Prisma Health Richland Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 28883 Based on facility policy review, medical record review, and interview, the hospital failed to provide an appropriate transfer for Patient (Pt) #3, one of two patients reviewed who had been transferred to an acute care hospital. Facility nursing staff failed to document that Pt #3’s medical records pertinent to his/her presentation and diagnosis of an emergency medical condition had been sent to Hospital #3. The findings included: Cross Refer to A-2409 related to the failure to provide an appropriate transfer for Pt #3. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 28883 Based on facility policy review, medical record review, and interview, the hospital failed to provide an appropriate transfer for Patient (Pt) #3, one of two patients reviewed who had been transferred to an acute care hospital. Facility nursing staff failed to document that Pt #3’s medical records pertinent to his/her presentation and diagnosis of an emergency medical condition had been sent to Hospital #3. The findings included: Record review for Pt #3 revealed an Emergency Department (ED) Provider note dated 6/5/26 at 3:36 PM for a date of service of 6/4/26 at 8:45 PM that documented an unidentified 46-year-old male presented for burns after having boiling water thrown onto his face. Patient was apparently intoxicated. No known medical problems. On physical exam vital signs were temperature 99.3 degrees Fahrenheit, pulse 74, respirations 18, blood pressure 100/73, and oxygen saturation 100%. The patient was awake, alert but thrashing around and combative complaining of eye pain. Second degree burns to 20% of total body surface area including the anterior face, superior chest, and bilateral anterior and posterior shoulders were noted. There were no acute injuries on CT (Computerized Tomography) imaging but patient had worsening combativeness and concern for his ability to protect his airway with burns to the face; and patient subsequently intubated. A note dated 6/4/26 at 10:05 PM documented an emergent intubation procedure. A Trauma Surgery note dated 6/4/26 at 11:43 PM for a date of service of 6/4/26 at 8:54 PM revealed a history and physical exam with review of labs and imaging studies. The diagnosis was acute pain due to trauma, burn involving 20-29% of body surface, respiratory distress, burn of left eyelid, high serum lactate, and elevated ETOH (alcohol) level. The plan was “ ...Transferred to (Hospital #3), Accepted by (Physician at Hospital #3) ...”. The note documented that ophthalmology had been consulted and evaluated the patient with pt at high risk for intraorbital compartment syndrome (OCS). Recommend patient be transferred to hospital with ophthalmology. Review of the electronic medical record revealed Physician Certification had been documented that included the name of the physician at Hospital #3 was the accepting Physician. Patient condition was “Patient stabilized”, Reason for Transfer “Qualified clinical personnel or service. Benefits of Transfer “Necessities available at receiving facility, Staff at receiving facility are capable of providing the level of care needed”. Review of the record revealed there had been no nurse certification documented for the transfer of Pt #3. Review of a blank nurse certification revealed it contained an entry to document that copies of medical records had been sent to the receiving hospital; but this was not able to be located in Pt #3’s medical record. During an interview on 6/30/26 at 10:20 AM, the Emergency Department (ED) Nurse Manager reviewed the record and verified there was no documentation in the record to show that pertinent medical records for Pt #3 had been sent to the receiving hospital. Review of the policy entitled Emergency Medical Treatment and Labor Act (EMTALA), effective 10/22/2024 revealed information that EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when and individual requests emergency medical care on hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made. If an EMC (emergency medical condition) is determined to exist, the hospital must provide either )1) further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital; or (2) an appropriate transfer to another medical facility ...A transfer to another medical facility will be appropriate in those cases in which the receiving hospital can provide medical treatment within its capability and/or capacity that can minimize the risks to the individual’s health ....The transferring hospital must send the medical records related to the EMC along with any history, preliminary diagnosis, results of diagnostic studies or telephone reports, and other medical records pertinent to the patient’s presenting EMC and the written informed consent or certification required for transfer. Test results that become available after the individual is transferred should be telephoned to the receiving hospital, and then mailed or sent via electronic transmission.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36779 Based on observations, record reviews, interviews, and a review of hospital policies and procedures, the governing body failed to ensure effective oversight of nursing services related to alarm monitoring for patients receiving continuous pulse oximetry. Patient #1, one of one patients reviewed with continuous pulse oximetry monitoring, was found unresponsive with a dislodged tracheostomy tube, without the alarm sounding, resulting in hypoxia and death. The findings included: Cross-refer to A-286 regarding the hospital’s failure to ensure patients receiving continuous pulse oximetry monitoring were protected from harm. Cross-refer to A-395 regarding the failure to ensure nursing staff set alarm volumes for pulse oximeters at an audible level, received appropriate education on the alarm management, and maintained adequate monitoring oversight.”

“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: 36779 Based on observations, record reviews, interviews, review of policies and procedures, and a review of manufacturer instructions, the hospital failed to ensure that nursing staff provided continuous pulse oximetry monitoring in a safe environment and failed to provide appropriate wound care services. Specifically, the hospital failed to ensure that alarm volumes for the pulse oximeters had been set at an audible level, that staff received and confirmed education on alarm management, and that adequate staffing was present at the central monitoring station. This failure contributed to Patient (P)1, one of one patients reviewed with pulse oximetry monitoring, being found unresponsive with a dislodged tracheostomy tube, without the alarm sounding, resulting in hypoxia and death. In addition, appropriate wound assessment and care was not provided for 7 of 22 patients reviewed with pressure ulcers that developed at the hospital, Patients #2, #15, #19, #21, #22, #23, and #25. The findings included: Cross refer to A-395 RN Supervision of Nursing Care- related to the lack of monitoring of alarms for (P)1 and lack of appropriate assessment and wound care by the licensed nursing staff for Patients #2, #15, #19, #21, #22, #23, and #25.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 36779 Based on observations, record reviews, interviews, and a review of hospital policies and procedures, the governing body failed to ensure effective oversight of nursing services related to alarm monitoring for patients receiving continuous pulse oximetry. Patient #1, one of one patients reviewed with continuous pulse oximetry monitoring, was found unresponsive with a dislodged tracheostomy tube, without the alarm sounding, resulting in hypoxia and death. The findings included: Cross-refer to A-286 regarding the hospital’s failure to ensure patients receiving continuous pulse oximetry monitoring were protected from harm. Cross-refer to A-395 regarding the failure to ensure nursing staff set alarm volumes for pulse oximeters at an audible level, received appropriate education on the alarm management, and maintained adequate monitoring oversight.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 36779 Based on observations, interviews, record reviews, and a review of hospital policies and procedures, the hospital failed to ensure that patients receiving continuous pulse oximetry (capnography) monitoring were protected from harm. Specifically, the hospital did not ensure that alarm volumes were set to an audible level, nor were alarms consistently documented or verified for Patient #1, one of one patients reviewed with continuous pulse oximetry. The failure of the hospital staff to monitor the pulse oximetry alarm contributed to Patient #1’s (P1) tracheostomy dislodgement, hypoxia, and death. Findings Included: Record Review: On 06/16/25 at 9:50 AM, review of P1’s record with Nurse Manager (NM)15 showed admission on 03/11/23 following a right MCA stroke. Discharge Summary dated 03/25/25 revealed P1 was found unresponsive, resuscitation was discontinued, and P1 was pronounced dead at 12:28 PM due to hypoxia. Nurse Manager and Leadership Interviews: NM15 stated staff were expected to document Capnostream settings, but were not doing so. She confirmed “all alarms should be loud and audible” and acknowledged patient names were not entered into the central monitor at the nurse’s station. Director of Nursing (DON)1 confirmed data from the Capnostream could not be retrieved for P1 because names were not entered in the system. NM15 reported post-incident audits showed inconsistent compliance with documentation of alarm settings (improved in May 2025, decreased in June 2025). She also stated staffing shortages resulted in no staff present at the nurse’s station when P1 was found. Direct Care Staff Interviews: On 06/16/25 at 11:34 AM, CN20 stated P1’s alarm was “turned down” at the time of the incident. On 06/16/25 at 3:04 PM, LPN1, P1’s assigned nurse, stated the tracheostomy tube was out, and the alarm was not sounding. She reported no recall of training on alarm management or related policies. On 06/17/25 at 8:40 AM, LPN2 confirmed patient names were later added to the monitor, but denied knowledge of requirements to document alarm volumes. On 06/18/25 at 11:05 AM, RN2 stated post-incident training only emphasized documenting pulse oximetry use, not alarm volume requirements. Unit Secretary (US) Interview: On 06/17/25 at 11:00 AM, US1 stated she was away from the nurse’s station during P1’s code and had not received education on alarm volume requirements. Policy Review: Review of the hospital’s policy “Clinical Alarms Management” (effective 02/10/22) showed requirements that: 1. Alarms are activated on admission and verified each shift. 2. Alarm volumes should be set at audible levels for the unit environment. 3. Staff respond immediately to alarms and document compliance. Education Review: On 06/16/25, NM15 provided an email instructing staff to connect pulse oximetry to the central monitor and set alarms at maximum volume. No evidence was provided that staff reviewed or acknowledged the education. A “Safety Alert” issued after the event noted failure to rescue due to inaudible alarms, highlighted that Capnostream monitors default to prior settings, and cited a lack of alarm verification each shift. Observations: On 06/17/25 at 11:42 AM, a Capnostream device was observed on the nephrology unit. NM15 demonstrated the alarm volume control knob. Multiple periods were observed when no staff were present at the nurse’s station to monitor alarms. On 06/17/25 at 2:43 PM, review of the Capnostream Operator’s Manual confirmed alarms can be adjusted louder or softer using the control knob. Conclusion: The hospital failed to ensure staff consistently verified, documented, and maintained audible alarm volumes for patients on continuous pulse oximetry. The lack of practical training, documentation, and monitoring oversight resulted in staff not recognizing P1’s tracheostomy dislodgement promptly, leading to hypoxia and death. These failures placed all patients on continuous pulse oximetry monitoring at risk for serious injury or death.”

