Cordell Memorial Hospital

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 12713 Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system quarterly. Findings: On 06/10/26, at 1:45 p.m the facility’s sprinkler records were reviewed for calendar year 2025 and 2026. The facility could not supply any dated or signed quarterly sprinkler inspections for the third and fourth quarters of calendar year 2025 and the first quarter of 2026. On 06/10/26 at 1:55 p.m., the maintenance supervisor was present during the record review. The maintenance supervisor stated they were not aware the quarterly sprinkler inspections had not been completed.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to maintain 2 of 2 smoke barrier walls to resist the passage of smoke. Findings: On 06/10/26 between 9:20 a.m. and 1:30 p.m., a tour of the facility was conducted. The following observations were made: a. the smoke barrier wall just outside the laboratory had one unsealed penetration associated with a pipe chase of coax wire and a blue computer wire above the smoke doors in the attic; and b. the smoke barrier wall by patient room #104 had unsealed penetrations associated with a water line above the smoke doors in the attic. On 06/10/26 at 11:40 a.m., the maintenance person was interviewed and acknowledged the unsealed penetrations to the smoke walls.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 12713 Based on record review and interview, the facility failed to properly maintain an emergency stop kill switch, remotely located for the generator. Findings: On 06/10/26 at 11:45 a.m., a tour of the facilities generator was conducted. The generator was not equipped with an emergency stop kill switch. In the event of a generator fire/emergency, the facility could not be assured the generator could be powered down remotely. On 06/10/26 at 11:50 a.m., the maintenance supervisor was interviewed and acknowledged the generator was not equipped with the required emergency stop kill switch.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 53719 Based on observation and interview, the facility failed to ensure prevention of staff access to equipment no longer utilized by the facility for one (Pharmacy medication room) of two medication rooms observed. Findings: On 04/15/26, during a tour of the facility from 9:06 am to 10:40 am, a container of glucometer test strips labeled Lot ZD6022S, and a personal TRUE METRIX glucometer were observed on a shelf in the pharmacy medication room. On 04/15/26 at 9:43 A.M., Staff D stated: 1. The facility moved away from using personal glucometers a few months ago and began using docked glucometers that integrated with their charting system. 2. There was no longer a need for the former test strips. 3. There was nothing preventing staff from grabbing and using the personal glucometer to test a blood sugar since it was still on the shelf.”

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 53719 Based on observation, record review and interview, the facility failed to maintain radiology equipment for one (X-ray tube) of two pieces of radiology equipment observed. On 04/15/26 during a tour of the facility from 9:06 am to 10:40 am , the X-ray tube labelled Model Number 03072456 and Model Number 03070013 on it’s second set of labels was observed to have a cord that was split exposing silver metal wires inside. Review of the [name omitted] Platinum Service Agreement with [name omitted] dated 12/01/21 read in part, “Within 60 days of contract coverage begin date, [name omitted] shall have the right to a walkthrough, in which [name omitted] will inspect, test, and perform a PM on all listed equipment. The X-ray tube was not listed. Review of the previous agreement dated 12/01/21 read in part, “[Name omitted] will provide 1 preventive maintenance inspection per year on all equipment listed on the signature page of this agreement.” The X-ray tube was not listed. On 04/15/26 at 10:22 am, Staff F stated: 1. The preventive maintenance company looked at the cord one month ago and said it was fine and not electrical. 2.The rubber covering of the cord made them think it was electrical. 3. They used the X-ray a lot, daily. They’ve used it today. On 04/16/26 at 9:00 am, Staff J stated the preventive maintenance company had not been out to service the X-ray tube in a long time. On 04/16/26 at 10:00 am, Staff F stated the X-ray tube was not on the signature page of the contract with the preventive maintenance company. On 04/16/26 at 10:10 am, Staff B stated: 1. The preventive maintenance company said the X-ray tube was 10 years past life. 2. There were no PM’s on the tube. On 04/16/26 at 10:28 am Staff F stated the preventive maintenance company said the cord looked fine two years ago and it was split then.”

