Baylor St Lukes Medical Center

“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: 33326 Based on interview and record review, the facility’s nursing staff failed to provide a safe environment and to minimize a patient’s risk of falling when, a self-report of a fall was not investigated to prevent further falls. (Patient #7) Findings include: During a telephone interview, Patient #7 stated, “I had my IV pump and pole on one side of the bed and a long IV tubing running behind my back to the IV site on the other side of the bed. When I tried to get up to go to the bathroom, I got tangled up in the tubing and fell on my stomach. I reported it to the nurse.” Patient #7 did not provide the date of the fall. Review of Patient #7’s nurse progress note dated 5/17/2026 11:18 am reflected, “Patient reports having 9/10 pain in the lower abdomen and stated “he is having internal bleeding after the fall. Abdomen soft and nondistended other than the bruising in abdomen. Patient is able to ambulate to restroom and take a sponge bath. Hemoglobin 13.6; vitals stable. Notified urology team about the concerns. Provided medicine for pain.” Review of the Patient #7 provided (undated) photograph of the bruising revealed an approximately 6-centimeter (cm) x 6 cm dark purple bruise below his umbilical surgical incision. There is a dark brown bruise noted to his left outer abdomen approximately 3 cm x 2 cm. Review of the facility provided policy “Fall Prevention and Maintenance” (last reviewed August 2025) reflected, “A. Assessment and Reassessment 1. The patient’s fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient fall per Core Standard of Practice ... G. Post Fall Management a. Assessment i. Immediately perform and document complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries. Identify changes from pre-fall status. Follow facility process to stabilize neck and spine if indicated based on assessment. ii. Determine if patient can be moved and returned to bed/chair using safe patient handling practices (including use of equipment as appropriate to get the patient off the floor). iii. Treat sustained injuries. iv. Monitor patient for any effects of the fall. v. Reassess patient as appropriate, including physical and neuro status. vi. Conduct Post Fall Debrief and complete Post Fall Debrief Form. Ask the patient what happened, if patient able to self-report. Information may be used to prevent repeat fall (see appendix E for adult/pediatric and newborn post fall debrief forms). b. Notify i. Notify the Licensed Independent Provider immediately at the time of the fall. Provide the following: a. Change in neurological status and vital signs; b. Injury or complaint of pain; c. Anti-coagulation medication; and d. Obtain order for medical interventions/diagnostic procedures. ii. Follow chain of command iii. Patient’s representative as appropriate iv. Risk Management/Patient Safety Officer - if the patient fall results in one of the following: a. Significant injury involving higher level of care or medical/surgical intervention b. Confirmed injury by diagnostic test c. Death ...” Review of the facility provided incident reports did not reflect Patient’s fall had been documented according to the facility’s “Fall Prevention and Maintenance” policy. During an interview, in a facility office, Staff #10, RN 16 tower Nurse Manager stated, “We did not know what was going on with him; he said he fell but his story kept changing where he fell and when he fell. The nurse assessed him and documented the bruise. She called the physician but did not fill out an incident report.” Staff #10, confirmed the nurse should have documented the fall in the IRIS (electronic incident reporting system) report.”

