Bay Area Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 40575 Based on interviews, review of medical record documentation, review of incident documentation for 1 of 1 patients reviewed for investigation of incidents (Patient 1), and review of hospital P&Ps and other documentation it was determined that the governing body failed to ensure the provision of safe care and failed to ensure those incidents and events did not recur for other patients in the future. This Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Condition Tag A-115 under CFR 482.13 - CoP: Patient’s Rights. Those findings reflected the hospital’s failure to ensure Patient 1’s rights were protected and promoted. The hospital failed to ensure the provision of care and services in a safe manner and in a safe environment (Tag A-144); failed to promptly and appropriately identify, investigate, and respond to allegations of neglect, and to develop and implement corrective action plans to prevent recurrence (Tag A-145). 2. Refer to the findings cited at Condition Tag A-263 under CFR 482.21 - CoP: QAPI. Those findings reflect the hospital’s failure to develop and implement an effective, ongoing, hospital-wide QAPI Program based on the findings cited in this CMS 2567 report.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40575 Based on interviews, review of equipment documentation and medical record documentation for 1 of 1 patients reviewed for incidents (Patient 1) review of P&Ps, and review of internal investigation documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured Patient 1’s right to receive care in a safe setting. The hospital’s failures contributed to actual significant harm and failed to ensure those incidents and events did not recur for other patients in the future. Those failures included: * Failure to ensure the sole paramedic on the ambulance for transport of Patient 1 from the BAH ICU to the receiving hospital for open-heart surgery, was familiar, trained, competent, and comfortable with all aspects of operation and management of the IABP to ensure the patient’s safe 2-hour 5 minute transport and arrival at the receiving hospital. * Failure to provide all items necessary to ensure the optimal function of the IABP for the 2-hour 5 minute transport in accordance with manufacturer’s instructions: Batteries and AC power cord. * Failure to ensure the IABP machine was secured properly in the ambulance in accordance with manufacturer’s instructions. * Failure to ensure Patient 1’s medical record reflected accurately and completely the hand-off for transport from the BAH ICU staff to the BCA EMS staff. * Failure to ensure the hospital’s internal investigation thoroughly evaluated all investigation findings and identified all relevant deficient practices and gaps. * Failure to ensure the hospital developed and implemented a thorough and complete action plan that addressed all deficient practices and gaps in a timely manner to prevent recurrence for other patients. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflected the hospital’s failure to ensure the provision of care and services in a safe manner and in a safe environment. The hospital’s failures contributed to patient harm and injury and created the likelihood of harm to other patients. 2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Patient Rights: Free From Abuse/Neglect. Those findings reflected the hospital’s failure to ensure the investigation of, and development and implementation of a corrective action plan, in response to an incident involving Patient 1 that resulted in actual harm was clear, complete and accurate to ensure those incidents and events did not recur for other patients.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 40575 Based on interviews, review of medical record documentation for 5 of 5 patients whose records were reviewed for aspects of transfer documentation (Patients 1, 2, 3, 4 and 5), review of documentation for 1 of 1 patients reviewed for incident investigation (Patient 1), and review of hospital P&Ps and other documentation it was determined that the governing body failed to ensure, through a hospital-wide QAPI program, the improvement of the hospital’s care and services performance, and the prevention and reduction of adverse events through investigation, analysis of findings, and implementation of corrective actions to prevent recurrence. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Condition Tag A-115 under CFR 482.13 - CoP: Patient’s Rights. Those findings reflected the hospital’s failure to ensure each patient’s rights were protected and promoted. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflected the hospital’s failure to ensure the provision of care and services in a safe manner and in a safe environment. The hospital’s failures contributed to patient harm and injury and created the likelihood of harm to other patients. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Patient Rights: Free From Abuse/Neglect. Those findings reflected the hospital’s failure to ensure the investigation of, and development and implementation of a corrective action plan, in response to an incident involving Patient 1 that resulted in actual harm was clear, complete and accurate to ensure those incidents and events did not recur for other patients.”

“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: 40575 Based on interviews, review of equipment documentation and medical record documentation for 1 of 1 patients reviewed for incidents (Patient 1), review of P&Ps, and review of internal investigation documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured Patient 1’s right to receive care in a safe setting. The hospital’s failures contributed to actual significant harm and failed to ensure those incidents and events did not recur for other patients in the future. Those failures included: * Failure to ensure the sole paramedic on the ambulance for transport of Patient 1 from the BAH ICU to the receiving hospital for open-heart surgery, was familiar, trained, competent, and comfortable with all aspects of operation and management of the IABP to ensure the patient’s safe 2-hour 5 minute transport and arrival at the receiving hospital. * Failure to provide all items necessary to ensure the optimal function of the IABP for the 2-hour 5 minute transport in accordance with manufacturer’s instructions: Batteries and AC power cord. * Failure to ensure the IABP machine was secured properly in the ambulance in accordance with manufacturer’s instructions. * Failure to ensure Patient 1’s medical record reflected accurately and completely the hand-off for transport from the BAH ICU staff to the BCA EMS staff. * Failure to ensure the hospital’s internal investigation thoroughly evaluated all investigation findings and identified all relevant deficient practices and gaps. * Failure to ensure the hospital developed and implemented a thorough and complete action plan that addressed all deficient practices and gaps in a timely manner to prevent recurrence for other patients. Findings include: 1. During interview on 02/03/2026 starting at 1029 with the Chief Nursing Officer (CNO), Risk Manager (RM) and Director of Quality (CQO) the following was revealed: * The patient had an ST-elevated myocardial infarction (STEMI) and was transferred from Peace Harbor Medical Center and admitted to hospital (BAH) to the Intermediate Care Unit (IMCU - step down from ICU) around 0700 on 01/06/2026. * The patient was taken to the Catheterization (Cath) lab at 1325 and had a GuideLiner provoked dissection (occurring when the extension catheter-designed to provide extra support-causes trauma to the arterial wall) during the procedure requiring an intra-aortic balloon pump (IABP - a temporary mechanical device inserted into the aorta to assist a weakened heart by increasing coronary artery perfusion and reducing left ventricular workload). * The patient was transferred to the ICU in stable condition from the Cath lab at 1615 awaiting transfer to another hospital with cardiovascular surgery for emergent open-heart surgery that was not within the capabilities of BAH. * Sacred Heart Riverbend (SHRB) accepted the patient. * Reach Air was called around 1600 on 01/06/2026 to transport but declined due to weather and staffing issues. * Air Medical would have staff available at 2200 on 01/06/2026 but it would be weather dependent at that time. * BAH reached out to local ground transport companies and Bay Cities Ambulance (BCA) reported their staff were comfortable with IABP and they were available to transport the patient to SHRB. They are equipped and trained to transfer critical patients. * On 01/06/2026 at approximately 1800, after receiving report from the ICU RNs, the BCA crew left the ICU with the patient. The crew was 1 EMT and 1 Paramedic, which is a typical transport team for this area (along the coast). * An ICU RN confirmed the Paramedic was comfortable transferring the patient with the IABP in place. The IABP was sent with 2 batteries. The AC plug was not sent with the patient for this transfer because the ICU RN believed the batteries were good for 6-8 hours each. However, according to the IABP manual they are only good for 60-90 minutes each. * The IABP was on the second battery, and the patient was alert and stable with no concerns when the ambulance was involved in a motor vehicle accident (MVA) one mile from SHRB hospital. *Due to the impact of the MVA the paramedic lost consciousness. The paramedic regained consciousness in front of the ambulance. They immediately heard an alarm sounding and moved back to where the patient was. * The IABP had fallen over, and the paramedic found the helium line had been disconnected from the impact. The paramedic hooked it back up to the patient in a panic and waited 15 seconds watching the monitor screen. There was no movement (flat line) on the IABP monitor screen, so they pushed the start button which turned the machine off. According to the IABP manual it is necessary to wait 30 seconds before restarting the machine. * The IABP had been secured to a pole in the ambulance with a tourniquet, which was a common practice used to secure IV bags and machines. * At some point the paramedic called 911 from their smart watch. * The patient went into cardiac arrest; the paramedic started cardiopulmonary resuscitation (CPR) and gave 2 rounds of epinephrine. * Patient had ROSC (return of spontaneous circulation-heart rhythm and pulse). * The local ambulance arrived and took over care of the patient. * Patient was taken to SHRB Emergency Department where they died. * The accident was not the BCA driver’s fault; it was the other driver who was not paying attention to lights and sirens. It was unknown if the driver was cited. * When the BAH Biomed personnel serviced the IABP after it was returned to the hospital, they found the battery in use at the time of the accident had 15 minutes of battery life left. * BCA is capable of emergency and non-emergency transportation. Air transport is preferred for critical patients but if they are unable to fly, BAH uses ground transport. Ground paramedics are trained to transport critically ill patients. 