Aiken Regional Medical Center

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 52066 Based on facility policy review, record review, and interview, the facility failed to ensure a discharge planning evaluation adequately addressed post-discharge barriers to obtaining prescribed medications for 1 (Patient #3) of 10 sampled patients reviewed for discharge planning. The hospital documented that Patient #3 was homeless at the time of discharge; however, the record lacked evidence that the discharge planning evaluation addressed the patient’s ability to obtain prescribed medications following discharge. Findings included: A facility policy titled, “Discharge Planning,” revised 07/2021, indicated, “B. Discharge planning should be a multidisciplinary effort. Therapy staff should be responsible, along with the multi-disciplinary treatment team, for assessing the needs of the patient post-discharge. Therapy staff should work to obtain necessary resources, help develop an adequate discharge safety plan and crisis safety plan, and coordinate referrals to help meet the patient’s needs.” A patient demographic record revealed the facility admitted Patient #3 on 09/12/2025. According to the patient demographic record, the patient was admitted for inpatient evaluation for psychiatry services. The demographic record was blank where the patient’s primary care physician (PCP) could be listed. Patient #3’s “Behavior Health Forms” included a “BH [Behavioral Health] Discharge Planning Assessment,” dated 09/18/2025 at 9:59 AM and completed by Social Services (SS) Therapist #1, that revealed Patient #3’s living situation was homeless. The assessment indicated that the patient was anticipated to discharge to an out-of-state shelter and that transportation was to be provided via bus by a local transportation company. The assessment revealed no indication of discharge follow-up appointments with a PCP or additional documentation and/or a review of Patient #3’s home medications. Patient #3’s “BH Patient Summary” “Final Report,” dated 09/19/2025, included a list of medications to be continued to be taken by the patient after discharge. The record revealed the following medication orders: - Carvedilol (a non-cardioselective beta blocker) 3.125 milligrams (mg), one tablet, two times a day with meals for hypertension. - Cyanocobalamin (vitamin B) 1000 mcg (microgram), one tablet daily for Vitamin B 12 deficiency. - Gabapentin (a gabapentinoid) 800 mg (milligrams), one tablet three times a day for pain. - Hydrochlorothiazide (a thiazide diuretic) 12.5 mg, one tablet daily for hypertension. - Levetiracetam (a pyrrolidine anticonvulsant) 500 mg, one tablet two times a day for seizures. - Sertraline (a selective serotonin reuptake inhibitor [SSRI] 50 mg, one tablet daily for major depression. - Zonisamide (a carbonic anhydrase inhibitor anti-convulsant) 50 mg two capsules at bedtime for seizure disorder. The record revealed that levetiracetam, sertraline, and zonisamide included instructions for pickup at a local pharmacy; the other medications contained no instructions for pickup and/or documentation for how the patient would obtain them after discharging from the facility. During a telephone interview on 07/27/2026 at 11:43 AM, Patient #3 stated that they were discharged to a homeless shelter in another state with three medications provided at discharge. Patient #3 stated that there were medications which were taken during their time at the facility and upon discharge, they were not provided. Patient #3 stated they were receiving medications needed for their heart condition. During an interview on 07/29/2026 at 8:37 AM, Registered Nurse (RN) #2 stated that during a patient’s discharge, the patient’s medications were reviewed by the nurse. She stated that she reviewed the discharge paperwork with the patient and let them know when their next medication doses were due and printed out education material related to the patient’s diagnosis and educational material for the medications prescribed to them. RN #2 stated that the educational material that she provided was for the patient’s psychiatric medications. She stated that when the facility had a homeless patient, those were the only patients that were provided medications through a program with a local pharmacy to take the medications with them to the shelter. She stated she could not remember Patient #3 to provide any additional information about them, even though she discharged the patient on 09/19/2025. During an interview on 07/29/2026 at 9:40 AM, Social Services (SS) Therapist #1 stated that the decision for patients who chose to go to the homeless shelters was made by the patient. She stated that when the patients went to the shelter, the shelter required that patients have their medications with them when they arrived. SS Therapist #1 stated that any medications the patient was discharged from