Baptist Memorial Hospital

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 32777 Based on policy review, personnel file review, facility documents and interviews, the Hospital failed to ensure it was in compliance with Federal, State and Local Laws when the hospital employed 1 of 1 imposter nurses (Imposter Nurse A) reviewed to work as a Registered Nurse while using another person’s (Nurse B) valid and current nursing license, and practiced professional nursing and provided nursing care to patients in the hospital. The findings include: 1. Review of the Hospital System’s policy, “CONTRACTED SERVICES - EMPLOYEES OF COMPANIES CONTRACT FOR PATIENT CARE ...” effective 11/11 revealed, “ ...Contracting Vendor Responsibilities ...Initial Documentation ...Confirmation of licensure, if required, in good standing with the State of Mississippi, Arkansas, Tennessee as appropriate ...Documentation confirming a criminal background check has been performed ...[Named Hospital] Entity Responsibilities ...” 2. Review of personnel files for Imposter Nurse A revealed the Imposter Nurse worked for the hospital from 07/22/2024 - 11/01/2024 on a travel assignment in the main hospital (Hospital A) and from 11/01/2024 to 02/25/2025 in a satellite hospital (Hospital B). There was no separation/termination documentation in Imposter Nurse A’s personnel file. Further review of Imposter Nurse A’s personnel file revealed the Imposter Nurse had used two (2) different Social Security Numbers (SSN) and three (3) different dates of birth on her employment Onboarding documents. There was no evidence the Hospital questioned or did any cross referencing that would have identified inconstancies in the pre-employment documents. Refer to A0023”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 32777 Based on policy review, personnel file review, facility documents and interviews, the Hospital failed to assure that personnel requiring a license to practice had a valid licensed and in compliance with the State’s licensure laws when the hospital employed 1 of 1 imposter nurses (Imposter Nurse A) reviewed who was using another person’s (Nurse B) current and valid Registered Nurse (RN) license and provided professional nursing care to the hospital’s patients. The findings include: 1. Review of the Hospital System’s policy, “CONTRACTED SERVICES - EMPLOYEES OF COMPANIES CONTRACT FOR PATIENT CARE ...” effective 11/11 revealed, “ ...Contracting Vendor Responsibilities ...Initial Documentation ...Confirmation of licensure, if required, in good standing with the State of Mississippi, Arkansas, Tennessee as appropriate ...Documentation confirming a criminal background check has been performed ...[Named Hospital] Entity Responsibilities ...” 2. Review of a copy of a Social Security Card in Imposter Nurse A’s personnel file revealed an issue date of 06/15/2023 with Imposter Nurse A’s first name, Nurse B’s last name as the middle name and Imposter Nurse A’s last name. The Social Security Card was signed using all three names. (Imposter Nurse A’s first, Nurse B’s last name as the middle name then Imposter A’s last name). Review of a pre-employment drug screening form with a verification date of 07/06/2024 revealed Imposter Nurse A used her first and last name (without Nurse B’s last name as her middle name) and the Social Security Number that was on the Social Security Card in Imposter A’s personnel file. This pre-employment drug screening form was identical to a drug screening form from another hospital where Imposter Nurse A worked. There were 2 Background Screening Reports from 2 different companies in Imposter Nurse A’s personnel file. (a). Review of the first background screening report ordered 07/01/2024 and completed on 07/17/2024 revealed Imposter Nurse A used Nurse B’s last name as her middle name and used a different Social Security Number (SSN). This background screening report documented, “ ...UNABLE TO VALIDATE SSN ...” (b). The second background screening report completed on 07/19/2024 revealed a different SSN from the SSN listed on the first background screening report. This report documented the name and SSN matched the information provided on the I-9 form which was a different SSN than on the Social Security Card in Imposter Nurse A’s personal file. (c). Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 10/21/2024 revealed Imposter Nurse A’s first and last name (without Nurse B’s last name as her middle name), along with a birth certificate and a valid Driver’s license from another state was used to verify identity. The last name used on the I-9 form was the same as the Driver’s license. (d). Review of an undated Staffing Agency document detailing Imposter Nurse A’s information revealed a work history verification, licensure verification, education, and references as follows: (i). Employment in a hospital in a local county from September 2023 to April 2024 and during the same time frame at a county over 200 miles from the local county. (ii). Employment in the local county from May 2023 to October 2023 and employment overlapping in a county over 100 miles away form the local county. (iii). Employment in an out- of- state county from December 2019 to April 2023 over 200 miles from the local county. There was no evidence the Staffing Agency or the Hospital System questioned or did any cross-referencing that would have identified inconstancies with social security numbers, birth dates, employment dates, distances of employment at the same time, different names on documents, different SSNs on various documents. 3. During the investigation, the Hospital System’s leadership team verified the discrepancies found in Imposter Nurse A’s personnel file.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 2 (Patient #4) sampled patients requiring a higher level of care, out of 20 total patients reviewed. The findings included: Medical record review revealed Patient #4 presented to the Emergency Department (ED) at Hospital #1 on 9/6/2025 at 6:12 PM as a “walk-in”. The patient presented with the chief complaint of Abdominal Cramping and Lower Back Pain that began the previous night. Patient #4 is 27 weeks pregnant. The patient also reports having a fever earlier and shortness of breath. A note written by Physician #1 on 9/6/2025 at 8:17 PM documented the patient had a past medical history of colitis (inflammation of the colon) and kidney stones. Over the past 24-48 hours, Patient #4 has developed more significant back pain. She was 27 weeks pregnant and stated the baby had been moving more and her abdomen felt more tense but it was not hurting. The patient had experienced no vaginal bleeding or leakage and her temperature had been 102 degrees Fahrenheit at the most today. The Fetal Heart Rate was 175 which was mildly elevated, had an elevated white blood cell count of 12,000 (normal value is 4000 - 11,000). The ED Physician communicated with Patient #4’s obstetrician for likelihood of inpatient treatment. The Obstetrician agreed and accepted the patient and she was to be transferred to Hospital #2 to receive further treatment in Labor and Delivery due to Hospital #1 did not have these services on its campus. Patient #4 was transferred to Hospital #2 via private vehicle on 9/6/2025 at 9:32 PM. Patient #4 did not transfer with qualified, trained personnel or equipment to address the medical condition requiring a higher level of care. There was no documentation Patient #4 signed a form of refusal for transfer by ambulance. Cross Refer to A - 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 2 (Patient #4) sampled patients requiring a higher level of care, out of 20 total patients reviewed. The findings included: 1. Review of Hospital #1’s “EVALUATION AND TRANSFER OF PATIENTS WITH EMERGENCY MEDICAL CONDITIONS/EMTALA” policy (revised 12/24) revealed, “...If the physician, or other qualified medical personnel...determines, based on the information available at the time of transfer, that reasonably expected medical benefits of the transfer outweigh any increased risks from transfer to the patient...and the following criteria are met...The receiving facility...Has agreed to accept transfer of the individual and to provide appropriate medical treatment...Transfer is affected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...” 2 Medical record review revealed Patient #4 presented to the Emergency Department (ED) at Hospital #1 on 9/6/2025 at 6:12 PM via “walk-in”. A triage assessment beginning at 6:16 PM documented the chief complaint as abdominal cramping, back pain and patient was 27 weeks pregnant. Further triage assessment revealed “Patient to er [emergency room] c/o [complains of] abdominal cramping and lower back pain that began last night. Reports fever earlier. Also admits to sob [shortness of breath]. States she is approximately 27 weeks IUP [intra uterine pregnancy - a pregnancy where the fertilized egg implants and develops in the uterus], 4th pregnancy, states OBGYN [obstetrician/gynecologist] with [named physician] at [named Hospital #2]. Denies any vaginal bleeding. The patient’s heart rate was 110 and temperature was 99.2 degrees Fahrenheit. A Medical Screening Exam (MSE) was initiated on 9/6/2025 at 8:17 PM by Physician #1 with documentation that revealed “...female with past medical history of colitis (inflammation of the colon), nephrolithiasis (kidney stones)...currently at 27 weeks pregnant who comes in for bilateral back pain, fever and some generalized fatigue. She denies any overt urinary symptoms but states over last 24-48 hours she has developed some significant lower back pain more so bilaterally. She is currently 27 weeks pregnant and states the baby has been moving more...abdomen feels more tense but it is not hurting per se [by or in itself]...She has also felt very lightheaded and dizzy today but otherwise denies any significant actual syncopal [dizziness or passing out] episodes, nausea, chest pain, shortness of breath or other symptoms. She has had no vaginal bleeding or leakage. T-max [temperature-maximum] of 102 [degrees Fahrenheit] today”. MSE review of systems revealed positive for fatigue, fever and flank pain. MSE physical exam revealed “...Gravid abdomen [a pregnant uterus with baby growing inside] with absolutely no left lower quadrant or right lower quadrant tenderness. Bilateral flank and CVA [costovertebral angle- the area where the ribs and the spine meet at the back of the chest] tenderness. Fetal heart rate of 175...” Physician #1’s Medical decision making revealed the patient was “...coming in for evaluation for bilateral flank pain, fever, general fatigue and dizziness. She is 27 weeks pregnant. Fetal heart rate of 175 which is mildly elevated. She has a mild leukocytosis [elevated white blood cell count] of 12,000 but urine is very infected. Given her objective fever with bilateral flank pain I am concerned about possible pyelonephritis [kidney infection] and pregnancy so will reach out to her OB [Obstetrician- physician who provides care to both mother and fetus during pregnancy] to discuss likely transfer for inpatient treatment. Ceftriaxone [brand name Rocephin- antibiotic used to treat infections] will be provided. Urine culture and blood cultures will be obtained...” Review of Physician #1’s ED course revealed, “...Spoke with [named physician] her OB and he agrees for transfer accepting physician to labor and delivery at [named Hospital #2]. Discussed with the patient, she is comfortable with plan for transfer. She is adamant on having her partner drive her. I offered and encouraged ambulance transfer as being the safest, but after discussion of risks and benefits she is still refusing and would like to go personal vehicle.” Review of ED nursing note on 9/6/2025 at 9:30 PM revealed, “Patient being transferred to [named Hospital #2], patient transferring via private vehicle, see EMTALA for [form] for details...” Review of EMTALA transfer form signed by Patient #4 dated 9/6/2025 at 9:26 PM revealed, “...Reason for Transfer...Hospital resources not available...Benefits of Transfer...Specialized services/specialist; Higher level of care...Risks of Transfer...Worsening of patients EMC [emergency medical condition] or death en route; Additional pain/trauma to existing injuries...Transport Mode...Private Car Offered encourage ambulance in transfer but after risks and benefits discussion patient has opted for private vehicle...I have been told and understand the risks and benefits of my (the Patient) transfer. [X marked in a box] I hereby CONSENT to transfer...” There was no documentation Patient #4 signed a form of refusal for transfer by ambulance. Discharge Information documented, “Date/Time: 09/06/2025 2132 [9:32 PM]...Disposition: Acute Care Facility...” In an interview on 9/23/2025 at 2:40 PM, the Chief Nursing Officer (CNO) verified Patient #4 was transferred to another facility and went by private vehicle. CNO verified Hospital #1 does not have labor and delivery services. In an interview on 9/23/2025 at 2:45 PM, the ED Medical Director stated each transfer case was different. “Every once in a while a case could not have to go by ambulance. Sometimes a patient refuses to go by ambulance. You would have them sign a refusal form.” Patient #4 was discharged from Hospital #1 per private vehicle on 9/6/2025 at 9:32 PM. Patient #4 required a higher level of care not available at Hospital #1. Patient #4 required transfer to another facility. Patient #4 did not transfer with qualified, trained personnel or equipment to address the medical condition requiring a higher level of care. There was no documentation Patient #4 signed a form of refusal for transfer by ambulance.”

