UT Health East Texas Tyler Regional Hospital

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the discharge process identified 1 of 21 sampled patients who was likely to suffer adverse consequences in the absence of adequate discharge planning for transportation (Patient #2). Patient #2 was an 80-year-old patient with a subdural hematoma and a documented history of dementia was discharged at 2:10 a.m from the hospital to a nursing home in a taxi cab. This deficient practice had the likelihood of causing harm to all patients needing transportation after being discharged from the ED. Findings include: Review of the ED record on Patient #2 revealed she was an 80-year-old female who presented on 04/28/2026 after a fall. An ED provider note dated 04/28/2026 revealed Patient #2 had a past medical history of some of the following diagnoses diabetes mellitus, Alzheimer’s dementia, atrial fibrillation, anxiety, asthma and bipolar depression. According to documentation at 12:48 p.m. Patient #2 had head pain which was a level of 4. The Glasgow (GCS) neuro assessment was a 15. At 12:53 p.m. Patient #2 was given an ESI level of 3 (meaning urgent). At 1:13 p.m., Patient #2 was given the pain medication Morphine 4 milligrams for a pain level of 10 (severe). At 1:29 p.m. the neuro assessment was a 15. There was documentation at 2:21 p.m. that the results of the Cat scan were: 1.Thin high density subdural hematoma along the left parietal lobe without any midline shift. 2.Generalized cerebral volume loss 3.Left posterior scalp soft tissue swelling. At 5:52 p.m. Morphine 4 milligrams were administered for head pain which was at a level 10. At 6:09 p.m. the pain level was a 5 out of 10. At 9:42 p.m. Morphine 4 milligrams were administered for pain. According to documentation Patient #2 was discharged back to the nursing home and was sent in a cab 02:10 a.m. During an interview on 06/08/2026 after 12:31 p.m., Staff #7 confirmed Patient #2 was sent to the nursing home in a to-go bus. Normally the case manager, house supervisor or charge nurse makes arrangements for transportation. During a confidential interview on 06/10/2026 it was reported that there was concern because Patient #2 was sent to the nursing home at 2:00 a.m. in the morning after a diagnosis of a subdural hematoma. The hospital called the nursing home and asked them to pick up Patient #2. The request from the nursing home was for Patient #2 to stay until the morning and they would send someone to pick her up. The nursing home was told that the hospital could not have a nursing home patient sitting up there in a packed emergency room. Review of a facility’s policy named “Discharge Planning Policy-UR-MKT” dated 05/06/2024 revealed the following: “ ...1)Discharge planning is the responsibility for all hospital staff within each department ... ...6) Nursing Discharge Assessment: a) The nursing Discharge Assessment will be completed prior to discharge. This may include: x) Anticipated discharge needs, patient/family anticipated discharge location, need for discharge transport, final disposition and patient family agreement with plan with choice provided ....””

“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 was appropriately organized to ensure continual care. The facility failed to ensure staff evaluated 7 of 21 emergency department (ED) patients (Patient #’s 1,2,4,7, 15,16 and 18). The facility failed to: A.) Ensure patients were evaluated prior to, during and after pain medication administration. The facility failed to ensure continual pain assessment and pain assessment prior to discharge. (Patient # ‘s 1,2,4,7,15,16, and 18). B.) Ensure a patient with an elevated blood pressure was evaluated prior to discharge (Patient #16). Findings include: Patient #1 Review of the emergency department (ED) record on Patient #1 revealed she was 22-year-old female who presented on 03/22/2026 at 1:19 a.m. Patient #1 presented with complaints of motor vehicle crash (MVC). Review of nurse’s notes timed for 1:23 a.m. revealed Patient #1 had a pain level of 8 (meaning severe pain) in her back. At 1:30 a.m. Patient #1 was given an emergency severity index of 3 (meaning urgent). At 1:57 a.m., the medical screening was started, and the clinical impression was MVC, pelvic pain and acute bilateral low back pain with sciatica. There was documentation that all Cat scans and x-rays were negative. Patient #1 received Acetaminophen 1000 milligrams infusion from 1:35 -3:50 a.m. Pain levels at 3:34 a.m. were level 8 and at 5:00 a.m. it was level 6. Patient #1 was discharged at 5:29 a.m., without any prescriptions addressing pain relief. According to documentation Patient #1 returned 4 days later on 03/26/2026 at 10:36 a.m. At 11:01 a.m. Patient #1 was given an ESI of 3 (meaning urgent) and had a severe pain level of 8 at 11:09 a.m.. There was no documentation as to the location of where the pain was. At 11:20 a.m., a cat scan revealed that Patient #1 acute fractures of the left first through fifth lumbar transverse processes (spinal fractures). Almost an hour later at 12:04 p.m., Tylenol 1000 milligrams and Robaxin 1000 milligrams were administered to Patient #1. There was no documentation of an assessment of what the pain level was at this time. Over an hour later at 1:12 p.m., there was documentation that Patient #1 had acute back pain at a level of 8 (meaning severe). Patient #2 Review of the ED record on Patient #2 revealed she was an 80-year-old female who presented on 04/28/2026 after a fall. According to documentation at 12:48 p.m. Patient #2 had head pain which was a level of 4. The Glasgow (GCS) neuro assessment was a 15. At 12:53 p.m. Patient #2 was given an ESI level of 3 (meaning urgent). At 1:13 p.m., Patient #2 was given the pain medication Morphine 4 milligrams for a pain level of 10 (severe). At 1:29 p.m. the neuro assessment was a 15. There was no documentation of a follow-up pain assessment until 5:53 p.m. (over 4 hours later). There was documentation at 2:21 p.m. that the results of the Cat scan were: 1.Thin high density subdural hematoma along the left parietal lobe without any midline shift. 2.Generalized cerebral volume loss 3.Left posterior scalp soft tissue swelling. At 5:52 p.m. Morphine 4 milligrams were administered for head pain which was at a level 10. At 6:09 p.m. the pain level was a 5 out of 10. At 7:14 p.m. there was a Glasgow (GCS) neuro assessment was a 15. At 9:42 p.m. Morphine 4 milligrams were administered for pain. There was no documentation about the location or level of pain. There was no documentation of the pain level after administration of the pain medication. According to documentation Patient #2 was discharged back to the nursing home and was sent in a cab. There was no documentation about what her pain level was at discharge. Patient #4 Review of the ED record of Patient #4 revealed he was a 58-year-old male who presented on 04/15/2026 at 6:17 p.m. Patient #4 presented with a possible wound infection of the right knee. At 6:37 p.m. Patient #4 was described as having a pain level of 7 and with severe pain. At 6:39 p.m. Patient #4 was given an ESI level of 3 (meaning urgent). There was no other assessment of pain on Patient #4 until 04/16/2026 at 11:15 a.m. where staff documented no pain. Patient #4 was discharged from the ED and admitted to a unit within the hospital on 04/16/2026 at 1:15 p.m. During an interview on 06/08/2026 after 12:31 p.m., Staff #7 confirmed the missing pain assessments on Patient #’s 1, 2 and 4 and stated that pain assessment for the ED should be within 1 hour for pain medications by mouth and within 30 minutes for intravenous and intramuscular administration. Patient #7 Review of the ED record of Patient #7 revealed he was a 47-year-old male who presented on 04/09/2026 at 8:57 p.m.. Patient #7 presented to the ED for back pain. At 9:00 p.m. the back pain was described as being at a level 10 (severe). At 9:05 p.m. Patient #7 was given an ESI level of 3 (meaning urgent). The first documentation of pain medication administration was at 3:34 a.m. when Dilaudid 0.5 milligrams and Robaxin 1000 milligrams was administered. At 3:45 a.m. the back pain level was described as being an 8. At 05:20 a.m. Patient #7 complained of hurting all over and having a pain level of 10 out of 10 (severe). At 5:22 a.m. she was given Dilaudid 0.5 milligrams. The next documented pain assessment was at 6:35 a.m. where the pain level was a 9 and again at 6:44 a.m. and the pain level was an 8. There was no documentation of the location of the pain. During an interview on 06/09/2026 after 10 a.m., Staff #2 confirmed the missing assessments for pain. Patient #15 Review of the ED record of Patient #15 revealed he was a 53-year-old male who presented on 02/15/2026 at 9:09 p.m.. Patient #15 presented for complaints of a fall and numbness. At 9:26 p.m. Patient #15 was given an ESI level of 3 (meaning urgent). There was documentation in nurses’ notes at 9:28 p.m. where Patient #7 complained of severe pain at a level 7. There was no assessment of where the pain was located. At 12:52 midnight there was documentation that Patient #15’s ED disposition was set at against medical advice (AMA). At 1:00 a.m. Patient #15 had vital signs of a blood pressure of 141/90, pulse of 101, respirations of 15 and oxygen saturation of 97 percent. At 1:03 a.m. he was given the pain medication Morphine 4 milligrams intravenously. There was no documentation of a pain assessment giving location and level of pain. At 1:29 a.m. Patient #15 was discharged from the ED. There was no follow-up assessment of the pain or vital signs after administration of the medication and before leaving the ED. Patient #16 Review of the ED record of Patient #16 revealed she was a 43-year-old female who presented on 05/29/2026 at 5:04 p.m.. Patient #16 presented after a motor vehicle accident and had left foot pain. At 5:23 p.m. there was documentation of Patient #16 having pain in the top of her chest and mild pain in the back and left foot. At 5:26 p.m. the vital signs were a blood pressure of 152/103, pulse of 93, respirations of 18, temperature of 97.9 degrees Fahrenheit, an oxygen saturation of 100 percent and a pain level of 8. There was no documentation about where the location of the pain was. Patient #16 was given an ESI level of 3 (meaning urgent) at 5:27 p.m. Review of the medical screening timed 6:38 p.m. revealed the following clinical impression: MVA, left leg pain and hypertension. Patient #16 was discharged at 7:16 p.m. and there was not another set of vital signs or pain assessment taken prior to discharge. During an interview on 06/10/2026 after 11 a.m., Staff #2 confirmed the missing assessments for the pain and vital signs. Patient #18 Review of the ED record of Patient #18 revealed she was a 52-year-old female who presented on 06/01/2026 at 9:06 a.m.. Patient #18 had complaints of back and pelvic pain. At 9:33 a.m. there was documentation that Patient #18 had left sided back pain at a level of 8 and an ESI level of 3 (meaning urgent). At 1:17 p.m. Patient #18 was given the pain medication Dilaudid for back pain at a level 8. Patient #18 was discharged from the ED at 4:16 p.m. and there was no documentation of a follow-up pain assessment after administration of the medication or prior to discharge. During an interview on 06/10/2026 after 11 a.m., Staff #2 confirmed the missing assessments for pain. Review of the facility’s policy named “Pain Management-NS-MKT” dated 03/11/2026 revealed the following: “ ...5) Nursing Staff... ...c) Pain Assessment: If pain is present, assess location-point to the body part affected. i)Description of the type of pain experienced (dull, aching, sharp, stabbing, etc.) ii)Intensity-use the pain intensity rating scale appropriate to the patient ... ...e) Reassessment: ii)Reassessment and documentation should take place within a clinically appropriate time frame, such as within an hour of the administration or oral medications or within a half hour of the administration of intramuscular or intravenous pain medications .... ...Appendix B: Pain Scales... ...0-10 Patients greater than 9 years of age who are verbal and capable of using a numeric scale should rate the pain on a scale of 0-10, with 0 being no pain and 10 being the worst imagined ...””

“A life safety code (LSC) survey was conducted onsite at the facility on 04/21/26 and 04/22/26. An entrance conference was held on 04/21/26 with the Plant Services Director, Facilities Compliance Officer, and Market Director of Quality and Patient Safety, to discuss the purpose of the unannounced LSC onsite visit and the survey process was explained. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. An LSC exit conference was conducted on 04/22/26 at the hospital. In attendance were the facility’s Plant Services Director, Facilities Compliance Officer, and Market Director of Quality and Patient Safety. The preliminary findings of the survey and the next steps of the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to maintain the fire resistance rating in a hazardous mechanical equipment room in 1 of 8 smoke compartments (containing the sterile supply and surgical department administration suite) on the basement level of the hospital, in accordance with NFPA 101, 19.3.2.1. This failure could allow fire/smoke to spread to adjacent areas and potentially adversely affect the safety of the building’s occupants in the event of a fire. Findings included: During observation and interview on 04/22/26 at 2:10 p.m., on the basement level near the surgical department administration suite, there were 5 scab patches of gypsum board on the fire-rated walls in the mechanical equipment room containing air handling equipment. The gypsum board patches measured approximately 4 inches by 8 inches, 4 inches by 6 inches, 4 inches by 6 inches, 6 inches by 12 inches, and 6 inches by 12 inches. The plant services director confirmed the observations when the surveyor discussed the finding.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 31958 Based on observation, interview, and record review, the facility failed to: *provide grease filters for 1 of 3 exhaust/fire suppression hood systems (in the main dietary cooking kitchen), in accordance with NFPA 96, 6.1.1, as referenced by NFPA 101, 19.3.2.5.1 and 9.2.3. *provide a liquid or grease tight seal for all seams and joints in 3 of 3 exhaust/fire suppression hood systems (in the main dietary kitchen), and 4 of 4 hoods (in the cafeteria area), in accordance with NFPA 96, 5.1.2 through 5.1.4 as referenced by NFPA 101, 19.3.2.5.1 and 9.2.3. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Chapter 5 Hoods 5.1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood’s lower outermost perimeter. 5.1.3 Seams, joints, and penetrations of the hood shall be permitted to be internally welded, provided that the weld is formed smooth or ground smooth, so as to not trap grease, and is cleanable. 5.1.4* Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight. Chapter 6 Grease Removal Devices in Hoods 6.1 Grease Removal Devices 6.1.1 Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided. 6.1.2 Listed grease filters and grease removal devices that are removable but not an integral component of a specific listed exhaust hood shall be listed in accordance with UL 1046. This failure could allow the buildup of grease in the exhaust hoods, increase the risk of a grease fire, and potentially adversely affect the safety of the building’s occupants in the event of a cooking related fire. Findings included: During observation, interview, and record review on 04/22/26 from 8:55 a.m. to 9:15 a.m., the following were noted: *in the main dietary cooking kitchen, there were no grease filters visibly present in the exhaust/fire suppression hood that was installed over the deep fryers, griddle, and ovens. All three exhaust/fire suppression hoods did not have a liquid or grease tight seal along all open joints along the perimeter and underside of the hoods. Some joints had deteriorated sealant while other joints had no sealant at all. *in the cafeteria area, all four exhaust/fire suppression hoods (2 at a grill servery, 1 at the salad bar, and 1 at the pizza oven) did not have a liquid or grease tight seal along all open joints along the perimeter and underside of the hoods. Some joints had deteriorated sealant while other joints had no sealant at all. *the plant services director confirmed the observations when the surveyor discussed the findings. *the exhaust/fire suppression hoods had maintenance records indicating they were all last cleaned in March 2026, but did not indicate any further information regarding maintenance of liquid or greasetight seals.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to maintain 9 of 9 fire sprinkler heads installed in the elevator penthouse room free of foreign materials, in accordance with NFPA 25, 5.2.1.1.1 and 5.2.1.1.2(5). NFPA 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition. 5.2.1 Sprinklers. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer This failure could prevent effective fire sprinkler performance, potentially allow fire/smoke to spread, and adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observation and interview on 04/21/26 at 11:30 a.m., in the elevator penthouse room accessed from level 7 of the hospital, all 9 fire sprinkler heads were loaded with dust. The director of plant operations confirmed the observations when the surveyor discussed the findings.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure the locations of fire extinguishers were conspicuously marked or identified on 7 of 7 floors (Level 1, 2, 3, 4, ,5 ,6 and 7), in accordance with NFPA 10, 6.1.3 through 6.1.3.10.2. NFPA 10, Portable Fire Extinguishers, 2010 Edition 6.1.3 Placement. 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. 6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view. 6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location. 6.1.3.10 Cabinets. 6.1.3.10.2 The location of fire extinguishers as described in 6.1.3.3.2 shall be marked conspicuously. This failure could delay access to fire extinguishers and prompt extinguishment of a potential fire, and adversely affect the safety of the building’s occupants in the event of a fire emergency. Findings included: During observations and interviews on 04/21/26 and 04/22/26, the following were noted during the tour and inspection of the hospital: *in the level 1 main dietary kitchen, an ABC type fire extinguisher was located in a visually obstructed area (around the corner to the hallway exit) and no signage was installed to conspicuously identify its location. In the dining area of the cafeteria, there was a fire extinguisher around a corner past the end of the dining area and no signage or markings was installed to conspicuously identify its location that would be visible from the dining area. *on the level 2 north patient care nursing unit, 6 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. *on the level 2 west patient care nursing units, Wings A, B, and C each had a fire extinguisher installed in recessed wall cabinets along the hallways that did not have any signage or markings to conspicuously identify their locations. *on the level 3 north patient care nursing unit, 6 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. *on the level 3 south patient care nursing unit, 4 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. *on the level 3 west patient care nursing units, Wings A, B, and C each had a fire extinguisher installed in recessed wall cabinets along the hallways that did not have any signage or markings to conspicuously identify their locations. *on the level 4 north patient care labor and delivery unit, 6 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously their locations. *on the level 4 west patient care nursing units, Wings A, B, and C each had a fire extinguisher installed in recessed wall cabinets along the hallways that did not have any signage or markings to conspicuously identify their locations. *on the level 5 north patient care nursing unit, 6 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. *on the level 6 north patient care nursing unit, 6 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. *on the level 6 south patient care nursing unit, 4 fire extinguishers installed in recessed wall cabinets along the hallways did not have any signage or markings to conspicuously identify their locations. The director of plant operations confirmed the observations when the surveyor discussed the findings and said they planned to added signage on the wall above the fire extinguisher cabinets for all similar conditions throughout the hospital.”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 31958 Based on observation, interview, and record review, the facility failed to ensure the travel distance from any point within a smoke compartment to a door in a smoke barrier did not exceed 200 feet in 1 of 3 smoke compartments (south patient care nursing unit) on level 6, in accordance with NFPA 101, 19.3.7.1(1). This failure could delay evacuation from one smoke compartment to another smoke compartment, and adversely affect the safety of the building’s occupants in the event of a fire emergency. Findings included: Record review of the facility’s life safety drawings indicated there were 3 smoke compartments on level 6 of the hospital. During observations and interviews on 04/21/26 between 12:30 p.m. and 12:45 p.m., there was a smoke compartment on level 6 that contained the south patient care nursing unit. The travel distance from the furthest patient room (room 6612) to a door in the nearest smoke barrier wall (pair of cross corridor doors just past the passenger elevator bays) measured between 220 to 230 feet. The director of plant operations confirmed the observations when the surveyor discussed the findings.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure: 1 of 6 smoke barrier walls on the basement level (separating smoke compartments C and D), 2 of 4 smoke barrier walls on the 2nd floor (separating smoke compartments A and B, and C and D), 1 of 3 smoke barrier walls on the 3rd floor (separating smoke compartments B and D), 1 of 4 smoke barrier walls on the 4th floor (separating smoke compartments A and D), 2 of 3 smoke barrier walls on the 6th floor (separating smoke compartments A and B, and B and C), were constructed to least a ½-hour fire resistance rating and all penetrations sealed, in accordance with NFPA 101, 19.3.7.3, 8.5, 8.5.6. This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 04/21/26 from 11:00 a.m. to 5:15 p.m. and on 04/22/26 from 9:30 a.m. to 2:30 p.m., the following were noted during inspection of smoke barrier walls: *at the basement level smoke barrier wall between the elevator lobby and surgical recovery area entrance (separating smoke compartments C and 1D), above the ceiling over the pair of smoke barrier doors there was yellow colored foam product sealing the wall to the underside of the above floor deck and between joints of gypsum board. The yellow foam was also present in numerous wall penetrations, including electrical conduit, fire sprinkler and plumbing piping. There was also a scab patch of gypsum board approximately 6 inches by 24 inches in size. *at the 2nd floor smoke barrier wall between the waiting area off the corridor and the north patient care nursing unit (separating smoke compartments A and B), above the ceiling over the waiting area there were 7 unsealed electrical conduit penetrations and a 1 inch hole. *at the 2nd floor smoke barrier wall between the corridor/stair H and patient care wings A, B and C (separating smoke compartments C and D), above the ceiling on the patient side over the corridor smoke barrier doors were 2 scab patches of gypsum board approximately 6 inches by 24 inches and 6 inches by 12 inches in size. *at the 3rd floor smoke barrier wall between the elevator lobby/Stair F area and the south patient care nursing unit (separating smoke compartments B and D), above the ceiling the smoke barrier wall was not sealed at the underside of the above floor deck and was not constructed continuous to the adjacent wall. *at the 4th floor smoke barrier wall between the corridor and back entrance/exit to the neonatal intensive care unit(separating smoke compartments A and D), above the ceiling over the pair of smoke barrier doors on the corridor/stair side, there was a scab patch of gypsum board approximately 8 inches by 8 inches in size. *at the 6th floor smoke barrier wall between the waiting area and the north patient care nursing unit (separating smoke compartments A and B), above the ceiling between the corridor and patient room 6836 there were 7 unsealed electrical conduit penetrations and a 1 inch hole. There were also 3 scab patches of gypsum board approximately 12 inches by 8 inches, 12 inches by 8 inches, and 6 inches by 8 inches in size. There were also unsealed openings above 10 electrical conduit penetrations. In the north nursing unit supply room, above the ceiling there were 3 scab patches of gypsum board approximately 4 inches by 18 inches, 8 inches by 24 inches, and 5 inches by 5 inches in size. In the elevator lobby, above the ceiling over the pair of smoke barrier doors was a one inch hole around a wire penetration. *at the 6th floor smoke barrier wall between the connecting corridor and the south patient care nursing unit (separating smoke compartments B and C), above the ceiling over the pair of smoke barrier doors there was a scab patch of gypsum board approximately 12 inches by 12 inches in size. *the plant services director confirmed the observations when the surveyor discussed the findings. He said a maintenance program was in place to seal penetrations, remove the scab patches and correctly repair the smoke barrier walls.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure items powered from the essential electrical system were correctly located on the Life Safety branch and Critical branch, in accordance with NFPA 99, 6.4.2.2.3 and 6.4.2.2.4. This failure could affect the facility’s continuity of operations during the event of power loss and adversely affect the health and safety of the building occupants. Findings included: During observations and interviews on 04/21/26 and 04/22/26, the following were noted regarding the hospital’s essential electrical system: *on 04/21/26 between 2:00 p.m. and 2:30 p.m., on the level 4 north maternity/labor and delivery unit, it could not be verified that there was any emergency lighting at the nurse station that was on the critical branch of the essential electrical system. *on 04/22/26 between 1:05 p.m. and 1:10 p.m., on lower level 2 there were mechanical rooms that contained the hospital’s 4 emergency generators. It could not be verified that the electrical receptacle (not a distinct color or otherwise marked) installed on the wall was on the life safety branch of the essential electrical system. The director of plant operations confirmed the observations when the surveyor discussed the findings.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s Governing Body failed to ensure that 1 (Davita Corporation) of 2 contracted services provided in the hospital were provided safely and effectively. The hospital failed to follow the “Governing Body Bylaws Section 6.7- Contracted Services”. Findings include: During patient medical record review, the surveyor observed that Staff # 53 (Davita Contracted Registered Nurse) and # 54 (Davita Contracted Registered Nurse) administered Packed Red Blood Cells (PRBCs) to Patient # 26 and Patient # 48 in April of 2026. The surveyor noted that the blood products were administered at an extremely rapid rate of 600 ml/hr (milliliters per hour) and were not administered slowly during the first 15 minutes to observe for potentially fatal transfusion reactions. During review of Staff # 53 and # 54’s personnel records, the surveyor observed that the “Hospital Services HD Annual Procedural Skills Verification Checklist” with a date of 03/02/2026 revealed, “Verbalizes or demonstrates proper administration of blood products: N/A.” Staff # 53 and # 54 were contracted employees through Davita Corporation and did not have appropriate training and competency for the administration of blood products at the time that Staff # 53 and # 54 administered PRBCs to Patient # 26 and Patient # 48 during hemodialysis treatment in April of 2026. The surveyor requested documentation of the Governing Body’s review and approval of the Davita Corporation contractual agreement. There was no documentation provided to the surveyor. The hospital’s Governing Body failed to ensure that services provided through the contract were safe and met the applicable Conditions of Participation (CoP at CFR 482.23- Nursing Services). An interview with Staff # 3 was conducted in the afternoon of 04/07/2026 in the hospital’s administrative conference room. Staff # 3 reported that the hospital staff was unable to find documentation of the Governing Body’s review and approval of the Davita and Sodexo Corporation contracts. Staff # 3 stated, “We went ahead and reviewed the contracts in the Medical Executive Committee (MEC) today, on 04/07/2026, and the contracts will go to the Quality Committee of the Board on 04/21/2026”. A review of the hospital’s “Governing Body Bylaws” adopted 03/01/2018 revealed, “ ...Section 6.7-Contracted Services: 6.7.1 The Board shall review and make recommendations on any contractual matter referred to it by the Member. The Member, through the CEO or other designee, shall have final authority with respect to all contracts affecting the Facilities. 6.7.2 The Board shall provide mechanisms to ensure that services provided under contract are in compliance with all applicable conditions of participation, regulations, and Accreditation Agency Standards for the contracted service. 6.7.3 The Board shall ensure that contracted services are performed safely and effectively through implementation of the Performance Improvement Plan (defined in Section 6.8 below), and through mechanisms used to ensure that contracted services staff members are qualified and competent. 6.7.4 The Board shall require that the Facilities maintain a list of all contracted services to include the nature, scope of services, and delineation of contractor responsibilities ...””

