Christus Mother Frances Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 32143 Based on medical record review, review of Emergency Medical Services (EMS) documentation, review of facility policy, and staff interviews, 1. The hospital failed to ensure appropriate nursing monitoring and assessment of a patient who received multiple sedating medications, including high-dose intramuscular ketamine. This failure had the potential to place 1 of 1 sampled patients (Patient #2) at risk for respiratory compromise, airway obstruction, and other adverse outcomes. Refer to Tag A 0395”

“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: 32143 Based on medical record review, review of Emergency Medical Services (EMS) documentation, review of facility policy, and staff interviews, the hospital failed to ensure appropriate nursing monitoring and assessment of a patient who received multiple sedating medications, including high-dose intramuscular ketamine. This failure had the potential to place 1 of 1 sampled patients (Patient #2) at risk for respiratory compromise, airway obstruction, and other adverse outcomes. Findings Include: Medical record review revealed Patient #2 was a 42-year-old male weighing approximately 186 pounds (84.4 kilograms) who presented to the Lindale Emergency Department on 11/30/2025 at 3:05 am with hallucinations after reportedly ingesting kratom, methamphetamine, delta 8, and delta 9 substances. Documentation indicated the patient was combative and received multiple psychotropic and sedating medications, including: Ziprasidone (Geodon) 20 mg IM administered at 9:33 AM Diphenhydramine (Benadryl) 50 mg IM administered at 10:10 AM Lorazepam (Ativan) 2 mg IM administered at 10:47 AM Haloperidol (Haldol) 5 mg IM administered at 11:19 AM Lorazepam (Ativan) 2 mg IM administered at 11:20 AM Further review of the records showed that Ketamine (Ketalar) 500 mg IM was administered on 11/30/26 at 11:28 AM in the emergency department before transfer. The EMS run sheet documented an additional Ketamine 400 mg IM (200 mg in each leg) at 11:54 AM during transport. These administrations resulted in a total ketamine dose of approximately 900 mg IM within 26 minutes. Based on the patient’s documented weight of 84.4 kg, the cumulative dose equaled approximately 10.7 mg/kg, which exceeds commonly referenced intramuscular ketamine dosing ranges of approximately 3-5 mg/kg per Drugs. com-ketamine. According to the DEA.gov/ketamine, Ketamine is an approved medical product as an injectable, short-acting anesthetic for use in humans and animals. Ketamine is a dissociative anesthetic that has some hallucinogenic effects. Ketamine distorts the perception of sight and sound and makes the user feel disconnected and not in control. It is referred to as a “dissociative anesthetic hallucinogen” because it makes patients feel detached from their pain and environment. Facility Policy Review Review of the facility policy titled ‘Moderate Sedation’ stated the registered nurse responsible for monitoring a patient receiving moderate sedation must provide continuous monitoring and should have no other responsibilities requiring the nurse to leave the patient unattended. An interview with Staff #16 (ED Pharmacist) on the morning of 1/21/26 revealed that intramuscular ketamine typically has an onset of approximately 3-4 minutes, reaches peak clinical effect within 5-10 minutes, and has a duration of approximately 30-60 minutes. Staff #16 stated that the combined use of psychotropic medications and ketamine could place a patient at risk for respiratory complications if not closely monitored. Interview with Staff #17 (Registered Nurse) on 1/21/2026 at 1:25 pm. Staff #17 stated she remembered patient #2’s visit. Staff #17 stated that when he came in, he was very sedated and “out of it.” Staff #17 stated that she was told by EMS that patient #2 had been administered ketamine for behaviors. Staff #17 stated that she was the pod leader that day and had 4 patients. Staff #17 stated that staff #18 RN came into the room to assist. Staff #17 confirmed the patient was not being monitored as a conscious sedated patient. Staff #17 stated, “Because he came in as a psychiatric patient, it didn’t occur to me to have him monitored as a conscious sedation patient.” Nursing documentation dated 11/30/2025 at 12:50 pm stated the patient was chemically restrained with multiple medications and was unresponsive, with a documented Glasgow Coma Scale (GCS) score of 7. According to NIH, the Glasgow Coma Scale (GCS) is a cornerstone tool in the neurological assessment of patients with acute brain injury and impaired consciousness. “Clinical Definition: A GCS of 7 (e.g., E2V2M3) means the patient is deeply unconscious, with minimal, if any, purposeful response to pain. Sedation Level: If this score is due to medication, it represents deep sedation, as the patient is unresponsive to verbal stimuli. Airway Management: Patients with a GCS of 7 frequently require intubation because they cannot maintain airway patency and are at high risk for aspiration.” A review of the patient #2’s chart revealed staff #17 documented on 11/30/25 at “13:18 Per sitter and security, patient looked like he had a seizure. Patient turned to his side, suctioned, and the MD was called to the room.” Staff #17 confirmed a nurse was not in the room when this occurred.”

“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: 40989 Based on document review and interview, the hospital failed to comply with 489.24 and provide an appropriate transfer for 1 (Patient #1) of 20 patients reviewed. The hospital failed to: 1. Provide a Memorandum of Transfer (MOT) for an appropriate transfer to an inpatient psychiatric treatment facility after the patient’s medical screening exam and psychiatric evaluation determined that 1 (Patient #1) of 20 patient medical records reviewed needed inpatient psychiatric treatment. 2. Notify the receiving hospital, Hospital B, of Patient #1’s transfer or secure an accepting physician. 3. Send all medical records available at the time of transfer to the receiving hospital for Patient #1. 4. Follow its policy titled, “Texas Department of Health/COBRA/Transfer EMTALA Policy Reference Number: 8575-0002. Refer to Tag A2409”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40989 Based on document review and interview, the hospital failed to: 1. Provide a Memorandum of Transfer (MOT) for an appropriate transfer to an inpatient psychiatric treatment facility after the patient’s medical screening exam and psychiatric evaluation determined that 1 (Patient #1) of 20 patient medical records reviewed needed inpatient psychiatric treatment. 2. Notify the receiving hospital, Hospital B, of Patient #1’s transfer or secure an accepting physician. 3. Send all medical records available at the time of transfer to the receiving hospital for Patient #1. 4. Follow its policy title, “Texas Department of Health/COBRA/Transfer EMTALA Policy Reference Number: 8575-0002. A review of medical records was completed on 8/25/2025 with Quality Director Staff #1, Administrative Director Staff #2, Registered Nurse Clinical Coordinator Staff #3, and Quality Program Manager Staff #4. Findings: Patient #1 was a 42-year-old female who arrived by personal vehicle at the Emergency Room (ER) on 7/23/2025 at 5:30 PM with a chief complaint of Suicidal Ideation (SI) with a plan to shoot herself. She was escorted to Room L06, and triage was initiated at 5:45 PM by RN #15. The triage acuity on admission was 2-Emergent. Triage levels are a numerical scoring system categorized using the Emergency Severity Index (ESI), which prioritizes patients based on the urgency of their medical condition, ranging from level 1, most urgent, to level 5, least urgent. A review of the medical record revealed that Physician Assistant (PA) #8 was the initial provider and initiated the Medical Screening Exam (MSE) at 5:53 PM. Further review of PA #8’s documentation stated Patient #1 endorsed homicidal ideation (HI) but declined to share details and had auditory hallucinations. Patient #1 had a past medical history of Borderline Personality Disorder, Schizophrenia, Seizures, Suicide Attempt, Endometriosis, and Polycystic Ovary Syndrome. PA #8 wrote orders to initiate psychiatric precautions, security to wand the patient, place the patient in safe clothing, and consult with psychiatric telemedicine on 7/23/2025 at 5:54 PM. At 6:18 PM, RN #15 documented that the chief complaints were updated and read, “Mental health Problem (she did not want to say who the other people were that she wished to harm, nor does she have a plan to harm. Only thoughts of harm towards others. She is also hearing voices. They are just random words that do not make sense. Suicidal, patient reports for the last week she has been having anxiety, depression, and confusion, like difficulty getting words out. She has also been having difficulty sleeping with nightmares and decreased appetite. She does report that her daughter just moved in with her and her parents, and her daughter is mean to her. She also reports thoughts of harming herself and others. She does have a plan to shoot herself in the head and has previously attempted to shoot herself in the chest over a year ago, no recent attempts.” A review of the medical record confirmed the tele-psych consultation was completed on 7/23/2025 at 7:13 PM by Advanced Practice Registered Nurse (APRN) Staff #11. A review of the clinical conclusion revealed that Patient #1 was at high risk for suicide and was a threat to herself and others, requiring inpatient care for safety, monitoring, and treatment. “Disposition Recommendations: Admit to inpatient psychiatry services”. Physician #10 documented at 6:53 PM on 7/23/2025. The documentation was as follows: “I personally took responsibility of the patient, and I agree with the documentation. I approve of the management plan performed by the provider for the patient. I had face-to-face time with the patient, and the majority of the visit was under my care. I reviewed the test results with the patient. A disposition plan was made between the patient and myself and all questions were answered”. Further review of the medical record documented by PA #8 was as follows: “ ...Consults & Re-Evaluations: 7:00 PM-Patient roaming hallways, pacing, agitated. Refusing to stay in room despite multiple requests from staff and security. 7:13 PM-Patient at desk, pacing, asking to leave. States “I want to go home”. Nursing staff to call PD as patient is voicing suicidal ideation and homicidal ideation with plan and access to gun. 7:45 PM-Patient evaluated by tele-psych who recommends inpatient as patient is a danger to herself and others. PD called just as patient was finishing with tele-psych. Took patient into their custody and took her to (Hospital B) for admission ...” A review of the nurse’s notes dated 7/23/2025 was as follows: RN #6 documented: “ ...RN #6 documented at 7:09 PM-“Patient agitated at repeated requests to stay in the room. Patient repeatedly walking up and down the hallway and standing at the nurse station during shift change. Security requested to speak to the patient to request the patient to stay in the room for the privacy of other patients and shift report”. RN Staff #15 documented: “ ...7:10 PM-Patient becoming increasingly agitated, and reports she wants to go home. Patient informed she was not allowed to leave at this time d/t SI and HI. Will call the Lindale Police Department (PD) for a possible Police Officers Warrant (POW). 7:17 PM-Called Lindale PD to have an officer come out and evaluate for POW ... 7:30 PM-Lindale PD arrived to evaluate for POW. Patient is currently in consult with tele-psych provider.” RN Staff #9 documented; “7:39 PM-Patient completed consult with tele-psych and preceded (sic) to close the door and take her scrub bottoms off. Patient was asked to put her pants back on, of which she reluctantly complied. 7:48 PM-Patient was placed into police custody. Police states that patient lives in the county and no deputy was available to assess, therefore, they took the patient into custody.” Physician #10 documented at 7:53 PM on 7/23/2025. The documentation was as follows: “7:50 PM patient was seen by police here patient has been threatening to leave and felt that she was a threat to herself and others as well. Please (sic) to patient to (Hospital B) for psychiatric evaluation. Feel this is safest thing to do given the of the (sic) threats given by the patient. Telepsych discussed case with the provider and recommended inpatient evaluation and Emergency Detention Warrant (EDW) secondary to threats to self and other, patient is very high risk for suicide.” ED Disposition documented by PA #8 on 7/23/2025 at 7:51 PM was as follows: “Discharge to (Hospital B) for psych evaluation in police custody. Condition at discharge good. MSE completed at (sic) 7/23/2025 7:51 PM.” An interview was conducted with RN Staff #6 on 8/25/2025 at 11:15 AM. RN Staff #6 stated that during the ER visit, Patient #1 got anxious waiting on the tele-psych visit, and security was called because she wanted to leave. RN Staff #15 called the police department for a POW. When they arrived, the patient was doing her tele-psych consult, so they waited to evaluate her until she was finished. RN Staff #6 was asked if the patient was transferred to Hospital B. RN #6 stated, “The police just took her into custody to transport her to Hospital B for a psych eval”. RN #6 was asked why the patient needed to go for a psychiatric evaluation when she had just completed one. RN #6 did not answer the question. RN #6 was asked if the police were allowed to just come in and take the patients without having a proper transfer completed. RN #6 stated, “What do you expect us to do? They are the police. We can’t stop them from taking the patient. Who would you expect us to call?” RN #6 was asked if Patient #1 had committed a crime and was under arrest. RN #6 confirmed Patient #1 was not under arrest. An interview was conducted with Staff #1 and Staff #2 on 8/25/2025 after 11:45 PM. Staff #1 and #2 confirmed that Patient #1 was taken into custody by the police and transferred to Hospital B for a psychiatric evaluation and admission. Staff #1 stated, “Usually, what happens is they will transfer patients to the main campus if they require more resources than what the emergency care center has. Staff #1 confirmed the ER did not transfer the patient to the main campus or call for assistance regarding Patient #1. Staff #1 and #2 confirmed the ER failed to complete a MOT and secure an accepting physician at Hospital B before the patient was released into police custody. An interview was conducted with Physician #16 on 8/26/2025 at 8:15 PM. Physician #16 confirmed that Patient #1 was brought to Hospital B by the police. Physician #16 was informed by the PD officer that Lindale ER could not accept patients on an Emergency Detention Warrant (EDW). Physician #16 confirmed that the PD arrived with no patient medical records, and the transferring physician had not contacted him or anyone at Hospital B regarding acceptance of this patient. Patient #1 was assessed and admitted involuntarily as an inpatient on the behavioral health unit. Physician #16 confirmed the medical information he was able to access was visible by the consent of Patient #1 for sharing information between providers, signed at the ER. A review of the Medical Decision Making documented by Physician #16 on 7/23/2025 at 8:25 PM was as follows: “MDM Diagnostic considerations and differential diagnoses: Schizophrenia, drug abuse, bipolar disorder, unlikely non-psychiatric illness at this time. Patient is seen at Christus Lindale Emergency room and then was subsequently brought here by police department without notification from the physician at that facility or any transfer request in place. It is unclear if she was even seen by a physician there. It was relayed to me by the police that they cannot have patients under emergency detention warrant there and so the police took her here. She was seen by tele-Psychiatry per chart review Patient states she has not seen by physician. Looking at the notes in the chart all I can see his nursing notes stating that she said she was suicidal and homicidal, and they were getting an emergency detention warrant. This is clearly an inappropriate transfer as it seems patient was discharged into police custody. Either way, I have reviewed the labs from their facility and they have generally completed the medical clearance labs. Her vitals are unremarkable. Will have our psychiatrist evaluate the patient. Psychiatry advises admission under involuntary status d/t her erratic and aggressive behavior with likely hallucinations. Medical clearance reviewed from outside facility and was appropriate ...” After requests for an interview with PA #8 and Physician #10, I was informed by Staff #1 that the providers were off the ER rotation and were unavailable for an interview. A review of the facility policy titled, “Texas Department of Health/COBRA/Transfer EMTALA Policy”, Reference Number: 8575-0002, was as follows: “ ...PURPOSE: To conform to federal and state guidelines relating to emergency medical treatment and the medically appropriate transfer of individuals between CHRISTUS Mother Frances Hospital (CMFH) and other hospitals. POLICY: I. CMFH acknowledges that the EMTALA screening and stabilization requirements apply when a patient a) comes to the CMFH Emergency Care Center, a dedicated emergency department b) comes to any department or outpatient area located at or adjoining to CHRISTUS Mother Frances Hospital, furnishing the same type of healthcare services as furnished by the main provider; and, is under the same name, ownership, financial and administrative control of the main provider. 2. The transfer of an individual may not be predicated upon arbitrary, capricious or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status ... 8. CMFH Medical Staff shall inform each individual (or a person acting on his or her behalf) of the risks and benefits to the individual of examination and treatment and/or transfer and take all reasonable steps to secure the individual’s written informed consent, for transfer. 9. CMFH shall provide to the receiving hospital all transfer records as well as records related to the emergency condition, which are available at the time of transfer. These include medical records related to the individual’s emergency medical condition, preliminary diagnosis, signs and symptoms, treatment provided, test results, informed written consent or physician certification and the name and address of any on-call physician who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment ... 