Insight Hospital and Medical Center Trumbull

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d)(5) The plan must be submitted for review to the planning agency designated in accordance with section 1122(b) of the Act, or if an agency is not designated, to the appropriate health planning agency in the State. (See part 100 of this title.) This Standard is not met as evidenced by: 33019 Based on review of the Institutional Plan and Budget and interview, the facility failed to ensure an institutional plan and budget was approved by a third party. This had the potential to affect all patients who presented to the emergency room or hospital who needed emergency or inpatient care. Findings include: The hospital Institutional Plan and Budget, undated, was provided to the State Agency on 10/09/25. Review of the plan and budget revealed it did not include any information about who prepared the budget or whether the budget was reviewed by a third party. During an interview on 10/09/25 at 6:45 P.M., Staff B, the VP of Patient Care and Safety, stated there was no documented evidence that the Institutional Plan and Budget provided by the hospital was reviewed by a third party.”

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d)(7) The plan must be prepared- o Under the direction of the governing body; and o By a committee consisting of representatives of the governing body, the administrative staff, and the medical staff of the institution. This Standard is not met as evidenced by: 33019 Based on review of the Institutional Plan and Budget, minutes from the Regional Hospital Board Meeting and interview, the facility failed to ensure the budget was prepared under the direction of the governing body. This had the potential to affect all patients who presented to the emergency room or hospital who needed emergency or inpatient care. Findings include: Review of the hospital’s plan of correction, received on 10/07/25, revealed an annual operating budget had been created to include anticipated income and expenses. A Board Meeting took place and approved a budget. The hospital Institutional Plan and Budget, undated, was provided to the State Agency on 10/09/25. The plan and budget did not include any information about who prepared the budget. There was no documented evidence that the budget was approved by the Board. During an interview on 10/09/25 at 6:40 P.M., Staff B, the VP of Patient Care and Safety, stated the evidence the budget was reviewed by the board was in the meeting minutes. On 10/09/25 at 8:24 P.M., Staff A, the Director of Quality and Risk Management, provided a document titled “2025 Budget” which listed four internal finance team members, two consultants and a capital expenditure. There was no evidence when this budget document was created and/or information as to the role of members listed for each area (internal finance team, consultant and capital expenditure). The hospital also provided a board meeting document titled “2025 Q2 Trumbull Insight Foundation of Trumbull”, dated 04/28/25, that documented Staff M advised “on the CMS tie in and opening plan” but failed to elaborate or contain evidence the facility had an overall institutional plan as required and had an effective budget that was approved by the Board. There was no record of any additional meetings to discuss or implement an effective institutional plan/budget between 04/28/25 and 10/09/25.”

“Basis and Scope CFR(s): §482.1 Basis and scope. (a) Statutory basis. (1) Section 1861(e) of the [Social Security] Act provides that- (i) Hospitals participating in Medicare must meet certain specified requirements; and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals. . . . (b) Scope. Except as provided in subpart A of part 488 of this chapter, the provisions of this part serve as the basis of survey activities for the purpose of determining whether a hospital qualifies for a provider agreement under Medicare and Medicaid. This Condition is not met as evidenced by: 32088 Based on record review, observation and interview, the hospital failed to be primarily engaged in providing services to function as a Hospital. The hospital failed to provide diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled or sick people, by or under the supervision of physicians. This had the potential to affect any and all patients who presented to the emergency room or hospital who were in need of inpatient and/or outpatient care. Findings include: During an interview on 03/27/25 at 9:55 AM, Patient Access Manager Staff HH stated a cath lab employee, Staff T, informed her that he received an email from leadership at 9:00 PM the night before saying they were to cancel all outpatient services and the only thing that is running will be the emergency department (ED). During an interview on 03/27/25 at 9:57 AM, Patient Access Registry Staff II stated she registers patients before their outpatient procedures. She stated she was told to cancel all cardiac catheterizations and surgeries when she arrived at 4:00 AM. During an interview on 03/27/25 at 10:00 AM with the Health Information Manager, Staff JJ, stated she was told to lock the hospital doors and put up signs directing patients to the ED. She stated patients would be directed to the registration desk from the ED if they are here to pick up their records. She stated they have discharged all inpatients. During an interview on 03/27/25 at 10:20 AM, the Lab Manager stated she was notified by the Director of