“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: 36779 Based on observations, record reviews, interviews, a review of policies and procedures, and a review of manufacturer instructions, the hospital failed to ensure that nursing staff provided continuous pulse oximetry monitoring in a safe environment and failed to provide appropriate wound care services. Specifically, the hospital failed to ensure that alarm volumes for the pulse oximeters had been set at an audible level, that staff received and confirmed education on alarm management, and that adequate staffing was present at the central monitoring station. This failure contributed to Patient #1, one of one patients reviewed with pulse oximetry monitoring, being found unresponsive with a dislodged tracheostomy tube, without the alarm sounding, resulting in hypoxia and death. Appropriate wound assessment and care was not provided for 7 of 22 patients reviewed with pressure ulcers that developed at the hospital, Patients #2, #15, #19, #21, #22, #23, and #25. The findings included: Record Review Patient #1 (P1) On 06/16/25 at 9:50 AM, P1’s record was reviewed with Nurse Manager 15 (NM15). P1 was admitted on 03/11/23 after a stroke. The hospital Discharge Summary (03/25/25) documented that P1 was found unresponsive, a Code Blue was called, and resuscitation was discontinued due to prolonged unresponsiveness. The cause of death was listed as hypoxia at 12:28 PM. Interviews - Leadership Nurse Manager (NM)15 stated staff were expected to document Capnostream alarm settings, but were not doing so. She said, “All alarms should be loud and audible,” and noted that patient names were not entered into the central monitoring system at the desk at the time of P1’s death. DON1 confirmed data from the Capnostream could not be retrieved because names were not entered into the system. NM15 reported post-incident audits showed inconsistent compliance with alarm documentation-improvement in May 2025, followed by decreased compliance in June 2025. She stated staffing shortages prevented consistent coverage at the nurse’s station. Interviews - Direct Care Staff On 06/16/25 at 11:34 AM, CN20 confirmed P1’s alarm was “turned down” when the tracheostomy tube was found dislodged. On 06/16/25 at 3:04 PM, LPN1 (assigned to P1) stated: “When we went in that room, it [alarm] wasn’t going off.” She did not recall receiving training on Capnostream alarms or policies. On 06/17/25 at 8:40 AM, LPN2 confirmed patient names were later entered into the central monitor, but denied awareness of documenting alarm volume settings. On 06/18/25 at 11:05 AM, RN2 stated post-incident education focused only on documenting pulse oximetry use, not alarm volume requirements. Interview - Unit Secretary On 06/17/25 at 11:00 AM, US1 stated she was away from the nurse’s station during P1’s code. She reported her only post-incident education was entering patient names into the monitor, not alarm volume management. Policy Review Review of “Clinical Alarms Management” (effective 02/10/22) showed: 1. Alarms must be activated on admission and verified each shift. 2. Alarm volumes must be audible considering the unit environment noise. Staff must respond immediately to alarms. 3. Alarm parameters cannot be turned off without an advanced practitioner’s order. Education Review On 06/16/25, NM15 provided an undated staff email directing staff to connect Capnostream devices, enter patient information into the central monitor, and set alarms at the highest sound. There was no evidence that staff confirmed receipt of this education. On 06/16/25, NM15 provided a staff “Safety Alert” that identified: failure to rescue due to inaudible alarms; Capnostream monitors defaulting to prior settings; and lack of alarm verification each shift. On 06/19/25 at 4:25 PM, review of “Clinical Orientation Infection Prevention, Quality & Clinical Best Practice for ALL Clinical Team Members” revealed education did not address alarm volume audibility requirements. Observation On 06/17/25 at 11:42 AM, a Capnostream device was observed on the nephrology unit. NM15 features an alarm volume knob that adjusts the volume up or down. During observations, multiple periods were noted when no staff were present at the nurse’s station to attend to the central monitor. Manufacturer’s Manual Review On 06/17/25 at 2:43 PM, review of the Capnostream 20 Operator’s Manual confirmed alarms could be adjusted louder or softer using the control knob, with audible feedback as adjustments were made. Conclusion P1: The hospital failed to ensure that staff consistently set, verified, and documented alarm volumes for continuous pulse oximetry, and failed to provide staff with adequate education and supervision in alarm management. The hospital also failed to ensure the central monitoring station was consistently staffed. These failures resulted in the alarm not sounding when P1’s tracheostomy tube became dislodged, leading to unrecognized hypoxia and death. This deficient practice placed all patients receiving continuous pulse oximetry at risk for serious injury or death. Wound Care: Patient #2 Review of Patient 2’s (P2’s) record on 06/17/25 at 11:40 AM with Nurse Manager 13 (NM13) revealed P2 was admitted to the hospital on 02/14/25 with a diagnosis of gangrene (death of tissue) of right toes. In a concurrent interview with NM13 on 06/17/25 at 11:45 AM, she stated a two-person skin assessment was supposed to be done every shift change by two nurses. Concurrent review of P2’s record revealed multiple instances a two-person skin assessment was not done, including the following shifts (in which AM is 7:00 AM to 7:00 PM and PM is 7:00 PM to 7:00 AM): 2/14/25 PM, 2/15/25 AM, 2/23/25 PM, 2/24/25 PM, 2/25/25 AM and PM, 2/27/25 AM and PM, 2/28/25 PM, 3/1/25 AM and PM, 3/1/25 AM and PM, 3/2/25 AM). NM13 confirmed the findings NM13 stated the expectation was for the nurses to document “what they see” when they do a skin assessment. Review of P2’s record continued with NM13 on 06/17/25 at 12:20 PM and P2’s record was reviewed for turning and repositioning, and for the Braden scores (indicates risk of skin breakdown in which 15-18 is mild risk, 13-14 is moderate risk, and 10-12 is high risk). In a concurrent interview, NM13 stated if the Braden score was less than 18, patients were supposed to be turned and repositioned every two hours. NM13 stated P2 “definitely would have been a q2 (i.e. turn and reposition every two hours).” NM13 reviewed P2’s record and confirmed there were multiple instances from 02/14/25 to 03/02/25 P2 was not turned every two hours. Continued review of P2’s record revealed Braden scores from 02/14/25 to 03/02/25 were as follows: Braden score was 12 and 13 on one day, 14 on four days, 14 and 15 on one day, 14 and 16 on one day, 15 on five days, and 16 on four days. NM13 confirmed there were multiple days and times from 02/14/25 to 03/02/25 (the day the Stage 3 pressure ulcer was discovered) P2 should have been turned every two hours and wasn’t. Continued review of the Flowsheet section of P2’s record on 06/17/25 at 12:20 PM revealed, “...03/02/25 Pressure Injury Right Buttock Distal [away from the trunk of the body] ...Date First Assessed ...03/02/25 ...Stage 3 ...” and “ ...03/03/25 Pressure Injury Right Buttock Proximal [closer to the trunk of the body]...Date First Assessed ...03/03/25 ...Stage 3 ...” There was a wound care order by a Wound Ostomy Certified Nuse (WOCN) dated 03/03/25 which indicated, “Right distal buttock/stage 3, right proximal buttock/stage 3 ...clean with saline and gauze. Pat dry. Apply triple paste twice daily and PRN [as needed] for ruboff.” During an interview and concurrent review of P2’s record with WOCN4 on 06/19/25 at 3:19 PM, she confirmed P2 initially had a fungal rash to her right buttock. WOCN4 confirmed P2 developed two Stage 3 pressure ulcers to the right buttock which were discovered on 03/02/25. WOCN4 stated, “It could happen if the patient wasn’t turned regularly.” 52713 Patient #15 P(15) was admitted on 2/25/25 after a fall. A skin assessment dated 2/25/25 revealed a Braden score of 14. Review of the hospital’s policy “Pressure Injury and/or Surgical Wounds”, dated 6/5/25, revealed information that a braden score of less than 19 requires implementation of pressure injury prevention interventions. Record review revealed the following instances in which P(15) had extended periods of time between turning/repositioning, even though the patient’s braden score indicated risk. 1. On 02/26/25, documentation identified that Patient #15 was turned to right side at 1:45AM and was not repositioned again until 11:00AM. 2. On 02/26/25, documentation identified that Patient #15 was turned to left side at 12:30PM and was not repositioned again until 02/27/25 at 1:00AM. 3. On 02/27/25, documentation identified that Patient #15 was turned to right side at 6:15PM and was not repositioned again until 02/28/25 at 12:43AM. 4. On 03/03/25, documentation identified that Patient #15 was turned to right side at 1:00AM and was not repositioned again until 11:14AM. 5. On 03/03/25, documentation identified that Patient #15 was turned to right side at 12:57PM and was not repositioned again until 10:15PM. 6. On 03/05/25, documentation identified that Patient #15 was turned to right side at 1:23PM and was not repositioned again until 10:45PM. 7. On 03/06/25, documentation identified that Patient #15 was up in a chair with a cushion at 1:44PM and was not repositioned again until 7:20PM. 8. On 03/09/25, documentation identified that Patient #15 was turned to right side at 6:28AM and was not repositioned again until 8:24PM. During an interview on 6/17/25 at 1:00 PM, Nurse Manager (NM) 3 stated that patients with braden scores under 19 would require to be turned at least every three hours. The manager stated, “There are huge gaps in the charting”, and could not give a reason as to why. 28883 Patient #19 P(19) was admitted on 4/8/25 with Sepsis and Respiratory Failure, along with a history of a left Below the Knee (BKA) amputation. An Admission nursing assessment dated 4/8/25 at 5:17 AM documented no wounds to the BKA site. A nursing assessment dated 4/28/25 documented redness to the BKA site. On 4/29/25, Wound Care Registered Nurse (WCRN)1 identified an unstageable pressure ulcer (3.4 cm x 2.1 cm, necrotic tissue) to the area. Review of the medical record revealed there had been no documentation by the floor nurses of the development/progression of the wound or that nursing staff had provided treatment prior to the WCRN seeing the patient on 4/29/25. During an interview on 6/19/25 at 11:08 AM, WCRN1 stated the wound did not just happen overnight and there would have been indication of a wound prior to 4/29/25. WCRN1 stated when s/he saw the patient on 4/29/25, the stump was in contact with the bed. S/he believed the floor nurses had not lifted up the stump to look underneath it to identify a wound. Physician orders dated 4/29/25 at 1:06 PM revealed nursing staff were to clean the wound with normal saline, pat dry, and appply Mepilex 4 x 4 foam and change every 3 days and when needed. The physician orders included to elevate the stump on pillows to keep it off the bed. Review of the medical record revealed nursing staff failed to document the ordered dressing changes/wound treatment had been performed as ordered on 5/2/25 and 5/8/25. Review of nursing documentation to check if the patient’s stump had been elevated on pillows as ordered from 4/29/25 onward revealed “heels” had been elevated but nothing about the stump. During an interview on 6/17/25 at 1:21 PM, the above findings were verified by Nurse Manager (NM)1. Patient #21 P(21) was admitted on 4/25/25 after a motor vehicle accident. An admission nursing skin assessment dated 4/26/25 at 3:30 AM documented no wounds to the ears. On 5/6/25 at 5:29 PM, a wound consult order had been placed for wounds behind the right and left ear. On 5/8/25, a WCRN documented a stage 3 pressure ulcer (pu) to the left ear and an unstageable pu to the right ear, device related from oxygen tubing. Review of flowsheets from 4/26/25 thru 5/10/25, revealed the right and left ears had been documented as “skin intact”, even though a wound consult order had been placed on 5/6/25 for wounds behind the ears and the WCRN had documented stage 3/unstageable pressure ulcers to the ears on 5/8/25. Physician orders dated 5/8/25 at 2:01 PM revealed to clean the ears with normal saline (daily), pat dry, and apply an EZ salter wrap to the oxygen strap.There was no documentation by nursing that the left ear had been cleaned (with normal saline) on 5/10/25 or 5/12/25; or that the right ear had been cleaned on 5/12/25. There were no physician orders prior to 5/8/25 that addressed treatment for the ears and no treatment documented by the nursing staff for the ear wounds prior to 5/8/25; though the wounds had been identified on 5/6/25. Further review of the medical record revealed that the ointment Mupirocin had been documented as applied to the right ear by nursing staff from 5/8/25 through 5/14/25, though this had been ordered for treatment of abrasions and not as treatment for the ears. Review of nursing documentation and flowsheets revealed nothing to indicate the EZ Salter wrap had been applied to the oxygen tubing. Review of Respiratory Therapy documentation revealed nothing to indicate P(21)’s ears had been protected from pressure injury or worsening (with the EZ Salter wrap or other device) once the pressure injuries had developed. During an interview on 6/17/25 at 10:52 AM, the Nurse Practice Coordinator for Critical Care (NPCCC) verified their was inaccuracy in the nursing assessment/flowsheet documentation showing the skin on the ears being intact when the patient had orders for wound consults for the ears. The NPCCC verified the lack of documentation by nursing staff of cleaning the ears with normal saline. During an interview on 6/18/25 at 10:30 AM, the Manager of Adult Respiratory Care and Respiratory Therapist (RT)1 verified the flowsheets and RT documentation did not indicate the placement/use of the EZ Salter wrap device or other ear protection device after it had been ordered. During an interview on 6/19/25 at 11:08 AM, WCRN1 reviewed the physician order for Mupirocin ointment to be applied to “abrasions”, and stated this would not be an appropriate treatment for pressure ulcers to the ears. WCRN1 verified s/he did not know where the EZ Salter device would be documented as applied, and stated it had been ordered and that the floor nurses would have placed the device on the patient tubing. According to WCRN1, the floor nurses should have contacted the phsician for orders for treatment once the ears opened. When asked about the lack of nursing documentation to show how the ear wounds had progressed, the wound nurse stated they stress documentation and s/he is not sure why the floor nurses are not documenting what the wounds look like when they see it. Patient #22 P(22) was admitted on 5/8/25 following motor vehicle accident. P(22) had orders dated 5/8/26 to wear a cervical collar at all times. Review of nursing flowsheets revealed that on 5/24/25 at 7:00 AM, the patient had a chin wound that was described as open, with a black and red wound bed. A nurse to nurse Wound Care Consult was placed on 5/25/25 at 4:21 PM, and a physician ordered wound care consult order had been placed 5/27/25 at 8:35 AM for the Wound Care Nurse to evaluate and treat the chin wound. No treatment had been documented for the chin until seen by the Wound Care RN on 5/27/25 at 11:00 AM (for 3 days); at which time it was documented as unstageable, measuring 2.5 cm (centimeters) x 3 cm with extensive eschar, and device related. Physician orders dated 5/28/25 at 10:36 AM revealed nursing staff were to clean the wound with normal saline, pat dry, cut Mepilex lite to fit over the wound, and change every 3 days and as needed. On 6/10/25, the order was changed to clean the chin wound with normal saline, paint