Baptist Beaumont Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29191 (Cross Refer to Tag A0131) Based on record review and staff interview, the hospital’s staff failed to ensure a properly executed informed consent was obtained prior to the insertion of a hemodialysis central catheter in 1 (Patient # 4) of 1 patient’s medical records reviewed. Additionally, the hospital staff failed to follow the “Informed Consent/Consent to Treat” policy. (Cross Refer to Tag: A 0144) Based on observation, record review, and interview, the hospital failed to ensure that: A. chlorine checks were conducted every 4 hours on the reverse osmosis (RO) water treatment system in the hemodialysis unit. B. the pick-up wands were securely attached to the acid and bicarbonate concentrate jugs that were utilized during the patient’s hemodialysis treatment. Securely attached wands are necessary to prevent bacterial contamination and evaporation. C. the R/O (reverse osmosis) water solution at the tri-station, used to perform conductivity checks, was changed every 24 hours. D. the bleach water container was labeled with the date that the solution was prepared. It was unknown when the bleach solution had been prepared and changed. E. hemodialysis patients’ access sites were not covered during hemodialysis treatment in 2 ( #31 and #32 ) of 2 patients”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s staff failed to ensure a properly executed informed consent was obtained prior to the insertion of a hemodialysis central catheter in 1 (Patient # 4) of 1 patient’s medical records reviewed. Additionally, the hospital staff failed to follow the “Informed Consent/Consent to Treat” policy. Findings include: A review of Patient # 4’s medical record was conducted on 02/11/2026 at 9:00 AM with Staff # 6 (Nursing Informatics) in the administrative conference room. Patient # 4 arrived at the hospital’s Emergency Department on 12/23/2025 with complaints of nausea and vomiting. The patient was admitted to the hospital for further care and treatment on 12/23/2025. During the course of the patient’s hospital stay, the patient developed acute kidney failure and required hemodialysis. A review of the patient’s laboratory results revealed that the patient’s creatinine was 1.2mg/dL (milligrams/deciliter) on 12/25/2025. The patient’s creatinine continued to rise and was 4.5 mg/dL on 12/31/2025. Due to the patient’s worsening kidney function, the decision was made to insert a hemodialysis central catheter (trialysis line) on 12/31/2025 by Physician # 22. A review of nursing notes revealed that Staff # 23 (Registered Nurse) documented the following on 12/31/2025 at 4:39 PM, “Right IJ (internal jugular) trialysis placed by (Physician # 22), pending stat cxr (chest x-ray) for placement confirmation. A review of the patient’s “Disclosure and Consent for Medical and Surgical Procedures” for “Trialysis Catheter Line Placement” on 12/31/2025 revealed the patient did not sign the informed consent until 12/31/2025 at 5:55 PM, over an hour after the procedure had taken place. A review of the hospital’s “Informed Consent/Consent to Treat” with a date of 05/23 revealed, “Policy Statement: This policy describes responsibilities and the authority for obtaining or giving consent to treatment. The parameters of consent are clearly stated and authorized for the protection of the patient, physician, staff, and the hospital. Process: ‘Consent or informed consent’ to treatment means the individual understands and agrees to any physical contact or other treatment. The concept of consent to treatment is of fundamental importance to the hospital-patient relationship. Informed consent should be obtained from patients prior to treatment. The legal relationship between the hospital and the patient is a contractual one. The patient has a basic right to self-determination ....Consent is only possible when the person consenting has enough information to understand the proposed treatment and the alternatives. Informed consent requires that the patient is informed of the nature of the contemplated treatment, the potential risks, the prospects for success, the possibility of complications, the risks and benefits of available alternatives, and the results likely if the patient remains untreated ...The following list of procedures requires written consent: ...All invasive procedures performed by a physician in the hospital ...” An interview was conducted with Staff # 1 and # 3 on 02/11/2026 at 1:00 PM in the administrative conference room. Staff # 1 and # 3 agreed that the informed consent should have been signed before the insertion of the trialysis catheter.”

“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: 29191 Based on observation, record review, and interview, the hospital failed to ensure that: A. chlorine checks were conducted every 4 hours on the reverse osmosis (RO) water treatment system in the hemodialysis unit. B. the pick-up wands were securely attached to the acid and bicarbonate concentrate jugs that were utilized during the patient’s hemodialysis treatment. Securely attached wands are necessary to prevent bacterial contamination and evaporation. C. the R/O (reverse osmosis) water solution at the tri-station, used to perform conductivity checks, was changed every 24 hours. D. the bleach water container was labeled with the date that the solution was prepared. It was unknown when the bleach solution had been prepared and changed. E. hemodialysis patients’ access sites were not covered during hemodialysis treatment on 2 ( #31 and #32 ) of 2 patients Findings include: A. During a tour of the hemodialysis unit’s water room on 02/11/2026 at 12:30 PM, the surveyor observed that the dialysis staff had not performed the chlorine check due at 12:15 PM. The chlorine check was 15 minutes late. A review of the log titled “Daily Total Chlorine log” for February 2026 revealed that the last chlorine check was conducted at 8:15 AM. Five patients were undergoing hemodialysis treatment at the time of the findings. The surveyor had to ask when the next chlorine check was going to be conducted. Also, the surveyor observed that the sample cup used for checking the chlorine sample was overfilled. On 02/11/2026 at 12:20 PM, the surveyor asked Staff #17 what the correct amount of solution the sample cup had to be filled with for chlorine testing. Staff #17 was unable to verbalize the correct amount of solution that was to be used for chlorine checks. An interview with Staff #16 on 02/11/2026 at 12:30 PM in the hemodialysis unit confirmed that chlorine checks were not performed every 4 hours per hemodialysis parameters. The surveyor observed that the times recorded on the “Daily Total Chlorine Log were precisely 8:15 AM, 12:15 PM, and 4:15 PM for 3 days in a row, 02/9, 02/10, and 02/11. A review of the policy titled “DAILY CHLORINE TESTING OF DIALYSIS WATER,” dated 6/24, revealed: “SUBJECT: DAILY CHLORINE TESTING OF DIALYSIS WATER POLICY STATEMENT The Renal Nurse who is trained and has demonstrated competency in dialysis water practices will use the procedure outlined in this document to collect dialysis water samples for chlorine testing, and to perform the necessary actions should test results for chlorine concentration exceed the acceptable limit. PROCESS The total chlorine concentration in a sample of dialysis water must be less than 0.1 mg/L (ppm). This is the maximum level allowed for patient exposure to chloramine (combined chlorine). Testing for total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and every 4 hours during operating hours. More frequent monitoring may be necessary during temporary operation with a single carbon tank, or single carbon filter for portable RO’s, or if changes in feed water quality have occurred. Te1-ting should also be completed after any work completed on the carbon tank treatment system, or when carbon filters for portables RO’s are replaced. Equipment: * E-Z Chek Sensitive and Ultra Low Total Chlorine Test Strips * Plastic Cup * Timer Procedure: Check the test strips expiration date. Make sure that the RO has been operating for 15 minutes. o Prior to collecting sample, flush sample port for 30 seconds and rinse the plastic cup with water to be tested at least 3 times. 2. Collect fresh 100 ml sample in a plastic cup post Carbon Tank 1 sample port. If temporarily operating with a single tank, collect the dialysis water sample after the single carbon tank. Ensure that the carbon bypass valves are not set to bypass the carbon tanks. These tanks should never be bypassed during regular operation of the RO system. For portable RO’s collect the sample between the primary and secondary carbon filters. 