Methodist Medical Center of Oak Ridge

“A Life Safety Code Complaint Investigation #TN00078170 was conducted by the State of Tennessee Health Facilities Commission on 08/24/2026. During this life safety survey, Methodist Medical Center was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid with Title 42 CFR Subpart 482, Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Life Safety Code Complaint Investigation #TN00078170 conducted on 08/24/2026, no deficiencies were cited under Title 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101, 2012 Edition.”

“Building Drawings Available: Yes Sprinklered: Yes Licensed Beds: 283 A Life Safety Code Complaint Investigation #TN00077972 was conducted by the State of Tennessee Health Facilities Commission on 07/07/2026. During this life safety survey, Methodist Medical Center was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid with Title 42 CFR Subpart 482, Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. During the Life Safety Life Safety Code Complaint Investigation #TN00077972 conducted on 07/07/2026, no deficiencies were cited under Title 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101, 2012 Edition.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 53251 Based on review of facility policy, medical record review and interviews, the facility failed to update security policies (in tandem with the contracted Security provider) related to the use of the Conducted Electrical Weapon (CEW/Taser) resulting in 1 patient (Patient #3) receiving inappropriate use of Tasers in the Emergency Department (ED) of 3 ED patients review. The findings include: Review of the facility’s policy, “Conducted Electrical Weapon (CEW) or Taser,” revised 12/2021 revealed “...To provide guidelines security officers assigned to [Named Facility] with guidance concerning the use of...the Taser...Only security officers who have completed appropriate training...shall carry or use the Taser...The Taser may be used only when physical force is appropriate under the [Named Facility] Use of Force policy...and the subject poses a physical risk to self or others...The Taser is programmed to deliver a 5-second exposure when deployed. A full 5-second cycle should be applied without interruption unless circumstances dictate otherwise...If the subject is not under control after the initial 5-second cycle, no more than two additional 5-second exposures can be given to gain control of the subject. The effects of an exposure to the Taser are normally not long lasting and should cease to exist once the exposure ends...” Review of the facility’s policy, “Use of Force,” revised 12/2021, revealed “...To clearly define the circumstances under which the use of force by a security officer is justified...The use of force necessary to manage a situation or individual will be justified: Whenever the clear and present danger of bodily injury to the security officer or another person is immediately present...When attempting to manage a violent and/or aggressive patient...Force: A physical means to direct the actions of others...All personnel designated to work armed shall be required to meet all standards of competency as established by the director of security...Officers approved for possession/carry of non-lethal weapons must comply with all directives and policies as described here-in...Use of non-lethal weapons: (CEW) Taser...may be deployed any time a person’s actions indicate an imminent threat to themselves or others...” Review of the medical record revealed Patient #3 was admitted to the ED on 2/20/2026 at 3:16 PM, with paranoid and delusional behaviors. The patient presented for psychiatric evaluation. Review of the medical record revealed diagnostic testing was completed and revealed no evidence of infection or intracranial pathology [causing or contributing to the behaviors]. Review of the medical record revealed Patient #3 was medically cleared, and a Certificate of Need (CON) was executed by the physician on 2/21/2026 at 1:49 AM. Review of the medical record revealed on 2/21/2026 at 10:20 AM, a physician’s Addendum Note “...Patient becoming progressively more aggressive and agitated. Took her clothes off. Yelling at staff. Appears to be acutely psychotic. Droperidol (a medication used to