Memorial Hospital

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure consideration of medical staff recommendation by the governing body for one (Memorial Hospital) of one hospitals reviewed. Review of credentialling records did not show documentation of appointment recommendation by the medical staff to the governing body and did not show governing body approval. Specifically: 1. The Appointment Page of the medical staff appointment application for Staff N read in part, “DATE: 6-20-23 CHIEF OF STAFF: [signed name withheld],” and appointment recommended was not marked and appointment not recommended was not marked. 2. The Appointment Page continued to read in part, “DATE: 5-1-24 CHAIRMAN, GOVERNING BOARD [signed name withheld],” and approved was not marked and disapproved was not marked. On 05/22/25 at 2:11 PM, Staff D reviewed the credentialing records and stated: 1. The medical staff recommendation was not marked and should have been. 2. The governing board approval or disapproval was not marked and should have been.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure medical-surgical care was not provided by non-clinical staff for one (Patient #5) of five patient records reviewed. Review of a document titled “HOSPITAL-ADMISSIONS CLERK JOB DESCRIPTION” did not show needle decompression as a job responsibility. Patient #5 Review of the Emergency Physician Report signed 04/08/25 at 7:54 PM read in part, “Chest Tube Placement ...completed without complication.” On 05/22/25 from 12:27 PM to 12:40 PM, Staff M stated: 1. They assisted the physician in a chest tube placement by inserting a needle into the patient’s chest. 2. They were not a nurse or in nursing or medical school. 3. Placing needles in patients was not part of their job description. 4. They thought they should not do it, but did because they were intrigued. On 05/22/25 from 12:51 PM to 1:10 PM, Staff K stated: 1. Having a non-healthcare associate participate in a procedure was not allowed and not appropriate. 2. There was nothing in print that said it was allowed and nothing that said it was not allowed. 3. The hospital was not a teaching hospital. On 05/22/25 at 3:56 PM, Staff B reviewed the job description for Staff M and stated needle decompression was not listed in the job duties.”

“PATIENT RIGHTS: REVIEW OF 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.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure grievance process for two (Staff J and Staff L) of seven staff reviewed for grievance. Review of a policy titled “Complaint/Grievance Policy” with a revision date of December 2024 read in part, “The Complaint and Grievance Policy will provide ...employees a mechanism to voice complaints and/or grievances concerning activities within the facility ...The following are automatically considered patient grievances ...3 ...safety of patient.” On 05/22/25 from 11:28 AM to 11:39 AM, Staff L stated: 1. A physician let an ED clerk do a needle decompression on a patient. 2. They notified administration of the occurrence. On 05/22/25 at 11:47 AM, Staff J stated they notified administration of the occurrence. On 05/22/25 at 12:41 PM, Staff M stated no follow-up conversation took place. On 05/22/25 at 12:51 PM, Staff K stated: 1. Administration was going to follow up on what occurred. 2. They were waiting to see what administration’s results were going to be. On 05/22/25 from 1:46 PM to 1:53 PM, Staff D stated medical staff was to review and investigate what occurred and then administration and the governing board would review and decide the result.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure medical staff recommendation to governing body for one (Memorial Hospital) of one hospitals reviewed. Review of credentialling records did not show appointment recommendation by the medical staff to the governing body. Specifically: 1. The Appointment Page of the medical staff appointment application for Staff N read in part, “DATE: 6-20-23 CHIEF OF STAFF: [signed name withheld],” and appointment recommended was not marked and appointment not recommended was not marked. On 05/22/25 at 10:34 AM, Staff E reviewed the credentialing records and stated: 1. Medical staff did not mark appointment recommendation. 2. They should have marked recommended or not recommended.”