3. Open a RPC test strip from its foil package and dip into sample and move back and forth for I minute or 60 seconds. 4. Remove test strip and shake once, briskly, to remove excess water. 5. Wait 20 seconds for RPC test strip color to develop. While waiting fold white plastic handle of the test strip under the reagent area aperture so that it provides a consistent viewing background. 6. After 20 seconds, immediately compare the test strip color to the Kl00-0118 color chart to determine the total chlorine level in the sample. 7. Review and document the test result in the chlorine log. * If the total chlorine concentration is less than 0. lmg/L , resume routine chlorine testing after 4 hours. * Record the test result in the Daily Total Chlorine Log. * Otherwise contact MarCor technician to take corrective measures. 8. Perform corrective action. * Retest immediately following the same procedure with a different strip. Record the results in the Daily Total Chlorine log. If the total chlorine concentration is less than 0.l mg/L, resume routine chlorine testing. Otherwise, continue to step 9. All daily chlorine testing results for dialysis water must be recorded on the Daily Total Chlorine Log and signed by an RN for verification. The results on these log sheets must be reviewed by the HD clinical coordinator and signed off by the Medical Director every month. SPECIAL CONSIDERATION * Since chloramine concentrations decrease with time, testing must be performed immediately after sampling. * The procedure should be done when the system is operating under stable conditions, representing normal operation. * The procedure should not be done within a 2-hour period following a heat clean procedure as the sample may be too warm. * The test method used must have sufficient sensitivity and specificity to resolve the maximum level of 0.lmg/L.” A review of the manufacturer’s guidelines for RPC Ultra-Low Total Chlorine revealed the following: “RPC Ultra-Low (Trademark) Total Chlorine Test Strips (K100-0118) measure 0-0.2 ppm total chlorine in water, typically for dialysis applications. Collect a 100 mL sample in a chlorine-free cup, dip the strip for 20 seconds with a gentle back-and-forth motion, shake off excess water, wait 20 seconds, and compare to the chart.” B. During a tour of the hospital’s hemodialysis unit on 02/11/2026 at 12:30 PM, the surveyor observed five patients receiving hemodialysis treatments. The pick-up wands were hanging out of the acid and bicarbonate jugs. There was no secure connection from the pick-up tube to the opening of the acid or bicarbonate jug. This deficient practice allowed for cross-contamination, acid spills, and bacterial growth in the bicarbonate jug. Acid concentrate is not susceptible to bacterial contamination, but every effort should be made to keep the system closed to prevent nonbacterial contamination and evaporation per the ANSI/AAMI standards. An interview with Staff #16 on 02/11/2026 at 1:00 PM confirmed that the pick-up tubes (wands) were hanging out of the acid and bicarbonate concentrate jugs. C. During a tour of the hospital’s hemodialysis unit with Staff # 16 on 02/11/2026 at 12:30 PM, the surveyor observed that the tri-station had 3 opened bottles of “Conductivity Standard Solution” in use without an open date. There was no label on 3 of the “Conductivity Standard Solution” bottles to indicate when the bottles were opened. According to the manufacturer’s instructions on the side of the bottles, “...Discard 30 days after opening..” D. During a tour of the hospital’s hemodialysis unit with Staff # 16 on 02/11/2026 at 12:30 PM, the surveyor observed a plastic bin filled with “bleach water solution” on the counter, located next to the sink. The plastic bin did not contain a label indicating when the solution was prepared. Bleach water solutions must be changed every 24 hours to maintain the integrity of the bleach solution in the disinfection of hemodialysis machines and other associated equipment. E. During a tour of the hospital’s hemodialysis unit with Staff # 16 on 02/11/2026 at 12:30 PM, the surveyor observed 2 of 5 patients (Patients # 31 and # 32) undergoing hemodialysis treatment with covered hemodialysis access sites. Patients # 31 and # 32 were at risk of extreme and potentially fatal blood loss due to the high risk of dislodgement of the AV (arteriovenous) fistula needle when covered. Staff must ensure hemodialysis access visibility at all times during hemodialysis treatment. An interview was conducted with Staff # 16 on 02/11/2026 at 12:40 PM in the hemodialysis unit. Staff # 16 confirmed that the staff should always ensure the patients have visible access during hemodialysis treatment. Also, Staff # 16 confirmed the plastic bleach bin and tri-station bottles should have been clearly labeled with a date of opening and/or preparation.”

“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: 48749 Based on record review and staff interview, the hospital staff failed to assess and treat patients with complaints of pain in 4 (#1, # 4, #8, and #9) of 4 patient medical records reviewed. Additionally, the hospital staff failed to follow the “Patient Rights: Care of the Patient with Pain” policy. Findings include: Patient #1 A review of Patient #1’s electronic health record (EHR) revealed that the patient arrived at the hospital’s Emergency Department (ED) on 10/06/2025 at 2:52 PM via private vehicle. The patient was triaged at 2:53 PM and reported to the ED triage nurse a chief complaint (C/C) of abdominal pain, nausea, and vomiting. The ED triage nurse documented that the patient “has been vomiting and looks like dark blood when she throws up. Feels like she has an infection in her abdomen. I’m also having chest pain and arm pain.” Triage Vital Signs: Blood Pressure (BP)-156/86, Heart Rate (HR)-100, Respirations (Resps)-20, Temperature (Temp)-98.4, Oxygen Saturations (O2 Sats)-99% room air (RA), Glascow Coma Scale (GCS)-15, Pain- 8/10, and an Acuity of 3-Urgent. A review of the ED nursing notes revealed the following entries; At 3:45 PM, the patient reported an 8/10 pain level and described it as “diffuse abdominal pain.” The ED nurse documented that the abdomen was “tender” upon palpation. At 5:45 PM, the ED nurse documented that the patient appeared “uncomfortable” and “fussy”. There was no documentation of an assessment/reassessment of the patient’s pain or pain scale. At 7:36 PM, the patient reported a 4/10 pain level. The ED nurse documented that the patient appeared “uncomfortable.” At 9:35 PM, the patient reported a 5/10 pain level. There is no assessment/reassessment of the patient’s pain documented at a 5/10 pain level. At 5:19 PM, Patient #1 was administered Ativan 1miligram (medication used for treating anxiety) intravenously. Patient #1 was discharged home on 10/06/2025 at 9:45 PM. The ED nurse documented “reassessment of C/C. Pt is in no apparent distress and is stable. Discharged home via wheelchair with family. Instructed on discharge instructions, follow-up, and referral plans.” There were no prescriptions at discharge. Further review of Patient #1’s medical record revealed that there was no documentation found to support that the ED nurse notified the ED Physician of the patient’s complaint of pain. No documentation was found to support that the patient was assessed and treated for the reported pain by the ED Physician. Patient # 4 A review of Patient # 4’s medical record was conducted with Staff # 6 on 02/11/2026 at 9:00 AM in the hospital’s administrative conference room. Patient # 4 arrived at the hospital’s Emergency Department on 12/23/2025 with complaints of nausea and vomiting. According to the Emergency Department nursing assessment completed on 12/23/2025 at 11:37 AM, the patient rated pain at “5/10”. There was no nursing intervention or medication administered to address the patient’s pain. Further review of nursing documentation completed on 12/23/2025 at 5:30 PM revealed the patient continued to complain of pain at “6/10”. There was no nursing intervention or medication administered to address the patient’s pain. The physician did not order any pain-relieving interventions for the patient while he was in the emergency department. The patient was admitted to the hospital on 12/23/2025 and continued to have complaints of pain. A review of the patient’s medication administration record (MAR) revealed that the patient was given “morphine sulfate injection 4 mg/ml (milligrams/milliliters) via intravenous push on 12/26/2025 at 1:39 AM. The patient rated his pain as “10/10”. There was no reassessment of the patient’s pain after medication intervention. Morphine is a powerful opioid with the potential to cause an allergic reaction, decrease blood pressure, and decrease respiratory