“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 hospital policy review, hospital document review, medical record review and interview, the hospital failed to maintain 1 of 4 (Patient #2) patient’s rights to receive care in a safe setting when Patient #2 was taken to the Discharge Lounge (DL) and left alone and unattended while waiting in the area for family to arrive to transport the patient home. Patient #2, who did not meet the hospital’s criteria to be taken to the discharge lounge, was alone in this area unattended by staff for 2 hours and 45 minutes on 7/31/2023. The findings included: 1. Review of the hospital’s “Patient Bill of Rights Policy” revised 4/2022 revealed, “...You or your legally designated representative has the right to be informed about your illness, possible treatment options, and likely outcome(s), including unanticipated outcomes, and to participate and make informed decisions regarding your care...You have the right to receive care in a safe setting...” Review of the hospital’s “Assessment/Reassessment Policy” revised on 4/27/2023 revealed, “Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient’s initial and continuing needs...” Review of the hospital’s “Documentation Policy” revised 3/2021 revealed, “...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. 2. Review of the hospital’s “Discharge Lounge Overview” document revealed, “...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out...Patient Selection Criteria Ambulatory Lounge...Alert and Oriented...Ambulatory with minimal assistance...Able to toilet with minimal PCA assistance...No behavioral issues...Able to self-administer medications - Non Isolation patients...Patient’s ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time...Transporting Patient to Discharge Lounge Ambulatory Staff from sending staff transports patient to Discharge Lounge nurses station: - provides patient’s name and estimated time patient’s ride will arrive...Key Points...Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location...Discharge Lounge Responsibilities...Every Patient must be signed in and out when they enter and leave the discharge lounge...Round hourly to check on patients Turn, Change and clean if needed...Assist to bathroom in [as] needed...Offer Drink, Water or Snack...If a patient is present during what would be meal time, offer snack pack...Prior to patient leaving, ensure patient is clean and dry...PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night...” Review of the “Second Amendment to the Master Services Agreement Between [named Hospital #1’s Health Care Corporation] and [named Ambulance Provider #1’s Parent Company] Relating to Discharge Lounge Operations” document signed on 10/17/2022 and 10/11/2022 respectively revealed, “...This Second Amendment sets forth the duties and responsibilities that [named Hospital #1’s Health Care Corporation]’s affiliate and [named Ambulance Provider #1] will each provide in connection with the operation of a “Discharge Lounge” (hereinafter referred to as the “Lounge”)...The purpose of the Lounge is to maximize the efficiency of discharge and transportation of patients from [named Hospital #1]. Whereas the operation of the Lounge allows [named Hospital #1] to increase the availability of rooms for patients awaiting admission and provides [named Ambulance Provider #1] with a staging area for patients awaiting transport, each party agrees that the operation of the Lounge is beneficial to its operations and enhances the delivery of patient care...[named Ambulance Provider #1] will provide one (1) Emergency Medical Technician (hereinafter referred to as the “EMT”) to staff the Lounge during its hours of operation. The EMT shall monitor patients in the Lounge for their personal comfort needs and changes in clinical condition and attend to them as necessary...It is intended that the EMT and the Unit Clerk shall support each other as may be necessary to ensure that patients are kept comfortable in the Lounge and that the Lounge operates as efficiently as possible with a goal that patients remain as comfortable as possible in the Lounge and that patients are conveyed from the Lounge as rapidly as possible...” 3. Medical record review revealed Patient #2 was admitted to the hospital on 7/29/2023 after having a syncopal episode and subsequent fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder. Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, “...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode...pain in her L hip and L shoulder...Of note, pt is blind. There are no other complaints at this time. No fractures noted on imaging studies...Physical Exam...Musculoskeletal...Tenderness over left elbow and hip area ROM [range of motion] OK [okay]...Alert, conversant, appropriate...Legally blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT [Physical Therapy] OT [Occupational Therapy], Ortho BP [orthostatic blood pressure] and HR [heart rate]...Hypernatremia [elevated sodium level]...Hypokalemia...Cont [contusion] left shoulder and hip, High risk falls...Diabetes mellitus Type 2: accu-checks [blood sugar checks] and SSI [sliding scale insulin] per protocol, Maintain BG [blood glucose] in acceptable range 140-180. Diabetic diet. Hypertension Adjust medications to keep BP in acceptable range. Prn antihypertensives to keep SBP [systolic blood pressure] less than 160...Updated daughter at bedside...Care Timeline 07/30 Admitted from ED 0101 [1:01 AM]...” Review of the flowsheets dated 7/29/2023 through 7/31/2023 revealed Patient #2 required assistance with all Activities of Daily Living (ADLs), was blind, confused, at high risk for falls and required the use of bed alarms and/or tether alarms to alert staff when the patient attempted to get up on her own. Patient #2 was considered safe for discharge on 7/31/2023 and was taken to the hospital’s DL at approximately 2:30 PM to wait for her daughter to pick her up after she got off work. There was no documentation the patient was taken to the discharge lounge and no documentation the patient’s daughter was informed of her location. Between 8:15-8:45 PM the same evening, Patient #2’s daughter arrived at the hospital to pick up the patient; however, hospital staff were only able to determine the patient had been discharged but were not able to determine the patient’s location. The House Supervisor was alerted, and subsequently found Patient #2 sitting in her wheelchair in the DL, alone and unattended. The House Supervisor reported the incident to the hospital’s Risk Management staff at 11:18 PM. There was no documentation indicating the actual time Patient #2 left the hospital. Refer to A-0144.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 33763 Based on hospital policy review, document review, medical record review and interview, Nursing Services failed to provide nursing supervision and oversight to ensure nursing staff followed the patient selection criteria for the Discharge Lounge (DL) for 1 of 3 (Patient #2) discharged patients reviewed, resulting in Patient #2 , an 81 year-old confused, wheelchair dependent, blind patient being left unattended in the DL area from approximately 8:15 PM until almost 11:00 PM while she was waiting for her family to arrive and take her home. The findings included: 1. Review of the hospital’s “Assessment/Reassessment Policy” revised on 4/27/2023 revealed, “Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient’s initial and continuing needs...The Registered Nurse [RN]creates an initial plan for care, treatment, and services appropriate to the patient’s specific assessed needs...” Review of the hospital’s “Documentation Policy” revised 3/2021 revealed, “...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation...” 2. Review of the hospital’s “Discharge Lounge Overview” document revealed, “...The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge...Alert and Oriented...Ambulatory with minimal assistance...Able to toilet with minimal PCA assistance...No behavioral issues...Able to self-administer medications - Non Isolation patients...Key Points...Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location...Discharge Lounge Responsibilities...Every Patient must be signed in and out when they enter and leave the discharge lounge...PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night...” 3. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia or (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure). Patient #2 complained of pain in the left shoulder and left hip and was unsure if she sustained a head injury when she fell. Further review revealed the patient required assistance with all Activities of Daily Living (ADLs), was at high risk for falls, confused, and required supervision from another person 24 hours a day 7 days a week. 4. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was “blind” and had a “Time In” documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented “Time Out” was at 8:00 PM when Patient #3 left the hospital. There was no “Time Out” documented for Patient #2. 5. Review of an email sent to Risk Manager #1 by the House Supervisor on 7/31/2023 at 11:18 PM revealed the House Supervisor was notified by the hospital operator informing her Patient #2’s daughter was at the hospital to pick the patient up and take her home. The operator was unable to tell the patient’s daughter where the patient was because she was no publicity. The House Supervisor reviewed the patient’s medical record and noted Patient #2’s daughter had been involved in the patient’s care. The House Supervisor called the 4th floor where Patient #2’s room had been and was told there was another patient in that room because Patient #2 had been discharged. The House Supervisor noted Patient #2 had signed her own discharge papers, so she called the ambulance service, but they had no record showing the patient had been picked up and taken home. The House Supervisor indicated Patient #2’s daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the Discharge Lounge, and documented, “There was no one on the floor but her.” The email revealed Patient #2’s daughter was taken to the Discharge Lounge where the House Supervisor and patient were located and the patient’s daughter “stated that the floor was deserted, her mother had not eaten and was she was in pain.” The email further revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing her that all patients had left the area and asked her where to send the PCA that was working that evening. The PCA was sent to work in the Emergency Room to complete her shift. 6. Review of the hospital’s investigation of the incident revealed Nursing Director #1 reached out to Patient #2’s daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient’s daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient’s daughter was concerned because the patient had been left alone on the unit. The Nursing Director “ensured [assured[ her that we were addressing the occurrence as that was not our expectation of the care for any of our patients...” Risk Managers #1 and 2 identified the DL Log was incomplete for Patient #2. Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident and he verified he didn’t check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night. Patient #2 was discharged on 7/31/2023 at 2:15 PM and was taken to the DL to wait for her daughter to arrive and pick her up. Patient #2 did not meet the hospital’s criteria to be taken to the DL to await transportation to leave the hospital. Refer to A-0395.