it with betadine, allow it to dry, leave open to air daily. Review of nursing documentation revealed nothing to show that chin wound had been cleaned with normal saline and painted with betadine on 6/12/25, 6/13/25, 6/14/25, 6/15/25, or 6/16/25. During an interview on 6/18/25 at 10:45 AM, Nurse Manager (NM)14 and Assistant Nurse Manager (ANM)9 stated that the wound had been hidden by the patient’s facial hair, and nursing staff had not identified the chin wound until the beard had been timmed on 5/24/25. They stated that nurses can assess the skin on the chin and neck without taking the cervical collar off, and verified the nurse assessments had not reflected any problems until 5/24/25. They verified a delay in identification of the wound and delay in treatment provided; along with the lack of nursing documentation to show that ordered treatments had been provided. Patient #23 P(23) was admitted on 5/12/25 with a Cerebrovascular Accident (CVA). Review of an admission skin assessment dated 5/12/25 at 5:00 AM revealed nothing documented about an alteration in skin integrity for the coccyx. On 5/23/25 at 7:30 PM, a nurse documented a small red open wound to the coccyx and documented the application of barrier cream. On 5/24/25 at 00:47 AM a Wound Care Nurse (WCN) consult order was placed. On 5/24/25 at 8:00 PM, a nurse documented a fragile pink wound, open to air. There had been no physician orders obtained for treatment of the wound. From 5/24/25 at midnight through 5/28/25 at 3:00 PM, nurses documented the area as open to air, with no real description of the wound or documentation of treatment provided. On 5/28/25 at 4:00 PM, the WCN saw the patient and described the coccyx wound as a stage 3, open with yellow slough measuring 1cm x 0.7cm x 0.1cm. S/he had cleaned the wound with bath wipes and applied barrier cream to the wound bed. The WCN had not seen the patient until 4 days after the consult had been ordered. There were no physician orders place for wound care to the coccyx after having been seen by the WCN on 5/28/25. During an interview on 6/17/25 at 4:20 PM, NM6 verfied the findings that the WCN had not seen the patient until the afternoon of 5/28/25. The Manager stated the wound had been identified on Friday night, and the Wound Care Nurses don’t work weekends or holidays; and Monday was Memorial Day. They probably had a full case load and could not see the patient until Wednesday. NM #6 verified that no orders for treatment had been placed for the coccyx wound when identified (on 5/23/25) or after the WCN saw the patient. The NM stated that when a wound is identified by nursing, they put in an order for a Wound Care Nurse consult, and wait for the WCN to write orders for treatment. They would not call the physician to get orders for wound care. During an interview on 6/19/25 at 3:09 PM, the WCNM stated they try to see patients with 48-72 hours, but there is no policy or set timeframe that says how soon they have to see patients once a consult order is written. Patient #25 P(25) was admitted on 4/30/25 with cardiogenic shock. On 5/27/25 at 12:11 PM, a photo of a head wound for P(25), dated 5/17/25, had been scanned into the medical record. There was no documentation in the medical record of a description of the wound, treatment provided,or physician orders from 5/17/25 through 5/26/25. On 5/27/25 at 12:10 AM, a nurse documented the patient had picked and scratched the wound making it bleed. A picture of the bleeding wound dated 5/27/25 had also been scanned into the medical record. The pictures showed an open wound to the scalp. A WCN saw the patient as ordered by consult on 5/27/25, and documented a stage 3 wound to the scalp, measuring 1.5cm x 1.5cm. During an interview on 6/18/25, the ANM of the Marion Unit and Nurse Practice Manager (NPM) of the Heart Hospital verified the findings noted for P(25) related to the lack of identification/description of the wound in the nursing notes, lack of physician orders and lack of documentation of treatment provided for the head wound from 5/17/25 through 5/26/25. The Managers verified that a Wound Care Consult order and treatment should have been provided on identification of the wound. Review of the policy “Pressure Injury and/or Surgical Wounds”, effective 6/5/25 revealed “...Care practices are employed to prevent skin breakdown by assessing for and identifying high risk patients. When identified, interventions to reverse tissue damage, prevent further damage, and maintain an optimal wound environment for healing are utilized... Notify the AP and obtain order for Wound/Ostomy Nurse consult for evaluation and treatment (where available), at minimum for pressure injuries identified as stage 3, stage four, unstageable injuires and deep tissue injuries. An AP order is required for wound treatment, management, or a wound culture. Perform Integumentary (Skin) physical examination at a minimum of every shift. Document any wounds to include characteristics, location, and appearance...Notify AP if there is an undesirable change in a wound...”. Conclusion: The hospital failed to ensure that nursing staff consistently assessed, documented, and intervened to prevent or treat pressure ulcers for 7 patients. Nursing staff were unable to obtain timely provider orders, failed to initiate wound care treatments as ordered, and failed to provide routine repositioning and protective measures. These failures resulted in delayed identification and treatment of multiple Stage 3 and unstageable wounds, placing patients at risk for infection, delayed healing, and harm.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36779 Based on document reviews, record reviews, policy reviews and interviews, the hospital failed to ensure Physician Certification for EMTALA was documented for one of 12 patient records reviewed for transfer from the Emergency Department (ED) to another hospital for Patient 2. Findings included: Review of Patient 2’s record on 03/26/25 at 10:22 AM revealed Patient 2 presented to the ED on 01/02/25 at 8:35 AM with complaints of shortness of breath. The final diagnoses were chronic obstructive pulmonary disease and acute respiratory failure. Patient 2 was transferred to a local sister hospital at 7:05 PM on the same day. Review of the ED Provider Note...ED Course revealed, “...Medical ICU consulted. Patient will be transferred to (name of local sister hospital) ICU. Patient stable at time of transport.” There was no documented evidence of a signed Physician Certification for EMTALA that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risks and no documented evidence of a summary of the risks and benefits upon which that would be based. There was no documented evidence of the receiving facility having the available space and qualified personnel for treatment or that the receiving facility agreed to accept the transfer of Patient 2. Patient 2’s record was reviewed with the ED Nurse Manager (EDNM) 2, Chief Nursing Officer (CNO) and ED Assistant Nurse Manager (EDANM) 1 on 03/27/25 at 10:35 AM. EDNM 1 confirmed the findings stating, “I don’t see one (Physician Certification for EMTALA.) On 03/27/25, review of the hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA)...” dated 10/22/24 revealed, “...6. Patient Transfers...6.2.2. An individual with an EMC that has not been stabilized may be transferred if the transfer is appropriate as defined by EMTALA, and...If a physician certifies in writing that based on the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual...A summary of the risks and benefits upon which the decision is based must be included...6.3...A transfer to another medical facility will be appropriate in those cases in which...the receiving hospital has agreed to accept the transfer...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 22198 Based on Emergency Department (ED) medical record reviews, interviews, transfer documents reviews, Emergency Medical Treatment and Labor Act (EMTALA) policy review, and staff’s EMTALA education and competency, the hospital failed to ensure EMTALA laws and hospital EMTALA policy were followed for all patients seeking emergency medical care in their hospital. This failure prevented the hospital from meeting the requirements for compliance with 42 CFR 489.20 and 42 CFR 489.24. Findings include: 1. The hospital failed to provide an appropriate medical screening exam for one of four obstetric patients (Patient (P)1) out of a total sample of 21 patients reviewed. Cross Reference: A2406 Appropriate Medical Screening Examination. 2. The hospital failed to: 1. have completed accurate transfer documentation for two of four patients (Patient) (P)2 and P15) reviewed for transfer to another acute care hospital, and 2. failed to care for their Emergency Department (ED) patients needing inpatient services when the hospital had the capability and capacity of transferring one of four patients (Patients (P)15) reviewed for transfer their Emergency Department (ED) to another acute care hospital in the Prisma Health system out of a total sample of 21 ED patients. Cross Reference: A2409 Appropriate Transfers. 5. Review of the Corporate Compliance training section, which was reviewed every two years, revealed the training all hospital staff received consisted of five slides, which were related to the money penalties involved with EMTALA violations. Two of the post training questions after the five EMTALA training slides were related to the money penalties related to EMTALA violations. During an interview on 03/12/25 at 10:30 AM, the Director of Clinical Education, the Associate Chief Nursing Officer (CNO) and the Clinical Care Experience Director-Richland Department of Clinical Care Experience confirmed that the “Corporate Compliance” training was the only training all hospital staff received every two years, with the exception of the additional training and competencies on EMTALA law provided during onboarding for each new ED nursing staff. Review of the ED staff competencies as follows: 1. Review of ED Director of Operation Emergency Services (DO-ES) personnel file revealed he/she received Corporate Compliance training last completed 07/17/24. 2. Review of ED Patient Support Technician (PST) 1’s personnel file revealed ED-PST1 received Corporate Compliance (the five slide EMTALA education) on 05/27/24. No other EMTALA training or competency was found in ED PST1’s personnel file. 3. Review of Obstetric (OB) RN1’s personnel file revealed OB-RN1 received Corporate Compliance training (the five slide EMTALA education) on 06/14/24. No other EMTALA training or competencies was found in OB-RN1’s personnel file. 4. Review of Obstetric (OB) RN2’s personnel file revealed, OB-RN2 received Corporate Compliance training (the five slide EMTALA education) on 08/28/24. No other EMTALA training or competencies was found in OB-RN2’s personnel file. 5. Review of Obstetric (OB) RN3’s personnel file revealed, OB-RN3 received Corporate Compliance training (the five slide EMTALA education) on 06/13/24. No other EMTALA training or competencies was found in OB-RN3’s personnel file. 6. Review of Obstetric (OB) RN4’s personnel file revealed, OB-RN4 received Corporate Compliance training (the five slide EMTALA education) on 06/01/24. No other EMTALA training or competencies was found in OB-RN4’s personnel file. 7. Review of Obstetric (OB) RN6’s personnel file revealed, OB-RN6 received Corporate Compliance training (the five slide EMTALA education) on 06/16/24. No other EMTALA training or competencies was found in OB-RN6’s personnel file. 8. Review of Obstetric (OB) RN7’s personnel file revealed, OB-RN7 received Corporate Compliance training (the five slide EMTALA education) on 08/16/24. No other EMTALA training or competencies was found in OB-RN7’s personnel file. 9. Review of Obstetric (OB) RN8’s personnel file revealed, OB-RN8 received Corporate Compliance training (the five slide EMTALA education) on 07/16/24. No other EMTALA training or competencies was found in OB-RN8’s personnel file. 10. Review of OB Surgical Technician (ST) (OB-ST1) personnel file revealed, OB-ST1 received Corporate Compliance training (the five slide EMTALA education) on 08/25/24. No other EMTALA training or competencies was found in OB-ST1’s personnel file. During an interview on 03/12/25 at 10:30 AM the above lack of EMTALA law training, education, and competencies for ED and OB staff was confirmed by the Director of Clinical Education. Review of the EMTALA training provided for by the contracted security staff (SS) 1 revealed the training consisted of a sixteen slide EMTALA training that discuss in plain language what EMTALA law consisted of and included application of EMTALA law scenarios and test questions. During an interview on 03/12/25 at 11:30 AM, the Associate CNO (also present was the Clinical Care Experience Director-Richland Department of Clinical Care Experience) confirmed that he/she understood, that the contracted security had a more in depth EMTALA training for the non-clinical security staff containing 16 slides versus the hospitals’ “Corporate compliance” five slide training.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 22198 Based on observations, interviews, and policy review, the facility failed to ensure the appropriate Emergency Medical Treatment and Labor Act (EMTALA) signage was displayed in areas where patients would be able to read it and know their EMTALA rights. Findings include: Observations on 03/10/25 at 9:26 AM while touring in the Emergency Department (ED) revealed two patient waiting areas, one was identified for the pediatric emergencies and the other side was for adult emergencies. Further observations revealed the pediatric side contained EMTALA signage. The ED was broken into color coded zones with a total of sixty-nine bays. Observations of the ED revealed EMTALA signage (notice of rights) was not displayed in places likely to be seen by patients upon entering the ED. During an interview on 03/10/25 at 9:26 AM, the Associate Chief Nursing Officer (A-CNO) confirmed that the ED lacked signage Observations on 03/10/25 at 10:16 AM during a tour revealed no signage was seen in the triage areas or rooms of the Labor and Delivery (L&D) unit where obstetric (OB) patients seeking emergency medical care would be likely to notice the EMTALA signs to see, read and know their rights. During an interview on 03/10/25 at 10:16 AM, the A-CNO confirmed that there was no EMTALA signage in the L&D unit triage area or rooms where OB patients seeking emergency medical care would come for triage and their Medical Screening Exam to rule in or out an Emergency Medical Condition. Review of the hospital’s policy titled “Emergency Medical Treatment and Labor Act (EMTALA): Prisma Health” last reviewed 10/22/24 revealed, “Signage will be posted conspicuously in the DED [dedicated emergency department], as well as those individuals waiting for examination and treatment in areas located on hospital property other than the DED (e.g., labor and delivery, waiting room, admitting area, entrance, and treatment areas).””