Landmark Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46539 Based on clinical record reviews, hospital policy reviews, and staff interviews, the facility failed to ensure accurate patient identification and registration within the Electronic Health Record (EHR) system. As a result, clinical documentation, laboratory results, and medication orders belonging to one patient were entered into the legal medical record of another patient and subsequently made accessible through the incorrect patient portal account. This deficient practice resulted in the unauthorized disclosure of protected health information (PHI) to an unrelated individual and failed to ensure the confidentiality of patient medical records, in violation of the patient’s right to personal privacy and confidentiality under 42 CFR §482.13(c)(1) (Tag A-0147).”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 46539 Based on clinical record review, hospital policy review, and staff interviews, the facility failed to ensure the accurate identification and registration of patients within the Electronic Health Record (EHR) system for 2 of 2 sampled patients (Patient IDs #1 and #2). Specifically, facility staff registered Patient ID #2 using the existing medical record of Patient ID #1, an unrelated individual with a similar name and the same date of birth. As a result, Patient ID #2’s clinical documentation, laboratory results, medication orders, insurance authorization information, and other protected health information (PHI) were entered into the legal medical record of Patient ID #1 and made available through Patient ID #1’s patient portal. In addition, after the registration error was identified, clinical information was transferred between medical records without evidence the facility followed its policy governing amendments to medical records. This deficient practice resulted in the unauthorized disclosure of PHI to an unrelated individual and failed to ensure the confidentiality, integrity, and accuracy of the medical records for Patient IDs #1 and #2. Findings are as follows: Review of the facility policy, “Patient’s Rights & Responsibilities,” revised June 2024, stated patients have the right to have medical records accessed only by individuals with a legitimate business purpose and to expect communications and records related to their care to be treated as confidential. Review of the facility policy, “Medical Records - Patient Request to Amend Medical Records,” revised January 2024, established a formal process for reviewing, approving, tracking, and implementing amendments to protected health information and required oversight by the designated Amendment Official. Record review revealed Patient ID #2 presented to the Emergency Department in December 2025 with stroke-like symptoms. During registration, staff selected the existing medical record belonging to Patient ID #1. Although the patients shared the same first name and date of birth and had similar last names, they were different individuals with different addresses. As a result of the registration error, Patient ID #2 was assigned Patient ID #1’s medical record number, and Patient ID #2’s Emergency Department and inpatient clinical information was documented in Patient ID #1’s legal medical record. Review of the Registration History for the encounter revealed that on 12/18/2025 the EHR generated the following warning: “Warning - There is a mismatch between the Guarantor last name and the last name of the Associated Patient for Guarantor: [Patient ID #1]. Verify that the Associated Patient is the correct patient record of the guarantor and update the necessary information.” During a telephone interview on 5/27/2026 at approximately 2:30 PM, Patient ID #1 stated he/she received automated notifications indicating new information had been added to the patient portal. Upon accessing the portal, Patient ID #1 viewed clinical information related to Patient ID #2’s December 2025 hospitalization. Patient ID #1 stated he/she notified the hospital, after which the information was removed from the portal. Record review revealed that on 12/29/2025, approximately 11 days after the registration error occurred, Emergency Department and inpatient documentation was transferred from Patient ID #1’s medical record into a separate medical record created for Patient ID #2. Further review revealed multiple documents associated with Patient ID #2 remained identified under Patient ID #1’s name. Review also revealed that prior authorization requests for services provided to Patient ID #2 were submitted using Patient ID #1’s insurance information. During an interview on 5/27/2026 at 11:50 AM, Employee A (Risk Manager) stated she was unaware that Patient ID #1 had obtained access to Patient ID #2’s clinical information through the patient portal. She confirmed the event had not been entered into the facility’s incident reporting system and no formal review of the medical record amendment process had been conducted. During an interview on 5/28/2026 at 9:21 AM, Employee B (Manager of Patient Access) acknowledged the December 2025 admission and registration were completed under Patient ID #1’s record rather than Patient ID #2’s record. She further acknowledged that multiple documents remained identified under Patient ID #1’s name and that prior authorization requests were submitted using Patient ID #1’s insurance information. During an interview on 5/28/2026 at approximately 12:15 PM, the Chief Nursing Officer and Risk Manager confirmed the admission and registration process was completed under the wrong patient record. They further confirmed facility leadership had not been notified of the medical record transfer that occurred on 12/29/2025 and acknowledged the transfer of information between records was not completed in accordance with the facility’s policy governing medical record amendments. They also acknowledged the facility could not ensure the confidentiality of Patient ID #2’s PHI because Patient ID #1 had been provided electronic access to Patient ID #2’s clinical information through the patient portal.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43881 46539 Based on review of hospital policies, clinical records, recorded surveillance video, and staff interviews, the hospital failed to ensure that the use of manual holds, and violent restraints was implemented in accordance with the order of a physician or other licensed independent practitioner responsible for the care of the patient. Specifically, the hospital failed to ensure physician orders were obtained for manual holds, physical restraint during forced medication administration, physical escort techniques, and continuation of restraint interventions for 3 of 5 patients reviewed for violent restraints in the Emergency Department (Patient IDs #1, #2, and #3). Findings are as follows: Review of the hospital policy titled, “Restraints: Violent Behavior or Seclusion,” last revised 6/2025, stated in part: “...Violent restraints are an emergency measure for those occasions when violent or self-destructive behaviors place the patient or others in imminent danger...” “Physical Restraint - A manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely by holding a patient with hands, arms, or body...” “Physical Restraint for Forced Medications - The application of force to physically hold a patient in order to administer a medication against the patient’s wishes...” “Physical Escort - A manual method of escorting a patient who is not voluntarily moving to a desired location...” The policy further stated: “...the use of restraint or seclusion is...in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient...” The policy additionally stated: “...when a patient is released from 4-point restraints, all limbs come out of restraints at the same time...” 1. Review of a complaint submitted to the Rhode Island Department of Health on 5/4/2026 alleged concerns related to the care of Patient ID #1 during an Emergency Department visit in April 2026, including allegations involving physical restraint. Clinical record review showed Patient ID #1 presented to the Emergency Department in April 2026 for alcohol intoxication. Nursing documentation dated 4/12/2026 at approximately 5:07 AM indicated the patient was arguing, yelling, and mocking staff. Review of recorded surveillance video dated 4/12/2026 showed that at approximately 4:55 AM, Patient ID #1 was pushed into the patient room by a police officer. Security Officer, Employee A, and Lead Security Officer, Employee B, were observed grabbing the patient’s arms and forcing the patient onto the bed. Employee A was observed holding the patient’s right arm while positioning the other hand over the patient’s head area; exact placement was unclear due to the patient’s hair obscuring visualization. Employee B was observed holding the patient’s left arm against the bed. Both arms were subsequently forced behind the patient’s back while a police officer straddled the patient’s lower extremities and applied handcuffs behind the patient’s back. At approximately 5:04 AM, following administration of injectable medications, the handcuffs were removed and the patient was placed in seclusion. Clinical record review confirmed a physician order for seclusion was obtained; however, the record lacked evidence of a physician order authorizing the manual holds utilized by Employees A and B. 2. Clinical record review showed Patient ID #2 presented to the Emergency Department in March 2026 for psychiatric evaluation. Review of recorded surveillance video dated 3/17/2026 showed that at approximately 6:52 PM, Security Officer, Employee C and Security Officer, Employee D utilized a two-person physical escort to return the patient to bed. Further video review showed that at approximately 8:00 PM, Security Officer E held the patient’s thighs while Registered Nurse Employee F administered injectable medication into the patient’s thighs. At approximately 8:35 PM, Employees C and E were observed in the patient room with RN Employee F while staff attempted to awaken the patient. Following verbal interaction, the patient’s behavior escalated. Employees C and E were then observed grabbing and holding the patient back onto the bed. One employee restrained one arm while the second employee restrained the opposite arm and both lower extremities, immobilizing the patient. Additional Security Officers entered the room, and the patient was subsequently placed into 4-point violent restraints involving both wrists and lower extremities. Clinical record review showed the physician order authorized 4-point violent restraints involving both wrists and both lower extremities. However, the record lacked physician orders authorizing the two-person physical escort, the manual hold utilized during forced medication administration, and the manual hold involving immobilization of all four extremities prior to application of 4-point restraints. During interview on 5/11/2026 at approximately 10:00 AM, the Director Security, Employee H, and the Director of Performance Improvement, Employee J, acknowledged the surveyor’s observations related to Patient IDs #1 and #2. Employee J was unable to provide documentation demonstrating the manual holds performed by Security Officers were conducted pursuant to physician orders. 3. Clinical record review showed Patient ID #3 presented to the Emergency Department in December 2025. Documentation dated 12/15/2025 showed the patient was placed in 4-point violent restraints. Further record review showed two restraint points were subsequently removed while the patient remained restrained at two extremities. Clinical record review showed the physician order authorized restraint of both wrists and both lower extremities; however, the record lacked evidence of a separate physician order authorizing continuation of 2-point violent restraints following discontinuation of the 4-point restraint intervention. During interview on 5/11/2026 at approximately 2:00 PM, the Director of the Emergency Department, Employee I, stated nursing staff are required to obtain a physician order each time any form of physical restraint is utilized. Employee I further acknowledged hospital policy requires all restraint points to be removed simultaneously upon discontinuation of 4-point restraints. Employee I stated that if continued restraint of two extremities is required, a separate physician order for 2-point restraints must be obtained.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 32374 Based on review of hospital policy, medical record review, and staff interviews, the hospital failed to ensure that nursing personnel adhered to standards of nursing practice related to wound care treatment, without documented practitioner orders (Tag A-0405), and failed to ensure nursing staff implemented wound care monitoring and documentation consistent with hospital policy and the patient’s plan of care (Tag A-0395), for 2 of 5 patients reviewed for wound care (Patient ID #11 and #12).”