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33763 Based on policy review, document review, medical record review and interview, the hospital failed to ensure interventions were provided for 1 of 4 (Patient #2) sampled patients to receive care in a safe setting when an 81-year-old, blind patient, at high risk for falls, was taken to the Discharge Lounge (DL) and left alone and unattended by staff on 7/31/2023 for 2 hours and 45 minutes while awaiting family to arrive to transport the patient home after discharge from the hospital. The findings included: 1. Review of the hospital’s “Patient Bill of Rights Policy” revised 4/2022 revealed, “...You or your legally designated representative has the right to be informed about your illness, possible treatment options, and likely outcome(s), including unanticipated outcomes, and to participate and make informed decisions regarding your care...You have the right to receive care in a safe setting, free from abuse, harassment, financial and other exploitation...You have the right to expect the hospital will give you necessary health services to the best of its ability...You have the right to considerate, dignified and respectful patient care, treatment and services...” Review of the hospital’s “Assessment/Reassessment Policy” revised on 4/27/2023 revealed, “Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient’s initial and continuing needs... The Registered Nurse [RN] creates an initial plan for care, treatment, and services appropriate to the patient’s specific assessed needs... Planning for care, treatment, and services is individualized to meet the patient’s unique needs and circumstances. Planning for care, treatment, and services involves using an interdisciplinary approach when warranted and involves the patient and family to the extent possible...” Review of the hospital’s “Documentation Policy” revised 3/2021 revealed, “...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation... Electronic and paper documentation of care, treatment and service is documented at or near the time it occurs... Documentation is completed by the person delivering the care or the caregiver named in the notes...” 2. Review of the hospital’s “Discharge Lounge Overview” document revealed, “...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out... The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge... Alert and Oriented... Ambulatory with minimal assistance... Able to toilet with minimal PCA assistance... No behavioral issues... Able to self-administer medications - Non Isolation patients... Patient’s ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time... Transporting Patient to Discharge Lounge Ambulatory Staff from sending staff transports patient to Discharge Lounge nurses station: - provides patient’s name and estimated time patient’s ride will arrive... Key Points... Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location... Discharge Lounge Responsibilities... Every Patient must be signed in and out when they enter and leave the discharge lounge... Round hourly to check on patients Turn, Change and clean if needed... Assist to bathroom in [as] needed... Offer Drink, Water or Snack... If a patient is present during what would be meal time, offer snack pack... Prior to patient leaving, ensure patient is clean and dry... PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night...” Review of the “Second Amendment to the Master Services Agreement Between [named Hospital #1’s Health Care Corporation] and [named Ambulance Provider #1’s Parent Company] Relating to Discharge Lounge Operations” document signed on 10/17/2022 and 10/11/2022 respectively revealed, “...This Second Amendment sets forth the duties and responsibilities that [named Hospital #1’s Health Care Corporation]’s affiliate and [named Ambulance Provider #1] will each provide in connection with the operation of a “Discharge Lounge” (hereinafter referred to as the “Lounge”)... The purpose of the Lounge is to maximize the efficiency of discharge and transportation of patients from [named Hospital #1]. Whereas the operation of the Lounge allows [named Hospital #1] to increase the availability of rooms for patients awaiting admission and provides [named Ambulance Provider #1] with a staging area for patients awaiting transport, each party agrees that the operation of the Lounge is beneficial to its operations and enhances the delivery of patient care as contemplated by the Agreement. It is anticipated that the Lounge’s hours of operation will be from 10:00 a.m. to 10:00 p.m., Monday through Friday. It is anticipated that the Lounge’s initial patient capacity will be ten (10) patients...[named Ambulance Provider #1] will provide one (1) Emergency Medical Technician (hereinafter referred to as the “EMT”) to staff the Lounge during its hours of operation. The EMT shall monitor patients in the Lounge for their personal comfort needs and changes in clinical condition and attend to them as necessary...[named Hospital #1] will provide the space in which the Lounge will operate, any equipment needed in the Lounge, and one (1) unit clerk (hereinafter referred to as the “Unit Clerk”). The Unit Clerk shall monitor patients in the Lounge for their personal comfort needs and attend to them as necessary... The Unit Clerk shall provide non-clinical assistance to the transporting ambulance crew as maybe necessary... It is intended that the EMT and the Unit Clerk shall support each other as may be necessary to ensure that patients are kept comfortable in the Lounge and that the Lounge operates as efficiently as possible with a goal that patients remain as comfortable as possible in the Lounge and that patients are conveyed from the Lounge as rapidly as possible...” 3. Medical record review revealed Patient #2 presented to the hospital’s Emergency Department (ED) on 7/29/2023 with complaints of syncope resulting in a fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder. Review of the ED Provider Note dated 7/29/2023 revealed Patient #2 “is a 81 y.o. [year old] Female with PMHx [past medical history] of DM [Diabetes Mellitus], HTN [Hypertension (high blood pressure)] and HLD [Hyperlipidemia, an imbalance of good and bad cholesterol] who presents to the ED complaining of syncope onset today. Pt [patient] states she was in a hotel room with her daughter when her daughter was locked out and the pt got up to unlock the door and fell. Pt is unsure if it was a mechanical fall or syncope episode. Pt is endorsing pain in her L [left] hip and L shoulder. Pt does not know if she hit her head upon the fall. Of note, pt is blind... Full workup was performed. EKG [electrocardiogram (measures electrical activity of the heart)] was reassuring... CT [computerized tomography] head CT C-spine [cervical spine] and CT abdomen pelvis were negative. Patient was found to be hypokalemic [low potassium level] and potassium was repleted. Patient was having difficulty ambulating [walking] prior to appropriate time for discharge so she will be brought in for observation to ensure hypokalemia resolves and that she has a safe disposition after appropriate physical therapy...” Review of the flowsheet dated 7/29/2023 at 5:49 PM revealed, “... HPI [History of Present Illness]/Pre-Hospital Tx [treatment]... Reason for Visit fell today at home. denies blood thinners. later had a syncopal episode. ems [emergency medical services] did sternal rub and was unable to get patient aroused until approx [approximately] 5 min. [minutes]” Review of the flowsheet dated 7/29/2023 at 5:50 PM revealed, “...High Fall Risk...” Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, “...Patient [pt] presents with Syncope... pt got up to unlock the door and fell. Pt is usure if it was mechanical fall or syncope episode... pain in her L hip and L shoulder... Of note, pt is blind. There are no other complaints at this time. No fractures noted on imaging studies... Physical Exam... Musculoskeletal... Tenderness over left elbow and hip area ROM [range of motion] OK [okay]... Alert, conversant, appropriate... Legally blind... Assessment and Plan: Syncope vs Fall... Fall precautions, PT [Physical Therapy] OT [Occupational Therapy], Ortho BP [orthostatic blood pressure] and HR [heart rate]... Hypernatremia [elevated sodium level]...Hypokalemia [low potassium level in the blood]... Cont [contusion] left shoulder and hip, High risk falls... Diabetes mellitus Type 2: accu-checks [blood sugar checks] and SSI [sliding scale insulin] per protocol, Maintain BG [blood glucose] in acceptable range 140-180. Diabetic diet. Hypertension Adjust medications to keep BP in acceptable range. Prn antihypertensives to keep SBP [systolic blood pressure] less than 160... Updated daughter at bedside... Care Timeline 07/30 Admitted from ED 0101 [1:01 AM]...” Review of the flowsheet dated 7/30/2023 at 12:52 AM revealed Patient #2 was “...chairfast” and her mobility was “slightly limited.” Review of the flowsheet dated 7/30/2023 at 1:47 AM revealed “...Anticipated Discharge Disposition/Services home or self-care; home with family...” Review of the flowsheet dated 7/30/2023 at 1:52 AM revealed, “...Vision Management blind...” Review of the flowsheet dated 7/30/2023 at 2:28 AM revealed, “...Safety Rounds/Standard Fall Preventions... Safety Additional... side rails raised x [times] 4 Activity Assistance Provided assistance, 1 person...” Review of the flowsheet dated 7/30/2023 at 4:20 PM revealed, “Safety Rounds/Standard Fall Preventions... Safety Additional - upper side rails raised x 2, lower side rail raised x 1...” Review of the flowsheet dated 7/30/2023 at 6:03 PM revealed, “Functional Screen... Ambulation 2 -assistive person... Transferring 2 - assistive person... Toileting 2 - assistive person... Bathing 2 - assistive person... Dressing 2 - assistive person...” Review of the flowsheet dated 7/30/2023 at 6:38 PM revealed, “...Fall Risk Interventions... yellow wrist band/fall signage present; Bed alarm set... High Fall Risk Interventions... Hourly rounding conducted... Enhanced Safety Measures bed alarm set...” Review of the flowsheet dated 7/31/2023 at 1:17 AM revealed, “Fall Risk Assessment History of fall within the last 3 months? Yes... Safety Rounds/Standard Fall Preventions Additional Safety upper side rails raised x 2, lower side rail raised x 1... Enhanced Safety Measures bed alarm set...” Review of the Discharge Planning Note dated 7/31/2023 at 8:33 AM revealed, “...Anticipated Discharge Disposition: home with family... Additional Comments: SW [Social Worker] completed patient’s assessment with her granddaughter... via phone... patient lives with her daughter... DME [Durable Medical Equipment]-wheelchair; no history of SNF [skilled nursing facility], IPR [inpatient rehabilitation], or HH [Home Health]. Patient’s discharge plan is home with family...” Review of the flowsheet dated 7/31/2023 at 8:45 AM revealed Patient #2 was provided “Perineal Care absorbent brief changed; diaper changed; perineum cleansed... Hygiene dressed/undressed; incontinence care... Bath, complete... Linen changed... Oral Care swabbed with sterile water...” Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, “...Hospital Course: This is an 81 year-old female who got admitted for syncope. Syncope is mostly due to dehydration and hypokalemia. Started on IV [intravenous] fluids and potassium was supplemented. She is back to her baseline now. Urinalysis is positive for possible UTI [urinary tract infection]. Started on IV antibiotics. Echo [echocardiogram, a scan used to look at the heart and nearby blood vessels] done and unremarkable. EKG is unremarkable. Evaluated by PT [Physical Therapy] OT [Occupational Therapy]. Discussed with case manager to discharge home if family is agreeable... Stable for discharge...” Review of a physician’s order dated 7/31/2023 at 9:26 AM revealed, “...Discharge patient... Discharge disposition: Home...” Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 from 9:27 AM through 9:44 AM revealed, “...Pt Post TX... in chair, instructed to call for assistance, call light in reach, bedside table in reach, tether alarm on... Recommended Discharge Disposition: skilled nursing facility (SNF) vs [versus] home with 24/7 assistance and HHOT/PT [Home Health Occupational Therapy/Physical Therapy]... Vision: legally blind; pt reports she can see lt/dark [light/dark]... Pt is a questionable historian, no family present during evaluation. Pt reports when her dtr [daughter] is at work she has someone that stays with her... SNF vs home with 24/7 assistance and HHOT/PT...” Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 from 9:28 AM through 9:45 AM revealed, “...Recommending home with 24 hour care vs SNF... Precautions/Limitations: Fall and Blindness... Transportation: family or friends will provide... Gait: Independence level: moderate assist (50% patient effort), 1 person assist... Pt took short shuffled steps... Balance... Standing... poor... PT Diagnosis: difficulty walking, muscle weakness, impaired balance... Plan for PT: continue PT... 3-5 times per week...” Review of the flowsheet dated 7/31/2023 at 11:46 AM revealed, “...Occupational Therapy... Pt Post Tx in chair; instructed to call for assistance; call light in reach; bedside table in reach; tether alarm on... Anticipated Discharge Disposition... home with assist; home with home health...” Review of the flowsheet dated 7/31/2023 at 12:59 PM revealed Patient #2 was “disoriented to; time; situation” and her “Best Verbal Response... confused...” Review of the flowsheet dated 7/31/2023 at 1:01 PM revealed Patient #2 was at “High Fall Risk.” Review of the flowsheet dated 7/31/2023 at 1:04 PM revealed Patient #2 was “...in chair; call light in reach; tether alarm on... Anticipated Discharge Disposition... home with assist; home with home health; skilled nursing facility...” Review of the After Visit Summary dated 7/31/2023 printed at 2:07 PM revealed, “Patient to Schedule MD [Medical Doctor] Follow-Up in 1 week... Instructions from your provider Your primary diagnosis was: Fainting Your diagnoses also included: Blindness, Type 2 Diabetes Mellitus With Manifestations, High Blood Pressure, Low Blood Potassium, high Sodium Levels, At High Risk for Falls, Contusion of Elbow, Contusion of Hip...” Review of the Summary Event Log dated 7/31/2023 at 2:15 PM revealed, “...Discharge... Discharge disposition: Home...” There was no documentation to indicate how Patient #2 was transported to her home and no documentation the patient’s family was notified she had been discharged and taken to the Discharge Lounge. 3. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was “blind” and had a “Time In” documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented “Time Out” was at 8:00 PM when Patient #3 left the hospital. There was no “Time Out” documented for Patient #2. 4. Risk Manager #1 shared an email she received from the House Supervisor on 7/31/2023 at 11:18 PM regarding an incident involving Patient #2. The email indicated the House Supervisor had been called by the operator to inform her that Patient #2’s daughter had arrived to pick her up and take her home, but the operator was unable to determine the patient’s whereabouts because she was listed as a no publicity. The House Supervisor reviewed the patient’s chart and called the 4th floor nurse’s station to inform them Patient #2’s daughter was there to pick her up. The person at the nurse’s station informed her the patient had been discharged and there was a different patient in Patient #2’s old room. The House Supervisor noted Patient #2 had signed her own discharge papers, so she called the ambulance service, but they had no record showing the patient had been picked up at the hospital and taken home. The House Supervisor indicated Patient #2’s daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the DL, and documented, “There was no one on the floor but her.” The House Supervisor told staff to tell the patient’s daughter to drive to the discharge area and they would bring her to her car; however, someone from the 5th floor took the patient’s daughter to the DL where the House Supervisor and Patient #2 were located. Patient #2’s daughter became upset because she “stated that the floor was deserted, her mother had not eaten and was she was in pain.” The House Supervisor requested someone follow up in the morning to call in a prescription for pain medications as the hospitalist on call would not call in the medication. Further review of the email revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing the House Supervisor all patients had left the area and asked her where to send the PCA that was working that evening for the rest of the shift. The PCA was sent to work in the Emergency Room to complete her shift. 5. Review of the hospital’s investigation of the incident revealed Nursing Director #1 reached out to Patient #2’s daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient’s daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient’s daughter was concerned because the patient had been left alone on the unit. The Nursing Director “ensured [assured] her that we were addressing the occurrence as that was not our expectation of the care for any of our patients...” Risk Managers #1 and 2 noted the DL Log was incomplete for Patient #2. Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident. EMT #1 verified he didn’t check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night. 7. In an interview conducted during a tour of the DL on 10/30/2023 beginning at 11:05 AM, Nursing Director #1 stated the DL consisted of 10 rooms on the hall and the remaining rooms at the end of the hallway were reserved for dialysis patients as needed. The director continued and stated the DL was usually staffed with an EMT and 2 PCAs or PCTs (Patient Care Technicians) and they were expected to assist patients with activities of daily living (ADLs) such as toileting, eating and drinking. They would sign the patients in and out on the log, obtain vital signs upon arrival and before they were discharged as well as check the patients at least every hour. When asked if any patients had ever been left unattended in the DL, Nursing Director #1 stated, “I’m not aware of any incidences of patients being left; there have been some conversations where the unit looked abandoned, but that has not ever been the case...” Nursing Director #1 was asked if she could recall the incident involving Patient #2. The director stated, “I do remember the patient’s name. The House Supervisor got involved with the patient’s daughter who didn’t know her room was in the DL. That unit didn’t notify the daughter where she [Patient #2] was; she [daughter] went to the unit where she [Patient #2] was discharged from. Then night shift didn’t know where she [Patient #2] went because it happened on day shift. I remember talking to the daughter on the phone because she [patient’s daughter] said it [DL] looked like an abandoned unit; it [DL] looked like things were being stored there. We were painting and had beds in the hallway while we were painting.” When asked if Patient #2 was left alone on the unit, Nursing Director #1 stated, “The EMT wasn’t on the unit at that time, he was downstairs. We looked at the logs and clarified all their [DL staff] responsibilities and expectations and retrained all staff.” The Nursing Director continued and stated, “To my knowledge, the PCA was still on the unit. The House Supervisor came up and talked with the daughter...” The director then stated the EMT that was involved in the incident was no longer working at the hospital. In an interview on 10/30/2023 at 3:35 PM, RN #1 RN #1 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated the patients “usually have to be alert; walky-talky.” The RN was asked if she could recall caring for Patient #2, the day she was discharged. RN #1 verified she was Patient #2’s nurse the day she was discharged from the hospital and stated, “She’s blind. My Charge Nurse wanted the patient to go to the DL. I was busy and I told her [charge nurse] I didn’t think she [Patient #2] qualified for it. She [charge nurse] told me to send her [Patient #2] anyway because they needed the room.” When asked if she [RN #1] called Patient #2’s daughter to inform her [daughter] the patient was going to the DL, RN #1 stated, “I tried to call her multiple times, but she never answered...I guess I didn’t document it, but I did call.” RN #1 continued and stated, “That night [7/31/2023] they told me the patient stayed there and nobody picked her up until late; I was told by staff the patient was there by herself because everybody [DL staff] had left.” In a telephone interview on 10/31/2023 at 8:42 AM, the House Supervisor stated she received a call from someone on the 5th floor informing her Patient #2’s daughter was trying to find Patient #2. The House Supervisor continued and stated, “I looked in the computer and saw she was discharged at about 1:30 -2:30 earlier in the day. I called to the 4th floor nurses station and asked where she [Patient #2] was, but they didn’t know because she left before they got there. I called the DL and there was no answer. I called back to the 5th floor and asked them to give me a moment...I physically went to the Lounge [DL], called them [5th floor staff] and told them I have her.” The House Supervisor stated Patient #2’s daughter “ended up on the unit [DL] with me.” The House Supervisor continued and stated, “When I found her [Patient #2], I did not see any staff; there was nobody in the room with her. I went to the desk and there was no one [staff] there and no other patients.” The House Supervisor was asked if Patient #2 appeared to be in distress or had any signs of incontinence. The House Supervisor stated, “She [Patient #2] was sitting there. I introduced myself then I realized she [Patient #2] was blind. I spoke with [Patient #2]. She was in a wheelchair. There was nothing visible to me as far as distress. I did ask [Patient #2] if she needed to go to the bathroom. [Patient #2] did tell me she was hungry and I got her a snack.” The House Supervisor was asked if she could recall what time the patient was found. The House Supervisor was unable to verify the exact time but stated, “I reported to Risk [Risk Management] immediately after.” [Note: The House Supervisor sent an email to the Risk Manager at 11:18 PM. See #4 above. ] The House Supervisor was asked if she had received any other complaints or reports of patients being left unattended in the DL. The House Supervisor stated, “No and I have an alarm set on my phone for 10:30 [PM]; I stop and call the DL and ask if there are any patients left on the unit and the estimated time of pick up as well as what types of patients are left.” When asked what criteria was used to determine if a patient was appropriate to go to the DL, the House Supervisor stated, “Those going have to be able to get in and out of a car, have to be able to stand and pivot. They have to be as close to walkie-talkie as possible.” When asked if Patient #2 met the criteria to go to the DL, the House Supervisor stated, “I would not have sent her there; I would have stopped with she was blind.” In a telephone interview on 10/31/2023 at 9:01 AM, PCA #1, who was scheduled in the DL on 7/31/2023, stated she did not recall Patient #2. The PCA continued and stated, “I’ve only worked there once or twice. The paramedic guy [EMT] just pretty much had me go in and do vital signs and when they leave, strip the bed.” The PCA was asked if she made rounds every hour and checked to see if the patients needed toileting or offered them food or water. PCA #1 stated, “no ma’am. I actually only worked once; the 2nd time I went I was told to go over to the ER [emergency room].” The PCA was asked if she received any orientation or training specific to the DL before she worked there. PCA #1 stated, “No ma’am. I had a nurse take me down there because I had never been on that unit...When they told me I was going there I asked, ‘what’s that?’