Tristar Skyline Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33763 Based on policy review, hospital document review, medical record review, incident report review, video recording review, and interview, the hospital failed to promote and ensure patient rights were protected for 1 of 4 (Patient #2) sampled patients when staff failed to adequately monitor and protect Patient #2 from alleged sexual abuse. The findings included: 1. Review of hospital policy, “Electronic Device Use – Employees” approved 6/2025, revealed, “...Any use of personal electronic devices during work time, must be approved in advance by the Director or Manager and must not interfere with patient care, patient/visitor experience or work completion...” Review of hospital policy, “Patient Rights and Responsibilities” approved 7/2025, revealed, “...We adopt and affirm as policy the following rights of patient/clients who receive services from our facilities...To be free from all forms of abuse...” Review of hospital policy, “Suspected/Alleged Abuse or Neglect (Elderly, Dependent Adults, Children, Domestic Situations or Sexual)” approved 9/2025, revealed, “...[Named hospital] supports and maintains a [an] environment for patients/residents that is free of abuse by anyone...Definitions...”Sexual Abuse” includes, but is not limited to...sexual coercion, or sexual assault...Alleged or Suspected Rape or Sexual Assault...Definitions: 1. Unwanted or non-consensual sexual contact...” 2. Review of page 29 from the hospital employee handbook revealed, “...Telephone Calls, Personal telephone calls, including cell phone use, must be limited and not interfere with an employee’s job responsibilities...” Review of hospital document titled “Patient Safety Attendant [PSA] Job Description” signed by PSA #1 on 10/5/2023, revealed, “...Major Responsibilities...Maintains a direct line of sight with patient at all times...Intervenes as needed to prevent patient from harming self or others...” 3. Medical record review revealed Patient #1 was a male who arrived at the hospital’s Emergency Department (ED) via ambulance on 2/10/2026 with a chief complaint of paranoid behaviors (intense, irrational, and persistent distrust or suspicion of others) after smoking crack cocaine. The Patient had a history of substance abuse and schizoaffective disorder (a mental health condition combining schizophrenia symptoms such as hallucinations, delusions and disorganized speech with mood disorder symptoms such as mania or depression). After receiving a medical work up, the Patient moved to Pod D where he was monitored for safety until he could be safely discharged to a group home. Patient #1 was deemed unsafe to care for himself on the streets due to intellectual delays. Nursing documentation completed by Registered Nurse (RN) #1 on 2/13/2026 at 3:42 PM, revealed, RN #1 was on the phone giving report to another nurse when she was alerted by PSA #1 to look at the monitors on the desk where she observed Patient #1 in Patient #2’s room having sexual intercourse with Patient #2. 4. Medical record review revealed Patient #2 was a female who arrived at the hospital’s ED via ambulance on 2/11/2026 after attempting to commit suicide by stepping into traffic. The Patient had a 6404 hold (involuntary psychiatric hold for safety) in place. The Patient was actively suicidal with a plan to step back into traffic upon release from the hospital. Patient #2 underwent a full trauma and medical evaluation and was medically cleared for a psychiatric evaluation. Suicide precautions were initiated. Once Patient #2’s condition began improving, the Patient was moved to Pod D to await transfer to an inpatient psychiatric hospital. A psychiatric consult note written by Psychiatric Nurse Practitioner (PNP) #1 on 2/13/2026 at 3:21 PM, revealed Patient #2 reported being afraid of people, “especially males”, and had difficulty determining right from wrong making her “very vulnerable....” Nursing documentation completed by RN #1 on 2/13/2026 at 3:42 PM, revealed RN #1 was on the phone giving report to another nurse when she was alerted by PSA #1 to look at the monitors on the desk where she observed Patient #1 in Patient #2’s room having sexual intercourse with Patient #2. Nursing documentation revealed Patient #2 was examined by PNP #1 as well as by the Sexual Assault Nurse Examiner (SANE), and an investigation by local police was started. 5. Review of the hospital Incident Report dated 2/13/2026, revealed security officers were called to Pod D for an alleged criminal sexual assault against involving Patient #1 and Patient #2. The report indicated local police officers were also involved in the investigation. 6. Observations of Pod D on 2/24/2026 at 11:55 AM, revealed the windows in the nurse’s station provided attentive staff an unobstructed view of the patient hallway where Patient #1 and Patient #2 were housed. Patient #1’s room was located across the hall from the nurse’s station and almost directly across the hall from Patient #2’s room. Attentive staff were also able to monitor all activities occurring in the patient rooms due the presence of video monitors showing camera views inside each patient’s room at all times. 7. Review of video footage from 2/13/2026 from 3:40:02 PM through 3:50:01 PM, revealed Patient #1 was observed on camera out in the hallway moving around Patient #2’s doorway in direct sight of the nurse’s station from 3:40:04 PM until 3:43:56 PM; however, RN #1 was observed sitting at the back of the nurse’s station using the hospital telephone and PSA #1 was observed sitting at the desk and appeared to be looking at her cell phone. At 3:43:56 PM, while both RN #1 and PSA #1 were not monitoring the hallway or video monitors, Patient #1 was observed entering Patient #2’s room out of view of the camera. At 3:44:33 PM, PSA #1 was observed putting her cell phone down and appeared to look at the video monitor on the desk. At 3:44:39 PM, PSA #1 began pointing at the room monitors and RN #1 turned toward PSA #1. At 3:44:44 PM, PSA #1 stood up, and both she and RN #1 appeared to be looking at the room monitors. At 3:44:51 PM, Patient #1 reappeared under the threshold to Patient #2’s room back into view of the camera. 8. During an interview on 2/24/2026 at 11:55 AM, the ED Director stated Pod D was a holding area used to house low risk psychiatric patients and/or substance abuse patients until they could be safely transferred or discharged. The ED Director stated the unit was designed and equipped with cameras so that patients could be monitored by staff at all times. During an interview on 2/24/2026 at 11:45 AM, PNP #1 stated she asked Patient #2 if the sexual activity with Patient #1 was consensual, and Patient #2 told her “No”. During an interview on 2/24/2026 at 12:00 PM, RN #1 stated when she looked at the monitor in the nurse’s station, she observed Patient #1 bent over Patient #2 “having sex with her.” During an interview on 2/24/2026 at 2:20 PM, the Regulatory Manager verified PSA #1 appeared to be on her cell phone instead of viewing the hallway and/or patient room monitors and did not see Patient #1 enter Patient #2’s room. During an interview on 2/24/2026 at 2:23 PM, the Interim Vice President of Quality (IVPQ) confirmed she had also observed PSA #1on her cell phone instead of watching the patients when Patient #1 entered Patient #2’s room. Both RN #1 and PSA #1 failed to monitor the Patient hallway and/or patient room monitors resulting in Patient #1 entering Patient #2’s room unobserved by staff during which time Patient #1 engaged in non-consensual sexual activity with Patient #2. Refer to A-0145”

