Chi St Lukes Health Memorial Lufkin

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 32143 Based on record review, policy review, and interview, the hospital failed to ensure that a member of the medical staff provided timely physician evaluation and medical management for 1 of 1 patient (Patient #1) reviewed who presented with an acute obstetrical condition requiring physician evaluation. The facility failed to provide written medical staff requirements or processes establishing physician response expectations for emergent clinical situations. This failure resulted in patient #1, who presented at approximately 18 weeks gestation with a twin pregnancy and evidence of spontaneous abortion of one fetus while the second fetus remained viable, not receiving an in-person physician evaluation by the responsible on-call physician after the physician was notified of the patient’s acute clinical condition. The responsible on-call physician provided telephone orders and subsequently transferred responsibility for the patient’s care to the next on-call physician. Patient #1 subsequently passed additional fetal tissue before the documented in-person physician evaluation. The findings include: 1. Patient #1’s Presentation A review of patient #1’s medical record revealed the patient presented to the hospital on 03/24/2026 at approximately 5:10 AM. The patient was approximately 18 weeks pregnant with twins. The triage record identified the patient as Acuity Level 3 - Urgent. The patient’s documented pain level was 7/10. The nursing triage documentation dated 3/24/26 at 5:12 am indicated patient #1 reported passing a large clot-like mass which appeared to contain an underdeveloped fetus. Patient #1 reported that there was “something still trying to come out.” Patient #1 was taken up to Labor and Delivery 2. Nursing Assessment Review of the nursing documentation revealed that at approximately 5:40 AM, Patient #1 reported spotting throughout the night, which had progressively become darker. The nursing documentation indicated that at approximately 4:45 AM, Patient #1 passed a large mass into the toilet. The nurse documented that Patient #1 had something appearing to be an umbilical cord hanging from the vagina. There was no fetus visualized at that time. 3. Notification of the On-Call Physician At approximately 5:49 AM on 3/24/26, nursing documentation revealed that a full report regarding patient #1’s condition was provided to Staff #2 (on-call OB physician) by phone. Staff #2 provided verbal orders for a STAT obstetrical ultrasound (US). An interview was conducted with Staff #9 RN on 8/4/23 at 3:32 pm. Staff #9 stated that she was the night nurse caring for patient #1. Staff # 9 stated that Staff #2 was the physician on call at the time patient #1 presented. Staff #9 stated she called Staff #2 regarding the patient’s status and described the patient’s condition. Staff #9 stated that Staff #2 never stated he was coming in to see the patient but gave a verbal order to have a sonogram. Staff #9 stated that she felt the patient was in an emergent situation. Staff #9 escalated to the charge nurse concerning the conversation and orders from Staff #2. There was no further documentation that the charge nurse escalated the concern. Staff #9 confirmed this behavior from Staff #2 was common practice. No documentation was found by Staff #2 that he reported the patient or patient concerns to the oncoming physician. 4. Diagnostic Findings Review of the obstetrical ultrasound revealed findings concerning for spontaneous abortion/nonviability of Twin A. The ultrasound documented that a fetal heart rate could not be obtained for Twin A. Twin B remained intrauterine with a documented fetal heart rate of approximately 153 beats per minute. The ultrasound further documented decreased amniotic fluid, with a maximum fluid pocket of approximately 1.57 centimeters. 5. Continued Physician Notification Review of nursing documentation on 3/24/26 revealed that at approximately 7:15 AM, Staff #2 was contacted and updated regarding patient #1’s condition and ultrasound findings. Orders were received to admit Patient #1 and obtain laboratory testing, including CBC, CMP, and type and crossmatch for two units of blood. Orders were also received for intravenous fluids and medications. The nursing documentation on 3/24/26 at 7:15 am stated: “_____(staff #2) will be turning pt over to ____(staff # 3). ____ Staff #2 stated he reported off to her.” There was no documentation in the medical record demonstrating that Staff #2 performed an in-person physician examination of patient #1 before transferring responsibility for the patient’s care to the subsequent on-call physician. 6. Subsequent On-Call Physician At approximately 8:40 AM on 3/24/26, nursing documentation revealed that the ultrasound report was communicated to Staff #3 MD. The nursing documentation stated: “____ (staff #3) will be coming by shortly.” Orders were received to obtain consent for a possible dilation and curettage (D&C). 7. Patient Passed Additional Fetal Tissue Before Documented Physician Evaluation At approximately 9:00 AM on 3/24/26, Patient #1 went to the bathroom and passed additional tissue. The nurse documented that the tissue “appears to be a head.” The material was collected and placed in a container. At approximately 9:45 AM, documentation indicated that staff #3 was present on the unit and reviewed Patient #1’s medical record. Subsequent physician examination documented findings consistent with the ongoing obstetrical condition, including a cord extending toward/to the introitus and continued viability/fetal cardiac activity of the remaining fetus. Patient #1 was transferred to a higher level of care per the patient’s request. 8. Medical Director Interview An interview was conducted with staff #1 Medical Director (CMO) on 7/28/26 at 2:15 pm. During the interview, the Medical Director stated that the hospital did not have a written requirement establishing when a physician was required to respond in person to an emergency clinical situation. Review of the medical staff bylaws revealed no defined physician response requirement for an emergent patient requiring physician evaluation. The hospital failed to ensure an effective medical staff process to provide timely physician evaluation and medical management when Patient #1 presented with an acute obstetrical condition. Despite notification of the responsible on-call physician regarding Patient #1’s condition and subsequent diagnostic findings concerning for spontaneous abortion of one fetus while a second fetus remained viable, the responsible on-call physician provided telephone orders without a documented in-person evaluation and subsequently transferred responsibility for patient #1 to the next on-call physician.”

“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: 48749 Based on record review, policy review, and interview, the hospital’s emergency department physician failed to conduct a complete medical screening prior to discharge in 1(#3) of 1 patient charts reviewed. Also, the hospital failed to follow its “Emergency Medical Treatment and Labor Act (EMTALA)” policy. This deficient practice had the likelihood to cause harm to all patients presenting to the Emergency Department (ED)with emergent medical conditions. Findings include: Patient #3 Hospital #1: 1201 West Frank Street, Lufkin, TX. 75901 A review of Patient #3’s medical record revealed that the patient arrived at Hospital #1’s Emergency Department (ED) via Emergency Medical Services (EMS) on 11/02/2025 at 8:27 AM with a chief complaint of an unwitnessed ground-level fall. A review of Hospital #1’s “Trauma Flow Sheet” revealed that the ED Nurse gave the patient an Emergency Severity Index (ESI) (The Emergency Severity Index has five levels, with Level 1 representing the most urgent cases requiring immediate life-saving intervention, and Level 5 being the least urgent, needing only a basic history and physical exam; essentially ranking patients based on their acuity and the resources needed for their care) of 2- Emergent. The ED Nurse documented; “Found on floor this AM. Abrasion to chin, left thigh pain, and possible right wrist fracture. Under the left eye swelling. Abrasion to the left scalp, left hip pain that is chronic. Pt does not normally ambulate on her own. Confused at baseline.” Patient #3’s initial vital signs were: Blood Pressure-226/91 Heart Rate-92 Respirations-20 Oxygen Saturations-95% on room air Glasgow Coma Scale (GCS) (a neuro assessment tool used to evaluate the level of consciousness in a person after a brain injury)-14 Patient #3 was evaluated by the ED Physician upon arrival at Hospital #1’s ED at 8:27 AM. A review of the ED Physician’s note revealed the following; “History of Present Illness Received via LFD Med 4 from Larkspur w/reported unwitnessed fall. Pt was found on the floor. She has an abrasion to her chin, left thigh & left side of scalp. She has a possible right wrist fracture w/deformity & bruising. She has some swelling under her left eye. Pt takes Eliquis & code trauma activated 08:27. Nursing hm staff state she also c/o of left hip pain.” Head-comments: Abrasion to chin· NECK-Abnormal findings: decreased ROM· EXTREMITIES-Lower extremities are nontender to palpation Normal findings: atraumatic, pelvis stable, hips nontender; comments: Soft tissue swelling to both wrists with some tenderness to palpation. Appears to have full range of motion. No true deformity.; Orders: Computed Tomography (painless imaging test that uses x-ray and computer to create detailed cross-sectional views of bones, organs, and tissues)(CT) Head without contrast, CT Spine without contrast, and a 3-view right wrist x-ray. Clinical Impression Facial contusion Cervical strain Bilateral wrist contusions Evaluation after ground-level fall Disposition to: Home; Patient dispositioned by clinician in: stable condition.” The ED Nurse documented on the trauma flow sheet that Patient #3 was having 10 out of 10 pain. There was no documentation found in Patient #3’s medical record to support that the ED Nurse notified the ED Physician about the patient’s pain. There was no documentation found in the medical record to support that pain medication was administered to Patient #3. There was no documentation found in the medical record to support that Patient #3 received treatment for facial contusions or wrist contusions. Patient #3 was discharged back to the nursing home at 9:52 AM with a prescription of Tramadol (pain medication). Patient #3’s discharge vital signs were: Blood Pressure-212/78 Heart Rate-82 Respirations-17 Oxygen Saturations-97% on room air Temperature-98.0 GCS-14 Pain-10/10 Hospital #2: 505 S. John Redditt, Lufkin, TX 75902 A review of Patient #3’s medical record revealed that the patient arrived at Hospital #2’s ED via EMS on 11/02/2025 at 3:46 PM with a request for a re-evaluation after an unwitnessed ground-level fall earlier in the morning. A review of the ED Nurse’s note revealed the following; “Presentation: 11/02 3:46 PM- Presenting complaint: EMS states: Pt sent from Larkspur for re-evaluation after a fall this morning, Pt has been seen.... family wanted Pt to be sent here to be re-evaluated.... 11/02 3:46 PM- Acuity: ESI Level 3... Primary Survey: 11/02 4:00 PM Respiratory: Airway is patent. Respiratory effort is regular, unlabored. Respiratory pattern is tachypnea. Chest movement is symmetrical. Cardiovascular: Capillary refill< 2 seconds. Rhythm is sinus rhythm. Secondary Survey: 11/02 4:00 PM- Neuro: Level of Consciousness is confused. General: Appears uncomfortable. Behavior is cooperative. Moaning and Groaning. EENT: Mouth Dentures present. Bleeding noted. Laceration noted inside mouth and also to chin. GI: No gross abnormalities. GU: No gross abnormalities. Musculoskeletal: Capillary refill < 2 seconds. Range of motion is limited in the right wrist. Other: Right wrist swelling present in right wrist and right hand. Reports pain in right hand/wrist, face, left shoulder. Pain: Complains of pain in right wrist, left shoulder, face, pain currently 10 out of 10 on the pain scale. Noted to be grimacing, moaning, resistant to movement.” Patient #3’s initial vital signs were: Blood Pressure-220/84 Heart Rate-88 Respirations-24 Temperature-98.4 Oxygen Saturations- 96% on room air Glasgow Coma Scale-14 ESI-3 Pain-10/10 The patient was evaluated by Hospital #2’s ED Physician at 3:46 PM on 11/02/2025. A review of the ED Physician’s note revealed the following; “HPI: This 84-year-old Black or African American Female presents to the ED via EMS - Ground with complaints of a fall injury. This is an 84-year-old African American female that resides in the nursing home facility secondary to mobility issues, ataxia, secondary to old CVA. Patient has a history of chronic kidney disease, gout, and seizure activity. Apparently, she took a fall this morning and was sent to a hospital for further evaluation. While the patient had a CT of her head performed, and an X-ray of her right wrist. Both studies were read as normal. Patient did sustain a facial injury, including contusion to the left side of her face, a small abrasion or small laceration to the lower lip and chin areas. She has a larger laceration on the inner aspect of her lower lip. When she was sent back to the nursing home, her family noted that she was having large amounts of bleeding in her mouth. They were also concerned about what appeared to be a deformity of her right wrist. Therefore, they called ambulance services to bring the patient to our facility for further evaluation. Patient is bedbound. She is not to be walking. She does go to therapy and transfers. The nature of her fall is unknown, as no witnesses were there. Patient is on Eliquis(Blood Thinner). Patient will answer questions. She says that she was at the foot of her bed and hit the right side of her face when she slid off her bed. Exam: Head/face: There is a laceration on the inner aspect of the lower lip on the vehicle mucosa, that is approximately 4-5 cm in linear length and about 2-3 cm in depth. Patient does have some malocclusion of her lower jaw. Along with bleeding of the inner aspect of her lip. Musculoskeletal/extremity: Extremities: grossly normal except: noted in the right wrist: deformity, pain, swelling, tenderness. Intact distal pulses but minimal movement. 6:51 PM- ED Course: This is an 84-year-old African American female with a history of stroke, multiple adult medical problems, including chronic kidney disease and morbid obesity, she is bed-bound. She has been residing at Larkspur Nursing Home- facility. Patient apparently had a ground-level fall after she had gotten up to walk. She was noted to have injury to her right wrist, facial abrasions, and a small laceration on the inner aspect of her lower lip. She has a contusion on the left side of her face. But she is complaining of low back pain. Patient went to have films performed, was not found to have any head trauma or fracture of her right wrist. She was released back to the nursing home. Family wanted her to be seen here since she was having bleeding from her mouth secondary to the inner lip laceration. On examination patient has a significant malocclusion of her lower jaw, a small abrasion on the outer aspect of her lower lip and chin. CT maxillofacial reveals a partially displaced, angulated, comminuted right mandibular fracture. In the setting of the laceration on the inner aspect of the patient’s mouth, this could be an open fracture. Patient is given Ancef 1 G IV. Repeat x-ray of the patient’s right wrist does not show any evidence of an acute fracture; however, there is a hematoma. There could be an occult fracture, we are going to CT the patient’s wrist, chest, abdomen pelvis, for any other injuries. Patient is given morphine sulfate for pain relief and nausea medication Zofran.” Further review of Patient #3’s medical chart at Hospital #2 revealed that the ED Physician ordered: Labs, CT wrist without contrast, left shoulder x-ray, CT maxillofacial /sinus without contrast, right wrist 3-view x-ray, CT chest without contrast, CT abdomen/pelvis without contrast, and a wrist splint. Patient #3 received Zofran (anti-nausea medication) 4 milligrams (mg) intravenous push (IVP), Morphine (pain medication) 4 mg IVP, Fentanyl (pain medication) 25 mcg IVP, Cefazolin (antibiotic) 1gm IVP, Hydromorphone (pain medication) 0.5 mg IVP, and Hydralazine (blood pressure medication) 10 mg IVP at Hospital #2. At 7:10 PM, the ED Physician initiated a transfer for Trauma Surgery services at a higher-level of care facility. Patient #3 had a diagnosis of a right mandible fracture, right wrist contusion, and right wrist scapho-lunate dissociation. Hospital #3: 1000 S. Beckham Ave, Tyler, TX. 75701 Patient #3 was transferred to Hospital #3 for further evaluation and treatment with Trauma Services at 11:41 PM on 11/02/2025 via EMS. A review of Hospital #1’s “Emergency Medical Treatment and Labor Act (EMTALA)” policy dated December 11, 2024 revealed the following; “1. Medical Screening Examination All individuals who come to the DED and all individuals who present on Hospital property requesting or requiring examination or treatment of an Emergency Medical Condition (EMC) shall receive an appropriate Medical Screening Examination (MSE). Additionally, the hospital shall not delay in providing the MSE or necessary stabilizing treatment in order to inquire about an individual’s ability to pay or to inquire about eligibility for financial assistance under Common Spirit Governance Policy, Finance G-003, Financial Assistance Program. Scope of MSE· The scope of the MSE must be tailored to the presenting complaint and the medical history of the individual. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include laboratory tests, diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of on-call physician specialists. A medical record documenting the history and physical examination, and any special reports such as consultations, clinical laboratory and diagnostic imaging, will be created to document the MSE. The MSE must include all services within the Capability of the hospital, which, in the judgment of the emergency physician, Qualified Medical Person (QMP), or other treating provider, are necessary to screen or Stabilize an individual with an EMC. These services include the use, when necessary, of on-call specialty physicians identified on the On-Call List.” An interview was conducted with Staff #22 on 12/02/2025 at 10:20 AM. Staff #22 confirmed that there was no documentation found in Patient #3’s medical chart to support that pain medication or wound care was administered to the patient. Staff #22 reported that CT scans and x-rays were determined by the treating physician. An interview was conducted with Staff #37 on 12/04/2025 at 12:10 PM. Staff #37 reported initially believed that the patient’s wrist was fractured and that it was hard to determine if Patient #3 had pain with baseline confusion. The surveyor asked what patient signs and symptoms would determine if a facial scan was needed. Staff #37 reported that obvious signs of injury, deformity, or malocclusion would be a reason for ordering facial scans on a patient. Staff #37 reported that an initial review of the CT scan did not show a fracture, but when reviewed at a later date, Staff #37 identified that a fracture was present.”