“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: 33326 Based on interview and record review, the facility’s nursing staff failed to evaluate the nursing care for patient #7, after a self reported fall placing the patient at risk for further falls and injuries. Findings include: During a telephone interview, Patient #7 stated, “I had my IV pump and pole on one side of the bed and a long IV tubing running behind my back to the IV site on the other side of the bed. When I tried to get up to go to the bathroom, I got tangled up in the tubing and fell on my stomach. I reported it to the nurse.” Patient #7 did not provide the date of the fall. Review of Patient #7’s nurse progress note dated 5/17/2026 11:18 am reflected, “Patient reports having 9/10 pain in the lower abdomen and stated “he is having internal bleeding after the fall. Abdomen soft and nondistended other than the bruising in abdomen. Patient is able to ambulate to restroom and take a sponge bath. Hemoglobin 13.6; vitals stable. Notified urology team about the concerns. Provided medicine for pain.” Review of the Patient #7 provided (undated) photograph of the bruising revealed an approximately 6-centimeter (cm) x 6 cm dark purple bruise below his umbilical surgical incision. There is a dark brown bruise noted to his left outer abdomen approximately 3 cm x 2 cm. Review of the facility provided policy “Fall Prevention and Maintenance” (last reviewed August 2025) reflected, “A. Assessment and Reassessment 1. The patient’s fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient fall per Core Standard of Practice ... G. Post Fall Management a. Assessment i. Immediately perform and document complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries. Identify changes from pre-fall status. Follow facility process to stabilize neck and spine if indicated based on assessment. ii. Determine if patient can be moved and returned to bed/chair using safe patient handling practices (including use of equipment as appropriate to get the patient off the floor). iii. Treat sustained injuries. iv. Monitor patient for any effects of the fall. v. Reassess patient as appropriate, including physical and neuro status. vi. Conduct Post Fall Debrief and complete Post Fall Debrief Form. Ask the patient what happened, if patient able to self-report. Information may be used to prevent repeat fall (see appendix E for adult/pediatric and newborn post fall debrief forms). b. Notify i. Notify the Licensed Independent Provider immediately at the time of the fall. Provide the following: a. Change in neurological status and vital signs; b. Injury or complaint of pain; c. Anti-coagulation medication; and d. Obtain order for medical interventions/diagnostic procedures. ii. Follow chain of command iii. Patient’s representative as appropriate iv. Risk Management/Patient Safety Officer - if the patient fall results in one of the following: a. Significant injury involving higher level of care or medical/surgical intervention b. Confirmed injury by diagnostic test c. Death ...” Review of the facility provided incident reports did not reflect Patient’s fall had been documented according to the facility’s “Fall Prevention and Maintenance” policy. The nurse did not document the size of the bruising or include the reported fall or make changes in the patient’s care plan. During an interview, in a facility office, Staff #10, RN 16 tower Nurse Manager stated, “We did not know what was going on with him; he said he fell but his story kept changing where he fell and when he fell. The nurse assessed him and documented the bruise. She called the physician but did not fill out an incident report.” Staff #10, confirmed the nurse should have documented the fall in the IRIS (electronic incident reporting system) report and the care plan needed to be revised.”

“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: 46010 Based on observation, interview and record review, the facility failed to provide care in a safe setting for 3 of 12 patients (ID #1, 9, 12) reviewed by: a. Failing to ensure a patient with dementia had a safe, secure environment that would not allow his elopement unaccompanied from the facility (Patient ID #1). b. Failing to ensure patients who had continuous visual observation for increased monitoring had documented assessments with tele-sitter or 1:1 sitter utilization in patient’s medical records (Patient ID # 1, 9, 12). Findings Included: Observation on 3/26/26 at 09:35 am during unit tours. Patient ID #12 had a “tele-sitter” electronic monitoring device in use at the bedside. Observation on 3/26/26 at 09:45 am during unit tours. Patient ID # 9 on the 24 Tower unit. 1:1 sitter was present with patient in the unit. Record review of Patient ID #1 with Quality RN #71. She confirmed that the medical record reflected that Patient ID #1 had presented to the facility on 2/9/26 at 00:30 to emergency department for shortness of breath and cough. The ED physician documentation reflected the patient had “dementia” and stated “History limited secondary to patient dementia.” The admission provider history and physician reflected diagnoses list including dementia. The assessment stated “Neurologic: He is alert. Comments: Oriented to person, partially to space, not to time.” The plan included continuing home Aricept used for dementia. The nursing note from Staff RN # 79 for 2/9/26 evening shift stated “1900PM ,This RN recieved bedside end shift report from Day shift RN, Patient sitted on the bed and wife at bedside, and at 1918pm RN was notified by Charge RN (redacted) that patient was off Telemetry monitor, as the Primary RN went back to patient room and put the patient back on the telemetry monitor, patient still sitted on the bed with wife (name redacted) at the bedside .... At 1950 this RN from room 2435 reported to the Nurses station ... 