manage acute agitation) and Versed (a sedative medication) were ordered. While nurse was attempting to administer medications, patient took the syringe. Security attempted to de-escalate however patient would not let go of the syringe. She was tased by security. I assessed her afterwards. Barbs were removed [from the chest, abdomen and left forearm]. Denies any chest pain or shortness of breath. Will obtain Electrocardiogram [EKG measures the electrical activity of the heart] and clean her puncture wounds...” Review of the medical record revealed a Nursing Note from 02/21/2026 at 11:13 AM, revealed Patient #3 became combative and lunged toward the Registered Nurse (RN), grabbed the nurse’s wrist, and stood up on the stretcher. Review revealed with her other hand she grabbed a syringe capped with an Intramuscular (IM) needle. The patient was noncompliant with multiple commands to drop the needle by nursing staff and then the security officers. Review revealed the 2 security officers “...had drew Tasers [a handheld electroshock weapon that fires 2 wire-tethered darts up to 25 feet to deliver a volt pulse] and asked the patient to drop the needle. The patient refused... standing on stretcher and pointing the needle at all staff in room. The security guards deployed Tasers [for a second time]...3 prongs (in the patient’s chest, abdomen, and left arm) removed by the physician...” During an interview on 04/15/ 2026 at 11:30 AM, RN #1 revealed the primary RN and 2 other staff members went in to give Patient #3 medications which were ordered by the physician. She stated Security “...came into the room, and I was stuck in the corner of the patient’s room. She was holding the needle in a threatening manner towards me. Security told her several times to drop the needle, but she didn’t. Security officers tased her...after she was tased, when the patient fell, she did not hit the floor, she landed on the stretcher...” During an interview on 04/15/2026 at 11:42 AM, with Patient #3’s assigned sitter, revealed “...They were going to give her a shot, and she grabbed the needle out of the nurse’s hand. Security came into the room. They kept asking her to put it down several times. They counted to 2 and then tased her. She fell down on the stretcher...she didn’t hit the floor...” During an interview on 04/15/2026 at 1:26 PM, with Security Officer #2, revealed “...2 RNs came running out of the patient’s room stating, ‘she has the needle,’ so we entered the room. The patient was standing on top of the stretcher naked, she was holding a needle like a weapon. We were concerned for everyone’s safety here, the RN in the corner, the patient, and ours as well. We drew our Tasers and gave verbal commands for her to drop it. She wouldn’t drop it. We requested it 4-5 times at least. [Security Officer #1] said, ‘Taser, Taser, Taser’ and tased the patient. She went down on her side onto the stretcher. She did drop the needle...” During a telephone interview on 04/15/2026 at 5:20 PM, with Security Officer #1, he revealed the nursing staff went in to administer medications to [Patient #3] and shortly after he heard the nurses call out the patient had ‘the needle.’ He and another officer went into the room and told the patient to drop the needle multiple times, and the patient was non-compliant. Security Officer #1 stated “... We drew our Tasers and [Officer #2] and I both painted her, and I know I told her at least 10 times to drop the needle. I told her again, ‘if you don’t drop the needle you are going to get tased.’ I said drop the needle again, and then I said one, two, three and then Taser, Taser, Taser...that is when we tased her...” During an interview with the Vice President and Chief Nursing Officer (CNO) on 04/16/2026 at 10:10 AM, they revealed the 2 security policies were last revised in 2021 and will be reviewed with the Security team. During a telephone interview with the Manager of Operations on 04/16/2026 at 12:35 PM, he confirmed the policies had not been revised since 2021 and confirmed that each officer fired their Taser in a manner that did not follow the policy as currently written. The delay was approximately 2-3 seconds between the Taser discharges, which did not follow the current policy requiring 5 seconds between discharges.”

