Ascension St John Sapulpa

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 42140 Based on record review and interview, the facility failed to ensure the stabilization of an emergency medical condition for one (Patient #6) of 20 patients reviewed. This failed practice had the likelihood to result in adverse patient outcomes. CHEMICAL RESTRAINT MONITORING Review of the medical record showed the patient presented to the ED on 02/04/26 at 1:01 PM with a chief complaint of chronic back pain and subsequent suicidal ideation. The medical record showed the patient was chemically restrained for aggressive behavior and did not show documentation of monitoring via continuous pulse oximetry and routine vital signs. Specifically: 1. The ED Physician Note dated 02/04/26 at 2:00 PM read in part, “The patient presents with suicidal ideation. Suicidal Ideation Degree of Symptoms Severe and Frequency Constant. Suicidal Plan Location Home ...Suicidal Intent Believes plan to be lethal, Believes plan to be self-injurious Does not expect to carry out plan ...Patient presents to the emergency room today with complaints of chronic back pain and thoughts of suicidal ideation. Patient has had chronic back pain since 2023 after an MVC ...[The patient] was recently fired by [the patient’s] pain management doctor last Friday because [the patient] stated over the phone that [the patient] ‘was going to put a gun in [the patient’s] mouth to end [the patient’s] life’ if [the patient’s] pain did not stop ...[The patient] does have a history of suicidal ideation and attempt in 2017 when [the patient] attempted to overdose. [The patient] did drink a lot of alcohol yesterday ...does use marijuana daily ...[The patient] was very upset ...[The patient] ripped out ...IV ...is yelling across the hall to nursing staff, security, and myself ...I have ordered droperidol, Ativan, and Benadryl for the patient in case [the patient] becomes more aggressive. The patient was medicated with ativan droperidol and benadryl.” The note showed no other patient behaviors. The note showed home medications of Effexor and Lyrica. 2. The Orders showed the following Vital Signs orders: a. “Order Vital Signs ...Ordering Provider: System, System ...Order Details: Routine 2/4/26 2:11:25 PM ...PRN. Order Comment: Ordered by SYSTEM due to patient admit.” 3. The Orders showed the following Pulse Ox orders: a. “Order: Documented Pulse Ox ...Ordering Provider: System, System ...Order Details: 2/4/26 1:37:11 PM ...Routine. Order Comment: Order is placed secondary to Pulse Ox documentation.” b. “Order: Documented Pulse Ox ...Ordering Provider: System, System ...Order Details: 2/4/26 8:46:30 PM ...Routine. Order Comment: Order is placed secondary to Pulse Ox documentation.” 4. The Orders showed the following medication orders: a. Droperidol order dated 02/04/26 7:42 PM read in part, “Order Details: Dose: 1.25 mg = 0.5 mL, Injection, IM, ONCE.” b. Diphenhydramine order dated 02/04/26 7:42 PM read in part, “Order Details: Dose: 25 mg = 0.5 mL, Injection, IM, ONCE ...Order Comment: Hold for respiratory rate less than 10 per minute, SBP less than 90 ...Caution in patients who are receiving other sedation medications ...for oversedation and respiratory depression.” c. Lorazepam order dated 02/04/26 7:43 PM read in part, “Oder Details: Dose: 2 mg = 1 mL, Injection, IM, ONCE ... Order Comment: Hold for respiratory rate less than 10 per minute, SBP less than 90 ...Caution in patients who are receiving other sedation medications ...for oversedation and respiratory depression.” 5. The Patient Care Nursing documentation dated 02/04/26 at 7:49 PM to 7:50 PM read in part, “Pt uncoopertive [sic] wanting to leave. Cursing at staff. Agitated, Uncooperative..verbally abusive.” 6. The Medication Administration Record showed the lorazepam, droperidol and diphenhydramine were administered to the patient on 02/04/26 at 8:01 PM. 7. The Patient Care Nursing documentation showed the following vital signs: 02/04/26 1:31 PM 37.3 T, 18 RR, 87 HR, 167/96 BP, 97% O2, RA 2:52 PM 81HR 3:59 PM 20 RR, 77 HR 8:45 PM 93 HR, 140/83 BP, 96% O2, RA 11:00 PM 17 RR, 89 HR, 142/81 BP, 97% O2, RA (2 hour 15 minute time lapse) 02/05/26 4:00 AM 15 RR, 78 HR, 132/80 BP, 98% O2. RA (5 hour time lapse) 6:53 AM 22 RR (nearly 3 hour time lapse) 7:53 AM 23 RR 9:00 AM 22 RR 10:00 AM 24 RR 11:00 AM 25 RR 12:00 PM 22 RR 1:00 PM 20 RR 1:42 PM 20 RR, 96 HR, 141/88 BP, 