1945 wife is reported to have gone to the nurses station to report that patient was missing ...”. Medical record review of medical hospitalist resident staff ID # 80 noted labeled “Brief Cross Cover Note” on 2/9/26 at 21:30 stated Brief Cross-Cover Note “I was notified by RN at 0120 that pt had left the floor around 1930 and that house supervisor, charge nurse, security, and police were aware and search for pt was ongoing. I spoke with RN and pt’s spouse at bedside. Per wife, pt left the room when she was in the bathroom and stated that he was going to go downstairs to smoke. Did not come back afterwards. Family called phone but was unable to reach him and unable to find him. Wife reports that due to his dementia, he often becomes confused and does not know where he is. Reported that earlier in the day he did not know that he was in the hospital ...Was updated by RN at 0650 that pt was found and will be readmitted to hospital.” Record review of Patient ID #12 with Quality RN # 71. She confirmed patient ID #12 had an order from 2/22/2026 at 11:16 am for continuous visual monitoring due to confusion and probability of self-removal of critical lines and tubes. The medical record failed to show the patient had tele-sitter documented on 3/22/26, 3/23/26 and 3/24/26 night shifts. The medical record showed “family, sitter, or virtual” documented though there was no clarification of which type of visual monitoring was being employed. Record review of Patient ID #9 with Quality RN #71. She confirmed patient ID #9 had an order for continuous visual monitoring on 3/24/2026 at 10:49 am. She confirmed that she was unable to locate documentation reflecting use or presence of 1:1 sitter or any visual monitoring on 3/25/26 dayshift. She confirmed that 1:1 sitter flowsheet documentation was initiated on 3/26/26 morning prior to surveyor tour. She confirmed the presence of documentation and location of documentation for continuous visual monitoring was inconsistent. Record review of facility policy titled “Patients Rights and Responsibilities (TX Markets), last reviewed on 11/6/2023, stated “b. The patient has a right to receive care in a safe setting. i. Follow current standards of practice for environmental safety, infection control and security. ii. Protect vulnerable patients ... iii. Provide protection for the patient’s physical safety ...” Record review of facility policy titled “Safety Attendant Policy”, last reviewed 4/1/2024, stated “Policy: 1. It is the policy of the Texas Division to provide a safe environment for patients ... 3. Patient may require varying degrees of observation, depending on identified risk factors, behaviors and needs ...” It further stated “Guidelines: ... 9. Criteria for assessing patient behaviors to determine the need for safety attendant include but are not limited to behaviors associated with: ...d: risk of elopement. e. Dementia (including wandering, getting out of bed without calling for help, Alzheimer’s).” The policy further stated “Safety attendant: i. Must be trained hospital personnel assigned to this role. A patient’s member, significant other, care partner or friend is not to be utilized.” Record review of facility policy titled “Continuous Visual Monitoring for Patient Safety”, last reviewed 6/13/23, stated “Appropriate patient inclusion criteria for initiation of continuous visual monitoring via Telesitter: a. patient warrants a closer level of observation based on the clinical judgement of the primary caregiver, but does not meet the exclusion criteria. Examples of inclusion criteria include: ... iii. Confusion, acute or chronic ...v. Elopement risk.” The policy further stated “7. Responsibility of the Primary Caregiver (RN): a. Assess patient for appropriateness of continuous visual monitoring ... d. Communication shall be entered in the patient electronic medical record as a nursing intervention to include: i. Tele Sitter Monitoring - Continuous ii. Reason for monitoring ...” Interview on 3/26/26 at 09:35 am with Staff RN # 66. He stated that he did not have a specific location to document use of tele-sitter for patient 12. He stated that this would be located in a narrative note. Interview on 3/26/26 at 09:37 am with Director Staff ID # 64. She was unaware of a specific location that presence/utilization of 1:1 sitter or tele-sitter would be consistently documented and stated this is not a component of the policy. She stated the documentation education would be provided as a part of orientation/onboarding. She confirmed that the documentation we were seeing on current patients demonstrated inconsistency in the process. Interview on 3/26/26 at 09:40 am with Charge RN #63. She stated that she documents use of 1:1 sitter and telesitter in 2 locations and demonstrated those to be “Environment Comfort and Safety Rounds” and under “High Fall Risks Intervention.” Interview on 3/26/26 at 11:45 am with Quality staff RN ID # 71 with record reviews. She confirmed that she was unable to locate the use or presence of a 1:1 sitter or telesitter for Patient ID #1 on the initial admission as well as on re-presentation after his elopement on 2/10/2026. She confirmed that there was an order placed by physician staff ID # 78 on 2/10/26 for visual observation. Interview 3/26/26 at 1:30 pm with Quality Director Staff ID # 51 with record review. She provided the “video monitoring log” from the off-site monitoring company which showed the