Texoma Medical Center

“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 interview and record review, the facility failed to ensure nursing services was organized in the area of blood administration. The facility failed to : A) Ensure blood transfusions were administered at a safe rate and per their policy in 1 of 3 patients sampled for blood administration (Patient # 11). Facility staff failed to document the initial infusion rate and rate throughout blood transfusions. Patient #11 had documented lung and heart effusions identified prior to the blood transfusion on 08/15/2025 which put the patient at risk for overload. Nursing staff provided 258 cc of packed red blood cells to the patient in 2 hours and 20 minutes. Patient #11 developed respiratory distress during the blood transfusion on 08/15/2025 and required placement on a ventilator. B) Ensure a patient that developed respiratory distress during a blood transfusion and was intubated and placed on a ventilator was reviewed for a potential transfusion reaction (Patient #11). As of 01/06/2026 (over 4 months later) lab did not know anything about the incident and no transfusion reaction workup had been performed. C) Ensure blood transfusion rates were monitored and documented in 3 of 3 sampled patients who were reviewed for blood transfusions (Patient #’s 11, 29 and 30). It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who received blood transfusion in the facility at risk for the likelihood of harm, serious injury, and possibly subsequent death. Refer to tag A 0410 for additional information.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36827 Based on review of records and interview, the facility failed to ensure care in an safe setting that provided for the emotional safety and care with respect and dignity for 1 (Patient #15) of 3 patients who made multiple visits to the obstetric emergency department in September of 2025. When patients are not provided an emotionally safe environment, it can delay or prevent them from seeking treatment in the future during a medical emergency due to previous care received, placing them at risk for health complications or death. The facility failed to ensure the policy addressing this, titled “Behaviors that Undermine a Culture of Safety”, contained effective processes to ensure patient’s rights to be cared for in an emotionally safe environment that provided for respect and dignity would be enforced. Findings include: Patient #15 was a 22-year-old who was in her third pregnancy. She had 1 birth and 1 fetal demise due to ectopic pregnancy. She had previously been diagnosed with preeclampsia with her first pregnancy which was a life-threatening condition of high blood pressure caused by pregnancy resulting in her baby being born early at 38 weeks 3 days. Preeclampsia could lead to stroke, seizures, organ failure, placental abruption, premature birth, or death of the mother or baby. The only true cure is delivery of the baby and placenta. Patient #15 had started contractions early in her third pregnancy and was placed on Procardia by her primary obstetrical physician, a medication that helps with preterm labor and also helps with preeclampsia. On 9-22-2025 at 11:49 PM, the patient called the Labor and Delivery (L&D) unit of the hospital and spoke with Nurse Staff #25. She explained that she had been experiencing wetness in her vaginal area and was concerned about possible premature rupture of membrane (when the water bag/amniotic sac breaks before labor has started). Premature rupture of membrane (PROM) can lead to serious infection in the mother and baby, umbilical cord compression that can cut off the baby’s oxygen, preterm birth, or stillbirth. Because of the seriousness of the potential condition, Nurse Staff #25 encouraged the patient to come in and get checked. Per the patient complaint, she did not want to come in because of the negative comments she had experienced from nursing and physician staff previously due to her frequent visits. She stated the pregnancy had been hard for her and she had gone to the L&D emergency room frequently when she felt something was wrong. She stated that she did go in to be checked, and the physician made a comment about how high her gasoline bill must be because she was always driving to the hospital. In her complaint, she stated, “last night was the final straw” and “this is not the first time bullying me and not treating me with the care I deserve like test and respect.” The patient stated that Nursing Staff #25 sat with her and comforted her while she cried about the way the physician had treated her. Review of patient medical records showed: The patient was registered in the Obstetric Emergency Room on 9-23-25 at 12:06 AM. On 9-23-25 at 12:59 AM, Physician Staff #21 was “notified of pt (patient) arrival, admitting complaint, negative AmniSure (test to determine if fluid is amniotic fluid), VE (vaginal examination) and fetal strip characteristic (results of fetal monitoring). Stated he would be at bedside momentarily for assessment.” On 9-3-25 at 1:14 AM, Physician Staff #21 charted: “Physical Examination This is a patient who presents to labor and delivery and extraordinarily frequent basis almost to an abusive degree, this time states that she had leaking fluid putting tissues up inside and the get wet “” however her AmniSure is negative she was placed on the monitor the baby’s fetal heart tones are very reactive and there are no contractions cervix was closed. Impression and Plan Normal examination and of leaking fluid she will be discharged again” (sic) Nurse Staff #25 charted on 9-23-25 at 1:24 AM, “RN providing pt with reassurance for coming in for assessment based off pts concerns, encouraged pt of positivity towards results being negative based off gestational age, pt verbalized agreement.” On 9-23-25 at 1:34 AM, “RN remains at bedside providing comfort and education over importance of Procardia, tips on medication administration to help decrease an upset stomach, further information provided over bed rest as prescribed by Dr. (primary obstetrical physician name redacted)’s office.” On 1-6-2026 at approximately 4:00 PM, an interview by telephone was conducted with Nurse Staff #25. Nurse Staff #25 stated that she remembered the patient and incident. Nurse Staff #25 confirmed that she was the staff member that had encouraged the patient to come into the hospital to be checked. Nurse Staff #25 stated that she was not present in the room and did not hear what the physician had said to the patient, so did not want to speculate about what may have been said. But she did confirm that the patient was crying and expressed feelings of her concerns not being taken seriously by medical staff, her feelings of her concerns being minimized, and her feeling of being disrespected because she came in often when she felt like something was wrong with her pregnancy. Nurse Staff #25 stated that she tried to provide comfort and reassurance to the patient and encouraged her to continue to seek medical assistance when she felt like something was wrong. Policy Review: Policy Title: PC 197_Patient Rights and Responsibilities was reviewed on 1-6-25. This policy did not address the patient’s right to respectful, dignified care in an emotionally safe setting. On 1-7-25, Staff #2 was asked if the facility addressed it in another policy. Staff #2 provided Policy Title: Behaviors That Undermine a Culture of Safety that addressed the hospital’s policy for Medical Staff to “treat others with respect, courtesy, and dignity and to conduct themselves in a professional and cooperative manner.” Review of the policy was as follows: I. Scope: Line of Responsibility: This is a Facility-wide policy and applies to all patient care settings and operations at Texoma Medical Center(“Facility”) II. Purpose: To establish standards for all individual exercising privileges awarded by the Medical Staff process (“Practitioners”) which prohibit behaviors that undermine a culture of safety. III. Policy and Procedures: A. It is the policy of TMC and Medical Staff for all Practitioners within or on behalf of TMC to treat others with respect, courtesy, and dignity and to conduct themselves in a professional and cooperative manner. The overarching goal of this policy is to cultivate a Facility-wide culture of safety, so it is furthermore the Practitioner’s responsibility to affirmatively hear concerns raised about patient safety and to respond to such concerns professionally and cooperatively. Specifically, Practitioners will respect requests to “stop the line” or other assertive statements or actions regarding potential patient safety issues and will interpret any such statements or actions as being made in good faith and in the patient’s best interest. ... E. In dealing with incidents of behaviors that undermine a culture of safety, the protection of patients, employees, physicians, and others in TMC and the orderly operation of TMC are paramount concerns. Behaviors that undermine a culture of safety are defined as those which adversely affect or impact TMC operations or the ability of others to perform their jobs competently or interferes or tends to interfere with the provision of safe, quality patient care at TMC. For the purposes of this Policy, examples of “undermining behaviors: include, but are not limited to: Disruptive Behaviors - Rude or abusive behavior, comments, or outbursts to Facility personnel, patients, Practitioners, vendors, or visitors. Demeaning Behavior - Negative comments to patients about other Practitioners, nurses or other TMC personnel or Medical Staff members or about their care and treatment in TMC. Verbal attacks which are of a personal, irrelevant or