Methodist Hospitals of Memphis

“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 hired 1 of 1 imposter nurses (Imposter Nurse A) as a professional Registered Nurse (RN) to provide professional nursing care to its patients in the Hospital’s satellite Hospital A and practiced as a Case Manager in the Hospital’s satellite Hospital B. The findings include: 1. Review of the Hospital System’s policy, “Associate Background Checks effective 01/06/2023 revealed, The Hospital conducts background checks on final candidates following a conditional offer of employment. These checks may include references, licensure checks, criminal history, and social security number validation. 2. Review of Hospital A’s event report and investigation revealed an event occurred on 12/30/2024 and confirmed the error occurred when Imposter Nurse A administered a drug incorrectly. Hospital A confirmed the severity level was “Actual Event/Harm” to Patient #1. 3. Review of personnel files for the Imposter Nurse revealed the Imposter Nurse worked in the Hospital’s satellite Hospital A from 09/16/2024 to 01/04/2025 as a RN and worked in the Hospital’s satellite Hospital B from 03/24/2025 to 08/29/2025 as a Case Manager and was terminated from the hospital on 09/05/2025. Further review of Imposter Nurse A’s personnel file revealed the Imposter Nurse had used two (2) different Social Security Numbers (SSN), two (2) different names and two (2) different dates of birth on her employment Onboarding documents. 4. During an interview on 9/09/2026 beginning at 11:20 AM, the Human Resource Director (HRD) verified the discrepancies in Imposter Nurse A’s personnel file.”

“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: 32777 Based on policy review, personnel file review, document review and interviews, the hospital failed to ensure Nursing Services provided care in a safe environment for 2 of 2 (Patient #1 and #2) sampled patients when the Hospital employed an Imposter Nurse (Imposter Nurse A) who administered an intravenous (IV) medication incorrectly which resulted in actual harm; and when Patient #2 received IV medication via the wrong route by Imposter Nurse A. The findings include: 1. Review of Imposter Nurse A’s personnel file revealed the Imposter Nurse had used two (2) different Social Security Numbers (SSN), two (2) different names and two (2) different dates of birth on her employment Onboarding documents. The Imposter Nurse used a valid Registered Nurse (RN) license belonging to real Nurse B. 2. Review of the facility’s policy, “Safety Reporting” effective 05/30/2025 revealed, “ ...Purpose ...To establish the process by which adverse drug events will be reported and reviewed to enhance patient safety at [Named Hospital System] Outpatient Pharmacies ...Definitions ...Near Miss: A near miss is an unintentional incident that could have caused damage, injury or death but was narrowly avoided ...Policy ...Near misses will be tracked separately from medication errors using the same Patient Safety Event Reporting system. Near-miss events are classified distinctly from medication errors during entry and review ...” 3. Review of Hospital A’s event reports and investigations confirmed two (2) separate events did occur to Patient #1 and Patient #2, with actual harm to Patient #1. 4. During an interview on 09/10/2025 beginning at 9:30 AM, the Vice President of Quality confirmed the medication errors occurred and were immediately investigated and Imposter Nurse A was re-educated after each incident. Refer to A-0405”

“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 personnel who required a license to practice nursing had valid license in compliance with the State’s licensure laws when the Hospital employed 1 of 1 imposter nurses (Imposter Nurse A) reviewed who was employed to practice nursing and provide nursing care to its patients by using a real nurse (Nurse B) valid license. The findings include: 1. Review of the Hospital System’s policy, “Associate Background Checks effective 01/06/2023 revealed, “ ... [Named Hospital System] conducts background checks on final candidates typically following a conditional offer of employment. These checks may include but are not limited to references, educational records, licensure checks, criminal history, social security number validation ...” Review of the Hospital System’s PowerPoint presentation titled, “Job Requisition Roles and Responsibilities” the document revealed the Primary Recruiter posted the jobs. Once the job is posted, external candidates can apply to posted requisitions through the organization’s external career site. The Primary Recruiter reviews the candidate’s background, contact information, resume, experience and eligibility and determines the next steps for the candidate. After reviewing the candidate’s details, the Primary Recruiter makes the decision whether to move the profile forward. If the candidate meets the required review criteria they are moved to the next stage. For RN Recruiters, the Recruiter will complete a screening. Once the candidate is vetted and screened, the Recruiter will decide to move forward or not. At that time, the Recruiter can elect to schedule an interview if the (hiring) manager prefers this or continue to the “Manager Screen”. The Manager and Primary Recruiter could schedule the interview. After a successful interview with a candidate, the Recruiter will move the candidate forward to an offer. As an additional step, the (Named Healthcare System) has a job application process for some set of roles and is routed to the “Assessment” stage. There are three types of assessments available depending on the role. (Named Healthcare System) had integration with an external third-party to conduct the assessment process. The results of the assessment are reviewed before moving the candidate forward. Once the candidate is moved forward, the candidate is ready for hire. The Primary Recruiter must initiate the offer. It is suggested that all negotiations happen prior to submitting the offer. The offer is then sent to the Manager for approval. Once approved, an offer letter is generated and sent to the candidate. Once the candidate accepts the offer, the Primary Recruiter will move to the background check. The background check request is directed to the Recruitment Specialist (Onboarding Specialist). The Onboarding Specialist with complete the hiring process when the candidate has cleared all onboarding requirements. The Onboarding Specialist role is responsible for choosing the type of background Check status and making the final decision. The background check is conducted by a third-party vendor. The vendor completes the background check, and the Onboarding Specialist reviews the background check results. If there is a background issue, the Onboarding Specialist will inform the Recruiter. The candidate will be marked “clear” on the Onboarding spreadsheet, and the Recruiter will then send the orientation information. 2. Review of a copy of a Social Security Card with a Social Security Number on it which was in Imposter Nurse A’s personnel file revealed an issue date of 06/15/2023 with Imposter Nurse A’s first name listed then Nurse B’s last name listed then Imposter Nurse A’s last name listed. The Social Security Card was signed with all three names. (Imposter Nurse A’s first name then Nurse B’s last name and then with 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 with the Social Security Number that was on Imposter Nurse A’s Social Security Card. Review of the background screening report dated 07/19/2024 revealed Imposter Nurse A used a different Social Security Number than what was on Imposter Nurse A’s Social Security Card. Review of the Offer Letter to Imposter Nurse A dated 08/29/2024 revealed, “...Your position will be Registered Nurse...Your regular work location will be [Named satellite Hospital A] ...This is a PRN [as needed] position and a 13 week assignment...Your employment will be contingent upon the successful completion of our pre-employment process...” The form was signed by a member of the Hospital System’s Recruitment Team. Review of the Background Report dated 09/02/2025 revealed Imposter Nurse A’s Social Security Number did not match the Social Security Number listed on the I-9 Verification Form. Imposter Nurse A’s birth date did not match the date listed on her birth certificate submitted with the I-9 form. Imposter Nurse A’s full name on the background report included Nurse B’s last name along with Imposter Nurse A’s first and last name. Because the background check was run on Nurse B’s information, all areas of the background were complete and cleared. The background check further revealed a Bachelor of Science Degree was obtained on 11/30/2021. 