patient was added to the tele-sitter observation monitoring system on 2/10/26 at 1:00 pm. The logs reflected continual monitoring during this visit including all activities during this period. It was discontinued 2/11/26 at 6:36 for “Discharge.” She confirmed this record is not a component of the medical record. Interview on 3/26/26 at 3:00 pm with Director Staff ID # 68. She confirmed that Patient ID #1 had presented to the nursing unit 24 tower for admission on the early morning hours on 2/9/2026 with a history of dementia stated in the ED medical record. She confirmed the patient’s wife was present continuously during the patient’s stay. She confirmed there was no use of continuous visual monitors provided by the facility prior to the patient’s elopement on 2/9/2026 at approximately 8:00 pm. Interview 3/26/26 at 2:45 pm with Hospital Medicine Physician and Chief of Staff Elect on 3/26/26 at 2:45 pm. She stated that she was unaware of any objective assessment tools applicable to dementia patient populations which would be utilized by ED and hospital medicine teams to assess risk of elopement, falls, impulsivity, etc. She stated that this is an assessment which is clinically performed at the time of the engagement and also by obtaining more history from the family. She stated that Patient ID #1 medical record reflected he was conversant, oriented to person and place, not time. She stated that many patients who are higher functioning with milder or earlier forms of dementia are hard to discern. She stated as patient progress to mid-level dementia patients, they can wax or wane or have worsening symptoms as the time of day progresses like “sundowning.” She noted that upon the patient’s readmission, his neurologic status appeared to be more confused than it was the first admission as he was only oriented to person at that point. Interview with Director staff ID # 68 on 3/26/26 at 3:00 pm. She stated at the time of the event, her investigation revealed that the ED had not reported that Patient ID #1 had alteration in mental status or significant dementia impacting care. She stated that the patient’s wife stayed with him in the room 24/7. She stated that Patient ID #1 was interactive and conversant with staff. She stated she could find no evidence of reports that patient had increasing confusion, had history of falls or wandering and that he did not meet criteria for tele-sitter without confusion, history of events, etc. She confirmed that there was not a standard assessment tool utilized to assess subjectively or objectively dementia/Alzheimers patients. She described dementia as a “spectrum”. She was asked about where safety measures such as use of sitter or telesitter would be documented. She stated that she believed this belonged under the “daily cares” tabs where the staff documents “comfort/safety rounds” every 2 hours. She confirmed that the facility allows nursing to implement tele-sitter use based on nursing assessment. However, she stated 1:1 bedside sitters require a physician order due to the increased resources needed.”

“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: 37490 Based on record review and interview the facility failed to ensure properly executed informed consents were completed for 2 of 3 patients (ID#s 10 and 11). Findings include: Review of facility policy titled “Disclosure and Consent for Medical and Surgical Procedures,” dated September 2024 showed the following: 1. Requirements for Disclosure and Consent Informed consent is one type of informed decision that a patient or his/her surrogate decision maker may need to make with respect to a medical treatment or surgical procedure related to his/her plan of care ... b. Written informed consent from the patient, or his/her surrogate decision maker is required for medical treatments and surgical procedures as indicated below except in medical emergencies. iii. Obtain informed consent from the patient’s surrogate decision maker if the patient lacks decision making capacity (In the following order of priority): 1. a court appointed guardian with guardianship over the person; 2. the patient’s agent under a medical power of attorney, or proxy under a directive to physicians and family or surrogates ... 3. the following individuals, in order of priority: a. patient’s spouse; b. patient’s reasonably available adult children; c. patient’s parents; d. patient’s nearest living relative or; e. the attending physician, with the concurrence of a second physician not involved in the treatment of a patient. Medical record review for patient (#10) showed Disclosure and Consent for Ultrasound Guided Percutaneous Intra-Abdominal Drainage w/ Cath Placement. On the consent form where the patient is to initial, the patients initials are written in and in parentheses it has verbal, i.e., (verbal). On the patient signature portion is has the patient’s name printed and in parentheses it has verbal, i.e., (verbal). Interview with quality director (staff A) on 4/2/2025 at 4 PM she acknowledged the above findings and stated that the consent does not address verbal consent. Medical record for patient (ID# 11) showed medical decision maker as his sister-in-law followed by his sister with names documented. Nursing note and Case Management notes have documented the patient’s sister-in-law was the Medical Power of Attorney (MPOA). There was no MPOA document in the medical record. Consent for Bronchoscopy with Possible Interventions dated 3/24/25 has the patient’s sister’ s name printed with telephone consent documented. Interview with quality staff (Q) on 4/2/2025 at 3:00 PM acknowledged the above findings.”