rate. Therefore, a reassessment after administration is imperative to patient safety. A review of the patient’s medication administration record (MAR) revealed that the patient was given “hydromorphone injection 1mg/ml, 0.5 mg via intravenous push for moderate pain” on 12/27/2025 at 8:39 PM. There was no pain assessment documented before the medication was administered by nursing staff. Hydromorphone (Dilaudid) is a powerful opioid used to treat moderate to severe pain. The nursing staff failed to follow the physician’s order when Dilaudid was administered without a pain assessment. The nursing staff was not able to determine the patient’s severity of pain and, therefore unable to determine the proper intervention necessary, according to the physician’s orders. Patient #8 A review of Patient #8’s EHR revealed that the patient arrived at the hospital’s ED on 10/05/2025 at 12:59 PM via Emergency Medical Services (EMS). The patient was triaged at 1:00 PM and reported to the ED triage nurse a C/C of “abdominal pain and bloody stools for 3 days.” Triage Vital Signs: BP-142/80, HR -62, Resps-18, Temp-98.2, O2 Sats-100% RA, GCS-15, and an Acuity of 3-Urgent. There was no documentation found of a numeric pain scale in Patient #8’s triage assessment. At 3:55 PM, the ED nurse documented “complains of pain in abdomen diffusely.” No documentation of a numeric pain scale was found in the ED nurse notes. At 3:57 PM, the ED nurse documented “complains of pain in abdomen diffusely. Pain does not radiate. Quality of pain is described as crampy.” No documentation of a numeric pain scale was found in the ED nurse notes. At 5:59 PM, there is no documentation found in the ED nurse’s note that a pain assessment/reassessment was performed. At 5:45 PM, Patient #8 was administered Pantoprazole 40 mg (a medication that reduces stomach acid to treat GERD, erosive esophagitis, and Zollinger-Ellison syndrome) intravenously. At 6:08 PM, the ED Physician documented “The patient presents with abdominal pain that is diffuse .... The symptoms are described as crampy, intermittent .... At its worst, the pain was mild in the emergency department the pain is unchanged.” Patient #8 was discharged home on 10/05/2025 at 7:14 PM with a diagnosis of ABD pain and GI Bleed. The ED nurse documented “reassessment of C/C. Patient breathing even and unlabored, no distress at time of discharge, vital signs stable, Patient denied pain at discharge .... Discharged to home, ambulatory ... Instructed on discharge instructions, follow-up, and referral plans.” The patient was discharged with a prescription for Protonix. Further review of Patient #8’s medical record revealed that there was no documentation found to support that the ED nurse notified the ED Physician of the patient’s complaint of pain. No documentation was found to support that the patient was treated for the reported pain by the ED Physician. Patient #9 A review of Patient #9’s EHR revealed that the patient arrived at the hospital’s ED on 10/06/2025 at 9:56 PM via private vehicle. The patient was triaged at 9:57 PM and reported to the ED triage nurse a C/C of “abdominal pain, described as crampy, nausea, and vomiting all day.” Triage Vital Signs: BP-113/80, HR -81, Resps-18, Temp-98.1, O2 Sats-97% RA, an Acuity of 3-Urgent, and a 4/10 pain scale. At 1:01 AM, the ED Physician documented, “The patient presents to the emergency department with nausea, vomiting.... abdominal pain, nausea, vomiting .... At their worst, the pain was moderate in the emergency department, and the symptoms are unchanged.” Further review of Patient #9’s medical record revealed that there was no documentation found to support that the ED nurse notified the ED Physician of the patient’s complaint of pain. No documentation was found to support that the patient was treated for the reported pain by the ED Physician. The patient was in the ED for approximately 4 hours and 38 minutes. There was no documentation found of a nursing assessment or reassessment during Patient #9’s ED visit. There was no documentation found that the patient received any medications during the ED visit. Patient #9 was discharged on 10/07/205 at 1:38 AM with a diagnosis of kidney stones and a urinary tract infection. There was no documentation found of a reassessment or discharge vital signs. The patient was discharged with a prescription for Macrobid 100mg, Phenazopyridine 200 mg, Ondansetron 4mg, and Flomax 0.4 mg. A review of the hospital’s “Patient Rights: Care of the Patient with Pain” policy dated 03/24 revealed the following; “SUBJECT: Patient Rights: Care of the Patient with Pain SCOPE AND INTENT: This policy addresses the assessment and reassessment of pain in all settings throughout the organization. When pain is identified, the patient shall be treated or referred for treatment as clinically pertinent. POLICY: All patients admitted as inpatients and presenting to the emergency department shall be questioned as to whether or not they are experiencing pain. Other ambulatory patients need not be assessed for the presence of pain unless a) pain is commonly associated with the condition for which they are seeking care, or b) pain may be induced by subsequent treatments or interactions (for example, patients undergoing an outpatient invasive procedure or potentially painful therapy. An age and ability-appropriate comprehensive initial pain assessment shall be conducted or any patient reporting or suspected of having pain. The comprehensive assessment shall include, to the extent relevant, intensity using an age-appropriate pain scale when practical1 and will also consider the patient’s statement of pain intensity sites, provoking factors, quality (e.g. dull, sharp, throbbing, stabbing), radiation, onset (timing) (e.g. when did the pain start, is it increasing or decreasing). The details of the initial pain assessment may vary depending on the clinical presentation and the nature of the interaction. Assess the effectiveness of pain-relief measures to include measures previously used to relieve pain and those currently being implemented. Reassessment of pain is conducted as indicated by plan of care and/or as warranted in change of patient’s condition. Validate the presence of physician orders for pain-relief medications or other measures. Administer medications or provide other prescribed measures in accordance with orders based on the assessed pain level and the corresponding intervention ordered for that level of pain. When medications are ordered to control pain that is labeled as mild, moderate, or severe, clinicians will refer to the Pain Scale. The FACES Scale is a numerical/visual scale, and pain rating will be noted as the following: rating of 0- no pain, 1 to 4 will be considered<I mild pain, ratio -6 will be considered moderate pain, and rating of 7 or greater will be considered as severe>pain. When there are orders for one or more medication treatment options for that severity of pain, initiate therapy with the less invasive and lower dose or strength (oral before injectable if patient tolerating orals) based on the options available. Subsequent dosing should be based upon patient response to the previous intervention(s). Interpreting the Behavioral Score Each category is scored on the 0-2 scale, which results in a total score of 0-10. 0 = Relaxed and comfortable, 4-6 = Moderate pain 1- = Mild discomfort 7-10 = Severe discomfort or pain or both Pharmacologic pain control: Narcotic analgesics are recommended when moderate to severe pain is assessed. Sedatives reduce agitation precipitated by painful events but do not provide pain relief. A review of the hospital’s “Emergency Department Assessments and Documentation” policy dated 02/23 revealed the following; “The ED physician and ED nurse discharging the patient are both responsible for making sure that the ED record is complete. PURPOSE: 1. To provide a legal document of the patient care rendered 2. To provide a reference source for health needs treatment rendered, referrals, and follow-up 3. To evaluate the quality of emergency medical care. 4. To provide a means for patient charges for care rendered. B. Primary Nursing Assessment * A physical assessment or focused assessment of the chief complaint will be done by the primary care nurse. Nursing interventions will be established by the primary care nurse. *Visual acuity, if any presentation of eye complaints. (Blurred vision, trouble seeing ooo) *VIS and re-assessment of pain scale will be obtained again before discharge. *Interventions and chief complaint will be re-assessed periodically.” A. Triage and/or Initial Nursing Assessment * A triage/initial assessment will be performed by a Registered Nurse; this will include an initial focused physical assessment. After completion of data gathering during this assessment, the triage nurse will assign a triage level using the ESI 5-level model, according to triage policy. Triage/Initial assessment data should include: l. Date, time, mode of arrival 2. Age, sex 3. Chief complaint 4. Brief assessment of chief complaint, including pain level Assessment on scale of 0-1 O and/m: LAC. 5. Vital signs: B/P, T, R, R, weight, eight, and Sa02. 