patient had two cardiac arrests and was status post placement of permanent pacemaker on 01/21/25. On the afternoon of 01/25/25, the patient had another cardiac arrest with a downtime of nine minutes. Neurology evaluated the patient at the outside hospital due to concerns for a seizure prior to the code as the nurse noted lip smacking prior to the arrest. The patient’s wife also reported staring spells at home. It was recommended that the patient be transferred to the facility’s Medical Intensive Care Unit (MICU) for continuous video electroencephalogram (cvEEG) and further evaluation. On admission to MICU, the patient was a full code. On arrival to MICU, the patient seemed to stir to voices, although requiring mechanical ventilation. The cvEEG Report revealed the continuous EEG began on 01/26/25 at 12:42 AM and ended on 01/26/25 at 11:41 AM. The report interpretation revealed there were no seizures seen over the entire monitoring period. A note composed by a pulmonology physician on 01/26/25 at 10:00 PM stated the patient had worsening hemodynamic instability with increasing oxygen requirements. A chest x-ray was obtained that revealed a large right pneumothorax with tension. A chest tube to waterseal was placed by a fellow under direct supervision and assistance. A post procedure chest x-ray showed resolution of the pneumothorax and chest tube in correct position. Oxygen requirements improved. A direct cardioversion (a procedure that uses a controlled electric shock to reset the heart’s electrical system and return it to a normal rhythm) was performed on 01/27/25. The patient was in normal sinus rhythm after the cardioversion. On 01/28/29, the patient was extubated and the decision was made to transfer the patient to a Cardiology Step Down Unit. Patient #1 was transferred on 01/29/25 at 5:35 PM. An attending physician ordered continuous remote cardiac monitoring by the Cardiac Monitoring Unit. A physician also ordered to be notified if the patient’s oxygen saturation was below 90 percent. At 6:29 PM, the patient’s oxygen saturation was 90 percent and at 8:12 PM, 94 percent. A nurse’s note at 11:01 PM stated the pulse oximeter was off at that time. The medical record lacked documentation the monitor watcher notified the nurse caring for the patient. Review of the alarm messages for room #6346, the patient’s room, revealed at 7:38 PM, the patient’s oxygen saturation was less than 88 percent at 86 percent for 193 seconds, at 10:39 PM, the patient’s oxygen saturation was less than 88 percent at 85 percent for 96 seconds, and for 38 seconds, the oxygen saturation was less than 88 percent at 87 percent. The medical record lacked documentation the monitor watcher notified the nurse caring for the patient. At 11:13 PM, the patient care timeline revealed a patient care assistant arrived in the patient’s room and found the patient unresponsive. The patient was extremely hypotensive with blood pressures of 50/20’s. A nurse’s note at 11:13 PM stated she was immediately notified and arrived to the room at 11:13 PM. The patient reportedly stopped moving and went pulseless. Chest compressions began. A code blue was initiated at 11:15 PM and the patient was intubated. Epinephrine 1 mg was administered at 11:18 PM. The patient was transferred back to MICU. The facility policy titled Caring for the Patient on CMU (Remote Telemetry Monitoring), effective 12/30/24, was reviewed on 05/06/25 at 12:00 PM. According to the policy, upon initiation of CMU order for the patient, the nurse will call CMU and confirm the patient’s room number, name, date of birth, code status, medical record number, telemetry box number, reason for monitoring, implantable devices, parameters as defined in the provider order, arrhythmia history, and nurse’s name. Staff nurses are instructed of indications of Priority 2 or urgent alarms. Among other indications, the list included oxygen saturation out of parameter range for greater than thirty seconds. The policy advised the nurse to immediately call the registered nurse caring for the patient. The registered nurses are also advised that priority 3 or non-critical alarms include indications such as pulse oximeter being off or malfunctioning. For non-critical alarms, the registered nurses are also instructed to call the registered nurse’s phone to inform the registered nurse caring for the patient. Review of the CMU Shift Change Report Sheet from 01/29/25 revealed there was no communication to the nurse providing care to the patient. Staff FF was interviewed on 05/06/25 at 3:30 PM. These facts were confirmed. Staff EE and Staff FF were interviewed on 05/06/25 at 3:30 PM and confirmed the monitor watcher was not notified when the patient’s oxygen saturations dropped. The facility policy titled “Caring for the Patient on CMU (Remote Telemetry Monitoring), effective 12/30/24, stated upon initiation of CMU order for the patient, the nurse will call CMU and confirm the patient’s room number, name, date of birth, code status, medical record number, telemetry box number, reason for monitoring, implantable devices, parameters as defined in the provider order, arrhythmia history, and nurse’s name. Staff nurses are instructed of indications of Priority 2 or urgent alarms. Among other indications, the list included oxygen saturation out of parameter range for greater than thirty seconds. The policy advised the nurse to immediately call the registered nurse caring for the patient. The registered nurses are also advised that priority 3 or non-critical alarms include indications such as pulse oximeter being off or malfunctioning. For non-critical alarms, the registered nurses are also instructed to call the registered nurse’s phone to inform the registered nurse caring for the patient. 