“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: 53719 Based on record review and interview, the facility failed to ensure staff certification for one (Staff D) of four personnel records reviewed. Findings: Staff D Review of the [job title omitted] Job Description last reviewed 09/06/22 showed CPR as a requirement under education and experience. Review of the education file showed a certification from the American Heart Association titled “Basic Life Support BLS Provider” with a renew by date of 02/2026. (one month and 15 days past due) On 04/16/26 at 1:18 pm, Staff E reviewed the education file and stated, Staff D knew it was expired, and they had a class scheduled next week.”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 53719 Based on record review and interview, the facility failed to ensure physician notification for two (Patient #1 and Patient # 18) of 19 patients reviewed. Findings: Patient #1 Review of the Results Review flowsheet dated 11/03/25 at 7:24 pm, showed a potassium level of 2.5 mmol/L and showed a red HH symbol, indicating a critical test result. Review of the policy titled “Reporting of Critical Results”, last revised 09/25/24, read in part, “Once a critical result is identified, a licensed independent caregiver must be notified within 30 minutes, so that treatment can be promptly initiated ...When a licensed independent caregiver has been notified of the critical result: a. Document the time and the name of the caregiver to whom it was reported on the Critical Result Notification Flowsheet in the patient’s electronic medical record.” On 04/15/26 at 12:26 pm Staff C reviewed the patient’s chart and stated: 1. The critical test report was the best place to chart physician notifications, but the notification was not documented there. 2. They were unsure when and who notified the provider of the critical result. Patient #18 Review of a physician order dated 02/09/26 at 7:51 PM read in part, “notify [provider] if ... · SBP greater than 170 · SBP less than 90 · DBP greater than 110 · DBP less than 50 ...” Review of the Flowsheet History showed documentation of the following blood pressure readings: · 02/09/26 at 3:22 pm 193/89 · 02/09/26 at 3:31 pm 173/102 · 02/09/26 at 3:45 pm 188/134 · 02/09/26 at 4:30 pm 177/112 · 02/09/26 at 4:45 pm 177/108 · 02/29/26 at 5:00 pm 217/105 · 02/09/26 at 5:15 pm 206/96 · 02/09/26 at 5:30 pm 187/106 · 02/09/26 at 5:45 pm 221/100 · 02/09/26 at 6:00 pm 239/114 · 02/09/26 at 6:15 pm 187/86 · 02/10/26 at 0746 am 186/83 There was no documentation a provider was notified. On 04/16/26 at 10:55 A.M., Staff K stated notification to a provider of out-of-range blood pressures was critical because if not, blood pressures could go untreated.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 54303 Based on record review and interview, the facility failed to ensure medication administration for one (Patient 11) of 19 patient records reviewed. Findings: Review of the policy titled “Medication Administration”, last reviewed 01/14/25, read in part, “Patients and/or family may not self-administer medications.” Review of the ED Note dated 08/13/25 at 6:07 P.M. read in part, “pt took oxycodone 15 mg PO at this time from her home meds.” On 04/16/26 at 09:38 A.M., Staff D stated patient self-administration could lead to overmedication.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 53719 Based on observation, record review, and interview, the facility failed to ensure safe maintenance of sharps containers for two (Drug Room and ED Medication Room) of two medication rooms observed. On 04/15/26, during a tour of the facility from 9:06 am to 10:40 am, a sharps container was observed to be filled above the labeled fill line in the Drug Room. Review of an informational fact sheet titled “Protecting Yourself When Handling Contaminated Sharps” from the Occupational Safety and Health Administration, dated 01/2011, read in part, “The [sharps] containers must be replaced routinely and not be overfilled, which can increase the risk of needlesticks or cuts.” Review of policy titled “Environmental Cleaning and Disinfection”, last updated 01/08/25, read in part, “EVS staff create a clean and safe environment for all residents, employees, and visitors by providing the following services:...Removing waste.” On 04/15/26 at 9:30 am, Staff D observed the sharps container and stated: 1. Sharps containers were to be changed when at the fill line. 2. Maintenance and environmental services checked once a week for overfilled sharps containers. On 04/15/26 at 10:16 am, Staff E stated: 1. They checked them on Monday, Wednesday, Friday, and as needed. 