“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 records and staff interviews, the facility failed to: A) ensure that 5 patients (Patient #67, #68, #69, #70, and #71) of 5 patients who presented to the emergency department after a sexual assault were not provided with notice of all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault and the Texas Code of Criminal Procedure, Chapter 56A Rights of Crime Victims, Subchapter G. Forensic Medical Examination of Sexual Assault Victim, Art. 56A.303. Forensic Medical Examination. Failure to provide the patient with notice of their rights as described on the State mandated information form as soon as possible prior to beginning services could result in the patient not receiving all the services entitled to. If the patient were forced to seek examination elsewhere or were to leave prior to receiving all the services they were entitled to, such as prophylaxis medications (medications meant to prevent disease), access to an advocate from the local crisis center if available and local resources for follow-up care, the patient could develop life threatening conditions such as sexually transmitted infections, acquired immunodeficiency syndrome (AIDS), or post-traumatic stress disorder leading to suicidal ideation. Refer to Tag A0117 B) ensure timely grievance resolution in 1 of 1 sampled patients reviewed for complaint and grievances (Patient #4). Patient #4’s family voiced a grievance regarding care issues and HIPPA violations on 01/26/2025 and the grievance was not resolved until 06/17/2025 (over 4.5 months later). Refer to TAG A0122 C) ensure timely communication of grievance results to the complainant in 1 of 1 sampled patients reviewed for complaint and grievances (Patient #4). Patient #4’s family voiced a grievance regarding care issues and HIPPA violations on 01/26/2025 and the grievance was not resolved until 06/17/2025 (over 4.5 months later). Patient #4’s family member who voiced the grievance was never informed of the results of the investigation. Refer to TAG A0123 D) ensure proper execution of informed consent in 7 (#7, #11, #21, #22, #23, #30, #31) of 7 patient medical records reviewed. Additionally, the hospital staff did not follow the “Disclosure and Consent for Medical and Surgical Procedures” policy. The hospital staff failed to ensure: A. proper execution of informed consent for Hemodialysis for Patient #7. B. patient # 11 was deemed competent to provide consent for blood transfusions prior to the initiation of blood products. C. the hospital’s “Refusal to Permit Examination, Treatment, Transport, or Transfer Form” listed the treatments refused, the risks for refusing treatment for Patient #21 and Patient #23. That all portions of the hospital’s “Refusal to Permit Examination, Treatment, Transport, or Transfer Form” was signed, dated, and timed for Patient #21, #22, and #23. D. consent to admission and notification of patient rights were obtained upon admission for Patient #31. Refer to TAG A0131”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, interview, and Texas state law, the facility failed to ensure that 5 patients (Patient #67, #68, #69, #70, and #71) of 5 patients who presented to the emergency department after a sexual assault were not provided with notice of all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault and the Texas Code of Criminal Procedure, Chapter 56A Rights of Crime Victims, Subchapter G. Forensic Medical Examination of Sexual Assault Victim, Art. 56A.303. Forensic Medical Examination. Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subsection (b) requires: (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: (1) subject to Subsection (b-1), a forensic medical examination in accordance with Subchapter B, Chapter 420, Government Code, and Subchapter G, Chapter 56A, Code of Criminal Procedure; ... (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; (4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...) ... (7) the name and telephone number of the nearest sexual assault crisis center; and ... CODE OF CRIMINAL PROCEDURE TITLE 1. CODE OF CRIMINAL PROCEDURE CHAPTER 56A. RIGHTS OF CRIME VICTIMS SUBCHAPTER G. FORENSIC MEDICAL EXAMINATION OF SEXUAL ASSAULT VICTIM Art. 56A.303. FORENSIC MEDICAL EXAMINATION. (c) A victim of a sexual assault may not be required to participate in the investigation or prosecution of an offense as a condition of receiving a forensic medical examination under this article. Failure to provide the patient with notice of their rights as described on the State mandated information form as soon as possible prior to beginning services could result in the patient not receiving all the services entitled to. If the patient were forced to seek examination elsewhere or were to leave prior to receiving all the services they were entitled to, such as prophylaxis medications (medications meant to prevent disease), access to an advocate from the local crisis center if available and local resources for follow-up care, the patient could develop life threatening conditions such as sexually transmitted infections, acquired immunodeficiency syndrome (AIDS), or post-traumatic stress disorder leading to suicidal ideation. Findings included the following: On 12-1-25 at 10:50 AM, Staff #128 and Staff #129 (patient registration staff) were interviewed in the Emergency Department (ED) at the Patient Registration Desk. Neither Staff #128 nor Staff #129 were aware of any handout to be given to Survivors of Sexual Assault when they presented to the ED for registration. Both stated they would register the patient, leave the reason for the visit blank, have the patient wait in the ED waiting area, and notify the triage nurse. On 12-1-25 at 10:57 AM, Staff #130 (triage nurse) was interviewed in the triage room of the ED. Staff #130 stated that she was not aware of any paperwork specific to Sexual Assault Survivors that she would provide to the patient. On 12-1-25 at 11:03 AM, Staff #48 (ED charge nurse) was interviewed in the ED. Staff #48 stated that they would call the police to obtain a police report. When asked what they would do if the patient did not want to involve the police, Staff #48 stated that they would still call the police even if the patient did not want them to. Staff #48 stated that they had to show that they “progressed” the case and reported the crime. Staff #48 stated that he was not aware of any specific handouts for patients who were sexual assault survivors but that the primary nurse would give a packet from DSHS (Department of State Health Services). Staff #48 said that they don’t call for a sexual assault patient advocate to come to the hospital, if available, to assist the sexual assault survivor through the process of obtaining treatment and examination. When asked who explains to the sexual assault survivor their rights under Texas law, Staff #48 answered, “Great question.” When Staff #48 was asked when during the visit the patient was provided a copy of their rights as required in Texas law, Staff #48 responded, “Great question. I would have to get the answer.” When asked if the sexual assault survivor receives a list of local resources, Staff #48 stated that he did not believe they had a ready-made list. Staff #48 stated that patients could not get a Sexual Assault Nurse Examiner (SANE) examination in the ED, and their staff did not perform sexual assault forensic evidence collection in lieu of a SANE examination. The patient would be referred to a local community-based sexual assault program that would provide the SANE examination. When asked what would happen if the patient didn’t want to go to the community-based program and wanted to have the examination at the hospital in the ED, Staff # 48 again stated that the patient was not able to have any type of sexual assault examination in the ED, only a medical screening examination per EMTALA (emergency medical treatment and active labor act). On 12-2-25, Policy Title: Patient Rights and Responsibilities (Texas Markets), Next Review Date: November 2025 was reviewed. The following was on page 2 under the heading Policy, A. “A. It is the policy of St. Luke’s Health to respect, protect, and promote each patient’s rights in accordance with regulatory and accreditation standards. This policy should not be construed as a complete notation of patient rights and responsibilities. There may be additional rights and responsibilities pertaining to identified patient populations that are not contained in this policy.” Further review of the policy showed it did not contain specific information on the rights of the Sexual Assault Survivor population. The following was listed on page 3 under the heading Procedures: 1. Notice of Rights: “1. Notice of Rights The patient or the patient’s representative (as allowed under State law) has a right to receive information about his/her rights. a. St. Luke’s Health will inform each patient (inpatient or outpatient) or when appropriate, the patient’s representative, of his/her rights at the time of admission and in advance of providing or discontinuing care or treatment whenever possible.” On 12-2-25, Policy Title: Care of the Sexual Assault Survivor, Next Review Date: December 9, 2026, was reviewed as follows: Page 2, Procedures; Item 1 b): “The patient will be provided a copy of the Texas Department of State Health Services Information Sheet for Sexual Assault Patients.” Page 2, Procedures; Item 1 d): “If a law enforcement agency has not been notified, the nurse will contact the appropriate agency. A law enforcement case number must be obtained and recorded in the triage entry, if the patient is an adult patient choosing to report the exam, prior to the beginning of the sexual assault exam. i) Adult patients are not required to report to law enforcement. If an adult patient wants to report, the exam must be authorized by law enforcement. Page 2, Procedures; Item 2: “A private area will be provided, if available, to wait or speak with the appropriate medical, legal, or sexual assault crisis staff until the QMP (qualified medical provider) is able to treat the patient. Page 2, Procedures; Item 3a): “Contact the (local crisis center name redacted) on the 24-hour hotline at (phone number redacted) Page 2, Procedures: Item 4: “If indicated by the history of sexual contact, the patient will be provided with appropriate prophylaxis medication for exposure to sexually transmitted infections. Any appropriate medical referrals and instructions for follow-up care will be included on the patient’s discharge instructions. a) Referrals should be made to the appropriate crisis intervention services even if the need is not apparent at the time. Page 3, Procedures; Item 5: “At the referring facility (local community-based program), the SANE nurse will complete any further assessments, exams, provision of kit, collection and chain of custody. A) the forensic file will be maintained by (name of community-based program redacted). Page 4 was the beginning of the English version of the Texas Health and Human Services required information handout that was incorrectly previously identified in this policy on Page 2, Procedures; Item 1 b) as “The patient will be provided a copy of the Texas Department of State Health Services Information Sheet for Sexual Assault Patients.” The handout was 8 pages and ended on policy page 11. This version of the handout was dated 3-18-2022 and was outdated without the most current information. The most recent handout was last updated on 12-20-2023. Page 12 was the beginning of the Spanish version of the Texas Health and Human Services required information handout. This version of the handout was dated 3-18-2022 and was outdated without the most current information. The most recent handout was last updated on 12-20-2023. Patient records were reviewed on 12-2-25 as follows: Patient #67 Patient #67 was a 3-year-old child brought in on 6-18-25 by her mother and grandmother for a possible sexual assault. The sexual assault was thought to have occurred at the end of March. Per the physician’s note under History of Present Illness, “Apparently the patient told her mother about a week ago that someone may have put a wooden block into her vagina. The details are very vague regarding this. Patient has seen her pediatrician for recurrent urinary tract infection and was placed on 2 different antibiotics. She apparently is still complaining of pain to the vaginal area and pain when she urinates. She has had no fever or chills.” Per the physician’s note under Medical Decision Making, “CPS (child protective services) report was conducted. Patient has great follow-up in caring mother and grandmother. Urinalysis reviewed which showed many budding yeast. No sign of bacterial infection at this time. Suspect candidiasis due to recent antibiotic therapy. Differential diagnoses considered are: UTI (urinary tract infection, candidiasis, sexual assault;” There was no evidence in the medical record review that the mother or grandmother was provided the State mandated information form. On page 2 of the State mandated information form under Your Rights as a Survivor, the form stated “For parents, or guardians of a minor child, your child has the right to receive the forensic medical examination at any time, regardless of when the assault occurred.” There was no evidence in the medical record review that the mother or grandmother was explained this right or that a referral to the local child advocacy center was made for a forensic interview and examination to rule out a sexual assault as listed in the physician’s notes as a considered differential diagnosis (a possible diagnosis that could be causing the symptoms presented by the patient). There was no evidence in the medical record that a sexual assault advocate had been requested if available to assist the family. Page 1 of the State mandated information form advised patient of their right to have a trained sexual assault advocate in the exam room with them. “If an advocate is available, they will come and have a confidential conversation with you. An advocate can answer any questions about the process and inform you of your options every step of the way.” There was no evidence in the medical record review that the mother or grandmother was provided the name and telephone number of the nearest sexual assault crisis center. Patient #68 Patient #68 was a 43-year-old who presented to the ED on 11-4-24 via Emergency Medical Services (EMS), stating she was sexually assaulted 2 days prior. Patient reported she was homeless. There was no evidence in the medical record review that the patient was provided the State mandated information form. There was no evidence in the medical record that a sexual assault advocate had been requested if available to assist the patient. Page 1 of the State mandated information form advised patient of their right to have a trained sexual assault advocate in the exam room with them. “If an advocate is available, they will come and have a confidential conversation with you. An advocate can answer any questions about the process and inform you of your options every step of the way.” The physician examination notes showed, “Progress comments: Spoke with Detective (name redacted) with ACSO (Angelin County Sherrif’s Office) and they are going to arrange for her to Shelter tonight and have SANE exam in am. Spoke with on call nurse with (name of community-based program redacted) and she requested UA (urine analysis) and UDS (urine drug screening)” There was no evidence in the medical record review that the patient was advised of her right to have an examination in the ED and not have to wait until the next day to have an examination performed by a SANE. On page 2 of the State mandated information form under Your Rights as a Survivor, the form stated, “Texas law requires health care facilities that are not SAFE-ready to give survivors of sexual assault this informational handout and notify of your right to choose to have an exam conducted at this facility or to be transferred to another facility. It is your decision about whether you want to be transferred to another facility.” There was no evidence that the patient’s right to receive prophylactic medications for sexually transmitted infections (STIs), human immunodeficiency virus (HIV), or unwanted pregnancy was discussed with the patient, offered, or ruled out for personal or medical reasons. Patient #69 Patient #69 was a 15-year-old who presented to the ED on 1-2-25. “Patient arrives to ER private vehicle with a friend to report a sexual assault, does not remember the exact day it happened, thinks it might have been Tuesday evening at a house she was staying at. Pt reports the incident happened while she was sleeping, the male living at the house got into her bed, started touching her lower body while the patient told the male to stop.” There was no evidence in the medical record review that the patient was provided the State mandated information form. There was no evidence in the medical record that a sexual assault advocate had been requested if available to assist the patient. Page 1 of the State mandated information form advised patient of their right to have a trained sexual assault advocate in the exam room with them. “If an advocate is available, they will come and have a confidential conversation with you. An advocate can answer any questions about the process and inform you of your options every step of the way.” The physician examination notes showed, “Progress comments: Patient reports alleged sexual assault 2 days ago. Patient medically cleared there is no evidence of other trauma or any other issue requiring workup in the ER. Patient is medically cleared to go to (name of community-based program redacted) for SANE exam.” There was no evidence in the medical record review that the patient was advised of her right to have an examination in the ED and not have to wait until the next day to have an examination performed by a SANE. On page 2 of the State mandated information form under Your Rights as a Survivor, the form stated, “Texas law requires health care facilities that are not SAFE-ready to give survivors of sexual assault this informational handout and notify of your right to choose to have an exam conducted at this facility or to be transferred to another facility. It is your decision about whether you want to be transferred to another facility.” There was no evidence that the patient’s right to receive prophylactic medications for sexually transmitted infections (STIs), human immunodeficiency virus (HIV), or unwanted pregnancy was discussed with the patient, offered, or ruled out for personal or medical reasons. Patient #70 Patient #70 was a 39-year-old who presented to the ED on 3-22-25 with complaint of “patient states she was sexually assaulted 16 days ago, she has not filed a police report at this time and is here today because (sic) he (sic) husband found out about the assault. She reports lower abdominal pain, pressure and frequency with urination. Information given to her about how to obtain resources through (name of community-based program redacted) and her rights.” There was no evidence in the medical record review that the patient was provided the State mandated information form. There was no evidence in the medical record that a sexual assault advocate had been requested if available to assist the patient. Page 1 of the State mandated information form advised patient of their right to have a trained sexual assault advocate in the exam room with them. “If an advocate is available, they will come and have a confidential conversation with you. An advocate can answer any questions about the process and inform you of your options every step of the way.” Patient #71 Patient #71 was a 35-year-old who presented to the ED on 5-2-25 with complaint of, “Pt accompanied by friend, reports she was sexually assualted on last Friday, states that her assaulter inserted either himself, and object or both into her rectum, states she has been experiencing rectal bleeding since then, also reports that last wednesday her assualter physically attacked her injuring her left wrist, pt also brings up complaints of generalized rash and states a sore on her left shin is leaking “lymphatic fluid”, reports SA occured in Nacogdoches county, Charge RN made aware and reports will contact that county to get a police report and case number.” (sic) “05/02/2025 17:26 Category Note: Patient reports physical assault on 4/23, went to (name of hospital redacted) for wrist/arm pain. Patient reports then a sexual assault on 4/25, did not go to hospital, states that she went to a homeless/domestic violence shelter where she has found a friend who has accompanied her to ER and has recommended having a ultrasound of her rectum. Patient reports sexual assault at (location redacted). I attempted to contact garrison pd, no answer. I then contacted Nacogdoches SO at 1726, spoke with (name redacted) #2461, states he will have garrison PD contact us. I then spoke with officer (name redacted) at 1734, states he will call me back shortly but he believes he is going to come out to speak with patient.” “05/02/2025 17:57 Category Note: Spoke with patient, patient states that she doesnt want to release name of the person who assaulted her. She states that she has a legal advocate that she is going thru and is filing this sexual assault on monday with S/O, S/O states that this is a garrison PD area. I explained that to patient and also officer (name redacted) who states he is in route to eval patient. Patient states that she will not speak to a male officer.” “05/02/2025 18:15 Category Note: Spoke with (name redacted) who is the forensic nursing coordinator at (name of community-based program redacted). She states that she has autism and that this assault is out of the time frame for a exam. That patient is strictly here for rectal pain. Patient does have a legal guardian that is helping her thru the family crisis center and (community-based program name redacted) to help her.” There was no evidence in the medical record review that the patient was provided the State mandated information form. There was no evidence in the medical record that a sexual assault advocate had been requested if available to assist the patient. Page 1 of the State mandated information form advised patient of their right to have a trained sexual assault advocate in the exam room with them. “If an advocate is available, they will come and have a confidential conversation with you. An advocate can answer any questions about the process and inform you of your options every step of the way.” The record reflected that Law Enforcement was notified but no evidence that the patient was asked if she wanted to involve Law Enforcement prior to contacting them. On page 2 of the State mandated information form under Your Rights as a Survivor, the form stated, “If you are 18 or older, you may choose whether or not to report the assault to law enforcement.””

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure grievances were resolved timely in 1 of 5 patients reviewed for complaint and grievances (Patient #4). Patient #4’s family voiced a grievance regarding care issues and HIPPA violations on 01/26/2025 and the grievance was not resolved until 06/17/2025 (over 4.5 months later). This deficient practice had the likelihood to affect all patients who filed a grievance. Findings include: Review of the ED (emergency department) record of Patient #4 revealed he was a 37 year old male who presented to the ED (emergency department) on 01/23/2025. Patient #4 came in with complaints of blood from his left nephrostomy tube for 1.5 days. According to the notes Patient #4 said he was told to come to the ED for emergent dialysis. Documentation in nurses notes dated 01/26/2025 revealed the house supervisor was informed of Patient #4’s mom was requesting to speak to him regarding the patient’s care and wanting to transfer her son. Review of the facility’s complaint and grievance log revealed Patient#4’s mom made a grievance on 01/26/2025. The following was documented: Patient #4’s mom”came up to the nursing station requesting to speak to the on call MD, house supervisor and patient advocate. “Wanting to initiate transfer to outside facility. (Patient #4’s mom) was visibly upset and was asked to lower her voice due to other patients on unit other staff present ... ... ....She state that her son is dying in room, suffering and fluid is building up and toxins are accumulating. Explained that is one doctor in house at this time, but ...RN would notify (the doctor) of her wishes to initiate transfer. I would reach out to ...the house sup and I would obtain information about patient advocate. These steps would be taken and asked her to go back to patient’s room and we would inform her of information as it became available. Once she was back in room she stated that when she requested those things to (Staff #139) he became “upset” and that’s why she came up to the nurses station. She also states that she could hear (Staff #139) giving everyone her son’s medical information and when she came outside to tell him that not everyone needed to know her son’s medical information (Staff #139) “got in her face and shook his finger at her” (Staff #139) present at bedside an states he was speaking to (the doctor). She also states that (Staff #86) was called yesterday and she was promised he would round and never did.” According to documentation on the form the complaint was escalated to a grievance and sent to legal. Review of another grievance form revealed the grievance was received on 05/23/2025 (almost 4 months later). The mother was upset and alleged medical negligence, nurses failed to render care, manage his pain, failed to insert a Foley catheter and the urologist failed to render care. There was documentation on the form that legal has agreed that we can go ahead with the process of investigating the mother’s allegations. According to the form the grievance was resolved, and the first letter was sent to Patient #4 on 05/29/2025 and the final response on 06/17/2025. During an interview on 12/03/2025 at 10:23 a.m., Staff #136 said the original complaint came in on 01/28/2025 and it was from the mom. Staff #140 told her to escalate to legal. Staff #136 said she tried to call Patient #4 but never got in touch with him. She reopened the complaint as soon as legal let her know something. Staff #136 said she sent the letter to Patient #4 instead of the mom. During an interview on 12/04/2025 at 9:28 a.m., Staff #140 revealed the complaints was originally made in January 2025. The family was threatening to get a lawyer, and they wanted their legal opinion. Staff #140 said their legal department dropped the ball and did not get back to them for about 3-4 months. Review of a facility’s policy named “Grievance and Complaint Management” dated June 2024 revealed the following: B. IDENTIFYING A GRIEVANCE ...2. Grievances may be made by patients, visitor or their representatives. If someone other than a patient or visitor complains about a patient or visitor’s experience at the organization, attempts shall be made to contact the patient or visitor to confirm that the individual making the complaint is their representative.(Note: References to patients and visitors throughout this Procedure are intended to include their representatives.) A. If the individual making the complaint is a patient’s representative, then the patient’s explicit permission is needed to discuss Personal Health Information (PHI) in accordance with applicable privacy laws ... ...D. PROCEDURES APPLICABLE TO ALL GRIEVANCES: .... ...2. The organization must attempt to resolve all grievances as soon as possible ... ...E. COMPLAINTS RELATED TO PATIENT CARE AND SERVICES (Patient Care Grievance(s)”):1. Grievance Process and Decision a. The Point of Contact shall provide a response to a Grievance in writing within seven (7) calendar days of the complaint. i. If the investigation will not be completed, or if the Grievance will not be resolved, within (7) calendar days, the organization shall inform the patient or visitor that the organization needs additional time to resolve the Grievance and indicate the timeframe in which the response will be provided. b. Reasonable efforts shall be made to resolve all Grievances within thirty(30) calendar days and in accordance with regulatory requirements. If the matter cannot be resolved within thirty (30) calendar days, then a written status report shall be provided to the patient or visitor within that time frame. This status report shall include the estimated timeframe for completing the investigation and issuing a written report. c. A written report regarding the outcome of the investigation as to each Grievance must be provided to the patient or visitor ...””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure communicate results of a grievance timely to the complainant 1 of 5 sampled patients reviewed for complaint and grievances (Patient #4). Patient #4’s family voiced a grievance regarding care issues and HIPPA violations on 01/26/2025 and the grievance was not resolved until 06/17/2025 (over 4.5 months later). Patient #4’s family member who voiced the grievance was never informed of the results of the investigation. This deficient practice had the likelihood to affect all patients who filed a grievance. Findings include: Review of the ED (emergency department) record of Patient #4 revealed he was a 37 year old male who presented to the ED (emergency department) on 01/23/2025. Patient #4 came in with complaints of blood from his left nephrostomy tube for 1.5 days. According to the notes Patient #4 said he was told to come to the ED for emergent dialysis. Documentation in nurses notes dated 01/26/2025 revealed the house supervisor was informed of Patient #4’s mom was requesting to speak to him regarding the patient’s care and wanting to transfer her son. Review of the facility’s complaint and grievance log revealed Patient#4’s mom made a grievance on 01/26/2025. The following was documented: Patient #4’s mom”came up to the nursing station requesting to speak to the on call MD, house supervisor and patient advocate. “Wanting to initiate transfer to outside facility. (Patient #4’s mom) was visibly upset and was asked to lower her voice due to other patients on unit other staff present ... ... ....She state that her son is dying in room, suffering and fluid is building up and toxins are accumulating. Explained that is one doctor in house at this time, but ...RN would notify (the doctor) of her wishes to initiate transfer. I would reach out to ...the house sup and I would obtain information about patient advocate. These steps would be taken and asked her to go back to patient’s room and we would inform her of information as it became available. Once she was back in room she stated that when she requested those things to (Staff #139) he became “upset” and that’s why she came up to the nurses station. She also states that she could hear (Staff #139) giving everyone her son’s medical information and when she came outside to tell him that not everyone needed to know her son’s medical information (Staff #139) “got in her face and shook his finger at her” (Staff #139) present at bedside an states he was speaking to (the doctor). She also states that (Staff #86) was called yesterday and she was promised he would round and never did.” According to documentation on the form the complaint was escalated to a grievance and sent to legal. Review of another grievance form revealed the grievance was received on 05/23/2025 (almost 4 months later). The mother was upset and alleged medical negligence, nurses failed to render care, manage his pain, failed to insert a Foley catheter and the urologist failed to render care. There was documentation on the form that legal has agreed that we can go ahead with the process of investigating the mother’s allegations. According to the form the grievance was resolved, and the first letter was sent to Patient #4 on 05/29/2025 and the final response on 06/17/2025. During an interview on 12/03/2025 at 10:23 a.m., Staff #136 said the original complaint came in on 01/28/2025 and it was from the mom. Staff #140 told her to escalate to legal. Staff #136 said she tried to call Patient #4 but never got in touch with him. She reopened the complaint as soon as legal let her know something. Staff #136 said she sent the letter to Patient #4 instead of the mom. During an interview on 12/04/2025 at 9:28 a.m., Staff #140 revealed the complaints was originally made in January 2025. The family was threatening to get a lawyer, and they wanted their legal opinion. Staff #140 said their legal department dropped the ball and did not get back to them for about 3-4 months. Review of a facility’s policy named “Grievance and Complaint Management” dated June 2024 revealed the following: B.IDENTIFYING A GRIEVANCE ...2. Grievances may be made by patients, visitor or their representatives. If someone other than a patient or visitor complains about a patient or visitor’s experience at the organization, attempts shall be made to contact the patient or visitor to confirm that the individual making the complaint is their representative.(Note: References to patients and visitors throughout this Procedure are intended to include their representatives.) A. If the individual making the complaint is a patient’s representative, then the patient’s explicit permission is needed to discuss Personal Health Information (PHI) in accordance with applicable privacy laws ... ...D. PROCEDURES APPLICABLE TO ALL GRIEVANCES: .... ...2. The organization must attempt to resolve all grievances as soon as possible ... ...E. COMPLAINTS RELATED TO PATIENT CARE AND SERVICES (Patient Care Grievance(s)”):1. Grievance Process and Decision a. The Point of Contact shall provide a response to a Grievance in writing within seven (7) calendar days of the complaint. i.If the investigation will not be completed, or if the Grievance will not be resolved, within (7) calendar days, the organization shall inform the patient or visitor that the organization needs additional time to resolve the Grievance and indicate the timeframe in which the response will be provided. b.Reasonable efforts shall be made to resolve all Grievances within thirty(30) calendar days and in accordance with regulatory requirements. If the matter cannot be resolved within thirty (30) calendar days, then a written status report shall be provided to the patient or visitor within that time frame. This status report shall include the estimated timeframe for completing the investigation and issuing a written report. c.A written report regarding the outcome of the investigation as to each Grievance must be provided to the patient or visitor ...””