1b. Although the skin assessment and pressure injury risk assessment, completed by a MICU staff nurse on 01/26/25, revealed Patient #1 received a Braden score of 11, a high risk for breakdown, there was no indication that the patient had any wounds. A registered nurse’s plan of care on 01/26/25 at 9:50 AM acknowledged the patient was at risk for skin breakdown due to his impaired mobility, however, the plan revealed the patient would be turned every two hours to relieve pressure. Review of the flow sheet containing patient repositioning every two hours revealed that from 01/25/25 through 02/07/25, the patient was repositioned every two hours as he was restrained with bilateral soft wrist restraints and restraint checks every two hours included position change every two hours. The restraints were discontinued on 02/07/25. On 02/08/25 at 12:00 PM, the patient was repositioned to a supine position. He remained in the supine position until 8:00 PM when he was repositioned to his right side at this time. On 02/11/25 at 5:30 AM, the patient was repositioned to a supine position. He remained in this supine position until 11:00 AM when he was repositioned to his left side. A wound care nurse’s note on 02/12/25 at 3:59 PM stated the patient had a partial thickness wound to his sacrum. On 02/14/25 documentation revealed the patient was reposition to a semi-Fowler’s position at 4:00 AM. He was not repositioned again until 8:00 AM and he was still positioned to a semi-fowler’s. He remained in this position until 4:00 PM, but repositioned again to semi-Fowler’s. There was no documentation his position was changed again until 02/15/25 at 8:00 AM on 02/15/25. He was repositioned to his right side at this time. The next documentation of repositioning was at 7:54 PM. He was again repositioned to his right side at this time. The next documentation of reposition was on 02/16/25 at 8:30 AM. At 8:00 PM, the patient was repositioned to his left side. There was no documentation the patient was repositioned again until 02/17/25 at 8:00 AM. A wound care nurse’s note on 02/20/25 at 4:04 PM stated the patient now had a full thickness wound on his sacrum. On 02/22/25 at 6:00 AM, 8:00 AM, 10:00 AM, and 12:00 PM the patient was repositioned to a semi-fowler’s position. A wound nurse’s note on 02/27/25 stated the sacral wound was moisture associated skin damage with erosion to sacrum that was an unstageable pressure injury. On 03/03/25 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 6:00 PM, and 8:00 PM, the patient was repositioned to a semi-fowler’s position. On 03/03/25 at 10:00 PM, the patient was repositioned to his right side. There was no documentation the patient was repositioned again until 03/04/25 at 8:00 AM. At 8:00 PM, the patient was repositioned to a semi-fowler’s position. There was no documentation the patient was repositioned again until 03/05/25 at 8:00 AM. He was repositioned to his right side at this time. A wound nurse’s assessment on 03/06/25 at 9:15 AM documented an unstageable pressure ulcer to the patient’s coccyx measuring 10 centimeters (cm) by 8 cm by 0.1 cm. On 03/10/25 at 12:00 AM, 4:00 AM, and 8:00 AM, the patient was repositioned to a semi-fowler’s position. On 03/10/25 at 10:00 AM, the patient was repositioned to his right side. There was no documentation the patient was repositioned again until 6:00 PM. The patient was repositioned to a semi-fowler’s position at this time. At 8:00 PM the patient was also repositioned to a semi-fowler’s position. There was no documentation the patient was repositioned again until 03/11/25 at 4:00 AM. He was repositioned to a semi-fowler’s position at 9:00 AM. A wound nurse’s assessment on 03/11/25 revealed the unstageable pressure ulcer was now 12.5 cm x 13 cm x 0.3 cm. An assessment by a wound nurse on 03/20/25 revealed the wound was now 13.5 cm x 10 cm x 2 cm. The coccyx wound was last measured on 03/27/25. The measurements were 13.5 cm x 11.2 cm x 3.1 cm. The patient was transferred to a long term acute care hospital on 04/03/25. During an interview on 05/07/25 at 11:45 AM, Staff A verified the patient was not turned and repositioned every two hours. The facility policy titled “Skin Care Prevention and Treatment”, effective 06/01/19, instructed staff to turn and reposition patients every two hours.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure a patient was provided community resources when they could not afford their medication. This affected one (Patient #3) of 20 medical records reviewed. Findings include: Review of the medical record of Patient #3 revealed the patient presented to the emergency department (ED) on 01/22/25 at 7:25 PM with complaints of a swollen and painful hand. She reported waking up on Sunday with pain and swelling of her hand. The patient also informed staff that she had gone to an urgent care but they advised her to go to the ED because her blood pressure was elevated. The patient stated she had a history of high blood pressure and ran out of medication about a month ago. At 7:32 PM, the patient’s blood pressure was elevated at 189/110. The Emergency Medicine Physician’s history of present illness stated the patient reported that she had not been taking her blood pressure medication for at least four months