Christus Good Shepherd Medical Center

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure blood was transfused in accordance with their approved policies. The facility failed to: Ensure blood was administered at the correct rate and vitals were accurate and completed on 2 of 21 sampled patients who received blood transfusions (Patient #’s 3 and 9). This deficient practice had the likelihood to affect all patients that received blood. Findings include: Patient #3 Review of the ED record on Patient #3 revealed he was a 34-year-old male who presented to the ED on 03/30/2026 at 5:46 p.m. for sickle cell pain crisis. The triage was initiated at 6:10 p.m. There was documentation in the record that Patient #3 had lower back pain since Monday. At 6:11 p.m. Patient #3 was given an emergency severity index score of 3. Review of lab results at 7:53 p.m., revealed the following: Red blood cells- 2.37 (reference ranges 4.27-5.49) Hemoglobin of 7.1(reference ranges 12.9-16.1) Hematocrit of 19.3(reference ranges 38.3-48.6) Physician orders on 03/31/2026 at 8:11 a.m. was to Transfuse RBC. The transfusion duration per unit was “(within): 3 hours.” According to the transfusion record the blood was started on 03/31/2026 at 10:54 p.m. and was at 75 ml per hour. There was no physician’s order for the rate of 75 ml per hour. The blood was increased to 175 ml per hour at 11:08 p.m. At 2:03 a.m., the vital signs were blood pressure of 111/64, pulse of 73, respirations of 18 and temperature of 98.5 degrees Fahrenheit. The stop time for the blood was 02:54 a.m. (4 hours later). A pulse of 62 was documented at 3:12 a.m. The next full set of vital signs was not documented until over 1.5 hours later at 4:31 a.m. Physician orders on 04/04/2026 at 4:23 a.m. read to Transfuse RBC. The transfusion duration per unit “(within): 3 hours.” According to the transfusion record the blood was started on 04/04/2026 at 6:21 p.m. at 100ml per hour. At 6:21 p.m., the vital signs were a blood pressure of 114/76, pulse of 76, respirations of 18 and temperature of 98.4 degrees Fahrenheit. The stop time for the blood was 9:37 p.m. The vital signs at 9:37 p.m. were a blood pressure of 105/45, pulse of 80, respirations of no respirations documented and a temperature of 98.2 degrees Fahrenheit. The vitals were logged for the same time as the start and stopping of the blood. Not prior to or afterwards as required per the facility’s policy. Patient #19 Review of the ED record on Patient #19 revealed she was an 87-year-old female who presented on 05/26/2026 at 3:45 p.m. for a decrease in her hemoglobin and fatigue. Patient #19 was documented as having an emergency severity index of 3. At 3: 58 p.m., the vital signs were documented as a blood pressure of 131/35, pulse of 58, respirations of 15 and oxygen saturation of 97% on room air. At 4:06 p.m. there was a physician’s order to Transfuse 2 units of red blood cells. Lab results at 4:26 p.m. revealed the following: Red blood cell count of 3.0(reference ranges 4.27-5.49) Hemoglobin of 8.3 (reference ranges 12.9-16.1) Hematocrit of 27.6 (reference ranges 38.3-48.6) At 7:02 p.m. the vital signs were a blood pressure of 126/37, pulse of 66 and oxygen saturation of 89% on room air. At 7:14 p.m. Patient #19 fecal sample tested positive for blood. Lab results at 9:27 p.m. revealed the following decrease: Hemoglobin of 7.6(reference ranges 12.9-16.1) Hematocrit of 24.7(reference ranges 38.3-48.6) According to the documentation a transfusion started at 75 cc per hour at 11:30 p.m. The first set of vital signs were a blood pressure of 126/46, pulse of 72, respirations of 15 and temperature of 97.9 degrees Fahrenheit. At 11:45 p.m. the vital signs were a blood pressure of 141/42, pulse of 67, respirations of 15 and temperature of 98.8 degrees Fahrenheit. At 11:48 p.m. the rate of the infusion was increased to 175 cc per hour. At 1243 midnight and 01:01 a.m. vital signs were documented and there was no temperature included. At 1:47 a.m. the transfusion was completed and the vital signs were a blood pressure of 138/37, pulse of 72, respirations of 16 and temperature of 98.3 degrees Fahrenheit. The total amount infused was 350 cc. The rate of 75 cc per hour was not ordered or mentioned in the facility’s policy. The vital signs were incomplete. During an interview on 05/29/2026 after 1:00 p.m. Staff #5 confirmed the rate of the transfusion and the vital signs. Review of the facility’s policy named “Blood Product Administration” dated 09/23 revealed the following: “ ...V. DEFINITION Duration of Blood Product Transfusion-The duration of blood product transfusion, in the provider order, is defined as infusing within the time specified ... ...B. Initiating and continuing the transfusion ... ...4. Check the patient’s vital signs and document in the electronic medical record: a. Baseline, within 30 minutes before initiating the transfusion. b. Within 15 minutes after initiating the transfusion. c. Upon completion of the transfusion d. Within 1 hour after the transfusion is completed in the in-patient setting or prior to discharge in the ambulatory setting .... 5 .... ...b. For Packed Red Blood Cells (PRBC)-Non-emergent transfusions should be initiated at a rate of 100 ml/hour for the first 15 minutes, unless otherwise specified by the provider ....””