2. Policy and procedure titled “Transfer of Patient Out of Bay Area Hospital - Ambulance or Secure Transport” dated 12/13/2021 was reviewed. It reflected: * “Transfer of a patient is to be initiated upon a provider’s order. No patient will be transferred arbitrarily or without confirmed acceptance by the receiving facility/provider. Patient’s mode of transport is determined per direction of the provider based on medical need for specific skills (such as Flight RN or Medic, ALS or BLS) to accompany the patient while out of hospital.” * “Objective: To facilitate the timely efficient transfer of a patient to an appropriate facility where specialized care may be received.” * “Procedure: Transfer to another hospital may be requested under the following conditions: A. Stable at request of the patient, family, or private provider. B. Stable on order of the provider when appropriate specialties (capabilities) or facilities (capacity) are not available at Bay Area Hospital (BAH.) [sic] May include, but not limited to: Neurosurgery, Cardiac surgery, Dialysis, Trauma, multi-system and /or isolated injury. C. Unstable after examination and stabilization, the provider recognizes the need for resources not available at BAH. May include, but not limited to: Neurosurgery, Cardiac surgery ...” * “Reason(s) for transfer: The provider must explain the reasonably expected medical benefits to a patient from the provision of appropriate medical treatment at the stated hospital outweigh the increased risk(s) to the patient ... certifying the transfer is medically appropriate and necessary.” * “The provider will issue an order for the transport of the patient in the electronic medical record. Initiate an Interfacility Transfer Form. Interfacility Transfer Consent needs to be completed by the provider or nursing personnel. Preference for mode of transport, if there is one. Skill level of transport team needed to accompany the patient (e.g., EMT, Paramedic, Registered Nurse (RN) and /or Provider). While it is not required, it is recommended the transferring provider will talk to the accepting provider at the receiving facility for approval. Documentation of the conversation shall be maintained in the patient record. The receiving provider/facility must agree to accept the patient before continuing with transport arrangements. Documents the first and last name of the admitting or supervisory personnel accepting the patient in transfer on the Interfacility Transfer form.” * “The provider indicates one of the three options for transfer: Ground ambulance, Air ambulance, Secure transport.” * “The provider must sign the Interfacility Transfer form.” * “The providers order will be communicated to the Unit Charge Nurse and Hospital Supervisor on duty ...Consult with patient and family regarding transportation arrangements to provide choice of selection when appropriate. The Hospital Supervisor or other designee will contact the emergency medical system (EMS) dispatcher and may have data faxed to the appropriate agency, as needed. The EMS dispatcher will obtain information from the Hospital Supervisor or designated personnel regarding the mode of transport, personnel needed for the transport (Paramedic, EMT, RN, provider), equipment needed for the transport, diagnosis and condition of the patient. Also note name of provider and facility to receive patient.” * “Problems which the EMS dispatcher identifies with any respect to the transport or accompanying personnel are to be communicated immediately to the provider writing the original order. The Unit Charge Nurse or Hospital Supervisor will then be made aware of any changes in the transport as negotiated between the provider and the EMS dispatcher.” * “The Unit Charge nurse or designee will next notify the admitting coordinator or appropriate unit at the receiving facility of the patient’s condition and estimated time for arrival at that facility.” * “The Unit Charge Nurse or other unit staff will assist in the preparation of the patient for transport by: Obtaining copies of patient’s record as indicated on the Interfacility Transfer form. Procuring and having equipment available with the patient. Medications ... Complete the Provider Certification Statement ... Complete the Interfacility Transfer form, making sure to fill out all spaces.” * “Options For Transport: Ambulance: provides ground transport to receiving facilities. Fixed-Wing: provides transport to and from fixed-wing. Helicopter: Helicopter transport is frequently accomplished through the receiving hospital providing the aircraft and crew for transport. Helicopter transport may also be provided by out of the area agencies as available and if deemed necessary for rapid transport to another facility. Helicopters land on the BAH helipad.” 3. Policy and procedure titled “Transfers - Transfer Center” dated 11/24/2025 was reviewed. It reflected: * “To effectively communicate and facilitate transfers in/out of Facility utilizing the Transfer Center.” * “Out Going Procedure; Physician will contact Transfer Center directly ... or place transfer order in Epic. Transfer Center specialist will gather the patient information from the sending provider (level of care needed, specialty requirement or needs). Transfer Center specialist will make contact to potential accepting facilities. Once bed availability is determined through transfer line then connect them with the appropriate specialty for physician-to-physician consult.” * “Physician may notify that they already have accepting physician or Facility. Notify Floor of Pending transfer via secure chat.” * “Accepting Facility will contact Transfer Center with Bed assignment and contact information. Transfer Center Specialist will start Transfer task: Notify the floor within Secure chat. Print Transfer Packet ...Obtain patient information need to arrange transport.” * “Arrange transportContact [sic] accepting facility with ETA for patient once transport arrives.” 4. Policy and procedure titled “Safety - Medical Equipment Management Plan” dated 04/08/2025 was reviewed. It reflected: * “The Medical Equipment Management Plan is designed to assess and limit the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring, and care of patients.” * “A continual process to minimize risks and to sustain operational reliability through inspection, testing, and maintenance.” * “Emergency procedures to be followed in the event of medical equipment defects and failures.” * “Reporting and investigating of medical equipment problems, failures, and user errors that are, or may be, a threat to patient care.” * “Monitoring and acting on equipment hazard notices and recalls.” * “Documentation of Biomedical services inspection will be kept in the Biomedical Services Department and available ... Evidence of routine inspections will be provided in the form of inspection stickers, and inspection documentation is kept in the Biomedical Services database.” * “When a problem is identified, actions are taken to resolve it. The actions are documented by Biomedical Services, and significant incidents are reported to the Safety/Environment of Care Committee. The Committee evaluates the effectiveness of the actions taken.” 5. Policy and procedure titled “Equipment - Preventive Maintenance Intervals” dated 12/06/2024 was reviewed. It reflected: * “Periodic preventive maintenance/inspection procedures are performed on Bay Area Hospital’s patient care equipment as appropriate to minimize the risk of failure and to ensure continued safe operation of the device for patients and staff.” * “Objective: To ensure patient care equipment is maintained at appropriate levels.” * “The inspection/maintenance frequencies for patient care devices are initially based on the manufacturer’s maintenance specifications for use in a patient care area.” * “Scheduled preventive maintenance work orders will be monitored and every effort to complete the procedure within the assigned month will be made. Life support patient care equipment must be completed within 30 days of scheduled maintenance or the appropriate manager is notified and equipment is removed from active service. Life support equipment is listed below ... Intra-aortic Balloon Pumps.” 6. Undated excel document titled “Medical Equipment Management Plan Addendum B Preventive Maintenance Procedures by Equipment Classification” was reviewed. It reflected: * “Balloon Pump” was a “Life-support equipment ... Risk Level 1” and that the “Electrical Safety, Physical Inspection, Battery Check, Adjustment/Lubrication, Accessories, Output and Calibration” were to be “Performed by Vendor.” 7. Document titled “Bay Area Hospital Scope of Service Fiscal Year 2025-2026” was reviewed. It reflected: * “The Bay Area Health District is a public entity encompassing most of Coos County.” 8. Document titled “Mutual Patient Transfer Agreement” dated “1.17.08” was reviewed. It reflected: * “The Parties to this Agreement are Sacred Heart Medical Center, an operating unit of PeaceHealth and Bay Area Hospital.” * “The Parties agree to be contractually bound by the terms of this Agreement in order to establish procedures and responsibilities that will facilitate the timely transfer of patients from one party (the ‘Sending Facility’) to the other (the ‘Receiving Facility’) the timely transfer of patients’ records, and the continuity of patient care.” * “Patient Transfer Process. When the patient’s attending physician has determined it is in the best interest of patient care to transfer him/her to the Receiving Facility, the Receiving Facility will review the transfer to determine whether it meets medical necessity ... Once the sending and Receiving Facilities have agreed to the transfer, the Sending Facility shall: Obtain the patient’s consent to transfer ... obtain the Receiving Facility’s consent to accept the patient (consent shall be given so long as adequate bed space and qualified personnel are available and there has been compliance with federal and state laws). Provide records sufficient to enable continuity of patient care to the Receiving Facility at time of transfer ... Secure transportation for the patient to the Receiving Facility by appropriate mode and with appropriate accompanying health care practitioners ...” * “Legal Responsibilities Between the Parties. The Receiving Facility’s responsibility for the patient’s care shall not begin until the Patient has been admitted.” * “This Agreement shall remain in effect until written notice of termination has been provided to either Party from the other.” 