.” In a telephone interview on 10/31/2023 at 9:15 AM, RN #2 verified she was the Charge Nurse on duty when Patient #2 was discharged to the DL. When asked what criteria was used to determine if a patient was appropriate to go the DL, RN #2 stated, “Patients that won’t be getting up out of bed.” The RN continued and stated, “We don’t send high fall risk patients.” RN #2 was asked if it was appropriate to send a blind patient who needed assistance to get up to the DL. The RN stated, “They have people in the DL there to assist.” RN #2 continued and stated, “When I said getting up on their own, I meant like confused patients getting up on their own; we wouldn’t send those patients.” The RN was asked if she had read the DL criteria. RN #2 verified she had read them in the past but was unable to recall them at this time. The RN was asked who determined if a patient met the criteria to go to the DL. RN #2 stated, “We ask the nurse and go by what the nurse says.” The RN was asked if she had ever told a nurse to take a patient to the DL even when the nurse thought patient didn’t meet the criteria. RN #2 stated, “No, I do not override them.” RN #2 was asked if she could recall sending Patient #2 to the DL. The RN stated, “I don’t remember the name.” RN #2 then stated she did recall the incident and stated, “The patient [Patient #2] was blind; we took her to the DL and communicated with staff that the patient is blind and wrote it in the comments. They [DL staff] tell us what room to put the patient and we put them where they tell us.” RN #2 was asked if the patient’s family was notified the patient was taken to the DL. The RN stated, “No, all we did was help provide transport to the DL.” This surveyor read the hospital’s criteria for the DL to RN #2 and asked if Patient #2 met the criteria for the DL. The RN verified Patient #2 should not have been taken to the DL. In an interview on 10/31/2023 at 10:47 AM, RN #3 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #3 stated, “Somebody that is able to feed themself. We don’t send if they need assistance with feeding, toileting, fall risk or confused.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #3 stated, “Most of the time I’m a Charge Nurse. If there is doubt, they [staff nurses] run it by me.” RN #3 was asked if she ever sent patients to the DL that the staff nurse felt was not appropriate. RN #3 stated, “I’m not going to override it [staff nurse’s judgement.]...” In an interview on 10/31/2023 at 10:50 AM, RN #4 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #4 stated patients that are “waiting for Skilled Nursing Facility [SNF] but not of on [receiving] tube feedings [a tube placed into the stomach and liquid nutrition can be given if a patient has difficulty eating]. Ambulatory and waiting for a ride to pick them up...independent.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #4 stated, “Usually it’s a nursing judgement; if there’s some question, we’ll confer with a Charge Nurse.” RN #4 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #4 stated, “No.” In an interview on 10/31/2023 at 11:01 AM, RN #5 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #5 stated “if they are not waiting on pain meds and waiting on their ride to arrive. Ambulatory and able to take self to bathroom with minimal assistance.” As a RN, she would send the patient if eligible. If there is a need for a unit bed, the charge nurse checks with the RN to see if there is an eligible patient. RN #5 stated, “If there is a need for a bed, we will send them down no matter what.” RN 5 stated, “As a charge nurse, I have never overridden a unit nurse decision [unit nurse decision on eligibility for DL.] She does not contact the patient’s family member to notify them that the patient is being sent to the DL.” In an interview on 10/31/2023 at 11:00 AM, RN #6 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #6 stated patients that are alert and oriented were appropriate to go to the DL. The nurse was asked who determined if a patient met the criteria to go to the DL. RN #6 stated that she had not sent patients to the DL. In an interview on 10/31/2023 at 11:03 AM, RN #7 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #7 stated, “stable and ambulatory.” RN #7 confirmed she had sent patients to the DL. RN #7 was asked who determines the patient’s eligibility to go to the DL. RN #7 stated, “nursing judgement and doctor. If patient family is available, I notify them the patient has been sent to the DL.” RN #7 stated that in her role as a charge nurse, she had never had a unit nurse question the eligibility decision regarding patient placement in the DL. RN #7 stated, “We always look for safety. Make sure they are safe.” In an interview on 10/31/2023 at 11:05 AM, RN #8 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #8 stated that they “ideally send patients that are alert and oriented times 4 [Alert and oriented times 4 means that a patient is aware of self, time, place and others]. The patients are waiting for and have an available ride to pick them up.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #8 stated that is usually determined during discharge planning rounds whether or not a patient can be sent to the DL. RN #8 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #8 stated, “No.” In an interview on 10/31/2023 at 11:11 AM, RN #9 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #9 stated, “medically stable, ambulatory, can safely wait for transport without nurse intervention.” RN #9 was asked who determines a patient’s eligibility to go to the DL. RN #9 stated, “The doctor decides who is eligible. I would have to assume the doctor makes the decision. I certainly wouldn’t want to make that call. None of my patients have ever qualified.” In an interview on 10/31/2023 at 11:14 AM, RN #10 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #10 stated she sent patients who were waiting on the ambulance for transport. The RN continued and stated she only sent patients to the DL who needed to be transported by ambulance. In an interview on 10/31/2023 at 11:16 AM, RN #ll was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #11 reported that she had never sent a patient to the DL. RN #11 stated, “I didn’t personally know it [DL] is a thing.” RN #11 reported she would refer to the Charge Nurse to see if a patient was eligible for the DL before sending the patient. In an interview on 10/31/2023 at 11:16 AM, RN #12 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #12 stated patients that are “ready for discharge and stable. The patients are neither in isolation nor on the ventilator; neither do the patients have a chest tube. Bedbound patients may be sent to the DL, because the DL is staffed with nurses and staff to assist the patients.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #12 stated, “discharged patients who are awaiting family for pick up, requiring transport by ambulance and already has medical equipment set up may be sent to the DL.” RN #12 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #12 stated, “No.” In an interview on 10/31/2023 at 11:22 AM, RN #13 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #13 reported she had never sent a patient to the DL, but she is aware of it. Regarding the criteria for a patient to go to the DL, RN #13 stated, “alert, oriented, not confused, not jumping out of bed, can take care of themselves, as long as can tend to themselves.” In an interview on 10/31/2023 at 11:25AM, RN #14 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #14 stated patients that are “waiting to be transported to SNF or rehab via ambulance. Ambulatory, alert and oriented, who are waiting for a ride to pick them up.” The RN continued and stated, “Patients who were high risks for falls, in isolation, on tube feedings or with increased level of confusion would not be taken to the DL.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #14 stated, “Usually it’s a nursing judgement; the assigned nurse might discuss with a Charge Nurse.” RN #14 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #14 stated, “No, she has not had an issue with a patient not meeting the criteria.” In an interview on 10/31/2023 at 11:30 AM, RN #15 reported she has utilized the DL for discharged patients. RN #15 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #15 stated, “The patient is able to state their needs, won’t need pain meds, needs to be able to use the call light if they need assistance. It doesn’t mean the patient needs to be out of bed. The patient eats a meal before going to the DL. They don’t provide meals there. Eligibility is discussed on rounds with the nurse.” RN #15 was asked if a patient who is wheelchair bound and requires assistance to stand/transfer would be eligible for the DL. RN #15 stated, “Yes. As long as the patient can use the call light to request assistance. There are employees there to assist.” In an interview on 10/31/2023 at 11:32 AM, RN #16 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #16 stated patients who are ambulatory, stable, alert and oriented, waiting on family for pick up. The nurse continued and stated alert and oriented bedbound patients who are able to call for assistance could also be sent to the DL. RN #16 was asked if the family is notified when a patient is taken to the DL. The RN stated, “ I do let my families know; I’ve called a few.” When asked if patients who were considered High risk for falls should be taken to the DL, RN #16 stated, “Nobody that’s a high risk for falls.” The RN was asked who determined if a patient met the criteria to go to the DL. RN #16 stated, “Usually it’s a nursing judgement; if there’s some question, we’ll confer with a Charge Nurse.” RN #16 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #16 stated, “No.” In an interview on 10/31/2023 at 11:40 AM, RN #17 identified herself as a Charge Nurse and verified she had utilized the DL for discharged patients. RN #17 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #17 stated, “patients going to another facility, ambulatory patients being picked up by family member, no diabetics, no isolation, confused, or high-risk patients.” RN #17 was asked who determines a patient’s eligibility for the DL. RN #17 stated, “head nurse, charge nurse.” RN #17 was asked if there had been any incidents when she disagreed with the RN’s nursing judgment of a patient’s eligibility to go to the DL. RN #17 stated, “Yes; if they’re appropriate, I have overruled them.” The RN was