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 32374 Based on record review, surveyor observation, and staff interviews, it was determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice and hospital policy related to skin assessments, documentation, wound care, and physicians ’ orders for 2 of 5 patients reviewed for wound care (Patient ID #11 and #12). Findings are as follows: Review of the hospital policy titled, “Pressure Ulcer/Skin Integrity/Mucosal Injury,” states in part: “Policy ... Skin Assessment and Monitoring of Wounds ... B. Pressure ulcers require a wound consult; staging is deferred to wound care nurses and physicians/licensed independent practitioners [LIP]... D. Skin Integrity ... The patient ’ s skin integrity from head to toe is assessed upon admission, each shift, and at discharge ... Wound Assessments and Follow-Up/Tracking Assessments ... A. Initial assessments are conducted within 24 hours of admission ... B. A lines, drains, and airway (LDA) form is initiated upon discovery for documentation ... C. Detailed assessments are completed upon discovery of any new wound ... Documentation ... B. Dressing Changes ...” 1. Patient ID #12 Record review revealed Patient ID #12 was admitted on 2/2/2026 with complaints of fever and altered mental status. Upon admission, a sacral pressure wound was identified. A physician ’ s order for a wound consultation was requested on 2/2/2026, and the consultation was completed on 2/3/2026. Review of the Wound Nurse’s documentation dated 2/3/2026 indicated assessment of the sacral ulcer as follows: “Unstageable pressure ulcer (characterized by full-thickness tissue loss covered by necrotic tissue or eschar, preventing determination of depth and stage), sacrum, 3 x 3 x 1 cm, 75% brown eschar in wound bed...” Wound care recommendations were documented in the Provider Orders section of the medical record as follows: “Sacrum unstageable pressure ulcer - wash with wound wash, apply Santyl to wound bed, pack loosely with gauze, cover with bordered foam daily ...” On 2/6/2026, a second wound consult was requested and completed on 2/9/2026 (three days after the request) for: Right ankle DTI (deep tissue injury) Right heel DTI Left heel DTI Left lower leg laceration Review of Wound Nurse documentation dated 2/9/2026 revealed: Right ankle DTI measuring 2 x 3 x 0 cm Right heel DTI measuring 0.6 x 0.6 x 0 cm Left heel DTI measuring 1 x 1 x 0 cm Left lower leg laceration measuring 2 x 0.5 x 0 cm The following recommendations were documented in the Provider Orders section: “DTIs right ankle, right heel, left heel - apply skin prep, cover with foam dressing daily. Keep Medline offloading boots on at all times while in bed.” Record review failed to reveal evidence of a treatment order or recommendation for the left lower leg laceration. The medical record also failed to reveal evidence that treatment was provided for the left lower leg laceration. During a surveyor interview on 2/11/2026 at 11:24 AM, the Wound Nurse acknowledged that Patient ID #12 had a laceration on the left lower leg since 2/6/2026, with no documented evidence of treatment. Additionally, the medical record revealed provider orders to “cleanse the wound with wound cleanser, apply Santyl to the base of the wound, pack loosely with gauze, and cover with bordered foam daily.” During surveyor observation and interview with the Wound Nurse on 2/11/2026 at 11:47 AM, the Nurse was observed using “Skintegrity” wound cleanser. Review of the manufacturer’s Santyl compatibility chart indicates that an inhibition level of 20% or less is considered acceptable for enzymatic activity when used with topical adjunctive therapies. Inhibition levels exceeding 20% may affect Santyl enzyme activity and efficacy. Further review of the chart revealed that Skintegrity is not deemed compatible with Santyl due to an inhibition level of 70%. During a surveyor interview on 2/11/2026 at 1:34 PM, the Wound Nurse and the Wound Care Director stated they were unaware that Skintegrity wound cleanser is not compatible with Santyl. 2. Patient ID #11 Record review revealed that Patient ID #11, a 66-year-old female, presented to the emergency department from a skilled nursing facility on 2/8/2026. Upon admission on 2/8/2026, a wound consultation was requested for a sacral pressure area. The consultation was completed on 2/9/2026. The Wound Nurse documented the following recommendation in the Provider Orders section of the medical record for treatment of a Stage 3 sacral pressure wound: “Apply zinc oxide and cover with bordered foam daily.” The record failed to reveal evidence that this order was authenticated by a Licensed Provider. Additionally, review of wound documentation dated 2/10/2026 and 2/11/2026 failed to reveal documentation of wound description or evidence of treatment provided. During a surveyor interview on 2/11/2026, the Nurse Manager (Staff G) was unable to provide evidence that wound treatments were completed and appropriately documented, including wound description and condition. The Nurse Manager stated that on the worksheet, the Nurse checked “dressing change” as “completed” but did not document a wound description or the treatment provided.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 32374 Based on record review and staff interview, it was determined that the hospital failed to ensure that all provider orders for medications and treatments were ordered by a physician or other Licensed Independent Practitioner (LIP) in accordance with State law, including scope of practice laws, and hospital policy related to wound care treatments for 2 of 4 patients reviewed (Patient ID #11 and #12). Findings are as follows: 1. Patient ID #11 Review of the record for Patient ID #11 revealed the patient was admitted to the hospital on 2/8/2026 from a skilled nursing facility. The patient had an order for a wound consultation. The patient was evaluated by the hospital ’ s Wound Care Nurse (Staff H) on 2/9/2026. Staff H, who is not a Licensed Independent Provider, documented that the patient had a “sacrum chronic full-thickness Stage 3 pressure ulcer” and entered treatment orders in the Provider Orders section of the medical record. The medical record failed to contain a written, signed order by a physician or other Licensed Independent Provider for the wound care treatment. 2. Patient ID #12 Record review revealed Patient ID #12 was admitted on 2/2/2026 with an elevated temperature and altered mental status. During hospitalization, the patient was noted to have pressure wounds. A provider ’ s order for a wound consultation was written on 2/2/2026, and the consultation was completed on 2/3/2026 by Staff H. Review of the Wound Care Nurse (Staff H) documentation dated 2/3/2026 indicated assessment of the sacral ulcer was completed, and wound care instructions were entered into the Provider Orders section of the medical record by Staff H, who is not a Licensed Independent Provider. The medical record failed to contain a written order by a physician or other Licensed Independent Provider for the wound care treatment. Further review of the medical record revealed an additional physician order for a wound consultation related to a new deep tissue injury (DTI) to the right ankle, submitted on 2/6/2026. The consultation was completed on 2/9/2026 (3 days after the intitial request). Review of documentation dated 2/9/2026 by Wound Care Nurse (Staff H), who is not a Licensed Independent Provider, revealed additional wound care recommendations were entered into the Provider Orders section of the medical record. The medical record failed to contain a written, signed order by a physician or other Licensed Independent Provider for the wound care treatment. During a surveyor interview on 2/11/2026 at 10:15 AM, Wound Care Nurse Staff H acknowledged that she completes the wound consultation and enters her wound care recommendations in the Provider Orders section for the physician to subsequently co-sign. During a surveyor interview on 2/11/2026 at 3:40 PM, the Risk Manager and Chief Nursing Officer stated they were unaware that the Wound Care Nurse was entering wound treatment orders in the Provider Orders section of the medical record. Both acknowledged that the Wound Care Nurse should document recommendations in the clinical notes, and that physicians or other Licensed Independent Providers are responsible for reviewing and entering the treatment orders.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to ensure that nursing personnel configured adequate volume settings on Patient ID #1’s bedside telemetry monitor, preventing the staff from being alerted to the patient’s lethal arrhythmia (irregular heartbeat) (A-0395); and failed to ensure that nursing personnel adhered to hospital policies related to the documentation and nursing care of a patient requiring continuous telemetry monitoring, (A-0398). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients. The hospital’s Director of Practice Improvement and Risk Manager were informed of the Immediate Jeopardy, which was identified on 6/5/2025 and were provided with the Immediate Jeopardy template at approximately 2:00 PM on this date. On 6/5/2025, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: - Biomedical Engineering reviewed each bedside monitor to ensure the audible alarms are at the factory setting. This is discussed at the ED safety Huddle at 7 AM, 3 PM and 7 PM. - The ED nurses will be educated on the telemetry policy via a “Did You Know” and sign-off on said education beginning June 5, 2025 with the completion date Monday June 9, 2025. - All ED staff working on June 6, 7, 8 & 9 will be re-educated to the policy. - All staff not working, on vacation or on an LOA will be re-educated prior to the start of their first shift back. Compliance will be monitored by the Quality Department. On 6/10/2025, it was confirmed by the State Surveyors during multiple observations in the emergency department that bedside telemetry monitors along with the central station telemetry monitors at the nurses’ station had audible alarms. Interviews conducted with staff on duty in the emergency department confirmed that staff received and reviewed the hospital’s telemetry policy. As of 6/10/2025, the IJ was removed.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet the Condition of Participation for Physical Environment, after the following was identified: - The hospital failed to maintain the emergency department’s monitoring equipment in a manner that ensures the safety and well-being of patients. Biomedical Engineering staff did not identify improperly connected cables, leading to the loss of audible alarms at the central telemetry station in the emergency department at the nurses’ station. This failure resulted in the inability to alert staff with an audible alarm when Patient ID #1 experienced a lethal arrhythmia (irregular heartbeat), (Refer to A-0701). Findings are as follows: As a result of the identified non-compliance, Patient ID #1 experienced Asystole (a severe form of cardiac arrest that requires immediate medical attention) unrecognized by staff at 6:38 AM on 5/27/2025 who did not enter the room until 7:14 AM and found the patient pulseless and cyanotic (blue). 45769”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet the requirements of §482.55 Condition of Participation: Emergency Services, related to the central telemetry monitoring system which failed to alert staff with an audible alarm that would have alerted them to a patient experiencing a lethal arrhythmia (irregular heartbeat). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients. As a result of the identified non-compliance, Patient ID #1 experienced Asystole (a severe form of cardiac arrest that requires immediate medical attention) unrecognized by staff at 6:38 AM on 5/27/2025, who did not enter the room until 7:14 AM and found the patient pulseless and cyanotic. (Refer to A-1103) The hospital’s Director of Practice Improvement and Risk Manager were informed of the Immediate Jeopardy, which was identified on 6/5/2025 and were provided with the Immediate Jeopardy template at approximately 2:00 PM on this date. On 6/5/2025, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: - Biomedical Engineering has implemented color-coding, and labeling of all cables and ports to prevent cables being plugged into the incorrect connector. - The ED Charge nurse will print a sample telemetry strip at 7:00 AM and 7:00 PM to validate the central monitor is working, effective June 6, 2025. - The house supervisor will ensure it is conducted. This data will be monitored by the Quality Department. - The Hospital’s telemetry policy will be reviewed by nursing management to standardize the process house wide. On 6/10/2025, it was confirmed by the State Surveyors, during multiple observations in the emergency department that bedside telemetry monitors along with the central station telemetry monitors at the nurses’ station had audible alarms. Additionally, that all cables in the server closet were color coded, labeled and secured, sample telemetry rhythm strips were printed to validate that the central monitor was working, and interviews with staff on duty in the emergency department confirmed that staff received and reviewed the hospital’s telemetry policy. As of 6/10/2025, the IJ was removed. 