Metro Nashville General Hospital

“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: 49570 Based on review of facility policy, review of facility documents, medical record review, video camera footage, American Heart Association document review, and interview, the facility failed to provide organized nursing services to ensure the emergent needs of the patients were met. The facility failed to ensure patients’ needs were identified and failed to respond immediately when 1 of 1 (Patient #4) sampled patients developed a life-threatening cardiac rhythm and staff failed to provide immediate interventions to prevent decline. Eight minutes after the life-threatening rhythm began, hospital nursing services identified the life-threatening rhythm and started chest compressions. Patient #4 expired 43 minutes after the life-threatening rhythm started. The findings revealed: 1. Review of the policy, “Patient Rights and Responsibilities” effective 06/2025, revealed, “...All patients have the...right to considerate, respectful care given by competent personnel in a safe environment...” Review of the policy, “Code of Conduct” effective 02/2025, revealed, “[FACILITY NAME] PATIENT RIGHTS: You (the patient) have a right to: Receive competent ...care ... promptly ...” Review of the policy, “Care & Treatment for Inmate/Forensic Patients” effective 09/2025, revealed, “[Name of facility] ... Ensure that forensic patients are cared for...” Review of the policy, “Care and Documentation of the Patient in the ICU [Intensive Care Unit] ...” revised 04/2021, revealed, “ ...4. Timely and accurate documentation is expected to facilitate the continuum of care ...” Review of the policy, “Hand-Off Communication” effective 08/2022, revealed, “ ... For shift-to-shift hand-off communication, the Electronic Medical Record is used at the bedside ...” Review of the policy, “Clinical Alarms System” effective 10/2025, revealed, “ ... shall not ...adjust alarm volumes to a level that cannot be readily heard when the alarm activates ...Hospital staff trained to treat the patient will immediately respond to alarms ... “ 2. The document titled, “Job Description: Registered Nurse [RN]” revealed, “...RN is a professional caregiver who assumes responsibility and accountability for a group of patients for a designed time frame and provides care to these patients... Reports immediately any finding...that may indicate patient health deterioration....Initiates emergency resuscitative measure according to ACLS guidelines...Documentation and Evaluation:...Documents changes from baseline assessment...” 3. Medical record review revealed Patient # 4 presented from Correctional Facility #1 to the facility via Emergency Room by Emergency Medical Services (EMS) with an admission date of 01/09/2026 at 7:36 AM with admitting diagnoses that included Atrial Fibrillation with Rapid Ventricular Response ((RVR); abnormal heart rhythm where heart beats irregular too fast). Patient #4 was admitted to the facility’s Intensive Care Unit (ICU) on 01/09/2026 at 9:00 AM for inpatient treatment. The form titled, “Order Details”, revealed Patient # 4 had a resuscitation status marked as “Full Code [cardiac pulmonary resuscitation (CPR)]” but there was no documentation of advance directives. 4. Review of the American Heart Association article dated 9/24/2024 revealed, “Ventricular fibrillation, or VF, is considered the most serious abnormal heart rhythm. VF is extremely dangerous and can lead to sudden cardiac death. Without treatment, the condition is fatal within minutes”. 5. Review of the facility’s video camera footage (with no audio) dated 01/09/2026 from 6:45 PM to 7:15 PM of the Pod B nurses’ station of the ICU revealed multiple staff members at the nurses’ station from 6:45 PM to 7:03 PM on 01/09/2026. Video footage revealed multiple staff members were seated and/or walking around the nurses’ station, but there was no staff observed seated where the cardiac monitoring equipment was located. At 7:03 PM, staff actions reflected recognition of a change in the cardiac status on the monitor for Patient #4. Staff members entered Patient #4’s ICU room, and Code Blue (cardiac pulmonary resuscitation (CPR)) was initiated. 6. Review of the cardiac monitoring documentation (EKG strips) dated 01/09/2026 at 6:55 PM revealed Patient # 4 developed ventricular fibrillation ((v-fib); a life-threatening cardiac rhythm causing the heart’s lower chambers to quiver instead of pump, leading to immediate cardiac arrest). Nursing Services failed to recognize the rhythm change until 7:03 PM, eight minutes after the life-threatening rhythm began. 7. Review of the “Code Blue Form” dated 01/09/2026 at approximately 7:03 PM, revealed CPR was initiated, and chest compressions were started. From 7:03 PM to 7:36 PM, advanced cardiac life support was implemented. The patient was pronounced dead at 7:38 PM. 8. Review of time sheets revealed RN # 1 clocked in on 01/09/2026 at 6:47 AM for her scheduled day shift and was assigned responsibility for Patient #4. 9. During an interview on 01/14/2026 at 9:05 AM, the Patient Safety Officer/Risk Manager stated the ICU nurses who were sitting at the nurses’ station in the ICU had not heard the cardiac monitor alarm. During an interview on 01/21/2026 at 2:15 PM, the Director of ICU stated there has been no one specifically assigned to monitor cardiac monitors during shift-change. During an interview on 01/21/2026 at 2:42 PM, the Clinical Director of Medical/Surgical (Med/Surg) stated it had not been an uncommon practice for Medical/Surgical nurses to be pulled to other floors, including specialty units like the ICU. Refer to A- 0395”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 49570 Based on review of facility policy, review of facility documents, medical record review and interview, the facility failed to ensure grievances were reviewed, investigated, and resolved within a reasonable timeframe for prompt resolution to expressed concerns for 1 of 1 patients (Patient #1) patient grievances reviewed for violating Patient choices based on religious beliefs. The findings revealed: 1. Review of facility policy, “Complaints and Grievances” revised 09/2024, revealed, “...grievances handled in consistent and timely manner ...B. Grievance: All written ...complaints are considered a grievance ...A. Patient Rights: [Name of Facility] will inform patient/representative of the internal grievance process ...B. Receiving a Patient ...Grievance: All ...grievances received by a department will be promptly logged using the hospital’s electronic system and a response made to the complainant ...C. Investigating a Grievance: Investigation of...grievances of a non-emergent nature will be initiated within 72 hours of receipt of grievance...All efforts will be made to begin and conclude the investigation within 7 business days...If grievance is unable to be resolved within 7 business days, a letter will be sent to complainant...All grievance investigations will be closed with a response to the complainant within 30 days...” Review of facility policy, “Code of Conduct” effective 02/2025, revealed, “[Facility Name] PATIENT RIGHTS: You (the patient) have a right: To voice any complaints, concerns, or grievances that you may have regarding your care and to receive a prompt response ...” 2. Medical record review for Patient #1 revealed an admission date to the facility’s emergency department (ED) on 08/22/2025 from a local jail on a 6404 hold (emergency involuntary psychiatric admission) with diagnoses that included Psychosis and the Inability to Care for Self. The patient was held in the ED for 3 days before being transferred to a medical surgical unit the facility. The Advanced Directive sent with the patient from the local jail revealed the patient had selected not to receive blood transfusions. Labs results drawn on admission to the ED on 8/22/2025 for Patient #1 revealed a Hemoglobin level (protein that is main component of red blood cells) low at 6.8 (normal Hemoglobin level in men is 13.5 - 17.5) and a Hematocrit level (blood test that measures percentage of red blood cells in blood) low at 22.1% (normal Hematocrit level for male is 40-50%). Review of the Patient Status Rounding Report revealed “...08/25/2025 10:00 AM... Pt [Patient #1] refusing blood transfusion. POA [Power of Attorney] - [Family Member #1] refusing blood transfusion” documented by LPN #1. Review of the ED documentation revealed Patient #1 refused blood transfusions on 8/25/2025 at 10:07 AM, 10:09 AM and 11:02 PM. On 08/26/2025 Patient #1’s Hemoglobin level had dropped to 5.8 at 12:20 AM and Physician Resident #1 ordered for 2 units to administered to Patient #1. Physician Resident #1 signed the consent for blood document and wrote Patient #1 was not capable of making own decisions. After the blood transfusion was administered, Patient #1 was admitted to the facility’s Intensive Care Unit (ICU). Review of Patient #1’s medical record revealed Family Member #1 was listed on his medical record for emergency contact and Power of Attorney; however, Family Member #1 was never contacted by Hospital #1 to discuss a blood transfusion. Family Member #1 only became aware that Patient #1 had received a blood transfusion when the Family Member went to visit the patient in the hospital. 3. Review of the facility document, “Grievance Log” revealed a formal grievance had been entered on 09/04/2025 and filed by Family Member #1 on behalf of Patient #1. The grievance was related to concerns of violating Patient Rights of refusing treatment based on religious beliefs. 4. During an interview on 12/03/2025 at 1:42 PM the Patient Experience Representative confirmed the grievance was filed on 09/04/2025 by Family Member #1. The Patient Experience Representative stated, “When I came in [named facility] there was a backlog [of grievances]. Because I did not enter it [Family Member #1’s grievance] into the system, it was not on my radar and did not get handled. It just fell through the cracks.” The Patient Experience Representative stated she would begin working on the grievance immediately and would reach out to Family Member #1. During an interview on 12/15/2025 at 11:00 AM, Family Member #1 stated the facility had not yet reached out to her in response to the grievance that she had filed on behalf of Patient #1. Family Member #1 started she had filed the grievance due to being “devastated” and “mentally torn-up” over Patient #1 having received a blood transfusion during his hospital stay, as it conflicted with his religious beliefs as a named Religious Affiliation. Family Member #1 stated, “As a [named Religious Affiliation], we make a vow to God that he is the only giver of life. A blood transfusion is life. They [the facility staff] said he [Patient #1] consented to the blood, but he [Patient #1] would never have done that.” During an interview on 12/17/2025 at 3:00 PM, Family Member #1 stated she had not received any communication from the facility in regard to the grievance.”