go beyond fair, professional conduct, and that are directed to TMC personnel, Medical Staff, Practitioners, contracted staff, or patients. Irrelevant or inappropriate comments, drawings, or illustrations made in a patient’s medical record or other TMC business records, impugning the quality of care in TMC or attacking a particular Practitioners, nurses, other TMC personnel, or TMC policies. Intimidating Behaviors - Criticism that is addressed to a recipient in such a manner as to intimidate, undermine confidence, belittle, imply stupidity or incompetence, or some other type of public humiliation. ... H. This Policy outlines initial collegial steps (i.e., warnings and meetings with a Practitioner) that may be taken in an attempt to resolve behaviors that undermine a culture of safety as may be exhibited by a practitioner ... I. Practitioners, nurses, other Facility employees, or other individuals who observe, or are subject behaviors that undermine a culture of safety by a Practitioner and are unable to collegially address the behavior shall notify their supervisor about the incident or, if their supervisor’s behavior is at issue, they shall notify the Chief Executive Officer (or designee). Any Practitioner who observes such behavior and is unable to address it shall notify the Chief Executive Officer directly. Upon learning of the occurrence of an incident of uncorrected undermining behavior, the supervisor/Chief Executive Officer shall request that the individual who reported the incident to document it in writing or in Midas and report to be referred to Quality/Peer Review. In the alternative, the supervisor/Chief Executive Officer shall document the incident as reported and send to Quality/Peer Review. ... K. If a reporting individual is unwilling or uncomfortable with reporting undermining behavior using the procedure described herein, then a report of the incident may alternatively be made to the TMC’s Patient Safety Council. L. After a determination that the incident of undermining behavior has occurred, the Chief of Staff, the Chief Executive Officer, the CMO, and /or the QUR Committee shall evaluate the behavior for an appropriate response commensurate with the severity of the undermining behavior after taking into account past instances or patterns of uncorrected behaviors, if any. Low level concerns should be addressed collegially but with a higher degree of formal communication and a specific set of interventions or action implemented to address the undermining behavior. High level concerns should be addressed in a formal manner with accompanying referral to a Medical Staff Executive Committee which has responsibility for Practitioner conduct. The following collegial interventions, in any combination, may be implemented at the discretion of said individual or Committee:” Review of the peer review reporting on 1-6-25 at 3:47 PM showed that a previous, similar issue had been reported in January 2025 for Physician Staff #21. However, the incident with Patient #15 was never reported by the staff present or the patient so could not be sent to peer review to investigate a possible trend in physician behavior.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure nurses developed and kept current care plans that met patient’s needs for care in 3 of 30 sampled patients (Patient #’s 8, 9, and 12). The facility failed to: A) Ensure nurses assessed and adjusted the care plan to address pain needs on 3 of 30 sampled patients (Patient #’s 8, 9 and 12). B) Ensure nurses evaluated and provided timely intravenous therapy as the care plan required on Patient #9. This deficient practice had the likelihood to cause harm to all patients. Findings include: Patient #8 Review of a facility’s face sheet revealed that Patient #8 was a 27-year-old female who had an initial admission date of 08/25/2025. Review of infusion orders signed off 08/21/2025 revealed Patient #8 had diagnoses of nausea, vomiting and gastroparesis. There were orders for sodium chloride 0.9 %, 1000cc at a rate of 500 cc per hour via port on Monday, Wednesdays and Fridays. Review of a “Pain Assessment” dated 08/27/2025 revealed documentation of a pain level of 7 at 12:00 p.m., 12:13 p.m., 2:26 p.m., and 2:27 p.m.. There was no documentation of the location of the pain or what intervention was taken. Review of progress notes dated 08/29/2025 at 12:05 p.m., revealed Patient #8 was there for hydration and her infusion was started. Patient #8 complained of generalized abdominal pain. There was documentation that Patient #8 said this was typical for her and denied needs. There was no documentation of the level of the pain or a follow-up on the pain on 08/29/2025. Review of treatment records and vital sign sheets revealed the following: September 2025 pain was assessed two times out of twelve documented treatments. October 2025 pain was assessed three times out of twelve documented treatments. On 10/23/2025 there was an assessment that Patient #8 had generalized pain, but there was no location or level of the pain. November 2025 pain was assessed two times out of seven documented treatments. December 2025 pain was assessed three out of sixteen documented treatments. January 3, 2026 (Saturday) there was documentation of a treatment, but there was no pain assessment documented. Patient #9 Review of a physician order dated 07/04/2025 at 9:00 a.m. revealed Patient #9 had an order for intravenous Lasix 40 milligrams every week for a total of 8 weeks and for the first dose to on 07/07/2025. The diagnosis for the medication was congestive heart failure (CHF). Review of an admission sheet revealed that Patient #9 was an 83-year-old female with an admission date on 07/14/2025 to the infusion unit. There was no evidence the first treatment was started on 07/07/2025 as ordered. There was no documentation that the physician was called about the first treatment not being started. Review of the problem list on Patient #9 from October 2025-01/2026 revealed a diagnosis of chronic rheumatoid arthritis. Review of assessment/treatment records, history forms, progress notes, and vital signs from 10/2025-01/2026 revealed no documentation of pain being assessed. During an interview on 01/05/2026 after 2:56 p.m., Staff #12 confirmed the missing assessments. During an interview on 01/05/2026 after 2:56 p.m., Staff #13 confirmed the missing pain assessments and stated they were supposed to documented in the area where they documented vital signs. Staff #13 said they would start documenting pain assessments. Staff #13 stated she could not find where the physician was notified of the treatment being started late on Patient #9. Patient #12 Review of the emergency department (ED) record on Patient #12 revealed he was a 63-year-old male who presented to the ED on 08/14/2025 with complaints of possible clots at 9:46 p.m. According to a triage assessment at 9:48 p.m. Patient #12 had an emergency severity index level of 3 (meaning urgent). The pain level was documented as a 9(severe) in the upper leg. At 9:52 p.m. the pain level was still at a 9 (severe). Review of the medication administration record revealed the pain medication Morphine 8 milligrams intramuscular was ordered “Stat” at 10:08 p.m. Patient #12 was documented as having a pain level of 9 (severe) at 11:44 p.m. The pain medication was administered at 11:46 p.m. over 1.5 hours after it was ordered. An ultrasound completed at 11:52 p.m. revealed Patient #12 had non-occlusive deep vein thrombosis to bilateral legs. There was no follow-up assessment on Patient #12’s pain after administration of the pain medication. According to documentation Patient #12 eloped from the ED on 08/15/2025 at 2:44 a.m. During an interview on 01/05/2026 after 3:59 p.m., Staff #12 confirmed the pain levels, medication administration and missing assessment. During an interview on 01/06/2026 after 10:20 a.m., Staff #26 stated that an order for stat meant to be done within 15 minutes and with pain medication they try to administer it within 30 minutes. During an interview on 01/06/2026 at 10:57 a.m., Staff #27 stated that stat meant to administer within 30 minutes. Review of a facility’s policy named “Infusion Center Guidelines” dated 01/07/2025 revealed the following: “ ...II. Guidelines ... ...For patients that miss their scheduled infusion: a call will be placed to the patient for a wellness check and ordering physician will be notified of missed appointment ... ...Patient Assessment: For non-recurring patients: Patient assessment and triage questions will be documented in the patient’s permanent record with each infusion or treatment and reported to the physician and other members of the health-care team as appropriate. *Vital signs will include temperature, blood pressure, heart rate, respiratory rate, oxygen saturation and pain assessment. They will be obtained before treatment and at discharge (on patients in the infusion center for greater than 30 minutes). Some medications or treatments may require more comprehensive monitoring of vital signs based on mediation guidelines or patient condition ...” Review of a facility’s policy named “NS 1.2 Patient Assessment, Admission and Ongoing Reassessment” dated 04/17/2024 revealed the following: ...Assessment *RN’s will conduct an initial and ongoing comprehensive assessment .... ...RNs will develop a plan of care based on the assessed needs of the patient, as outlined in policy and guideline ... ...ER ...Dependent on ESI: Patients will have additional vital signs completed using the following criteria: ESI-as patient condition and physicians indicate, no less than every 2 hours ... ...With changes in patient’s conditions. When medications administered warrant reassessment ...””