45769”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to ensure that nursing personnel configured adequate volume settings on a patient’s bedside telemetry monitor, preventing the staff from being alerted to the patient’s lethal arrhythmia (irregular heartbeat), for 1 of 4 patients reviewed who were on continuous cardiac monitoring and awaiting transfer from the emergency department (ED) to the Progressive Care Unit, (Patient ID #1). Findings are as follows: Review of the patient’s medical record revealed that the patient arrived at the ED by rescue on 5/26/2025 at 6:37 PM. According to the record, based on the patient’s bloodwork, chest x-ray, and electrocardiogram results, it was determined that the patient would be admitted to the inpatient Progressive Care Unit with a diagnosis of a Non-ST Segment Myocardial Infarction (heart attack) and congestive heart failure. Review of a Significant Event Note dated 5/27/2025 by Employee H, Internal Medicine Resident, revealed that at 7:15 AM, nursing staff found the patient unresponsive, cyanotic (blue) and pulseless and a Code Blue was initiated. At 8:11 AM, on 5/27/2025, the patient was pronounced dead. During a surveyor interview on 6/5/2025 at 12:00 PM with Employee C, Registered Nurse (RN), she indicated that she came in for her shift the morning of 5/27/2025 and received report at the nurses’ station. She explained that after morning huddle, she “looked up at the monitor and saw that the patient’s heart beat was 20” but did not remember hearing the monitor alarm, nor if the monitor was flashing red. She stated that she then entered the patient’s room, she saw the patient lying on the stretcher with his/her head “in between the railing” and the patient’s face was blue. She stated that she then hit the code button and started compressions. She indicated that upon entering the patient’s room, she did not pay attention to the bedside monitor and indicated that she did not know if the bedside monitor was alarming. She revealed that Employee E, another nurse, went back to central station to see when things changed for the patient and determined that at 6:38 AM, the patient “went asystolic (a cardiac rhythm characterized by the complete absence of electrical activity in the heart, resulting in a flatline on an electrocardiogram constituting a severe form of cardiac arrest that requires immediate medical attention)” but they were unable to print the telemetry strip that showed this. During a surveyor interview on 6/9/2025 at 9:56 AM with Employee D, RN, she indicated that she was the Charge Nurse for the day shift on 5/27/2025. She explained that when she sat down at the nurses’ station, she looked up at the central station telemetry monitors and noticed a rhythm that looked like asystole, but stated that it did not feel real since there was no alarm. She then looked at Employee C, RN, asked her what she had received in report for this patient and questioned whether the rhythm she was looking at was real. She stated that Employee C started to walk down to the room, and then they all took off running into the patient’s room. She stated that when she ran into the room, the patient was “blue-gray” and “halfway off the stretcher, as if trying to get off it”. She then picked up the patient’s legs, placed them onto the bed, and cardiopulmonary resuscitation (a life-saving technique used when someone’s heart stops beating) was started. She revealed that another nurse checked central station and “saw that at 6:38 AM, the patient went asystolic.” When asked if she heard the bedside monitor alarming when she entered the patient’s room, she stated, “everything was silent” but when she looked at the rhythm on the bedside monitor, it was the same one she saw at central station. During a surveyor interview on 6/4/2025 at 1:05 PM with the Director of Practice Improvement, she stated that they did not find out the alarm to central station was down until after the event occurred. She explained that the monitors at central station in the emergency department had visual alarms, but no audible alarms, and further explained that the bedside monitor had both audio and visual alarms. She revealed that a team of staff, including the Biomedical Manager, checked the patient’s bedside monitor, increased its volume as it was identified that the volume was low, and then increased the volume on all bedside monitors.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to ensure that nursing personnel adhered to hospital policies related to the documentation and nursing care of a patient requiring continuous telemetry monitoring, for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer to the Progressive Care Unit (PCU), (Patient ID #1). Following this event the hospital failed to reeducate the nursing staff on the hospital’s policy titled, “Continuous Electrocardiographic Monitoring; Telemetry”. Findings are as follows: The hospital’s policy titled, “Continuous Electrocardiographic Monitoring; Telemetry” last revised on 3/2024, states in part, “...Policy ...7. Rhythm strips are printed and posted in the patient’s medical record every 4 hours and with any rhythm change or significant arrhythmia. Analysis and documentation on the strip include: a. Patient specific label b. PR interval [the brief pause in your heart’s electrical activity that occurs between the contraction of the upper chambers (atria) and the lower chambers (ventricles)] if applicable c. QRS interval [represents the rapid contraction of the heart’s lower chambers, known as the ventricles] d. QT interval [measures the time it takes for your heart’s lower chambers (ventricles) to contract and then relax] e. Rhythm identification f. RN signature ...” Record review for Patient ID #1 revealed that an admission order was entered into the record at 9:20 PM on 5/26/2025 for further management and monitoring. However, the patient remained in the ED due to lack of an available bed in the Progressive Care Unit. The record failed to reveal evidence that a rhythm strip was printed and posted in the patient’s medical record every 4 hours and with any rhythm change or significant arrhythmia in accordance with the hospital’s policy. During a surveyor interview with the Nursing Director of the ED on 6/10/2025, she was unable to provide evidence that staff printed and posted rhythm strips for this patient in accordance with the hospital’s policy.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the hospital failed to maintain the emergency department’s monitoring equipment in a manner that ensures the safety and well-being of patients. Biomedical Engineering staff were unable to identify improperly connected cables, leading to the loss of audible alarms at the central telemetry station in the emergency department. This failure resulted in the inability to alert staff with an audible alarm when a patient experienced a lethal arrhythmia (irregular heartbeat), for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer from the emergency department (ED) to the Progressive Care Unit, (Patient ID #1). Findings are as follows: During a surveyor interview on 6/4/2025 at 11:02 AM with Employee F, Interim Biomedical Manager, he stated that on 5/27/2025 when he was informed by staff that central station in the emergency department was not alarming, he went to the server closet. He stated that while in the server closet, he pulled the computer from the server, which provides remote access to central station in the ED, and connected his external speaker identifying that he was unable to hear the alarm. He then went behind the server, checked all connections, ensured everything was plugged in, but did not check for correct cable placement. He then reset the server but was still unable to hear the alarm. He revealed that when the manufacturer representative came to the hospital on 5/28/2025, it was the representative who determined that the external speaker cable was connected into the microphone port instead of the external speaker port. During an additional surveyor interview with Employee F, on 6/9/2025 at 9:23 AM, and review of the Central Display Annual Maintenance work order for the emergency department, he confirmed that a vendor completed maintenance on the system on 3/21/2025. The vendor cleaned the unit and documented that it was functioning properly. Employee F indicated that he was unable to determine who entered the server closet and may have incorrectly connected the cable into the incorrect port, nor how long the cable was transposed. During a surveyor interview with the Director of Practice Improvement on 6/4/2025, she was unable to provide a report regarding the findings identified by the manufacturers representative who presented to the hospital on 5/28/2025. An outreach was attempted by the Survey investigation team to the manufacturer but went unanswered.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 43881 45769 Based on record review and staff interviews it was determined that the Hospital failed to ensure the emergency department’s (ED) central telemetry monitoring system was functioning properly after it failed to alert staff with an audible alarm that would have alerted them to a patient experiencing a lethal arrhythmia (irregular heartbeat), resulting in the failure of staff to respond timely to an emergent event and render appropriate emergency care since central station tele-monitors did not alarm as they should have when the patient experienced a severe cardiac arrythmia for 1 of 4 patients in the emergency department reviewed who were on continuous cardiac monitoring and awaiting transfer to the Progressive Care Unit, (Patient ID #1). Findings are as follows: Review of the patient’s medical record revealed the patient arrived at the ED by rescue on 5/26/2025 at 6:37 PM. According to the record, based on the patient’s blood work, chest x-ray, and electrocardiogram results, it was determined that the patient would be admitted to the inpatient Progressive Care Unit with a diagnosis of a non-ST segment myocardial infarction, (heart attack) and congestive heart failure. On 5/26/2025 at 9:21 PM, an inpatient bed was requested for further management and monitoring and the plan was discussed with patient. However, the patient remained in the ED due to the lack of an available bed in the Progressive Care Unit. Review of a Significant Event Note dated 5/27/2025 by the Internal Medicine Resident, Employee H, revealed that at 7:15 AM on 5/27/2025, the nursing staff found the patient unresponsive, cyanotic (blue) and pulseless; a Code Blue was initiated. At 8:11 AM, on 5/27/2025, the patient was pronounced dead. During a surveyor interview on 6/5/2025 at 12:00 PM with Employee C, Registered Nurse (RN), she explained that she came in for her shift the morning of 5/27/2025 and was assigned to Patient ID #1. After morning report was over, she looked up at the monitor and saw that Patient ID #1’s heart rate was 20, but did not remember hearing the monitor alarm sound nor if the monitor was flashing red. She stated that she then entered the patient’s room, she saw the patient lying on the stretcher with his/her head “in between the railing” and the patient’s face was blue. She stated that she then hit the code button and started compressions. She indicated that upon entering the patient’s room, she did not pay attention to the bedside monitor and indicated that she did not know if the bedside monitor was alarming. She revealed that Employee E, RN, went back to the central station to review Patient ID #1’s cardiac rhythm event history which identified that at 6:38 AM, the patient “went asystolic (a severe form of cardiac arrest that requires immediate medical attention)” but they were unable to print the telemetry rhythm strip that showed this. During a surveyor interview on 6/9/2025 at 9:56 AM with Employee D, RN, she explained that she was the Charge Nurse for the day shift on 5/27/2025. She stated that after the morning huddle, she sat down at the nurses’ station, looked up at the central station monitors and noticed a rhythm that looked like asystole, but stated that it did not feel real since