Risk Management, Staff A, during the morning huddle that they were ceasing all outpatient operations. Lab would only service the ED. She stated no staff were laid off yet and they were unsure what to do. She stated they completed the patients that were already registered upon opening that morning as registration staff came in at 4:30 AM and were not made aware of the cessation of operations yet. All others were contacted and informed that they would need to reschedule elsewhere. She stated ED staff were to draw the labs, and they would process them. During an interview on 03/27/25 at 10:30 AM, the Radiology Manager, Staff L stated she was informed by Staff U, the owner of Insight, on 03/26/25 at 8:08 PM that they were ceasing all outpatient operations, and they would only be servicing ED. She stated they would provide the following services to the ED: diagnostic x-ray, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). No staff had been laid off as of that time. She stated they found another surgical facility to complete the special procedures that they had on the schedule and contacted everyone else on the schedule to notify them of the need to find somewhere else for radiology services. She stated they have more than enough staff and supplies to service the ED. Tour of the ED on 03/27/25 at 11:18 AM revealed they had two patients, four RN’s, two nurse aides, one secretary, one sitter, and two providers. Interview during the tour with a RN, Staff KK, revealed they were still on diversion for STEMI and trauma. They had four patients that they planned to discharge sometime that day unless after their work-up they identified a concern. They had one doctor, five RN’s, one secretary and one nurse aide on duty at that time. Behavioral Health had one patient who was being placed on a cot by emergency medical services (EMS) to be taken to the receiving skilled nursing facility. There was one RN and one nurse aide on the unit. Interview with a RN,Staff CC, during the tour revealed no staff had been officially let go but they were canceled from coming in that morning. During an interview on 03/27/25 at 2:46 PM, the Director of Emergency Services, Staff D, the Quality Coordinator, Staff C and Staff A stated the hospital was officially closing on 03/27/25 at 3:00 PM. The ED would continue to care for the emergency room patients they had but would accept any new patients as of 3:00 PM. They said they were working on setting up EMS at the ED doors for the next seven days post closure in the event someone showed up thinking the hospital was open and then EMS would be there to transport any patients to another area hospital. The owner, Insight, said they planned to re-open in three to six months. This decision was made because Insight was supposed to receive ten million dollars in funds from Steward Healthcare that day, but the funds did not come. Staff A stated the following email message was sent to all staff from the Chief Medical Officer: “Due to additional abrupt developments in Steward Health Care’s bankruptcy proceedings and the mounting lack of transferred dollars owed for healthcare services delivered to patients at Trumbull and Hillside hospitals, all inpatient, outpatient, and ER services are paused as of 3:00 p.m. today, March 27th, 2025. Current patients are being transferred, and future appointments are canceled in the interest of patient safety. While the plan remains in place to redesign the hospitals’ operations fully independent of Steward, we apologize for the confusion this transition has caused the community and for the undue burden it has placed on patients and employees.” Tour of the ED on 03/27/25 at 3:40 PM revealed they currently had four patients. There were two providers, five RN’s, one secretary, and one nurse aide working. Interview at that time with the Director of Emergency Services and Behavioral Health, Staff D, revealed the physicians planned to get the last patients out within the next couple of hours and they were no longer accepting patients. He stated they would only stabilize and transfer if someone showed up before they discharged or transferred the last patient. There were no other patients in the hospital at that time. On 03/28/25 at 8:54 AM, a visit was made to the hospital. The Emergency Room Entrance had signs on the door that stated “All services closed at 3:00 P.M. on 03/27/25”. There were no emergency vehicles in the parking lot. At the main entrance there was an employee, Staff NN, at the front desk, who stated there were no patients in the hospital. Staff NN stated the employees had not received their paychecks. The memo provided to staff, dated 03/27/25, stated: “Dear Employees, We regret to inform you that due to some unforeseen circumstances, there will be a delay in the release of this week’s payroll. If you received a check in the mail, it was voided by UKG. If you deposit this check you could incur NSF [non-sufficient funds] fees. We are working diligently to resolve the issue and we expect payment to proceed soon. We apologize for any inconvenience this may cause and appreciate your patience and understanding.””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 32088 Based on record review and interview, the hospital failed to ensure discharge planning was implemented to ensure a safe transfer. See A0800.