“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: 33763 Based on policy review, hospital document review, medical record review, incident report review, video recording review, and interview, the hospital failed to ensure patient rights were protected for 1 of 4 (Patient #2) sampled patients by failing to adequately monitor and protect Patient #2 from alleged sexual abuse. The findings included: 1. Review of hospital policy, “Electronic Device Use - Employees” approved 6/2025, revealed, “...Use of personal electronic devices (includes phone, tablets, laptops, ear buds, watches, headphones or wireless ear buds) during unpaid break is appropriate. The use of personal electronic devices must be in recognized break areas...or when outside the building on break...Any use of personal electronic devices during work time, must be approved in advance by the Director or Manager and must not interfere with patient care, patient/visitor experience or work completion...” Review of hospital policy, “Patient Rights and Responsibilities” approved 7/2025, revealed, “...We adopt and affirm as policy the following rights of patient/clients who receive services from our facilities...To be free from all forms of abuse...” Review of hospital policy, “Suspected/Alleged Abuse or Neglect (Elderly, Dependent Adults, Children, Domestic Situations or Sexual)” approved 9/2025, revealed, “...[Named hospital] supports and maintains a [an] environment for patients/residents that is free of abuse by anyone, including but not limited to: staff, other patients/residents...Definitions...Sexual exploitation “Sexual Abuse” includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault...Alleged or Suspected Rape or Sexual Assault...Definitions: 1. Unwanted or non-consensual sexual contact as may be evidenced by...verbalization of allegations of rape or sexual assault by the patient...” 2. Review of page 29 from the hospital employee handbook revealed, “...Telephone Calls, Personal telephone calls, including cell phone use, must be limited and not interfere with an employee’s job responsibilities...” Review of hospital document titled, “Patient Safety Attendant [PSA] Job Description” signed by PSA #1 on 10/5/2023, revealed, “...Position Summary The Patient Safety Attendant (PSA) participates in high-quality, patient-centered care by providing continuous observation and monitoring for high risk patients...Major Responsibilities...Maintains a direct line of sight with patient at all times, including while family and/or visitors are in the room...Reports any changes in status promptly while remaining in direct line of sight with the patient...Intervenes as needed to prevent patient from harming self or others...” 3. Medical record review revealed Patient #1, was a male with a history of substance abuse and schizoaffective disorder (a mental health condition combining schizophrenia symptoms such as hallucinations, delusions and disorganized speech with mood disorder symptoms such as mania or depression) who presented to the hospital’s Emergency Department (ED) via ambulance on 2/10/2026 exhibiting paranoid behaviors (intense, irrational, and persistent distrust or suspicion of others) after smoking crack cocaine. A full medical workup was completed, and the Patient’s urine drug screen (UDS) was positive for amphetamines (stimulants that speed up the body’s system), benzodiazepines (psychoactive drugs that act as central nervous system depressants), cocaine, and cannabinoids (chemical compound found in cannabis (marijuana) plant). Psychiatric Consult note completed on 2/11/2026 at 10:49 AM, revealed Patient #1 stated he “feels as though somebody is going to do something to him...” The Patient denied suicidal ideations (SI), homicidal ideations (HI), and auditory or visual hallucinations (avh). “Pt [patient] is very paranoid, minimizing, confused, irritable, and impaired. He became angry, posturing and threatening staff, throwing objects, broke hospital property. Pt required medications to help calm, secluded for safety...Pt will be reassessed in the am...” Patient #1 was placed in a legal, involuntary hold with diagnoses of Substance-induced psychotic disorder, Schizoaffective disorder, and Psychosis. Follow up psychiatry note completed by Psychiatric Nurse Practitioner (PNP) #1on 2/11/2026 at 8:58 PM, revealed Patient #1 reported feeling better and acknowledged his need to stop using drugs and focus on his recovery. The Patient further reported some anxiety but was overall ready to be discharged to a new group home where he could focus on his recovery and attend “Narcotics Anonymous” meetings. The note further revealed, “Pt is cleared of his drug induced state, however, he is intellectually delayed. Pt lived at group home and then left and was living on the street for the past week or so. Pt is childlike and impulsive. Pt denies si/hi/avh...father is conservator and states he does not want his son [Patient #1] discharged but can not come and pick him up...I spoke with father and explained that patient does not meet criteria for inpatient psychiatric hospitalization, however is not capable of safely caring for him self on the streets due to his intellectual delay...Pt does not meet placement criteria for inpatient psychiatric hospitalization but is unsafe to discharge to self at this time. Psychiatry is signing off at this time. Pt has social issues as a barrier to discharge...Pt will remain on Zyprexa [antipsychotic medication used to treat schizophrenia] for control of agitation and anxiety...” Nursing documentation completed by Registered Nurse (RN) #1 on 2/13/2026 at 3:42 PM, revealed “This RN was giving report to another nurse when the Pod D [Secure Patient Unit] sitter, [PSA #1] was calling this RNs name and poking my arm to get my attention to the cameras. While on phone giving report, this RN looked at the cameras and saw this patient [Patient #1] in another female pt [Patient #2] room having sexual intercourse with her. This RN immediately ran to the patients and told them to stop and this RN called security. This RN separated both patients away from each other...This Pt [Patient #1] became upset with this RN and stated...’I didn’t have sex with anyone...’ This RN called for extra security and [local police]. [Local police] came into Pod D and was able to successfully and calmly get Patient into his room. Seclusion [seclusion] orders placed on patient...Charge RN...Psych [Psychiatric] NP [PNP #1] and... ED Manager notified...” 4. Medical record review revealed Patient #2 was a female who presented to the hospitals’ ED via ambulance on 2/11/2026 under involuntary hold status after stepping into traffic in an attempt to commit suicide. Patient #2 was struck by a moving vehicle causing her to fall to the ground. Patient #2 was unsure if she’d lost consciousness but complained of pain to the back of her head and right hip region. Ambulance providers informed the ED provider Patient #2 “attempted to put a bag over her head since this incident occurred...” Patient #2 reported on-going SI with a plan and her judgement and insight were abnormal. Suicide precautions were initiated and the Patient underwent a medical evaluation and trauma work up. There were no significant medical problems identified and no fractures were noted. The Patient was deemed medically cleared for a psychiatric evaluation at 1:21 PM. Initial psychiatric consultation completed by PNP #1 on 2/12/2026 at 10:07 AM, revealed Patient #2 was alert and oriented, “disheveled, dismissive, and has some behavioral disturbances...Pt is mostly noncompliant with medication regimen due to lack of funding. Pt mood is flat, affect is blunted. Pt currently endorses suicidal ideations and plan to walk back into traffic. Pt denies homicidal/avh...