Christ 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: 42492 Based on interviews, review of patient medical records and acute hospital policies, the acute hospital failed to ensure medication administration records were accurately documented. Findings include: Review of the records for Patient #54 revealed an admission to acute hospital from 04/15/26 to 05/08/26 for intractable pain related to newly diagnosed poorly differentiated neuroendocrine tumor, extensive bony metastasis, extensive hepatic metastasis, and brain metastasis, hypotension/shock, acute renal failure, non-ST elevation myocardial infarction (NSTEMI), and Candida auris. Review of the flow sheet dated 05/07/26 at 8:00 P.M. documentation of the Critical Care Pain Observation Tool (CCPOT) revealed Patient #54 exhibited a pain level three of maximum eight. Review of electronic medication administration record (MAR) revealed on 05/07/26 at 8:40 P.M. Tylenol 1,000 milligrams (mg) (for pain), melatonin 6 mg (for sleep), and sennosides 24.6 mg (for constipation) were administered. Review of flow sheet dated 05/07/26 at 9:40 P.M. revealed pain assessment for non-verbal was negative one (-1), which meant eyes closed and resting. Review of MAR revealed on: 05/07/26 at 10:15 P.M. Zofran 4 mg was given intravenously (IV) (for nausea). 05/07/26 at 10:30 P.M. oxycodone 5 mg (for pain) and Trazodone 50 mg (a sleep aide). 05/07/26 at 11:06 P.M. cyclobenzaprine 10 mg (muscle relaxer) and Risperidone 0.5 mg (for agitation) During an interview on 06/03/26 at 3:30 P.M., RN E verified there were no nursing notes or flow sheet notes on 05/07/26 from 9:40 P.M. to 11:33 P.M. to indicate why Patient #54 received medication for pain, sleep, muscle spasms, or agitation; however, a reasoning should have been documented. Review of the policy “Pain Management,” dated 09/2022, revealed nurses were responsible for pain assessment and management, including administering pain medications and evaluating the effectiveness of the pain management regime. Further under Assessment of Patient’s pain and Its Documentation, the policy stated, assess all patients for the INITIAL presence of pain and on an ongoing basis.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 32088 Based on staff interview, review of facility policy, review of the Center for Disease Control and Prevention (CDC) Guidelines, and review of the the CDC guidelines ‘Toolkit: Developing a Legionella Water Management Program,” the hospital failed to ensure the water management program policies and procedures included the nationally recognized guidelines for identifying and investigating Legionnaires’ disease. (A0772).”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 32088 Based on staff interview, review of facility policy, review of the Center for Disease Control and Prevention (CDC) Guidelines, and review of the the CDC guidelines ‘Toolkit: Developing a Legionella Water Management Program,” the hospital failed to ensure the water management program policies and procedures included the nationally recognized guidelines for identifying and investigating Legionnaires’ disease. This had the potential to affect all persons who use the hospitals water supply. The census was 418. Findings include: Review of the website www.cdc.gov/control-legionella/php/toolkit/wmp-toolkit.html revealed the CDC information titled “Toolkit:Developing a Legionella Water Management Program.” This included the resource titled “ Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings,” dated September 30, 2025. Review of information under Special Considerations for Healthcare Facilities contained under the heading Identifying & Investigating Legionnaires’ Disease Cases revealed “Healthcare facilities are often uniquely positioned to identify and respond to cases of Legionnaires ’ disease. A healthcare facility ’ s water management program to limit Legionella growth and spread should include the actions to take when a patient is diagnosed with Legionnaires ’ disease or environmental triggers occur.” Review of the hospital policy titled, “Waterborne Management Program Policy,” last revised 02/01/25, revealed the guideline was intended to inform hospital staff and facility engineers regarding the bacteria Legionella and other waterborne pathogens and its potentially negative outcomes. The ability to infect and colonize both utility and domestic water systems, coupled with their potential to cause severe health complications presents a very real concern to building owners and operators. Fortunately, there are engineering strategies that can be followed to reduce risk associated with waterborne pathogens. Establishing a proactive approach within the context of a Water Management Plan (WMP) for building water systems is the best way to reduce the risk. The policy did not address the actions to take when a patient is diagnosed with Legionnaires’ disease. Interview on 01/08/26 at 3:10 PM with Staff A stated it was the hospital’s belief the CDC Toolkit directs the hospital to have a plan pertaining to water management after a patient tests positive for hospital acquired Legionella. She stated the hospital water management plan did not provide clinical guidance on patients. Interview on 01/13/26 at 11:29 AM with the Chief Medical Officer agreed the current water management policy did not address identifying and investigation of Legionnaires’ disease cases and the actions to take when a patient is diagnosed with Legionnaires’ disease.