“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: 29191 Based on record review and staff interviews, the hospital staff failed to ensure proper execution of informed consent in 7 (#7, #11, #21, #22, #23, #30, #31) of 7 patient medical records reviewed. Additionally, the hospital staff did not follow the “Disclosure and Consent for Medical and Surgical Procedures” policy. The hospital staff failed to ensure: A. proper execution of informed consent for Hemodialysis for Patient #7. B. patient # 11 was deemed competent to provide consent for blood transfusions prior to the initiation of blood products. C. the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Form” listed the treatments refused, the risks for refusing treatment for Patient #21 and Patient #23.That all portions of the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Form” was signed, dated, and timed for Patient #21, #22, and #23. D. consent to admission and notification of patient rights were obtained upon admission on Patient #31. Findings include: A. A review of medical records was conducted with Staff #29 on 12/01/2025 at 3:30 PM. Patient # 7 A 57-year-old with CKD, diabetes, hypertension, CHF, and CAD presented to the outside ER with complaints of volume overload and fluid retention for the last several weeks. Patient states that she has been compliant with medications, but has progressively gotten more swollen. The Patient denies any worsening dyspnea. Patient states that she is on a 2 L nasal cannula at night. Denies any chest pain, fever chills currently. Patient #7 was receiving hemodialysis on 12/01/2025 with complaints of weakness. A review of the consent for Hemodialysis on 12/01/2025 indicated that the patient’s signature was not signed with the patient’s actual signature. The surveyor confirmed that the signature differed from her usual signature by reviewing other hospital consents that the patient had signed. Additionally, the informed consent had the wrong date (1/14/2025) signed by staff # 34. There was no indication of who signed the patient’s name to the consent, and if it was a verbal consent, there were no witnesses. If the signature was signed by a family member, there was no indication of which family it was. An interview was conducted with Staff #30 (ICU Director) on 12/01/2025 at 4:00 PM and confirmed that hospital Staff #34 did not follow the procedure for obtaining informed consent for Hemodialysis for Patient #7. There were no witnesses to the signature on the consent or to who had signed the consent. An interview was conducted with Staff #29 on 12/01/2025 at 4:30 PM and confirmed that the hospital staff were not obtaining proper consent before performing treatment and care on patients at the hospital. Staff #29 confirmed that the hospital staff were not following the hospital’s Informed Consent policy in obtaining two signatures if a patient could not sign. 48653 B. A review of Patient # 11’s medical record was conducted with Staff # 20 on 12/01/2025. Patient # 11 was admitted to the hospital on 11/26/2025 with a diagnosis of AMS (Altered Mental Status). A review of Staff # 124’s (ER Physician) provider note dated 11/26/2025 revealed, “A 86 year old male with a history of diabetes mellitus and deep vein thrombosis presents to the ED via EMS with complaints of altered mental status. EMS reports that the patient’s neighbor found him confused this morning. The patient reports that he has been having diarrhea for the last 2 days ....Physical Examination: Neuro: Appears confused ....” A review of nursing assessment completed on 11/26/2025 at 2:30 PM revealed, “Neurological: Weakness, and confused ...” The patient had severe anemia (low blood levels) and required a blood transfusion. A review of the “Disclosure and Consent for Medical Care and Surgical Procedures, Blood Transfusion” revealed that the patient signed the consent form on 11/26/2025 at 5:53 PM after ER Physician Staff # 124 and nursing staff documented that the patient was confused. The ER Physician Staff # 124 obtained consent from a patient with a known altered mental status and confusion. An interview was conducted with Staff # 20 on 12/01/2025 at 2:00 PM, which confirmed the patient was documented as being confused and having an altered mental status, which would render the patient incompetent to provide consent. 48749 C. Patient #21 Patient #21, a 56-year-old male, arrived at the Hospital’s Emergency Department (ED) on 11/13/2025 at 6:20 PM for complaints of numbness and weakness. The ED Triage nurse activated a Code Stroke at 6:20 PM. The ED Physician evaluated patient #21 at 6:24 PM. The ED Physician documented admission for an MRI and further workup. Patient #21 refused admission and requested discharge. Patient #21 signed the hospital’s “Refusal to Permit Examination, Treatment, Transport, or Transfer Form. Further review of the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Form” revealed that the section for the declination of services provided and the risks of refusing services was blank. Also, the ED staff did not date and time the form. Patient #22 Patient #22, a 13-year-old female, arrived at the Hospital’s Emergency Department (ED) on 11/19/2025 at 7:46 PM for complaints of headache, chest pain, dizziness, and middle back pain. At 23:02, the ED nurse documented that the patient’s mother did not want an intravenous line or medication. The patient’s mother signed the hospital’s against medical advice form. A review of the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Form” revealed that it was not dated, timed, or signed by the ED Physician. Patient #23 Patient #23, a 56-year-old male, arrived at the Hospital’s Emergency Department (ED) on 11/05/2025 at 1:20 PM with a complaint of a hole in the bottom of the right foot. The patient was evaluated by the ED Physician at 2:40 PM and was diagnosed with sepsis and diabetic foot wound. The ED Physician recommended admission and transfer to a higher level of care. The patient refused transfer and admission. A review of the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Form” revealed that the risks for refusing treatment were not listed, and there was no witness signature. An interview conducted on 12/02/2025 at 10:20 AM with Staff #22 confirmed that the hospital’s ‘Refusal to Permit Examination, Treatment, Transport, or Transfer Forms” were not completed in their entirety. 51905 D. A review of Patient #31’s medical record was conducted with Staff #58 on 12/03/2025. Patient #31 was admitted to the hospital on 11/27/2025 at 8:24 P.M. with a diagnosis of sepsis. A review of Staff #151’s (ER Physician) provider notes on 11/27/2025 at 11:28 P.M. revealed, Patient #31 presented to the ER (emergency room) via ambulance from a nursing home, with a critical blood glucose level of 30. Patient #31’s Glasgow Coma Scale (a scale used to determine a patient’s level of consciousness) was 15, indicating that the patient was conscious and alert, and oriented times three, knowing person, place, and time. A review of the “General Consent on Admission” and “Patient Rights” revealed that Patient #31 was “medically unable to sign”. There was no hospital representative signature or witness signature to verify that Patient #31 was unable to sign. Patient #31 was admitted to the hospital without consent to admission or notification of patient rights. An interview was conducted with Staff #58 on 12/03/2025 at 1:45 P.M., which confirmed Patient #31 was documented as being alert and oriented and competent to provide consent. A review of the hospital’s policy titled “Disclosure and Consent for Medical and Surgical Procedures” with a date of September 2024 revealed the following: “Policy: DEFINITIONS Analgesia -Medication to provide relief of pain through the blocking of pain receptors in the peripheral and/or central nervous system. Anesthesia -Medication to produce a blunting or loss of: * pain perception (Analgesia); * voluntary and involuntary movements; * autonomic function; and/or * memory and/or consciousness, depending on where along the central neuraxial (brain and spinal cord) the medication is delivered. Decision-Making Capacity -The ability to understand and appreciate the nature and consequences of a decision regarding medical treatment and the ability to reach and communicate an informed decision in the matter. Disclosure -In the context of informed consent, means communicating the risk, benefits and alternatives to medical treatment. The act of making something known. Informed Consent - The permission given by a patient to perform a medical treatment or surgical procedure after the patient has been advised of and fully understands the risks, benefits and alternatives or hazards that could influence a reasonable person in deciding whether or not to consent. In order for the patient to make an informed decision about whether to consent, the patient needs information from the Responsible Practitioner about the treatment or procedure, including the associated risks, benefits and alternatives. Informed Consent deals with the information provided by the Responsible Practitioner to the patient, in a language or means of communication he/she understands, and how it is provided when obtaining the patient’s permission to perform the treatment or procedure. List A Procedures - Medical treatments and surgical procedures that the Texas Medical Disclosure Panel has determined require a full Disclosure of specific risks and hazards when obtaining Informed Consent. List B Procedures - Medical treatments and surgical procedures that the Texas Medical Disclosure Panel has determined do not require any Disclosure of specific risks or hazards associated with the treatment or procedure. Minor - A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes. Responsible Practitioner - The attending practitioner or the practitioner performing the treatment or procedure. Surrogate Decision Maker - An adult (18 years of age or older) who may consent to medical treatment or surgical procedures on behalf of a patient lacking capacity, provided such Surrogate Decision Maker: 1. Has Decision-Making Capacity; 2. Is available after a reasonably diligent inquiry; and 3. Is willing to consent to medical treatment or surgical procedures on behalf of the patient. In the case of a Minor, the Surrogate Decision Maker is a parent, managing or possessory conservator or guardian. Texas Medical Disclosure Panel (TMDP) - A panel appointed by the Texas Commissioner of Health to determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients, and to establish the general form and substance of such Disclosure. A. It is the policy of St. Luke’s Health (St. Luke’s) Texas Division to comply with applicable regulatory and accreditation requirements pertaining to Disclosure and Informed Consent for medical treatment or care and surgical procedures, including specific procedures outlined by: * Code of Federal Regulation ( 42 CFR Part 482), CMS Conditions of Participation, Appendix A * DNV NIAHO Interpretive Guidelines and Surveyor Guidance * Texas Administrative Code (TAC) Hospital Licensing Rules, Title 25 Part 1 Chapter 133 * Texas Medical Disclosure Panel (TMDP), Chapter 601, Informed Consent, Title 25 Part 7 Chapter 601 B. It is the policy of St. Luke’s Health (St. Luke’s) Texas Division entities that physicians, employees and individuals associated with a St. Luke’s organization are required to abide by the Ethical and Religious Directives for Catholic Health Care Services (“Directives”). a. Per Directive #26: The free and informed consent of the person or the person’s surrogate is required for medical treatments and procedures, except in an emergency situation when consent cannot be obtained and there is no indication that the patient would refuse consent to the treatment. Per Directive #27: Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all. C. The patient or his/her Surrogate Decision Maker, as allowed under Texas law, has the right to make informed decisions regarding his/her care, including consent to or refusal of medical treatments and surgical procedures, including transfusion of blood and blood components. Exceptions to individuals authorized to consent for a patient are addressed in Procedure. D. The attending practitioner, the practitioner providing the medical treatment or performing the surgical procedure, including transfusion of blood and blood components, the practitioner’s associate, or a practitioner under the Responsible Practitioner’s supervision is responsible for discussing the process of and obtaining Informed Consent from the patient or his/her Surrogate Decision Maker. PROCEDURES: 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. a. In order for the patient or his/her Surrogate Decision Maker to make an informed decision, it is necessary to provide adequate information in a manner that he/she can understand about: the planned medical treatment or surgical procedure in a manner that he/she can understand and the potential for examinations or invasive procedures by students, residents, advanced practice providers (such as nurse practitioners and physician assistants), and fellows for educational and training purposes, including but not limited to, breast, pelvic, prostate, and rectal examinations, as well as others specified under state law which are not a medically necessary part of the planned procedure while anesthetized or unconscious. 2. Discussion for Informed Consent a. Medical Treatments or Surgical Procedures The attending practitioner, the practitioner performing the treatment or procedure, the practitioner’s associate, or a practitioner under the Responsible Practitioner’s supervision conducts the Informed Consent discussion with the patient or his/her Surrogate Decision Maker. b. Anesthesia and/or Analgesia An Anesthesia provider and/or the Operating practitioner administering the Anesthesia and/or Analgesia conducts the Informed Consent discussion with the patient or his/her Surrogate Decision Maker. Non-physician health care providers, such as a Certified Registered Nurse Anesthetist (CRNA) or an Anesthesiologist Assistant (AA), are also qualified to conduct the Informed Consent process for Anesthesia and/or Analgesia if they are credentialed and privileged to administer Anesthesia. c. The Informed Consent responsibility may not be delegated to members of the nursing staff or other members of the hospital’s workforce. d. Verify that the consent form is completed and patient or his/her Surrogate Decision Maker signed the Informed Consent form prior to commencing the medical treatment or surgical procedure. e. Sign, with date and time, the statement on the consent form that the medical treatment or surgical procedure including the risks, benefits and alternative were explained to the patient or his/her Surrogate Decision Maker prior to commencing the medical treatment or surgical procedure. a. Include the following components in the discussion with the patient or his/her Surrogate Decision Maker: 1. A description of the proposed medical treatment or surgical procedure including the Anesthesia to be used. 11. Indications for the proposed medical treatment or surgical procedure, including: 1. Disclosure of the risks, benefits, and alternatives of the medical treatment or surgical procedure. 2. List A Procedures, the Disclosure of risks must comply with the requirements of the TMDP and The Texas Medicaid Program (sterilization). 3. List B Procedures or other procedures not on List A or List B, Disclosure of specific risks is at the discretion of the attending practitioner or practitioner performing the medical treatment or surgical procedure. iii. Material risks and benefits for the patient related to the surgery and Anesthesia, if applicable, including the likelihood of each. b. Telephone Consent Oral consent over the telephone may be obtained when the patient lacks capacity to give Informed Consent, and the patient’s Surrogate Decision Maker is not physically present at the healthcare facility where the treatment or procedure will be performed and cannot reasonably be expected to attend such facility prior to the start of the treatment or procedure. i. The Responsible Practitioner obtains verbal consent in accordance with the procedures described for obtaining written consent. ii. The Responsible Practitioner [see Procedure Section 2. above] is required to obtain oral consent by talking with the patient’s Surrogate Decision Maker in the presence of a witness who is listening to both parties as Informed Consent is obtained. iii. Record the name of the Surrogate Decision Maker giving Informed Consent and that individual’s relationship to the patient on the consent form. iv. Record the name of the Responsible Practitioner obtaining consent and the witness on the consent form with a notation that Informed Consent was obtained by telephone. 6. Informed Consent - Adult Patient a. Decision-Making Capacity Adult patients (18 years or older) must sign authorizations for treatment on their own behalf unless they lack Decision-Making Capacity to give Informed Consent. b. Lack of Decision-Making Capacity A patient lacks Decision-Making Capacity if he/she is less than 18 years old or when his/her mental status is altered and he/she cannot comprehend information regarding the proposed treatment or procedure as a result of his/her underlying medical condition (as determined by the Responsible Practitioner). 1. If the patient lacks Decision-Making Capacity, the Responsible Practitioner, or the Responsible Practitioner’s designee, will make an entry into the Progress Notes documenting the following: 1. Patient’s mental status; 2. Physical condition; 3. Patient’s inability to make informed decisions; and 4. The proposed medical treatment or procedure. ii. The Responsible Practitioner, or the Responsible Practitioner’s designee, shall make a reasonably diligent effort to contact or cause to be contacted the persons eligible to serve as surrogate decision-makers. Efforts to contact those persons shall be recorded in detail in the patient’s medical record. 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; refer to St. Luke’s policy and procedure regarding advance directives; or 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 the patient...””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 51905 Based on observation, interview and record review, the facility failed to ensure adequate staffing on 2 of 2 units reviewed for staffing (Progressive care unit/PCU, Intensive Care unit/ICU): The facility failed to: A.Ensure adequate numbers of licensed nurses and patient care techs on PCU. B. Ensure patient acuity was utilized and appropriately used to staff on ICU and PCU. This deficient practice had the likelihood to cause harm on all patients housed on both units. Findings include: Observations Progressive Care Unit on 12/3/2025 at 11:47 A.M.: The floor nurse currently has 3 patients, and 1 is an ICU patient. The charge nurse was assigned 2 patients. During the survey, multiple phone calls rang while on the unit. No nurse was available to answer them. Staff #58, from Quality, who was assisting the surveyors, was answering the calls. This was observed from 11:47 A.M. to 1:12 P.M. During confidential interviews the following was stated about staffing: The ICU patient had been on the PCU floor since “12/02/2025 at 12:04 P.M.The ICU patient currently on the PCU floor was stable and on a Lasix drip.” “The nurse-to-patient ratio is still 1 to 4 with ICU patients, though 1 to 3 is ideal. Technicians are 1 to 15. It was stated that” the unit has had 2 to 3 sheaths on the unit before, with only 2 to 3 nurses available. When discontinuing a sheath, the patient has to be monitored every 15 minutes and pressure has to be held on the site for an hour. This ties up a nurse and isn’t safe for patient care. Nurses are responsible for their own EKGs, lab work, vital signs, and transport. Nurses have difficulty obtaining timely lab work due to the workload and no techs until the census reaches 12-18. There is typically not a unit secretary available.” “The charge nurse is assigned to patients and is typically unable to assist other nurses. Though we currently have 2 patients, 1 patient became agitated and was running out of the room into other patient rooms. A “code gray” was called for physical assistance. The patient was subsequently medicated and ordered a sitter.” “Nurses are responsible for their own patient transport. If only 2 nurses are on the unit, the nurse cannot go, and the plan is for the house supervisor to take the patient.” “Day shift staffing is an issue. Nurses are assigned to 4 patients each. Sometimes there are 2 to 3 sheaths on the floor with only 2 to 3 nurses, and it takes 2 nurses to discontinue the sheath.” “Staffing on the ICU floor is 1 nurse to 2 patients. However, it isn’t unusual to have 1 nurse to 3 patients. I had 3 patients as recently as the week before.” 10135 During confidential interviews the following was stated about staffing: “We have new levels of care. We have observation and cath lab patients. We have the same acuity tool as before. There has been conversation about using the tool in ICU instead of here. It doesn’t really fit us now. The patient census is 1:4. We get a tech when there are 12 patients and a unit secretary at 18. The unit secretaries and tech are trained to draw blood, but that does not help when we are under those numbers.” “Patient census is down. Only thing we have trouble with is not having a tech. If we have 6 patients, the nurse takes 4 and the charge nurse takes 2. We could run into issues if the nurses are in patients room. There is no one to answer the phone or call lights. We could use a tech to answer call lights and phones promptly and assist with total patient care and turning.” “Have to have up to 12 patients to get an aide. On the day shift we have baths, foley cath care, turning and repositioning and incontinent care.” “Problem with staffing is the acuity of patients. When the patients are admitted they are classified as observation, but the doctor changes them to inpatient which increases the care they need.” “Sometimes the PCU patients come to ICU and the nurses have to take 3 patients” “The patient census has increased (on ICU) we do not use an acuity tool to determine staffing.” Review of assignment sheets, staffing sheets and the staffing matrix on 12/03/2025 after 3:11 p.m. for the timeframe of 11/19/2025 to 12/01/2025 the following was revealed: Every shift during this timeframe the charge nurse took patients except for 11/21st night shift. On 11/22,24,25 (night shift only),26,27,28,29,30/2025 there were two nurses on duty and both nurses had patients. On 11/25/2025 the census increased to 11 patients during the day shift. The staffing matrix called for 4 nurses and there was only 3 nurses. On 11/30/2025 the census increased to 9 patients during the day shift. The staffing matrix called for 3 nurses and there was only 2 nurses. There was no patent care techs mentioned except for when there was a patient needing a sitter. Staff #63 and 137 confirmed the numbers. During an interview on 12/03/2025 after 3:11 p..m. Staff #63 stated they took care of patients who had heart catherization during the pre and post operative timeframe. When reviewing the staffing sheets Staff #63 said she could not tell the surveyor which patients were catherization patients from looking at her assignment sheets. The information was not being kept up with. Protocols were provided for care on catherization patients and the following was revealed: “TR Band Patent Hemostasis Protocol” TR Band (Radial compression device) “Monitor access site and extremity distal to puncture wound every 15 minutes until TR Band is removed ... ...Limit movement in the affected arm for 6 hours post procedure ... ..Bed rest until 2 hours after device placement .... ...90 minutes after TR Band is applied, deflate 2 cc of air from the curr. If no bleeding occurs from the site, deflate 2 cc of air from the TR Band every 10 minutes until all air has been removed ...” “Skills: Femoral Arterial and Venous Sheath Removal..” “Maintain manual pressure for 15 to 30 minutes ...” Review of the facility’s policy named “Nurse Staffing Plan-Nursing Services (TX Markets)” dated March 2025 revealed the following: “...The Nurse Staffing Plan Characteristics:.. ...h. Is consistent with current standards established by the Texas Board of Nursing for RNs and LVNs, applicable private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations, as appropriate; ... ...l. Sets minimum staffing levels for patient care units as determined by the nursing assessment and in accordance with evidenced-based safe nursing standards as based upon multiple nurse and patient considerations; m. Includes a method for adjusting the nurse staffing grid for each patient care unit to provide staffing flexibility to meet patient needs; ... ...Nurse staffing are to be used by the hospital as a component in setting the nurse staffing budget and as a guide in assigning nurses hospital- wide ...””

