Metrohealth System

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 21893 Based on policy review, medical record review, and staff interview; the facility failed to ensure restraints were used in accordance with physician orders. This affected two (#25 and #33) of two restraint records reviewed. The facility census was 456. Findings include: 1. Review of the medical record for Patient #25 revealed the patient was restrained starting on 07/28/25 at 8:00 PM through 08/03/25 at 8:00 AM. The restraint flowsheet documented soft wrist/ankle restraints times two, right upper extremity and left upper extremity restraints were in place. The medical record contained restraint orders for soft wrist/ankle restraints times two on 07/28/25, 07/30/25, 07/31/25, 08/01/25, and 08/03/25. The restraint orders lacked clarification as to which two extremities were to be restrained. The medical record lacked documentation of any restraint orders on 07/29/25 and 08/02/25. Interview on 03/25/26 at 11:58 AM Staff C verified the findings. 2. Review of the medical record for Patient #33 revealed a restraint order dated 03/26/26 for soft wrist/ankle times two, mittens, and soft waist restraint. The restraint orders lacked clarification as to which two extremities were to be restrained. The restraint flowsheet documented mittens, bilateral soft wrist restraints, and a soft waist restraint in place. Interview on 03/25/26 at at 2:50 PM Staff D verified the findings. Review of the hospital policy titled “PC-16-The Use of Restraint and Seclusion,” effective 01/9/2026, stated restraint orders must be reissued at least every calendar day.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29000 Based on tour of the labor and delivery triage area, staff interview, and policy review, the facility failed to post signage regarding treatment for emergency medical examination and treatment of women in labor (A-2402). Based on medical record review, policy review, and staff interview, the facility failed to complete an appropriate medical screening exam and failed to call the on call attending obstetric physician,as required by the hospital’s screening process, for three pregnant patients (A-2406). Based on medical record review, policy review, and staff interview, the facility failed to have a signed consent to transfer a patient to another hospital (A-2409).”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 29000 Based on tour of the labor and delivery triage area, staff interview, and policy review, the facility failed to post signage regarding treatment for emergency medical examination and treatment of women in labor. This has the potential to affect all patients cared for in labor. Findings include: Observations on 03/25/26 at 2:55 PM during a tour of the labor and delivery triage area revealed no signage was found in the waiting room or triage area for Emergency Medical Treatment and Labor Act (EMTALA). Interview during the observation with the Manager for Labor and Delivery (Staff K) revealed this area is where patients come for testing and to rule out labor. Review of the facility policy titled “Emergency Medical Treatment and Labor Act (EMTALA)” outlines the responsibilities of Workforce Members to ensure compliance with EMTALA when an individual presents with a potential medical emergency or in active labor at any Metrohealth Services facility with an Emergency Department (ED) with the locations identified. For purposes of this policy, the Main Campus Labor and Delivery Unit is considered an ED because individuals might present for emergency services or receive a medical screening exam at that location. Interview on on 3/25/26 at 3:30 PM Staff C and Staff K verified the findings of not having the required EMTALA signage posted in the labor and delivery triage area.”