9. Policy and procedure titled “Helicopter Transport” dated 11/22/2021 was reviewed. It reflected: * “Policy: Patients arriving at or leaving the Emergency Department (ED) by helicopter will be transported in a safe manner. Objective: To coordinate and implement standards of care within agencies by assuring proper policies and procedure are abided to produce Emergency Medical Services (EMS) in safe and timely manner.” 10. Policy and procedure titled “Patient Rights” dated 04/03/2025 was reviewed. It reflected: * “A system shall be in place to assure that every patient is advised of his/her rights as a patient.” 11. The medical record for Patient 1 was reviewed and reflected the following: * The patient was transferred from a critical access hospital (CAH), Peace Harbor Medical Center Emergency Department with chest pain and elevated troponins and was admitted to Bay Area Hospital IMCU (Intermediate Care Step Down Unit) at 0656 on 01/06/2026. * The H&P Note dated 01/06/2026 at 0721 by the Internal Medicine MD reflected Patient 1 “is an 84 y.o. [gender] known to have multiple medical comorbidities ... presented to the emergency department at outside facility complaining of chest pain. Patient is known to have coronary artery disease with history of stent placement ... Troponin was noted to be elevated. Apparently they initially consulted Riverbend cardiology team and recommended to start the patient on heparin drip and hence patient was already started on it but since they did not have any beds requested to transfer to our facility.” * The Clinical Note dated 01/06/2026 at 0841 by Cardiology NP reflected “Interviewed and examined ... Discussed options of 24 hours heparin ... stress testing versus angiography ... Risk and benefits of diagnostic potential interventional procedure were reviewed. This includes the risk of death MI [myocardial infarction or heart attack] acute renal insufficiency arterial and nerve injury potential for acute closure need for emergent CABG [coronary artery bypass graft] or vascular surgery. Reviewed that this is a stand-alone center at [sic] in the event of emergency heart or certain vascular surgery may require transportation to a center that provides [those surgical interventions]. The risks of delay to that surgery and risks of travel were reviewed and emphasized.” * A Post Procedure Note dated 01/06/2026 at 1606 by Cardiology MD reflected “Successful stent deployment second OM [obtuse marginal] mid circumflex. Balloon angioplasty distal LAD (left anterior descending artery-largest coronary artery) with complication secondary to catheter and/or GuideLiner provoked dissection left main LAD ... unable to address in the lab this dissection and preparing for transfer for emergent CABG” and “ ... patient is waiting in ICU [Intensive Care Unit] because we simultaneously contacted Sacred Heart Riverbend for emergency transfer. I was able to talk to cardiothoracic surgeon [surgeon name] who is kind enough to let [Patient 1] for [sic] transfer for the possibility of emergency surgery. I will monitor [them] until transfer in the ICU with balloon pump heparin therapy morphine for pain,” and “We are still waiting for ambulance transfer as the initial ‘reach’ system refused transfer because they cannot handle higher level of care and were seeking other transport. Transfer center at BH [BAH] is working diligently on this.” * The patient was sent to the ICU at 1617 on 01/06/2026. * The BAH Hospitalist note dated 01/06/2026 at 1657 reflected “Initially admitted in the IMCU after transfer from outside facility. While at the IMCU patient has been hemodynamically stable with a heparin drip, went to Cath Lab around 2 PM. Troponin went up to 2.02. Patient has a remote two-vessel stenting in circumflex and LAD [left anterior descending] with CTO [chronic total occlusion] of right in 2015 with chronic diastolic heart failure.” * “1/6 Echo showed probably normal biatrial volume enlargement. LV [left ventricle] internal dimensions and left ventricular wall thickness are normal. Mild right ventricular dilatation. Mild dilatation ascending aorta with a diameter of 3.8 cm. LV global regional systolic function is preserved with an LVEF [left ventricle ejection fraction] of 60% and there is grade 1 diastolic dysfunction. RV [right ventricle] systolic function appears mildly impaired with an RVEF [right ventricle ejection fraction] estimated 40%. Mild MV [mitral valve] insufficiency and right sided pressure estimate is at the upper limits of normal.” * “Transfer to ICU post cath.” * “Pls [please] see cardiology notes for Left heart cath results. Coronary intervention to distal LAD was complicated by catheter provoked dissection through the left main proximal LAD, intra-aortic balloon pump was then placed.” * “continue fixed dose heparin after Cath” * “Lipitor increased to 80 daily.” * “Continue metoprolol extended release 12.5 mg nightly and HOLD Losartan for now” * “Morphine 2 IV every 4 as needed” * “repeat CMP [comprehensive metabolic panel] and CBC [complete blood count] ordered” * “Transfer to Sacred Heart Riverbend being coordinated at this time.” * “N.p.o. [nothing by mouth] for now awaiting transfer for possible urgent CABG [coronary artery bypass graft].” * “Patient was seen at the ICU after transfer for the Cath Lab. Patient is lying flat, comfortable ... 2 L [liters] nasal cannula ... denies any worsening shortness of breath still has the same chest pain prior to cath ... Balloon pump in place. Discussed extensively with the patient findings in the Cath Lab, need for transfer to higher level care with cardiovascular surgery. Patient was able to call [family member] on the phone updated regarding plan of care ... Care coordinated with multidisciplinary team, regarding transfer patient to Sacred Heart Riverbend.” * A Discharge Summary Note by the Internal Medicine MD dated 01/06/2026 at 1810 reflected “ ... brought to Cath Lab, patient is noted to have three-vessel coronary artery disease ... Successful stent deployment second OM mid circumflex. Patient had GuideLiner provoked dissection of the left main, LAD. Intra-aortic balloon pump was subsequently placed and patient was sent to ICU. At the ICU, patient was hemodynamically stable, awake, coordinated transfer for emergent CABG through Sacred Heart Riverbend. Overall patient condition is clinically and hemodynamically stable at the time of discharge.” * A Clinical Note by an RN dated 01/06/2026 at 1831 reflected “Received from cath lab. Balloon in place to right groin. Leg immobilizer in place. EKG (electrocardiogram) and labs completed. Bay Area ambulance arrived for transfer to Riverbend. Report given. Went over balloon pump with paramedic, denies any questions. Portable part of pump removed for transport. Show [sic] EMS were to find emergency numbers to call if any issues with pump. Assisted out to ambulance and loaded up. Report called to [name] RN at Riverbend.” 12. The Interfacility Transfer form was reviewed, it reflected: * “Date of transfer 1/6/25” * “Transfer from (unit) ICU” with the Sending Provider’s name, the receiving provider’s name, receiving facility name “Riverbend” and “Date/Time notified 1/6/26” * “Person at receiving facility confirming adequate staff/facilities, and authorized to accept transfer” [name] with the box next to “Admitting Coordinator” checked. * “Bed assignment RM 4203, Date/Time received 1/6/26 @ 1700.” * “Nurse-to-Nurse Report - Sending RN [name] Date 1-6-26 Time 1730 Report to Include First and Last Name [first name of RN]” * “Method of Transfer and Orders” with the box checked for “Ground Ambulance.” * “Skill level of transport team” with the box checked for “Paramedic.” * “Transport company name Bay cities” and “Transport co. notified at 1700. Transfer co. ETA (estimated time of arrival) 1730. Transfer co. arrived at 1715.” * “Sufficient continuous medication infusions for duration of transport” with the box yes checked. * “Patient record copied and sent with patient by [employee signature] Time 1710” with multiple boxes checked for example: ED medical record, History and Physical/Consultations, Provider Progress notes, Medication Administration Record, Discharge Summary, Patient Demographics, EKG(s), Medical Imaging, Labs, Personal belongings list and Copy of Interfacility Transfer form. The second page of the Interfacility Transfer Form reflected: * Patient 1 signed the “Transfer Consent” dated 01/06/2026 at 1600. * “Specialized care, specify: Cardiovascular Surgery.” * “Individualized benefits: Higher Level of care.” * “Individualized risks of transport: Worsening Condition, Possible Death.” * The provider certification was not signed by the provider, dated 1/6/2026 at 4:00PM. 13. During interview with the CQO on 02/03/2026 during the medical record review the following information was revealed: * “Reach” is the name of a flight company that transports medical patients. When they were contacted regarding Patient 1 they did not have the staff available for transport. * The patient was transferred to SHRB because they needed a Cardiothoracic Surgeon and that service is not available at Bay Area Hospital. * The IABP had emergency phone numbers on it to call for assistance if the paramedic had any issues or questions regarding the pump. The phone numbers were for people representing the manufacturer and specialize in the use of the machine. There was also a QR code on the pump that takes you directly to the “Cardiosave IABP Operation - Transport Quick Reference Guide.” * There have not been any other issues regarding ground ambulance transfers reported to the hospital such as equipment failures, usage or not having proper staff to manage the patient. * The paramedic did not have any concerns or issues during the transport until the collision occurred. * The BAH Biomed tech inspected the IABP after the accident and did not identify any issues or defects and found it had 15 minutes of battery remaining when it was turned off. * The BCA General Manager reported to the BAH EMS liaison that a police report was made regarding the collision that found the other driver was at fault. The police report reflected that the driver was not paying attention to the lights and sirens on the ambulance and did not yield to the ambulance causing the collision. * Sacred Heart Riverbend CMO (Chief Medical Officer) reached out to the CMO at Bay Area Hospital on 01/07/2026 to relay the information that the patient passed away and that there were concerns about the IABP batteries. 14. A manufacturer’s “CM Cardiosave Hybrid Balloon Pump Corrective Recall 13-701-066 Service Report” dated 01/19/2024 was reviewed. It reflected: * “Serial CA223093A3.” * “Service Ticket Details: Completed CardioSave coiled cord field safety corrective action ... Product passed all functional and safety tests per factory specifications.” * Work performed dates of 01/18/2024 and 01/19/2024. 