97% O2, RA Review of a policy titled “Restraint Chemical, Physical Hold and Seclusion” last approved 11/2024 read in part, “Restraint is ...any drug or medication used as a restriction to manage the patient’s behavior ...that is not a standard treatment or dosage for the patient’s new or continuing medical or behavioral condition ...The intent of the medication will be included in the medication’s order detail ...Assessment and Monitoring: The nurse is responsible for the continued reassessment of the patient. Ongoing assessments by the nurse should be performed at a minimum of hourly or more frequently as indicated by the patient’s condition with special attention to potential side effects of the medication.” On 03/04/26 at 11:59 AM, Staff Staff K reviewed the medical record and stated they did not see where any monitoring devices were placed on the patient. On 03/05/26 11:54 AM , Staff O stated: 1. The droperidol, lorazepam and Benadryl cocktail required monitoring like telemetry, continuous pulse ox and hourly vital signs. 2. They did not recall whether that was done. SUICIDE PRECAUTIONS Review of the medical record and facility camera footage showed the patient was placed on suicide precautions and did not show constant patient observation or the maintenance of a safe environment per facility policy. Specifically: 1. A Suicide Precautions order dated 02/04/26 1:58 PM with no order comment provided and with nurse review dated 02/04/26 2:20 PM. 2. The Constant Observer Handoff Form dated 02/04/26 day shift showed the reason for constant observation was “MODERATE suicide risk.” 3. The facility camera footage titled “ED Desk 2026-02-04 13:19:56” a. From approximately the 1:03:10 minute mark to the 1:24:11 minute mark (11 minutes 01 seconds), the patient went unobserved six times during which the CO was facing away from the patient at either the nurses station or in the hallway. Approximate minute marks were as follows: i. 1:03:10 - 1:03:45 (15 seconds) ii. 1:03:58 - 1:06:27 (2 minutes 29 seconds) iii. 1:07:03 - 1:07:43 (40 seconds) iv. 1:08:22 - 1:09:05 (43 seconds) v. 1:10:57 - 1:11:12 (15 seconds) vi. 1:22:37 - 1:23:38 (1 minute 1 second) b. The CO placed and left a black clipboard in the patient’s room unattended from approximate minute marker: i. 1:07:43 - 1:24:11 (16 minutes 28 seconds) 4. The Patient Care Nursing documentation dated 02/05/26 at 2:47 PM read in part, “Pt discharged with safety plan and discharge paperwork.” Review of a policy titled “Suicide Risk Screening, Suicide Risk Assessment & Response Policy” last approved 07/2025 read in part, “The purpose of this policy is ...providing a safe environment and interventions for patients who are at risk for suicide ...1:1 Direct Observation by Constant Observer ...Provides uninterrupted visual observation of a single patient ...Must be positioned in close proximity with a full view of the patient ...Constant Observer ...provides continuous visualization of the patient, including but not limited to in-room observation and maintaining a safe environment ...Provide the 1:1 observation and monitoring of the patient at HIGH or MODERATE risk for suicide. “ On 03/05/26 at 11:01 AM, Staff B reviewed the camera footage and stated: 1. The CO was expected to observe the patient at all times and ensure the patient was safe. 2. The CO should not have had their back to the patient. 3. The patient could have harmed themself. On 03/05/26 at 11:15 AM, Staff F stated it was not acceptable to leave a clipboard in the room of a patient on suicide precautions.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 39648 Based on record review and interview the hospital failed to ensure wound care orders were obtained for one (Pt #1) of five patients. Findings: Pt #4 Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. The patient was a 95 year old with diagnoses of Influenza, Catheter-associated urinary tract infection, Acute Kidney Injury and Chronic Kidney Disease. The patient weighed 117 pounds and had a height of 5’11”. A review of nursing assessments, nurses notes, and physician orders showed no physician notification of the wound to the right heel. No verification of wound documentation was provided to the surveyor showing wound measurements. On 06/03/25 at 10:50 am Staff M stated: 1. there was no documented physician notifiation of the right heel wound and 2. no orders were obtained for the wound.”