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 32088 Based on record review, interview and policy review, the hospital failed to ensure restraint orders were placed and renewed appropriately after restraints were applied, failed to check the patient every fifteen minutes and failed to release the restraints periodically and when the restraints were not necessary. This affected one (Patient #2) of three patient records reviewed for restraints. The census was four. Findings include: Record review revealed Patient #2 was brought to the hospital’s emergency department (ED) via Emergency Medical Services (EMS) on 03/04/25 at 12:15 PM after running out of his psychiatric medications on 03/01/25. He was diagnosed with acute psychosis, seizure disorder and hyperlipidemia. The patient was combative upon arrival and at 2:48 PM he was given Ativan (anti-anxiety), but he remained combative. At 3:11 PM he was given intravenous Ketamine, a sedative, which had the patient “resting calmly.” They also gave Ativan (anti-anxiety) at 10:56 PM because the patient kept trying to throw himself out of the bed. On 03/05/25 at 1:45 AM the physician noted the patient had required sedation due to his combative behavior throughout his stay in the emergency department. A nursing note at 7:57 AM documented Patient #2 was combative, punching and kicking, grabbing the sitter causing injury to her wrist. A progress note from the physician, Staff MM, at 8:10 AM documented he could not assess Patient #2 because he was sleeping and deeply sedated. Review of the restraint flow sheets revealed on 03/05/25 at 8:13 AM, non-violent restraints were applied for agitation and kicking. Review of the restraint orders revealed on 03/05/25 at 8:18 AM the physician ordered violent restraints for physical assault. The provider noted every 15-minute checks. This order was discontinued at 10:56 AM. On 03/05/25 at 8:33 AM, there was an order for non-violent restraint order for soft wrist restraints to be applied to both wrists because the patient was causing harm. The order was to be renewed every two hours for a total of twelve hours. Violent nylon four-point restraints were assessed as being applied on the patient starting on 03/05/25 at 9:00 AM through 03/06/25 at 8:30 AM. On 03/05/25 at 9:25 AM there was an order for four-point nylon restraints, and staff noted the patient was a risk to others and himself. At 2:56 PM there was another order for four-point nylon restraints, and staff noted the patient was a risk to others and himself. On 03/05/25 at 5:00 PM a physical hold was ordered, and staff noted the patient was a risk to himself and others. On 03/05/25 at 8:15 PM there was a physical hold order and staff noted this was due to the patient being a risk to others and himself. On 03/06/25 at 12:00 AM staff noted “sitter at bedside, patient resting in bed, quiet.” At 2:30 AM the nurse noted, “There is no sitter at bedside. Nursing supervisor aware. The patient is sleeping. Needs MD to set eyes on patient.” At 3:45 AM the nurse noted the patient was sleeping. On 03/06/25 at 6:57 AM the nurse noted the patient was sleeping and a sitter was at the beside. The patient was restrained while sleeping and being educated. At 7:34 AM an order for soft bilateral wrist restraints was placed and staff noted the patient had confusion that was impacting care and behaviors that were impeding care In addition to the four point nylon restraints being used, the nurses documented mitts as being applied to the patient from 03/05/25 at 9:00 AM until 8:45 PM when the left mitt was removed but the nurse noted the patient started scratching so she put the mitt back on. The mitts were not taken off until 03/06/25 at 6:00 AM. The nurse failed to document the 15-minute restraints checks on 03/05/25 from 4:45 PM through 6:39 PM. There were no interventions to include restraint release assessments, skin integrity/circulation assessments, interventions offered or psychological assessments documented on 03/05/25 at 7:30 PM, 8:30 PM, 9:30 PM, 10:00 PM, 10:15 PM, 10:30 PM, and 11:45 PM; and on 03/06/25 at 12:00 AM through 2:45 AM and from 3:00 AM through 8:30 AM. There was no restraint face to face assessment noted from 03/05/25 at 6:39 PM through the removal of the restraints on 03/06/25 at 8:30 AM. Review of the one to one observation flow sheets revealed there was documentation that noted the patient had a sitter. On 03/05/25 at 7:00 PM through 03/06/25 at 6:30 AM the nurse documented, “patient and charge RN, no sitter at this time.” On 03/06/25 at 6:44 AM the nurse documented, “Patient in 4-point restraints. Charge RN and Supervisor aware of need for sitter. No sitter available at this time.” On 03/19/25 at 12:40 PM these findings were verified with Staff E. Review of the policy titled “Restraint and Seclusion”, dated 01/06/25, stated a renewal order is required every four hours for 4-point nylon restraints. The Licensed provider must conduct a face to face prior to renewing the order and within one hour of application. Respiratory status, circulation, and skin integrity must be monitored continuously and documented every 15 minutes. If the patient appears to fall asleep while in mechanical restraint or seclusion, the registered nurse shall assess the patient to determine if the patient is asleep. If the patient is determined to be asleep, the registered nurse shall instruct an authorized staff member to immediately release the patient from restraint or unlock the seclusion room door. Authorized staff members shall maintain constant one-to-one observation until the patient is awake and re-evaluated by the registered nurse.”