6. Weight (actual or stated) D All pediatric patients should have measured weight recorded in kilograms 7. Allergies 8. Medical history 9. TB/Flu/Recent travel assessment 10. LMP (last menstrual period) 11. Immunization history (e.g., COVID, Flu, Tetanus, Pneumonia) D For Pediatric patients’ assessment of current childhood Vaccines. 12. Treatment prior to arrival 13. Home meds if pertinent to visit 14. Triage treatments 15. Triage signature (electronic or written) D If the patient has a prolonged stay due to a congested ED, any abnormal V/S will be reassessed periodically to ensure that the triage level has not changed.” An interview was conducted with Staff #2, Staff #5, and Staff #7 on 02/11/2026 at 10:00 AM. Staff #2, Staff #5, and Staff #7 acknowledged the surveyor’s findings of pain management.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s nursing staff failed to ensure that 1 (Patient # 7) of 1 patient received care in a safe setting when Staff # 14 (Registered Nurse) failed to ensure that appropriate fall risk interventions were implemented as required by the hospital’s “Fall Prevention Program” policy. The hospital’s nursing staff failed to follow the “Fall Prevention Program” policy. Findings include: A review of Patient # 7’s medical record was conducted on 11/03/2025 at 3:00 PM with Staff # 6 (Nurse Informatics Director). The patient was admitted to the hospital’s 2NE post-operative orthopedic unit on 06/22/2025 after a ground-level fall at home. The patient was diagnosed with a right intertrochanteric fracture (hip fracture). The patient was identified as an “Elevated Fall Risk” during the initial nurse assessment completed on 06/22/2025 at 6:10 PM by Staff # 17 (Registered Nurse). The patient underwent a right hip cephalomedullary nail (a surgical fixation device used to treat certain hip fractures) on 06/23/2025 at 1:53 PM by Surgeon # 15. The patient tolerated the procedure well and was sent back to the hospital’s 2NE post-operative orthopedic unit following the procedure at 4:02 PM. Staff # 16 (2NE Charge Nurse) documented the following on 06/23/2025 at 5:45 PM, “wife and son leaving, patient still yelling ‘help me’, no distress, monitors on.” On 06/23/2025 at 6:08 PM, the patient was found on the floor of his hospital room unresponsive without respirations or a pulse after an unwitnessed fall from the hospital bed. A review of the “Falls Debriefing Tool” revealed, “ ...Did bed/chair alarm sound at time of the fall?: No”. The bed alarm was not activated by Staff # 14 (Primary Registered Nurse for Patient # 7 on 06/23/2025) at the time of the patient’s fall, despite the patient’s fall risk rating being documented as “Elevated fall risk” and the patient having anesthesia within the last 24 hours. A review of Staff # 14’s personnel file revealed that Staff # 14 completed “Fall Prevention Training” on 05/31/2025. An interview with Staff # 16 (2NE Charge Nurse) was conducted on 11/03/2025 at 4:30 PM. Staff # 16 was asked to recall the patient’s events occurring on 06/23/2025. Staff # 16 stated that she remembered the event and that she “had just come out of the break room and walked by the patient’s room and laid eyes on the patient not even a minute before”. A review of the hospital’s “Fall Prevention Program” policy with a revision date of 4/2025 revealed, “POLICY STATEMENT: Baptist Hospital of Southeast Texas prioritizes patient safety and quality of care. A fall prevention program has been established to identify patients at risk for falls and to establish a standardized, proactive approach and guidelines for the prevention of patient falls. The fall prevention program is applicable to all patients identified as a risk for falls...Types of falls: ...Anticipated physiological: This is the most common type of patient fall and occurs in patients who have risk factors that can be identified in advance, including abnormal gait, high-risk medication, urinary frequency, or dementia ....PROCESS: An environmental assessment in addition to specific physiological criteria is considered to address those settings and patient populations that are at risk for falls, with these areas outlined below: 1. A patient-specific fall risk assessment will be conducted on all patients admitted to inpatient status with the exception of neonatal, infant, and toddler patients as these patients’ developmental age inherently places them at risk for drop or fall. 2. All other areas, including ambulatory and clinic environments, visitors are determined to be at minimal risk of harm from falls, with individual patient fall assessment not required, however, an environmental assessment to identify and correct hazards that could contribute to a fall should be completed. a) Should patients receiving care in ambulatory /clinic environments present as unsteady or otherwise obvious at risk for fall, a fall assessment is not required, however staff will provide safety measures and assistance with ambulation to protect the patient during the clinical encounter. 3. To the extent possible prior to bed assignment for inpatients, the transfer center nurses and/or nurses receiving report on the patient will attempt to identify if the reason for admission is related to a fall, or if the patient experienced a fall in the ED. This information is for all adult admissions from the ED to determine if a patient meets criteria as an elevated fall risk for placement in a remote video monitored room. PROCEDURE: 1. At a minimum, for all patients the bed will be in the lowest position possible, the call light will be within patient’s reach and frequent monitoring will occur. 2. At the time of admission an RN will complete an assessment to determine if the patient is at risk for falling based on the following criteria: patient age, weakness, unsteady gait, difficulty transferring, requires use of assistive device(s), alteration in mental status, medications including sedatives, bowel preparation/diuretics and antihypertensive medications, sensory disturbances (altering sight or hearing), the presence of medical equipment that may impair movement (chest tubes, wound vacs, SCDs, etc.), a patient who has experienced an operative or invasive procedure in the past 24 hours. A patient who meets any of the criteria in addition to being 64 years of age or older is then considered as a high risk for falls. Those identified as high fall risk will have fall precaution interventions implemented. 3. Reassessment of fall risk will be completed each shift and/or if there is a change in the condition of the patient, the patient experiences a fall or if the patient is moved to another level of care. 4. If the patient has been identified as a high fall risk and is unable to be redirected, and/or continues to attempt to get out of bed despite staff instruction, is unable to toilet independently etc. the patient will then be considered an Elevated Fall Risk and will be placed on CareView monitoring, in addition to the appropriate high fall risk prevention interventions. At any time during hospitalization, any patient who falls will be considered an Elevated Fall Risk and will be placed on CareView monitoring as available, appropriate high fall risk prevention interventions. Based on nursing judgment patients assessed as high risk for fall and elevated risk for falls will receive interventions assessed to be the most appropriate in preventing the patient from falling. Patients assessed as high or elevated fall risk should have the door to the room labeled as “High Fall Risk” (denoted by yellow sign) or “Elevated Fall Risk” (denoted by red sign). A Yellow Fall Risk Armband: should be placed on the patient’s wrist to alert other departments of the patient’s risk for falling. Interventions may include some, or all, of the following as appropriately related to the patient’s identified risk factors: The bed will be placed in a low position and locked. Call light within reach. Frequent toileting and assistance with ADLs should be offered. Patients identified as high or elevated fall risk WILL NOT BE LEFT UNATTENDED DURING TOILETING, SHOWERING ETC. All ambulation and transfers should be assisted. When the patient is in Radiology, Physical Therapy, etc., the patient will not be left unattended. Non-slip socks placed on the patient. Side rails up to prevent the patient from falling. The 4th side rail is generally recommended to remain lowered. Side rails are never used to prevent the patient from getting out of bed; side rails up are used as a reminder for the patient to prevent falling 1. Patients should be moved closer to the nurses station if bed is available. The patient should have use of bedside commode or other equipment, as needed if appropriate; Bed alarm/chair alarm in use ...” An interview was completed with Staff # 1 (Director of Quality) on 11/03/2025 at 3:30 PM in the administrative conference room. Staff # 1 confirmed that the bed alarm was not activated after the patient had been identified as an “elevated fall risk”. Staff # 1 confirmed that the patient should have had a bed alarm activated due to the patient’s elevated fall risk level and recent procedure.