Saint Thomas Rutherford Hospital

“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: 37530 Based on policy 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 assess, monitor, and provide wound care treatments for 2 of 4 (Patient #21 and #25) sampled patients reviewed for wound care management. The findings included: 1. Review of the facility’s policy titled “Basic Wound Intervention Policy” dated 9/5/2024, revealed “...The purpose of the Basic Wound Intervention Policy is to provide guidelines to address skin tears, moisture management, incontinent associated dermatitis, fungal rash, pressure injuries, and patient with negative pressure therapy in progress on admission...All patients will be assessed for potential and actual alteration in skin integumentary. Patient identified as having the indicators listed below will require the initiation of the Basic Wound Policy...intervention policy. Stage I/II/SDTI [one/two/Suspected Deep Tissue Injury] Pressure injury or Partial Thickness Wounds...Cleanse area with normal saline and pat dry...Apply Board Foam ...Change every three days and PRN [as needed] for loosening...Stage III/IV [three/four; 3-4] Pressure Injury or Full Thickness Wounds...Cleanse area with normal saline...Apply Saline moist dressing...Change BID [twice a day] and PRN [as needed]...Unstable Pressure injury or Brown/Black Dry Eschar...Leave area clean and dry...Dry dressing as needed for comfort or drainage...” Review of the facility’s policy titled “Admission Assessment/Reassessment,” dated 2/7/2025, revealed “...Each patient will receive an admission assessment by a Registered Nurse which will include the patient’s...in order to determine care needs, the type of care to be provided, and the need for further assessment...identify those at risk for the potential for skin breakdown...” 2. Review of the closed medical record revealed Patient #21 was admitted on to the hospital on 1/2/2025 at 11:24 AM with diagnoses of Pressure Ulcer of Right heel Stage 2, Pressure Ulcer of Sacral Unstageable, Sepsis, Acute Kidney Failure, Diabetes and Pressure Wound Infection. Patient #21 was discharged from the hospital on 1/6/2025 at 2:43 PM. Review of the Nursing Home Progress Note, dated 1/2/2025 revealed, “... right breast ulceration measuring 3.7 cm [centimeters] x [times] 8.8 cm x 0.4 cm. Wound bed consists of 100% [percent] pale pink moist tissue, edges are uneven and sharp oval shaped, induration [the hardening and thickening of the skin and surrounding tissue around a wound] palpated with erythema [redness] observed to ensure right breasts moderate amount of purulent [pearl colored] drainage and malodor when dressing removed and cleansed. UNST [unstageable] to right heel now appear as stage 2 measure 1.1cm x 0.2cm x 0.1cm wound bed 100% pink moist smooth tissue, margin is flat and uneven, no drainage or malodor observed ...UNST pressure ulcer to sacrum measures 4.2cm x 4.4cm x UTD [undetermined], wound bed consist of 75% of light yellow slough and 25% black necrotic tissue foul odor observed before and after cleansing the wound, margin sharp and circular, small amount of malodorous purulent drainage observed when dressing removed and odor continued to be present after wound was cleansed...” Review of the Emergency Medical Services (EMS) Run Sheet,” dated 1/2/2025 revealed “...Nurses states that patient has a pressure ulcer on the right hip area where humeral head meets pelvis. Nurse was performing wound care today and notice that the wound seems to be getting worse and is possibly becoming infected due to abnormal drainage and smell...” Review of the “Pre-arrival Communication From,” dated 1/2/2025 revealed “...SACRAL WOUND W[with]/FOUL SMELL...” Review of the ED (Emergency Department) Records, dated 1/2/2025, revealed “...sent to the ED via [by] EMS ...for an evaluation of multiple wounds...Patient presenting with multiple wounds which have worsened...patient is normally bed bound...” Review of the Physician’s Orders dated 1/2/2025, revealed Wound Ostomy Referral. Review of the Incision/Wound Information, dated 1/2/2025 through 1/6/2025 revealed there was no documented wound care on the sacral wound. Review of the “Incision/Wound Information,” dated 1/3/2025 through 1/6/2025 revealed there was no documented wound care on the right heel. Review of the “Incision/Wound Information,” dated 1/3/2025 through 1/6/2025 revealed there