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 09/17/2024 revealed Imposter Nurse A’s legal first and last name, along with a birth certificate and a valid Driver’s license, from another state. The last name used on the I-9 form was the same as the Driver’s license. The Social Security number on the I-9 was different from the Social Security Number on Imposter A’s Social Security Card. Review of a second Offer Letter to Imposter Nurse A dated 02/26/2025 revealed, “...Your position will be Case Manager 1...Your regular work location will be [Named satellite Hospital B] ...This is a Day shift, Regular, Salary, Full time position...” The form was signed by a member of the Hospital System’s Recruitment Team. 3. During an interview on 9/09/2025 beginning at 11:20 AM, the Human Resource Director (HRD) verified Imposter Nurse A changed the online background check demographic fields. The HRD stated, “ ...we thought they were hard fields ...not aware this could be done ...” This was how the background check cleared. Imposter Nurse A changed the fields to match Nurse B’s information. During the investigation, Hospital A’s staff and the Hospital System’s leadership team verified the discrepancies found in Imposter Nurse A’s personnel file. There was no information given to this surveyor as to the specifics of what was reviewed on the background check or if there was any communication between the Onboarding Specialist and the Recruiter regarding cross referencing of inconsistencies with social security numbers, or different names listed on the background check, employment application, I-9 form and/or the resume that was submitted by the candidate. There was no evidence that the Hospital questioned the difference in names, birth dates, or Social Security Numbers on the pre-employment forms submitted by Imposter Nurse A.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 32777 Based on policy review, personnel file review, document review and interviews, the hospital failed to ensure medications were administered per physician orders for 2 of 2 (Patients #1 and #2) sample patients when the hospital employed 1 of 1 imposter nurses (Imposter Nurse A) who administered a high alert intravenous (IV) medication too fast to Patient #1 which resulted in actual harm. Patient #2 received IV medication via the wrong route by Imposter Nurse A. 1. Review of the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications in Acute Care Settings revealed, “ ...High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error ...the consequences of an error are clearly more devastating to patients ...Specific Medications ...potassium chloride ...potassium phosphates ...” Review of a StatPearls article titled “Potassium” by Moushumi Sur; Shamim S. Mohiuddin updated October 5, 2024 and published January, 2026. Available from https://www.ncbi.nlm.nih.gov/books/NBK53979 revealed, “ ...Adverse Effects ...Extravasation, local irritation, and phlebitis may occur due to improper dilution of intravenous preparations or administration through a peripheral vein ... Precautions IV infusion: Potassium should be infused slowly (? [greater than or equal to] 20 mEq/hour) [milliequivalents per hour] ...” Review of the facility’s policy, “Safety Reporting” effective 05/30/2025 revealed, “...Purpose ...To establish the process by which adverse drug events will be reported and reviewed to enhance patient safety at [Named Hospital System] Outpatient Pharmacies ...Definitions ...Near Miss: A near miss is an unintentional incident that could have caused damage, injury or death but was narrowly avoided ...Policy ...Near misses will be tracked separately from medication errors using the same Patient Safety Event Reporting system. Near-miss events are classified distinctly from medication errors during entry and review...” Review of the facility’s policy, “Medication Administration” effective 03/2025 revealed, “PURPOSE To ensure medications are administered by authorized individuals in a safe and timely manner to meet the needs of the patient...POLICY Medications are administered by authorized licensed independent practitioners and clinical staff that are authorized to do so by State and Federal law and hospital policy...Personnel Authorized to Administer Medication Registered nurses may administer parenteral, oral, rectal, and topical medications, and medications by other administration routes within their scope of practice, including blood and blood products, if not specifically excluded elsewhere by medical staff by-laws or rules and regulations...Medication Administration Procedure...Right Route: Verifies that the medication is administered by the correct route and that the route is appropriate for the medication and patient...Right Time: Verifies that the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration...” 2. Review of satellite Hospital A’s event report and investigation revealed an event occurred on 11/16/2024 and confirmed the error occurred when Imposter Nurse A was going to administer an oral liquid medication through a patient’s IV line, however Imposter Nurse A had realized the error and did not administer the oral liquid medication via the IV. The event report documented the severity level as a “Good Catch”. Review of satellite Hospital A’s event report and investigation revealed an event occurred on 12/30/2024 and confirmed the error occurred when Imposter Nurse A administered IV Potassium too fast and caused burning at the patient’s IV site. Satellite Hospital A confirmed the severity level was “Actual Event/Harm” to Patient #1. 3. During an interview on 09/10/2025 beginning at 9:30 AM, the Vice President (VP) of Quality confirmed the near miss medication error and the medication error had occurred. The VP of Quality stated the events were immediately investigated and Imposter Nurse A had been re-educated after each incident. The Hospital did not provide evidence that Imposter Nurse A was disciplined for the errors.”

“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: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of treatment were explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 20 (Patient #16) sampled patients. The findings included: Patient #16 presented to the ED on 3/22/2025 at 3:40 AM, with complaints of back pain. The Medical Screening Examination (MSE) was initiated at 3:43 AM by a Nurse Practitioner (NP). Triage was initiated by an Registered Nurse (RN) at 3:45 AM. The NP who conducted the MSE ordered a Computed Tomography (CT scan - uses x-rays to create cross-sectional images of the inside of the body) of the lumbar spine at 3:46 AM with the results available at 5:45 AM. At 6:55 AM, the nurse documented, “Pt [patient] escorted to the hallway [ED Hallway bed] but refused to be in the hallway and would rather go home. I explained that since he wanted to be seen by a doctor, I need to put him there as there are no available rooms. Patient refused still and left without signing the AMA form.” There was no documentation Patient #16 was informed of the risks and benefits by a medial provider or a completed AMA form in the medical record. Cross Refer to 2407.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of treatment were explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 20 (Patient #16) sampled patients. The findings included: 1. Review of the policy “Screening Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services- EMTALA [Emergency Medical Treatment and Labor Act] revised 8/29/2024, revealed, “...Policy: It is the policy of each [named hospital] to comply with the...EMTALA... Patients Leaving Hospital against Medical Advice [AMA], Left Without Being Seen [LWBS], or Without Informed Refusal (Elopement) If an individual attempts to leave the Hospital AMA, LWBS, or elopes, personnel should reasonably attempt to obtain the individual’s signature on the appropriate form and should attempt to inform the individual of the risk of not waiting to be examined by a provider. Hospital personnel should appropriately document in the medial record or on the Patient Refusal of Medical Treatment And/Or Leaving Hospital Against Medical Advice that the patient was advised of the risks but left AMA/LWBS or had eloped without informed refusal of treatment...” 