there was no alarm. She then looked at Employee C, RN, and asked her what she had received in report for this patient, wondering whether the rhythm she was looking at was real. Both she and Employee C ran into the room, and Patient ID #1 was “blue gray” and “halfway off the stretcher, as if trying to get off it”. She then picked up the patient’s legs, placed them onto the bed, and cardiopulmonary resuscitation (a life-saving technique used when someone’s heart stops beating) was started. She indicated that one of the ED Attending Physicians, Employee K, and Employee E, RN, reviewed the telemetry monitor at central station and “saw that at 6:38 AM, the patient went asystolic.” When asked if she heard the bedside monitor alarming when she entered the room, she stated, “everything was silent” but when she looked at the rhythm on the bedside monitor, it was the same one she saw at central station. During a surveyor interview on 6/9/2025 at 10:25 AM with Employee E, RN, she stated that on 5/27/2025, she came in for her shift and clocked in at 6:32 AM. She indicated that after huddle, she looked up at the central station telemetry monitors and noticed that Patient ID #1 was asystolic. She indicated that she and other staff were questioning if the patient’s rhythm was real since the monitor was not alarming and when they went into the patient’s room, “he was found to be deceased.” When asked what she saw upon entering the patient’s room, she stated that the patient was lying on the stretcher, she/he was blue, and his/her head was against the railing. She indicated that she did not remember if the bedside telemetry monitor was alarming. She explained that she went to central station and noticed that Patient ID #1’s display was “frozen” and so she unplugged the mouse with the help of a nursing assistant and plugged it back in. When the monitor started working, she reviewed the event history and saw that at 6:38 AM, the patient went asystolic. She explained that she was unable to print the waveform because the option to print was not working. After identifying that the patient went asystolic at 6:38 AM, she revealed that she then went into the patient’s room and let the ED physician and the code team residents who were present, know. During a surveyor interview on 6/4/2025 at 1:05 PM with Employee J, the Emergency Department Medical Director, he stated that he was made aware that the patient had voided and shortly after was found unresponsive but was unable to indicate how long the patient had been unresponsive.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 45769 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet §482.22 Condition of Participation: Medical Staff after the following was identified: - The hospital failed to ensure that medical staff responsible for the quality of medical care provided to the patient was in accordance with the rules and regulations of the medical staff relative to discharging patients from the hospital (A-0353). - The hospital failed to ensure that the appropriate medical staff maintained their Basic Life Support training and their Advanced Cardiac Life Support training up to date (A-0353). The failure related to discharge resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment, or death to all patients. Findings are as follows: A CMS authorized Substantial Allegation Survey was conducted from 11/19/2024 through 11/27/2024, at Landmark Medical Center to determine compliance with the requirements of §482.22 Condition of Participation: Medical Staff following a community reported complaint that alleged a patient was discharged home in unstable condition without the appropriate follow appointments, no medical insurance, no plan for after care nor hospice or palliative care, which resulted in the patient being readmitted to another acute care hospital within fifteen hours. On 11/25/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under §482.22 Condition of Participation: Medical Staff , related to Patient ID #1 who was discharged home in unstable condition without an adequate discharge plan and appropriate and accurate follow up care. As a result of the identified non-compliance, Patient ID #1 was readmitted to another acute care hospital the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge with a diagnosis of decompensated liver failure after presenting by ambulance to the emergency room with shortness of breath, severe abdominal pain and continued diarrhea. In addition, the patient’s physical exam revealed that the patient’s abdomen was distended with ascites and a positive fluid wave, indicating the presence of free fluid, his/her skin was jaundiced, the whites of the eyes were yellow, and she/he had pitting edema of the lower extremities. The hospital’s Director of Practice Improvement was informed of the Immediate Jeopardy on 11/25/2024 and was provided with the Immediate Jeopardy templates at approximately 12:00 PM on this date. On 11/25/2024, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: - An updated list of community physicians and clinic residents with names and contact information will be emailed to the medical staff and residents and provided to the nursing units and case management on 11/26/2024 by 10:00 AM. - A memo will be sent on 11/26/2024 to Residents and medical staff that an order for a PT consult is required when there is a change in functional status and if a patient has a new oxygen requirement, an ambulatory trial will be ordered. - An attestation will be signed by residents, medical staff and registered nurses beginning 11/25/2024 at 4:30 PM and continuing until substantial compliance is met to address staff agreement and understanding of the above that in addition includes the requirement to follow the chain of command for any patient safety issues. - A conference will be held on 11/26/2024 for the residents to present the case in question and to review the following: - If decreased mobility, order a PT consult. - If new oxygen requirements, order an ambulatory trial. - Document patient goals of care. - Document hospice instructions. - When restarting blood pressure medications, conduct a trial. - Document family/patient discussions. - Document outpatient instructions for managing paracentesis. On 11/26/2024, interviews with staff on duty were conducted by the State Surveyors on the Labor and Delivery Unit, the Behavioral Health Unit, 1 East Medical Surgical Unit, the Progressive Care Unit, and the Intensive Care Unit to confirm staff agreement and understanding of the IPOC. The State surveyors verified that the updated list of community physicians and clinic residents was posted on the units that were toured. In addition, the State Surveyors attended the resident conference conducted on 11/26/2024 at 12:00 PM to confirm that the case was presented as outlined on the IPOC and signed attestations were reviewed to ensure that residents, attendings, and registered nurses received and understood the new requirements as stated on the IPOC. The hospital’s IPOC was verified as being fully implemented as of 11/27/2024 and the IJs were abated.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 45769 43881 Based on review of medical records, review of facility documents, and staff interviews, it was determined that the Hospital failed to meet §482.43 Condition of Participation: Discharge Planning after the following was identified: - The hospital failed to re-evaluate the patient’s change in condition and reflect these changes in the patient’s discharge plan relative to new oxygen requirements, deteriorating renal and mobility status, and increasing abdominal distention that required the removal of excess fluid in the abdomen multiple times (A-0802). - The hospital failed to ensure the patient’s discharge evaluation included a referral to an existing outpatient Gastroenterology service following discharge (A-0807). - The hospital failed to complete the patient’s initial discharge evaluation (A-0808). These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment, or death to all patients. Findings are as follows: A CMS authorized Substantial Allegation Survey was conducted from 11/19/2024 through 11/27/2024, at Landmark Medical Center to determine compliance with the requirements of §482.43 Condition of Participation: Discharge Planning following a community reported complaint that alleged a patient was discharged home in unstable condition without the appropriate follow appointments, no medical insurance, no plan for after care nor hospice or palliative care, which resulted in the patient being readmitted to another acute care hospital within fifteen hours. On 11/25/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under §482.43 Condition of Participation: Discharge Planning, related to Patient ID #1 who was discharged home in unstable condition without an adequate discharge plan and appropriate and accurate follow up care. As a result of the identified non-compliance, Patient ID #1 was readmitted to another acute care hospital the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge with a diagnosis of decompensated liver failure after presenting by ambulance to the emergency room with shortness of breath, severe abdominal pain and continued diarrhea. In addition, the patient’s physical exam revealed that the patient’s abdomen was distended with ascites and a positive fluid wave, indicating the presence of free fluid, his/her skin was jaundiced, the whites of the eyes were yellow, and she/he had pitting edema of the lower extremities. The hospital’s Director of Practice Improvement was informed of the Immediate Jeopardy on 11/25/2024 and was provided with two Immediate Jeopardy templates at approximately 12:00 PM on this date. On 11/25/2024, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: - An updated list of community physicians and clinic residents with names and contact information will be emailed to the medical staff and residents and provided to the nursing units and case management on 11/26/2024 by 10:00 AM. - A memo will be sent on 11/26/2024 to Residents and medical staff that an order for a PT consult is required when there is a change in functional status and if a patient has a new oxygen requirement, an ambulatory trial will be ordered. - An attestation will be signed by residents, medical staff and registered nurses beginning 11/25/2024 at 4:30 PM and continuing until substantial compliance is met to address staff agreement and understanding of the above that in addition includes the requirement to follow the chain of command for any patient safety issues. - A conference will be held on 11/26/2024 for the residents to present the case in question and to review the following: -If decreased mobility, order a PT consult. -If new oxygen requirements, order an ambulatory trial. -Document patient goals of care. -Document hospice instructions. -When restarting blood pressure medications, conduct a trial. -Document family/patient discussions. -Document outpatient instructions for managing paracentesis. On 11/26/2024, interviews with staff on duty were conducted by the State Surveyors on the Labor and Delivery Unit, the Behavioral Health Unit, 1 East Medical Surgical Unit, the Progressive Care Unit, and the Intensive Care Unit to confirm staff agreement and understanding of the IPOC. The State Surveyors verified that the updated list of community physicians and clinic residents was posted on the units that were toured. In addition, the State Surveyors attended the resident conference conducted on 11/26/2024 at 12:00 PM to confirm that the case was presented as outlined on the IPOC and signed attestations were reviewed to ensure that residents, attendings, and registered nurses received and understood the new requirements as stated on the IPOC. The hospital’s IPOC was verified as being fully implemented as of 11/27/2024 and the IJs were abated.