14. Responsibilities of the Medical Staff: ...14.6 Prior to transfer, the transferring physician shall secure a receiving physician and hospital that are appropriate to the medical needs of the individual as well as accept responsibility for the individual’s medical treatment and hospital care ...” An interview was conducted with Staff #1 and #2 on 8/25/2025 after 3:30 PM. It was confirmed that the hospital failed to complete an MOT before transferring Patient #1 to Hospital B. It was also confirmed that there were no medical records sent to Hospital B and that the transferring provider failed to secure an accepting physician for the care of Patient #1 before transferring her to Hospital B.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 40989 Based on document review and interview, Nursing Services failed to document verbal orders from 3 (Physiciain #13, #14, and #15) of 3 physicians for moderate sedation medications in the Radiology Department in 3 (Patient #2, #3, and #4) of 3 medical records reviewed. Also, the hospital failed to ensure physicians signed verbal orders for sedation medications according to the facility’s Verbal Order Policy. Findings: Patient #2 Patient #2 was a 53-year-old female scheduled for a CT-guided intra-abdominal abscess drainage in the Radiology Department by Physician #13 on 9/09/2024. A review of the medical record revealed Registered Nurse (RN) Staff #8 was the assigned nurse for the procedure. A review of the medication orders revealed that Versed (Midazolam, a sedative medication) 2 milligrams/milliliter (mg)/(ml) and Fentanyl (an opioid pain medication) 100mcg/2ml were removed from the medication cabinet on 9/09/2025 at 3:57 PM by RN #8. The administration instructions read, “RN #8, cabinet override and Medication Comments: RN #8, cabinet override”. There was no ordering or authorizing physician on the medication order. A review of the Medication Administration record for Midazolam (Versed) was as follows: “Ordering Provider: Physician #13, Ordered on: 09/09/2024 at 4:33 PM, Frequency: Intra-op PRN (as needed) Performed 9/09/2024 at 4:29 PM, 1 mg Intravenously (IV) by RN #8 Performed 9/09/2024 at 4:33 PM, 0.5 mg IV by RN #8 Performed 9/09/2024 at 4:36 PM, 0.5 mg IV by RN #8 Performed 9/09/2024 at 4:40 PM, 0.5 mg IV by RN #8. A review of the Medication Administration record for Fentanyl was as follows: “Ordering Provider: Physician #13, Ordered on: 09/09/2024 at 4:33 PM, Frequency: Intra-op PRN Performed 9/09/2024 at 4:33 PM, 50 mcg (micrograms) IV by RN #8 Performed 9/09/2024 at 4:36 PM, 25mcg IV by RN #8 Performed 9/09/2024 at 4:37 PM, 25mcg IV by RN #8 Performed 9/09/2024 at 4:40 PM, 50 mcg IV by RN #8.” Patient #3 Patient #3 was a 63-year-old male scheduled for a CT Biopsy of a left lower lung nodule on 8/12/2025 by Physician #15. A review of the medical record revealed RN #16 was the assigned nurse for the procedure on 8/12/2025. A review of the medication orders revealed that RN #16 wrote an order on 8/12/2025 at 8:35 AM that read, “Fentanyl IV Intra-op PRN and Versed IV Intra-op PRN”. A review of the Medication Administration record for Versed was as follows: “8/12/2025 at 8:28 AM 1mg IV administered by RN #16, 8/12/2025 at 8:34 AM 0.5mg IV administered by RN #16, 8/12/2025 at 8:42 AM 0.5mg IV administered by RN #16.” A review of the Medication Administration record for Fentanyl was as follows: “8/12/2025 at 8:28 AM 50 mcg IV administered by RN #16, 8/12/2025 at 8:34 AM 25mcg IV administered by RN #16, 8/12/2025 at 8:42 AM 25mcg IV administered by RN #16.” An interview was conducted with RN #7 on 8/12/2025 after 2:00 PM. RN #7 confirmed that Physician #15 did not enter the orders for the Versed and Fentanyl for the procedure, and that RN #16 did not write any verbal orders for the moderate sedation medications administered to Patient #3 during the procedure. Patient #4 Patient #4 was a 90-year-old male scheduled for an Arteriogram on 8/12/2025 by Physician #14. A review of the medical record revealed RN #9 was the assigned nurse for the procedure. A review of the medication orders revealed that RN #9 wrote an order on 8/12/2025 at 8:21 AM that read, “Fentanyl IV Intra-op PRN and Versed IV Intra-op PRN”. A review of the Medication Administration record for Versed was as follows: “8/12/2025 at 8:21 AM 1mg IV administered by RN #9.” A review of the Medication Administration record for Fentanyl was as follows: “8/12/2025 at 8:21 AM 50 mcg IV administered by RN #9.” An interview was conducted with RN #7 on 8/12/2025 after 2:00 PM. RN #7 confirmed that Physician #14 did not enter the orders for the Versed and Fentanyl for the procedure, and that RN #9 did not write any verbal orders for the moderate sedation medications administered to Patient #4 during the procedure. An interview was conducted with RN Staff #8 on 8/12/2025 after 2:00 PM. RN Staff #8 was asked who gave the sedation medication orders for the intervention radiology procedures. RN Staff #8 stated that the physician performing the procedure gave verbal orders during the procedure. RN #8 was asked if the physician put any of the orders in the computer. RN #8 stated, “We put the order in that says ‘Intra-op PRN’ ordered by the physician, but there is no specific dose entered before the start of the procedure. The physician will tell us the dose to give during the procedure.” RN #8 was asked if she put in the verbal orders for the sedation medications during the procedure. RN #8 confirmed she did not enter any verbal orders in the computer for any of the medications that she administered during the procedure. An interview was conducted with Staff #1 on 8/12/2025 after 2:00 PM. RN Staff #1 was asked if the physicians performing the procedures did not enter the moderate sedation orders, who signed the orders for the sedation drugs. RN Staff #1 stated, “It should be the physician who is doing the procedure”. RN Staff #1 was asked if verbal orders do not get entered, how does the physician know he had to sign the order? “Staff #1 replied that he would not know. There would not be an outstanding order for him to sign. RN Staff #1 confirmed there were no signed physician orders or verbal orders for the moderate sedation medications administered by the nursing staff for 3 (Patient #2, #3, and #4) of 3 patient medical records reviewed. A review of the hospital policy titled, “Verbal/Telephone Orders” Number 3.140, with a revised/reviewed date of 3/24 was as follows: “ ...II. OBJECTIVE/S: This policy delineates the CHRISTUS Health Associates that are qualified to receive verbal/telephone orders, the individuals from which verbal/telephone orders may be received, and the process for recording, transcribing, transmitting, and authenticating verbal/telephone orders with the goal-of maximizing patient safety. III. POLICY STATEMENT: CHRISTUS Health IS committed to the promotion of patient safety and compliance with regulatory requirements, IV. DEFINITIONS: A. Verbal Order: An order which is given face-to-face in an urgent. or emergent situation from a licensed approved member of the Medical Staff to a qualified CHRISTUS associate ... V. PROCESS: A. Verbal Orders: 1. In the Interest of patient safety and to minimize errors, Providers should write/enter their orders, not give verbal orders, when present and able to do so themselves. The exception is during urgent or emergent situations when a Provider will verbally relay an order to a qualified associate in real-time, face-to-face, Providers should subsequently enter their orders in the computer system once they are able to access a computer. 2. All verbal orders must be documented in the medical record. 3. When using CPOE, the appropriate individual will access the patient within the EHR, enter the ordering provider, enter the order source as VERBAL, and then enter the order as directed by the provider. a) The order is then verbally read back to the provider. Any alerts/rules/reminders that are presented during the order entry process are read to the provider and the provider’s response to the alerts/rules/reminders are entered into the computer. b) Once the order is confirmed by the provider, the order is filed in the EHR and is considered to have been ‘read back’. c) The order may then be carried out or sent to the appropriate department for validation/processing,..””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s staff failed to ensure that 1 (Patient # 2) of 1 patient was safely discharged from the hospital when Patient # 2 was discharged without access to necessary post-hospital services and care at discharge. The hospital staff failed to follow the “Care Management and Discharge Planning Policy”. (Cross Refer to Tag A0807)”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 10135 Based on record review and staff interview, the hospital failed to ensure prompt resolution of complaints and grievances for 3 (Patient #’s 3, 5, and 6) of 9 sampled patients. The hospital failed to ensure: A. grievances of patient mistreatment and care complaints were thoroughly investigated on 3 (Patient #’s 3, 5, and 6) of 9 patients. B. a grievance involving patient care was properly identified as a complaint/grievance, logged in the complaint/grievance log and thoroughly investigated and resolved on Patient #6. Findings include: Patient # 3 Review of the Emergency department (ED) record on Patient #3 revealed she was a 61-year-old- female who was transferred from another hospital on 07/15/2024. Patient #3 had diagnoses which included respiratory failure and acute kidney injury. Review of the hospital’s grievance dated 12/19/2024 revealed Patient #3 said she was in the intensive care unit in July and was” abused by not one but two of the nursing staff.” She stated that one male nurse had a really bad bedside manner the whole time but came in and startled her instead of calmly waking her up. Patient #3 reported that she coughed and instinctively went to put her hand over her mouth, and the nurse attacked her, grabbed her arms, and held her down until she stopped coughing and then looked at her “like he didn’t know if he killed her or not” ... Review of the investigation revealed no documentation about the allegations being investigated. During an interview on 06/23/2025 after 12:32 p.m., Staff # 23 confirmed there was no documentation of the allegation being investigated. Patient #5 Review of the Emergency department (ED) record on Patient # 5 revealed she was an 85-year-old- female who presented to the hospital on 01/28/2024 at 3:34 a.m. with right shoulder pain. Review of a grievance dated 10/02/2024 revealed Patient # 5 reported that on discharge she was going to use a Lyft to transport home., as she did not have her car there, but states that someone in the lobby told her Lyft may not take her home since she was unstable on her feet. She states at this time she walked back into the hospital to “check herself into the hospital” and a hospital doctor pulled her aside into a “cubby” and began shouting at her stating nothing was wrong with her and she did not need to be in the hospital. She reported that at that time the doctor “slapped her back, pushed her down, kicked her and broke her hip.” During an interview on 06/23/2025 after 12:32 p.m., Staff #23 confirmed there was no documentation of the allegations being investigated. During an interview on 06/24/2025 after 9:40 a.m., Physician # 28 revealed he had just found out today that Patient # 5 made the allegation against him. Physician # 28 said that he had not been talked to about the allegation prior to today. Patient # 6 Review of Patient # 6’s Emergency Department (ED) record revealed he was a 51-year-old- male who presented on 04/21/2025 at 3:45 p.m. with complaints of chest pain. Review of the hospital’s April complaint log revealed no complaints involving Patient # 6. Review of a hospital call log revealed that Patient #’s 6 family complained on 04/22/2025 that staff did not give him a urinal for three hours and then put it out of reach. The family complained that staff were not being responsive, failing to give pain medication and they had poor attitudes. During an interview on 06/24/2025 after 10:58 a.m., Staff #23 said she received a call from Patient # 6’s sister on 04/22/2025. Staff # 23 said one of the concerns was that staff were going to assign Patient # 6 to a medical surgical floor instead of the heart hospital. Patient # 6’s sister said that staff were not responding to him, staff had poor attitudes and were placing the urinal out of reach. Staff # 23 said she did not consider it a complaint and just verbally informed the assistant chief nursing officer of the unit about it, and she responded that she would take care of it. Staff # 23 said she had not gotten any communication about what happened, and she did never considered it to be a complaint. Staff # 23 said she was reading from her call log about the call, but it was not logged on the complaint and grievance log. Review of a facility’s policy named “Title: Management of Patient Grievance” dated 08/24 revealed the following: “...IV.DEFINITIONS. ...COMPLAINT: An expression of dissatisfaction from patient or patient’s representative regarding the patient’s care or the services provided and is resolved at the point of service. This does NOT include allegations of abuse, neglect, or harm. GRIEVANCE: A “patient grievance “is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, when a patient issue cannot be resolved promptly by staff present.” ... ...V.PROCESS... ...2. Processing a Grievance a. All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s dialysis staff failed to ensure: A. One (Patient # 7) of 4 patients’ hemodialysis access was visible to dialysis staff at all times throughout hemodialysis treatment, in accordance with the hospital policy, “Arteriovenous Fistula or Graft Cannulation”. B.One (Patient # 7) of 4 patients’ hemodialysis prescriptions was administered in accordance with the physician’s order as required by the hospital policy, “Acute Hemodialysis Prescription”. C. Four (Machine # 47, 49, 77, and 78) of 4 Hemodialysis machines were cleaned and disinfected in accordance with the hospital policy, “Infection Control and Precautions for All Dialysis Patients”. D. The PM (preventative maintenance) sticker on hemodialysis machine #78 was current. Findings include: A. During a tour of the hospital’s hemodialysis unit on 06/23/2025 at 3:00 PM with Staff # 18, the surveyor observed Patient # 7 receiving hemodialysis treatment in room # 124. The patient’s door was closed, and the curtain was pulled closed. The patient was not visible to the staff members. Upon looking into the patient’s room further, it was discovered that the patient’s hemodialysis access was covered and not visible to the hemodialysis staff. Failure to ensure the patient’s hemodialysis access was visible throughout treatment had the likelihood to result in the patient’s needle becoming dislodged. A dislodged needle could result in the patient bleeding out without the hospital staff recognizing it. A review of the hospital policy, “Arteriovenous Fistula or Graft Cannulation” with a date of 02/2022 revealed, “OBJECTIVE: To ensure safe cannulation of the fistula or graft. POLICY STATEMENT: This guideline will provide guidance to ensure adherence to state and federal regulations as well as provide consistent, safe, high-quality hemodialysis to all patients who require therapy. This guideline reflects evidence-based practices derived from contemporary literature review as well as regulatory requirements. Individual patient assessment and other clinical situations may influence specific course of action ... PROCEDURE: ...R. Document access site is visible and secure with treatment initiation and every 15 minutes throughout the duration of treatment ...” An interview was conducted with Staff # 18 on 06/23/2025 at 3:15 PM, which confirmed Patient # 7 was not visible to dialysis staff. Staff # 18 stated, “I will make sure the nurse uncovers the patient’s access”. B. A review of Patient # 7’s medical record was conducted with Staff # 18 on 06/23/2025 at 3:45 PM in the hemodialysis unit. A review of the patient’s hemodialysis order revealed, “2K/2.25Ca”. A review of the patient’s dialysate prescription during treatment revealed the patient was receiving “2K/2.5Ca” during treatment on 06/23/2025. The patient was receiving the incorrect prescription. Staff # 19 (Dialysis Registered Nurse) did not verify the prescription prior to the initiation of hemodialysis treatment to ensure the patient was receiving the correct dialysate composition according to the physician’s orders. A review of the hospital’s policy, “Acute Hemodialysis Prescription” with a date of 02/2022 revealed, “OBJECTIVE: This guideline will address the components of acute HD prescription that are necessary for an effective and safe treatment regimen that can be individualized for the heterogeneous population requiring acute HD. Therefore, this guideline will focus on important areas including choice of dialyzer, dialysate composition, blood and dialysate flow rates, length of treatment, amount and rate of ultrafiltration, choice of anticoagulation, and total dialysis dose ...GUIDELINE STATEMENT: Hemodialysis prescription is crucial for patients commencing HD, either as planned and unplanned new starters with end-stage renal disease (ESRD), or as patients suffering from acute kidney injury (AKI) requiring renal replacement therapy (RRT). Individualized HD prescriptions are required because of the varied indications for starting patients on HD and patient-specific variables that may affect delivery of HD in this heterogeneous population ...Accountability and reporting structures: All healthcare professionals involved in the prescribing and altering of HD prescriptions, as well as those assessing and monitoring the efficacy of the HD regimen, are expected to act in accordance with their professional standards and codes of conduct in relation to promoting patient safety. Although the HD prescription is written by the medical team, the regular assessment of its efficacy is made by the nurse. The nurse commencing the HD session is required to ensure that the appropriate HD components, such as dialyzer size, dialysate composition, blood and dialysate flow rate, and UFR, are used. The aim of nursing care pre-, intra-, and post-HD treatment is to monitor the treatment and