Norman Regional

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 54303 Based on observation, record review and interview, the hospital failed to ensure: 1. Chemical cleaners were secured out of the reach of the public. 2. Emergency supply carts were secured for one (Emergency Bay 1 Supply Cart) of two ED supply carts. 3. It followed its own policy for EMTALA signage for one (ambulance entrance) of two ED entrances observed. 4. It followed its own policies (“AMA/Elopement” and “Patient Transfer and EMTALA”) for six (Patient #1, #2, #3, #4, #7, and #8) of 20 sampled patients. Findings: CHEMICALS: During a tour of the emergency department on 04/22/26 from 9:06 AM to 9:15 AM, a bottle labeled “Virax II” was observed on the countertop in Bay 1. On 04/23/26 at 9:50 AM, Staff B stated: 1. Someone could drink chemicals that were left out. 2. Housekeeping chemicals, including Virax II, should have been locked in housekeeping carts to prevent this. SUPPLY CART: During a tour of the emergency department on 04/22/26 from 9:06 AM to 9:15 AM, the supply cart in Bay 1 was observed to be unlocked. The cart was observed to contain PIV catheters, tourniquets, sterile urine cups, and phlebotomy kits. On 04/22/26 from 9:06 AM to 9:15 AM, Staff D stated: 1. The cart should have been locked. 2. The cart contained sharps. 3. The unlocked supply cart posed a safety risk to the patient. SIGNAGE: During a tour of the ED on 04/22/26 from 9:06 AM to 9:15 AM, EMTALA signage was observed posted at the hospital’s main ED entrance and no EMTALA signage was observed at the ambulance entrance. Review of a policy titled “Patient Transfer and EMTALA” dated 10/2017, read in part, “Each [facility] department that provides emergency or clinic services post a sign ... in a place or places likely to be noticed by all individuals entering the department.” On 04/22/26 at 9:15 AM Staff D stated: 1. The only signage the facility had posted was at the main ED entrance. 2. A patient would not see an EMTALA sign if they were brought into the ED from the ambulance bay. AMA/ELOPEMENT POLICY: AMA Review of a policy titled “AMA/Elopement” dated 12/10/21, showed patients who left against medical advice required documentation. Specifically: 1. An AMA form signed by the patient or, if refused, two staff members. 2. Completion of MIDAS Variance. Patient #2 Review of a document titled, “Summary Report” dated 04/23/26 at 9:43 AM showed: 1. The patient presented to the ED on 04/03/26 at 9:27 PM with a chief complaint of chest pain. 2. The patient disposition was documented as “AGAINST MEDICAL ADVICE” on 04/03/26 at 11:46 PM. Review of a document titled “Patient Safety Events” dated 2026 did not show Patient #2. Patient #3 Review of a document titled “Emergency Department Report” dated 03/17/26 at 7:58 PM showed: 1. The patient presented to the ED on 03/17/26 at 6:30 PM with a chief complaint of postprocedural bleeding. 2. The patient left the facility AMA. Review of a document titled “Patient Safety Events” dated 2026 did not show Patient #3. On 04/23/26 at 8:55 AM, Staff H reviewed the policy and the patient safety events document and stated: 1. The policy required a MIDAS Variance for patients who left AMA. 2. The Patient Safety Events document and the MIDAS report were the same document. 3. Patient #2 and #3 were not on the patient safety events document. On 04/23/26 at 9:15 AM, Staff B reviewed the policy and the medical chart and stated Patient #3 did not have a signed AMA form. ELOPEMENT Review of a policy titled “AMA/Elopement” dated 12/10/21, showed patients who eloped required documentation. Specifically: 1. Documentation of all search efforts and notifications. 2. Completion of MIDAS Variance. Patient #7 Review of a document titled, “Summary Report” dated 02/01/26 at 12:08 AM showed: 1. The patient presented to the ED on 01/02/26 at 3:08 PM with a chief complaint of flu like symptoms. 2. The patient disposition was documented as “ELOPE” on 01/02/26 at 6:08 PM. 3. No documentation of notifications or search efforts. Review of a document titled “Patient Safety Events” dated 2026 did not show Patient #7. On 04/22/26 at 11:27 AM, Staff M stated: 1. The care team was supposed to attempt to look for or call the patient and notify the provider. 2. There was no documentation of search efforts or provider notification. On 04/23/26 from 8:55 AM to 8:59 AM, Staff H reviewed the policy and the patient safety events document and stated: 1. The policy required a MIDAS Variance for patients who eloped. 2. The Patient Safety Events document and the MIDAS report were the same document. 