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45769 Based on record review and staff interviews it was determined that the hospital failed to follow its policy for prompt resolution of a patient or family members grievance regarding an unsafe discharge for 1 of 6 patients reviewed for discharge planning, (Patient ID #1). Findings are as follows: Review of the hospital policy titled,” Complaint/Grievance Process” last reviewed 6/2023 states in part, “...Purpose...To describe the process for prompt resolution of a patient grievance... ...Grievance Process...The Grievance Committee will assure that the grievance is investigated. Investigation is to occur in a timely manner...” Review of a Patient Access Note dated 10/18/2024 at 11:45 AM by Staff L, Financial Counselor, revealed Patient ID #1’s Power of Attorney (POA), ID # 10, had contacted the department to provide the patient’s newly acquired Medicaid information to them. During her call she disclosed numerous complaints that she had about the patient’s care and the overall hospital experience. The POA was provided with the name of the Patient Experience Manager, Staff K. After the phone call, the documentation revealed that Staff L then notified the Patient Access Manager of the details in the phone call and sent an email to Staff K. Review of a hospital email sent on 10/18/2024 at 12:27 PM, indicated that Staff L sent the email to Staff K informing her of a phone call that she had with the patient’s POA. Staff K provided the name and contact number of the POA and stated that the POA had disclosed multiple complaints she had about the patient’s care and overall hospital experience. During a surveyor interview on 11/21/2024 at 2:12 PM with the Patient Experience Manager, Staff K, she confirmed that she did receive the email from Staff. She explained she spoke to the Patient Access Manager about the email she had received from Staff L last week and he informed her that Staff L was on vacation, and he did not have the details. Staff K confirmed that she never reached out to Staff L or the POA to inquire and investigate the POA’s concerns and stated that she was waiting for the patient and the POA to call her. During a surveyor interview on 11/19/2024 with Patient ID #1’s POA, ID # 10, she explained that she spoke with Staff L and voiced her complaints regarding the patient’s discharge and the way that she/he was sent home without a physical therapy evaluation. She stated that Staff L was going to send her information to Staff K and let her know about her concerns. ID #10 confirmed that she never received a call from anyone at the hospital about her concerns and complaints. 43881”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43881 Based on record review and staff interview, it has been determined that the hospital failed to enforce rules and regulations established by the hospital for the medical staff relative to patient discharges for 1 of 6 patients reviewed (Patient ID #1). Additionally, the hospital failed to ensure 13 medical staff were up to date with their Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications in accordance with hospital policy (Employees A, H, K, N, O, P, Q, R, S, T, U, V, and W). Findings are as follows: 1. The hospital’s “Medical Staff Rules and Regulations” last revised on 10/1/2023 state in part, “...1.5 Discharge of Patients ...1.5 (d) The Attending Physician/LIP or designee shall keep the patient and the patient’s family informed concerning the patient’s condition throughout the patient’s term of treatment...The Attending Physician or designee shall ensure that the patient (or the appropriate family member...) is provided with information that includes, but is not limited to, the following: ...(3) The clinical basis for the discharge; (4) The anticipated need for continued care following discharge; (5) When indicated, educational information regarding how to obtain further care, treatment, and services to meet the patient’s needs, which are arranged by or assisted by the hospital; and (6) Written discharge instructions in a form and manner that the patient or family member can understand...” Record review revealed that Patient ID #1 presented to the hospital’s Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism. During the evaluation, the patient’s physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician, were unable to pay for some of their medications and would like help getting insurance. The patient was subsequently admitted to the Progressive Care Unit due to abnormal bloodwork and a concern for spontaneous bacterial peritonitis (an acute fluid infection in the abdomen). Additionally, the patient’s diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection). During the patient’s admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters. Review of the patient’s last Internal Medicine progress note dated 10/10/2024 at 11:25 AM authored by Employee F, Medical Resident failed to reveal evidence of the clinical basis to discharge the patient. The note further identified that the patient’s oxygen saturation was 98% but failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024. The note continued to state that the patient was “hemodynamically stable for discharge” even though Employee F described the patient as having abdominal distention “again” despite having 4 liters of fluid removed from the abdomen the day before. The patient was discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient’s family member, ID # 10. Review of the patient’s Discharge Summary dated 10/10/2024 at 1:15 PM authored by Employee F, revealed the patient had a diagnosis of liver failure. Further review failed to reveal evidence that future appointments were established for this patient. The patient was instructed to follow up with Employee H from Gastroenterology. However, Employee H does not have an outpatient practice and therefore does not see patients outside of the hospital. Review of the patient’s After Visit Summary dated 10/10/2024, revealed that the patient was instructed to “get ascitic fluid drained outpatient as needed,” however, no educational information or instructions on how to obtain this service were provided to the patient. Additionally, the patient was instructed to resume their home dose of Lisinopril, a medication used to treat high blood pressure, after it had been withheld during the entire inpatient stay due to “low blood pressure. On the day of discharge, the final blood pressure reading was 95/57 at 3:44 PM. The medical record failed to reveal evidence that a trial to restart the medication was conducted prior to discharge to ensure the patient was safe to take the medicine. Patient ID #1 was then readmitted to another acute care hospital the following day on 10/11/2024, approximately 15 hours following discharge. Record review of the patient’s readmission record from the other acute care hospital revealed that the patient was transferred by ambulance to the emergency room per the patient and family’s request on 10/11/2024 at 11:52 AM with a chief complaint of shortness of breath, severe abdominal pain and continued diarrhea. The patient’s physical exam described the patient’s abdomen as distended with ascites and positive fluid wave. The patient was diffusely jaundice with sclera icterus (whites of the eyes appear yellow), and pitting edema of the lower extremities was observed. The patient was then admitted to the acute care hospital with a diagnosis of decompensated liver failure. In addition, the patient was found to have Hepatorenal Syndrome, a serious complication of kidney function in individuals with liver failure, his/her BUN/Creatine (kidney function markers) continued to rise, and dialysis was initiated. During a surveyor interview on 11/24/2024 with the Gastroenterologist, Employee H, he revealed that he only saw the patient once during his/her hospitalization and that he had performed the upper endoscopy on the patient. When asked if he provided any follow up instructions to the patient or the physicians, he replied that he does not see any patient on an outpatient basis and that his office has been closed since 2020. He then stated that his current role at the hospital is as a Gastroenterology Hospitalist and Proceduralist. He went on to say that the Internal Medicine Physicians are in charge of making the follow up referrals for the patients upon discharge. When asked if he would be involved in arranging an outpatient paracentesis for the patient, he indicated he would not be. During a surveyor interview on 11/20/2024 with Employee F, Internal Medicine Resident, in the presence of Employee G Assistant GME Program Director, Employee F revealed that the patient asked her about what she/he should do when the fluid in his/her stomach reaccumulates and she told the patient to call Gastroenterology to set up an appointment without further details. Employee F stated that she does not remember being told that the patient was on oxygen or that the patient’s nurse and family had concerns over the patient being discharged. When asked about the patient ‘s follow up at the time of discharge, Employee F explained that if a patient does not have a Primary Care Physician, they are instructed to call the Residents Clinic to set up an appointment. When asked if they are able to call the clinic to set up the appointment for the patient before they leave, she stated that they do not have the ability to do this. Employee G then explained that the hospital does not have a Gastroenterology Physician on staff that specializes in Hepatology (medical specialty that focuses on the treatment of liver disorders) and they do not have the same connections as some of the academic medical centers. Employee G indicated that they have reached out to transplant centers in the past, however, they usually stabilize the patient and transfer them to a larger hospital for follow up care. During a surveyor interview on 11/27/2024 at approximately 11:00 AM with Employee I, Third Year Medical Resident, she revealed that as a Resident, she and the other resident’s do have the ability to request an appointment for a patient at the Resident Clinic through the medical record system. However, not all Residents are familar with the process. During a surveyor interview on 11/21/2024 with Employee A, Attending Physician, he indicated that the nurses did not tell him about the patient having concerns related to his/her discharge and indicated that the patient’s initial Case Management evaluation showed that the patient was independent and did not use any visiting nurses at home. When asked if he had any conversations regarding the patient’s goals of care with the Residents who cared for the patient, he revealed that the Residents told him they called the patient’s family and saw the patient and expects the Residents to document these encounters in the medical record. During a surveyor interview on 11/19/2024 with Patient ID #1’s family member, ID #10, she explained that she received a call from the patient’s Case Manager, Employee C, on 10/10/2024 around noon informing her that the patient was going to be discharged from the hospital on this day. ID #10 revealed that she voiced her concerns to Employee C about the patient not being able to walk without being short of breath and never being evaluated by Physical Therapy and revealed that Employee C told her that the patient did not need Physical Therapy. ID #10 revealed that while at the hospital, the patient told her that she/he had spoken to the Attending Physician, Staff A, about how she/he did not feel safe to go home and ID #10 asked the patient’s nurse, Employee E, that she would like to speak to one of the physican’s, but no physician came to speak with her. 2. The hospital’s policy titled, “BLS [Basic Life Support] & ACLS [Advanced Cardiac Life Support] Requirements” last revised in August of 2022 states in part, “...Policy The following individuals must maintain certification in BLS and ACLS: all LIPS who are credentialed to perform procedures with moderate sedation; all intensivists; all Hospitalists and Nocturnists; all Anesthesiology providers; all emergency Medicine providers...” Record review of the medical staff credentialing filed on 11/21/2024 revealed that the following individuals had expired BLS and ACLS certifications: - Employee A, MD: BLS and ACLS certifications expired on 9/7/2024 - Employee H, MD: BLS and ACLS certifications expired on 1/1/2000 - Employee N, MD: BLS certification expired on 5/31/2024 - Employee O, MD: BLS certification expired on 9/22/2024 - Employee P, CNP (Certified Nurse Practitioner): BLS certification expired on 9/24/2024 - Employee Q, MD: BLS certification expired on 3/10/2023 - Employee R, PA (Physician Assistant): BLS and ACLS certifications expired on 6/30/2024 - Employee S, MD: BLS certification expired on 9/30/2023 - Employee T, NP: BLS certification expired on 10/3/2024 - Employee U, MD: BLS certification expired on 3/31/2024 and ACLS certification expired on 4/28/2024 - Employee V, APRN (Advanced Practice Registered Nurse): ACLS certification expired on 11/5/2024 - Employee W, MD: BLS certification expired on 9/16/2024 - Employee X, PA (Physician Assistant): BLS and ACLS certifications expired on 8/31/2024 During a surveyor interview on 11/21/2024 and on 11/25/2024, the Medical Staff Coordinator, Employee Y, was unable to provide evidence that the above-mentioned individuals were up to date with their BLS and ACLS certifications in accordance with hospital policy.