2. Medical record review for Patient #16 revealed an elderly male who presented to the ED on 3/22/2025 at 3:40 AM, with complaints of chronic back pain that was worse on the day of the ED visit. The Medical Screening Examination (MSE) was initiated at 3:43 AM by Nurse Practitioner (NP #1). Triage was initiated by a RN at 3:45 AM with the following vital signs: BP- 120/86, Temperature- 97.5, Heart Rate- 77, Respirations- 18, Oxygen- 94%. Patient #16 was assigned an ESI acuity level 4. The NP who conducted the MSE and ordered a Computed Tomography scan (CT- a painless medical imaging test that uses x-rays to create cross-sectional images of the inside of the body) of the lumbar spine at 3:46 AM. The CT of the lumbar spine result were documented at 5:45 AM with no acute osseous abnormalities (no recent or serious issues detected in the bones) Chronic anterior vertebral body height loss (the progressive thinning and collapse of the front part of the spine’s vertebrae, often caused by repeated or severe osteoporosis-related compression fractures or trauma) and relatively stable grade 1 anterolisthesis (a condition where one vertebra (bone in the spine) slips forward over the vertebra below it) at Lumbar 5 (the lumbar region of the back is the lower back, made up of five vertebrae that are the largest in the body) - Sacrum 1 (the sacrum is a large, triangular shield-shaped bone at the base of the spine, formed by the fusion of five vertebrae; connects to the lumbar spine (S1) secondary to bilateral degenerative facet (a condition affecting both sides of the spine where the cartilage in the facet joints wears away, causing pain, stiffness and potential bone spurs). At 6:55 AM, RN #2 documented, “Pt [patient] escorted to the hallway [ED Hallway bed] but refused to be in the hallway and would rather go home. I explained that since he wanted to be seen by a doctor, I need to put him there as there are no available rooms. Patient refused still and left without signing the AMA form.” There was no documentation the nurse notified the Nurse Practitioner or a physician so they could discuss the risks of leaving the ED without a full medical examination to determine if his chief complaint at the time he presented to the ED was an emergency medical condition. There was no documented AMA form in the medical record with the patient refusal to sign. During an interview on 8/19/2025 at 3:00 PM, the ED Nursing Manager verified there should be an AMA form in the medical record, even if the patient refused to sign. He stated the expectation was for staff to complete the AMA form, attempt to get the patient to sign the form and if the patient refused, the staff would document the refusal on the form. The ED Nursing Manager stated any staff member that learns a patient is attempting to leave should notify the provider (NP/Physician) so the provider can fully explain the risks of leaving the ED.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to follow physician orders for 1 of 3 (Patient #1) sampled patients reviewed. The findings included: 1. Review of the facility’s “Medical Order Policy-Hospitals” (revised 2/7/25) revealed, “ ...the RN/LPN [Registered Nurse/Licensed Practical Nurse] is primarily responsible for receipt and recording of physician orders and any necessary transferring onto proper forms, requisitions and computer entries ...” 2. Medical record review revealed Patient #1 was admitted to Hospital #1 on 7/11/25 with diagnosis of acute left leg deep venous thromboembolism (blood clot). Review of a 7/12/2025 physician’s order revealed “Continuous Pulse Oximetry” (test used to measure the oxygen level of the blood). Record review for Patient #1 from 7/12/2025 through discharge on 7/15/2025 revealed no documentation continuous pulse oximetry was initiated as ordered. In an interview on 8/7/2025 at 10:15 AM, the Senior Director of Quality verified there was no documentation that continuous pulse oximetry was initiated for Patient #1 as ordered. The Director stated they determined the nursing staff didn’t realize they had to call the Respiratory Therapy department to inform them of the order. In an interview on 8/7/2025 at 10:20 AM, Respiratory Therapist (RT) #1 verified they are notified by nursing staff of an order for continuous pulse oximetry. RT #1 stated there should be a note in the medical record from the RT that delivered the continuous pulse oximetry machine to the patient. No note from RT was found in Patient #1’s medical record to indicate continuous pulse oximetry was delivered and initiated.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 33763 Based on document review, policy review, medical record review, and interview, the hospital failed to ensure Medical Staff Bylaws, Rules and Regulations and hospital policies regarding on-call physicians were followed by 1 of 1 (Hospitalists Group #1) hospitalists groups of physicians providing coverage for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of the hospital document titled, “Medical Staff Bylaws, Policies, and Rules and Regulations” revised 12/14/2022 revealed, “...Substantial Compliance While every effort will be made to comply with all provisions of these Bylaws, substantial compliance is required...” Review of the hospital document titled, “Unified General Rules & Regulations” revealed, “...On Call Coverage A credentialed physician can provide on-call coverage (including hospital rounds) for a credentialed sub-specialist as long as the credentialed physician does not exceed his/her level of approved privileges. During the period in which the credentialed physician provides on-call coverage the credentialed sub-specialist must be available (immediately by phone and within 30 minutes to the applicable... location) to ensure appropriate subspecialty coverage if needed... Physician Response to Phone Calls/Pages Physicians are expected to return appropriately placed phone calls and pages from hospital personnel within 30 minutes of the time the call/page is made. Physicians in provider-based clinics shall address inquiries from patients seeking clinical advice within the guidelines established by the practice...” Review of the hospital document titled, “Medical Staff/Allied Professional Code” signed by Physician #1 on 10/30/2024 and Physician #2 on 5/8/2024 revealed, “...The goal of the Medical Staff is to provide the highest quality of care to our patients... In an effort to accomplish this, the medical staff has articulated the generally accepted criteria, which govern the practice of medicine at our facility. Each member of the medical staff is expected to adhere to these principles as a member of a community of health care professionals engaged in the delivery of high quality medical care. These criteria are...Abide by the Bylaws, Rules, and Regulations and other policies and procedures, including the Standards of Conduct and all-applicable accreditation and regulatory requirements... Communicate timely and effectively with other members of the health care team including nurses, therapists, other physicians, and anyone involved in the safety and welfare of patients. This includes...Responding promptly to pages...” 