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 32088 Based on record review, review of email correspondences, and staff interview it was determined the hospital failed to ensure infection control interventions were timely implemented after notification of a presumptive case of hospital acquired Legionella. This had the potential to affect all patients who receive care at the hospital. The census was 370. Findings include: Review of an email dated 10/09/25 at 1:44 P.M. from the Cincinnati Health Department (CHD) Director of Environmental Health X to the hospital revealed they were writing informing of a presumptive case of Legionnaires’ where the patient was at the hospital prior to symptom onset on 09/13/25. They were directing the hospital to follow the Centers for Disease Control (CDC) guidelines, complete a full investigation, and complete a call with the CHD. In addition, they directed the hospital to consult a Legionella consultant, implement water use restrictions using point of use filters that were to be installed within two to three days, communicate the water restrictions to staff and patients, conduct a new risk assessment, create a Legionella sampling plan following the CDC guidelines, implement any identified corrections, collect a second set of samples 72 hours after the first, and revise their Water Management Program based on the Ohio Department of Health (ODH) and local health district recommendations. The Cincinnati Health Department (CHD) Director of Environmental Health X offered to set up a call with them and ODH for 10/10/25 or 10/13/25. The CHD Director of Environmental X also requested the hospital send in items prior to the call to include: the most recent version of the facility’s water management program, and environmental Legionella samples obtained in the past year, a floor plan of the facility to include the water loops, temperature and chlorine monitoring logs, maintenance monitoring logs of the secondary disinfection system if available and maintenance and monitoring logs for any additional water features. Another email from the CHD Director of Environmental Health X on 10/13/25 at 9:58 A.M. to Staff B revealed the CHD was to set up a call to “get things moving.” In addition, the email stated the facility should have already began working on implementing water use restrictions using point of use filters and directed the hospital to begin sending the items requested. On 10/15/25 Staff A replied to the CHD that he/she did believe further Legionella investigation and remediation was required because he/she was skeptical SP #1 had Legionella pneumonia. Staff A noted the patient experienced improvement prior to the Legionella treatment being administered. Staff A stated he/she had concerns with the accuracy of their assay in regard to the urine antigen test they use. Staff A noted that the hospital has not had any additional Legionella pneumophilia cases that would meet the case definition for healthcare associated Legionnaires’ disease. On 10/22/25 at 12:14 P.M. the CHD Director of Environmental Health X emailed the hospital stating that after reviewing some of the materials it was noted the hospital had experienced recurring detections of multiple Legionella serogroups, particularly in the West Tower. He/she noted that several exceeded the one Colony Forming Unit per milliliter (CFU/mL) threshold so he/she instructed them to consult with their water management expert about the installation of a secondary disinfection system. On 10/23/25 and 10/27/25 the CHD Director of Environmental Health X emailed again requesting a reply from his/her previous inquiries about whether filters have been installed and if so, where. On 10/27/25 at 12:59 P.M. Staff B replied that the hospital had began installing the filters on oncology and transplant patients and they were in the process of notifying patients, staff and providers of what they were doing. Interview on 10/29/25 at 10:30 A.M. with the Chief Medical Officer, Staff C revealed the hospital had spoke with the local and state health departments in response to the Legionella concerns. He/She stated the hospital did not agree with SP #1’s diagnosis of healthcare associated Legionnaires’ disease and they were unaware of the team member becoming sick until Friday (10/24/25). He/She stated water testing for Legionella is completed continuously and for the past year they have had good results. As of 10/28/25 they have started applying filters to the water fixtures, re-sampled the water and the water signage is up. Interview on 10/29/25 at 11:43 A.M. with Staff B revealed the hospital follows the CDC guidelines in regards to Legionella. He/She stated the nurses look in the electronic