“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: 49570 Based on review of facility policy, medical record review, review of video camera footage, facility document review, American Heart Association document review, personnel record review, employee timecard review, and interview, the Registered Nurse (RN) failed to assess the patients’ care needs and health status by failing to monitor the cardiac monitors for 1of 1 (Patient #4) sampled patient’s admitted with Ventricular Fibrillation (V fib - life threatening heart rhythm where the heart does not pump effeciently). The findings revealed: 1.Review of facility policy, “Patient Rights and Responsibilities” effective 06/2025, revealed, “...All patients have the rights and responsibilities referenced in this policy regardless of a patient’s... prior conviction of a crime...Patient Rights: Safe and Respectful Care:...right to considerate, respectful care given by competent personnel in a safe environment free from all forms of abuse, neglect or mistreatment...” Review of facility policy, “Code of Conduct” effective 02/2025, revealed, “[FACILITY NAME] PATIENT RIGHTS: You (the patient) have a right to: Receive competent ...care ... Receive care ...promptly ...” Review of facility policy, “Care & Treatment for Inmate/Forensic Patients” effective 09/2025, revealed, “[Name of facility] and incarcerating institutions collaborate to ensure that forensic patients are cared for...All hospital policies pertaining to consent for care and treatment will be followed, including for routine and emergency care...inmates are still entitled to certain medical rights as a patient. These rights are outlined in [Facility Name] ‘Patient Rights & Responsibilities’...” Review of facility policy, “Care and Documentation of the Patient in the ICU [Intensive Care Unit (ICU)]...” revised 04/2021, revealed, “...4. Timely and accurate documentation is expected to facilitate the continuum of care ...H. EKG [Electrocardiogram]...2. Event/change in cardiac rhythm - print strip and put in chart ...” Review of facility policy, “Hand-Off Communication” effective 08/2022, revealed, “... [Facility Name] has a standardized hand off procedure to ensure patient safety ...F. For shift-to-shift hand-off communication, the Electronic Medical Record is used at the bedside to assure that the report is inclusive ...” Review of facility policy, “Clinical Alarms System” effective 10/2025, revealed, “ ...4. Hospital or medical staff shall not ...adjust alarm volumes to a level that cannot be readily heard when the alarm activates ...Hospital staff trained to treat the patient will immediately respond to alarms ...Clinical manager will audit clinical alarms ...yearly ...and correct deficits with an action plan ...” 2. Review of facility document, “Job Description: Registered Nurse” revealed, “...RN is a professional caregiver who assumes responsibility and accountability for a group of patients for a designed time frame and provides care to these patients...Certification & Licensures:...BLS: Required; ACLS: Required...Clinical Performance:...Reports immediately any finding...that may indicate patient health deterioration....Initiates emergency resuscitative measure according to ACLS guidelines...Documentation and Evaluation:...Documents changes from baseline assessment...” 3. Review of the American Heart Association article dated 9/24/2024 revealed, “Ventricular fibrillation, or VF, is considered the most serious abnormal heart rhythm. VF is extremely dangerous and can lead to sudden cardiac death. Without treatment, the condition is fatal within minutes”. 4. Review of medical record revealed Patient # 4 presented from Correctional Facility #1 to the facility via Emergency Room (ER) by Emergency Medical Services (EMS) with an admission date of 01/09/2026 at 7:36 AM with admitting diagnoses that included Atrial Fibrillation with Rapid Ventricular Response (RVR; abnormal heart rhythm where heart beats irregular too fast), Hypotension (low blood pressure), Fluid Overload (excess fluid buildup in body), and End-Stage Renal Disease ((ESRD); kidneys have failed and can no longer remove waste and excess fluid from body). Patient #4 was transferred from the facility’s ER to the facility’s Intensive Care Unit (ICU) at approximately 9:00 AM on 01/09/2026 for inpatient treatment. Patient #4 was assigned to the care of Registered Nurse (RN) #1. Review of the form, “Order Details”, revealed Patient # 4 had a resuscitation status marked as “Full Code [cardiac pulmonary resuscitation (CPR)]” on 01/09/2026 at 7:40 AM; however, there was no documentation of advance directives found in the medical record. 5. Review of video camera footage with no audio dated 01/09/2026 from 6:45 PM to 7:15 PM, of the Pod B nurses’ station in the ICU, revealed multiple staff members, including RN #1 and RN #2, present at the nurses’ station during the time period of approximately 6:45 PM to 7:03 PM on 01/09/2026. Video footage revealed multiple staff members were seated toward the rear of the nurses’ station and/or up ambulating around the station during this time. The video camera footage further revealed no staff members were seated at the front of the nurses’ station where the patients’ cardiac monitoring equipment was located. Although there was no audio to the video footage, staff actions reflected recognition of a change on the cardiac monitor for Patient #4 at approximately 7:03 PM. At that time, staff members, including RN #1 and RN #2, were observed entering Patient #4’s ICU room, and a Code Blue (cardiac pulmonary resuscitation (CPR)) was initiated at 7:03 PM. Review of cardiac monitoring (EKG strips) for Patient #4 revealed on 01/09/2026 at 6:55 PM Patient # 4 developed ventricular fibrillation (v-fib; a life-threatening cardiac rhythm causing the heart’s lower chambers to quiver instead of pump, leading to immediate cardiac arrest); however, the rhythm change was not recognized by nursing staff until approximately 7:03 PM, a total of 8 minutes after the life-threatening cardiac rhythm began. Review of “Code Blue Form” dated 01/09/2026 at approximately 7:03 PM, revealed CPR was initiated, and chest compressions were started on Patient #4. The “Code Blue Form” documented on 01/09/2026 from 7:03 PM to 7:36 PM multiple rounds of Automated External Defibrillator (AED) shocks (a portable life-saving device to treat sudden cardiac arrests by analyzing heart rhythms and delivers electric shock to heart, if needed, to restore cardiac rhythm) were delivered; and multiple doses of emergency medications were administered according to Advanced Cardiac Life Support (ACLS) guidelines; however, despite resuscitative efforts spontaneous return of circulation was not achieved, and Patient # 4 was pronounced deceased at approximately 7:38 PM, 43 minutes after the EKG strips documented Patient #4 went into v-fib. 6. Review of employee timecard records revealed RN # 1 clocked in on 01/09/2026 at 6:47 AM for her scheduled day shift and was assigned responsibility for Patient #4. Review of “ICU Charge Hand-Off Report” dated 01/09/2026 for AM shift (first shift of the day, 7:00 AM - 7:00 PM) revealed Registered Nurse (RN) #1 had been assigned to care for Patient #4 from 9:00 AM until shift change at 7:00 PM. Review of personnel records for RN #1 revealed completion of the “Nurse Knowledge Exchange” checkoff form dated 06/13/2025. The documentation reflected the RN acknowledged competencies related to bedside shift report at shift change, including acknowledgement of the patient and introduction of the oncoming nurse at the bedside. The checkoff form further included the statement, “Ask [the patient] if it is OK to give report in the room,” indicating the facility’s expectation that bedside shift report be conducted as part of the handoff process. Personnel records further reflected RN #1 was currently certified in Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS), and documentation of ICU-specific training was identified in the personnel record. 7. Review of employee timecard records revealed RN # 2 clocked in on 01/09/2026 at 6:42 PM to begin her scheduled evening shift and was assigned responsibility for Patient #4. Review of video camera footage on 01/09/2026 confirmed RN # 2 was present on the ICU unit during the time period preceding and following Patient #4’s change in condition from 6:45 PM to 7:03 PM. Review of “ICU Charge Hand-Off Report” revealed RN#2 had been assigned to care for Patient #4 from 7:00 PM on 01/09/2026 to 7:00 AM (on 01/10/2026). Review of personnel records for RN# 2 revealed completion of the “Nurse Knowledge Exchange” checkoff form dated 05/15/2025. The documentation reflected the RN acknowledged competencies related to bedside shift report at shift change, including acknowledgement of the patient and introduction of the oncoming nurse at the bedside. The form further included the statement, “Ask if it is OK to give report in the room,” indicating the facility’s expectation that bedside shift report be conducted as part of the handoff process. Personnel records further reflected RN #2 was currently certified in BLS; however, no documentation of ACLS certification or additional ICU-specific training was identified in the personnel record. 8. During an interview on 01/14/2026 at 9:00 AM with multiple members of Leadership present, the Director of Nursing (DON) stated her expectation was for nursing staff to perform beside shift report when changing shifts. This expectation was for nursing staff in the ICU as well as nursing staff in the rest of the hospital. During an interview on 01/14/2026 at 9:05 AM, the Patient Safety Officer/Risk Manager stated that ICU nurses had been sitting at the nurses’ station in the ICU talking/giving shift-change report and had not heard the cardiac monitor alarm. When the abnormal rhythm was noticed the Code Blue was initiated; however, it was eight minutes after Patient #4 went into v-fib. During an interview on 01/21/2026 at 2:15 PM, the Director of ICU stated she had been involved with management regarding handling of the situation. When asked about any potential changes that had been put into effect since the incident ,she stated, “I am aware of immediate changes to the ICU that include, all ICU patients are now being monitored by the 6th floor telemetry technician and we have a nurse in ICU that monitors the telemetry [monitors] during shift change.” When asked who was responsible for monitoring the telemetry monitors during shift change, the Director of ICU stated, “It changes based on who is available to monitor them. No one is specifically assigned.” When asked about what her expectations were for bedside shift report, the Director of ICU stated, “Bedside shift report should happen every time [that there is a shift change].” When asked if any disciplinary actions had been administered regarding the incident, she stated, “RN #1 will not be in a charge [nurse] capacity moving forward. There will be disciplinary action taken against her for failure to conduct bedside shift report on this patient [Patient #4].” During an interview on 01/21/2026 at 2:42 PM, the Clinical Director of Medical/Surgical (Med/Surg) stated RN #2 had been a staff nurse for Med/Surg and had been pulled to the ICU on 01/09/2026 to assist with the need for additional staff. It had not been an uncommon practice for Med/Surg nurses to be pulled to other floors, including specialty units like the ICU. When asked if Med/Surg nurses had received any additional training for specialty units like the ICU, the Director of Med/Surg stated, “Not to my knowledge.” When the Clinical Director of Med/Surg was asked about his knowledge of the incident involving Patient #4, he stated he had a conversation with RN #2 regarding the incident after the Director of Nursing had made him aware. He stated, it was “My understanding, RN #2 was floated to ICU, and was receiving report from the day shift nurse at the nurses’ pod [station], when she [RN #2] or someone else noticed a patient [Patient #4] on the monitor was in v-fib (Ventricular Fibrillation). They [nurses] then coded [performed CPR] the patient but could not get him back [a normal rhythm].” When asked about expectations for bedside