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the emergency department (ED) was organized in a manner to provide safe patient care in 7 of 21 sampled patients (Patient #’s 3,5,7,9,16,17 and 20). The facility failed to ensure: A. Patient #’s 3 and 9 were assessed for pain and reassessed timely after receiving pain medication. B. Patient #17 who had an elevated blood pressure and who received a blood pressure medication was reassessed prior to discharge from the ED. C. Patient #’s 5, 7, 16 and 20 signed appropriate against medical advice (AMA) paperwork or refusal of treatment paperwork before leaving the emergency department ED. This deficient practice had the likelihood to affect all patients presenting to the Emergency department (ED). Findings include: Pain assessment Patient #3 Review of the ED record on Patient #3 revealed he was a 34-year-old male who presented to the ED on 03/30/2026 at 5:46 p.m. for sickle cell pain crisis. The triage was initiated at 6:10 p.m. There was documentation in the record that Patient #3 had lower back pain since Monday. There was no documentation of what the pain level was. At 6:11 p.m. Patient #3 was given an emergency severity index score of 3. At 6:24 p.m. the pain medication Droperidol 2.5 milligrams was ordered, once and STAT. At 6:25 p.m., the pain medication Hydromorphone 1 milligrams tab was order once and STAT. The first documentation of a pain assessment was at 7:49 p.m., 2 hours and 3 minutes after presenting to the ED. Patient #3’s pain level was described as being a level 8 (meaning severe) and stabbing back pain. At this time Patient #3 received Dilaudid 1 milligrams. At 8:22 p.m. Patient #3 was described as having a pain level of 7 and it was generalized. At 9:00 p.m. Dilaudid 1 milligrams was administered. At 10:00 p.m. Patient #3 was described as having a pain level of 7 and Dilaudid 1 milligrams was administered. There was no documentation of the location of the pain. At 10:24 p.m. Patient #3 received an order to admit to inpatient. There were physician orders written for Dilaudid tablet 2 milligrams every 4 hours whenever needed and Oxycodone tablet immediate release 5 milligrams every 4 hours whenever needed. At 10:57 p.m. Patient #3 had a pain level of 8 and at 11:09 p.m. it was an 8. There was no documentation for an assessment of the location of the pain. At 11:09 p.m. the pain medication Dilaudid 2 milligrams was administered. At 11:40 p.m. and 12:09 midnight Patient #3 still had a pain level of 8. At 12:59 midnight Patient #3 was admitted to the ortho floor. Patient #9 Review of the ED record on Patient #9 revealed he was a 33-year-old male who presented to the ED on 05/03/2026 at 6:48 p.m. for sickle cell pain crisis. At 7: 53 p.m. there was documentation that Patient #3 was called three times and there was no answer. The triage was initiated at 8:24 p.m. There was documentation in the record that Patient #9 had leg and back pain. There was documentation that the pain level was a 7. At 8:44 p.m. Patient #9 administered the pain medication Dilaudid 1 milligrams. At 8:27 p.m., Patient #9 was given an emergency severity index score of 3. At 9:25 p.m., Patient #9 had a pain level of 8 and it was described as generalized pain. Patient #9 received the pain medication Percocet at this time. At 9:28 p.m. (three minutes later) Patient #9 was discharged from the ED. There was no assessment of the Patient #9’s pain after administration of the pain medication and before leaving the facility. During an interview on 05/28/2026 after 11:58 a.m., Staff #7 said pain relief was supposed to be assessed 30-40 minutes after administration. Review of a facility’s policy named “Pain Management” and reviewed 02/12/2026 revealed the following: “ ...EMERGENCY DEPARTMENT Initial Assessments Patients seen in the Emergency Department (ED) shall receive a screening during the triage or initial assessment process to identify the presence of pain. If the screen is positive, then the patient shall receive an assessment to gather sufficient information to identify the pain. The information that may be obtained during this assessment includes, but is not limited to: The intensity of pain using age or condition appropriate assessment tools; The location and nature of pain; The patient’s tolerance to pain and acceptable intensity of pain (pain goal); ... Routine Reassessment ... ...If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain... ...Reassessment Following Treatment for Pain ... If a treatment intervention for pain is provided, then the response to that intervention must be assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15 -60 minutes following treatment ....” Blood pressure medication assessment Patient #17 Review of the ED record on Patient #17 revealed he was a 49-year-old male who presented to the ED on 02/06/2026 at 11:21 a.m. for a psych evaluation. At 11:35 a.m. the triage was started and at 11:36 a.m. Patient #17 had an elevated blood pressure of 194/106. At 11:36 a.m., Patient #17 was given an emergency severity index score of 2 (meaning emergent). At 2:14 p.m. Patient #17 had an elevated blood pressure of 185/110 and at 2:35 p.m. he was given the blood medication Lisinopril 10 milligrams. At 3:09 p.m. Patient #17 was discharged from the ED, and another blood pressure was not taken prior to leaving. During an interview on 05/29/2026 after 1:00 p.m. Staff #5 confirmed there was no other blood pressure taken. Review of a facility’s policy named “Vital Signs Reassessment in the Emergency Department per ESI” dated 03/2025 revealed the following: “ ...V. PROCESS OR PROCEDURES ... ...2.ESI Level 2: Reassessment Frequency: No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable. b. Discharge Requirement: Vital sign assessment should be current within 30 minutes before discharge ...” Against medical advice (AMA) or refusal of treatment Patent #5 Review of the emergency department (ED) revealed that Patient #5 was a 46-year-old male who presented to the ED on 03/18/2026 for a psych evaluation. Review of a psych consult dated 03/19/2026 revealed that Patient #5 was to be admitted to inpatient due to MDD (major depressive disorder) psychosis. On 03/19/2026 at 11:16 a.m., Patient #5 said he was not going to the inpatient facility. The patient’s intravenous (IV) was removed. At 11:28 a.m. the Marshall police department was at the bedside. At 11:39 a.m., Patient#5’s belongings were given to him and he left at this time. There was documentation on the record at 11:54 a.m. that Patient #5 eloped. There was no documentation of an against medical advice (AMA) or refusal of treatment forms on the chart. During an interview on 05/28/2026 after 11:58 a.m., Staff #7 confirmed the forms were not on the chart. Patient #7 Review of the emergency department (ED) record on Patient #7 revealed she presented to the ED on 03/31/2026 at 4:01 p.m., for medical clearance and a psych evaluation. According to the ED record Patient #7 was brought in for attempting to jump in front of vehicles. There was documentation that the police department was at the bedside. At 8:17 p.m., Patient #7 was requesting to leave and at 8:54 p.m. there was documentation that Patient #7 was discharged. There was documentation under the ED disposition that Patient #7 eloped. There was no documentation of an against medical advice (AMA) or refusal of treatment forms on the chart. During an interview on 05/28/2026 after 11:58 a.m., Staff #7 confirmed the forms were not on the chart. Patient #16 Review of the ED record on Patient #16 revealed she was a 47-year-old male who presented to the ED on 02/06/2026 at 6:59 p.m. for psych evaluation. There was documentation at 7:57 p.m. that Patient #16 refused treatment and left after talking to the social worker. At 7:58 p.m. documented that Patient #16 was discharged. There was documentation in the physician’s screening that Patient #16 eloped from the ED. There was no documentation of an against medical advice (AMA) or refusal of treatment forms on the chart. Patient #20 Review of the ED record on Patient 20 revealed she was a 78-year-old female who presented to the ED on 05/26/2026 at 5:38 p.m. for kidney issues. Patient #20 was triaged at 6:10 p.m. and an intravenous was inserted at 6:27 p.m. There was documentation at 6:37 p.m. that Patient #20 eloped. At 6:38 p.m. the physician documented that Patient #20 was leaving against medical advice. There was no documentation in the chart of an attempt to get Patient #20 to sign an AMA form. During an interview on 05/29/2026 after 1:00 p.m. Staff #5 confirmed there was form on the record. Review a facility’s policy named “Against Medical Advice” dated 05/08/2023 revealed the following: “ ...V. DEFINITIONS .... ...A. Discharge AMA: defined as a patient discharge from the hospital before the treating physician recommends discharge ... ...C. Elopement: when a patient leaves the hospital without knowledge of staff ... ...H ...Refusal of Treatment AMA: defined as a patient or parents/legal guardians of a minor patient or patient’s personal representative refusing medical treatment or diagnostic studies as recommended by the physician .... ADULT PATIENTS ... Advice (AMA) form applicable to the AMA situation (i.e. Discharge AMA or Refusal of Treatment AMA). If the patient or patient’s personal representative refuses to sign the AMA room, review the form with the patient and/or patient’s representative. The nurse shall make a notation of the circumstances and patient’s refusal to sign the form in the patient’s medical record, as well as on the form, requiring one additional witness to sign the form as acknowledgement of the patient’s refusal to sign. The AMA form is to be included in and is part of the patient’s medical record ...” Review a facility’s policy named “Patient Screening and Transfer (EMTALA)” dated 08/01/2023 revealed the following: “ ...VI. POLICY ... ...B. INDIVIDUAL REFUSING EXAMINATION AND/OR PROCEDURE 1. If an individual declines the appropriate medical screening examination or the physician recommends further medical examination and treatment but the individual (or legally responsible person acting on the individual’s behalf) refuses to consent, the individual shall be informed of the hospital’s obligation to provide the examination and/or treatment and of the risks and benefits of the examination and/or treatment and of refusing the examination and/or treatment. 2. The individual shall be asked to sign the Refusal of Treatment form acknowledging receipt of this formation and the refusal. If the individual refuses to sign the form, the staff should sign the form confirming the request and that the required information was provided to the individual. 3. A description of the examination and/or treatment refused shall be documented in the medical record ...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 32143 Based on medical record reviews, the facility failed to ensure an appropriate transfer in accordance with EMTALA requirements for 1 (#1) of 19(#2-15) sampled patients. Findings include: A review of patient #1’s medical record revealed the facility failed to ensure the patient was informed of the risks and benefits of transfer and failed to obtain a physician’s certification for transfer. A review of the Memorandum of Transfer (MOT) dated 09/20/2025 at 1014 showed no documented explanation of the risks and benefits specific to the patient’s condition. The form indicated “involuntary transfer” in place of the patient’s signature. Further review revealed the MOT was signed by the RN House Supervisor rather than a physician or qualified medical provider, and there was no physician certification that the medical benefits of transfer outweighed the risks. The MOT included pre-printed language stating the risks, benefits, and alternatives to transfer were explained; however, the medical record lacked evidence that such discussion occurred or was individualized to the patient’s condition. The MOT stated, “Transfer: I acknowledge that a physician and/or mid-level provider has explained to me the medical condition(s) for which I need treatment and that they recommend that I be transferred to the services of Dr. Peddireddy at Ocean’s Longview. The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risks of not being transferred have been explained to me. I fully understand that there are risks to being transferred to another hospital and that such transfer may jeopardize my health and life. With this knowledge and understanding, I agree and consent to be transferred. I release and hold harmless this health care facility and the health care personnel attending to the patient from any liability that might be assert against them for any adverse outcomes resulting from the transfer. “ This deficient practice failed to ensure compliance with EMTALA requirements for an appropriate transfer and has the potential to place the patient at risk for harm during transfer.