system called, Surveillance every morning and at different times throughout the day for reportable’s to include Legionnaires’ disease. Staff B stated the electronic system automatically sends over the positive test results from the lab to the health department. He/She stated the health department would contact the hospital if they determine that a positive case is hospital acquired. If a positive result is indicated, staff would notify water management and discuss the case with the Infectious Disease physician, Staff A. She stated they would look further to see what symptoms the patient arrived with, whether the patient was in the hospital and if so when within 14 days prior to symptom onset. They’d also ask if they use a home Continuous Positive Airway Pressure (CPAP). He/She stated the hospital does not call patients to question them regarding the positive Legionella test once they are discharged that is the health departments jurisdiction. He/She stated the hospital did not agree that SP #1’s case was hospital acquired so they did not begin implementing/submitting the health department requested items right away. He/She stated the health department missed the fact that the patient used his/her home CPAP machine at the hospital and verified that SP #1 tested positive three times (09/16/25, 09/17/25 and 10/03/25) using the same urine antigen tests that the hospital currently uses. Staff B stated Staff A determined SP #1 did not have Legionnaires’ disease because despite the positive tests, the patient got better with no Legionella treatment. He/she verified there was a delay in the health department request for installation of the water filters and sampling because the hospital did not feel it was hospital acquired Legionella. However the hospital was installing the filters now and would be finished within the next few days. He/She stated she is not sure what the CDC expert decided from the 10/24/25 call related to SP #1 but he/she verified that during the call they were initially informed that a hospital employee, Staff D tested positive for Legionnaires’ disease. He/She stated Staff D is an Environmental Specialist (EVS), and part of his job is to instruct new staff and flush water around the hospital. He/She stated Staff D worked 9/30/25 through 10/03/25, 10/06/25 through 10/10/25 and 10/13/25 through 10/17/25 and was everywhere in the hospital. He/She stated the employee has not returned back to work and was still hospitalized. He/She stated now Environmental Services staff are required to wear masks when flushing and they have provided some direction to Plant Operations staff in regards to focusing on obtaining water samples from floors three, four and seven where SP #1 was located during the admission. Interview on 10/29/25 at 2:05 P.M. with the Cincinnati Health Department (CHD) Director of Environmental Health X revealed the initial case (SP #1) identified on 09/2025 was confirmed by three positive tests and the patient met the case definition for Legionnaires’ disease. The hospital argued different issues to include that something was wrong with the tests but the argument did not stand. The hospital requested the case be reviewed at a higher level so on 10/24/25 the CHD, the ODH and the CDC were on a call with the hospital to discuss SP #1’s case. The CDC agreed with the health department. During the call on 10/24/25, they were notified that a hospital employee tested positive for Legionnaires’ disease. The Director of Environmental Health notified the hospital on 10/09/25 of the presumptive healthcare associated case of Legionnaires’ and what was required of the hospital. He/She stated the hospital was to install filters within three days of notification, however the hospital just started installing them a couple of days ago. He/She stated they expected the filters to be on and water restrictions were just implemented on Friday (10/24/25). Interview on 10/30/25 at 9:32 A.M. with Assistant Nurse Manager, Staff F during SP #1’s medical record review revealed SP #1 is frequent on his/her unit and stated the patient was currently in the hospital after being directed by his cardiologist to go during a visit. He/She stated the patient was a seen frequently at the hospital. Staff F stated SP #1 was on his/her unit for most of his stay starting 08/28/25 and comes often. Staff F stated that when a patient uses a home CPAP or Bilevel Positive Airway Pressure (BiPAP) machine respiratory staff have them sign a form and look over the machine. Staff then documented in the notes. Staff F verified there was no signed home BiPAP consent form and stated the nurse documented the patient had a home issued device the first two entries within two hours a part and every entry after, to include the respiratory therapist notes the patient was using a hospital issued device. Staff F stated the hospital encourages patients to use the hospital machines because they are usually better. Staff F verified the 10/28/25 urine antigen test had not resulted for SP #1 and stated SP #1 could keep having positive Legionella urine antigen tests because it may