the facility with were reviewed by the nurse discharging the patient because that was their responsibility, and she did not review any medications with the patient. During an interview on 07/29/2026 at 11:27 AM, RN #4 stated that the discharge process involved a review of discharge appointments, reconciled medications sent to the pharmacy of choice of the patient, printouts of patient diagnoses, and psychiatric medication printouts. She stated that case management staff offered homeless patients the ability to obtain their medications from a local pharmacy program to deliver their medications to the facility prior to discharge. RN #4 stated that when patients went to a shelter, they were required to have their medications go with them to the shelter. She stated that only medications that were specified to the doctor had electronic prescriptions sent to the pharmacy by the physician. She stated discharged medications were noted for the patient to be continued at home, and for any new medications and/or changes made to the patient’s medications, the patient may have an order for the new medications sent to the pharmacy. RN #4 stated that the nurses were responsible for contacting the pharmacy and verifying if the patient had any medications and the last time, they were filled by the pharmacy. During an interview on 07/28/2026 at 2:30 PM, SS Therapist #5 stated that a patient and family should know the process for discharge and what to expect. She stated that she ensured a patient understood their treatment plan and ensured they were familiar with having a provider, as it related to their medications for refills after discharge. SS Therapist #5 stated that social services staff’s responsibility included discussion about where patients wanted their prescriptions sent. During an interview on 07/28/2026 at 4:24 PM, Advanced Practice Registered Nurse (APRN) #3 stated that the doctors did the discharge planning and saw the patient on the day of discharge. During a follow-up interview on 07/29/2026 at 10:07 AM, APRN #3 stated that the doctor wrote the prescriptions for Patient #3 on discharge and she was not sure who managed the patient’s home medications. During an interview on 07/30/2026 at 10:45 AM, the House Supervisor stated that the discharge process for patients involved the psychiatrist, who reconciled the patient’s psychiatric medications, and the medical team worked with the psychiatrist. She stated that if there were medical issues, the medical provider from the main hospital came to reconcile the patient’s medications, and they would have already seen the patient and prescribed their medications prior to discharge. The House Supervisor stated that if the patient came in on home medications, then the patient’s PCP was responsible for the patient’s home medications, and the psychiatrist only completed prescriptions for what he prescribed. She stated that she assumed that the case manager would follow up with the patient to know if they needed other medications. The House Supervisor stated that she thought a collaboration between the nurse and social worker would occur for a patient going to the homeless shelter to ensure the patient had the medications they needed. She stated that she would think that whoever had the discussion about the patient’s medications would document it somewhere if more medications were needed. During an interview on 07/30/2026 at 12:34 PM, the Quality Director stated that the facility policy only required the staff to provide the patient with their medication list, and the facility would not provide the patient with home medications. She stated that the patient’s PCP would provide those medications. During an interview on 07/30/2026 at 12:58 PM, the Quality Director stated that Patient #3 signed a copy of their discharge form that indicated oral instructions regarding current medical problems, arrangements for follow-up care as instructed and outlined, and a list of home medications with information on the importance of management of those medications and that this proved that the patient had been made aware of what to do post discharge regarding all of their medications. During an interview on 07/30/2026 at 10:12 AM, the Director of the Emergency Department, who was also the previous Interim Unit Manager, stated the discharge process involved the physician, who decided what medications the patient would be on at discharge. She stated Patient #3’s discharge medication list section titled “Instructions” were the medications that the patient would get from their PCP. She stated that she expected the nurse would document if the patient had the medications that they needed for discharge. She stated that she would think that the nurse or social worker would have documented somewhere in the chart if the patient had home medications filled, and the last date noted. During an interview on 07/30/2026 at 