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s infection control and prevention program failed to provide and maintain a clean and sanitary environment in 1 (Emergency Department) of 1 unit of the hospital. The hospital’s staff failed to follow the “Cleaning and Low-Level Disinfection” policy. Findings include: During a tour of the hospital’s Emergency Department on 11/03/2025 at 1:00 PM with Staff # 2 and # 3, the following infection control issues were identified: *There was a cast cart stored in the hallway across from the moderate care nurses’ station. There was a clear plastic covering over the cast cart. The bottom of the cast cart was exposed and had a thick build-up of dust and dirt debris. The cast cart contained sterile patient supplies. *There was a vaginal delivery cart stored in the hallway across from the moderate care nurses’ station. There was a clear plastic covering over the vaginal delivery cart. The bottom of the cart was exposed and had a thick build-up of dust and dirt debris. The cart contained sterile patient supplies. *There were 2 computers on wheels (COWs) stored in the hallways between the moderate and main nurses’ stations. The top and bottom surfaces of the COWs were covered in a thick layer of dust and dirt. Staff # 3 donned a glove and used Sani-wipes to disinfect the bottom of the COWs. The layer of dirt and dust came off after cleaning with the Sani-wipe. *There were 2 sets of 3M hair clippers in the medication hallway. The hair clippers were not cleaned and had hair, dust, dirt, and other unknown stains in the clippers. A review of the hospital’s “Cleaning and Low Level Disinfection” policy with a date of 09/2024 revealed, “Outcome Standard: The risk of microbial contamination of the environment and non-critical reusable equipment will be reduced. Definitions: ...Cleaning: is the physical removal of foreign material (e.g., dust, soil, and organic material such as blood, secretions, excretions) from objects and is required before disinfection and sterilization can occur since these materials interfere with the effectiveness of these processes. Cleaning physically removes rather than kills microorganisms and is accomplished with water, detergents, and mechanical action. Disinfection: a thermal or chemical process for inactivating microorganisms on an inanimate object. Disinfectants: Chemical compounds that inactivate pathogens and other microbes and fall into categories (low-level, mid-level, or high-level) based on chemical formulation ...Process Standard: Attainment of the outcome standard will be facilitated by: ...3. Manufacturer’s instructions should be followed for cleaning and maintaining noncritical medical equipment ....6. In the absence of a manufacturer’s cleaning instructions on cleaning instructions, certain procedures should be followed: a) Clean noncritical medical equipment surfaces with a detergent/disinfectant. This may be followed with an application of an EPA-registered hospital-approved disinfectant with or without tuberculocidal claim, in accordance with disinfectant label instructions ....C) Use barrier protective coverings as appropriate for noncritical equipment surfaces that are 1) touched frequently with gloved hands during the delivery of patient care. 2) likely to become contaminated with blood or other bodily substance or 3) difficult to clean, such as a computer keyboard 7. Surfaces (e.g., floors, walls, tabletops) should be kept visibly clean on a regular basis and clean up spills promptly ...Computers, Keyboards, and Mouse: a) It is an expectation that hands are disinfected before touching clean equipment and prior to contact with patients. B) Keyboards and computer mouse can be wiped with a cloth moistened with a hospital approved disinfectant. C) The computer monitor (screen) can be wiped with an alcohol swab or a cloth very lightly moistened with alcohol. D) The top of the keyboard, top of the mouse, and the handle on the computer arm that sticks out in front of the keyboard (the surfaces that are frequently touched by staff) should be wiped down every day when the room is cleaned. E) The keyboard, the entire mouse, the entire computer arm (from the handle, all the way to the wall) and the computer monitor screen are to be terminally cleaned with each patient discharge ...” A review of the 3M Hair Clippers Manufacturer’s Instructions For Use (IFU) revealed, “ ...Care and Cleaning of the Clipper Body: The housing of the clipper body is made of durable plastic and is water-resistant. It may be wiped off with a damp cloth containing a small amount of alcohol, disinfectant, or a mild detergent solution. It can also be rinsed under running water or submerged in a high-level disinfectant solution. Approved chemicals for use in cleaning include 70% alcohol, 2% bleach, Quaternary ammonium chloride, or Chlor?clean solution. Allow to dry completely before placing clipper back into drop?in charger or reusing ...” An interview was conducted with Staff # 1, # 2, and # 3 on 11/03/2025 at 2:30 PM. The staff members confirmed that there were infection control issues in the emergency department.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s infection prevention and control professional failed to ensure staff adherence to infection prevention and control policies and procedures when 1 (Patient # 9) of 1 patient was not placed in isolation status after a suspected infection with an infectious organism. The hospital’s staff failed to follow the “Isolation Precautions, Transmission-Based” policy. Findings include: During a tour of the hospital’s 2NE post-operative orthopedic unit on 11/03/2025 at 4:00 PM with Staff # 2, # 3, and # 16, the survey observed that Patient # 9 was assigned to room #242. The surveyor requested the staff to test the nurse call cord inside of room # 242. Staff # 16 (Charge Nurse) replied, “I don’t know if you want to go in there. I am pretty sure the patient’s urine culture will come back positive for growth”. The surveyor replied, “why isn’t the patient in isolation precautions for suspected organism growth?” Staff # 16 responded, “We do not isolate the patient until the culture comes back positive”. Patient # 9 did not have isolation precautions implemented. There was no isolation signage on the door and Staff # 16 did not don personal protective equipment upon entering the patient’s room despite having a suspicion for infectious organisms in the patient’s urine. A review of Patient # 9’s medical record was conducted with Staff # 6 (Nurse Informatics Director) on 11/04/2025. Patient # 9 was admitted to the hospital on 11/02/2025 with pneumonia, dysuria, and dehydration from a nursing home. An order for a urine culture was placed on 11/02/2025 at 1:52 PM by Physician # 18. On 11/3/2025, the patient’s urine culture preliminary report resulted with gram-negative bacilli. The culture did not have a final result yet. A review of the hospital’s “Isolation Precautions, Transmission-Based” policy with a revision date of 7/24 revealed, “Policy Statement: Use Transmission-Based Precautions in addition to Standard Precautions for patients with suspected or confirmed diseases that require Airborne, Contact (including /with mask and for Contact with Bleach) or Droplet Precautions. A physician order is not required to initiate transmission-based precautions. Process: 1. Responsibilities: a) Standard Precautions shall be used in addition to any Transmission-Based Isolation Precautions for patients known or suspected to be infected or colonized with epidemiologically important pathogens. B) Nursing staff is to convey isolation information during change of shift, huddles, etc. and before transferring the patient to another department. 