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 45769 Based on record review and staff interviews, it was determined that the hospital failed to re-evaluate the patient’s change in condition and reflect these changes in the patient’s discharge plan relative to new oxygen requirements, deteriorating renal and mobility status, and increasing abdominal distention that required the removal of excess fluid in the abdomen multiple times, for 1 of 6 patients reviewed for discharge planning, (Patient ID #1). Findings are as follows: Review of the hospital policy titled,” Discharge Planning” last reviewed 2/2023 states in part, “...Reassessment...A patient’s discharge plan is reassessed by the multidisciplinary team as needed throughout the patient’s stay. Factors that may trigger a reassessment include an extended stay, change in condition or function...” Record review revealed that Patient ID #1 presented to the hospital’s Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism. During the evaluation, the patient’s physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient’s diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital. During the patient’s admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters. Review of the patient’s last Internal Medicine progress note dated 10/10/2024 at 11:25 AM, failed to reveal any documentation that the patient was using oxygen. The note further identified that the patient’s current oxygen saturation was 98% but failed to state that the patient was using 3 liters of oxygen since 12:39 AM on 10/10/2024. Review of the patient’s initial discharge planning note by Case Manager RN, Staff B, dated 10/3/2024 revealed that the patient lives with their family in a private residence and is independent with activities of daily living and drives. The note went on to say the patient’s discharge plan will be discussed further with Social Work. During the interview the patient was unsure of the number of steps to their residence. The patient’s medical record failed to reveal evidence that the patient’s initial discharge plan was updated to reflect the changes in the patient’s condition or functional status. The patient was then discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient’s family member. During a surveyor interview with the Attending Physician, Employee A on 11/21/2024 he was asked if he was aware that the patient was still requiring oxygen on the day of discharge, to which he replied that that he did not remember, despite stating that he had just reviewed the patient’s medical record. When he was asked if he or any of the Residents contacted the patient’s family regarding their concerns over the discharge, he indicated that the Residents told him that they spoke to the family, but stated, “I am not sure what the conversation was about”. He then stated that it is his expectation that the Residents document all family conversations in the medical record, however, the patient’s medical record lacked evidence of any family discussions. The Attending was then asked the reason why the patient was not evaluated by Physical Therapy, to which he responded that the patient was not very mobile, but was getting up to walk. However, the patient’s medical record showed no documentation that the patient was walking. Additionally, the Attending was asked if he was aware that the patient’s family requested a Physical Therapy evaluation, to which he indicated he was was not aware. During a surveyor interview with Case Manager Staff B, on 11/20/2024, at 12:48 PM, she stated that she only was assigned to Patient ID #1 on 10/3/2024 and she never had the patient again. Staff B remembered that the patient was unable to answer a question about his/her home and number of stairs. However, she stated that the completion of the discharge plan should be updated by the covering Case Manager. During a surveyor interview with Case Manager, Registered Nurse Staff C, on 11/19/2024 at 2:45 PM, she stated that she could not recall Patient ID #1, however she did remember a patient with end stage liver disease and stated that she did not know anything about “liver failure”. When asked if she remembered any time that palliative care services were mentioned, she replied “that would be initiated by the physician, and she would not be involved”. Staff C stated, she was not aware of any conversations that the physicians may have had with the patient or family regarding any discharge concerns. She then stated she vaguely remembered that the patient had a family member that was a nurse. Staff C went on to say, “if the physician does not tell me there is a change in the patient’s condition, I would not know”. Staff C was then asked to explain about the length of stay rounds (LOS) that are held weekdays at 11:00 AM, to which she replied that she does attend the LOS rounds and any changes in the patient’s condition would be discussed there. During a surveyor interview with the Director of Case Management, Staff D on 11/19/2024 at 10:00 AM, she acknowledged that after reviewing Patient ID #1’s medical record, there is no evidence of any follow up notes by Case Management after the initial discharge planning note on 10/3/2024. She then stated that it is her expectation that a reassessment of the patient’s discharge plan would have been completed per the hospital’s policy. She also acknowledged that there was no documentation from the physicians that the patient was on oxygen the morning of their discharge. She stated that the record failed to reveal evidence of a walk test prior to discharge to evaluate the patient’s oxygen needs while walking. The Director confirmed that the discharge planning note did not accurately reflect the patient’s condition at the time of the discharge on 10/10/2024. During a surveyor interview on 11/19/2024 with Patient ID #1’s family member, ID # 10, she explained that she had received a call from the patient’s Case Manager, Employee C, on 10/10/2024 around noon informing her that the patient was going to be discharged from the hospital “today.” She stated that she voiced her concerns about the patient not being able to walk without being short of breath and never being evaluated by Physical Therapy to Employee C who told her that the patient did not warrant physical therapy. The patient’s family member then stated that she came to the hospital and spoke to the patient’s nurse, Employee E, regarding her concerns about the patient’s unsafe discharge due to his/her increased level of care and acute medical issues. She stated that the nurse also stated that she agreed that the patient was not ready for discharge and the nurse contacted the Physician. ID #10 stated that the Physician never came up to speak to her before the discharge and although the nurse stated that she voiced her concerns about the discharge to the Physician, the nurse indicated there was nothing she could do and the patient would still be discharged. During a surveyor interview with Registered Nurse, Employee E, on 11/20/2024, she explained that she was the patient’s nurse from 7:00 AM to 7:00 PM on 10/10/2024. When she came on duty, Patient ID # 1 had been using 3 liters of oxygen most of the day. After Physician and discharge rounds, she was notified that a discharge order was entered for the patient. She then stated that she went to speak to the Residents about not feeling comfortable with the patient’s discharge and that the patient was still using oxygen at 3 liters and needed assistance to get out of bed and to use the commode. The Physician told her to take him/her off the oxygen and “see how [she/he] does.” Employee E stated that the patient’s family member, ID #10, arrived at the hospital and voiced her concerns over the patient’s discharge. She stated that the family was concerned about the patient having to go up 17 stairs at home. The nurse confirmed that she informed the Case Manager, Employee C, about the patient still requiring oxygen and the concerns about the patient not being ready for discharge and she was told that the patient was still going to be discharged later. Employee E was then asked if she used the chain of command to voice her concerns regarding the patient’s unsafe discharge, and she stated she did not. 43881”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 45769 Based on record review and staff interview, it has been determined that the hospital failed to include an accurate discharge planning evaluation of a patient’s need for post hospital discharge services for 1 of 6 patients reviewed (Patient ID #1). Findings are as follows: Record review revealed that Patient ID #1 presented to the hospital’s Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism. During the evaluation, the patient’s physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient’s diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital. During the patient’s admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters. The patient was discharged home from the hospital on 10/10/2024 by wheelchair accompanied by a Registered Nurse and the patient’s family member. Review of the patient’s Discharge Summary dated 10/10/2024 at 1:15 PM authored by Employee F, revealed the patient had a diagnosis of “Liver failure.” Further review failed to reveal evidence that future appointments were established for this patient. The patient was instructed to follow up with Employee H from Gastroenterology. However, Employee H does not have an outpatient practice and therefore does not see patients outside of the hospital. Review of the patient’s After Visit Summary dated 10/10/2024, revealed that the patient was instructed to “get ascitic fluid drained outpatient as needed,” however, no educational information or instructions on how to obtain this service were provided to the patient. During a surveyor interview with the patient’s family member, ID #10, on 11/19/2024, she revealed that she is a nurse that is currently working as a Case Manager and indicated that she voiced her concerns about the patient’s discharge and his/her deconditioned status to the Case Manager, Employee C, and the patient’s Primary Nurse, Employee E. ID #10 revealed that she told Employee C she wanted the patient to be seen by Physical Therapy because she/he still required assistance getting in and out of the bed, she/he was only able to go from the bed to the chair or commode, and she/he was not ambulating while in the hospital, but her request was denied since Employee C said that the patient did not need Physical Therapy. She also stated that she was concerned that the patient was told that she/he needed to contact physicians to make follow up appointments and call the state health insurance program establish health insurance, but at this point she felt that the patient was in no condition to be making phone calls. She then revealed that after the patient was sent home, she/he became more short of breath and 15 hours later she needed to call rescue and the patient was brought to an acute care hospital per the patient and family request. The patient was then admitted to the hospital and was transferred to an out of state hospital for a liver transplant evaluation on 10/17/2024. During a surveyor interview on 11/24/2024 with the Gastroenterologist, Employee H, he revealed that he only saw the patient once during his/her hospitalization and that he had performed the upper endoscopy on the patient. When asked if he provided any follow up instructions to the patient or the physicians, he replied that he does not see any patients on an outpatient basis and that his office has been closed since 2020. He then stated that his current role at the hospital is as a Gastroenterology Hospitalist and Proceduralist. He went on to say that the Internal Medicine Physicians are in charge of making the follow up referrals for the patients upon discharge. When asked if he would be involved in arranging an outpatient paracentesis for the patient, he indicated he would not be. During a surveyor interview on 11/20/2024 with Employee F, Internal Medicine Resident, in the presence of Employee G, the Assistant GME Program Director, Employee F revealed that the patient asked her about what she/he should do when the fluid in his/her stomach reaccumulates and she told the patient to call Gastroenterology to set up an appointment without further details. Employee G then explained that the hospital does not have a Gastroenterology Physician on staff that specializes in Hepatology (medical specialty that focuses on the treatment of liver disorders) and they do not have the same connections as some of the academic medical centers. Employee G indicated that they have reached out to transplant centers in the past, however, they usually stabilize the patient and transfer them to a larger hospital for follow up care. 43881”