12:03 PM, the Interim Chief Executive Officer (CEO) stated that when staff discharged patients, she expected them to ensure the patient’s continuum of care was being met. She stated that she expected that patients were educated on their medications, and if medications were continued, the patient could pick them up or have them delivered to the facility prior to their discharge. The interim CEO stated that psychiatric medications were the responsibility of the psychiatric physician to treat the patient’s mental health conditions, while home medications that the patient may need were typically not prescribed by the psychiatrist. She stated that the patient’s PCP would generally manage those medications once the patient was home. She stated a plan would be established for the patient to ensure that they had a choice about how they obtained medications they would need. During an interview on 07/30/2026 at 12:59 PM, the CEO stated that his expectations regarding patient discharges were that the facility staff provided a safe discharge and met the letter of the law and supported the patients. He stated that he expected that the facility had a plan for homeless patients to have access to the resources that they would need for their care and that the patients were offered medications through their pharmacy program. The CEO stated that he expected homeless patients to receive an explanation of their medications and the facility to ensure coordination with the homeless shelters to make sure that the patients were able to obtain what they needed after discharge.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 18947 Based on observation, interview, electronic medical records (EMR) review, and facility policy review, the hospital failed to recognize and address potential abuse of one out of a total of five patients (Patient (P) P3) reviewed in the sample. This had the potential to affect all patients receiving care in the hospital. Findings include: Review of the hospital’s policy and procedure titled “Abuse and Neglect,” last reviewed and revised 07/2024 revealed, “Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. It is hospital policy that any/all suspected cases of physical abuse, neglect, or exploitation of individuals admitted as patients are reported in accordance with the hospital policy and state law;” and “Adult Abuse - means intentionally inflicting or allowing to be inflicted physical injury on a vulnerable adult by an act or failure to act.” Although the hospital’s Abuse and Neglect Policy indicated verbal abuse in its initial Policy Statement, it did not address the definition of verbal abuse or expected facility/staff response when an allegation of potential verbal abuse was made anywhere in the document. Review of the hospital’s policy and procedure titled “Behaviors That Undermine a Culture of Safety,” with a current effective date of 03/06/24 revealed, “It is the policy of the Facility and the Medical Staff for all Practitioners within or on behalf of the Facility to treat others with respect, courtesy, and dignity and to conduct themselves in a professional and cooperative manner;” and “E. In dealing with incidents of behaviors that undermine a culture of safety, the protection of patients, employees, physicians, and others in the Facility and the orderly operation of the Facility are paramount concerns. Behaviors that undermine a culture of safety are defined as those which adversely affect or impact the Facility operations or the ability of others to perform their jobs competently, or interfere or tends to interfere with the provision of safe, quality patient care at the Facility. For the purposes of this Policy, examples of “undermining behaviors: include, but are not limited to: - Disruptive Behaviors - Rude or abusive behavior, comments, or outbursts to Facility personnel, patients, Practitioners, vendors, or visitors ...;” and “G. An independent Practitioner who engages in behaviors that undermine a culture of safety shall be dealt with in accordance with this Policy or in accordance with the due process rights afforded to the Practitioner as defined in the Medical Staff Bylaws.” Review of the hospital’s “Medical Bylaws,” last dated 02/2025 read, in pertinent part, “BYLAWS (definition): The Medical Staff Bylaws provide the framework for the organized Medical Staff, its responsibilities, and mechanisms for self-governance of the Medical Staff; and the working relationship and accountability to the Board;” and “Article II Purposes, Responsibilities, and Participation; Purposes ....The purpose of the Medical Staff shall be to: 1. Ensure the provision of appropriate and high quality health care to patients admitted to the Hospital. 