2. Review of the hospital policy titled, “Chain of Command and Physician Notification Policy” revised 9/23/2024 revealed, “...Patient care requires communication between the team members responsible for providing that care. A provider should be accessible for communication with other team members regarding any aspects of patient care including, but not limited to: discussing change in status, patient/family requests, medication clarification, receive reports of lab/diagnostic values, or coordinate care plan with other team members including physicians, or concerns with the current plan of care. The provider should respond, after notification, as soon as possible, but not to exceed 30 minutes...” Review of the hospital policy titled, “Pain Assessment Policy” revised 12/16/2024 revealed, “...All patients will be assessed for pain based upon their clinical presentation, services sought, and in accordance with the care, treatment, and services provided. When pain is identified, the patient is treated or referred for treatment... The identification of pain is an important part of the plan of care because unrelieved pain has adverse physical and psychological effects... Pain scales used... Numeric Rating Scale...0 (no pain) to 10 (worst pain)...” 3. Medical record review for Patient #1 revealed a 46 year old female admitted under the care of Physician #1 on 12/15/2024 with diagnoses which included Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest), Metastatic Breast Cancer (the most advanced stage of breast cancer; occurs when cancer cells spread from the breast and nearby lymph nodes to other parts of the body, such as the brain, bones, liver, or lungs), Asthma and Acute Respiratory Failure with Hypoxia (a condition where the body is unable to adequately oxygenate the blood due to a sudden decline in lung function, resulting in low oxygen levels in the bloodstream and requiring immediate medical attention). Review of the History and Physical completed by Physician #1 on 12/15/2024 at 11:36 PM revealed, “...Plan: Admit to stepdown ER [emergency room]; called interventional radiology who would like patient to be admitted and they will evaluate in a.m. [morning] for therapeutic thoracentesis of the left side...” (Thoracentesis is a medical procedure that involves removing fluid or air from the pleural space, the space between the two layers of tissue that cover the lungs and line the chest wall.) “...Pain medication to be ordered for patient as patient is significantly uncomfortable...Restart selected home medications as medically prudent...” Patient #1’s home medications used to treat pain were continued which included Flexeril 10 milligrams (mg) by mouth twice a day, Fentanyl Patch 25 micrograms per hour (mcg/hr) topically every 72 hours, and Percocet 10mg-325mg four times a day by mouth as needed for pain. (Flexeril is a muscle relaxant used to treat pain and stiffness caused by muscle spasms. A Fentanyl patch is an opioid medication applied to the skin for long-lasting pain relief. Percocet contains a combination of acetaminophen (Tylenol) and oxycodone which is an opioid medication use to treat pain.) The report indicated Patient #1’s most recent dose of Flexeril had been taken on 12/14/2024; and the fentanyl patch in place upon arrival had been placed on 12/15/2024 at 5:00 PM. There was no documentation noted indicating the date and time of the last Percocet dose. Review of the nursing documentation and medication administration records (MARs) for Patient #1 dated 12/16/2024 revealed the Patient complained of pain in the right side at a level of 7 on a scale of 0 - 10, with 10 being the worst, at 12:54 PM. Patient #1 was given 1 Percocet tablet to address the pain and was then transported to Interventional Radiology to undergo thoracentesis. Review of the US (ultrasound) Guided Thoracentesis W (with) Image Guidance report dated 12/16/2024 at 3:28 PM revealed, “...Successful ultrasound-guided thoracentesis on the left with 1.2 liters of fluid removed...” Review of the nursing documentation and MARs revealed Patient #1 complained of severe pain on the right side at a level of 10 on 12/16/2024 at 4:51 PM and was administered 0.5 mg of Dilaudid intravenously (IV) per physician’s orders. (Dilaudid is an opioid medication used to treat moderate to severe pain.) Continued review of the nursing documentation and MARs revealed Patient #1 rated her pain level as 10 on 12/16/2024 at 6:42 PM. Physician #4 was notified, and orders were received to increase the Dilaudid to 1 mg IV which was administered. A nursing note written by RN #2 on 12/16/2024 at 7:39 PM revealed, “...Patient was in pain today, so I gave her oxycodone [Percocet]...After the patient got back [from thoracentesis procedure] I started doing routine vitals [vital signs]. Patient started complaining of pain, so I gave her 0.5mg of dilaudid and some heat packs. An houe [hour] later the patient and patient’s family got irate and started yelling because she was in so much pain. I tried to call [Physician #1] and he did not answer so I also texted him. In the mean time [RN #1] was calling [Physician #2] pager line to get in touch with someone. [Physician #4] called back and gave me oral orders to discontinue the 0.5mg, add 1 mg Q [every] 4 hr [hours] for pain...[RN #1] gave the patient the 1mg of Dilaudid this evening...” Review of the nursing documentation and MARs dated 12/16/2024 revealed the following: At 8:10 PM Patient #1 complained of pain at a level of 10 and was given Percocet 10 mg per physician’s orders. At 8:42 PM, RN #1 documented she attempted to reach Physician #1 because Patient #1 was complaining of “excruciating pain” on the right side. The RN further documented she was “waiting on response” from Physician #1. At 9:29 PM, RN #1 documented she paged Physician #1 again and was “waiting on response.” Review of a Care Plan Addendum written by RN #4 on 12/16/2024 at 10:15 PM revealed, “...Patient stated she is in agonizing pain. Pain is located on the patient’s right side that radiates to the patient’s back. She described the pain as cramping, squeezing and stabbing. She also stated that she has SOB [shortness of breath] along with the pain. O2 Sat [oxygen saturation] was 90% [percent]. Patient was put back on BNC at 2L [by nasal cannula at 2 liters (Oxygen)]. She stated that the oxygen relieved her SOB. HR is 113 Sinus Tach [tachycardia, or rapid heartbeat]. She refused a BP [blood pressure] check. Patient received 1mg of Dilaudid and 10mg of Roxicodone [Percocet] for the pain. She states that the Dilaudid made the pain worse, but the Roxicodone slightly relived [relieved] the pain. House Supervisor also spoke with patient and family per family request. The on-call for the provider has been paged twice. No response received at this time. Patient is currently sleeping...” Review of a Significant Event note written by RN #3 on 12/16/2024 at 10:40 PM revealed, “...Called by house supervisor - Patient is having extreme pain on the right flank. Pt [patient] had thoracentesis today on the Left. Significant history includes BC [breast cancer] with mets [metastasis]. Patient has diminished breath sounds throughout left side, right side is clear. Chest x-ray ordered...[Pulmonary Group] NP [nurse practitioner] consulted for pain management. 1x [1 time] dose of Toradol ordered. Given to patient. Pt is resting on departure of MRT [medical response team]. Bedside RN updated...” There was no documentation in Patient #1’s medical record to indicate Physician #1 or Physician #2 ever responded to the phone calls and/or pages placed by the nursing staff. 4. During an interview on 1/7/2025, the Clinical Director for 3 West (CD3W) stated she recalled making rounds on Patient #1 and was informed by the Patient and her family Physician #1 and #2 didn’t respond quick enough to address the Patient’s pain on 12/16/2024. The CD3W continued and stated when she investigated the incident, she discovered nursing staff reached out to a different group of physicians (the Pulmonology Group) and obtained medication orders to address the Patient’s pain after they were unable to reach the physicians from Hospitalists Group #1. During an interview on 1/7/2025 at 11:51 AM, the Director of Quality (DQ) stated Physician #1 and Physician #2 worked for Hospitalists Group #1 and their on-call procedure was for hospital staff to call their office number call center. The call center would take the message and then notify the appropriate physician. During an interview on 1/7/2025 at 12:20 PM, the Chief Medical Officer (CMO) stated on-call physicians were expected to return calls within “30 minutes” for life-threatening conditions and “in a timely manner” for all other calls. During an interview on 1/8/2025 at 8:15 AM, the House Supervisor (HS) verified he responded to a call from Patient #1’s family on the night of 12/16/2024. The