15. A Word document titled “Intra-Aortic Balloon Pump Recall June 2024” with an unknown author was reviewed. It reflected: * “The FDA has issued a letter to Health Care Providers regarding our Getinge/Maquet Cardiosave Intra-Aortic Balloon Pumps. BAH has two of these devices in house. They are very infrequently used but when they are needed, they are absolutely life saving.” * “On May 24, 2024, the FDA published Safety and Quality Concerns with Getinge Cardiovascular Devices.” * “In June of 2023, Getinge/Maquet/Datascope initiated voluntary recalls of the equipment for the following: Unexpected Shutdown Electrical Failures in the Power Management Board, PCBA Failures Affecting the Ability to Charge the Batteries Leading to Unexpected shut downs, Power Failures when IABP is unseated from Cart, Autofill Failure Alarms, Gas Loss and Gas Gain Failures, System Over Temperature Alarms Causing Pump Stops” * “BAH will confirm that our IABP are part of this recall. BAH will need to replace both IABP. Current equipment can continue to be used until replacements are available.” * “As per FDA recommendations: BAH will have a fully charged back-up device available when an IABP is in use. This limits BAH to using only one IABP at a time to have the second device available to the patient as a backup. Any device failures will be immediately reported ... device usage and outcomes will be monitored monthly at Safety Committee. All ICU and Cath Lab staff will be advised of this plan. Cardiology medical Staff will be notified ...” 16. Document titled “Bay Area Hospital Safety/Environment of Care Minutes” dated 06/25/2024 was reviewed. In relation to the IABP recall it reflected only: * Topic “Medical Equipment ... Discussion/Information Intra-Aortic Balloon Pumps, not a lot of options and alternates have a lot of issues.” The “Action Required” section reflected “N/A.” * The “options” and “alternates” were not specified in the minutes and it was unclear why “actions” were not applicable. 17. A manufacturer’s “Preventive maintenance checklist for Cardiosave” dated 07/01/2025 was reviewed. It reflected: * “Serial number CA223093A3” * Preventive maintenance checklist of Inspection Results, Visual inspection checklist, cleaning and internal inspection, consumable parts, runtime minutes, voltage with everything checked ok and digitally signed by the manufacturer’s technician on 07/01/2025 at 1342. 18. A letter from the Getinge Vice President titled “Cardiosave Lithium-Ion Battery Maintenance Notification” dated “August 2025” was reviewed. It reflected: * “Getinge is currently experiencing a supply issue that is limiting the availability of components to properly maintain your Cardiosave Hybrid and Rescue Intra-aortic Balloon Pump (IABP) according to the preventative maintenance schedules provided in the operations manual.” * “Based on these supply limitations, we are temporarily modifying the recommended maintenance schedule of the Cardiosave Lithium-Ion batteries. Battery replacement may not be necessary at 200 full discharge cycles or after 4-years of operation. This modification is contingent on the individual battery run time being [greater than or equal to] 45-minutes at a heart rate that is less than or equal to 120 beats per minutes. This temporary extension to the maintenance schedule should only be followed when your total battery runtime is [greater than or equal to] 90-minutes ... this modification to the maintenance schedule will not impact the performance of the system or alarms in any way. However, it’s important that you continue to monitor the performance of these batteries routinely.” 19. The manufacturer’s “Cardiosave IABP Operation - Transport Quick Reference Guide/Cardiosave IABP software B.17” undated was reviewed. It was an 18-page abbreviated guide that describes instructions for use and Cardiosave operating instructions with pictures. It reflected: * “Portable Operation, Getinge recommends: - Sufficient supply of fully charged batteries for use during transport. - Use of the Transport Power Supply for AC operation during transport. - Verifying internal helium reservoir is full when using the Transport System. - System must be properly secured in the transport vehicle.” * “Removing Pump Console from the Cart” * “Helium Supply” * “Viewing Battery Status on Monitor Display (examples)” * “Viewing Battery Status on Battery” * “Changing the Battery” * “IAB Transport Fixation with the Mounting Plate” * “Cardiosave Operation Modes” * “Cardiosave Monitor Display and Touchscreen” * “Cardiosave Lock Screen Feature” * “Alarms” * “Cardiosave Symbols” * The guide reflects that the batteries last approximately 90 minutes each and the AC cord should always be sent with the portable unit and positioned securely during transport. 20. An email string from the BAH Bio-Medical Support Tech wrote to the Getinge Technician with subject line “FW: Semi-Annual Cardiosave PMs” dated 01/01/2026 at 0833 was reviewed. It reflected: * “I show we are once again coming due for Cardiosave Balloon Pump PMs this month. Can you shoot me a couple days that work for you, and I will check in with my Cath Lab staff?” * On 01/06/2026 at 0824 the Getinge Tech wrote to the BAH Bio-Medical Support Tech, “Would next week work on your end, possibly the 14th, 15th, or 16th?” * On 01/06/26 at 1429 the BAH Bio-Medical Support Tech wrote to the Getinge Tech, “It sounds like the 16th is the best day. The Cath lab will be down that day anyways for repair.” 21. An email string from the BAH Bio-Medical Support Tech wrote to the Getinge Technician with subject line “FW: Semi-Annual Cardiosave PMs” dated 01/07/2026 at 1201, after the incident that involved Patient 1, was reviewed. It reflected: * “We have a unit that was transporting a patient to Eugene and transportation had an accident on the way. They are not sure if it was damaged at all. It does not show any physical damage. This unit’s battery had also died or was extremely low during transportation. They mentioned having an issue with the battery. This unit is due this month for a new battery. Are you aware that it is due? SN CA223093A3” * In an email on 01/08/2026 at 1416 the Getinge Tech wrote to the BAH Bio-Medical Support Tech, “I am aware it is due for new batteries, and they are on order for this month! I am catching up to the rental request as well ...I may be able to get down there Monday (12th) to take a look at this unit and PM both units if that would work on your end!” * In an email on 01/08/2026 at 1448 the BAH Bio-Medical Support Tech wrote to the Getinge Tech, “It would be great if you can come on the 12th to PM and look over out units. My only concern is if you find something wrong with the one that was in the MVA and we delay getting a loaner coming. I’m happy to lean on your expertise and opinion though.” * In an email on 01/08/2026 at 1454 the BAH Bio-Medical Support Tech wrote to the Getinge Tech, “Also, this unit cannot be used even if it was not in an accident. The unit’s battery will not last for even a trip to Eugene.” * In an email on 01/08/2026 at 1505 the Getinge Tech wrote to the BAH Bio-Medical Support Tech, “Let’s continue the path for the loaner for that exact reason, just in case something is wrong with the unit and needs parts. Each battery usually has a life of 60 minutes if it’s actively pumping, so yes a trip to Eugene would require running through 2-3 batteries!” * In an email on 01/12/2026 at 0812 the Getinge Tech wrote to the BAH Bio-Medical Support Tech, “I am hoping the rental unit made its way to you all over the weekend? I know our rental company was working on it on Friday. I will be driving down from Portland today and plan on being on site to address this first thing tomorrow morning!” * In an email on 01/12/2026 at 0853 the BAH Bio-Medical Support Tech wrote to the Getinge Tech, “Yes, the loaner unit arrived on Saturday [01/10/2026].” * In an email on 01/16/2026 at 1007 the Getinge technician wrote to the BAH Bio-Medical Support Tech, “There was no evidence of unit failure during transport. The logs verify that the unit had run down both batteries to zero percent before ultimately losing power. The unit has passed all functional and safety tests and has been returned to the customer for use.” 22. An email from the BAH Biomedical Engineer wrote to the Cath Lab Nurse Manager with subject line “FW: Balloon Pump (13-701-066) dated 01/07/2026 at 1201, after the incident that involved Patient 1, was reviewed. It reflected: * “We just received word that the Balloon Pump 13-701-066 was inside an ambulance that was involved in an accident. Biomed does not have the test equipment needed to test this piece of equipment. On Jan 16 this pump is schedule for preventative maintenance by the OEM. My question is, can we wait until Jan 16? If we bring the OEM [original equipment manufacturer] out early there will be a considerably higher cost and the earliest they are available is Jan 14. Can we get by with just having one ballon pump?” 23. An email from the SHRB CMO to the BAH CMO with subject line “NSTEMI Case turned dissection” dated 01/07/2026 at 1409, after the incident that involved Patient 1, was reviewed. It reflected: *”Just got off phone with Riverbend CMO. Sounds like we had the following case: Patient information: [Patient 1 and DOB]. NSTEMI, transferred from Florence to BAH, at PCI had L main coronary dissection with occlusion of LAD and extension of the dissection ... IABP placed and transferred here for CT surgery ... Overall topics discussed: EMS crew involved in MVC during transport ... Battery pack for IABP died, and no backup battery pack was available ... dissection occurred during the PCI ... sending the case for review ... Transfer request to Riverbend at 1522 ... REACH contacted and declined due to weather at 1559 ... Accepted at Riverbend 1609 ... REACH again called declined due to discomfort w/patient ‘outsourcing to Life Flight at 1627’ ... Lifeflight [sic] unable to respond till 2200, unless we send a RN, called Bay Cities for ground transport (code 3) with approve by MD ... Patient pick up by Bay Cities at 1806.” 24. An email from the ICU Clinical Nurse Manager to all ICU staff with subject line “Fw: Action Required: Balloon Pump Transfers - Backup Batteries” dated 01/09/2026 at 2127, after the incident that involved Patient 1, was reviewed. It reflected: * “Effective immediately, for any patient transferring to another facility with a balloon pump in place, please ensure that spare backup batteries are sent with the transport crew. Please coordinate with the Cath Lab team to obtain the backup batteries as needed.” The email was sent out to ICU, Cardiovascular Laboratory (CVL) and ED staff. 