asked if the patient’s families were notified when a patient was taken to the DL. RN #17 stated, “I usually take the patient down [to the DL] with the manager and let the family know.” In an interview on 10/31/2023 at 11:52 AM, RN #18 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #18 stated patients that are “stable” and ambulatory and meet the criteria. RN #18 continued and stated patients who are in isolation, have a PEG (percutaneous endoscopic gastrostomy tube), confused, demented or a high fall risk would not meet the criteria. The RN was asked who determined if a patient met the criteria to go to the DL. RN #18 stated, “Usually it’s a nursing judgement.” The RN was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #18 stated, “No.” In an interview on 10/31/2023 at 11:50 AM, RN #19 verified she had sent discharged patients to the DL. RN #19 was asked what criteria was used to determine a patient’s eligibility to go to the DL. RN #19 stated, “no medication, sugar checked, and insulin given; there would need to be someone there to do that.” When asked if a high fall risk patient met eligibility for the DL, RN #19 replied, “if requires only one person assist. I wouldn’t send a bedbound patient.” RN #19 was asked who determines a patient’s eligibility to go to the DL. RN #19 stated, “I don’t know. I guess it changes depending on who’s down there to man it.” In an interview on 10/31/2023 at 11:52AM, RN #20 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #20 stated, “stable or safe to be alone or only need a small amount of assistance. I keep the high fall risk patients on the floor with me.” The RN was asked who determined if a patient met the criteria to go to the DL. RN #20 stated “I usually consult with the Charge Nurse or manager” regarding the patient’s eligibility. The RN was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN#20 stated, “No.” In an interview on 10/31/2023 at 11:54 AM, RN #21 stated, “They told me yesterday it [DL] was on 4-West now.” RN #21 was asked what criteria was used to determine a patient’s eligibility for the DL. RN #21 stated, “be independent. self-reliant. a walkie talky. alert. oriented.” RN #21 was asked if patients who were high fall risks would be eligible for the DL. RN#21 stated, “We don’t put those up there.” RN #21 was asked if a blind patient would be eligible for the DL. RN #21 stated, “depends on how self-reliant they are. It would be patient specific.” RN #21 was asked who determines the eligibility of a patient for the DL. RN #21 stated, “ It would be a discussion between the staff nurse, charge nurse, and nurse supervisor.” RN #21 was asked if anyone notified patient’s family members when a patient was taken to the DL. The RN stated, “Usually we tell them.” In an interview on 10/31/2023 at 11:57AM, RN #22 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated, “patients that are not getting out of bed too much and stable patients.” RN #22 was asked if patients at high risk for falls should be taken to the DL. The RN stated, “No, we wouldn’t send high fall risk patients or ones that needed a lot of assistance.” RN #22 was asked who determined if a patient met the criteria to go to the DL. The RN stated, “the discharge nurse and the Charge Nurse.” RN #22 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #22 stated, “No.” In an interview on 10/31/2023 at 12:00 PM, RN #23 was asked what criteria was used to determine if a patient was appropriate to go to the DL. The RN stated, “stable patients, vital signs stable.” RN #3 continued and stated, “I’ve not sent anyone there. [DL].” In an interview on 10/31/2023 at 12:02AM, RN #24 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated, “those waiting for a ride that were safe to go, able to follow commands.” When asked if a patient at high risk for falls or was blind should be taken to the DL, RN #24 stated, “No.” RN #24 was asked who determined if a patient met the criteria to go to the DL. The RN stated, “The Charge Nurse; they are more aware of how the patients are and how soon they need the room.” The RN was asked if the patients’ families were notified when a patient was taken to the DL. RN #24 stated, “Yes, we document it in the progress notes and let the discharge nurse know.” In an interview on 10/31/2023 at 12:02 PM, RN #25 stated she was an Advanced Nurse Clinician working as a staff nurse. The RN then verified she had sent patients to the DL. RN #25 was asked what criteria was used to determine if a patient was appropriate to go to the DL. The RN stated, those in a “wheelchair, alert and oriented and their ride is not there yet.” When asked if a high fall risk patient would meet eligibility for the DL, RN #25 stated, “That’s why they have staff there. If they are unable to call for help, we wouldn’t send them.” RN #25 was asked who determined if a patient met the criteria to go to the DL. The RN stated, “The nurse taking care of the patient.” The RN was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #25 stated, “No, because I’d overrule the Charge Nurse. If there was a problem, I would escalate it to the Nurse Managers.” In an interview on 10/31/2023 at 12:12 PM, RN #26 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #26 stated that she had not sent a patient to the DL; however, a patient should be “ambulatory and independent.” The RN was asked who determined if a patient met the criteria to go to the DL. RN #26 stated, “I would check with my Charge Nurse or manager.” When asked if it was appropriate to send a patient to the DL who was at a high risk for falls, RN #26 stated, “I would get clarification to make sure it was okay to send them.” In an interview on 10/31/2023 at 12:15 PM, RN #27 verified she had sent patients to the DL. RN #27 was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #27 stated, “Alert, oriented, stable, independent and can take self to the bathroom.” The RN was asked if the patients’ families were notified when a patient was taken to the DL. RN #27 stated, “Yes.” The RN was asked who determined if a patient met the criteria to go to the DL. RN #27 stated, “We [unit nurse] determine.” The RN was asked if a high fall risk patient and/or blind patient would be eligible for the DL. RN #27 stated, “No.” In an interview on 10/31/2023 at 12:15 PM, RN #29 verified she had sent patients to the DL. The RN was asked what criteria was used to determine if a patient was appropriate to go to the DL. RN #29 stated, “ambulatory or waiting on an ambulance, no isolation, not confused, waiting for family.” The RN continued and stated they “do not typically send patients at high risk for falls or require a lot of assistance.” RN #29 was asked who determined if a patient met the criteria to go to the DL. RN #29 stated, “It’s nurse driven.” RN #29 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #29 stated, “I’ve not been overruled; they [Charge Nurses] listen to us.” In an interview on 10/31/2023 at 12:18 PM, RN #28 was asked what criteria was used to determine if a patient was appropriate to go the DL. RN #28 stated “We can’t send isolation patients. Most of the time they are ambulance pickups or walkie talkies. They need to be stable and must not need a lot of care.” The RN was asked if a patient at high risk for falls and/or blind should be taken to the DL. RN #28 stated, “No.” The nurse was asked who determined if a patient met the criteria to go to the DL. RN #28 stated, “Usually it’s a nursing judgement; if there’s some question, we’ll confer with a Charge Nurse.” RN #28 was asked if a Charge Nurse had ever overruled her nursing judgement regarding a patient’s appropriateness for the DL and had her send them anyway. RN #28 stated, “No.” In an interview conducted in the DL, on 10/31/2023 at 12:27 PM, EMT #2 stated patients that had been discharged from their room waiting on an ambulance to pick them up as well as “ambulatory” patients that were waiting on family members to pick them up were brought to the DL. The EMT continued and stated the patients were placed in a room if they were in a hospital bed, and the other patients were placed in the “Ambulatory” room that has a TV and call light. The EMT was asked how often he checked on the patients in the DL. EMT #2 stated, “It depends on how the patient is and what they were seen for; I can’t give them meds [medications]. Ambulatory patients more like every 20 minutes or so; they’re just waiting.” The EMT was asked if patients were ever brought to the DL that he didn’t feel were appropriate to be there. EMT #2 stated, “Several times, but I still do my due diligence to check them. We have protocols to determine who can come; they [floor staff] call report and let us know their needs.” The EMT was asked how he would respond if a patient went into distress or collapsed. EMT #2 stated, “I would do the ABCs [Airway, Breathing, Circulation], assess the patient and call for help.” EMT #2 continued and stated, “I ask [person calling report] what type of precautions, if they’re incontinent, diabetic because there’s so much I can’t do for the patient on this unit.” The EMT was asked if he ever refused to accept a patient in the DL. EMT #2 stated, “No, but there were several I could have refused; I only decline them due to transportation. I’m not allowed to give insulin, pain meds, or do accu checks [blood glucose checks]...I don’t like to reject patients.” The EMT was asked to describe his duties at the end of his shift before closing the DL for the night. EMT #2 stated, “I check every room, turn off every TV, turn off all the lights, check in the bathrooms; I walk through every room.” The EMT stated all patients brought to the DL were documented on the DL Log and vital signs were obtained upon arrival and prior to discharge. The EMT then walked to the computer at the nurses’ station and showed the surveyors where the patients’ vital signs were documented. When asked to show the surveyors the documentation of Patient #2’s vital signs, the EMT pulled up the spread sheet dated 7/31/2023. Patient #2’s name and/or vital signs were not noted on the spread sheet. EMT #2 was asked what additional staff worked in the DL. The EMT stated, the DL is usually staffed with 2 PCAs; they check for incontinence, strip down the beds after the patient leaves and check to see if the patients have any concerns. When asked if the patients were ever offered food or water while in the DL, EMT #2 stated, “Yes; I try to keep sandwiches, juice, drinks, water and graham crackers down here for them.” In an interview conducted in the DL on 10/31/2023 at 12:28 PM, Nurse Manager #1 stated the DL utilized the hospital’s Emergency Response Team (ERT) when patients in the DL were in crisis. The Nurse Manager continued and stated the ERT would respond to the DL and take the patient to the Emergency Room as needed for further treatment. Observations in the DL on 10/31/2023 at 12:29 PM, revealed a room with a sign on the door labeled, “Ambulatory” was located down the hallway and out of the direct line of sight from the nurse’s station. The room contained a chair, sofa and loveseat. A call light was noted hanging on the wall. The room also contained a standard bathroom. There were no patients in the DL at that time. In an interview on 11/1/2023 at 3:12 PM, Risk Manager #1 stated the hospital was “on diversion for med/surg [medical/surgical] and step-down beds” on 7/31/2023 and there was a total of “24 bed holds in the Emergency Department” when Patient #2 was taken to the DL and left unattended by staff.”

