Marietta Memorial Hospital

“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: 33019 Based on medical record review, policy review, and interview, the facility failed to timely complete a thorough and comprehensive wound assessment and wound care consult and timely initiate wound treatments. This affected one (Patient #7) of three patients reviewed for pressure ulcers. The facility identified eight patients with pressure ulcers. Findings include: Medical record review revealed Patient #7 was admitted on 11/18/25 and discharged on 11/27/25 to a skilled nursing facility (SNF). The 66-year-old male presented to the emergency department on 11/17/25 secondary to a hemoglobin of 6.8 grams per deciliter (g/dL) (normal levels being around 12 to 17.5 g/dL) from an outside facility. The patient was hospitalized for acute exacerbation of congestive heart failure (CHF). Review of nursing progress note dated 11/19/25 at 8:00 P.M. revealed Patient #7 had a sacral pressure ulcer and an unstageable pressure ulcer located on the left heel. The assessment did not include any measurements or descriptions of the pressure ulcers. It also did not include information about a right lateral foot wound. Review of the plan of care revealed pressure injury prevention interventions were in place and included turning and repositioning and skin assessments twice per day. Review of physician progress note dated 11/24/25 at 12:36 P.M. revealed a Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer and may also present as an intact or open/ruptured blister) located on the sacrum, present on admission. The note did not include information about a left heel wound or right lateral foot wound. Review of a physician order dated 11/26/25 at 10:28 A.M. revealed the order to consult wound care for pressure ulcers. Review of a physician order dated 11/26/25 at 1:30 P.M. revealed the order for wound care for a pressure ulcer Stage 2 located on the left heel (intact serous fluid blister) and for an unstageable pressure ulcer located on the right lateral foot with instructions to clean with soap and water, rinse, and dry, paint with Betadine, leave right lateral foot wound open to air, pad left heel with dry gauze, secure with Optifoam Gentle Bordered (GB), and to change the dressing daily as well as turn and reposition every two hours and float heels at all times by placing a pillow under each leg from behind knee to ankle region. The orders did not include treatments for a sacral wound. Review of a Wound Care Registered Nurse (RN) progress note dated 11/26/25 at 1:23 P.M. revealed the reason for the consult was pressure ulcers and the initial wound assessment was to the left heel and right lateral foot. It stated they were unsure if the patient had any wounds to the buttocks/sacrum due to the family stating that physical therapy had just gotten the patient up to the chair and they did not want him to go back to bed at this time, and they refused to allow nurse to assess while standing. Family stated that when the patient was cleaned, he did not notice any wounds, but stated as soon as the patient went back to bed, he would notify staff. Measurements of the left heel pressure wound were 4.3 centimeters (cm) length by 5.2 cm width. The old dressing was removed with no drainage noted. Wound was a large serous fluid blister and the peri-wound was clean, dry, and intact. The treatment was for the wound to be cleaned with soap/water, rinsed, patted dry, painted with Betadine, padded well with dry gauze and secured with Optifoam GB. The unstageable pressure wound located on the right lateral foot pressure wound measured 5.7 cm length by 1.2 cm width. The assessment revealed a wound cluster of two. The wound was open to air with no signs of drainage or odors. The wounds were large with black eschar and the peri-wounds were calloused. The treatment was for the wound to be cleaned with soap/water, rinsed, patted dry, painted with Betadine, padded well with dry gauze and secured with Optifoam GB. The patient tolerated wound care without complaints and the note indicated they were uncertain of the time frame of the wounds. Interview on 03/18/26 at 10:32 A.M. with Wound Nurse RN (Staff B) confirmed wound care was not consulted until 11/26/25 though he was admitted with wounds on 11/18/25. She stated during her assessment on 11/26/25, Patient #7’s son refused to allow her to assess the patient’s sacral area because physical therapy had just gotten him up into the chair. Wound Nurse RN (Staff #B) confirmed she did not complete a comprehensive and thorough skin assessment and did not return later that day to perform further assessment; the patient discharged the next day, and she was unable to verify if he had a sacral pressure ulcer. Interview on 03/18/26 at 10:40 A.M. with Chief Nursing Officer (Staff C) stated Patient #7’s medical record first revealed documentation on 11/19/25 at 8:00 P.M. of the patient having pressure ulcers located on his right foot, heel, and sacrum. Documentation revealed a Stage 2 sacral pressure ulcer, and pressure ulcers located on the left heel and right foot, but there were no measurements or descriptions of the pressure ulcers. Staff C stated it was her expectation that wound measurements should have been obtained and wound care consulted for a Stage 2 or greater pressure ulcer. Staff C stated if Staff D had documented properly, this documentation would have prompted Wound Care to follow-up. Staff C further confirmed there were no treatment orders for the sacrum wound and that the wound treatments for the left heel and right lateral foot werent initiated until 11/26/25. Interview on 03/19/26 at 8:02 A.M. with RN (Staff D) revealed she completed a head-to-toe assessment on Patient #7 after he was admitted to the floor from the ED. Staff D confirmed she did not obtain measurements or document characteristics of Patient #7’s pressure ulcers. She further stated the hospital’s policy was to consult wound care if an admission assessment revealed a pressure ulcer, however, she was unsure if she did so in this case. Review of the facility’s policy titled, “Pressure Ulcer Prevention,” dated 09/02/20, revealed upon admission all adult patients will have a Braden Scale Pressure Ulcer screening and a head-to-toe skin assessment completed by the nursing staff. Based on this assessment, the nurse will categorize the patient as a moderate or high risk and will implement nursing interventions that target the potential causes as per the category. Documentation of an existing pressure ulcer will be noted on the admission assessment and described thoroughly, noting shape, measurements, stage (using the definitions as presented by the National Pressure Ulcer Advisory Panel), description of wound bed, edges, surrounding tissue, exudates, odor, and signs of infection. All dressings must be removed from existing ulcers in order to capture present on admission pressure ulcers.”