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47892 Based on document review and interview, the hospital failed to comply with §489.24 and complete a medical screening exam (MSE) and provide stabilizing treatment in the Emergency Department (ED) in 1 (patient #1) of 20 patient medical records reviewed. Findings: A document review of patient #1’s medical record was conducted on 9/03/2025 after 10:00 AM with Staff #6. Patient #1 was a 25-year-old male presenting to the ED on 7/07/2025 at 4:26 PM with a complaint of constipation. In the initial assessment performed by Staff #13 on 7/07/2025 at 4:35 PM, the medical record states that patient #1 has a pain assessment of 9 out of 10 (0 being no pain and 10 being the worst pain) in patient #1’s abdomen. There is no documentation after this initial pain assessment that states what measures were taken to address Patient #1’s pain. There is no documentation of any medications given to address Patient #1’s pain. The initial pain assessment is the only pain assessment noted at discharge. There is no documentation of reassessment of pain before discharge. Physician #11’s History and Physical (H&P) states, “Patient is a 25-year-old male with schizoaffective disorder presenting again to the emergency department today. Patient was seen earlier today for head injury and had some stitches placed. He comes back today, stating that he is constipated. He states that he is not having any significant bowel movements. Just very small pellet-like feces. Patient states he has to strain hard and sometimes feels that his rectum protrude from his body.” In the Physical Exam performed by Physician #11, there is no documentation that Patient #1’s pain was addressed, that a rectal exam was done, nor is there any documentation on whether Physician #11 palpated (to examine a part of the body by touch, usually with the hands and fingers, to feel size, shape, firmness, or location of an organ, swelling or abnormality) Patient #1’s abdomen to check for tenderness. Also, no diagnostic tests were ordered to examine the patient’s abdomen. Staff #12 states in the nursing notes that during an attempt to discharge patient #1, patient #1 refused to be discharged and requested to speak with Physician #11. Patient #1 was angry upon discharge and did not take his discharge paperwork. Patient #1 was discharged on 7/07/2021 at 5:16 PM. There is no documentation that Physician #11 ever went back to see the patient before discharge. An interview was conducted on 9/08/2025 at 2:10 PM with Staff #4, 6, and 13. Staff #6 and #13 were asked why there was no reassessment of pain on Patient #1. Staff #13 stated that patient #1 “was triaged, seen by the physician, and placed back in the lobby”. Staff #13 stated that once Patient #1 “realized he was to be discharged, he became angry and left the lobby without receiving his discharge paperwork”. Staff #13 stated, “Because of HIPAA, I would have brought the patient back from the lobby into a private room to get a set of vitals, reassess his pain, and go over his discharge paperwork. This would also be when the doctor would have seen him before he was discharged. But I was unable to do these things because the patient left before, I could bring him back to the room for discharge.” Staff #6 and 13 were asked where this is documented in the chart. Staff #6 stated that there is documentation stating that the patient left angry and without his discharge paperwork”. Staff #6 and #13 were asked where in Patient #1’s medical record it is documented why Staff #13 was unable to perform the discharge vital signs and pain reassessment. Staff #6 and 13 confirmed that there is no documentation stating why the discharge vital signs and pain reassessment were not performed in Patient #1’s medical record. Staff #6 and #13 were asked where in Patient #1’s medical record it is documented why Physician #11 did not see the patient before discharge, as Patient #1 requested. Staff #6 and #13 confirmed that there is no documentation stating why Physician #11 did not see Patient #1 before discharge.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, interview, and Texas state law, the facility failed to ensure that 14 patients (Patient #1, #2, #3, #4, #6, #7, #8, #9, #11, #12, #13, #14, #15, and #17) of 17 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault and the Texas Code of Criminal Procedure, Chapter 56A Rights of Crime Victims, Subchapter G. Forensic Medical Examination of Sexual Assault Victim, Art. 56A.303. Forensic Medical Examination. Refer to Tag A0117”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, interview, and Texas state law, the facility failed to ensure that 14 patients (Patient #1, #2, #3, #4, #6, #7, #8, #9, #11, #12, #13, #14, #15, and #17) of 17 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault and the Texas Code of Criminal Procedure, Chapter 56A Rights of Crime Victims, Subchapter G. Forensic Medical Examination of Sexual Assault Victim, Art. 56A.303. Forensic Medical Examination. Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subsection (b) requires: (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: ... (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; (4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...) ... (7) the name and telephone number of the nearest sexual assault crisis center; and ... CODE OF CRIMINAL PROCEDURE TITLE 1. CODE OF CRIMINAL PROCEDURE CHAPTER 56A. RIGHTS OF CRIME VICTIMS SUBCHAPTER G. FORENSIC MEDICAL EXAMINATION OF SEXUAL ASSAULT VICTIM Art. 56A.303. FORENSIC MEDICAL EXAMINATION. (c) A victim of a sexual assault may not be required to participate in the investigation or prosecution of an offense as a condition of receiving a forensic medical examination under this article. Findings included the following: Review of the State required information form showed the form explained to the patient their rights as a sexual assault survivor. Information on rights included: When an assault is required to be reported law enforcement (LE) and the Texas Department of Family and Protective Services (DFPS). The right to have an examination even if the assault was not reported to LE. The right to have someone with you during the examination. The right to have an advocate who “can answer any questions about the process and inform you of your options every step of the way.” A section on what advocacy is and how to access free services. Information on the benefits of a Medical Forensic Examination for a Sexual Assault. Information on Informed Consent. Information on what to expect during a Medical Forensic Examination for a Sexual Assault. Evidence storage. How to track your evidence kit. Sexually Transmitted Infections (STI)s and the right to receive testing and treatment. HIV/AIDS testing and treatment. Pregnancy and emergency contraception medication. What to do if you think drugs or alcohol were involved in the assault. Costs and Payments. Crime Victims’ Compensation Program. How to submit a complaint against a regulated health facility. The information contained in the State required information form was necessary for patients to be able to exercise all of their rights provided by Texas state law and make an informed decision about care they chose to receive. The right to access to a sexual assault program advocate provided the patient with a trained advocate who could answer any questions about the process and inform the patient of their options every step of the way. By delaying