“CONTRACTED SERVICES CFR(s): 482.12(e)(2) The hospital must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 43853 Based on the interview and record review, the facility failed to maintain and provide a list of all contracted services - including the nature and scope of services and delineation of contractor responsibilities as required by 42 C.F.R. § 482.12(e) and as further required by the facility’s own governing body bylaws. An entrance conference was held on 04/06/26 at 8:30 AM in the administrative conference room. A document request list was provided to facility administration and Staff # 3 (COO) following the entrance conference. The document request included multiple documents being requested by survey staff and included a specific request for a list of all contracted services. The document request was provided in writing to facility leadership at that time. On 04/06/26, the facility provided a list of contract radiologists only. No comprehensive list of all contracted services was provided at that time. On 04/07/26, during an interview at 10:30 AM in the administrative office, Staff #3 (COO) was asked to provide a list of all contracted services approved by the governing body. Staff #3 (COO) had Staff #142 (Contract Manager) on speakerphone. Staff #3 (COO) explained that Staff #142 (Contract Manager) oversaw contracts. When asked whether she could generate or provide a list of approved contracted services, Staff #142 (Contract Manager) stated that there was no list of facility contracts available or that could be generated. Staff #1 (CEO) was present and reported that there was no list of contracts, and further reported that not all services required a contract to be reviewed and approved by the governing body. No list of contracted services, in whole or in part, was provided on 04/07/26. On 04/07/26, a review of the “Bylaws of The Board Of Trustees Tyler Regional Hospital, LLC dba UT Health Tyler,” adopted 03/01/18, revealed the following at Section 6.7, Contracted Services, subsection 6.7.4: “The Board shall require that the Facilities maintain a list of all contracted services to include the nature, scope of services, and delineation of contractor services.” The facility’s own governing body bylaws, therefore, independently require a comprehensive list of contracted services. Despite this explicit requirement, facility leadership confirmed no such list existed. In a subsequent interview with Staff #6 (Chief Medical Officer/CMO) and Staff #1 (CEO) in the administrative office on 04/08/26 at 1:30 p.m., contracted services were again discussed. Staff #1 (CEO) again reported that not all contracts required review or approval by the governing body; however, he did not provide a list of any approved contracts, nor did he clarify which contracts, if any, were subject to governing body review and approval. A list of contracted services was not provided on 04/08/26 or 04/09/26. The facility failed to maintain a comprehensive list of all contracted services as required by 42 C.F.R. § 482.12(e). The absence of such a list prevents the governing body from demonstrating oversight and accountability for the safety and quality of all services furnished to patients, including those provided under contractual arrangements. This failure was confirmed through interviews with Staff #3 (COO), Staff #142 (Contract Manager), and with Staff #1 (CEO), and is further substantiated by the facility’s own governing body bylaws at Section 6.7.4, which independently require maintenance of this list.”

“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: 29191 Based on a record review and interview, the hospital staff failed to ensure that chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water systems in the hemodialysis unit for 2 (#230101 and #230113) of 4 portable water units. Findings include: RO #1 (serial number # 230101) On 04/01/2026, a chlorine check was completed at 10:10 AM. The next documented chlorine check was at 2:25 PM, which was 15 minutes late by Staff member #48. RO #9 (serial number # 230113) On 04/02/2026, a chlorine check was completed at 6:30 AM. The next documented chlorine check was at 10:45 AM, which was 15 minutes late by Staff member #49. On 04/04/2026, a chlorine check was completed at 11:20 AM. The next documented chlorine check was at 4:00 PM, which was 40 minutes late by Staff member #50. A review of the log titled “Water Treatment Safety Record” for April 2026 for RO #1 (serial number # 230101) and RO # 9 (serial number # 230113) revealed that the documentation was not legible. The times and results of the chlorine checks were difficult to read. Signatures of the dialysis staff were not legible. An interview with Staff # 52 on 04/06/2026 at 2:30 PM in the hemodialysis unit confirmed that chlorine checks were not performed every 4 hours per hemodialysis parameters. A review of the policy titled “Total CHLORINE Monitoring of Portable Reverse Osmosis (RO) Water Treatment Systems,” dated October 2025, revealed the following: “PURPOSE: To establish total chlorine testing is regularly performed and within the limits specified by the International Organization of Standardization (ISO)/Association for the Advancement of Medical Instrumentation (AAMI) and DaVita standards. POLICY: 1. Only trained teammates may perform daily water system total chlorine testing. 2. DaVita hospitals/facilities measure Total Chlorine to verify that levels are less than or equal to 0.1 ppm (< 0.1 ppm) as specified by ISO/AAMI and DaVita standards. 3. Total Chlorine testing is performed prior to the use of dialysis quality water for any process, prior to treatment, and within every four (4) hours after the initial test while dialysis quality water is being utilized. A final Total Chlorine test is recommended to be performed at the end of the treatment day to verify that the portable carbon tank/filters have not exhausted. 4. All samples are to be drawn after the portable RO has been operating for at least 15 minutes at the location in which the treatment is being performed. 5. The hospitals/facilities maintain current Directions for Use of the approved total chlorine option used. Trained teammates will follow the current Directions for Use. 6. Verify that all supplies used for total chlorine testing have not expired. Discard any expired supplies. Verify cap is in place and tightly secured both pre and post-use of test strips. 7. Total chlorine test option used will have sufficient sensitivity to differentiate results that are 0.1 ppm or less (< 0.1ppm) (acceptable) from those that are greater than 0.1 ppm (> 0.1 ppm) (unacceptable). If using test strips, only quantitative methodology is performed. The following are approved options for Total Chlorine testing of water used for dialysis in monitoring acute water treatment systems, etc.” A review of the manufacturer’s guidelines for RPC Ultra-Low Total Chlorine revealed the following: “RPC Ultra-Low (Trademark) Total Chlorine Test Strips (K100-0118) measure 0-0.2 ppm total chlorine in water, typically for dialysis applications. Collect a 100 mL sample in a chlorine-free cup, dip the strip for 20 seconds with a gentle back-and-forth motion, shake off excess water, wait 20 seconds, and compare to the chart.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the hospital’s nursing staff failed to ensure that nursing care plans were kept current and reflected the needs of the patients in 1 (Patient #12) of 1 patient medical record reviewed. Additionally, the hospital staff failed to follow the “Central (Telemetry) Monitoring” policy. Findings include: A review of Patient # 12’s medical record was conducted with Staff # 68 and # 135 on 04/06/2026 at 11:00 AM in the hospital’s administrative conference room. Patient # 12 Patient # 12 was admitted to the hospital with a cardiac history and a low serum potassium level of 2.9 g/dL. A review of the patient’s History and Physical (H&P) dated 04/06/2026 revealed, “ ...89-year-old man with a history of congestive heart failure, COPD, atrial fibrillation on Eliquis, cholecystitis status post cholecystostomy drain placed in May 2025, followed by multiple tube dislodgements, prostate cancer status post radiation therapy, and embolic CVA. He was sent from the nursing home due to cholecystostomy tube dysfunction, as he had pulled out his tube. The patient has been seen 6 times this year for the same complaint. On arrival to the emergency room, his blood pressure was 127/81, heart rate of 76, saturating 92% on 2 liters of oxygen by nasal cannula. He was afebrile. Laboratory workup showed hypokalemia of 2.9, normal white cell count, stable hemoglobin, normal INR ...” An order for continuous cardiac telemetry monitoring was placed on 04/06/2026 due to the patient’s hypokalemia (low potassium levels). Low potassium levels commonly cause muscle weakness, arrhythmias, palpitations, and light-headedness. Extremely low potassium levels can lead to cardiac arrest. During a tour of the hospital’s central telemetry monitoring unit, the surveyor observed that Patient # 12 was assigned to room # 2216. The surveyor observed that the monitor screen did not show a rhythm for the patient, and the monitor screen for patient room # 2216 displayed “leads off, no signal”. The surveyor questioned Staff # 13 (Monitor Tech), asking why the patient’s leads were off and why the patient was not showing up on the monitor. Staff # 13 stated, “I called the nurse, the patient is confused and keeps taking the leads off”. Further review of Patient # 12’s medical record revealed that Staff # 138 (RN) documented, “cognition: pleasantly confused” on 04/06/2026 at 08:43 AM. The surveyor asked if the physician had been notified of the patient’s cognition and refusal of telemetry monitoring. Staff # 68 reported that there was no physician notification, and the patient had an active order for continuous telemetry monitoring. The hospital’s nursing staff failed to follow the physician’s orders for continuous telemetry monitoring and failed to update and keep current a nursing care plan that addressed the patient’s needs, including the need for continuous telemetry monitoring due to hypokalemia in the setting of congestive heart failure and known arrhythmias. A review of the hospital’s “Central (Telemetry) Monitoring” policy with a date of 12/11/2025 revealed, “Policy: Patients requiring electrocardiogram (ECG) monitoring are monitored from a central designated location, referred to as Central Monitoring Area (CMA) ....Monitoring includes observation and recognition of ECG changes and/or possible arrhythmias, as well as any necessary notifications to the clinical staff attending to the patient. The scope of this policy includes all patients admitted to the geographic inpatient units regardless of admission classification. Procedure: 1. Provider orders telemetry in the EHR. 2. Cardiac monitoring telemetry boxes, or tele boxes, may be kept on the unit or at the central monitoring area. Staff should obtain telemetry boxes based on the process set up at their individual facility. 3. Electrode placement for telemetry boxes should be applied to the patient based on the approved clinical reference procedure or according to the manufacturer’s instructions for use. 4. Cardiac telemetry monitoring orders should be carried out as soon as reasonably possible once received. The nurse should verify the order for monitoring and the identification of the patient prior to placing a telemetry box on the patient. A. Telemetry should not be initiated, discontinued, or paused without a provider order ....7. a. Cardiac telemetry monitoring is a treatment and requires a provider’s order to initiate, pause, or discontinue. B. A patient can only be removed from the telemetry monitor once the provider has given an order for the removal of the telemetry unit. This includes bathing, ambulation, transport, or any other reasons that might apply to a hospitalized patient requiring continuous monitoring of any parameters ...10. Notification Escalation: a. If continuous cardiac monitoring has been ordered by a provider, it is imperative that the telemetry box remain placed on the patient and observable at all times. For this reason, any issue that results in the patient showing no activity on the monitor will be treated as a cardiac emergency. B. Notifications from the central monitoring unit to the patient care unit will be escalated based on the classification of the notification. C. There will be two classifications of issues that require notification. These two classifications are 1. Unidentified monitored patient, leads off, low battery, pulse oximetry changes, or non-lethal rhythm changes, with a readable rhythm by the monitor tech, and 2. Lethal rhythm changes or loss of monitor signal. i. Classification 1: Unidentified monitored patient, leads off, low battery, pulse oximetry changes, non-lethal rhythm changes, with a readable rhythm by the monitor tech. Steps must be followed in the order listed below. 1. Initial call placed by central monitoring station to unit, RN or designee will respond to call within 5 minutes and close the loop on the issue by placing a call to the central monitoring unit to verify correction of the issue. 2. If there is no resolution after 5 minutes from the initial call (5 minutes total), the issue is escalated, and a call is placed to the unit charge nurse. 3. If there is no resolution after 5 minutes of notifying the charge nurse (10 minutes total), the issue is escalated, and a call is placed to the Unit Director or House Supervisor. 4. If there is no resolution after 5 minutes (15 minutes total), the issue is escalated by the central monitoring station, initiating the Rapid Response Team ...” An interview was conducted with Staff # 68 on 04/06/2026 at 11:15 AM. Staff # 68 confirmed that the patient should have been on continuous telemetry monitoring if there was an active physician order. Additionally, Staff # 68 confirmed the patient’s nursing care plan should have reflected the need for continuous telemetry monitoring due to hypokalemia in the setting of congestive heart failure and arrhythmias.”

“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: 48653 Based on observation, record review, and staff interview, the hospital staff failed to ensure that: A. there was a complete physician’s order before the administration of blood products in 5 (Patient # 23, # 26, # 48, # 58, and #59) of 5 medical records reviewed. B. blood products were administered in accordance with the hospital’s policy and procedures for the administration of blood products in 5 (Patient # 23, # 26, # 48, # 58, and #59) of 5 medical records reviewed. C. two (Staff # 53 and # 54) of 2 contracted staff had competency and training for the administration of blood products. D. staff # 140 followed the manufacturer’s instructions for use when priming blood tubing in 1 (Patient # 20) of 1 transfusion observation. Findings include: Patient # 20 The surveyor observed Staff # 140 (Charge Nurse 4WA) transfuse 1 unit of packed red blood cells to patient # 20 in the afternoon of 04/06/2026. Staff # 140 was observed spiking the bag of PRBCs and priming the Y-Set Blood Tubing with the packed red blood cells instead of 0.9 % Normal Saline, as required by the hospital’s policy and the manufacturer’s instructions for use (IFU). Failure to prime the Y-Set Blood Tubing with 0.9% Normal Saline increases the risk of hemolysis (the rupture or destruction of red blood cells) and, therefore, increases the risk of the patient having a transfusion reaction. A review of the Y-Set Blood Tubing manufacturer’s instructions for use revealed, “...to prime Y-set blood tubing, connect 0.9% normal saline, open the upper clamp, and squeeze the drip chamber until the filter is submerged. Priming the filter with saline prevents hemolysis by covering the mesh, preventing red blood cells from trapping and being damaged upon contact with air...” An interview with Staff # 68 in the afternoon of 04/06/2026 confirmed that Staff # 68 witnessed Staff # 140 prime the tubing with the blood instead of the 0.9% normal saline. Staff # 68 reported that the nurses had just been taught this process in skills lab. Patient # 23 A review of Patient # 23’s medical record was conducted with Staff # 68 in the afternoon of 04/06/2026. Patient # 23 was admitted to the hospital on 04/04/2026 with a chief complaint of “Anemia concerning for GI (gastrointestinal) bleed”. A review of the patient’s History and Physical (H&P) dated 04/04/2026 revealed, “Patient is a 79-year-old male with a past medical history of congestive heart failure, type 2 diabetes, transverse myelitis, and coronary artery disease status post CABG ...who presents for evaluation of abnormal labs, specifically anemia ...There has been an acute drop in the patient’s hemoglobin ...” The patient’s hemoglobin was 7.3 g/dL on admission and demonstrated a downward trend in the setting of a positive fecal occult blood test. A review of physician orders revealed an order for “Transfuse leukoreduced RBC: 2 Units” placed on 04/04/2026 at 9:20 PM. There were no further instructions in the physician’s order indicating how the packed red blood cells were to be administered by nursing staff, including the transfusion rate, transfusion duration, or “administer per hospital policy”. A review of the transfusion record revealed that the transfusion of PRBCs (Packed Red Blood Cells) was started on 04/04/2026 at 10:09 PM at a rate of 125 ml/hr (milliliters per hour). The transfusion was started at a rate higher than 1-2 ml/min during the first 15 minutes, as required by hospital policy. Patient # 26 A review of Patient # 26’s medical record was conducted with Staff # 68 in the afternoon of 04/06/2026. Patient # 26 was admitted to the hospital on 04/01/2026 with a chief complaint of “Melena”. A review of the patient’s History and Physical (H&P) dated 04/01/2026 revealed, “ ...70-year-old male with a history of COPD, recurrent GI bleeds, chronic hepatitis C, T2DM, ESRD on dialysis who presents for melena ....he reported dizziness and black tarry stools ...His hemoglobin was 5.5 g/dL on arrival ...” A review of physician orders revealed an order for “Transfuse leukoreduced RBC: 1 Units” on 04/02/2026 at 10:54 AM. There were no further instructions in the physician’s order indicating how the packed red blood cells were to be administered by nursing staff, including the transfusion rate, transfusion duration, or “administer per hospital policy”. A review of the transfusion record revealed that the transfusion of PRBCs (Packed Red Blood Cells) was started on 04/02/2026 at 12:43 PM at a rate of 600 ml/hr (milliliters per hour) by Staff # 54 (Contracted Dialysis Registered Nurse). The patient was undergoing hemodialysis treatment at the time of the transfusion. The transfusion was started at a rate higher than 1-2 ml/min during the first 15 minutes, as required by hospital policy. The unit was completed on 04/02/2026 at 1:11 PM, 28 minutes after the transfusion started. The patient received a total of 310 ml of PRBCs in 28 minutes, which is faster than Davita Corporation policy allows. A review of Staff #54’s personnel file revealed that the Registered Nurse was a contracted employee through Davita Corporation. Further review of the “Hospital Services HD Annual Procedural Skills Verification Checklist” with a date of 03/06/2026 revealed, “Verbalizes or demonstrates proper administration of blood products: N/A.” Staff # 54 was a contracted employee through Davita Corporation and did not have appropriate training and competency for the administration of blood products at the time that Staff # 54 administered PRBCs to Patient # 26 during hemodialysis treatment. Patient # 48 A review of Patient # 48’s medical record was conducted with Staff # 68 in the afternoon of 04/06/2026. Patient # 48 was admitted to the hospital on 04/04/2026 with a chief complaint of “Abdominal pain, left-sided rib pain, headaches”. A review of the history and physical (H&P) dated 04/04/2026 revealed, “ ...64-year-old female with a past medical history of ESRD (end stage renal disease) on Hemodialysis, left BKA (below the knee amputation) 11/2025 converted to an AKA (above the knee amputation) in 12/2025 followed by stump lean out/debridement in 02/2026 ...who presents today with complaints of abdominal pain, left rib pain, headache worsening today, and sacral wound that has been present for reportedly 1.5 months ...Review of Systems: ...Acute on Chronic Anemia of CKD (chronic kidney disease), hemoglobin 7.3 on arrival, receiving 1 unit PRBCs per Nephrology ...” A review of physician orders revealed an order for “Transfuse leukoreduced RBC: 1 Units” on 04/04/2026 at 07:49 AM. There were no further instructions in the physician’s order indicating how the packed red blood cells were to be administered by nursing staff, including the transfusion rate, transfusion duration, or “administer per hospital policy”. A review of the transfusion record revealed that the transfusion of PRBCs (Packed Red Blood Cells) was started on 04/04/2026 at 10:51 AM at a rate of 600 ml/hr (milliliters per hour) by Staff # 53 (Contracted Dialysis Registered Nurse). The patient was undergoing hemodialysis treatment at the time of the transfusion. The transfusion was started at a rate higher than 1-2 ml/min during the first 15 minutes, as required by hospital policy. A review of Staff #53’s personnel file revealed that the Registered Nurse was a contracted employee through Davita Corporation. Further review of the “Hospital Services HD Annual Procedural Skills Verification Checklist” with a date of 3/2/2026 revealed, “Verbalizes or demonstrates proper administration of blood products: N/A.” Staff # 53 was a contracted employee through Davita Corporation and did not have appropriate training and competency for the administration of blood products at the time that Staff # 53 administered PRBCs to Patient # 48 during hemodialysis treatment. Patient #58 A review of patient # 58’s medical record was conducted with Staff # 5 on 04/08/2026 at 1:30 PM in a hospital administrative office. Patient # 58 arrived at the hospital’s ED on 03/26/2026 at 9:21 AM. The patient was transferred for a higher level of care from another hospital for nausea, vomiting, abdominal pain, black stools, and hematemesis (vomiting blood). The patient’s hemoglobin was 7.1 g/dL on the initial ED lab collection at 10:29 AM. A review of the admitting physician’s orders revealed an order for “Transfuse leukoreduced RBC: 1 Unit” was placed on 03/26/2026 at 10:40 AM. There were no further instructions in the physician’s order indicating how the packed red blood cells were to be administered by nursing staff, including the transfusion rate, transfusion duration, or “administer per hospital policy”. A review of the transfusion record revealed that the transfusion of PRBCs was started on 03/26/2026 at 11:24 AM at a rate of 125 ml/hr. The transfusion started at a rate higher than 2 ml/min during the first 15 minutes, as required by hospital policy. Also, at 11:44 AM, patient #58’s administration rate was increased to 150ml/hr. A full set of vital signs were taken at 11:44 AM, 20 minutes after the transfusion started. There was no documentation found that vital signs were completed within the first 15 minutes prior to increasing the blood administration rate per the hospital’s policy. The patient was admitted to the floor on 03/26/2026 at 11:55 AM. Patient # 59 A review of patient # 59’s medical record was conducted with Staff # 5 on 04/08/2026 at 1:30 PM in a hospital administrative office. Patient # 59 arrived at the hospital’s ED on 03/30/2026 at 6:16 PM. The patient’s primary physician instructed the patient to go to the ED for vaginal bleeding, fatigue, and a hemoglobin of 6.9 g/dL status post miscarriage at 5-6 weeks gestation. The patient’s hemoglobin was 7.2 g/dL on the initial ED lab collection at 7:36 PM. A review of the ED physician’s orders revealed an order for “Transfuse leukoreduced RBC: 2 Units” was placed on 03/30/2026 at 8:59 PM. There were no further instructions in the physician’s order indicating how the packed red blood cells were to be administered by nursing staff, including the transfusion rate, transfusion duration, or “administer per hospital policy”. A review of the second transfusion record revealed that the transfusion of PRBCs was started on 03/31/2026 at 1:51 AM at a rate of 125 ml/hr. The transfusion started at a rate higher than 2 ml/min during the first 15 minutes, as required by hospital policy. The patient was admitted to the floor on 03/31/2026 at 2:32 AM. An interview was conducted with Staff #5 on 04/08/2026 at 2:00 PM. Staff #5 acknowledged the surveyor’s findings of the physician’s order did not indicate how the packed red blood cells were to be administered by nursing staff, or that the hospital’s “Blood and Blood Products Administration” policy was followed. A review of the hospital’s policy, “Blood and Blood Product Administration,” with a date of 11/12/2025, revealed, “Policy: The provider is responsible for ordering the blood component and obtaining the consent by explaining the risks, benefits, and alternatives of transfusion to the patient, except in an emergency situation where the patient or appropriate representative is unable to be involved in the decision-making process. The provider or designee may witness the signature of the patient on the consent form once it is received. 