“Construction Type: II (222) Building Drawings Available: Yes Sprinklered: Yes Licensed Beds: 283 A Life Safety Code Complaint Investigation #TN00077030 was conducted by the State of Tennessee Health Facilities Commission on 11/19/2025. During this life safety survey, Methodist Medical Center was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid with Title 42 CFR Subpart 482, Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Life Safety Code Complaint Investigation #TN00077030 conducted on 11/19/2025, no deficiencies were cited under Title 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101, 2012 Edition.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 30553 Based on review of facility policy, medical record review, and interviews, the facility failed to ensure an accurate and complete medical screening examination and failed to provide stabilizing treatment for 1 patient (#24) who presented to the Emergency Department (ED) after suffering a burn of 25 patients reviewed. The findings include: Medical record review showed Patient #24 presented to the ED on 4/26/2023 with burns to the right wrist and hand, the right forearm, second degree burn to abdominal wall, and first degree burn to the right breast after a grease fire. The patient was assessed by the ED Physician. While in the ED, the wounds were cleaned with sterile water and dressed with Silvadene cream (ointment to prevent wound infection) and a non-adhesive dressing was applied. There was no documentation regarding the patient’s tetanus status and no tetanus booster was given. The patient was informed to contact and follow-up with her primary care provider or the regional burn center (Facility C). There was no documentation related to consult with the regional burn center for the patient’s burns. Medical record review showed on 4/27/2023 Patient #24 presented to Facility B for a second opinion and pain control. A tetanus booster and antibiotics were administered. The regional burn center (Facility C) was consulted and agreed to accept the patient for further treatment. Medical record review showed on 4/27/2023 Patient #24 presented to Facility C where she was admitted to the step-down burn unit. Review showed on 5/1/2023 the patient required excision and grafting of right hand, forearm, breast, and abdomen. The patient was discharged on 5/6/2023. Refer to A-2406 and A-2407”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30553 Based on review of facility policy, medical record review, and interview, the facility failed to provide a complete and ongoing medical screening examination for one patient (#24) who presented to the Emergency Department (ED) after suffering a burn injury of 25 patients reviewed. The findings include: Review of facility policy, “Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines” last reviewed 10/2022, showed “...Medical Screening Examinations [MSE] will be conducted by a Qualified Medical Professional [QMP]...MSE may include any of the following elements; assessments of chief complaint as recorded in the patient’s triage record; vital signs upon admission and upon discharge or transfers...focused physical examination of affected and//or potentially affected system...an exam appropriate to the organ system related to the chief complaint...notification and use of on-call physicians to diagnose and/or stabilize the patient’s condition...Emergency Medical Condition [EMC]; a medical condition manifesting itself by acute symptoms of sufficient severity...such as the absence of immediate medical attention could reasonably be expected to result in [a] placing the health of an individual...in serious jeopardy...[b] serious impairment to bodily organs...[c] serious dysfunction of any bodily organ or part...” Medical record review showed Patient #24 was admitted to Facility A on 4/26/2023 with complaints of burns to her hand and body. Medical record review of an ED Nursing Triage record dated 4/26/2023 at 4:59 PM, showed the patient was moving hot oil off the stove after the pot had caught on fire. The patient stated she had burns to her right hand and part of her stomach. There was unblanchable skin to the right hand with sloughing skin. Medical record review of an ED Physicians Record dated 4/26/2023 at 6:09 PM, showed the patient had burns to her right hand, forearm, and the right side of her body due to cooking with oil and it caught on fire and splashed onto her body. The burn caused blistering to the dorsal aspect of the right hand and wrist, the pads of her right 3rd and 4th fingers, her forearm, her right lateral and inferior breast, and her right abdomen. The patient complained of severe pain. The physical examination showed “...second degree burns with blistering to the right hand and dorsal wrist and forearm with some denuded skin. Some of these areas are erythematous, some white, sensation is intact, no definite circumferential burns to the fingers, hand or wrist. Large area of redness and early blistering to the right lateral abdomen, approximately 40 cm [centimeters] and right breast...” Medical record review of an ED Physicians Disposition dated 4/26/2023 at 6:10 PM, showed her diagnoses included burn to the right wrist and hand, burn to right forearm, second degree burn to abdominal wall, and