2. INITIATION OF PRECAUTIONS a. LIPs, Nursing, and Infection Prevention have the authority to order and implement transmission-based or isolation. Isolation orders should be placed at the time isolation is initiated. b. Place appropriate signage on the door or the door jamb. c. Educate patients and others, as appropriate, on their role in assuring isolation precautions are appropriately implemented. This education should be documented in the medical record. d. Ensure availability of appropriate PPE ...11. Contact Precautions: Includes but is not limited to: wounds or abscesses with uncontained drainage, respiratory syncytial virus-RSV, scabies, lice, multi-drug-resistant organisms (MDROs that are NOT in the respiratory system). 1. Patient Placement: patients should be housed in single patient rooms when possible or cohosted a. Private room is preferred. In multi-patient rooms, beds must be separated by at least 3 feet. Draw the privacy curtain. b. When private rooms are in short supply i. Prioritize patients who have uncontained drainage or incontinence of urine or stool ii. Cohort patients who are infected or colonized with the same organism. c. If it becomes necessary to place a patient in a room with someone who is not infected or colonized with the same organism: d. Avoid placement with someone who is immunocompromised, have open wounds or have an anticipated prolonged length of stay e. Change PPE and perform hand hygiene between contact with patients in the same room, regardless of whether one or both are in Contact Precautions ...” An interview was conducted with Staff # 2 and # 3 on 11/04/2025 at 11:30 AM in the administrative conference room. Staff # 2 and # 3 confirmed that the patient should have been placed in isolation precautions due to the suspicion of an infectious organism growing in the patient’s urine. Staff # 2 and # 3 confirmed the hospital’s policy requires suspected cases to have isolation precautions implemented.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 47892 Based on document review and interview, the hospital failed to ensure that Contracted Staff #8 adhered to the scope of practice for a Surgical Technologist in accordance with the Health and Safety Code Chapter 259. Refer to A0945”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 47892 Based on document review and interview, the hospital’s Medical Staff failed to ensure that Contract Staff #8 had the proper credentials to perform Surgical Assistant (SA) tasks during a surgical procedure. Also, the hospital’s Medical Staff Failed to follow their bylaws and the policy titled “Allied Health Credentials”. A review of the credentialing file for Contract Staff #8, Medical Executive Committee meeting minutes, and Governing Body meeting minutes was conducted with Staff #11 on 7/01/2025. In the Credentialing file, was the delineation of privileges for Contract Staff #8. The delineation of privileges revealed: “Baptist Beaumont Delineation of Privileges Provider: Contract Staff #8 C.S.T . ID: AHP584 Department: Physician’s Employee-Licensed/Certified Status: Current Category: Allied Health Professionals Privileges I. General Statement This listing of functions for this category of physician’s employee is not all inclusive and may be changed from time to time through addition or deletion. This category of physician’s employee may work Skilled care Unit only under the direct supervision of the physician employer. (Direct supervision is defined as “in the presence of the physician employer”.) II. Medical Records May access the medical records- Approved 12/15/2015 Start 12/13/2024 End Date 12/12/25. III. Patient Contact- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25. May visit patient- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25. May relay general information- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25. IV. Orders V. Other- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25 Assist the physician employer in surgery (as approved by the physician Annual Renewal: Demonstrate current competence and evidence of the provision of surgical assisting services for at least 48 cases within the past appointment period. Attached log sheet. Assist the physician employer in treatments and procedures (as approved by the physician). Please list: open or endoscopic vein harvest” A review 07/09/2025 at 1:05 PM of the Delineation of Privileges form, Contract Staff #8 was listed as a CST (Certified Surgical Technologist). Contract Staff #8 did not have the proper certificatation to work as a Surgical Assistant. A review on 07/09/2025 at 1:05 PM of “Baptist Hospital of Southeast Texas, INC Medical Staff Bylaws and Rules and Regulations MS.01.08.001” last reviewed on 12/09/2024 stated: “ ...Definition ALLIED HEALTH PROFESSIONAL or AHP means an individual, other than a Physician, Dentist, or Podiatrist, not in a recognized training program within or affiliated with the Hospital, who may or may not exercise independent judgment within the scope of his/her lawful professional practice and who is legally qualified to render direct or indirect medical, surgical, dental, podiatric, or health care under the supervision of a Staff member who has been accorded Privileges to provide such care in the Hospital. Allied Health Professionals shall be divided into two categories: (rev. 12/2024) (a) Privileged Allied Health Professionals (Advanced Practice Professionals) shall consist of Physician Assistants, Advanced Practice Registered Nurses (i.e. nurse practitioners, clinical nurse specialists and CRNA), Certified Anesthesiologist Assistants, Psychologists and Clinical Pharmacists. (rev. 12/24) (b) Non-Privileged Health Professionals shall consist of Registered Nurses, Licensed Vocational Nurses, Medical Assistants, Certified Podiatric Assistants, Dental Assistants, Surgical Assistants, Surgical Technicians, Ophthalmic Assistants, Audiologists, Prosthetists, Orthotists, Histotechs and neurological monitoring technicians ... 2.2 RESPONSIBILITIES OF THE MEDICAL STAFF ... To implement and conduct the following specific activities in order to supervise the quality and efficiency of patient care provided by all Practitioners authorized to practice in the Hospital: (1) review and evaluation of the quality of patient care through an appropriate patient care quality assessment plan; (2) on-going monitoring of selected patient care practices through defined mechanisms and Staff organization components; (3) credentials evaluation of Practitioners practicing or seeking the privilege to practice in the Hospital and for defining privileges for Practitioners and Specified Services for Allied Health Professionals; ... ...(b) To make recommendations to the Board regarding Staff and AHP appointments, Staff category and section assignments, AHP section assignments, Clinical Privileges and Specified Services for Allied Health Professionals; ... ...(g) To seek compliance with these Bylaws, the Rules and Regulations of the Staff and other Hospital policies by Practitioners and Allied Health Professionals at the Hospital; ... ...4.10 ALLIED HEALTH PROFESSIONALS Allied Health Professionals shall not be eligible for Medical Staff membership nor shall these professionals be assigned to a specific Staff category. Allied Health Professionals shall be divided into two categories: Privileged Allied Health Professionals (Advanced Practice Professionals) and Non-Privileged Health Professionals. Both categories shall act as an adjunct to the Medical Staff in accordance with these Bylaws and should comply with the responsibilities of membership as they are applicable to the AHP/APP. The qualifications and procedures for obtaining AHP affiliation and authorization to provide services/clinical privileges in the Hospital are outlined in the Allied Health Professional’s Credentials Policy and Procedure Manual ...” A review on 07/09/2025 at 1:05 PM of the Hospitals Policy Manual title “Allied Health Credentials AH.01.01.001” reviewed by the Credentials Committee & MEC (Medical Executive Committee) with a last revision date of 12/4/2024 stated: “ ...2. Procedure for Appointment 2.1 Application. A person desiring membership on the Allied Health Professional Staff, or a medical staff member who desires to utilize an Allied Health Professional, shall submit an application in writing, on a form or forms provided by the Hospital. 2.2 Required Information. It is the applicant’s responsibility to provide all documentation necessary to complete an application. No application will be deemed completed without the following: ... Copies of certificates or letters confirming completion of training programs (if applicable) or other educational curricula ...” In interview on 07/01/2025 with Staff 11 it was confirmed that contract Staff #8 had only a CST certification. The hospital failed to ensure that Contract Staff #8 had the appropriate certification, training and education to act as a Surgical Assistant.”