2. A qualified transfusionist will initiate blood and monitor for the first 15 minutes, then the qualified transfusionist or licensed vocational nurses may finish the transfusion ....5. Documentation: a. Documentation in the EMR: All IV or central line sites, verifications, start/stop times, and vitals should be documented in the EMR ...8. Equipment: ...b. Y-type Blood Administration Set with 170-260 micron filters for RBCs, FFP, Cryoprecipitate, and platelets. Y-type blood tubing should be changed every 4 hours or after 2 units, whichever comes first. C. 0.9% sodium chloride (normal saline, NaCl) or plasmalyte should be used for priming and administering blood components ...9. Administration: a. Blood transfusion should be started as soon as the product arrives on the floor. If a delay of 20 minutes or more occurs, call the lab for instructions ...b. The transfusionist will observe, and patients will be continuously assessed at the bedside for signs and symptoms of transfusion reactions during the first 15 minutes of the transfusion. Life-threatening reactions can occur after the infusion of only a small volume of blood. c. Vital signs will be taken and recorded in the EMR. i. Assess the complete set of vital signs within 15 minutes prior to starting the transfusion. This will serve as the baseline. Then assess for adverse reactions and document vital signs after the first 15 minutes (plus or minus 5 minutes) and then every hour until the transfusion is complete. D. Document the date and time the transfusion was stopped and document post-transfusion vital signs up to 20 minutes post-transfusion. F. Time frame for infusions: In general, for simple, non-emergent blood transfusions, the following transfusion rates are recommended; however, in emergent conditions, such as shock or severe bleeding, a rapid infusion may be required. i. RBCs should be infused within 4 hours from issuance per the American Association of Blood Banks due to the danger of bacterial growth. 1. RBCs can be infused over 1-2 hours unless otherwise specified by the provider ....iii. All blood products should be infused at a rate of 2mL/min or less during the initial 15 minutes of a non-emergency transfusion while an RN monitors the patient for signs of transfusion reactions. An elevation in temperature or heart rate may be one of the first signs that a person is having an adverse reaction to a transfusion. The rate may increase if no adverse reaction is noted after the first 15 minutes. Suggested Infusion Rate of Components in Nonemergency Setting After the First 15 Minutes: Red Blood Cells: 150-300 ml/hr ....” A review of the Davita Corporation’s policy, “Administration of Blood and Blood Products” with a date of 03/2016 revealed, “Purpose: To establish guidance for the administration of blood and blood products during hemodialysis. Policy: 1. Blood and blood products are administered per the physician’s order and hospital policy. If administering platelets, they are administered post-dialyzer via an infusion pump. 2. Blood is to be initiated within the time frame established by the hospital blood bank. Blood is not to be stored in an unmonitored refrigerator once released from the hospital blood bank. If blood is not to be transfused, return blood to the hospital blood bank per hospital policy. 3. Blood must be administered through a transfusion set with a filter. 4. Only normal saline is to be used to prime the transfusion set prior to the initiation of the infusion. 5. Blood is administered during dialysis at a rate of no less than 30 minutes per unit and not to exceed three (3) hours per unit unless otherwise ordered by the nephrologist....” An interview was conducted with Staff # 2 (CNO) in the afternoon of 04/06/2026 in the hospital’s administrative conference room. Staff # 2 was shown Patient # 26’s transfusion record. Staff # 2 acknowledged that the physician’s order was incomplete, and the hospital’s policy was not followed in the administration of multiple units of blood to multiple patients.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 29191 Based on observation, record review, and interview, the hospital staff failed to ensure unusable medications were properly discarded in the pre-operative and post-operative units for cardiology patients undergoing cardiac procedures for 1 of 1 anesthesia carts. Findings include: During a tour of the Pre-operative and Post-operative units for Cardiology patients on 04/08/2026 at 1:00 PM, a list of medications was observed on the top of the anesthesia medication cart. Ketorolac 30 mg (milligrams) had an expiration date of 03/31/2026. The pharmacy was called to unlock the anesthesia medication cart. When the pharmacy clerk arrived, the surveyor asked the clerk which medication on the list had expired. The clerk reported that none of the medication had expired. The surveyor had to point out that the Ketorolac 30 mg vials had expired. The anesthesia medication cart was opened by the pharmacy technician, and there were 6 vials of Ketorolac 30 mg with an expiration date of 03/31/2026. An interview with Staff # 136 and # 137 on 04/08/2026 at 1:20 PM confirmed that the Ketorolac 30 mg expired on 03/31/2026. A review of the hospital’s policy, “Obtaining and Storage of Pharmaceuticals-DIV-MM” dated 04/02/2020, revealed that “...Any drugs past their expiration will be quarantined in pharmacy for subsequent disposal according to applicable rules and regulations...””

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 36594 Based on review of hospital policy, review of hospital documentation, and staff interview, the hospital staff failed to ensure proper temperature and humidity controls for 4 areas of the facility (Electrophysiology [EP] lab, professional outpatient building CT room, respiratory bronchoscopy cleaning room, and North Substerile Supply Room on the Women’s Unit) throughout the facility. Findings include: Facility policy titled, “Humidity/Temperature Control-SS-MKT” effective Date: 5/21/25 states in part, “Policy: To provide guidelines for the environmental control systems in the operating rooms, Sterile Processing Department, and other areas where a large bulk of sterile items are stored. Purpose: ...2) To comply with American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE) 170, 2008 the rooms should maintain the following: a) The Operating Room (OR) temperatures between 20°C and 24°C (68°F and 75°F), and a relative humidity between 30%-60%... b) The Sterile Processing (clean and dirty side) temperature 22°C and 26°C (72°F and 78°F), and a relative humidity between 30%-60%... c) The Sterile Storage Room temperatures between 22°C and 26°C (72°F and 78°F), and a relative humidity maximum of 60%... Procedure: 1) Relative humidity/temperature levels will be monitored and recorded daily. a) Relative humidity will typically be maintained between 30% and 60%. b) If during the year the recommended limits cannot be maintained due to extreme outside air conditions and the limitation of the Heating Ventilation and Air Conditioning (HVAC) equipment, contact Plant Services to evaluate. ...4) A daily log is kept of temperatures and humidity for the operating rooms, Sterile Processing Department, and the Sterile Storage Room. a) If the recommended limits are in range in the operating rooms, sterile processing department, or sterile storage room, the charge nurse, or designee, tasked with checking the temp and humidity will adjust the thermostat in an effort to reach the desired ranges and check back in 90 minutes. If the room is not in the recommended ranges, they shall inform plant services and make a note on the log that they have done so, with the ticket number and notify department manager.” Review of the temperature and humidity log for April 2026 in the EP lab stated, “Temperature Range: Max 80; Humidity Range: Max 60%” and had no minimum temperature or humidity. The following was documented for temperature and humidity, respectively: *04/01/26: 70.5, 48.4 *04/02/26: 69.4, 50.4 *04/03/26: 69.9, 52.0 *04/06/26: 66.2, 36.7 *04/07/26: 64.5, 39.4 Review of the temperature and humidity for April 2026 in the professional outpatient building CT room stated in part, “temperature range 72-78 degrees Fahrenheit; Humidity Range 30-60%.” The following were out-of-range (2 of 5 days for temperature and 5 of 5 days for humidity): *04/01/26: 19% *04/02/26: 19% *04/03/26: 19% *04/06/26: 71.1; 20% *04/07/26: 70.9; 20% Review of the temperature and humidity log for April 2026 in the respiratory bronchoscopy cleaning room had a temperature range of “Min 59, Max 86” and no ranges for humidity. All recorded temperatures were recorded in °C [Celsius] despite the written range on the form being in °F [Fahrenheit]; and the following were out-of-range for humidity and/or temperature (8 of 8 days were out-of-range) according to policy, with no follow-up or reassessment of temperature and/or humidity: *04/01/26: 15.9° (60.2°F) *04/02/26: 15.7° (60.26°F) *04/03/26: 17.8° (64.4°F) *04/04/26: 26%; 18.1° (64.58°F) *04/05/26: 23 - 42%; 15.4-19.8° (59.72°F - 67.64) *04/06/26: 26%; 17.9° (64.22°F) *04/07/26: 23%; 17.6° (63.68°F) *04/08/26: 21%; 22° (71.6°F) In an interview on the morning of 4/8/2026, Staff #143, Plant Ops reported each area is responsible for monitoring their temperatures and humidities according to facility policy. Staff #143 verified no work orders were open for any of the above areas and reported each area should adjust, recheck, and if remains out-of-range, put in a work order. In an interview on the afternoon of 4/8/2026, Staff #119, Infection Preventionist, confirmed the above findings and reported they’ve noted an issue with temperature and humidity, including the forms, and will address these issues. 40989 Findings include: A review of the temperature and humidity log for April 2026 in the North Substerile Supply Room on the Women’s Unit read, “Temperature Range: 72-78 degrees Fahrenheit (F) and Humidity Range: 30-60%. Further review of the temperature and humidity for April 2026 for the 4 North Substerile Room confirmed the temperature was out of range for 6 of 6 days reviewed (April1-6, 2026). The following days were out of range: *04/01/26: 67.6°F *04/02/26: 68.2°F *04/03/26: 67.9°F *04/06/26: 66.2°F *04/07/26: 66.4°F During an interview on 04/06/2026 after 11:00 AM, Registered Nurse (RN) Staff #132 confirmed there were no documented actions by the staff on the Temperature and Humidity Log, and no work orders could be provided to ensure that plant services were notified of the out-of-range temperatures or if the issue was corrected. RN Staff #132 confirmed that sterile supplies were stored in this room and that the temperature was out of range per the policy.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40989 Based on observation, document review, and interviews, the hospital failed to maintain a clean and sanitary environment in 9 (Women’s Unit, 2 North Medical-Surgical Unit, 4 WA Intermediate Care Unit, Main Emergency Department, Emergency Department West, Main Operating Room, Radiology, Professional Outpatient Building, and Cardiovascular Operating Room) of 9 areas observed. Also, the hospital failed to follow the policies titled “Hand Hygiene-IFC MKT” and “Cleaning of Non-Critical Equipment-IC-MKT”, Policy Number: 47447.3. Findings: Women’s Unit An observation tour of the Women’s Unit was conducted on 4/06/2026 at 10:10 AM with Registered Nurse (RN) Staff #119, RN Staff #132, and Staff #31. The following was observed; In the Labor and Delivery Operating Room (OR) #1, the OR table base was observed to have areas of rust and flaking metal. This OR was identified by RN Staff #132 as clean and ready to receive a new surgical patient. When the table was flexed, a small amount of material, approximately the size of a pencil eraser, appearing consistent with blood-covered human tissue, was observed on the table surface beneath the mattress. Labor and Deliver Room #4501 was identified as ready to receive a new laboring patient. In the bathroom, there was a shower chair marked clean. The shower chair was turned upside down, and the underside of the seat was observed to have what appeared to be multiple spots of old dried blood. An interview was conducted with RN Staff #132 on 4/06/2026 at 10:20 AM. RN Staff #132 confirmed the infection control findings in OR #1 and Patient Room #4501. Central Supply A tour of the central supply was conducted on 4/08/2026 after 12:40 PM with RN Staff #119 and Central Supply Director Staff #133. During the observation tour, it was observed that there was no clear separation between clean and dirty supplies. The central supply storage room was the main storage room for the hospital. Once supplies were delivered, the department separated the supplies and either stored them in the appropriate storage location or delivered them to the unit that ordered the supplies. After entering the supply room, looking to the right of the room were multiple metal shelves with blue bins used to store clean and sterile supplies. Sitting next to one of the metal racks that stored sterile supplies were 5 metal transport dollies used to transport oxygen tanks throughout the hospital. The dollies were observed to be dirty with dust and chipped paint. During an interview with Staff #133 on 4/08/2026, Staff #133 could not confirm if the transport dollies were cleaned before bringing them into a clean area. There was no clear bag or other visual sign to confirm they had been cleaned. To the left of the room, it was observed that there were multiple 3-drawer mobile carts, 6 bear huggers (a machine used to blow warm air on a patient to prevent a low body temperature), mobile trauma carts, mobile emergency carts, and other hospital equipment covered with clear plastic bags indicating that the carts were clean and ready to be distributed to departments within the hospital. There was a metal rack that had multiple black containers labeled as intubation boxes that were not identified as clean or dirty. Directly across from where the storage of the 3-drawer mobile carts was a red emergency cart that was not covered with a clear plastic bag or other visual tag to identify if the equipment had been cleaned. An interview was conducted with Staff #133 on 4/08/2026 after 12:40 PM. Staff #133 was asked about the process for the mobile carts that were covered in clear plastic bags. Staff #133 replied that the department is responsible for stocking and restocking all Personal Protective Equipment (PPE) carts, trauma carts, intubation boxes, and emergency carts. She stated, “They have these carts on the floor, but when they get used, the staff bring them to us to restock”. Staff #133 was then asked if the carts or intubation boxes were wiped down or cleaned before they were brought through the doors next to all the clean equipment. Staff #133 confirmed that the carts were not always cleaned when they received them, and they would have to wipe them down once they received them. She confirmed that sometimes they would come with dirty surgical instruments on top of the cart in the enclosed bin, and they would have to either take them to sterile processing or have them come and pick them up so they could be processed. Staff #133 confirmed that dirty equipment, carts, and intubation boxes were brought to the central supply area to be restocked and placed in an area that stored clean equipment. A review of the hospital policy titled “Cleaning of Non-Critical Equipment-IC-MKT”, Policy Number: 47447.3, was as follows: Purpose: To prevent cross-contamination between patients when using patient care equipment, to include use in Transmission Based Precaution rooms. Policy: UT Health East Texas is dedicated to minimizing the risk of healthcare-acquired infection by establishing guidelines for the cleaning and disinfection of shared equipment. This policy provides guidelines for recognizing clean or soiled equipment and guidelines for storage or treatment after use. The following procedures define and establish standards for assuring that non-critical (defined by the Centers for Disease Control as items that come into contact with intact skin not mucous membranes), shared patient care equipment is clean before use and tat all used or contaminated equipment is appropriately cleaned before reuse. Procedure: Cleaning and Disinfection Instructions ... 5) Identify clean patient care equipment by placing a clear/transparent bag or a toilet seat band over the piece of equipment. If not applicable, then identify in another visual way...” 48653 Findings include: 2 North Medical-Surgical Nursing Unit During a tour of the hospital’s 2 North Medical Surgical Unit with Staff # 68 on 04/06/2026 at 10:30 AM, the surveyor observed the following infection control issues Staff # 15 (Patient Care Technician) was observed leaving patient room # 2523 with a DINAMAP (Device for indirect, non-invasive mean arterial pressure monitoring) on wheels. Staff # 15 did not perform hand hygiene upon leaving the patient room and did not clean and disinfect the DINAMAP machine before entering the next patient room # 2524. In an interview on 04/06/2026 at 10:45 AM, Staff # 68 was asked what the hospital’s policy and procedure states for the cleaning and disinfecting of patient care equipment in between patient encounters. Staff # 68 reported that Staff # 15 should have performed hand hygiene, donned new gloves, and cleaned the DINAMAP with the appropriate Sani-wipes before entering the next patient room. Further observation of the 2N patient care unit revealed that the A/C return vents in rooms 2533 and 2534 were dirty and had a thick layer of dust and other unknown debris on the inside and outside of the vents. The exhaust fans in the patient bathrooms were also dirty with a thick build-up of dust and other unknown debris on the inside and outside of the vents. The IV (intravenous) poles in the rooms had rust, dirt, and dust on the bottom of the poles. There was a build-up of hair in the wheels of the IV poles. The IV pumps attached to the poles had previously used Kuros caps hanging from the IV pumps. The Kuros caps had not been discarded after the previous patient was discharged from the room, which posed a potential cross-contamination risk between patients. The shower curtains inside the patient bathrooms of rooms 2533 and 2534 were not properly cleaned and disinfected. There was an unknown, dried, brown substance on the curtains. 4 WA Intermediate Care Unit During a tour of the 4 WA Intermediate Care Unit with Staff # 68 on 04/06/2026 at 12:00 PM, the surveyor observed that 2 (Staff # 139 and # 140) of 2 staff members had failed to perform hand hygiene upon entering and exiting patient rooms. Staff # 139 (Clinical Manager) entered patient room # 4430 without performing hand hygiene. Upon exiting the patient’s room, Staff # 139 failed to perform hand hygiene. An interview with Staff # 139 was conducted on 04/06/2026 at 12:05 PM. Staff # 139 reported that she failed to perform hand hygiene before entering the patient’s room and upon exiting the patient’s room. Staff # 140 (Registered Nurse) entered the patient room # 4430B without performing hand hygiene. A review of the hospital’s “Hand Hygiene” policy with a date of 05/19/2023 revealed, “Policy: 1. Hand hygiene is the single most important action in preventing and controlling infection in healthcare facilities. 2. Many types of infections may be caused by organisms transmitted on the hands of personnel. 3. Personnel must decontaminate their hands before and after contact with any patient and at the beginning and end of their shift. Staff may carry hospital-provided hand sanitizer in their pockets unless contradicted by Department policy ....Procedure: 1. Indications for hand hygiene include inpatient and outpatient settings: a. When entering and leaving a patient’s room/environment or at the end of caring for a patient, sanitize in and sanitize out. B. Before and after contact with the patient or items in the immediate vicinity ....” An interview was conducted with Staff # 68 on 04/06/2026 at 12:15 PM. Staff # 68 confirmed that there were several staff members who failed to follow hospital policy for the control and prevention of infectious organisms. 48749 Findings include: Main Emergency Department: During a tour of the hospital’s main emergency department with Staff # 5 on 04/06/2026 at 9:45 AM, the surveyor observed the following infection control issues: *There was an unknown, yellow, sticky substance on the frame of the stretcher in room #10. *There was an accumulation of dust and an unknown dried black substance on the top of the supply cart #75 in the back hallway. The wheelbases of the cart were broken and chipped. *There was an unknown, dried white substance on the glass door of the Pyxis (automated medication dispensing system) located in the medication preparation hall. *There was an accumulation of dust on the bottom shelf inside of the Pyxis. *There was an accumulation of dust and debris inside the bins holding medical equipment. The bins were in a locked cabinet in the medication preparation hall. *There were dead insects in the light covers above the Pyxis and supply cabinets in the medication preparation hallway. *There was an accumulation of dust on the exhaust vent. *There was dead insects in the light covers above the main nurse’s station and the hallway outside of triage. Emergency Department West: *There was rust on the floor tiles around the blanket warmer in the supply room. *There was an accumulation of dirt and debris around the base of the ice machine in the supply room. *There was an accumulation of dust and debris on the floor of the biohazard room. *There was an unknown dried black substance on the floor of the biohazard room. *There was an unknown dried brown substance on the lid of a bedside commode stored in the biohazard room. *There was an unknown dried brown substance on the side of a food cart and on the floor tiles next to the food cart stored in the biohazard room. *There was an unknown brown substance on the counter, near the wall of the biohazard room. *There was a missing ceiling tile in the hallway above the door to the biohazard room. *There was an accumulation of dust on top of the crash cart in the hallway. *There were 23 cotton tip applicators with an expiration date of 01/25 and 10/24 in a cabinet behind the nurse’s station. *There was an accumulation of dust on the top of the supply cart #38 in the hallway near the nurse’s station. The wheelbases of the cart were broken and chipped. An interview was conducted with Staff #5 on 04/06/2026 at 10:45 AM. Staff #5 confirmed the surveyor’s infection control and safety issues found during the tour of the emergency department. 