or never notifying a sexual assault program advocate, patients were left to make crucial decisions without all of the information and resources necessary. Patient records were reviewed on 7-2-25 as follows: Patient #1 Patient #1 was a 24-year-old who presented to the Marshall Emergency Department location on 6-20-25 with concerns for sexual assault. Patient #1 advised the hospital staff that she was 21 weeks and 3 days pregnant. Review of records show that she was seen by Physician Assistant (PA) Staff #13. Staff #13 charted under the History section of ED Provider Notes, “Patient was told that we would need her to speak with the police in order to establish a case number for her sexual assault in order for SANE exam to be performed. Patient does not want to speak with police. Patient was explained that a SANE exam as part of a chain of evidence and if we do not follow the proper protocol and chain of evidence the same (sic) exam kit and evidence collected during that exam would not be useful in a court of law. Patient was informed that she would need to speak with a police detective at the very least to establish an incident report and receive a case number. Patient has give (sic) me very limit details on what happened and does not want to convey any more information to me or anyone else.” Staff #13 charted under the ED Course, “Patient stated that she wanted a few minutes to think about whether or not she went (sic) to talk with the police. Patient states she is currently on probation and is concerned that if she talks with the police she will get in trouble. When I went to speak with the patient again to see if she had decided if she wanted to proceed forward with the SANE exam she had eloped form the department. Initially I discussed prophylactic treatment options as far as Rocephin and azithromycin with the patient. Patient did not wait to have any of these medications administered. Patient initially mentioned some mild left-sided abdominal cramping and pain. Patient was informed that we could do an ultrasound to evaluate her abdominal pain in pregnancy. Patient eloped prior to having any further evaluation done. Patient did not speak with police or file a report. SANE exam was not performed as no case number was ever established. Patient eloped from the department prior to any evaluation or workup being performed. Patient was seen and evaluated by myself initially upon presentation to the department.” Information provided by Staff #13 about the patient being required to contact law enforcement, file a report, and obtain a case number in order to receive a SANE examination was incorrect and directly violated the patient’s rights to an appropriate SANE examination. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Had the patient been provided access to an advocate and the mandated information form, both would have explained her right to have a SANE examination without having to involve law enforcement. As a result of the incorrect information provided by Staff #13, Patient #1 left the ED without receiving the appropriate SANE examination and prophylactic treatment for potential exposure to sexually transmitted infections she was entitled to under Texas state law. Patient #2 Patient #2 was a 34-year-old who presented to the North Park Emergency Department location on 6-1-25 following a sexual assault earlier that day. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. On 6-3-25, the patient was admitted to the main Longview hospital through 6-6-25. The medical record reflected that she presented with severe anxiety and alcohol intoxication following recent assault. Patient #3 Patient #3 was a 30-year-old who presented to the Longview Main ED location on 6-13-25 with a complaint of sexual assault that began the previous week with multiple encounters. The SANE nurse was at the North Park ED location. Medical Screening Examination showed the patient was stable for discharge and referral to the North Park location for a SANE exam. Patient #3 presented to the North Park ED location on 6-13-25 for the SANE exam. Patient #3 reported to the North Park staff that the assault had occurred between March and April and was requesting an exam to document the scarring to the perineum. Due to the time frame of the assault, the examination could not be performed. The patient was living in a shelter and was discharged to the shelter. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #4 Patient #4 was a 2-year-old who presented to the Longview Main ED location on 6-8-25 with suspicion of possible sexual assault. Patient received a medical screening examination and was determined to be stable for discharge to return later that day when a SANE nurse was on duty. The patient returned later that day. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient or that a referral had been made to the child advocacy center. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient’s family The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient’s family. Patient #6 Patient #6 was a 36-year-old who presented to the North Park ED location on 6-1-25 with concerns of possible sexual assault. SANE examination was performed. The patient believed she had been drugged while out a casino the night before. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #7 Patient #7 was a 42-year-old who presented to the Longview Main ED on 3-15-25 with complaint of vaginal pain, vaginal discharge, rectal pain, and lower back and abdominal pain. She claimed these symptoms have increased since she was sexually assaulted in July 2024. She claimed she would wake up to pain in the vaginal area during the night and that something is happening to her during the night but hasn’t seen anyone. During the medical screening examination, she became tearful and anxious. The medical record showed she left against medical advice. She returned to the ED on 5-20-25 with similar complaints. The medical screening examination was initiated. From 9:02 AM until 10:50 AM, the record reflects that no one communicated with the patient. At 10:50 AM, the patient was discharged from the computer after finding the patient had eloped. The medical records did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical records did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #8 Patient #8 was a 22-year-old who presented to the Longview Main ED location on 5-11-25 with complaint of sexual assault. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical records did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #9 Patient #9 was a 42-year-old who presented to the Marshall ED location on 5-28-25 via ambulance due to sexual assault. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. Patient #11 Patient #11 was a 31-year-old who presented to the North Park ED location on 4-9-25 with a possible sexual assault after being drugged. The patient became anxious and upset. She declined the SANE examination. Patient #11 returned to the North Park ED location of 4-10-25 stating she now wanted to complete the SANE examination. The medical records did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical records did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #12 Patient #12 was a 19-year-old who presented to the Marshall ED location on 3-16-25. She reported the assault took place 2 weeks prior and now she had a positive pregnancy test. The police advised her to go to the ED. Since the time frame for a SANE exam had expired and no SANE nurse was available, the patient was advised to follow up the next day with the SANE nurse at the Longview location. The medical records did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical records did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. On 3-17-25, Patient #12 presented to the Longview Main ED location. The patient was evaluated by the SANE nurse. The medical records did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical records did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical records did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #13 Patient #13 was a 33-year-old who presented to the Longview Main ED location on 2-23-25 with multiple complaints. Patient reported she had been sexually assaulted that morning. Nurse Practitioner Staff #14 examined the patient. Staff #14 documented that the patient had not contacted law enforcement and did not want to file a police report. The patient was worried if she did that she would be kicked out of her home and that she was unable to go to a shelter. The local police were contacted and came to the ED and spoke with Patient #13. Patient #13 declined to file a police report and declined to have the SANE examination. The patient eloped. No evidence was found that Staff #14 explained to the patient that she was not required to contact law enforcement, file a report, and obtain a case number in order to receive a SANE examination per Texas state law. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #14 Patient #14 was a 27-year-old who presented to the Longview Main ED location on 2-17-25 after an attempted sexual assault. Patient #14 reported she was able to extricate herself before “genital-genital or oral-genital contact was made. No SANE examination was required. The patient did make a police report. Examination showed that she was very anxious and tachycardic. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #15 Patient #15 was a 40-year-old who presented to the Longview Main ED location on 2/3/25 after a domestic abuse with sexual assault. SANE examination performed. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Patient #17 Patient #17 was a 38-year-old who presented to the Kilgore ED location on 5-18-25 with complaint of possible sexual assault. Patient declined a SANE exam. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. The medical record did not contain evidence that the state mandated information form explaining the rights of a sexual assault survivor had been provided to the patient. The medical record did not contain evidence that the name and telephone number of the nearest sexual assault crisis center had been provided to the patient. Interviews were conducted on 7-2-25 with Staff #1, #8, and #9. All three stated they were aware that a patient was not required to file a police report in order to receive a SANE examination. Staff #8 stated they did not know why Staff #13 would tell Patient #1 that she had to have a police report in order to have a SANE examination. Review of Policy Title: Medical-Forensic Examination of the Sexual Assault Patient; Created: 5/1/2019; Revised/Reviewed: (no date) was made on 7-2-25. On page 1 of 6, section VI. Policy/Guideline/Procedures; A. Examination of the Patient; Item 2 b.; was as follows: “Adults age 18-64 who report a sexual assault within 120 hours of the assault who do not want to cooperate with law enforcement may have forensic evidence collected without a report being made to an investigating agency.” Page 2 of 6, section VI. Policy/Guideline/Procedures; A. Examination of the Patient; Item 4; was as follows: “Patients will be provided the Texas Department of State Health Services Information Sheet for Sexual Assault Patients.” Interview with Staff #12 was made in the Emergency Department on the afternoon of 7-1-25. Staff #12 stated they did not have a specific room for sexual assault patients. Staff #12 stated that once the SANE Nurse was called, the patient was moved to a room on the third floor and all everything for the SANE examination was done upstairs. Staff #12 stated they believed the SANE nurse was responsible for contacting the advocate for the patient and providing the information sheet. This statement was consistent with the policy review of Policy Title: Medical-Forensic Examination of the Sexual Assault Patient; Created: 5/1/2019; Revised/Reviewed: (no date) was made on 7-2-25. The policy statement on page 1 indicated the policy was for the Sexual Assault Nurse Examiner to follow. Review was as follows: “IV. Policy Statement. The forensic nurse examiner will perform a medical forensic examination on persons with reported or suspected sexual assault/abuse. The examination will include ...””

“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: 48653 Based on medical record review, policy review, and staff interview, the hospital’s nursing staff failed to ensure nursing care was provided and/or delegated to meet the needs of the patients admitted to the hospital. Also, the hospital’s nursing staff failed to follow the hospital’s policy, “Pressure Injury Prevention and Management”. During a review of Patient # 1’s medical records on 10/08/2024 at 12:45 PM with Staff # 13 the following was revealed, Patient # 1 Patient # 1 was admitted to the hospital on 07/27/2024 at 4:47 PM with pneumonia and generalized weakness. The patient had a history of esophageal cancer requiring radiation treatment, immunosuppression, and stroke. At the time of admission, the patient had a low BMI (body mass index), decreased mobility, malnutrition secondary to esophageal cancer, dehydration, and confinement to the bed. Staff # 26 (Emergency Room Physician) documented the following assessment on 07/27/2024 at 10:59 AM, “Review of Systems ... Gastrointestinal: Positive for diarrhea and vomiting Skin: Negative ... Physical Exam: Constitutional: .... He is well-developed and underweight. He is ill-appearing. Skin: Skin is warm and dry. No rash.” Staff # 27 (Emergency Room Triage Registered Nurse) documented the following triage assessment on 07/27/2024 at 10:25 AM: “Skin Color/Condition Assessment: WDL (within