shift report, the Clinical Director stated, “It is a known expectation on the med/surg floors to do report at the bedside.” The Clinical Director was unsure why a bedside report had not taken place in the ICU at shift change. When asked about any potential disciplinary actions for RN #2, the Clinical Director stated that after speaking with the Director of Nursing, it had been decided to administer a written warning to RN #2 for lack of conducting bedside shift report in this incident and, “That was delivered to her this morning.” During an interview on 01/23/2026 at 11:30 AM, RN #1 stated she had been the day shift nurse in ICU assigned to Patient #4 on 01/09/2026. She stated that throughout the day Patient #4 began exhibiting EKG changes, including episodes of Premature Ventricular Contractions ((PVC)- extra, early heartbeats originating in the heart’s lower chambers) and bigeminy (abnormal heart rhythm with extra beats in that every normal heartbeat is followed by an abnormal premature contraction); RN #1 stated, “Around 7:03 PM we [RN #1 and RN#2] were sitting at the nurses’ station and I [RN #1] was giving report to the night shift nurse [RN#2]. She [RN#2] looked over at the [telemetry] monitors and asked, ‘Who’s heart rate is that? ’. I got up and went to the monitor and saw [Patient #4] was in v-Fib. I rushed to the room, started CPR, and a Code Blue was called. Neither myself nor any of the nurses heard the telemetry alarm. I never left the code; I finished the code and code sheets before I left”. When asked why beside report had not been given, RN #1 stated, “Nobody does bedside shift report, we never do it. Most people sit at the nurses’ pod [station] and get report, then go see their patients. But we are now. I insisted we do it [bedside shift report] today”.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 49570 Based on review of facility policy, review of facility documentation, review of facility video camera footage, observation, and interview, the facility failed to ensure a safe physical environment by failing to ensure wet floor signs were used when liquid spills/puddles were present on the facility’s floors in multiple locations, creating a potential slip/fall risk for 2 of 2 (Outpatient #2 and Visitor #1) customers of the facility when they were reviewed for falls. The facility also failed to ensure the physical environment was constructed, arranged, and maintained in a manner to ensure patient safety, by failing to maintain restroom flooring in 2 of 2 (Bathroom #1 and Bathroom #2) bathrooms in a safe and sanitary condition, which created potential trip hazards and infection control concerns. The findings revealed: 1. Review of facility policy, “Safety Management Plan” revised 07/2021, revealed, “ ...designed to provide a physical environment free of hazards ...and shall provide the patients, visitors ...with highest obtainable level of safety available ...” Review of facility policy, “Infectious Waste Spills” revised 05/2021, revealed, “ ...Place wet floor signs around spill to avoid slips and falls ...H. Always leave wet floor signs out until floor is completely dry...” Review of facility policy, “Safety Management Plan” revised 07/2021, revealed, “ ...designed to provide a physical environment free of hazards ...and shall provide the patients, visitors ...with highest obtainable level of safety available ...” 2. Review of facility document, “Environmental Services (EVS) - Safety & Compliance Requirements” revealed, “...Use wet floor signs...” Review of facility document, “Floor Tech [Technician] Responsibilities and Standards” revealed, “...expectations and responsibilities for all Floor Technicians to ensure floors, equipment, and designated work areas remain clean, safe, and presentable at all times...2. Floor Care Responsibilities: Address spills immediately and place appropriate wet floor signage...3. Machine Cleaning...Report mechanical issues immediately to a supervisor...Removal of Signs: Wet floor signs must remain in place until the floor is completely dry...Accountability & Compliance: Failure to use wet floor signs correctly is a safety violation...” Review of facility, “Grievance Log” dated 08/01/2025 through 11/30/2025 revealed a grievance was filed on 10/06/2025 by Outpatient #2 regarding a fall she sustained on 09/23/2025 when walking to the lab inside of the facility. Review of facility document, “Fall Event” dated 10/06/2025, revealed Outpatient #2 “...event date 9/23/2025 at 15:51 [3:51 PM] ...fell in a puddle of water in the hallway and no floor signs were present... a floor cleaning machine was sitting in the area where she [Outpatient #2] fell but was not turned on [at the time of the fall.]” Outpatient #2 was seen at a clinic located inside the facility on 09/23/2025 and was walking to the laboratory for blood collection when Outpatient #2 slipped and fell in a puddle of water. Outpatient #2 was immediately seen in the facility’s Emergency Department and treated for pain in her left hip and femur. Diagnostic testing showed no acute bony injury, and Outpatient #2 was discharged home in stable condition with an outpatient follow-up. 3. Review of facility document, “Incident Log” dated 12/01/2025 through 01/05/2026, revealed a fall was sustained on 12/19/2025 by Visitor #1 after exiting one of the first-floor elevators on the first floor of the facility. Review of facility video camera footage dated 12/19/2025 revealed the EVS Technician exiting a first-floor elevator on 12/19/2025 at approximately 8:06 AM with a floor cleaning machine. The EVS Technician (Tech) walked straight out of the elevators, left to the floor cleaning machine in front of the elevators and walked away to gather cleaning supplies. Upon returning, the EVS Technician moved the floor cleaning machine out of sight of the camera and walked away. After the EVS Tech removed the floor cleaning machine, the video camera footage revealed a puddle of water where the machine was parked. A few moments later on 12/19/2025 at 8:11 AM, Visitor #1 exited the elevator and immediately slipped in the puddle of water. There was no wet floor sign present. Facility Management Mechanic #1 exited the elevator at same time as Visitor #1 and witnessed the fall. Facility Management Mechanic #1 stated he asked Visitor #1 if she was ok and promptly notified Security and Emergency Department (ED) staff. Within a matter of seconds, the EVS Technician and Security arrived and assisted Visitor #1 into a chair. At 8:13 AM, the facility s ED staff arrived with a wheelchair and Visitor #1 was taken to ED for treatment. 4. Observations on the first floor in front of the double doors leading into the facility’s ED on 12/18/2025 at 12:18 PM, revealed a large area of standing water, approximately 4 inches wide x 12 inches in length, on the floor with no wet floor signage. Observations inside the men’s restroom located outside of the facility’s cafeteria on 01/06/2026 at 11:30 AM, revealed a large area of standing water present in the men’s restroom with no wet floor signage. Observations inside the men’s restroom located outside of the facility’s cafeteria on 01/07/2026 at 9:30 AM, revealed a large area of standing water present in the men’s restroom with no wet floor signage. Observations on the third floor of the facility on 01/07/2025 at 12:44 PM, revealed two Unisex Handicap accessible bathrooms (Bathroom #1 and Bathroom #2) outside the visitor elevators. Both bathrooms had multiple large areas of missing tiles and areas of tiles that were buckling in front of the toilet areas and middle of floors. The spots were black, dirty, and appeared to not have been cleaned thoroughly. The floors were uneven in areas and presented a trip hazard to an already vulnerable population. 5. During an interview on 12/11/2025 at 1:00 PM, Outpatient #2 stated she was walking to the lab to have blood drawn when she slipped and fell in the hallway. Outpatient #2 stated, “...it [the fall] did aggravate the issues with my leg I was already having. I have been sore...” During an interview on 01/05/2026 at 3:08 PM, Visitor #1 stated she had fallen outside the first-floor elevators in some water and there had been no wet floor sign in place. Visitor #1 stated, a security guard assisted her to the ED where x-rays were performed and showed no broken bones. She was discharged in stable condition. She stated, “However, I continue to have right knee pain,” but had not informed the facility of the continued pain. During an interview on 01/07/2026 at 10:45 AM, the EVS Director stated that Environmental services staff were expected to put out “Wet Floor” signage anytime a liquid substance was found on the floor and were expected to clean up spills immediately. The EVS Director also stated, “The bathroom floors have been impossible to clean on the 3rd floor. We have tried everything to clean them.” When asked who used these bathrooms, the EVS Director stated, “Everyone ...including patients. They [patients] even take pregnancy tests in there.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 51739 Based on review of facility policies, document review, medical record review and interview, the Governing Body failed to ensure staff policies and procedures for the treatment of all emergency medical conditions for all patients and medical staff were accountable, treated all patients the same and honored all patient’s Advanced Directives for treatment and care when the medical staff failed to administer blood products to 1 of 1 (Patient #1) sampled forensic patients transferred from a local prison seeking medical care for an emergency medical condition. The findings included: 1. Review of the facility policy titled “Patient Rights and Responsibilities Policy” dated 6/2025, revealed, “...all patients have the rights and responsibilities regardless of a patient’s prior conviction of a crime or membership in any other protected classes as set forth in state or federal law...The facility honors advance directives to the fullest extent possible within the limits of law, regulation and the policies and capabilities of our institution...” Review of the facility policy titled “Care and Treatment for Inmate/Forensic Patients Policy” dated 7/2023, revealed, “...inmates retain the right to provide consent for health care services. All hospital policies pertaining to consent for care and treatment will be followed...” Review of the facility policy titled “Blood Transfusion & Suspected Reaction Policy” dated 7/5/2025, revealed, “... In the event of an emergency, as documented in the Progress Note by the physician, a consent may not be possible until improvement of patient’s condition...” 