29191 Findings include: During a tour of the facility on 04/08/2026 on the morning and afternoon, the following infection control issues and safety issues were observed. CT Scanner #2 Closet * Observed in the floor of the CT Scanner #2 closet was an equipment cover lying directly on the floor in the back corner of the closet. The piece of equipment ( computer stand) was broken, according to the staff member cleaning the CT room. There was trash, white and orange caps off of tubing, and the corners of the closet were dirty. There was dust, dirt, and black build-up along the floor and the molding of the closet. There was a red bio-hazard container with no lid sitting on the floor of the closet. The closet had a very unclean appearance. Imaging hallway leading to the MRI room on the First floor of the Hospital * The surveyor observed 4 EKG (electrocardiogram) machines in the hallway of the exit door. There was no 5-foot width clearance for exiting the building. There were 3 EKG machines on one side of the hallway and 1 EKG machine on the other side of the hallway, which only allowed a 3-foot clearance on exiting the building. There was no indication label on the EKG machines; rather, they were clean or dirty. There was one machine that had a clean label and another EKG that had a clear plastic bag over the top of it. The surveyor asked what the process was for knowing if the EKG machines were clean. Staff member #141 reported that if the machines are in the hallway, the EKG machines have been cleaned. There was no consistent process for noting if the EKG machines were clean. Washroom for TEE ( Transesophageal Echocardiogram) Scopes * The surveyor observed an open container of Cidex OPA (cold disinfectant) used to disinfect scopes. The surveyor asked why there was Cidex OPA stored in the disinfectant cabinet. Staff #141 stated, “I kept the Cidex OPA in case the washer broke down, and I need it to disinfect the TEE scopes. The container of Cidex OPA was half empty, and there was no date as to when the Cidex OPA had been opened. Cidex OPA accoeding to the label and manufacturing guidelines, was only good for 75 days once opened. There was no way to determine how long the Cidex Opa had been opened. Professional Outpatient Building CT Room The surveyor observed at least 10 cardboard boxes piled in the hallway underneath a fire extinguisher that was for the MRI (Magnetic Resonance Imaging Room). The fire extinguisher had a blue label (Dry powder extinguishers can be used in the event of class A, B or C fires.) The cardboard boxes were piled in front of an exit door. Cardiovascular Operating Room (CVOR) During a tour of the Cardiovascular Operating Room #2, Staff #127 was observed cleaning the room. The surveyor lifted the operating room table mattress, and the mattress was wet from the disinfectant solution. According to the disinfectant guidelines, the disinfectant should be allowed to air dry. A review of the “Oxivir Tb” manufacturer disinfectant guidelines revealed the following: “Hospital Grade Disinfectant Use instructions Ready to Use (RTU) Liquid 1. Apply Oxivir Tb undiluted to surfaces by spray, cloth or disposable wipe. 2. All surfaces must remain visibly wet for 1 minute for viruses and bacteria. For fungi, surfaces must remain visibly wet for 10 minutes. 3. Allow to air dry.” A review of the competency checklist for Staff #127 revealed the following: “OR & Perioperative Environmental Cleaning Competency Validation Ardent ~ UT Health Tyler Hospital Applies the disinfectant for the contact time required on the product label and, if the IFU require that the surface remains wet, reapplies. Cleans and disinfects reusable noncritical, nonporous surfaces (mattress covers, pneumatic tourniquet cuffs, blood pressure cuffs) after each patient’s use.” The competency checklist was signed by Staff #127 and the qualified observer on 03/03/2026. A review of the document titled “Nam-Soft-clea HLC_ 033_ S_Opearating room surgical invasive areas and delivery rooms terminal cleaning at the end of each day” revealed the following: “17. Cleaning equipment should be disassembled. cleaned with the approved disinfectant and air dried before storage.” An interview with Staff #135 and #137 on 04/8/2026 during the morning and afternoon hospital tour acknowledged the infection control and safety issues. 47892 Findings include: A tour of the main operating room (OR) was conducted with Surgery Administrator RN Staff # 91, RN Scribe Staff # 92, Main OR Manager RN Staff #96, Main OR Supervisor RN Staff #97, and Clinical Operations Manager RN Staff #134 on 04/06/2026 after 10:00 AM. The Main OR has 12 operating rooms and 2 cystoscopy rooms (surgical rooms used for urologic procedures). OR #1 1. The OR table (specialized, adjustable table used to position and support a patient during surgery) mattress pad had multiple tears on the top and underside of the mattress, exposing the foam. Foam is porous and can be contaminated with human blood and tissue. Foam cannot be sanitized. 2. The Neptune Suction (mobile suction and fluid disposal system) machine had a used single-use manifold still inserted in the machine. Inside the manifold was a bright red substance resembling blood. 3. On the floor of the OR next to the OR table, there was what resembled human tissue and blood about the size of a ballpoint pen. There was also a suture (a stitch or strand of material used to close wounds or surgical incisions) thread that had been used on a previous surgery. OR #4 1. On the floor of the OR, there was what resembled human tissue and blood. 2. The OR table mattress pad had multiple tears in the seams of the mattress, exposing the foam. 3. The base of the OR table was rusted on all 4 sides. 4. When the bed was raised, the sleeved columns covering the pedestal of the OR bed had a dry reddish-brown substance that resembled dry blood. OR #5 1. A green rolling office chair had holes in the upholstery with foam padding exposed. 2. An endotracheal tube (a flexible plastic tube inserted through the mouth into the windpipe to help a person breathe) was opened with a stylet and a 10cc syringe attached and lying on the anesthesia machine. The Endotracheal tube is a sterile item and should not be opened until the staff are ready to bring a patient to the OR for surgery. There was no surgical case scheduled in this OR for at least 2 hours. 3. A clear plastic cover over the anesthesia machine’s work surface had come loose and could be peeled back. Underneath the plastic cover was a clear sticky substance. 4. In the 1st drawer under the anesthesia locked narcotics pyxis was a single-dose vial labeled “Precedex 4mg”. The plastic safety seal was removed, and there was no open date or expiration date on the medication vial. Once a vial is open or a solution is mixed, it is no longer considered sterile indefinitely. Without an expiration date, staff cannot determine how long it has been open. This increases the potential for cross-contamination. An interview was conducted on 04/06/2026 after 10:00 AM with RN Staff #91, 92, 96, 97, and 134. The staff was asked if they agreed with the findings in OR #1, 4, and 5. The staff confirmed that they agreed with the findings in ORs #1, 4, and 5. The staff was asked if ORs #1, 4, and 5 were set up and ready to receive a patient for surgery. The staff confirmed that ORs #1, 4, and 5 were not set up and ready to receive a patient for surgery. 36594 Based on a review of facility policy and observation, the facility failed to provide a sanitary environment and enforce the written hand hygiene policy when an environmental services (EVS) employee failed to perform hand hygiene per facility policy. Findings include: An observation of waste management practices on the loading dock on the afternoon of 4/8/26 revealed an environmental services (EVS) employee failed to perform hand hygiene after placing waste in the trash compactor, removing her gloves, and re-opening the trash compactor to discard her gloves. This observation was verified with Staff #119, Infection Preventionist, during the tour. Staff #119 noted there were no alcohol-based hand sanitizer stations accessible on the dock; staff must walk into the building through automatic doors, walk approximately 20 paces, and turn a handle to the restrooms before they are able to perform hand hygiene. Facility policy titled “Hand Hygiene - IC MKT” effective date 5/19/23 states in part, “ ...Other aspects of hand care and protection (glove use): ...b) Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities.””

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 36594 Based on a review of facility policy, pulmonary services staffing matrix, and an interview, the facility failed to ensure the frequency of ventilator checks was specified and approved by the Medical Staff. Findings include: Facility policy titled “Ventilator Management - RC”, effective date: 4/12/2025: states in part, “Purpose: To facilitate initiating and managing mechanical ventilation ...” The policy does not specify how frequently respiratory therapists should assess the ventilators for intubated patients. The “clear prioritization matrix” changes the frequency of ventilator checks based on staffing levels characterized as: *green - “Vent checks Q3 [every 3 hours] (will change to Q4)” *yellow - “Vent checks Q3 (will change to Q4)” * red - “Vent checks Q6.” In an interview on the afternoon of 4/8/2026, Staff #120, Director of Pulmonary Services, verified that the current policy - “Ventilator Management - RC” did not specify the frequency that respiratory therapists should conduct ventilator checks. Staff #120 also verified that the “clear prioritization matrix” had not been approved by the Medical Staff.”

“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: 10135 Based on observation, interview and record review, the facility failed to ensure supplies were maintained in 1 of 2 areas of the Emergency department (West). The facility failed to ensure: Expired supplies were discarded in a patient exam room, an airway cart and a pediatric emergency cart in the emergency department. This deficient practice had the likelihood to cause harm to all patients presenting to the Emergency department (ED). Findings include: During an observation on 02/23/2026 after 1:11 p.m., on the West side of the ED the following was found: Exam Room #4 Strips of disinfecting intravenous caps were found in a drawer which expired on 01/06/2026. A bag of electrocardiogram (EKG) electrode pads expired on 10/26/2025. Airway cart in the hallway A sterile laryngeal mask airway (LMA) expired on 11/07/2025. A sterile laryngeal mask airway (LMA) expired on 01/21/2026. Oral nasal tracheal cuffless expired 01/21/2026 and 02/08/2026. Pediatric crash cart Fiber optic laryngoscope handle with batteries expired 02/01/2023. Tracheal tube with stylet expired 09/03/2024. Polyurethane umbilical vessel catheter expired 10/22/2024. Introcan Safety intravenous catheter expired on 07/01/2025. A box with tracheostomy tube cuffed with inner cannula expired 07/02/2025. An intubating stylet expired 08/13/2025. “Y” tubing connector expired 05/30/2025. A neonatal electrodes expired 12/31/2025. Staff #’s 5 and 14 confirmed the observations. Review of “ED CHECK OFFS” forms from 2/01-22/2026 revealed staff were signing as checking the carts daily. During an interview on 02/23/2026 after 1:11 p.m., Staff #14 confirmed the forms and stated he felt like the nurses were checking the dates on the outside of the supply packets only. They were not checking dates on the loose supplies in the carts.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48653 Based on a record review and staff interviews, the hospital staff failed to ensure that 1 (Patient #4) of 18 patient encounters was documented in the hospital’s central emergency room log. Findings include: A review of the hospital’s “General and Special Hospitals Facility Incident Report” dated 08/14/2025 revealed Patient # 4 had arrived at Hospital # 1 on the evening of 08/10/2025 seeking care. The hospital staff documented the following on the self-report: “A patient 27 weeks of gestation presented to the UTHET Tyler OB unit seeking care. The patient was directed to the registration area for intake. During the registration process, the registration staff contacted the Labor and Delivery unit to advise of the patient’s arrival. L&D clinical staff communicated that the unit was at capacity with no available beds. Based on this information, the patient was not registered, was not brought to an appropriate clinical area, and was not provided with a medical screening examination (MSE) by a qualified medical person as required under EMTALA. The patient subsequently left the facility and went to another hospital, where she received an MSE and treatment ...” A review of Hospital # 1’s EMTALA Log for the date of 08/10/2025 revealed that Patient # 4 was never registered, and Patient # 4 does not appear on the EMTALA log. A review of the hospital’s registration clerk employee schedule revealed that Staff # 9 (registration clerk) was working on the evening of 08/10/2025. Staff # 9 had been involved in an EMTALA violation against Hospital # 1 in March of 2025 with the same central log non-compliance. Staff # 9 failed to register a patient on the hospital’s central EMTALA log in March of 2025 and in August of 2025. The hospital’s administrative staff and leadership did not address the noncompliance with Staff # 9 despite Staff # 9’s involvement in the hospital’s EMTALA violation in March of 2025. A review of Staff # 9’s personnel file revealed that Staff # 9 had EMTALA training and education titled “Front End: EMTALA Overview and SOP Review” in April and July of 2025. A review of Patient # 4’s medical record from Hospital # 2, with a date of service of 08/10/2025, revealed the following: Patient # 4 arrived at Hospital # 2 on 08/10/2025 at 6:44 PM with a chief complaint of left flank pain. A review of the Emergency Room Provider’s note dated 08/10/2025 at 7:05 PM revealed, “The patient is a 27 year old female G3P0020 at 26 weeks, 6 days presenting with left sided low pack and flank pain radiating to pelvis for the past 3 days. PNC has been with 4 seasons and reports that she was sent away from their ER because they did not have the appropriate level NICU for her. She is concerned because she has a history of ureteropelvic junction anomaly, ultimately necessitating a nephrectomy performed last year. She also just had a lap chole. She denies any dysuria or fever, just some mild nausea and pelvic cramping. Mainly wants to make sure there is nothing happening that could be compromising her remaining kidney ...Review of Symptoms: ...Genitourinary: positive for pelvic pain. Musculoskeletal: positive for back pain ...” The patient had laboratory and radiology tests including a urinalysis, complete blood count, comprehensive metabolic profile, ultrasound renal kidney, and an obstetrics ultrasound. The patient also underwent a fetal nonstress test, cervical exam, and fetal heart tones by doppler. All exams and tests were within normal limits. The patient was discharged from Hospital # 2 on 08/10/2025 at 9:13 PM. A review of Hospital # 1’s policy, “EMTALA-Medical Screening Examination and Stabilization” with an effective date of 04/19/2023 revealed, “PURPOSE: To ensure that all individuals who come to the Emergency Department receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder ... POLICY: 1. Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition, within UT Health East Texas’s capability and capacity ....” An interview was conducted with Hospital # 1’s Staff #48 and Staff #52 on 12/18/2025 at 1:50 PM. Staff #48 reported that the normal process for pregnant patients when they arrive at the hospital’s ED (emergency department) is to stop at the registration desk in the ED (Emergency Department) waiting room. The registration clerk would then register the patient and call the nursing staff in L&D (labor and delivery). The L&D nurse would give the registration clerk a room assignment for the patient, and the registration clerk would escort the patient to their assigned room. When the patient arrives at their room, the L&D nurse initiates the triage process. Staff #48 reported on the day of the incident that the hospital’s neonatal intensive care unit (NICU) was full. The L&D staff were informed that the hospital could not take any transfers for pre-term deliveries at that time. Staff #48 reported that there was a miscommunication, and the L&D nurse instructed the registration clerk (Staff # 9) that L&D was on diversion. Staff # 9 was working in the ED and notified Patient # 4 that L&D was full and not able to see them. Staff # 9 then told Patient # 4 that they would have to be seen at another facility. Staff # 48 reported that Patient # 4 should have been seen in the ED if there were no beds available in L&D, and an L&D nurse would come down to the ED to assist with the patient. Staff # 48 and Staff # 52 confirmed the findings that the L&D nurse and Staff # 9 did not follow the hospital’s EMTALA policy titled, “EMTALA-Medical Screening Examination and Stabilization”.”

“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: 48653 Based on record review and staff interviews, the hospital staff failed to ensure that 2 (Patient # 1 and # 18) of 2 patients received a notice of Patient Rights and Responsibilities before receiving care at the hospital. Additionally, the hospital staff failed to follow the hospital’s “Patient Rights and Responsibilities” policy. Findings include: Patient # 1 A review of patient # 1’s medical record was conducted on 12/18/2025 with Staff # 18 in the hospital’s administrative conference room. Patient # 1 was admitted to the hospital on 08/23/2025 at 5:56 PM. The patient arrived critically ill, intubated, and sedated. The patient was diagnosed with Acute COPD Exacerbation, Acute Respiratory Failure, Hypertension, and Pneumonia. Further review of the patient’s hospital course revealed the patient was extubated on 08/24/2025 at 10:20 AM. Staff # 55 (Registered Nurse) documented the following neurological assessment on 08/25/2025 at 12:46 PM, “Neurological: Within Defined Limits, Awake, Alert, and Oriented x4” The patient did not receive a “Notice of Patient Rights and Responsibilities” when the patient became alert and oriented. There was no documentation in the patient’s medical record to support that the hospital staff attempted to contact a surrogate decision maker or that the patient was unable to sign the notice of patient rights due to the patient’s condition. There was no documentation in the medical record regarding the patient’s rights and responsibilities. An interview was conducted with Staff # 47 (Registration Manager) on 12/18/2025 at 3:15 PM in the administrative conference room. Staff # 47 stated that all patients should receive a “Notice of Patient Rights and Responsibilities”. Staff # 47 stated that the registration staff should have attempted to contact the patient’s surrogate decision maker or attempted to obtain the patient’s acknowledgment of patient rights and responsibilities once the patient was alert and oriented. Staff # 47 confirmed that the registration staff did not document either in Patient # 1’s medical record. Patient # 18 Patient #18 is a 64-year-old male with end-stage renal disease, hypertension, secondary hyperparathyroidism of renal origin, and anemia, who presented to the Hospital via transfer for increased shortness of breath and acute hypoxic respiratory failure. A review of Patient #18’s medical record revealed that the patient did not receive a “Notice of Patient Rights and Responsibilities. There was no documentation in the patient’s medical record to support that the hospital staff attempted to contact a surrogate decision maker or that the patient was unable to sign the notice of patient rights due to the patient’s condition. There was no documentation in the medical record regarding the patient’s rights and responsibilities. An interview with Staff #18 on 12/18/2025 at 3:30 PM confirmed that there was no “Notice of Patient Rights and Responsibilities” documented in the medical record. A review of the hospital’s “Patient Rights and Responsibilities policy dated 12/18/2023 revealed the following: “Policy: A written copy of the hospital’s statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate to the patient’s age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient’s understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient’s assessment of understanding his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission, and in a manner that he/she can understand. Complaints and concerns regarding a patient’s rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department who will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patient’s regarding their rights to health care and health care-related activities during hospitalization. Procedure: 1. Provide information that outlines the patient or someone acting on the patient’s behalf for all inpatients, outpatients and ER patients. A. Patient Rights Information will be provided to the patient in the form of the Hospital’s Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgement document which will acknowledge their receipt of the patient rights. A. This document will be maintained in the patient’s medical record. 3. The admitting or nursing staff may refer to the Interpreter List for patients with language barriers. 4. Obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment. 5. Provide the patient with access to the patient complaint procedure if requested by the patient. 6. Documentation: -Treatment Authorization and Terms of Treatment Agreement. Procedure: Outpatient: 1. When patient enters an outpatient area of the hospital: A. Patient rights are available in English and Spanish and are posted on a visible area of the outpatient area. B. Patient Rights will be provided to the patient or surrogate in the form of a handout when the patient enters an outpatient area of the hospital under any type of procedure. 2. The outpatient staff should obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment. 3. If the patient has a complaint, provide the patient with access to register complaints or concerns with a patient advocate/patient representative. 4. Documentation- Treatment Authorization and Terms of treatment.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital’s staff failed to ensure that 2 (Patient # 1 and # 2) of 2 patients were free from all forms of abuse or harassment. Additionally, the hospital failed to follow the “Contract Staff Agency Request Procedure and Background Investigation Procedure” policies. A review of the hospital’s “General and Special Hospitals Facility Incident Report” self-reported incident dated 08/29/2025 revealed, “Illegal, unprofessional, or unethical conduct related to operation of facility or services: On August 27th, 2025, a female patient (Patient # 1) reported to Staff # 56, the day shift nurse, that Staff # 54, RN traveler nurse employed under a contract with Aya Healthcare, Inc., sexually assaulted her the previous night. Staff # 56 reported the allegation to the charge nurse, who spoke with the patient. The patient said Staff # 54 forced the patient to rub his penis and subsequently exposed himself. The patient objected to the behavior and refused to let Staff # 54 change the patient’s pure wick later that same night. The patient did not sustain any physical injuries. The patient was provided with immediate support in accordance with the hospital’s Sexual Assault policy, offered and declined a SANE exam, and was appropriately discharged .... The hospital initiated an investigation, and Staff # 54 was immediately removed from the facility ...In light of the incident on August 27, 2025, a previous unsubstantiated report is included in this report. On July 9, 2025, at the time of discharge, a female patient (Patient # 2) reported to a staff member that a male nurse made her feel uncomfortable because he rubbed against the patient with his penis and put his penis in her hand ‘a couple of nights ago’. At the time of the alleged incident and the start of that particular night shift, the patient was having bleeding, and there were multiple residents involved in the care, and the doctor had to come assess. There was documentation of an eventful few hours heading into the night, and documentation that the patient was disoriented. However, the staff member described the nurse, who was identified as Staff # 54, RN. Staff # 39, Human Resources Director, Staff # 4, ACNO, and Staff # 8, DON, subsequently interviewed Staff # 54, who denied any inappropriate behavior and asserted that he was not alone in the room with the patient. There were no other witnesses. After an internal investigation, the event was unsubstantiated.” A review of Staff # 54’s personnel file was conducted on 12/18/2025 at 1:00 PM with Staff # 37 (Human Resources Specialist) in the administrative conference room. The following was revealed, Staff # 54 (Registered Nurse) was hired as a contract staff member for the hospital with a prior history of sexual abuse allegations against patients. Staff # 54 had his nursing license suspended in North Carolina before working at the current hospital. Staff # 54 was employed at the hospital through a contract with a Staffing Agency from May 19th, 2025, to August 27th, 2025 despite the previous alleged sexual assault allegations and RN license suspension in North Carolina. The Registered Nurse license verification in Staff # 54’s personnel file indicated an active RN license with the following note under the “license status” section: “Unencumbered- RN privilege adverse action by: North Carolina (see History)”. Further review of Staff # 54’s personnel file revealed the following from North Carolina’s Board of Nursing: “Published Consent Order in the matter of Staff # 54 Findings of Fact: 1. The North Carolina Board of Nursing is a body duly organized under the laws of North Carolina and is the proper body for this proceeding under the authority granted in it Article 9A, Chapter 90 of the General Statutes of North Carolina and the rules and regulations promulgated hereunder. 