“DISCHARGE PLANNING EVALUATION CFR(s): 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: 45769 Based on record review and staff interviews, it was determined that the hospital failed to complete the patient’s initial discharge planning evaluation for 1 of 6 patients reviewed for discharge planning, (Patient ID #1). Findings are as follows: Review of the hospital policy titled,” Discharge Planning” last reviewed 2/2023 states in part, “ ...Objectives ...Promotes high quality patient care, which identifies early in the hospitalization patients at risk for discharge planning barriers or with extended length of stay related to inadequate resources ...” Record review revealed that Patient ID #1 presented to the hospital’s Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism. During the evaluation, the patient’s physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician and were unable to pay for some of their medications and would like help getting insurance. Additionally, the patient’s diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection) and the patient was admitted to the hospital. During the patient’s admission, the patient required drainage (paracentesis) of his/her abdominal ascites on two occasions. The first removal occurred on 10/3/2024 with a removal of 2.7 liters of fluid and the second occurring on 10/9/2024 the day before their discharge with a removal of 4.1 liters. Review of the patient’s initial discharge planning note by Case Manager RN, Staff B, dated 10/3/2024 it was documented that the patient lives with their family in a private residence and is independent with activities of daily living and drives. The note went on to say the patient’s discharge plan will be discussed further with social work. During the interview the patient was unsure of the number of steps to their residence. The patient’s medical record failed to reveal any evidence that the patient’s initial discharge plan was updated to reflect the changes in the patient’s condition or functional status. Review of Internal Medicine progress notes from 10/10/2024 failed to reveal evidence of the clinical basis to discharge the patient and further identified that the patient’s oxygen saturation was 98%, but documentation failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024 consistently. The patient was described as “hemodynamically stable for discharge” even though the Medical Resident described the patient as having abdominal distention “again” despite having 4 liters of fluid removed from the abdomen the day before. The patient was discharged home from the hospital on 10/10/2024 with a discharge diagnosis of Liver failure but was readmitted to another acute care hospital with a diagnosis of decompensated liver failure the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge. During a surveyor interview with Case Manager Staff B, on 11/20/2024, at 12:48 PM, she stated that she only was assigned to Patient ID #1 on 10/3/2024 and she never had the patient again. Staff B remembered that the patient was unable to answer a question about his home and number of stairs. However, she stated that the completion of the discharge plan should be updated by the covering case manager. During a surveyor interview with Case Manager, Registered Nurse Staff C, on 11/19/2024 at 2:45 PM, she stated that she could not recall Patient ID #1, however she did remember a patient with end stage liver disease and stated that she did not know anything about “liver failure”. Staff C stated, she was not aware of any conversations that the physicians may have had with the patient or family regarding any discharge concerns. She then stated she vaguely remembered that the patient had a family member that was a nurse. Staff C went on to say, if the physician does not tell me there is a change in the patient’s condition “I would not know.” Staff C was then asked to explain about the length of stay rounds (LOS) that are held weekdays at 11:00 AM. Staff C stated that she does attend the LOS rounds and any changes in the patient’s condition would be discussed there. When asked when would you update a patient’s discharge plan, she responded by saying when there is a change in the patient the plan would be changed to accommodate the patient’s needs. During a surveyor interview with the Director of Case Management, Staff D, on 11/19/2024 at 10:00 AM she acknowledged that after reviewing Patient ID #1’s medical record there is no evidence of any follow up notes or changes made by Case Management after the initial discharge planning note on 10/3/2024. She also acknowledged that the number of stairs in the patient’s home was never clarified during his/her admission nor added to the inital discharge planning note. 43881”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 43881 Based on record review and staff interviews, it has been determined that the hospital failed to ensure Social Services staff effectively participated in the arrangement of the patient’s discharge plan and follow up care for 1 of 6 patient’s reviewed for discharge planning, (Patient ID #1). Findings are as follows: The hospital’s policy titled, “Social Service General Policy” last revised in April of 2020 states in part, “ ...Scope of Service and Referrals: Depending on the needs of the hospital and the surrounding community, the following services may be provided: ...Education/consultation for staff, patients and/or their families; Family conferencing/counseling; Financial/insurance counseling ... ...supportive counseling ... Referral Process: Referrals for service may be initiated by any party ...” Record review revealed that Patient ID #1 presented to the hospital’s Emergency Department in October of 2024 with complaints of chest pain and shortness of breath upon exertion. His/her past medical history included hypertension and alcoholism. During the evaluation, the patient’s physical exam revealed she/he had generalized jaundice, abdominal distention, pitting edema, and a cough. In addition, the patient disclosed that they did not have a primary care physician, she/he was unable to pay for some medications and would like help getting insurance. The patient was subsequently admitted to the Progressive Care Unit due to abnormal bloodwork and a concern for spontaneous bacterial peritonitis (an acute fluid infection in the abdomen). Additionally, the patient’s diagnostic imaging results revealed she/he had Hepatomegaly (an enlarged liver) with moderate abdominal and pelvic ascites (fluid collection). Record review revealed that the patient was seen by Social Services on 10/3/2024 regarding his/her alcoholism, and not having a Primary Care Physician (PCP) nor health insurance. At this time, the Social Worker indicated that screening for state health insurance was pending and a Social Worker would follow up with the patient regarding this. However, the record failed to reveal evidence that Social Services followed up with this matter. Review of the patient’s initial discharge planning note dated 10/3/2024 revealed that the patient lived with their family in a private residence, she/he was independent with activities of daily living but was unsure of the number of steps to their residence. The note further indicated that the patient’s discharge plan would be discussed further with Social Work. However, the record failed to reveal evidence that this coordination of care took place. Record review revealed that on 10/4/2024, Employee J, Social Worker, attempted to see the patient twice on this day but the patient was either asleep or in a procedure. Further record review failed to reveal evidence that additional attempts to see the patient were made by Social Services on 10/4, 10/5, 10/6, 10/7, and 10/8, until 10/9/2024, the day before the patient was discharged. Record review of a Social Work note dated 10/9/2024 at 4:18 PM, revealed that Employee J saw the patient who reported she/he smoked cigarettes and used alcohol, she/he did not have a PCP nor health insurance. The note further indicated that the patient understood his/her possible limited accessibility to alcohol use programs due to his/her lack of insurance but was provided with resources for substance use treatment centers and programs anyway. The note failed to reveal evidence that the patient was provided with specific details about which program or center would provide services to him/her about his/her alcohol use without insurance. Review of Internal Medicine progress notes from 10/10/2024 failed to reveal evidence of the clinical basis to discharge the patient and further identified that the patient’s oxygen saturation was 98%, but documentation failed to state that the patient had been using 3 liters of oxygen since 12:39 AM on 10/10/2024 consistently. The patient was described as “hemodynamically stable for discharge” even though the Medical Resident described the patient as having abdominal distention “again” despite having 4 liters of fluid removed from the abdomen the day before. Review of Social Services progress notes revealed that the patient was seen by Employee J on 10/10/2024, the day of discharge. Employee J indicated in her note that the patient was provided with information about shelters. The patient was discharged home from the hospital on 10/10/2024 with a discharge diagnosis of Liver failure but was readmitted to another acute care hospital with a diagnosis of decompensated liver failure the following day on 10/11/2024 at 11:52 AM, approximately 15 hours following discharge. During a surveyor interview with Employee A, Attending Physician, he indicated that he relies on the Social Worker to ask about issues at home if a patient indicated they did not feel safe going home. During a surveyor interview on 11/25/2024 at 10:00 AM with Employee J, Social Worker, in the presence of the Director of Case Management, she indicated that she briefly remembered the patient and recalls the patient did not have health insurance and she gave the patient information related to his/her alcoholism. When asked if she was aware of the patient’s diagnosis, she replied, “Kind of, not how severe it was.” When asked if she spoke to the physician about the patient, she stated, “Just about length of stay.” When asked if the patient voiced any concerns regarding his/her discharge plan, she indicated that she did not remember. When asked if she spoke to the patient’s family or the patient’s nurse about concerns related to discharge, she stated, “No,” and acknowledged she did not have any conversation about goals of care for the patient with other providers. When asked if she was aware that the patient was on oxygen consistently, she indicated that she was not aware of the patient’s oxygen use despite seeing him/her on the day of discharge. When asked about what the protocol is related to assisting a patient with health insurance coverage, she indicated that “Patient Access” is usually in charge of this, and this was discussed during “rounds.” When asked if she was aware that the patient voiced concerns related to his/her inability to afford his/her medications which was documented in the medical record, she stated she was not aware of this despite indicating that she had reviewed the patient’s medical record. When asked how often Social Services sees patients, Employee J indicated that there is no specific timeframe, but she will see the patient based on the need to follow up and stated that it is usually “not normal practice” to go without seeing a patient for 5 days. The Director of Case Management indicated that patients are seen according to what is appropriate for the patient and acknowledged that a change in condition would warrant a visit by Social Services. In addition, Employee J did not remember why she gave the patient information about shelters and indicated that she would have offered information related to his/her inability to purchase medications. 