was no documented wound care on the right breast. Review of the “Progress Note,” dated 1/3/2025 revealed “... Assessment/Plan Diagnosis... Wound of right breast with complications... Sacral decubitus ulcer...Acute kidney injury...Diabetes...Metabolic acidosis... Urinary tract obstruction...Depression...” Review of the “Wound/Ostomy Report,” dated 1/3/2025 and 1/6/2025, revealed Patient #21 had a wound to the sacral, right heel, and a wound to the right chest. Review of the “Discharge Summary,” dated 1/6/2025, revealed “...Patient reportedly has right breast ulceration measuring 3.7 cm [centimeters] x 8.8 cm x 0.4 cm...moderate amount of purulent malodorous drainage...dressed with VASHE [a topical solution primarily used for wound care. It contains hypochlorous acid...known for its antimicrobial properties, making it effective in cleansing, irrigating, and moistening wounds] applied dry. We have an accompanying ulcer to the sacrum 4.2 cm x by 4.4 cm in addition to a right heel stage II [two] decubitus ulcer 1.1 cm x 0.2 cm x 0.1 cm it is not apparent the patient has received antimicrobial treatment for these lesions due to the breast lesion. Due to breast and sacral decubitus wound care was consulted...” Review of Hospital #2 “Office Visit in Wound Care,” dated 1/7/2025, revealed “...Wound Length...2.8 cm...Wound Width...7.9 cm...Wound Depth...0.7...” Review of the Named Hospital #3’s “Progress Note, dated 1/7/2025, revealed “...ED Dx [diagnosis]...Sacral decubitus wound, infected...” Review of the Named Hospital #3’s “WOUND CARE INPATIENT CONSULT NOTE,” dated 1/9/2025 “...Upon admission to the hospital patient is documented to have right breath [breast] wound with small amount of serous drainage, deep tissue injury to right heel and right 5th toe, stage 4 pressure injury to sacrum. Stage 1 to right buttock and abrasion to right elbow and left knee. Patient seen by outpatient wound clinic on 12/30/2024 for ulcers to right breast, sacrum, right ischium and right heel. Wound care treatment recommended for the right breast 3 x [times] a week with Vashe [wound cleanser] wound solution, Promogran [primary dressing for moist wound healing] and Allevyn [indicated for moderate to high exudating wounds] foam dressing. For right heel ulcer Vashe, hydrogel, Promogran and Allevyn foam dressing to be changed 3x per week. To the right ischium normal saline and small allevyn foam dressing 3 x a week. To the sacrum daily dressing changes with Vashe, Santyl [ointment used to remove damaged or burned skin], Hydrofera [offering antimicrobial protection, moisture management] blue and Allevyn foam dressing...Unable to performed skin and wound assessment on 1/8/2025 due to patient hemodynamically unstable with need of vasopressor therapy...wounds...Right breast...2.7 cm [centimeters] x 8.8 cm x 0.5...Right heel...3.6 cm x 2.4 cm x 0.1...The base is 20% bone exposed...Right lateral 5th toe...1.5 cm x 0.4 cm...Sacrum...5.0 cm x 3.5 cm x 1.0 cm...Assessment...right heel stage 4...lateral right 5th toe Deep tissue injury...Non-pressure ulcer...right breast...” During a telephone interview on 6/2/2025 at 1:10 PM, Family Member #1 was asked to tell me about his complaint. Family Member #1 stated, “...She had a wound on her bottom...her heel...her breast...she stayed there for six days...they sent her back to the [Named Nursing Home] at the hospital here at [Named Hospital #1]...they failed to treat her wound for six days...” During an interview on 6/3/2025 at 1:01 PM, with the Wound Care Nurse was asked during Patient #21’s hospitalization should she have documentation of wound care treatments. The Wound Care stated, “...we have no wound care documentation...” The Wound Care Nurse was asked if have a patient admitted with wounds how do they get on your list. The Wound Care Nurse stated, “...we get a list essentially of our patients in the morning...first thing we do is come in and look at our list...our list will have consults from hospitalists...surgeons...doctors...who are following up on them [patient]...there will be a nurse referrals... system referrals...that populates our list...we kind of prioritize who we’re seeing based on the type of referral or consult...what kind of wounds... diabetic wounds...pressure ulcers...surgical wounds...dermatology with rashes...” The Wound Care Nurse was asked how many pressure ulcers are currently being treated in the hospital. The