2. Licensee is the holder of a Texas multistate Registered Nurse license, which expires on December 31, 2025. 3. On October 23, 2023, the Board received a complaint from Trusted Health regarding the licensee’s nursing practice. 4. On May 17, 2023, Licensee began a twenty-six-week travel assignment with a North Carolina Hospital through a Health Travel Company. The licensee was assigned to the Neurotrauma ICU stepdown unit, working the night shift. The licensee’s contract was cancelled following a facility investigation on October 2, 2023. 5. On September 24, 2023, Licensee was assigned to the care of Patient R.M., who had recently undergone an open ventral hernia repair. 6. On September 25, 2023, prior to being discharged, Patient R.M. reported to facility staff that Licensee had touched her inappropriately during the night shift. Leadership conducted an interview with the patient and consulted the facility forensic nurse. Patient R.M. reported that the Licensee took her breasts out of her gown without consent, claiming it was necessary to apply lotion to the EKG leads. Despite her objections, he continued to grope and knead her breasts, stating it was part of his job and he could be fired if she spoke out. He repeated this behavior at 1 a.m. and made inappropriate comments about her breast size. Facility leadership conducted an interview with the Licensee, during which time he acknowledged applying lotion to the patient’s breasts. 7. Board staff reviewed the care record of Patient R.M. Licensee documented the patient’s skin assessment as ‘Normal’. The licensee did not document the assessment of the patient’s abdominal incision. Additionally, no nurses’ notes were found regarding any breakdown of the patient’s skin, the application of lotion, or issues with EKG leads sticking to the patient’s skin. 8. On March 18, 2023, Licensee was interviewed by Board Staff. During the interview, the Licensee admitted to applying lotion on the upper abdomen, breast folds, and outer area of the breasts of the patient. The licensee claimed that the patient’s skin was excoriated. When questioned by Board Staff concerning the lack of documentation of the patient’s incision assessment, the presence of an abdominal binder, lotion application, and reason for skin intervention, Licensee stated that he could not remember documenting it because it was a busy night. The licensee also mentioned that he came in once during the night shift on September 24, 2023, to apply lotion. However, he admitted coming into the room several times to fix EKG leads. Regarding the allegation of telling patient R.M. that he could lose his job, the Licensee denied it and stated that the patient misunderstood him. Licensee also mentioned that the patient never told him or any other staff members during the night that she was upset of that he made her uncomfortable .... ORDER: 1. Licensee’s privileges to practice I North Carolina shall be suspended for a minimum of 12 months ...3. All disciplinary actions taken by the Board will be reported to the appropriate entities as outlined in Board policy and as required by state and/or federal regulations. Those entities include, but are not limited to, NURSYS, the National Practitioner Data Bank, the Office of the Inspector General, and any other jurisdiction in which Licensee is or has been licensed ...” An interview with Staff # 57 (Human Resources Agency Staff Coordinator) was conducted on 12/18/2025 at 1:15 PM in the administrative conference room via telephone. Staff # 57 was asked to recall what information was found when reviewing Staff # 54’s background check and license verification. Staff # 57 stated, “He had a background check flag. I reviewed it and looked over everything. From my perspective, the allegations seemed more like a misunderstanding.” Staff # 57 was asked what the hospital’s policy and process was for contract staff who have a background check flag. Staff # 57 stated, “We did not have a process before this event. I didn’t have any formal training on it”. Staff # 57 was asked if she had alerted anyone to the background check flag that appeared for Staff # 54. Staff # 57 responded, “No, I did not tell anyone because I thought it sounded like a misunderstanding”. Staff # 57 proceeded to onboard Staff # 54 despite the background check flag and registered nurse license suspension in North Carolina. Staff # 57 failed to follow the “Background Investigation Procedure” policy. An interview was conducted with Staff # 4 (ACNO) on 12/18/2025 at 3:00 PM in the administrative conference room. Staff # 4 was asked about the internal investigation that took place for the alleged July 19, 2025, incident, and Staff # 4 was asked if the investigation included a review of Staff # 54’s personnel record. Staff # 4 reported that Staff # 54’s personnel record was not reviewed, and Human Resources was not contacted for the investigation. Staff # 4 (ACNO), Staff # 8 (DON), and Staff # 39 failed to identify a pattern and trend in Staff # 54’s patient care and behavior when Patient # 2 reported inappropriate sexual behavior from Staff # 54 on 07/19/2025. The lack of a thorough investigation into this claim and the past behavior of Staff # 54 allowed other patients, including Patient # 1, to be at risk of sexual abuse and harassment from Staff # 54. A review of the hospital’s “Contract Staff and Agency Procedure” with a date of 03/05/2025 revealed, “Purpose: This policy establishes the guidelines for appropriate authorization for contract personnel. Policy: 1. All agency and contract staff requests must be made through Laborlytics using the temporary staff request process. A: Contract Requirements: i. The standard Employer contract must be used; ii. Must include effective dates, terms of renewal, and rates; iii. Supplying agency must provide employment application, initial assessment of competence, two verified references, license or certification, signed job description, verification of BCLS, ACLS, PALS (if required), physical exam, current PPD and HIV, blood-borne pathogens training, HIPPA Training, PIG and EPLS report, drug screen, and criminal background screen in accordance with ‘Background Investigation Procedure-HR-Corp” policy. These documents may be tracked on the contract staff and agency checklist; and b. Contract and/or agency employees onboarding and off-boarding procedures: i. The supervisor must oversee and ensure the orientation of contract/agency employees in accordance with the ‘New Employee Orientation Procedure’. All employment and educational requirements must be fulfilled prior to the contract/agency employee initiating work and being permitted access to the physical facility and electronic systems. ii. The supervisor must notify the Human Resources Department of the contract/agency employee’s last day of work to ensure the Termination Checklist is completed ...” A review of the hospital’s “Background Investigation Procedure” with a date of 03/01/2024 revealed, “Purpose: The purpose of this policy is to provide a standard requirement and process for obtaining and evaluating background information prior to employment and/or placement of agency staff. Such background information may include various degrees of information based on the levels of responsibility as outlined below. Policy: Offers of employment will be conditional upon the successful completion of a background investigation. Background investigations, including verification of the applicant’s name against the OIG database, must be completed prior to commencing employment. Procedure: 1. Notice of Investigation: a. A release of Information Authorization form must be signed or electronically authorized by the applicant and must be on hand prior to ordering a background investigation. 2. Conditional Job Offers and Background Checks: a. New hires: Qualified individuals seemed to be the best candidate for a position will be extended an offer of employment by the Talent Acquisition Department contingent upon, at a minimum, completion of a background investigation, drug screen, I9 with E-Verify and e-signed application of employment ...d. Staffing Agencies, Volunteers, and Independent Contractors: The same background investigation process applies to individuals who provide services pursuant to contracts with staffing agencies or independent contractors. For those working in patient care, the background investigation process must be completed prior to placement of the individual. It is required to secure the background investigation results or a certification of completion notice from the contracting agency and validate that the result was secured within the last year ....6. Analysis of Background Investigation: a. The Human Resources Department will notify the hiring manager if a discrepancy arises between the applicant’s disclosed credentials and the verified information or if the applicant is unqualified for the position based upon the results of the background investigation. i. Derogatory information learned during a background investigation will be considered with all other information known about an applicant’s sustainability for employment. The Human Resources department and, when appropriate, the hiring manager may determine that the derogatory information is sufficient reason not to hire an individual. The Human Resources Department may seek clarification from the applicant regarding the derogatory information. ii. When a facility receives derogatory information for the following nature as the result of a background investigation, the facility should no longer consider the applicant qualified for a position ...3. Termination from a previous job related to criminal conduct or sexual predatory behavior ...iii. This list is not exclusive or exhaustive. The facility will use good judgment when evaluating information and, when in doubt, consult with their regional VP of HR, whom may likewise consult with the VP of HR Operations ....” An interview was conducted with Staff # 4 and Staff # 38 on 12/19/2025 at 2:45 PM. Staff # 4 and # 38 confirmed that Staff # 54 should not have been hired under a contract based on the hospital’s “Contract Staff and Agency Procedure and Background Investigation Procedure”.”

“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: 48653 Based on record review and staff interviews, the hospital’s nursing leadership failed to: A. determine the types and numbers of nursing personnel and staff necessary to provide nursing care for 4 (CVICU, 2WB ICU, 3WB ICU, and 4WB ICU) of 4 units of the hospital. Also, the hospital’s nursing leadership failed to follow the “Nurse Staffing Advisory Committee” policy and the “Nurse Organizational Plan” policy. (Cross Refer to Tag A0386) B. have an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients as needed in 3 (2WB ICU, 3WB ICU, and 4WB ICU) of 3 units of the hospital. The hospital failed to follow the “Nurse Organizational Plan” and “Staffing Plan” policies. (Cross Refer to Tag A0392)”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48749 Based on observation, record review, and interview, the hospital’s infection prevention and control program failed to: A. provide and maintain a clean and sanitary environment to avoid sources and transmission of infection in 5 (Medical-Surgical Intensive Care Unit (ICU), Trauma ICU, Medical ICU, Electrophysiology (EP) lab, and Hemodialysis) of 5 areas observed. The hospital failed to follow the “Infection Prevention and Control Surveillance” and “Cleaning of Non-Critical Equipment” policies. (Cross Refer to Tag A0750) B. develop and implement hospital-wide policies and procedures for infection surveillance, prevention, and control. The hospital failed to follow the “Infection Prevention and Control Surveillance” policy. (Cross Refer to Tag A0772)”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital’s nursing leadership failed to determine the types and numbers of nursing personnel and staff necessary to provide nursing care for 4 (CVICU, 2WB ICU, 3WB ICU, and 4WB ICU) of 4 units of the hospital. Also, the hospital’s nursing leadership failed to follow the “Nurse Staffing Advisory Committee” policy and the “Nurse Organizational Plan” policy. Findings include: A review of the “ICU/IMC Staffing Matrix” with Staff # 4 (ACNO) on 10/23/2025 at 3:00 PM revealed the following, There were 2 different staffing matrixes in use by unit staff in the ICUs (Intensive Care Units). The staffing matrixes were not consistent and gave different staffing guidelines and ratios. ICU/IMC Unit Staffing Matrix # 1 revealed the following ratios: “M/S, Neuro, Trauma ICU: 8 Patients = 0 charge nurse, 4 registered nurses, 0 patient care techs (PCTs). 9 Patients = 1 charge nurse, 5 registered nurses, 0 PCTs. 10 Patients= 1 charge nurse, 5 registered nurses, 0 PCTs. 11 Patients = 1 charge nurse, 6 registered nurses, 0 PCTs. 12 Patients = 1 charge nurse, 6 registered nurses, 1 PCTs. CVICU: 5 patients = 0 charge nurses, 3 registered nurses, 0 PCTs. 6 Patients = 1 charge nurse, 3 registered nurses, 0 PCTs. 7 Patients = 1 charge nurse, 4 registered nurses, 0 PCTs. 8 Patients = 1 charge nurse, 4 registered nurses, 1 PCTs. ICU/IMC Unit Staffing Matrix # 2 revealed the following ratios: “M/S, Neuro, Trauma ICU: 8 Patients = (no charge nurse included in matrix) 5 registered nurses, 1 PCT. 9 Patients = (no charge nurse included in matrix) 5 registered nurses, 0 PCTs. 10 Patients = (no charge nurse included in matrix) 6 registered nurses, 0 PCTs. 11 Patients = (no charge nurse included in matrix) 6 registered nurses, 0 PCTs. 12 Patients = (no charge nurse included in matrix) 7 registered nurses, 0 PCTs.” A review of the “CVICU Staffing Guidelines” (no date) revealed, “How to Staff: Census must be 8 or greater to hold a PCT. Census must be 5 or greater to hold a free charge.” A review of the “CVICU Staffing Matrix” (no date) revealed, “CVICU: 5 Patients = 0 charge nurse, 3 registered nurses, 0 PCTs. 6 Patients = 1 charge nurse, 3 registered nurses, 0 PCTs” A review of an email sent by Staff # 10 (Critical Care Director) on 10/16/2025 at 8:18 AM revealed the following, “Based on the ratio guidelines from corp, please review the below and let me know if you have any questions or concerns. Still working on the 1:1’s for the ICUs ...” The email included an attachment of “ICU/IMC Unit Staffing Matrix” # 1. A review of the hospital’s “Nurse Staffing Advisory Committee” with a date of 9/11/2024 revealed, “Policy: 1. Each patient care unit shall outline a staffing plan that shall be used as a guideline to determine the personnel recommended for each shift as needed to provide the unit’s scope of service. 2. Department staffing plans are evaluated at least semi-annually. The effectiveness of the staffing plans and variations between the plan and actual staffing trends will be reviewed. 3. The Chief Nursing Officer or delegate is responsible for the provision of nursing services 24 hours a day, 7 days a week ....Nurse Staffing Committee: 1. Procedure: The Nurse Staffing Committee is responsible for: A. Developing a nurse staffing plan that protects patients, supports greater retention of registered nurses, and promotes adequate nurse staffing. B. Soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. C. Evaluating the effectiveness of the nurse staffing plan. 2. Hospital leadership will adopt the hospital’s official nurse services staffing plan. 3. Guidelines for safe and appropriate staffing patterns are established by the Nurse Staffing Committee and recommended to the Hospital Board for adoption, implementation, and enforcement. 4. The Nurse Staffing Committee is a standing committee of the hospital that meets at least quarterly. A. Voting members: 1. Chief Nursing Officer II. Registered Nurses represent the types of nursing services provided in the hospital. 1. 60% of the committee must be RNs who provide direct patient care at least 50% of their work time and are selected by their peers who also provide direct care at least 50% of their work time. 2. Meetings are considered part of an employee’s work time. Committee members are relieved of work duties during committee ....” A review of the “Nurse Organizational Plan” policy with a date of 05/03/2023 revealed, “Hospital Mission Statement: Our purpose is to care for our patients, their families and each other. We do so while educating and developing the caregivers of the future...Philosophy of Nursing: 1) Rhe Division of Nursing at UT Health East Texas believes that our nursing care is centered on our patients and their families. Compassionate care is the essence of our practice encompassing the mind, body, and spirit or those we serve. The nurse and the patient share the responsibility for developing an individualized plan of care in collaboration with the multidisciplinary team. This therapeutic relationship is the model by which we achieve quality outcomes...Responsibility: The registered nurse is responsible for planning, implementing, delegating and coordinating nursing care in his/her area of responsibility. The Chief Nursing Officer of UT Health East Texas is responsible and accountable to assure that consistent standards are utilized wherever nursing care is delivered....” An interview was conducted with Staff # 4 on 10/23/2025 at 3:30 PM. Staff # 4 (ACNO) was asked when the staffing guidelines and matrices were reviewed by the hospital’s Leadership and Board for adoption, implementation, and enforcement. Staff # 4 stated, “Those guidelines had not been approved and should have never been sent to the units for use. I have created a new staffing guideline with consistent and clear ratios for the units”.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital’s nursing services failed to have an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients as needed in 3 (2WB ICU, 3WB ICU, and 4WB ICU) of 3 units of the hospital. The hospital failed to follow the “Nurse Organizational Plan” and “Staffing Plan” policies. Findings include: 2WB A review of patient care assignments for the 2WB Intensive Care Unit (ICU) revealed that the nursing unit was not staffed with an adequate number of licensed registered nurses and other personnel in accordance with the unit’s staffing guidelines and matrix on the following shifts: September 30, 2025, 7 PM- 7 AM Patient Census: 14 Free Charge Nurse: 0 Registered Nurses: 8 Patient Care Techs: 0 The unit had 14 patients and 8 registered nurses. There was no free charge nurse available, as the charge nurse was assigned as the primary registered nurse to patient rooms # 54 and # 55. There was no additional support staff/PCT assigned to the unit. According to the unit’s staffing matrix, the unit was short 1 registered nurse and 1 patient care tech. October 18, 2025, 7 PM to 7 AM Patient Census: 7 Free Charge Nurse: 0 Registered Nurses: 3 Patient Care Techs: 0 The unit had 7 patients and 3 registered nurses. There was no free charge nurse available, as the charge nurse was assigned as the primary registered nurse to patient rooms # 52, # 53, and # 63A. There was no additional support staff/PCT assigned to the unit. According to the unit’s staffing matrix, the unit was short 1 registered nurse. October 20, 2025, 7 AM to 7 PM Patient Census: 9 Free Charge Nurse: 0 Registered Nurses: 5 Patient Care Techs: 0 The unit had 9 patients and 5 registered nurses. There was no free charge nurse available as the charge nurse was assigned as the primary registered nurse to patient rooms # 51 and # 53. The patient in room # 60 was assigned as a 1:1 nurse to patient ratio due to the complexity of care involved in CRRT (Continuous Renal Replacement Therapy). The registered nurse assigned 1:1 care for patient room # 60 was also assigned a patient admission to room # 57. According to the unit’s staffing matrix, the unit was short 1 registered nurse. 3WB ICU A review of patient care assignments for the 3WB Intensive Care Unit (ICU) revealed that the nursing unit was not staffed with an adequate number of licensed registered nurses and other personnel in accordance with the unit’s staffing guidelines and matrix on the following shifts: September 27, 2025, 7 PM- 7 AM Patient Census: 9 Free Charge Nurse: 0 Registered Nurses: 4 Patient Care Techs: 0 The unit had 9 patients and 4 registered nurses. There was no free charge nurse available as the charge nurse was assigned as the primary registered nurse to patient rooms #53, #57, and # 62. According to the unit’s staffing matrix, the unit was short 2 registered nurses. September 29, 2025, 7 AM- 7 PM Patient Census: 13 Free Charge Nurse: 0 Registered Nurses: 6 Patient Care Tech: 1 The unit had 13 patients and 6 registered nurses. There was no free charge nurse available as the charge nurse was assigned as the primary registered nurse to patient rooms #58 and #63A. According to the unit’s staffing matrix, the unit was short 2 registered nurses. October 14, 2025, 7 AM- 7 PM Patient Census: 15 Free Charge Nurse: 0 Registered Nurses: 8 Patient Care Tech: 1 The unit had 15 patients and 8 registered nurses. There was no free charge nurse available as the charge nurse was assigned as the primary nurse to patient rooms #50B and #54. According to the unit’s staffing matrix, the unit was short 1 registered nurse. 4WB ICU A review of patient care assignments for the 4WB Intensive Care Unit (ICU) revealed that the nursing unit was not staffed with an adequate number of licensed registered nurses and other personnel in accordance with the unit’s staffing guidelines and matrix on the following shifts: October 13, 2025, 7 PM- 7 AM Patient Census: 11 Free Charge Nurse: 0 Registered Nurses: 6 Patient Care Tech: 0 The unit had 11 patients and 6 registered nurses. There was no free charge nurse available because the charge nurse was assigned as the primary nurse to patient rooms #53 and #56. According to the unit’s staffing matrix, the unit was short 1 registered nurse. October 14, 2025, 7 AM- 7 PM Patient Census: 11 Free Charge Nurse: 0 Registered Nurses: 6 Patient Care Tech: 0 The unit had 11 patients and 6 registered nurses. There was no free charge nurse available because the charge nurse was assigned as the primary nurse to patient room #53. According to the unit’s staffing matrix, the unit was short 1 registered nurse. October 15, 2025, 7 AM- 7 PM: Patient Census: 13 Free Charge Nurse: 0 Registered Nurse: 7 Patient Care Tech: 0 The unit had 13 patients and 7 registered nurses. There was no free charge nurse available because the charge nurse was assigned as the primary nurse to patient room #50B and #57. According to the unit’s staffing matrix, the unit was short 1 registered nurse. An interview was conducted with Staff # 35 (ICU Charge Nurse) on 10/21/2025 at 10:45 AM. Staff # 35 was asked how nurse staffing assignments are made and what process was used to determine how many nursing staff would be needed for the shift. Staff # 35 informed the surveyors that, “the charge nurses were told to watch productivity. The charge nurses take patient assignments, and that is the new expectation”. An interview was conducted with Staff # 2 (CNO) on 10/22/2025 at 8:30 AM. Staff # 2 was asked when the staffing matrix was changed and what the evidence and reasoning for the change in staffing matrix was. Staff # 2 stated, “I will get that information for you”. The information was never provided to the surveyors. Staff # 2 was asked if the staffing matrix changes had gone through the nurse staffing advisory committee or governing body. This information was not provided to the surveyors. Staff # 2 was asked if the expectation was for charge nurses to take patient assignments. Staff # 2 stated, “It is not preferred that charge nurses take patient assignments; we would prefer for them to be free.” Staff # 2 also stated, “The unit managers take care of patients, and (Staff # 12) is a new manager and started in the last 6 months, so she has current competencies and helps out on the floor a lot”. A review of the hospital’s “Nurse Organizational Plan” policy with a date of 05/03/2023, revealed, “Hospital Mission Statement: Our purpose is to care for our patients, their families, and each other. We do so while educating and developing the caregivers of the future ...Philosophy of Nursing: 1) The Division of Nursing at UT Health East Texas believes that our nursing care is centered on our patients and their families. Compassionate care is the essence of our practice, encompassing the mind, body, and spirit for those we serve. The nurse and the patient share the responsibility for developing an individualized plan of care in collaboration with the multidisciplinary team. This therapeutic relationship is the model by which we achieve quality outcomes ...3) We are committed to using the most current research and evidence to define and support our practice. We are dedicated to contributing to the global database of nursing knowledge. It is through this commitment that we continually strive for excellence in patient care. Responsibility: The registered nurse is responsible for planning, implementing, delegating, and coordinating nursing care in his/her area of responsibility. The Chief Nursing Officer of UT Health East Texas is responsible and accountable to assure that consistent standards are utilized wherever nursing care is delivered. Plan: 1) UT Health East Texas plan for providing nursing care is designed to support improvement and innovation in nursing practice. It is based on both the needs of the patients to be served and the hospital’s mission statement. Within this plan, time and FTEs are allocated for nursing management and staff to: a) attend nursing and hospital committee meetings. b) Attend external and internal educational programs. c) Participate in quality improvement activities. d) Plan and implement projects to enhance the provision or nursing care. e) Participate in community projects ...5)Nursing plan for the provision of nursing care provides an overview of each unit’s system for providing nursing care. Each overview includes the individual staffing plans, which are based on current nursing standards (Reference ANA website). 