“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: 33763 Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure nursing services provided adequate oversight and supervision to ensure patient’s needs were met when direct care staff failed to follow the hospital’s guidelines to determine if 1 of 3 (Patient #2) discharged patients reviewed met criteria to be taken to the Discharge Lounge (DL) to await transportation after discharge from inpatient care. The findings included: 1. Review of the hospital’s “Assessment/Reassessment Policy” revised on 4/27/2023 revealed, “Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient’s initial and continuing needs... The Registered Nurse [RN] creates an initial plan for care, treatment, and services appropriate to the patient’s specific assessed needs... Planning for care, treatment, and services is individualized to meet the patient’s unique needs and circumstances...” Review of the hospital’s “Documentation Policy” revised 3/2021 revealed, “...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation... Electronic and paper documentation of care, treatment and service is documented at or near the time it occurs... Documentation is completed by the person delivering the care or the caregiver named in the notes...” 2. Review of the hospital’s “Discharge Lounge Overview” document revealed, “...The Discharge Lounge was established to address capacity challenges within the hospital. The goal of the Discharge Lounge is to provide an area for patients who are medically ready for discharge and awaiting transportation out. The Discharge Lounge is staffed by an EMT [Emergency Medical Technician] and PCA [Patient Care Assistant] (for ambulance patients) and a PCA (for ambulatory patients). Patient Selection Criteria Ambulatory Lounge... Alert and Oriented... Ambulatory with minimal assistance... Able to toilet with minimal PCA assistance... No behavioral issues... Able to self-administer medications - Non Isolation patients... Patient’s ride must be pre-arranged and anticipated to arrive by Discharge Lounge closing time... Key Points... Please notify family if you are sending a patient to this discharge lounge so they are aware of patient location... Discharge Lounge Responsibilities... Every Patient must be signed in and out when they enter and leave the discharge lounge... PRIOR to closing each night, the entire hall need to be checked to ensure ALL patients are gone. Log needs to be checked to ensure each patient has left. Call [phone number] and notify house supervisor you are leaving for the night...” 3. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia or (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure). Patient #2 complained of pain in the left shoulder and left hip and was unsure if she sustained a head injury when she fell. Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, “...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode... pt is blind... No fractures noted on imaging studies... Physical Exam... Alert, conversant, appropriate... Legally blind... Assessment and Plan: Syncope vs Fall... Fall precautions, PT [Physical Therapy] OT [Occupational Therapy]...” Review of the flowsheets for Patient #2 dated 7/29/2023 through 7/31/2023 revealed the patient required assistance completing all Activities of Daily Living (ADLs), the patient was blind, alert, but confused, and was at high risk for falls. The patient required the use of a bed alarm while in the bed and a tether alarm while up in a chair to alert staff when the patient attempted to get up on her own. Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, Patient #2 was admitted to the hospital for syncope which was likely the result of dehydration and low potassium levels. The patient was treated with Intravenous (IV) fluids and potassium, started on IV antibiotics for a possible urinary tract infection, was evaluated by Physical Therapy and Occupational Therapy and was “Stable for discharge.” Review of a physician’s order dated 7/31/2023 at 9:26 AM revealed, “...Discharge patient... Discharge disposition: Home...” Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 at 9:27 AM to 9:44 AM, revealed Patient #2 was legally blind but could differentiate between light and darkness. The evaluation further revealed the patient required assistance of another person 24 hours a day, 7 days a week. Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 at 9:28 AM to 9:45 AM, revealed Patient #2 was at risk for falls, had functional limitations due to blindness, had poor balance and required moderate assistance to complete “short shuffled steps.” The evaluation further revealed the patient required assistance of another person 24 hours a day, 7 days a week. There was no documentation Patient #2 was taken to the DL to wait for her daughter to pick her up and take her home. There was no documentation the patient’s daughter was informed the patient had been taken to the Discharge Lounge. 4. Review of the Discharge Lounge (DL) Log dated 7/31/2023 revealed Patient #2 was “blind” and had a “Time In” documented at 2:18 PM. A total of 4 other patients arrived in the DL after Patient #2 arrived and the last documented “Time Out” was at 8:00 PM when Patient #3 left the hospital. There was no “Time Out” documented for Patient #2. 5. Review of an email sent to Risk Manager #1 by the House Supervisor on 7/31/2023 at 11:18 PM revealed the House Supervisor was notified by the hospital operator informing her Patient #2’s daughter was at the hospital to pick the patient up and take her home. The operator was unable to tell the patient’s daughter where the patient was because she was no publicity. The House Supervisor reviewed the patient’s medical record and noted Patient #2’s daughter had been involved in the patient’s care. The House Supervisor called the 4th floor where Patient #2’s room had been and was told there was another patient in that room because Patient #2 had been discharged. The House Supervisor noted Patient #2 had signed her own discharge papers, so she (House Supervisor) called the ambulance service, but they (ambulance service) had no record showing the patient had been picked up and taken home. The House Supervisor indicated Patient #2’s daughter was no longer waiting in the lobby area and had gone to the 5th floor looking for her mother. The email further indicated the House Supervisor found Patient #2 in a room in the Discharge Lounge, and documented, “There was no one on the floor but her [the patient].” The email revealed Patient #2’s daughter was taken to the Discharge Lounge where the House Supervisor and patient were located and the patient’s daughter “stated that the floor was deserted, her mother had not eaten and was she was in pain.” The email further revealed the House Supervisor had received a call from the EMT in the DL between 8:00 PM and 8:15 PM informing her that all patients had left the area and asked her where to send the PCA that was working that evening. The PCA was sent to work in the Emergency Room to complete her shift. 6. Review of the hospital’s investigation of the incident revealed Nursing Director #1 reached out to Patient #2’s daughter who thought Patient #2 was found on a deserted unit. The Nursing Director informed the patient’s daughter the unit appeared to be deserted because some of the furniture had been placed in the hallway while the rooms were being painted. The Nursing Director also indicated the patient’s daughter was concerned because the patient had been left alone on the unit. The Nursing Director “ensured [assured] her that we were addressing the occurrence as that was not our expectation of the care for any of our patients...” Risk Managers #1 and 2 identified the DL Log was incomplete for Patient #2. Risk Managers #1 and 2 interviewed EMT #1 who was on duty the night of the incident and he verified he didn’t check each room or check the DL Log to ensure all patients had been picked up before he left the unit that night. 7. In an interview conducted during a tour of the DL on 10/30/2023 beginning at 11:05 AM, Nursing Director #1 stated the DL was usually staffed with an EMT and 2 PCAs or PCTs (Patient Care Technicians) and they were expected to assist patients with activities of daily living (ADLs) such as toileting, eating and drinking. They would sign the patients in and out on the log, obtain vital signs upon arrival and before they were discharged as well as check the patients at least every hour. When asked if any patients had ever been left unattended in the DL, Nursing Director #1 stated, “I’m not aware of any incidences of patients being left. There have been some conversations where the unit looked abandoned, but that has not ever been the case...” Nursing Director #1 was asked if she could recall the incident involving Patient #2. The director stated, “I do remember the patient’s name. The House Supervisor got involved with the patient’s daughter who didn’t know her room was in the DL. That unit didn’t notify the daughter where she [Patient #2] was; she [patient’s daughter] went to the unit where she [the patient] was discharged from. Then night shift didn’t know where she [the patient] went because it happened on day shift....” When asked if Patient #2 was left alone on the unit, Nursing Director #1 stated, “The EMT wasn’t on the unit at that time; he was downstairs...To my knowledge, the PCA was still on the unit.” The director then stated the EMT that was involved in the incident was no longer working at the hospital. In an interview on 10/30/2023 at 3:35 PM, RN #1 RN #1 was asked what criteria was used to determine if a patient was appropriate to go the DL. The RN stated the patients “usually have to be alert; walkie-talkie.” RN #1 confirmed she was Patient #2’s nurse the day she was discharged from the hospital and stated, “She’s blind. My Charge Nurse wanted the patient to go to the DL...I told her [charge nurse] I didn’t think she [Patient #2] qualified for it. She [charge nurse] told me to send her [the patient] anyway because they needed the room.” When asked if she [RN #1] called Patient #2’s daughter to inform her [the daughter] the patient was going to the DL, RN #1 stated, “I tried to call her multiple times, but she [the daughter] never answered...I guess I didn’t document it, but I did call.” RN #1 continued and stated, “That night [7/31/2023] they told me the patient stayed there and nobody picked her up until late. I was told by staff the patient was there by herself because everybody [DL staff] had left.” In a telephone interview on 10/31/2023 at 8:42 AM, the House Supervisor stated she received a call from someone on the 5th floor informing her Patient #2’s daughter was trying to find Patient #2. The House Supervisor continued and stated, “I looked in the computer and saw she was discharged at about 1:30 -2:30 earlier in the day. I called to the 4th floor’s nurses’ station and asked where she [Patient #2] was, but they didn’t know because she [the patient] left before they [staff] got there. I called the DL and there was no answer. I called back to the 5th floor and asked them to give me a moment...I physically went to the Lounge [DL], called them [5th floor staff] and told them I have her [the patient].” The House Supervisor stated Patient #2’s daughter “ended up on the unit [DL] with me.” The House Supervisor continued and stated, “When I found her [Patient #2], I did not see any staff. There was nobody in the room with her. I went to the desk and there was no one there and no other patients.” The House Supervisor was asked if she could recall what time she found the patient. The House Supervisor verified she didn’t know exactly when but stated, “I reported to Risk [Risk Management] immediately after.” (The House Supervisor reported the incident via email to Risk Management at 11:18 PM; see #4 above.) When asked what criteria was used to determine if a patient was appropriate to go to the DL, the House Supervisor stated, “Those going have to be able to get in and out of a car, have to be able to stand and pivot. They have to be as close to walkie-talkie as possible.” When asked if Patient #2 met the criteria to go to the DL, the House Supervisor stated, “I would not have sent her there; I would have stopped with she was blind.” In a telephone interview on 10/31/2023 at 9:01 AM, PCA #1, who was scheduled in the DL on 7/31/2023, stated she did not recall Patient #2. The PCA further stated she had only worked in the DL once and was sent to the ER the second time assigned to work in the DL. The PCA stated she did not receive any orientation or training specific to the DL before she was assigned to work there. In a telephone interview on 10/31/2023 at 9:15 AM, RN #2 verified she was the Charge Nurse on duty when Patient #2 was discharged to the DL. When asked what criteria was used to determine if a patient was appropriate to go the DL, RN #2 stated, “Patients that won’t be getting up out of bed.” The RN continued and stated, “We don’t send high fall risk patients.” RN #2 was asked if it was appropriate to send a blind patient who needed assistance to get up to the DL. The RN stated, “They have people in the DL there to assist.” The RN was asked if she had read the DL criteria. RN #2 verified she had read them in the past but was unable to recall them at this time. RN #2 was asked if she could recall sending Patient #2 to the DL. The RN stated, “I don’t remember the name.” RN #2 continued and stated she did recall the incident. The RN stated, “The patient [Patient #2] was