“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 patients receiving blood transfusions received care per their approved policy. The facility failed to: A) Ensure blood transfusions were administered at a safe rate and per their policy in 1 of 3 patients sampled for blood administration (Patient # 11). Facility staff failed to document the initial infusion rate and rate throughout blood transfusions. Patient #11 had documented lung and heart effusions identified prior to the blood transfusion on 08/15/2025 which put the patient at risk for overload. Nursing staff provided 258 cc of packed red blood cells to the patient in 2 hours and 20 minutes. Patient #11 developed respiratory distress during the blood transfusion on 08/15/2025 and required placement on a ventilator. B) Ensure a patient that developed respiratory distress during a blood transfusion and was intubated and placed on a ventilator was reviewed for a potential transfusion reaction (Patient #11). As of 01/06/2026 (over 4 months later) lab did not know anything about the incident and no transfusion reaction workup had been performed. C) Ensure blood transfusion rates were monitored and documented in 3 of 3 sampled patients who were reviewed for blood transfusions (Patient #’s 11, 29 and 30). It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who received blood transfusion in the facility at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings include: Patient #11 Review of the emergency department (ED) record on Patient #11 revealed she was a 61-year-old female who presented on 07/31/2025 and was given an emergency severity index number of 3 (meaning urgent) at 4:06 p.m. According to medical screening at 4:07 p.m. Patient #11 had a history of diabetes mellitus and hypertension. Patient #11 presented to the ED with altered mental status. ED lab results timed 4:23 p.m. revealed Patient #11 had a low hemoglobin of 8.9 (reference ranges being 12-16) and a low hematocrit of 25.7 (reference ranges being 34-45). On 07/31/2025 at 5:37 p.m., a cat scan of the chest/abdomen and pelvis showed findings which included scant bilateral pleural effusion and small pericardial effusions. The ED physician’s impression and plan were focused on a urinary tract infection, hyperglycemia and altered mental status. Review of a final blood culture dated 08/03/2025 revealed Patient #11 was positive for Methicillin Resistant Staphylococcus aureus. A final sputum culture dated 08/09/2025 revealed a heavy growth of Klebsiella pneumoniae ESBL. Review of a chest x-ray dated 08/09/2025 revealed Patient #11 had cardiomegaly with mild pulmonary edema and layering pleural effusion. Lab results revealed the following: On 08/15/2025 at 9:13 a.m. revealed Patient #11 had a low hemoglobin of 6.9 (reference ranges being 12-16) and a low hematocrit of 22.1(reference ranges being 34-45). Review of physician’s progress notes dated 08/15/2025 at 10:30 a.m. revealed Patient #11 needed 2 units of red blood cells transfused now. Review of a physician’s order dated 08/15/2025 at 10:31 a.m. revealed staff were to Transfuse Blood product, now, 2 units. The physician’s orders did not specify a rate to infuse the blood or timeframe. Review of a blood transfusion record dated 08/15/2025 revealed Patient #11’s blood transfusion started at 3:20 p.m. and at 4:20 p.m. Patient #11 complained of a slight headache. At 5:00 p.m. (over 1.5 hours later) there was documentation that Patient #11’s blood transfusion was not completed because she was experiencing shortness of breath and her oxygen saturation dropped to 82 percent. There was documentation on the record that the transfusion was stopped at 5:40 p.m. (40 minutes after documentation of respiratory difficulty starting). Review of an intake and output sheet dated 08/15/2025 revealed Patient #11 had 258 cc of packed red blood cells in. There was no documentation of the rate the blood was infusing. Patient #11 received 258 cc of blood in a 2 hour and 20-minute timeframe. There was no documentation in the record of what was done with the remaining blood after it was stopped. Review of vital signs records revealed some of the following: At 3:20 p.m. the following revealed: temperature of 97.7 degrees Fahrenheit, pulse of 76, respirations of 19, blood pressure 147/64 and oxygen saturation of 91 percent on 4 liters of oxygen. At 3:35 p.m., the temperature was 98.4 degrees Fahrenheit, pulse of 75, respirations of 19, blood pressure 144/62 and oxygen saturation of 93 percent on 4 liters of oxygen At 4:20 p.m. and 5:21 p.m. the oxygen saturation was 93 percent on 4 liters of oxygen. At 5:40 p.m. the oxygen saturation was 87 percent. Review of a nurse’s progress note dated 08/15/2025 revealed the following documentation: “Primary nurse and charge nurse decided to call a rapid at 17:40 (5:40 p.m.) when patient experienced shortness of breath. It was noted that SPO2 dropped to 82 percent and patient would not leave O2 on as she started to panic. A blood transfusion was being administered. It appears to primary nurse that the increase in fluid with the transfusion cause the shortness of breath. Respiratory team was able to increase her SPO2 and patient was transferred to 206 ....” Review of a physician’s note dated 08/15/2025 revealed the following: “Responded to code rapid for (Patient #11). (Patient #11) was found to be in respiratory distress, sating in 70’s . She was placed on bipap at 100 % oxygen initially then was able to get downgraded to 15L on non-rebreather. Blood transfusion was stopped. Patient earlier today as declined thoracentesis per pulmonary Pt given 20mg IV Lasix initially then another push after STAT CXR with volume overload. STAT ABG ordered. Pt was transferred to ICU ...” According to an operative note dated 08/15/2025 signed off by the physician at 7:02 p.m. revealed Patient #11 had an endotracheal tube placed in for acute respiratory failure. Review of a chest x-ray dated 08/15/2025 at 7:16 p.m. revealed placement of the endotracheal tube and mentioned there was cardiomegaly with “progression of now moderate fluid overload.” During an interview on 01/06/2026 after 10:17 a.m. Staff #12 confirmed the vital signs, nursing documentation, physician documentation, missing transfusion rate, and the missing nursing response to the potential transfusion reaction. During an interview on 01/06/2026 after 1:00 p.m., Staff #5 confirmed the information in the chart about the vital signs and transfusion rate. Staff #5 said she could not find the transfusion rate. During an interview on 01/06/2026 after 3:14 p.m., Staff #28 revealed not having all of the information on the 08/15/2026 transfusion. Staff #28 said she was showing where the blood was picked up at 3:07 p.m. on the lab side, but to explain other events she would have to look at nursing documentation. Staff #12 informed Staff #28 the system was down so lab wouldn’t be able to see the information on the transfusion. Staff #28 said she did not receive information about what happened during the transfusion and could not find evidence of any blood being returned to the lab on Patient #11 on 08/15/2025. Staff #28 read the nursing notes on what occurred on 08/15/2025 and said had lab received that, nursing would have had to start the transfusion reaction workup. Review of 2025 lab blood transfusion reaction workups revealed no documentation of what occurred with Patient #11. During an interview on 01/07/2026 after 9:28 a.m., Staff #2 revealed that the 08/15/2025 incident with Patient #11 had not been reported to Quality. Staff #2 said if she known, it would have been reported to the Chief executive officer and they would have made sure the nurses and lab were doing what they were supposed to do. Review of the facility’s policy named: “NS 3.2_Blood and Blood Product Transfusion and Reaction” dated 05/01/2025 revealed the following: “ ...GUIDELINES FOR ADMINISTRATION OF BLOOD/BLOOD PRODUCTS AND PLASMA DERIVATIVES: a. Blood/Blood Products are infused within 4 hours from the time it is removed from the refrigerator in the lab. a) To calculate rate of infusion over 4 hours, the RN will take the total volume of the PRBC bag and divide by 4 hours. Example:350 ml bag, divided by 4 hours. 350 ml/4+87.5 ml/hr. b)Calculating over 4 hours is the maximum rate of infusion ... ...h. Blood is infused slowly, for the first five to fifteen minutes with the RN or physician at the bedside observing the patient for any adverse reactions... VI. Transfusion Reaction: ..If a reaction develops, immediately: 1. Stop the transfusion. 2. Begin saline infusion on primary tubing 3. Take vital signs and call the physician 4. Notify the Blood Bank Department. 5. If the blood/blood product is not completed due to a potential reaction, note this in the electronic medical record. 6. Document the symptoms and interventions...” Review of the facility’s policy named “Transfusion Reaction Workup” dated 11/13/2024 revealed the following: “...Principle: Transfusion of blood and components is usually a safe and effective way to correct inadequate perfusion, but on occasion an adverse event may occur. Timing is crucial when a determination is made to “call” a transfusion reaction and often the nurse must initiate after conferring with the physician to determine if the transfusion needs to be designated as a reaction. Regardless we will follow the steps as outlined in this procedure and in the nursing transfusion policy NS 3.2. Any adverse or unexpected symptoms(s) or physical changes may be considered life-threatening ... ....A.Uticarial (Hives) and Febrile: ... ...B. All other Transfusion Reactions (Extended transfusion reaction protocol): 1. Nursing Services staff will be REQUIRED to return the Blood with the attached tubing and solution to the Blood Bank-NO EXCEPTIONS (unit may be placed in red biohazard bag and returned to lab if outside is dirty with blood leaking from the bag ... ...12. The interpretation/classification of the reaction is the sole responsibility of the Blood Bank Medical Director ... ...Classification of Transfusion Reactions: ...C. Circulatory Overload 1. Congestive heart failure 2.Dyspnea (shortness of breath) 3. Severe headache 4. Peripheral edema (swelling) 5. Suggest to provider or PCN a pre-transfusion bNP test to assess for increased bNP in post transfusion bloodwork. This reaction occurs during or soon after transfusion and nursing staff need not remove the I.V. and blood but stop the transfusion. The nurse should obtain physician approval to transfuse increments of 250 ml at a time at a slow rate of infusion (60-80 ml per hour). If the physician deems it unsafe to continue than a transfusion reaction work-up is necessary .....” 