“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: 32088 Based on record review and interview, the hospital failed to ensure physicians were notified of low blood pressures and neurological changes in condition. This affected one (Patient #1) of three patients reviewed. The census was four. Findings include: Record review revealed Patient #1 arrived to the Emergency Department (ED) via emergency medical services (EMS) on 01/24/25 at 12:30 PM. The patient lived alone and was found in her home, on the floor. A neighbor called the police for a well visit check after seeing the patient’s delivered meals stacked up on her porch. The patient was confused and could not account for how long she lay on the floor after falling or the details leading up to the fall. The neighbor reported she thought the patient may have been on the floor for at least two days. The last time someone spoke to the patient was on 01/20/25. Her triage vital signs were a temperature of 98.7 degrees Fahrenheit (F), heart rate 81 beats per minute, respirations 20 breaths per minute, blood pressure 145/72 millimeters of mercury (mm/Hg) and oxygen saturation 98 percent on room air. Patient #1 was a full code. The ED provider noted on admission that the patient had an altered mental status, was not following commands and was repeating words. Patient #1 was diagnosed with transaminitis, rhabdomyolysis, lower right lobe pneumonia and constipation. The patient was admitted a to the intensive care unit (ICU) on 01/25/25. On 01/31/25 at 1:35 PM SP #1 was taken to the cardiac catheterization lab for right and left heart catheterization and coronary angiography, percutaneous transluminal coronary angioplasty and drug-eluting stent placement to the right coronary artery. The pre-operative diagnosis was noted as non-ST-segment elevation myocardial infarction type 2. The post operative diagnosis was noted as two vessel native artery coronary artery disease, myocardial infarction type 2 and atherosclerotic heart disease of the native coronary artery with unstable angina pectoris. An order on 01/31/25 revealed the doctor was to be notified of a systolic blood pressure lower than 90. While in the ICU the patient’s oxygen saturation dropped to the 80’s and the patient was placed on six liters of oxygen via nasal cannula to keep her oxygen saturation above 90 percent. The patient was diagnosed with acute hypoxic respiratory failure. Review of the vital sign flow sheets revealed on 02/03/25 at 8:00 AM, Patient #1’s blood pressure was 89/36 and at 9:00 AM it was 80/47. There was no physician notification of the low blood pressures. Review of the cardiology progress note dated 02/03/25 revealed the provider noted he was aware of, “the events of the weekend noted,” but did not further elaborate. The provider noted a blood pressure of 118/42 and pulse oximetry of 95 percent on four liters of supplemental oxygen. He noted that the patient’s lungs sounds were clear without crackles or wheezes and that there was no peripheral edema. The impression included elevated Troponin secondary to non-ST-segment elevation myocardial infarction in the setting of hypoxemic respiratory failure secondary to community-acquired pneumonia, left bundle branch block, aortic stenosis, aortic regurgitation, and acute diastolic heart failure. The provider documented the patient was acceptable for discharge from a cardiovascular standpoint. On 02/04/25 the patient transferred to the medical surgical unit (4 East). Review of Patient #1’s neurological assessment flowsheets revealed on 02/04/25 at 10:00 AM, Patient #1 had confusion. She was awake, alert, appropriate, followed commands and was alert to person and place. The patient had spontaneous eye opening, the recent memory was impaired, and the speech pattern was delayed. The next neurological assessment completed on 02/04/25 at 4:00 PM revealed the patient had confusion and weakness and was drowsy. She was alert to person only, eye opening to voice and localizes to pain. The remote memory was impaired, and the speech pattern was delayed and garbled. The assessment remained the same until 02/05/25 at 3:41 PM when the nurse documented Patient #1’s speech was delayed and had abnormal hearing. There was no documentation the physician was notified of the change in condition. Review of the discharge summary dated 02/06/25 revealed the discharge diagnosis was listed as hyperbilirubinemia and acute hypoxic respiratory failure and the disposition was set to transfer the patient to a skilled nursing facility in fair condition. Review of the Patient Transfer form dated 02/06/25 at 8:30 AM revealed the patient had a good prognosis and was stable for transfer. The daughter was notified. The patient passed away two days later at the skilled nursing facility. During a interview on 03/18/25 at 1:00 PM, Staff C stated he nurse should notify the physician of changes in condition.