Las Palmas Medical Center A Campus of Lpds Healthc

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 51738 Based on a review of facility documents and policies, medical records, and interviews, the facility Las Palmas Del Sol Freestanding Emergency Room (FSER) Horizon Campus and the parent facility Del Sol Medical Center failed to ensure the right of patients or their representatives to make informed decisions regarding his or her care when staff failed follow policies meant to ensure these rights by not completing treatment consent forms, by not accurately documenting witness signatures on these consent forms for 4 of 20 patients (#1, #2, #4, and #19), and by not documenting medical reasons a patient is unable to sign consent forms. Findings include: Review of Facility Document: A review of the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” form, partially reveals: Page 1: “1. Consent to Treatment. I consent to the procedures that may be performed during this episode of care ...” Page 8: “21. Acknowledgement of Notice of Patient Rights and Responsibilities” and “22. Acknowledgement: I have been given the opportunity to read and ask questions about the information contained in this form ...” Page 9: “I, the undersigned, as the Patient or Patient Representative ...have read, and fully and completely understand this Conditions of Admission and Consent for Inpatient Care ...and that I have signed ...knowingly, freely, voluntarily ...” On the bottom of Page 9 there is a “Patient/Patient Representative Signature” box, a checkbox “Patient is Unable to Sign” and signature boxes for a “Witness Signature and Title”, and “Additional Witness Signature and Title”. Review of Facility Policy: A review of facility policy titled, “PARA.PP.PTAC.038 Procedure for Registration Forms and Signatures” (Revised: 05/01/2024) reveals in part: “Policy: The Patient Access Department obtains signatures on all registration forms ... The Consent form is signed upon the first registration ... The Consent should be obtained for each account within the episode of care ... Documentation requirements when a patient is unable to sign: A physician or a licensed clinical person should document a medical reason why the patient is unable to provide a signature, within the medical record. The documentation should include the physician’s or licensed clinical person’s signature and title including the last and first name ... The witness signature area, when signed with a second witness signature and title, indicates a patient’s inability to sign with a representative not present ... Guidelines for witness signatures and titles: In the event a patient, a legally authorized individual, or a family member is medically unable to sign, two staff members can act as a witness on the consent form. The two witnesses may be registration and clinical staff. A witness’s signature includes a staff member’s full first name, last name and title ... Special Note: If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency.” Medical Record Review: A review of the Conditions of Admission and Consent for Inpatient and/or Surgical Care” form for patients #1 (8/30/25), #2, #4, and #19, partially reveals that on page 9, there is no “Patient/Patient Representative Signature”, and the box “Patient is Unable to Sign” is checked. There is an electronic “Witness Signature and Title”, but the electronic “Additional Witness Signature ...” is illegible, and there is no title. A further review of the medical records for patients #1 (8/30/25), #2, #4, and #19, reveals there is no documentation of a medical reason why the patients are unable to provide a signature on their consent forms. Interviews: In interviews conducted during the review of medical records on the afternoon of 12/2/2025, Staff #6, VP of Quality, and Staff #7, Quality Management Coordinator, acknowledged that the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” forms were incomplete for patients #1 (8/30/25), #2, #4, and #19. Staff #6 and #7 also acknowledged that staff did not follow facility policies including “Guidelines for witness signatures and titles”.”

“PROVISIONS CFR(s): Provisions include equipment, supplies, and medication used in treating emergency cases. Such provisions must be kept at the hospital and be readily available for treating emergency cases to meet the needs of patients. The available provisions must include the following: (i)Drugs, blood and blood products, and biologicals commonly used in life saving procedures; (ii) Equipment and supplies commonly used in life-saving procedures; and (iii) each emergency services treatment areas must have call in system for each patient. This Standard is not met as evidenced by: 51738 Based on observations of Las Palmas Del Sol Freestanding Emergency Room (FSER) Horizon Campus and interviews, the facility failed to ensure equipment and supplies commonly used in life-saving procedures were readily available for treating emergency cases to meet the needs of patients, when 40 expired supplies were found in the trauma bay including laryngoscopes and endotracheal tubes and other emergency supplies. Findings included: During a tour of Las Palmas Del Sol FSER Horizon Campus on the afternoon of 12/2/2025, 40 expired supplies were observed in the only trauma bay at this facility. These expired supplies included: twelve Mac 4 laryngoscopes (expired 10.18.2025); four Mac 3 laryngoscopes (expired 9.21.2025); sixteen PVC (polyvinyl chloride) thoracic catheters (expired 11.15.2025); three IO (intraosseous) kits (two expired 5.31.2024 and one expired 6.30.2024); one pelvic binder (expired 8.5.2025); one NG (nasogastric) connector (expired 9.1.2025); one 10 mL (milliliter) syringe (expired 7.31.2025); one liter of Lactated Ringers (LR) (expired 11.2025); and one triple lumen central venous catheter (CVC) (expired 8.31.2025). In interviews conducted during this tour, staff #6, VP (Vice President) of Quality, staff #7, Quality Management Coordinator, and staff #8, Director of Patient Safety, verified that there were 40 expired supplies in the trauma bay at Las Palmas Del Sol FSER Horizon Campus.