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 22198 Based on review of the Emergency Department (ED) log including the Obstetric ED cases, interviews, and policy review, the facility failed to register one of a total sample of 21 patients (Patient (P) 1) seeking Emergency care on their ED log. This failure to maintain a log of all obstetric patients seeking emergency medical care placed all obstetric patients at risk. Findings include: During a telephone interview on 03/10/25 at 10:23 AM, P1 stated he/she had come to the hospital ED to seek emergency medical care for possible premature labor, with a complaint of nausea vomiting and stomach pain. P1 stated he/she first went to the ED registration, but in the ED only entered his/her social security number to verify P1 was in the system. Because P1 was greater than 16 weeks pregnant, P1 was told he/she would need to be triaged and screened in the Labor and Delivery Unit (L&D). P1 was placed in a wheelchair with his/her toddler and wheeled up to L&D by an ED staff (later identified as Patient Support Technician (PST) 1). During our interview P1 stated that at the registration desk, “I was yelled at by a staff [in L&D] with black hair and green scrubs.” P1 went on to state that the L&D staff told him/ her could not be seen in L&D because P1 had a toddler, and the hospital had a new policy since December, no one under the age of 16 was allowed in the hospital. P1 stated, “I was in pain and nauseated and uncertain if I was in premature labor and was so taken back and upset with the unprofessional demeanor of the [L&D] staff yelling at me because I had my toddler, not caring that I could lose my unborn baby. I had no one to call to get my toddler, I just started crying and could not speak. When I tried to walk out the way I came up, the same staff yelled at me that I could not use those elevators because they were staff elevators. The ED staff was there with a wheelchair and offered to take me back down in the wheelchair and the L&D staff stated told the ED technician [PST1] that he/she should not wheel me down, that I should walk.” Review of security video for 02/15/25 the date P1 identified coming into the ED to seek emergency medical care revealed: At 2:55 PM P1 and his/her toddler were observed past Security Staff (SS) 1. At 2:57 PM P1 and toddler were at the Unit secretary directed to the registration desk. At 2:59 PM P1 interacted with ED Registered Nurse (RN) 1. ED-RN1 was observed making a call (later identified as a courtesy call to L&D that P1 was being sent up to their department) at 3:00 PM. At 3:01 PM P1 was observed in a wheelchair with a Patient Support Technician (PST) 1. At 3:02 P1 was wheeled out of ED and up to L&D, using the “yellow zone” elevator at 3:03 PM P1 was on the elevator. No video was available for the L&D unit. During an interview of 03/10/25 at 4:15 PM, ED-RN1 stated “I do not remember his/her name, but I do remember this day, per our protocol I asked [P1] to enter in his/her social security number that brought up [P1’s] information to confirm that [P1] was in our hospital’s record system.” ED-RN1 stated, “I did not continue with registration because [P1] stated he/she was greater than 16 weeks and explained his/her symptoms, per the hospital protocol, I had [P1] go up to L&D for the triage and MSE [Medical Screening Exam].” ED-RN1 stated “I made a courtesy call” to L&D to let them know P1 was coming. ED-RN1 stated registration was fast, the patient just needed to enter their social security number, and it brings up all the demographics for that patient if they are in their system and we verify that. ED-RN1 confirmed P1 was in the hospital’s medical record system. During an interview on 03/10/25 at 3:55 PM, PST1 stated that he/she had taken P1 up to the fourth floor L&D on 02/15/25 through the back staff elevators (identified as the yellow zone elevators) and P1 had a toddler. P1 had complained of abdominal cramping and pain was her chief complaint and was worried she was going to deliver prematurely. The Charge RN (OB-RN1) told him/her to leave P1 at registration, and then he/she went back down to the ED. “I had to return to L&D with another patient when I saw [P1] was trying to leave, and was distraught, crying and saying they would not take care of him/her because he/she had his/her three-year-old with him/her.” During an interview on 03/12/25 at 4:02 PM, the Obstetric Registered Nurse (OB-RN) 1 confirmed he/she was the Nurse in Charge on the L&D Unit on 02/15/25 who engaged P1 to registered P1 for triage. OB-RN1 confirmed P1 was not registered P1 because P1 did not fill out the information on their registration clipboard. OB-RN1 confirmed that they just needed a patient’s social security number to pull up all their information. When asked why P1 was not logged into their emergency department log on 02/15/25, OB-RN1 stated “P1 did not fill out the clipboard information.” Review of the Emergency Department log that included obstetrics for 02/15/25 from 00:01 AM to 11:59 PM revealed P1 was not entered into the ED log. During an interview with on 03/10/25 at 3:00 PM, the Associate Chief Nursing Officer (ACNO) and the Clinical Care Experience Director-Richland Department of Clinical Care Experience confirmed P1 was not on the ED log in the ED or OB. Review of the hospital’s policy titled “Emergency Medical Treatment and Labor Act (EMTALA): Prisma Health” last reviewed 10/22/24 revealed, “Central log is a log that a hospital is required to maintain on each individual who comes to the hospital seeking assistance. The purpose of the central log is to track the care provided to each individual where EMTALA triggered. ... Each department where medical screening occurs will maintain an EMTALA Central Log, which includes the following required elements: 4.3.1 Whether the patient refused treatment, 4.3.2 Whether the Patient was refused treatment, 4.3.3 Whether the patient was transferred, admitted, and treated, stabilized and transferred or discharged.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 22198 Based on interviews, medical record review, and policy review, the hospital’s emergency department (ED) failed to provide an appropriate medical screening examination (MSE) when it failed to follow their ED policies for triage and assessment for anyone seeking emergency medical care for one of four ED obstetric (OB) patients (Patients (P)1 and for one of 17 ED patients (P13) out of a total sample of 21 patients. The failure to triage and assess each patient seeking emergency medical care on the Labor and Delivery (L&D) unit and ED had the potential to delay care and treatment for all ED and those patients sent to L&D and resulted in delayed emergency care and treatment for P1. Findings include: 1. During a telephone interview on 03/10/25 at 10:23 AM, P1 stated he/she had come to the hospital ED to seek emergency medical care for possible premature labor, with a complaint of nausea vomiting and stomach pain. P1 stated he/she first went to the ED registration, but in the ED only entered his/her social security number to verify P1 was in the system. Because P1 was greater than 16 weeks pregnant, P1 was told he/she would need to be triaged and screened in the Labor and Delivery Unit (L&D). P1 was placed in a wheelchair with his/her toddler and wheeled up to L&D by an ED staff (later identified as Patient Support Technician (PST) 1). During our interview P1 stated that at the registration desk, “I was yelled at by a staff [in L&D] with black hair and green scrubs.” P1 went on to state that the L&D staff told him/ her could not be seen in L&D because P1 had a toddler, and the hospital had a new policy since December, no one under the age of 16 was allowed in the hospital. P1 stated, “I was in pain and nauseated and uncertain if I was in premature labor and was so taken back and upset with the unprofessional demeanor of the [L&D] staff yelling at me because I had my toddler, not caring that I could lose my unborn baby. I had no one to call to get my toddler, I just started crying and could not speak. When I tried to walk out the way I came up, the same staff yelled at me that I could not use those elevators because they were staff elevators. The ED staff was there with a wheelchair and offered to take me back down in the wheelchair and the L&D staff stated told the ED technician [PST1] that he/she should not wheel me down, that I should walk.” Review of security video for 02/15/25 the date P1 identified coming into the ED to seek emergency medical care revealed: At 2:55 PM P1 and his/her toddler were observed past Security Staff (SS) 1. At 2:57 PM P1 and toddler were at the Unit secretary directed to the registration desk. At 2:59 PM P1 interacted with ED Registered Nurse (RN) 1. ED-RN1 was observed making a call (later identified as a courtesy call to L&D that P1 was being sent up to their department) at 3:00 PM. At 3:01 PM P1 was observed in a wheelchair with a Patient Support Technician (PST) 1. At 3:02 P1 was wheeled out of ED and up to L&D, using the “yellow zone” elevator at 3:03 PM P1 was on the elevator. No video was available for the L&D unit. During an interview of 03/10/25 at 4:15 PM, ED-RN1 stated “I do not remember his/her name, but I do remember this day, per our protocol I asked [P1] to enter in his/her social security number that brought up [P1’s] information to confirm that [P1] was in our hospital’s record system.” ED-RN1 stated, “I did not continue with registration because [P1] stated he/she was greater than 16 weeks and explained his/her symptoms, per the hospital protocol, I had [P1] go up to L&D for the triage and MSE [Medical Screening Exam].” ED-RN1 stated “I made a courtesy call” to L&D to let them know P1 was coming. ED-RN1 stated registration was fast, the patient just needed to enter their social security number, and it brings up all the demographics for that patient if they are in their system and we verify that. ED-RN1 confirmed P1 was in the hospital’s medical record system. ED-RN1 stated that after hearing the concerns PST 1 stated were expressed by P1 from his/her experience of being refused care in the L&D unit for having a toddler with him/her, ED-RN1 stated he/she went to his/her ED Associate Manager -Nursing, who documented the potential EMTALA concerns and sent them to the Director of Operation Emergency Services. Review of the email sent from ED Associate Manager -Nursing to Director of Operation Emergency Services on 02/15/25 at 5:17 PM revealed, P1 “did not have a choice and had to bring his/her toddler” P1 “was in tears” the ED-RN (1) who sent P1 to L&D called up to L&D to talk with the L&D RN (OB-RN1) “was rude ... making comments like ‘Why isn’t she going to Lexington then?” A previous encounter occurred with the L&D staff when a patient 36 weeks pregnant with twins taken to L&D there where “3 [sic] staff members at the desk had an attitude” about signing in the 36-week pregnant with twins patient. During an interview on 03/10/25 at 4:30 PM, the ED Manager confirmed he/she was not aware of the incident with P1, or the email sent from ED Associate Manager -Nursing to the Director of Emergency Services on 02/15/25. During an interview on 03/11/25 at 2:09 PM, the Director of Operations for Emergency Services was asked if the internal concerns voiced by PST1, ED-RN1 and sent to him/her by the Director of Operations for Emergency Services were addressed and reviewed under EMTALA law violations. The Director of Operations for Emergency Services stated it was not an EMTALA violation because it happened in the ED. The Director of Operations for Emergency Services confirmed that he/she did not know that EMTALA laws covered L&D or anywhere that a patient presented on the hospital grounds seeking emergency medical care. The Director of Operations for Emergency Services confirmed the concerns brought forward by his/her staff regarding P1 had not been addressed. The Director of Operations for Emergency Services confirmed the only EMTALA training he/she has received was from their online “Corporate Compliance” training. During the following interviews on 03/11/25 the following OB-RNs confirmed that the only EMTALA training they received online “Corporate Compliance” training that included “EMTALA” that did not include competencies but did include test questions at the end. OB-RN2 03/11/25 at 11:00 AM OB-RN3 03/11/25 at 10:47 AM OB-RN4 03/11/25 at 10:04 AM OB-RN6 03/11/25 at 10:25 AM Review of the Corporate Compliance training section that was the only EMTALA training L&D received every two years and what the entire hospital, including ED staff, received every two years after their onboarding was completed included five training slides. Two of the post training questions after the five EMTALA training slides were related to the violations and money penalties involved with EMTALA violations. During an interview on 03/12/25 at 10:30 AM, the Director of Clinical Education, the Associate Chief Nursing Officer (ACNO) and Clinical Care Experience Director-Richland Department of Clinical Care Experience confirmed that the “Corporate Compliance” training was the only training all hospital staff received every two years, with the exception of the additional training and competencies on EMTALA law provided during onboarding for each new ED nursing staff. During an interview on 03/12/25 4:02 PM the Obstetric Registered Nurse (OB-RN) 1 confirmed he/she was the Nurse in Charge on the L&D Unit on 02/15/25 who registered P1. OB-RN1 confirmed he/she did not register or triage P1 on 02/15/25. OB-RN1 confirmed P1 was not seen by a qualified medical professional (QMP) to have an MSE performed on P1 to ensure that a medical emergency was ruled in or out. OB-RN1 confirmed that he/she was aware P1 was leaving the unit and told P1 he/she could not leave on the same elevator he/she came up on. OB-RN1 stated he/she did not document P1 had come to the L&D seeking emergency medical care. During an interview on 03/10/25 at 3:00 PM the Associate Chief Nursing Officer (ACNO) and the Clinical Care Experience Director-Richland Department of Clinical Care Experience confirmed P1 was not on the ED or OD/ED log and that there was not a medical record for P1 on 02/15/25 and no MSE was performed for P1 who came to the ED seeking emergency medical care. 2. Review of the ED record revealed P13, a 13-year-old came to the ED seeking emergency medical care on 10/28/24 at 10:09 PM with a chief complaint of “chest pain.” Review of the ED notes failed to include the RN triage or a medical screening exam (MSE) by the QMP to determine if chest pain was cardiac related. The only note found in the medical record was that P13 was not in the ED at 10:28 (19 minutes) from the time P13 came to the ED seeking emergency medical care for chest pain. During an interview 03/12/25 at 2:00 PM the Medical Record Navigator, the Associate Chief Nursing Officer (ACNO) and the Clinical Care Experience Director-Richland Department of Clinical Care Experience confirmed there was no documentation from the ED RN or QMP in P13’s ED medical record. The ACNO confirmed that it is not the ED standard to wait 19 minutes for an RN to triage a patient that complains about chest pain, usually they are “seen right away.” Review of hospital’s policy titled Emergency Medical Treatment and Labor Act (EMTALA): Prisma Health” “last reviewed” 10/22/24, revealed “Hospitals with a dedicated emergency department (ED) must provide to any individual including any infant born alive at any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition (EMC) exists ... EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care on hospital property ...