40989 Findings: Patient #29 A review of Patient #29’s medical record was completed with Registered Nurse (RN) Staff #45 on 1/07/2025 at 10:25 AM. A review of Physician #46’s order dated 12/25/2025 at 4:52 PM revealed an order to transfuse “1unit” of Red Blood Cells (RBC). There was no rate or duration for the blood transfusion documented on the order. A review of the blood transfusion record revealed: On 12/25/2025, RN Staff #44 started the blood transfusion at 2158 (9:58 PM). The transfusion was completed at 0028 (12:28 AM). The blood transfusion lasted a total of 2 hours and 25 minutes. There was no rate documented on the blood transfusion flowsheet. There was no way to determine at what rate the transfusion was started or when and how much the rate was increased. A review of the Transfusion Summary revealed the total volume transfused was 500 milliliters (ml) and included RBC AS-1 (AS-1 is an Additive Solution added to RBCs by the blood banks for extended storage) and 500mls of Lactated Ringer’s (LR-a sterile intravenous fluid). There was no way to determine the total amount of RBCs transfused. An interview was conducted with RN Staff #45 on 1/07/2025 at 10:45 AM. RN Staff #45 was asked if the physician was required to write an order for the transfusion rate. RN Staff #45 stated that the nurses use the formula that’s in the blood transfusion policy to calculate the rate. RN Staff #45 was asked if the blood was administered faster than 4 hours, who determined the rate. RN Staff #45 confirmed that the policy gave instructions and a formula to transfuse blood over 4 hours. If the physician requested that the blood transfusion be administered faster than 4 hours, the physician was required to write specific parameters on the blood transfusion order per the hospital policy. RN Staff #45 confirmed that Physician #46 did not write a specific rate infusion or transfusion duration on the order for the 1 unit of blood ordered on 12/25/2025. RN Staff #45 confirmed that the RN did not document the transfusion rate on the transfusion flowsheet and that the blood transfusion was completed in 2 hours and 25 minutes. Patient #30 A review of the medical record of Patient #30 was conducted with RN Staff #45 on 1/07/2025 at 10:25 AM. A review of Physician #42’s order dated 12/27/2025 at 9:09 AM revealed an order to transfuse “2 Units” of RBCs. There was no infusion rate or transfusion duration ordered by Physician #42. A review of the blood transfusion record revealed: On 12/27/2025, RN Staff #43 started the blood transfusion at 1357 (1:57 PM). The transfusion was completed at 1650 (4:50 PM). The blood transfusion lasted a total of 3 hours and 52 minutes. There was no starting rate documented for blood transfusion, and no documentation of when or how much the rate was increased to complete the blood transfusion. A review of the Transfusion Summary revealed the total volume transfused was 300 mls. An interview was conducted with RN Staff #45 on 1/07/2025 at 11:10 AM. RN Staff #45 was asked if the nurse did not document the rate of administration on the transfusion flowsheet, how do you know what rate the blood was started at, and when and how much it was increased during the transfusion? RN Staff #45 confirmed the nurses did not document the rate of the administration on the transfusion flowsheet, and there was no way to confirm the rate it was started, or when and how much it was increased. RN Staff #45 confirmed that the hospital policy stated to start the blood transfusion slowly, but it did not give a specific rate. A review of the facility policy titled “NS 3.2 Blood and Blood Product Transfusion Reactions”, with a revision date of 5/21/2025, was as follows: “ ...IV Policy: A. It is the policy of Texoma Medical Center that blood, blood products and plasma derivatives are administered only by physician’s order, that should include: the cross-matched blood/blood product to be given, the date the number of units or volume to be administered. If the physician wants to modify the blood administration, the physician will write an order for parameter changes different from the guideline. The physician’s order will include blood product, number or volume, the date, and the duration outside the 4 hours ... Guidelines: A. PREPARATIONS ... B. OBTAINING THE BLOOD/BLOOD PRODUCT FROM THE LABORATORY ... C. ADMINISTRATION OF PRODUCTS WHICH REQUIRE COMPATIBILITY VALIDATION ... D. EMERGENCY RELEASE OF UNCROSSMATCHED BLOOD ... E. SAFEGUARDING THE BLOOD BRACELET ... F. GUIDELINES FOR ADMINISTRATION OF VLOOD/BLOOD PRODUCTS AND PLASMA DERIVATIVES: a. Blood/Blood Products are infused within 4 hours from the time it is removed from the refrigerator in the Lab. a) To calculate rate of infusion over 4 hours, the RN will take the Total volume of the PRBC bag and divide this by 4 hours. Example: 350 ml bag, divided by 4 hours. 350ml/=87.5 ml/hr b) Calculating over 4 hours is the maximum rate of infusion ...” b ... ...h. Blood is infused slowly, for the first five to fifteen minutes with the RN or physician at the bedside observing the patient for any adverse reaction ...” During an interview on 1/07/2025 at 11:15 AM with RN Staff #45, it was confirmed that there was no starting rate documented and no time or increased rate documented for the blood transfusions for 2 (Patient #29 and #30) of 2 patient medical records reviewed. RN Staff #45 confirmed that RN Staff #43 failed to follow the hospital policy and obtain a physician’s order to transfuse the RBCs faster than 4 hours in Patient #29.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 10135 Based on observation, interview and record review,the facility failed to ensure infusion pumps at 3 of 4 stations had preventative maintenance performed timely (Stations #’s 1, 2 and 3). This deficient practice had the likelihood to affect all patients receiving infusions in the unit. Findings include: During an observation on 01/05/2026 after 1:39 p.m. the following was observed in the infusion room: There were 4 stations with infusion pumps at each station. The infusion pumps did not have the preventative maintenance information on them. Patient #8 was observed receiving an intravenous infusion in Station #1. During an interview on 01/05/2026 at 2:29 p.m., Staff #16 said he could only find that two of the machines received preventative maintenance and they were the ones at Station 4. Annually during the month of March they get preventative maintenance on the equipment. Staff #16 said the infusion room was overlooked. They received the pumps in the room in 2024 and March 2025 this would have been the first time the pumps would have received preventative maintenance. Staff #16 provided the list of equipment that needed to have preventative maintenance done. Review of facility’s “Work Order Laser Report” revealed the following infusion pumps that needed to receive preventative maintenance as of 04/14/2025: Serial number 16861893 Serial number 16867779 Serial number 16657633 Serial number 16657592 Serial number 16809055 Serial number 16808903 Serial number 16862131 There was documentation on the forms under service outcome that they were “Unable to Find Equipment.” Review of the facility’s policy named “Medical Equipment Testing-Schedule Service (PM & ES)” dated 09/02/2025 revealed the following: “...III Policy:.. ...7. All medical equipment found to be in use during the scheduled PM (Planned Maintenance) month should be brought to the attention of the Department Head of the owning department or his/her assignee and a schedule should be established to service that medical equipment immediately upon discontinued use. The HTM (Healthcare Technology Management) technologist assigned the planned maintenance for a device “in use” will document, in the CMMS (Computerized Maintenance Management Systems), the efforts to locate the device AND the communications and plan with the owning department head or designee to perform the maintenance after discontinued use... ...11. It should be the responsibility of the owning-department Department Head or designated contact to locate and notify the HTM Department when the medical equipment is available for service and/or report medical equipment lost ...””

“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: 45847 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review, and interview, and the hospital, failed to stabilize 1 of 20 patients whose medical records were reviewed (Patient #1). Patient #1, a 66-year-old female arrived at the Emergency Department (ED) on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and signs of dehydration. The hospital diagnosed Patient #1 with emergency medical conditions (EMCs) to include: severe sepsis with lactic acidosis, cholecystitis, acute renal failure with hyperkalemia, and Type 2 Non-ST- elevation myocardial infarction (NSTEMI). The hospital failed to provide stabilization for the EMCs. . Based on record review and interviews, the hospital failed to provide an appropriate transfer for 1 of 20 patients whose records were reviewed (Patient #1). Patient #1, a 66-year-old female arrived at the Emergency Department (ED) on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and signs of dehydration. The hospital, Facility A diagnosed Patient #1 with emergency medical conditions (EMCs) to include: severe sepsis with lactic acidosis, cholecystitis, acute renal failure with hyperkalemia, and Type 2 Non-ST- elevation myocardial infarction (NSTEMI). Facility A failed to: 1. Provide treatment within its capabilities to minimize the risks of the transfer to Patient #1. 2. Ensure that the receiving facility, Facility B, had the required specialized capabilities to treat Patient #1. 3. Provide a summary of risks and benefits ensuring that the benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient. Patient #1 was being transferred to a facility that lacked the capability to perform an Endoscopic Retrograde Cholangiopancreatography (ERCP), a necessary procedure in treating Patient #1. These failures by the hospital resulted in Patient #1 requiring a second transfer from Facility B to Facility C on 03/01/2025 at 12:38 AM. Patient #1 died upon arrival to Facility C before any necessary treatment could be provided. . Cross Reference: Tag A-2407 - §489.24(d)(1)(i) - Stabilize the medical condition A-2409 - §489.24(e)(1) - Appropriate Transfer .”

“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: 45847 . Based on record review, and interview, and the hospital, failed to stabilize 1 of 20 patients whose medical records were reviewed (Patient #1). Patient #1, a 66-year-old female arrived at the Emergency Department (ED) on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and signs of dehydration. The hospital diagnosed Patient #1 with emergency medical conditions (EMCs) to include: severe sepsis with lactic acidosis, cholecystitis, acute renal failure with hyperkalemia, and Type 2 Non-ST- elevation myocardial infarction (NSTEMI). The hospital failed to provide stabilization for the EMCs. . Findings included: Medical Record Review at Facility A, the sending hospital: Patient #1, a 66-year-old female, arrived at the hospital’s Emergency Department (ED) by private vehicle on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and suspected (by her husband) dehydration. . An electrocardiogram (EKG) was obtained at 11:48 AM. The EKG noted “low voltage QRS; inferior infarct, age undetermined; T wave abnormality, consider lateral ischemia; Abnormal EKG”. There was no documentation by the ED physician, Staff #7, indicating that the EKG had been reviewed or considered in his medical decision making. . The Impression and Plan by the ED physician, Staff #7, included diagnoses of EMCs as follows: 1. Acute Kidney Injury (AKI) 2. Cholecystitis (gallbladder inflammation) 3. Elevated troponin (indicator of heart muscle damage) 4. Severe sepsis . Review of Systems (ROS) included constitutional symptoms of weakness and fatigue and respiratory symptoms of shortness of breath and cough. . Abnormal chemistry results related to Patient #1’s EMCs resulted at 12:04 PM were as follows: 1. Potassium level -- 5.6 mmol/L -- Normal range is between 3.4 mmol/L and 4.5 mmol/L. 2. Lactic Acid Level -- 7.61 mmol/L -- Normal range is between 0.50 mmol/L and 2.20 mmol/L. 3. Troponin TNIH -- 763.73 ng/L -- Normal range is between 0.00 ng/L and 34.11 ng/L. 4. BNP (B-type natriuretic peptide) -- 714 pg/mL - Normal is less than 100 pg/mL. . According to the National Library of Medicine https://medlineplus.gov/ revealed: “ Lab indicators for a Type 2 NSTEMI (a heart attack caused by an imbalance between heart muscle oxygen supply and demand) include elevated cardiac troponin levels. “ An elevated BNP indicates that the heart is under strain, most commonly from heart failure or kidney failure. . Patient #1’s potassium elevation/hyperkalemia was not documented in the Impression and Plan nor was it treated by the ED physician, Staff #7. Additionally, the patient did not receive aspirin for NSTEMI. . The patient received Doxycycline for sepsis syndrome at 1:43 