“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: 23032 Based on interview and record review, an RN failed to adequately supervise and evaluate the nursing care for four (4) of 12 sampled patients ( Patient ID # 1, 2, 11 and 12 ). Nursing staff failed to reposition the patients at least every 2 hours and perform skin assessments per hospital policy. Findings included: Review of facility policy titled “Hospital-Acquired Pressure Injury (HAPI) Prevention, Assessment and Documentation (Adult),” dated December 2024, showed: “B. Perform Assessment: 1. Perform the Braden Scale Risk Assessment and 2 RN head-to-toe skin assessment at the following intervals: a. Within 4 hours of admission b. Within 4 hours of the start of the shift... C. 3 (a) If Braden mobility subscale score is less than or equal to 2; reposition the patient at least every 2 hours or more frequently based on patient risk factors ( e.g. skin and tissue tolerance, medical condition, comfort and pain); level of activity; and ability to independently reposition.” ~~~~~~~~~ Patient ID # 2: Review of Patient ID # 2’s History & Physical exam, dated 2/15/2025, showed he was a 49 year-old male with past medical history of quadriplegia with neurogenic bladder with suprapubic catheter , and status post-colostomy. This patient sustained a total spinal cord injury (TSCI) following a motor vehicle accident in 2009. Further review of Patient ID #2’s electronic medical record was conduced with Staff-M, RN, Patient Safety Program Manager on 4/1/2025. Review of the flowsheets ( 2/16/25 through 2/25/2025) indicating daily care /safety & comfort measures; and Braden scale showed the following: - 2/16/2025 : repositioned only twice: 11 hours apart [midnight and 1121 AM] ; Braden subscore for mobility was assessed as “2” at 1121 and 2100. - 2/17/2025: repositioned only twice: 12 hours apart [ 1047 AM and 1144 PM] ; Braden subscore for mobility was assessed as “1” for both shifts. - 2/19/2025: no repositioning between 6 AM and 1 PM ( 7 hours) ; Braden subscore for mobility was assessed as “2” at 0800 and 1431. - 2/21/2025 : no repositioning between 4:30 AM and 7 PM ( 14 hours); Braden subscore for mobility was assessed as “1” for night shift. During an interview with Staff-M, RN, Patient Safety Program Manager, during the record review, she verified the findings. She said that given Patient ID #2’s diagnosis of quadiplegia and Braden mobility score, he should be repositioned every 2 hours, unless he refused. Both should be documented. 37490 Medical record review for patient (ID# 1) on 4/2/2025 showed that the patient had been in the hospital for 105 days. The only 2 RN skin assessment titled “4 eyes in 4 hours” was documented on 3/19/2025. On 3/19/2025-3/20/25 there was a ten-hour period where there was no documentation demonstrating the patient was repositioned per facility policy. Braden scale risk assessments were not documented per policy. Medical record review for patient (ID #11) showed that he did not receive any 2 RN skin assessments performed from 3/23/25-3/28/25. Braden scale risk assessments were not documented per policy. Medical record review for patient (ID# 12) showed that he did not receive any 2 RN skin assessments performed from 3/18/25-3/24/2025. Braden scale risk assessments were not documented per policy. Interview with staff (Q) on 4/2/25 at 4 PM acknowledged the above findings.