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 22198 Based on interviews medical record reviews, hospital bed capability, transferring data, hospital capability and capacity data, and policy and procedure the hospital failed to 1. have completed and accurate transfer documentation for two of four patients (P) (P2 and P15) transferred to another acute care hospital, and 2. failed to care for their Emergency Department (ED) patients (P) needing inpatient services when the hospital had the capability and capacity by transferring one of four (P15) transfer reviewed from their Emergency Department (ED) to another acute care hospital in the Prisma Health system, a total of 21 ED medical records were reviewed. This failure to provide care in the hospital where the patient was treated in the ED, when it has both capability and capacity places all patients being transferred at risk for delays in care and treatment. Findings include: 1. a. Review of the ED medical record for P2 revealed P2 arrived at the ED on 02/24/25 at 8:31 AM via emergency medical service (EMS) and presented with “Altered Mental Status Stroke-like symptoms.” After stabilizing care was completed, the ED physician’s decision was to transfer P2 to another acute care hospital. No signed or documented “Physician Certification” was found in P2’s transfer that included verification of a physician-to-physician consultation, a nursing-to-nursing consultation, and/or the risk and benefits if the patient and/or family accepted or refused the transfer. No physician’s order to transfer was found and the hospital failed to obtain “consent to transfer” signed by P2 and/or the family member. b. Review of the ED medical record for P15 revealed P15 arrived at the ED on 02/21/25 at 3:59 PM with no chief complaint noted by emergency medical services (EMS) of “Stroke/TIA stroke” (a medical condition where blood flow to the brain is interrupted, leading to brain damage or death). After care was completed, the ED physician decided to transfer P15 to another acute care hospital. The hospital failed to obtain “consent to transfer” signed by P15, and no physician’s order to transfer was found. During an interview on 03/12/25 at 3:30 PM, the Medical Record Navigator, Clinical Care Experience Director-Richland Department of Clinical Care Experience, and the Associate Chief Nursing Officer (ACNO) confirmed the above information was missing from the patients’ records who were transferred to Prisma Baptist Hospital. 2. Review of P15’s ED medical record revealed P15 came to the ED on 02/20/25 at 5:30 PM via ambulance with a chief complaint of “Cerebrovascular Accident” (commonly known as a stroke, a medical condition where blood flow to the brain is interrupted, leading to brain damage or death). The physician’s note documented on 02/22/2025 5:40 PM for discharge disposition: “Patient was reevaluated. The results and disposition were discussed. Disposition: Admit: The decision to elevate care was made and plan is for admission to the hospital. Given capacity, transfer to Baptist for admission to the BIMA with neuro to follow.” Review of the census and bed capacity for Patient Care Unit (PCU) at Prisma Richland equivalent to the PCU unit that P15 was sent to at Prisma Baptist hospital revealed Prisma Richland’s PCU identified at 10 West was staffed for twenty-eight beds and indicated twenty-seven beds were occupied. The hospital had one bed available. During an interview on 03/12/25 at 3:42 PM the Associate Chief Nursing Officer (ACNO) and the Clinical Care Experience Director-Richland Department of Clinical Care Experience who provided the census, bed count, and staffed beds information for all the transfers reviewed and confirmed for the 02/20/25 the date P15 was transferred from Prisma Richland to Prisma Baptists the PCU was at 96% capacity but had one bed available and was staffed to accommodate the admission. Review of a twelve-month February 2024 to February 2025 revealed the following: February 2024 out of the 144 transfers 43 patients were transferred to Prisma Baptist (29.9%) March 2024 out of the 164 transfers 68 patients were transferred to Prisma Baptist (41.4%) April 2024 out of the 126 transfers 44 patients were transferred to Prisma Baptist (34.9%) May 2024 out of the 152 transfers 61 patients were transferred to Prisma Baptist (40.1%) June 2024 out of the 140 transfers 66 patients were transferred to Prisma Baptist (41.1%) July 2024 out of the 166 transfers 75 patients were transferred to Prisma Baptist (45.2%) August 2024 out of the 180 transfers 84 patients were transferred to Prisma Baptist (46.6%) September 2024 out of the 171 transfers 73 patients were transferred to Prisma Baptist (42.7%) October 2024 out of the 133 transfers 60 patients were transferred to Prisma Baptist (45.1%) November 2024 out of the 136 transfers 75 patients were transferred to Prisma Baptist (55.1%) December 2024 out of the 119 transfers 44 patients were transferred to Prisma Baptist (37%) January 2025 out of the 150 transfers 66 patients were transferred to Prisma Baptist (44%) February 2025 out of the 132 transfers 77 patients were transferred to Prisma Baptist (58.3%) During an interview on 03/11/25 at 3:00 PM with the ACNO, who provided the transfer documentation, confirmed that the highest number of transfers for each of the 12 months are to Prisma Baptist. The ACNO confirmed that Prisma Richland Hospital has more services and a larger capacity than Baptists. During an interview on 03/11/25 at 11:32 AM the Interim Division Chief Pulmonary, Critical Care, and Sleep Medicine stated, “when we initiated the internal transfers in August of 2022, there were concerns brought forward, it was new, and there were safety concerns, and criteria. It was an adjustment. Prisma Richland Hospital’s Intensive Care Unit (ICU) is consulted and determine if we have capability and capacity, but patient safety is number one.” Interim Division Chief Pulmonary, Critical Care, and Sleep Medicine, verified there are times the hospital has capacity but each case is individually reviewed by the critical care team to make that decision, considering patient safety first. During an interview on 03/11/25 at 12:01 PM the ED Assistant Director stated, “I am not aware of any complaints regarding our transfers. Our process is to consult ICU, to determine if the patient can be treated at a sister facility [within the Prisma Health system].” When asked if there is a bed open at this hospital why don’t the patients stay here? The ED Assistant Director stated that because we have ICUs at other hospitals, we rely on “bed board” people to let us know where (within our system) beds are available [to transfer patients to]. Review of the hospital’s policy titled “Transferring and Accepting Patients from Another Facility, including a Prisma Health Hospital: Prisma Health” effective date 04/27/22 revealed “In preparation for and prior to transfer, the appropriate communication and documentation must be completed. ... When it has been determined that a patient needs to be transferred to another facility, the physician will: Explain to the patient the risks and benefits of transfer. Obtain the consent to transfer. The “Transfer Consent” section of the form will be completed and placed in the patient’s medical record. Complete the EMTALA/Transfer to another facility - Section 1: Physician Certification. Contact the Transfer center to identify a physician at the facility who is on-call to accept the patient. The transferring physician will speak with accepting physician to transfer. The sending physician will be responsible for any orders for anticipated treatment or medications needed during transport. EMTALA/electronic document-Transfer to another facility Section 2: Nurse Certification” Review of the hospital’s policy titled “ Emergency Medical Treatment and Labor Act (EMTALA): Prisma Health” effective date 10/22/24, reveled, “Appropriate Transfer occurs when: (i) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health ... and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual to provide appropriate medical treatment; ... the transferring hospital sends to the receiving hospital ... the informed written consent for transfer or certification ... Capability means that an organization has the physical space, equipment, supplies, and services including ancillary services available at the hospital. The capabilities of the hospital’s staff mean the level of care that the hospital’s personnel can provide within the training and scope of their professional licenses. The hospital is responsible for treating the individual within the capabilities of the hospital as a whole, not necessarily in terms of the particular department at which the individual presented. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity encompasses the number and availability of qualified staff, beds, equipment, and the hospital’s past practices-of accommodating additional patients in excess of its occupancy limits, including if the hospital has customarily accommodated patients by, for example, moving patients to other units, calling in additional staff , or borrowing equipment from other facilities.””

“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: 28883 Based on record review and interviews, the hospital failed to implement a discharge planning process that ensured an effective transition for Patient #28 from hospital to post-discharge care (one of one patients with a lab that was outstanding on discharge). The findings included: Cross Reference to A 0813: The hospital failed to ensure that pertinent information about a pending lab result that required follow-up and medical treatment for Patient #28 had been communicated to the patient’s outpatient neurologist.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28883 Based on record reviews, interviews, and review of the policy “Pressure Injury Prevention”, hospital nursing staff failed to ensure “As Needed” blood pressure medications had been administered to maintain blood pressure at goal range for Patients #20 and #21, 2 of 15 patients reviewed for medication administration with parameters. Nursing staff failed to document turning and repositioning of Patients #5, #13, #20, #21 and #26, five of 20 patients reviewed with limited mobility. The findings included: The hospital admitted Patient #20 on 7/20/24 with diagnoses including Cerebral Infarction due to embolism of the right middle cerebral artery. Record review on 12/3/24 at 10:30 AM revealed physician orders for Patient #20 dated 7/21/24 through 7/24/24 for a systolic blood pressure goal of less than 160 mm/Hg (millimeters/Mercury). Review on 12/4/24 at 12:03 PM of nursing flow sheet documentation revealed systolic blood pressures for Patient #20 that were over the systolic blood pressure goal of 160 mm/Hg. The following blood pressures and pulse rates had been documented for 7/24/24: At 10:14 AM- 184/94, pulse 73, at 11:00 AM- 176/87, pulse 63, at 12:00 noon- 171/86, pulse 68, at 1:00 PM- 179/86, pulse 70, at 2:00 PM-178/83, pulse 73, at 2:15 PM- 178/83, pulse 76. Patient #20 had physician orders in place for PRN (As Needed) blood pressure medication that had not been administered as ordered to maintain the systolic blood pressure at the goal of less than 160. The medication Labetalol 10 mg (milligrams) IV (intravenous) had been ordered from 7/23/24 at 7:11 PM through 7/25/24 at 1:31 PM, every hour as needed to maintain the blood pressure goal. The labetalol had been administered on 7/24/24 at 10:14 AM but not again until 2:15 PM even though the blood pressure had been documented over the 160 mm/Hg systolic goal. The finding was verified by Nurse Manager #1 during an interview on 12/4/24 at 12:15 PM. Review on 12/4/24 at 11:17 AM revealed nursing flows that documented Patient #20 had been turned/repositioned on 7/23/24 at 5:00 AM by nursing staff. The flowsheets documented the patient had been turned/repositioned by nursing staff next on 7/23/24 at 7:00 PM, which was 14 hours later. The finding was verified by Nurse Manager #1 during an interview on 12/4/24 at 11:20 AM. Review on 12/6/24 at 1:51 PM of flowsheet documentation revealed Patient #20’s mobility had been documented as “slightly limited” on 7/23/24. The documentation was verified by Registered Nurse #2 during an interview on 12/6/24 at 1:52 PM. Review on 12/6/24 at 1:35 PM of the policy “Pressure Injury Prevention”, revised February 20,2024, revealed that “slightly limited” mobility meant “Patient makes frequent (although slight) changes in body or extremity position independently”. The hospital admitted Patient #21 on 11/26/24 with diagnoses including Acute Ischemic Left MCA (Middle Cerebral Artery) Stroke. Review on 12/6/24 at 11:15 AM revealed physician orders to treat blood pressure with ordered medications to maintain blood pressure stroke goal, which on 11/26/24 at 02:46 AM, had been ordered to be maintained at less than 160 mm/Hg (millimeters of mercury) systolic blood pressure. Review of documented blood pressures and the medication administration record revealed Patient #21 had systolic blood pressures greater than 160 mm/Hg (millimeters of mercury) documented on 11/28/24 between 12:00 noon and 2:00 PM that had not been treated with ordered PRN (As needed) blood pressure medication to maintain the stroke blood pressure goal. On 11/28/24 the following blood pressures/pulse rates had been documented for Patient #21: at 12:00 noon 213/96, pulse 93; At 12:30 PM, 180/82, pulse 93; At 12:45 PM 191/88, pulse 90, At 1:00 PM 176/82, pulse 88; At 1:30 PM 193/90, pulse 92; At 1:45 pm 184/86, pulse 95, and at 2:00 pm 172/81, pulse 90. The patient had orders for intravenous labetalol 10 mg (milligrams) every hour as needed and intravenous hydralazine 10 mg every hour as needed; both medications to maintain stroke blood pressure goal but not documented as administered during this time frame. During an interview on 12/6/24 at 11:45 AM, Registered Nurse #2 reviewed the record and verified the finding. Review of nursing flowsheets on 12/6/24 at 11:50 AM revealed documentation that Patient #21 had been turned on 11/27/24 at 9:00 PM but not again until 11/28/24 at 8:00 AM (11 hours). The finding was verified with Registered Nurse #2 during an interview on 12/6/24 at 11:52 AM. Record review on 12/6/24 at 1:48 PM of flowsheet documentation revealed Patient #21’s mobility status was very limited to completely immobile from 11/26/24 through 11/28/24. The documentation was verified by Registered Nurse #2 during an interview on 12/6/24 at 1:49 PM. Review on 12/6/24 at 1:35 PM of the policy “Pressure Injury Prevention”, revised February 20, 2024, revealed that “very limited” mobility meant “Patient makes occasional slight changes in body or extremity position, but can’t make frequent or significant changes independently”. “Completely immobile” meant “Patient doesn’t make even slight changes in body or extremity positions without assistance.” According to the policy, prevention is the key to avoiding extensive therapy, with preventive measures listed which included ensuring mobility to relieve pressure and promote circulation. The policy included information to turn and reposition the patient regularly and frequently unless contraindicated. Base the frequency of repositioning on the patient’s tissue tolerance, skin condition, mobility, medical condition, and treatment goals. 36779 Review of Patient #5’s record on 12/04/24 at 10:06 AM revealed Patient #5 was admitted to the hospital on 10/16/24 with a diagnosis of stroke. Review of the nursing assessments dated 11/10/24 at 8:00 AM, 12:00 PM, 4:00 PM and 10:47 PM revealed Patient #5 had paralysis of both upper extremities (arms) and an “Absence of movements ...” Review of the nursing flowsheets dated 11/10/24 revealed no documented evidence Patient #5 was turned from 10:00 AM until she/he was moved to another unit at 10:23 PM (over 12 hours). In a concurrent interview with Registered Nurse (RN) #1, she/he confirmed the findings. Review of Patient #13’s record on 12/05/24 at 2:25 PM revealed Patient #13 was admitted to the hospital on 11/06/24 with a diagnosis of small bowel obstruction. Review of the nursing flowsheets dated 11/10/24 revealed no documented evidence Patient #13 was turned from 11/10/24 at 12:36 PM until 4:57 PM (over four hours) and then from 4:57 PM until 10:30 PM (over five hours). In a concurrent interview with RN #1, she/he confirmed the findings. Review of Patient #26’s record on 12/06/24 at 11:31 AM revealed Patient #26 was admitted to the hospital on 10/22/24 with a diagnosis of subdural hematoma (a serious condition involving bleeding in the brain). Review of the nursing flowsheets dated 11/06/24 and 11/07/24 revealed Patient #26 was not able to move independently and required repositioning. Review of the nursing flowsheets also revealed no documented evidence Patient #26 was turned from 11/06/24 at 4:46 PM until 11/07/24 at 8:30 AM (over 15 hours). In a concurrent interview with RN #1, she/he confirmed the findings. In an interview with RN #1 on 12/06/24 at 12:36 PM she/he stated the hospitals policy for turning dependent patients was usually every two to three hours.”