“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: 31597 Based on record review, interview and policy review, the facility failed to ensure a patient was transferred to the correct accepting facility. This affected one (Patient #1) of six patients reviewed for transfer. This had the potential to affect all patients who arrive at the facility’s emergency departments. The average daily census of the facility’s emergency departments for the past year was 171. Findings include: Patient #1 arrived at the facility’s emergency department on 06/09/24 at 4:56 PM. Patient #1 received a medical screening exam and it was determined that Patient #1 needed to be transferred to a higher level of care for vascular surgery. Patient #1 was transferred to Hospital B in West Virginia on 06/09/24 at 11:12 PM. Resident Physician H filled out the receiving provider and facility information on the Physician Certification for Transfer form. ED Physician K signed the physician certification for the transfer of Patient #1. It was later discovered that Resident Physician H filled out the incorrect location of the hospital where Patient #1 was supposed to be transferred to. Patient #1 was supposed to be transferred to Hospital A in West Virginia. He was transported to Hospital B in West Virginia, about 150 miles past Hospital A. An addendum by Resident Physician H on 06/10/24 at 2:01 AM stated “I was informed by EMS (Emergency Medical Services) crew that patient was apparently dropped off at the incorrect location. Originally had requested to talk to vascular surgery at [Hospital A]. After numerous attempts we were unable to contact the physician there. I have then asked to speak with [Hospital B]. I was then contacted back by a vascular surgeon via the transfer center. I was under the impression that this was a vascular surgeon at Hospital B who had accepted the patient to the emergency department when in fact this was the vascular surgeon [Physician X] we had difficulties getting ahold of at [Hospital A]. Paperwork was filled out and patient was transferred out of the emergency department and had incorrectly arrived at Hospital B with no accepting physician. It was then confirmed that patient was accepted at [Hospital A]. After some discussion with Hospital B, they had then accepted the patient for vascular services. The new accepting physician is Physician Z in the emergency department. This plan was discussed with the transfer team and the patient.” During an interview on 07/30/24 at 9:30 AM, Resident Physician H stated Patient #1 came in for vascular issues, Patient #1 had procedures done in an outside facility. “We talked to our vascular, he (the facility’s vascular surgeon) doesn’t do peripheral vascular things, we had difficulty getting ahold of vascular, we started looking elsewhere, we were contacting multiple facilities at the same time and getting calls back from transfer centers”. Resident Physician H stated there was a breakdown in communication which resulted in the facility transferring Patient #1 to the wrong hospital. He stated the facility contacted Hospital A initially, for Physician X, a vascular surgeon. When Physician Z also a vascular surgeon, returned the call, Resident Physician B thought he was on the phone with Hospital A the entire time. Resident Physician H said Hospital B then called and said they never accepted the transfer of Patient #1. Patient #1 was accepted at Hospital A by Physician Y. Resident Physician H gave the Physician Certification for Transfer form to the health unit coordinator, who contacts the transport team based on the information on the form. Resident Physician H stated Hospital B called them around midnight regarding the arrival of Patient #1. During an interview on 07/30/24 at 2:19 PM, Staff A verified Patient #1 was transferred to the wrong hospital. Review of the facility policy titled “EMTALA -Transfer Policy”, reviewed 12/13/23, stated, in part, the physician certification that the benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risk of the transfer is not required for transfers of individuals who no longer have an emergency medical condition, unless otherwise required by state law. A stabilized patient may be transferred upon request or pursuant to prearranged transfers/treatment plans of state, county or other entities if the following conditions are met: i. Documentation of patient stabilization has been prepared by a physician or a qualified medical person in consultation with a physician (physician’s counter-signature is required on documentation; ii. The transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer; iii. If the transfer is requested by the patient, the request must be in writing and must indicate the reason(s) for the request as well as indicate that the patient is aware of the risks and benefits of the transfer; iv. The patient has been informed of the hospital’s obligation to provide an emergency medical screening and the necessary stabilizing treatment; v. The receiving facility: has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer of the individual and to provide appropriate medical treatment; and vi. The individual agrees to the transfer. h. A transfer to another facility will be appropriate only in those cases in which: i. The facility provides medical treatment within its capabilities 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 has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate treatment. iii. The facility 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 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 written certification as required in section “e” or “g” above. This documentation must also include the name and address of any on-call practitioner 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 from the transferring hospital at the time of the patient transfer) must be sent as soon as practical after such transfer. Records must accompany the patient whether or not the patient’s emergency medical condition is stabilized. 