[Patient #2] presents with the chief complaint of ‘I don’t want to live.’ Patient reports intentionally running out in front of a car yesterday due to not wanting to live anymore. She states this occurred following the loss of her grandmother...reports being homeless and living alone. She endorses a history of sexual trauma and domestic violence...Pt meets criteria for inpatient psychiatric hospitalization...” The Patient’s home medications were restarted, and she remained in the hospitals secured unit in the ED under involuntary hold for diagnoses which included Chronic Suicidal Ideations, Major Depressive Disorder, recurrent severe, Anxiety, and Emotional Lability (rapid, intense, and often uncontrollable mood swings, where a person experiences emotions that are inconsistent or disproportionate to the situation). Psychiatric Consult note completed by PNP #1 on 2/13/2026 at 1:04 PM revealed, Patient #2 was “currently unemployed, housing concerns/homeless, limited education, limited support system, needs structed milieu, no insight into problems, non-compliance with meds, poor coping skills, poor work history, previous hospitalization, recurrent hospitalization, somatic complaints, tendency toward SI, unstable finances, poor insight...” Follow up note written by PNP #1 on 2/13/2026 at 3:21 PM, revealed Patient #2 was still expressing suicidal ideations which had been present for the past month. PNP #1 documented, “...Patient endorses severe social anxiety that prevents her from maintaining employment, stating she experiences anxiety attacks and cannot focus or complete work tasks. She reports being ‘scared of people, especially males’ and describes fight-or-flight response when homeless that lead to self-harm behaviors including cutting. Per pt ‘I have a learning disorder affecting ability to distinguish right from wrong and making her very vulnerable’...pt is not psychotic, delusional, hallucinating, manic, internally preoccupied or showing signs of depression. Pt has some degree of intellectual delay noted, however is completely functional and can maintain her own ADL’s [activities of daily living] without difficulty...Pt is attention seeking, monopolizes staff’s time, frequent redirection [easy to redirect], and has some behavioral component to her presentation...Pt does present as a safety risk to herself at this time, therefore meets criteria for inpatient hospitalization, 6404 [psychiatric hold]...” Review of the nursing documentation completed by RN #1 on 2/13/2026 at 3:42 PM revealed, “This RN was giving report to another nurse when the Pod D sitter, [named PSA #1] was calling this RNS name and poking my arm to get my attention to the cameras. While on phone giving report, this RN looked at the cameras and saw a male patient [Patient #1] from Pod D, having sexual intercourse with this Pt [Patient #2] in her room. This RN immediately ran towards the patients and told them to stop and called security. This RN separated both patients away from each other. This Pt [Patient #2] stayed in her room. Pt [Patient #2] is laying in bed calmly and comfortably, resp [respirations] E/U [even and unlabored], and NAD [no apparent distress] noted. This RN requested security to stay in Pod D and monitor the patients while this RN reports the sexual encounter...notified...Charge RN...Psych NP [PNP #1], and...ED Manager...” Review of the nursing documentation completed by RN #1 on 2/13/2026 at 4:42 PM revealed, “This RN contacted [local police] to speak with Patient [Patient #2]...” Review of the nursing documentation completed by RN #1 on 2/13/2026 at 4:46 PM, revealed, “Patient [#2] moved from Pod D to Room 8 [out of Pod D to room 8 in the main ED] Pt transferred with security and this RN...” Review of the nursing documentation completed by RN #2 on 2/13/2026 at 4:48 PM, revealed, “ Pt [#2] care taken over from previous nurse [RN #1] at this time. Pt was placed in room 08 from Pod D due to an incident that took place. [Local police] officer at bedside speaking to Pt at this time. She is alert and oriented and stable at this time...” Review of the nursing documentation completed by RN #3 on 2/13/2026 at 5:01 PM revealed, “SANE [sexual assault nurse examiner] nurse contacted at this time...” Review of the ED Provider documentation dated 2/13/2026 at 5:27 PM revealed, “...pt [Patient #2] has become risk to self and staff and is requiring 1/1 sitter observation at this time...” Review of the nursing documentation completed by RN #2 on 2/13/2026 at 5:42 PM revealed, “At 1700 [5:00 PM] Pt [Patient #2] ran down the hall next to this RN, RN asked what the pt needed and then helped pt to the bathroom. RN collected urine and set it to the side in case the SANE nurse were to need it. After taking the pt back to her room at 1721 [5:21 PM] this RN found a comb, and a tissue box with an unidentified item inside. These items were then handed over to security. This RN again asked for a sitter. Sitter arrived at 1735 [5:35 PM] and the 15 min [minute] check sheet was handed off to the sitter. Prior to pt entering the room, this RN along with an additional RN did check the room and ensure it was empty and safe for a psych pt...” Review of the “Medical Legal Exam Report of Sexual Assault Complaint - Female Victims” dated 2/13/2026 at 6:30 PM, revealed Patient #2 consented to the examination. Patient #2 reported Patient #1 had walked into her room and asked her if she had a boyfriend, then asked her if she wanted “oral or vaginal” [sex] and then told her to “turn around.” Patient #2 told the examiner, “I felt very trapped. I turned around, then he stuck his penis in my vagina. I was frozen and couldn’t move. Staff got called in and said ‘hey, what’s going on?’.” Patient #2 then stated Patient #1 stopped. The report indicated Patient #1 used his body to intimidate Patient #2 and used his body as a restraint. Patient #2 indicated Patient #1 “cornered me.” The report indicated Patient #1 penetrated Patient #1’s vulva and no condom was used during the encounter. The “Examination” portion of the report indicated Patient #2 was alert and oriented, calm and cooperative during the examination. “Summary of Findings...Urine, blood, labs collected & [and] sent for STI [sexually transmitted infections] testing. Std [standard] pregnancy prophylaxis [Plan B oral tablet] initiated. Follow up instructions discussed & verbalized understanding. [local police] report made & pt on 6404 hold...The Patient was placed on HIV [human immunodeficiency virus] prophylaxis medication...” The report also indicated Patient #2 was treated with prophylactic antibiotics which included Rocephin injection, Doxycycline and Flagyl by mouth. Review of the nursing documentation completed by RN #2 on 2/13/2026 at 7:48 PM, revealed, “SANE nurse completed exam. Pt remains in room with safety precautions in place and Pt sitter at bedside...” An ED Provider Patient Addendum note dated 2/14/2026 at 12:05 AM, revealed “Care assumed at shift change, patient [Patient #2] seen and examined by myself...During her time in the ER [emergency room] she had sex with a male patient with unclear consent, so she was evaluated by the SANE team, and the two patients [Patient #1 and #2] were placed in separate parts of the ER...She was accepted by a transferring facility, so on my repeat examination she is sleeping comfortably, awakens easily, moves all extremities with no focal deficit, and reports feeling fine physically. I signed her transfer form...” Patient #2 was transferred to an inpatient psychiatric hospital on 2/14/2026 at 1:48 AM. 5. Review of the hospital Incident Report dated 2/13/2026 revealed, “...Incident category: Criminal: Assault...Sexual: Against Patient...Narrative Security was called to the ER [Emergency Room] Pod D. When security arrived nurse [RN #1] let security know that the patient in room 49 [Patient #1] had went into the patient in room 54 [Patient #2] room and started having sexual intercourse with her. The nurse also let security know that as soon as they saw what was happening she went and she put a stop to it. The nurse went and talked to her supervisors to see what the next steps were going to be. The patient in room 49 was asked to go back to their room and he refused. Security call [local police] and after [local police] came in and told him the same thing the patient went back to their room. Eventually the patient in room 54 [Patient #2] was moved to ER room 8...