“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: 10135 Based on interview and record review, the facility failed to ensure nurses evaluated care on 2 of 3 sampled patients who were reviewed for Foley catheter care (Patient #’s 30 and 39). The facility failed to ensure: A. Nurses obtained physician orders for continued use of Foley catheters and for placement of purewick catheters on Patient #39. B. Nurses obtained physician orders for continued use of a Foley catheter on Patient #30. This deficient practice had the likelihood to cause harm patients with Foley catheters. Findings include: Patient #39 Review of the clinical record of Patient #39 revealed he was a 92-year-old male who transferred from a sister facility on 11/17/2025. According to an admission assessment report Patient #39 arrived on the unit at 2:10 a.m. and had a diagnosis of a urinary tract infection. Staff documented that Patient #39 was a direct admit and had a Foley catheter that was inserted on 11/16/2025. At 4:30 a.m. there was documentation in nurses notes of Patient #39 being confused and trying to pull his Foley catheter out. At 10:50 p.m., there was documentation that Patient #39 had an indwelling catheter. On 11/18/2025 at 11:30 a.m. the Foley catheter was clamped for bladder training. On 11/19/2025 at 7:00 p.m., 11/20/2025 at 10:46 a.m. and 11/22/2025 at 12:29 p.m. there was documentation that Patient #39 had a pure wick Foley (external catheter). There was no documentation of nursing, changing out the Foley catheter that Patient #39 came into the facility with. Review of the clinical record revealed no physician’s order for an indwelling catheter or a purewick catheter. During an interview after 10:14 a.m., Staff #4 confirmed there was no physician orders for Patient #39 to have the Foley catheters. 51905 Patient #30 Review of the clinical record of Patient #30 revealed she was an 81-year-old female who presented from home via EMS (emergency medical services) on 11/30/2025 at 10:40 A.M. Patient #30 had a diagnosis of altered mental status and seizures. Patient #30 was intubated and sedated in the ER. At 2:21 P.M., an order was placed to admit Patient #30 to the intensive care unit. There was no documentation in the ER (emergency room) nurses’ notes of Patient #30 having a Foley Catheter inserted. No order for a Foley Catheter was placed at that time. On 12/01/2025 at 12:54 A.M., a nurse’s assessment documented Patient #30’s indwelling Foley catheter. Documentation of Patient #30’s Foley catheter continues throughout Patient #30’s admission. Review of the clinical record revealed no physician’s order for an indwelling catheter during Patient #30’s admission to the intensive care unit. During an interview on 12/02/2025 at 4:31 P.M., Staff #75 confirmed that there was no Foley catheter order documented in Patient #30’s clinical record. Staff #75 indicated that during interdisciplinary rounds on patients, Foley catheters are discussed as to when they need to be removed. Additionally, Staff #75 stated that the Foley catheter order prompts the Foley discontinuation. Review of a facility’s policy named “Indwelling Urinary Catheter and Care Policy” dated 05/11/2023 revealed the following: “B. Present on Admission (POA) 1. Assess indication and possibility of use of alternatives 2. Indications for replacing a Foley Catheter that is POA include: a. suspicion of infection bono-aseptic insertion is reported schoolyard catheter malfunction d. broken seal e. device cannot be properly maintained 3. If Foley is still indicated, get order for continuation through physician order ...””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 29191 Based on record review and staff interviews, the hospital’s emergency room staff failed to ensure vital signs were obtained and documented according to each patient’s Emergency Severity Index (ESI) level on two patients (#16 and #54) of the two medical records reviewed. Additionally, the hospital staff did not follow the policies, “Assessment/Reassessment and Core Nursing Standards of Practice - Med Surg, Telemetry, Ortho, Acute Rehab.” This inadequate practice could lead to delays in care and treatment because the emergency room staff did not obtain and document the patient’s vital signs promptly. All healthcare staff involved in the patient’s treatment and care could not monitor and provide the appropriate medical care because they did not have the most up-to-date information, including the patient’s vital signs. A review of patient medical records was conducted with Staff #24 on 12/03/2025 at 11:00 AM. Patient # 16 Patient # 16 was admitted to the Emergency Department on 11/18/2025 at 2:45 AM with complaints of Shortness of breath and black toe. The patient was rated as ESI level 3. Patient #16 was admitted with influenza, Pneumonia, Steph, and had a black toe with Staph. The patient had the last set of vital signs documented in the Emergency Department visit at 6:31 AM. The following vital signs were documented: “6:31 AM: Heart Rate: 98 H, Respirations: 7” L, Blood Pressure: 142/46, Pulse Oxygen Saturation: 93 % on Room Air.” Patient #16 was admitted as an inpatient at 5:30 AM but remained in the emergency room. According to policy, vital signs are taken every 4 hours. There were no documented 4-hour vital signs taken or with a change in condition, and there was a noted change in the condition. The patient was discharged from the Emergency Department and transferred to dialysis on 11/18/2025 at 10:27 AM. Patient #16’s next set of vital signs was 4 hours later in the dialysis unit: B/P 125/74, Heart rate 95. The patient’s blood pressure continued to decrease during treatment with a low BP of 63/40, and then respiratory arrest occurred. Patient #16 had a respiratory arrest in dialysis at 2:23 PM. Patient expired in the Intensive Care Unit on 11/20/2025 at 6:00 PM. Patient # 54 Patient # 54 was admitted to the Emergency Department on 11/21/2025 at 11:07 AM with complaints of a burning sensation all over her body. The patient was rated as ESI level 3. The patient had 1 set of vital signs documented during the entire Emergency Department visit. The following vital signs were documented: “11:07 AM: Heart Rate: 65, Respirations: 18, Blood Pressure: 112/50, Pulse Oxygen Saturation: 98 % on Room Air.” The patient was discharged from the Emergency Department to go home on 11/21/2025 at 1:23 PM. There were no other Vital signs taken. A review of the hospital policy, “Level 3 Urgent: Assignment to be within 10 minutes of bedding and Vital signs, depending on patient stability or the physician’s order. After interventions or a change in condition.” A review of the hospital policy “Nursing interventions minimum frequency and documentation” revealed the following: * Upon admission(within 30 min.) * Approximately Q8 h. * telemetry patients: Q4h. while awake, minimum of Q6h. * within 1 hour prior to discharge.” An interview with Staff # 24 (Quality Department) on 12/3/2025 at 11:00 AM confirmed that the Emergency Department staff were not obtaining and documenting the patient’s vital signs according to the hospital’s policies and /or a change in condition.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 10135 Based on observation and interview, the facility failed to ensure narcotics were destroyed in accordance to acceptable professional principles and in a safe manner on 1 of 1 medication room on K5 Medical-Surgical unit. This deficient practice had the likelihood to affect all patients on narcotics. Findings include: During an observation on 12/01/2025 after 11:12 a.m. the following was found: Medication room K5 Medical surgical unit The Stericycle hazardous waste container was stored inside a metal bin in the medication room. The top of the bin was soiled with a black buildup and remnants of white pills. When the top was opened pieces of medications were still sitting on top of the bin. They were not pushed down into the solution to properly dissolve. Staff #’s 58 and 59 confirmed the observation. Review of a facility’s policy named “Controlled Substance Management “ dated March 2024 revealed the following: ...A controlled substance is not considered wasted until the waste is documented and the controlled substance has been destroyed ....” Staff #’s 58 and 59 confirmed the observation.”

“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: 48653 Based on observation, record review, and staff interviews, the hospital failed to maintain a clean and sanitary environment to avoid sources of infection in 9 (Clinical Laboratory, Kitchen, Emergency Department, Inpatient Rehabilitation Unit, Intensive Care Unit/ICU, Progressive care unit/PCU, K5 Medical/Surgical unit, Labor and Delivery unit, and the outside biohazard storage room) of 9 areas of the hospital when the hospital failed to: A. ensure the clinical laboratory was free of dust, dirt, rust, and other unknown debris, and that all laboratory supplies were within the manufacturer’s expiration date. B. maintain one commercial ice machine in the kitchen in a clean and sanitary condition, creating a potential risk for contamination of ice used in patient food service. The hospital failed to follow the “Environmental Infection Prevention” policy. C. ensure the emergency department was free of dust, debris and other unknown substances, creating a potential risk of contamination. D. ensure their infection control policy was followed for patients in contact isolation. E. ensure hazardous and nonhazardous waste stored in medication rooms were free from rust and not soiled with dried spills. The facility failed to ensure supply storage bins in the medication room and emergency supply cart supplies were stored in a manner to prevent contamination. They failed to ensure expired medications were discarded (K5 medical surgical unit). The facility failed to ensure the emergency supply cart supplies were bagged to prevent contamination (PCU unit). The facility failed to ensure sterile supplies, medication and medication labels were stored in a manner to prevent contamination. Expired storage supplies were discarded, expired anesthesia filters were changed in Operating room 1 and 2 on the labor and delivery unit. A. Findings include: During a tour of the hospital’s clinical laboratory with Staff # 8 on 12/01/2025 at 10:41 AM, the surveyor observed the following infection control issues: *Expired Iris System Cleanser (425 milliliters) with an expiration date of 10-31-2025. The bottle was labeled as open on 10-28-25. *Expired Reagent A Buffer Solution Lot 238288 with an expiration date of 10/01/2025. The bottle was labeled as open on 09/23/2025. *Expired 2440-058MC:BHB Method Comparison Set Lot # 213645 with an expiration date of 07/31/2024. *There were two large wooden islands in the center of the clinical laboratory. The islands had areas where the wood was chipped, leaving pieces of raw wood exposed. The raw wood could not be adequately cleaned and disinfected. The hinges on the cabinet doors and drawers were covered in rust. There were areas where the rust was flaking off onto the floor. *There were old newspapers, dust, dirt, and other unknown debris located in the cabinets under the sink. The cabinet and associated piping had areas of corrosion and water damage inside the cabinets. *The freezer labeled “Chemistry Control Freezer # 8” had a thick buildup of ice on the walls and shelves of the freezer. The freezer could not be adequately cleaned and disinfected due to the large amount of ice buildup. *The freezer labeled “Calibrator Freezer #11” had a thick buildup of ice on the walls and shelves of the freezer. The freezer could not be adequately cleaned and disinfected due to the large amount of ice buildup. An interview was conducted with Staff # 8 on 12/01/2025 at 11:30 AM in the Clinical Laboratory. Staff # 8 confirmed the infection control issues in the Clinical Laboratory and stated, “We will get work orders placed”. 43853 B. Findings include: On December 1, 2025, at 11:11 a.m., during a kitchen tour, the commercial ice machine adjacent to the Chemical Storage Room was inspected in the presence of Staff #16 and #17. The interior upper edge of the ice machine and bin was examined from below, revealing visible brown and black build-up along the seam where the upper panel meets the side panels. The substance appeared as dark, irregular patches and streaks concentrated in the caulked areas, indicating accumulated residue that resembled mold or biofilm. On December 1, 2025, at 1:25 p.m., during an interview in the Nutrition Director’s office, Staff #17 indicated that Facilities Management was responsible for the cleaning and maintenance of the ice machine. Staff # 17 also stated that the infection control preventionist made frequent observation rounding of the kitchen and dietary areas; issues identfied were then corrected by staff. On December 1, 2025, at 1:40 p.m., an interview with Staff #13 in the conference room revealed that hospital staff were responsible for routine cleaning of the exterior of the ice machine, while the vendor conducts annual preventive maintenance (PM). A review of the facility’s Annual Ice Machine Preventive Maintenance binder showed that the last documented vendor maintenance occurred on June 6, 2025. Staff #13 confirmed that during the vendor PM, the ice machine and bin would be emptied, cleaned, and sanitized, and presented an invoice documenting that the machine had been descaled, sanitized, and that filters were replaced on June 6, 2025. The Ice Machine Preventive Maintenance- Semi Annual log reflected maintenance occurring on June 6, 2025. Staff #13 was asked if there was a policy regarding the cleaning of the ice machine and bin located in the kitchen, no policy was presented. Staff #20 provided a copy of the Environmental Infection Prevention policy, effective August 30, 2022. The policy stated: “6) Ice machines: Should be maintained to help to prevent water-borne illnesses. EVS (Environmental Services) should wipe down the machine cabinet and clean the tray routinely. Facilities Management is responsible for management of the cleaning of filters and components as well as Preventive Maintenance including monitoring for rust.” The policy section on ice machines appeared to address maintenance of the ice and water dispensers (hydration stations) located in the nourishment rooms found on patient units. However, it did not appear to include the commercial ice machine and bin located in the kitchen. On December 2, 2025, Staff #13 provided a copy of the Hoshizaki Instruction Manual for the Modular Flaker (ice machine) and noted the following under A. Maintenance Schedule: Frequency “Monthly”, Area “Underside of Icemaker and Top Kits; Bin Door and Snout”, Task “Wipe down with a clean cloth and warm water”. Frequency of “Every 6 Months”, Area included “Icemaker and Dispenser Unit/Ice Storage Bin”, Task “Clean and sanitize per the cleaning and sanitizing instructions provided in this manual.” On December 1, 2025, at 11:15 a.m. Staff #16 and #17 confirmed the findings related to the commercial ice machine adjacent to the Chemical Storage Room. 32143 Findings; A tour was conducted of the Inpatient Rehabilitation unit on 12-2-2025 at 9:13 AM with staff #78 marketing director of rehab services, and staff #24 RN. Patient room 176 was confirmed as a terminally cleaned room and was waiting for a patient. The bedside table base was covered in food crumbs, spilled dried fluids, dust, and hair. The seat cushions were removed from the two chairs. Under the seat cushions were food crumbs, dust, and hair. On the base of the bed, there was a dried, spilled liquid, off white in color. The mattress was removed, and the metal bed was rusted in multiple places underneath. There was rust, dirt, hair, and unidentifiable debris in the head and foot of the bed. The bathtub was heavily stained with minerals, and there was no cover for the overflow drain. The waterspout was heavily covered in mineral deposits, preventing the tub and faucets from being cleaned properly. Staff # 78 stated the patient did not use this bathtub and was taken across the hall to a shared shower room. The bathroom was larger and had a walk-in shower and a bathtub. A sign in the room stated the shower was clean. The tub was heavily stained with minerals, causing a black ring in the tub. The non-slip decals that were on the bottom of the tub were missing pieces and worn, allowing bacteria to grow. ICU Equipment Room 3079 A tour was conducted with staff #24 RN, staff #38 Nurse Manager, 4th floor on 12-02-2025 at 3:40 PM. The storage room had clean and sterile supplies in the room, on shelves against the wall. The nurse manager confirmed these were clean and sterile patient supplies in the room. In the middle of the room were multiple pieces of equipment, 12 ventilators, and 2 wound care carts. The equipment had clear plastic bags over it. The nurse manager was asked why the equipment that went back and forth to patient rooms was in the clean supply room. Staff #38 stated the vents were wiped down thoroughly before being covered and placed in the supply room. The surveyor pulled one of the vents out of the pile and uncovered the vent, exposing the soiled equipment. The vent was soiled on the bottom with a brown, dried liquid and dust. Staff #38 wiped off the dried liquid with a Sani wipe. Staff #38 confirmed the vent was not thoroughly cleaned. The clean and sterile supplies were exposed to soiled equipment and could cross-contaminate the supplies. ICU Equipment Storage 3056 A tour was conducted with staff #24 RN, staff #30 nurse manager, and staff #20 ortho coordinator on 12-02-2025 at 3:43 PM. The storage room had clean and sterile supplies in the room, on shelves against the wall. The nurse manager confirmed these were clean and sterile patient supplies in the room. In the middle of the room were multiple pieces of equipment, such as a portable EKG, and 4 large rolling carts with wheels against the clean and sterile patient supplies. The equipment was covered with a clear plastic bag to show that the equipment was clean. The bases of the carts were soiled with dried liquids, dirt, and hair. Staff #30 confirmed the carts were not cleaned appropriately. The clean and sterile supplies were exposed to soiled equipment and could cross-contaminate the supplies. 48749 C. Observation rounds were conducted on 12/01/2025 after 10:00 AM of the Emergency Department(ED) and the Outside Biohazard Storage. The following was observed. Emergency Department(ED) *There was an accumulation of dirt and debris on the floor of the helipad foyer. *There was trash overflowing from the trash can onto the floor of the helipad foyer. *There was an accumulation of dead insects inside the light covers of the elevator that accesses the helipad. Foyer. *There was an accumulation of dust and dirt on the floor of Trauma Room #3. *An uncovered ultrasound machine was sitting in the main hallway by the nurse’s station. There was an accumulation of dust on the base and shelf. There was an unknown dried, clear substance on the wands and in the wand holders. The Surveyor was unable to determine if the ultrasound machine was clean and ready for patient use. *There was an accumulation of dust and white particles in the plastic bins storing sterile supplies in the ED medication room. *There was an accumulation of dust and debris on the bottom of the Pyxis and inside the plastic bins in the Pyxis of the ED Medication room. *There was an unknown yellow substance stuck on the top shelf of the freezer, and there was an accumulation of food debris on the bottom of the freezer used to store patient nutrition. Outside Biohazard Storage *There were holes in the walls, broken drywall, and exposed insulation in the biohazard storage room. An interview was conducted with Staff #22 on 12/01/2025 at 3:20 PM. Staff #22 confirmed the Surveyor’s infection control findings in the Emergency Department. An interview was conducted with Staff #15 on 12/01/2025 at 11:00 AM. Staff #15 confirmed the Surveyor’s infection control findings in the biohazard storage room. 51905 D. On 12/01/2025 at 4:25 P.M., during a tour of the intensive care unit, Patient #30’s room had a contact precaution isolation sign on the door. On 12/02/2025 at 4:31 P.M., during a tour of the intensive care unit, Patient #30’s room did not have a contact precaution isolation sign on the door. A review of Patient #30’s chart revealed an order to discontinue isolation. On 12/02/2025 at 4:31 P.M., an interview with Staff #75, RN, Staff #75 indicated that Patient #30 no longer met the requirements for isolation as their wound culture came back as negative gram rods. Review of “Standard and Transmission-Based Precautions” policy, under “Multi-drug resistant organisms (MDROs),” gram-negative bacilli meet the requirement of contact precautions to prevent transmission of MDROs. On 12/03/2025 an interview with Staff #95, Infection Prevention nurse, stated the units do not isolate for ESBL, VRE, or MRSA (multi-drug resistant organisms (MDROs)). Staff #95 indicated that gram-negative bacilli is not isolated. Staff #95 was shown the “Standard and Transmission-Based Precautions” policy that lists the MDROs and gram-negative bacilli under contact isolation. Staff #95 agreed Patient #30 should be in isolation. On 12/03/2025 an interview with Staff #4, Quality Manager, revealed that the units do not isolate for ESBL, VRE, or MRSA. Staff #4 was shown the “Standard and Transmission-Based Precautions” policy. Staff #4 stated the hospital “needs to review the policy on isolation.” 10135 E. During observations on 12/01/2025 after 11:12 a.m. the following was found: K5 Medical Surgical unit Medication room The Stericycle hazardous waste container was stored inside a metal bin in the medication room. The bin was rusted and missing paint in areas. The top of the bin was soiled with a black buildup and remnants of white pills. A nonhazardous waste bin was stored underneath a supply shelf. The outside of the bin was soiled with a dried white substance. Supply bins which had sterile needles, intravenous tubing and lubricating jelly stored in them were soiled with white particles. Emergency crash cart Triple lumen central venous catheter kit expired 12/31/2024 was found on the emergency crash cart. Ambu bag with mask attached was stored in the respiratory box unbagged. Progressive care unit (PCU) After 12:44 p.m., an Ambu bag with mask attached was stored in the respiratory box unbagged on the emergency crash cart. Labor and delivery (L&D) unit Operating room #1 After 3:24 p.m., the anesthesia cart bins had a buildup of spills and black debris in the supply drawers. Two pressure infusion extension sets expired on 08/01/2025. A pulse oximeter sensor expired on 05/25/2025. A syringe with a needle attached was in the drawer along with batteries and cords. An unopened multidose vial of the paralytic agent succinylcholine which was tagged 11/25/2025 was still in the drawer. A non-sterile, single patient use pressure infuser was hanging up in the room. There was no indication as if it was clean or dirty. The filter on the anesthesia cart expired on 08/2021 (over 4 years ago). Operating room #2 A forehead oxygen saturation sensor was stored in the anesthesia cart which expired on 03/31/2025. The labels used to attach to vials of medication when opening them were housed on a metal container which was covered in brown rust. Staff 58 and 59 confirmed the observation.”