“SURGICAL PRIVILEGES CFR(s): 482.51(a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. This Standard is not met as evidenced by: 47892 Based on document review and interview, the hospital failed to ensure that Contracted Staff #8 adhered to the scope of practice for a Surgical Technologist in accordance with the Health and Safety Code Chapter 259. Findings: A review of Contract Staff’s #8 credentialing file, Medical Executive Committee meeting minutes, and Governing Body meeting minutes occurred on 7/1/2025 after 1:30 PM with Staff #11. The Medical Executive Committee and Governing Board approved Contract Staff #8 to perform surgical assistant duties. The Medical Staff failed to ensure that contract Staff #8 had the appropriate certification to perform surgical first assistant duties. Contract staff #8 was a certified surgical technologist (CST) and not a certified surgical first assistant (CSFA). The scope of practice for a CST and a CSFA require a different set of skills to be performed during a surgical procedure. These two scopes of practice have two different sets of skills to be performed during a surgical procedure. According to The Health and Safety Code Chapter 259 the scope of practice for a CST was as follows: “Sec. 259.001. DEFINITIONS. In this chapter: (1) “Department” means the Department of State Health Services. (2) “Surgical technologist” means a person who practices surgical technology. (3) “Surgical technology” means intraoperative surgical patient care as follows: (A) preparing the operating room for surgical procedures by ensuring that surgical equipment is functioning properly and safely; (B) preparing the operating room and the sterile field for surgical procedures by preparing sterile supplies, instruments, and equipment using sterile technique; (C) anticipating the needs of the surgical team based on knowledge of human anatomy and pathophysiology and how they relate to the surgical patient and the patient’s surgical procedure; (D) as directed in an operating room setting, performing the following tasks at the sterile field: (i) passing supplies, equipment, or instruments; (ii) sponging or suctioning an operative site; (iii) preparing and cutting suture material; (iv) transferring and pouring irrigation fluids; (v) transferring but not administering drugs within the sterile field; (vi) handling specimens; (vii) holding retractors and other instruments; (viii) applying electrocautery to clamps on bleeders; (ix) connecting drains to suction apparatus; (x) applying dressings to closed wounds; and (xi) assisting in counting sponges, needles, supplies, and instruments with the registered nurse circulator; (E) cleaning and preparing instruments for sterilization on completion of the surgery; and (F) assisting the surgical team with cleaning of the operating room on completion of the surgery.” This law states what duties a surgical technologist can perform prior to, during, and after a surgical procedure. According to the Association of Surgical Technologists (AST) and NBSTSA (National Board of Surgical Technologists and Surgical Assisting), the credentials and education requirements for a Surgical First Assistant are: “Education Surgical assistants graduate from surgical assisting programs accredited through ARC/STSA” (Accreditation Review Council on Education in Surgical technology and Surgical Assisting) “Credentials Certification is conferred by the National Board of Surgical Technology and Surgical Assisting (NBSTSA). Initial certification as a Certified First Assistant (CSFA) is based upon satisfactory performance on the national certifying examination following completion of an accredited program in surgical assisting or another pathway acceptable to the NBSTSA. CSFAs maintain their certification by earning 75 hours of approved continuing education in a four-year period or by successfully retaking the certifying examination at the conclusion of the four-year period.” Role of the Surgical Assistant (SA)/First Assist (FA)/Certified Surgical First Assist (CSFA) The following description of the surgical assistant has been approved by the American College of Surgeons and Association of Surgical Technologists: 1. Positioning the patient A. The surgeon shall convey the exact position that will give the best exposure for the surgical procedure. The surgical assistant will carry out this order. Consideration will be given to the patient’s comfort and safety. B. Points of pressure shall be padded: elbows, heels, knees, eyes, face, and axillary region. C. Circulation shall not be impaired. (A tourniquet may be required for some procedures.) D. Nerve damage shall be guarded against. E. The temperature of the patient should be discussed with the anesthesia personnel and methods employed to maintain the desired temperature range. F. The surgical assistant shall be familiar with common positions related to the surgical procedure and will be able to use the equipment necessary to provide the position. Competencies will include the following: (1) Fracture tables (2) Head stabilizers (3) Body stabilizers (4) C-arm extensions (5) Any other equipment needed G. Upon completion of the procedure, the patient shall be evaluated for any possible damage from positioning which will include assessment of the skin. The abnormal condition shall be reported to the surgeon and treatment and documentation shall be carried out. 2. Providing visualization of the operative site by the following: A. Appropriate placement and securing of retractors with or without padding B. Packing with sponges C. Digital manipulation of tissue D. Suctioning, irrigating, or sponging E. Manipulation of suture materials (e.g., loops, tags, running sutures) F. Proper use of body mechanics to prevent obstruction of the surgeon’s view 3. Utilizing appropriate techniques to assist with hemostasis A. Permanent (1) Clamping and/or cauterizing vessels or tissue (2) Tying and/or ligating clamped vessels or tissue (3) Applying hemostatic clips (4) Placing local hemostatic agents B. Temporary (1) Applying tourniquets and demonstrating awareness of the indications/contraindications for use with knowledge of side effects of extended use (2) Applying vessel loops (3) Applying noncrushing clamps (4) Applying direct digital pressure 4. Participating in volume replacement or autotransfusion techniques as appropriate 5. Utilizing appropriate techniques to assist with closure of body planes A. Utilizing running or interrupted sutures with absorbable or nonabsorbable material of wound layers, including muscle and fascia. B. Utilizing subcuticular closure technique with or without adhesive skin closure strips C. Closing skin with method per surgeon’s directive (suture, staples, etc D. Postoperative subcutaneous injection of local anesthetic per surgeon’s directive 6. Selecting and applying appropriate wound dressings, including the following: A. Liquid or spray occlusive materials B. Absorbent material affixed with tape or circumferential wrapping. C. Immobilizing dressing (soft or rigid) 7. Providing assistance in securing drainage systems to tissue.” An interview was conducted on 6/30/2025 after 2:30 PM with Contract Staff #8. Contract Staff #8 was asked what part of the surgical procedure he performed. He stated that he performed as a surgical first assistant in cardiovascular (operating procedures dealing with the heart and blood vessels of the human body) procedures only. He stated that he had a certification of training in the Vasoview Endovascular Harvesting System (VEHS). The VEHS is a medical device system used to harvest blood vessels endoscopically, most commonly the Saphenous vein from the leg or the radial artery from the arm, for use in coronary artery bypass (CABG) surgery (surgery that replaces vessels of the heart). The VEHS is a minimally invasive surgical tool set that enables the removal of blood vessels through a small incision using an endoscopic tissue dissector and cautery tools to minimize trauma, reduce wound complications, and improve recovery time. Contract staff #8 was asked if he made the incisions (cuts into human tissue) and if he sutured (sewing material for human tissue) the incisions closed. Contract Staff #8 stated, “I do make the incisions and suture them closed”. A review of the operating room log revealed Contract Staff #8 was documented as the FA and performed FA duties in 6 (Patient 7, 8, 9, 10, 11, and 12) out of 6 patients having a CABG performed in the operating room (OR). An interview was conducted with Contract Staff #8 on 07/08/2025 after 1:00 PM. Contract staff #8 confirmed he performed FA duties in 6 (Patient #7, 8, 9, 10, 11, and 12) of 6 patients reviewed. According to the AST, a CST must not manipulate (alter living tissue during a surgical procedure) unless they have completed a recognized first assistant program and earned CSFA certification. This would include making incisions, suturing, or taking a vein for grafting. A review of the credential file for Contract Staff # 8 confirmed he had a current certification for a CST. There was no certification for a SA/FA/CSFA. Contract Staff #8 was working outside his scope of practice as a CST. During a review of the scope of practice for a CST and a SA/FA/CSFA on 07/01/2025 after 2 PM with Staff #1, 2, 3, 4, and 5 it was confirmed that the scope of practice required different training and certification.