25. A manufacturer’s “CM Cardiosave Hybrid Balloon Pump 13-701-066 Service Report” dated 01/13/2026, after the incident that involved Patient 1, was reviewed. It reflected: * “Order Type ... Service Repair - On-Site.” * “Work Order Description: Tubing became dislodged, unit shut down. Dislodging occurred during a car accident with the ambulance. Yes: patient involvement.” * “Serial Number CA223093A3.” * “Fault Code: Alarm - IAB Disconnected.” * “Compliance Approved Remarks (CAR). Completed product inspection per customer/manufacturer requirements; Completed repair successfully. Product passed all functional and safety tests per manufacturer specifications.” - “Car Comment: Unit has been fully evaluated after involvement in car accident. Unit is passing all functional and safety checks. Returned unit to customer.” - Signed by a Field Engineer from the manufacturer Getinge on 01/13/2026 at 1640. 26. A manufacturer’s “PM Cardiosave Hybrid Balloon Pump 13-701-066 Checklist” dated 01/13/2026, after the incident that involved Patient 1, was reviewed. It reflected: * Preventive maintenance checklist of Inspection Results, Visual inspection checklist, cleaning and internal inspection, consumable parts, runtime minutes, voltage with everything checked ok and digitally signed by the manufacturer’s technician on 01/13/2026 at 1624. 27. An email from the Cardiovascular Center Clinic Manager to the Risk Manager with subject line “Battery approval” dated 01/14/2026 at 1040, after the incident that involved Patient 1, was reviewed. It reflected: * A requisition showing Approval by cost center manager to purchase 4 more batteries for the IABP entered by the Cardiovascular Center Clinic Manager on 01/13/2026. 28. “Cardiosave Global Service Product Catalog” undated one page document that displays Cardiosave Hybrid accessories and replacement parts with the part numbers used to purchase batteries for the IABP. 29. During interview with the CQO on 02/03/2026 at 1208 during the documentation review, the following information was revealed: *The first notice of the voluntary recall on the IABP hybrid machine was in 2024. There was one other manufacturer type for this type of machine that was also being recalled so no good alternatives were available at this time. *The new plan was to send two extra batteries with the two batteries that already go with the pump along with the AC cord for every patient transfer. *The Getinge technician is scheduled for semi-annual preventive maintenance checks on the IABP every year in July and January. *The Getinge tech determined that when the IABP start button was pushed by the paramedic after the crash, it turned the machine off and drained the remaining battery. * The Quick Reference Guide reflected that the batteries last approximately 90 minutes and the AC cord should be sent with the portable unit. 30.a. An email with subject line “Re: Urgent - IABP Action Plan” dated 01/07/2026 at 1651 reflected an email string that started with “Need to gather after safety huddle to determine IABP action plan.” Sent out to Risk Manager, Cath Lab manager, Cath Lab Lead Tech, Director of Quality and other leadership with a meeting date and time of 01/08/2026 at 9:15 AM-9:45 AM. 30.b. The email string also contained information that a loaner IABP arrived on Saturday 01/10/2026 in case the machine being used during the accident needed to be repaired. The string continued after the manufacturer inspection was completed. The IABP (involved in the accident) was returned to the Cath Lab, a full PM had been completed and everything checked out fine. New batteries were also installed and the BAH Biomed person was in the process of ordering extra batteries. 31. The “January 9, 2026 IABP Failure [internal investigation]” sign in sheet reflected printed names with signatures and titles of 14 staff from BAH and BCA (Bay Cities Ambulance). Those staff were identified as: *From BAH: CNO, Risk Manager, Patient Care Supervisor, ICU Manager, Cath Lab Manager, Cath Lab Lead Tech, Facilities Director, IMCU Manager, and EMS Liaison. *From BCA: General Manager, Dispatch Manager, “Dispatch”, “EMS,” & Paramedic. 32. The hospital’s internal investigation Excel workbook titled “Intra-Aortic Balloon Pump ... Cause Mapping ... Investigation File” was provided on 02/03/2026 in an electronic file named “IABP Failure Cause Map_01.06.2026 event”. The Excel workbook contained “tabs” for various aspects of the investigation. 33. The “Problem” tab on the investigation Excel workbook included the following information: * “Problem(s) - IABP failure during patient transfer to HLOC [higher level of care]” * Date 01/06/2026 * Time approximately 2245 * “Different, unusual, unique - IABP on national recall without reliable comparable option” * “Facility, site - Bay Area Hospital/Bay Cities Ambulance” * “Unit, area, equipment - Cath Lab/ICU/Biomed - IABP” * “Task being performed - IABP in use during transfer to HLOC failed; EMS in MVA during transport” * “Impact to each GOAL - Patient Safety ... plan for use of recalled equipment due to no other comparable equipment available on market - Employee staff education on safety plan” 34. The undated “Cause Map” tab on the investigation Excel workbook contained the following information written in squares that had no arrows or connections to each other: * “IABP on national recall with no good replacement” * “EMS in MVA approx. 1 mile from receiving hospital” * “BAH Safety Plan includes having two IABP available when one in use” * “BAH sends one IABP with EMS for transport” * “Pts are uaually [sic] flown” * “Machines aon [sic] recal [sic] what about batteries” * “Reach uncomfortable no RN trained on IABP” * “[Patient Care Supervisor] to cath lab to find out if RN could go” * “Checkeed [sic] policies. CALLED [CNO]” * “[Cardiologist MD] wanted to ground. [Internal Medicine MD] wanted to wait for Cal Ore [sic] at 2200 (crew [sic]” * “[CNO] told [RN House Supervisor] tht [sic] BCA has a crew that is comfortable” 35.a. The undated “Solutions” tab on the investigation Excel workbook included the following information in table format: 35.b. “Ref 1 ... Cause controlled: EMS team reports they were told by ICU staff that the batteries lasted 6-8 hours when they requested a back=up [sic].” * “Process to be improved: All team members should have accurate information that is data driven (refer to equipment manual for information to verify).” * “Possible Solution: ICU manager to send out alert to staff that IABP battery run time is approximately 90 minutes.” * “Status: completed 1/9/2026” 35.c. “Ref 2 ... Cause controlled: EMS team was not provided backup batteries or power supply cord when they requested; ICU staff erroneously believeing [sic] that battery packs for IABP lasted 6-8 hours each and communicating that to EMS paramedic; after incident it was identified that Cath Lab did have two AC back-up power cords for the protable [sic] IABP pump but it was unknown if they work - 1/12/26 biomed tested and cords work.” * “Process to be improved: Transporting patients on IABP is essentially a life support and for patient safety, BAH should provide IABP equipment to support duration of transfer for unanticipated events that may cause a delay in projected arrival time to receiving hospital (i.e., car crashes, road hazards, weather, diversion from originally planned route).” * “Possible Solution: Cath lab to order 4 battery packs ... for back-up and adequate support in providing transport supplies to EMS.” * “Status: pending” 35.d. “Ref 3 ... Cause controlled: provides double the battery supply for unanticipated events that may cause delay in arrival at receiving facility.” * “Process to be improved: FDA recall for IABP recommends that when in use, a back-up is readily available. This has been our practice when an IABP is in use onsite but not for transport with EMS.” * “Possible Solution: Air transport EMS teams transferring patient with IABP will be given two fully charged back-up batteries (placed in designated cases from Cath lab) in addition to the two batteries in the IABP connected to the patient and the back up ac power cord for transport.” * “Status: completed 1/12/2026” 35.e. “Ref 4 ... Cause controlled: These are critical patients on a life support system and require 1:1 nursing when in ICU who has all the resources of the hospital - EMS has much more limited resources.” * “Process to be improved: [Staff name], EMS liaison to work with EMS on how this can be supported; BAH cannot require EMS partners to do this but can prefer it and make that known. When critical patients need to be transferred, there may be staffing limitations that would not be able to suppor [sic] this.” * “Possible Solution: BAH discuss with air and ground EMS partners how to facilitate BAH recommendation for making critical care patients (includes IABP) a three-man transport team when staffing is available.” * “Status: pending” 35.f. “Ref 5 ... Cause controlled: during this event, the IABP was secured by EMS using IV tourniquets and when MVA occurred, the IABP fell forward and landed on the front facing down.” * “Process to be improved: Work with EMS to identify what is needed for this.” * “Possible Solution: Develop plan for securing IABP device in ambulance so [sic] decrease equipments [sic] ability to be tipped over.” * “Status: Pending” 35.g. “Ref 6 ... Cause controlled: performing annula [sic] training to BCA rather than only educating with in the moment training during a transfer, will improve BCA staff familiarity with device and provide better support to their team.” * “Process to be improved: Cath lab staff [staff name with question mark] to review what basic training is needed to maintain IABP and troubleshoot some issues EMS may have; [EMS liaison] to facilitate scheduling trainings” * “Possible Solution: Provide inperson [sic] training sessions for EMS on IABP device management during patient transport (initial training within 45 days and then annually).” * “Status: pending” 35.h. “Ref 7 ... Cause controlled: currently there is some info on IABP in initial department RN competency and then ICU RNs are requried [sic] to review the policy annually.” * “Process to be improved: Improve ICU staff familiarity with high risk/low volume patient equipment” * “Possible Solution: Add to ICU skills day annually: competency on IABP, focusing on: preparing patient for transport; removal of console from docking unit; securing connection points; securing device for transport” * “Status: pending” 35.i. “Ref 8 ... Cause controlled: should connection sites be secured with tape or something, similar to chest tubes securing?” * “Process to be improved: Research best practice for securing connections for IABP tubing to patient - if it is recommended or contraindicated (would this have potentially dislodged from the patient if it had been secured