2. The risk of not checking was people could get stuck.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 53719 Based on observation, record review, and interview, the facility failed to ensure decreased risk of infection transmission for four (Med Surg, ER, Radiology, and Dietary) of four patient care areas observed. Findings: MED SURG On 04/15/26 from 9:06 am until 10:40 am during a tour of the facility, the following items were observed: 1. Visible fuzzy, grey debris on an overhead vent in patient room 103. 2. Disposable blood pressure cuffs attached to cardiac monitors in terminally cleaned room med Surg room 103 Review of policy titled “Environmental Cleaning and Disinfection”, last updated 01/08/25, read in part, “Disposable patient care equipment shall be immediately discarded in the appropriate trash container after use.” Review of a print-out from the Strategic Quality Support System titled “Cleaning Outside of Overhead Vents” showed the task was completed on 04/14/26 at 9:12 am and showed 100% compliant. On 04/15/26 at 9:51 am, Staff D observed the blood pressure cuff and stated the blood pressure cuffs were not reusable and she didn’t know if they were clean. On 04/15/26 at 10:16 am, Staff F observed the vent and stated: 1. The vents were checked on and logged into the quality system, SQSS. 2. The risk of a dusty vent was that the unit could not work properly, it could cause allergies, and dust could fall on the patient. 3. The room was likely missed or there may have been a patient in it and staff intended to get it later that day or the next. ER On 04/15/26 from 9:06 am until 10:40 am during a tour of the facility, a disposable blood pressure cuff was observed attached to the cardiac monitor in the terminally cleaned ER trauma room. Review of policy titled “Environmental Cleaning and Disinfection”, last updated 01/08/25, read in part, “ Disposable patient care equipment shall be immediately discarded in the appropriate trash container after use.” On 04/15/26 at 9:51 am, Staff D observed the blood pressure cuff and stated the blood pressure cuffs were not reusable and she didn’t know if they were clean. RADIOLOGY On 04/15/26 from 9:06 am until 10:40 am during a tour of the facility, reusable patient positioning wedges were observed in the CT area with dried visible white debris on them. Review of policy titled “Environmental Cleaning and Disinfection”, last updated 01/08/25, read in part, “All reusable patient care equipment must be cleaned, disinfected, and/or reprocessed before reuse with another patient and/or before being placed in storage.” On 04/16/26 at 10:19 am, Staff G observed the wedges stated: 1. The patient positioning wedges were reusable 2. The patient positioning wedges were cleaned after each patient use. 3. “Since there’s contrast on it, it was probably just used.” DIETARY On 04/15/26 from 9:06 am until 10:40 am during a tour of the facility, a five gallon bucket of Sanitizer E.S. kitchenware sanitizer was observed in the kitchen. The container showed an expiration date of 08/06/25. On 04/15/26 at 10:40 am, Staff G observed the bucket of sanitizer and stated the risk to the patient of using expired Sanitizer E.S. was that the product may not sanitize the dishes or kill bacteria.”

“DISCHARGE PLANNING EVALUATION CFR(s): (3) The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 53719 Based on record review and interview, the facility did not document involvement of the patient/caregiver in discharge planning in one (Patient #2) of 19 patients reviewed. Findings: Review of the hospital and medical records did not show involvement of the patient and/or caregiver in discharge planning. Patient # 2 1. Review of the Admission Navigator flowsheet did not show documentation of patient discharge needs. 2. Review of a document titled “Patient’s Bill of Rights”, last revised 08/01/13, read in part, “You have the right to know your treatment options and take part in decisions about your care.” On 04/15/26 at 12:50 pm, Staff C reviewed the record and stated: 1. Case Management usually put in discharge planning notes after patients were admitted inpatient. There were no notes on the record from Case Management. 2. The Admission Navigator should have been completed by the admitting nurse but nursing understood Case Management would do it.”