[local police] has started talking to both of the patients...Was an arrest made following this incident? No...” 6. Observations made in Pod D on 2/24/2026 at 11:55 AM with the ED Director, the Regulatory Manager and the Interim Vice President of Quality, revealed the area could only be accessed by staff with a badge lock. The area had a set of double doors that exited out into a corridor in the hospital. Signs on the double doors showed “Stop! Check with nursing prior to entering.” A single door just to the right of the double doors with badge only access also had a sign directing people to knock and check with nursing prior to entering the area. The double doors opened directly into the patient care area. The single door opened into the nurse’s station. where the medication dispensing machine and supply storage was located on the right side of the room along with the patient nourishment station. The opposite side of the nurse’s station had a refrigerator and a single doorway that opened into the patient area. The doorway was designed so that the upper portion of the door could be opened without opening the lower portion of the doorway as needed. Just past that doorway on the left side of the room, a desk area with video monitors that showed camera views inside each patient room was observed. The monitors could only be viewed by personnel sitting directly in front of the desk. Above the monitors, was a wall of windows where staff would have direct views into the patient hallway. The desk top area made a 90-degree turn to the right and went across the back wall of the nurse’s station. There were no windows or monitors on the back wall. The patient hallway area consisted of 8 patient rooms, a bathroom with a shower, a closet for patients’ personal items, and a closet where the emergency cart and clean linens were stored. The rooms where Patient #1 and Patient #2 were housed were located almost directly across the hallway from one another. 7. The hospital’s video recording of the event was reviewed on 2/24/2026 at 2:15 PM in the presence of the Director of Security and the Regulatory Manager. The camera screen was split into 4 different views running simultaneously, with 3 of the views showing the patient hallway areas, doors to rooms and bathroom, and the 4th camera showing the nurses station. The video recordings started on 2/13/2026 at 3:40:02 PM and revealed the following: At 3:40:02 PM, the video showed an empty patient hallway. Patient #1’s doorway was across the hall from the nurses’ station and Patient #2’s doorway. Both Patient #1 and Patient #2’s doorway were open. RN #1 was sitting at the back of the nurse’s station and appeared to be on the hospital phone. PSA #1 was sitting at the desk just inside the nurse ’ s station. At 3:40:04 PM, Patient #1 exited his room into the hallway dressed in a purple hospital gown and began walking toward Patient #2’s room. At 3:40:11 PM, Patient #1 was observed standing at his doorway. At 3:40:20 PM, RN #1 was still at the back of the nurse’s station on the hospital phone, and PSA #1 was observed sitting at the desk looking at her cell phone. At 3:42:11 PM, RN #1 was still sitting at the back of the nurse’s station. It was unclear if RN #1 was still on the hospital phone at this time. PSA #1 was still sitting at the desk holding her cell phone in her hand with her head tilted downward facing the phone. Patient #1 was observed standing just outside the doorway to Patient #2’s room. At 3:42:19 PM, RN #2 was still at the back of the nurse’s station and was on the hospital phone. PSA #1 was still seated at the desk and appeared to be looking down at her cell phone. Patient #1 was still standing just outside Patient #2’s doorway and appeared to be talking. At 3:43:01 PM, Patient #1 was observed standing at the threshold to Patient #2’s room and appeared to be talking. RN #1 was still on the hospital phone, and PSA #1 was still seated and appeared to be scrolling on the cell phone in her hand. At 3:43:47 PM, another Patient entered the hallway from a room down the hallway into view of the camera. Patient #1 was still standing just inside the threshold to Patient #2’s room. Observations of RN #1 and PSA #1 remained unchanged. At 3:43:56 PM, Patient #1 entered Patient #2’s room out of view of the camera. RN #1 was still at the back of the nurse’s station on the hospital phone, and PSA #1 was still sitting at the nurse’s desk and appeared to be looking down at her cell phone. There was no indication on the video RN #1 or PSA #2 observed Patient #1 enter Patient #2’s room. At 3:44:12 PM, the other Patient in the hallway walked back down the hallway into the room at the end of the hallway and out of view of the camera. Patient #1 was still in Patient #1’s room out of view of the camera. RN #1 was still on the hospital phone at the back of the nurse’s station, and PSA #1 was still looking down at her cell phone. At 3:44:33 PM, PSA #1 put her cell phone on the desk and appeared to look up at the room monitors on the desk. At 3:44:39 PM, PSA #1 began pointing at the room monitors, and RN #1 turned toward PSA #1. At 3:44:44 PM, PSA #1 stood up and both she and RN #1 appeared to be looking at the room monitors. At 3:44:48 PM, PSA #1 opened the doorway into the patient hallway and RN #1 began walking toward the opened door. At 3:44:51 PM, Patient #1 reappeared under the threshold to Patient #2’s room back into view of the camera. PSA #1 was still standing holding the door open, and RN #1 appeared to be looking at PSA #1. At 3:44:54 PM, Patient #1 moved out into the hallway in full view of the camera. The Patient’s gown was off his right shoulder exposing his shoulder and chest. RN #1 was exiting the nurse’s station through the door held by PSA #1. At 3:44:57 PM, RN #1 was in the patient hallway walking toward Patient #1 and appeared to be talking into the radio attached to her uniform. PSA #1 was still holding the door open at the nurse’s station. At 3:45:33 PM, Patient #1 walked back into his room and closed the door behind him. At 3:46:48 PM, Security Officer #1 entered the nurse’s station. At 3:50:01 PM, the video ended. 