7) Staffing levels are based on benchmark data, and adjustments are made as necessary on a shift-by-shift basis by the Nursing Directors, Supervisors, Clinical Managers, and/or charge nurses. Staff adjustments are based on acuity of patients, workload distribution and specialization of the unit ...Unit Specific Plans: Due to the uniqueness of each unit, a specific unit plan is required for all areas in which nursing care is provided. This individualized plan will provide for increased efficient and effective patient care ....2) Unit staffing plans ensure sufficient nursing staff to meet the patient care needs of the individual patients and provide sufficient time for RNs to fulfill their accountability to prescribe, delegate, coordinate, and evaluate nursing care. The staffing plan/matrix is available to nurses for their patient care unit at the beginning of each shift ...” A review of the “Staffing Plans” for 2WB ICU, 3WB ICU, and 4WB ICU revealed, “ ...The standard ICU nurse-to-patient ratio is one licensed nurse for every two patients. In critical staffing situations, this may be adjusted to one nurse for every three ICU-level patients. When intermediate care or medical surgical patients are housed in the unit, they are staffed according to their respective care standards- one nurse for every four IMC patients and one for every six med-surg patients. A designated charge nurse, who must be a registered nurse, is required to be assigned at all times. In the absence of an available charge nurse, the house supervisor may assume this role. The use of patient care assistants (PCAs) and/or nurse externs to assist with patient care is both allowed and encouraged. When staffing levels permit, a minimum of one PCA should be present on the unit. If PCAs and/or nurse externs are unavailable, the charge nurse may staff additional licensed nurses at their discretion to compensate for the absence of support staff ....Patient safety remains the highest priority. As a last resort, the CNO holds the authority to close unit beds in order to maintain safe staffing levels for both patients and staff. These staffing grids are intended to serve as guidelines. Final staffing decisions should account for patient acuity, unit layout and activity, staff competencies, and overall skill mix. Productive hours include all worked hours from charge nurses, RNs, LVNs, PCAs, NEs, and Unit Clerks, and must not exceed the total number of hours allocated per shift ...” A review of the “American Nurses Association Principles for Nurse Staffing” on 10/29/2025 revealed, “Principle 1: Healthcare Consumer: Nurse staffing decisions are based on the number and needs of the individual healthcare consumer, families, groups, communities, and populations served. In any approach to determining appropriate nurse staffing levels, consideration must be given to the elements affecting care at the level of the individual practice setting ...Principle 2: Interprofessional Teams: ...Regular monitoring of specified indicators such as nurse satisfaction, burnout, turnover and retention, and workplace injuries, can help ensure that staffing outcomes are evaluated and adjusted ...Principle 3: Workplace Culture: ...To that end, healthcare leaders and organizations must create a workplace environment that values registered nurses to practice to the full extent of their license, education, scope of practice, and documented competence ....Principle 4: Practice Environment: Staffing includes structures and processes that affect the safety of patients and nurses. Institutions employing a culture of safety must recognize appropriate nurse staffing as integral to achieving goals for patient safety and quality. Registered nurses have a professional obligation to report unsafe conditions or inappropriate staffing that adversely impacts safe, quality care, and they have the right to do so without reprisal ....Principle 5: Evaluation: Staffing plans must be conducive to adjustment to reflect changes in evidence and outcomes, care scenarios, and the needs of the population served, all of which vary from hour to hour, shift to shift, and day to day. Evaluation of any staffing system should include examination of environmental factors affecting the healthcare consumers’ safety and outcomes, in addition to the evaluation of nurse-specific indicators such as work-related staff illness and injury rates, turnover/vacancy/retention rates, and levels of healthcare consumer satisfaction and nurse satisfaction ...” A review of the American Nurses Association (ANA), “Principles for Nurse Staffing: 3rd edition”, “...Appropriate nurse staffing is a critical requisite for the delivery of safe, quality health care at every practice level and in every setting. Evidence demonstrates that nursing care has a direct impact on the overall quality of services received, and that when nurse staffing is appropriate, adverse events decline and overall outcomes improve...The core components of appropriate nurse staffing are:...All settings should have well developed staffing guidelines with measurable nurse-sensitive outcomes specific to that setting and healthcare consumer population that are used as evidence to guide daily staffing....Staffing needs must be determined based on an analysis of consumer healthcare status (e.g., degree of stability, intensity, and acuity) and the environment in which the care is provided. Other considerations include professional characteristics; competencies, experience, and skill set; staff mix; and previous staffing patterns that have been shown to improve care outcomes. ? Appropriate nurse staffing should be based on allocating the appropriate number of competent practitioners to a care situation, meeting consumer-centered and organizational outcomes, pursuing quality of care indices, meeting federal and state laws and regulations, and assuring a safe, high-quality work environment...” A review of the hospital’s open nursing vacancy positions revealed that there was a total of 71 open nursing vacancies for inpatient departments as of 10/22/2025. A review of the hospital’s voluntary resignations in September and October of 2025 revealed that a total of 38 staff members voluntarily resigned. A review of the Infection Control Meeting Minutes for quarter 1 and quarter 2 of 2025 revealed, “Quarter 1 total employee injuries: 65 -Needlestick/Sharp Injury: 0 -Needlestick/Sharp Injury with blood-borne pathogen: 18 -Blood/Body Fluid Exposure: 4 -Falls: 6 -Physical Assault or Altercation: 24 -Other: 13 Quarter 2 total employee injuries: Unknown total, data not completed. -Needlestick/Sharp Injury: 3 -Needlestick/Sharp Injury with blood-borne pathogen: 22 -Blood/Body Fluid Exposure: 11 -Falls: No data provided -Physical Assault or Altercation: no data provided -Other: No data provided” Employee injuries increased overall from quarter 1(Q1) to quarter 2(Q2) of 2025. There were 3 more needlestick/sharps injuries in Q2 than in Q1. There were 4 more needlestick/sharps injuries with blood-borne pathogens in Q2 than in Q1. There were 7 more blood/body fluid exposures in Q2 than in Q1. An interview was conducted with Staff # 4 (ACNO) on 10/23/2025 at 3:00 PM. Staff # 4 confirmed that the staffing matrices were not approved and stated, “Those matrices should have never made it to the units. I have started a new one after speaking to the unit staff yesterday. Charge nurses should not be worried about productivity numbers, and that has been taken off the new matrix.” Staff # 4 confirmed that after speaking with the unit managers, educators, and charge nurses on 10/22/2025, there was an education gap when making patient care assignments.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48749 Based on observation, record review, and interview, the hospital’s infection prevention and control program failed to provide and maintain a clean and sanitary environment to avoid sources and transmission of infection in 5 (Medical-Surgical Intensive Care Unit (ICU), Trauma ICU, Medical ICU, Electrophysiology (EP) lab, and Hemodialysis) of 5 areas observed. The hospital failed to follow the “Infection Prevention and Control Surveillance” and “Cleaning of Non-Critical Equipment” policies. These findings had the potential to cause harm by increasing the risk of infection to all patients and staff at the facility. During a tour of the facility on 10/21/2025 at 10:30 AM with Staff #2 and Staff #8, the surveyor observed the following infection control issues: Medical-Surgical ICU (2WB): Room #2256 *There was a tear in the vinyl of a chair, exposing the padding in the seat. *There was an accumulation of dust and dirt on the back wall behind the patient bed. *There was no written date for disposal found on the panel curtains hanging in the patient room. Trauma ICU (3WB) Room #3359 Patient room #3359 was designated as “clean and ready for a patient”. Staff #11 stated, “a patient has been assigned to this room and is on the way”. *There were “clean” linens stored close to the trash can and floor. There was a build-up of unknown debris, dust, and dirt on the cart that the linens were stored on. *There was a build-up of dirt, dust, and other unknown debris on the IV (intravenous pump). *There was an unknown yellow and orange substance on the inside of the IV pump’s chamber. *There was an unknown yellow and orange substance on the back of the cardiac monitor. The substance was splattered on the cords and was sticky. *There was a thick build-up of dust and dirt inside the vent and on the grate of the vent. The vent was blowing air out into the patient room. *There were open suction canisters and associated tubing on the wall behind the patient bed. The surveyor was unable to determine if the suction tubing, canisters, and yankers had been previously used. *There was a thick build-up of dust and dirt on the ledge behind the patient’s bed. *There was an unknown sticky brown and black substance on the floor. The surveyor was able to remove the substance from the floor with a Sani-wipe. *There was a damaged patient chair in the hallway of 3WB. The chair’s handle had areas of the paint chipping off, causing rust to accumulate. Medical ICU (4WB) Room #4450 Patient room #4450 was reported as “clean and ready for a patient.” *There was an unknown brown substance on the cardiac monitor cords lying on the patient’s bed. *There was an unknown brown substance inside the IV pump chamber. *There was dust, dirt, and other debris on the IV pumps and poles. It was unknown if the pumps had been cleaned and disinfected after use by the previous patient. *There was a thick build-up of dust and dirt on the base and wheels of the IV pole. *There were open suction canisters and associated tubing on the wall behind the bed. The surveyor was unable to determine if the suction tubing, canisters, and yankers had been previously used. *There was a thick build-up of dust on the window shades in the room. *There was a thick build-up of dust, dirt, and other unknown black substance that appeared to be mold inside the vent of the bathroom in the patient’s room. *There was a build-up of dust, dirt, and other unknown substances on the wall and floor. Electrophysiology (EP) Lab Room #1 *There was a thick build-up of dust, dirt, and other unknown debris on the floor under the scrub sink before entering the EP lab. *There was black duct tape covering holes in the wall above the scrub sink. *There was raw wood exposed on the door going into the procedure lab. *There was an accumulation of dust on the cardiac defibrillator and code cart inside the procedure lab. *There were 2 bags of expired 100 ml sodium chloride injections that had a use-by sticker of 12/30/2024 and an expiration date of 09/2025 on the anesthesia cart. *There was dust and other debris inside the drawer of the anesthesia cart. * There was a red, blunt fill needle that was loose inside the drawer and not in the original packaging. *There was dirt, dust, and other debris at the bottom of the anesthesia cart. The crack inside the bottom of the cart had a thick build-up of dirt, hair, and other debris. *There was an arterial line set-up on the anesthesia medication Pyxis. The surveyor was unable to determine when the arterial line was set up or if it had been previously used. *There were rips on the underside of the patient’s “return electrode pad” on the procedure table. The “return electrode pad” had an expiration date of 11/2019. *There was a build-up of dirt, dust, and other debris at the bottom of the EP table. Room #2 *There was a thick build-up of dust, dirt, and other unknown debris on the floor under the scrub sink before entering the EP lab. *There was trash overflowing from the trash can onto the floor next to the scrub sink. *There was erosion on the floor under the procedure table. The floor surface was rough and porous, making disinfection and cleaning ineffective. *There was an unknown red splatter on the top of the overhead light that appeared to be blood. *There was a clutter of supplies in the basket attached to the side of the anesthesia cart. There were supplies that had been opened and were out of the original packaging. There was an accumulation of dust at the bottom of the basket. Hemodialysis Center *There was an unknown red splatter on the bottom of the IV pole and pump at dialysis station #9. The dialysis station was reported “clean and ready for use.” *There was an unknown orange and yellow splatter on the back of the pump and on some of the cords at Station #9. There was also an unknown yellowish tan appearing splatter on the knob of the IV pole. The substance was sticky. *There were hemodialysis pick-up wands sticking out of the acid jugs on the dialysis machines. The wands did not have a proper seal, possibly exposing the acid solution to blood, bacteria, or other substances due to the loosely fitting pick-up wands. *There was a build-up of dirt, dust, and other unknown debris in the bottom of the medication Pyxis. *There was an accumulation of dust, dirt, and other unknown debris on the outside packaging of the sterile saline bags in a bin of the Pyxis. A review of the facility’s “Infection Prevention and Control Surveillance” policy dated 05/22/2024 revealed the following; “Purpose: Surveillance is defined as a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist in improving those outcomes. Surveillance is an essential component of an effective infection prevention and control program. This is completed to protect the patient, the health care worker, visitors, and others in the health care environment in a timely, efficient, and cost-effective manner. Surveillance data have been successfully used in a variety of healthcare settings to reduce the occurrence of infections when used to identify risk factors, implement risk reduction measures, and monitor the effectiveness of interventions. Scope: The scope of the UT Health East Texas Infection Prevention and Control program is hospital-wide and includes departments on and off campus. These areas include: 1) Inpatient Areas 2) Outpatient Areas 3) Service/Diagnostic Areas 4) Support Services 5) Administrative Areas Infection Preventionist will: 3)Conduct regular hospital rounds to review infection prevention practices with the latest evidence-based practice.” A review of the facility’s “Cleaning of Non-Critical Equipment” policy dated 08/23/2024 revealed the following; “Purpose: To prevent cross-contamination between patients when using patient care equipment, to include use in Transmission-Based Precaution rooms. Policy: UT Health East Texas is dedicated to minimizing the risk of healthcare-acquired infections by establishing guidelines for the cleaning and disinfection of shared equipment. This policy provides guidelines for recognizing clean or soiled equipment and guidelines for storage or treatment after use. The following procedures define and establish standards for assuring that non-critical (defined by the Centers for Disease Control (CDC) as items that come into contact with intact skin but not mucous membranes), shared patient care equipment is clean before use and that all used or contaminated equipment is appropriately cleaned before reuse. Procedure: Cleaning and Disinfection Instructions Contaminated devices should be cleaned and disinfected before moving to the storage room or if the equipment remains in the room between patients. If possible, patient care equipment should be dedicated to a single patient and cleaned, disinfected, and/or reprocessed before reuse for another patient. Where appropriate, dismantle the devices to ensure that all surfaces can be cleaned using the hospital-approved disinfectant. The application of tape on patient care equipment is discouraged. General Principles of Infection Control 2)All equipment must be cleaned immediately if visibly soiled, regardless of the cleaning schedule. 3)Any damaged equipment must be removed from service and reported to the department manager for the decision regarding replacement or the ability to clean. 4)Disposable patient care equipment and supplies shall be immediately discarded after use.” An interview was conducted with Staff #2 on the afternoon of 10/21/2025. Staff #2 confirmed the surveyor’s infection control findings in 5 (Medical-Surgical Intensive Care Unit (ICU), Trauma ICU, Medical ICU, Electrophysiology (EP) lab, and hemodialysis) of 5 areas observed.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interviews, the hospital’s infection control program failed to develop and implement hospital-wide policies and procedures for infection surveillance, prevention, and control. The hospital failed to follow the “Infection Prevention and Control Surveillance” policy. These findings had the potential to cause harm by increasing the risk of infection to all patients and staff at the hospital. Findings include: During a tour of the hospital on 10/21/2025 at 10:30 AM with Staff #2 and Staff #8, the surveyor observed infection control issues in 5 (Medical-Surgical Intensive Care Unit (ICU), Trauma ICU, Medical ICU, Electrophysiology (EP) lab, and hemodialysis) of 5 areas observed. The surveyors requested the last completed Environment of Care (EOC) rounds for Medical-Surgical ICU, Trauma ICU, and Medical ICU. A review of the 3 surveillance round sheets provided by Staff #19 (Infection Preventionist) revealed that the facility was utilizing the Joint Commission’s “Tracer Observation Detail Report-2025 Environmental Tour” form. Further review of the surveillance round sheets revealed; The last “Tracer Observation Detail Report-Environmental Tour” was completed on 04/03/2025 for Trauma ICU (3WB), 6 months prior. The last “Tracer Observation Detail Report-Environmental Tour” was completed on 04/24/2025 for Medical-Surgical ICU (2WB), 6 months prior. The last “Tracer Observation Detail Report-Environmental Tour” was completed on 04/28/2025 for Medical ICU (4WB), 6 months prior. There was no further documentation provided to the surveyors to show that EOC rounds were done after 04/28/2025, 6 months prior to the survey. There was no documentation provided to the surveyors to show that there was a process in place to monitor the environments on a routine schedule and identify risk factors present to protect the patient, the health care worker, visitors, and others in the health care environment A review of the facility’s “Infection Prevention and Control Surveillance” policy dated 05/22/2024 revealed the following; “Purpose: Surveillance is defined as a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist in improving those outcomes. Surveillance is an essential component of an effective infection prevention and control program. This is completed to protect the patient, the health care worker, visitors, and others in the health care environment in a timely, efficient, and cost-effective manner. Surveillance data have been successfully used in a variety of healthcare settings to reduce the occurrence of infections when used to identify risk factors, implement risk reduction measures, and monitor the effectiveness of interventions. Scope: The scope of the UT Health East Texas Infection Prevention and Control program is hospital-wide and includes departments on and off campus. These areas include: 1) Inpatient Areas 2) Outpatient Areas 3) Service/Diagnostic Areas 4) Support Services 5) Administrative Areas Infection Preventionist will: 2)Provide education on infection prevention matters relating to the prevention and management of HAIs. 3)Conduct regular hospital rounds to review infection prevention practices with the latest evidence-based practice.” A review of the Infection Preventionist job description revealed the following: “POSITION SUMMARY: Performs necessary surveillance, prevention, and control activities through data collection and analysis. From these activities, makes recommendations to ensure that the goals of the UT Health Infection Prevention program are met. The position is under the general supervision of the Infection Prevention Manager. DUTIES, ACCOUNTABILITIES, AND RESPONSIBILITIES include the following: *Analyzes the data gathered through surveillance activities in order to make recommendations for improving approaches to patient care to decrease the risk of infection. *Identifies potential transmission situations by evaluating transmission risks to determine the interventions necessary to control transmission of disease in potential outbreak situations. *Assesses the Infection Prevention educational needs of personnel, physicians, and patients, designs educational programs based on current scientific knowledge, and practices to meet mandatory educational requirements and to increase general knowledge of infection control principles. *Evaluates possible infection prevention problems/issues and consults with departments to provide infection control expertise for problem resolution.” An interview was conducted with Staff #19 (Infection Preventionist Director) on 10/21/2025 at 3:15 PM. Staff #19 reported that environmental facility rounds were completed monthly until April 2025, and then staff were redirected to other surveillance duties and rounds have not been completed. Staff #19 reported that in April 2025, the focus for infection control staff was shifted to central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). An interview was conducted with Staff # 3 on 10/21/2025 at 3:15 PM. Staff # 3 reported that the infection control staff were directed to monitor CLABSI and CAUTI lines and were completing surveillance rounds while on the units. There was no documentation provided to the surveyors to support surveillance rounds were completed after 04/2025. Staff #3 acknowledged the surveyor’s findings of environmental surveillance rounds not being completed over the last 6 months in Medical-Surgical ICU, Trauma ICU, and Medical ICU.”