prevent the occurrence of complications through comprehensive assessments and planning. Named nurses and team leaders are required to communicate with the unit consultants regarding HD prescription issues ...” An interview was conducted with Staff # 19 on 06/23/2025 at 3:50 PM which confirmed Patient # 7 was receiving the incorrect dialysate composition. Staff # 19 stated, “I didn’t reach out to the doctor to verify that he wanted 2K/2.5Ca instead of 2.25Ca. We don’t even carry 2.25Ca here”. C. During a tour of the hospital’s hemodialysis unit on 06/23/2025 at 3:10 PM with Staff # 18, the surveyor observed 4 (Machine # 47, 49, 77, and 78) hemodialysis machines in the clean storage room. When the surveyor checked the back of the dialysis machines, there was a thick build-up of dust, dirt, and other unknown debris on the back of the machines. A review of the hospital policy, “Infection Control and Prevention for All Dialysis Patients” with a date of 12/2020 revealed, “OBJECTIVES: To educate staff on general guidelines in the prevention of infection while providing dialysis services in CHRISTUS health facilities. To reduce the transmission of pathogenic microorganisms and the incidence of healthcare-associated infections caused by these organisms ...POLICY STATEMENT: Christus Health endorses the current Centers for Disease Control and Prevention (CDC) guidelines to provide a ‘sanitary environment’ that meets the standard precautions for an inpatient hospital setting. ‘Standard Precautions’ apply to the care of all patients in any healthcare setting and include the use of gloves, gown, or mask whenever needed to prevent contact of the healthcare worker with blood, secretions, excretions, or contaminated items ...Process or Procedures: ...E. Clean areas should be clearly designated for the preparation, handling, and storage or medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled ....G. Clean and disinfect the dialysis station (chairs, beds, tables, keyboards, machines) between patients. H. Give special attention to cleaning control panels on the dialysis machine and other surfaces that are frequently touched and potentially contaminated with patients’ blood ...” An interview was conducted with Staff # 18 on 06/23/2025 at 3:10 PM, which confirmed the machines were considered “clean”. Staff # 18 stated, “The staff are supposed to clean the entire machine after treatment.” D. During a tour of the hospital’s hemodialysis unit on 06/23/2025 at 3:10 PM with Staff # 18, the surveyor observed hemodialysis machine # 78 with a PM sticker dated “due 02/25”. The preventive maintenance sticker was not changed when preventive maintenance was completed on the machine. An interview was conducted with Staff # 18 on 06/23/2025 at 3:00 PM, which confirmed the PM sticker needed to be changed to indicate the correct and current PM date.”

“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 interview, the hospital nursing staff failed to develop and keep current care plans that met the patients’ needs for pain assessment and reassessment in 2 (Patient # 2 and # 6) of 9 patients. The hospital staff failed to follow the policy, “Patient Assessment and Reassessment”. Findings include: Patient # 2 A review of Patient # 2’s medical record was conducted on 06/23/2025 at 11:00 AM with Staff # 3 and # 14 and revealed the patient was seen in the hospital’s emergency room on 05/07/2025 and 05/22/2025. 05/07/2025 visit Patient # 2 arrived at the hospital’s emergency room with complaints of “seizure activity”. The patient remained in the hospital’s emergency room until 05/12/2025. On 05/08/2025 at 7:41 PM, Staff # 39 documented that the patient complained of a pain score rated “8/10”. The patient was given ibuprofen 800mg (milligrams) by mouth at 7:41 PM. There was no reassessment of the patient’s pain score after the nursing intervention was performed. 05/22/2025 visit Patient # 2 arrived at the hospital’s emergency room on 05/22/2025 at 7:06 PM with complaints of “chest pain”. A review of the triage nursing assessment completed on 05/22/2025 at 7:15 PM by Staff # 38 revealed the patient had a pain score rated “6/10”. The first nursing intervention was documented at 9:37 PM when the patient received 650 mg (milligrams) of Tylenol by mouth. There was no reassessment of the patient’s pain score until 1:31 AM on 05/23/2025, when the patient rated his pain as “4/10”. An interview was conducted with Staff # 15 on 06/23/2025 at 2:00 PM in the administrative board room. Staff # 15 confirmed that the nursing staff were not reassessing the patient’s pain after a nursing intervention was performed. 10135 Patient # 6 Review of the Emergency Department (ED) record revealed Patient # 6 was a 51-year-old male who presented with complaints of chest pain on 04/21/2025 at 3:45 p.m. At 4:19 p.m. (over 30 minutes after presenting), there was documentation that the triage was started. Patient # 6 had complaints of chest pain for two days and complained of dehydration. At 4:21 p.m., Patient #6’s vital signs were 82/50 blood pressure, 90 pulse, 16 respirations, 98.6 degrees Fahrenheit, and an oxygen saturation of 97 percent. There was no documentation of an assessment of what his pain level was from the chest pain. At 4:25 p.m., Patient # 6 was given an emergency severity index level of 2 (meaning emergent). At 4:30 p.m., 45 minutes after presenting, there was documentation that there were no complaints of pain. At 5:38 p.m., the lab results for the Pro BNP was 3710 with reference ranges being 0-300. This is a marker for determining heart failure. At 10:27 p.m., Patient # 6 complained of lower back pain and had a pain level of 7/10. Staff administered the pain medication Tramadol 50 mg (milligrams) by mouth. The physician’s order called for Tramadol 50 milligrams every 6 hours prn (as needed) for mild pain rated 1-3/10. At 11:21 p.m., Patient # 6 had a pain level of 8 and was given the pain medication Morphine 1 milligram intravenously. There was no documentation of the location of the pain. At 11:27 p.m., Patient # 6 was documented as having a pain level of 4/10 without any documented pain location. The next documented pain level on Patient #6 was almost 5 hours later at 4:22 a.m. on 04/22/2025. The pain level at this time was a 4/10, and there was no location documented. There was no continual documentation of a pain assessment after 4:22 a.m. On 04/22/2025 at 1:08 p.m. Patient # 6 was transferred from the emergency department to an inpatient unit. Review of the hospital’s policy titled, “Patient Assessment and Reassessment” dated 04/24 revealed the following: “ ...IV. PROCESS OR PROCEDURES: B. Pain 1. Responsibilities a. Health care providers will: ... ii. Review and modify the plan of care for patients who have unrelieved pain .... ...d. Pain, as reported by the patient, will be assessed, documented, and addressed on admission, after each know pain-producing event, at each new report or pain or inadequate control of pain ... ...2. Guidelines for Care a. Assessment: i. Methods used to assess a patient’s pain is consistent with the patient’s age, condition, and ability to understand using an appropriate pain scale for the patient population including, but not limited to: i.The Numeric Pain Rating Scale of 0-10 is used for adult patients able to verbalize pain intensity ... ...ii. Assessment includes a description of pain, intensity of pain, location, and frequency ... b.Reassessment : i. If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 60 minutes following treatment ... 3.Care Settings ... b.Emergency Care Center (ECC) i. Patients will be assessed in triage or initial assessment process to identify the presence of pain ... iii. ECC patients shall receive treatment for acute pain relate to their chief complaint or presenting condition when intensity exceeds their acceptable level. ... iv. If a treatment intervention for pain is provided, then the response to that intervention should be assessed within 60 minutes or at the time of discharge or transfer, whichever occurs first ...” During an interview on 06/24/2025 after 9:50 a.m., Staff # 25 confirmed the lack of documentation of pain assessments and the administration of the pain medication on Patient # 6.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s staff failed to ensure that 1 (Patient # 2) of 1 patient was safely discharged from the hospital when Patient # 2 was discharged without access to necessary post-hospital services and care at discharge. The hospital staff failed to follow the “Care Management and Discharge Planning Policy”. The hospital staff failed to ensure an effective transition of Patient # 2 from the hospital to post-discharge care and therefore failed to reduce the factors leading to a preventable hospital readmission. Findings include: A review of Patient # 2’s medical record was conducted on 06/23/2025 at 11:00 AM with Staff # 3 and # 14. Patient # 2 Patient # 2 arrived at the hospital’s emergency room on 05/07/2025 at 8:42 PM via EMS from the Salvation Army with a chief complaint of “witnessed seizure”. The patient was a 49-year-old male with a past medical history of seizures, failure to thrive, polio, alcohol use, and homelessness. The patient was in the hospital’s emergency room from 05/07/2025 to 05/12/2025 pending placement to a skilled nursing facility or homeless shelter. On 05/12/2025, the patient was admitted to the hospital as an inpatient due to the patient needing inpatient rehabilitation services. The patient was admitted to the hospital from 05/12/2025 to 05/22/2025. A review of Physician # 33’s History and Physical Note completed on 05/12/2025 revealed, “ ... A 49-year-old male who is homeless was at the Salvation Army shelter on Friday and had a seizure, so he was brought into the ED. He was supposed to have been taking Keppra twice a day, but he says he had not taken it for several months. He says his Medicaid would cover the medication, but he has no transport to get the medication from the pharmacy. He says he has not had alcohol in 3 months, typically had been admitted previously for alcohol abuse and withdrawal. He uses a four-wheel walker and a wheelchair and has difficulty walking due to debilitation and arthritis. Case management attempted to place him over the weekend but was unable for various reasons. We are being asked to admit him to work on therapy stabilization and placement ...” On 05/12/2025, the patient was admitted to the hospital as an inpatient by Physician # 33 due to inability to walk, failure to thrive, gait instability, and seizures. Physician # 33 placed an order for physical therapy and occupational therapy to evaluate and treat the patient as indicated. The patient had physical therapy and occupational therapy evaluations and treatments while admitted to the hospital. A review of Staff # 34’s (Occupational Therapist) treatment evaluation on 05/21/2025 at 8:21 AM revealed, “Patient is found in supine, agreeable to therapy today. Patient is making progress toward goals but remains functionally quite limited and requires greater assistance to complete simple ADLs than baseline due to increased generalized weakness, chronic contractures of the left upper extremity, limited use of both hands (loss of function in left hand is greater than right hand), unable to tolerate weight bearing through left lower extremity due to left heel ulcer, impaired balance, decreased endurance/activity tolerance. Today, patient was able to incorporate right upper extremity into wheelchair mobility, but still needs moderate assistance with wheelchair propulsion. Patient is homeless and is not safe to return home/to the streets. Highly recommend discharge to inpatient rehab post-acute when medically cleared. Continue skilled occupational therapy ...” A review of the case management and social worker progress notes revealed the hospital staff had difficulty placing the patient in an inpatient rehab, skilled nursing facility, and homeless shelter due to a lack of funding, proper documentation, and a safe discharge plan. The patient had no familial or social support. A review of Staff # 35’s (Licensed Medical Social Worker) Clinical Note on 05/15/2025 revealed the patient did not pass the SLUMS exam. According to the patient’s medical record, the patient’s SLUM score was “18”. A SLUMS exam (Saint Louis University Mental Status Examination) is a screening test for Alzheimer’s disease and other forms of dementia. SLUM scores are interpreted as follows: 27 to 30: Normal in a person with a high school education 21 to 26: Suggests a mild neurocognitive disorder 0 to 20: Indicates dementia There was no documented psychiatric or neurological consultation made for the patient following the low SLUMS examination. A review of the clinical note documented by Staff # 36 (Medical Social Worker) on 05/21/2025 at 3:15 PM revealed, “Discussed with team lead, she advised having the bill presented to encourage the patient to leave. All discharge options have been exhausted. Patient unable to go to homeless shelter due to not having any form of ID. He also reportedly had a debit card to access his disability money but has lost it. He has no access to his income, which further complicates us finding any placement. Patient discharge plan to the street, homeless. Will have bill presented and encouraged to leave.” Physician # 12 placed an order for the patient’s discharge on 05/22/2025 at 12:35 PM with the discharge disposition of “Rehab Facility”. A review of Physician # 12’s Discharge Summary on 05/22/2025 at 12:36 PM revealed, “This is a 49-year-old male with no significant past medical history other than seizures presented to the hospital with breakthrough seizures. Following admission to the hospital patient was placed on Keppra. Patient is homeless. PT OT evaluated the patient and recommended rehab but patient is unfunded and today patient is being discharged from the hospital in hemodynamically stable condition with oral Keppra ...Physical Exam: Constitutional: Appearance: Appears ill ...Disposition: Home. Patient screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. No needs were identified ...” The patient was discharged to the community in a wheelchair on 05/22/2025 at 5:19 PM by Staff # 37 (Registered Nurse) without a safe discharge plan. The patient had significant cognitive impairment, was unable to walk, perform ADLs (activities of daily living) independently, and perform wound care for the wound on the left lower extremity. The patient did not have psychosocial support to assist with obtaining the prescriptions necessary to prevent seizures (Keppra), and did not have access to transportation, food, or housing. The patient sat outside of the hospital for approximately 2 hours until he began to have chest pain. The patient was seen in the hospital’s emergency room on 05/22/2025 at 7:06 PM for chest pain shortly after being discharged as an inpatient. The patient was transferred from the emergency room on 05/23/2025 at 1:54 PM to an inpatient rehabilitation facility. A review of the hospital’s policy, “Care Management and Discharge Planning Policy” with a revision date of 04/10/2025 revealed, “ ...Objectives: The purpose of the discharge planning process is to provide the patients with a safe, coordinated, comprehensive discharge plan that ensures transition from the hospital to an alternate care setting or home based on the patient’s needs.Policy Statement: A hospital, as part of its effective Discharge Planning Process, must focus on the patient’s goals and treatment preferences and include the patient (and/or the patient’s representatives and caregivers) as active partners in the discharge planning for post-discharge care. The discharge plan must ensure an effective transition of the patient from the hospital to post-discharge care, and reduce factors leading to preventable hospital readmissions ...Process: A. Initial identification of patients with discharge needs may be identified, including but not limited to, the following ways: 1. Admission screening (nursing) 2. Interdisciplinary team meetings/rounds 3. Referrals from physicians, nursing staff or any member of the health care team. 4. Communication with patient, caregivers, or family members 5. Identified high-risk cases. B. For patients identified as in need of a discharge planning evaluation CM will assess whether or not the patient’s care needs can be met in the environment from which he/she entered the hospital. With consideration of impacts of SDOH, this should include: 1. Assessment of the patient’s ability to perform activities of daily living and/or access to supports and services in the prior environment, 2. Assessment of access to, and the anticipated need for, specialized medical equipment, 3. Assessment of post-acute needs and available providers/services including but not limited to medical equipment, home health care, extended care services, hospice services, or other placement that may be required upon discharge, and 4. Documentation in the electronic medical record of these assessments. C. This discharge planning evaluation must be developed by, or under the supervision of, a registered nurse or social worker. D. The discharge planning evaluation will be completed at an early stage of hospitalization to ensure that appropriate arrangements for post-hospital care can be made before discharge. E. The discharge planning evaluation, and all steps taken by the CM in the development of the discharge plan, will be documented in the electronic medical record and will be discussed with the patient and the patient’s representative to prepare them for post-hospital care. F. The CM team will continually reassess the need for modifications to the discharge plan to ensure any changes in treatment or condition are considered and that the plan is adapted as needed. Reassessments and change to the discharge plan will be updated, as needed, will be documented in the electronic medical record ....” An interview was conducted with Staff # 11 (Case Management Team Lead) and Staff # 22 (Case Management Director) on 06/24/2025 at 10:00 AM in the administrative board room. The surveyor asked the staff members if there was a process they were supposed to follow to escalate the discharge planning and placement concerns that arose for this patient. Both staff members agreed that this patient was difficult to find a safe and appropriate placement for, and there was room for improvement in the escalation of this case to a higher authority within the hospital for recommendations and additional support with discharge planning.”