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 37490 Based on interviews and record review, the facility failed to ensure the discharge planning process included the regular re-evaluation to identify changes that required modification to the discharge plan ensuring a safe discharge. (Patient ID #1). Findings Included: Record Review of facility policy titled “Care Coordination Discharge Planning” dated November 21, 2022, showed the following information: POLICY: Discharge planning is a collaborative process that includes the patient, family/caregiver or other patient identified support person(s), attending physician, nursing and other member(s) of the multidisciplinary care team in the post-acute transition. The discharge plan needs to be consistent with the patients’ goals of care and treatment preferences as appropriate and is completed by the RN care coordinator or a social worker when discharge needs are identified during the first stage screening or at the request of the patient, family, or representative or physician/healthcare team member. All activities related to discharge planning, patient’s choice, and referrals are documented in the medical record, including screenings, assessments/reassessments, evaluations, and arrangements made for implementation of the discharge plan, refinement or changes to the discharge plan, as well as education/training and materials provided to the patient or caregiver. Development of the Discharge Plan ...The hospitals discharge planning process must require regular re-evaluation of the patient’s condition to a identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Record Review of Patient ID #1 Medical Record showed the following information: Patient ID# 1 was admitted 4/30/2024 and discharged 5/14/2024. Case management note dated 5/3/24: Discharge Planning Arrangements Patient identified by name and date of birth. Care management responded to inpatient consult for post-acute levels of care: skilled nursing facility(SNF). Case Management note dated 5/3/24: Discharge Planning Evaluation. Transition Needs Home or Post Acute Services- Post Acute facilities (Rehab/SNF/ect). Case Management Note dated 5/13/24: CM called SNF and spoke with DON .... she stated that they cannot take this patient due to history. CM will have to find another facility. CM called patient’s mother and she was given list for SNF and chose facility (named). Addendum: CM called facility to talk to Admission Coordinator but was told she was gone for the day. CM to follow-up tomorrow. CM received call from patient’s mother saying that after talking to family members, they would like to change to facility (named). Case Management note dated 5/14/24: CM called facility (named) and spoke to Admission Coordinator. She stated that they are not able to take this patient. CM notified MD who said patient is medically cleared to discharge. CM called the patient’s mother to let her know the situation. She is willing to accept patient at her house. Physical Therapy note dated 5/14/24: PT Recommendations for Discharge: therapy discharge recommendations, patient would benefit from three hours of intensive multidisciplinary therapy per day to maximize functional outcomes and address functional limitations to return to the highest level of functioning. Occupational Therapy Note dated 5/14/2024: OT recommendations for Discharge: Based on today’s therapy session, pt would benefit from low to moderate intensity therapies post-acute care prior to his discharge home. Requires a wheelchair and hoyer lift. Interview with Manager of Social Work staff (M) and Division Director of Care Coordination staff (N) on 7/25/24 at 1:0f PM confirmed the above findings that no post-acute services were provided including DME, stating that if SNF was the plan but unable to obtain a facility that would accept the patient, home health services should have at least been offered.”