“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: 29000 Based on medical record review, policy review, and staff interview, the facility failed to complete an appropriate medical screening exam and failed to call the on call attending obstetric physician,as required by the hospital’s screening process, for three pregnant patients (#2, #34, and #36) out of 16 records reviewed for patients who presented to the Emergency Department (ED) at greater than 16 weeks gestation. Findings include: 1. Review of the medical record revealed Patient #2 presented to the ED with complaints of abdominal pain on 01/16/26 at 7:44 AM. The ED physician (Staff G) examined the patient at 8:04 AM with orders received to obtain a urine test to rule out a urinary tract infection (UTI) and complete a pregnancy test. Review of the laboratory tests revealed a positive pregnancy test. Staff G ordered an ultrasound for viability at 8:40 AM. An ultrasound was completed at 8:46 AM with results showing a twin pregnancy at approximately 24 weeks gestation. Review of notes by resident physician (Staff H) at 9:32 AM listed under disposition, to go home. This note further stated the patient has received a medical screening examination and within reasonable clinical confidence an emergency medical condition has not been identified. Staff G signed the above notes on 01/16/26 at 1:44 PM stating they approve the management plan for this patient and take responsibility for the plan as documented. The ED medical record revealed Patient #2 went home at 9:48 AM with instructions to follow up with an obstetrician. The medical record revealed Patient #2 returned on 01/16/26 at 3:31 PM to Labor and Deliver per rescue squad. Review of the obstetrician notes revealed the patient was seen in the ED earlier this morning, at which time she had an ultrasound describing a dichorionic, diamniotic twin pregnancy of approximately 24 weeks gestational age. On presentation to Labor and Deliver triage the patient was in acute abdominal pain and felt a gush of fluid. A quick ultrasound was completed with fetal presentations of Baby A as cephalic and Baby B breech, measuring 21-22 weeks gestation. A cervical exam was performed and this patient was found to be completely dilated. The decision made to move to the OR. On presentation to the OR Patient #2 began to feel pressure and spontaneously delivered Baby A at 3:50 PM. Baby B delivered breech at 4:02 PM. Review of the medical record for Baby A revealed the baby was born on 01/16/26 at 3:50 PM. Apgars were zero at one minute, and two at five, ten and fifteen minutes. Baby A weighed one pound three ounces, was intubated at delivery, and currently remains on a ventilator in the NICU as of 03/26/26. Review of the medical record for Baby B revealed the baby was born on 01/16/26 at 4:02 PM. Apgars were two for one minute, three at five minutes, and seven at ten minutes. Baby B weighed 15 ounces at birth, was intubated, and taken to the NICU. A head ultrasound (HUS) on 01/26/26 revealed a Grade 3 intraventricular hemorrhage. On day 13 of life the family made Baby B a Do Not Resuscitate Comfort Care (DNR-CC). Baby B was removed from the ventilator on 01/28/26 with the time of death recorded at 12:06 PM. Review of the hospital policy titled “Clinical Practice Guideline (CPG): Triage of Obstetrical Patients in the Emergency Department (ED) and Labor and Deliver (L&D),” effective April 2024, revealed the purpose was to determine the appropriate location for the triage and evaluation of pregnant patients with varying medical complaints. If an OB/GYN consult is appropriate, page OB if greater than 16 weeks. If no response, call front desk of Labor and Deliver to speak with the senior resident. Patients who should stay in the ED regardless of gestational age included imminent deliver, prehospital delivery, primary psychiatric complaint, rash, medically unstable, physical injury, trauma, primary dental complaint, soft tissue abscess of infections, and Narcan. If a patient was 16 weeks pregnant through delivery who doesn’t meet the exceptions to stay in the ED, should be escorted to labor and delivery. The hospital has an in house obstetric physician and an on call obstetric physician available around the clock available as a resource to the ED physicians and for L&D. Review of the hospital Root Cause Analysis (RCA) initiated on 01/30/26 for the event dated 01/16/26 involving Patient #2. Review of an email sent out to all ED providers on 02/09/26 informed the ED providers that obstetrics has clarified they want to be called for anyone who presents to the ED at 16 weeks gestation or over. On 02/23/26 the RCA Action Plan noted the root cause of the event as the ED team was unaware obstetrics should be consulted for gestational ages over 16 weeks. Another email was sent to the ED staff on 02/23/26 informing them the clinical practice guidelines were updated. Interview on 03/16/26 at 3:17 PM ED Physician/ Chief Quality Officer (Staff R) stated if a patient is greater than 16 weeks gestation