“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, and interview, the facility failed to ensure that 18 patients (Patient #1, #2, #4, and #6 through #20) 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, and interview, the facility failed to ensure that 18 patients (Patient #1, #2, #4, and #6 through #20) 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, Subchapter (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: On 6-18-2025, review of the Table of Contents for Christus Trinity Mother Frances Tyler Emergency Care Center (ECC) was reviewed. It contained 15 policies with only one pertaining to “Treatment of Sexual Abuse or Assault”. Review was made on 06-18-2025 of the Policy Title: Treatment of Sexual Assault Survivors in the Emergency Care Center (ECC), Approved by: Chief Nursing Officer (no name or signature), Created: 08/2023, no policy number, no reviewed date. The policy did not contain information or procedures for ensuring patients were provided the following rights as required by state law. The right to: access to a sexual assault program advocate, if available; the information form required by the commission detailing survivor rights and required information; or the name and telephone number of the nearest sexual assault crisis center. Review of patient charts on 06-19-2025 revealed that Patient #1, #2, #4, and #6 through #20 did not contain evidence that the required information form or information on the nearest sexual assault crisis center had been provided. Interview was conducted with Staff Member #8 in her office. Staff Member #8 provided a copy of the information packed that Advocacy Center handed out when they came. Review of packet content showed that while the packet contained local resources, there was no record that the Advocacy Center ever gave the packets to the patients. Review of patient records showed that 6 patients (Patients #2, #4, #6, #10, #14, and #20) did not have evidence of access to an advocate as required. Since they did not have access to an advocate, no packet of local resources was given. The Advocacy Center packet did not contain the state required information form. Staff Member #8 stated that the hospital had just become aware of state required information form last week. She stated that they were going to start giving the form out but hadn’t had any SANE cases since they had become aware. When patients declined the SANE exam or were not provided a SANE exam, the state required information form and the name and telephone number of the nearest sexual assault crisis center was not being given by nursing staff. This information was expected to be given by the SANE nurse. If the patient never saw the SANE nurse, the information was not given. This was confirmed during interview with Staff #4 and Staff #7 during interview on 06-19-2025 in the conference room during record reviews.”

“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: 48653 Based on observation, record review, and staff interview, the hospital’s infection prevention and control program failed to ensure a clean and sanitary environment and avoid sources of infection transmission in 4 (Main Respiratory Room, 6th Floor Ornealas Tower, 4th Floor Bradley Thompson Tower, Neonatal Intensive Care Unit) of 4 areas of the hopsital when, A. Patient equipment was not cleaned and stored in a manner which prevented contamination (Main Respiratory Room, 6th Floor Ornelas Tower, and 4th Floor Bradley Thompson Tower). B. Biohazard waste was not properly discarded (6th Floor Ornelas and 4th Floor Bradley Tompson Tower). C. Personal protective equipment (PPE) was not worn as required per the hospital’s policy and isolation precautions were not initiated timely in 2 (Patient #’s 1 and 8) of 9 sampled patients D. One (Staff # 5) of 4 staff members entered Patient # 1’s room without any personal protective equipment (PPE). The hospital staff failed to follow the hospital policy, “Standard and Transmission Based Precautions”. E. Dust, dirt, and other unknown debris were found within the hospital’s Neonatal Intensive Care Unit (NICU) and breast milk storage and supply room. The hospital failed to follow the policy titled “Neonatal Intensive Care Unit Standards of Care”. (Cross Refer to Tag A0747)”

“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: 10135 Based on observation, record review, and staff interview, the hospital’s infection prevention and control program failed to ensure a clean and sanitary environment and avoid sources of infection transmission in 4 (Main Respiratory Room, 6th Floor Ornealas Tower, 4th Floor Bradley Thompson Tower, Neonatal Intensive Care Unit) of 4 areas of the hospital when, A. Patient equipment was not cleaned and stored in a manner which prevented contamination (Main Respiratory Room, 6th Floor Ornelas Tower, and 4th Floor Bradley Thompson Tower). B. Biohazard waste was not properly discarded (6th Floor Ornelas and 4th Floor Bradley Tompson Tower). C. Personal protective equipment (PPE) was not worn as required per the hospital’s policy and isolation precautions were not initiated timely in 2 (Patient #’s 1 and 8) of 9 sampled patients D. One (Staff # 5) of 4 staff members entered Patient # 1’s room without any personal protective equipment (PPE). The hospital staff failed to follow the hospital policy, “Standard and Transmission Based Precautions”. E. Dust, dirt, and other unknown debris were found within the hospital’s Neonatal Intensive Care Unit (NICU) and breast milk storage and supply room. The hospital failed to follow the policy titled “Neonatal Intensive Care Unit Standards of Care”. Findings include: During an observation on 04/08/2025 at 10:09 a.m. the following was observed: Main Respiratory Storage Room Ten (10) plus ventilators were stored in a room and were tightly packed together on one side of the room. The ventilators were identified as being clean. Some of the ventilators in the room had the tubing attached. The electrical plugs were wrapped around the back of the equipment and hanging loosely. When staff were walking by the ventilators to get other equipment, they were brushing up against the tubing that was attached to the ventilators. The equipment was not covered to prevent dust and contamination. There were four shipping boxes sitting on the floor in the room and were sitting next to open bins of respiratory supplies. An electrostatic spirometry filter was found on top of one of the shipping boxes. An unbagged respiratory tubing was lying on the floor next to one of the ventilators in the room. Staff #19 and 37 confirmed the observations. 6th Floor Ornelas An isolation cart in front of Room #6606 had a base that was soiled with dust and dirt particles. The white rubber protective covering at the base was soiled with brown and black marks. An isolation cart in front of Room #6619 had a base that was soiled with dust and dirt particles. The white rubber protective covering at the base was soiled with brown and black marks. Hair was tangled in one of the wheels on the cart. At the front of the bottom drawer of the cart there was a buildup of dried brown substance. Behind the cart was a glove and paper on the floor. A Stryker wheelchair was stored in a nook in the hallway. The wheels and frame of the chair was soiled dirt, dust and black substance. One section of the frame had an area that was cracked and there soiled peeling tape over the area. An isolation cart in front of Room #6647 had a white base which was covered in black scuff marks. Soiled utility room #OT60037 Had an open hard plastic biohazard bin which had a blue bag stored in it. The blue bag was closed and full. On top of the blue bag was an empty blood bag with the tubing attached. The tubing line was full of red blood. The blood and bag were not contained within a red bag. According to signs on the wall above the biohazard box the following was recorded: “ALL ITEMS MUST BE PLACED IN RED BAGS PRIOR TO PLACEMENT IN HAZMAT CONTAINER” “REGULATED MEDICAL WASTE. These DO go in the red bag: Saturated Gauze Saturated Bandages Blood Saturated Items Blood & Body Fluids Closed Sharps Disposable Containers Visibly Bloody Gloves Visibly Plastic Tubing” Visibly Contaminated PPE In the hallway on the 6th floor there was a food tray cart which was filled with patient trays. The outside of the cart was covered with dried brown spills. The base of the cart had a build-up of dried brown substance. Soiled utility room #OT600014 An oxygen tank holder had a base that was covered in rust. The rust build-up prevented the ability to sanitize the equipment. Staff #’s 19 and 20 confirmed the observations. 4th Floor Bradley Thompson Tower BT4055 (intensive care unit) Soiled utility room An open trash can was in the room and did not have a bag lining it. Inside the trash can was used intravenous bag, tubing, respiratory tubing and gloves. BT4041 (intensive care unit) Soiled utility room Two clean pillows were on top of a soiled cart. The top and back of a bear hugger in the room was soiled with white debris. A rapid infuser pump had dried red substance on the wheels which had the appearance of blood. Staff #34 identified the room as a clean utility room and said that the equipment was cleaned daily. Patient #8 Review of the record of Patient #8 revealed she was a 55 -year -old female who presented to the Emergency department (ED) on 04/03/2025 for left flank pain. Patient #8 had diagnoses which included sepsis, urinary tract infection and pyelonephritis. Review of lab revealed Patient #8 had a blood culture collected on 04/02/2025 and it resulted on 04/04/2025 as being positive for gram positive clusters. Review of a lab communication record revealed that nursing was notified of the results on 04/04/2025 at 8:05 a.m. Review of lab revealed Patient #8 had a second blood culture on the specimen collected on 04/02/2025 and it resulted on 04/05/2025 as being positive for Staphylococcus aureus. Review of lab revealed Patient #8 had a third blood culture collected on the specimen that was collected on 04/02/2025 and it resulted on 04/06/2025 as being positive for Methicillin-Resistant Staphylococcus aureus (MRSA). Review of a lab communication record revealed that nursing was notified of the results on 04/06/2025 at 6:31 a.m. Review of nursing documentation revealed that on 04/06/2025 at 7:52 a.m., the physician was notified that the cultures were growing MRSA. “Waiting for response and no new orders.” According to the medical record Patient #8 was placed on contact isolation on 04/07/2025 3:51 am was the first documentation of Patient #8 being in isolation. Patient #8 was not placed in isolation timely. During an interview on 04/09/2025 after 9:00 a.m., Staff #28 confirmed the lab results, not finding a physician order for isolation and that the first mention of isolation was by nursing on 04/07/2025. During an interview on 04/09/2025 after 11:58 a.m.., lab Staff #’s 35 and 36 confirmed the lab results and notification made to nursing staff. Review of the hospital’s policy titled, “Standard and Transmission Based Precautions” dated 02/2023 revealed, “...In addition to standard precautions, transmission-based precautions should be used for patients with documented or suspected infection with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission.” 48653 Findings include: D. A review of Patient # 1’s medical records with Staff # 11 on 04/08/2025 in the administrative board room revealed, Patient # 1 Patient # 1 was admitted to the Neonatal Intensive Care Unit (NICU) on 10/18/2024 at 7:25 PM following an emergent cesarean section due to maternal hemorrhage. The patient was born extremely pre-maturely at 22 weeks and 0 days of gestation and required neonatal resuscitation protocol (NRP). The patient tested positive for MRSA (Methicillin-Resistant Staphylococcus Aureus) of the nares on 02/04/2025 at 5:20 AM. The patient was placed on contact isolation precautions on 02/04/2025 by Physician # 38. A review of video footage dated 02/18/2025, released by the hospital’s risk management department, revealed the patient was in contact isolation precautions and required respiratory therapy support. Staff # 5 (Respiratory Therapist) was seen on the video entering the patient’s room on 02/18/2025 at 1:29 PM without any personal protective equipment (PPE) donned. Staff # 5 entered the patient’s contact isolation room without taking the required precautions, including donning an isolation gown. This deficient practice had the likelihood to result in the spread of MRSA to other neonatal patients in the hospital’s NICU by failure to wear the required personal protective equipment. A review of the hospital’s policy titled “Standard and Transmission-Based Precautions” dated 02/2023 revealed, “...In addition to standard precautions, transmission-based precautions should be used for patients with documented or suspected infection with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission.” A review of the hospital’s policy titled “Neonatal Intensive Care Unit Standards of Care” with a date of 08/2024 revealed, “...POLICY: 1. Safety: 1.1 General: a. All healthcare team members will provide safe and secure environment for patients, employees, medical staff, and visitors....d. PPE. i. PPE will be worn as directed based on the potential risk of exposure. ii. Entrance to room without PPE is prohibited and will only increase the spread of nosocomial infections, especially to our extremely vulnerable population...” A review of Staff # 5’s personnel file revealed Staff # 5 received training titled, “Personal Protective Equipment (PPE)” on 04/04/2024. The training includes, “Verbalizes understanding of Standard, Airborne, Droplet & Contact isolation precautions”. An interview was conducted with Staff # 11 on 04/08/2025 at 11:45 AM. Staff # 11 confirmed that Staff # 5 entered the patient’s room without the appropriate PPE. Staff # 11 confirmed Staff # 5 did not receive any additional education or corrective action following the video footage findings. E. During a tour of the hospital’s Neonatal Intensive Care Unit (NICU) on 04/08/2025 at 9:30 AM with Staff # 11 and # 12, the surveyor observed the following environmental infection control issues, There was a build-up of dust located on top of patient care supplies and equipment within the “acute side” of the neonatal intensive care unit’s supply storage area. There were various arts and crafts supplies mixed in with patient care supplies. The counters were cluttered, and there was a thick layer of dust buildup on the patient supplies. The hand sanitizer dispenser located outside of the milk storage and supply room had a thick build-up of dust on the top. The surveyor entered the milk room storage and supply room and observed 3 large refrigerators and 1 large freezer used to store breast milk. The refrigerators had a build-up of a dried, white, crusty substance on the bottom shelf. There was also a build-up of dust, dirt, and other particles located in the bottom of the refrigerator. The vents located at the top of the refrigerators had a build-up of unknown black substances. There was dust, dirt, and other unknown debris located inside 4 clear, plastic storage bins within the milk storage and supply room. The bins were used to hold supplies used in patient care. There were computers and keyboards located at the stations outside of the patient rooms. There was a build-up of dust on the computer and keyboard located on the “acute side” directly in front of the patient’s cardiac monitoring screens. A review of the hospital’s policy titled “Neonatal Intensive Care Unit Standards of Care” with a date of 08/2024 revealed, “...POLICY: 1. Safety: 1.1 General: a. All healthcare team members will provide a safe and secure environment for patients, employees, medical staff, and visitors....d. PPE. i. PPE will be worn as directed based on the potential risk of exposure ... g. Cleaning: i. Patient care areas will be cleaned using hospital-approved disinfectant at the start of every shift, including monitors, keyboards, mouse, bedside carts, chairs, pumps, isolette doors and drawers, cribs and drawers, milk warmers, etc. iv. Computer stations will be cleaned using hospital-approved disinfectant at the start of every shift, including monitors, keyboards, mouse, chairs, countertops, etc ....” An interview was conducted with Staff # 11 and # 12 on 04/08/2025 at 10:30 AM, which confirmed the presence of environmental infection control issues in the NICU. Staff # 11 and # 12 were present during all of the observations inside the NICU.”