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. i. Appropriate transfer documentation, as outlined above, must be included in the patient’s medical record. j. Each facility, through its designated personnel and/or Emergency Department physicians must obtain the consent of the receiving or recipient hospital and the receiving physician before the transfer of the patient and must make the appropriate arrangements for the patient transfer with the receiving hospital and physician. k. The physician at the transferring facility has the responsibility to determine appropriate mode of transportation, equipment and attendants necessary to effect a transfer to a receiving or recipient facility.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 33020 Based on record review, and staff interview, the facility failed to ensure all patient records must document all nursing notes and other information necessary to monitor the patient’s condition for one of 10 patients reviewed (Patient #2). The census was 122. Findings include: On 11/02/23 at 11:11 A.M. a review of the Grievance List for December 2022 revealed grievances were submitted on 01/27/23, 06/05/23, 07/10/23, and 07/27/23 concerning issues related to Patient #2 and events that took place between 12/13/22-12/18/22, and all were investigated and closed. A review of the conclusion of each grievance revealed multiple issues were addressed and no concerns were substantiated because of the hospital investigation, but multiple dictation documentation errors were noted/documented in the investigation conclusion packet. On 11/06/23 at 1:17 P.M. an interview with Staff B and Staff D revealed there was unclear documentation concerning code status, but communication with the family was difficult. On 11/07/23 at 11:53 A.M. an interview with Staff O and Staff A during Patient #2’s medical record review revealed that on 12/13/22 there was no documentation supporting the hospital staff attempted to contact the patient’s spouse who was listed as the next of kin. Further review and interview revealed a Registered Nurse attempted to call the patient’s daughter at 6:00 A.M. on 12/15/22 and another Registered Nurse documented a physician attempted to call the daughter at 6:00 P.M. on 12/15/22. No other information was documented about the family being notified. An interview with Staff A, Staff D and Staff O revealed all three agreed that there should have been better documentation to clarify who specifically attempted to contact the patient’s family instead of multiple staff members documenting someone else attempted to contact the family and whether or not they reached the family regarding the patient’s changes in condition. Further interview revealed all three staff members believed the family was notified, but they could not confirm the family was notified based on the documentation provided in the medical record.”

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 33020 Based on record review, staff interview, and policy review, the facility failed to provide outpatient services that meet the needs of the patients for one of 10 patients reviewed (Patient #1). The census was 122. Findings include: On 11/06/23 at 2:40 P.M. a review of the discharge instructions provided for Patient #1 at the time of discharge after surgery on 09/14/23 revealed the signed discharge instructions instructed the patient to call the after-hours nurse hotline if he had concerns like pain. Further review of the email thread/discharge instructions and an interview with Staff D during the record review confirmed the patient’s wife called the after-hours nurse line at 6:29 P.M. on 09/14/23 to report the patient was having post-surgical pain, but the nurse working the call line sent a message to the office for them to read the next day during business hours. On 11/06/23 at 3:08 P.M. an interview with Staff M revealed patients were instructed to call the after-hours nursing line as described on the discharge instructions. She stated 6:29 P.M. would be considered after hours. Further interview confirmed that the nurse took a call after hours on 09/14/23 at 6:29 P.M., but she did not document the call, and did not follow the process for the after-hours call center policy. On 11/07/23 at 9:52 A.M. a review of the policy titled, Memorial Health System Nurse Line, reviewed 08/26/21, revealed the nurse line is open to Marietta Memorial Hospital (as well as all Memorial Health System facilities) 24 hours per day. An interview with Staff D at the time of the policy review confirmed this was the policy that was not followed by the nurse working the call center. Further review of the policy revealed all triage calls were documented in the “NCentaurus” system with a report generating the electronic medical record. An interview with Staff D confirmed that the nurse did not document anything about the call. Further interview revealed there was an investigation completed on 11/07/23 and Staff M listened to the recording of the nurse and Patient #1’s spouse discussing the patient having increased pain levels. Further interview with Staff D and a review of the investigation revealed all contact center nursing staff were educated and the policy was reviewed about documentation of all calls, and the situation involving the nurse was discussed after the surveyor identified the call was not documented, and the policy was not followed. This deficiency represents non-compliance investigated under Substantial Allegation OH00146592.”