at the connection site, rather than just disconnecting?)” * “Possible Solution: Implement new practice of securing connection sites from IABP to patient.” * “Status: TBD” 36. In an email from the CQO received on 03/24/2026 at 1931 they reported that an assistant taking notes during the meeting documented the following information during the RCA on 01/09/2026 from 1000-1130. The following undated information under the “Timeline” tab appears below as written in the hospital’s internal investigation Excel workbook. Please note that due to the multitude of misspellings and grammatical errors the [sic] notation for each of those has not been included. “4:30 AM BCA disparch reeived pc to xxfer [Patient 1] with iABP. Waiting room placement. Askd if air was asked. Infoemd that air refused. arrived at BAH,, met wth staff, informed that patient was sgtable went to ICU 3 met RN Paramedic, 2 iv pumps, nc, supine, Rn gae handover report that pt must remain uspine, Rn didn’t now too much, they only got pt an hour ago. Rn went and got ICU charge to explain device. Paramedic asked if [they] took the whole deive (dockiing station) worried tht it would fit in ambulance. RN told [them] tht whole devince don’t go handle and wheels. Asked if [they] gets a power cords was told no. Chrage RN gave documents to paramedic who was infamiliar with device. Showed recording every 15 minutes. Paramedic asked if [they] needed to touch machine was told no. paramedic asked again if the macchine would last for the trip and was told yes and didn’t need the power cord clarified that BAH employee told [them] that batteries last 6 hours paramadeic asked if she had questions duering the trip. Was given an 888 number EMT asked if battery would lasgt if stuck in traffic. Was told again battery would last RN assisted with patin and trolley to amb Trip stareted, pt was given morphine at [the town of Elkton, approximately 62 miles from BAH], first battery was at less than 10 percent approximation. Had 54 minutes [approximately 55 miles] left to get to RB. 2nd battery was full Tried to look through paperwork but nothing about battery., 3rd green column ([Cath Lab Tech] clarified that is for helium) Tired to go online trying to research but with 15 minute checks. About 15 minutes from [SHRB] the last bettery flashed yellow. Paramedic contacted RB to let them know. Gave pateint room and was told that someone would meet them at ED About 6 minutes from [SHRB] started to prep patient for unload due to low battery. Pulling IV cords. Accident Checked EMT and went back to check patient. [Patient] was still on table due to straps unsure if ;pst consciousness pt chest pain 11 uut 10. IABP tipped but attached with straps. IABP made noises. Pt said something wrong. Battery. Checked all tubing and made sure they were conneted. Pressed start. fan noises, pushed sgtart button but everything went black Pt not rsponsivce. Sgtart CPR. Called 911 code 3. 911 said mutlple calls and she didn’t need anything. [Cath Lab Tech] clarified that helium tube likely got dislodged due to slip tip Backdoors open midvalley, fire hiled and helped get pt out of ambulance and put in new ambulance. Checked rhythm, v fib, shock, cpr resume another started breath lucas [LUCAS Chest Compression System] sometime called RB asystole, PRA, Arrived [SHRB] and had pulse [SHRB] staff questioned why not flown [SHRB] connected to a new IABP [SHRB] todl [paramedic] that patine was stabilizing and going to xrag Accident at gagteway and beltine driving code 3 dur regard and caution clered all lanes proceeded with caution looked slightly to right and looked like clear with 2 lanes 3rd lane was clear but a car came full speed and stuck the ambulance about 750 paramedic landed next to EMT pain in lower back, crying (pain and circumstances) proceeded to call supervisor, [first name of supervisor]” 37. The undated “Photos” tab on the investigation Excel workbook contained the following information: “Cardiosave IABP Operation - Transport Quick Reference Guide” “Portable Operation Getinge recommends: - Sufficient supply of fully charged batteries for use during transport. - Use of the Transport Power Supply for AC operation during transport. - Verifying internal helium reservoir is full when using the Transport Systems. - System must be properly secured in the transport vehicle.” 38. The undated “Notes” tab on the investigation Excel workbook contained the following information: * The meeting start time at “100 am [sic]” and a list of the 18 individuals using first name only, or no name with only reference to the company as “5 BCA”, were documented as in attendance. However, the list did not entirely align with the sign-in sheet referenced in Finding 18 above. * A link that did not work titled “UPDATE: Risk of Device Failures for Getinge’s Maquet/Datascope Cardiosave Intra-Aortic Balloon Pump (IABP) - Letter to Health Care Providers / FDA” * “[ICU Manager] communicated plan for backup batteries being sent with EMS” * “Talk with education about IABP video training for EMS” * “[Cath Lab Manager] to get dates/times to [BAH EMS Liaison] for EMS training demo on IABP” 39. The remaining tabs on the investigation Excel workbook had not been completed. Those were: Matrix, Diagram, Work Process, Info to Get, Data, and End. 40.a. Internal emails related to the hospital’s internal investigation included: 40.b. An email with subject line “Re: [Internal investigation corrective action plan] - What am I missing” dated 01/09/2026 at 1642 reflected an email string from Risk Manager to CNO asking for input/recommendations with a copy of the [internal investigation] IABP Failure map. 40.c. The CNO responded to the Risk Manager in an email on 01/10/2026 at 1108 with “ ... batteries are being ordered ... found AC chargers and sending for QC ... we need something about updated training for all ICU/ED staff on IABP with annual or bi-annual competency specific: Preparing for transport Removal of consul Securing connection points Securing of device” 40.d. In an email on 01/14/2026 at 1041 the Risk Manager replied to the Cath Lab Manager with “I actually think our staff doing a short and sweet demo on the basics of the machine would be best for out EMS partners, so if we could schedule something for a Monday or Tuesday and another session for a Wednesday or Thursday in February that could invite our EMS partners to attend, that would be amazing!” 40.e. An email with subject line “Re: IABP education sessions” dated 02/02/2026 at 0838 from the Cath Lab Manager to the Risk Manger reflected “I’m working through my to-do list in between patient care, which has been a bit challenging this week. I reached out to the IABP rep to explore scheduling some refresher training, as I think it would also be beneficial for both ICU and Cath Lab staff, along with EMS. Unfortunately, the rep is not available until the first week of March. If you’d like, I’m happy to coordinate an earlier session in early February with EMS (by Cath lab staff) to provide a basic introduction to the IABP and allow them to see the device.” 41. During interview with the CQO on 02/03/2026 at 1205 they stated they were unsure if the IABP competencies were currently done upon hire only or more often such as annually. 42. During interview with the CQO and RM on 02/03/2026 starting at 1450 they provided the following information: * There were no issues with the IABP prior to the accident except that the machine was secured in the ambulance using tourniquets. * After the ambulance was struck, the paramedic lost consciousness. They woke up in front of ambulance, heard an alarm and went to check on patient. * The machine (IABP) had fallen over and the helium line disconnected. * The paramedic hooked it back up to the patient and waited 15 seconds (supposed to wait 30 seconds according to staff) waiting to see a waveform on the monitor screen before pushing the start button, which turned the machine off. * The paramedic was in a panic, calling 911 from an apple watch, starting CPR on the patient and giving two rounds of epinephrine. * There was ROSC, a return of heart rhythm. * An ambulance then transported the patient to SHRB ED where they passed away. * The Gentinge tech from the IABP manufacturing company determined there was 15 minutes of battery left on the second IABP battery before it was turned off. * Two additional batteries and the AC cord should have gone with this patient for transport. * The BAH ICU staff thought each battery for the IABP lasted 6-8 hours each. 43. In an email received from the BAH CQO on 03/24/2026 at 1931 the following information was provided: * Regarding the author of the IABP Failure Cause Map the CQO stated “[name], RN, MSN Risk Manager.” * Regarding whether the ED physicians involved with Patient 1 were interviewed during the hospital’s investigation the CQO stated “They were not interviewed.” * Regarding if there are P&Ps regarding who decides ground versus air transport, the CQO stated “The doctor decides which mode of transportation is appropriate based on their clinical judgment [sic] and the resources available at the time. There is no policy that determines mode of transport.” * Regarding the author of the “Timeline” in the IABP Failure Cause Map the CQO stated “[name] Assistant taking notes during meeting.” * Regarding the “4:30 AM” section of the “Timeline” in the IABP Failure Cause Map the CQO stated that was the paramedic’s account of the events on the day of the incident that was being recorded by the assistant.” * Regarding the “Accident” section of the “Timeline” the CQO stated that was the EMT’s (driver’s) account of the accident. * Regarding the date the “Timeline” in the IABP Failure Cause Map was created the CQO stated it was “Documented at the time of the [internal investigation] 1/9/2026 1000-1130.” * Regarding the documents given to the paramedic referenced in the timeline the CQO stated “No physical documents were given to the paramedic.” * Regarding whether the trolly referenced in the “Timeline” by the paramedic had the handle and wheels (Transport System) the CQO stated “yes.” * Regarding how the paramedic landed next to the EMT after the collision the CQO stated “The paramedic made that recollection in the [internal investigation meeting] so it was recorded. Most ambulances have a large pass through compartment between the cab and the back.” * Regarding if there is any documentation about the accident such as fault, police report, etc. the CQO stated “As the ambulance service is a private company not associated with the hospital we do not have any police report for this event. I believe it would be available from the Springfield PD. It has been said through unofficial channels that it was determined to be the driver of the other car at fault but I have no documentation to support that.” * Regarding the documentation “IABP tipped but attached with straps” are the straps the tourniquets the CQO stated “yes.” * Regarding the 3rd green column for helium and if there was any documentation that showed the internal helium reservoir was full and/or checked when the patient left BAH the CQO stated “I am unable to locate any documentation saying such. I do not have access to the EMS documentation. It may be in their documentation. There is no indication that there was a problem with the helium levels.” * Regarding the Solutions tab that has “Cause Controlled” on it, what is the source of the information the CQO stated “The Cause controlled is identified at the time of the RCA as a result of the investigation and meeting. ‘Cause controlled’ is analogous to a defect identified and the corresponding mitigation.” * Regarding the PM for Cardiosave IABP Hybrid from January 2025 the CQO stated “Attached you will notice in the Jan 2025 PM that the batteries are dated to expire at the end of June. Attached is a document from the device maintenance company detailing that there was a nation wide back order on the batteries so they were tested and found to be within specifications for performance so the battery life was extended through January of this year. I know that you didn’t ask for it but I attached the July 25 PM because it makes the picture clearer. You will notice that in the PM for July of 2025, the expiration date for the batteries (same serial number) was extended out through January.” 