PM, followed by Ceftriaxone at 1:47 PM for a urinary tract infection. However, the patient did not receive appropriate antibiotics to treat the intra-abdominal infection. . A CT of abdomen and pelvis (for elevated liver function testing results) results at 2:45 PM, and noted by the ED physician, Staff #7, at 3:30 PM confirmed cholecystitis and mild fluid in the patient’s pelvis. The ED physician, Staff #7, following a reassessment and the review of CT results documented the patient’s condition as, “Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently ... manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. ... Due to sepsis concerns, 30 ml/kg fluid bolus was given due to either an anticipated or confirmed lactic being greater than 4.0 and/or SBP <90. ...” . The patient was transferred to facility B. However, the facility failed to stabilize the patient’s emergency medical conditions which included hyperkalemia, intra-abdominal infection and NSTEMI. The hospital did not provide appropriate antibiotics for an intra-abdominal infection or administer aspirin for the patient NSTEMI, which was within the hospital’s capabilities. . Policy Review: Facility A’s “Patient Transfer Policy”, last reviewed and implemented on 05/28/2025, were reviewed. The policy stated on pages 2-3 of 8: “ ...4. Requirements for All Transfers of Individuals Who Are Not Medically Stabilized. After Hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, Hospital may arrange an Appropriate Transfer for the individual to another more appropriate or specialized facility. For any transfer of an individual with an EMC that has not been Stabilized, all of the following circumstances must be met: a. Minimize the Risk. Before any transfer may occur, Hospital, as the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. b. Individual’s Request or Physician’s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf indicating the reasons for the request and stating he/she is aware of the risks and benefits of the transfer, or by a physician order with the appropriate physician certification as required under EMTALA. c. Request to Transfer. Hospital as the transferring hospital must call the receiving hospital to verify the receiving hospital has available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment ...” . Interviews: The Chief Executive Officer, Staff #13, was interviewed on 07/31/2025 at 3:20 PM. Staff #13 indicated that the hospital had 2 Interventional Radiologists who are required to take 5 call days leading to no coverage on 02/28/2025, the day of Patient #1’s ED visit. . The ED Medical Director, Staff #6, was interviewed on 07/31/2025 at 3:36 PM. Staff #6 indicated that the care provided to Patient #1 was appropriate and that Patient #1 was stable at the time of her transfer. . The treating ED Physician, Staff #7, was interviewed by phone on 08/13/2025 at 12:17 PM. Staff #7 was asked about the care provided to Patient #1 and the care she needed upon transfer. Staff #7 indicated that Patient #1 did not need an ERCP (a procedure for draining bile ducts) but needed a cholecystostomy (a skin-to-gallbladder drain) for draining the gallbladder because she was not stable enough for surgery. Staff #7 indicated that he was “confident” in the care provided to Patient #1. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 . Based on record review and interviews, the hospital failed to provide an appropriate transfer for 1 of 20 patients whose records were reviewed (Patient #1). Patient #1, a 66-year-old female arrived at the Emergency Department (ED) on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and signs of dehydration. The hospital, Facility A diagnosed Patient #1 with emergency medical conditions (EMCs) to include: severe sepsis with lactic acidosis, cholecystitis, acute renal failure with hyperkalemia, and Type 2 Non-ST- elevation myocardial infarction (NSTEMI). Facility A failed to: 1. Provide treatment within its capabilities to minimize the risks of the transfer to Patient #1. 2. Ensure that the receiving facility, Facility B, had the required specialized capabilities to treat Patient #1. 3. Provide a summary of risks and benefits ensuring that the benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient. Patient #1 was being transferred to a facility that lacked the capability to perform an Endoscopic Retrograde Cholangiopancreatography (ERCP), a necessary procedure in treating Patient #1. These failures by the hospital resulted in Patient #1 requiring a second transfer from Facility B to Facility C on 03/01/2025 at 12:38 AM. Patient #1 died upon arrival to Facility C before any necessary treatment could be provided. . Findings included: Medical Record Review at Facility A, the sending hospital: Patient #1, a 66-year-old female, arrived at the hospital’s Emergency Department (ED) by private vehicle on 02/28/2025 at 11:26 AM with chief complaints of shortness of breath and signs of dehydration. . An electrocardiogram (EKG) was obtained at 11:48 AM. The EKG noted “low voltage QRS; inferior infarct, age undetermined; T wave abnormality, consider lateral ischemia; Abnormal EKG”. . The Impression and Plan by the ED physician, Staff #7, included diagnoses of EMCs as follows: 1. Acute Kidney Injury (AKI) 2. Cholecystitis (gallbladder inflammation) 3. Elevated troponin (indicator of heart muscle damage) 4. Severe sepsis . A CT of abdomen and pelvis (for elevated liver function testing results) resulted at 2:45 PM, and noted by the ED physician, Staff #7, at 3:30 PM confirmed cholecystitis and mild fluid in the patient’s pelvis. The ED physician, Staff #7, following a reassessment and the review of CT results documented the patient’s condition as, “Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently ... manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. ... Due to sepsis concerns, 30 ml/kg fluid bolus was given due to either an anticipated or confirmed lactic being greater than 4.0 and/or SBP <90. ...”. . The hospital did not provide appropriate antibiotics for an intra-abdominal infection or administer aspirin for the patient NSTEMI, which was within the hospital’s capabilities. The hospital did not provide these treatments to minimize the risks for Patient #1 prior to transfer. . A transfer request was entered by the ED physician, Staff #7, at 3:43 PM. . The transfer line was contacted by Staff #11, an ED PCT, at 4:03 PM to request a transfer for Patient #1. The notes included that Staff #11 called Facility B & C’s contracted transfer lines and spoke with (Staff #22, the transfer coordinator at Facility B) at 4:03 PM. . Results for an ultrasound (US) of the right upper quadrant resulted at 4:43 PM: “IMPRESSION: 1. Cholelithiasis with positive sonographic Murphy’s sign and wall thickening. This would be supportive of a clinical diagnosis of acute cholecystitis in the appropriate clinical setting. 2. Nonvisualization of the pancreas. Mild acute pancreatitis cannot be excluded with imaging.” . The US results were received after the transfer documents were gathered by Staff #11, an ED PCT, at 4:03 PM. Facility A failed to provide or inform Facility B of US results. . The transfer line was contacted again by the ED PCT, Staff #11, at 5:20 PM to follow up on the transfer request from 4:03 PM. The notes for the call included the following: Facility B & C’s contracted transfer line was contacted at 5:20 PM to follow up on the transfer that was initiated for Patient #1 at 4:03 PM. Staff #11 was informed that the contracted transfer line had paged their on-call gastroenterologist twice with no response. Staff #11 was informed she would receive a call back once the contracted transfer line had consulted with the gastroenterologist for the Memorandum of Transfer (MOT). . A nursing note by Staff #8, the ED RN at Facility A, was documented at 6:43 PM indicating that Patient #1 was leaving the hospital. Staff #8, ED RN, documented that Patient #1 was in stable condition at the time of the transfer although the patient required further stabilization of their EMCs. . The transfer was affected via (an ambulance service) at 6:50 PM with documented diagnoses of severe sepsis without shock, cholecystitis, abnormal findings of blood chemistry, suspected exposure to Covid, and for a gallbladder drain placement. . Summary of the Transfer Center’s audio calls from Facility B’s hospital system (HCA) Transfer Center: The combined transfer calls (6 audio clips were provided) lasted 33.58 minutes. The time from the first call to acceptance was 1 hour and 37 minutes. . (Facility A’s) staff mentioned several times during the transfer calls that Patient #1 was requested to be transferred for Interventional Radiology (IR) for drain placement in the gallbladder. . The transfer coordinator, Staff #22 (for Facility B & Facility C) called Staff #21, the Gastroenterologist (GI) on-call at Facility B, despite their decision to not accept Patient #1 as a transfer due to a “potential need for an ERCP”, which was stated as not being available at Facility B. Staff #21, the transfer coordinator, did attempt to explain to Staff #21, the GI, that (Facility A) was not requesting an ERCP. Staff #21, the transfer coordinator, then proceeded to obtain permission to admit Patient #1 to the medical floor from the General Surgeon on-call at Facility B, Staff #23. . Staff #7, the ED Physician (at Facility A), stated to Staff #22, the transfer coordinator, that there was “no biliary obstruction” for Patient #1. Staff #7, the ED physician at Facility A, could be heard explaining that Patient #1 had cholecystitis and a “really high” AST of 1,657 and ALT of 1,100, with normal T bili (total bilirubin), high white count, high troponin of 736.73, AKI (acute kidney injury), and that his GI (at Facility A) said Patient #1 was not a surgical candidate and needed a drain placed in the gallbladder prior to any surgery the GI consult (at Facility A) and needed both GI and Interventional Radiology (IR) from the receiving facility (Facility B). . Staff #25, the accepting administrator at Facility B, stated to Staff #22, the transfer coordinator, that he would uphold Staff #21’s decline Patient #1, and that if they (Facility A) were willing to go through general surgery it would be ok (to accept Patient #1) based on the information Facility A provided regarding the patient’s status. . Patient #1 was transferred to Facility B, the receiving facility, despite Facility B communicating they did not have the required specialized capabilities to treat and stabilize the patient’s emergency medical. In addition, the hospital, Facility A, failed to provide a summary of risks and benefits ensuring that the benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient. . SPS Ambulance Trip Report Review (for the transfer from Facility A to Facility B): Incident# 3086-25 CMS Service Level: ALS, level 1 Actual Mileage: 41.8 miles . Pre-Hospital Care Report summary: The unit arrived on location to find a 66-year-old female in semi-Fowler appearing to be in no distress. Nursing staff stated that the patient was being transferred due to a diagnosis of cholecystitis requiring IR guided drainage tube placement and cardiology consult due to an elevated troponin. Diagnostics were not available at sending facility. Patient was moved to the unit where baseline vitals were taken, and an electrocardiogram (EKG) was obtained. During transport the patient became nauseated and was given 4mg Zofran IV with an improved patient response and desired effect. The patient was transported to the specified facility without incident or change in patient condition. Upon arrival patient care was transferred to nursing staff and report was given. . Medical Record Review at Facility B, the first receiving hospital: On 02/28/2025 an “EMS or Call-in Pre-Approval” was documented as occurring at 6:33 PM. and “EMS or Call-in Check-in (arrival time)” at 8:11 PM for Patient #1. . Patient #1’s Past Medical History (PMH) was documented by Staff #17, the ED Physician at Facility B for Patient #1. The documentation included: Stated complaint: cholecystitis; cholelithiasis . Aspirin 324 mg was given to Patient #1 at 8:36 PM. . Staff #17 consulted with Staff #23 (General Surgeon) at 8:50 PM. . Abnormal Hematology at 9:22 PM: WBC (white blood cells) 21.2 K/mm3 Normal 4.8-10.8 K/mm3 . Staff #17, the ED provider at Facility B, consulted with Staff #21, the on-call Gastroenterologist at Facility B, at 9:46 PM. Staff #17, Facility B, ED provider, documented that Staff #21, GI on-call at Facility B, stated that he spoke to the transfer center about Patient #1 and he had refused the transfer due to the inability to properly care for her. Facility B currently did not have the equipment required to obtain an ERCP. Staff #17, Facility B, ED provider, documented that Staff #2, GI on-call provider at Facility B wanted Patient #1 to be transferred to a facility that could obtain an ERCP. Facility B initiated a transfer to Facility C due to not having the capability to stabilize Patient #1’s EMCs. . The decision to transfer was documented by Staff #17 at 9:58 PM with the accepting hospital being to (Facility C - MCP), acceptance by Staff #25 (the accepting physician on the departing MOT). The transfer reason was “Higher level of care”. . Staff #20 (ED RN for Patient #1) documented a “Reason for transfer: Services not offered; specialist not available Services required for transfer, Gastroenterology” at 12:37 AM. . Patient #1 departed (Facility B) at 12:38 AM and was transported to Facility C via ambulance service. . Diagnoses for this ED Visit included: Primary Diagnosis: Calculus of gallbladder with acute cholecystitis without obstruction. Other Diagnoses: Sepsis, unspecified organism; severe sepsis without septic shock; personal history of other venous thrombosis and embolism; and long term (current) use of Aspirin; and other specified abnormal findings of blood chemistry. . Medical Record Review at Facility C, the final receiving hospital: On 03/01/2025 Staff #28, the ED Triage RN, documented at 1:20 AM assigned a Priority level 1 (Resuscitation - immediate, life-saving intervention is required). Vital signs documented: Oxygen delivery: resuscitation bag/mask, temperature 97.5 degrees Fahrenheit, and pulse 0. . Staff #28’s notes included: Patient #1 was brought in as a transfer. Upon the arrival of Patient #1, staff were called to the ambulance bay to find Patient #1 unresponsive and pulseless. CPR was started immediately, and Patient #1 was rolled into room 7. Staff #28 noted that Patient #1 was blue, pulseless, made no respiratory effort, had no neurological responses to person, place, time, or situation, and had a Glasgow coma scale (GCS) score of 3. . Death Certificate Review: Immediate Cause of Death: “Sepsis” Underlying Causes: “choledocholithiasis, cholangitis, bile acid disorder, family history of same”. . Policy Review: Facility A’s “Patient Transfer Policy”, last reviewed and implemented on 05/28/2025, were reviewed. The policy stated on pages 2-3 of 8: “ ...4. Requirements for All Transfers of Individuals Who Are Not Medically Stabilized. After Hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, Hospital may arrange an Appropriate Transfer for the individual to another more appropriate or specialized facility. For any transfer of an individual with an EMC that has not been Stabilized, all of the following circumstances must be met: a. Minimize the Risk. Before any transfer may occur, Hospital, as the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. b. Individual’s Request or Physician’s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf indicating the reasons for the request and stating he/she is aware of the risks and benefits of the transfer, or by a physician order with the appropriate physician certification as required under EMTALA. c. Request to Transfer. Hospital as the transferring hospital must call the receiving hospital to verify the receiving hospital has available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment ...” . And on page 6 of 8: “ ...M. USE OF TRANSFER CENTERS 1. Outbound Transfers. a. Hospital may utilize a Transfer Center to facilitate the transfer of any individual from the DED of the transferring institution to the receiving facility. The transferring ED physician, after discussion with the individual in need of transfer or his or her authorized representative, determines that the appropriate receiving facility with the capacity and capability to provide the care necessary to stabilize and treat the individual’s EMC. The Transfer Center may provide to the transferring facility a listing of those facilities with the capability and capacity to treat the individual requiring specialized care. The Transfer Center then facilitates the transfer from the transferring facility to the receiving facility selected by the transferring physician and/or the individual being transferred. Transfer Centers do not: 1) diagnose or determine treatment for medical conditions; 2) make independent decisions regarding the feasibility of transfer; 3) make independent decisions as to where the individual will be transferred; or 4) determine how a transfer will be affected. The ED physician and the individual to be transferred then make the decision on the receiving facility ...” . Interviews: The ED Medical Director at Facility A, Staff #6, was interviewed on 07/31/2025 at 3:36 PM. Staff #6 indicated that he felt the transfer was appropriate due to the documentation of acceptance by (Facility B). Staff #6 stated, “The ER physician then contacted the (transfer system for Facilities B & C) transfer line, as per standard protocol. Relevant labs, imaging, and vital signs were provided to the receiving facility. The ER physician spoke directly with the general surgeon at (the transfer system for Facilities B & C) who accepted the patient, and the patient was ultimately directed to (Facility B) ER. The transferring facility does not control (transfer system for Facilities B & C) transfer line nor determine which hospital (Facilities B & C) is appropriate because transferring facility is not aware of their capabilities.” . The ED Physician at Facility A, Staff #7, was interviewed by phone on 08/13/2025 at 12:17 PM. Staff #7 indicated that he didn’t have any say in who the recipient hospital would be, that it was arranged by the transfer coordinator. Staff #7 indicated that he had reservations (about sending Patient #1 to Facility B) and got assurance that they could handle it during the report call and that he had pointed out the details of a bad lactic acid level and other vital information. . Staff #19, the ED RN at Facility B, was interviewed on 08/05/2025 at 2:35 PM. Staff #19 indicated that she felt the transfer for Patient #1 was not appropriate because their gastroenterologist GI (Staff #23) had refused the patient. . Staff #18, the ED Medical Director/accepting physician at Facility B, was interviewed on 08/25/2025 at 4:35 PM. Staff #18 indicated that the transfer for Patient #1 was not appropriate because the sending facility (Facility A) knew we (Facility B) didn’t have ERCP capability. Staff #18 stated, “The stones (gall stones) would have to be removed to treat the patient (Patient #1).” . The Staff #18 indicated that he felt that they (Facility B) did not get an accurate picture of the patient’s (Patient #1’s) condition. Patient #1 was clinically “sicker” than the labs and information shared by (Facility A). The Staff #18 further indicated that it was the responsibility of the sending facility physician to determine the appropriateness of the transfer and that he had concerns about the changes in the LFT’s upon arrival. The Staff #18 further indicated that the sending facility (Facility A) stated an ultrasound was pending (on Patient #1) at the time of the report, and that no additional callback occurred after the ultrasound had resulted. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 36827 Based on review of medical records, policy, and interview, the facility failed to properly classify the medications given as Chemical Restraints to 2 patients (Patient #2 and Patient #21) of 3 patients medical records reviewed. Failure to properly classify medications as Chemical Restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility with the potential to result in harm to the patients. Findings were as follows: Patient #2 On 5-20-25, a list of psychoactive medications commonly used during psychiatric emergencies was reviewed. Patient #2 was identifies as having an order for Haldol (an antipsychotic medication) on 2/13/2025. Review of the Patient Safety Event Report showed that the medication was given on 2-13-25 for, “Patient acting out, threatening, yelling etc. Physical restraint and medication used.” On the afternoon of 5-20-25 at 1:30 PM at the Behavioral Health Center, patient charts were reviewed with Staff #4 and Staff #5. Staff #23 joined in the review at the end of the review. Patient #2’s chart contained a restraint package dated 2-14-25. The package indicated the patient received a physical hold (time of intervention was documented as 4:55 PM). The reason listed was the patient was an “imminent danger to self”. The patient behaviors described were, “Pt running into door & falling, internally preoccupied unable to be verbally redirected.” Prior to initiating a restraint, less restrictive interventions should be attempted and documented on the restraint form. Less restrictive interventions listed included non-emergency medication ordered. The form indicated the patient was given Haldol, 5 milligrams, injected with a syringe and needle into a muscle once for agitation and Cogentin, 2 milligrams injected with a syringe and needle into a muscle once for side effects possible from receiving Haldol. Review of the Medication Administration Record showed it was administered at 4:55 PM, the same time as the physical restraint. Patient #21 Review of Patient #21’s chart revealed the patient had restraint packages completed on 3-3-25, 3-4-25 and 3-5-25. Each one identified a physical restraint used because the patient was identified to be an imminent risk to self or others. Each one identified that a psychoactive medication was administered as a “non-emergency medication” as a less restrictive intervention prior to initiating a restraint. The Medication Administration Record showed that all were given after the initiation of a physical restraint and not prior to the restraint in an attempt to use less restrictive measures. When questioned as to why these medications for Patient #2 and Patient #21 were not documented as an Emergency Psychoactive Medication (Chemical Restraint) administration, Staff #4 first explained that it had been given prior to the hold. When the time discrepancy was pointed out, Staff #4, Staff #5, and Staff #23 explained that if the medication was a standard dose (not higher than a normal dose) and the patient accepted it willingly, it was not classified as an Emergency Psychoactive Medication (Chemical Restraint) administration by the hospital. When asked why it wasn’t given in the pill form (since pill form is the standard treatment) and instead was given in shot form (injected with a syringe and needle into a muscle), they agreed there was a need for the rapid onset of medication to control the patient behavior. Pill form would take longer to have an affect on behaviors, allowing patients to remain a threat to themselves and others. When asked what would have been done if the patients had refused to accept the shot willingly, Staff #4, Staff #5, and Staff #21 agreed that the patients’ behaviors would have required administration of medication without patient consent to protect the patients and others.”