Wound Care Nurse stated, “...I know for certain roughly 4 patients that we’re following...” The Wound Care Nurse was asked if how does a patient that admitted through the Emergency Room (ER) with multiple wounds that have worsening and infected and there’s no documentation of any wound care for six days. The Wound Care Nurse stated, “...if it was just a system referral consult that’s lowest priority...the system will kick a referral to us based on what is charted in by a nurse or by an LPN [Licensed Practical Nurse]...if they charted a wound...it’ll automatically shoot a referral to us...it’s all based on charting...those are lower priority...if we get a direct consult from the hospitalist or a surgeon...we go and see the patient...” The Wound Care Nurse was asked when that patient go to the floor are the nurse doing a head to toe assessment to identify the wounds. The Charge Nurse stated, “...Yeah, so essentially if they document something on their skin assessment it will trigger a system referral versus an actual order in the system...an actual surgeon or physician requesting a wound care...the wound care nurse goes to see them versus just a system referral...that could be anything that a nurse documented under that skin assessment...a lot of times it’ll trigger saying they got a pressure injury...” The Wound Care Nurse was asked should the patient have been missed treatments/wound care. The Wound Care Nurse stated, “...it was just a system referral based on that first skin assessment...there was no actual physician order...” The Wound Care Nurse was asked if the patient was admitted on Thursday at on 1/2/2025 at 11:24 AM and discharged on Monday at 1:45 PM. The Wound Care Nurse stated, “...I believe she was admitted on Thursday night they were not here...they had Friday to see her...they had several other higher priority patients...they were not here on weekends...” The Wound Care Nurse was asked when you go in on an initial assessment what is involved. The Wound Care Nurse stated, “...It’s based on kind of the consult or whatever type of referral...if it’s the first time we see them...we get an idea of what the wound is...if it’s an actually a pressure ulcer...it’s a different type of wound...a pressure ulcer we’ll stage it...get measurements and then come up with a treatment plan...then follow them...we will write wound care orders for the bedside nurses to accomplish with a kind of schedule...if it’s a more complex wounds...we stick with it...we are the ones that will go back either daily or every other day depending on the schedule...” The Wound Care Nurse was asked if you have a patient admitted with infected wound and not to have wound care for six days is that acceptable practice. The Wound Care Nurse confirmed typically no. The Wound Care Nurse was asked should Patient #21 have had wound care complete. The Wound Care Nurse stated, “...Probably, I will say even though they did not necessarily get to her because of the timing of the schedule...we also have a policy as far as standard dressings changes that the nursing staff should be doing...to change the dressing regularly...that’s something that also should have been done while she was here...obviously it’s very important that these wounds be changed, cleansed, and assessed...it’s also part of our policy...they do have standing orders or standing for policy what can be done in the meantime throughout the weekend...so yes if they’re admitted throughout the weekend...the wound care should have been done...it should be completed and cleansed per our policy by the bedside nursing...” 3. Review of the medical record revealed Patient #25 was admitted on 5/19/2025 with diagnoses of Pleural Effusion, Constipation, Small Bowel Obstruction, Liver Abscess and Fractured Femur. Review of the “History of Physical,” dated 5/19/2025, revealed “...70-year-old male with a past medical history of adenocarcinoma on chemotherapy, liver access with drain in place, atrial flutter, and type 2 diabetes mellitus, who presented in the ER with abdominal pain and distention, associated with nausea and vomiting over the past few days. The patient underwent knee surgery three days ago and was started on oxycodone. Since then, he has not had a bowel movement for two days, though he reports passing gas recently as of yesterday...” Review of the “Physicians Orders,” dated 5/19/2025, revealed Skin Care