“ADMISSION, TRANSFER, & DISCHARGE RIGHTS CFR(s): Admission, Transfer and Discharge Rights (§483.5 definition of transfer & discharge, §483.15(c)(1), (c)(2), (c)(3), (c)(4), (c)(5), (c)(7), (c)(8), and (c)(9) of this chapter). “ §483.5 definition of transfer & discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. “ §483.15(c)(1) Transfer and discharge-(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. “ §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident (B) Resident representative information including contact information. (C) Advance Directive information. (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals, (F) All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2), as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. “ §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii)Include in the notice the items described in paragraph (c)(5) of this section. “ §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii)Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. “ §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. “ §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. “ §483.15(c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.70(l). “ §483.15(c)(9) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5) are subject to the requirements of §483.10(e)(7) and must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part’s locations. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure all necessary discharge instructions were included in the discharge paperwork for one (Pt #4) of five patients. Findings: Review of the policy titled “ Discharge Planning” and approval date of 04/2025 read in part, “The patient and persons acting on his/her behalf are counseled by the interdisciplinary team to ensure that the patient/caregiver is: a. Prepared for post-hospital care b. Kept informed of the status or progress of the discharge plan including any financial liability c. Able to verbalized and/or demonstrate the care needed by the patient.” Pt #4 Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. Pt #4 had wounds (stage II pressure ulcer to coccyx and an area to the right heel that developed as a blister). The discharge information did not include where the wounds were located, what type of wounds were present, or wound care instructions. Documentation showed the patient lived with family. On 06/03/25 at 10:50 am Staff M stated instructions regarding wounds (location, type, etc.) and wound care should be included in discharge instructions.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 39648 Based on record review and interview the hospital failed to ensure patient care services were provided in accordance with acceptable professional standards of practice for two (Pt #1 and 4) of five patients. Findings: Reveiw of “AACN Updates Bathing Practices Protocol” dated 04/18/13 showed, “Based on the latest available evidence, the expected practice related to bathing adult patients includes: Provide a daily bath for bed-bound patients to improve hygiene and promote comfort. More frequent baths may be performed upon patient request or to respond to patient needs.” Review of “Bed Bath and Hygiene Care” (an education website geared towards helping student and registerd nurses) Updated on July 6, 2024 showed, “Bed bath and hygiene care are fundamental aspects of nursing, essential for maintaining patient health and comfort. These practices involve cleaning the patient ’ s body when they are unable to bathe themselves due to illness, injury, or immobility. This care also offers an opportunity for nurses to assess the patient ’ s skin condition, identifying any potential issues early. Ultimately, bed bath and hygiene care are crucial for preserving patient dignity and ensuring a high standard of health care.” Pt #1 Reveiw of the medical record showed an inpatient swing bed stay 03/21/25 to 03/27/25. Pt #1was an 82 year old with a diagnoisis of Physical Debility. A review of clinical documentation showed patient received a shower once 03/25/25 during the swing bed stay. No offer of a bath/shower or a refusal was documented for 03/21/25, 03/22/25, 03/23/25, 03/24/25, 03/26/25, or 03/27/25. Pt #4 Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. Pt #4 was a 95 year old with diagnoses of Influenza, Catheter-associated urinary tract infection, Acute Kidney Injury and Chronic Kidney Disease. The patient weighed 117 pounds and had a height of 5’11”. A review of the clinical record showed not documentation that Pt #4 received a bath/shower or refused a bath/shower during the hospitalizaton. Review of the document titled “Ambulance Transport Certificate of Medical Necessity” dated 02/11/25 showed “Pt is weak and bed bound at this time.” On 06/03/25 at 10:50 am Staff M stated: 1) my expectation would be that a bath/shower would be offered to patients and if refused staff should document the refusal; 2) Pt #1 had one shower during the admission 03/21/25 to 03/27/25; 3) Pt #4 had no bath or shower during the admission 02/04/25 to 02/11/25.”