“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: 42140 Based on record review and interview, the hospital failed to ensure: 1. Patient assessment for one (Patient #3) of five patient records reviewed. 2. Timely intervention for one (Patient #3) of five patient records reviewed. Patient #3 - Assessment Review of the medical record showed no assessment for allergies or date of last dialysis. Specifically: 1. The Emergency Triage Note dated 03/26/25 at 3:58 AM read in part, “pt havig [sic] shortness of breath. audible breath sounds ...pt has hemodialysis ...ALLERGIES No Allergy Assessment.” 2. The Emergency Nursing ED Assessment dated 03/26/25 at 4:00 AM read in part, “CARDIOVASCULAR ...NARRATIVE: htn noted ...GENITOURINARY Exam deferred.” On 05/21/25 at 2:05 PM, Staff C reviewed the medical record and stated: 1. The medical record did not show allergies were assessed by nursing. 2. All patients should be assessed for allergies. 3. The risk to the patient was receiving the wrong medications and death. 4. The nurse did not chart when the patient last received dialysis and should have. On 05/22/25 at approximately 2:44 PM, Staff F reviewed the medical record and stated nursing was to assess patients for allergies and the risk to the patient was a compounded problem of stridor and breathing. Patient #3 - Intervention Review of the medical record showed no documentation of physician notification of elevated blood pressure and showed delayed intervention. Specifically: 1. The Vitals Summary read in part: a. “03/26/2025 3:54 am ...Blood Pressure: 239/92” b. “03/26/2025 5:00 am ...Blood Pressure: 253/112” c. “03/26/2025 5:50 am ...Blood Pressure: 211/103” 2. The Emergency Department Drug Administration Form dated 03/26/25 at 6:21 AM read in part, “0619 [6:19 AM] - hydralazine 20mg ivp.” (2 hours 25 minutes after initial blood pressure reading) 3. The Orders Summary read in part, “03/26/2025 06:20 New Order entered by ...(ED NURSE) ...hydrALAZINE HCL 20mg ...IV NOW.” On 05/21/25 from 1:00 PM to 2:34 PM, Staff C reviewed the medical record and stated the patient’s blood pressure was 239/92 at 3:54 AM and the nurse put in the order for hydralazine at 6:20 AM.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure policy was followed for one (Patient #3) of five patient records reviewed. Patient #3 Review of the medical record showed an oxygen rate adjustment by nursing and showed no order for oxygen. Specifically: 1. The Emergency Nursing ED Assessment addendum dated 03/26/25 at 6:05 AM read in part, “0550 [5:50 AM] ...pt o2 sats 98-100 on room air. pt is asking for oxygen.” 2. The Emergency Nursing ED Assessment addendum dated 03/26/25 at 9:14 AM read in part, “at 0630 [6:30 AM] ...89o2 sat on 2lpm bumped pt to 4lpm and came up to 92%.” Review of a policy titled “Oxygen Therapy” effective date November 2010 read in part, “Oxygen ...may be considered medically necessary for appropriately selected patients in cases when a physician prescribes oxygen.” On 05/21/25 at 1:53 PM, Staff C reviewed the medical record and stated there was no order for oxygen. On 05/21/25 at 1:56 PM, Staff B reviewed the policy and stated: 1. There were no standing orders for oxygen in the ED. 2. A physician order was required for oxygen. 3. If a patient’s oxygen dropped below 90%, nurses were to call the physician and obtain an order for oxygen.”