44. A media article in “The Register-Guard” dated 01/07/2026 at 1116 reflected “An ambulance transporting a patient from Coos Bay to PeaceHealth Sacred Heart Medical Center at Riverbend in Springfield was involved in a crash a [sic] the intersection of Gateway Street and Beltline Highway the night of Jan. 6. According to Springfield Deputy Chief of Police [name], the police response to the incident was significant due to the location of the crash and involvement of an ambulance. Medics with the Eugene-Springfield Fire department arrived on scene to stabilize the patient and complete transport to the hospital. It was not immediately clear whether the patient sustained any injuries resulting from the crash. The driver of the ambulance was transported to the hospital with minor injuries. [Springfield Deputy Chief of Police] said no one in the other involved vehicle sustained injuries. The Register-Guard reached out to Bay Cities Ambulance for comment but did not receive a response in time for this report.” 45. An email from the BCA paramedic to the BCA General Manager was dated 01/08/2026 at 1424 and the subject line indicated it was in regard to “Run # 4928.” The email included the following information about the paramedic’s encounter with BAH staff prior to transport of Patient 1 and their experience on the ambulance during the transfer to SHRB: * “Dispatched to a scheduled inter-facility transfer from BAH-ICU to Sacred Heart Riverbend for a pt with NSTEMI needs cardiology, balloon pump and 2IV’s [intravenous], run #4928. While walking in BAH towards ICU we crossed paths with [Cardiologist MD] who advised the pt is stable and is being transported for cardiac surgery that’s if [Patient 1] still gets the surgery. No other information about the statement made and walked away. * Crew arrive on scene to find an 84 y/o [year old] [Patient 1] supine in ICU bed in care of RN. Pt presents AOx4 [alert and oriented to person, place, time and event], GCS [Glasgow Coma Scale - neurological tool assessing consciousness] 15, conscious, strong radial pulse and a patent airway. Pt presents annoyed and irritated. RN established an 18g in the RAC [right antecubital] saline locked and a 20g in the left wrist with Heparin and NS [normal saline] running via IVPB [intravenous piggyback] with an IV pump. Heparin is running at 11.6 units/kg/hr with NS at 100mL/hour. RN states the pt came from the Cath lab approximately an hour ago for a LAD stent and had complication resulting in a LAD dissection. RN states the pt has been in 11/10 chest pain that radiates to the right shoulder and the pt had just received 2mg of Morphine and compazine for nausea. Otherwise the pt has been stable. * RN further states the pt strictly has to remain supine due to the balloon pump. I state I have never encountered a balloon pump and do not know how to use. RN states [they are] not familiar with the machine either and left to get assistance. At this point the ICU charge nurse [name] and another RN present. I asked questions regarding the balloon pump: 1. Do we take the whole device? 2. Do I need to do anything with the machine during transport? 3. Who can I call if I have trouble with the machine? * The second RN states ‘no’ we remove part of the balloon pump and it is like a brief case. At this point I notice there is no power cord. I ask will we get a power cord? [ICU Charge RN] says ‘no’ we do not need a power cord. RN shows how the case comes out and a handle lifts and the pump has two wheels at the rear. I ask the RN to put the device back as we are not ready for the pt. * [ICU Charge RN] states we will not have to touch the machine and walked away and came back with a print out of Intraaortic balloon pump management document and an intra-aortic balloon pump flowsheet. [ICU Charge RN] states we have been filling the flowsheet every 15mins and showed me where to obtain the values. At this point I asked again about the power cord for the device and expressed concerns as the crew at this point identified the balloon pump is vital and critical for the pt. [ICU Charge RN] said no again. My partner at this point asks what if we are stuck in traffic? [ICU Charge RN] states there are two batteries and each battery has 6-8 hours each and the machine will make it to Riverbend. * I asked then who do I call if I have trouble with the machine? RN pointed out a 24hr Emergency number [manufacture’s] 1.800.777.4222 printed on the machine. * I review the vitals and obtain remainder of information and then began to transition the pt to our stretcher. Pt is secured using the legs, waist and chest straps. Pt right foot reassessed and vitals reassessed. At this point [ICU Charge RN] states [they were] just told to tell us ‘I won’t get you to sign paperwork, but I was told to tell you the equipment is very Expensive’ At this point I again asked are you sure I don’t need a power cord? I expressed my concern that IV pumps don’t last. [ICU Charge RN] states the balloon pump has a more detailed and regular maintenance review. I then state and look [ICU Charge RN] in the eyes ‘Do you promise me I will get to Riverbend and not have battery issues’ [ICU Charge RN] states ‘yes’.[sic] * Crew with assistance from ICU RN and ER RN transfer the pt to the ambulance. I used our second seat belt extension to secure the last chest strap and I used a gait belt to secure a pillow to the side of the stretcher so pt could rest [their] right arm. I tie down the balloon pump to the handles of the driver side rear door using IV tourniquets. Machine appears stable and not to move. IV pumps plugged into power in the ambulance. Pt is transported critical code 3 [lights and sirens on]. I do my intraaortic balloon pump flowsheet every 15 mins as instructed and provide the pt with a total of 4mg of Morphine during transport to get the pt pain from a 11/10 to a 7/10. Pt states thank you and manages to get some sleep during transport. * Reviewing pt paperwork I notice that it states on page 44 ‘Reach system refused transfer because they cannot handle a higher level of care and were seeking other transport. Transfer centre at BH is working diligently on this’.[sic] I was under the impression that REACH could not fly due to weather but was not sure of the full story behind this. *Just before Elkton I notice that battery one of two has only what looks to me at 10-15% left. At this point I am truly disappointed. I look for close hospitals and I also attempted to calculate. We were driving for 1hr 10mins and according to my apple map I only had 54 mins to Riverbend. I was looking through the documentation they gave me to look for battery information and was looking online how long a battery should last and any information about the balloon when I got reception on my phone. The picture to me looks like it has the two batteries on the left and a third looking battery on the right that was 100% green. I wasn’t sure if the two batteries filled the third column and the third column was a reserve. I advised my partner that we are down to one battery and made a comment ‘so much for the promise’ and continued to Riverbend. I closely monitored the battery and the last battery is down to what looks like less than 1/3 and is now yellow and the machine is beeping and flashing ‘Low battery’ 14 minutes out from Riverbend. I call Riverbend Hospital and advise of my issue at 7:43 pm. I advised of the pt, room number and that we are coming in code 3 and the balloon pump is advising Low battery, is yellow and beeping. They advised they will have someone meet us at the ER. I advise [EMT/driver] at this point the machine is beeping due to the critical low battery and staff are going to meet us at Riverbend. * I began to prepare the pt to be ready as possible to be taken out of the ambulance. I transferred the pt oxygen to the portable oxygen and as I was pulling the IV pump power plug out from the near rear end of the ambulance I noticed I was at the front with [EMT/driver] with my head resting on the drink holders. I look up at [EMT/driver] and ask what happened? [EMT/driver] is distressed and tells me we had an accident. I look and see my partner is wearing a seatbelt, no airbag deployment and windshield cracked. I don’t see any obvious traumatic bleeding from [EMT/driver], [EMT/driver] is conscious, moving all limbs and has a patent airway. [EMT/driver] states I am going to Call [BCA Paramedic Supervisor], I say ok and I ask are you okay? [They state] yes but I have lower back pain but I am ok. As [EMT/driver] proceeds to Call [BCA Paramedic Supervisor] I get up as quick as I can and check the pt. Pt is still on the stretcher and the pt states “what happened?” I said we have been involved in an accident. I asked the pt are you okay? [Patient 1] states yes but [their] chest pain is 11/10. Our cardiac monitor, a lot of equipment including the balloon pump is on the floor and making strange loud fan sound. The balloon pump is still attached to the door but is now laying face down. I quickly pick up the balloon pump. Pt states something is wrong. I look at the balloon pump and there is no longer any pressure visible for the pump (Blue line) I urgently look for the tubing and trace it down, it is not attached to the pt right leg. The tubing attached to the pt right leg is still present. I connect both, hit start on the machine