“A life safety code (LSC) full survey was conducted on site on 09/09/2025 - 09/10/2025. An entrance conference was held for the Market SVP Patient Care Services, Market Director Quality & Patient Safety, Market Director Patient Care, and Facility Manager on 09/09/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 09/10/2025 in the hospital. In attendance was the Facility Manager, Director of Plant Ops, Marketing Director, and Compliance. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 35321 K521 - HVAC Findings: The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues: 1) Observed in Main Building Level 1 Mechanical Room - the mechanical unit drain pan was filled with stagnant water due to poor drainage. 2) Observed on Fifth floor CV Tower - there was peeling of HVAC duct insulation. 3) Observed on Third floor Doctors Tower Mechanical Room - there was peeling of HVAC duct insulation.”

“Gas and Vacuum Piped Systems - Central Supply CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Central Supply System Operations Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers. 5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99) This Standard is not met as evidenced by: 35321 K906 - Gas and vacuum piped systems - central supply systems operations Findings: The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues: 1) Based on observations in Medical Gas Room - the mechanical exhaust air grille was clogged with debris thus restricting its airflow.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35321 K907 Gas and Vacuum Piped Systems - Maintenance Program Findings: The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues: 1) Based on observations in Fifth floor CV Tower Mechanical Room - the medical air pipe was rusting.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 35321 K914 - Electrical Systems - Maintenance and Testing Findings: The surveyor observed, while accompanied by the Facility Manager, Director of Plant Ops, and Maintenance Tech Lead, during the hours of the survey from 3:30 pm - 9:15 pm on 09/09/2025 and 8:45 am - 10:45 am on 09/10/2025 that there were the following issues: 1) Based on further review of the codes and records, facility failed to perform any receptacle maintenance and testing at all in patient care areas at least once per year. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 40989 Based on document review and interview the Governing Body failed to ensure: 1. Physician #20 reported a blood transfusion reaction in 1 (Patient #1) of 6 medical records reviewed. The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. 2. Physician #21 followed hospital policies when ordering the emergent release of uncrossmatched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed. 3. Physician #20 and #22 ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed. Refer to Tag A0347 4. Nursing Services obtained and followed the physician’s orders for blood/blood product transfusion rates in 3(Patient #1, #8, and #9) of 6 patient medical records reviewed. 5. Nursing Services followed the hospital policy titled Transfusion of Blood Products. Refer to Tag A0410”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 40989 Based on document review and interview, the Medical Staff failed to ensure 3 (Physician #20, #21, and #22) of 3 physicians provided safe medical care to 4 (Patients #1, #5, #8, and #9) of 6 (Patients #1, #2, #4, #5, #8, and #9) patients receiving blood/blood product transfusions. The Medical Staff failed to: 1. ensure 1 (Physician #20) of 1 physician reported a possible blood transfusion reaction in 1 (Patient #1) of 7 medical records reviewed. The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. 2. ensure 1 (Physician #21) of 1 physician followed hospital policies when ordering the emergent release of uncrossmatched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed. 3. ensure 2 (Physician #20 and #22) of 2 physicians ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed. Refer to Tag A0347”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 40989 Based on document review and interview, the Medical Staff failed to ensure 3 (Physician #20, #21, and #22) of 3 physicians provided safe medical care to 4 (Patient #1, #5, #8, and #9) of 6 (Patient #1, #2, #4, #5, #8, and #9)patients receiving blood/blood product transfusions. The Medical Staff failed to: 1. ensure 1 (Physician #20) of 1 physician reported a blood transfusion reaction in 1 (Patient #1) of 6 medical records reviewed. The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. 2. ensure 1 (Physician #21) of 1 physician followed hospital policies when ordering the emergent release of uncross matched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed. 3. ensure 2 (Physician #20 and #22) of 2 physicians ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed. Findings: Medical Record reviews were completed with Registered Nurse (RN) Staff #2, RN Staff #7, and RN Staff #13 on 6/30/2025 and 7/01/2025 in the administrative conference room. 1. Patient #1 Patient #1 was a 54-year-old female who presented to the Emergency Room (ER) on 6/23/2025 with complaints of increased weakness, fatigue, belly pain, decreased appetite, and her urine was brown. She had a history of Breast Cancer that had spread to the bones. A review of the ER Physician Note revealed the patient was jaundiced (yellow). Her vital signs upon admission to the ER were Blood Pressure (BP) 78/61 (normal 120/80), Pulse 80 (Normal 60-100), Respirations 21 (normal range 12-20), oxygen level was 93 % on room air, and Temperature was 97 degrees Fahrenheit. She was placed on 2 liters of oxygen via nasal cannula. Patient #1 had no other complaints. Lab work was completed and resulted in a Hemoglobin of 4.5 (normal reference range 12.0-14.0) and a low platelet count of 65 (normal reference range 130-400). On 6/23/2025 at 5:22 PM, Physician #21 ordered 3 units of Packed Red Blood Cells (PRBC) to be transfused. A review of the transfusion record revealed that Unit #1 was started in the ER on 6/23/2025 at 8:00 PM and ended on 6/23/2025 at 11:50 PM. Further review of the transfusion record revealed there were no adverse reactions during the blood transfusion. Patient #1 was admitted as an inpatient to the ICU on 6/23/2025 at 10:22 PM with a diagnosis of Acute Anemia, Cholecystitis, and Urinary Tract Infection-possible sepsis. At this time, she was on 2 liters of oxygen via nasal cannula. A review of the transfusion record for Unit #2 revealed the Registered Nurse documented the unit was started on 3/24/2025 at 12:05 AM and ended on 6/24/2025 at 4:00 AM. Further review of the transfusion record revealed there were no adverse reactions during the blood transfusion. During the medical record review with Registered Nurse (RN) Staff #2, it was confirmed that the RN documented the wrong date on the transfusion record for Unit #2. The start date for Unit #2 should have been 6/24/2025 and not 3/24/2025. On 6/24/2025, the patient’s oxygen flow was increased to 3 liters and increased again at 9:00 PM to 6 liters of oxygen. Patient continued to complain of shortness of breath, and on the morning of 6/25/2025 at 2:11 AM, she was placed on a non-rebreather (an oxygen mask used to deliver a high concentration of oxygen in an emergency). At 6:51 AM, she was placed on BiPAP (a machine that delivers pressurized air through a mask and helps to open the airway and improve airflow in and out of the lungs). A rapid response was called at this time, and it was recommended that the patient be transferred to a higher level of care. At 10:27 AM on 6/25/2025, the patient’s respiratory status continued to decline, and the patient was intubated at 10:27 AM. Patient #1 was transported to a higher level of care on 6/26/2025 at 2:00 AM. Patient #1 expired on 6/27/2025. A review of Physician #20’s progress note dated 6/25/2025 at 7:44 PM was as follows: “ ...Pt. had respiratory depression today requiring intubation. Assessment and Plan of Treatment Respiratory failure-most likely 2/2 volume overload in the setting of acute renal failure. Pt did receive 2 units of blood and boluses of IVF for renal failure. TRALI should also be in consideration, but timing does not fit perfectly. ... Hypotension-likely related to ARF and metabolic acidosis, though TRALI and sepsis are considerations ...” According to the Association for the Advancement of Blood and Biotherapies, transfusion-related acute lung injury (TRALI) is a rare but serious complication of blood transfusions and can lead to respiratory failure requiring intubation of a patient. An interview was conducted on 6/30/2025 at 10:25 AM with Laboratory Manager Staff #11. Staff #11 was asked if there were any blood transfusion reactions reported for June 2025. Staff #11 confirmed that no blood transfusion reactions were reported for June. Staff #11 was asked what the process was for a transfusion reaction. Staff #11 replied, “The nurse calls the lab and lets the lab know of a possible reaction, and fills out the transfusion reaction form. The blood bag and the tubing get sent to the blood bank immediately. The nurse also gets a urine sample from the patient and a blood sample for a type and screen and a Direct Antiglobulin Test (DAT, also known as a Direct Coombs Test, that detects the presence of antibodies or complement proteins attached to the red blood cells, which aids in the detection of a transfusion reaction). The pathologist was notified of the results, and then they will determine if further testing is needed”. An interview was conducted with Laboratory Director Staff #10 on 6/30/2025 after 1:30 PM. Staff #10 confirmed that no transfusion reactions were reported for June 2025. An interview was conducted with Physician #16 on 7/01/2025 after 1:00 PM. Physician #16 was asked if he was aware of a possible TRALI blood transfusion reaction for Patient #1. Physician #16 stated, “No, I am not aware of this. TRALIs are a very rare reaction”. Physician #16 was asked if he thought the possibilities of a TRALI for Patient #1 were likely. Physician #16 replied, “These reactions usually happen shortly after the blood transfusion has started, and in this case, it was several hours later. It does not fit the timeline for a TRALI”. Physician #16 was asked if the patient could have had a delayed adverse reaction to the blood transfusion. Physician #16 replied that it was unlikely that the patient had a transfusion reaction, and especially a TRALI. Physician #16 was asked if he could confirm that Patient #1 did not have a blood transfusion reaction. Physician #16 confirmed he could not confirm or deny that the patient had a transfusion reaction. Physician #16 was asked if other physicians called him with concerns of a possible transfusion reaction. He confirmed physicians will call him if they suspect a transfusion reaction has occurred, and we will start the process of the reaction protocol at that time. Most of the time, it was the nurses who initiated the protocol”. A telephone interview was conducted with Physician #20 on 7/02/2025 at 1:27 PM. Physician #20 was asked if he thought that Patient #1 had a TRALI. Physician #20 stated, “I had just seen her at 7:00 PM on 6/24/2025 and she was good. It did not fit the timeline perfectly for a TRALI, but it was a consideration.” Physician #20 was asked if he had told the family that he thought Patient #1 had a severe blood transfusion reaction. Physician #20 stated, “I saw the patient and the family on 6/25/2025 and told them that a TRALI was a consideration. I also told them that it could be other things as well, like Hemolytic Anemia caused by the oral chemotherapy drugs she was on, Sepsis, Fluid Volume Overload, or Acute Renal Failure. I spent time with the family and explained that it was a consideration of multiple things. Her hemoglobin was 4.5 when she came in, and after 2 units of blood, it was up to 10, so I felt like the initial result was likely incorrect. I told them every single thing that was going through my head.” Physician #20 was asked if he reported the possible transfusion reaction to the lab, and he confirmed he did not. Physician #20 stated, “I did talk to her Primary Care Physician/Intensivist about all the possibilities”. Physician #20 was asked what he would normally do in the event of a possible blood transfusion reaction. Physician #20 replied that he would give some steroids and contact the pathologist immediately. A review of the medical record did not reveal any documentation by the intensivist (a physician caring for critically ill patients) that a possible blood transfusion occurred. A review of the hospital policy titled “Transfusion of Blood Products” with a revised date of 8/12/2024 was as follows: “Policy ... P. Transfusion reactions: a ... b ... c. Signs or symptoms of a transfusion reaction may occur 24 hours after a transfusion is complete. Q. All suspected transfusion reactions should be immediately reported to the Blood Bank at extension 7918 ...” An interview was conducted with Chief Medical Officer (CMO) Staff #3 on 6/30/2025 after 1:30 PM. Staff #3 was informed that the patient’s family made a written public statement on social media that the patient’s family was told by the physician the patient had a severe reaction to a blood transfusion. Staff #3 was informed that Physician #20 documented in his note that Patient #1 had a possible TRALI, and it was not reported to the blood bank for the transfusion reaction protocol to be implemented. Staff #3 confirmed that Physician #20 should have reported the possible transfusion reaction to the blood bank. Staff #3 was asked if Physician #20 would have a Focused Professional Practice Evaluation (FPPE) regarding the care of this patient. Staff #3 confirmed that Physician #20 would go through FPPE due to the care of this patient. A review of the Medical Staff Bylaws approved on 8/29/2024 was as follows: “ ...12.C.2 Ongoing and Focused Professional Practice Evaluation (OPPE/FPPE) Concerns raised about a Practitioner’s practice during the FPPE process will be evaluated or otherwise addressed through the Initial focused professional practice evaluation process which may include an analysis of data to provide feedback, to validate clinical competence, and to identify issues in Practitioner’s professional performance, if any. (1) Practitioners who are initially granted Clinical Privileges, whether at the time of the initial grant, renewal, or during the term of Clinical Privileges, will be subject to focused professional practice evaluation to confirm their competence.” (2) All Practitioners who provide patient care services at the Hospital, pursuant to Clinical Privileges that have been granted, will have their care evaluated on an ongoing basis. This ongoing professional practice evaluation process may include an analysis of data to provide feedback, to validate clinical competence and to identify issues in Practitioner’s professional performance, if any. (3) Concerns raised about a Practitioner’s practice through the ongoing professional practice evaluation process or through a specialty-specific performance measure, a reported concern, or other triggers (e.g., clinical trend or specific case that requires further review, patient feedback, or sentinel event) will be evaluated or otherwise addressed through the focused professional practice evaluation process, collegial Intervention or other progressive steps, as defined in this Section. Serious concerns shall be referred immediately to the MEC ...” An interview was conducted with CMO Staff #3 and Staff #6, Market Director of Patient Care Services on 7/01/2025 after 12:00 PM. Staff #3 and #6 confirmed that Physician #20 should have reported the possible TRALI to the blood bank so that the transfusion reaction protocol could be implemented. 2. Patient #5 Patient #5 was a 77-year-old female who presented to the ER via Emergency Medical Services (EMS) on 6/15/2025 with a Gastrointestinal Bleed and was given a triage level of 2-Emergent. A review of Physician #21’s ER Note dated 6/15/2025 revealed Patient #5’s vital signs on admission were BP-156/71, Pulse-90, Respirations-21, and O2 Sat-100%. No Temperature was measured. Physician #20’s physical exam revealed the patient was in no apparent distress, alert and oriented X 4, no respiratory distress, normal breath sounds, regular heart rate and rhythm, delayed capillary refill time noted, abdomen soft and non-tender, skin was warm, dry, and normal in color. The patient’s eyes appeared a pale conjunctiva (this is a sign of anemia). A review of the nurse’s note dated 6/15/2025 at 6:15 PM, documented by RN Staff #24, revealed the patient was taken to the trauma room upon arrival. She was noted to be covered with blood and emesis. The patient was in no apparent distress, and vital signs remained stable. “Crash blood” was started by the charge nurse (no identification of the charge nurse noted and there was no unit number of the blood documented in the patient’s medical record), and medications were started. The patient was taken to Endo for an EGD. A review of the document titled “Emergency Request for Uncrossmatched Blood” revealed 1 (one) unit of uncrossmatched blood was released to the RN on 6/18/2025 at 5:11 PM. There was no physician signature, and there was no additional signature of an authorized person on the physician’s behalf. A review of the hospital policy titled “Transfusion of Blood Products” with a revised date of 8/12/2024 was as follows: “POLICY A. A provider order is required for the preparation and transfusion of blood products ... PROCEDURES: All Patient Care Areas ...7. Emergency Release of Uncrossmatched Blood a. Uncrossmatched blood is ordered when blood is needed emergently and the current type and screen is not available. b. For emergent transfusions, group O RBC’s should be issued emergently, if full testing of ABO/Rh has not been completed. c. Call the Blood Bank to request the emergency release of uncrossmatched blood. d. The Blood Transfusion Emergency Request form is taken to the Blood Bank to pick up the blood products requested. The ordering provider authenticates a Blood Transfusion Emergency Request within 24 hours ...” A review of the hospital policy titled “Emergency/Uncrossmatched Blood” with a review date of 12/31/2023 was as follows: “POLICY 1.0 PRINCIPLE: When there is a desperate requirement for blood, the patient’s physician must weigh the hazard of transfusing uncrossmatched or partially crossmatched blood against the risk of waiting while testing is completed. When blood is released before the crossmatch is completed, the records must contain a statement of the requesting physician indicating that the clinical situation was sufficiently urgent to require release of blood. Such a statement does not absolve the blood bank from its responsibilities to issue properly labeled donor blood of an ABO group compatible with the patient. 