“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: 28883 Based on record review and interviews, the hospital failed to ensure that pertinent information about a pending lab result that required follow-up and medical treatment for Patient #28, (one of one patients reviewed who had lab results outstanding upon discharge), had been communicated to the patient’s outpatient neurologist. The findings included: The hospital admitted Patient #28 on 10/24/24. Diagnoses on discharge included Cerebral Infarction and unspecified Degenerative Disease of the Nervous System. Patient #28 was discharged from the hospital to a skilled nursing facility for rehabilitation on 11/8/24. Review of grievances on 12/4/24 at 10:10 AM revealed an e-mail had been submitted on behalf of Patient #28 by his/her daughter-in-law to the hospital on 11/9/24 stating the patient had been discharged on 11/8/24, and that s/he (daughter-in-law) had discovered a lab result on 11/8/24 while reviewing the patient’s “My Chart” (computer/phone application where medical test results are posted and communication is possible from hospital medical providers to and from patients). The daughter-in-law stated that the patient had a specific lab that was released (on 11/8/24), that was indicative of a condition of “Meningoencephalomyelitis”, which she stated was treatable, but that the patient had received no treatment. The e-mail stated the patient’s name, date of service, location where the patient had been hospitalized, and which medical group had been following the patient. The e-mail documented, “Requested Follow-up: Please ask the Neurology staff to review the new labs and advise on a treatment plan!! Per the lab, early treatment is imperative to favorable outcomes!” A note inputted by Patient Advocate #1 on 11/11/24 at 4:27 PM stated “She (daughter-in-law) found the result on Patient #28’s MyChart and is wondering why (patient) was discharged if it came back on Friday afternoon (11/8/24). According to what she saw, (Patient #28) has a positive GAFD (spelling error) (GFAP) test and it is treatable, but Patient #28 was not treated for this because (patient) was sent home likely before a physician saw the result. She (daughter-in-law) is asking what they need to do. Does (Patient #28) need to come back in? A note added on 11/13/24 at 1:50 PM to the communication thread by Patient Advocate #1 stated the neurological testing from [outside laboratory] was not reviewed and that Patient Advocate #1 had e-mailed Neurologist #1, who asked Resident physician #1 to review the results and contact Patient #28’s daughter-in-law. Review of the Grievance provided by the hospital revealed the concern about the lab result had been received from the patient’s daughter-in-law on 11/11/24 through an on-line form. Patient Advocate #1 had called and spoke with the daughter-in-law on 11/11/124. “Spoke with (daughter-in-law) of Patient #28. (Patient) was not supposed to have been discharged on Friday from what they were told. They were here (Friday 11/8/24) and spoke with MD and (had been) told that the test ordered by Neurologist #1 went to [outside laboratory] and they were still waiting for the results. Then when they got home, HCM (Hospital Case Management) called and said transport was taking (Patient #28) to a facility. See Notes...”. A phone interview was conducted on 12/5/24 at 9:00 AM with Neurologist #1 and Resident Physician #2. Resident Physician #2 stated s/he saw Patient #28 for mental status changes the first week the patient had been admitted. They ordered a lot of testing and the test results had been pending after s/he had handed over the care for Patient #28 on 10/27/24 to other members of the neurology team. Resident Physician #2 stated the GFAP was a neoplastic autoimmune antibody. It was part of the paraneoplastic panel. Resident Physician #2 stated s/he had been unaware the GFAP had been completed or that it had resulted as positive. S/he stated it had been resulted by the [outside laboratory] on 11/7/24 at 6:22 PM and scanned in to Patient #28’s hospital medical record on 11/8/24 at 4:01 PM, after the patient had been discharged. S/he stated the patient had been discharged around 2:00 PM (on 11/8/24). When asked, Neurologist #1 and Resident Physician #2 stated Patient #28 had an appointment for 12/6/24 in the neurology clinic. As far as they knew, Patient #28 had not been treated for the positive GFAP. Resident Physician #2 stated there was treatment for GFAP (Glial Fibrillary Acidic Protein) disease that included a progression of medications (until one was successful) that consisted of high dose corticosteroids, intravenous immunoglobulin, and/or a plasma exchange. Resident Physician #2 and Neurologist #1 stated they were not notified that the GFAP result was positive. When asked about the follow-up appointment for Patient #28 scheduled for 12/6/24, Resident Physician #2 stated this appointment had nothing to do with the GFAP being positive. S/he stated there was no way for the neurology group to know the result had been positive as no one reached out to us or told us the results had been available. Review on 12/5/24 at 12:15 PM of an e-mail dated 11/12/24 at 1:26 PM from Patient Advocate #1 to Neurologist #1 revealed “...I received a call from (Patient #28’s daughter-in-law), medical record #, and she has seen his/her GAFD (sp) (GFAP) testing results from [outside laboratory] that were not back before (Patient #28) was discharged from (hospital). S/he has questions about the results and the treatment available. S/he is asking what are the next steps? Can you or someone on your team please call her at (phone #). An e-mail response from Neurologist #1 to Patient Advocate #1 and Resident Physician #2 dated 11/13/24 at 10:56 AM documented “(Resident Physician #2 name), Can you please look into this and talk to her please. Thank you. (Initials of Neurologist #1). A second phone interview was conducted on 12/5/24 at 2:52 PM with Resident Physician #2. Resident Physician #2 stated s/he had called and spoken with Patient #28’s son (today 12/5/24) to set up treatment for the positive GFAP, and the son had informed Resident Physician #2 that Patient #28 had received corticosteroid treatment from the outpatient neurologist who had sent the patient to the hospital. When asked if Resident Physician #2 had received and read the e-mail dated 11/12/24 from Neurologist #1, asking him/her to look into the positive GFAP result and call the daughter-in-law; Resident Physician #2 stated s/he had received the e-mail but did not read it. Resident Physician #2 stated Neurologist #1 had texted him/her previously to the e-mail about following up on the other labs for the patient. Resident Physician #2 stated s/he had called and spoken with the son about the other labs and scheduled the follow-up for 12/6/24 to have additional testing done based on those results. Resident Physician #2 stated s/he had not read this particular e-mail about the positive GFAP result as s/he assumed Neurologist #1 was talking about the other labs s/he had already spoken to the son about. Resident Physician #2 stated the positive GFAP result had not been sent to the consulting neurology team and they were unaware it was pending. Resident Physician #2 stated the positive GFAP result may have been sent to the Medical Teaching Service (Admitting and Discharging Provider Group for Patient #28). During a TEAMS (Messaging computer application) meeting on 12/5/24 at 4:00 PM, Physician #3 with the Medical Teaching Service, the Chair of Internal Medicine, and the campus Chief Medical Officer were present (along with others). The interview was to ascertain to whom the positive GFAP lab result went to, and if there had been anyone that could have acted upon this result to communicate the need for treatment with the patient or other Provider. The physicians interviewed stated that if the patient is still in the hospital (admitted), the physicians go in to the computer system and review labs. They believed the ordering result would be available to the neurology team who was the ordering physician group. The physicians believed that there was a way for the primary care physician (PCP) to get the result after patient discharge, if the primary care physician is listed in the patient record. The Chief Medical Officer stated that when patients are discharged with a pending test, most times the patient has a follow-up appointment. The consensus of the interview was that Neurology was responsible to follow up on the positive GFAP for Patient #28. During a TEAMS interview on 12/6/24 at 9:15 AM, Resident Physician #1, who was with the neurology group and spoke with the patient’s son and daughter-in-law on the day of Patient #28’s discharge on 11/8/24, stated s/he nor anyone on the neurology team knew the paraneoplastic panel was still outstanding (had not resulted). S/he was unaware of a messaging system where Providers are alerted of labs that are resulted after a patient’s discharge. Resident Physician #1 stated that there is a way a Provider can set the electronic medical record system (EPIC) to show a result for a set of patients, but the physician/Provider has to go in and set the patients they want to see and these patients are currently inpatients (admitted), and not discharged. Resident Physician #1 was unsure the positive GFAP lab result went to any Physician or Provider. S/he stated that Patient #28’s outpatient neurologist who had sent him/her to the hospital was not a hospital system Provider and did not have access to the hospital’s electronic medical record system. S/he stated that s/he does not get alerts about patient lab results. When s/he looks at particular patient sets (that s/he has set up for review), there is a notation that a lab has recently resulted and if it is out of range; but nothing as far as messaging. Once a patient is discharged, s/he no longer checks on their lab results. S/he does not know what a GFAP is, that it had been ordered, or that it was outstanding at the time of Patient #28’s discharge. Resident Physician #1 stated that upon discharge, Patient #28 had been instructed to followup with the outpatient neurologist. S/he stated s/he had attempted to get ahold of Patient #28’s outpatient neurologist on 11/8/24 to inform him/her of the patient’s discharge but was unable to contact him/her. During an interview on 12/6/24 at 9:30 AM, The Executive Director of Informatics stated the time Patient #28 had been discharged was close to the time when the positive GFAP lab result had been scanned in to the electronic medical record. S/he stated the Provider would have had to go into Patient #28’s electronic medical record and look for any new lab results in order to have seen the positive GFAP lab. S/he stated there is an indicator on the lab results if they are new and resulted from a hospital lab, but not for scanned in results like the GFAP that was scanned in from the outside laboratory. The record would still show a new result was available, but not have a visual cue marker on it. S/he stated that because the lab had been scanned in at 4:01 PM and the discharge had been completed in the computer system at 4:05 PM, s/he doubts any Provider had been in the chart and probably would not have seen it even if they were already in the chart at the time. The Director of Informatics stated the hospital does have a system where if the patient is discharged and PCP identified in the electronic medical record system, the test results are sent to the PCP. S/he verified a PCP had not been listed for Patient #28. They also have a “pool” of Providers that the pending results go to for patients that have been discharged. This lab result fell out (was not reviewed) due to the timing of the discharge. The results had been scanned in while Patient #28 had still been listed as an inpatient. For example, in the ED (Emergency Department) they have a pool of Providers that have the additional duty to look at test results that come back after patients leave. They review the test results and if the patient needs to come back in for follow up they call and let them know. They do not take full responsibility for the test results but make sure the test results are addressed.”