the ED physicians should send her to labor and delivery, if less than 16 weeks gestation they keep her in the ED. Interview on 03/18/26 at 3:30 PM, Registered Nurse (RN) Discharge Nurse (Staff J) stated when a patient comes to the ED with abdominal pain and they don’t know they’re pregnant the physician orders a urine or blood test. If the test is positive for a pregnancy they then order an ultrasound. The physician or resident physician contacts the obstetrician depending on the patient’s complaints. Staff J further stated they received updates on this procedure after the incident with Patient #2. They were informed no matter what the situation was the doctor was to contact the obstetrician. If the ED physician doesn’t then they need to go over their head and do it. Interview on 03/18/26 at 4:10 PM Staff G stated he was the ED physician who cared for Patient #2. Patient #2 came in reporting she was having suprapubic pain, which was worse with peeing. The resident physician interviewed the patient who stated they thought they were pregnant. Staff G talked with her, got the same story, and realized she had a Gravid abdomen. Patient #2’s mother said they were at the ED to establish the pregnancy. The patient had no leakage of fluid. An ultrasound was completed with twins noted. Staff G discussed following up with an obstetrician. Staff G stated they discharged the patient and she ended up coming back on her own with worsening pain and went to labor and delivery. Staff G stated in hindsight she should have gone to Labor and Deliver when she first presented to the ED, but instead they discharged her. Staff G further stated they were treating her as newly diagnosed pregnancy. If there had been a conversation with an obstetrician most likely they would have said to send her up to labor and delivery. After this event the hospital did an Root Cause Analysis and put in safeguards. When a second trimester ultrasound is ordered it automatically consults an obstetrician. Staff G stated the physicians were educated when to involve an obstetrician and believed nursing received education as well. Interview on 03/18/26 at 4:30 PM Resident Physician (Staff H) stated Patient #2 came to the ED in the morning with abdominal pain, as well as pain with urination and walking. Her abdomen was tender, and her last menstrual period was in August 2025. Thinking she may be pregnant they ordered an ultrasound and urine tests. The urine came back positive for pregnancy and a urinary tract infection (UTI) so they sent her home with antibiotics. After this patient’s ED visit the physicians attended a meeting telling them of the need to notify obstetrics if a pregnant patient is greater than 16 weeks gestation. Review of the hospital policy titled “Clinical Practice Guideline (CPG): Triage of Obstetrical Patients in the Emergency Department (ED) and Labor and Deliver (L&D),” updated February 2026, revealed for any patient seen in the ED identified as greater than/equal to 16 weeks, call the obstetric attending physician. Interview on 03/19/26 at 3:20 PM the Accreditation Specialist (Staff D) verified Patient #2 was not taken to Labor and Deliver when it was discovered she was greater than 16 weeks gestation and did not meet the exceptions to remain in the ED. Staff D also verified no obstetrician was consulted for Patient #2. 2. The medical record revealed Patient #36 came to the ED on 02/16/26 at 11:58 AM at 17 weeks gestation with flu-like symptoms complaining of abdominal pain, back pain and pain with urination. The patient verbalized thoughts of self-harm with no plan in place. The ED physician ordered a psychiatric evaluation. An ultrasound was ordered due to difficulty in obtaining fetal heart tones and completed at 5:15 PM. Notes from the psychiatric consult at 5:03 PM stated this patient did not require inpatient treatment. No obstetrical consult was found in the record and the patient was discharged home at 7:04 PM. Interview on 03/31/26 at 9:25 AM with one of the physicians who cared for Patient #36 (Staff S) revealed they recently received an email from their director stating if someone is pregnant greater than 16 weeks the physicians need to consult an obstetrician regardless of the reason they are in the ED. Interview on 03/31/26 at 9:40 AM with the Director of Quality (Staff A) and Staff D verified the attending obstetric physician was not called when Patient #36 presented to the ED. 3. Review of the medical record revealed Patient #34 presented to the ED at this facility’s Parma location on 03/18/26 at 9:15 AM with complaints of mild cramping and bleeding which started in the morning. Patient #34 was at 19 weeks gestation Review of the history and physician completed by a nurse practitioner (Staff N) revealed the patient was Gravida 3 Para 2. Notes stated the patient awoke and noticed a scant amount of blood on her underwear, and when she wiped she had a small amount of blood with a small clot. An ultrasound was completed the day prior, identifying the patient was 20 weeks pregnant. A