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 32088 Based on record review and interview, the hospital failed to ensure discharge planning was implemented to ensure a safe transfer. This affected two (Patients #3 and #4) of two patients reviewed for discharge planning. The census was four. Findings include: 1. Record review revealed Patient #3 was admitted on 03/20/25 from the county jail for bipolar disorder, acute mania and a long history of mental illness. Review of a psychiatric assessment completed on 03/20/25 at the jail prior to her arrival revealed Patient #3 was put in jail for a domestic violence charge and repeatedly kept asking why the jail was holding her there. The assessment stated Patient #3 was a risk for physical aggression to others after lunging at jail staff when she was asked to leave the shower. Patient #3 was delusional, hallucinating, easily agitated, and irritable, requiring inpatient mental health treatment. Review of the General Medicine Consult Note dated 03/21/25 revealed the patient was sent from the county jail for increased agitation, delusions, paranoia, poor sleep and refusing to eat. Review of the Admission Consult Note by Staff F and co-signed by Staff GG, revealed the patient was sent to the hospital after a domestic incident at the jail and the doctor noted the patient had been seen for similar symptoms previously in May 2024. The Patient was diagnosed with schizoaffective disorder and manic episode of bipolar disorder. The patient was started on Abilify for her manic symptoms and Risperdal for the schizoaffective disorder. Staff were to monitor for side effects and efficacy of the medications, provide psychoeducation, medication adherence education and assess the patient daily for the continued need for inpatient services. Review of physician progress notes revealed on 03/21/25 the patient required five to seven days of therapeutic inpatient hospitalization, and this was continuously noted by physicians. Throughout her stay, Patient #3 exhibited grandiose delusions, mood swings, argumentative behaviors, and some sleep disturbance. On 03/25/25 at 11:10 AM the physician, Staff F documented Patient #3 was “still manic and the patient was discharged without a discharge order or any medications. The patient was sent back to jail with sheriff transport.” Review of the medical record revealed no discharge planning and no physician order to discharge the patient. The medications had not been reconciled by the provider prior to discharge. There was no Psychiatric Discharge Note or discharge summary in the medical record. 2. Record review revealed Patient #4 was admitted on 03/21/25 for schizoaffective disorder bipolar type and psychotic disorder. Review of physician progress notes revealed on 03/21/25 Staff F documented the patient needed five to seven days inpatient hospitalization, a therapeutic milieu, and to consider rehabilitation after discharge for substance abuse and psychiatric issues. Review of a General Medical Consult Note dated 03/21/25 revealed the physician documented the review of systems was “unobtainable” due to the patient’s mental condition. Review of the Psychiatric Admission Consult Note dated 03/21/25 revealed Patient #4 was psychotic and was sent to the hospital via sheriff after a “breakdown in jail.” The provider noted the patient reported she could communicate with Lucifer and was being stalked by jail staff and the “thousand-dollar seed church guy.” She reported to Staff F that she wanted to “kick someone’s face in,” and sometimes she is smiling but she really wants to hurt people. She was additionally diagnosed with schizophrenia, started on Invega (medication to treat schizoaffective disorder), referred to psychotherapy for trauma and the substance abuse program. The physician noted, “consider referral to residential treatment program after discharge for intensive treatment of both psychiatric symptoms and substance use.” On 03/22/25 Staff F noted the patient was responding to internal stimuli, having paranoid delusions and auditory hallucinations. The patient reported feeling like people were watching her everywhere she went and all of that made her want to, “kill somebody.” On 03/25/25 Staff F started a noted at 10:48 AM stating Patient #4 wanted to kill the people that were stalking her. Staff F noted, “the patient was discharged without a physician order. The patient was not ready to be discharged.” The note was signed by Staff F on 03/25/25 at 6:41 PM. Patient #4 was sent to another psychiatric hospital after being sent back to jail and asking staff to separate her from the general population for psychiatric reasons. Review of the medical record revealed no discharge planning or physician order for discharge. The medications had not been reconciled by the provider prior to discharge. There was no Psychiatric Discharge Note or discharge summary in the medical record. During an interview on 03/26/25 at 10:16 AM, a resident physician for behavioral health, Staff F, stated there were two patients (Patients #3 and #4) who were sent to the hospital for psychiatric services from the county jail. He stated these patients were really sick and required more treatment but on 03/25/26 the nurses “took it upon themselves” to discharge these two patients back to the jail without an order or and medications. He stated the nurse wrote she received a verbal order but neither of the residents nor Staff GG, the attending physician, gave the order. He stated staff went to lunch, came back, and the patients had been discharged and picked up by the sheriff already. The nurse, Staff CC said she discharged the patients because she felt the urge to do it as they were to be discharging all patients per leadership. Patient #3 was the “sickest” and once she got back to the jail, she asked staff to isolate her because she believed the staff was stalking her. Jail staff eventually got this patient into a psychiatric treatment facility sometime between the discharge on 03/25/25 and now. He also stated while she was being treated, she reported to him that she wanted to kick the people at the jail’s faces in, this included her cell mates. He stated they did not send any of their medications with them because they did not complete the discharge orders, so the medications were not automatically generated and sent to the pharmacy. He stated he was instructed by his attending doctor not to