HS continued and stated Patient #1’s family member stated Patient #1 was in pain and staff hadn’t been able to reach Physician #1 via phone or page. The HS stated he went to Patient #1’s room and “she looked like she was in pain.” The HS continued and stated Patient #1’s nurse, RN #2 informed him she had called and/or paged Physician #1 three times attempting to get something else ordered to address the Patient’s pain without success. The HS stated he called the Medical Response Team (MRT) for assistance who came and assessed the Patient, ordered a chest x-ray, and reached out to another physician’s group (Pulmonology Group) and got something ordered to address the Patient’s pain. During an interview on 1/8/2025 at 1:30 PM the DQ stated Hospitalists Group #1 did not provide an official on-call list to the hospital. Hospital staff merely called the office and they in-turn routed the calls to the appropriate physician. During an interview on 1/8/2025 at 2:30 PM, Physician #2 stated his group of physicians were available 24 hours a day, 7 days a week. When asked how staff could reach those physicians, Physician #2 stated staff should call the answering service and “a lot of the nurses have our personal cell phone numbers, but the default is to call our answering service.” Physician #2 stated he was unaware staff were unable to reach Physician #1 regarding Patient #1’s pain, “I don’t think I got involved until around Christmas.” During a telephone interview on 1/8/2024 at 4:57 PM, RN #4 confirmed she was Patient #1’s primary nurse during the evening/night shift on 12/16/2024. RN #4 stated Patient #1 was very anxious and complained of pain in her right side. RN #4 continued and stated Patient #1 had been given Dilaudid during the previous shift, but Patient #1 informed her it didn’t help as much as the oxycodone did. RN #4 stated she attempted to reach Physician #1 by calling his office/answering service, but he did not respond. RN #4 stated she tried to call him again about 20 minutes after the first call, but he never responded. RN #4 stated she called the HS and informed him of the situation and the HS called the MRT who came and evaluated the Patient. The MRT was able to reach one of the nurse practitioners with the Pulmonology Group present in the hospital and got orders for a chest-ray and Toradol. RN #4 stated Patient #1 calmed down and “went to sleep” after receiving the Toradol. During a telephone interview on 1/8/2025 at 9:55 PM, RN #3 stated she was the nurse on the MRT who responded to Patient #1 on 12/16/2024. The RN stated she had already gotten orders for a chest ray before she assessed Patient #1 who reported pain at a level of 10. The RN continued and stated Patient #1 had a Fentanyl patch in place and informed her the oral pain medication hadn’t worked. RN #3 continued and stated Patient #1 refused to take any more Dilaudid. RN #3 stated she called the Pulmonology Group’s nurse practitioner, who was present in the hospital and got orders to give the Patient a Toradol injection. The RN continued and stated she helped reposition Patient #1, administered the Toradol, and assisted the Patient with deep breathing and relaxation exercises. RN #3 stated she went back to check on Patient #1 about 1 and a half hours later, and the Patient was asleep. When asked if she was aware of any issues with Physicians #1 and #2’s response times, the RN stated she didn’t “believe so”, but it was sometimes more difficult to reach them [Hospitalists Group #1] because they weren’t on-site. RN #3 stated staff call the exchange service and “sometimes they call quickly, but sometimes, the nurse practitioner is on call and she’s not real good at responding.” Hospitalists Group #1 failed to respond to calls from the nursing staff in a timely manner to address Patient #1’s pain.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 33487 Based on policy review, observation, and interview, the daily managment of the Dietary Service failed to ensure policies and procedures were not implemented when hair restraints were not effectively used for 4 of 7 (Director of Food Service, Cook, Sous Chef, and Dipper) dietary staff and 6 of 11 handwashing sinks were not not clean. The findings revealed: Review of the hospital’s “Sanitation and Infection Prevention/Control ...Hand Hygiene,” policy dated 1/24 (2024) revealed “...All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times...Before putting on gloves...After removing gloves...Use only sinks designated for hand washing...” Review of the hospital’s “Orientation and Education ...Uniform Dress Code,” policy dated 1/24 (2024) revealed “...Associates working with food wear the approved hair restraint when on duty regardless of length or presence of hair ...” Review of the hospital’s “Associate Handbook,” revealed “...For Associates working in food service accounts...Hair nets or hats should be worn as appropriate...HANDWASHING...The most important personal hygiene rule is proper hand washing...Wash hands before and/or after...Changing gloves...” Observations on 11/6/2024 beginning at 9:05 AM, in the Kitchen/Cafeteria revealed: a. Director of Food Service - walked through the kitchen with a hair net only covering the top of her head. Her hair was not completely restrained. b. Cook - preparing vegetables for out front (cafeteria) was wearing a hairnet but her hair was not completely restrained. c. Sous Chef - wearing a baseball cap. His hair was not completely restrained. d. Dipper - her hair was not completely restrained. e. Hand washing sinks in the Dish room, Pot room, Back room, and Production area - unidentified build up on the sides of the sink. f. Cafeteria Hotline hand washing sink - unidentified build up on the sides of the sink. g. Retail Manager for Dietary- observed donning new gloves 3 times while setting up the line. She failed to wash her hands between glove changes. h. Deli - Utility sink - dirty serving utensils were in the sink. There was unidentified substances which appeared to be food on the top, bottom, and sides of the sink. During an interview on 11/6/2024 beginning at 9:10 AM, the Director of Dietary Services stated “...the hand washing sinks are cleaned multiple times a day...the hand washing sinks could be scrubbed better...staff should wash their hands between glove changes...All food should be prepped in the back and brought out...and dirty pans and utensils should be removed from their stations and taken to the back...The cafeteria is opened at 6:30 AM ad closes at 8:00 PM. All of the stations are closed at 2:00 PM, except for the Grill...” During an interview on 11/6/2024 at 9:42 AM, the Sous Chef stated “...I oversee the daily operations of the kitchen and make sure things are getting done from the production side and I do oversee the cleaning...No one has said anything to me about my hair. It depends on the strictness of the day...” During an interview on 11/6/2024 at 10:10 AM, the Director of Quality stated “...they’ve only been open for 3 hours and that doesn’t look like 3 hours of stuff [build up in the hand washing sinks]...” During an interview on 11/6/2024 at 10:20 AM, the Chef stated “...I have the cooks choose the largest pieces of chicken to temp and even have them cut them in half if they are really big...No one has ever brought to my attention, food was served raw...” During a telephone interview on 11/6/2024 at 11:32 AM, the Complainant stated “...This isn’t the first time...I got a fried chicken dinner in the cafeteria 10/9/2024 and got back to my floor to eat my lunch and my chicken wasn’t cooked...I took it back down and the girl [named cafeteria staff] said “you too?” They offered me another fried chicken plate but at that time, I asked to speak to a manager and spoke to [named shift leader]. She said she couldn’t give me a refund but gave me her business card for a free meal and I used it to get breakfast one morning...This isn’t the first time that I have gotten food that wasn’t fully cooked...” During a telephone interview on 11/6/2024 at 1:57 PM, the Shift Lead stated “...Thighs are supposed to cook longer...It could have been a bad thermometer...The employee brought it back around the first of the shift I believe...I wouldn’t have eaten it...There was red around the bone...””