2. Assist the Hospital in meeting its mission and to carry out duties assigned to it by the Board to enhance the quality and safety of care, treatment, and services provided to patients;” and 3.4 Responsibilities of Membership ...Each member of the Medical Staff must comply with the provisions of these Bylaws, the Ancillary Manuals and Medical Staff General Policies. Members shall: ... 11. Treat employees, patients, visitors, and other physicians in a dignified and courteous manner at all times ...” and “Article XI Corrective Action and Fair Hearing ....Investigations ....When reliable information indicates that a physician may have exhibited acts, demeanor, or conduct reasonably likely to be listed below, a request for an investigation or action against such Physician may be initiated by the Board, Chief of Staff, Department Chief, Peer Review Committee, MEC (Medical Executive Committee) member, or the hospital CEO and must be submitted in writing to the MEC. Grounds to request and investigation include acts, demeanor, or conduct reasonably likely to but not limited to: 1. Detrimental to patient safety or to the delivery of quality patient care within the Hospital; 2. Unethical or illegal; 3. Contrary to the Medical Staff Bylaws or General Policies; 4. Harassing or intimidating to Hospital employees, Medical Staff Colleagues, patients, or their families; 5. Disruptive of Hospital or Medical Staff operations; 6. Below applicable professional standards for competency or as established by the Medical Staff; or 7. Harmful to the reputation of the Hospital and/or Medical Staff;” and “The investigation shall proceed in a prompt manner and a written report of the investigation findings will be submitted to the MEC as soon as practicable.” Review of P3’s Electronic Medical Record (EMR) revealed that P3 was admitted to the hospital through the hospital’s Emergency Department (ED) on 04/08/25 with diagnoses including ST-Elevated Myocardial Infarction (Heart Attack). The record indicated P3 was transferred to the hospital’s cardiac catheterization lab and received a right and left heart stenting procedure conducted by Medical Doctor (MD1) at 1:18 PM on the same date. The record indicated MD1 obtained right wrist arterial vascular access to complete the procedure, and indicated the access was lost during the procedure and vascular access had to, alternatively, be obtained again via the patient’s right groin. The operative record dated 04/08/25 indicated “Aborted right radial artery access the patient inadvertently pulled out the sheath during the procedure.” Review of the hospital’s “Patient Safety Event Report,” dated 03/30/25 through 04/28/25 revealed and entry, dated 04/09/25 and referencing an event that occurred on 04/08/25, that read, in pertinent part, “Patient in cath lab for right and left heart cath. Access obtained through right artery.” Per the document, (P3) stated she felt something leaking from her wrist and reporter stated site had bled about 2-3 minutes. The document indicated MD1 blamed P3 for pulling the right artery access out and indicated MD1 stated to the patient, “he was going to kill her for it.” The hospital’s investigation of potential verbal abuse of P3 by MD1 was requested by the survey/investigation team on 04/30/25 at 12:00 PM, on 05/01/25 at 9:30 AM, and again on 05/02/25 at 8:47 AM. Documentation to indicate the allegation of potential verbal abuse of P3 by MD1 had been investigated was not provided to the survey team prior to the exit date of 05/02/25. During an interview with P3 on 04/30/25 at 4:34 PM, she stated during her procedure on 04/08/25 she felt something gushing out of her hand and MD1 told her to not worry about it. She stated then a nurse in the room noticed blood on the floor and stated, “What is that?” and MD1 looked down at the blood and stated, “You did this (to P3).” P3 stated, “This man turned around and told me it’s my fault (the right wrist arterial vascular access came out). The thing is, I couldn’t move my arm and he (MD1) was arguing with me and he was doing surgery on me.” P3 stated, “I don’t ever want to see (MD3) again. I don’t. He has bad table manners.” P3 stated the Cardiopulmonary Director spoke with her after the incident and she reported the incident to her. P3 confirmed MD1 stated he would kill her and stated this was upsetting to her. During an interview with Registered Nurse (RN1) on 04/29/25 at 10:50 AM, he stated he was present in the cath lab during R3’s procedure on 04/08/25 and witnessed the above referenced incident. He confirmed P3’s arterial access sheath came out during the procedure, P3 bled heavily related to the lost access, and MD1 blamed P3 for dislodging the access and told P3 he was “Going to kill her” related to the incident. RN1 stated P3’s right wrist and arm were restrained during the procedure and so the patient would not have been able to dislodge the access sheath. He stated P3 stated, “I didn’t even move.” And MD1 stated, “I’m going to kill you.” And she said “Who?” and he said “You!” RN1 stated P3 was very upset by