put discharge orders in for these two patients when he called him to inform him the nurses discharged the patients without an order. He stated his attending physician did instruct him to send the medications to the pharmacy for the two patients that were sent back to jail so they could at least receive the medications. He stated both patients were extremely sick and were not ready to be discharged to jail and he noted this in the medical record. During an interview on 03/26/25 at 10:17 AM, resident physician Staff G stated Patients #3 and #4 were jail holds that were sent to the facility for psychiatric treatment. They were discharged on 03/25/25 back to the county jail before completing appropriate treatment and without a discharge order from a doctor. She stated the nurse in charge, Staff CC, told her before lunch on 03/25/25 that the patients needed to be discharged back to jail before they could be placed in an appropriate psychiatric facility as jail staff would help with the transfers once they arrived. She said she replied to the nurse, “if that is the only way they would be transferred to a psychiatric facility, then I don’t think the attending physician would mind”. She stated she never gave a verbal order to discharge the patients. She stated staff knew the attending physician was not on the unit, so they were trying to push the discharges even though they were told by the attending physician that the two patients required inpatient psychiatric placement. During an interview on 03/26/25 at 10:35 AM, Staff CC stated she received the verbal discharge orders for Patients #3 and #4 from Staff G. Staff CC stated Staff G said that Staff GG should be okay with the discharges. Staff CC stated she thought that she had to get the patients out of the hospital because they were closing the unit. She verified that patients who require additional psychiatric treatment should not be transferred to a facility that cannot provide the services required. She verified that Patients #3 and Patient #4 do not have discharge orders in the medical record, and they were discharged on 03/25/25. During an interview on 03/26/25 at 1:49 PM, Staff GG, the attending physician, stated neither him nor his residents gave verbal orders for Patients #3 and #4 to be discharged on 03/25/25. He stated Patients #3 and #4 were the sickest on the floor and not ready to be discharged. He stated he received a message from one of his resident physicians, Staff G, stating the nursing staff had discharged the two patients back to jail without an order. He stated once he arrived to the unit, he spoke with each of his resident physicians, who all denied giving the verbal order for the discharges. He spoke with Staff CC who stated she told Staff G that in order to discharge the patients they had to send them back to the jail, then jail staff would be able to place the patients in an appropriate psychiatric inpatient treatment facility. She said Staff G said that Staff GG may be okay with that. Staff GG stated he told the resident physicians not to discharge Patients #3 and #4 and to go back and document what happened. Staff GG stated he would only discharge or transfer the patients to safe locations where they could have the psychiatric care needed. He stated this should not have happened. He stated that the usual protocol for discharging patients at this hospital was to put the discharge orders and medications in before the patients are physically discharged. He stated this is something that they were adamant about prior to this situation as he remembers them calling him and he had to pull over and stop what he was doing to put the orders in before they would discharge a patient. He said he has only been at the hospital for around two months. He stated Patient #4 was still having homicidal ideations the day she was discharged back to the jail. Once she arrived to the jail, she asked to be separated from general population due to her psychiatric issues and they eventually got her sent to another inpatient rehabilitation facility. He stated he was going to write the discharge order for her because she was now receiving the treatment needed. He stated he did have one of the resident physicians send the medications to the pharmacy this morning as he wanted the patient to have medications even though they had not treated the patient for long enough to even know if they were helping the patient. He stated Patient #3 is still at the jail waiting to be placed.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 28999 Based on Medical Executive Committee Meeting minutes, review of Profit and Loss reports, staff interview,and interview of utility company representatives, the facility failed to ensure an annual institutional plan and budget including an operational budget with anticipated income and expenses was prepared under the direction of the governing body. The facility also failed to ensure it’s utility bills were current. This had the potential to affect all patients receiving care in the facility in the event utilities were shut off. (A0073)”