“ORDERS FOR RESPIRATORY SERVICES CFR(s): 482.57(b)(3) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 10135 Based on observation, interview and record review the facility failed to ensure 2 of 9 sampled patients who were on non-invasive ventilation and oxygen therapy had physician’s orders and waivers for home equipment usage (Patient #’s 3 and 9). Patient #9 was on continuous positive airway pressure (C-PAP) ventilation and staff failed to get physician’s orders for settings and usage. Staff failed to obtain a waiver for home equipment usage. Patient #3 was on a Bilevel positive airway pressure (Bi-PAP) ventilation and continuous oxygen therapy and staff failed to get physician’s orders for rate and settings for both. Staff failed to obtain a waiver for home equipment usage. This deficient practice had the likelihood to affect all patients on non-invasive ventilation and oxygen therapy. Findings include: Patient #9 During an interview on 04/08/2025 at 11:05a.m, Staff #24 said that respiratory staff were responsible for setting up C-PAP and BIPAP’s and then nursing takes over the care. During an observation on 04/08/2025 at 11:15 a.m., Patient #9 was observed to have a C-PAP on the nightstand at bedside. Patient #9 and his spouse confirmed it belonged to him and that he uses it at night and anytime during the day when he is sleeping. Review of the clinical record on Patient #9 revealed he was a 53-year-old male who presented to the Emergency department (ED) on 04/05/2025 for complaints of a possible seizure. Review of a physician’s history and physical dated 04/05/2025 revealed Patient #9 was C-PAP dependent and had sleep apnea. Review of the record revealed no documentation of physician’s orders for usage and settings for the C-PAP. During an interview on 04/08/2025 after 11:20 a.m. the following was stated: Staff #21 confirmed she could not find a physician’s order for the usage of a C-PAP on Patient #9. Respiratory staff #25 said that usually when the patient comes in through the ED with a C-PAP the ED physician writes an order for it. That order follows the patient throughout their stay. If they bring theirs from home, they have to sign a waiver that they are responsible for it. The physician writes an order for usage of the equipment. Staff #25 confirmed she could not find a physician’s order nor a waiver for Patient #9. Staff #’s 19 and 20 said a waiver had been found. The waiver was provided to the surveyor, it was dated for 04/08/2025, but it was not timed. When asked when it was signed, they said today at 11:15 a.m. Patient #3 Review of the clinical record of Patient #3 revealed she was a 63-year-old female who presented to the ED on 01/23/2025 with complaints of shortness of breath. According to the record Patient #3 had Stage IV chronic obstructive pulmonary disease (COPD) and hypertension. There was documentation that Patient #3 was held overnight at Good shepherd, on continuous oxygen at 3 liters per nasal cannula and uses a BIPAP at night. On 01/24/2025 Patient #3 was transferred to the Tyler facility and admitted to inpatient status. Review of physician’s orders revealed Patient #3 was to have oxygen to keep her oxygen saturation above or equal to 92 percent. There was no order for how many liters to infuse the oxygen. Review of nurses and respiratory notes revealed the following: On 01/26/2025 at 8:00 a.m. Patient #3 was on oxygen at 3 liters per nasal cannula. At 10:34 a.m. Patient #3 had an oxygen saturation of 91 percent. On 01/26/2025 at 8:10 p.m. Patient #3 was on oxygen at 3 liters per nasal cannula. At 11:16 p.m. Patient #3 had an oxygen saturation of 90 percent. On 01/28/2025 at 8:51 a.m. Patient #3 was on oxygen at 3 liters per nasal cannula and had an an oxygen saturation of 90 percent. On 01/28/2025 at 11:32 p.m. and 01/29/2025 at 3:52 a.m. there was documentation of Patient #3 being on a BiPAP home unit. On 01/28/2025 at 11:32 p.m. and 01/29/2025 at 3:52 a.m. there was documentation of Patient #3 being on a BiPAP home unit. During an interview on 04/09/2025 after 9:00 a.m., Staff #28 confirmed not finding documentation of interventions for the decreases in the oxygen saturations, no physician’s order for the BIPAP, nor a waiver for usage of a home unit. Review of a facility’s policy named “Patient Privately-Owned Medical Equipment” revised on 10/2021 revealed the following: “ ...VI STAKEHOLDERS: ... . B. Physician: The physician is responsible for determining the suitability of using the patient’s privately-owned equipment. The physician is also responsible for documenting, in the patient’s medical record, the basis for the decision to approve or deny its use, and, if approved, and preparing an order for the use of the equipment. C. Clinical Department: The appropriate clinical department is responsible for obtaining a signed Consent & Waiver upon admission or initiation of privately -owned equipment use ...””

“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: 10135 Based on interview and record review, the facility failed to ensure plans of care were followed and updated as needed in 2 of 11 sampled patients reviewed for plans of care (Patient #’s 2 and 3). Nursing staff failed to notify the physician of a need to update the plan after a decrease in oxygen saturation on Patient #3. Nursing staff failed to follow the plan of care on Patient #2 and obtain vital signs as ordered by the physician. This deficient practice had the likelihood to cause harm to all patients. Findings include: Review of physician’s surgical progress notes revealed Patient #3 was a 61 -year-old female admitted on 01/26/2024 for a laparoscopic cholecystectomy with intraoperative cholangiogram (gallbladder surgery). On 01/26/2024 Patient #3 also had an endoscopic retrograde cholangiopancreatography (ERCP) to remove stones in the bile duct. According to critical care notes dated 01/28/2024 at 9:57 a.m., a provider documented that post ERCP Patient #3 developed pancreatitis. This AM she developed worsening shortness of breath and she would be transferred to the intensive care unit (ICU). The plan was for chest x-ray, bipap and Lasix. There was documentation in the notes that Patient #3 was on oxygen at 2 liters and had audible wheezing upon entering the room. According to nursing notes on 01/28/2024 at 10:42 a.m. Patient #3 was in acute respiratory distress with a respiratory rate of 26 and heart rate of 134. Patient #3 is now on a continuous BiPap (non-invasive ventilator). According to documentation Patient #3 was placed on the Bipap on 01/28/2024 at 12:12 p.m. Review of a respiratory flow sheet dated 01/30/2024 at 4:52 a.m. revealed the last documentation of Patient #3 having the Bipap on. According to vital sign flow sheets dated 01/30/2024 the following was documented: At 07:15 a.m. the oxygen saturation was 97 percent. At 07:30 a.m.the oxygen saturation was 96 percent. At 0745 a.m. the oxygen saturation had dropped to 67 percent and no there was no documentation of the Bipap being on or off. There was no documentation of the nurse notifying the physician that the oxygen saturation had dropped to 67 percent. At 08:00 a.m. the oxygen saturation was documented as being 96 percent. According to a Code blue sheet Patient #3 coded and was provided cardio-pulmonary resuscitation from 8:09 a.m.- 8:24 a.m. on 1/30/2024. Patient #3 was intubated and placed on a ventilator after being coded. Documentation on a critical care attending progress note dated 01/30/2024 at 1:45 p.m. revealed” This morning nurse reported she had pulled her BIPAP off. After her BIPAP was replaced, she did not recover her hypoxia and had a bradycardic to PEA arrest (pulseless electrical activity) ...” During an interview on 10/01/2024 after 1:00 p.m., Staff #13 (Registered nurse/RN preoperative) confirmed the missing documentation in the chart of the physician not being notified of the oxygen saturation and if the Bipap was on or off. During an interview on 10/01/2024 after 2:00 p.m., Staff #10 (RN quality) stated there was no order to discontinue the Bipap in the record. During an interview on 10/01/2024 after 2:00 p.m., Staff #3 (RN Quality director) confirmed she could not find documentation of the physician being notified of the drop in oxygen saturation or the Bipap being discontinued. During an interview on 10/01/2024 after 3:00 p.m., Staff #16 (Pulmonary staff) confirmed there was an order for a continuous Bipap, settings and where the documentation should be in the chart. During an interview on 10/01/2024 after 4:45 p.m., Staff #12 (RN) confirmed she was the nurse working during the timeframe in question. Staff #12 (RN) stated she kept educating Patient #3 and the family about keeping the bipap on. Staff #12 (RN) stated she could not remember if the Bipap was on or if the physician was called about the oxygen saturation drop. Review of “Hospital Quality and Safety Committee Minutes” from April- September 2024 revealed no performance improvements addressing physician notification or assessment/reassessment. Review of an e-mail dated 10/09/2024 at 10:03 a.m., Staff #3 (RN Quality) confirmed there were no general performance improvements addressing these areas. Review of a facility’s policy named “Title: Patient Assessment and Reassessment” revised on 04/2024 revealed the following: “...IV.PROCESS OR PROCEDURES: A. Patient Assessment and Reassessment... 2.Consultation of disciplines, other than nursing, is determined by the initial and ongoing assessment data collected by nursing in collaboration with Physician oversight...” 47892 A review of physician’s note, Patient #2 was a 95-year-old male admitted to the Intermediate Care Unit (6th floor Ornelas) of the hospital on 7/25/2024 with a diagnosis of COVID-19 and Pneumonia. A review of Patient #2’s medical record was conducted on 10/01/2024 with Registered Nurse (RN) Staff #10. Further review was conducted on 10/07/2024 at 11:30 AM. A review of the physician admission orders dated 7/26/2024 at 2:49 AM revealed vital signs (blood pressure, temperature, respiration count, and heart rate) were to be taken every 4 hours. Physician #17 wrote an order on 7/27/2024 at 1723 (5:23 PM) that read, “Vital signs, Q (every) 15 minutes x (times) 4, q 30 minutes x 2, and q 1 hour x 2 then per unit routine”. Registered Nurse (RN) Staff #18 acknowledged the order on 7/27/2024 at 5:34 PM. Further review revealed there was no vital signs documented in the medical record after 1:37 PM on 7/27/2024 until 7:33 PM. This was over two hours after Physician #17 wrote the order for specific time parameters for vital signs on 7/27/2024 at 5:23 PM. There should have been 6 sets of vital signs documented from 5:23 PM to 7:33 PM. An interview was conducted with Quality Director, Staff #3 on 10/07/2024 at 12:59 PM. Staff #3 confirmed no vital signs were documented in the medical record from 1:37 PM until 7:33 PM on 7/27/2024. An interview was conducted with RN Charge Nurse, Staff #6 on 10/01/2024 after 10:00 AM. RN Saff #6 was asked how often vital signs were taken in the Intermediate Care Unit. RN Staff #6 stated, “Every four hours on this unit unless the physician has written a different order”. A review of the nursing documentation on 7/27/224 at 7:12 PM was as follows: “Patient found unresponsive in the room. Code initiated”. Code (a term used to indicate a patient requires CPR or is?otherwise in need of immediate medical attention, most often as the result of a heart attack or respiratory arrest) was called and Patient #2’s heartbeat returned after cardiopulmonary resuscitation (CPR) was performed for 22 minutes. A telephone interview was conducted with Staff #3 on 10/07/2024 at 12:59 PM. Staff #3 was asked if any vital signs were documented between 1:57 PM and 7:33 PM on 7/27/2024. Staff #3 confirmed there was no vital signs documented in the medical record during that time. Staff #3 confirmed Physician #17 wrote a new order on 7/27/2024 at 5:23 PM for vital sign monitoring. Staff #3 was asked if the facility had a Vital Sign Policy. Staff #3 confirmed the facility did not have a specific policy for routine vital signs. Staff #3 stated, “No, there is not a specific policy for vital signs, but the vital signs were addressed in the Nursing Assessment Policy”. Review of “Hospital Quality and Safety Committee Minutes” from April- September 2024 revealed no performance improvements addressing physician notification or assessment/reassessment. Review of an e-mail dated 10/09/2024 at 10:03 a.m., Staff #3 (RN Quality) confirmed there were no general performance improvements addressing these areas. In an interview conducted on 10/07/2024 at 12:59 PM, Staff #3 confirmed the nursing staff failed to assess and document the vital signs per facility policy and physician order. A review of the hospital policy titled, “Assessment and Reassessment” with a review date of 4/2024 was as follows: “ ...III Policy Statement: A. It is policy of CHRISTUS Trinity Mother Frances that all patients admitted to the facility receive a complete head to toe assessment by a qualified individual to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient. The assessment of the care and/or treatment needs of the patient is continuous throughout the patient’s hospitalization. B. All disciplines deemed competent upon initial or ongoing assessment by Physicians, Nursing, Pharmacy, Therapy Services, Respiratory, and Case Management teams, participate in the assessment process to provide a comprehensive, collaborative approach to patient care. Personnel are qualified by level of licensure to perform a complete assessment and reassessment of the patient. A complete assessment includes physical, psychological, emotional, social status, nutritional status, as well as educational needs ... IV. Process of Procedure A. Patient Assessment and Reassessment 1 ... 6. Intensive Care and Intermediate Care patients receive an initial assessment upon arrival to the unit. They are reassessed at least every four (4) hours by a RN or sooner based on changes in the patient’s condition. Prior to discharge, ICU patients are assessed to determine if they meet discharge criteria...””