3. Patient #7 was not on the patient safety document. PATIENT TRANSFER AND EMTALA POLICY: LWOBS Review of a policy titled “Patient Transfer and EMTALA” dated 10/2017, showed patients awaiting a MSE who decided to leave before being examined by the provider required documentation. Specifically: 1. The benefits of staying for the MSE. 2. The risks of not staying for the MSE. 3. The request of the patient to sign out AMA if they were not willing to stay for MSE. 4. The refusal to sign or the signed AMA form. Patient #1 Review of a document titled “Summary Report” dated 04/22/26 at 1:20 PM showed: 1. The patient presented to the ED on 04/09/26 at 8:48 PM with a chief complaint of chest pain and head injury. 2. An ED nurse’s note dated 04/09/26 at 10:11 PM read in part, “Pt no longer wished to wait to be seen.” 3. No documentation of risks of leaving without being seen. 4. No documentation of benefits of staying to be seen. 5. No documentation of refusal to sign or a signed AMA form. Patient #8 Review of a document titled “Summary Report” dated 02/26/26 12:07 AM showed: 1. The patient presented to the ED on on 01/27/26 at 2:40 PM with a chief complaint of substance withdrawl. 2. The patient disposition was charted as LWOBS on 01/27/26 at 4:06 PM. 3. No documentation of risks of leaving without being seen. 4. No documentation of benefits of staying to be seen. 5. No documentation of refusal to sign or a signed AMA form. On 04/23/26 at 8:45 AM, Staff H reviewed the policy and stated a patient who was awaiting a MSE and decided to leave before being seen by a provider would be considered a LWOBS and should have the documentation as described in the policy. On 04/23/26 at 8:50 AM, Staff B reviewed the policy and the patients’ charts and stated there was no documentation as described in the policy for Patient #1 or #8. TRANSFER Review of a policy titled “Patient Transfer and EMTALA” dated 10/2017, read in part, “Transfer Requirements ... Patient Transfer Certification form is completed [sic] a patient is transferred to another facility.” Patient #4 Review of a document titled “Summary Report” dated 04/22/26 at 1:22 PM showed: 1. The patient presented to the ED on 04/08/26 at 2:55 AM with a chief complaint of suicidal ideation. 2. The patient was transferred to a psychiatric facility on 04/08/26 at 4:06 PM. 3. No transfer paperwork. On 04/23/26 at 9:06 AM, Staff H stated: 1. All transfers, internal or external, were to have a signed transfer document on file. 2. Nursing Staff were to sign the transfer documentation for patients with EOD. On 04/23/26 at 9:25 AM, Staff B reviewed the medical chart and stated there was no transfer paperwork documented.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 54216 Based on record review and interview, the hospital failed to ensure patients and/or responsible persons had accurate notice of patient rights regarding the grievance and complaint processes for the facility for all patients. Findings: Review of a policy titled “Patient Rights and Responsibilities” last reviewed January 2016, read in part: 1.”If concerns in question cannot be resolved at this level, they are encouraged to (sic)... State Department of Health.” 2. “Oklahoma State Department of Health Medical Facilities Service - Complaints 1000 NE 10 Street OKC, OK 73117-1299 405-271-6576” The policy documented a previous OSDH address and phone number that was obsolete since 2020. On 03/06/26 at 3:50 PM, Staff A stated: 1. The contact information for OSDH was outdated.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 54216 Based on record review and interview, the hospital failed to ensure policy was followed for two (Patients #7 and14) of 20 patients reviewed. Findings: Review of a policy titled “AMA Elopement” last updated 01/20/20, defined AMA as a patient leaves the hospital against medical advice and defined elopement as leaving the hosptial without notifying staff. Review of a policy titled “AMA/Elopement” last updated 01/20/20, read in part, “In the event the patient decides to leave Against Medical Advice ... Complete the AMA form to include patient’s signature and one staff/witness signature ... If the patient refuses to sign the AMA form, document refusal on the form and obtain two staff/witness signatures.” Patient #7 Review of the medical record showed documentation consistent with leaving AMA and did not show a signed AMA form. Specifically: 1. The visit summary dated 02/05/26 at 1:45 AM showed a departure disposition of “Elope” at 1:49 AM on 02/05/26. 