Interventions...Skin Care intervention ordered based on Nursing Documentation...” Review of the “Physicians Orders,” dated 5/21/2025, revealed “...Wound Care...Site...Midline coccyx...Cleanse with...Saline...Apply...medihoney [when applied to the skin, honey might serve as a barrier to moisture and keep skin from sticking to wound dressing...Frequency...QDay [every day]...Special Instructions...apply medihoney and cover with border foam dressing...” Review of the “CT (Computed Tomography) AbdomenPelvis (Abdomen Pelvis) With Contrast dated 5/29/2025, revealed “...IMPRESSION...Small region of induration at the base of the coccyx which could relate to developing decubitus ulcer...” Review of the “Progress Note,” dated 5/30/2025, revealed “...No over night events of note...Discussed plan for wound care to come evaluate the patient for his decubitus ulcer noted on the CT [computed tomography]...” Review of the “Orders Detail,” dated 5/31/2025, revealed “...to Coccyx...Cleanse with Wound Cleanser Spray, Apply Normlgel AG [antimicrobial hydrogel that assists in debridement and desloughing in dry necrotic wounds...the gel creates a barrier against bacterial penetration], petroleum gauze, boarder foam, QDay [every day]...” Review of the “Wound Ostomy Services,” dated 5/20/2025, revealed “...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 1 cm [centimeters], Width 1 cm, dept 0.3 cm...” Review of the “Wound Ostomy Services,” dated 5/30/2025, revealed “...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 2 cm [centimeters], Width 1.8 cm, dept 0.5 cm...” Review of the “Wound Ostomy Services,” dated 6/2/2025, revealed “...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 1.8 cm [centimeters], Width 1.6 cm, dept 0.6 cm...” Review of the “Incision/Wound Assess/Care,” revealed on the following day there was no wound care treatments performed 5/21/2025, 5/23/2025, and 6/3/2025. Review of the “Quality of Care Meeting Minutes,” for the November 11/15/2024, 1/19/2025, 2/21/2025, 3/21/2025, and 4/25/2025 revealed the facility had no documentation of the wound management. Review of the “QUALITY AND PATIENT SAFETY MANAGEMENT PLAN FISCAL YEAR 2025,” revealed there was no documentation of the wound management. During an interview on 6/4/2025 at 1:20 PM, with the Director of Wound Care was asked what it means in the documentation under the wound information, clean, covered, intact, dry and boarder foam. The Director of Wound Care stated, “...they would have looked under the dressing make sure the wound is clean covered dressing dry intact...” The Director of Wound Care was asked does it mean the wound care treatment was provided. The Director of Wound Care stated, “...No, they would document applied if the wound care was provided...” The Director of Wound Care was asked about Patient #25 treatment orders. The Wound Care Director stated “...he had an ostomy order for 5/19/2025...there was one on 5/23/2025 ...an order placed on 5/21/2025 and on 5/31/2025 for daily dressing changes...” The Director Wound Care was asked should Patient #25 have missing treatment. The Director Wound Care Director stated, “No.” The facility failed to follow their policy for wound care treatment for Patient #21 and #25. The facility failed to ensure the patient’s were provided the care and services while admitted to the facility.”

“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: 51389 Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate and ongoing medical screening examination for one (1) patient (#14) of 23 Emergency Department patients reviewed. The findings include: Patient #14, a 17-year-old male, arrived at facility A’s ED on 8/15/24 at 7:40 PM, via ambulance, after a motor vehicle accident that involved intrusion into the vehicle, requiring extrication of Patient #14 from the vehicle. The patient arrived at the ED complaining of left leg and hip pain and received X-rays of the chest, left femur, and left hip, which did not show any abnormalities. No further testing was completed. The patient was discharged from the hospital 8/15/2024 at 11:50 PM. The following morning, 8/16/2024, the patient developed Hematuria, had increasing pain, and presented to Hospital B where he was found to have multiple Pelvic Fractures and a possible Hematoma or Rupture of the Bladder. The patient was admitted, received therapy, and was discharged 8/19/2024. Cross Refer to A2406.”