and it shuts off. I look at my pt, [Patient 1] is not responsive and has no palpable pulse. I begin CPR [cardiopulmonary resuscitation] and call 911 via speaker at 7:54pm. I request an ambulance code 3 due to accident and starting CPR. 911 operator tells me yes. I ask do you need any other information. She says no I have multiple calls on the incident and I say okay and hang up. * At some point I quickly pick up the monitor and the back doors open. I see [EMT/driver] and [Mid Valley Ambulance staff] from Mid-valley. I ask [EMT/driver] please check out the other pt from the car accident. I asked [Mid Valley Ambulance staff] where is your ambulance. [They] said it was parked in the front of ours and [they are] here for us. I gratefully said thanks, please help me get my pt out. I saw Springfield Fire approach us and I grabbed their attention to help get the pt out. I called Riverbend ED at 7:57 pm advising of the update that there is CPR in progress and we are coming in with a different ambulance code 3 and that we have been involved in a MVC [motor vehicle collision] and the balloon pump is not working. [EMT/driver] approached me and quickly advised the other pt is okay and does not want [their] help. I advised [EMT/driver] to stay at the scene with Springfield Fire and PD. I approach an ambulance with doors wide open parked in front of ours, I ask to pull the other stretcher out and we placed ours in. The person inside said what will we do with the stretcher. One of the Fire Paramedics said we will deal with it later. We got the pt in, I looked at the monitored and saw the pt is in v-fib. I checked, no pulse and told everyone to clear and defibrillated the pt. I asked the Fire Paramedic to continue CPR, another Fire [staff] approached the doors, I told [them] I have two Fire with me I am good to go. [They] offered the Lucas [Lund University Cardiopulmonary Assist System] and brought in the side door. Doors closed and transported code 3. I pointed to the BVM [bag-valve-mask] and asked one of the Fire Paramedic to start breathing for the pt and the other loaded the Lucas and the Lucas was started. At this point 2 mins had passed and pulse and rhythm check done pt is in asystole, no pulse. I found the 1mg of Epi [Epinephrine-adrenaline] and gave to the pt in the RAC. Continued CPR. Second Rhythm PEA [pulseless electrical activity], idioventricular I got a second Epi 1mg and administered. Continued CPR. Upon arrival another pulse check, Fire Paramedic states we have a weak pulse. I gave hand over report to ER team and physician. Pt was connected within minutes to another balloon pump in the ER and I was advised the pt is stabilizing and is being sent to x-ray. * At this point I asked Springfield Fire where the mid-valley driver was and they said they were at the scene. I then asked what ambulance did I get into?, they said Springfield Fire Medic 6. I apologized [sic] and said I thought I was in our Mid-Valley Ambulance and profusely thanked the crew. They asked if I was okay, I advised I have a pretty bad headache. I found the pt paperwork and submitted to ER team. At this point an RN approached me and I was asked why I transported without a power cord? And why was this pt not flown. I told the RN that I was advised that REACH could not fly due to weather and the BAH ICU RN would not give me a power cord and was told that the machine will last 6-8 hours for each battery. RN advised this is not true about the batteries and [they] will be talking to [their] supervisor. I collected my equipment, pumps and balloon pump. At this point [EMT/driver] arrived with the Mid-Valley Crew with back pain. Mid-Valley Crew advised that there are no other pt coming from the scene and refusals are being completed. [Mid Valley Ambulance staff] from Mid-Valley states she has called the supervisors and provided updates. I checked on my partner and [they] advised [they have] back pain and presents distraught. I advised [EMT/driver] we will take great care of [them] and I asked if there was anything I can do to help [them]. I was also encouraged to seek care and was diagnosed with mild closed head injury and bruising and discharged. I waited with [EMT/driver] in [their] room while communicating with Mid-Valley, [BCA Paramedic Supervisor] and [BCA GM]. [EMT/driver] x-ray came back clear, [they were] given Toradol for pain management and [they were] discharged. * At some point RN advised the pt had been declared deceased. Supervisors updated. Mid-Valley collected all our equipment and personal [sic] and transported both of us back to Coos Bay.” 46.a. An email dated 04/02/2026 at 1010 from the SA to CQO requesting information on if the BAH primary ICU RN was interviewed for the hospitals investigation was sent. No response was received. 46.b. An additional email dated 04/27/2026 at 1700 from the SA to CQO was sent requesting information regarding whether the BAH primary ICU RN had been interviewed and if there were any other BAH ICU RNs involved with the hand-off to the BCA EMS staff, such as the BAH ICU Charge RN, interviewed as part of the hospital’s internal investigation. The SA also requested clarification on the IABP training and competencies ICU nurses received prior to and after the 01/06/2026 incident and how often training/competencies are done (annually/upon hire). 46.c. An email from the CQO to the SA dated 04/29/2026 at 1134 reflected “I received your email and am looking into your questions. I anticipate having a response to you by EOB Friday.” 46.d. The last email received from the CQO to the SA dated 05/06/2026 at 1930 reflected “Following up on your request, I am waiting to get some time with the ICU manager this Friday. I will send you an update after I meet with [them]. I just didn’t want you to think I had forgotten your request.” As of 05/18/2026 there has been no other responses.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40575 Based on interviews, review of incident and medical record documentation for 1 of 1 patients who were reviewed for incidents (Patient 1), review of internal investigation and corrective action documentation, and review of P&Ps it was determined that the hospital failed to ensure each patient’s right to be free from all forms of neglect. Prevention of, identification of, investigation of, and response to this incident, an incident for Patient 1 that resulted in actual significant patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. The hospital failed to ensure the hospital’s internal investigation thoroughly evaluated all investigation findings and identified all relevant deficient practices and gaps, failed to ensure the hospital developed and impletmented a thorough and complete action plan that addressed all deficient practices and gaps in a timely manner to prevent recurrence for other patients. The CMS Interpretive Guidelines for this requirement at CFR 482.13(c)(3) reflects “Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” Further, the CMS Interpretive Guidelines reflect those components necessary for effective abuse protection include, but are not limited to: o Prevent. o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. Findings include: 1. Refer to incident investigation findings 31-46 cited at Tag A-144 under CFR 482.13(c)(2), Patient Rights: Care in Safe Setting. Those findings reflect the hospitals failure to ensure the investigation of and development and implemetation of a correction action plan, in response to an incident involving Patient 1 that resulted in actual harm to Patient 1 was clear, complete and accurate to ensure those incidents and events did not recur for other patients.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 40575 Based on interviews and review of medical record documentation for 5 of 5 patients whose records were reviewed for aspects of care and services (Patients 1, 2, 3, 4 and 5) it was determined the hospital failed to ensure that medical record documentation was clear, complete, and accurately described all aspects of the patient’s transfers. Failures included: * Failure to ensure Patient 1’s medical record reflected accurately and completely the hand-off for transport from the BAH ICU staff to the BCA EMS staff. * Patient transfer form documentation for Patients 1, 2, 3, 4 and 5 was not complete. Findings include: 1. For Patient 1 refer to the findings under Tag A-144 that reflected the medical record did not include accurate information in the hand-off for Patient 1 from the BAH ICU to the BCA EMS staff. 2. Four other medical records were reviewed for patients that transferred from the IMCU at BAH to other hospitals using ground and air transport. The four patients were in stable condition and transferred using ground and air transport. Patient 2 transferred from IMCU at BAH to SHRB for neurosurgery/epidural abscess with spinal cord compression by air ambulance on 11/14/2025 in stable condition. * The “Date of transfer” section reflected “11/14.” * The “Interfacility Transfer” form lacked the date/time the receiving facility was notified of transfer request. * The “Person at the receiving facility confirming adequate staff/facilities, and authorized to accept transfer” section was blank. * The “BAH personnel confirming the above contact” section was blank. The “Skill level of transport team” requested was not checked. * The “Transport company name” was blank. The “Transfer co. arrived at” was blank. * The “Patient record copied and sent with patient by” section was blank. * The “If additional records needed, contact (phone #)” section was blank. * The “Provider Certification” was signed and dated but the “Time” section was blank. 3. Patient 3 transferred from IMCU at BAH to SHRB for a CABG (coronary artery bypass graft - open heart surgery) by air ambulance on 12/02/2025 at 1045 in stable condition. * The “Interfacility Transfer” form lacked the skill level of transport team requested and the dates were conflicting. * The MD certification and patient signature were dated 12/01/2025 at 2:10 pm and the receiving provider date/time notified reflected “12/2/25 10am.” 4. Patient 4 transferred from IMCU at BAH to McKenzie Willamette Medical Center for a CABG by ground ambulance (Bay Cities Ambulance) with an EMT on 12/09/2025 at 1420 in stable condition. * The “Interfacility Transfer” form lacked patient specific risks of transfer. The “Individualized risks of transport” reflected “MVA.” 5. Patient 5 transferred from IMCU at BAH to SHRB for a CABG by ground ambulance (Bay Cities Ambulance) with a paramedic on 12/24/2025 at 1510 in stable condition. * The “Interfacility Transfer” form lacked patient specific risks and benefits of transfer. The “Individualized benefits” section reflected “Higher level of care” and the “Individualized risks of transport” section reflected “Low Risk, Patient is stable.””