“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 hospital failed to ensure a medical screening examination was conducted for one (Pt #21) of 23 patients. This failed practice had the likelihood for an emergency medical condition to go unidentified and untreated; thereby increasing the risk of undesirable health outcomes. (see 2405) Based on record review and interview, the hospital failed to ensure a medical screening examination was conducted for one (Pt #21) of 23 patients. This failed practice had the likelihood for an emergency medical condition to go unidentified and untreated; thereby increasing the risk of undesirable health outcomes and resulting in no identification of patients requiring immediate care. (see 2406)”

“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: 39648 Based on record reviews and interview, the hospital failed to ensure patients presenting to the ED for treatment were documented in a central log for one (Pt #21) of 23 patients ED patients reviewed. This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum. Findings: On 03/28/25 at 10:00 am, the surveyor reviewed the previous six months’ entries in the ED log. Patient #21 was not listed for any ED visits during this time, despite the reported ED visit on 03/14/25. On 03/28/25 at 12:15 pm Staff F stated: 1. On 3/14/25 EMS called report. 2. Our power was down. We were on CT divert. 3. The provider told the nurse to call EMS back to divert them. 4. Three to four minutes later EMS arrived. I met them and told them they had to go to another facility. 5. The provider told them they had to go to another facility. 6. EMS left and returned a minute later, unloaded the gurney containing the patient from the ambulance. 7. The provider met EMS outside and again told them they needed to go to another facility. 8. EMS loaded the patient back in the ambulance and transported to another facility. 9. The provider spoke to the EMS director and told them EMS was delaying care for the patient.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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 hospital failed to ensure a medical screening examination was conducted for one (Pt #21) of 23 patients. This failed practice had the likelihood for an emergency medical condition to go unidentified and untreated; thereby increasing the risk of undesirable health outcomes. Findings: A review of a telephone recording dated 03/14/25 at 1:28 pm found the complainant was talking to the EMS crew and later Staff G. The EMS crew reported the driving conditions were poor (wind gust up to 70 miles per hour) and was instructed by the complainant to return to the ED. The complainaint stayed on the telephone and when Staff G went outside the ED entrance, the complainanat asked to speak with Staff G. The complainant told Staff G that refusing to complete an MSE and provide treatment to the patient was an EMTALA violation. Staff G reported that the hospital was on CT divert and the EMS crew needed to go to a hospital with a working CT scan. A review of a security camera footage from the facility dated 3/14/25 from 1:28 pm to 1:37 pm showed two views. One view captured the outside of the facility and the other view captured the ED inside at the entrance doors to the ED. The outside ED view showed the following: 1:28 pm The ambulance arrived at the facility. 1:32 pm The ambulance left the ED. 1:34 pm The ambulance returned to the ED and opened the back door of the ambulance. 1:35 pm The ambulance crew removed Patient #21 from the ambulance. Staff G was shown outside speaking with theEMS crew. 1:37 pm The ambulance crew reloaded Patient #21 into the ambulance, closed the doors, and walked around (outside the camera view). Inside the ED view showed the following: 1:28 pm The ambulance arrived at the ED and Staff F went outside. 1:29 pm Staff F and EMS Staff #1 walked into the ED where Staff G met them. It appeared a conversation was conducted with the EMS Staff #1, Staff F and Staff G, the EMS Staff #1 then exited the ED. 1:34 pm The ambulance was seen pulling into the ED entrance area. 1:35 pm Staff F went outside followed by Staff G. Patient #21 was on a gurney with EMS Staff #1 visible at the end of gurney. 