“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 4 (pts. #1, #2, #16, and #19) of 20 patients reviewed. Findings: A review of medical records showed that 4 (Pt #1, #2, #16, #19) patients did not have the H&P signed within 24 hours of admission. Documentation showed the folowing. Pt. #1 was admitted on 10/04/24 and their H&P was signed on 10/07/24. Pt. #2 was admitted on 10/07/24 and their H&P was signed on 10/10/24. Pt. #16 was admitted on 09/18/24 and their H&P was signed on 09/23/24. Pt. #19 was admitted on 04/23/24 and their H&P was signed on 04/27/24. During an interview on 12/18/24 at 8:00 a.m., Staff L stated: 1. the hospital had no policy requiring completion of the H&P within 24 hours and 2. their policy required completion of the H&P within 30 days of discharge.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50779 Based on record review and interview, the hospital failed to ensure: 1. organized nursing services were available and supervised to provided services per the facilities policies and procedures for 1 (Pt #2) out of 20 patients reviewed and 2. drugs and biological protocals for IV fluids were followed by nursing staff. Findings: A facility policy titled “Pain Management” read in part: that vistal signs should be monitored prior to administering the prn pain medication and the patient should be reassessed within 1 hour after receiving the medication. Pain Reassessment for Patient #2 A review of clinical documentation showed on 10/08/24 at 8:22 a.m. Staff Q administered PRN pain medication (Demerol 50mg). Continued review showed no reassessed after the administration of the medication. On 10/08/24 at 10:09 a.m. Pt #2 was discharged to an outside facility without the post medication assessment completed. IV fluids on the nursing floor On 12/18/24 at 8:18 a.m. the surveyor observed a warming cabinet on the nursing floor with a sign that read “IV FLUIDS are to be warmed for 14 DAYS ONLY. Please write date 1st warmed on the bag.” The surveyor opened the warmer to find 3 bags or NaCl inside the top warming cabinet and each bag had a sticker that read “ in: 12-1 out 12-14”. A review the manufacturer recommended guidelines stated the IV fluids were to be stored at room temperature and not to be chilled or heated. Staff L During an interview on 12/17/24 at 8:30 a.m., Staff L stated the post medication administration assessments were to be completed within one hour after administration. During an interview on 12/18/24 at 8:18 a.m. Staff L stated they were uncertain if there was a policy about warming IV fluids and that we should talk to the pharmacist. During an interview on 12/18/24 at 8:25 a.m. Staff U stated: 1. there were no policies about warming IV fluids, 2. they do not allow IV fluids to be warmed in their facility, and 3. the IV fluids should not have been in the warmer. -”

“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: 39648 Based on review and interview, the hospital failed to provide the correct information to patients on how to contact the Oklahoma State Department of Health for the resolution of complaints and grievances for 20 of 20 (Patients #1 - 20) of 20 patients reviewed. Findings: A Review of “Patient Handbook” in the admissions paperwork showed the following obsolete information for the State Survey Agency: “Concerns regarding patient care issues may be sent to Oklahoma State Department of Health (1000 NE 10th Streeet, OKC, OK 73117-1299) ..... the phone number for the Department of Health is (405) 271-6576.” Staff B reviewed complaint and contact information with the surveyor from the OSDH website which showed current information as follows: “Complaints against non-long term care facilities may be filed electronically by email: medfaccomplaints@health.ok.gov or by calling (405) 426-8470 or by written statements using the Medical Facilites complaint form and mailed to the mailing address listed below: Oklahoma State Department of Health Medical Facilities 123 Robert S. Kerr Ave., Suite 1702 Oklahoma City, OK 73102-6406” On 12/03/2024, Staff B stated, the hospital’s information was incorrect.”

“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: 39648 Based on record review and interview, the facility failed to ensure: 1. An appropriate medical screening examination was conducted for patients presenting to the ED requesting an examination of a medical condition for one (Patient #2) of 20 patients records reviewed and 2. This failed practice had the potential to delay needed lifesaving treatment to all patients who present to the ED. (see 2406)”