be colonized versus active. Staff F verified that there was no sputum sample obtained to verify whether the patient had an active infection for either of the three positive tests. Interview on 10/30/25 at 12:42 P.M. with the ODH Environmental Specialist Y revealed the hospital was first notified by the local health department on 10/09/25 that SP #1’s case was determined presumptive healthcare associated Legionnaires’ disease and informed of the CDC guidelines for hospitals to complete a full investigation. He/She stated, “Epidemiology is how we classify Legionella. The first case (SP #1) was presumptive and we treat one presumptive or two possible’s the same.” The hospital was instructed to send in various documents to include the water management plan, past Legionella water sampling results, a floor plan and current Legionella water sampling plans, for review to ensure they sample all of the possible areas of contamination based off of where the patient stayed. He/She stated the hospital was to install point of use filters within two to three days of notification and implement water-use restrictions. He/She stated the hospital argued that SP #1 was not positive for Legionnaires’ disease and wanted a second opinion. They set up a call on 10/24/25 to discuss SP #1’s case with the local health department, the hospital, a CDC representative and during the meeting another positive Legionnaires’ case in connection to the hospital was confirmed. It was a hospital employee who tested positive after presenting to an outside hospital. As of 10/30/25 they have not received the water sampling plans. Interviews with the staff revealed that there are three water loops on the campus. Filters are currently being installed at all point-of-use locations throughout the entire campus. These filters began installation on Friday, October 21, 2025. The process is progressing smoothly but also depends on supply and demand. Orders have been placed to install filters across the campus and are being executed as soon as deliveries arrive. Several units have already been completed. The most critical units are where the filter installation has started. Only one room is currently under construction, and this room is not in the same area or on the same water loop as the location of the positive test patient. All water loops have a chloride system in place, which operates during the first week of each month. During this time, the water lines are also flushed in different parts of the facility. Three West is a critical area, and all faucets in this section are flushed weekly. Updates are being made to the water system to ensure areas have a fully looped water system. Review of SP #1’s medical record revealed the patient went to an outside hospital complaining of rectal bleeding and shortness of breath (sob) that started that day on 08/28/25. The patient was given packed red blood cells at the outside hospital and transferred to this hospital on 08/28/25 at 9:04 A.M. for an acute transverse colon bleed. After several attempts to find the bleed, they were able to clip the bleeding vessels to stabilize the bleed. On 08/13/25 a Computed Tomography (CT) scan revealed the patient had bilateral pleural effusions and some consolidation in the lower lobes. The doctor noted diuresis was held related to the patient not making urine. The patient had a history to include diabetes, end stage renal failure status post transplant times two, chronic kidney disease of transplanted kidney, Gastrointestinal (GI) bleed, hemodialysis status post transplant, hypertension, atrial fibrillation and pulmonary hypertension. On 09/03/25 the pulmonary doctor noted the bilateral effusions were worsening and on 09/04/25 the provider noted the patient had increased work of breathing (wob), diminished lungs sounds to the lung bases and shortness of breath with moving around. On 09/04/25 at 9:27 A.M. the pulmonary doctor added a diagnosis of acute hypoxic respiratory failure and ordered Zosyn (antibiotic medication) be discontinued and to resume chronic amoxicillin (antibiotic medication). The patient was on two Liters (L) nasal cannula (nc). On 09/08/25 the provider noted pulmonary edema and mild crackles on auscultation, the patient was now on 3L nc. The patient continued to report shortness of breath. On 09/10/25 at 9:35 P.M. the breathing treatments were increased to every four hours. On 09/11/25 at 5:13 A.M. the nurse noted the lung sounds were diminished but the cough resolved with diuresis. On 09/13/25 the patient’s white blood cells elevated to 21,000 cells per microliter (uL). On 09/15/25 at 12:30 A.M. a rapid response was called for increased work of breathing and hypotension. The provider noted the patient was septic and transferred the patient to the intensive care unit. The patient was started on vancomycin and Zosyn (antibiotic medications). On 09/15/25 at 7:00 A.M. the patient was intubated related to a new onset of mental changes, cough and rhonchi and the provider added the diagnosis mild septic shock. On 09/16/25 at 10:48 A.M. the patient tested positive for Legionnaires’ disease. A retest was ordered as the provider noted he/she thought it was a false positive. On 09/17/25 at 1:39 P.M. the patient tested positive for Legionnaires’ disease for the second time. On 09/18/25 the provider started the patient on meropenem (broad spectrum antibiotic) and levaquin (antibiotic medication). On 09/19/25 at 5:29 P.M. the patient was removed from the ventilator and placed on oxygen at 2L via a nc. On 09/15/25 at 1:14 A.M. the patient was started on the BiPAP, it was stopped related to the patient being intubated and re-started nightly on 09/19/25. There was a note by the nurse on 09/15/25 where he/she clicked the patient was using the BiPAP from home. However, review of the respiratory therapist notes revealed the patient was using a hospital issued device. On 09/26/25 at 2:56 P.M. the patient was discharged to a skilled nursing facility. Further review of the medical record revealed on 10/03/25 the patient was at the hospital for shortness of breath and at 3:22 P.M. the SP #1 tested positive for Legionella for a third time via the urine antigen test. The patient was provided treatment and discharged. On 10/27/25 at 10:26 A.M. SP #1 was admitted to the hospital for shortness of breath and bilateral leg edema. The patient was diagnosed with pneumonia and was being treated with broad spectrum antibiotics. On 10/28/25 the patient was tested for Legionella and the results the patient is a current patient during the investigation.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 28999 Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff checked for patient allergies prior to placement of peripherally inserted central catheters (PICC) lines. This affected one patient (Patient #3) out of ten reviewed. The facility census was 353 . Findings include: Review of the medical record of Patient #3 revealed the patient presented to the facility’s emergency Department (ED) on 12/03/24 at 3:25 PM with one to two days of left eye pain and blurry vision. The patient stated her eye was nearly swollen shut and she presented to the ED due to concern for infection. The patient was prescribed the antibiotic erythromycin, advised to follow-up with an ophthalmologist, and discharged home. According to a hospitalist’s History and Physical the patient saw an ophthalmologist who wasn’t able to determine optic nerve etiology. The patient saw a second ophthalmologist and there was concern for possible optic neuritis with suspicion for infection versus multiple sclerosis. Patient #3 presented to the ED again on 12/04/24, was admitted, and neurology was consulted. A neurology note on 12/05/24 stated results of an magnetic resonance imaging scan were consistent with bilateral optic neuritis. Allergies listed in the record included Lidocaine which causes an anaphylactic reaction. Review of the physician order dated 12/11/24 revealed an order for a double lumen PICC line to be placed for inpatient vascular access. A note on 12/11/24 at 4:56 PM, composed by an intravenous (IV) therapy registered nurse (RN), stated the nurse arrived to the patient’s bedside to place a PICC line. A pre-procedure and timeout were performed with the bedside nurse. A consent was confirmed, vital signs were stable, and no contraindications were noted. The note further stated laboratory tests, allergies, medications, and code status were reviewed. The note stated Lidocaine was administered. The procedure note documented the patient reported her tongue was swelling a short time after the Lidocaine was administered. A rapid response was called due to the possibility of an anaphylactic reaction. The rapid response team note stated the team was called to the patient’s bedside due to the patient’s tongue swelling after Lidocaine, a medication she was allergic to, was administered. Upon arrival of the rapid response team the patient was noted to be alert and oriented, however she was complaining of tongue swelling. Benadryl 25 milligram (mg), Solumedrol 125 mg, and Epinephrine 1 mg were administered via IV and the tongue-swelling improved. Review of the Discharge Summary revealed the PICC nurse was able to complete placement of the PICC line. The PICC line was successfully used for administration of medication. The patient was discharged on 12/17/24. The PICC line was discontinued prior to discharge. Review of the facility policy titled “Peripherally Inserted Central Insertion per Vascular Access Services,” last reviewed in 08/2024, revealed a peripherally inserted central catheter is a central venous catheter inserted percutaneously through the veins of the upper extremity. The staff nurses are instructed, in step two of the procedure, to verify allergies prior to pre-procedure. Interview on on 04/10/25 at 2:00 PM, Staff C confirmed this finding.”