“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 16 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16 and #18) of 18 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. 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 16 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16 and #18) of 18 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. 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 ... Findings included the following: Review of the State required information form showed that 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 and not providing the patient with the State mandated information sheet at the beginning of the patient encounter, patients were left to make crucial decisions without all of the information and resources necessary. Patient records were reviewed on 6-30-25 and 7-1-25 as follows: Patient #1 Patient #1 was a 38-year-old who presented to the Emergency Department (ED) on 3-6-25 for a SANE (Sexual Assault Nurse Examiner) examination. The facility did not have a SANE nurse on call. Another hospital was contacted and would have a SANE nurse available the next morning. The patient received a medical screening examination and was treated for her medical complaints. 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 #2 Patient #2 was a 20-year-old who presented to the ED on 3-6-25 with a complaint of sexual assault. No SANE nurse was available. The patient was medically cleared and chose to be referred for a SANE examination at another facility. The local sexual assault program advocate was present to assist the patient during the visit. 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 #3 Patient #3 was a 34-year-old who presented to the ED on 3-25-25 with a complaint of sexual assault. No SANE nurse was available. The patient was medically cleared and was offered the option of seeing a SANE nurse at another facility or coming back later when a SANE nurse was available. The patient opted to discharge but had not decided if she was coming back or going to the other facility. The local sexual assault program advocate was present to assist the patient during the visit. 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 The patient was a 4-year-old brought to the ED by her parent on 3-24-25 due to reported sexual assault. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. There was a note in the patient record that read, “Patient is to follow up with the CAC (child advocacy center)”. However, there was no evidence that the hospital contacted the CAC to make the referral to ensure the patient would have access to an advocate. Review of the printed discharge instructions, After Visit Summary, stated “Patient is to follow up with the CAC” but did not provide the name, location, or contact information for 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. 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 #5 The patient was a 3-year-old brought to the ED by her parent on 3-24-25 due to reported sexual assault. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient. There was a note in the patient record that read, “Patient is to follow up with the CAC (child advocacy center)”. However, there was no evidence that the hospital contacted the CAC to make the referral to ensure the patient would have access to an advocate. Review of the printed discharge instructions, After Visit Summary, stated “Patient is to follow up with the CAC” but did not provide the name, location, or contact information for 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. 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 #6 Patient #6 was a 38-year-old who presented to the ED on 6-25-25 who came in requesting a 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. Patient #7 Patient #7 was a 3-year-old brought to the ED on 6-9-25 by her parent alleging sexual assault. 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. Patient #8 Patient #8 was a 12-year-old brought to the ED on 1-23-25 by her guardian. The exam was unable to be obtained due to patient’s behavior. Psychiatric consult made. Patient returned on 1-24-25 to complete the exam. 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 #10 Patient #10 was a 21-year-old who presented to the ED on 12-4-24 requesting a SANE examination. 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. Patient #11 Patient #11 was 3-year-old brought to the ED on 12-30-24 by her parent for suspected sexual abuse. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient or a referral was 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. 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 #12 Patient #12 was a 19-year-old who presented to the ED on 5-12-25 with complaint of sexual assault. The patient was stabilized medically and discharged to get a SANE exam at another hospital. 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 #13 Patient #13 was a 9-year-old brought to the ED on 5-20-25 by her parent for reported sexual assault. There was no SANE nurse available, and patient was told to follow up with the CAC. Information on CAC provided. 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. Patient #14 Patient #14 was a 3-year-old brought to the ED on 5-19-25 by parent for a reported sexual assault. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient or a referral was 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. 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 an 18-month-old brought to the ED on 5-19-25 by parent for a reported sexual assault. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient or a referral was 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. 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 #16 Patient #16 was a 4-month-old brought to the ED on 5-19-25 by parent for a reported sexual assault. The medical record did not contain evidence that a local sexual assault program advocate had been contacted to assist the patient or a referral was 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. 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 #18 Patient #18 was a 59-year-old who presented to the ED on 6-5-25 with complaint of sexual assault. 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. The following discharge instructions were provided: “Follow up with your doctor/specialist as directed -your primary care doctor and/or East Texas crisis (sic) Center as needed” However, the address and phone number for the crisis center was not provided. Policy Title: FNE-Sexual Assault Policy-ED-MKT; Policy Number: 49512.2; Market Approval Date: 06/05/2024; Next Review Date: 06/05/2026; was reviewed on 7-1-25. The Objective of the Policy was: “1) Provide a timely medical-forensic examination of the patient who presents with a history of sexual assault at the victim’s discretion. 2) Report concomitant injuries to the physician. 3) Collect and document such evidence as is available for the prosecution or defense of sexual assault according to the Texas Evidence Collection Protocol. 4) Provide prompt and timely Prophylaxis for Sexually Transmitted Infections, Emergency Contraception and Post Exposure Prophylaxis for HIV as indicated and at the victim’s discretion. 5) Counsel the patient regarding the follow up care, indicated lab testing, and behavioral health referrals.” The policy did not address the need to provide the sexual assault survivor with an advocate if available and the State mandated information sheet. On 7-1-25, Staff #6 provided a copy of the State mandated information form. Staff #6 explained that SANE nurses gave this form to sexual assault survivors as part of the SANE examination. The form that was being presented was an outdated version from 2020 and did not contain the most current information to include the patient’s rights. On 7-1-25 during record reviews, Staff #1 and Staff #6 confirmed the medical records review findings.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital staff failed to ensure that 1 (Patient # 1) of 20 patient encounters was documented on the hospital’s central emergency room log. Additionally, the hospital staff failed to follow the hospital’s policy, “EMTALA-Medical Screening Examination and Stabilization”. Findings include: A review of Patient # 1’s medical records with Staff # 5 on 03/25/2025 at 11:30 AM revealed, Patient # 1 (67-year-old male) arrived at Hospital # 1’s Emergency Department (1000 South Beckham Avenue, Tyler, Texas) on 02/17/2025 at 1:01 AM. There was no documentation of the patient’s emergency room encounter because the patient’s emergency room encounter was cancelled by Staff # 9 (Registration Clerk) on 02/17/2025 (time unknown). The patient was never triaged or provided a medical screening examination at the hospital’s emergency department. A review of the “Patient Care Timeline” for Patient # 1 revealed Staff # 9 (Registration Clerk) created an “emergency encounter” on 02/17/2025 at 1:01 AM and an “ED FCC Start Event” at 1:02 AM. There was no other documentation for the patient’s encounter. The patient was not categorized as “left without being seen” because the encounter was cancelled by Staff # 9. An interview was conducted with Staff # 9 (Registration Clerk) on 03/25/2025 at 1:30 PM. Staff # 9 was asked to recall the events of 02/17/2025, when Patient # 1 arrived at the hospital’s emergency department, seeking psychiatric care. Staff # 9 stated, “I remember this patient, he was seeking psychiatric care and wanted to go to hospital # 2. I told him I couldn’t help him with getting to hospital # 2 but that I could get him checked in. I know that sometimes hospital # 2 is the best place to go for that situation. I cancelled the check-in so he could go to hospital # 2.” A review of Staff # 9’s personnel file revealed Staff # 9 completed “Front End EMTALA Overview and SOP Review” training on 11/11/2024. A review of Patient #1’s medical records with Staff # 5 on 03/25/2025 at 11:45 AM revealed, Patient # 1 arrived at Hospital # 2’s Emergency Department (11937 US Hwy 271 Tyler, Texas 75708) on 02/17/2025 at 2:06 AM with a chief complaint of “Psychiatric Evaluation”. The patient’s past medical history included post-traumatic stress disorder (PTSD), homelessness, schizophrenia, past suicide attempts, and traumatic brain injury(TBI). Staff # 12 (Triage Registered Nurse) documented the following “ED Triage Note” on 02/17/2025 at 2:31 AM, “Patient arrived to ED via cab with complaints of AVH (auditory-verbal hallucinations), SI (suicidal ideation) without a plan, and paranoia. Stated he was instructed by (hospital #1) to come over here. He stated they told him they couldn’t send him here in an ambulance, so he had to pay $35 for a cab. He states he is paranoid and sees ‘people coming out of the wall, acting crazy’ and chasing him. He also reports auditory hallucinations. States that his car, ‘the steering wheel’, tried to attack him, but now it’s impounded and his medications are in the car. States he has been out of his medications for 33 days.” A review of Physician # 13’s (ER Physician) “History and Physical” note on 02/17/2025 at 5:53 AM revealed, “67-year-old male with history of homelessness, schizoaffective disorder, schizophrenia, PTSD presenting via taxi. Patient stated he was at the (hospital # 1) and checked into the emergency room. When he told them what was going on, they said that it would be better for him to come to this hospital. He tells me the lady at the desk called a taxi for him that he paid for and they brought him here. He states he has active hallucinations of seeing people coming out of the walls, jumping out at him, and people chasing him down the street. He states his vehicle was impounded recently and had all of his medications therefore, he is not taking them. He states he drinks one 24-oz beer a day for knee pains. He reports swelling behind the right knee. He denies any chest pain, trouble breathing, or headache. He reports cramping in the left calf. Denies any vision changes. Denies any drug use or tobacco use ....Behavioral Risk Documentation: Behavioral Risk Assessment: I have seen and evaluated this patient. I have assessed the patient’s risk of danger to self or others. In my professional judgement, I have determined the patient is: Moderate Risk- SI (suicidal ideation) without a plan, intent or attempt, moderate intoxication or psychosis.” Physician # 13 placed a consult for a psychiatric evaluation for Patient # 1 on 02/17/2025 at 2:11 AM. A review of “Psychiatry Consult Recommendations” by Physician # 14 on 2/17/2025 at 7:49 AM revealed, “Disposition: Given the high likelihood of severe deterioration secondary to decompensated mental status, which is believed to be an imminent risk outside of a secure environment, recommend inpatient psychiatric admission once medically cleared.” A review of “Application for Voluntary Inpatient Admission (Mental Health)” revealed Patient # 1 signed the form on 02/17/2025 at 3:46 AM and Patient # 1 was admitted to inpatient psychiatry on 02/17/2025 at 10:38 AM. A review of Hospital # 1’s policy, “EMTALA-Medical Screening Examination and Stabilization” with an effective date of 04/19/2023 revealed, “PURPOSE: To ensure that all individuals who come to the Emergency Department receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder ... POLICY: 1. Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition, within UT Health East Texas’s capability and capacity ....” An interview was conducted with Staff # 4 on 03/25/2025 at 3:30 PM which confirmed that Patient # 1 did arrive to Hospital # 1 seeking care and there was no documentation of a triage or appropriate medical screening examination. Staff # 4 confirmed the patient did not appear on the hospital’s EMTALA logs for the date of 02/17/2025 and the patient was not listed as “left without being seen”.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital staff failed to ensure a pediatric patient presenting to the hospital’s emergency department with complaints of suicidal ideation received an appropriate medical screening examination prior to discharge in 1 (Patient # 1) of 26 patient medical records reviewed. Also, the hospital staff failed to follow the hospital’s policy, “EMTALA-Medical Screening Examination and Stabilization”. (Cross Refer to Tag 2406)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital staff failed to ensure a pediatric patient presenting to the hospital’s emergency department with complaints of suicidal ideation received an appropriate medical screening examination prior to discharge in 1 (Patient # 1) of 26 patient medical records reviewed. Also, the hospital staff failed to follow the hospital’s policy, “EMTALA-Medical Screening Examination and Stabilization”. Findings include: A review of Patient # 1’s medical records with Staff # 5 on 10/29/2024 at 11:30 AM revealed, Patient # 1 (11-year-old female) arrived at the hospital’s Emergency Department (1000 South Beckham Ave, Tyler Texas) on 10/15/2024 at 10:42 AM with complaints of suicidal ideation. Patient arrived via private vehicle and was accompanied by her mother and grandmother. The patient reported a history of self-harm in the past. The most recent episode of self-harm occurred in July of 2024 when she attempted to choke herself. Staff # 21 (Registered Nurse) documented the following suicide screening questionnaire on 10/15/2024 at 11:12 AM: “1. In the past few weeks, have you wished you were dead? Yes 2. In the past few weeks, have you felt that you or your family would be better off if you were dead? Yes. 3. In the past week, have you been having thoughts about killing yourself? Yes 4. Have you ever tried to kill yourself? No. *How did you try to kill yourself? Choking herself. *When did you try to kill yourself? July 2024 5. Are you having thoughts of killing yourself right now? No.” The patient’s Calculated Suicide Risk Score was documented by Staff # 21 (Registered Nurse) as a “Potential Risk” on 10/15/2024 at 11:14 AM. A review of the patient’s “Emergency Department Course and Impression” documented by Staff # 12 (Emergency Room Physician) on 10/15/2024 revealed, “Patient is an 11-year-old female with a history of anxiety who presents with suicidal ideation. Prior to arrival patient’s mother was contacted by school counselor regarding patient having suicidal ideations. Mother was instructed to take the patient to (Hospital #2) for psychiatric evaluation. Patient appears non-toxic and clinically stable. Vital signs stable. Physical exam as noted above. Per mother, patient has no history of suicidal ideation or previous suicidal attempts. Spoke with mother and grandmother in depth regarding the process of psychiatric evaluation and disposition. Discussed plans for medical clearance and psychiatric disposition to pediatric facility. Mother was under the impression patient will be evaluated in the emergency department by a psychiatrist with options of the patient undergoing outpatient versus inpatient treatment. Mother has elected for evaluation at (Hospital #2) given the ability for psychiatric evaluation in the emergency department. Given the patient is deemed low risk and under in the custody and direct supervision of mother and grandmother we will elect for discharge and immediate follow up at (Hospital #2). All questions were answered at bedside. Patient remained clinically and hemodynamically stable in the emergency department.” There was no suicide 1:1 watch implemented for the patient during the Emergency Room visit. There was no documentation to support the patient or family were offered a transfer to another facility. There was no documentation to support the patient or family’s refusal to transfer to another facility for further evaluation and treatment. An interview was conducted with Staff # 4 (Assistant Director of Nursing) on 10/29/2024 at 11:35 AM. Staff # 4 confirmed there was a psychiatrist in-house and working on 10/15/2024 at the time Patient # 1 presented to the Emergency Department. Staff # 4 confirmed no consultation was made with the Psychiatrist (Staff # 22) working in the hospital on 10/15/2024 for the care of Patient # 1. Staff # 12 (Emergency Room Physician) discharged the patient to “home or self-care” on 10/15/2024 at 11:13 AM. The patient was not seen by the hospital’s covering psychiatrist and there was no attempt documented to transfer the patient to another facility for further evaluation and treatment. A review of the hospital’s policy, “EMTALA-Medical Screening Examination and Stabilization” with an effective date of 04/19/2023 revealed, “PURPOSE: To ensure that all individuals who come to the Emergency Department receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder ... POLICY: 1. Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition, within UT Health East Texas’s capability and capacity .... PROCEDURE: ... 7. Further Examination and Stabilizing Treatment: If the treating physician or qualified medical person determines that an individual has an Emergency Medical Condition, UT Health East Texas, within its Capability and Capacity, will provide further examination and Stabilizing treatment for the individual, or if the individual requires a specialty or level of care not available at UT Health East Texas for an Appropriate Transfer of the individual to another health facility ...” A further review of Patient # 1’s medical records revealed the patient arrived at another hospital’s Emergency Department (Hospital #2) on 10/15/2024 at 12:09 PM via private vehicle with complaints of suicidal ideation. The patient was accompanied by her mother. A review of Staff # 23’s (Psychiatrist) Psychiatry Consult Recommendations documented on 10/15/2024 at 12:57 PM revealed, “History of Present Illness: ... 11 y.o. female w/a Hx of autism spectrum disorder presenting to UTN ED (Hospital #2) va POV (personal vehicle) for proximal suicide attempt and SI (suicidal ideation) in the context of a 6-month history of pervasive depression. (Patient #1) reports that approximately six months ago, she started feeling ‘really sad’ and thinks that going to school makes it worse. This sadness has been accompanied by fluctuations in appetite, feelings of hopelessness and guilt, crying, trouble concentrating, disengaging from previously enjoyable activities such as drawing, and persistent pervasive suicidal ideation. Additionally, she reports feeling like a perfectionist but also like she procrastinates. She describes anxiety about not knowing if she is liked or if people would even care if she were dead. Additionally, she talks about difficult to describe ‘breakdowns’. Her mother details these events as hyperventilation, panicking, crying uncontrollably, profound aversion to being touched or hugged, and even marked fear that something bad is going to happen. Episodes can be brief or last hours at a time. These symptoms have culminated in attempting to take her own life via strangulation approximately 4 to 7 times during the past 6 months, with the most recent episode being sometime this week. She reports she has attempted to cut off her airway because she thinks that this would be a painless way to die. States that prior attempts have resulted in her head ‘going numb’ but denies that she has ever passed out. She has pursued self-strangulation because ‘there is nothing to attach to my ceiling’. When asked why she would like to die, she states that she does not want to grow up and she wants to start a new life because she feels like she has messed this life up. On interview today, she cannot describe any happy events in her life. Even when prompted by her mother’s about joyous events, such as their time together at a recent violin concert or previous ski trips, (Patient #1) does not view these events as particularly happy ...” Patient # 1 was transferred from the hospital’s Emergency Department (Hospital #2) to an in-patient psychiatric facility on 10/15/2024 at 11:31 PM. An interview was conducted with Staff # 4 and # 5 on 10/29/2024 at 2:00 PM. Staff # 4 and Staff # 5 confirmed the patient was not seen by the hospital’s covering psychiatrist who was available for consultation. Also, Staff # 4 and Staff # 5 confirmed there was no attempt to transfer the patient to another facility for further evaluation and treatment on 10/15/2024.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40989 Based on document review and interviews, the facility failed to ensure that a properly executed informed consent was present in the medical record before initiating surgical or medical treatment for 1 of 3 medical records reviewed (Patient #1). Additionally, the facility did not adhere to its own “Informed Consent Policy.” Findings: Patient #1 A review of the medical record for Patient #1 was completed on 9/11/2024 at 12:45 PM with Registered Nurse (RN) Staff #15. A review of the informed consent dated 2/17/2024 for an Open Left lower Thrombectomy (surgical removal of a blood clot) was as follows: “ ...I voluntarily request my physician/healthcare provider (Physician last name only) and other healthcare providers to treat my condition which is:(this information was left blank) ...” Patient #1’s wife gave telephone consent on 2/17/2024. A review of the informed consent dated 2/22/2024 for a Bronchoscopy (a long video scope placed into a patient’s lungs via the mouth or nose for the physician to evaluate the patient’s airway) was as follows: “ ...I voluntarily request my physician/healthcare provider (this information was left blank) and other healthcare providers to treat my condition which is:(this information was left blank) ...” Patient #1’s wife gave verbal consent on 2/22/2024. A review of the informed consent dated 2/17/2024 for moderate sedation was as follows: “ ...I voluntarily request my physician/healthcare provider (this information was left blank) and other healthcare providers to treat my condition which is:(this information was left blank) ...” Patient #1’s wife gave telephone consent on 2/17/2024 at 4:11 AM. There was no physician’s signature on the informed consent. A review of the informed consent dated 2/22/2024 for a Transesophageal Echocardiogram the insertion of a probe down the esophagus so that the physician can get a clearer image of the heart) was as follows: “ ...I voluntarily request my physician/healthcare provider (this information was left blank) and other healthcare providers to treat my condition which is:(this information was left blank) ...” The wife’s name was documented on the informed consent on 4/22/2024 at 2:58 PM and witnessed by two RN’s. There was no physician’s signature on the consent. During an interview with RN Staff #15 on 9/11/2024, RN Staff #15 confirmed there was no telephone or verbal consent written on the consent. The surveyor and RN Staff #15 were unable to determine if the patient’s wife signed the consent or if it was a verbal or telephone consent for the procedure. A review of the informed consent dated 2/22/2024 for a Tracheostomy (a surgical opening into the windpipe) was as follows: “ ...I voluntarily request my physician/healthcare provider (this information was left blank) and other healthcare providers to treat my condition which is:(this information was left blank) ...” The consent was signed by the patient’s wife on 3/12/2024 at 11:56 AM. The provider’s signature was illegible and dated on 3/12/2024. There was no time documented. An interview was conducted with RN Staff #15 on 9/11/2024 at 1:00 PM. RN Staff #15 was asked if the informed consent was to be signed by the physician. RN Staff #15 stated, “Yes the physician is supposed to sign the consent”. RN #15 was asked if the nurses were obtaining the informed consent and how they verified if the physician discussed the risks and benefits before they had the consent signed. RN Staff #15 stated, “It is the physician’s responsibility to obtain the consent but the nurses do complete them. The nurse is sometimes in the room with the physician when they talk to the patients”. RN Staff #15 confirmed the missing information on the informed consents for Patient #1. A review of the facility policy titled, “Informed Consent Policy” Policy Number 46950.3, with an effective date of 2/16/2023, was as follows: “ ...Policy: 1) It is the policy of UT Health East Texas to fully comply with the Texas Medical Disclosure Panel’s rules on informed consent for medical treatment and procedures. 2) Consent will be obtained in writing prior to performing surgical procedures, non-surgical procedures, diagnostic and/or therapeutic procedures, and all procedures in which anesthesia or sedation is used ... Procedure: 1) It is the duty of the treating provider to obtain a patient’s consent for treatment or procedure; this duty cannot be delegated nor is it eliminated, lessened, or spread by having the nurse secure the patient’s signature before surgery or procedure ...””