“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: 51389 Based on review of facility policy, medical record review, emergency department logs, and interviews, the facility failed to provide an appropriate and ongoing medical screening examination for one (1) patient (#14) who presented to the emergency room (ED) following a motor vehicle accident of 23 ED records reviewed. The findings include: Review of facility A’s policy, “Screening, Transfer, and Acceptance of Patient’s with a Possible Emergency Condition (EMTALA)” revised 2/3/2023, showed “Patients...requesting examination and treatment will...receive a Medical Screening Examination by a qualified medical provider...A Medical Screening Examination is defined by policy as...process required to reach with reasonable clinical confidence the point at which it can be determined whether an Emergency Medical Condition exists. Screening is to be conducted to the extent necessary...and is an ongoing evaluation including ancillary services available to the emergency department.” Review of the ED Central Logs showed Patient #14 arrived at the Facility A’s ED on 8/15/24 at 7:40 PM, via ambulance, after a motor vehicle accident involving intrusion into the vehicle and required Patient #14 be extricated from the vehicle. Medical record review of an ED Provider note, dated 8/15/2024 at 7:47 PM, showed Patient #14 complained of left hip and pelvis pain and minimal pain over left bicep laceration. There were 1 cm (centimeter) superficial (existing on the surface) lacerations to left inner upper arm, posterior upper arm, and left upper back. The patient had tender and painful ROM (range of motion) around left hip and pelvis and mild tenderness to left thigh. Medical record review of ED Provider note, dated 8/15/2024 at 7:54 PM, showed the following orders: Clean off glass, X-ray (XR) chest portable, XR left femur, and XR left hip with pelvis 2 or 3 views. Medical record review of XR of left pelvis, hip, and femur completed 8/15/2024 at 8:52 PM, showed “impression” was possible foreign body at the left inguinal (groin) region. Medical record review showed on 8/15/2024 at 10:59 PM, Physician #1 considered inpatient admission versus discharge with close outpatient follow up. He stated the patient’s ED workup is “...without major, life threatening abnormalities requiring admission.” The patient “doing well” and he felt the “risk of acute decompensation is low” and stated “discharge is reasonable...The patient is comfortable with his pain, x-rays are ok, and no traumatic processes is found.” Medical record review showed no urinalysis or CT (Computed Tomography) imagining of abdomen or pelvis were performed during the patient’s admission. Medical record review showed Patient #14 was discharged from the ED at 11:50 PM. Medical record review of the discharge summary from Hospital B, dated 8/19/2024 at 10:12 AM, revealed Patient #14 presented on 8/16/2024 with Hematuria and worsening abdominal pain. CT of chest, abdomen, pelvis, thoracic and lumbar spine showed “...thickened heterogeneous material anterior to the urinary bladder involving the space of Retzius (space located in front of the pubic symphysis) [joint that joins the left and right pelvis] and anterior to the urinary bladder...concerning for hematoma (abnormal pooling of blood under the skin) and/or extraperitoneal bladder rupture...Multiple pelvic fractures involving the bilateral pubic bones, dislocation of the pubis symphysis and with a 1 cm fragment displaced posteriorly/internally.” X-rays of pelvis showed a “4 mm vertical displacement of the left pubic bone on the left leg weight bearing view suggesting instability of the pubic symphysis. Known pelvic fractures are better appreciated on same day CT.” CT cystogram (contrast dye placed in the bladder and a CT scan to detect potential leaks) showed “no evidence of bladder injury...Pubic symphysis injury with symphysis disruption and associated tiny avulsive fractures from the medial pubic bones...1 cm fracture fragment from the right posterior public bone is embedded in the obturator internus muscle [muscle of the hip joint]...Equivocal nondisplaced right anterior sacral fracture...” Continued review of the discharge summary revealed a urinalysis with a small amount of blood (reference = negative). Urology was consulted and a urinary catheter was placed. During an interview on 11/13/2024 at 9:15 AM, with Physician #1, he stated Patient #14 did have pain and difficulty getting up, but did better after pain medications. He did not remember if he assisted the patient with ambulation. The physician stated “patient did not have fractures identified” when he reviewed the x-rays with the Radiologist. He stated based on the injury and patient’s complaints, he would first order X-rays. If there was any indication there was a fracture, he would order a CT scan.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 36006 Based on observations, the facility failed to protect the hazardous areas. The findings included: Observation on 08/30/2024 at 9:04 AM, revealed a door closer with a manual hold open device was installed on the commercial laundry room door. NFPA 101, 19.3.2.1.3 (2012 Edition) The EVS Director and Assistant COO was present when this finding was identified and the Assistant COO acknowledged this finding during the exit conference on 08/30/2024.”