2.0 PROCEDURE: 2.1 Perform an ABO and Rh on the patient’s specimen, if possible type specific units may be given ... 2.6 The requesting physician or authorized person must sign the Emergency Request form prior to issuance of blood ...” An interview was conducted with Staff #10 in the afternoon on 6/30/2025. Staff #10 was asked to explain how a unit of uncrossmatched blood was released to the nurse in an emergency. Staff #10 replied, “The nurse comes to the blood bank and fills out the request form for the uncrossmatched blood. Once the nurse and the employee in the blood bank sign the form, it gets released to the nurse”. Staff #10 was asked how she ensured that the physician ordered the uncrossmatched blood before it was released. Staff #10 stated, “We just take their word for it. The physician can sign the form within 24 hours.” Staff #10 was asked which policy the lab followed because the policy titled, Transfusion of Blood Products states the ordering provider can have up to 24 hours to authenticate the Blood Transfusion Emergency Request document and the policy titled Emergency/Uncrossmatched Blood states the requesting physician or authorized person must sign the Emergency Request form prior to issuance of blood. Staff #10 stated, “If it’s not signed at the time, we have to go find the form and bring it back and put it in our book.” (The emergency request form is a triplicate document.) In an interview on 7/01/2025 after 12:00 PM, Staff #10 confirmed that as of 7/1/2025, Physician #21 had not signed for the emergency release of the uncrossmatched blood administered to Patient #5. This was 16 days after Patient #5 received the uncrossmatched blood transfusion. 3. Patient #8 Patient #8 was an 83-year-old male who presented to the hospital for outpatient services for a blood transfusion on 6/25/2025. Patient #8 had a history of Acute Myeloblastic Leukemia. A review of the Blood Transfusion Orders by Physician #20, dated 6/24/2025 at 12:30 PM, was as follows: “Type and Crossmatch for Packed Red Blood Cells-Irradiated 2 Units and Transfuse 2 Units of Packed Red Blood Cells Irradiated.” A review of the blood transfusion record dated 6/25/2025 revealed RN Staff #26 started Unit #1 at 10:20 AM at 75 milliliters/hour (ml/hr) and increased the rate at 10:35 AM to 200ml/hr and increased the rate again at 11:30 AM to 300 ml/hr. The blood transfusion was completed at 12:30 PM. RN Staff #26 started Unit #2 at 12:50 PM at 75 ml/hr and increased the rate at 1:05 PM to 200 ml/hr and increased the rate again to 300 ml/hr at 1:15 PM. The blood transfusion was completed at 1:55 PM. In an interview with RN Staff #13 on 7/01/2025 at 1:30 PM, RN Staff #13 confirmed that Physician #20 did not order a rate of infusion for the blood transfusions Patient #8 received on 6/25/2025. Patient #9 Patient #9 was a 78-year-old female who presented to the hospital for outpatient services for a blood transfusion on 6/26/2025. Patient #9 had a history of Acute Myeloblastic Leukemia. A review of the Blood Transfusion Orders by Physician #22, dated 6/26/2025 at 9:15 AM, was as follows: “Type and Reserve for Plateletpheresis-1 Unit and Transfuse Platelets-Single Donor 1 Unit”. A review of the Transfusion Record dated 6/26/2025 revealed RN Staff #25 started the platelet transfusion at 12:55 PM and it was completed at 1:24 PM. RN Staff #25 documented the rate as “Open to gravity”. In an interview with RN Staff #13 on 7/01/2025 at 1:30 PM, RN Staff #13 confirmed that Physician #22 did not order a rate of infusion or duration for the Platelet transfusion Patient #9 received on 6/26/2025. An interview was conducted with RN Staff #6 on 7/01/2025 at 2:30 PM. RN Staff #6 was asked if all outpatient blood transfusion orders are sent from the physician’s clinic. RN Staff #6 stated, “Yes, there are some that come like that. Our computer system places a hard stop when they order blood and forces the provider to order a rate, or they cannot continue with the order. I do not think that we talked about outpatient orders from the clinics, but the providers know they have to order a rate for the transfusion.””

“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: 40989 Based on the document review and interview, Nursing Services failed to: 1. Obtain and follow the physician’s orders for blood/blood product transfusion rates in 3 (Patient #1, #8, and #9) of 6 patient medical records reviewed. 2. Follow the hospital policy titled Transfusion of Blood Products. Findings: Patient #1 Patient #1 presented to the Emergency Room on 6/23/2025 with complaints of increased weakness, fatigue, belly pain, decreased appetite, and her urine was brown. She had a history of Breast Cancer that had spread to the bones. A review of the orders dated 6/23/2025 at 5:22 PM by Nurse Practitioner (NP) Staff #28 was as follows: “Transfuse 3 units Packed Red Blood Cells (PRBC); Initiate blood/blood products at a rate of 75 milliliters per hour (ml/hr) for the first 15 minutes (mins); after 15 mins, increase infusion rate to 150 ml/hr.” A review of the transfusion record dated 6/23/2025 revealed Registered Nurse (RN) Staff #27 started the blood transfusion at 8:44 PM at an initial rate of 75 ml/hr. At 9:00 PM, RN Staff #27 increased the rate of infusion to 125 ml/hr. This rate was less than what NP Staff #28 ordered, and there was no documentation in the patient’s medical record that NP #28 changed the order. Patient #1 was admitted to the hospital Intensive Care Unit at 10:22 PM. The blood transfusion was completed at 11:50 PM. A review of the orders dated 6/23/2025 at 11:06 PM by Physician #29 was as follows: “Transfuse 2 units Packed Red Blood Cells (PRBC); Initiate blood/blood products at a rate of 75 ml/hr for first 15 mins; after 15 mins, increase infusion rate to 125 ml/hr.” A review of the blood transfusion record dated 6/23/2025 revealed RN Staff #23 started the transfusion on 6/24/2025 at 12:05 AM at an initial rate of 50 ml/hr and increased the infusion rate to 75 ml/hr at 12:20 AM. The transfusion was completed at 4:00 AM. An interview was conducted with RN Staff #4 and RN Staff #6 on 6/30/2025 at 2:45 PM. RN Staff #6 was asked if the nursing staff could change the infusion rate of a blood transfusion without a physician’s order. RN Staff #6 replied, “No, and they know they have to have a rate and follow the physician’s order or call the physician and have the order changed depending on the patient’s needs.” RN Staff #6 confirmed there was no documentation in Patient #1’s medical record that the physician had been contacted regarding a rate change for the transfusion. Patient #8 Patient #8 was an 83-year-old male who had a history of Acute Myeloblastic Leukemia. He was admitted for an outpatient blood transfusion on 6/25/2025. A review of the orders given by Physician #20 was as follows: “Transfuse 2 Units of Packed Red Blood Cells (PRBC)-Irradiated”. A review of the Transfusion record dated 6/25/2025 revealed RN Staff #26 started the blood transfusion for Unit #1 at 10:20 AM at a rate of 75 ml/hr. RN Staff #26 increased the rate to 200 ml/hr at 10:35 AM and increased the rate again to 300 ml/hr at 11:30 AM. The blood transfusion was complete at 12:30 PM. A review of the Transfusion record dated 6/25/2025 revealed RN Staff #25 started the blood transfusion for Unit #2 at 12:50 PM at a rate of 75 ml/hr. RN Staff #25 increased the rate to 200 ml/hr at 1:05 PM and increased the rate again to 300 ml/hr at 1:15 PM. The blood transfusion was completed at 1:55 PM. RN Staff #25 documented that the patient refused to stay for the 1-hour post-transfusion vital sign check. Patient #9 Patient #9 was a 78-year-old female who had a history of Acute Myeloblastic Leukemia. She was admitted for an outpatient blood/blood product transfusion on 6/26/2025. A review of the orders given by Physician #22 was as follows: “Transfuse 1 Unit of single donor platelets”. A review of the transfusion record dated 6/26/2025 revealed RN Staff #25 started the platelet transfusion at 12:55 PM. RN Staff #25 documented the rate as “open to gravity”. The transfusion was completed at 1:24 PM. RN Staff #25 documented Patient #9 refused to stay for the one-hour post-transfusion vital sign check. An interview was conducted with RN Staff #7 on 7/01/2025 after 1:00 PM. RN Staff #7 was asked how fast a platelet transfusion can infuse. RN Staff #7 replied that platelets can be transfused faster than blood. RN Staff #7 was asked if the hospital policy required a rate of infusion for platelets. RN Staff #7 confirmed the hospital policy did not say anything specific regarding platelet transfusions and that all transfusions required a physician order. RN Staff #7 confirmed RN Staff #25 administered the platelet transfusion without a rate or duration ordered by Physician #22. An interview was conducted with RN Staff #13 on 7/01/2025 after 1:00 PM. RN Staff #13 was asked if the physician did not order a rate for the blood transfusion, how did the RN know what rate to infuse the blood. RN Staff #13 stated, “The RN should have called the physician and gotten an order for the transfusion rate before starting the blood transfusion.” An interview was conducted with RN Staff #9 on 7/01/2025 after 1:00 PM. RN Staff #9 confirmed 2 (RN Staff #25 and #26) of 2 RN’s administered blood transfusions without a completed transfusion order from 2 (Physician #20 and #22) of 2 Physicians. RN Staff #9 confirmed there was no order for the starting rate or the increase in rate for the blood/blood products transfused in 2 (Patient #8 and #9) of 2 outpatients that received a blood/blood product transfusion. A review of the hospital policy titled, Transfusion of Blood Products with a revised date of 8/12/2024 was as follows: “POLICY A. A provider order is required for the preparation and transfusion of blood products. ... K. Transfusions should be administered per provider order, not to exceed expiration date and time listed on the blood product. L. Maximum time for the use of a blood filter and tubing is 4 hours. M. Transfusion reactions can be life-threatening and occur with exposure to even a small amount of blood; therefore, transfusions should be started at a rate of< 100 ml/hour unless the patient’s condition requires a rapid, life-sustaining transfusion. Following a provider’s order, and as tolerated by the patient, the rate may be increased after the initial 15 minutes ...” According to the Texas Board of Nursing (BON), the BON requires that any initiation or change to a continuous infusion, including blood products, must be based on a specific provider order or a facility-authorized written protocol signed by a licensed independent provider, MD/DO/APRN. A RN initiating or titrating blood/blood products without a provider’s order is practicing outside the scope of practice for a Registered Nurse. During an interview on 7/01/2025, after 10:00 AM with RN Staff #4 and RN Staff #6, it was confirmed that the Nursing Services failed to obtain or follow physician orders when administering a blood transfusion in 3 (Patient #1, #8, and #9) of 6 patient medical records reviewed. Also, it was confirmed that the Nursing Services failed to follow the hospital policy titled Transfusion of Blood Products. RN Staff #4 confirmed the hospital did not have a written protocol for the infusion rate of a blood/blood product transfusion.”

“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: 48749 Based on record review and interview, the hospital’s emergency department physician failed to complete a complete medical screening prior to discharge or transfer in 3 (#1, #2, and #11) of 3 patient charts reviewed. Also, the hospital failed to follow its “Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services” policy.. Cross Refer to 2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48749 Based on record review, policy review, and interview, the hospital’s emergency department physician failed to complete a complete medical screening prior to discharge or transfer in 3 (#1, #2, and #11) of 3 patient charts reviewed. Also, the hospital failed to follow its “Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services” policy. This deficient practice had the likelihood to cause harm to all patients presenting to the emergency department (ED)with emergent medical conditions. Findings include: Patient #1 A review of the electronic health record (EHR) for Patient #1 revealed the following: Patient #1 was a 68-year-old who arrived at the ED via Emergency Medical Services (EMS) on 02/09/2025 at 6:53 PM. EMS documented that Patient #1 was observed to have facial injuries, bleeding from the mouth, and hypoxia with an oxygen saturation (O2 sat) of 89%. Patient #1 was triaged at 8:52 PM by the ED nurse who charted the patient as “autistic and non-verbal” and had a chief complaint of a ground-level fall (GLF) on concrete, with a laceration above the left eye and a nosebleed. Patient #1’s vital signs (VS) were as follows: Blood Pressure (BP) -118/92 Heart Rate (HR) -86 Respirations (Resps) -18 Temperature (Temp) -98.1 Oxygen Saturation (O2 sat) 98% Glasgow Coma Scale (GCS) (a neuro assessment tool used to evaluate the level of consciousness in a person after a brain injury)-14 The patient’s record revealed that an ED trauma flow sheet was initiated. The ED nurse documented a bedside report of “GLF hitting face, bleeding from nose and mouth, attempted to place a C-collar, patient became agitated.” Also, the ED nurse documented that the patient arrived at the ED with “lacerations to the face, raccoon eyes, abrasions, and bleeding from the nose and mouth.” The ED nurse gave the patient an Emergency Severity Index (ESI) (The Emergency Severity Index has five levels, with Level 1 representing the most urgent cases requiring immediate life-saving intervention, and Level 5 being the least urgent, needing only a basic history and physical exam; essentially ranking patients based on their acuity and the resources needed for their care) of 3- Urgent. Further review of the ED trauma flow sheet revealed the following; At 7:01 PM, the ED nurse documented that the patient became agitated with the pulse oximeter (a non-invasive device that measures blood oxygen saturation and heart rate) and did not want to keep pulse oximeter on. At 7:10 PM, Patient #1 received an initial Medical Screening Exam (MSE) by the ED Physician. The ED Physician noted that the patient had a facial laceration of 2 centimeters. There was no documentation found that the ED Physician documented characteristics of the wound or if the wound was actively bleeding. In addition, the ED Physician did not note any other abnormalities in the MSE assessment and documented a normal exam. A review of the nurse’s documentation on the trauma flow sheet revealed that the patient had “raccoon eyes, deformity to the nose with nasal bleeding, and the patient had blood in the mouth.” There was no documentation found that the ED Physician performed an assessment of Patient #1’s oral or nasal airway. There was no documentation found to support that the ED Physician assessed Patient #1’s eyes due to the “raccoon” bruising or performed an extraocular movement exam (EOM) (assessment for how well the eyes move in all directions). There was no documentation found that the patient received wound care or repair of the laceration. There was no documentation found that a tetanus (a vaccine that protects against tetanus, a serious and potentially fatal bacterium) was offered or administered. The ED Physician ordered a Computed Tomography scan (CT) of the cervical spine, head, and maxillofacial. There was no documentation found to support that the ED Physician ordered labs after performing the MSE assessment. In addition, Patient #1 was administered 4 milligrams of morphine intramuscularly. At 8:00 PM, the ED nurse documented that Patient #1 had an O2 saturation “in the 70s.” The patient was placed on a nasal cannula (NC) with oxygen at 4 liters per minute, and documented that there was no improvement. The ED nurse placed a non-rebreather mask (NRB) with oxygen at 15 liters per minute and documented that the patient had “improvement with O2 and that respiratory was at the bedside.” There was no documentation found to support that the patient had a chest x-ray ordered or had an Arterial Blood Gas (ABG) (a blood test that measures the levels of oxygen and carbon dioxide in the blood) for hypoxia. There was no documentation found to support that the ED nurse notified the ED Physician of the patient’s abnormal O2 saturation. There was no documentation found to support that the patient received a reassessment from the ED Physician. At 8:25 PM, the patient returned from CT to the ED. Patient #1’s CT scan results revealed that the patient had significant facial fractures for a ground-level fall. There was no documentation found that the ED Physician completed a reassessment or ordered additional imaging of the patient after the CT scan findings. There was no documentation found that the patient received prophylactic antibiotics. A review of Patient #1’s vital signs revealed that between 8:00 PM and 10:15 PM (135 minutes), the patient did not have a full set of vital signs documented. A further review of the trauma flow sheet revealed that at 9:00 PM, the ED nurse documented suctioning blood from the patient’s mouth. There was no documentation found of reassessment or intervention for the patient’s bleeding. There was no documentation to support how much blood was suctioned from the patient by the ED nurse. There was no documentation found that the ED nurse notified the ED Physician that Patient #1 continued to bleed from the mouth. ED Physician failed to reassess blood coming from the mouth. At 10:09 PM, the ED Physician ordered labs, an ABG, and an EKG. There was no documentation found that the ED Physician completed a reassessment or why the additional tests were ordered. A review of Patient #1’s ABG results revealed a pH of 7.26, pCO2 of 56, and a pO2 of 40, indicating hypercapnic respiratory acidosis and hypoxia. There was no documentation found of reassessment or intervention by the ED Physician. At 10:35 PM, the ED nurse documented, “Patient becoming increasingly more agitated and oxygen saturations decreasing into the 70s. Patient blood pressure dropping.” The vital signs documented for the patient at this time were “BP 99/56, HR 121, Resps 32, O2 sats 75%.” There was no documentation found to support that the ED nurse reported the abnormal vital signs to the ED Physician. There was no documentation found to support that the patient received a reassessment from the ED Physician. A further review of Patient #1’s chart revealed that at 10:56 PM, Patient #1 was intubated (a medical procedure where a tube is inserted into the trachea to maintain an open airway) by the ED Physician due to “Acute Hypoxic Respiratory Failure.” The ED nurse documented that Patient #1 was started on a Levophed (a vasoconstrictor used to treat life-threatening low blood pressure) drip. At 11:15 PM, the Levophed drip was discontinued, and a Propofol (intravenous anesthetic formulation used for induction and maintenance of anesthesia) drip was initiated at 11:20 PM. At 11:06 PM, Patient #1 was taken to radiology for a chest x-ray to check the endotracheal tube placement. A review of the chest x-ray revealed that “diffuse bilateral airspace opacities may represent pulmonary edema or pneumonia.” There was no documentation found that this was noted or that treatment was initiated by the ED Physician. In addition, Patient #1 received an X-ray of the left hand. A review of the X-ray results revealed a “comminuted minimally displaced fifth metacarpal neck fracture.” There was no documentation found in the ED Physician’s MSE to indicate why this x-ray was ordered. The ED Physician failed to assess or treat the fracture. At 11:39 PM, the ED nurse documented that EMS was at the bedside to transfer the patient, and Patient #1 was “rolled and cleaned.” Patient #1 was transferred via EMS to Hospital #2 with a diagnosis of closed head injury, acute hypoxic respiratory failure, nasal bone fractures, zygomatic arch fractures, pterygoid plate fractures, and orbital wall fractures. There was no documentation found that wound care was provided or that there was an attempt to control Patient #1’s bleeding during the ED visit. An interview was conducted on 03/13/2025 at 9:00 AM with Staff #16. Staff #16 reported the patient did not present in bad shape upon arrival, and a trauma call wasn’t called because the patient was at baseline. Staff #16 reported that the patient continued to deteriorate and had to be intubated. Staff #16 reported that the patient was bleeding from facial fractures, and they were draining blood down the back of the patient’s throat. Staff #16 was questioned about providing wound care to the patient. Staff #16 stated, “I sat for 45 minutes, cleaned