“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: 28883 Based on record reviews, interviews, and review of the hospital’s policies and procedures, the hospital failed to ensure that patients received care and services in accordance with the hospital’s policies and procedures and acceptable standards of practice for 5 of 18 patient charts reviewed for nursing care and services. The findings include: Cross reference to A 0392: The hospital nursing staff failed to intiate a nutrition consult timely for Patient #12, who was diagnosed with malnutrition and at risk for pressure injury and to consistently document either meal intake, turning and/or repositioning every 2 hours, and/or ordered wound care for Patients #1, #7, #12, #13, and #15.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 28883 Based on review of grievances, interviews, and review of facility policy “Patient and Family Complaint & Grievance: Prisma Health”, the hospital’s Patient Advocacy staff failed to ensure grievances for Patient #12, one of three patients reviewed with grievances, had been reviewed, investigated, and resolved. Two grievances for Patient #12 sent by electronic mail (e-mail) had not been addressed. The findings include: Record review on 9/12/24 at 8:01 AM of grievances for nursing unit 10 East from June 2024 to present revealed no grievances had been documented for Patient #12. During a video conference interview with the Patient Advocacy Director on 9/13/24 at 11:40 AM, the Patient Advocacy Director stated there was no e-mail complaint or other grievances documented for Patient #12. During a 2nd video interview on 9/13/24 at 1:00 PM, the Patient Advocacy Director stated that she/he had just discovered that Patient #12’s adult child had sent an e-mail on 7/17/24 at 7:49 AM to corporate. The patient’s adult child had a concern that Patient #12 had end stage dementia, that Patient #12’s spouse had wanted to get information about Patient #12 and had been upset/disturbed that the hospital staff would not provide the information. Patient #12’s adult child asked that hospital staff provide information to his/her parent that had been requested. The Advocacy Manager stated that the complaint had been assigned as”out for review”, but it was not documented that Advocacy staff had tried to contact Patient #12’s adult child or that this e-mail concern had been investigated or resolved. The Patient Advocacy Manager was not clear as to who had not provided information to the patient’s spouse or what information had been requested. The Advocacy Manager stated a second e-mail had been discovered, sent by Patient #12’s adult child on 7/23/24 at 2:24 PM. It went to an e-mail address at the main contact center for outreach. Patient #12’s adult child complained that the Social Worker had hung up on him/her and the Administrator on Duty had not returned his/her call. The adult child stated Patient #12 was being released with a bedsore, that Patient #12 had not eaten, and the IV (Intravenous line) had not been taken out. The Advocacy Manager stated that Advocacy staff had documented they had called the patient’s adult child back and left a message on voice mail, but did not get a response back. She/he stated that both these concerns should have been documented as grievances and addressed. According to the Advocacy Manager, she/he thinks that Advocacy staff were waiting for a response from the adult child before putting the information into the system as a formal grievance. Review on 9/19/24 at 11:00 AM of the facility policy, entitled “Patient and Family Complaint & Grievance: Prisma Health, approved 7/21/21, revealed information that “...Grievances may be received in any number of ways, including telephone, e-mail, in writing, patient satisfaction surveys, face to face, staff referral, or public or social media (e.g., Google reviews, YELP, Facebook, etc.). Complaints or grievances may be received from a patient or from a person submitting the complaint or grievance on the patient’s behalf and are to be referred to Patient Advocacy Department as soon as possible. Patient Advocacy will coordinate the investigation, ensure that all CMS (Center for Medicare & Medicaid Services) and accrediting body grievance management guidelines are followed, and respond to the grievance in writing... Handling a complaint while the patient is still in the building (inpatient or outpatient). Team members should always attempt to remedy the situation at the time of communication of a concern with Service Recovery... The team member should inform their manager or supervisor (or his/her designee) of the occurrence... Complaints are referred to the next level of management when the matter is unresolved or is outside the manager or supervisor’s (or his/her designee) span of authority, and the issue becomes a grievance... Handling a complaint after a patient is discharged or left the service. The concerns shall be designated as a grievance and investigated. Resolution shall be documented via the electronic complaint system. Patient Advocacy will be responsible for investigating and/or coordinating the appropriate response. Efforts will be made to resolve grievances within seven (7) calendar days. If the grievance review cannot be completed within seven (7) days, the current status will be communicated to the complainant in writing or via verbal communication, stating the reason for the delay and that a resolution letter should be sent within thirty (30) days. The complainant will be provided written notification of the outcome of the grievance review and investigation, including: The name of the Prisma Health contact person; The steps taken on behalf of the patient to investigate the grievance; The results of the complaint process; and the date of completion...”.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28883 Based on record reviews, interviews, and review of facility policy the “Palmetto Health Adult Skin Care Orders and Treatment Guidelines”, the hospital nursing staff failed to initiate a nutritional consult timely for Patient #12 after documentation revealed a low Braden Scale score while implementing the hospital’s Pressure Ulcer Prevention Plan, document meal intake consistently for Patient #12, one of six patients reviewed with documented nutritional needs, document wound cleansing care with normal saline and/or the application of ordered creams or antiseptic (betadine) for 5 of 10 patients reviewed with nursing wound care orders, (Patients #1, #7, #12,#13, and #15), and consistently document nursing interventions to prevent or reduce pressure injury, to include turning/repositioning for 2 of 13 patients reviewed with mobility issues (Patients #7 and #12). The findings include: Review on 9/11/24 at 11:30 AM of History and Physical/ Discharge summary for Patient #12’s hospitalization from 6/4/24 to 7/26/24, revealed Patient #12 presented to the hospital for weakness on 6/4/24 with admission on 6/6/24 with diagnoses of Sepsis, Hypotension, History of GI (Gastrointestinal) Bleed, History of ESRD (End Stage Renal Disease) s/p (status/post) renal transplant, AKI (Acute Kidney Injury), Malnutrition, and Cognitive Decline. Patient #12 was noted with the following lab values: Albumin level of 2.8. (normal range is 3.5-5.5 grams/deciliter) and Total Protein level of 5.2 (normal range is 6.0-8.3 grams/deciliter). (Albumin and Total Protein are measures of nutritional status which were low). The patient was found to have a Common Bile Duct Ampullary Stricture with a prolonged hospital stay due to adult Failure to Thrive (FTT) and poor PO (oral) intake. The summaries indicated Patient #12’s Adult FTT and severe chronic malnutrition were acute issues prior to admission per PCP (Primary Care Physician) notes. Review on 9/11/24 at 3:15 PM of the nursing flowsheets for Patient #12 from 6/6/24 through 6/15/24 revealed a Nutrition Screen was completed by nursing staff on admission on 6/6/24 at 2:40 PM, with information obtained from patient’s spouse. Questions included, “Have you lost weight recently without trying-No, Have you been eating poorly/poor appetite-Yes”. The Nutrition Screening Score for Patient #12 was a “1”. A score of “2” will trigger a nutritional consult by hospital stay day 6. Further review of flow sheets revealed nursing staff failed to document consistently the % (percent) of meals consumed by the patient. Nursing documentation revealed the following: Meal Intake on 6/8/24, 0% breakfast, 0% lunch and 0% dinner eaten. On 6/9/24, appetite poor, 0% breakfast, 0% lunch, 0% dinner, and 0% snack. On 6/10/24, 0% dinner. On 6/14/24, 0% breakfast eaten. On 6/15/24, 0% breakfast, 0% dinner. During an interview on 9/12/24 at 11:30 AM, Nurse Manager #1 reviewed Patient #12’s record and verified documentation missing related to meal intake. The Nurse Manager stated that she/he would expect nursing staff to document the meal percentage in real time. She/he verified they had not documented as they should. Review on 9/12/24 at 12:15 PM with Nutrition Manager #1 of the initial nutrition consult for Patient #12 dated 6/16/24 revealed under “Diet and Weight History” that the patient’s significant other provided the information. “...States that Pt (patient) has been eating poorly for the past 2 months. Reports that initially had decreased appetite from diarrhea. When diarrhea improved still had no appetite. Frequently offers oral nutrition supplements but Pt does not drink. Estimates Pt has lost 5 lb in the past 2 months...”. Under Diet Tolerance was documented “Confirms poor appetite/intake during admission. There has been no improvement. Overall Pt with inadequate intake during admission x (times) almost 2 weeks. No actual weight history from entire admission. Pt’s significant other on board with starting ONS (Oral Nutritional Supplements) with meals...Impression and Plan- Inadequate intake almost 2 weeks. See recommendations above...”. Review on 9/12/24 at 2:00 PM of “Palmetto Health Adult Skin Care Orders and Treatment Guidelines- For use only for those patients 18 years or older” revealed “...Initiate Pressure Ulcer Prevent Plan if Braden Score is less than or equal to 18. a. If possible, off-load pressure to the area. Example: if wound is on sacrum then turn patient from right to left only and avoid positioning on back. b. Order a low air loss mattress (Envision of P500) for any patient with a Braden score less than or equal to 12...c. Float heels. d. Consult dietitian if nutritional deficits are suspected or PO (oral) intake is poor. e. Keep skin clean and dry...”. Review on 9/13/24 at 11:20 AM of nursing documentation revealed between 6/6/24 and 6/16/24, the nursing staff documented Patient #12 scored from 13 to 18 on the Braden screening tool. Review of the record revealed the WOCN (Wound, Ostomy, Continence Nurse) saw the patient on 6/10/24, due to a consult for occurrence validation of PI (Pressure Injury) staging. The WOCN note dated 6/10/24 documented calluses on the patient’s feet and a moisture related wound to the sacrum, with intact blanchable moist pink skin. A nutrition consult was not recommended at that time. During a phone interview on 9/13/24 at 11:08 AM, WOCN #1 stated that it was not the role of the WOCN to place a consult for the nutritionist, that the floor nurses are responsible for completing the Braden scale and scoring. “They are the ones working with the patient every day and if the Braden score is low they can contact the dietitian”. Review of the medical record revealed an order for a nutritional consult for poor PO intake and malnutrition was documented on 6/15/24, with a nutrition consult completed on 6/16/24. During an interview on 9/13/24 at 11:20 AM, Nurse Manager #1 reviewed the nursing documentation of the Braden risk scores documented by nursing and the consult order for the nutritionist. She/he was asked about the timing as to when nursing would consult the nutritionist if a patient had poor intake and a low Braden score. Nurse Manager #1 stated they rounded on Patient #12 and talked about getting Patient #12 to the point of getting her/him to eat. Review with Nurse Manager #1 revealed an Internal Medicine Physician note by Nephrology services dated 6/10/24 that documented the patient had been started on maintenance IV fluids given poor intake. Nurse Manager #1 stated that it looks like they had been trying to push palliative/hospice care for Patient #12 and when it didn’t go that way, the nutritionist had been consulted. Review on 9/11/24 at 11:13 AM revealed the following physician orders and wound consult notes. Nursing staff failed to document wound treatments to include cleansing wounds with normal saline and the application of barrier/zinc oxide cream and betadine. On 6/9/24 there was an order to consult the Wound Ostomy Continence (WOC) nurse for validation of PI (Pressure Injury) staging. A WOC nurse documented an initial consult on 6/10/24 at 11:59 AM, “WOCN consulted for the feet and sacrum. Assessed sacrum skin intact pink moist blanchable. Recommend to apply barrier cream due to incontinence. Right plantar foot has callous’s to the medial and lateral foot and posterior 1st toe. The left heel is dry and intact no wounds noted. See orders below. Right medial, lateral, posterior 1st toe and heel, callous. Tx (Treatment): Clean with bath wipes, pat dry. Paint with Betadine, leave OTA (Open to Air). (The order indicated this should be done daily). Sacrum moisture related. Clean with bath wipes. Apply barrier cream. Re-apply for each incontinence episode and rub off”. Review on 9/11/24 at 3:37 PM of wound treatment documentation revealed the WOC nurse completed the treatments (cleaning and application of Betadine) to the right medial, lateral, posterior 1st toe and heel callus on 6/10/24 at 11:49 AM, during the initial consult. The WOC nurse also documented cleansing of the sacrum with normal saline and (bath wipes) and the application of moisture barrier at that time. On 6/10/24 at 11:42 PM, a floor nurse documented barrier cream had been applied as part of wound care to the sacrum along with application of betadine to the callus on the posterior 1st toe on the right foot only. There was no further documentation by nursing staff of daily betadine application to the calluses on the right foot from 06/11/24 through 6/18/24, when the order for betadine to the calluses on the right foot was discontinued. Review of wound care treatment revealed no further documentation of barrier cream applied as part of wound care. Review of a consult note dated 6/18/24 at 12:05 PM revealed the wound on the right buttock measured 2 cm (centimeters) x (by) 2 cm, with the wound bed dry with a purple discoloration, caused by friction. Under “Product to Wound Bed” was documented “(recommend barrier cream)”. Further review revealed a unit nurse wound order dated 6/18/24 at 1:58 PM for a wound to the right buttock, shear friction, to clean patient with barrier shield cloths, apply zinc barrier cream twice daily and after each soiling. Only remove enough zinc barrier cream so there is no visible excrement and reapply cream. During an interview on 9/11/24 at 4:00 PM, Registered Nurse (RN) #2 was ask about where unit nursing staff would document wound care orders completed for zinc barrier cream twice daily. RN #2 post review nurse’s notes, medication administration record, and nursing wound care documentation on the flowsheets from 6/18/24 through 6/26/24 (when the order was discontinued) verified no documentation by the unit nurses using the zinc barrier cream twice daily. Continued review on 9/11/24 at 11:30 AM of Patient #12’s chart revealed a wound care order dated 6/26/24 for “Right buttock DTI (Deep Tissue Injury), to clean patient with barrier shield cloths, apply zinc barrier cream to area twice daily and after each soiling. Only remove enough zinc barrier cream so there is no visible excrement and reapply cream”. Review of nursing flowsheets from 6/26/24 through 7/12/24 revealed no nursing documentation for wound care that included the application of the zinc barrier cream to the right buttock twice daily. Review of the WOC nurse documentation dated 6/26/24 at 2:14 PM revealed the wound measured 3 cm x 5 cm with the wound bed dry with a dark purple discoloration. The note included documentation that the WOC nurse cleansed the area with a bath wipe and “...