“INSTITUTIONAL PLAN AND BUDGET CFR(s): 482.12(d) The institution must have an overall institutional plan that meets the following conditions: (1) The plan must include an annual operating budget that is prepared according to generally accepted accounting principles. (2) The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense. (3) The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable. (4) The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following: (i) Acquisition of land; (ii) Improvement of land, buildings, and equipment; or (iii) The replacement, modernization, and expansion of buildings and equipment. This Standard is not met as evidenced by: 28999 Based on Medical Executive Committee Meeting minutes, review of Profit and Loss reports, staff interview,and interview of utility company representatives, the facility failed to ensure an annual institutional plan and budget including an operational budget with anticipated income and expenses was prepared under the direction of the governing body. The facility also failed to ensure it’s utility bills were current. This had the potential to affect all patients receiving care in the facility in the event utilities were shut off. The current census was 63. Findings include: The Medical Executive Committee Meeting minutes from the meeting held on 02/11/25 noted the hospital president reported there was currently a “cash crunch” at the hospital due to the transfer service agreement with the previous owner being unexpectedly increased. Interview on 02/19/25 at 3:15 PM with Staff A, Director of Quality, and Staff B, President and Chief Executive Officer revealed on 10/30/24 the sale of the hospital to the current owners was finalized. Staff B stated the previous owners created a trust, sold all of their buildings to the trust, and established a lease agreement in which the hospital was required to pay an exorbitant fee to remain in their own building. The new owners are currently paying this transfer service agreement monthly and recently the previous owner unexpectedly increased the transfer service agreement amount by $500,000.00 monthly. This increase has caused the cash crunch mentioned in the Medical Executive Committee meeting minutes from 02/11/25. A review of a report titled Profit and Loss dated 09/30/24 revealed the hospital had a net income of $164,513.28. On 10/31/24 the hospital had a loss of $2,560,098.55. On 11/30/24, the hospital had a loss of 2,031,339.31. For the month ending 12/31/24, the hospital had a loss of $1,006,953.55. The hospital was unable to provide an annual institutional plan and budget, or any document outlining the hospital’s anticipated income and expenses. Interview on 02/26/25 at 2:14 PM with a representative from the water company revealed the balance owed by the hospital was $115,127.37. The representative denied any payment arrangements being made. Interview on 02/26/25 at 2:57 PM with a representative for the electric company revealed the hospital had not paid an electric bill for three months. The balance was quoted as $301,967.94 and due on 03/11/25. The representative stated although there was no notice of disconnection on this account there might be a disconnect notice on the next bill to be issued on 03/18/25. Interview on 02/26/25 at 3:45 PM with Staff A, who was present during the utility companies interviews, revealed the facility’s mailroom received the utility bills. However, there was no one in the mailroom to sort the mail and the bills continued to accumulate. According to Staff A they were not aware of the water or the electric bills until now. It was confirmed with Staff A during this interview the utility bills owed by the hospital have accumulated to $417,095.31 and they haven’t paid for more than three months. Interview on 02/26/25 at 5:10 PM with Staff A and Staff F confirmed there was no annual institutional plan and budget. According to Staff , they have not had time to put pen to paper as of yet.”

“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: 28999 Based on medical record review, facility policy review, review of physician credentialing, staff interview, review of an ambulance run report, and interview with staff of the receiving hospital, the facility failed to conduct a medical screening exam on a pregnant patient to determine if the patient was stable prior to transferring the patient to another hospital. This affected one (Patient #1) patient reviewed. The hospital census was 63. Findings include: The medical record of the SP revealed the patient presented to the facility ED as a walk-in on 01/08/25 at 3:09 AM. Although non-English speaking, with the use of telephonic/video interpretation at 3:38 AM, the patient reported severe lower abdominal pain rating it a nine on a 0-10 number scale. A nurse’s triage note stated although the patient was obviously pregnant she was unsure how pregnant she was. The patient reported only a last menstrual period more than a month ago. She was seen by the ED Physician at 3:51 AM. The physician’s history and physical stated the patient was a Gravida 2 Para 1 at an unknown gestational age with no prenatal care. The patient reported pain and cramps that developed four hours prior to her arrival to the ED. The ED Physician’s history and physical also stated the patient developed vaginal bleeding and possible rupture of membranes while in the ED. The Physician noted results of a digital examination showed the fetal head was engaged. Fetal heart tones were determined to be 141 beats per minute via doppler. The physician stated in the history of present illness the receiving hospital was contacted and they were “Kind enough to accept the patient.” The name of the obstetric physician whom the patient was accepted under was also documented. The patient was discharged at 5:26 AM. The physician noted the discharge clinical impression was active labor and urinary tract infection as urinalysis results revealed there were many bacteria in the patient’s urine. The medical record lacked documentation the physician or any qualified medical personnel performed a cervical exam to determine the cervical dilation. The medical record lacked documentation the regularity and duration of the patient’s uterine