the patient’s wounds, and suctioned the blood. I took several breaks to keep the patient calm. After the patient was intubated, I continued to clean the patient. Staff #16 was asked if the treatment was documented in the patient’s chart. Staff #16 stated, “I did not document my treatment or wound care on the trauma flow sheet.” Patient #2 A review of the EHR for Patient #2 revealed the following; Patient #2 was a 64-year-old who arrived at the ED via EMS on 02/18/2025 at 8:44 PM. Patient #2 had a chief complaint of headache, facial pain, and neck pain secondary to an assault with a broomstick. Patient #2 was triaged at 8:52 PM by the ED triage nurse, and the vital signs (VS) were as follows: Blood Pressure 155/77 Heart Rate 67 Respirations 16 Temperature 98.3 Oxygen Saturation (O2 sat) 97% Glasgow Coma Scale (GCS) (a neuro assessment tool used to evaluate the level of consciousness in a person after a brain injury)-15 The ED triage nurse gave the patient an ESI 3- urgent. Further review of the ED triage nurse’s documentation revealed that Patient #2 arrived at the ED with bilateral swollen black eyes, a swollen busted lip, and kerlex wrapped around the patient’s head with blood. Also, the ed nurse documented that Patient #2’s” nose was bleeding with a postnasal drip that caused the patient to vomit blood clots”. At 8:59 PM, Patient #2 received an initial MSE by the ED Physician. The ED Physician documented that the patient had periorbital edema with ecchymosis and mild distress. The ED Physician documented that the patient had a cervical collar in place. There was no documentation found to support the ED Physician evaluated the patient’s cervical spine for pain with movement or tenderness with palpation. The ED Physician documented that the patient had left-hand pain. There was no supporting documentation found to indicate if the patient had swelling, deformity, or wounds causing the patient’s hand pain. The ED Physician documented a normal exam, but there was no documentation found to support that Patient #2 was undressed and received a full trauma exam to include an assessment of the patient’s back, thoracic, and lumbar spine. The ED Physician ordered an EKG, labs, and a CT of the cervical spine, head, and maxillofacial. In addition, Patient #2 received a hand x-ray, Cefepime 2 grams intravenously (IV), Morphine 4 milligrams IV, 2 doses of Zofran 4 milligrams, and a Tetanus booster intramuscularly. A review of the ED nurse’s documentation revealed that the patient had “bilateral black eyes, nasal bleeding, and bloody post-nasal drip.” There was no documentation found that the ED Physician performed an assessment of Patient #2’s oral or nasal airway. There was no documentation found to support that the ED Physician assessed Patient #2’s eyes due to the bruising or performed an extraocular movement exam. At 9:40 PM, the ED nurse documented that Patient #2 continued to “vomit blood clots” in the CT room. The patient had received Zofran 4mg for vomiting. There was no documentation found that the ED Physician completed a reassessment of the patient after the ED nurse reported the patient continued vomiting blood clots. A review of Patient #2’s CT scan revealed the patient had a “left retrobulbar hemorrhage” and significant facial fractures. There was no documentation found that the ED Physician reassessed Patient #2 after receiving the CT findings. In addition, a review of the patient’s hand x-ray revealed a “minimally displaced fifth metacarpal shaft fracture”. There was no documentation found to support the ED Physician reassessed or splinted the patient’s hand after the x-ray findings were received. Further review of the ED nurse’s documentation revealed that at 10:05 PM, the ED nurse documented that the ED Physician was notified that Patient #2 had become more lethargic and confused. The patient had a change in GCS from a 15 to an 11. There was no documentation to support that the ED Physician completed a reassessment of Patient #2 after being notified by the ED nurse that there was a change in the patient’s mental status. At 11:35 PM, the ED nurse documented that the ED Physician did not remove Patient #2’s kerlex dressing and evaluate the patient’s facial wounds during the patient’s ED visit. There was no documentation to support that the ED Physician removed the dressings, evaluated, or treated Patient #2’s wounds. At 11:55 PM on 02/18/2025, Patient #2 was transferred to another hospital for a higher level of care with a diagnosis of Pneumocephalus, complex facial fractures, retro-orbital hemorrhage, and a metacarpal fracture. Patient #11 A review of the EHR for Patient #11 revealed the following; Patient #11 was a 74-year-old who arrived at the ED via private vehicle on 12/17/2024 at 8:26 AM. Patient #11 had a chief complaint of a ground-level fall while walking, hitting the patient’s head on the asphalt. Patient #11 reported head, neck, right knee, and right-hand pain. The ED nurse documented that the patient was on a prescription of Plavix (a blood thinner). The ED nurse activated the trauma code at 8:26 AM. The vital signs documented for Patient #11 were as follows; BP 178/78 HR 60 Respirations 16 O2 sat 98 % on room air, Temperature 97.9 GCS of 15 At 8:26 AM, Patient #11 received an initial MSE by the ED Physician. The ED Physician ordered a CT scan of the pelvis, a right wrist x-ray, and Norco 5/325 (pain medication) milligrams by mouth. There was no documentation found to support that the patient received a cervical spine examination by CT scan or x-ray to rule out a cervical spine injury after a fall. There was no documentation found to support that the patient received a CT scan of the head or brain to rule out bleeding in the brain after a fall for a patient on blood-thinning medication. There was no documentation found to support that the ED Physician assessed the patient for a scaphoid fracture of the right wrist ( snuffbox tenderness,a key indicator for a break in one of the small bones of the wrist often not found on x-ray during the acute period). At 10:11 AM, Patient #11 was discharged home with no documentation of discharge vitals signs. A review of the hospital’s “Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services” policy dated 06/2017 revealed the following: “Medical Screening Examination (MSE) 1. The Hospital will provide an MSE for an individual who: a. Comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual’s appearance or behavior, the individual appears to need an examination or treatment for a medical condition; or b. Comes to an off-campus department that is a DED, requesting examination or treatment for a medical condition or bas such request made on his/her behalf, or if based on the individual’s appearance or behavior, the individual appears to need an examination or treatment for a medical condition; or..... 3. The MSE will be performed by a physician or other QMP as designated by the Hospital’s governing body, within the scope of the QMP’s state license and privileges. The physician or QMP will determine with reasonable clinical confidence whether the individual has an EMC, as defined by EMTALA, utilizing the services within the capabilities of the DED and ancillary services and resources routinely available to the DED for individuals with similar symptoms. 4. The MSE is an ongoing process. The medical record will reflect an ongoing assessment of the individual’s condition. Monitoring of the individual will continue until the individual (i) is stabilized, (ii) is admitted to the Hospital, (iii) is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital’s Capabilities, (iv) is discharged, or (v) expires. The MSE process must be documented in the medical record.” An interview was conducted on the afternoon of 03/12/2025 with Staff #4, Staff #5, and Staff #6 during the surveyor’s medical records review. Staff #4, Staff #5, and Staff #6 acknowledged the surveyor’s findings of incomplete medical screening exams.”

“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: 10135 Based on observation, interview, and record review, the facility failed to ensure there was an organized nursing service. The facility failed to ensure: A. anti-coagulants were administered in accordance to the facility’s policies and protocol in 2 of 3 sampled patients reviewed for intravenous Heparin therapy (Patient’s 17 and 20). B. nurses followed their policies and protocol on collecting lab timely to determine rate of administration of medications. Refer to Tag A0405 for additional information. C. nurses identified signs and symptoms of a possible blood/blood products transfusion reactions in Patient #’s 1 and 15. D. nurses obtained post-transfusion vital signs per their policy in Patient #’s 1 and 15. E. nurses obtained and followed physician orders for blood/blood product transfusion rates. in Patient #’s 15 and 21. Refer to Tag A0410 for additional information.”

“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: 10135 Based on observation, interview, and record review, the facility failed to ensure anti-coagulants were administered per physician orders and their procedures in 2 of 3 sampled patients reviewed for intravenous Heparin therapy (Patient’s 17 and 20). This deficient practice had the likelihood to cause harm in all patients who were on Heparin therapy. Findings include: During an interview on 10/14/2024 after 12:42 p.m., Staff #16 (Registered nurse/RN) stated that the nurses were responsible for drawing their own blood on the Progressive care unit (PCU). If after two sticks, they completed a form and sent it to the lab so lab could send a phlebotomist up to the floor. Staff #16 (RN) stated the only thing that causes delays is that the lab labels print out in Intensive care unit (ICU). ICU sends the lab labels up to them, but they are old and past the due time. Staff #16 (RN) said the printer on their unit has never worked. There was push back from the night nurses because they got all the morning labs to draw. After 1:09 p.m., Staff #16 (RN) showed the surveyor the printer in ICU. There were an approximate 4-foot strip of labels hanging from the printer that was touching the floor. Some of the following PCU patient’s labels were found: Patient #20 had a Heparin XA label that was to be drawn at 8:18 a.m. Patient #17 had a Heparin XA label that was to be drawn at 10:45 a.m. Heparin XA is a lab test to determine how much heparin is in the blood stream and used to adjust the rate of therapy. During an interview on 10/14/2024 after 1:20 p.m., Staff #21 (lab director) stated the nurses had been drawing blood since November 2023. The nurses always late and the mornings are the worst. The morning lab results should be in the chart by 8:00 a.m... Timed labs should be around the time the lab is put into the computer and depending on the medication. Staff #21 (lab director) said she allows 15 before or 15 minutes after for timed labs. Patient #20 Review of an emergency department (ED) record revealed that Patient #20 was a 66-year-old female who presented to the facility on 10/11/2024. Patient #20 had a chief complaint of chest pain. Review of physician orders revealed Patient #20 was admitted to the PCU unit on 10/12/2024. Review of the orders revealed Patient #20 was started on the anti-coagulant Heparin in 0.45 percent sodium chloride, 25,000 units. It was written to start at 1:00 a.m. STAT (immediately), titrate (prn) and to follow hospital protocol. According to the “Drips Titration Log” Patient #20’s starting dose was 700 units per hour at 1:49 a.m. on 10/12/2024. There was documentation on the log that nurses were to dose every 6 hours per XA results. There was documentation that the next XA was due at 7:49 a.m. and that the order was placed in the system. According to lab reports Patient #20 had a Heparin XA timed order for 7:50 a.m., collected 10:33 a.m. and received 10:43 a.m. and released at 11:05 a.m. (over 3 hours later after the time due). The results were .31 (reference ranges 0.30-0.70. The next documentation on the “Drips Titration Log” was at 11:00 a.m. where nursing documented a XA lab result of 0.31 and that the next XA was due in 6 hours. Staff failed to document what the Heparin was running at 11:00 a.m... According to lab the next Heparin XA timed was ordered for 5:00 p.m., collected 4:30 p.m. and received 4:35 p.m. and released at 4:56 p.m. The results were low at .20 (reference ranges 0.30-0.70). The next documentation on the “Drips Titration Log” was at 5:00 p.m. when the Heparin was increased by 50 units. According to the “Drips Titration Log” on 10/13/2014 there was documentation for 6:09 a.m. and 12:40 p.m. At 12:40 p.m. there was no need for titration because the lab results were .33 and according to the Heparin protocol there was no rate change. There was documentation on the titration log that there would be an XA in 6 hours. According to lab a Heparin XA timed was ordered for 6:30 p.m., collected 7:30 p.m. and received 7:38 p.m. and released at 7:59 p.m. The results were low at .26 (reference ranges 0.30-0.70). The intervention for this lab result was documented on the “Drips Titration Log” at 8:08 p.m. (over 1.5 hours late). At this time the Heparin was increased by 50 units. Review of lab results dated 10/14/2024 revealed there were Heparin XA levels for 2:08 am and 8:18 a.m. The lab for 8:18 a.m. was ordered at this time, collected over an hour later at 9:20 a.m., received at 9:37 a.m. and released at 10:16 a.m. Review of the “”Drips Titration Log” on 10/14/2024 after 3:00 p.m., revealed no documentation of what the rate of the drip, changes, or lab results for this day so far. During an interview on 10/14/2024 after 3:00 p.m., Staff #17 (RN) confirmed the missing information on the forms. Patient #17 Review of the emergency department (ED) record revealed that Patient #17 was a 60-year-old female who presented to the facility on 10/13/2024. Patient #17 had a chief complaint of chest pain. Review of physician orders revealed Patient #17 was admitted to the PCU unit on 10/13/2024. Review of physician orders revealed Patient #17 was started on the anti-coagulant Heparin in 0.45 percent sodium chloride, 25,000 units. The order was written at 12:30 p.m. and staff were to titrate (prn) and follow the facility’s acute coronary syndrome protocol 50 units per milliliters concentration. According to the “Drips Titration Log” Patient #17’s starting dose was 1000 units per hour at 2:00 p.m. on 10/13/2024. There was documentation on the log that staff would titrate every 6 hours per protocol. On 10/13/2024 at 8:24 p.m., the Heparin was on standby because the Heparin XA was elevated at 1.11. According to the facility’s “Low Dose Acute Coronary Syndrome” Heparin protocol staff were to stop the dose for 6o minutes and decrease by 3 units per kilograms per hour and repeat the XA in 6 hours. According to the “Drips Titration Log” Patient #17’s Heparin was started back up on 10/13/2024 at 9:30 p.m. and the drip was decreased by 3 units. The next Heparin XA was due on 10/14/2014 at 3:30 a.m. On 10/14/2024 at 4:45 a.m. (1 hour and 15 minutes later) the Heparin was decreased because of a Heparin XA of .80. The next Heparin XA and dose change was supposed to be 6 hours later according to the facility’s “Low Dose Acute Coronary Syndrome” Heparin protocol. The next timed lab and dose monitoring should have been 10:45 a.m... There was nothing documented for 10:45 a.m. on the “Drips Titration Log.” According to lab results a Heparin XA timed was ordered for 10:45 a.m., collected 12:41 p.m. and received 12:59 p.m. and released at 1:46 p.m. The results were low at .24 (reference ranges 0.30-0.70) and the Heparin was increased. The intervention for this lab result was documented 2:15 p.m. on the “Drips Titration Log” which was over 9 hours since the 4:45 a.m. rate change. Review of a facility’s “Request for Phlebotomy Draw” form dated 10/14/2024 revealed documentation the reason for the late Heparin XA draw was a code at 12:00 p.m. Where nursing documented they asked lab staff to draw the lab for them. During an interview on 10/14/2024 after 3:00 p.m., Staff #17 (RN) confirmed the missing information on the forms. During an interview on 10/15/2024 after 10:01 a.m., Staff #21 (lab director) stated that nursing had not put in a request for her staff to come up before the code and draw the lab. One of her staff participated in the code and a nurse from the floor asked the lab staff member to draw the blood then. Staff #21 said the lab was due at 10:45 a.m. and it was not collected until 12:41 p.m... Staff #21 stated they were tracking the problems with late morning labs on the unit but did not have a performance improvement on it. Review of a facility’s policy named “Specimen Priority” reviewed 03/2024 revealed: ...” A test is ordered as TIMED when it needs to be drawn at a specified time due to medication, etc. ...””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure blood transfusions were administered in accordance with their approved policies in 3 of 21 sampled patients reviewed for blood administration (Patient #’s 1, 15 and 21). The facility failed to ensure: A. Nurses identified signs and symptoms of possible blood/blood product transfusion reactions in Patient #’s 1 and 15. B. Nurses obtained post transfusion vital signs per their policy in Patient #’s 1 and 15. C. Nurses obtained and followed physician orders for blood/blood product transfusion rates in Patient #’s 15 and 21. This deficient practice had the likelihood to cause harm in all patients receiving blood transfusions. Findings include: Review of a physician’s consult note dated 03/26/2024 revealed that Patient #1 was a 36-year-old female who was admitted into the facility with shortness of breath, palpitation, and chest pain. Review of the clinical record revealed Patient #1 had the following lab results on 03/27/2024 at 5:02 a.m.: Low red blood cell counts 2.32 of (reference ranges 4.20-5.40). Low hemoglobin 7.1 of (reference ranges 12-14). Low hematocrit 20.5 of (reference ranges 37-47). Low platelets count 18 of (reference range 130-400). Physician progress notes dated 03/27/2024 revealed Patient #1 was diagnosed with TTP (Thrombotic Thrombocytopenia Purpura, a rare life-threatening clotting blood disorder). According to the progress notes Patient #1 was to receive 2 units of fresh-frozen plasma while waiting for transfer. Review of a physician’s order dated 03/27/2024 at 10:20 a.m., revealed Patient #1 was to receive one unit of fresh frozen plasma as soon as possible. According to the “BLOOD TRANSFUSION RECORD” dated 03/27/2024 at 12:30 p.m., Patient #1 had a blood pressure of 123/81, pulse of 87, respirations 14 and a temperature of 98.4. At this same time nurses documented starting a unit of fresh frozen plasma. At 12:45 p.m., 15 minutes after the infusion Patient #1’s blood pressure dropped to 91/58. The systolic dropped more than 30 mm of Hg (millimeters of mercury). There was an adverse reaction category underneath the vital signs on the form. Nursing checked Patient #1 had no adverse reaction. One of the symptoms listed to determine a reaction was a decrease in blood pressure of greater than or equal to 30 mm Hg. There was no documentation of the physician being notified of a possible adverse reaction or a directive as to if nursing was to continue with the transfusion. According to the “BLOOD TRANSFUSION RECORD” the transfusion was completed at 2:30 p.m. There was a slot on the form for nursing to document a one-hour post transfusion set of vital signs. Post vital signs were not recorded. During an interview on 10/14/2024 after 4:00 p.m., Staff #17 confirmed the missing physician notification and vital signs. Patient #21 Review of a physician’s history and physical revealed Patient #21 was a 66-year-old female who was admitted to the facility on 10/08/2024 with diagnoses which included congestive heart failure, hypertension, and anemia. Review of the clinical record revealed Patient #21 had the following lab results on 10/08/2024 at 12:34 p.m.: Low red blood cell counts of 1.97 (reference ranges 4.2-5.4) Low hemoglobin of 4.3 (reference ranges 12-14) Low hematocrit of 17.1 (reference ranges 37-47) Low platelets count of 64 (reference range 130-400) Review of a physician’s order dated 10/08/2024 revealed Patient #21 was to receive four units of packed red blood cells. The transfusion rate was to run at 75 cc per hour for the first 15 minutes and then 100 cc per hour. According to the “BLOOD TRANSFUSION RECORD” dated 10/08/2024 at 5:15 p.m., 10/08/2024 at 10:52 p.m.,10/09/2024 at 2:27 a.m., and 10/09/2024 at 6:15 a.m. nursing ran the transfusions at 75 cc per hour for the first 15 minutes but increased them up to 125cc per hour. The physician’s order called for the transfusions to be increased to 100 cc per hour. Review of a physician’s order dated 10/09/2024 revealed Patient #21 was to receive two units of packed red blood cells. The transfusion rate was to be 75 cc per hour for the first 15 minutes. There was no rate written for the continuation of the transfusion. According to the “BLOOD TRANSFUSION RECORD” dated 10/09/2024 at 11:08 p.m. and 10/10/2024 at 2:10 a.m., nursing ran the transfusions at 75 cc per hour for the first 15 minutes but increased them up to 125cc per hour. There was no physician’s order for the transfusions to infuse at 125 per hour. During an interview on 10/15/2024 after 9:00 a.m., Staff #17 confirmed the transfusion orders and rates. 