45769”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation (COP) relative to providing the necessary treatment and services, consistent with professional standards of practice, and hospital policy to prevent, identify, and/or treat new wound areas for 3 of 8 patients reviewed related to wounds. Additionally, the hospital failed to follow their own policy related to “Discharge Planning”. Findings are as follows: -The hospital failed to follow their policy related to “Pressure Ulcer/Skin Integrity/Mucosal Injury”. (Refer to A 0395) -The hospital failed to ensure that all staff adhere to the policies and procedures related to “Discharge Planning”. (Refer to A 0813)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 32374 Based on record review, surveyor observation and staff interviews, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice, and hospital policy relative to skin assessments, documentation, wound care, and physicians’ orders for 3 of 8 patients reviewed for wound care, Patient ID #1, 2, and 3. Findings are as follows: Review of the hospital Policy titled, “Pressure Ulcer/Skin Integrity/Mucosal Injury” which states in part: “Policy: 1. Skin Assessment and monitoring of wounds... B. Pressure ulcers require a wound consult, and staging, are deferred to wound care nurses and physicians/licensed independent practitioners (LDA)... D. Skin Integrity a. The patient’s skin integrity from head to toe is assessed upon admission, on each shift, and at discharge... Wound Assessments and Follow up/tracking assessments; a. Initial assessments are conducted within 24 hours of admission; b. An LDA is initiated for documentation on discovery; c. Detailed assessments are completed; -Upon discovery of any new wound” 1. Record review for Patient ID #1 revealed s/he was admitted to the hospital on 9/15/2024 with a complaint of a rapid heart rate and a fever of 102 degrees Fahrenheit (F; the normal body temperature range varies from 97°F to 99°F) after transfer to the emergency department (ED) from a skilled nursing facility for an evaluation. While at the hospital, the patient was noted to have wounds on his/her right leg, which the patient has reportedly had for approximately a year. A physician’s order for a wound consult was provided on 9/16/2024. Record review of Wound Nurse, Staff B’s, documentation dated 9/16/2024 indicated an assessment of the wounds on the patient’s right lower extremity was conducted and documented as follows: “RLE [right lower extremity] wound fully granulating [new connective tissue that forms in a healing wound], right ankle 75% slough [slough can impede healing if left untreated]. Right heel unstageable pressure ulcer [an unstageable pressure ulcer is a pressure ulcer characterized by full thickness tissue loss that’s covered by necrotic tissue, eschar, or a non-removable dressing, making it difficult to determine the wound’s depth and stage] due to 100% eschar.” Treatment orders provided for all wounds revealed the following “Alginate covered with rolled gauze daily.” Review of a nursing skin assessment conducted by Nurse, Staff G, dated 9/21/2024 revealed “buttocks/coccyx” and “thigh/coccyx.” Review of a nursing skin assessment conducted by Nurse, Staff G, dated 9/22/2024 revealed “buttocks/coccyx.” During a surveyor interview with Wound Nurse, Staff B, on 9/26/2024 at approximately 1:15 PM, she revealed that she was consulted on 9/16/2024 regarding Patient ID #1’s leg wounds. Additionally, she indicated that she saw the patient and implemented treatments for those areas. Staff B further revealed that once she implements a treatment for a patient, she does not continue to follow them, unless another consult is requested. Lastly, Staff B revealed that she was not contacted or made aware that Patient ID #1 had developed new pressure areas on his/her coccyx, and buttocks. During an interview with Nurse, Staff G, on 9/26/2024 at approximately 3:00 PM, she revealed that she documented the wounds on the patient’s coccyx and buttocks on 9/21 and 9/22/2024 which were red, and that she photographed and documented the areas. She further revealed that on 9/22/2024 the coccyx wound had opened, and she recorded the measurements. Lastly, Staff G revealed that she did not contact the physician or Wound Nurse and therefore did not follow protocol and procedure in accordance with the hospital’s policy, to make them aware of Patient ID #1’s newly identified pressure areas. During a surveyor interview with Physician, Staff I, on 9/26/2024 at approximately 3:15 PM he revealed that he was assigned to the patient on 9/23/2024, the day of the patient’s discharge from the hospital. Additionally, he revealed that he had not cared for the resident prior to that day and was unaware that the patient had pressure wounds on his buttocks, coccyx, and scrotum. When Staff I revealed that when he documented on the patient’s discharge summary that his/her skin was “color good, texture, turgor normal, no rashes or lesions, Genitalia, normal male without lesion, discharge, or tenderness” that he checked off his answers with the use of a template and did not actually turn or look at the patient’s skin because he was not informed that there were any concerns with Patient ID #1’s skin, other than the wounds on his/her right leg. During a surveyor interview with the Risk Manager and Unit Manager, Staff F, on 9/26/2024 at approximately 3:50 PM, they were unable to provide evidence that the hospital’s policy regarding the identification of wounds was followed relative to notifying the Physician and requesting a consult with the wound nurse to assess the wounds and put a treatment in place was followed for Patient ID #1. 2. Record review for Patient ID #2, revealed s/he was admitted to the hospital from the ED on 9/17/2024 with diagnoses of pneumonia related to the Covid 19 virus, and a non-healing surgical wound on the patient’s back. Record review of Patient ID #2’s Braden Scale (for predicting the risk of acquiring a pressure wound) revealed a risk score of 12, indicating s/he was at a high risk for developing a pressure ulcer. Additionally, the record revealed a wound consult was ordered upon admission for his/her non-healing surgical wound. Review of the skin assessments for Patient ID #2, dated 9/17 and 9/18/2024, revealed integumentary (skin) as Within Defined Limits (WDL), indicating the assessments failed to identify the non-healing surgical wound on the patient’s back. During a surveyor interview with the Risk Manager and Unit Manager, Staff F, on 9/26/2024 at approximately 3:50 PM, they were unable to provide evidence that the skin assessments completed by nursing staff on 9/17 and 9/18/2024 were complete and accurate. 3. Record review for Patient ID #3, revealed s/he was admitted to the hospital on Friday, 9/6/2024. Additionally, the record revealed s/he was transferred to the ED for evaluation of hypernatremia (a condition where there is too much sodium in the blood) and lethargy. Further record review for Patient ID #3 revealed diagnoses of Parkinson’s disease, diabetes, stage 4 pressure ulcer (the most severe type of pressure ulcer which involves full-thickness skin lass that extends into the muscle, bone, tendon or joint) to the right buttock, and dementia. Review of the Physician orders revealed an order dated 9/6/2024 for a wound nurse consult was ordered for the patient’s stage 4 pressure ulcer on his/her right buttock. Review of a nursing skin assessment dated 9/7/2024 revealed that the patient had a stage 4 pressure ulcer on his/her right buttocks and a newly identified deep tissue injury (a type of pressure ulcer that occurs when prolonged pressure or shear forces damage the tissues beneath the skin) was identified on the patient’s right heel. Record review revealed that Patient ID #3 was not seen by the wound nurse until 9/9/2024, 3 days after his/her admission and 2 days after the newly identified pressure injury was found on the patient’s right heel. Further record review failed to reveal evidence that a physician’s order to treat the wound on the patient’s right heel or for the stage 4 pressure ulcer on his/her right buttocks were implemented from the patient’s admission on Friday, 9/6/2024 until s/he was seen by the wound nurse on Monday, 9/9/2024, indicating the wound went untreated for approximately three days. During a surveyor interview with the Risk Manager on 9/26/2024 at approximately 2:15 PM, she revealed that the Wound Nurse works Monday through Friday and is not available on the weekends. Additionally, she was unable to provide evidence that Patient ID #3’s stage 4 pressure wound on his/her right buttocks or the newly identified deep tissue injury on the patient’s right heel were treated until 9/9/2024.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 32374 Based on record review and staff interview it has been determined that the hospital failed to adhere to hospital policy and procedures to ensure that the After Visit Care Summary (AVS) form, which is used in place of the Continuity of Care form, and discharge summary, includes the patient’s diagnosis, and information regarding follow-up care. The hospital failed to provide complete documentation and communicate to the clinical caregiver accepting responsibility of the patients’ post discharge, for 4 of 4 patients reviewed, Patient ID #’s 1, 2, 3 and 4. Findings are as follows: Review of the hospital policy titled “Discharge Planning” Revised 8/2023 states in part: Continuity of Care Post Discharge 2. The system will include the following: 2.1 Discharge instructions prepared for each patient and communicated at the time of discharge to the clinical caregiver accepting responsibility post discharge. 2.2 Discharge instructions will include the patient’s diagnosis, information re: follow-up care and discharge instructions prepared for each patient and communicated to the clinical caregiver accepting responsibility post discharge care at the time of discharge. 2.3 any arranged services or appointments, special instructions/restrictions, and education regarding post hospital care and medications. Review of the hospital policy titled “Provider Orders”, revised 7/2024, states in part: Purpose: to establish procedures for obtaining complete medication orders from authorized members of the medical staff. “Definition: Substances included in the joint Commission definition of medications are as follows ... Any product designated as a drug by the FDA, including enteral nutrient solutions, oxygen, and other medical gasses.” 1. Review of the record for Patient ID #1, admitted on 9/15/2024, with rapid heart rate and fever of 102, was sent to the ED from a skilled nursing facility for evaluation. The patient was noted to have chronic wounds on their right leg. On 9/21/2024 and 9/22/2024, nursing skin assessments noted new wounds on the patient’s coccyx and buttocks. Further review of the record for patient ID #1, revealed he/she was discharged to a skilled nursing facility on 9/23/2024. A review of the “After Visit Summary” (AVS) report (used in place of the continuity of care form), which was sent to the skilled nursing facility upon Patient ID#1’s discharge from the hospital, lacked identification, and treatment for, the pressure wounds on the patient’s buttocks, and coccyx. 2. Record review for Patient ID #2, reveals she/he was admitted to the hospital from the emergency department (ED) on 9/17/2024 with a diagnosis of pneumonia related to the Covid 19 virus, and a non-healing wound surgical wound on the patients back. The patient was maintained on 2-4 liters of oxygen while inpatient. The patient was discharged on 9/23/2024 to a skilled nursing facility. A review of the AVS report which was sent to the skilled nursing facility failed to include orders for oxygen, and failed to provide orders for the treatment of the non-healing wound surgical wound on the patients back. 3. Record review for Patient ID #3, admitted to the hospital on 9/6/2024, reveals she/he was sent to the emergency department (ED) for evaluation of hypernatremia and lethargy. The medical history includes Parkinson’s disease, diabetes, stage 4 pressure ulcer to the right buttock, and dementia. During a review of the wound nurse’s consultation dated 9/9/2024, the following was identified: -The right heel deep tissue injury, treatment with skin prep daily. -The ischium a stage 4 pressure, treatment with Alginate AG packing daily. The patient was discharged on 9/12/2024 to a skilled nursing facility. A review of the “After Visit Summary” (AVS) report lacked physician’s orders, and did not provide documentation or treatments related to a pressure ulcer on the patient’s right ischium and deep tissue injury on the patient’s right heel. 4. Review of the record for patient ID #4, revealed that he/she was admitted to the hospital on 9/22/2024, from home, for evaluation of bilateral lower leg cellulitis. The patient had a wound nurse consult on 9/23/2024, which identified the following wounds: -Bilateral lower extremity scattered full thickness venous stasis ulcers, not measurable, serous drainage, provide a xeroform cover with rolled gauze daily. -Right hallux (the innermost digit, such as the big toe) ulcer, treatment order xeroform cover rolled gauze daily. -Bilateral posterior upper thighs pressure ulcers, treatment order Triad every shift. The patient was discharged home on 9/26/2024. A review of the AVS report failed to identify the wounds and provide treatment orders for the above identified wounds. The AVS indicated a referral to home healthcare, for nursing, physical therapy, and occupational therapy, however it does not identify a home care agency. During surveyor interview with the Risk Manager and the Chief Nursing Officer on 10/2/2024, via phone at 1:45 PM, they were unable to produce evidence that the AVS reports contain all of the necessary information required for the continuity of care for each patient upon discharge relative to the conditions, treatments, and physician orders.”