the incident and requested to speak with someone in patient relations about it. RN1 stated the patient relations representative was out of town and so P3 spoke with the Cardiopulmonary Director about the incident instead. During an interview with Registered Cardiovascular Invasive Specialist (RCIS2) on 04/29/25 at 9:45 AM, he stated he was present in the cath lab during P3’s procedure on 04/08/25 and witnessed the above referenced incident. He stated MD1 was completing a right and left heart stenting procedure on P3 and the patient had right radial (wrist) arterial access obtained for the procedure. He stated the patient’s arm and wrist were restrained with a brace which was a normal part of the procedure to prevent the patient from moving and dislodging the access. He stated P3 said she felt something was dripping from her wrist and MD1 stated that could be normal, but when RCIS2 looked at the ground he saw the IV access sheath had come out and P3 was bleeding heavily from her wrist onto the floor. RCIS2 stated at that point MD1 told P3, “Do you know what you just did? You ripped the sheath out! I’m going to kill you.” RCIS2 stated P3 kept saying “I didn’t do that. I couldn’t have done that. I can’t even move my wrist.” RCIS2 stated P3 was distressed due to the incident. He stated the incident was reported to administration via the hospital’s incident reporting system. During an interview RCIS3 on 04/29/25 at 12:34 PM, she stated she was working in the recovery room after P3’s procedure on 04/08/25 and spoke with P3 after the above indicated procedure. She stated she asked P3 how the procedure went and P3 stated, “That was the worst thing I have ever experienced.” RCIS3 stated P3 appeared to be very distressed and was crying about the incident and stated MD1 blamed her for pulling out the access sheath and told her, “You did that. You pulled it out.” RCIS3 stated P3 was so upset she was saying MD1 did not need to be practicing medicine and so the incident was reported to administration through the hospital’s incident reporting system. RCIS3 stated the Cardiopulmonary Director came in to P3’s room and spoke with the Patient. During an interview with the Cardiopulmonary Services Director on 04/30/25 at 10:31 AM, she confirmed the above referenced incident was reported to her on 04/08/25 and indicated she spoke to P3 about the incident immediately after it occurred. She stated P3 was crying when she reported it to her. The Cardiopulmonary Director stated P3 reported MD1 blamed her for the vascular access sheath coming out of her right wrist artery and P3 stated, “It wasn’t me. I couldn’t move my arm” and MD1 said to P3 “Look what you did. I’mma kill you.” (She stated “These were exact works reported to me by the patient.” The Cardiopulmonary Director stated she spoke with MD1 after the incident and he stated he did not recall making the statements and did not know P3 was upset. She stated the incident was reported to administration in the next day’s Safety Huddle Meeting but stated she did not know what happened after incidents were reported to Administration. She indicated she did not know if the reported incident was being addressed or not. During a follow-up interview with the Cardiopulmonary Services Director on 05/01/25 at 11:32 AM, she confirmed she had not initiated a formal grievance related to the 04/08/25 incident involving P3 and MD1. She stated, “In hindsight I guess I probably should have. There was an (incident report) placed by staff. I did give (P3) my card. She stated the hospital’s process was when someone reported a grievance, the grievance was entered into the incident reporting system as a grievance and then the report was escalated to the appropriate administrative staff from there. She stated she was not aware of any action taken regarding the 04/08/25 reported incident other than her initial conversation with P3 on the date of the incident and the verbal report she made in the safety huddle meeting the following day. The Cardiopulmonary Services Director stated she did not recognize the incident as potential verbal abuse of P3 at the time of her conversation with the patient and so had not reported the incident as such. During an interview with the Administrative Director of Support Services on 05/02/25 at 12:14 PM, he confirmed patient grievances normally came to him, however he had been out of the hospital on the date of the above referenced incident. He stated the incident should have been reported as a grievance and should have been immediately investigated as potential verbal abuse of P3 by MD1. During an interview with the CEO on 04/30/25 at 5:09 PM, he stated the hospital had reached out to all three of the cardiologists working routinely in the hospital and stated all three, including MD1, had declined to speak with the survey team. During an interview with the Chief of Staff on 05/02/25 at 