“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: 33763 Based on policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 6 of 11 (Patient #1, 2, 3, 4, 6, and 20) sampled patients with chest pain and 1 of 1 (Patient #19) sampled patients with back pain. The findings included: Refer to 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 35244 Based on policy review, document review, video footage review, medical record review and interview, the facility failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE), monitoring and treatment for 6 of 11 (Patients #1,2,3,4,6 and 20) sampled patients with chest pain, and 1 of 1 (Patient #19) sampled patients with back pain. The findings included: 1. Review of the hospital policy “Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA” revised on 3/4/2021 revealed, “...Definitions...”Medical screening examination” [MSE] means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC [Emergency Medical Condition] or not. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage...If an individual who is not already a patient presents to the Hospital with an apparent emergency medical condition and a request is made for (or prudent layperson would believe patient is in apparent need of) treatment, then EMTALA procedures below should be initiated to the extent required by the EMTALA law...Hospital QMP [qualified medical personnel] or trained Labor and Delivery registered nurses should provide a MSE appropriate to the individual’s presenting symptoms that is within the capacity and capability of Hospital, to determine whether or not an EMC exists...” Review of the hospital policy “Triage of Emergency Patients” revised on 12/16/2022 revealed, “...Triage of patients arriving to the Emergency Department will be conducted by a RN [Registered Nurse]. The triage RN shall verify the data collected by the Emergency Department Technician [EDT] and assign the final triage acuity based upon a five-level triage system known as the Emergency Severity Index [ESI]... Acuity is determined by the stability of vital signs and potential for life, limb or organ threat based on ESI five level triage system... The Acuity assignments include the following categories... Level I: Emergent - requires immediate life-saving intervention... Level II: High risk situation, is confused/lethargic/disoriented, severe pain/distress, or vitals are in danger zone... Level III: Multiple resources (lab, x-ray, IV [intravenous], etc.) are required to stabilize the patient, but vitals are not in the danger zone... Level IV: One resource needed to stabilize the patient... Level V: No resources required to stabilize patient... Patients will be assigned to available treatment rooms based upon acuity of condition. Emergent patients will be the highest priority and will be taken to the treatment area immediately. Levels 2, 3, 4, and 5 will be seen in the appropriate care area as condition warrants...” Review of the hospital policy “Assessment, Re-assessment, and Plan of Care” revised on 7/25/2023 revealed, “... Emergency Department: A complete assessment and history is performed for emergency department patients with an Emergency Severity Index [ESI] level of 1 or 2. A focused severity index level of 3, 4, or 5 minimally includes... Vital Signs... Pain Assessment... A focused reassessment based on presenting complaint can be performed by a RN, LIP [licensed independent provider] or Emergency Department Technician with completed competency. Frequency of reassessment is determined by ESI level or significant change in patient condition...” Review of the hospital’s “Pain Assessment Policy” revised on 3/5/2020 revealed, “...all patients will be assessed for pain based upon their clinical presentation... When pain is identified, the patient is treated or referred for treatment... pain Assessment Frequency Outpatients... During the initial evaluation and managed based on each individual’s needs 2. If pain medication is administered, patients will be reassessed for intensity of pain or sleeping within 2 hours... Pain assessment and interventions are documented in the medical record...” 2. Review of the hospital document “Emergency Department Waiting Room Reassessment Guidelines” reviewed on 2/24/2023 revealed, “...this document is intended to be used as a guide for approximate reassessment times for patients in the waiting room... The ED Triage Nurse or Waiting Room Coordinator will assess and reassess patients according to guidelines below. For patient who have notified the staff of leaving the waiting room, the patient be called 3 times 15 minutes apart. If no response, the triage nurse will depart the patient from the ED as eloped, Left Without Being Seen (LWBS) or AMA [against medical advice]...The Medical Screening Exam is a process, and continues throughout the visit until the LIP [licensed independent provider] determines an Emergency Medical Condition does not exist. Document focused reassessments and vital signs (BP [blood pressure], HR [heart rate], RR [respiratory rate], Temp [temperature] if pertinent to the presenting complaints, and pain level) of patients based on their acuity level per ESI guidelines... Level 1... Q [every] 1 Hour... Level 2... Q 3 Hours... Level 3... Q5 Hours... Level 4/Level 5... Q8 Hours... Take vital signs within 1 hr. [hour] prior to discharge...” Review of the hospital document “Physician Orders Adult ED Triage Standing Chest Pain/ACS [acute coronary syndrome] Symptoms Orders” revised 6/8/2022 revealed, “...Criteria for use: Chest pain/discomfort...Vital Signs... Routine... NPO [nothing by mouth]... PIV [peripheral intravenous catheter] insert... O2 Sat Spot Check... Telemetry (ED Only) (Cardiac Monitoring (ED Only) STAT [immediately]... Send patient to chest pain center... CMP [comprehensive metabolic panel]... STAT... ED Troponin-1 HS [high sensitivity] Series (0 and 3 hour)... STAT... CBC [complete blood count]... STAT... If patient complaints of abdominal pain, order Lipase Level... STAT... If patient complains of shortness of breath, order... BNP Pro... STAT... Electrocardiogram (EKG) Stat... Obtain left sided for MI [myocardial infarction or heart attack happens when an artery supplying blood to the heart suddenly becomes partially or completely blocked by a blood clot]... Chest 2 views...and present to MD [medical doctor] immediately...” (Telemetry or cardiac monitoring is used to continuously monitor the patient’s heart rate and rhythm, respiratory rate and/or oxygen saturations while automatically transmitting information to a central monitor. Troponin 1 is a test that measures the protein troponin in the blood stream. Those types of troponin only occur in heart muscle cells and only enter the blood because of heart muscle damage. An EKG records the electrical signals in the heart.) 3. Medical record review revealed Patient #1, a 39 year old male, presented to the hospital’s ED via private vehicle on 2/12/2024 at 8:08 AM with complaint of chest pain. A triage assessment was completed at 8:12 AM and revealed, “Chief Complaint: pcp [primary care physician] for uri [upper respiratory infection] not ge3tting [getting] better for 1 wk [week] is on abx [antibiotics]. States has lost voice and chest pain when take deep breath...” The patient’s presenting vital signs were Blood Pressure (BP) 161/94, Pulse (P) 67, Respirations (R) 16, Oxygen saturation (O2 sat) 95 percent (%). The patient was assigned an ESI level 3. The Standing Chest Pain order set was initiated at 8:14 AM. A respiratory virus panel was collected at 8:13 AM. All results were negative. A chest x-ray was completed at 8:14 AM and interpreted at 8:38 AM and showed, “ ...No acute findings ...” An EKG was obtained at 8:19 AM that documented, “Normal sinus rhythm with sinus arrhythmia” The EKG was reviewed and signed by the ED provider at 8:19 AM who documented, “NO STEMI.” (A STEMI, ST- Segment Elevation Myocardial Infarction is the most severe type of heart attack.) Patient #1’s lab work, including a CMP, CBC, GFR and initial Troponin, was collected at 8:21 AM. (Initial Troponin was within normal limits). Nursing documentation dated 2/12/2024 revealed, “First call from waiting room/no answer...19:28 [7:28 PM]...Second call from waiting room/no answer...20:10 [8:10 PM]...Third call from waiting room/no answer...20:44 [8:44 PM]” Nursing documentation dated 2/12/2024 at 9:22 PM revealed, “...ED Depart LWBS...No meds [medications] given on this visit...” There was no documentation Patient #1 was re-assessed