2. Review of the “[named state] Health Care Decisions Act” dated 2024, Section 68-11-1803, revealed, “...No health care provider or institution, and no health care service plan, insurer issuing disability insurance, self-insured employee welfare benefit plan, or non-profit hospital plan, shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care...” 3. Review of the “Emergency Documentation” dated 8/19/2025, revealed Patient #1 was transferred from Forensic Facility #1 via Emergency Medical Services (EMS) to Hospital #1. EMS reported last known well for patient was 10:00 PM the night before on 8/18/2025. Patient #1 arrived at Hospital #1 on 8/19/2025 at 9:01 AM, with a diagnosis of Low Blood Pressure and Altered Mental Status. Patient #1 was triaged and classified as having an Emergent medical condition. In Hospital #1’s Emergency Department (ED), Patient #1 had lab tests and radiology tests performed. Patient #1’s hemoglobin level (Hgb - carries oxygen in the blood) results were 9.8 (normal for adult make is 14-17.5) and the patient’s hematocrit level (Hct - measures the percentage of red blood cells in the total volume of blood) results were 31.1 (normal for adult male is 41-50). There was no documentation of treatment ordered for the patient’s low Hgb or Hct levels. Patient #1 was admitted to Hospital #1 for further work-up and management. At Hospital #1 the patient was found on 8/19/2025 to be confused, diaphoretic, weak, and unable to follow the Provider’s finger with movement of his eyes. On 8/20/2025 at 3:39 AM, Patient #1’s Hgb level was at a critical level of 6.9 and Patient #1’s Hct level was critical at 23.3. An order was received to administer one unit unit of packed red blood cells (PRBC) to Patient #1, however the unit of PRBC was not administered. Nursing and Medical Staff stated since Patient #1 was a forensic patient they would not administer the PRBC to the patient until they contacted the prison Warden and obtained the Warden’s consent. Patient #1 began actively bleeding as evidenced by bright red blood in the stool and suffered a respiratory-cardiac arrest (the patient’s breathing and heart beating stop). Advanced cardiac life support (a set of clinical guidelines established by the American Heart Association (AHA) for the urgent and emergency treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) was provided without success and Patient #1 expired and was pronounced dead on 8/20/2025 at 9:28 AM. The medical staff failed to provide treatment, care and services to Patient #1 who was experiencing a medical emergency, actively bleeding and required a blood transfusion. Refer to A-0049, A-0115, & A-0132”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51739 Based on facility policy, document review, medical record review and interview, the hospital failed to honor the patient’s right of Advanced Directives and have hospital staff and practitioners who provide care in the hospital comply with these Directives for 1 of 6 patients (Patient #1) who experienced an emergency medical condition which required treatment, services and blood transfusions to prevent further health deterioration and decline. Patient #1 died 24 hours and 27 minutes after being transferred to the hospital seeking emergency medical treatment. The findings included: 1. Review of the facility policy titled “Patient Rights and Responsibilities Policy” dated 6/2025, revealed, “...all patients have the rights and responsibilities regardless of a patient’s prior conviction of a crime or membership in any other protected classes as set forth in state or federal law...1. The right to considerate, respectful care given by competent personnel in a safe environment free from all forms of abuse, neglect or mistreatment, and in a manner that optimizes the patient’s comfort and dignity...2. Patient rights may be exercised through the patient individually and/or through individuals authorized to represent their interests...7. The facility honors advance directives to the fullest extent possible within the limits of law, regulation and the policies and capabilities of our institution...” Review of the facility policy titled “Care and Treatment for Inmate/Forensic Patients Policy” dated 7/2023, revealed, “...Consent for Treatment: Inmates retain the right to provide consent for health care services...” Review of the facility policy titled “Blood Transfusion & Suspected Reaction Policy” dated 7/5/2025, revealed, “... PROCEDURE: In the event of an emergency, as documented in the Progress Note by the physician, a consent may not be possible until improvement of patient’s condition...” 2. Review of the “[named state] Health Care Decisions Act” dated 2024, Section 68-11-1803, revealed, “ ...(i) No health care provider or institution, and no health care service plan, insurer issuing disability insurance, self-insured employee welfare benefit plan, or non-profit hospital plan, shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care ... “ 3. Medical record review revealed Patient #1 was transported by emergency medical services (EMS) from Forensic Facility #1 and arrived at Hospital #1’s emergency department (ED) on 8/19/2025 at 9:01 AM for treatment of altered mental status and a low blood pressure (BP). Patient #1 received a liter of normal saline during transport to treat the Patient’s low BP. Patient #1 was triaged at Hospital #1’s ED on 8/19/2025 at 9:17 AM as a level “2” which indicated the patient was emergent (an unexpected situation that requires immediate action to prevent an imminent threat to life, health, public safety or property. It is a severe crisis demanding immediate intervention such as a medical emergency such as a cardiac arrest, severe trauma or respiratory failure). Medical record review revealed Patient #1’s laboratory testing results revealed the following: Hemoglobin level (Hgb) revealed the patient’s Hgb was low at 9.8 (normal for male is 14 - 17.5), Hematocrit (Hct) level was low at 31.1 (normal for male is 41 - 50. (Low levels of Hgb and Hct means the body does not have enough red blood cells to carry oxygen effectively throughout the body). The lactic acid test results revealed the patient’s lactic acid was elevated at 3.2 (normal 0.5 - 2.2, lactic acid levels are high when cells in the body lack sufficient oxygen), The patient’s Troponin test results were 68 (normal is less than 0.03 - high Troponin levels means the heart muscle is damaged), and the patient’s Brain Natriuretic Peptide (BNP) level was elevated at 2077 (BNP means the heart has increased strain and stress - normal is less than 100). There was no documentation of additional physician orders based on the results of the abnormal laboratory test results. The physician’s Emergency Documentation revealed Patient #1 was admitted to Hospital #1 on 8/19/2025 at 12:27 PM, “Given the patient had altered mental status, with transient hypotension [a temporary drop in blood pressure that lasts for a short period] prior to arrival to the ED, and has several lab abnormalities of unclear chronicity [ the duration or persistence of a condition] and clinical significance, patient will be admitted to hospital for further workup and management. Hemodynamically [relating to or involving the study of the dynamics of blood flow through the circulatory system] improved at the time of admission....” Review of the admission History and Physical dated 8/20/2025 at 3:26 PM revealed the physician confirmed Patient #1’s Advanced Directives was present in the medical record and the code status was documented. The Advanced Directive documented Patient #1’s consent for medical treatment which included blood transfusions. On 8/20/2025 at 3:39 AM, Patient #1’s Hgb dropped to 6.9 and the patient’s Hct dropped to 22.3. On 8/20/2025 at 6:13 AM, the nurses observed “pure blood” in Patient #1’s stool. On 8/20/2025 at 7:30 AM, the nurses documented Patient #1 was actively bleeding. On 8/20/2025 at 8:41 AM, Patient #1 became unresponsive without a heart rate and respirations. Cardiopulmonary resuscitative measures (life-saving interventions) were unsuccessful. Patient #1 died on 8/20/2025 at 9:28 AM. Review of the Record of Death Form dated 8/20/2025, revealed Patient #1’s death was caused by Hypovolemia (condition in which your body loses to much fluid and/or blood volume) secondary to Arterial Gastrointestinal (GI) Bleed. There was no documentation Patient #1 was administered blood transfusions for the continued low and dropping Hgb and Hct and the signs of actively bleeding. Refer to A-0049 and A-0132”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51739 Based on review of hospital policies, document review, medical record review, and interview, the Governing Body failed to ensure the hospital’s medical staff assumed responsibility and provided the necessary care and treatment to prevent further patient decline for 1 of 1 (Patient #1) forensic patients who was exhibiting signs and symptoms of deterioration requiring a blood transfusion and who had Advanced Directives in the medical record identified by the hospital’s medical staff as patient consent for blood transfusions. The medical staff failed to honor the patient’s Advanced Directives and failed to administer blood transfusions. Patient #1’s health and medical condition deteriorated. Patient #1 expired 24 hours and 27 minutes after being transferred to the hospital for emergency medical treatment. The record of death documented Patient #1’s cause of death was Hypovolemia secondary to Arterial Gastrointestinal Bleeding. The findings included: 1. Review of the facility policy titled “Patient Rights and Responsibilities Policy” dated 6/2025 revealed, “...all patients have the rights and responsibilities regardless of a patient’s prior conviction of a crime or membership in any other protected classes as set forth in state or federal law...” Review of the facility policy titled “Care and Treatment for Inmate/Forensic Patients Policy” dated 7/2023, revealed, “...inmates retain the right to provide consent for health care services. All hospital policies pertaining to consent for care and treatment will be followed...” Review of the facility policy titled “Blood Transfusion & Suspected Reaction Policy” dated 7/5/2025 revealed, “... PROCEDURE: In the event of an emergency, as documented in the Progress Note by the physician, a consent may not be possible until improvement of patient’s condition...Indications for Transfusion...Hypovolemia [low fluid volume] due to surgery, trauma, or gastrointestinal bleeding documented by one of the following...Systolic blood pressure [top number] less than 100 or diastolic blood pressure [bottom number] less than 60...Acute anemia with Hematocrit [(Hct) - the measurement of the percentage of red blood cells in the total volume of blood] < [less than] 20 OR Hemoglobin [(Hgb)- a protein that carries oxygen in the blood] < 8...Active GI bleed...Documented symptomatic regardless of the Hgb level...Acute blood loss with symptoms and signs of hypovolemia [such as tachycardia (heart 100 or more), tachypnea (a term used to describe breathing 20 or more times per minute], orthostatic hypotension [a condition where blood pressure drops significantly when a person stands up from sitting or lying down], low urinary output [UOP], poor peripheral perfusion [poor flow of blood through the extremities of the body], change in sensorium [a change in mental status or consciousness, leading to a person’s reduced or abnormal awareness of themselves and their surroundings] ...” 2. Review of the (named State) Department of Correction policy titled “ADMINISTRATIVE POLICIES AND PROCEDURES” (where Patient #1 was housed prior to coming to the hospital) dated October 15, 2022 revealed, “...PURPOSE: To establish guidelines for an inmate’s informed consent or refusal of health care services... PROCEDURES: 2. Emergency Treatment: The healthcare informed consent requirement shall be waived when, in the opinion of the health provider, an emergency situation exists that requires immediate medical or psychiatric intervention to prevent loss of life or limb...and the inmate lacks the capability to make an informed decision to consent to or refuse treatment...” 