first degree burn to the right breast. Medical record review of an ED Nurses Note dated 4/26/2023 at 7:01 PM, showed the patient was discharged at 7:10 PM. Medical record review of an admission History and Physical from Facility C dated 4/28/2023 at 12:03 AM, showed the patient was transferred from Facility B with 3% Total Body Surface Area (TBSA) mixed deep partial and full thickness burn wounds to right chest, right abdomen, and right hand/forearm. She had been seen at (Facility A) after the initial event and had ‘some simple wound care’ and was discharged home with Silvadene cream. The next morning, she had woken up with severe pain and bleeding to the hand. She was given a tetanus booster, Rocephin 1 gram IM and the wounds were treated [at Facility B]. Medical record review of a Discharge Summary from Facility C dated 5/6/2023 at 11:24 AM, showed the patient was admitted to the Burn Stepdown unit for treatment. On 5/1/2023 the patient was taken to the Operating Room for excision and grafting of R hand, forearm, breast, and abdomen. The patient’s wound and graft healed well and she was placed on oral pain medications. The patient was discharged home with follow-up appointments scheduled for 5/12/2023. During an interview on 3/28/2024 at 1:50 PM, Registered Nurse (RN) #1 stated burns were treated and dressed depending on the physician’s orders. The patient’s tetanus status would be assessed by the nurse and the physician, and a booster would require a physicians order. During a telephone interview on 3/28/2024 at 2:25 PM, ED Physician #2 stated the patient’s burns were not circumferential. She had second degree burns to the abdominal wall and first and second to the right arm. ED Physician #2 stated “...I did not think the burns would require any skin grafting or any need for transfer. I talked to the patient about the wounds and the plan of care for the wounds. I did discuss with her related to follow up with her primary care provider or with [Facility C]. She was given [Facility’s C’s] burn center number for follow-up. I normally would document any concerns related to the tetanus status but there was no documentation...” In summary, the hospital did not consult or transfer the patient to a burn unit for definitive care. In addition, the patient’s tetanus immunization was not updated.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 30553 Based on review of facility policy, medical record review, and interview, the facility failed to provide stabilizing treatment for one patient (#24) who presented to the Emergency Department (ED) after suffering a burn injury of 25 patients reviewed. The findings include: Review of facility policy, “Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines” last reviewed 10/2022, showed “...stabilizing treatment: if an individual has an emergency medical condition, further medical examination and treatment as is within the hospital’s capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility...” Medical record review showed Patient #24 was admitted to Facility A on 4/26/2023 with complaints of burns to her hand and body. Medical record review of an ED Nursing Triage record dated 4/26/2023 at 4:59 PM, showed the patient was moving hot oil off the stove after the pot had caught on fire. The patient stated she had burns to her right hand and part of her stomach. There was unblanchable skin to the right hand with sloughing skin. The patient was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent needs. Medical record review of an ED Physicians Record dated 4/26/2023 at 6:09 PM, showed the patient was cooking with oil, it caught on fire and splashed onto her body. The burn caused blistering to the dorsal aspect of the right hand and wrist, the pads of her right 3rd and 4th fingers, her forearm, her right lateral, inferior breast, and right abdomen. The patient complained of severe pain. The physical examination showed “...second degree burns with blistering to the right hand and dorsal wrist and forearm with some denuded skin. Some of these areas are erythematous, some white, sensation is intact, no definite circumferential burns to the fingers, hand or wrist. Large area of redness and early blistering to the right lateral abdomen, approximately 40 cm [centimeters] and right breast...” Medical record review of an ED Physicians Disposition dated 4/26/2023 at 6:10 PM, showed “...presented with fairly significant burns to her right upper extremity and right chest abdomen...a few of these areas have blistered. Denuded skin was removed with cool water and washed. Silvadene [cream used to prevent infection] dressings applied. Patient will be prescribed Ibuprofen [anti-inflammatory medication] and Hydrocodone [pain medication] for pain control. Recommended Silvadene dressing changes once daily for the next several days. Wound recheck with primary care or at [Facility C] burn center, although do not anticipate any of these will require skin grafting or any significant intervention...” Her diagnoses included burn to the right wrist and hand, burn to right forearm, second degree burn to abdominal wall, and first degree burn to the right breast. There was no documentation of a consult with the regional burn center related to the patient’s injuries or the patient’s tetanus