40989 Patient #15 A review of the medical record for Patient #15 was completed on 10/15/2024 after 9:30 AM with RN Staff #4 and RN Staff #13. Patient #15 was a 62-year-old male who presented to the Emergency Room (ER) on 10/05/2024 with complaints of chest pain and abdominal cramping with black tarry stools. (black tarry stools are an indication that the patient may be bleeding internally). He had a history of gastrointestinal bleeding. He was admitted to the Hospital on 10/05/2024 in critical condition. An order was written on 10/06/2024 at 2:27 AM by Physician #22 that read, “Transfuse 2 units PRBCs (packed red blood cells)”. There was no rate for the initiation of the blood transfusion in the physician’s order. A review of the transfusion record dated 10/06/2024 at 3:13 AM revealed Unit #1 was started by RN Staff #26 on 10/06/2024 at 3:13 AM. The initial rate of infusion was 75 milliliters (ml) per hour. The blood transfusion was completed on 10/06/2024 at 3:50 AM. Further review revealed the transfusion rate was increased to “999” and given as a rapid infusion on 10/06/2024. There was no time documented when the rate was increased. There was no physician order to increase the rate. A review of the nurse’s note documented by RN Staff #26 on 10/06/2024 at 3:38 AM was as follows: “Physician #22 is recommending that Patient #15’s blood be changed to a rapid infusion. Infusion rate adjusted per his instruction”. A review of the transfusion record dated 10/06/2024 at 7:50 AM revealed Unit #2 was started on 10/06/2024 at 7:50 AM by RN Staff #23. The initial rate of infusion was 75 mls per hour. The rate of infusion was increased by RN Staff #23 at 8:50 AM to 125 ml’s per hour. The transfusion was completed on 10/6/2024 at 10:15 AM. There was no order to increase the rate of the blood transfusion by a physician in the medical record. Vital signs were taken at 7:45 AM, 8:00 AM, 8:50 AM, 9:50 AM, 10:00 AM, and 11:00 AM. There were no vital signs documented for 45 minutes after the blood transfusion was completed. A review of the order dated 10/06/2024 at 5:08 PM by Physician #24 was as follows: “Fresh Frozen Plasma (FFP-a blood product) x 1”. A review of the Transfusion Record dated 10/06/2024 at 8:35 PM revealed the transfusion was started on 10/06/2024 at 8:35 PM by RN Staff #25 and the initial rate was documented as “free flowing”. Physician #24 did not order a transfusion rate for the FFP. The transfusion was completed at 9:15 PM. A review of the order dated 10/06/2024 at 3:28 PM by Physician #28 was as follows: “Fresh Frozen Plasma x 1”. A review of the Transfusion Record dated 10/06/2024 at 6:14 PM revealed the transfusion was started on 10/06/2024 at 6:14 PM by RN Staff #27 and the initial rate was documented as “free flowing”. Physician #28 did not order a transfusion rate for the FFP. The transfusion was completed at 6:45 PM. A review of the order dated 10/07/2024 at 7:39 AM by Physician #24 was as follows; “Transfuse 1 unit of PRBCs at 50 ml’s per hour”. A review of the transfusion record dated 10/07/2024 documented by RN Staff #29 revealed the blood transfusion was started at 10:30 AM at 50 ml’s per hour as ordered. Further review revealed RN Staff #29 increased the transfusion rate to 125 ml’s per hour at 10:45 AM without a physician order. In an interview on 10/15/2024 after 10:00 AM, RN Staff #4 confirmed there was no physician order to increase the rate of infusion. An interview was conducted with RN Staff #13 on 10/15/2024 after 9:30 AM. RN Staff #13 was asked when the physician writes an order for a blood or blood product transfusion, was the physician supposed to order the rate of the infusion at the same time. RN Staff #13 stated, “Yes, they are supposed to. It is documented on the actual order for the blood transfusion. There is also a drop-down box for them to write an order for the nurse to increase the rate after 15 minutes”. RN Staff #13 confirmed Physician #22 wrote an order to transfuse 2 units of PRBCs on 10/06/2024 at 2:27 AM but failed to include a rate for the transfusion. It was also confirmed by RN Staff #13, that Physician #24 failed to order the rate of infusion for the FFP that was administered to the patient on 10/06/2024 at 5:08 PM. A review of the facility policy titled; “Transfusion of Blood Products” was as follows: “Blood Products- Red blood cells, plasma, platelets, cryoprecipitate, albumin, intravenous immune globulin ... POLICY A. A provider order is required for the preparation and transfusion of blood products. B. Informed consent for blood products should be obtained from the patient or legal guardian (unless emergent). Consent should be obtained prior to pre-transfusion testing ABO/Rh if possible. If patient refuses blood products a Release from Liability - Refusal of Blood and Blood Products must be completed ... K. Transfusions should be administered per provider order, not to exceed the expiration date and time listed on the blood product .... N. Pre transfusion vital signs should be obtained and documented within the 15 minutes prior to the initiation of the transfusion. 0. Once the transfusion has started, a full set of vital signs should be obtained and documented: a. 15 minutes after the transfusion begins b. One hour after the transfusion begins c. Every hour thereafter during the transfusion d. At the completion of the transfusion e. One hour after completion of the transfusion ...” During an interview on 10/15/2024 after 10:30 AM with RN Staff #4, RN Staff #13, and Physician #7 it was confirmed that all physicians ordering blood or blood products must document in their order the initial rate of infusion and any changes to the rate of the infusion before the blood or blood product administration begins. RN Staff #4 confirmed the order set for blood and blood products does allow the physician to order the rate at the time of the initiation and any changes to the rate of infusion for blood and blood products. RN Staff #13 confirmed the nursing staff failed to follow the facility policy and document the patient’s vital signs according to facility policy.”

“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: 49344 Based on interviews and record reviews, the hospital failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that 1 of 1 patient (Patient #1) who presented to the center on 02/23/24 and was transferred to Facility 2 without being stablized. Cross refer to: Tag A2404 - 42 CFR §489.20(r)(2) and §489.24(j)(1-2) On Call Physicians Tag A2407 - 42 CFR §489.24 (d)(1-3) Stabilizing Treatment”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 49344 Based on record review and interview, the facility’s on-call physician, Staff #9, MD, failed to respond to a request or page from the Emergency Department resulting in patient #1 being transferred to another hospital for evaulation and treatment. Physician Staff #9 failed to follow Medical Staff Bylaws Rules and Regulations, Revised December 17, 2020, 6.1 Emergency Coverage. A review of records on 6/26/2024 revealed Patient #1, arrived at Facility #1 on 2/23/2024 at 5:44 PM for “Fever; Code Sepsis” with an ESI Level 2. ESI (Emergency Severity Index) is a five-level triage system used in emergency departments to prioritize patients based on the severity of their condition and the resources they are likely to need. Level 2 patients require urgent care to prevent further deterioration, though they are not as critically unstable as ESI Level 1 patients. Patient #1 was a 32-year-old, female with a history of kidney stones, tubal ligation, C-Section, Left Below the Knee Amputation (LBKA), and left kidney stent. The patient arrived at Facility #1, via private vehicle on 2/23/2024 at 5:44 PM for complaints of “fever onset 4 days ago”. A review of the Intake record revealed, “The patient states she had a stent placed 8/2023 by ____ (Staff #10), on her left side. The patient states she has not followed up since because of insurance and financial difficulties. The patient states she was recently treated for UTI with IV antibiotics. The patient’s LBM (last bowel movement) was yesterday. No other complaints at this time.” A ureteral stent is a soft, hollow tube that a urologist places in the ureter to help urine drain from the kidney to the bladder when a kidney stone is blocking the ureter. “History and Present Illness by Staff 11, MD, 2/23/2024: Reviewed; Complaint: abdominal pain, flank pain-left; Symptoms have been persistent; Timing of symptoms still present; Pain Severity/Quality/Location Pain Severity - current 7, Pain Scale: Numeric; Associated Symptoms Fever, nausea, vomiting, back pain” Vital signs 2/23/2024 at 6:27 PM “Temp: 103 F (H) Resp: 26 (H) Pulse:130 (H) BP: 115/75 O2 Sat: 97% RA” A review of the progress notes on 2/23/2024 from emergency department physician, Staff #11, MD revealed: Progress: “2047: Requested records from (Hospital Facility #3). CT scan results discussed with _____(Staff #9, MD) who is on call urologist this weekend. He states he will not see patient and will wait until Monday for ______(Staff #10, MD) to see his own patient. Discussed with ____(Staff #16, MD), regarding admission - she does not feel comfortable taking admission without urology consulted. 2240: Spoke to _____(Staff #12, MD), urologist at Facility #2 concerning the pt. _____(Staff #12, MD) recommended medical admission to treat the UTI infection. Then when the infection is resolved removal of the stent. 2313: Discussed with ______(Staff #17, MD) regarding patient. She agrees to admission.” (sic) Clinical Impression: “Left Pyelonephritis Left Hydronephrosis Left Hydroureter” Interview During an interview with Staff #6, MD, Chief Medical Officer (CMO) on 6/26/2024 at 11:45 AM, it was revealed that she was not aware of the situation that occurred on 2/23/2024 with Staff #9 and his refusal to come see Patient #1. She mentioned that there is an escalation process that should have been followed. Staff #6, MD, CMO explained, “If staff refuse to come to see a patient, there should be a phone call made to me so that I can address it.” She also expressed that this situation did not surprise her, as there have been ongoing issues with Staff #9. Staff #9 had a recent incident that required a peer review just a few weeks ago, involving a racial slur. Additionally, Staff #9 has a habit of not using the EMR (electronic medical record), and instead calls after leaving the hospital to have nurses put in telephone orders. Staff #6, MD, CMO described him as hard to get along with and mentioned that he does not get along with Staff #10, the other urologist on staff. Therefore, Staff #6, MD, CMO reported that she was not surprised by Staff #9, MD’s refusal to see the patient, and she finds it very concerning. Interview In a phone interview with Staff #9, MD on 6/26/2024 at 2:20 PM with Staff #6, MD, CMO, present, the surveyor asked how he handles patients that need consultations in the emergency room, and he stated, “If they can wait, then I do not come up to the hospital. I won’t clean up other doctor’s messes.” During a review of Patient #1’s record with Staff #9, MD via telephone, the surveyor asked if the temperature of 103 F, Pulse of 130, Respirations of 26, and WBC of 14.1 with a CODE SEPSIS protocol in place would constitute a visit from him. Staff #9, MD stated, “No one told me this patient was sick and I want all of my interactions with staff recorded going forward!” This surveyor asked Staff #9, MD if he was familiar with Medical Staff Bylaws Rules, and Regulations regarding Emergency Room Coverage for on-call physicians. Staff #9, MD stated “I go see the patient if I feel it is necessary. I am very prompt and see patients that are sick.” This surveyor read the section of the Medical Staff Bylaws to Physician # Staff #9 from page 124, EMERGENCY ROOM SERVICES “6.1 Emergency Room Coverage ... ...6.1-5 The on-call physician is expected to respond to a request or page from the ED within 30 minutes and to present in the Emergency Department within 30 minutes of a request by the Emergency Department physician (or time frame agreed upon by the on-call physician and the Emergency Department physician) ....” Interview In a phone interview on 6/26/2024 at 7:08 PM with Staff #17, MD, Hospitalist, that was treating Patient #1 in the ED and requested consult from on-call Physician Staff #9, stated, “We have chronic problems with the urology team, especially Staff #9, MD. I am always very hesitant when he is involved. This patient had a grossly positive UA, and she had hydronephrosis and hydroureter which is an indicator of a possible obstruction. The CT scan showed there was no obstruction, but this patient was very sick and after discussion with the ER physician and the Nurse Practitioner, in the ER, we felt a transfer was the safest option for the patient. The patient had a temperature of 103 F and WBC over 14 and this man refused to come to see her, saying “The patient can just wait, I am not coming in.” This is very frustrating and again, there are lots of problems.” Interview In a phone interview with Staff #12, MD, urologist, at Facility #2, on 6/27/2024 at 1:00 PM, it was confirmed that Patient #1 was transferred to Facility #2 and treated.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 49344 Based on document review and interviews, the facility failed to stabilize 1 of 1 patient (Patient #1) before transfer. The on-call urologist, Staff #9, refused to see the patient and deferred care to another urologist scheduled to return two days later. The hospitalist, Staff #17, declined to admit the patient without a urology consult. After consulting with a urologist from Facility #2, the patient was transferred for further treatment. A review of records on 6/26/2024 revealed Patient #1, arrived at Facility #1 on 2/23/2024 at 5:44 PM for “Fever; Code Sepsis” with an ESI Level 2. ESI (Emergency Severity Index) is a five-level triage system used in emergency departments to prioritize patients based on the severity of their condition and the resources they are likely to need. Level 2 patients require urgent care to prevent further deterioration, though they are not as critically unstable as ESI Level 1 patients. On 6/26/2024, a review of records revealed that Patient #1, a 32-year-old female with a medical history including kidney stones, tubal ligation, C-section, left below-the-knee amputation (LBKA), and a left kidney stent, arrived at Facility #1 on 2/23/2024 at 5:44 PM for fever and was triaged as ESI Level 2. The patient, who reported a four-day fever, had a ureteral stent placed in August 2023 but had not followed up due to financial and insurance barriers. Based on review of Patient #1’s medical record, the patient exhibited severe symptoms, including a temperature of 103°F, a heart rate of 130, and left flank pain. Laboratory results indicated a urinary tract infection (UTI) with large amounts of blood and leukocyte esterase in the urine, and a CT scan showed left hydronephrosis, hydroureter, and fat stranding, suggesting a possible infection or obstruction. The patient had early sepsis related to pyelonephritis with a 6-month, indwelling ureteral stent. Patient #1 was dehydrated from vomiting, had ketones present in her urine, mildly acidotic, and had significantly abnormal vital signs. According to the Centers for Disease Control (CDC), sepsis is the body’s extreme response to an infection and can lead to tissue damage, organ failure, and death if not treated promptly (https://www.cdc.gov/sepsis/about/?CDC_AAref_Val=https://www.cdc.gov/sepsis/what-is-sepsis.html). A review of the progress notes on 2/23/2024 from emergency department physician, Staff #11, MD revealed: Progress: “2047: Requested records from (Hospital Facility #3). CT scan results discussed with _____(Staff #9, MD) who is on call urologist this weekend. He states he will not see patient and will wait until Monday for ______(Staff #10, MD) to see his own patient. Discussed with ____(Staff #16, MD), regarding admission - she does not feel comfortable taking admission without urology consulted. 2240: Spoke to _____(Staff #12, MD), urologist at Facility #2 concerning the pt. _____(Staff #12, MD) recommended medical admission to treat the UTI infection. Then when the infection is resolved removal of the stent. 2313: Discussed with ______(Staff #17, MD) regarding patient. She agrees to admission.” (sic) Clinical Impression: “Left Pyelonephritis Left Hydronephrosis Left Hydroureter” Disposition: “Transfer” Medical Decision Making “Differential diagnoses considered are: Pyelonephritis, urosepsis” Interview During an interview with Staff #6, MD, Chief Medical Officer (CMO) on 6/26/2024 at 11:45 AM, it was revealed that she was not aware of the situation that occurred on 2/23/2024 with Staff #9 and his refusal to come see Patient #1. She mentioned that there is an escalation process that should have been followed. Staff #6, MD, CMO explained, “If staff refuse to come to see a patient, there should be a phone call made to me so that I can address it.” She also expressed that this situation did not surprise her, as there have been ongoing issues with Staff #9. Staff #9 had a recent incident that required a peer review just a few weeks ago, involving a racial slur. Additionally, Staff #9 has a habit of not using the EMR (electronic medical record), and instead calls after leaving the hospital to have nurses put in telephone orders. Staff #6, MD, CMO described him as hard to get along with and mentioned that he does not get along with Staff #10, the other urologist on staff. Therefore, Staff #6, MD, CMO reported that she was not surprised by Staff #9, MD’s refusal to see the patient, and she finds it very concerning. Interview In a phone interview with Staff #9, MD on 6/26/2024 at 2:20 PM with Staff #6, MD, CMO, present, the surveyor asked how he handles patients that need consultations in the emergency room, and he stated, “If they can wait, then I do not come up to the hospital. I won’t clean up other doctor’s messes.” During a review of Patient #1’s record with Staff #9, MD via telephone, the surveyor asked if the temperature of 103 F, Pulse of 130, Respirations of 26, and WBC of 14.1 with a CODE SEPSIS protocol in place would constitute a visit from him. Staff #9, MD stated, “No one told me this patient was sick and I want all of my interactions with staff recorded going forward!” Staff #9, MD was asked if he was familiar with Medical Staff Bylaws Rules and Regulations regarding Emergency Room Coverage for on-call physicians. Staff #9, MD stated “I go see the patient if I feel it is necessary. I am very prompt and see patients that are sick.” A review of the Medical Staff Bylaws, page 124, EMERGENCY ROOM SERVICES, revealed the following: “6.1 Emergency Room Coverage ... ...6.1-5 The on-call physician is expected to respond to a request or page from the ED within 30 minutes and to present in the Emergency Department within 30 minutes of a request by the Emergency Department physician (or time frame agreed upon by the on-call physician and the Emergency Department physician) ....” Interview In a phone interview on 6/26/2024 at 7:08 PM with Staff #17, MD, Hospitalist, that was treating Patient #1 in the ED and requested consult from on-call Physician Staff #9, stated, “We have chronic problems with the urology team, especially Staff #9, MD. I am always very hesitant when he is involved. This patient had a grossly positive UA, and she had hydronephrosis and hydroureter which is an indicator of a possible obstruction. The CT scan showed there was no obstruction, but this patient was very sick and after discussion with the ER physician and the Nurse Practitioner, in the ER, we felt a transfer was the safest option for the patient. The patient had a temperature of 103 F and WBC over 14 and this man refused to come to see her, saying “The patient can just wait, I am not coming in.” This is very frustrating and again, there are lots of problems.” The surveyor thanked Staff #17, MD, Hospitalist, for her time and asked if she had any further concerns or questions. She denied any additional needs at this time. Despite the critical findings, the on-call urologist, Physician Staff #9, refused to see the patient, deferring her care to another urologist scheduled to return two days later. The hospitalist, Staff #17, declined to admit the patient without a urology consult. After consulting with a urologist from Facility #2, who recommended medical admission for the UTI, the patient was ultimately transferred for further treatment. Interview In a phone interview with Staff #12, MD, urologist, at Facility #2, on 6/27/2024 at 1:00 PM, it was confirmed that Patient #1 was transferred to Facility #2 and treated.”