“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: 32143 Based on record review, observation, and interview the facility failed to ensure the physicians were providing information to patients regarding risks and benefits before administering blood to patients in 1 of 1 (#9) chart reviewed. A review of patient # 9’s medical chart revealed she was to receive blood products on 7/31/24. The patient had signed the blood consent along with the nurse on 7/31/24. There was no physician signature or any progress notes that the risks and benefits of blood had been given to the patient before administration. Staff # 12 RN administered the blood product. An interview was conducted on 7/31/24 with patient #9 and staff #12 RN and #14 RN. Patient #9 stated that she was aware she was getting blood and she did sign the consent, but she stated that she didn’t believe anyone told her the risks and benefits. Pt. #9 stated the physician assistant spoke with her about it but not the physician. Staff #12 stated that she obtained the consent and witnessed it. Staff #12 was not aware that the physician had to give the risks and benefits. Staff # 14-unit director of orthopedics reported that she was not aware that the physician had to give the risk and benefits. Staff #14 confirmed the nurses had been getting the consent and giving the risks and benefits. A review of the Blood Product Administration policy and procedure stated, “Informed consent will be obtained before the transfusion of blood/blood products.” The policy failed to state the physician shall provide the benefits and risk to the patient before or while obtaining the consent. A review of the policy and procedure for Informed Consent for Invasive/Surgical Procedure” Stated, “KEY WORDS: Informed Consent, Consent, Risks, Hazards, Benefits I. OBJECTIVE/S: To ensure patients are apprised of their rights and afforded the opportunity to make voluntary and informed decisions about medical care and treatment. II. POLICY STATEMENT: A competent adult patient or a surrogate decision-maker acting on the patient’s behalf has the right to receive from the patient’s physician/practitioner information necessary to make informed choices and decisions regarding the patient’s medical care and treatment. The primary purpose of the informed consent process is to ensure that the patient or his/her surrogate decisionmaker is provided information in a manner that the patient and/or the patient’s surrogate decisionmaker can understand to enable the patient and/or the patient’s surrogate decision-maker to effectively exercise the right to make informed decisions.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure the patient or patient representative was clear on how to submit a grievance and failed to ensure that all verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements, are considered a grievance in 2 of 2 (#1 and #3 )patient charts reviewed. A review of patient #3’s medical record revealed he was a 28-year-old male admitted to the hospital on 10/11/23 for periorbital cellulitis of the right eye (primary). Patient #3 also had a diagnosis of autism(non-verbal), Severe intellectual disability, cerebral palsy, and seizure disorders. Patient #3’s mother was the primary caregiver and advocate. Patient #3’s mother made a complaint with the HHSC-SO Consumer Rights & Services on 10/9/23. The mother stated that she had asked staff # 21 RN for “briefs”. The mother stated that staff #21 stated, “We don’t supply them ...we don’t stock them here, guess I will have to go to central supply.” She asked for the briefs around 3:00 PM and did not receive them until after midnight. The house supervisor brought the briefs after the mother complained multiple times. The mother continued to have the following issues that she brought forward to the nursing staff and administrative staff, Patient #3 was given ketamine before a procedure. Staff # 22 RN left the room and the unused medication in a syringe within reach of her son. The mother put the syringe in her pocket and forgot it was there. Later when the patient was moved from the ER to the floor, staff #21 asked the mother if she had picked up the syringe and she stated she did that she had forgotten. (Ketamine is a dissociative anesthetic used medically for induction and maintenance of anesthesia.) Patient #3’s mother had multiple complaints about seizure medications ordered at the wrong dosages, staff not maintaining his airway properly after a sedated procedure, multiple requests for wrist restraints to prevent the patient from hitting his face after facial surgery, staff refusing to assist with the patients ADL’s, and a documentation error on the MRI results. The mother stated that on 11/15/2023 Staff # 10 (program manager for patient experience) arrived in the room around 9:00 AM and the floor RN (nursing director). The mother explained to them the complaints she had of general nursing care, medication issues, the ketamine syringe being left in the room, and the overall experience. The mother stated that staff # 10 was talking over her and dismissing her issues. The mother stated she was taken to a board room on 11/16/23 by staff #10. The mother stated it lasted 37 minutes. The mother stated that there were 9 people in the room, and she had to stop the meeting and insist they introduce themselves, so she knew who was attending this meeting. She stated that staff #10 began to ask her about her experiences. The mother stated after the meeting she shared with staff #10 that she was not satisfied and felt staff #10 was intimidating and “ she focused on putting a Band-Aid on the situation prevented me from getting my thoughts across.” The mother stated, “I felt she was trained on intimidation tactics to bully me into silence, and I was not ok with this.” The mother stated that she had also spoken with Staff # 2 (Regional Director over Quality and Risk) on 11/20/23. The mother stated she felt she was being run over by yet another verbal train of gaslighting.” A review of the policy and procedure “Patient Grievances and Complaint Resolution” stated, DEFINITIONS: A. Complaint: An issue considered resolved by staff present when the patient is satisfied with actions taken on their behalf, or the nature of the complaint does not meet the definition of a grievance. l. Post-discharge verbal communication regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay, are not required to be defined as a grievance. B. Grievance: A formal or informal written (written communication is always considered a grievance) or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or patient’s representative, regarding any of the following: 1. The patient’s care 2. Abuse of neglect a. If there is an immediate patient safety concern suspected, procedures will be followed as outlined in the “Suspected Abuse or Neglect While Under the Care of the Hospital” policy. 3. Issues relating to the organization’s compliance with the CMS Hospital Conditions of Participation {COP}, or 4. A Medicare beneficiary billing complaint related to rights and limitations provided 42 CFR 489 ... C. Processing a Complaint 1. Complaints given to staff members by patients, or their representatives should be addressed in a timely manner and an attempt to resolve the issue should be made. If resolution is achieved, then no further action is required. However, if resolution is not achieved after attempts have been made to resolve the complaint it should be forwarded to Patient Advocate Office. Unresolved complaints or those requiring additional investigation or intervention should be listed on the Patient Grievance Tracking Log as a complaint for reporting purposes.” A review of the grievance log for October, November, and December 2023 revealed there was no grievance logged for patient #3. An interview was conducted with staff # 21 RN on 1-9-24 at 3:50 PM. Staff # 21 stated that she remembered patient #3 and his mother. Staff #21 confirmed that the patient’s mother did ask for diapers (briefs) several times and staff # 21 stated she told the mother they had blue pads but no diapers for the patient. Staff #21 confirmed he did not know they could get diapers till later on and that they were kept in central supply. Staff #21 stated that she received a call from the ER on 11/13/23 to go into patient #3’s room and ask if the mother had picked up a syringe of ketamine. Staff #21 stated the mother pulled the syringe out of her pocket and handed it over to staff #21 RN. Staff #21 stated that Staff #22 RN came to the floor and retrieved the syringe for waste. Staff #21 stated that she did not fill out an incident report or document the incident in the chart. An interview was conducted with Staff #22 on 1-9-24 at 4:08 PM. Staff # 22 confirmed she administered ketamine to patient #3 and had medication left over that had to be wasted with a witness. Staff #22 stated that she thought she put the syringe in her pocket and got busy with the patient. Staff #22 stated she did not realize the syringe was not in her pocket and was missing. Staff #22 stated that the patient’s mother had put it in her pocket and had moved to the floor. Staff #22 stated she retrieved the medication and wasted it with a witness. Staff #22 confirmed this was not protocol and she should have wasted the unused medications immediately. Staff #22 stated that she did not do an incident report nor was the incident reported. An interview was conducted with Staff # 2 REG. DIR. Quality/Risk and Staff #10 on 1-9-24. Staff #10 was asked if there were any grievances or written information on patient #3’s mother’s complaints or allegations. Staff #10 stated, “No. we were able to address her complaints.” Staff #10 stated the facility did not log a complaint as a grievance unless it was in writing. Staff #10 was asked if she had multiple meetings with the mother and a meeting on the 16th in the conference room meeting with multiple staff. Staff #10 confirmed that there were multiple meetings. Staff #10 stated that she had talked to the mother, but she kept bringing up the same things and complaints that they had discussed previously. Staff #10 stated she was never satisfied. Staff #10 was asked why a grievance was not started on this patient’s complaints. Staff #10 stated that a grievance was not done unless it was in writing. Staff # 2 was holding the grievance policy and procedure and read from the policy. Staff #2 stated that a grievance should have been started and processed when the complaint was not immediately resolved. Staff #2 stated that they just received a written complaint from the mother today and they would be working it up as a grievance and responding to each of the allegations. 48749 Findings; A review of patient #1 electronic health record (EHR) reveals the patient arrived by Emergency Medical Services (EMS) at the facility’s emergency room (ER) on 06/05/2023 with a complaint of unresponsiveness and intubation (a process where a tube is inserted through a person’s mouth, down their trachea. The tube keeps the airway open so that air can get through). Patient #1 was admitted to the Neuro ICU (an intensive care unit devoted to the care of patients with life-threatening neurological problems) with a diagnosis of Acute Encephalopathy (an acute functional alteration of mental status due to systemic factors), Respiratory Failure (a serious condition that makes it difficult for a person to breathe on their own) and Leukocytosis (a high level of white blood cells in the blood). Further review of patient # 1’s EHR revealed the patient was seen by case management staff regularly during admission. On 06/12/2023 case management staff documented the patient’s family was unwilling to discuss discharge planning, the family requesting to discharge the patient home and verbalizing complaints about the care received. It was documented that the charge nurse was notified of the family’s concerns. On 06/13/2023, case management staff documented in the patient’s EHR that the family voiced concerns that the patient was not ready for discharge. The family was unwilling to discuss any options. Steps to an appeal were discussed and the charge nurse and nursing director were notified. On 06/19/2023 case management documented that the family reported they would take the patient to another hospital. Adult Protective Services (APS) were notified over concerns about the patient’s care at home. A review of the June, July, and August 2023 grievance logs revealed no grievance logged for patient #1. The facility failed to proceed with the grievance process to address the patients’ complaints that could not be immediately resolved. An interview was conducted with Staff #12 on 01/09/2024 at 2:30 PM. Staff #12 reported “There are no complaint logs kept on the floor and complaints are not tracked. If I am told about an issue, we try to resolve it here.” An interview was conducted with Staff #11 on 01/09/2024 at 2:40 PM. Staff #11 reported “We do not keep any logs or track complaints. The patient advocate is contacted by the nursing director if an issue is reported.” An interview was conducted with Staff #10 on 01/09/2024 at 3:20 PM. Staff #10 reported “Any nursing Director can fill out a complaint form if they feel like the issue can’t be resolved. Most complaints are resolved on the floor, I only track them if they are reported to me. I was not notified of any incidents.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 32143 Based on review and interview nursing failed to ensure that Ketamine, a controlled substance, was safely secured by the RN, and excess medication was promptly wasted after use in 1 of 1 (#3) patient charts reviewed. A review of patient #3’s medical record revealed he was a 28-year-old male admitted to the hospital on 10/11/23 for periorbital cellulitis of the right eye (primary). Patient #3 also had a diagnosis of autism(non-verbal), Severe intellectual disability, cerebral palsy, and seizure disorders. Patient #3’s mother was the primary caregiver and advocate. Patient #3’s mother made a complaint with the HHSC-SO Consumer Rights & Services on 10/9/23. The mother stated patient #3 was given Ketamine (a dissociative anesthetic) before the procedure. The mother stated staff # 22 RN left the room and the unused medication syringe within reach of her son. The mother stated that she put the syringe in her pocket and forgot it was there. Later when the patient was moved from the ER to the floor, staff #21 RN asked the mother if she had picked up the syringe and she stated she had that she had forgotten to turn it in. A review of patient #3’s chart revealed a physician order dated 11/13/23 at 11:13 AM. The order stated, “ Ketamine in 0.9% sodium Chloride (Ketalar) 50 mg/5 mL NS injection 59 mg, once, intravenously.” A review of the medication removal log revealed staff #22 ER RN removed 2-50mg/5ml syringes from the medication cabinet on 11/13/23 at 11:30 AM. Staff #22 documented in the nursing notes that patient #3 was administered 59 mg IV on 11/13/23 at 11:32 AM. The medication log revealed the remaining 4.1mls not used were not wasted with a witness until 3:16 PM, 4.25 hours later. According to https://www.fda.gov/drugs/ketamine, “Ketamine is a controlled substance. Specifically, it is a Schedule III substance under the Controlled Substances Act. Schedule III drugs, which include codeine and anabolic steroids, have less potential for abuse than Schedule I (heroin) or Schedule II (cocaine) drugs. However, abuse of Schedule III substances may lead to physical or psychological dependence on the drug.” An interview was conducted with staff # 21 RN on 1-9-24 at 3:50 PM. Staff #21 stated that she received a call from the ER on 11/13/23 to go into patient #3’s room and ask if the mother had picked up a syringe of Ketamine. Staff #21 stated the mother pulled the syringe out of her pocket and handed it over to staff #21 RN. Staff #21 stated that Staff #22 RN came to the floor and retrieved the syringe for waste. Staff #21 stated that she did not fill out an incident report or document the incident in the chart. An interview was conducted with Staff #22 on 1-9-24 at 4:08 PM. Staff # 22 confirmed she administered Ketamine to patient #3 and had medication left over that had to be wasted with a witness. Staff #22 stated that she thought she put the syringe in her pocket and got busy with the patient. Staff #22 stated she did not realize the syringe was not in her pocket and was missing. Staff #22 stated that the patient’s mother had put it in her pocket and had moved to the floor. Staff #22 stated she retrieved the medication and wasted it with a witness. Staff #22 confirmed this was not protocol and she should have wasted the unused medications immediately. Staff #22 stated that she did not do an incident report nor was the incident reported.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on document review and interview the facility failed to: A. ensure that chemical restraints/emergency behavioral medications (EBM) administered were identified as a chemical restraint in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. B. ensure staff was educated on the administration of chemical restraints/EBM for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. C. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. D. ensure the policy and procedure gave clear guidelines on assessing and reassessing a patient after administering a chemical restraint/EBM. E. Ensure a face-to-face by the provider or trained RN was completed within one hour of the administration of a chemical restraint The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. Refer to A0160”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to: A. ensure that chemical restraints/emergency behavioral medications (EBM) administered were identified as a chemical restraint in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. B. ensure staff was educated on the administration of chemical restraints/EBM for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. C. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed. D. ensure the policy and procedure gave clear guidelines on assessing and reassessing a patient after administering a chemical restraint/EBM. E. Ensure a face-to-face by the provider or trained RN was completed within one hour of the administration of a chemical restraint/EBM. The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. A review of medical records was completed on December 13-14, 2023, with Staff #6, #7, and #15. Findings: Patient #1 Patient #1 was a 74-year-old male admitted to the hospital ER on 11/05/2023 at 9:28 PM. He was transferred from an outside Emergency Room with left upper quadrant pain, progressive dyspnea on exertion (shortness of breath while walking), and, increased bilateral lower extremity edema (swelling in the legs). He had a past medical history of Atrial Fibrillation, arrhythmia, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Ischemic Cardiomyopathy, and Myocardial Infarction. A review of the H&P documented by Physician #18 on 11/05/2023 at 10:55 PM revealed Patient #1 was negative for confusion, memory loss, anxiety, depression, and agitation. He was awake, alert, and oriented to time place, and person. 11/06/2023 A review of the medical record with Staff #6 revealed Patient #1 was given a chemical restraint/emergency behavioral medication on 11/06/2023 at 3:30 AM and 11/07/2023 at 2:23 AM. A review of the progress note dated 11/06/2023 at 3:00 AM by RN Staff #19 was as follows: “Found pt on the side of the bed. Pt confused. Called UT (Unit tech) to help RN (Registered Nurse) get pt back to bed. Pt refuses. Charge RN notified. Pt states “I got to go home to my wife.” Reoriented pt that he’s at the hospital. Called pt’s wife to speak to pt. Pt refuses. Pt started cursing and threatening to leave. NP (Nurse Practitioner) called at bedside. See NP (Nurse Practitioner) notes and orders.” A review of the progress note dated 11/06/2023 at 3:07 AM by NP Staff #10 was as follows: “Called by bedside RN that patient is very aggressive and trying to leave. Also, that patient has refused all nursing care. On arrival, patient 74 Y.O male being managed for left upper abdominal pain was seen sitting at the edge of the bed agitated and asking to go home. Patient refused to answer questions and all efforts to redirect and get him to calm down failed including charge RN arranging for patient’s wife to speak to him. Patient denies pain of any kind. Charge RN paged security and code BERT (Behavioral Emergency Response Team) team to bedside. Plan -IM Haldol 2mg x1 -Monitor.” A review of the document titled, “BERT TEAM” was as follows: “WHEN A PATIENTS BEHAVIOR ESCALATES BEYOND THE CAPABILITY OF THE NURSING STAFF-ACTIVATE CODE BERT BY DIALING EXT. ****. EXAMPLES INCLUDE BUT NOT LIMITED TO: *VIOLENT BEHAVIOR *THREATENING BEHAVIOR *RISK OF VIOLENT BEHAVIOR *HARM TO SELF OR OTHERS *BEHAVIOR REQUIRING PHYSICAL HOLD *THREATENING AMA WITHOUT DECISION-MAKING CAPACITY B.E.R.T. (BEHAVIORAL EMERGENCY RESPONSE TEAM) WILL RESPOND TO THE ACTIVATION AND CONSISTS OF THE FOLLOWING PEOPLE: *HOUSE SUPERVISOR *CHARGE NURSE FOR THE UNIT *PRIMARY NURSE FOR THE PATIENT *SECURITY PERSONNEL *DURING WORKING HOURS THE FOLLOWING WILL RESPOND: CLINICAL DIRECTOR, TEAM LEADER, SOCIAL WORKER.” During an interview with RN Staff #6 on 12/13/2023, RN Staff #6 confirmed the BERT TEAM was used for de-escalation or assistance when a patient became aggressive or violent. She was asked if the patient became physically aggressive with the staff or if Patient #1 was actively trying to leave. She confirmed there was no documentation of any physical aggression and that he was only threatening to leave. He also refused to answer any questions and refused all nursing care. She stated they tried to talk to him and get him to talk to his wife on the phone, but he refused that also. RN Staff #6 was asked if any oral medications were offered to him at the time before the IM injection and she confirmed there was no documentation that any oral medications were offered or given to the patient. She also confirmed there was no documentation of who arrived for the Code BERT, who assisted with the code, and what was done. An email dated 11/06/2023 at 5:39 AM from Security Staff #25 titled “Significant Events” provided for review was as follows: “Patient disturbance for the patient in room D381. Patient #1 was confused and being aggressive towards staff. Staff gave patient some medication with no issues. Security was stand by only.” RN Staff #6 confirmed there was no documentation that a Physician was notified that a chemical restraint/EMB was ordered by NP Staff #10 on 11/06/2023. A review of the medication order dated 11/06/2023 at 3:23 AM by NP Staff #10 was as follows: “ ...Haldol 2mg (antipsychotic medication) IM (intramuscular) Routine Once Indications for Use: Severe agitation Indications comment: Acute Undifferentiated Agitation Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Haldol 2mg IM was administered by RN Staff #19 on 11/06/2023 at 3:30 AM. RN Staff #6 confirmed the Haldol medication given to Patient #1 was to control his unwanted behavior. The medication was not given to make the patient therapeutic in his environment at 3:30 AM. The patient was not given any other options such as oral medications. Further review revealed NP Staff #10 wrote additional orders on 11/06/2023 at 3:23 AM. The orders were as follows: “ ...BP (blood pressure), HR (Heart rate), RR (respiratory rate), SPO2 (oxygen level), and LOC (level of consciousness) immediately prior to administration Vital signs (BP, HR, RR, SPO2, and LOC). Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals Richmond Agitation Sedation Scale (A scale that is mostly applied in mechanically-ventilated patients, but may be used for any individual who is hospitalized. Regular administration and assessment is particularly useful for patients who are critically-ill, are receiving sedative medications, and/or demonstrate fluctuating levels of consciousness) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ...” A review of the vital signs flow sheet dated 11/06/2023 documented by RN Staff #19 revealed vital signs (BP, Pulse, Respirations, Temperature, and O2 Saturations) were documented at 12:15 AM. Patient #1 refused all vital signs at 3:30 AM. Staff #6 confirmed the next set of vital signs was taken at 5:36 AM and 7:01 AM. RN Staff #19 documented a RASS score at 3:30 AM-Very agitated (+3), 3:45 AM- alert and calm (0), 4:00 AM -drowsy (-1), 4:15 AM - drowsy (-1), 4:30 AM -drowsy (-1). According to asahq.org, the Richmond Agitation Sedation Scale was as follows: “ ...+4- Combative +3- Very agitated +2- Agitated +1- Restless 0 -Alert and calm -1 Drowsy -2 Light sedation -3 Moderate Sedation -4 Deep sedation -5 Unarousable ...” Staff #6 confirmed there was no further documentation explaining the missed vital signs or RASS Score documentation. An interview was conducted with RN Staff #7 and RN Staff #15 on 12/14/2023 at 11:05 AM. RN Staff #7 was asked how frequently and how long the nurse was supposed to monitor the patient after a chemical restraint/EBM was given. RN Staff #7 stated, “If a medication is ordered as a chemical restraint an additional order will populate and give strict instructions on how often and how long the patient is to be monitored. If the medication order is not ordered as a chemical restraint, then the provider gives additional orders for the monitoring of the patient or the patient will be monitored according to the original orders when they were admitted.” 11/07/2023 A review of the medication order dated 11/07/2023 at 1:57 AM by NP Staff #10 was as follows: “Haldol 2mg IM Routine Once Indications Comment: Acute Undifferentiated Agitation. Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Haldol 2mg IM was administered by Staff #17 on 11/07/2023 at 2:23 AM. Further review revealed NP Staff #10 wrote additional orders on 11/07/2023 at 1:57 AM. The orders were as follows: “ ...BP, HR, RR, SPO2, and LOC immediately prior to administration. Vital signs - BP, HR, RR, SPO2, and LOC. Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals. Richmond Agitation Sedation Scale (RASS) Order Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times...” A review of the vital signs flow sheet revealed the only set of vital signs taken before the Haldol IM injection was given was at 12:07 AM on 11/07/2023. The Haldol IM injection was given to Patient #1 at 2:23 AM. The UT (unit tech) documented that Patient #1 was irritable, and no vital signs were taken at 3:00 AM and the next vital signs were taken at 5:36 AM. This was greater than 3 hours after the Haldol injection was administered IM. RN Staff #6 confirmed there was no further documentation explaining the missed vital signs and no documentation that the patient refused his vital signs. A RASS Score was documented by RN Staff #17 on 11/07/2023 at 2:23 AM as very agitated (+3), RN Staff #29 documented a RASS Score at 7:15 AM as Alert and calm (0), and Staff #30 documented a RASS Score at 8:43 PM as Alert and calm (0). RN Staff #6 confirmed there was no progress note by a physician or NP that documented the patient’s behaviors before ordering the chemical restraint/EBM to control the patient’s unwanted behavior. It was also confirmed there were no de-escalation techniques documented or oral medication offered before the IM Haldol administration. A review of a progress note dated 11/07/2023 at 5:56 AM by RN Staff #20 was as follows: “ ...Patient unable to rest and became agitated last night and threatening the staff while trying to leave his room. IM (Intramuscular) Haldol given by charge nurse. Patient able to rest afterwards ...” RN Staff #6 confirmed there was no documentation in the medical record that the patient’s behavior or imminent threat to himself or others described the need for an IM injection of antipsychotic medication for the use of a chemical restraint/emergency behavioral medication. There was also no documentation on how this medication would benefit the patient in a therapeutic situation if it was for medical use. A review of the progress note dated 11/07/203 at 5:32 PM by RN Staff #29 was as follows: “Patient’s wife expressed concerns over patient left upper arm swelling and significant bruising stating “What happened to his arm, this wasn’t there yesterday”. Patient was given Haldol last night due to confusion and aggressive behavior threatening staff members and threatening and attempting to leave. The patient states a man tried to stop him from leaving grabbed his arm and threw him back in the bed. An ultrasound of the patient’s left arm was completed this afternoon which showed no signs of DVT but a large hematoma. Patient has been drowsy on and off this shift. Patient’s wife states she believes patient has dementia but that he has not been diagnosed with it. Patient is currently sitting up in chair eating his dinner, on room air and calm and cooperative. Sitter is in room and tele sitter will also be placed in room this evening to monitor patient.” During an interview with Staff #7 on 12/13/2023, RN Staff #7 stated,” It looks like the staff gave the medication for the patient’s behavior but they failed to document what the behavior was for several hours after the antipsychotic medication was administered. An interview was conducted on 12/13/2023 after 11:00 AM with Physician #8, CMO (Chief Medical Officer). He was not the patient’s treating physician, nor was he involved in his care. CMO, Physician #8 stated the medications given IM to Patient #1 were not given as a chemical restraint/emergency behavioral medication but were given to the patient to control his delirium. CMO, Physician #8, stated, “The patient was already on this classification of medication.” During the interview with the CMO, Physician #8, it was confirmed the documentation by the staff read the IM Haldol medication was given for an unwanted behavior that needed to be stopped before the patient hurt himself or the staff on 11/06/2023. Then given to the patient again on 11/07/2023 but there were no documented aggressive behaviors until hours after the medication was given on 11/07/2023. The surveyor went over the findings with the CMO, Physician #8 concerning the fact that Patient #1 was not monitored closely or according to the physician’s orders and that any patient receiving Haldol should be monitored closely for heart arrhythmia and other complications. CMO Physician #8 said, “Well the warning is for a possible QT-prolongation and that is rare.” According to the Texas Administrative Code, Rule 415.260 (b)(1) only a physician member of the facility’s medical staff may order restraint or seclusion for a behavioral emergency. Nurse Practitioners were not allowed to order restraint or seclusion for behavioral emergencies. CMO Physician #8 stated, “Well they are not ordering them as a restraint. If the provider orders the medication as, “Management of Acute Agitation/Delirium or Undifferentiated Agitation/Delirium (to allow the patient to better interact with his/her environment)” it was not a chemical restraint or an emergency behavioral medication.” During an interview on 12/14/2023 at 9:20 AM with RN Staff #3 and RN Staff #5, RN Staff #3 stated, “If the patient has a history of an illness and they are already on the same classification of antipsychotic medications then an IM injection was not considered a chemical restraint.” According to the FDA, precautions must be taken when administering Haldol to patients . “ ...PRECAUTIONS HALDOL (haloperidol) should be administered cautiously to patients: ? with severe cardiovascular disorders, because of the possibility of transient hypotension and/or precipitation of anginal pain ...” Patient #1 had a known history of Atrial Fibrillation, arrhythmia, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Ischemic Cardiomyopathy, and Myocardial Infarction. Without proper monitoring of patients receiving IM Haldol, patients are at a greater risk of complications and subsequent death. RN Staff #6 and RN Staff #7 confirmed there was no 1-hour face-to-face evaluation completed by a physician, LIP (Licensed independent practitioner), or a trained RN for the chemical restraints/emergency behavioral medications administered to Patient #1 on 11/06/2023 or 11/07/2023. Patient #2 Patient #2 was a 68-year-old female who arrived at the hospital by ambulance on 11/21/2023 at 11:12 PM. She had a history of alcohol abuse and high blood pressure. Her chief complaint was nightmares/hallucinations. A review of the History documented by Physician #34 at 11:13 PM was as follows: “ ...68-year-old female with a history of alcohol abuse and Hypertension presents to the ER by EMS (Emergency Medical Services) complaining of nightmare. Pt declined to provide more information. Review of systems limited due to patient being uncooperative ... Physical Exam: Neurological: She is alert and oriented to person, place, and time. Psychiatric: Behavior is uncooperative ...” RN Staff #35 documented at 11:43 PM that the patient was recently discharged after being admitted on 11/11/2023 for ETOH (alcohol) withdrawal. Got home and started hallucinating. The nursing assessment documented on 11/21/2023 at 11:48 PM revealed the patient was alert, hallucinating, had poor concentration, and was confused. The patient was placed on suicide precautions and a sitter was assigned for observations. Behavioral monitoring by the RN was scheduled for every hour. RN Staff #21 was assigned as the primary nurse at 1:17 AM on 11/22/2023. A review of the documentation by RN Staff #35 dated 11/22/2023 at 1:00 AM was as follows: “ ...Patient was anxious, non-compliant, uncooperative, aggressive verbally, angry, and confused. Sitter at bedside.” On 11/21/2023 at 1:25 AM Physician #22 documented that the RN notified her that the patient was requesting to leave. Further documentation revealed, “Upon re-evaluation pt denies SI, HI. Pt has very poor insight, with rambling and nonsensical answers to questions. Do not feel discharge appropriate at this time. Discussed with RN that pt will need to be evaluated for POW if she tries to elope.” At 1:42 AM RN Staff #21 documented, “RN contacted Tyler PD and spoke with **** to establish POW (police Officers Warrant). RN was informed that an officer would be up here at the ER shortly. MD aware.” Further review of the medical record revealed Physician #22 placed an order for Zyprexa. The order was as follows: “ ...11/22/2023 at 1:43 AM Zyprexa 10mg IM STAT Once Indication of use: Severe Agitation Indications comment: Bipolar Mania ... Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Zyprexa (antipsychotic medication) 10mg IM was administered by the RN at 1:55 AM on 11/22/2023. RN Staff #6 confirmed vital signs were taken by RN Staff #23 on 11/22/2023 at 1:55 AM and a RASS Score of “Very Agitated” was documented by Staff #23 at 1:55 AM. This was completed at the same time the Zyprexa medication was given IM to the patient. RN Staff #23 completed another RASS Assessment at 2:00 AM with a RASS score of “Alert and Calm”. The next set of vital signs was not taken until 11/22/2023 at 7:24 AM. This was greater than 4 hours after the administration of a chemical restraint/EBM. A review of the Behavioral Monitoring documented on 11/22/2023 at 1:00 AM revealed the patient was anxious, noncompliant, uncooperative, confused, and verbally aggressive. RN Staff #6 confirmed that Behavioral Monitoring was usually completed every hour on a patient in the Emergency Room (ER). RN Staff #6 confirmed there was no documentation of less restrictive interventions attempted before giving a chemical restraint/emergency behavioral medication to Patient #2 to control the patient’s behavior. She also confirmed there was no documentation of the effects of the Zyprexa or the patient’s response to the medication. Further review of the physician orders revealed; “ ...11/22/2023 at 9:31 PM Haldol 5mg IM STAT Once Indication of use: Severe Agitation ... Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Staff #6 confirmed the behavioral monitoring documented on 11/22/2023 at 9:00 PM revealed the patient was calm and sleeping. Haldol IM was given at 9:58 PM and the behavioral monitoring at 10:00 PM was documented as the patient was awake and verbally aggressive. Haldol 5mg IM was administered by the RN at 9:58 PM on 11/22/2023. “ ...11/23/2023 at 3:47 PM Haldol 5mg IM STAT Once Indication of use: Psychosis ... Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Haldol 5mg IM was administered by the RN at 5:41 PM on 11/23/2023. This medication was administered 1 hour and 54 minutes after a STAT order was placed for Psychosis. Staff #6 confirmed there was no documentation that the physician was notified of the late administration of the IM Haldol and no documentation was found if the patient was still experiencing a behavioral emergency that required an emergency behavioral medical/chemical restraint. There was no documentation of the behaviors the patient was exhibiting at the time the RN gave the IM injection. Vital signs were taken at the time of the administration of the IM Haldol and not again until 12:24 AM on 11/24/2023. This was greater than 6 hours after the chemical restraint/emergency behavioral medication was administered. An interview was conducted on 12/14/2023 after 10:00 AM with RN Staff #12 and RN Staff #13. RN Staff #12 was asked what was the least restrictive restraint used on a patient who was a threat to himself or others. RN Staff #12 replied, “I would think it would be a shot.” Staff #13 was asked if he would try to de-escalate the patient or place them in restraints before giving medication to control the patient’s behavior. RN Staff #13 replied, “We do not have a vest or a restraint chair and we prefer not to tie the patient down so we would give them a shot if we were not able to redirect them or de-escalate them by talking to them.” RN Staff #13 was not aware that the “shot” was the most restrictive form of restraint due to no antidote was available for the injection. The medication cannot end immediately and would require hours for the medication to metabolize. Patient #3 Patient #3 was a 63-year-old male admitted to the Emergency Room on 12/03/2023 after a fall at the Nursing Home. He was transferred to the ICU (Intensive Care Unit) on 12/03/2023. The patient had a medical history of Chronic back pain, Chronic Obstructive Pulmonary Disease (COPD), Stroke, Depression, Type 2 Diabetes, Gastroesophageal Reflux Disease, Hypertension, Seizures, and at the time of admission he was positive for COVID-19. A review of the ER Physician note dated 12/03/2023 at 7:16 AM revealed the patient was alert and oriented to person, place, and time with no cranial nerve deficit on admission. His behavior was noted as normal. RN Staff #13 documented a verbal order was given to the ER Nurse to start Precedex (a medication used for sedation) on 12/03/2023 at 1:00 PM. There was no indication for use documented on the medication order. Staff #15 also confirmed there was no documentation in the ER medical record indicating the need for a sedating medication. Patient #3 was started on an IV (intravenous) continuous infusion of Precedex on 12/03/2023 at 1:00 PM for agitation. Precedex was discontinued by Physician #31 on 12/05/2023 at 9:34 due to bradycardia (low heart rate). A review of Physician #36’s documentation on 12/05/2023 at 8:35 AM revealed the patient was on Precedex for agitation. A review of the medication order dated 12/05/2023 at 9:36 AM by Physician #31 was as follows: “ ...Zyprexa (antipsychotic medication) 5mg IM Routine Once Indications for Use: Severe agitation Is this medication being used for a chemical restraint? No. This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ...” Zyprexa 5 mg IM was administered by RN Staff #33 on 12/05/2023 at 10:24 AM. A review of the chemical restraint/frequent monitoring documentation dated 12/05/2023 at 10:18 AM with RN Staff #15 revealed the patient was physically and verbally aggressive, he was severely confused, had impaired judgment, combative, climbing out of bed, violent towards self, and others, and unable to control destructive behavior. RN Staff #15 confirmed the Zyprexa 5mg IM administered on 12/05/2023 at 10:24 AM was not ordered by Physician #31 as a chemical restraint Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 9:36 AM. The orders were as follows: “ ...BP, HR, RR, SPO2, and LOC immediately prior to administration. Vital signs (BP, HR, RR, SPO2, and LOC). Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals. Richmond Agitation Sedation Scale (Richmond Agitation Sedation Scale-a scale used to determine the sedation score of someone deeply sedated in the ICU on a ventilator) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ...” A review of the progress note dated 12/05/2023 at 6:27 PM by RN Staff #33 was as follows: “ ...Multiple attempts to hit at staff, verbally aggressive Continuously yells out despite attempts to calm Continuously attempts to jump out of the bed 10 mg Zyprexa IM given total- ineffective 10 mg Geodon given- ineffective ...” A review of the progress note dated 12/05/2023 at 6:40 PM by Physician #31 stated, “ ... Patient is agitated and combative, restless, Precedex causes bradycardia, Zyprexa, x 2, and Geodon x 1 administered during the shift ...” Further review of the medical record on 12/14/2023 with RN Staff #15 revealed vital signs were taken at 10:00 AM, 11:00 AM, 11:30 AM, 12:00 AM, 1:00 PM, and 1:30 PM. RN Staff #15 confirmed nursing staff failed to monitor Patient #3’s vital signs as ordered by Physician #31. RN Staff #7 was asked how she was able to monitor chemical restraints if the IM/IV psychotropic medications were not ordered as a chemical restraint. She stated, “The medications have to be ordered as a chemical restraint for them to populate to the restraint log. If they are not ordered correctly then they do not populate to the restraint log and there is no way for me to know that the medication was given. We do monitor the medications that are used and identified as a chemical restraint. It is clear that we are not capturing all of these restraints that are ordered for behavioral emergencies because of the way they are ordered by the provider. Further review of medication orders for Patient #3 revealed the following: “ ...12/05/2023 at 12:52 AM by Physician #31 Zyprexa 5mg IM STAT (immediate/rush) Once Indications for use: Aggressive Behavior and Severe Agitation. Is the patient an immediate threat to self or others? Yes Is this being used as a chemical restraint? Yes Chemical Restraint: Use of a sedating psychotropic drug to manage, control behavior or restrict patients freedom that’s not a usual or customary standard of treatment for patients medical or psych conditions. Have non-chemical restraints been used and failed: Yes ...” Zyprexa 5 mg IM was administered on 12/05/2023 at 1:45 PM by RN Staff #33. This was 52 minutes after Physician #31 ordered the medication STAT when Patient #3 was experiencing a behavioral emergency exhibiting Aggressive Behavior and Severe Agitation. Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 12:52 PM. The orders were as follows: “ ...BP, HR, RR, SPO2, and LOC immediately prior to administration. Vital signs (BP, HR, RR, SPO2, and LOC). Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals. Richmond Agitation Sedation Scale (Richmond Agitation Sedation Scale-a scale used to determine the sedation score of someone deeply sedated in the ICU on a ventilator) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ...” A review of the medical record with RN Staff #15 confirmed Vital signs were taken at 1:30 PM, 2:50 PM (pulse only), 3:00 PM, 3:30 PM (pulse only), and 4:00 PM. It was also confirmed the RASS Score was documented at 2:00 PM, 2:15 PM, 2:30 PM, 3:00 PM, and 3:30 PM. All times were documented as Very Agitated/+3 RASS Score. RN Staff #15 confirmed vital signs and RASS assessments were not conducted according to Physician #31’s orders. Further review of medication orders for Patient #3 revealed the following: “ ...12/05/2023 at 2:24 PM by Physician #31 Geodon (antipsychotic medication) 10 mg IM STAT Once Indications for use: Aggressive Behavior and Severe Agitation. Is the patient an immediate threat to self or others? Yes Is this being used as a chemical restraint? Yes Chemical Restraint: Use of a sedating psychotropic drug to manage, control behavior or restrict patients freedom that’s not a usual or customary standard of treatment for patients medical or psych condition. Have non-chemical restraints been used and failed: Yes ...” Geodon (antipsychotic medication) 10mg IM STAT was administered on 12/05/2023 at 3:03 PM by Staff #33. This was 38 minutes after Physician #31 ordered the medication STAT when Patient #3 was experiencing a behavioral emergency due to Aggressive Behavior and Severe Agitation. Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 2:24 PM. The orders were as follows: “ ...BP, HR, RR, SPO2, and LOC immediately prior to administration. Vital signs (BP, HR, RR, SPO2, and LOC). Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals. Richmond Agitation Sedation Scale: Order Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ...” A review of the medical record with RN Staff #15 confirmed Vital signs were taken at 3:00 PM (no blood pressure), 4:00 PM, 4:30 PM, 5:00 (no blood pressure), 5:08 PM, and 5:30 PM. It was also confirmed the RASS Score was documented at 3:00 PM, 3:30 PM, 3:45 PM, 4:00 PM, 4:30 PM, 5:00 PM, and 5:30 PM. All times were documented as Very Agitated/+3 RASS Score. Staff #15 confirmed vital signs and RASS assessments were not conducted according to Physician #31’s orders. A review of the progress note dated 12/05/2023 at 6:44 PM was as follows: “ ...Patient is agitated and combative, restless, Precedex causes bradycardia, Zyprexa, x 2, and Geodon x 1 administered during the shift ...” A review of the Medline Plus website was as follows: https://medlineplus.gov/ency/article/003212.htm “Agitation Agitation is an unpleasant state of extreme arousal. An agitated person may feel stirred up, excited, tense, confused, or irritable. Considerations: Agitation can come on suddenly or over time. It can last for a few minutes, for weeks, or even months. Pain, stress, and fever can all increase agitation. Agitation by itself may not be a sign of a health problem. But if other symptoms occur, it can be a sign of disease. Agitation with a change in alertness (altered consciousness) can be a sign of delirium. Delirium has a medical cause and should be checked by a health care provider right away.” While there is an objective scale of agitation developed for patients who are sedated, there is not one for patients who are not sedated. There were no objective criteria or scale that distinguished what agitation was. This required the nurse to assess the patient and decide when to medicate the patient without objective guidelines. Based on the order parameters, the patient could have been medicated for shouting at the staff or demanding that he wanted to go home. Without objective parameters, the nurse must decide what agitation means to the nurse and what behaviors to give medication for every 6 hours without a physician assessment of the behaviors to ensure something hasn’t medically changed and the least restrictive intervention was used. As Haldol has no reversal agent, once given, the patient must wait for the effects to wear off. No rationale was found documented in the chart for why the medication was chosen to control behaviors for which the patient was already being mechanically restrained. A review of the policy titled, “Standardized Use of Restraint and/or Seclusion,” Number 3.080 with a reviewed date of 8/21 was as follows: “ ...IV. Definitions: ... (3) Chemical Restraints: The use of a sedating psychotropic drug to manage or control behavior or restrict a patient’s freedom that is not a usual or customary standard of treatment for the patient’s medical or psychiatric condition. (a) Use of medication to modify behavior or induce normative sleep patterns that is standard treatment for the patient’s condition is NOT considered a chemical restraint ... V. PROCESS: Patient Monitoring and Documentation: Violent or self-destructive behavior 1. The patient restrained/secluded for behavioral reasons is assessed at the initiation of the restraint/seclusion event and every 15 minutes thereafter ...” The statement was followed by information concerning the patient in a physical restraint and not a chemical restraint. There was no guidance or instruction on how soon to evaluate the patient after the medication administration, how frequently, or for how long. There was no instruction on what to assess and what to report as a change in condition for a chemical restraint. RN Staff #7 confirmed the facility policy did not give clear direction on what to assess, when to reassess, what changes to report to a physician, and how long to monitor a patient that received a chemical restraint. RN Staff #7 also confirmed staff education was based on the facility policy that did not give clear guidelines on how to safely manage and care for a patient who received a chemical restraint/EBM. RN Staff #6, RN #7, and RN #15 confirmed antipsychotic medications given IM to patients for behavioral emergencies were not identified as a chemical restraint, or monitored as a chemical restraint, and there was no face-to-face completed by a physician, LIP, or a trained RN.”

“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: 35089 Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital’s emergency department to determine whether an emergency medical condition existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1’s VP shunt was not examined and evaluated for shunt infection after coming to the ED complaining of fever, vomiting, and fussiness. The complete medical record of Patient #1’s first ED visit on 9/24/23 was reviewed. It was noted: Patient #1 was brought to the ED for vomiting. Patient #1 had a past medical history of spina bifida and a past surgical history of ventriculoperitoneal (VP) shunt placement. Initial vital signs showed Patient #1 had a fever (103.2 F) and a fast heart rate of 194 beats per minute. Patient #1 had multiple laboratory and diagnostic tests performed. The urinalysis came back abnormal and Patient #1 was diagnosed with a bacterial urinary tract infection. Patient #1 was discharged to home with a prescription for oral antibiotics. There is no documentation to indicate that the ED physician evaluated the patient’s VP shunt during examination. There is no documentation to indicate that a pediatric or neurosurgical consult was performed to address a differential diagnosis of shunt infection. There is no physician order to assess the patient’s blood for contamination of microorganisms [sepsis]. There is no repeat temperature assessment after administration of Tylenol or prior to discharge. 1. ED Nursing Note: “Chief Complaint: Shortness of breath (Pt [patient] mother states that the patient had an episode this afternoon of ‘gurgling’ and states her feet turned purple. Reports pt appears back to baseline but seems tired. 98% on RA [room air]. 103.2F rectal temperature in triage.” 2. ED Provider Note: “Patient with a PMHX [past medical history] of spina bifida and ventriculoperitoneal shunt presents to the ED with one episode vomiting ... She is fussy throughout the exam but is easily consoled. Work-up does reveal bacterial UTI but discussed this at length with mom. She had fever initially which was treated and has resolved ... Multiple differential diagnoses were considered in this patient based upon history, physical exam, and workup. These include Shortness of breath, asthma exacerbation, COPD exacerbation, pneumonia, viral illness, pulmonary embolism, acute coronary syndrome, traumatic injury, pneumothorax, anxiety, panic attack, among others. and sore throat, viral pharyngitis, bacterial pharyngitis, anaphylaxis, angioedema, epiglottitis, peritonsillar abscess, Ludwig’s angina, retropharyngeal abscess, deep space infection, foreign body, trauma, mass tumor.” 3. Vital Signs (ED Care Timeline) 1304: Temp 103.2 F (rectal); Heart Rate 194; Resp 40; SpO2 98%; Pain Assessment: Hurts little bit 1331: Heart Rate 165 1426: Heart Rate 143; SpO2 96% The surveyor interviewed Staff #7 (the initial ER physician that took care of Patient #1 on 9/24/23) on 11/28/23 via telephone. Staff #7 recalled that Patient #1 was “fussy but interactive” and that vital signs were “better at discharge” but could not recall what the vital signs were. Staff #7 stated that there was no need for transfer or that the patient required a higher level of care that was provided in the ED. Patient #1 was seen at the facility’s other ED location approximately eight hours later for skin discoloration, chills, labored breathing, cough, and vomiting. Blood test revealed elevated white blood cell count and lactate levels. Patient #1 was admitted by pediatric service for urinary tract infection and sepsis. Patient was hospitalized for three days and received IV antibiotics.”