or monitored by hospital staff after lab work was obtained at 8:21 AM. There was no documentation why the second Troponin level was not obtained. There was no documentation Patient #1 was seen or evaluated by an ED Provider. Patient #1 was at the hospital’s ED from 8:08 AM until staff documented the patient LWBS at 9:22 PM, a total of 13 hours and 14 minutes. Review of video footage dated 2/12/2024 verified Patient #1 entered the hospital’s ED at 8:08 AM. Patient #1 is seen walking into the waiting room area and sitting down at 8:34 AM. Patient #1 is seen departing the ED at 3:32 PM. There was no video footage of hospital ED staff reassessing or monitoring Patient #1 while in the ED waiting room from 8:34 AM until 3:32 PM. 4. Medical record review revealed Patient #2, a 39 year old male, presented to the hospital’s ED via private vehicle on 2/12/2024 at 8:38 AM with complaints of chest pain. A triage assessment was completed at 8:46 AM and revealed, “Chief Complaint: reports yesterday at work started feeling like bp [blood pressure] was high and this am [morning] started having chest pain when woke up...” The patient’s presenting vital signs were BP 151/98, P 84, R 16 and O2 sat 96 %. The patient was assigned an ESI level 2. The Standing Chest Pain order set was initiated at 8:49 AM. An EKG was completed at 8:55 AM which showed the patient had a normal sinus rhythm with a nonspecific T wave abnormality. The patient’s lab work, including an initial Troponin 1 HS level, CBC, GFR, and CMP was collected at 8:59 AM. A chest x-ray was completed at 9:09 AM and interpreted at 9:17 AM and showed, “...No acute cardiopulmonary abnormality...” The EKG was reviewed and signed by the ED provider at 9:19 AM who documented, “No STEMI.” There was no documentation Patient #2 was re-assessed or monitored by any hospital staff from 9:09 AM when the chest x-ray was completed until 5:23 PM, a total of 8 hours and 14 minutes later. At 5:23 PM, the patient’s vital signs were BP 169/96, P 75, R 20, and O2 sat 98% and the patient reported chest pain at an intensity level of 10 on a scale of 0 to 10. There was no documentation Patient #2 received any interventions to address his reported pain. A second Troponin 1 HS level was collected at 5:37 PM, a total of 8 hours and 38 minutes after the 1st level was collected. Review of the ED Provider Note dated 2/12/2024 revealed Patient #2 wasn’t seen by the ED Provider until 7:30 PM, a total of 10 hours and 52 minutes after his arrival time. The ED Provider documented, “...patient presents with chest pain...Risk factors consist of hypertension and family history of coronary artery disease...Cardiovascular: Regular rate and rhythm...Pain intensity...10...Troponin...normal limit...Labs unremarkable...Diagnosis Chest pain...Family history of heart disease...HTN [hypertension]...Condition: Stable...EMC ruled out...Discharged...” Patient #2’s vital signs were re-assessed prior to his discharge from the ED at 8:38 PM with BP 137/88, P 72, R 18, and O2 sat 99%. There was no documentation Patient #2 was re-assessed for pain. 5. Medical record review revealed Patient #3, a 75 year old female, presented to the hospital’s ED via private vehicle on 2/12/2024 at 8:56 AM with complaints of chest pain. A triage assessment was completed at 9:11 AM and revealed, “Chief Complaint: reports hcest [chest] pain and diaphoresis [excessive sweating due to an underlying health condition or medication] for 1 day...” The patient’s presenting vital signs were BP 155/63, P 79, R 16 and O2 sat 97%. The patient was assigned an ESI level 2. The Standing Chest Pain order set was initiated by the triage nurse at 9:13 AM. An EKG was completed at 9:04 AM which showed “...Normal sinus rhythm...Possible Left atrial enlargement...Septal infarct [infarction], age undetermined...Abnormal...” The EKG was reviewed and signed by the ED provider at 9:19 AM who documented, “No STEMI.” The patient’s lab work, including an initial Troponin 1 HS level, CMP, CBC, GFR (a test to check how well the kidneys are working) was collected at 9:22 AM. The patient had a low Potassium level of 3.1, (normal level is 3.5 - 5.2 milliequivalents per liter (mEq/L) and an elevated Troponin-1 HS of 16.2 (normal is less than 14 nanograms per liter (ng/L). There was no documentation the ED provider reviewed the patient’s lab work. A chest x-ray was completed at 10:05 AM and interpreted at 10:11 AM and showed, “...No acute pulmonary findings...” A second Troponin-1 HS level was collected at 1:30 PM. Patient #3’s Troponin level had increased from 16.2 to 16.5. There was no documentation the ED Provider reviewed the patient’s Troponin Level. There was no documentation Patient #3 was re-assessed or monitored by any hospital staff from 1:30 PM when the chest x-ray was completed until 5:23 PM, a total of 8 hours and 14 minutes later. At 5:32 PM, the patient’s vital signs were BP 159/84, P 69, R 20, and O2 sat 97% and the patient reported chest pain at an intensity level of 10 on a scale of 0 to 10. There was no documentation the patient’s pain was addressed. The nursing documentation dated 2/12/2024 revealed, “First call from waiting room/no answer...17:33 [5:33 PM]...Second call from waiting room/no answer...19:29 [7:29 PM]...Third call from waiting room/no answer...20:44 [8:44 PM]...” The nursing documentation dated 2/12/2024 at 9:06 PM revealed, ED Depart LWBS [left without being seen]...No meds given on this visit...” There was no documentation Patient #3 was seen or evaluated by the ED Provider. Patient #3 was at the hospital’s ED from 8:56 AM until staff determined the patient left without being seen at 9:06 PM, a total of 12 hours and 10 minutes. In an interview on 2/21/2024 at 10:24 AM, the ED Director confirmed there was no documentation the patient was evaluated by the ED Provider. 6. Medical record review revealed Patient #4, a 33 year old female, presented to the hospital’s ED via private vehicle on 2/12/2024 at 8:03 AM with chief complaint of “other chest pain”. A triage assessment was completed at 8:34 AM and revealed, “Chief Complaint: reports chest pain for 1 day that radiates to back. Had back pain for months is upper right side hx [history] of htn [hypertension] ...” The patient’s presenting vital signs were BP 182/103, P 69, (R) 16, O2 sat 97%. The patient was assigned an ESI level 2. The standing Chest Pain order set was initiated at 8:36 AM. A chest x-ray was completed at 8:36 AM and interpreted at 8:56 AM and showed, “No acute findings” A Urine Pregnancy test was completed at 8:43 AM with negative results. An EKG was obtained at 8:46 AM that showed, “Sinus rhythm with fusion complexes...Marked ST abnormality...Abnormal...” Lab work was collected at 9:07 AM that included a CMP, GFR, initial Troponin level and CBC. An EKG was reviewed and signed by the ED Provider at 9:19 AM who documented, “NO STEMI” An order for Labetalol (a medication used to treat high blood pressure) 100 milligram (mg) tablet, 1 tablet by mouth, was initiated at 12:00 PM. Review of a Medication Administration Record (MAR) revealed the Labetalol was not administered to Patient #4. The nursing documentation dated 2/12/2024 revealed, “First call from waiting room/no answer...12:05 [12:05 PM]...Second call from waiting room/no answer...17:17 [5:17 PM]...Third call from waiting room/no answer...17:56 [5:56 PM]” The nursing documentation dated 2/12/2024 at 5:56 PM revealed, “ED Depart LWBS...No meds given on this visit...” There was no documentation Patient #4 was re-assessed or monitored by hospital staff after lab work was obtained at 9:07 AM. There was no documentation why elevated blood pressure was not addressed until an order for medication at 12:00 PM. There was no documentation why the second Troponin level was not obtained. There was no documentation why ED staff waited 5 hours between the first call from the waiting room until the second call. There was no documentation Patient #4 was seen or evaluated by an ED Provider. Patient #4 was at the hospital’s ED from 8:03 AM until staff determined the patient LWBS at 5:56 PM, a total of 9 hours and 53 minutes. 