contractions were assessed or a contracture pattern was identified. The medical record also lacked documentation an ultrasound was performed. Review of the Ambulance Run Report stated the ED Physician informed Emergency Medical Services (EMS) staff the fetal head was in the canal, but the patient wasn’t crowning. The Ambulance Run Report stated the SP was having contractions every two to three minutes. Interview on 02/26/25 at 1:52 PM with the Labor and Delivery Manager at the receiving hospital, Staff E, revealed the SP was fully dilated on admission. The patient received nothing for pain as staff members were uncertain if she was full term. Once the obstetric physician arrived to the facility an ultrasound was performed that determined the patient was full term. She pushed two times and the infant was delivered at 6:25 AM. Interview on 02/19/24 at 4:00 PM with the Emergency Department Physician, Staff C, revealed the patient spoke no English and it was difficult to get needed information when using an interpreter. Staff C also stated the patient was sitting in the lobby for approximately an hour prior to being seen by ED staff. Although Staff C reported feeling the patient was in active labor he also stated he felt the patient wasn’t in danger of imminent delivery. Staff C stated he was unsure of the patient’s gestational age or her cervical dilation. Staff C stated there was no ultrasound as an ultrasound technologist is not available 24/7. He stated there is an ultrasound machine in the ED that is used for trauma patients or to initiate an intravenous (IV) catheter. Staff C stated performing an ultrasound would’ve been a waste of time. He stated he spoke with a nursing supervisor at the receiving hospital who agreed to accept the transfer on behalf of the obstetric physician on call. Staff C stated he wouldn’t have transferred the patient without an accepting physician. The physician credentials for Staff C were reviewed on 02/26/25 at 4:50 PM. Staff C was approved for gynecological and obstetric care including pelvic exam, intrauterine device removal, fetal heart monitoring, and emergent delivery of newborn, including peri-mortem cesarean section. Staff C was also approved to perform and interpret emergent, focused, or investigational ultrasound. Interview on 02/25/25 at 5:32 PM with the Labor and Delivery Charge Nurse at the receiving hospital, Staff D, stated she answered a call from a nurse at the transferring ED early the morning of 01/08/25. Although the nurse was talking to her on the phone she would yell out questions to the ED physician so Staff D could hear his answers. The nurse initially stated they had a patient who was a Gravida 2 Para 1 at an unknown gestational age in active labor. Staff D reported the nurse at the transferring hospital stated it had been a busy night and there was a patient that had been sitting in the hall for approximately an hour before they discovered she was in active labor. Staff D asked the patient’s gestational age to which the transferring hospital stated they were unsure. Staff D also asked the patient’s cervical dilatation. The nurse at the transferring facility was given the name and number of the on-call obstetric physician as he was not currently in the hospital. Staff D stated it was the belief of the staff at the receiving hospital the ED physician would get acceptance of the transfer directly from the on-call obstetric physician, however, this did not occur. According to Staff D the on-call physician was not contacted by the transferring hospital. The patient arrived at the transferring facility and the on-call physician was notified of the patient’s arrival. The patient was very uncomfortable, screaming, and thrashing in the bed. A second nurse performed a cervical exam and announced the patient was fully dilated. Staff D called the special care nursery staff. All three staff nurses encouraged the patient not to push until the obstetric physician arrived. Once the physician arrived an ultrasound was performed that revealed the fetus was full term and the patient was permitted to push. The patient pushed two times and the infant delivered. Interview on 02/25/25 at 1:30 PM with the Labor and Delivery Staff Nurse at the receiving hospital, Staff F, revealed she performed a cervical exam and the SP was fully dilated. Review of the facility policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Chapter: Rights and Responsbilities,” revised 10/04/22, revealed a medical screeing examination (MSE) means the screening process required to determine with reasonable clincical confidence whether an emergency medical condition (EMC)does or does not exist. Depending ont he patient’s presenting symptoms, the MSE represents a spectrum ranging from a simple process involving ony a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures within the capability of the hospital Triage does not constitute a MSE. Stabilized means the treating physician or qualified medical professional attending thepatient has deterined within reasonable medical probability that no deterioration of the EMC is likely to result from or occur during the trasfer of the patient from the hospital. With respect to a woman in active labor “Stabilized” means that the woman has delivered the baby and the placenta. Interview on 02/25/25 at 2:00 PM with Staff A confirmed there was no evidence the patient’s contractions were assessed or a contraction pattern established, there was no evidence the patient’s cervix was assessed for dilation, and no ultrasound was performed to determine a gestational age to determine if the patient was stable prior to transferring to another hospital.”