8. During an interview on 2/24/2026 at 11:45 AM, PNP #1 stated Patient #1 was in Pod D waiting to be transferred out of the hospital. The PNP stated Patient #2 had been “highly sexual” and the nurse on the unit (RN #1) called her and asked her to come and assess the Patient. The PNP stated Patient #2 told her Patient #1 came into her room and asked her if she wanted to “do it so she bent over.” The PNP stated Patient #2 did not appear to be upset and wasn’t crying. The PNP stated she asked Patient #2 if the sexual activity was consensual, and Patient #2 told her “no”. The PNP continued and stated when she asked her if Patient #1 raped her, Patient #2 stated, “no, but it wasn’t consensual.” PNP #1 stated she examined Patient #2 and found no evidence of sexual penetration or trauma. The PNP stated both Patient #1 and Patient #2 were “a little lower functioning,” and there were no reported events of fighting or arguing between them. PNP #1 stated Patient #2 was competent to make decisions for herself regarding the sexual encounter. During an interview on 2/24/2026 at 11:55 AM, the ED Director stated Pod D was a holding area used to house low risk psychiatric patients waiting to be transferred to inpatient psychiatric facilities. The ED Director stated the area was also used to house patients with substance abuse until they were safe to be discharged, usually a period of 3 days. The ED Director stated the unit had video cameras that record activity in the patient hallway, and each room was equipped with a camera visible only on the monitors at the nurse’s station, but those cameras did not record, they were only used to help staff visualize the patients at all times. During an interview on 2/24/2026 at 12:00 PM, RN #1 stated when she looked at the monitor in the nurse’s station, she observed Patient #1 bent over Patient #2 “having sex with her.” The RN stated she immediately walked out of the nurse’s station and told him (Patient #1) to go back to his room and security had already been called at that time. RN #1 stated she contacted PNP #1 and informed her of the incident along with the ED Director and the ED Manager. RN #1 stated, “I did actually see them having sex on the camera at the nurse’s station.” The RN continued and stated PSA #1 tapped her on her shoulder and had her look at the monitor. RN #1 was asked if Patient #2 was competent to give consent. RN #1 stated, “yes, she [Patient #2] was supposed to be discharged that day. She [Patient #2] wasn’t upset, she was just laying there on the bed when the nurse practitioner [PNP #1] went in a saw her.” During an interview on 2/24/2026 at 2:16 PM, the Director of Security stated the cameras in the patient rooms on Pod D did not record, they were used as a tool to monitor patients for safety, but the hallway cameras recorded anytime activity was detected in the patient hallway area. The Director of Security also informed the surveyor a member of the local police department was always on duty in the hospital and available to respond to calls for assistance. During an interview on 2/24/2026 at 2:20 PM, the Regulatory Manager verified PSA #1 appeared to be on her cell phone instead of viewing the hallway and/or patient room monitors and did not see Patient #1 enter Patient #2’s room. During an interview on 2/24/2026 at 2:23 PM, the Interim Vice President of Quality (IVPQ) confirmed she had also observed PSA #1 was on her cell phone instead of watching the patients when Patient #1 entered Patient #1’s room. During an interview on 2/24/2026 at 2:35 PM, the Regulatory Manager stated the hospital reviewed the incident and developed actions to decrease the risk of recurrence. The Regulatory Manager stated the actions included: reviewing the process for behavioral health patients including assessment, dressing, monitoring, education and auditing; reviewing criteria to cohort patients in Pod D and audit the patients cohorted to Pod D to ensure criteria are met, and education of Emergency Department staff regarding distractions while monitoring patients and have staff attest to understanding. Both RN #1 and PSA #1 failed to monitor the Patient hallway and/or patient room monitors resulting in Patient #1 entering Patient #2’s room unobserved by staff during which time Patient #1 engaged in non-consensual sexual activity with Patient #2.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 37530 Based on policy review, medical record review and interview, the facility failed to ensure patient respect, dignity, and privacy were maintained for 1 of 3 (Patient #9) sampled patients reviewed for patients rights. The findings included: 1. Review of the facility’s policy titled “Patient Rights and Responsibilities,” dated 10/2024, revealed “...respects the dignity and pride of each individual we serve...To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment...” Review of the facility’s policy titled “Information Protection,” dated December 23, 2024, revealed, “...the purpose of this Policy is to establish general requirements for the patient privacy program and provide pertinent definitions and provide guidance for some aspects of the Health Insurance Portability and Accountability Act (HIPAA)...To establish the requirements for each Company-affiliated facility to protect patients’ privacy rights and their individually identifiable Health Information as required by the HIPAA Privacy Standards...” 2. Review of the closed medical record revealed Patient #9 was admitted on 9/17/2024 with diagnoses of Post Traumatic Stress Disorder, Bipolar Disorder, and Suicidal Ideation. Review of the History of Present Illness (HPI) dated 9/17/2024, revealed “...Patient presents to the ER [Emergency Room] with mental health concerns. Patient reports a history of bipolar disorder...He [she] presents to the ER today reporting suicidal ideation. She will not disclose to me any particular stressors or other reason why she has suicidal ideation today. She does report compliance with current medication...” Review of the “UNLOCKED PROGRESS NOTE,” dated 9/17/2024, revealed “...Crisis Narrative...location...[hall bed]...C [Client] reported endorsing SI [Suicidal Ideation] with plan to “slit wrist” using a razor blade...reported having 7/10 intent to follow through with this plan...reported struggling with SI “on and off of years,” however this episode has been consistent for two weeks...reported engaging in SIB [Suicidal Ideation Behavior] via cutting on 9/15/2024...reported major stressor is mom moving back...meets criteria for IP [In-patient] due to SI with plan, access, and intent...Consent was given from Dad...[Named Family Member #2]...” 3. During a telephone interview on 12/2/2024 at 11:16 AM, Family Member #1 was asked to tell me about Patient #9’s ER visit. Family Member #1 stated “...Seen in the Emergency Department [ED] for suicide risk...she had been to therapy and revealed to the therapist she had a plan...my 21-year-old son took her to the appointment...then he took her to the hospital...to the ER...once her father and I got there...she was just on a gurney in the hallway...at no time did put her in a room...the crisis person came, they talked to her in the hallway around other patients...there was no privacy for her what so ever...they were so busy and did not have a room to take her to...everything they did it was in the hallway...there was a patient across from her...2 other patients out in the hallway as well...” During an interview on 12/4/2024 at 10:14 AM, the ED Director was asked if the patient was provided privacy in the hallway beds. The ED Director stated, “...It’s not conducive. We try to respect their privacy. We pull the screen so the other patients cannot see on the other side.” The ED Director was asked if the other patients in the hallway could hear other conversation. The ED Director confirmed the patients could be heard by other patients in the hallway. The ED Director confirmed Patient #9 was positioned in the hallway bed.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 37530 Based on facility policy, record review, facility document review, facility email review, and interview, the facility failed to ensure that privacy was protected for 1 of 3 (Patient #31) sampled patients reviewed for Health Insurance Portability and Accountability Act (HIPAA) privacy. The findings included: 1. Review of the facility’s policy titled “Information Protection,” dated December 23, 2024, revealed, “...the purpose of this Policy is to establish general requirements for the patient privacy program and provide pertinent definitions and provide guidance for some aspects of the Health Insurance Portability and Accountability Act (HIPAA)...To establish the requirements for each Company-affiliated facility to protect patients’ privacy rights and their individually identifiable Health Information as required by the HIPAA Privacy Standards...” 