1:36 pm Staff F returned to the ED, Staff G stepped inside, Staff G went back outside, and Staff G stepped back into the ED. A review of the EMS Prehospital Report dated 3/14/25 read in part: “Dispatched for a male complaining of dizziness and weakness...Went to the doctor yesterday and put back on all... medications... Patient denies having fallen, denies chest pain and difficulty breathing... does not appear to have any injuries... Medical history of HTN, severe seasonal allergies, bipolar disorder, depression, anxiety, ADD (an attention deficit disorder), ADHD (an attention deficit with hyperactivity disorder), scoliosis, and arthritis... Patient’s daily medications include pantoprazole, montelukast, abilify, hydrochlorothiazide, buspirone, and nifedipine... Patient states I want to go to Cordell...Cordell Memorial Hospital is called at 1:22 pm and given prehospital patient care report and ETA of 3-5 minutes... Hospital notifies EMS personnel That CT is down due to power outage caused by extreme winds during call... 1:26 pm Cordell Memorial Hospital calls EMS personnel back at 1:26 pm and states Dr. on duty is calling for a CT, so you guys will need to take him somewhere else... Burns Flat unit 4 arrives at ER at 1:27 pm as the call ends... EMS personnel enter Cordell memorial Hospital and was informed that Cordell Hospital ED cannot take the patient. Patient is advised that we are being diverted... Medical direction is called at 1:28 pm , and EMS personnel are advised to take the patient back to Cordell Memorial Hospital... Medical direction remains on the phone. Patient is unloaded from the back of the ambulance and physician and RN on duty meet the EMS crew and patient outside of the ER. Physician on Duty approaches EMS personnel and begins to point at the patient and yell we are declining this patient!! WE ARE DECLINING THIS PATIENT!!... Physician was advised by EMS personnel that medical direction is on the phone and we have been advised to bring the patient back. Physician on duty takes the phone and begins to yell into the phone. Physician on duty advises that his name is XXXX and that this is not an EMTALA violation. Physician on duty turns around and screams you are the reason for delay of care at this point!!” The EMS Prehospital Report dated 3/14/24 showed Patient #21 was taken to another hospital with a working CT scan. A review of the State EMResource record dated 3/14/25 showed no notification of divert status was reported by the hospital that day. The ED log did not have show Pt #21 was logged in or assessed at the hospital on 03/14/25 at or around 1:35 pm. On 03/28/25 at 10:15 am Staff A stated: 1. On 3/14/25 the EMS presented with a patient who had a possible head diagnosis. 2. The provider didn’t feel comfortable examining without a CT scan. 3. We did not have use of our (CT Scan) due to a power outage. 4. Our generator did not support the use of the CT scan. 5. The EMS was notified prior to leaving with the patient that we were on divert. On 03/28/25 at 12:15 pm Staff F stated: 1. On 3/14/25 EMS called report. 2. Our power was down. We were on CT divert. 3. The provider told the nurse to call EMS back to divert them. 4. Three to four minutes later EMS arrived. I met them and told them they had to go to another facility. 5. The provider told them they had to go to another facility. 6. EMS left and returned a minute later, unloaded the gurney containing the patient from the ambulance. 7. The provider met EMS outside and again told them they needed to go to another facility. 8. EMS loaded the patient back in the ambulance and transported to another facility. 9. The provider spoke to the EMS director and told them EMS was delaying care for the patient. On 03/28/25 at 1:00 pm Staff G stated: 1. No ambulance was turned away while on hospital property, but there was one that was diverted due to CT divert. 2. EMS was told to divert. 3. EMS showed up and we told them to divert. (Name omitted - another hospital) was called and told to expect patient. 4. EMS was delaying patient care. 5. EMS came twice - the first time they arrived the nurses told them they were on divert and they drove off. 6. They came back and offloaded the patient in a hurry like they were trying not to delay care. 7. They could have been to (name omitted - another hospital) by this time. 8. I didn’t performed an MSE on the patient.”

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances 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. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure notice of patient rights for 22 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, and 23) of 22 records reviewed. Findings: A Review of a facility document titled, “Notice of Privacy Practices” (page 4) showed no contact information for the SSA . On 03/28/25 at 10:15 am Staff A stated the “Notice of Privacy Practices” contact information for the Oklahoma State Department of Health was not included in their patient rights documents.”