3. Review of a progress note from Forensic Facility #1 dated 8/19/2025 at 7:50 AM revealed Emergency Medical Services (EMS) was called to the facility due to Patient #1 had become diaphoretic, and exhibited poor responses to verbal and tactile stimuli. Patient #1 was cold and clammy with poor grips and partial weakness of the left arm. The patient was pale, sweating and unable localize any pain or area of discomfort. The patient was observed to have a poor visual gaze and was unable to track the healthcare provider’s finger with his eyes. Patient #1 was tachycardic and had mild wheezing throughout the lungs fields with no cough. Patient #1 was transferred to Hospital #1’s emergency department (ED) by EMS to rule out stroke. Review of the EMS trip report dated 8/19/2025 at 8:13 AM revealed the rapid assessment for Patient #1 was documented as the Patient’s skin was cool, diaphoretic and the Patient hd an altered mental status. An Intravenous (IV) access was started in the Patient’s right hand and fluids were given to Patient #1 for low blood pressure. The patient’s vital signs were monitored during transport to Hospital #1 with the following low blood pressures: at 8:45 AM, blood pressure was 59/40; at 8:50 AM, blood pressure was 99/42; and, at 8:59 AM, blood pressure was 73/33. An electrocardiogram (EKG - shows the heart’s rhythm and rate) performed on 8/19/2025 at 8:39 AM, while enroute to Hospital #1 revealed sinus rhythm with multiple supraventricular premature complexes (extra heartbeatsthat originate above the top chambers of the heart). Review of the ED note revealed Patient #1 arrived at Hospital #1’s ED on 8/19/2025 at 9:01 AM via EMS with the chief complaint of low blood pressure and altered mental status. The patient was described as tachycardic (no specific documentation of the heart rate at the time). The patient also had mild wheezes throughout his lung fields with no cough. EMS reported Patient #1 was last known well the previous night around 10:00 PM. There was no further documentation of blood pressure readings until the patient arrived at Hospital #1. Patient #1 was triaged at Hospital #1 on 8/19/2025 at 9:17 AM as a level “2” which indicated the patient was emergent (an unexpected situation that requires immediate action to prevent an imminent threat to life, health, public safety or property. It is a severe crisis demanding immediate intervention such as a medical emergency such as a cardiac arrest, severe trauma or respiratory failure). Patient #1’s blood pressure was 98/72, heart rate 74, respiratory rate 18, temperature 98.1 Fahrenheit, and the patient’s oxygen level (O2 saturation (sat) the percent of oxygen in the blood stream normal 95 - 100) was 96 on room air. Patient #1 was described as alert, but slow to answer questions and his psychosocial interactions were documented as slow. Review of Patient #1’s Computed Tomography scan (CT) results (a CT scan is a medical imaging procedure that uses x-rays to create detailed cross-sectional images of internal organs, bones and other tissues) of the Chest/Abdomen/Pelvis performed 8/19/2025 at 10:21 AM revealed peptic ulcer disease (sores on the inner lining of the stomach and upper part of the small intestines) as a concern; and a mild nonspecific ileus (a temporary, nonspecific dysfunction of the intestines where they stop moving normally) enteritis (inflammation/infection) of the small bowel bowel; and inflammatory changes surrounding the pancreas, that may indicate early acute pancreatitis. Review of the CT of the head results performed on 8/19/2025 at 10:57 AM revealed no acute intracranial abnormalities but it did show findings consistent with remote vascular insult (damage or disruption to blood vessels that do not occur at the site of initial injury but rather affects distant parts of the body). On 8/19/2025 at 11:18 AM a physician ordered for nursing to obtain a stool specimen for an Immunological Fecal (Stool) Occult Blood specimen test (test to check for blood in stool that is not visible to the naked eye but can be detected through laboratory tests). There was no documentation nursing obtained a specimen to determine if Patient #1 had any blood in the stool. There was no documentation of physician follow-up to the order. Review of Patient #1’s laboratory test performed on 8/19/2025 at 11:29 AM for Hemoglobin level ((Hgb) revealed the patient’s Hgb was low at 9.8 (normal for male is 14 - 17.5) and the patient’s Hematocrit (Hct) level was low at 31.1 (normal for male is 41 - 50; low levels of Hgb and Hct means the body does not have enough red blood cells to carry oxygen effectively throughout the body). There was no documentation of new physician orders based on the low Hgb and Hct test results. Review of Patient #1’s lactic acid test results revealed the patient’s lactic acid was elevated at 3.2 (normal 0.5 - 2.2; lactic acid levels are high when cells in the body lack sufficient oxygen); the patient’s Troponin test results were 68 (normal is less than 0.03 - high Troponin levels means the heart muscle is damaged), and the patient’s Brain Natriuretic Peptide (BNP) level was elevated at 2077 (elevated BNP means the heart has increased strain and stress - normal is less than 100). There was no documentation of additional physician orders based on the results of the abnormal laboratory test results. Review of the physician’s Emergency documentation revealed “...Neuro: AO [alert, oriented] X 2 [times 2], normal speech; not oriented to location/time; normal strength and sensation bilateral upper and lower extremities...Given the patient had altered mental status, with transient hypotension [a temporary drop in blood pressure that lasts for a short period] prior to arrival to the ED, and has several lab abnormalities of unclear chronicity [the duration or persistence of a condition] and clinical significance, patient will be admitted to hospital for further workup and management. Hemodynamically [relating to or involving the study of the dynamics of blood flow through the circulatory system] improved at the time of admission...” Review of the History and Physical dated 8/19/2025 revealed the physician confirmed Patient #1’s Advanced Directives was present in the medical record and the code status was documented. Review of an “Advance Care Plan” dated and signed by Patient #1 on 2/27/2020 revealed, “...I [Patient #1’s name] hereby give these advance instructions on how I wan/t to be treated by my doctors and other healthcare providers when I can no /longer make those decisions myself... I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my ageny must follow my instructions below. (The area designated for the name of the agent, along with telephone number, relationship to the patient, and the agent’s address was blank.)... Treatment... [box checked indicating yes] Treatment of New Conditions: Use of surgery, blood transfusions or antibiotics that will that will deal with a new condition but may not help the main illness... Signature: Your signature must either be witnessed by two competent adults or notarized. If witnessed, neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate... [Signature of Patient #1]... [Signature of two witnesses]...” On 8/19/2025 at 12:27 PM Patient #1 was transferred from Hospital #1’s ED to the forensic floor (floor in Hospital #1 that is for incarcerated patients who have security guards present at all times) for continued treatment; the medical record revealed “...Advance Directives...No...Mode of Arrival...Stretcher...Accompanied by other: security...” On 8/19/2025 at 12:35 PM, the nursing assessment documented Patient #1 was experiencing dizziness, syncope (fainting or passing out), cough, incontinence (loss of bladder or bowels), concentration difficulties, Parkinson’s tremors (involuntary, rhythmic movements that typically affect the hands, feet, and head ) and, “...character of communication expressive language difficulty; character of speech, needs time to answer...” The nursing assessment documented Patient #1 was alert, and wearing “BNO2 [binasal oxygen- supplemental oxygen delivered to a patient through a binasal cannula, a device with two prongs that are placed in both nostrils] at 2 LPM [liters per minute]”. On 8/19/2025 at 1:45 PM the nursing assessment documented Patient #1 had expiratory wheezes in all lobes of the lungs. Review of the History and Physical dated 8/19/2025 at 3:26 PM revealed, “... Upon evaluation, the patient maintains eye contact but does not engage in conversation... In the ED, the patient was given 2 L [liters] NS [normal saline], vancomycin [antibiotic]. [Blood] Pressures improved to 123/65. He was sating [oxygen saturation] 96% on 2 L [2 liters of oxygen] NC [nasal cannula]. Lab values were notable for elevated WBC [measured in microliters- a millionth of a liter; white blood cells, indicate infection with normal between 4500 and 11000] at 14.6K [14600], anemia with hemoglobin 9.8, lactic acid elevation of 3.2, Troponin of 68, BNP of 2077...No acute distress...Respiratory: Bilateral bibasilar wheezing. Good inspiratory and expiratory effort...Neurological: AO X 0 [the patient is not alert and oriented to person, place, time]. Patient follows commands but does not respond to questioning. Patient has notable tremors full body tremors...” There was no documentation of new physician orders for treatment. On 8/19/2025 at 8:15 PM the nursing assessment documented Patient #1’s blood pressure was 127/72, heart rate 98, respiratory rate 18, O2 sat 99% with oxygen at 2 LPM. Nursing documented Patient #1 was experiencing dizziness, syncope, cough, incontinence, concentration difficulties, Parkinson’s tremors, and “...character of communication, slight delay; charter of speech, slight delay...”. On 8/19/2025 at 8:26 PM, the physician ordered for Patient #1 to receive intravenously (IV) Protonix (medications to treat high levels of acid in the stomach). On 8/20/2025 at 2:05 AM the nursing assessment documented Patient #1’s blood pressure was 131/93, heart rate 93, respiratory rate 20, BNO2 at 2 LPM with all lobes of the lungs clear but breath sounds were diminished. Patient #1’s abdomen was firm and round and Patient #1 was experiencing Parkinson’s tremors, and “... characteristics of communication - slight delayed; character of speech slight delay; LOC (level of consciousness) alert” Nursing documented Patient #1 was experiencing dizziness, syncope, cough, incontinence, concentration difficulties. There was no documentation of physician interventions. On 8/20/2025 at 3:39 AM the nursing assessment documented Patient #1’s hemoglobin level results had dropped to 6.9 and the patient’s hematocrit had dropped to 22.3. There was no documentation Patient #1’s vital signs and O2 sat were taken at this time. The physician ordered for a unit of packed red blood cells (PRBC) to be administered to Patient #1. There was no documentation the PRBC were administered to Patient #1 and no physician follow-up. A Nursing Narrative Note dated 8/20/2025 at 6:13 AM revealed, “...Cleaned pt [patient] and stool was pure blood with clots. The Physician was made aware. No orders received...” There was no documentation Patient #1’s vital signs or O2 sats were taken. The Nursing Narrative Note dated 8/20/2025 at 7:30 AM revealed Patient #1 was actively bleeding and had a change in condition and Patient #1 was now diaphoretic and lethargic. There was no documentation Patient #1’s vital signs and O2 sat were taken and recorded. The internal medicine physician was asked to come to the patient’s bedside to assess Patient #1 (The medical record documentation revealed the internal medicine physician was notified at 7:30 AM and did not respond until 8:32 AM via telephone communication). Review of the Pharmacist Intervention note dated 8/20/2025 at 8:15 AM revealed, “ ...Patient admitted for possible Gastrointestinal [GI] Bleed and order placed for Protonix drip overnight (and current active order), but no administration