9:05 AM, he confirmed he was responsible for the supervision of MD1 and stated he did not become aware of the 04/08/25 incident of potential abuse of P3 by MD1 until 04/25/25 (more than two weeks after the incident occurred). He stated abuse was not tolerated in the hospital and any allegation of abuse was expected to be investigated timely. During an interview with the Director of Medical Staff Services (DMSS) on 05/02/25 at 12:55 PM, she confirmed she received hospital incident reports and confirmed she received the 04/08/25 incident of potential verbal abuse of P3 by MD1. She stated she normally met with the Chief of Staff every two weeks and usually reported non-emergent incidents to him during those meetings. She stated she reviewed the 04/08/25 incident but did not recognize the incident as potential verbal abuse and so did not escalate the incident for an expedited review by the Chief of Staff. The Director of Medical Staff Services confirmed investigation of the 04/08/25 incident or potential verbal abuse of P3 by MD1 was not initiated until 04/24/25. She confirmed the investigation was delayed because it was not recognized as potential abuse and stated the investigation should have been initiated immediately after the initial report of potential abuse. In addition, she confirmed the hospital’s policies should address the subject of verbal abuse.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 30011 Based on interview, record review, review of hospital policy and procedure, the hospital failed to ensure patient rights were followed for 2 of 20 patient charts reviewed for advance directives. The findings include: Cross reference A 131: To ensure an incapacitated patient unable to make healthcare decisions for him/herself had his/her representative contacted to make informed decisions regarding his/her care. Cross reference A 132: To ensure that hospital staff complied with the patient advance directives.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 30011 Based on interview, record review, review of hospital policy and procedure and coroners report, the hospital failed to ensure an incapacitated patient unable to make healthcare decisions for him/herself had his/her representative contacted to make informed decisions regarding his/her care for 1 of 20 patient charts reviewed. (Patient #1) The findings include: Record review on 10/28/24 at 4:30 PM of Patient #1’s medical record revealed Patient #1 presented to the Emergency Department via Emergency Medical Services (EMS) on 03/14/23 at 2:22 PM after being found down in a ditch next to the road by a bystander with “palpable pulses, noted gunshot wound to posterior right occipital scalp, left clavicle and right hand. After EMS arrival on the scene, Patient #1 lost pulses with CPR started with return of spontaneous circulation achieved and brought to emergency room with apparent prolonged transport secondary to remote location with obvious bleeding from right occipital scalp, pupils fixed and dilated, i-gel (supraglottic airway device) in place with good end-tidal and bilateral breath sounds, does have good peripheral pulses. No other information is available at this time, no identification noted on patient. Trauma red (code called overhead for all department notification of emergent trauma) called prior to patient arrival and anesthesia and general surgery at bedside”. Review of Patient #1’s chart revealed a DNR form signed by ED Physician #1 and Registered Nurse (RN) #1 on 03/14/23 and a physicians order for “Discharge Request (Transfer Out of Facility Request)” dated 3/14/23 at 4:21 PM. Further review of the chart revealed no documentation of a family member and/or a representative for Patient #1 who was contacted and/or present to make informed decisions on behalf of the patient for his/her care. Review of General Surgery consult dated 3/14/23 at 3:15 PM revealed “Assessment/Plan: Patient has life-threatening injury to the brain. Neurosurgery has been consulted and Neurosurgeon #1 notified ...We will defer care to ER physician and Neurosurgeon #1 concerning further resuscitation and if not salvageable, organ donation ...”. Review of Neurosurgery consult dated 3/14/23 at 3:19 PM revealed “Assessment/Plan: Patient has sustained a gunshot wound to the head with a wound of entry in the right parieto-occipital region. A retained metallic fragment is in the right frontal lobe. There is generalized cerebral edema. Basilar cisterns around the midbrain are totally effaced. The patient is unresponsive. He/she is not breathing spontaneously. I concur with the recommendation to transfer the patient for organ donation”. Review of Hospital #1’s “EMTALA Memorandum of Transfer” form revealed Patient #1 under “Medical Condition” was identified as “Patient unstable” at 3:14 PM; Risk and benefit analysis for transfer: Trauma Service; Patient consent to “medically indicated” or “Patient requested” transfer: marked as I hereby consent to transfer and signed by RN #1 and RN #2 at 3:35 PM. EMS #1 arrived at Patient #1 at 3:25 PM. Review of EMS Patient Care Report on 10/29/24 at 6:45 PM revealed EMS crew was dispatched emergent for “Stat Transfer” to Hospital #1 to find a “male/female, unresponsive, airway intact, ventilations controlled, and weak carotid pulse. Unknown HX (history). Valid SC DNR”. Review of the County Coroners Case Report on 10/29/24 at 7:30 PM revealed the Coroner received notification of Patient #1’s identification on 3/15/23 and Patient #1’s identity was not made known to the patient’s mother until 2:02 PM via telephone call. During an interview on 10/31/24 at 3:45 PM to 4:00 PM, the ED Director stated “when a patient is unidentifiable, we use an alias name for the patient and if identified prior to leaving then we can merge the chart (with their name). We usually get law enforcement involved, and law enforcement is responsible for identification. A patient can be treated and transferred out as a John or Jane Doe. A physician would decide if a patient needs to be a DNR and transferred out to a higher level of care”. During an interview on 11/01/24 at 4:12 PM to 4:19 PM, ED Physician #1 stated, “The patient was a gunshot wound to the head, hand, and arm. He/she was found in the ditch and it was a prolonged arrival with EMS coming here. Once here we stabilized the airway with an ET (endotracheal tube), consulted with general surgery, trauma, and neurosurgeon. Sent for CT (Computed Tomography) scans. Based on the CT scans the Neurosurgeon said the patient was nonsurvivable injuries, the patient had a previous craniotomy with a pop off valve to allow for swelling of the brain which helped him/her out. Once neurosurgeon said unsurvivable- we transferred the patient out and he/she stated we should consult out for organ procurement. I spoke to trauma surgeon at Hospital #2 and he/she accepted the patient and we transferred him/her out to Hospital #2”. Facility policy, entitled “Advance Directives: Withholding or Withdrawing Treatment” last revision date 10/2021, revealed “(From SC law regarding Durable Power of Attorney): T. Where a patient is unable to consent , decisions concerning his/her healthcare may be made by the following persons in the following order of priority: 5. A parent of the patient; 6. An adult sibling of the patient, or if the patient has more than one adult sibling, a majority of the adult siblings who are reasonably available for consultation; ...9. A person given authority to make healthcare decisions for the patient by another statutory provision. 10. If, after good faith efforts, the hospital or other health care facility determines that the person listed in 1-8 ar unavailable to consent on behalf to the patient, a person who has an established relationship with the patient, who is acting in food faith on behalf of the patient, and who can reliably convey the patient’s wishes but who is not a paid caregiver or a provider of healthcare services to the patient. For the purposes of this item, a person with an established relationship is an adult who special care and concern for the patient, who is generally familiar with the patient’s health care views and desires, and who is willing and able to become involved in the patient’s health care decisions and to act in the patient’s best interests. The person with an established relationship shall sign and date a notarized acknowledgement form, provided by the hospital or other healthcare facility in which the patient is located, for placement in the patient’s records setting forth the nature and length of the relationship and certifying that he meets such criteria. Along with the notarized acknowledgement form, the hospital or other health care facility shall include in the patient’s medical record documentation of its efforts to locate persons with higher priority under this statue as required by subsection (B) of the Adult Health Care Consent Act (Title 44 Chapter 66). Documentation of efforts to locate a decision maker who is a person identified above should be recorded in the patient’s medical record ...2. A patient’s inability to make decisions for themselves should be certified by two (2) physicians, each of whom has examined the patient. In an emergency, the patient’s inability to make healthcare decisions may be certified by a physician responsible for the care of the patient. The physician should document in the patient’s record that the delay occasioned by obtaining certification from two (2) physicians would be detrimental to the patient’s health ...”.