status. Medical record review of an ED Nurses Note dated 4/26/2023 at 7:01, PM showed “...burns cleaned with sterile water and dried. Silvadene placed to burns and telfa used to cover. Patient tolerated well...” The patient was discharged at 7:10 PM. Medical record review of an ED Nursing Triage record from Facility B dated 4/27/2023 at 2:30 PM, showed the patient was heating oil on 4/26/2023 where the oil caught on fire. She picked the pan up and spilled the oil of her right hand and right chest resulting in immediate blistering. She was evaluated at (Facility A) on 4/26/2023 where they “...cut the skin off and cleaned it up and told pt. [patient] to follow-up with her PCP [primary care provider] in two weeks. Last tetanus shot was unknown. Came to ED today for pain and concern that she needs to follow-up sooner than two weeks. There is a large area of open skin on top of the right hand and blister on top of pointer finger, also has open blisters on R [right] chest and small spots on feet and L [left] hand...” Medical record review of an ED Physicians record from Facility B dated 4/27/2023 at 4:12 PM, showed the patient suffered a burn to the right hand, right breast, and right abdominal wall on 4/26/2023. She had been evaluated at a local ED and discharged home with Silvadene cream. The patient came to the ED for second opinion due to worsening pain and bleeding of the right hand. She was not sure when she had received a tetanus booster. Facility C’s burn center was consulted at 3:20 PM and discussed with the transfer center. Picture of the burns were sent and the patient’s presentation was discussed with the burn specialist at (Facility C). The recommendation was for transfer for admission to the burn center. The plan of care was discussed with the patient and spouse who were in agreement with the plan. The patient received a tetanus booster and 1 dose of Rocephin (antibiotic) 1 gram intramuscular (IM). The burns were dressed with Bacitracin (antibiotic ointment), Xeroform (dressing) and bulky dressing. The patient was discharged in stable condition for transfer to Facility C. Medical record review of an admission History and Physical from Facility C dated 4/28/2023 at 12:03 AM, showed the patient had 3% Total Body Surface Area (TBSA) mixed deep partial and full thickness burn wounds to right chest, right abdomen, and right hand/forearm. She had been seen at an outside hospital (OSH) after the initial event and had ‘some simple wound care’ and was discharged home with Silvadene cream. The next morning, she had woken up with severe pain and bleeding to the hand and went to Facility B for further evaluation. She was given a tetanus booster, Rocephin 1 gram IM and the wounds were treated. She was transferred to Facility C for treatment. The patient was admitted the step-down burn unit. Medical record review of a Discharge Summary dated 5/6/2023 at 11:24 AM, showed on 5/1/2023 the patient was taken to the Operating Room for excision and grafting of R hand, forearm, breast, and abdomen. The patient’s wound and graft healed well. Wound care was discussed with the patient and her parents. The patient was discharged home with follow-up appointments scheduled for 5/12/2023. During an interview on 3/28/2024 at 1:35 PM, ED Physician #1 stated burn wounds would be assessed during the medical screening examination and the plan of care would be addressed depending on the findings. Transfer would be based on the severity of the assessment findings. Physician #1 stated [Facility C’s] burn specialist were very helpful and were very open to consult, review of pictures, and advisement for wound care. During an interview on 3/28/2024 at 1:50 PM, Registered Nurse (RN) #1 stated burns were treated and dressed depending on the physician’s orders. The physician would make the decision for transfer or the disposition of the patient. If a patient was discharged home, the patient would be informed of how to change the dressing. The patient’s tetanus status would be assessed by the nurse and the physician, and a booster would require a physician’s order. During a telephone interview on 3/28/2024 at 2:25 PM, ED Physician #2 stated the patient’s burns were not circumferential. She had second degree burns to the abdominal wall and first and second to the right arm. The patient was assessed, her pain was treated, and she was monitored for several hours in the ED. The burns did not progress, and the patient was stable from a pain standpoint and related to the burns. The burns did require some debridement and were cleaned with sterile saline. The wounds were dressed with Silvadene cream, a non-adhesive dressing and wrapped with kling. ED Physician #2 stated “...I did not think the burns would require any skin grafting or any need for transfer. I talked to the patient about the wounds and the plan of care for the wounds. I did discuss with her related to follow up with her primary care provider or with [Facility C]. She was given [Facility’s C’s] burn center number for follow-up. I normally would document any concerns related to the tetanus status but there was no documentation...” In summary, the hospital did not consult or transfer the patient to a burn unit for definitive care. In addition, the patient’s tetanus immunization was not updated.”