7. Medical record review revealed Patient #6, a 44 year old female, presented to the hospital’s ED via private vehicle on 1/10/2024 at 2:52 PM with complaints of chest pain. A triage assessment was completed at 3:02 PM and revealed, “Chief Complaint: Patient c/o [complains of] chest pain and palpitations [abnormally rapid or irregular beating of the heart] x’s [times] 30 min [minutes] ago; patient states that she took phentermine [prescription medication used to decrease the appetite and promote weight loss] and a weight loss shot today...” The patient’s presenting vital signs were BP 151/87, P 108, R 20 and O2 sat 100%. The patient rated her pain at level 4 on a scale of 0-10. The patient was assigned an ESI level 2. Orders for Troponin-1 HS Series, CMP, CBC, and Urine Pregnancy Screen were initiated by the triage nurse at 3:10 PM. An EKG was completed at 3:01 PM which showed “...Sinus tachycardia [a regular heart rhythm where the heart beats faster than normal]... Septal infarct, age undetermined...ST & T wave abnormality, consider inferolateral ischemia...Abnormal...” (Ischemia is inadequate blood supply due to blockage of the blood vessels supplying the area.) There was an apparent signature on the EKG; however, there was no date and time the signature was placed. The patient’s lab work, including an initial Troponin 1 HS level, CMP, CBC and GFR was collected at 3:10 PM. The patient had a low Potassium level of 2.9. There was no documentation the ED provider reviewed the patient’s lab work. Orders for a chest X-ray were entered by the triage nurse at 5:38 PM. There was no documentation the chest x-ray was completed. There was no documentation the second Troponin-1 HS level was collected. There was no documentation Patient #6 was re-assessed or seen by any hospital staff after 3:10 PM when the lab specimens were collected. The nursing documentation dated 1/10/2024 revealed, “First call from waiting room/no answer...19:36 [7:36 PM]...Second call from waiting room/no answer...20:00 [8:00 PM]...Third call from waiting room/no answer...20:46 [8:46 PM]...” The nursing documentation dated 1/10/2024 at 9:12 PM revealed, ED Depart LWBS [left without being seen]...pt [patient] no answer in the waiting room...no meds given on this visit...” There was no documentation Patient #6 was seen or evaluated by the ED Provider. Patient #6 was at the hospital’s ED from 2:52 PM until staff documented the patient left without being seen at 9:12 PM, a total of 6 hours and 20 minutes. In an interview on 2/21/2024 at 11:08 AM, the ED Director confirmed there was no documentation the patient was evaluated by the ED Provider. 8. Medical record review revealed Patient #19, a 20 year old female, presented to the hospital’s ED on 9/3/2023 at 2:38 PM with complaint of back pain. A triage assessment was completed at 2:52 PM and revealed, “Chief Complaint: c/o [complained of] headache, backache, diarrhea, cough productive, slight sore throat” The patient’s presenting vital signs were BP 135/89, P 78, R 20, O2 sat 97 %. The patient was assigned an ESI level 3. Nursing documentation dated 9/3/2023 revealed, “First call from waiting room/no answer...22:29 [10:29 PM]...Second call from waiting room/no answer...23:02 [11:02 PM]...Third call from waiting room/no answer...23:15 [11:15 PM]” Nursing documentation dated 9/3/2023 at 11:23 PM revealed, “ED Depart LWBS...No meds given on this visit...” There was no documentation why 30 minutes passed between the first and second call from the waiting room. There was no documentation Patient #19 was re-assessed or monitored after the first triage assessment at 2:52 PM, until being documented as LWBS at 11:23 PM. There was no documentation Patient #19 was seen or evaluated by an ED Provider. Patient #19 was at the hospital’s ED from 2:38 PM until staff documented the patient LWBS at 11:23 PM, a total of 7 hours and 45 minutes. 9. Medical record review revealed Patient #20, a 65 year old female, presented to the hospital’s ED via private vehicle on 9/3/2023 at 2:56 PM with complaint of chest pain. A triage assessment was completed at 3:12 PM and revealed, “Chief Complaint: c/o [complained of] chest pains with productive cough since yesterday” The patient’s presenting vital signs were Blood Pressure 125/81, Pulse 84, Respirations 20, Oxygen Saturation 100 percent. Pain intensity was rated 7 on a scale of 0-10. The patient was assigned an ESI level 3. The Standing Chest Pain order set was initiated at 3:21 PM. The patient’s lab work was collected at 3:14 PM which included a CMP, GFR, initial Troponin level and CBC. An EKG was completed at 3:15 PM which showed sinus rhythm with baseline wander. There was no documented signature by an ED Provider to indicate the EKG was reviewed by an ED Provider. A chest x-ray was completed at 3:21 PM and interpreted at 3:38 PM and showed, “ ...Patchy airspace opacities in the lung bases possibly representing early airspace disease ...” Nursing documentation dated 9/3/2023 revealed, “First call from waiting room/no answer...22:29 [10:29 PM]...Second call from waiting room/no answer...23:02 [11:02 PM]...Third call from waiting room/no answer...23:15 [11:15 PM]...” Nursing documentation dated 9/3/2023 at 11:24 PM revealed, “ED Depart LWBS...No meds given on this visit...” There was no documentation Patient #20 was re-assessed or monitored by hospital staff after chest x-ray was obtained at 3:21 PM. There was no documentation Patient #20’s pain level of 7 was addressed. There was no documentation Patient #20 was seen or evaluated by a ED Provider. Patient #20 was at the hospital’s ED from 2:56 PM until staff documented LWBS at 11:24 PM, a total of 8 hours and 28 minutes. In an interview on 2/21/2024 at 8:50 AM, the hospital’s SVP (Senior Vice President) stated they had begun using a new ED provider group as of January 28th (2024). The SVP stated there had been an adjustment period, that was still ongoing. Stated things had been slower (in the ED) at times. In an interview on 2/22/2024 at 10:04 AM, the ED Medical Director (EDMD) was asked what measures have been put in place to decrease the waiting times and number of patients leaving the ED without being seen. The EDMD stated the hospital had been working on a “Blue Dot” system which signifies which patients had already had a workup and were waiting for disposition. The EDMD continued and stated the hospital was also working to transition Fast Track providers to work in both Fast Track and assist with performing MSEs in the main ED. The EDMD was asked how often patients waiting in the waiting room should be reassessed. The EDMD stated, reassessments are “based on their ESI” and the hospital’s “formal policy.” The EDMD continued and stated he was unable to recall the exact policy the triage nurse follows regarding reassessments. The EDMD verified cardiac monitoring is a standing order for patients that present to the ED with complaints of chest pain. When asked how cardiac monitoring is completed on patients who were triaged then sent to the waiting room, the EDMD stated, the triage nurse gets an EKG on the patient and shows it to the ED provider. If the EKG is normal, there would be less need to use the cardiac monitor. The EDMD continued and stated if the EKG was abnormal or concerning for a STEMI, that would signify immediate concern. The EDMD was asked how the flow of the ED changed during times of Critical Advisory. The EDMD stated, “Critical Advisory doesn’t change anything we do.” In an interview on 2/21/2024 at 9:40 AM, the ED Director stated, “vital signs should be taken every 4 hours for patients with an ESI level 2.” In an interview on 2/22/2024 at 10:27 AM, the ED Director stated if staff called for a patient in the waiting room and the patient didn’t respond, they should go back every 15 minutes and call the patient 2 more times before determining the patient left without being seen. In an interview on 2/22/2024 at 11:20 AM, the ED Director stated the ED providers sign the EKGs when they’ve reviewed them. In an interview on 2/22/2024 at 12:30 PM, the ED Director stated she expected pain to be addressed. The Director stated Tylenol could be given without physician consultation. In an interview on 2/23/2024 at 9:00 AM, ED RN #1 verified nurses are able to initiate the chest pain standing orders without consulting the physician. The nurse stated they are able to give Tylenol for pain without a physician’s order. The nurse stated there is a tab in Cerner (their computer system) to tag them of patients, and vitals/re-assessments. Stated patients are re-assessed every 3-5 hours depending on their level (ESI). The nurse stated the back-up in the waiting room is often caused from the “holds” that are in the non-acute area of the ED. This takes up beds that could be used for waiting room patients. When a bed does come free, if an ambulance patient is waiting, they get that room before a waiting room patient.”