“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: 19966 Based on record review, interview and policy review, the facility failed to ensure a resident received care and services to prevent the development of a pressure ulcer. The patient census was 346. Findings include Review of the medical record revealed Patient #3 was admitted to cardiovascular step-down unit (CVSU) on 04/22/24 at 2:40 AM. Patient #3’s Braden score was 18, which was mild risk for skin breakdown. Interventions to prevent skin breakdown included a Mepilex dressing to the coccyx, keeping skin dry, linen clean and dry, and repositioning Patient #3. Patient #3 required assistance with turning and repositioning. Patient #3 was incontinent of bowel and bladder on admission and had a Purewick catheter placed. There were no pressure ulcers present on admission. Review of the medical record revealed on 05/03/24, a Friday, at 6:00 PM, a stage II pressure ulcer was discovered to Patient #3’s sacral area. The area was cleaned with normal saline, a moisture barrier cream and then Mepilex was applied. An image was taken of the sacral area. There was also a consult order placed to the wound nurse on 05/03/24. There is no wound care nurse on the weekends. The wound care nurse assessed the wound on Monday 05/06/24. The area measured 1 centimeter (cm) by 2 cm by 2 cm. Another image was taken. The surrounding skin texture was friable and the color and temperature was consistent with the rest of her skin. The orders by the wound care nurse were for a cream moisture barrier two times a day and as needed and Mepilex. There were also orders to re-consult the wound care team if the wound were to worsen. Review of the flow sheet revealed the Mepilex to the coccyx was not documented as being place on 04/29/24 and 04/30/24. Review of Patient #3’s flow sheet for turning and repositioning revealed on 04/22/24 no documentation Patient #3 was turned and repositioned from 2:50 PM to 6:18 PM and then again from 9:20 PM to midnight; on 04/27/24 from 5:00 PM to 8:35 PM up in chair sitting semi-fowlers; on 04/29/24 from 3:30 PM to 8:00 PM up in chair; and on 05/03/24 from 1:01 PM to 4:05 PM, up in chair. Review of the medical record revealed images of Patient #3’s coccyx on 05/03/24, 05/05/24, 05/06/24, and 05/09/24 and the area looked the same. Patient #3 was discharged on 05/13/24 to a skilled nursing facility (SNF). Review of a complaint filed by Patient #3’s representative on 05/03/24 revealed the representative reported that physical therapy (PT) wanted Patient #3 up in the chair while she is eating. The representative visited on 05/03/24 at 3:00 PM and Patient #3 said she had been up in the chair since that morning. When staff got Patient #3 up from the chair, her brief was soiled with feces. The Purewick external catheter was not working properly which caused the brief to be full of urine. Review of a nurse practitioner palliative care progress note dated 05/07/24 documented Patient #3’s representative R made a strong goal for her to be out of bed at mealtime and is very important to maintain every two hour turns due to the pressure ulcer on the buttock. During an interview on 10/09/24 at 3:28 PM, the Assistant Manager of CVSU stated Patient #3 had three episodes of bowel incontinence on 05/03/24 at 1:30 AM, 5:00 AM and 10:00 AM. Peri care was documented at 1:30 AM and 10:00 AM, but there was no documentation of peri care at 5:00 AM. During an interview on 10/10/24 at 4:30 PM, Staff D confirmed the above information. Review of the policy titled “Pressure Injury Prediction, Prevention, and Treatment”, revised November 2021, stated it is the goal of the hospital to prevent pressure injury development in all patients while receiving care in our facilities. Patients who develop pressure injuries while receiving care in any of our facilities will receive assessment and treatment for their skin breakdown with a goal toward healing and prevention of wound deterioration. A component of the assessment may include, but is not limited to, photography. Photographs will be taken to provide documentation of each patient’s pressure injury and serve as a resource for quality assessment as well as re-evaluation. Prophylactic pressure redistribution dressing is to be used for patients at high risk for skin breakdown with a Braden score of less than 18 or equal to and should have approved pressure re-distribution dressing applied over bony prominences at high risk for pressure including the coccyx area. For urinary incontinence consider the use of external catheter options when applicable. Pressure injury for Stage 1 or Stage 2 is including pressure injuries can be managed by nursing staff. The nurse may consult the Wound Nurse if the wound is not responding to standard care or the primary nurse identifies that the patient has factors inhibiting would healing. Initiate all preventative interventions to prevent further deterioration of the wound. Review of the guidelines for Mepilex border revealed it can be used for up to seven days.