“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: 45521 Based on a review of record review and interviews, the facility failed to provide a complete medical screening examination (MSE) in 1 of 20 sample records (Pt # 1) that were reviewed. The facility did not perform and document a neurological consult, coagulation labs, National Institutes of Health Stroke Scale (NIHSS), and additional diagnostics-MRI when Patient # 1 returned a second time with the symptoms of severe headache, high blood pressure, and weakness, to determine if the patient was stable or had an emergency medical condition. Patient #1 went to Facility B on 09/21/2025 at 8:25 PM and was diagnosed with Cerebrovascular accident (CVA) and admitted inpatient for an emergency medical condition. Medical Record Facility A, Visit # 1 on 09/20/2024 A review of the document titled “Patient Medical Chart” for Patient # 1 revealed the patient arrived at the facility on 09/20/2024 at 2:00 PM. The document titled “Triage Note” completed by Staff # 4, RN, on 09/20/2024 at 2:07 PM revealed Patient # 1 had head pain at a numeric rating of “5=moderate pain. “ A review of the document titled “History of Present Illness” by Staff # 1, MD Emergency Medicine, on 09/20/2024 at 3:19 PM revealed the following: “A 49-year-old male presents to the ED today with complaints of headache that began upon waking up this morning. Has associated dizziness and bilateral leg weakness. Has family hx [history]of Barry aneurysm. Review of Systems Additional review of systems information: All other systems reviewed and otherwise negative.” ... “ ...Inpatient Medications Ordered Fioricet: 1 Tabs, Oral, Once-No notes on effectiveness NS Bolus (ADULT): 1,000 mL, 983.61 mL/hr, IV Piggyback, Once Reglan: 10 mg, 2 mL, IV Push, Once..” ...”Physical Examination Cardiovascular: Regular rate and rhythm, Normal peripheral perfusion. Neurological: No focal neurological deficit observed, normal speech observed. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making Differential Diagnosis: Migraine, tension headache, hypertension, dehydration, viral syndrome. Rationale: 49-year-old male with severe headache. Computed Tomography (CT) independently reviewed and negative for gross bleed or mass. No focal neurologic deficits appreciated. Labs reviewed. Headache resolved after medication. Return precautions given. Will send home with primary MD follow-up..” ... Diagnostics: ... “Electrocardiogram: Time 9/20/2024 14:11:00, rate 87, normal sinus rhythm.” ... Abnormal Labs: ... “Chloride 110 mmol/L HI [98-107] Alk Phos 132 Intl_units/L HI [46-114] CK 36 Intl_units/L LOW [46-171] Head Computed Tomography: Time reported 9/20/2024 16:49:00, EXAM: CT Head or Brain w/o Contrast IMPRESSION: 1. No acute intracranial pathology 2. Minimal sinus disease” ... ... “Reexamination/ Reevaluation Time: 9/20/2024 17:10:00. Assessment: The patient had an elevated blood pressure reading during their visit today. I discussed their elevated blood pressure readings with the patient and we decided to have the patient keep a log of their blood pressure readings at home and follow up with their PCP. Impression and Plan Headache - ICD10-CM R51.9, Medical Plan Condition: Improved, Stable. Patient was given the following educational materials: Self-Care for Headaches, Understanding Headache Pain, HYPERTENSION, To Be Confirmed. Follow up with: Follow up with primary care provider Within 1-2 days. Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Patient indicated understanding of instructions. Disposition: discharge.” Facility A, Visit # 2 on 09/21/2024 A review of the document titled “EMS Patient Care Record” by Crew Lead on 09/21/2024 revealed the following: EMS arrived at Patient # 1 home on 09/21/2024 at 8:15 AM. The patient was noted in a fetal position in his bed and was moved to a “cot.” The patient had complaints of vomiting. The patient was administered 4mg of Zofran via a 20 gauge IV placed in the patient’s left forearm. The patient was taken to the ambulance and loaded into it. The patient was also administered 15mg of Ketorolac and a saline bag via the IV. During transport, the patient had an episode of vomiting “orangish fluid.” The patient was transported to Facility A and was transferred from the cot to a stretcher using a draw sheet. A verbal report was given to the ED Staff. A review of the document titled “Assessments” by Staff # 6, RN-ED, on 09/21/2024 revealed the following: Vital signs were as follows on 09/21/2024: 2:53 PM, Temperature was 97.3F, Pulse was 88, Respiration was 18, BP was 128/93-right arm, and SPO2 was 100% on room air. 1:29 PM, Temperature was 97.3F, Pulse was 91, Respiration was 18, BP was 129/101-right arm, and SPO2 was 95% on room air. 10:29 AM, Temperature was 97.3F, Pulse was 84, Respiration was 18, BP was 129/92-right arm, and SPO2 was 100% on room air. 9:16 AM, Temperature was 97.3F, Pulse was 82, Respiration was 18, BP was 139/92-right arm, and SPO2 was 98% on room air. A review of the document titled “ED Physician Record” by Staff # 2, NP, on 09/21/2024 at 2:12 PM revealed the following: ... “9/21/2024 9:24 CDT Chief Complaint: Pt to Ed[ED] via Bryan CO from home, pt headache started this am again, given 15mg toradol and 4mg zofran pta [prior to arrival] by EMS. Pt seen here yesterday for same thing, having N/V[nausea/vomiting], ongoing migraines for approx 1 week. Pt seen here yesterday for same thing, having N/V: 9/20/2024 14:07 CDT Chief Complaint: the patient has been having migraines x[for] about a week. states that both of his legs just completely gave out. states this morning, the migraine was bad.” ... ... “History of Present Illness The patient presents with headache and dizziness. The onset was this am. The course/duration of symptoms is constant. Location: Left parietal. Radiating pain: none. The character of symptoms is achy and throbbing. The degree at onset was moderate. The degree at maximum was moderate. The degree at present is moderate. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes: occasional. Therapy today: see nurses notes. Preceding symptoms: none. Associated symptoms: nausea, vomiting and photophobia. Additional history: seen yest[yesterday] for headache and had ct[CT] scan.. ems[EMS] records reviewed- zofran and toradol and ns[normal saline] bolus by ems.. mother had barry aneurysm at age 40.. no injury. no fever..” ... Review of Systems: ... “Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Headache, dizziness. Psychiatric symptoms: Negative except as documented in HPI.” ... Physical exam: ... “Back: Nontender, Normal alignment, no step-offs. Musculoskeletal: Normal ROM, normal strength, no tenderness. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Lymphatics Psychiatric: Cooperative, appropriate mood & affect. Medication provided: DexAMETHasone 10 mg IV Push diphenhydrAMINE (Benadryl) 25 mg IV Push Sodium Chloride 0.9% intravenous 1000 mL IV Piggyback prochlorperazine (Compazine) 10 mg IV Push butalbital/acetaminophen/caffeine (Fioricet) 1 Tablet Oral methocarbamol (Robaxin) 1000 mg IV Push ondansetron (Zofran) 4 mg IV Push meclizine (Antivert) 25 mg Oral diazePAM (Valium) 5 mg IV Push Abnormal Labs: WBC 10.26 x10e3/mcL HI Neut % Auto 84.70 % HI Lymph % Auto 9.90 % LOW Neut # Auto 8.69 x10e3/mcL HI Lymph # Auto 1.02 x10e3/mcL LOW Sed Rate 16 mm/hr HI Glucose Level 121 mg/dL HI Potassium 4.9 mmol/L HI Chloride 113 mmol/L HI BUN 8.0 mg/dL LOW BUN/Creat Ratio 6.7 LOW Alk Phos 118 Intl_units/L HI 9/21/2024 12:37 CDT SARS-CoV-2: Negative” ... ... “Impression and Plan Dizziness - ICD10-CM R42, Medical[billing term] Other headache syndrome - ICD10-CM G44.89, Medical[billing term] Elevated blood pressure reading - ICD10-CM R03.0, Medical[billing term] Plan Condition: Improved, Stable. Prescriptions: sent to the Pharmacy. ... “Patient was given the following educational materials: DIZZINESS, Unknown Cause, VERTIGO, Unspecified, Self-Care for Headaches [and a stroke screen]. Limitations: activity as tolerated.. Follow up with: NEU[Neurology] Within 3-5 days. Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions, return if not improving.” The facility failed to perform and document a neurological consult, coagulation labs, National Institutes of Health Stroke Scale (NIHSS) assessment, and additional diagnostics when Patient # 1 returned a second time with the same symptoms. ... “Discharge Request (Order): 9/21/2024 14:11 CDT, Home Routine, Dispositioned by: DC Home, Patient care was supervised by: Staff # 7.” Facility A failed to recognize the symptoms of Patient # 1, who arrived for both visits to Facility A’s ED on 09/20/2024 and 09/21/2024. Symptoms documented for 09/20/2024 by Staff # 1, MD, in the ED Physician Record were: “patient has been having migraines x[for] about a week. states that both of his legs just completely gave out. states this morning, the migraine was bad. “ Patient # 1’s second visit to Facility A revealed the following: The patient arrived at the ED via EMS with complaints of a headache that had been ongoing for a week, nausea, vomiting, and dizziness. These symptoms are noted as constant; an associated symptom was photophobia. This was acknowledged in Staff # 2, NP’s “ED Physician Record,” dated 09/21/2024 at 9:23 AM. Facility A failed to recognize these symptoms, and a CTA, MRI, and a PT/INR PTT were not ordered to help diagnose a stroke. Patient # 1, Facility B, University of Texas Southwestern Medical Center (UTSW) A review of the documentation for Patient #1’s stay at Facility B, on 09/21/2024 revealed the following: Arrival Date/Time: 09/21/2024 8:25 PM Medical Screening exam: 09/21/2024 at 9:21 PM Adm. Date/Time: 09/21/2024 11:12 PM A review of the “ED Provider Notes” by Staff # B1, MD on 9/21/2024 2121 revealed the following: ... “Organ system impairment: Neurovascular given evidence of acute cerebellar stroke, large volume with evidence of large vessel occlusion of the left vertebral V3/V4 [artery] segment portending significant risk of morbidity and mortality. Vital sign derangements/lab abnormalities: Tachycardia, large ischemic posterior infarct on MR [MRI], V3/V4 segment vertebral artery, large vessel occlusion on CTA Interventions: Stat MRI, stat neurology consultation, neurocritical care unit admission to monitor for cerebral edema Emergency Medicine Attending Physician Note CC: Chief Complaint Patient presents with: o Generalized Weakness With HA [headache]x 10 days, nausea. Per pt[patient] family, pt has been seen by neurologist in the past week for bilateral upper extremity pain and HA- reports testing, CT[computed tomography] scan and EEG[electroencephalogram] WNL[within normal limits]. Worsening generalized weakness today/continued HA (denies change in character)- pt unable to get to restroom unassisted.” ... ... “HPI[History of present illness]: male with PMHx[past medical history52[49]y/o male[correct date of birth is 8/10/1975]as below who presents with headache, onset 10 days ago, severe, associated with 36 hours of vertigo (room-spinning, supposedly intermittent but severe and unable to open eyes due to severity). States he has been seen at outside hospital x 2 and possibly by a neurologist for which has undergone CT and EEG that were reassuring. Due to persistent symptoms, family decided to seek an additional opinion. Patient reports associated numerous episodes of NBNB[non-bloody, non-bilious] emesis. Also states that at time of onset of dizziness yesterday morning, he had a brief period of vision loss that sounds like a left visual field deficit that improved slowly over a couple of hours. No associated speech changes, numbness or weakness of limbs.” ... ... “Vitals: 09/21/24 2027 BP: (!) 157/91 Pulse: 99 Resp: 16 Temp: 36.3 °C (97.4 °F) TempSrc: Temporal SpO2: 98% Weight: 79.4 kg (175 lb) Height: 1.829 m (6’) Physical Exam Constitutional: Well-developed and well-nourished. Answers questions appropriately. Patient appears in significant discomfort. Head: Normocephalic and atraumatic. Mouth/Throat: Oropharynx clear; mucosa moist. Eyes: Non-icteric; pupils equal round, reactive. Neck: Neck supple, trachea midline Cardiovascular: regular rate and regular rhythm without MGR; distal pulses 2+ Pulmonary/Chest: No respiratory distress; breath sounds clear without WRR, effort normal Abdominal: Soft, non-tender, non-distended without masses or guarding Musculoskeletal: No deformity, no edema. Neurological: AOx3, PERRL, EOMI, right-sided nystagmus, CN 2-12 intact, facial symmetry, grip strength 5/5 bilaterally, hip flexion 5/5 bilaterally, gross sensation intact throughout, abnormal FNF on the left Skin: Warm and dry, no rash noted Psych: Mood and affect normal 52[49]y/o male[ correct date of birth is 8/10/1975] with PMHx as above presenting with headache with associated vertiginous symptoms. Headache onset 10 days ago, vertigo approximately 36 hours ago. At time of onset of vertigo, there was no associated left-sided visual field deficit that resolved slowly over the course of a couple of hours. Tachycardic but vitals otherwise acceptable. Evaluated at an outside hospital and by neurologist with CT and EEG that were reassuring against acute pathology. Given persistence of symptoms and general concern for posterior ischemic infarct based on active vertiginous symptoms and positive hints exam, plan for MR[Magnetic resonance imaging], CT/CTA [computed tomography/Computed Tomography Angiography.” ... ... “MRI reveals a large left-sided cerebellar infarct. CTA with left V3/V4[vertebral arteries] segment large vessel occlusion. Neurology consulted who agrees to admit.” “Discharge Information Date/Time: 09/26/2024 4:10 PM Disposition: To Rehab Unit Destination Provider: Unit: Staff # B2, Acute Stroke Unit Policy A review of the document titled “ PC_251 Stroke Alert.” The last approval date was 03/11/2024; pages 2 and 3 revealed the following: “Emergency Department Activation: 1. Triage nurse assesses patient for signs and symptoms using BEFAST tool, determines LKW, and rules out stroke mimics.” Facility A failed to document the utilization of the BEFAST assessment tool during both visits to screen for a stroke. The assessment included screens for balance, vision, facial appearance, arm weakness/numbness, speech, and inability to speak. This tool was included in the discharge paperwork for the patient’s visits on 09/20/2024 and 09/21/2024. A review of the document titled “ PC_251 Stroke Alert.” The last approval date was 03/11/2024, Page 3 revealed the following: “Level 1 code stroke orders include the following: 1. CT brain without contrast 2. CTA of head and neck and /or CT perfusion for patients that meet LVO criteria 3. Labs: CBC, PT/INR, PTT, BMP, Troponin, and HCG[pregnancy test] if female and childbearing age) 4. EKG 5. NIH Stroke Scale [identifies a stroke severity and monitors for neurological changes over time] 6. POC glucose 7. Continuous monitoring of EKG, BP, and 02 saturations 8. Oxygen to keep saturations> 94%” Interviews: 1. An interview with Staff # 2, NP, Emergency Department, on 01/28/2025 at approximately 1:45 PM revealed the following: I remember this patient; he was in a curtained room on 09/21/2024. I was not told about him not being able to walk. I heard about his headache and being dizzy. I saw him, and he said he had a headache (HA); a family member was giving me information. The patient had no prior history of headaches. I looked at yesterday’s notes[9/20/2024] and saw I gave him medication for dizziness. Also, I saw he had Labs and a scan completed. On 9/21/24, I added more information to my notes and gave the patient more medication; the patient said his pain was relieved. A CT was not repeated as the medication relieved the symptoms. I did not observe him walk; he never said he couldn’t walk. 2. An interview with Staff #5, LVN, on 01/28/2025 at approximately 2:23 PM revealed the following: A male came in on 09/20/2024 with complaints of being dizzy, headaches, and nausea. He was taken to a curtain room with a recliner chair. He was in the recliner. I started an IV and took labs. The wife came out and told me something was wrong with her husband. I went to see him, and he was crying. I asked what was wrong, and he said he “didn’t feel normal; something was off.” I reclined him in the chair. I told the Charge RN, then told. The doctor said I’ll give him something for nausea and fluids. Later, the patient didn’t want to lie down anymore. I said ok, and he sat up. Later, I asked him and his wife how he was doing, and both said he was doing fine. He said the meds worked great. He walked well, opened the car door, and transferred to the car without assistance. Legend: Emergency Department-ED History-hx NS-normal saline ml/hr-milliliter per hour Computed Tomography-CT mmol/L -Millimoles per liter Intl_units/L-international unit per liter PCP-Primary Care Physician EMS-Emergency Medical Service IV- Intravenous BP-blood pressure SPO2- Peripheral capillary oxygen saturation (the oxygen level in your blood) CDT- Central Daylight Time Bryan CO- Bryan County, Oklahoma N/V-nausea/vomiting Approx.-approximately am-morning HPI-history of present illness WBC-white blood count Neut % Auto-Neutrophils in the blood Lymph-Lymphocyte in the blood Sed Rate-Sedimentation Rate BUN/Create Ratio- urea nitrogen in your blood/ Creatinine Ratio ALK Phos- Alkaline Phosphatase CTA- Computed Tomography Angiography MRI- Magnetic Resonance Imaging PT/INR-Prothrombin Time/International Normalized Ratio (blood lab) PTT- Partial Thromboplastin Time (blood lab) HA-headache EEG-electroencephalogram PMHx-past medical history NBNB- non-bloody, non-bilious [emesis] BEFAST tool - warning signs for a stroke: Balance, eyes, face, arms, speech, and time. LKW-last known well LVO- Large Vessel Occlusion”