blind; we took her to the DL and communicated with staff that the patient is blind and wrote it in the comments...” RN #2 was asked if the patient’s family was notified the patient was taken to the DL. The RN stated, “No, all we did was help provide transport to the DL.” This surveyor read the hospital’s criteria for the DL to RN #2 and asked if Patient #2 met the criteria for the DL. The RN verified Patient #2 should not have been taken to the DL. A total of 25 RNs (RN #3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27), representing every patient care unit that would possibly send patients to the DL, were interviewed regarding the criteria used to determine if a patient was appropriate to send to the DL. Of the 25 nurses interviewed, RN #10 stated only patients that were waiting on an ambulance would be taken to the DL; RN #11 was unaware the hospital had a DL; RN #12 stated the DL was staffed with “nurses;” RN #15 stated a patient was appropriate if they were able to use a call light; and RN #25 stated it was okay to send patients that were at a high risk for falls if they were able to call for help. The remaining 20 nurses interviewed verified patients at high risk for falls and/or blind patients would not meet the criteria to be taken to the DL. In an interview conducted in the DL, on 10/31/2023 at 12:27 PM, EMT #2 stated patients that had been discharged from their room waiting on an ambulance to pick them up as well as “ambulatory” patients that were waiting on family members to pick them up were brought to the DL. The EMT was asked if patients were ever brought to the DL that he didn’t feel were appropriate to be there. EMT #2 stated, “Several times... We have protocols to determine who can come. They [floor staff] call report and let us know their needs... I ask [person calling report] what type of precautions, if they’re incontinent or diabetic because there’s so much I can’t do for the patient on this unit.” The EMT was asked if he ever refused to accept a patient in the DL. EMT #2 stated, “No, but there were several I could have refused...I’m not allowed to give insulin, pain meds [medications], or do accu checks [blood glucose checks]...” The EMT stated all patient’s brought to the DL were documented on the DL Log and vital signs were obtained upon arrival and prior to discharge. The EMT then walked to the computer at the nurses’ station and showed the surveyors where the patient’s vital signs were documented. When asked to show the surveyors the documentation of Patient #2’s vital signs, the EMT pulled up the spread sheet dated 7/31/2023. There was no documentation of Patient #2’s name and/or vital signs on the spread sheet. Nursing Services failed to ensure Patient #2 met the hospital’s criteria before she was taken to the DL to await family to arrive to transport home. Refer to A-0144.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 33763 Based on hospital policy review, medical record and interview, the hospital failed to re-evaluate the discharge plan to ensure post-hospital care needs were secured after Rehabilitative Services determined home health Physical Therapy (PT) and Occupational Therapy (OT) services were recommended for 1 of 3 (Patient #2) discharged patients. The findings included: 1. Review of the hospital’s “Discharge/Transition Planning” policy revised 7/2022 revealed, “...The patient and or family and multidisciplinary team are included in the discharge planning to promote safe, effective, and a timely discharge/transition. Refinement of the initial discharge plan takes place throughout stay...The Case Managers/Social Workers evaluate current and anticipated needs of patients and document into the electronic system...The Case Manager assesses the patient and/or family’s ability to safely continue post-hospital care...The Case Manager/Social Worker provides a list of SNF [skilled nursing facilities] and/or home health agencies when indicated...The Case Manager/Social Worker arranges for the post-hospital care and documents the plan in the patient record...The Case Manager and/or Social Worker update the plan every 72 hours as changes in patient’s condition indicates...The discharge plan and/or patient discharge instructions include post-hospital appointments, equipment, and services arranged...” Review of the hospital’s “Assessment/Reassessment Policy” revised on 4/27/2023 revealed, “Purpose: To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient’s initial and continuing needs...Planning for care, treatment, and services involves using an interdisciplinary approach when warranted and involves the patient and family to the extent possible...” Review of the hospital’s “Documentation Policy” revised 3/2021 revealed, “...The primary purpose of patient care documentation is to communicate patient information to other health care professionals caring for the patient. Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation...” 2. Medical record review revealed Patient #2, an 81-year-old blind female, was admitted to the hospital following a fall on 7/29/2023 with diagnoses which included Syncope versus a Fall; (Syncope is used to describe a sudden loss of consciousness for a short period of time. Syncope may also be called fainting or passing out.) Hypernatremia (elevated blood sodium level), Hypokalemia (low blood potassium level), Diabetes mellitus Type 2, and Hypertension (high blood pressure). Review of the Admission History and Physical completed on 7/29/2023 at 11:48 PM revealed, “...Patient presents with Syncope...pt [patient] got up to unlock the door and fell. Pt is unsure if it was mechanical fall or syncope episode...pt is blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT [Physical Therapy] OT [Occupational Therapy]...” Review of a physician’s order dated 7/29/2023 at 11:56 PM revealed “...Consult to Physical Therapy...Consult to Occupational Therapy...” Review of the Discharge Planning Note dated 7/31/2023 at 8:33 AM revealed, “...Anticipated Discharge Disposition: home with family...Additional Comments: SW [Social Worker] completed patient’s assessment with her granddaughter...via phone...patient lives with her daughter...DME [Durable Medical Equipment]-wheelchair; no history of... HH [Home Health]. Patient’s discharge plan is home with family...” Review of the Hospitalist Discharge Summary dated 7/31/2023 at 9:26 AM revealed, “...Hospital Course: This is an 81-year-old female who got admitted for syncope. Syncope is mostly due to dehydration and hypokalemia. Started on IV [intravenous] fluids and potassium was supplemented. She is back to her baseline now...Evaluated by PT OT. Discussed with case manager to discharge home if family is agreeable...Stable for discharge...” Review of a physician’s order dated 7/31/2023 at 9:26 AM revealed, “...Discharge patient...Discharge disposition: Home...” Review of the Occupational Therapy Evaluation completed with the Physical Therapist on 7/31/2023 from 9:27 AM through 9:44 AM revealed, “...Recommended Discharge Disposition: skilled nursing facility (SNF) vs [versus] home with 24/7 assistance and HHOT/PT [Home Health Occupational Therapy/Physical Therapy]...home with 24/7 assistance and HHOT/PT...” Review of the Physical Therapy Evaluation completed with the Occupational Therapist on 7/31/2023 from 9:28 AM through 9:45 AM revealed, “...Recommending home with 24 hour care vs SNF...Precautions/Limitations: Fall and Blindness...PT Diagnosis: difficulty walking, muscle weakness, impaired balance...Plan for PT: continue PT...3-5 times per week...” Review of the After Visit Summary dated 7/31/2023 printed at 2:07 PM revealed, “Patient to Schedule MD [Medical Doctor] Follow-Up in 1 week...Instructions from your provider Your primary diagnosis was: Fainting Your diagnoses also included: Blindness, Type 2 Diabetes Mellitus With Manifestations, High Blood Pressure, Low Blood Potassium, high Sodium Levels, At High Risk for Falls, Contusion of Elbow, Contusion of Hip...” Review of the Summary Event Log dated 7/31/2023 at 2:15 PM revealed, “...Discharge...Discharge disposition: Home...” There was no documentation the PT and or OT discussed their recommendations for Home Health PT and OT with the physician or the Social Worker that completed the patient’s Discharge Plan. The Hospitalist Discharge Summary was completed and the discharge orders were written after the social worker evaluated the patient and before the OT and PT evaluations were completed. There was no documentation Patient #2’s need for home health OT and PT was discussed with the Hospitalist and social worker; therefore, Patient #2 was discharged home without orders for home health services. 3. In an interview on 11/6/2023 at 3:29 PM, the Director of Rehabilitative Services, after reviewing the PT and OT evaluations for Patient #2, stated “They [PT and OT] are recommending “Home Health OT/PT...” The Director was unsure if the Case Manager or physician was made aware of the recommendations for Home Health services. In an interview on 11/6/2023 at 3:36 PM, Risk Manager #1 verified the discharge order was for “Home only” and did not contain orders for Home Health PT and/or OT. In an interview on 11/6/2023 at 3:44 PM, Risk Manager #1 stated, “I looked in the communication log and there was nothing in there, but they are told to put it in their progress notes” regarding their recommendations for Home Health PT and OT services.”

“ORGANIZATION OF REHABILITATION SERVICES CFR(s): 482.56(a) The organization of the service must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 33763 Based on hospital policy review, medical record review and interview, the hospital’s rehabilitation services failed to complete ordered Physical Therapy (PT) and/or Occupational Therapy (OT) evaluations per hospital policy for 2 of 4 (Patient #2 and #4) sampled patients. The findings included: 1. Review of the hospital’s “Initiation of Therapy Services” policy revised 2/2023 revealed, “...The Rehabilitative Services Department is notified of new patient admissions...A physician’s order for therapy services is obtained...PT/OT: Therapy services are initiated within the next working shift following the shift in which the order is received...” 2. Medical record review revealed Patient #2 presented to the hospital’s Emergency Department (ED) on 7/29/2023 with complaints of syncope resulting in a fall. (Syncope is used to describe a sudden loss of consciousness for a short period of time. It can happen when there is a sudden change in the blood flow to the brain. Syncope may also be called fainting or passing out.) The patient reported pain in the left hip and left shoulder. Review of the ED Provider Note dated 7/29/2023 revealed Patient #2 was “...81 y.o. [year old] Female with PMHx [past medical history] of DM [Diabetes Mellitus], HTN [Hypertension (high blood pressure)] and HLD [Hyperlipidemia, an imbalance of good and bad cholesterol] who presents to the ED complaining of syncope onset today...pt [patient] is blind...Full workup was performed...pt was found to be hypokalemic [low potassium level] and potassium was repleted. Patient was having difficulty ambulating [walking] prior to appropriate time for discharge so she will be brought in for observation to ensure hypokalemia resolves and that she has a safe disposition after appropriate physical therapy...” Review of the Admission History and Physical completed on 7/29/2023 at 11:48 AM revealed, “...Patient presents with Syncope...pt got up to unlock the door and fell. Pt is usure if it was mechanical fall or syncope episode...pain in her L hip and L shoulder...Of note, pt is blind...Assessment and Plan: Syncope vs Fall...Fall precautions, PT, OT...” A physician’s order dated 7/29/2023 at 11:56 PM revealed, “...Consult to Physical Therapy - Eval...consult to Occupational Therapy - Eval...” Review of the Hospitalist Daily Note dated 7/30/2023 at 12:09 PM revealed, Patient #2 “...Orders I’ve place in the past 24 hours...PT Eval and Treat...Disposition: TBD [to be determined] based on clinical course. Not medically stable for dc [discharge]...Discharge barriers: PT, hypokalemia...” Review of the PT and OT evaluations revealed the evaluations were not completed until 7/31/2023 beginning at 9:27 AM, during the 2nd working shift after the order was written. 3. Medical record review Patient #4 was admitted to the hospital on 9/26/2023 with diagnoses which included Acute Metabolic Encephalopathy with Superimposed dementia, Acute Urinary Tract Infection (UTI), and Hypertension. Review of the Admission History and Physical completed on 9/27/2023 revealed, “...The patient has dementia hypertension. Recently he sustained a change in mental status and was not really eating. Came to the emergency room. He was diagnosed with UTI sent home with oral antibiotics however is not taking the antibiotics and appetite has remained low therefore daughter brought him here...Assessment and plan...Orders I’ve authorized in the past 24 hours...Consult to Occupational Therapy...” Review of the physician’s orders dated 9/27/2023 at 5:24 AM revealed, “...Consult to Occupational Therapy-Eval...” Review of the OT evaluation revealed it was not completed until 9/29/2023 beginning at 10:02 AM, during the 3rd working shift after the order was written. 4. In a telephone interview on 11/7/2023 at 11:41 AM, Risk Manager #1 verified the PT and OT evaluations should have completed within 24 hours after the order was written. The Risk Manager further stated she was informed staffing had been a contributing factor to the delays.”