vaginal exam completed by Staff N who noted the cervix was closed. Review of the orders revealed orders were written to complete a urine test and quantitative blood pregnancy test. Review of the urine test results revealed a large amount for blood present. The record revealed Patient #34 was discharged home at 2:15 PM with instructions to continue antibiotic, follow up with obstetrician, and return if symptoms worsen. Staff N’s notes were co-signed by the ED attending physician (Staff M) on 03/18/26 at 2:15 PM documenting Staff M agreed with the assessment and plan by Staff N. No documentation was found that an obstetrician was called. Interview on 03/26/26 at 3:22 PM Staff M stated they received education from their Director that any patient greater than 16 weeks gestation need to get an obstetric consult and communicate to Labor and Delivery. Staff M stated they have no idea why they did not contact the obstetrician for Patient #34 since they are the final decision maker. Interview via telephone on 03/31/26 at 1:08 PM Staff N stated the Director sent a notice out to the providers if a patient was 16 weeks or greater gestation the obstetrician needs to be consulted. Staff N stated they usually get an obstetric consult, however in this situation the patient stated they didn’t want to wait for the consult, but they didn’t document this conversation. Interview on 03/31/26 at 9:40 AM with the Staff A and Staff D verified the attending obstetric physician was not called when Patient #34 presented to the ED.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29000 Based on medical record review, policy review, and staff interview, the facility failed to ensure an appropriate transfer to another hospital based on medical necessity or patient request. This affected one (#17) of two records reviewed with transports. The average transfers are 70 patients per month. Findings include: The medical record revealed Patient #17 came to the emergency department (ED) per ambulance on 01/24/26 at 11:37 PM with complaints of diffuse muscle pain, chest pain and shortness of breath in a sickle cell crisis (severe pain due to blood cells blocking vessels). A pain score of 10/10 was given with the completion of vital signs. This patient received various pain medication intravenously (IV) while in the ED. Review of the Pertinent Past History revealed the patient was dismissed from the Metrohealth system effective 11/29/22 for excessive disruptive and harassing ehavior. Patient may receive emergency careat a Metrohealth systems ED. IIf patient presents in the ED she will receive emergency care. Review of the notes and orders on 01/25/26 at 5:21 PM revealed to transfer the patient to another facility. Review of the ED note on 01/25/26 at 12:38 PM states “UH transfer for pain crisis. Banned from Metro for Assai;t tp RN staff.” A note at 12:41 PM states the patient transfer is for sickle cell crisis. The On 01/25/26 at 6:41 PM Patient #17 was transferred to another hospital. The record contained no evidence the patient requested the transfer in writing after being informed of the hospital’s obligations and of the risk of transfer. The record did not indicate the patient was made aware of the risks and benefits of the transfer. There was no physician signed certification stating the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks. Review of the hospital policy titled “Emergency Medical Treatment and Labor Act (EMTALA)” instructs the discharging physician to verify the patient was informed of the risks and benefits of the transfer and to document this on the Transfer Form. Interview on on 03/25/26 at 2:00 PM Staff D verified the 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: 22432 Based on medical record review, the adverse event log review, policy review, review of facility documentation, and staff interviews, the facility failed to provide documentation it had initiated an investigation into an adverse event in response to an alleged homicide.(A0286)”

“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: 22432 Based on medical record review, the adverse event log review, policy review, review of facility documentation, and staff interviews, the facility failed to provide documentation it had initiated an investigation into an adverse event in response to a patient death classified as a homicide. This deficient practice affected one patient (Patient #1) and had the potential to affect any patient who sought care at the facility. Findings include: Review of the discharge roster revealed Patient #1 arrived at the facility’s emergency department on 05/02/25 at 3:21 PM via emergency medical squad from the county sheriff’s corrections institution with a complaint of chest pain. Additional diagnoses included bipolar affective disorder, history of hyperkalemia, hypertension, acute renal failure with acute tubular necrosis, chronic kidney disease, acute on chronic systolic heart failure, poorly controlled diabetes mellitus, history of bilateral below the knee amputations, substance use