“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: 39648 Based on record review and interview, the facility failed to ensure: 1. An appropriate medical screening examination was conducted for patients presenting to the ED requesting an examination of a medical condition for one (Patient #2) of 20 patients records reviewed. This failed practice had the potential to delay needed lifesaving treatment to all patients who present to the ED. Findings: Patient #2 Review of a document titled “Emergency Physician Report New” dated 09/13/23 read in part: 1. “Per chart review [the patient] was brought in by EMS after being found decreased level of consciousness. Patient is from the local nursing home... is a dialysis patient and had dialysis yesterday... Reported feeling tired but did not seem to act normal... Morning rounds she was harder to arouse and sent her to the Emergency department to be evaluated.” 2. “Patient does respond to noxious stimuli and loud verbal stimuli but then goes right back to sleep. VS within normal limits” 3. “Urine drug screen is positive for oxycodone (routine medication for this patient) and TCAs.” 4. “09/13/23 at 7:40 am Patient received Narcan 0.4 mg IV and showed increased alertness but still compared to previous lab test and feel like her electrolytes are in good position. Her TNI may be slightly elevated but I believe that is due somewhat lethargic... More responsive to verbal stimuli am going to give her another does and reassess... 09/13/23 at 08:20 am appears more responsive to verbal commands and questions. She still is unable to answer questions coherently. But she is much more awake after second dose of Narcan.... I reviewed today’s labs (urine drug screen, UA, troponin, BNP, CMP, and EKG) and to her renal disease. I feel that she had an imbalance of oxycodone versus fluids and this is correctable by holder her oxycodone and continue to care for her with hydration. I will discharge patient back to the nursing home.” 5. “09/13/25 EMS loaded pt on cot, EMS concerned about pt mentation and VS. Informed EMS crew that she would get better as oxycodone metabolized. EMS states that they do not want to take pt back to NH then get another call back to NH to get her again. ER MD evals pt again with EMS crew, states she is ok to go back to NH. EMS remains concerned about patient going back to nursing home. They placed patient in back of ambulance at this time 10:47 am.” Review of a document titled “Adair County EMS Patient Care Record” dated 09/13/23 read in part: 1. “When EMS arrived to ER patient was in room 1... Nurse reports patient was brought in for AMS and tested positive of oxy ... was given Narcan with minimal change in mental status. EMS hooked patient up to monitor... Noticed patient was only AOX1 GCS was 10... Hypotensive (79/58)... EMS called nursing home to give report of patient status... Nursing home refused to take patient back at this time and the hospital refused to continue care for the patient... Nursing home physician gave an order to take patient to Northeastern Health System at Tahlequah, OK.” ER documentation showed no documented assessment of the patient’s stump, no assement of possible needs for medication related to hypotention and reduced blood flow to the stump, and showed no assessment of possible needs for antibiotiic therapy. Review of a document (from the receiving hospital) titled “ED note - Physician” Northeastern Health System Tahlequah dated 09/13/24 read in part: 1. “Sepsis cellulitis of lower extremity on the right side of stump... She will need admission to the ICU for continued pressor therapy and continued antibiotic therapy... The patient was admitted.” On 12/23/24 at 1:15 pm, Staff #10 stated: 1.”I did the standard documentation.” 2. “I went to the bedside and re-examined the patient with EMS present and felt she was safe to return to the nursing home.” 3. “The BP had been 117/62, but nothing was recorded at time of discharge. I looked at the monitor, but nothing jumped out at me. But the nurse didn’t document VS prior to discharge.””

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 47809 Based on recod review and interview, the hospital failed to ensure adequate laboratory services were available to meet the needs of the patients. This failed practice has the likelihood to result in delayed recognition and/or treatment of patients functional status and quality of life. Findings: Review of records: 4 of 6 charts reviewed showed that ABGs were not completed on patients as ordered by the provider from 10/19/23 through 11/20/23. Patients #2, 3, 4 and #6 did not receive ABGs as part of the labs ordered on admission. The ABG Analyzer was out of cartridges and no ABG tests where able to be completed on site. There was no backup lab close enough to complete ABGs in the 30-minute time frame that is required for processing prior to sample breakdown and sample is no longer viable. Maintenance Log for Arterial Blood Gas Analyzer shows entries made from 10/19/23 through 11/20/23 had a line drawn or the word “out” was written in lieu of a value. Interview with Staff A on 11/21/23 at 01:30 p.m. stated the cartridge supply for the ABG Analyzer was out of stock from 10/19/23 through 11/20/23. Staff A Stated that they realized doctor’s orders were not able to be followed and that they had a problem with ordering supplies for ABG Analyzer.”