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 30011 Based on interview, record review and review of hospital policy and procedure, the hospital failed to ensure that hospital staff complied with the patient advance directives for 1 of 20 patient charts reviewed for advance directives. (Patient #18). The findings include: Record review on 10/30/24 at 9:55 AM of Patient #18’s chart revealed Patient #18 was from the nursing home and presented to the hospital on 10/14/24 at 9:59 AM with a “Physician’s Certification of Resident’s Decision” dated “10/09/24 stating he/she is able to make Health Care Decisions”. Review of “Resident/Family Consent for Cardiopulmonary Resuscitation” revealed Patient #18 marked “I understand that CPR constitutes an extraordinary measure and SHOULD be done on Patient #18” dated 10/04/24. Record review on 10/30/24 at 9:55 AM of Patient #18 revealed Patient #18 presented to the Emergency Department (ED) on 10/14/24 with a chief complaint of cardiac arrest at 9:59 AM. Review of ED Physician #1’s History of Present Illness” revealed “Patient is a male with metastatic melanoma with obvious tumors noted throughout his/her body, presents from nursing home with cardiac arrest according to EMS the patient had been given pain medications this morning and became very dyspneic and was noted to be breathing about 60 times a minute, before EMS could administer Narcan the patient apparently coded and they began CPR, he/she was intubated by EMS with a 7 oh ET (endotracheal tube), they state he/she went into V. tach (ventricular tachycardia) and was defibrillated was given multiple rounds of epinephrine, he/she presents with Lucas device administering compressions and he/she is currently being bagged via ET tube, he/she is otherwise unresponsive. Per nursing home the patient was a full code but on further discussion with ICU (intensive care unit) physician here the patient had been made a DNR on his/her most recent visit and is unclear how there was communication with the nursing home. No family is available. No other history available”. Review of Patient #18’s “Summary of Care” revealed documentation that the patient’s daughter and power of attorney confirmed that she was under the impression the patient was a DNR and wants him/her to be a DNR, apparently there was confusion at the nursing home as they needed the daughter to sign a form of a.m. DNR therapy and would not except the form that was sent form the hospital...the daughter is requesting that we withdraw care she does not want the patient intubated she would like the ET tube to be removed, she will also wants us to stop all antibiotics and pressors as she knows this is end-of-life for patient. She understands that with the withdrawal of all the support that the patient will likely pass quickly, she is asking that we keep him/her comfortable, this conversation was confirmed with charge nurse and ICU physician who with me signed a DNR and we proceeded with extubation given the futility of continuing care for this critically ill patient with metastatic melanoma who was obvious daily at end-of-life”. Further review of the chart revealed an undated SC Emergency Medical Services DNR order for Patient #18 signed by 2 physicians. Review of the chart revealed no documentation of the patient’s daughter being the designated power of attorney. During an interview on 10/31/24 at 11:12 AM, the Emergency Department (ED) Manager stated, “the daughter made the decision for the patient because he/she was unable to make the decision for him/herself. The two doctors signing the DNR is our standard for a patient to be considered a DNR”. Facility policy, entitled “Advance Directives: Withholding or Withdrawing Treatment” revealed “IV. Policy:...B. The patient (inpatient and outpatient) has the right to formulate advance directives, and to have hospital staff implement and comply with their advance directive...”.”

“STAFF EDUCATION CFR(s): 482.45(a)(5) Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This Standard is not met as evidenced by: 30011 Based on interview and record review, the hospital failed to ensure hospital staff involved with patient care received training in Organ Procurement Organization (OPO) for 39 of 39 ED Medical Providers educational files reviewed. The findings include: Review of Emergency Department (ED) Providers educational files on 10/31/24 between 1:51 PM to 2:46 PM revealed no documentation of OPO education for 39 of 39 providers. Review of Lifelink Organ Procurement Agreement dated 12/17/14 revealed “Education and Collaboration: D.1. The Foundation and Donor Hospital shall work collaboratively to provide and receive ongoing education of their respective staffs to ensure all appropriate personnel are knowledgeable regarding the organ donation program and are able to function within each other’s procedures and protocols and to encourage cooperation in assessing donor suitability for the organ recovery and transplant programs...”. During an interview on 11/01/24 at 9:08 AM, the Administrative Director of Patient Safety stated that the doctors do not get any OPO training, only the nursing staff.”