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 19966 Based on record review, interview and policy review, the facility failed to ensure a patient who presented to the emergency department (ED) was listed as a patient on the emergency department log. This affected one (Patient #21) of 20 records reviewed. Findings include: Review of the transport documentation for Patient #21 dated 05/10/24 revealed he was transported from an area hospital to a separate, unaffiliated rehabilitation hospital on the third floor of The Christ Hospital for admission. Upon arrival to the rehab floor (no time documented), Patient #21’s tracheostomy cuff was leaking. The Nurse Practitioner at the rehab hospital ordered the patient to be returned to the transferring hospital. The transport crew stated they could not return him without an order from the physician at the transferring hospital. The Nurse Practitioner ordered Patient #21 to be taken to the ED of The Christ Hospital, since it was in the same building as the rehab hospital. The transport team approached the EMS triage desk and explained the situation. Medical Doctor (MD) Staff G came to the stretcher and told the transport team Patient #21 needed to be taken back to the transferring hospital. The team explained they could not return him there without an accepting physician. Patient #21 was then moved into an ED room due to low oxygen level in the transport oxygen tank. Patient #21 was placed to wall suction and was orally suctioned by a Christ Hospital staff member. Review of the emergency department log dated 05/10/24 did not include Patient #21. During an interview on 07/02/24 at 10:30 AM, MD Staff G revealed he worked on 05/10/24 in ED and was aware of Patient #21. That evening of 05/10/24 all of a sudden there was a medical transport team in the ambulance bay and they were somewhat confused. A gentleman walks into the ED and said they were not sure what to do with Patient #21. He was talking to the charge nurse. He explained Patient #21 just left an area hospital neurointensive care unit to the rehab hospital on the third floor. When medical transport arrived to the rehab hospital, they would not accept Patient #21 because they thought there was a small air leak in the trach, but patient #21 was stable the entire time and had an oxygen saturation of 100 percent. Patient #21 was never in the ED and only in the ambulance bay. MD Staff G stated he offered to have Patient #21 come into our ED and change the trach and then have Patient #21 go back upstairs to the rehab hospital. Medical transport said multiple times the patient was stable and only the staff at the transferring hospital were the ones to take care of the tracheostomy. Review of the policy and procedure titled “EMTALA-Emergency Care and Transfer of Patients with an Emergency Medical Condition”, revised August 2022, stated hospitals that operate dedicated emergency department and participate in the medicare program are required to comply with the EMTALA. The hospital will provide an appropriate Medical Screening Examination (MSE) for all individuals within the capability of the hospital’s emergency department and ancillary departments for all individuals regardless of ability to pay, who present to the dedicated emergency department requesting examination or treatment of emergency medial condition. An appropriate medical screening examination will also be provided for all individuals presenting to the the dedicated emergency department on hospital property and which a reasonably prudent layperson would conclude, based upon the individual’s appearance or behavior, is in need of emergency treatment. For patients determined to have and emergency medical condition, including pregnant women in labor, the hospital will provide necessary stabilizing treatment or will provide an appropriate transfer. The purpose of this policy is to provide guidelines for hospital employees and associates to screen, stabilize and, if applicable, safely transfer patients for continuation of medical care in accordance with all applicable laws and regulations relating to the provision of emergency services, including EMTALA. The hospital must maintain a central log on each individual who comes to the ED seeking assistance and whether that person refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and transferred, or discharged. The central log will include patient logs from non-emergency department patient areas where patients may present directly for emergency services, such as labor and delivery.”

“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: 19966 Based on record review, interview and policy review, the facility failed to complete a medical screening examination (MSE) on a patient that presented to the emergency department (ED). This affected one (Patient #21) of 20 patient records reviewed. Findings include: Review of the transport documentation for Patient #21 dated 05/10/24 revealed he was transported from an area hospital to a separate, unaffiliated rehabilitation hospital on the third floor of The Christ Hospital for admission. Upon arrival to the rehab floor (no time documented), Patient #21’s tracheostomy cuff was leaking. The Nurse Practitioner at the rehab hospital ordered the patient to be returned to the transferring hospital. The transport crew stated they could not return him without an order from the physician at the transferring hospital. The Nurse Practitioner ordered Patient #21 to be taken to the ED of