due to financial constraints. The note further stated that the patient reported shortness of breath when lying down at nighttime. The patient stated she was supposed to have a sleep study, however, she did not have the time or money to get that done. In the ED Course, the Emergency Medicine Physician’s noted that the patient’s blood pressure was likely elevated because she hadn’t taken her medication. He stated he wasn’t acutely treating the patient’s blood pressure because she was otherwise asymptomatic. The physician phoned-in three refills of the patient’s blood pressure medication. The patient was discharged home. The medical record lacked documentation any community resources were provided upon discharge to assist Patient #3 with obtaining blood pressure medication. The patient presented to the ED again on 02/26/25 at 2:24 PM with complaints of a sore throat. The patient reported that she had been around sick people. At 2:28 PM, the patient’s blood pressure was 219/131. At 3:56 PM, the patient’s blood pressure remained extremely elevated at 260/135. At 4:23 PM, the patient was medicated with Toradol 15 mg intramuscularly as the patient rated her throat pain a 10 on a 0-10 scale. At 4:24 PM, the patient’s blood pressure was 191/117. An ED physician’s history and physical stated the patient reported not picking up the medications from the prescriptions that were phoned-in due to the expense. The patient denied chest pain, headache, or lower extremity swelling. The patient was tested for Influenza A and B, Covid-19, Strep A, and RSV. All tests were negative and the patient was discharged home. Review of the discharge instructions revealed the patient was instructed to pick up three blood pressure medications that were again phoned-in to a pharmacy. The medical record lacked documentation any community resources were provided upon discharge to assist Patient #3 with obtaining blood pressure medication. The patient presented to the ED a third time on 03/02/25 at 9:18 AM with complaints of left eye pain. At 9:28 AM, the patient’s blood pressure was 189/150. According to the Medication Administration Record (MAR), the patient was medicated with tetracaine HCL 0.5% ophthalmic solution two drops in both eyes. The decision was made to admit the patient to complete MRI imaging with neurology planning to see the patient the next day. The patient was admitted to the facility Short Stay Unit where MRI imaging was performed, a CT scan was performed, and the patient was treated for severe hypertension. During an interview on 05/01/25 at 2:00 PM. Staff P stated two social workers are available in the ED on a 24/7 basis. They are available to provide assistance for patients being discharged from the ED including financial assistance for discharge medications. Review of the facility policy titled “Discharge Planning” stated the discharge process begins upon admission. An evaluation is conducted by physicians to determine the patient’s care needs upon discharge. Staff is instructed that the discharge plan must include the determination of discharge medications and referral for appropriate community resources.”

“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: 28999 Based on record review and interview, the facility failed to ensure a skin laceration was treated. This affected one (Patient #3) of 20 medical records reviewed. Findings include: Review of the medical record of Patient #3 revealed the patient and her significant other were crossing the street when they were struck by a motorcycle, sustaining injuries. Review of the ambulance run report dated 07/27/24 at 12:42 AM documented a laceration on the lateral side of her right thigh about four inches long and two inches wide. Bleeding was controlled with a few rolls of gauze. The patient arrived to the ED at 12:51 AM. The patient was triaged at 12:52 AM. Review of the nursing notes dated 07/27/24 at 12:54 AM revealed the patient had a teeth laceration to the lateral right thigh, a laceration to the left elbow, and an abrasion to the left calf. An emergency department attending physician was assigned at 1:05 AM. The attending physician’s attestation note stated he examined the patient and noted a large laceration to the patient’s right thigh extending into the deep tissue oozing blood “but no significant bleeding,” and a laceration to the left posterior elbow. A nurse’s note at 3:29 AM stated the gauze covering the right thigh laceration was saturated with blood and the resident physician was notified. At 4:13 AM, the resident physician was at the bedside of the patient to repair the laceration to the right thigh. The resident physician’s progress note at 4:51 AM stated the laceration was cleaned and sutured and covered with sterile gauze. There was no documentation any treatment was provided to the patient’s laceration on the left elbow. During an interview on 09/19/24 at 10:50 AM, Staff D stated the protocol for nursing care of lacerations that don’t require stitches includes cleaning the wound to prevent infection. No physician order is required. If sutures are required, the provider cleans the wound prior to placement of stitches and after stitching has occurred, places a preferred dressing. Staff D stated although there is no written policy instructing staff nurses how to care for skin lacerations, all ED nurses are required to complete wound care education as part of orientation to the department. Staff D confirmed there was no documentation related to the patient’s lacerated elbow.”