found. Notified physician of patient bleeding with potentially major implications. Confirmed with primary team that drip to continue. Communicated need for medication to [named RN #1], who states she will start medication ...” The nurse started the Protonix drip on 8/20/2025 at 8:15 AM, 12 hours and 11 minutes after the Protonix had been ordered. The Nursing Narrative Note dated 8/20/2025 at 8:21 AM revealed, “...Internal Medicine team made aware at 0820 [8:20 AM] about patient being lethargic... GSC of 9 [Glasgow Coma scale- a tool used to assess a person’s level of consciousness after a brain injury or acute medical event by scoring their eye-opening, verbal, and motor responses, totaling a score from 3 to 15; a score of 15 is a person who is awake and alert to person, place, time; a score of 9 signifies moderate traumatic brain injury; Patient #1 had been deemed to have a GSC of 15 on admission meaning the patient was alert to person, place, time and situation], increased tremors, and perspiration. Patient is unable to swallow at this time due to inability to follow commands, stay awake, or protect airway with swallowing... Bedside RN [registered nurse] brought concern to team about potential Parkinson’s Crisis due to symptom presentation, inability to swallow Parkinson medications, and increasing symptoms...Charge RN made aware...” There was no documentation of physician assessment or orders. Review of the physician’s Progress Note for Patient #1 dated 8/20/2025 at 8:59 AM (before Patient #1 expired)revealed, “...overnight Patient #1 was noted to have melanotic [black or tarry-looking] stools. Patient was placed NPO [nothing by mouth] and started on IV pantoprazole [protonix - this medication was not started by nursing until 8/20/2025 at 8:15 AM, 12 hours and 11 minutes after being ordered] with plans for GI [gastroenterology] consult. He remained hemodynamically stable throughout the night. This morning, patient was noted to have an acute drop in Hgb down to 6.9 from 9.8. A unit of blood was ordered. Given the patient could not consent, the blood was not given pending permission from Warden. Shortly after, RN called stating patient was more confused and altered. He remained hemodynamically stable at this point. The ICU resident was called at 8:41 AM to transfer the patient to the ICU. During handoff, a RRT was called. When we arrived to the room, active chest compressions were being given. At this point, it escalated to a Code Blue. ACLS [Advanced Cardiac Life Support] protocol was started. Cardiac monitor showed PEA [pulseless electrical activity - no pulse or heartbeat is felt but when a patient is hooked up to the heart monitor, there is activity showing on the screen] for first 20 minutes of the code. Bag-mask ventilation followed by ET [endotracheal ] intubation ... Patient with frank blood coming out of oropharynx, 500 ml was suctioned out into canister. Patient soiled with bright red hematochezia [blood in stool] ... Left Tibia IO [intraosseous - a needle is inserted into the bone marrow to administer fluids, medications or blood products] access was initialed, along with left AC [anticubital area- bend of the arm] and right dorsal hand. 2 units of PRBC’s were given with pressure bag along with epinephrine. Pulse checks were done with Doppler, with no pulse present. Persistent Asystole [straight-line on cardiac monitor; no activity from the heart] on cardiac monitor... Given prolonged downtown without ROSC [return of spontaneous circulation], poor prognosis, and no acute reversible cause, decision was made to terminate resuscitation. Time of death pronounced at 9:28 AM...” The total duration of the code blue for Patient #1 was documented as approximately 50 minutes and “based on the prolonged downtime of [Patient #1] without return of spontaneous circulation, poor prognosis, and no acute reversible cause, the decision was made to terminate resuscitation efforts”. The patient’s date and time of death were documented at 8/20/2025 at 9:28 AM, 24 hours and 27 minutes after being transferred to Hospital #1 for treatment of an emergency medical condition. Review of the Discharge Documentation for Patient #1 electronically entered/signed by the physician on 8/20/2025 at 3:11 PM revealed, “...8/20/2025 Time of death: 9:28 AM On exam, no heart sounds or breath sounds were noted after 1 minute of auscultation. Pupils were fixed and dilated without pupillary light reflex. No work of breathing, cardiac monitor with asystole and no blood pressure on cuff reading. Patient was pronounced dead on 8/20/2025 at 9:28 AM. Attending [named attending physician] present...Patient suffered cardiac arrest earlier this morning in the setting of a massive GI bleed. Full ACLS protocol was initiated. Despite resuscitative efforts, patient remained pulseless with asystole on cardiac monitoring. Disposition: Prison has been notified. Body disposition per hospital policy and prison protocol... Cause of death: Cardiac and respiratory arrest, secondary to hemorrhagic blood loss due to GI bleed...” Review of the Patient #1’s Record of Death document dated 8/20/2025, revealed Patient #1’s death was caused by Hypovolemia (condition in which your body loses to much fluid and/or blood volume) secondary to Arterial Gastrointestinal (GI) Bleed. During an interview on 9/4/2025 at 9:00 AM with RN #2, when asked why nursing failed to obtain a fecal specimen from Patient #1 for the Immunological Fecal Occult Blood test, RN #2 stated the physician should have obtained the specimen for the Immunological Fecal Occult Blood test and not a nurse. During an interview on 9/4/2025 at 9:15 AM when asked about Patient #1’s hospital stay, Physician #1 stated, “...his hemoglobin was 9.8, with him being hemodynamically stable and he was admitted to the medical floor...overnight the nurse reported the patient started having melena or black stool but otherwise his vital signs stable...we did stop the Prednisone because of a upper GI bleed and ordered Immunological Fecal Occult Blood specimen test [this test was never obtained and there was no physician follow-up]...the overnight resident did order one unit of blood [this blood was never administered]...when we got the hemoglobin result of 6.9, we did communicate with the ICU [Intensive Care Unit] team for possible transfer...while we were giving report to the ICU team the patient coded [lost heart and respiratory function]...” Physician #1 was asked about the missed Protonix medication that was not administered intravenously (IV) and the missed Immunological Fecal Occult Blood specimen test order and Physician #1 stated, “...I forwarded a text from the pharmacist to the 7th floor director around 7:30 AM that the ordered Protonix was not given...” When asked about not administering blood transfusions to forensic patients and waiting on consent from the Warden instead, Physician #1 stated, “...the patient was unable to give consent [although there was a copy of the patient’s Advanced Directives on the chart consenting to blood transfusions] and at that point we would have called the facility [prison], the medical facility doctor who transferred the patient. I would have called the physician covering that facility again to ask him if there is a power of attorney or see who we can get the consent from. With inmates it is different to be honest. We try to check the chart to see if there is a conservator who would make decisions for them. The next option would be the prison medical director or their facility medical director or the provider who transferred the patient for more guidance...” There was no documentation the Prison Physician had been contacted by Hospital #1. During an interview on 9/4/2025 at 9:30 AM, when asked why Patient #1 was not given blood products RN #1 stated, “ ...I called the physician because we didn’t have consent for blood. The patient was confused and altered, and I told the physician he would have to consent with the Warden ...” RN #1 was asked if they always consulted with the Warden regarding emergency medical decisions for inmates RN #1 stated, “ ...if the patient is not able to give consent, we cannot contact family. The consent has to come from the facility they transferred from...” During an interview on 9/4/2025 at 1:00 PM when asked what was the procedure if a forensic patient has Advance Directives and the Director of the 7th floor stated, “ ...if an inmate [forensic patient] has an advanced directive the nurse would chart it in the electronic record, and it should be scanned into the medical record ...” When asked who gives medical consent for forensic patients the 7th floor Director stated, “ ...if the patient does not have an advanced directive and they are unable to make decisions for themselves then the physicians would have to confer with the Correctional Facility [prison]. If it is an emergency, then the physicians can do an emergency override. If it is not an emergency, then the physician must get permission from the Correctional Facility. The Correctional Facility makes medical decisions on behalf of inmates because they own them. The Correctional Facility makes the medical decisions because they are the inmates POA [Power of Attorney]. If a prisoner has a designated POA we still have to work through the Correctional Facility to be able to talk with the POA...” The facility did not provide a policy that detailed the warden must be contacted before any emergency life-saving treatment was provided to a forensic patient. During an interview on 9/4/2025 at 1:30 PM when asked if there is a protocol for consent for forensic patients, the Internal Medicine Resident who worked the night of 8/19/2025 with Patient #1 stated, “if an inmate does not have medical decision capabilities, you would speak to the Warden or the physician on call at the facility they came from. I received a phone call from the nurse stating I could not consent, and I needed to call the Warden and get a consent.” During an interview on 9/8/2025 at 9:10 AM when asked about the consent process for forensic patients, the Director of Quality stated, “if we provide care to an inmate that is different from what they came here for we have to get the authorization from prison over billing. It had nothing to do with consent but preauthorization for services. I wonder over the years this somehow got overinterpreted into the world of consent. This is something that we are going to work on internally. Historically speaking, [the name of the State Correctional Facility Organization] came over and really tore us a new one, saying they looked at what we were doing, and we were advocating for criminals. They impressed on us that inmates are their property and belong to them and make sure the hospital has consent from them before we do anything, and anything outside of that, we are advocating for criminals and that is not a good look. This happened many years ago and I think we have people who are still working here and that that became the unintended culture ...” During an interview on 9/11/2025 at 09:40 AM, Correctional Facility Guard #1 stated, “...I am just here for security and know nothing about patient consent...” During an interview on 9/11/2025 at 09:50 AM, Correctional Facility Guard #2 stated, “...we have nothing to do with consent of a patient...” During a telephone conference interview on 9/18/2025 at 3:00 PM, when asked if she was approached by hospital staff inquiring about consent for Patient #1, Correctional Facility Guard #3 stated, “... I was not asked for any permission for Patient #1 to have a blood transfusion... if there was any request for prior