2. The nurse’s documentation dated 02/05/26 at 1:52 AM read in part, “patient became anxious and stated [Patient #7] wanted to leave ... pt informed of risks and states [Patient #7] still wants to leave.” On 03/11/26 at 1:07 PM, Staff K reviewed patient chart and stated there was no signed AMA form. On 03/11/26 at 2:14 PM, Staff D stated they weren’t sure if the documented situation was elopement or leaving against medical advice. Patient #14 Review of the medical record showed the patient left the ED AMA on 02/05/26 at 7:08 PM and did not show a signed AMA form. Specifically: 1. Provider note dated 02/05/26 read in part, “Patient states she wants to sign out AMA ... verbalized understanding of risks ... is alert and oriented x4.” 2. Summary Report documented patient disposition as AMA on 02/05/26 at 7:08 PM. On 03/11/26 at 2:14 PM, Staff L reviewed the patient chart and stated: 1. The disposition stated AMA. 2. There was no signed AMA form in the patient’s chart.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 54216 Based on observation and interview, the hospital failed to ensure emergency management supplies were not expired for one of one emergency room bronchoscope observed. Findings: During a tour of the emergency department on 03/11/26 from 8:35 - 8:50 AM, an expired bronchoscope was observed hanging on a pole next to a crash cart in an alcove. Specifically: 1. The bronchoscope labeled Model #0570-0432 Lot #KR234600 showed an expiration date of 11/17/24. On 03/11/26 at 8:40 AM, Staff F examined the bronchoscope and stated: 1. The expiration date had passed. 2. There was an infection risk if expired equipment were used. 3. They could not know if the bronchoscope was operational.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 53719 Based on record review and interview, the hospital failed to ensure policy was followed for two (Patient 7 and Patient 15) of 20 patients reviewed. Findings: Review of the medical records and pertinent documents showed that the patients eloped and did not show documentation of notifications or search efforts. Review of patient care policy “AMA/Elopement”, effective 12/13/2021 read in part, “If it is detected that a patient has left the patient care unit, immediately notify: a. the House Supervisor b. the Security Department ...Document all search efforts and notifications in the patient’s electronic medical record.” Patient 7 1. Review of the ED log showed departure disposition “ELOPE” at 1:49 am on 02/05/26. 2. Review of the EDM Patient Record report on 02/05/26 at 1:52 am read in part, “patient became anxious and stated she wanted to leave ...pt informed of risks and stated she wanted to leave.” The record did not show documentation supporting notification of leadership, security, or search efforts to locate eloped patient. On 03/11/26 at 2:14 pm, Staff D reviewed the policy and the patient chart and stated they weren’t sure if the documented situation was elopement or leaving AMA and there was no documentation the House Supervisor was notified or of search efforts. Patient 15 1. Review of the EDM Patient Record report, dated 10/02/25, read in part, “This nurse was informed by Xray that pt had let [sic] after refusing imaging. Pt left wo receiving paperwork or speaking w ERP.” 2. ED log review showed departure disposition “ELOPE” at 1:49 am on 10/02/25. On 03/11/26 at 2:14 pm, Staff L reviewed the medical record and stated there was no documentation of notification to House Supervisor or search efforts.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50779 Based on Record review and interview, the hospital failed to ensure patients received BLS from BLS trained personnel for 1 (Staff E) of 7 employees reviewed requiring BLS training and potentially affecting all patients receiving care at the facility. Findings: A review of RN Job description code 1132 stated, “Basic Life Support training or retraining was required during orientation prior to providing patient care... Current BLS was required throughout duration of employment.” Staff E A review of the employee file showed BLS certification expired 06/2024. During an interview with Staff J, K and V on 12/02/24 at 1:00 p.m., Staff V stated Staff E slipped through the cracks with her BLS certification due to a job status change.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 50779 Based on Record review and interview, the hospital failed to ensure the medical history and physical was documented in the patient medical record in a timely fashion per policy/bylaws for 2 (pts. #6 & #8) of 21 patients reviewed. Findings A review of the medical bylaws section 5.7 stated completion of the H & P must be completed 24 hours after admission. A review of the medical records showed the H&Ps for 2 (Pt #6 and Pt #8) of 21 charts were signed in excess of 24 hours as follows: 1. Pt #6 was admitted on 03/21/24 and the H&P was signed on 04/22/24 2. Pt #8 was admitted on 04/16/24 and the H&P was signed on 04/28/24. During an interview on 12/02/24 at 1:12 pm, Staff R stated that the physicians should have signed the H&Ps within 24 hours of admission.”