disorder, intellectual disability, schizoaffective disorder, psychosis, borderline personality disorder, and recurrent nonadherence to medical treatment. Patient #1 was admitted on 05/03/25 at approximately 2:49 AM for further management. The patient remained incarcerated (police custody) during her emergency department and inpatient hospital stays with constant guard by a sheriff’s deputy. The patient had a history of aggressive and abusive treatment of both staff and others and had an on-going violent care plan. The physician’s discharge note dated 05/05/25 documented in the late afternoon on 05/05/25 Patient #1 was noted to be agitated and screaming out from her room. She was throwing objects in reach onto the floor and being verbally abusive of the hospital staff and the correctional officers at bedside. Multiple attempts at verbal redirection were not successful and the patient put herself out of bed onto the floor. She required a manual hold by the hospital police so intramuscular olanzapine could be administered. At approximately 5:50 PM she was noted to be not responsive, without a pulse and a Code Blue was initiated. At 6:29 PM resuscitation efforts were halted. Review of Patient 1’s Certificate of Death, signed by the local county medical examiner on 09/19/25, documented the immediate cause of death as “Physical restraint in the setting of congestive heart failure due to ischemic cardiovascular disease and type 1 diabetes mellitus.” The description of how the injury occurred was documented as “Homicide during legal intervention.” Review of the facility’s timeline of events regarding Patient #1’s death on 05/05/25, provided by the facility’s Administrative Staff Member M, documented on 05/05/25 The patient was pronounced dead. The body was transported to the medical examiner’s office later that evening. On 09/18/25 the local sheriff Deputy Detective made an initial request to the facility to interview 17 facility employees related to the clinical event of 05/05/25. On 09/23/25 the facility received a media request about the event involving Patient #1 from an investigative reporter requesting police and/or investigative reports relating to the 05/05/25 event. On 09/25/25 Patient #1’s death certificate and toxicology report were made publicly available. The hospital obtained a copy of the death certificate on this day. The hospital provided no evidence they began an investigation into this adverse event resulting in Patient #1’s death while admitted to the hospital. Interview with Medical Staff A on 10/23/25 at 11:01 AM revealed the facility reviewed one adverse event report for Patient #1’s hyperkalemia (elevated serum potassium), which was received on 05/06/25. Staff A verbalized the event went through the facility’s investigative process, peer review, and an action plan developed and was in place. Medical Staff A verified there were no other adverse events identified or investigated associated with Patient #1. On 11/13/25 at 3:00 PM a review of the adverse event log with Quality Staff C and Quality Staff D revealed no additional adverse event for Patient #1 despite the death certificate for the patient documenting the death as a homicide. Interview with the Medical Examiner on 11/13/25 at 1:30 PM revealed she could not discuss specifics with the case as there was a criminal investigation occurring. The medical examiner verbalized that many sources of information would be obtained and reviewed when available and was dependent upon the circumstances at the time of death. All information collected would be considered when making a determination of whether a death was a homicide or not as the patient died in the presence of others and there was a history of a restraint/hold prior to her death. Review of the policy titled “Compliance Accreditation Manual for Hospitals,” update of July 2023, directed the following careful identification, investigation, and analysis of patient safety events, as well as strong corrective actions that provide effective and sustained system improvement, is essential to reduce risk and prevent patient harm. This policy contained a Sentinel Event Policy which explained The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect future patients, improve systems, and prevent further harm. Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and resulted in death, severe harm, or permanent harm. Sentinel events are not only events that occur during the care and treatment of individuals. Physical and verbal violence, abductions, and power failures are all potential sentinel events that can affect the health care organization and its patients. The Joint Commission considers the following to be sentinel events if they occur under any Joint’ Commission-accredited health care organization; Homicide of any patient receiving care, treatment, and services while on site at the organization or while under the care or supervision of the organization. Interview on 11/13/25 at 3:00 PM Quality Staff C and Quality Staff D verified the deficient practice.”