(barrier cream applied and recommended) the wound open to air”. A wound care order dated 7/3/24 revealed Patient #12 with an order to treat a left unstageable sacrum wound and left lateral buttock pressure ulcer DTI (deep tissue injury). The treatment is to “clean with normal saline, pat dry. Apply barrier cream, re-apply with each incontinence episode or rub off. Use pillows or turning wedge for repositioning”. The order was canceled on 7/12/24. During an interview on 9/11/24 at 4:56 PM, WOC nurse #1 stated the treatment was to be done daily, but not limited to one time a day. WOC nurse #1 stated the left sacrum and the left lateral buttock (whole wound area) should be cleaned with normal saline with each incontinent episode. The nurses would need to do it because it is in the unit nurse orders.WOC nurse #1 stated the WOC nurses put the order on the the unit nurse’s orders, but she/he was not sure how the task list comes up in the electronic medical record or how the nurses document the treatment. She/he was not sure about the nurse technicians, where they documented on flow sheet the use of barrier cream with each incontinence episode. The measurements of the wound on 7/3/24 had been documented as 2.3 cm x 5 cm right buttock, 0.8 cm x 1 cm sacral left, 2.5 cm x 4 cm left lateral buttock. On 7/3/24, the WOC nurse documented moisture barrier application to the right buttock pressure injury, cleaning the left sacral and the left lateral buttock with normal saline and the application of barrier cream. Review of documentation completed by the nurses and technicians of incontinence care revealed no documentation of cleaning with normal saline. There was also no continuous documentation of barrier cream being applied with each incontinent episode. When asked about the use of barrier wipes versus barrier cream, WOC nurse #1 stated that they use the barrier wipes first to clean and then apply the barrier cream. WOC nurse #1 stated that using the barrier wipes is not the same as using barrier cream. On 7/12/24, there was a unit nurse wound order for treatment to the right buttock DTI, which is documented as a Stage 3 wound measuring 2 cm x 4 cm with a depth of 0.3 cm. Treatment is to clean the patient with barrier shield cloths, apply zinc barrier cream to area twice daily and after each soiling. Only remove enough zinc barrier cream so there is no visible excrement and reapply cream. This was documented as completed by the WOC nurse, but there was no documentation that the unit nurses had applied the zinc barrier cream twice daily. There was no continuous documentation of barrier cream being applied after each incontinent episode. On 7/12/24, the left lateral buttock pressure injury measured 2 cm x 3.6 cm and was documented as cleaned with a bath wipe and barrier cream applied. The left sacral pressure injury was documented as dry, hypopigmented and healed. On 7/18/24, the WOC nurse documented the pressure injury to the right buttock as a Stage 3 wound measuring 2 cm x 4.5 cm with a depth of 0.1 cm. The nurse documented the application of moisture barrier cream. The left lateral buttock pressure injury was documented as intact, hypopigmented and healed. During an interview on 9/12/23 at 11:30 AM, Nurse Manager #1 reviewed the record and verified the nurses did not document the application of ordered barrier cream and/or zinc oxide cream twice daily as part of wound care nursing documentation. Nurse Manager #1 stated they used barrier cream if a patient was at risk. She/he verified there was spotty/missing documentation by staff of the use of barrier cream with each incontinence care provided for Patient #12. Nurse Manager #1 verified that cleansing with normal saline had not been documented to the sacrum/left buttock deep tissue injury. If it had been listed as a wound treatment, the nurses would do it. If it was for incontinence episodes, the nursing technicians would document. Nurse Manager #1 stated that if it was a wound treatment intervention, when the nurse completed the treatment, the nurse would then document completion on the “Brain” (electronic medical record application) and it would carry over as having been completed to the flow sheets. Nurse Manager #1 stated there was no place on the flowsheets to document the use of “zinc” barrier cream. She/he was not sure if there was a difference in the use of zinc barrier cream and the other barrier cream they use. Nurse Manager #1 reviewed the treatment documentation for the betadine daily to the calluses on the right foot and verified there was no further documentation by nursing that the treatment had been completed daily after 6/10/24 and before being discontinued on 6/18/24. Review on 9/11/24 at 2:00 PM with Registered Nurse (RN) #2 revealed the following flow sheet documentation dated 6/6/24 through 6/25/24 for nursing staff failed to document that Patient #12 had been turned frequently, at least every two hours (which was the protocol on the unit at the time) to prevent pressure injury to the skin. Review of the mobility screening for Patient #12 revealed Patient #12 required assistance with turning. On 6/6/24 at 6:07 PM, the patient was turned to the left with no documentation of being turned again until 6/7/24 at 7:46 AM. On 6/8/24 at 5:45 AM, Patient #12 was turned to the left, with the next documentation on 6/8/24 at 12:46 PM to the right and then documented again on 6/8/24 at 5:30 PM, supine. On 6/8/24, Patient #12 was turned at 9:15 PM, then again on 6/9/24 at 1:00 AM. On 6/11/24 at 5:46 AM, 10:31 AM, and 9:23 PM, it was documented the patient’s caregiver refused positioning. There was no documentation of patient turning on 6/12/24 or 6/13/24. The next documentation of the patient being turned was on 6/14/24 at 5:22 AM and 12:00 noon. On 6/15/24 at 8:00 AM, 12:57 PM and then at 9:35 PM. On 6/16/24 at 3:28 AM, 8:00 AM and 9:46 PM. On 6/17/24 at 10:46 AM, 12:59 PM, 8:16 PM, and at 9:31 PM. On 6/18/24 at 10:46 AM. On 6/19/24 at 9:30 AM (able to turn independently) and again on 6/19/24 at 2:00 PM. On 6/20/24 at 12:45 AM, 6:15 AM, 2:16 PM, 4:31 PM, and at 9:16 PM. On 6/21/24 at 6:01 AM and at 10:00 PM. On 6/22/24 at 6:03 AM, 12:00 noon at which time the patient’s caregiver refused positioning, and at 4:00 PM. On 6/23/24 at 6:45 AM with no additional documentation after this date. During an interview on 9/12/24 at 11:30 AM, Nurse Manager #1 reviewed documentation of the flowsheets related to turning and repositioning Patient #12. Nurse Manager #1 stated that at the time the patient was on the unit, they turned patients every 2 hours using the clock method. She/he verified the documentation Patient #12 was not turned every 2 hours. She/he stated the dates missed for turning were probably mostly weekends when they had less technicians. 36779 Review of Patient #15’s record on 09/12/24 at 4:47 PM revealed Patient #15 was admitted to the hospital on 07/23/24 with a diagnosis of Acute Metabolic Encephalopathy (caused by lack of oxygen, glucose, or vitamins, and characterized by altered consciousness and behavior changes). The Wound Ostomy Certified Nurse (WOCN) assessment dated 07/24/24 indicated Patient #15 had sacral (i.e. coccyx - tail bone area) excoriation at the time of admission. The WOCN recommended Citric Acid Barrier Cream for treatment of the wound. Continued record review on 09/13/24 at 9:37 AM revealed a “Unit Nurse Wound Order” dated 07/24/24 which read, “ ...Perianal/perineum [area between the genitals and the anus] MASD [moisture associated skin damage] - apply and maintain covering of Citric Acid barrier cream. Reapply as needed after incontinence/rub off..”. The order was signed by the physician on 07/24/24 at 12:04 PM. In a concurrent interview with Registered Nurse (RN) #5, she/he stated the Citric Acid Barrier Cream was a type of Barrier Cream and the Certified Nurse Assistants (CNA’s) were responsible for applying it. When asked how the CNA’s know which patients have an order for Barrier Cream to be applied, she/he stated the nurses tell them. Continued review of Patient #15’s record on 09/13/24 at 9:37 AM revealed the admission nursing assessment on 07/24/24 indicated Patient #15’s mobility was “very limited.” Continued record review on 09/13/24 at 9:37 AM of all nursing flow sheets for Patient #15’s hospital stay from 07/23/24 to 08/02/24 revealed two documented instances of Barrier Cream applied on 08/02/24. There was no documented evidence Barrier Cream was applied on 07/24/24, 07/25/24, 07/26/24, 07/27/24, 07/28/24, 07/29/24, 07/30/24, 07/31/24 or 08/01/24. In a concurrent interview with RN #5, she/he confirmed the findings. Review of Patient #13’s record on 09/13/24 at 10:41 AM revealed Patient #13 was admitted to the hospital on 07/02/24 with a diagnosis of Pancytopenia (low levels of red blood cells, white blood cells, and platelets). The admission nursing assessment on 07/02/24 indicated Patient #13’s mobility was “very limited,” and Patient #13 was incontinent of urine. Patient #13’s admission nursing assessment also indicated Patient #13 had a Stage 3 (full thickness tissue loss) Pressure Ulcer (PU) Wound to the coccyx (i.e. sacrum - tail bone area) and a Stage 2 (partial thickness skin loss) PU Wound to the Right Buttock. The WOCN assessment on 07/03/24 indicated Barrier Cream was ordered with each incontinent episode. The “Unit Nurse Wound Orders” dated 07/03/24 indicated, “ ...Left coccyx pu stage 3. Right buttock pu stage 2 Tx [treatment]; Clean with NS [normal saline], pat dry. Apply barrier cream. Re-apply for each incontinence episode or rub off ...”. The order was signed by the physician on 07/03/24 at 12:57 PM. Continued record review on 09/13/24 at 10:59 AM of all nursing flow sheets for Patient #13’s hospital stay from 07/02/24 to 07/14/24 revealed no documented evidence Barrier Cream was applied during Patient #13’s hospital stay, including 07/03/24, 07/04/24, 07/05/24, 07/06/24, 07/07/24, 07/08/24, 07/09/24, 07/10/24, 07/11/24, 07/12/24, 07/13/24 and 07/14/24. In a concurrent interview with RN #5, she/he confirmed the findings. 41879 On 09/13/24 at 08:00 AM the medical record for Patient #1 is reviewed. Patient #1 is admitted on 08/06/24 with Chronic Osteomyelitis of the Coccyx. Patient #1’s skin asssement noted the following findings upon admission: coccyx area wound, excoriated redness on the buttocks, rash on the groin area, open boggy area on left ankle, left trochanter reddness, and a left thigh non stageable, non blanchable wound. On 08/07/24, the Wound Care nurse saw the patient and noted the coccyx wound as a Stage 4, measuring 7 cm x 6 cm x 1 cm. Wound care orders placed on 08/07/24 at 10:15 AM, state “pressure ulcer stage 4, TX: (treatment) moistened with 4 x 4 gauze with skin integrity wound gel. Cover with dry gauze and secure with tape daily and as needed when soiled. A review of Patient #1’s medical record revealed dressing changes done on 8/7/24, 8/8/24, 8/10/24 and 8/11/24. No dressing change was noted on 8/9/24 and/or 08/12/24. Patient #1 was discharged back to a skilled nursing center on 8/12/24. During an interview on 09/13/24 at 8:32 AM, Registered Nurse (RN) #6 verified the findings. On 09/13/24 at 11:11 AM, the medical record for Patient #7 is reviewed. Patient #7 is admitted on 09/08/24 with Stroke, Dementia, and Positive for Covid-19. Patient #7’s medical record revealed a Braden score of 14 which indicated, “...Initiate Pressure Ulcer Prevent Plan if Braden Score is less than or equal to 18. a. If possible, off-load pressure to the area. Example: if wound is on sacrum then turn patient from right to left only and avoid positioning on back. b. Order a low air loss mattress (Envision of P500) for any patient with a Braden score less than or equal to 12...c. Float heels. d. Consult dietitian if nutritional deficits are suspected or PO (oral) intake is poor. e. Keep skin clean and dry...”. Review of the chart revealed Patient #7 no documentation of turning every two hours and/or skin breakdown prevention interventions consistently documented for 09/10/24 through 9/12/24. Further review of the chart revealed the wound care nurse evaluated the patient on 09/09/24 and identified a healed hyperpigmented area to the sacrum. Review of wound care orders revealed use barrier cream daily and as needed. Further review of the chart revealed no documentation of barrier cream applied to the patient between 09/10/24 to 09/11/24. During an interview on 09/13/24 at 11:30 AM, RN #6 verified the findings.”