“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 record review and staff interviews, the hospital’s nursing staff failed to ensure patients presenting with complaints of pain were promptly treated and reassessed for the effectiveness of pain-alleviating interventions in 3 (Patient #4, # 16, and # 17) of 5 patient medical records reviewed. During a review of patient medical records with Staff # 18 on 09/10/2024 at 11:00 AM the following was revealed, Patient # 16 A review of Patient # 16’s medical records revealed Patient # 16 arrived at the hospital’s Emergency Department (ED) with a chief complaint of a “Fall” on 08/18/2024 at 2:24 AM. Triage was started at 2:26 AM by Staff # 19 (Registered Nurse). The following was documented in triage notes, “Pain Assessment: 0-10 Pain Score: 5 Pain Location: Head” The patient was not given any medication for the reported pain and there were no pain-alleviating nursing interventions performed until 5:56 AM, 3 hours and 32 minutes after the patient complained of pain 5/10. At 5:56 AM the patient was given Norco (Hydrocodone-Acetaminophen) 5/325mg for pain. The patient was discharged from the hospital’s ED on 08/18/2024 at 6:00 AM, 4 minutes after the narcotic was administered. No reassessments were completed by Staff # 19 (Registered Nurse) after the administration of Norco at 5:56 AM. It is unknown if the patient had previously taken Norco in the past and if there were any adverse side effects associated with the administration of the narcotic. Patient # 17 A review of Patient # 17’s medical records revealed Patient # 17 arrived at the hospital’s ED with a chief complaint of “Right Knee Pain, Ground Level Fall” on 08/18/2024 at 2:36 AM. Triage was started at 2:42 AM by Staff # 20 (Registered Nurse). The following was documented in the triage notes, “Pain Assessment: 0-10 Pain Score: 7-Severe Pain Pain Location: Back” The patient was discharged from the ED on 08/18/2024 at 6:42 AM. The patient did not receive any pain medication or pain-alleviating nursing interventions during the ED visit. There was no reassessment of the patient’s pain documented by ED staff. A review of the hospital’s “Pain Management” policy with a date of 01/31/2023 revealed, “PURPOSE: To provide clinical guidance in facilitating the effective pain management of patients thereby enhancing their comfort, function, outcomes, and personal/family satisfaction. Pain management is an organizational priority. POLICY: 1. As an organization, UT Health East Texas recognizes the patient’s right to the appropriate assessment, management, and reassessment of pain. Caregivers from all disciplines will acknowledge, assess, and document, as appropriate, throughout the continuum of care the patient’s self-report of pain or observable responses to pain utilizing cognitively and age-appropriate pain scales. Patient descriptions of pain may include existence, nature, location intensity, aggravators, and relievers. Pain is to be recognized as the 5th vital sign and will be documented before and after pain medication and as indicated by the patient’s care, treatment, and services. 2. Pain is usually, but not always, assessed upon entry to an outpatient setting. Pain assessment is not a requirement in all settings. The assessment may be verbal and not recorded in the medical record such as an assessment done by the phlebotomist performing a venipuncture or a radiological technician performing an outpatient chest x-ray. An in-depth, documented, pain assessment may be warranted and documented depending on individual circumstances ... PROCEDURE: 1. Orders for the management of pain will be based on the patient’s diagnosis, assessment, and/or reassessment. The plan of care may contain both pharmacological and non-pharmacological treatments for patient pain or discomfort. 2. The assessment and reassessment will take into account the individual patient’s response to treatments, both physiologically and emotionally ... 5. Nursing Staff: ... b. If pain is present or anticipated, educate as appropriate the patient and their family about effective pain management practices ... iv. Based upon observations and collaboration with the physician, pain medication will be administered appropriately ... vii. Reassessment/Evaluation should occur: ... 2. Such reassessment and documentation should take place within a clinically appropriate time frame, such as within an hour of the administration of oral medications or within a half hour of the administration of intramuscular or intravenous pain medications ...” An interview was conducted with Staff # 18 (ED Manager) on 09/10/2024 at 12:00 PM in the ED Director’s office. Staff # 18 acknowledged that the emergency room staff were not consistently addressing pain and confirmed that the staff had failed to follow the hospital policy. 32143 Findings include: Patient # 4 A review of patient #4’s chart revealed the patient presented with a complaint of left ankle pain. Patient #4 had known Tri malleolar (Left ankle fracture) from a fall in April 2024. Date of Service: 6/10/2024 5:46 PM A review of the nurse’s documentation revealed patient #4 reported he tripped and hit the affected leg on the door frame today causing acute worsening of pain. The nurse documented the patient’s pain was a 6 out of 10 pain on the pain scale. There was no documentation that the provider was informed of the patient’s pain level. There was no medication ordered for pain and no documentation that the nurse practitioner (provider) addressed the patient’s pain in the provider notes. A review of the nurse notes dated 06/10/24 1825, “This patient called from his cellphone and requests to have his IV removed so that he can leave. He wants to seek treatment at a “private hospital” and does not want any further care here.” A review of the AMA form revealed the form was dated and timed on 6/10/2024 Time: 18:46. The form was signed by two nurses. A review of the nurse notes dated 06/10/24 at 1847 stated, “IV removed from the patient. Pt denies wanting to sign any paperwork. States “this is a worthless hospital.” Pt ambulated out of ER with crutches.” The documented pain level in the nursing flow sheet at departure was a 10 out of 10. There was no documentation that the patient’s pain levels were ever addressed by the nurse practitioner. Patient #4 returned to the ER on 6/12/24 for left ankle pain due to an old fracture in April of 2024. The nurse’s notes dated 6/12/24 at 1237 stated the patient’s pain level was a 6 out of 10. There was no documentation by the nurse practitioner of any pain and there was no medication ordered for pain.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32143 Based on record review and interview, the facility failed to; A. follow the policy and procedure on restraints to ensure chemical restraints/ emergency behavioral medications (EBM) were not ordered or administered as PRN (as needed), failed to ensure the face-to-face, nursing assessment, and patient care plan were performed and addressed in 1 of 1 (#11) patient charts reviewed. Refer to Tag A0169 B. follow its policy and procedure to ensure that non-violent restraints were applied, monitored, and released to ensure patient safety. A. The facility failed to ensure all staff were educated on restraint use. B. Nursing failed to document the patient’s behavior in descriptive terms to evaluate the appropriateness of the interventions used, no nursing assessment after restraints were applied to ensure that restraints were properly and safely applied, and the effectiveness of the restraints. C. Nursing failed to document the Q 4-hour assessment review of the patient restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM. D. Quality failed to monitor all restraints to ensure appropriateness, use, and discontinuation when ordered and applied. Quality failed to ensure all restraints were logged on the restraint log and appropriately identified as non-violent (medical) vs violent restraints (behavioral). Refer to Tag A073 The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 32143 Based on record review and interview, the facility failed to follow the policy and procedure on restraints to ensure chemical restraints/ emergency behavioral medications (EBM) were not ordered or administered as PRN (as needed), failed to ensure the face-to-face, nursing assessment, and patient care plan were performed and addressed in 1 of 1 (#11) patient charts reviewed. The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Patient #11 A review of the physician’s History and Physical (H&P) dated 10/02/23023 at 10:32 AM, stated “30 y/o Male, _____ (Patient #11), presents to the (Emergency Department) ED via EMS after being the unrestrained driver of a vehicle that was rear¿ended causing severe damage to vehicle and “breaking the drivers seat so that it lays in a flat position. EMS states that pt was c/o severe headache/neck pain, and slightly combative/concussed on scene. EMS reports perseveration. LOC in not known. Patient endorses SOB, chest pain, severe neck pain and headache. Patient is in a confused state and presents himself tearful and yelling. (sic) ...A review of the urine drug screen on 10/02/2023 at 9:19 AM revealed cocaine and cannabinoids were detected. Patient #11 was admitted to the facility on 10/02/2023 at 9:26 AM with, “SDH (subdural hematoma), Right Subdural hematoma, Right clavicle fracture, T 4, T6 superior endplate compression fractures.” A review of the medication administration record (MAR) revealed patient #11 had received PRN chemical restraint/ EBM while in 4-point restraints, with a lap belt, and mittens. The following medications were ordered and administered. On 10/3/23 at 10:44 am the order read, “Haldol (psychotropic) 2.5mg IM q 6 hours PRN.” There was no reason on the physician’s order why this medication was ordered. A review of the Medication Administration Record (MAR) revealed that the nurse administered the medication on 10/3/23 at 10:49 AM. There was no documentation on the patient’s behaviors that would require him to receive an IM psychotropic medication. A review of the nursing restraint flowsheet dated 10/30/23 revealed the patient was currently in 4-point restraints, a lap belt, and bilateral mittens when the Haldol order was written and administered. There was no face-to-face performed and no documentation of a behavioral restraint nursing assessment. A review of the nursing flowsheet dated 10/3/23 at 5:00 PM stated the patient was, “confused, awake, and agitated.” There was no documentation of what the nurse described as “agitation.” A review of the MAR dated 10/3/23 at 5:29 PM revealed patient #11 received an injection of Haldol 2.5 mg as a PRN at the nurse’s discretion. There was no evidence that the physician was notified of the injection. A review of the nursing restraint flowsheet dated 10/30/23 at 5:55 PM revealed the patient was currently in 4-point restraints, a lap belt, and bilateral mittens. The nurse documented, “Continues to attempt to remove essential lines/tubes or interfere with medical treatment; confused; Agitated.” There was no further documentation on how the patient had interfered with lines and care when he was in bilateral wrist restraints, bilateral ankle restraints, a lap belt, and hand mittens. There was no documentation on how the patient was agitated and what behaviors constituted a chemical restraint/EBM. A review of patient #11’s chart revealed a face-to-face was not completed after the administration of the Haldol IM injection on 10/3/23 at 5:28 PM for agitation. There was no 15-minute nursing assessment for 1 hour after administering a chemical restraint/EBM. There was no documentation on the effectiveness of the medication nor was there any documentation on the care plan about the chemical restraint/EBM use. Nursing failed to recognize, assess for, or document the psychotropic IM/IV medications as a restraint. A review of the facility policy and procedure “restraints” stated, “ ...b) Requires the Physician to examine the patient Face-to-Face within ONE hour of restraint application with order validation within 24 hours. As authorized by statutory regulations and this policy, the physician may delegate the ·face-to-face evaluation to an Advanced Practice Registered Nurse (APRN), a physician assistant (PA), or an RN who has current competency as demonstrated by completion of: ( 1) Study guide for Conducting the One Hour Face to Face Assessment of a Patient in Restraints for Behavioral Emergency (2) UT Health Restraint Education Module (3) Review of Administrative Policy 40039.4 ’’Restraint Policy-NS-MKT’’ ...d) There is no time limit when a single “STAT’’ dose (orally, IM or IV) is administered for a behavioral emergency. The nurse will document every 15 minutes for up to one hour following the administration or longer if clinically indicated to ensure stability ...” A review of the facility policy and procedure “restraints” stated. “1) Initial Orders ...d) The order must never be written as a standing or PRN order. e) The use of restraint must be in accordance with the written modification to the patient’s Plan of Care; and implemented in accordance with safe and appropriate restraint techniques ...” An interview was conducted with Staff # 6 on 12/12/24. Staff #6 stated that over a year ago the hospital system had a computer program change and went from One Source to EPIC. Staff #6 stated in One Source the system was more user-friendly, helped the staff maneuver through the documentation of restraint use, and had hard stops for the pharmacy to review. The program allowed staff to make sure the reason for the medications was clear on the physician’s orders. Staff #6 stated after the EPIC program was started, they found issues where things needed to be changed and added to ensure safe patient care was given. Staff #6 confirmed there was an issue with the monitoring and documentation of restraints and the process needed to be evaluated as soon as possible. Staff #6 stated that there has also been an increase in Residents practicing in the facility that had not received restraint training. Staff #6 confirmed there needs to be retraining and processes put back into place in all departments to ensure the policy for restraints was being followed and understood. An interview was conducted with Staff # 8 and #9 on 12/12/24. Staff #8 stated the process for Quality Assessment Performance Improvement (QAPI) was to place the restraints on the restraint log. The QAPI department would review the restraint logs and pull charts to audit to ensure the patient’s restraints were appropriate, safe, and documented. Staff #8 confirmed not all restraints were being logged correctly. Staff #6 confirmed that QAPI was not catching all the restraint patients. Staff #8 and #6 confirmed there was an issue with the review process in QAPI and the process would need to be reevaluated. Staff #8 stated the chemical restraints were being ordered and not placed on the restraint log due to staff not recognizing the medications as a chemical restraint/EBM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 32143 Based on record review and interview, the facility failed to follow its policy and procedure to ensure that non-violent restraints were applied, monitored, and released to ensure patient safety. A. The facility failed to ensure all staff were educated on restraint use. B. Nursing failed to document the patient’s behavior in descriptive terms to evaluate the appropriateness of the interventions used, no nursing assessment after restraints were applied to ensure that restraints were properly and safely applied, and the effectiveness of the restraints. C. Nursing failed to document the Q 4-hour assessment review of the patient restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM. D. Quality failed to monitor all restraints to ensure appropriateness, use, and discontinuation when ordered and applied. Quality failed to ensure all restraints were logged on the restraint log and appropriately identified as non-violent (medical) vs violent restraints (behavioral). The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Patient #11 A review of the physician’s History and Physical (H&P) dated 10/02/23023 at 10:32 AM, stated “30 y/o Male, _____ (Patient #11), presents to the (Emergency Department) ED via EMS after being the unrestrained driver of a vehicle that was rear¿ended causing severe damage to vehicle and “breaking the driver’s seat so that it lays in a flat position. EMS states that pt was c/o severe headache/neck pain, and slightly combative/concussed on scene. EMS reports perseveration. LOC in not known. Patient endorses SOB, chest pain, severe neck pain and headache. Patient is in a confused state and presents himself tearful and yelling. (sic) ...A review of the urine drug screen on 10/02/2023 at 9:19 AM revealed cocaine and cannabinoids were detected. Patient #11 was admitted to the facility on 10/02/2023 at 9:26 AM with, “SDH (subdural hematoma), Right Subdural hematoma, Right clavicle fracture, T 4, T6 superior endplate compression fractures.” A review of patient #11’s chart revealed the nurse had obtained a verbal physician order dated 10/02/2023 at 9:47 AM. The order read, “NON-violent- Bilateral Soft wrist restraints and Lap belt/buddy (NV), Clinical Justification: Interfering with essential medical treatment”. A review of patient #11’s chart revealed the restraint flowsheet dated 10/2/23 at 9:47 AM revealed the nurse applied the right and left wrist restraints due to “interfering with essential medical treatment. Nursing interventions previously ineffective- Change in environment, (pain, position, clothing); Discontinue non-essential devices, diversional activity; Reduce environmental stimuli; Reorientation.” The nurse documented in the flowsheet that patient #11 was sleeping on 10/2/23 from 11:00 am until 3:00 pm. There was no documentation that he was interfering with any medical care at that time. The nurse failed to document the patient’s behavior in descriptive terms to evaluate the appropriateness of the interventions used. A review of the policy and procedure “restraint” stated, “ ...5) Non-Violent Restraint/Medical is a medical restraint used for Behavior driven by a medical condition. The patient is attempting to Remove lines, tubes, surgical dressing or otherwise interfering with Essential medical treatment. (Example: The patient whose confusion Is due to a medical condition; this patient has no control over this behavior). 3) Monitoring and Documentation a) Upon initiation and release i) Alternatives to restraint ii) Circulation assessed iii) Laboratory results reviewed iv) Medications reviewed v) Skin assessed vi) Date and time of restraint initiated vii) Description of the patient’s behavior viii) Patient’s condition or symptom(s) that warranted the use of restraints ix) Patient’s response to less restrictive alternatives b) Daily i) Restraint type ii) Reason for restraint iii) Check if ordered within last calendar day iv) Patient/family education v) Restraint education comprehension _ c) Requires monitoring at least every four hours by a licensed nurse for the following: i) Signs of injury associated with restraint application ii) Assessed for release iii) Restraint correctly applied iv) Circulation and respiratory status v) Fluid and nutrition vi) Release for range of motion vii) Positioned, repositioned _ viii) Rationale for continued use of restraints ix) Skin assessment x) Emotional support provided xi) Toileting xii) A description of the patients’ behavior and any change in intervention required xiii) Mental status, cognitive function, presence of agitation 4) Criteria for release: a) Does not attempt to remove tubes, dressings, equipment, etc. b) Least restrictive interventions are successful. c) Under RN supervision, staff may remove restraints when criteria for release have been met. d) Restraint use should be discontinued when there is no longer adequate and appropriate justification for continued use and before an order expires. e) The use of restraint must be discontinued as soon as possible, based on an individualized patient assessment and re-evaluation.” A review of patient #11’s chart revealed a verbal physician order on 10/2/23 at 4:20 PM. The order stated to discontinue the previous restraint order and ordered, “bilateral wrist restraints and a lap belt/buddy; interfering with essential medical treatment.” A review of the restraint flowsheet on 10/02/2023 at 4:21 PM revealed that the lap belt was applied. The nurse documented, “bilateral soft wrist restraints for interfering with essential medical treatment. Confused; Disoriented; Continues to attempt to remove essential lines/tubes or interfere with medical treatment”. There is no nursing or physician note for 10/02/2023 at 4:21 PM to describe what the patient is attempting to remove or how the patient is interfering with medical treatment. There was no further documented justification on why the patient needed the added lap belt. The nurse failed to document a description of the patient’s behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied. A review of patient #11’s chart revealed a verbal physician order on 10/2/23 at 10:35 PM to discontinue the previous restraint order. An order was written for “bilateral wrist restraints, bilateral ankle restraints, and a lap belt/buddy; interfering with essential medical treatment.” A review of the restraint flowsheet on 10/2/23 at 10:52 pm revealed the nurse applied patient #11’s bilateral ankle restraints. The patient now had 4-point restraints on and a lap belt. There was no further documented justification on why the patient needed the added bilateral ankle restraints. The nurse failed to document a description of the patient’s behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied. A review of the restraint flowsheet revealed there was no documentation of restraints or a patient assessment for the ordered restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM. A review of the clinical note dated 10/3/23 at 3:21 AM revealed staff # 37, CT Tech, documented the “CT scan completed without complication. Patient came to CT by bed on a monitor, with nurse. No O2 or IV. Nurse will take patient to 3356A.” There was no documentation that the patient restraints were removed. A review of the medication administration record (MAR) revealed the IV medication was “paused.” There was no nursing documentation of the patient restraints. The nurse had previously documented the patient was interfering with lines and medical care that justified restraints. A review of patient #11’s chart revealed a verbal physician order on 10/3/23 at 7:46 AM to discontinue the previous restraint order. A physician order was written for bilateral wrist restraints, bilateral ankle restraints, mittens, and a lap belt/buddy; “interfering with essential medical treatment.” A review of the restraint flowsheet dated 10/3/23 at 7:52 AM revealed the nurse applied patient #11’s bilateral mittens. The nurse documented that patient #11 had 4-point restraints on, mittens, and a lap belt. There was no further documented justification on why the patient needed the added bilateral mittens. The nurse failed to document a description of the patient’s behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied. A review of the medication administration record (MAR) revealed patient #11 had received chemical restraints/ Emergency Behavioral Medications (EBM) while in 4-point restraints, with a lap buddy and mittens. The following medications were administered. Ativan (sedative) 0.5mg IV on 10/2/23 at 7:33 am, no reason indicated on the order. Ativan 1 mg IV on 10/2/23 at 5:00 pm and 10:39 pm no reason indicated on the order. Ativan 1 mg IV on 10/3 at 6:50 am and 10:05 pm no reason indicated on the order. Haldol (psychotropic) 2mg IV 10/3/23 at 7:30 pm no reason indicated on the order. Haldol 2.5 mg IV 10/3/23 at 5:28 pm and 10:49 am, no reason indicated on the order. Geodon (psychotropic) 20mg IM 10/3/24 at 10:00 pm no reason indicated on the order. A physician order on 10/3/23 at 10:39 PM revealed a sitter was ordered on 10/03/2023 at 10:39 PM for “restraint alternative”. There was no found documentation or evidence that a sitter was provided at any time in this timeframe of the active order. There were no other documented interventions for PO (oral) medications before restraints were applied or the reaction of the patient when restraints were applied or administered. There was no documentation found of the effectiveness of the restraints. Multiple restraints were added to the patient within 24 hours without evidence of 1 to 1 evaluation or line of sight to ensure patient safety. A review of the nursing notes dated 10/03/2023 at 10:23 PM stated, “Due to patient’s aggressive behavior and physicality with nurses, this nurse is transferring care to _____ (staff # 35 RN) after one-time medication given to calm patient down.” A review of the nursing notes dated on 10/03/2023 at 10:25 PM revealed staff # 28 (student nurse) documented, “Patient agitation increasing. The patient had an incontinent episode and urinated on himself. While changing patient, he was yelling and cussing at staff and hit Nurse ______ (floor nurse) hard in the stomach. Attempted to redirect patient, unable to calm him down or de-escalate him.” A review of the restraint flow sheet revealed all restraints were discontinued on 10/3/23 at 10:38 PM, 13 minutes after he had a violent behavioral incident. There was no nursing documentation explaining the patient’s condition, mental status, or justification for release. Patient #11 had been given a chemical restraint for his behaviors with Ativan 1 mg IV and Geodon 20mg IM at 10:00 PM before the patient was released from his physical restraints. A review of the physician’s (Staff #33) notes on 10/04/2023 at 12:59 PM revealed “24-Hour Events: Still agitated, confused to nurses. Took off his strains. (sic) Ziprasidone (Geodon) and haloperidol (Haldol) were given for sedation.” The physician stated the medications of Geodon and Haldol were given to sedate the patient. An interview was conducted with Staff # 6 on 12/12/24. Staff #6 stated that over a year ago the hospital system had a computer program change and went from One Source to EPIC. Staff #6 stated in One Source the system was more user-friendly, helped the staff maneuver through the documentation of restraint use, and had hard stops for the pharmacy to review. The program allowed staff to make sure the reason for the medications was clear on the physician’s orders. Staff #6 stated after the EPIC program was started, they found issues where things needed to be changed and added to ensure safe patient care was given. Staff #6 confirmed there was an issue with the monitoring and documentation of restraints and the process needed to be evaluated as soon as possible. Staff #6 stated that there has also been an increase in Residents practicing in the facility that had not received restraint training. Staff #6 confirmed there needs to be retraining and processes put back into place in all departments to ensure the policy for restraints was being followed and understood. An interview was conducted with Staff # 8 and #9 on 12/12/24. Staff #8 stated the process for Quality Assessment Performance Improvement (QAPI) was to place the restraints on the restraint log. The QAPI department would review the restraint logs and pull charts to audit to ensure the patient’s restraints were appropriate, safe, and documented. Staff #8 confirmed not all restraints were being logged correctly. Staff #6 confirmed that QAPI was not catching all the restraint patients. Staff #8 and #6 confirmed there was an issue with the review process in QAPI and the process would need to be reevaluated.”

“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: 49344 Based on record review and staff interview, nursing staff failed to change the Peripherally Inserted Central Catheter (PICC) line dressing every 7 days as specified by hospital policy and per Centers for Disease Control (CDC) guidance in 4 (Patient #2, #10, #22 and #23) of 5 (Patient #2, #10, #22, #23, #24) patient charts reviewed. The PICC line dressing covers and protect the PICC insertion site, preventing infection and maintaining the line’s position. Findings include: A review of the medical records for patients #2, #10, #22, #23, and #24 for proper dressing changes of PICC lines was conducted with Staff #2, on 12/11/2023 at 11:00 AM in the conference room. Record review found that four (patients # 2, 10, 22, and 23) of the five patient’s charts reviewed documented dressing changes on PICC lines having occurred outside of the minimum seven-day timeframe required by facility policy, “Vascular Access and Maintenance (Adult), Policy Number: 39220.4.” A review of the hospital policy titled, “Vascular Access and Maintenance (Adult), Policy Number: 39220.4” with an “effective” date of 11/04/2022 revealed, “Purpose: To provide guidelines and recommendations for insertion and maintenance of vascular access in the hospital setting that will reduce incidents of phlebitis, infiltration, and central venous catheter-related bloodstream infections ... ...4) Maintenance ... ... iv) Dressing change procedure: (1) Hospital-approved dressings are to be changed at a minimum every seven days as designated by each facility’s policy. Dressing must be changed if the dressing is wet, soiled, not occlusive, bloody, or not dated. Clean and intact dressing may remain in place for up to 7 days ... ...d) Patients being discharged with central venous access... Clinical practice with dressings and flushing will continue per this document until the patient is discharged. Prior to discharge, the site should be inspected, and dressing changed ...” The hospital policy refers to CDC guidelines for dressing changes to any vascular access recommending to “Replace dressings used on short-term CVC (Central Venus Catheter) sites at least every 7 days for transparent dressings” https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf Patient #2 A review of patient #2’s medical record revealed a physician order dated 10/13/2023 for PICC line placement. The PICC line was inserted on 10/13/2023 and a new dressing was applied. Nursing documentation revealed the dressing was changed on 10/24/2023, 11 days later, there was no documented evidence the dressing was changed within 7 days of insertion per the hospital policy. Patient #10 A review of patient #10’s medical record revealed a physician order dated 10/28/2023 for PICC line placement. The PICC line was inserted on 10/28/2023, and three of the four dressing changes documented by Nursing staff occurred for more than seven days. Dressing changes were documented for the following dates: 10/31/2023 (3 days later), 11/13/2023 (13 days later), 11/21/2023 (8 days later) and 12/06/2023 (15 days later). There was no documented evidence the dressing was changed within the 7 days per the hospital policy. Patient #22 A review of patient #22’s medical record revealed a physician order dated 10/25/2023 for PICC line placement. The PICC line was inserted on 10/25/2023 and a new dressing was applied. Nursing documentation revealed the dressing was changed on 11/04/2023, 10 days later. There was no documented evidence the dressing was changed within 7 days per the hospital policy. Patient #23 A review of patient #23’s medical record revealed a physician order dated 10/31/2023 for PICC line placement. The PICC line was inserted on 10/31/2023 and a new dressing was applied. The patient was discharged seven days later, on 11/06/23, with a PICC line in place for long-term antibiotic treatment, however, there was no documented evidence the dressing was changed on or before discharge as required by facility policy. In an interview on 12/12/2023 at 4:00 PM in the conference room, Staff #6 stated, “We used to do PICC line dressing changes every Friday and that process worked well. However, at some point, the staff decided to change that process and wanted to change the dressing on the 7th day, instead of a particular day of the week. The nurses should have been changing the dressing on the 7th day but in review of these charts, that has proven to be a problem throughout the hospital. We will go back to changing the dressings on PICC lines on certain days, such as every Friday to better monitor and ensure PICC line dressings are being changed per our hospital policy.” In an interview on 12/11/2023 at 11:00 AM in the conference room with Staff #2 and Staff #8 confirmed that the nursing staff did not follow the policy for “Vascular Access and Maintenance” consistently and acknowledged that monitoring and reporting from the quality and infection control department were “insufficient”.”