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility failed to ensure the patient right to be free from all forms of abuse or harassment, as evidence by staff members failing to appropriately report suspected abuse/neglect per facility policy. Findings included: Facility policy entitled, “PC 214 Abuse and Neglect Guidelines and Indications for Referral” stated in part, “PROCEDURE: ... 3. Patient care personnel who suspect a presenting patient to be a victim of abuse, neglect or exploitation should immediately notify the charge nurse and the assigned Social Worker/Case Manager (if after hours, the assigned Social Worker/Case Manager on call) to facilitate communication with TDFPS ...” Review of the medical record revealed Patient #1 had two episodes of potential abuse by a family member: On the evening of 04/15/24, the patient’s son restrained their arms to bed rail with bed linens, the linens were removed when discovered by staff, no injuries noted. * Nursing staff that observed the son restrain the patient’s arms on 04/15/24 failed to notify the social worker per facility policy. According to documentation by the social worker, they were notified of the incident on the afternoon of 04/16/24 by the nurse case manager. The social worker had to educate the staff member on the need to report the incident to Adult Protective Services (APS). * It appeared nursing staff was unaware of their mandatory reporter status. On 04/16/24 at 1706 the social worker documented, “...SW asked nurse and charge nurse to inform the night bedside nurse to please make APS report. SW educated the Director that all nurses are mandatory reporters and need to make reports if they are witness to abuse or neglect. SW educated staff of option to call APS to make report or how to make report online...” * According to documentation a report was made by the witnessing nursing staff on 04/17/24 at 0500. * In interview on 05/07/24 the nurse witnessing the events of 04/15/24 stated they are now aware of their mandatory reporting status and how to file a report online (after being educated by their manager). On the evening 04/17/24 the patient’s son was heard yelling in the patient’s room and proceeded to barricade himself in the patient’s room, requiring removal by facility security and the local police department. * The social worker made a report for the incident on 04/17/24 with APS on 04/18/24. Social worker note on 04/18/24 at 0818 stated in part, “...SW informed of overnight incident with patient and son.” It is not clear how the social worker was notified about the event on 04/17/24. It is not documented whether the nurse witnessing the event on the evening 04/17/24 notified the social worker and charge nurse per policy. It does not appear the nursing staff that witnessed the events first hand on 04/17/24 made the report to APS. In the 2 incidents above, the facility policy to report suspected abuse/neglect was not followed appropriately by nursing staff. It appears nursing staff is not aware of their role as mandatory reporters. In interview on 05/07/24 the Quality Director confirmed the current facility policy does not clearly state mandatory reporter requirements for nursing staff. The current policy reads the “charge nurse and the assigned Social Worker/Case Manager (if after hours, the assigned Social Worker/Case Manager on call)” are to “facilitate communication with TDFPS” which does not provide direction to nursing staff to mandatoryily report and the process for filing a report with TDFPS. The above findings were verified with staff members #1 and 2 on 05/07/24.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to maintain a safe environment when 3 (three) out of 3 (three) rooms were found to have copious amounts of dust on the facility’s patient bathroom air vents. The possible exposure to dirt and dust places patients at risk of respiratory discomfort, illness, and infections. (Las Palmas patient rooms 507, 598, and 518) Findings include: Observations were made in the Del Sol Administrative conference room on the afternoon of 4/09/24, in the presence of the Las Palmas CNO during a virtual call. Staff #12, Las Palmas nurse manager, was asked to enter several patient rooms to check the air vent cleanliness. A tour of three inpatient rooms revealed copious amounts of gray debris inside the patient’s bathroom air vents in room 507, 508. And 518. The air vents were located directly above the patient’s toilets. During an interview on the afternoon of 4/09/24, in the Del Sol Administrative conference room, Staff #6, Las Palmas CNO confirmed the dirty air vents. When asked who was responsible for maintaining the cleanliness, Staff #6 stated, “The EVS (environmental services) clean the patient rooms, if they see something broken or if they can’t access the vents, they will put in a work order; facilities will have to remove the vents to clean them ...The vents look like they have been painted, creating rough edges.” During an interview on the afternoon of 4/09/24, in the Del Sol Administrative conference room, Staff #10, Las Palmas Engineering/Facilities director stated in part, “EVS is responsible for the exterior, if they see dust inside, when they are dusting, they need to put a work order in. We do monthly rounding.” When asked if the bathroom vents are part of the rounding, Staff # stated, “They must not look up.” During an interview on the afternoon of 4/09/24, in the Del Sol Administrative conference room, Staff #14, Las Palmas EVS director stated in part, “The superficial areas is us, anything inside my staff will report it to us, me or my manager will put in the work order. We do the inspections; I have a few new employees.” Review of the facility provided policy, “RI 115 Notification of Patient Rights and Responsibilities, (last reviewed dated 1/2016) reflected, “Access to Services, To safe, secure and sanitary accommodation ...” EC 720 Indoor Air Quality Plan Dated (last reviewed 11/5/21) “PURPOSE: To assist the facilities in achieving an Indoor Air Quality (IAQ) program that protects patients, visitors, employees, and other building occupants and complies with implied and/or published recommendations of the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE), Environmental Protection Agency (EPA). Occupational Safety & Health Administration (OSHA), Joint Commission on Accreditation of Healthcare Organizations (TJC) and other regulatory agencies. POLICY: A. The Environment of Care will provide oversight as the facility IAQ Team.””