2. Review of the “Patient Information Form,” revealed Patient #31’s name, room number, social security number, date of birth, next of kin information, and insurance information. 3. Review of the “Text Message,” dated 12/3/2024 at 9:03 AM, revealed Patient #31’s Patient Information Forms which contained personal information. The text of Patient #31’s Patient Information Forms was provided by Patient #22’s Family Member #3. 4. Review of the “Complaint Form,” dated 11/4/2023, revealed “...I [Patient #22] also received someone else’s case paperwork when being dismissed. I [Patient #22] had the lady [Patient #31] in room [Named room number] personal information (emergency number, her address, phone, [Named Insurance] ID [identification], social security number)...” 5. Review of the email dated 11/11/2023, revealed “...The below action still needs to occur...were you able to determine the identity of the lady [Patient #31] in [Named room number]...Can provide the name of the nurse who provided the discharge instructions to [Named Patient #22]...” 6. During a telephone interview on 12/2/2024 at 3:33 PM, Family Member #3 [for Patient #22] was asked to tell me about the incorrect information she received at discharge from the hospital. Family Member #3 stated, “...right before we got ready to leave the hospital...they brought me all these papers, and I saw it had some other lady’s stuff [Patient #31]...I kept that too...it had the lady’s social security number, telephone number and all her insurance information...” During a telephone interview on 12/30/2024 at 4:13 PM, the Vice President of Quality stated the hospital was unable to to identify the person whose records were compromised. The hospital failed to ensure the HIPAA privacy of Patient #31’s personal information. The hospital failed to identify and inform Patient #31 that her personal information was disclosed to Patient #22 and her family.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 37530 Based on medical record review and interview, the nursing staff members failed to ensure the patients were observed and monitored during seclusion and after medication administration for 2 of 3 (Patient #1 and #23) sampled patients reviewed for behavioral management. The findings included: 1. Review of the facility policy titled “Patient Restraint/Seclusion,” dated 11/2024, revealed “...This policy/procedure applies to health care professionals operating within... Healthcare facilities that have responsibility for ordering, assessing... monitoring... Patient in... seclusion... must have an individual performing and documenting real time... This can be evidenced through a monitoring log or form or electronic means to determine these checks were performed...” 2. Review of the medical record revealed Patient #1 was admitted on 11/11/2024 with diagnoses of Paranoid Schizophrenia, Bipolar Disorder, Borderline Personality and Homelessness. Review of the “Physician’s Orders,” dated 11/11/2024, revealed, “...Suicide precautions... Observation time... Line of sight... Midazolam [Versed - medication used to produce sleepiness or drowsiness and to relieve anxiety] Inj [injection]...Dose...5 MG [milligrams]...IM [intramuscular]...” Review of the “Physician’s Orders,” dated 11/13/2024 revealed “...Midazolam Inj... Dose... 10 MG... IM... Ziprasidone [Geodon - psychotropic medication used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder] Inj (Geodon Inj)... Dose... 20 MG...IM...RESTRAINTS...Violent restraint device...Seclusion...4 hours...” Review of the “Current Hospital Medication,” revealed “...11/11/2024...10:23 PM ...Midazolam... (VERSED)... 5 MG... X1ED...IM...” Review of the “ADMINISTRATION PERIOD,” dated 11/11/2024, revealed “...VERSED 5 MG/1 ML [milliliter]...IM...Right Upper Arm 22:22 [10:22 PM] GAVE 5 MG...” Review of Emergency Note dated 11/12/2024 revealed “...PT [patient] CONTINUALLY COMING OUT OF TREATMENT ROOM, COMING TO NURSES STATION DEMANDING TO LEAVE. PT PROCEEDS TO BANG ON WINDOW OF NURSES STATION AND SCREAMING IN THE HALLWAY...PT ALSO SEEN PEEKING INTO OTHER PT TREATMENT ROOMS. SECURITY CALLED TO ASSIST GETTING THE PT BACK TO TREATMENT ROOM. BEHAVIORAL HEALTH NURSE RESPONDED AND ATTEMPTED TO DEESCULATE [De-escalate] PT. PT PROCEEDED TO SCREAM AND BANG ON WALLS/DOORS. SECURITY ARRIVED AND SUCCESSFULLY GOT PT BACK INTO TREATMENT ROOM. PT IS NOW ON SECLUSION ORDERS...” Review of the “ADMINISTRATION PERIOD,” dated 11/13/2024, revealed “...VERSED 5 MG/1 ML...IM...Left Hip 11:41 [11:41 AM] GAVE 10 MG...” Review of the “ADMINISTRATION PERIOD,” dated 11/13/2024, revealed “...GEODON...20 MG IM...Left Hip 11:41 [11:41 AM] GAVE 20 MG...” Review of the “Follow-up Note,” dated 11/13/2024 revealed “...Today the patient had to be sedated due to inappropriate behavior...” Review of the Follow up Note dated 11/14/2024 revealed “...Today the patient is up walking around peering in [named patient]’s window...During follow up we asked the patient about the encounter she had with the pt in [patient’s room number]. She began to laugh and states “women are mystical creatures we have the power of the gods, but only when we know we have the goods we can control men and get them to do what we want from them.” The patient presents in a manic state she believes that she can control men with her sexual allure. Her speech is rapid she has been presenting with hypersexual behavior with an elevated confidence accompanied by being provocative, attention seeking, removing her own clothes and exposing herself to the men in the POD [psychiatric unit in the Emergency Department]...” There was no documentation provided that Patient #1 was monitored during seclusion and following the administration of medications for behavioral management. 3. Review of the medical record revealed Patient #23 was admitted on 11/12/2024 with diagnoses of Restlessness and Agitation, Psychosis, Anxiety Disorder, Insomnia, and Homelessness. Review of the “ADMINISTRATION PERIOD,” dated 11/12/2024, revealed “...HALDOL [antipsychotic medication used to treat mental/mood disorder]... 5 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 5 MG... ATIVAN [medication used to treat anxiety disorders]... 2 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 2 MG... BENADRYL [antihistamine which can cause drowsiness]... 50 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 50 MG...” Review of the “ADMINISTRATION PERIOD.” dated 11/13/2024, revealed “...ATIVAN... 2 MG IM EVERY 6 HOURS AS NEEDED... Both Hips 10:39 [10:30 AM] GAVE... 2 MG...” Review of the “ADMINISTRATION PERIOD,” dated 11/14/2024, revealed “...GEODON... 40 MG PO [By mouth] TWICE DAILY... 23:11 [11:11 PM] GAVE 40 MG...” Review of the Psychiatric Consultation Noted dated 11/14/2024, revealed “...Psych [Psychiatric] Consult HPI [History of Present Illness]... Pt is a 30yo [30-year-old]... with a past psych hx [history] of schizophrenia who presents for capacity eval [evaluation]. Pt is in the hospital for reported being disorganized and erratic... In hospital, Pt has been manic, hyper-verbal, restless, easily agitated, appears to be responding to internal stimuli. Pt also has grandiose delusions...” Review of the Follow UP dated 11/14/2024, revealed “...This writer asked patient about an incident that happen today with another female patient in the pod. I asked patient if had any sexual activity with female patient. Pt said, “that’s over, I know we can’t do anything here”. I asked patient to tell me about the incident, and patient described that female patient kept following him around, taking her clothes off, standing at his door. Pt said they were flirting with eachother [each other]...” 