authorization it did not come through me...” During a telephone conference interview on 9/18/2025 at 3:10 PM, Correctional Facility legal representative stated, “...the hospital was to follow its own protocols and procedures regarding the treatment and care of an inmate in the Department of Corrections custody. Once they are admitted to the hospital, we are not making those decisions...we don’t weigh in on medical decisions...” Refer to A-0115 and A-0132”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 51739 Based on review of hospital policy, document review, medical record review, and interview, the hospital failed to honor patient’s rights and comply with patient’s Advanced Directives for 1 of 6 (Patient #1) sampled patients reviewed who had Advanced Directives in the medical record to receive blood transfusions. Patient #1’s medical condition deteriorated after admission when the patient began losing a large amount of blood, and laboratory results revealed the patient’s blood levels had dropped to a critical level and required a blood transfusion to treat the emergency medical condition. The hospital failed to administer the blood transfusions to Patient #1. Patient #1 expired 24 hours and 27 minutes after arriving at the hospital for emergency medical treatment. The record of death documented the cause of death as Hypovolemia [low blood volume] secondary to Arterial Gastrointestinal Bleeding. The findings included: 1. Review of the facility policy titled “Patient Rights and Responsibilities Policy” dated 6/2025, revealed, “...all patients have the rights and responsibilities regardless of a patient’s prior conviction of a crime or membership in any other protected classes as set forth in state or federal law...The right to considerate, respectful care given by competent personnel in a safe environment free from all forms of abuse, neglect or mistreatment, and in a manner that optimizes the patient’s comfort and dignity...Patient rights may be exercised through the patient individually and/or through individuals authorized to represent their interests...The facility honors advance directives to the fullest extent possible within the limits of law, regulation and the policies and capabilities of our institution...” Review of the facility policy titled “Care and Treatment for Inmate/Forensic Patients Policy” dated 7/2023, revealed, “...Consent for Treatment: Inmates retain the right to provide consent for health care services. All hospital policies pertaining to consent for care and treatment will be followed...” Review of the facility policy titled “Blood Transfusion & Suspected Reaction Policy” dated 7/5/2025, revealed, “... PROCEDURE: In the event of an emergency, as documented in the Progress Note by the physician, a consent may not be possible until improvement of patient’s condition... Indications for Transfusion... Hypovolemia due to surgery, trauma, or gastrointestinal bleeding documented by one of the following... Systolic blood pressure less than 100 mm [millimeters]/Hg [mercury] or diastolic blood pressure less than 60... Acute anemia with Hematocrit [Hct] < [less than] 20 OR Hemoglobin [Hgb] < 8 GM [grams]... Active GI [gastrointestinal] bleed... Documented symptomatic regardless of the Hgb level... Acute blood loss with symptoms and signs of Hypovolemia (i.e. for blood pressure, tachycardia, tachypnea, orthostatic hypotension, low urinary output [UOP], poor peripheral perfusion, change in sensorium)...” 2. Review of the (named State) Department of Correction policy titled “ADMINISTRATIVE POLICIES AND PROCEDURES” dated October 15, 2022, revealed, “...PURPOSE: To establish guidelines for an inmate’s informed consent or refusal of health care services...PROCEDURES... Emergency Treatment: The healthcare informed consent requirement shall be waived when, in the opinion of the health provider, an emergency situation exists that requires immediate medical or psychiatric intervention to prevent loss of life or limb or to prevent the inmate from harming himself or others, and the inmate lacks the capability to make an informed decision to consent to or refuse treatment...” Review of the (named State) Department of Corrections policy titled “HEALTH RECORDS” with an effective date of February 2, 2024, revealed, “ ...inmates may make advance directives to express their choices regarding their healthcare services. In some cases, a “healthcare agent” may be appointed to make healthcare decisions for an inmate in circumstances where the inmate cannot do so for him/herself ... Health services staff ensure that inmates may make advance directives to express their choices regarding their healthcare services. When an inmate is transferred to a community hospital, a copy of the advance directive, healthcare agent appointment, and/or Tennessee Physician Orders for Scope of Treatment (POST), PH-4193, is forwarded to that hospital. A responsible individual at the community hospital signs for the receipt of the advance directive and/or documentation of the health care agent appointment ... Emergency Treatment: The healthcare informed consent requirement shall be waived when, in the opinion of the health provider, an emergency situation exists that requires immediate medical or psychiatric intervention to prevent loss of life or limb or to prevent the inmate from harming himself or others, and the inmate lacks the capability to make an informed decision to consent to or refuse treatment ... If it appears that an inmate lacks the capability to make rational decisions due to mental incapacity, the provider will refer to the inmate’s advance directive if any ... In the absence of an advance directive, the provider shall seek informed consent from the inmate’s healthcare agent, if the inmate has such a representative. For general medical care, in the absence of effective consent from the inmate or from an agent, the provider may implement a decision on behalf of the inmate after consultation with another physician who is not involved in the inmate’s care as provided by the [named State]Healthcare Decisions Act ... An inmate may make an advance directive at any time...When information is received that an inmate has made an advance directive, the Health Services Administrator/designee shall record the advance directive in the Health Record and shall document the fact of the advance directive on the Major Medical Conditions Problem List ... If an inmate has not designated a legal surrogate, the provider may identify an appropriate surrogate in accordance with the provisions of the [named State] Healthcare Decisions Act ... A healthcare agent for health care decisions can make any decision that the inmate could make about healthcare services, except that the agent cannot revoke an advance directive or make a decision that is contrary to the advance directive ... When it appears that an inmate lacks mental capacity and has no legally authorized representative, a physician, psychologist, or psychiatrist shall evaluate the inmate to confirm his/her mental capacity. If the evaluation concludes that the inmate is unable to give informed consent and is unlikely to regain the capacity in the immediate future to give informed consent, the evaluating provider shall advise the Warden/Superintendent and Deputy Commissioner/General Counsel of the inmate’s need for a guardian or conservator to make health care decisions for the inmate ... Staff may encounter circumstances wherein an inmate’s healthcare agent is deceased, incapacitated, unavailable, unresponsive, or (in the opinion of the provider) has wrongfully refused treatment. In these cases, the Health Services Administrator/designee shall advise the Warden/Superintendent and request that the Deputy Commissioner/General Counsel determine whether a different agent shall be identified or appointed ...” Review of the “[named State] Health Care Decisions Act” dated 2024, Section 68-11-1803, revealed, “...(i) No health care provider or institution, and no health care service plan, insurer issuing disability insurance, self-insured employee welfare benefit plan, or non-profit hospital plan, shall require the execution or revocation of an advance directive as a condition for being insured for, or receiving, health care...” 3. Medical record review for Patient #1 revealed the patient arrived to Hospital #1 Emergency Department (ED) from Forensic Facility #1 via emergency medical services (EMS) on 8/19/2025 at 9:01 AM due to an altered mental status and low blood pressure (BP). Patient #1 was triaged in the hospital’s emergency department (ED) has a level “2” which indicates the patient was emergent (an unexpected situation that requires immediate action to prevent an imminent threat to life, health, public safety or property. It is a severe crisis demanding immediate intervention such as a medical emergency such as a cardiac arrest, severe trauma or respiratory failure). Patient #1 was described as alert, but slow to answer questions and his psychosocial interactions were documented as slow. Review of Patient #1’s Laboratory Results dated 8/19/2025 at 11:29 AM revealed the patient’s Hemoglobin (Hgb) level was low at 9.8 (normal for male is 14 - 17.5) and the Hematocrit (Hct) level was low at 31.1 (normal for male is 41 - 50. Low levels of Hgb and Hct means the body does not have enough red blood cells to carry oxygen effectively throughout the body). There was no documentation of new orders based on the lab results. Patient #1 was admitted to the hospital for further treatment on 8/19/2025 at 12:27 PM. Review of the “History and Physical Reports” dated 8/19/2025, revealed the physician confirmed Patient #1’s Advance Care Plan was present and the code status was documented. The Advance Care Plan documented Patient #1’s consent for medical treatment which included blood transfusions. Review of an “Advance Care Plan” dated and signed by Patient #1 on 2/27/2020 revealed, “...I [Patient #1’s name] hereby give these advance instructions on how I wan/t to be treated by my doctors and other healthcare providers when I can no /longer make those decisions myself... I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my ageny must follow my instructions below. (The area designated for the name of the agent, along with telephone number, relationship to the patient, and the agent’s address was blank.)