“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: 37322 Based on observation and interviews, the hospital failed to uphold patients’ right to receive care in a safe setting and ensure crash carts were checked daily to ensure compliance in two areas (ED and CV-ICU) of the facility during the tour on 05/30/2024. It was also noted in the reusable clean equipment in the ED was not covered and ready for patient use. Based on observation and interview the facility failure to ensure the signage for patient rights, sexual trafficking and other required signage were present in the patient waiting rooms and bathrooms in the emergency department. Findings Include: Record review of the policy “ Emergency Care Maintenance-Patient Care” effective June 2019. Procedures: Emergency carts will be checked daily. Review of the crash carts in ED at 1240 on 05/29/2024 revealed one crash cart in the ED for the month of May 2024, had not been checked on May 15/16, barcode # 24, as well as other items on the crash cart. These items included, the orange tackle box, defibrillator, ambu bags and oxygen tanks, that had not been inspected and checked on May 11, 14, 15, and 16, 2024. Interview with the ED manager (staff ID# 9), during rounds verified the finding. Observation of multiple (3) crash cart in CV-ICU on 05/29/2024 at 1320 for the month of May 2024 revealed the carts had not been inspected on the following dates (cart #2) May 3, 9,21, (cart #4) May 3, (cart 2) May 9,11, 21. Other emergency items (defibrillator) had not checked on May 21, 2024. Interview with the charge nurse (ID#10) during rounds in the CV-ICU , verified the findings and stated one day the pod where the crash cart was stored had been closed on those days. Record review of the “Cleaning of Non-Critical Portable Patient Care Equipment-Infection Prevention” effective January 2023, stated “ Free Standing Equipment Use and Cleaning Procedure, i. Store equipment with a clean, clear plastic cover or place in a designated clean storage area. Note: If equipment has been stored uncovered, inspect item for dust and wipe clean as necessary. Interview on 05/29/2024 at 1310 with staff nurse (#ID 17) working in the area, was asked about the supplies in hallway C which consist of several uncovered items (vital sign machines, and a glidescope, and two blood pressure machines), who responded they were clean and ready to use. The director (ID # 18) walked by and stated the equipment should be covered. Based on observation and interview the facility failure to ensure the signage for patient rights, sexual trafficking and other required signage were present in the patient waiting rooms and bathrooms in the emergency department. Findings Include: Observation on 05/29/2024 at 1240 of the emergency department waiting room or where patient congregate revealed no required signage related to patient rights and care were posted in . These signs were posted at check in. Observation on 05/29/2024 during the tour, also revealed the sexual trafficking signs were not present both the mens and womens (106B, 106Q, 012N) bathrooms in the emergency center. Interview on during the tour on 05/29/2024 at 1240, nurse manager (ID#2) validated the finding. Based on observation and interview the facility failure to ensure the signage for patient rights and other required signage were present in the patient waiting rooms and bathrooms in the emergency department. Findings Include: Facility Policy, dated December 2022, “Emergency Medical Screening, Stabilization, and Individual Transfers (EMTALA) Regulatory Compliance. A. Signage Posting Requirements. A sign shall be posted in a conspicuous location in the Emergency Department specifying the rights of Individuals with EMCs and women in Labor who Come to the Emergency Department for health care services. A sign shall also be posted indicating participation in the Medicaid program under Title XIX of the Social Security Act”. Observation on 05/29/2024 at 1220 of the emergency department waiting room revealed no required signage related to patient rights was posted in the ambulatory entrance, ambulance entrance or waiting room. Observation also revealed the sexual trafficking signs were not present in 4 of 4 bathrooms (106A, 106B, 160Q, 012N) in the emergency center. Interview on during the tour on 05/29/2024 at 1140, nurse manager (ID#9) validated the finding.”

“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: 37490 Based on record review and interview, the facility failed to follow established Grievance Management Process in 1 of 3 grievances reviewed. (ID # 1) Findings include: Record review of facility policy titled “Patient Grievance Management” dated June 2023, showed the following: POLICY It is the policy of BSLMC to formally receive, review, and respond to complaints and/or grievances from patients or patients’ representatives, their family members, and guests of CHI St. Luke’s. DEFINITIONS * A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or a patient’s representative regarding the patient care provided, abuse or neglect, or the hospital’s compliance with CM’S Conditions of Participation (Cops). Procedures 3. Management of Grievances b. following receipt of a written or verbal grievance, the hospital’s grievance coordinator or designee reviews, documents, and coordinates the investigation... Record review of Return Receipt of complaint letter from patient (ID#1) to facility showed a facility stamped acknowledgement of receipt of the letter dated 3/8/2024. Interview with facility grievance coordinator (ID# 59) on 4/17/2024 at 11:58 AM stated that there was no documented grievance for patient (ID #1). She was able to verify complaint and grievance procedures. She stated that one items are received via “mail” there is a box that they are put in and retrieved by her department. At that point they get logged in. Any complaints/ Grievances that are received by Administration are forwarded to her department, get logged in and follow the process. Interview with facility Director of Quality (ID # 55) on 4/17/2024 at 1:00 PM verified the letter was received in the mail room and was routed to administration as it was addressed to the facility CEO. She stated that the administrative staff was unfamiliar with the name on the letter (previous CEO) and the letter was returned to sender.”