The Christ Hospital, since it was in the same building as the rehab hospital. The transport team approached the EMS triage desk and explained the situation. Medical Doctor (MD) Staff G came to the stretcher and told the transport team Patient #21 needed to be taken back to the transferring hospital. The team explained they could not return him there without an accepting physician. Patient #21 was then moved into an ED room due to low oxygen level in the transport oxygen tank. Patient #21 was placed to wall suction and was orally suctioned by a Christ Hospital staff member. Review of the ED log for 05/10/24 revealed Patient #21 was not on the log. There was no medical record started for Patient #21 and no documentation an MSE was completed. During an interview with Medical Doctor Staff G on 07/02/24 at 10:30 AM revealed he worked on 05/10/24 in ED and was aware of Patient #21. The evening of 05/10/24 all of a sudden there was a medical transport team in the ambulance bay and they were somewhat confused. A gentleman walked into the ED and said they were not sure what to do with Patient #21. He was speaking to the charge nurse. He stated they had transported Patient #21 fro an area hospital to the rehab hospital on the third floor. When medical transport arrived to the rehab hospital, staff would not accept Patient #21 because they thought there was a small air leak in the trach, but Patient #21 was stable the entire time and had an oxygen saturation of 100 percent. When Staff G heard this, he got involved. Staff G stated Patient #21 was never in ED and only in the ambulance bay. The transport staff stated only staff at the transferring hospital were able to assess Patient #21’s tracheostomy. Staff G called the transferring hospital, who agreed to accept the patient back. During an interview on 07/02/24 at 11:12 AM, the rehab hospital nurse practitioner, Staff K, stated when Patient #21 arrived he was breathing around his tracheostomy rapidly and his oxygen saturation was declining rapidly and down into the 70’s. Medical transport said Patient #21 was that way when they picked up from the transferring hospital. The ear nose and throat surgeon at the transferring hospital is the one who placed the tracheostomy and it had a flap. Staff at the rehab hospital were told “not to mess with it.” They could not bag (provide oxygen via an ambu bag) Patient #21 because the air was not reaching his lungs and the air was coming out around his trach and making noises and so was his mouth. They are located inside of Christ hospital on the third floor. Staff K stated she called Staff G at Christ hospital ED and explained the situation and Staff G called us back and got more information from the case manager. Staff K did not think Patient #21 would make it from the unit back to the transferring hospital, so they sent him downstairs to the ED at Christ Hospital. Staff G called back and stated they were sending him back to the transferring hospital. Review of the procedure for medical screening exam (MSE) was including all individuals who present on hospital property requesting examination or treatment of an emergency medical condition or who reasonably appear to need examination or treatment for an emergency medical condition, the hospital will provide an MSE by qualified medical personnel to determine whether or not the patient has an emergency condition. Depending on the patients presenting symptoms, the MSE may range from a simple process involving only a brief history and physical exam to a compel process that also involves performing ancillary studies and procedures, including but not limited to, clinical laboratory tests, CT scans, MRI’s and diagnostic tests and procedures. Review of the policy and procedure titled “EMTALA-Emergency Care and Transfer of Patients”, revised August 2022, stated that operate dedicated emergency department and participate in the medicare program are required to comply with the EMTALA. The hospital will provide an appropriate Medical Screening Examination (MSE) for all individuals within the capability of the hospital’s emergency department and ancillary departments for all individuals regardless of ability to pay, who present to the dedicated emergency department requesting examination or treatment of emergency medial condition. An appropriate medical screening examination will also be provided for all individuals presenting to the the dedicated emergency department on hospital property and which a reasonably prudent layperson would conclude, based upon the individual’s appearance or behavior, is in need of emergency treatment. For patients determined to have and emergency medical condition, including pregnant women in labor, the hospital will provide necessary stabilizing treatment or will provide an appropriate transfer. The purpose of this policy is to provide guidelines for hospital employees and associates to screen, stabilize and, if applicable, safely transfer patients for continuation of medical care in accordance with all applicable laws and regulations relating to the provision services, including EMTALA.”