defined limits). The patient did not have any skin rashes or wounds present on admission on 07/27/2024. The Patient was at risk for skin breakdown and pressure injury due to low mobility, decreased BMI (body mass index), poor nutritional status, and excessive moisture due to diarrhea. On 08/06/2024, the patient was noted to have a hospital-acquired deep tissue pressure injury to his buttocks by the wound care nurse. The wound care nurse reported a safety incident through the hospital’s internal safety event reporting on 08/06/2024. A review of the hospital’s policy, “Pressure Injury Prevention and Management” with a revision date of 07/2021 revealed, “OBJECTIVE: To establish guidelines in an effort to prevent and assist in the management of pressure injuries; to establish guidelines for the systematic assessment of patients for risk of pressure injury development and the identification of the specific factors placing them at risk for development of a pressure injury; provide guidelines for preventative interventions based upon the risk assessment; provide guidelines for the initial response to an identified pressure injury; and outline procedures for documentation and communication procedures ... Interventions to Address Increased Risk for Pressure Ulcers: Reposition at least every 2 hours and based on risk for additional pressure ulcers; document position change ...Check incontinent patients for urine/stool at least every 2 and PRN ...” An interview was conducted with Staff # 28 (Clinical Director of West 3B) (Medical Intermediate Care Unit) on 10/08/2024 at 2:45 PM. Staff # 28 stated, “During my investigation into the hospital-acquired deep tissue injury the patient sustained, I found that turns were not being consistently done every 2 hours with documentation and the consult to the wound care nurses was completed too late.””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 48653 Based on medical record review and staff interviews, the hospital’s pharmacy staff failed to follow the drug manufacturer’s prescribing information when verifying the physician’s order for a patient’s prescription. During a review of Patient # 1’s medical records on 10/08/2024 at 12:45 PM with Staff # 13 the following was revealed: Patient # 1 Patient # 1 was admitted to the hospital on 07/27/2024 at 4:47 PM with pneumonia due to Klebsiella, and generalized weakness. The patient had a history of esophageal cancer requiring radiation treatment, immunosuppression, and stroke. Due to the patient’s esophageal cancer, the patient was unable to swallow food or medications by mouth and required a PEG (Percutaneous Endoscopic Gastrostomy) tube for nutrition. A PEG tube is a flexible feeding tube that is inserted through the abdominal wall into the stomach to provide nutrition to patients who are unable to eat or drink. Medications administered through a PEG tube must be liquid or crushed. On 08/04/2024, the patient tested positive for the COVID-19 virus after requiring increased oxygen support. Physician # 25 ordered Paxlovid (nirmatrelvir 150 mg tablets; ritonavir 100 mg tablets) on 08/04/2024. The order revealed, “Ordered Dose: 3 Tablets. Frequency: 2 times daily. Admin Instructions: Follow package instructions. Route: Gastric Tube.” Staff # 21 (Registered Pharmacist) verified the order and gave instructions, “crush via GT” (GT refers to Gastric Tube or PEG tube). The medication administration of Plaxlovid to Patient # 1 was as follows: “08/04/2024 at 9:36 PM administered via PEG tube. 08/05/2024 at 8:52 AM administered via PEG tube. 08/05/2024 at 9:52 PM hold administration due to displaced PEG tube. 08/06/2024 at 9:18 AM not given. 08/06/2024 at 9:17 PM administered via PEG tube. 08/07/2024 at 10:06 AM not given due to “cannot be crushed.” 08/07/2024 at 9:34 PM administered via PEG. 08/08/2024 at 9:54 AM not given due to “cannot be crushed per pharmacy.” 08/08/2024 at 9:20 PM administered via PEG tube. 08/09/2024 at 10:33 AM not given due to “cannot be crushed.” A review of the Manufacturer’s Prescribing Information for Paxlovid revealed, “Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death ... 2.1. Important Dosage and Administration Information ... The tablets should be swallowed whole and not chewed, broken, or crushed ...” An interview was conducted with Staff # 21 (Registered Pharmacist) on 10/08/2024 at 1:00 PM in the administrative conference room. Staff # 21 was asked if he recalled the order for Patient # 1. Staff # 21 acknowledged the order for Patient # 21 and confirmed he was the pharmacist who verified the order with instructions for crushing via PEG tube. Staff # 21 was asked to verify the prescribing information for Paxlovid given by the manufacturer. Staff # 21 acknowledged the prescribing information which included the guidance to not crush the tablets. Staff # 21 stated, “It does say not to crush the tablets, but it doesn’t say why”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48653 Based on record review, and staff interviews, the hospital failed to ensure the dialysis department had, at a minimum, 2 trained Registered Nurses readily available to provide direct patient care to patients receiving hemodialysis in 1 (Satellite Hospital- 811 South Washington Ave, Marshall, Texas) of 2 dialysis departments. Also, the hospital failed to have a staffing matrix and plan for 2 (Main Hospital, Satellite Hospital) of 2 dialysis departments. (Cross Refer to Tag A 0144)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48653 Based on record review, and staff interviews, the hospital failed to ensure the dialysis department had, at a minimum, 2 trained Registered Nurses readily available to provide direct patient care to patients receiving hemodialysis in 1 (Satellite Hospital- 811 South Washington Ave, Marshall, Texas) of 2 dialysis departments. Also, the hospital failed to have a staffing matrix and plan for 2 (Main Hospital, Satellite Hospital) of 2 dialysis departments. This deficient practice had the likelihood of resulting in a delay in hemodialysis patient care and/or an incomplete dialysis treatment. Dialysis patients who do not complete or miss treatment are at an increased risk of electrolyte imbalances which can cause heart arrhythmias, cardiac arrest, and death. A review of the staffing assignments and on-call list for the hospital’s dialysis department was conducted with Staff # 12 on 07/12/2024 at 1:30 PM. A total of 3 patients (# 6, # 7, and # 8) were treated at the Satellite Hospital from July 01, 2024 to July 07, 2024. Patient # 6 Patient # 6 underwent hemodialysis treatment on 07/01/2024 at the Satellite Hospital. Staff # 24 was the Registered Nurse who provided care to the patient. Staff # 24 was clocked in on 07/01/2024 from 3:45 PM to 9:25 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/01/2024. Patient # 7 Patient # 7 underwent hemodialysis treatment on 07/06/2024 at the Satellite Hospital. Staff # 25 was the Registered Nurse who provided care to the patient. Staff # 25 was clocked in on 07/06/2024 from 7:30 AM to 3:42 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/06/2024. Patient # 8 Patient # 8 underwent hemodialysis treatment on 07/10/2024 at the Satellite Hospital. Staff # 25 was the Registered Nurse who provided care to the patient. Staff # 25 was clocked in on 07/10/2024 from 7:02 AM to 3:01 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/10/2024. The surveyor requested a staffing plan and matrix for the Dialysis Units and no such documents were provided. A review of the hospital policy, “Incapacitated Acute Dialysis Nurse” with a revision date of 11/2022 revealed, “OBJECTIVE/S: To ensure the patient’s safety will be immediately attended to in the case the hemodialysis nurse becomes incapacitated during dialysis treatment. POLICY STATEMENT: ... This policy provides guidance to the hospital nursing staff in immediate interventions to apply in order to ensure patient safety should the hemodialysis nurse become incapacitated during a dialysis treatment ... DEFINITIONS: A. Incapacitated: unable to act, respond, or the like, deprived of strength or power; debilitated ... PROCESS OR PROCEDURES: A. Intervention: 1. Call for medical assistance to treat the incapacitated nurse. Safely move the dialysis nurse from the immediate area. 2. Temporary disconnection procedure: a. Immediately turn the power switch to OFF position on the dialysis delivery system. b. Clamp each blood line ... c. Do not attempt to return the blood to the patient. 4. Notify the Acute Dialysis Charge Nurse and program Director via the emergency contact phone number provided. 5. Notify the patient’s nephrologist and document any verbal orders given in the patient EMR for the dialysis nurse reporting to resume the patient’s dialysis care as needed. 6. Complete an incident report for review in the quarterly QAPI meeting.” An interview was conducted with Staff # 12 on 07/10/2024 at 1:30 PM. Staff # 12 reported the hospital had stopped contracting out dialysis services in May of 2021. The hospital has been performing dialysis services and treatment at both the Main and Satellite Hospitals since May 2021. Also, Staff # 12 reported that hemodialysis trained Registered Nurses commute from the Main Hospital to the Satellite Hospital to provide hemodialysis treatment to patients. Staff # 12 reported there was only 1 trained and qualified Registered Nurse available at a time to care for hemodialysis patients at the Satellite Campus. When the surveyor asked who would provide care to the dialysis patients in the event the primary Registered Nurse became incapacitated, Staff # 12 stated, “There are instructions printed on every TABLO (hemodialysis) machine to instruct staff on how to clamp the dialysis blood lines and turn the machine off”. Staff # 12 confirmed the registered nurses at the Satellite campus had not been trained or deemed competent in hemodialysis patient care and treatment. The surveyor asked if there were any additional Registered Nurses staffed 24/7 who were trained in hemodialysis. Staff # 12 reported there were no Registered Nurses at the Satellite Hospital who had been trained and deemed competent in hemodialysis to resume care in the event the primary hemodialysis nurse became incapacitated.”

“A life safety code (LSC) investigation was conducted on-site on 3/25/24 to investigate incident TX00494655. An entrance conference was held with the following facility personnel: the Chief Operating Officer, Plant Operations Director, Director of Emergency Management, and the Director of Quality Management, to discuss the purpose of the LSC onsite visit and the investigation process was explained. An opportunity was provided for questions and discussion. The LSC investigation was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, to determine the hospital’s compliance with 42 CFR §482.41 Condition of participation: Physical environment. An LSC exit conference was conducted on 03/25/24 at the hospital. In attendance were the facility’s Chief Operating Officer, Plant Operations Director, Director of Emergency Management, and the Director of Quality Management. There were no preliminary findings found that would result in non-compliance. An opportunity was provided for questions and discussion. Complaint TX00494655: was in substantial compliance, no deficiencies cited.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure that the equipment used for the hearing impaired was in an acceptable working condition and failed to follow the policy and procedure for obtaining an approved and certified individual to interpret for the hearing impaired when requested in 1 of 1(#1) patient reviewed. Patient #1 had complained that on 10-26-23 that she was unable to use the remote video interpreter in the Emergency Department to communicate with the staff and physician. Patient #1 stated the video would continue to freeze and she was unable to communicate with the remote interpreter and did not understand her treatment or discharge planning. Patient #1 stated that she had requested a certified interpreter to come in and assist her. Patient #1 was told there was no one who could come in and her only choice was the video remote screen that continued to freeze. A tour was conducted in the ED on 12-7-23 with Staff #9 at 10:30 a.m., to view the language line teleprompter. The language line is used for video remote interpretation for language and the hearing impaired. The surveyor called the language line for services and the interpreter came up on the screen. The interpreter was informed of the call and that the surveyor was wanting to see if there was connection issues. Three times during the conversation the screen would freeze. I was able to hear the interpreter but could not see her. An interview was conducted with Staff #8 on 12-7-23. Staff #8 stated that she was the nurse for patient #1 and remembered the conversation and patient visit on 10-26-23. Staff #8 stated that patient #1 had her mother there interpreting but there was some sort of conflict between them. Staff #8 stated that patient #1 requested a “real person” to interpret because the screen on the language line was frozen. I explained to her that this was the only option. I was not aware we could request a person to come in and interpret. A review of the policy and procedure “ Language Access Services -Interpretation Services and Communication” stated, “ An associate or clinician must follow the following procedures when obtaining an onsite professional interpreter for sign language with the Tyler Deaf and Hard of Hearing Center.” The policy gave a phone number and email.”