4. During an interview on 12/6/2024 at 8:44 AM, the management staff was asked to describe the process for monitoring of patients in seclusion and receiving medication considered as a form of restraint. The Regulatory Manager stated, “...The process is we are not fully electronic charting the component of the 15-minute checks are on paper...we don’t have them scanned in the system... the break down is... documents are put in a basket and are picked up and scan into the legal records... we don’t know where they are...” During an interview on 12/6/2024 at 9:47 AM, the Regulatory Manager confirmed the facility was unable to provide documentation of the observation monitoring for Patient #1 and Patient #23. The facility failed to monitor patient in seclusion and following the administration of medications used for behavioral management.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure all licensed nurses followed the policies and procedures of the hospital regarding assessing patients for pain and reassessing the patients’ response to interventions for pain for 3 of 21 (Patient #1, 5 and 7) sampled patients who presented to the Emergency Department (ED) with complaints of pain. The findings included: 1. Review of the hospital “[named Hospital] Medical Screening Examination and Stabilization Policy” last revised 09/2022, revealed, “Purpose: To establish guidelines for providing appropriate medical screening examinations (MSE)...The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and is he or she does, until he or she is stabilized and appropriately admitted or transferred...7. Stabilizing Treatment Within Hospital Capability...b. Stabilizing treatment within the hospital capability and transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected...” Review of hospital policy, “Assessment and Reassessment of the Emergency Department Patient” approved on 04/2019, revealed “...a rapid assessment is the initial assessment performed upon any patient arrival to the Emergency Department ...the rapid assessment include ...pain leve ...a focused nursing assessment evaluates pertinent information related to the patient’s chief complaint, condition and symptom ...a focused nursing assessment is required for patients with acuity levels of 1, 2, and 3 following the rapid initial assessment ...a detailed nursing assessment is an assessment to further assess the patient’s chronic conditions, health history, and additional screenings for nutrition, substance abuse, and safety/abuse to determine holistic health care needs. A detailed nursing assessment is required for patients with acuity levels of 1, 2, and 3 following the rapid and focused assessment ...Triage Acuity Level 2 patients should have hourly focused reassessments and the ED physicians is notified of all changes in patient status ...Triage Acuity Level 3 patient should have hourly focused assessment and the ED physician notified of any change ...Those who are admitted or transferred will have vital signs and a focused reassessment completed within 30 minutes prior to transfer from the ED...those who are discharged will have vital signs and a focused reassessment completed within 1 hour prior to departure from the ED.” Review of the hospital policy, “Pain Management” approved on 07/2019, revealed “ ...Patients have the right to appropriate pain assessment and management...non-pharmacological management of pain will be considered for each patient...staff will be educated regarding pain assessment, treatment, and follow-up...” 2. Medical record review for Patient #1 revealed a 51-year-old male, presented to the hospital’s ED via walk in on 02/14/2024 at 11:21 AM with a complaint of swelling to the face and pain. A triage assessment was initiated at 11:30 AM and revealed the chief complaint “dental pain/injury”. The triage nurse documented, “Pt [patient] reports having a teeth cleaning last Thursday, reports after the cleaning began having jaw pain, states starting last night the right side began to swell and the pain worsened...” Patient #1 was assigned a triage acuity level 3. During triage, Patient #1 rated his pain a 9 on a scale from 1-10 with 10 being the most severe pain. The MSE was initiated at 11:30 AM and revealed, “...he has several teeth that are decayed to the gumline along with large cavities. He is preparing to get dentures. He has had pain in his face since the [dental] cleaning performed last week...the pain is rated as severe...Review of Systems:...ENT [Ear Nose Throat] Several teeth with poor dentition, tender top palpation along the upper molars, there is no obvious drainable abscess, there is swelling noted along the right upper cheek...” The physician ordered Morphine Sulfate (narcotic used for pain management) 4 milligrams via Intravenous [IV] route that was administered at 11:48 AM to treat Patient #1’s pain. The physician ordered Ampicillin Sodium [Unasyn, antibiotic] 3 grams IV that was administered at 11:47 AM to address the infection. A Computed Tomography of the face completed on 02/14/2024 revealed a Right maxillary(upper jaw) lateral incisor periapical dental abscess (a periapical abscess is a pocket of infection [pus] around your tooth root) with cortical dehiscence (the loss of alveolar bone on the front of the tooth) and associated 1.3 X [by] 0.8 X 0.5 centimeter abscess in the overlying soft tissues with moderate associated facial Cellulitis (bacterial infection of the skin-can become red and painful) After the pain medication (Morphine Sulfate 4 mg IV) was administered at 11:48 AM, a “Dental/ Pain reassessment was documented at 12:57 PM with “No Change”. There were no other pain assessments documented by the nurse. At 3:52 PM, a second dose of Morphine Sulfate 4 milligrams IV was administered for pain. At 5:32 PM, Patient #1 rated his pain a 9 out of 10 and at 6:41 PM, Patient #1 rated his pain an 8 out of 10. Patient #1 was transferred to another hospital on 02/14/2024 at 7:15 PM for oral surgery and dental services not available at Hospital #1, related to his dental abscess and cellulitis There was no documentation Patient #1’s continued pain was communicated to the ED Physician. The nursing staff failed to follow written protocols for pain reassessment. There was no documentation Patient #1 pain was assessed prior to transfer at the time of discharge from Hospital #1. Patient #1 was assigned an acuity level 3, and according to hospital policy, should have had hourly focused assessment with the physician notified of any changes and a focused reassessment within 30 minutes of transfer from the ED. 3. Medical record review for Patient #5 revealed a 35-year-old female who presented to the hospital’s ED via walk-in on 04/08/2024 at 10:19 AM with a complaint of dental pain and facial swelling. A triage assessment was initiated at 11:18 AM and revealed the chief complaint of “Dental Pain/Injury.” Patient #5 was assigned a triage acuity level 3. The triage nurse documented, “Pt here with c/o lt [left] sided facial swelling of the lower jaw ...” During triage, Patient #5 rated her pain an 8 on a scale from 1-10 with 10 being the most severe pain. The MSE was initiated at 10:40 AM and revealed, “ ...left lower dental pain and swelling ...reports that she is having some pain with swallowing on the left side...” The physician ordered the following IV (intravenous) medications: Ceftriaxone Sodium (antibiotic) 1 GM (gram) at 10:49 AM, Clindamycin Phosphate (antibiotic) 50 ML (milliliters) at 10:48 AM, lopamidol 100 ML at 12:46 PM and Dexamethasone Sodium Phosphate 10 MG (milligram) at 10:48 AM to address the infection. A CT of the Neck revealed, “...left mandibular tooth #19 with dental carrie and periapical lucency (favoring periapical abscess) with infectious extension into the subcutaneous soft tissues overlying the left mandible (lower left jaw)...” Patient #5 was discharged home on 04/08/2024 at 3:30 PM with instructions to follow-up with her dentist or return to the ED if symptoms worsened. There was no documentation in Patient #5’s medical record that pain was assessed or treated after the initial triage assessment at 11:18 AM. 4. Medical record review for Patient #7 revealed a 53-year-old male, who presented to the hospital’s ED via ambulance on 02/14/2024 at 8:50 AM with a complaint of chest pain. A triage assessment was initiated at 8:58 AM and revealed the chief complaint of chest pain. Patient #7 was assigned a Triage acuity level 2. The triage nurse documented, “Pt from home via [ambulance] c/o [complains of] chest pain, sob [shortness of breath], and fluid overload d/t [due to] not having dialysis in a week...” During triage, Patient # 7 rated his pain a 7 on a scale from 1-10 with 10 being the most severe pain. The MSE was initiated at 9:05 AM and revealed,”...he has not dialyzed since last Wednesday...he was given Nitro [nitroglycerin] due to blood pressure of 190. He reports chest pain on and off since Friday. It is worse today. He was given aspirin by EMS [Emergency Medical Services]. He does report a history of MIs [myocardial infarction] but is unable to tell me the last time he had a stent or an MI ...wants to be transferred to [ named another hospital]...” The physician ordered lab work, chest X-ray, and ECG [electrocardiography]. No medication was ordered to address the pain. Follow up physician note revealed,”...Patient is adamant he wants to be transferred to [another hospital]...Patient was accepted to [named another hospital]...He will be transferred for emergent dialysis.” Patient #7 was transferred to another hospital on 02/14/2024 at 11:52 AM for continued treatment due to patient’s personal choice. There was no documentation in Patient #7’s medical record that pain was assessed or treated after the initial triage assessment at 8:58 AM. 5. In an interview on 04/09/2024 at 9:32 AM, the Interim ED Director and the ED Nursing Manager both confirmed that neither Patient #5 nor Patient #7 had their pain reassessed at discharge. Both stated it was expected of ED staff to assess pain at triage, then at minimum every 2 (two) hours, unless the patient was administered pain medications, then assessments should be every hour, and at discharge. In an interview on 04/09/2024 at 12:35 PM, the ED Medical Director stated that he expected nursing staff to assess pain at triage, at least every 2 (two) hours and then at discharge. In an interview on 04/9/2024 at 3:10 PM, the Director of Informatics verified that after the pain medication was administered to Patient #1 on 2/14/2024 at 11:48 AM and when he reported no change in the pain at 12:57 PM, there was no documentation the continued pain was communicated to the physician. The Director of Informatics further verified the nurse documented Patient #1’s pain as “9” at 5:32 PM and documented his pain as “8” at 6:41 PM, but no medication was administered after the Morphine Sulfate 4 mg IV was given at 3:52 PM, and that Patient #1’s pain was not reassessed prior to discharge. In an interview on 04/09/2024 at 3:20 PM, Registered Nurse (RN) #1 stated that he had worked in the ED for a little over 2 years. He knew that pain was checked at triage, then an hour after pain medication administration and every 1 to 2 hours after, depending on how the patient was doing. He stated that the pain was always reassessed at discharge. He happened to be the discharge nurse for Patient #7 and could not recall checking her pain level at discharge. He stated that it had been an oversight on his part. He stated that the electronic medical record (EMR) did prompt warnings to check pain levels but that the nurses had to manually go in and check them in the system. He was unaware of how many times he received training on pain assessment but figured he had received the training at hire. In an interview on 04/09/2024 at 3:30 PM, RN #2 stated that she had been working in the ED for 7 years. She stated that pain levels were checked at triage, an hour after pain meds were administered, and if no pain meds had been administered then just “whenever the text turned red.” The text would turn red in the EMR when something was overdue. She could not tell the surveyor the frequency of how often the pain levels needed to be assessed. She stated that it “should” be reassessed at discharge. RN #2 stated she recalled helping with Patient #7 but could not recall why his pain had not been reassessed at discharge. She could not recall receiving any pain assessment training other than upon hire.”

“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: 37533 Based on the facility policy review, medical record review and interview, the facility failed to ensure vital signs were monitored according to physician orders or facility policy for 1 of 3 (Patient #2) sampled patients reviewed for vital sign monitoring. The findings included: 1. Review of the facility policy titled, “Standards of Practice Guidelines for Patient Care Units.” dated 4/2017 and last revised 11/2021, revealed, “...The following standards of practice are provided to patients...who are being cared for on any of the Nursing units...Documentation of these standards in process interventions by the registered nurse confirms that these standards of practice have been met...DOCUMENTATION...Document Vital Signs per unit standard or as ordered including, Temperature, Heart Rate, blood pressure and level of consciousness...Medical-Surgical Unit every 4 hours...” 2. Review of the medical record Patient #2 was admitted on 8/18/2023 with diagnoses of Abdominal Pain, Nausea and Vomiting. A physician’s order dated 8/18/2023 at 9:10 AM, revealed “...Vital Sign Parameter...Notify HR [Heart Rate] below: 50...” Review of the CLINICAL DOCUMENTATION RECORD revealed on 8/18/2023 at 9:19 AM, vital signs were as follows: blood pressure (BP) 170/90, pulse 47, respiratory rate 18, SPO2% (oxygen saturation, which is a measurement of the amount of oxygen in the arterial blood)100, room air. Review of the CLINICAL DOCUMENTATION RECORD revealed on 8/18/2023 at 9:41 PM, vital signs were as follows: BP 141/87, pulse 54, respiratory rate 16, SPO2% 100 room air. There was no documentation the physician was notified of Patient #2’s heart rate of 47 (less that the 50 parameter in the physician’s order). There was no documentation Patient #2’s vital signs were taken from 8/18/2023 at 9:19 AM to 8/18/2023 at 9:41 AM (12 hours 22 minutes, instead of every 4 hours per policy). During an interview on 5/1/2024 at 12:24 PM, the Vice President of Quality and Risk Management stated staff were supposed to take patients’ vital signs every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The Vice President of Quality and Risk Management stated, “We are missing the 12 noon and 4 PM [for Resident #2].” During an interview on 5/1/2024 at 12:43 PM, the the Assistant Chief Nursing Officer confirmed Patient #2 had orders to notify the physician if the heart rate was less than 50. During an interview on 5/1/2024 at 1:10 PM, the Vice President of Quality and Risk Management stated, “There is an opportunity for improvement on the heart rate, it was missed.””