... Treatment... [box checked indicating yes] Treatment of New Conditions: Use of surgery, blood transfusions or antibiotics that will that will deal with a new condition but may not help the main illness... Signature: Your signature must either be witnessed by two competent adults or notarized. If witnessed, neither witness may be the person you appointed as your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate... [Signature of Patient #1]... [Signature of two witnesses]...” Review of a nursing assessment on 8/20/2025 at 3:39 AM revealed Patient #1’s hemoglobin level had dropped to 6.9 and the patient’s hematocrit had dropped to 22.3, indicating low blood volume. The Resident Physician on call ordered a unit of packed red blood cells (PRBC) to be administered to Patient #1. There was no documentation the PRBC’s were administered. Review of a Nursing Narrative Note dated 8/20/2025 at 6:13 AM revealed, “...Cleaned pt and stool was pure blood with clots. Physician was made aware. No orders received...” Review of a nursing assessment on 8/20/2025 at 7:30 AM revealed Patient #1 was bleeding and had a change in condition. Patient #1 diaphoretic/lethargic. The internal medicine physician was asked to come to the patient’s bedside. There was no documentation the internal medicine physician assessed Patient #1 at this time. Review of a nursing assessment on 8/20/2025 at 8:00 AM revealed Patient #1’s blood pressure was 138/65, heart rate 98, respiratory rate 18. Patient #1 had dizziness, cough, incontinence of stools, black/bloody appearance; concentration difficulties, confusion disorientation. Patient #1 had diminished breath sounds in all lobes, received O2 at 2 LPM. The patient’s abdomen was firm and round, black blood tinged stool; Parkinson’s tremors, characteristics of communication is delayed; characteristics of speech is delayed. The patient is lethargic, has concentration difficulties, confusion/disorientation, and drowsy. Review of the Nursing Narrative Note dated 8/20/2025 at 8:21 AM revealed, “...Internal Medicine team made aware at 0820 [8:20 AM] via telephone about patient being lethargic...GSC [GSC is Glasgow Coma Scale - measures brain activity] to 9 [signifies moderate traumatic brain injury], increased tremors, and perspiration. Patient is unable to swallow at this time due to inability to follow commands, stay awake, or protect airway with swallowing... Bedside RN brought concern to team about potential Parkinson’s Crisis due to symptom presentation, inability to swallow Parkinson medications, and increasing symptoms... Charge RN made aware...” On 8/20/2025 at 8:41 AM, the Intensive Care Unit (ICU) Resident (Physician in training) was called to transfer Patient #1 to the ICU. During handoff to the ICU team, Patient #1 became unresponsive without a heart rate and respirations. A rapid response team ((RRT) - team to provide emergency interventions to save a life) was called. When the RRT arrived to the Patient #1’s room, chest compressions were being administered to Patient #1. The RRT was escalated to code blue (code blue means cardio-pulmonary resuscitation (CPR)) at this point. The cardiac monitor placed on Patient #1 showed pulseless electrical activity (PEA - no heart activity) for the first 20 minutes of the code blue on 8/20/2025. Patient #1 was intubated (a tube was inserted into the patient’s trachea/windpipe to maintain an open airway) as CPR continued. The RRT staff documented Patient #1, “ had frank blood coming out of oropharynx (mouth and throat), 500 milliliters (of blood) was suctioned out into canister”. Patient #1 was soiled with bright red blood in the stool. Two units of packed red blood cells were administered with pressure bag along with epinephrine. Pulse checks were performed with a Doppler (device to assist with checking pulse rate), and no pulse was present. Persistent asystole (no heart rate) was revealed on the cardiac monitor. Patient #1 expired with time of death 9:28 AM. Review of the physician’s Progress Note for Patient #1 dated 8/20/2025 at 8:59 AM revealed, “...overnight Patient #1 was noted to have melanotic [black or tarry-looking] stools...This morning, patient was noted to have an acute drop in Hgb down to 6.9 from 9.8. A unit of blood was ordered. Given the patient could not consent, the blood was not given pending permission from Warden....” Review of Patient #1’s Record of Death document dated 8/20/2025, revealed Patient #1’s death was caused by Hypovolemia (condition in which your body loses to much fluid and/or blood volume) secondary to Arterial Gastrointestinal (GI) Bleed. During an interview on 9/4/2025 at 9:15 AM when asked about Patient #1’s hospital stay, Physician #1 stated, “...his hemoglobin was 9.8, with him being hemodynamically stable and he was admitted to the medical floor...overnight the nurse reported the patient started having melena or black stool but otherwise his vital signs stable...we did stop the Prednisone because of a upper GI bleed and ordered Immunological Fecal Occult Blood specimen test...the overnight resident [physician in training] did order one unit of blood...when we got the hemoglobin result of 6.9, we did communicate with the ICU (Intensive Care Team) team for possible transfer...while we were giving report to the ICU team the patient coded...” When asked about not administering blood transfusions to forensic patients and waiting on consent from the Warden instead, Physician #1 stated, “...the patient was unable to give consent [although there was a copy of the patient’s Advanced Directives on the chart consenting to blood transfusions] and at that point we would have called the facility [prison], the medical facility doctor who transferred the patient. I would have called the physician covering that facility again to ask him if there is a power of attorney or see who we can get the consent from. With inmates it is different to be honest. We try to check the chart to see if there is a conservator who would make decisions for them. The next option would be the prison medical director or their facility medical director or the provider who transferred the patient for more guidance...” During an interview on 9/4/2025 at 9:30 AM, when asked why Patient #1 was not given blood products RN #1 stated, “...I called the physician because we didn’t have consent for blood. The patient was confused and altered, and I told the physician he would have to consent with the warden...” RN #1 was asked if they always consulted with the Warden regarding medical decisions for inmates she stated, “...if the patient’s not able to give consent, we cannot contact family. The consent has to come from the facility they transferred from...” During an interview on 9/4/2025 at 1:00 PM when asked what was the procedure if a forensic patient has an Advance Care Plan and the Director of the 7th floor stated, “...if an inmate [forensic patient] has an advanced directive the nurse would chart it in the electronic record, and it should be scanned into the medical record...” When asked who gives medical consent for forensic patients 7th floor Director stated, “...if the patient does not have an advanced directive and they are unable to make decisions for themselves then the physicians would have to confer with the Correctional Facility [prison]. If it is an emergency, then the physicians can do an emergency override. If it is not an emergency, then the physician must get permission from the Correctional Facility. The Correctional Facility makes medical decisions on behalf of inmates because they own them. The Correctional Facility makes the medical decisions because they are the inmates Power of Attorney (POA). If a prisoner has a designated POA we still have to work through the Correctional Facility to be able to talk with the POA...” During an interview on 9/4/2025 at 1:30 PM when asked if there is a protocol for consent for forensic patients, the Internal Medicine Resident who worked the night of 8/19/2025 with Patient #1 stated, “if an inmate does not have medical decision capabilities, you would speak to the Warden or the physician on call at the facility they came from. I received a phone call from the nurse stating I could not consent, and I needed to call the Warden and get a consent.” During an interview on 9/8/2025 at 9:10 AM when asked about the consent process for forensic patients, the Director of Quality stated, “if we provide care to an inmate that is different from what they came here for we have to get the authorization from prison over billing. It had nothing to do with consent but preauthorization for services. I wonder over the years this somehow got overinterpreted into the world of consent. This is something that we are going to work on internally. Historically speaking, [the name of the State Correctional Facility Organization] came over and really tore us a new one, saying they looked at what we were doing, and we were advocating for criminals. They impressed on us that inmates are their property and belong to them and make sure the hospital has consent from them before we do anything, and anything outside of that, we are advocating for criminals and that is not a good look. This happened many years ago and I think we have people who are still working here and that that became the unintended culture ...” During an interview on 9/11/2025 at 09:40 AM, Correctional Facility Guard #1 stated, “...I am just here for security and know nothing about patient consent...” During an interview on 9/11/2025 at 09:50 AM, Correctional Facility Guard #2 stated, “...we have noting to do with consent of a patient...” During a telephone conference interview on 9/18/2025 at 3:00 PM, when asked if she was approached by hospital staff inquiring about consent for Patient #1, Correctional Facility Guard #3 stated, “... I was not asked for any permission for Patient #1 to have a blood transfusion... if there was any request for prior authorization it did not come through me...” During a telephone conference interview on 9/18/2025 at 3:10 PM, Correctional Facility legal representative stated, “...the hospital was to follow its own protocols and procedures regarding the treatment and care of an inmate in the Department of Corrections custody. Once they are admitted to the hospital, we are not making those decisions...we don’t weigh in on medical decisions...” Refer to A-0049”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 35244 Based on policy review, record review and interview, the facility failed to ensure a death of a patient in seclusion was reported for 1 of 1 (Patient #1) secluded patients reviewed. The findings included: 1. Review of the facility’s “Restraints and Seclusion” policy (effective 12/2021) revealed, “...Death Associated with the Use of Restraints/Seclusion...The nursing supervisor will report the following to the Compliance Office...Any death occurring while the patient is in restraints or seclusion...Any death that occurs within 24 hours after the patient has been removed from restraints or seclusion...The Compliance Officer will be responsible for notifying Centers for Medicare/Medicaid (CMS) no later than the close of the next CMS business day following knowledge of the patient’s death. The Compliance Officer will place a written verification in the patient’s medical record of the date and time of report to CMS...” 2. Record review for Patient #1 revealed arrival to the hospital’s Emergency Department (ED) on 2/24/2023 at 2:05 AM with chief complaint of violent behavior. Patient #1 was brought to the ED by his Mother, who informed staff that he had not been taking his psychiatric medications and had not slept for 3 days. Patient #1 was documented as having violent behavior toward staff upon arrival to the ED. Patient #1 remained in the ED until his death on 3/2/2023. Review of nursing assessments beginning 2/24/2023 at 7:15 AM revealed “...Seclusion Order Received and Implemented...” Review of “PHYSICIAN ORDERS Behavioral Restraint/Seclusion” orders revealed Patient #1 was placed on Seclusion beginning 2/24/2023 and remained in Seclusion through 3/2/2023. Further review of nursing assessments beginning 3/2/2023 at 2:00 AM documented, “...Pt [patient] was sitting in what looked like Feces was able to get Pt dressed put him on a shirt but unable to get his pants on pt stood up and was walking to bathroom as he we escorted him to the bathroom the pt colasped [collapsed] and started to have what looked like seizure activity...CPR [cardiopulmonary resuscitation] started...” Review of a 3/2/2023 “DEATH NOTIFICATION FORM” revealed time of death as 2:42 AM. There was no documentation in the medical record of CMS being notified of Patient #1’s death while in seclusion. In an interview on 6/25/2024 at 11:00 AM, the facility’s Interim Quality Director verified there was no documentation of CMS being notified of Patient #1’s death.”