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 32143 Based on record reviews and interviews, the facility failed to ensure the physician documentation was obtained on the risks and benefits of blood transfusion to the patient while consenting for blood administration in 3 (#6, 7, and 9) of 3 charts reviewed. A review of patient #7 revealed he was administered blood on 9/8/24 at 11:15 PM for a nosebleed in the emergency room. The blood consent was signed on 9/8/24 at 10:20 PM. The consent revealed there was no physician signature and no documentation that the patient was given his risk and benefits by the physician. A review of patient # 9’s chart revealed patient #9 was administered blood products due to intermittent nose bleeding on 9/13/24 at 11:20 am. The blood consent was signed on 9/13/24 at 10:40 am. The consent revealed there was no physician signature and no documentation that the patient was given his risk and benefits by the physician. A review of patient #6’s chart revealed patient #6 had a blood administration of packed red blood cells on 9/23/24 a review of the consent dated 9/23/24 revealed the patient had signed the consent with the nurse but there was no physician signature that the patient received information on the risk and benefits of blood administration. An interview was conducted on 9/24/24 with Staff # 5 RN Women’s Care Director. Staff #5 stated the physician documents the risks and benefits in the physician’s history and physical or progress notes. A review of the chart revealed there was no physician documentation of the risks and benefits. An interview was conducted on 9/24/24 with physician # 14. Physician #14 stated that patient #6 was her patient. Physician #14 stated that she did discuss the risks and benefits but had not been documenting the risks and benefits in the physician notes.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 32143 Based on reviews and interviews the facility failed to ensure the physician ordered an infusion rate for the administration of blood products in 2 of 2(patient #7 and #9) charts reviewed. A review of patient #7 revealed he was administered blood on 9/8/24 at 11:15 PM for a nosebleed in the emergency room. The physician order stated “LPC (PRBC) priority Lab: stat.” There was no number of units ordered or a rate. While nurses administer the transfusion, they must follow the physician’s orders regarding the infusion rate. There was no documented rate of the blood that was infused in the nursing documentation. A review of patient # 9’s chart revealed patient #9 was administered blood products due to intermittent nose bleeding on 9/13/24 at 11:20 am. The physician order stated, “9-13-24 at 5:00 am “Transfuse 2 u of PRBC.” There was no rate ordered. A review of the nurse’s documentation revealed there was no documented rate at which blood was transfused. An interview was conducted with Staff #6 on 9/24/24. Staff #6 stated the nurses set the rate by the pump. Staff #6 was asked if the pumps were set just for blood and at one specific rate and she stated no. Staff #6 confirmed the physicians were not writing orders and the nurses were setting their rates to administer blood. A review of the policy and procedure of “Blood or Blood Component Therapy/Management of Transfusion Reaction” stated, “16. After the first 50mls (15 minutes for pediatric patients) is transfused and no reaction is noted increase the blood flow to the prescribed rate. The transfusion must be completed within 4 hours.” There was no other direction in the policy and procedure for the nurse to determine the rate of infusion.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40989 Based on medical record review and interview the Nursing failed to ensure obstetrical (OB) patients were assessed according to facility Policy Number, “ED.04.01.0005, Subject: Obstetrical Patient in the Emergency Department” 5 of 5 (Patient #14, #20, #23, #27 and #28) medical records reviewed. Findings: Medical record reviews were completed in the administrative conference room on 7/17/2024 at 12:40 pm with RN Staff #7. Patient #14 Patient #14 was a 22-year-old female who presented to the Emergency Room (ER) on 5/15/2024 at 4:43 pm. She was referred by the ophthalmologist (eye doctor) for an evaluation of acute papilledema (swelling of the optic nerve), headache, and photophobia (sensitivity to light). Also, Patient #14 was 30 weeks pregnant. She was triaged on 5/15/2024 at 4:46 pm by the Registered Nurse (RN) Staff #14 and assigned an ESI-3, Urgent. The ESI-Emergency Severity Index is a numeric tool used in the emergency room that scores a patient between 1 and 5. An ESI 1 is emergent/life threatening and an ESI 5 is non-urgent. The patient was moved to minor care patient room #6 at 6:52 pm. A review of the vital signs (Blood Pressure, Pulse, Respirations, Temperature, Pulse Ox, and Pain scale) documented by Registered Nurse (RN) #14 at 4:48 pm revealed Patient #14 had a high pulse rate of 120 beats per minute (BPM), the normal pulse rate is 60-100, and the pain level was documented as a 2 (a pain scale is a numerical scale of 0-10 with 0 meaning no pain and 10 being the worst pain). A review of the nursing assessments documented by Licensed Vocational Nurse (LVN) Staff #12 on 5/15/2024 at 7:17 pm, 9:30 pm, 11:38 pm, and on 5/16/2024 at 1:44 am and 2:35 am (time of transfer for a higher level of care) revealed there was no fetal heart tones (FHT’s) assessed by nursing during the patients ER visit. A review of Family Nurse Practitioner (FNP) #13’s documentation revealed Patient #14 was medically screened at 8:30 pm. This was greater than 4 hours after the patient’s arrival to the emergency room. A review of the documentation by FNP #13 on 5/15/2024 at 9:11 pm was as follows: “ ...HPI: This 22-year-old white female presents to the ED (Emergency Department) via (by) walk-in with complaints of Blurry Vision, Vision Problem, and Headache. An emergency medical condition exists: yes .... 22-year-old presents to the ED with complaints of blurred vision and headache. She went to see he (sic) was told she had an inflamed optic nerve and was needed to come to the ER. She was diagnosed with Myopia and Papilledema according to paperwork ...She is also 30 weeks pregnant ... 21:13 (9:13 pm) ROS (Review of Systems): ... Neuro: Negative for headache, weakness, numbness, tingling, and seizure ... (Patient complained of a headache at 9:11 pm per FNP #13’s documentation) Eyes: Positive for blurry vision, pain, swelling, Papilledema, and double vision. Exam: Periorbital structures: appear normal, no abrasion (scratches), no cellulitis (swelling), no contusion (bruising), no erythema (rash). Pupils: no acute changes, normal size ...” A STAT order was written by Physician #15 for a CAT scan (a radiological exam) of the Brain/Head on 5/15/2024 at 7:30 pm and resulted in negative findings on 5/15/2024 at 10:16 pm. Further review of the medical record revealed on 5/16/2024 at 6:23 pm FNP #13’s documentation was as follows: “ ...ED Course ...Discussed case with ER attending doctor (Physician #15) he spoke with (accepting hospital name) physicians and determined that patient should be transferred for a higher level of care due to high-risk pregnancy ...” Patient #14 was transferred by ambulance to another hospital for a higher level of care on 5/16/2024 at 2:35 am. During an interview on 7/17/2024 at 12:45 pm, Staff #7 confirmed no fetal heart tones (FHTs) were taken. Also, RN Staff #7 confirmed Patient #14 had an abnormal pulse rate of 120 at the time of admission. An interview was conducted with RN Staff #7 and #4 on 7/17/2024 at 12:45 PM. RN Staff #7 was asked if Physician #15 examined Patient #14 while she was in the ER. RN Staff #7 confirmed there was no documentation of an examination by Physician #15. RN Staff #7 was asked if FHTs were assessed by the ER Staff or the OB Department during Patient #14’s ER visit. RN Staff #7 and #4 confirmed there were no FHTs, or fetal movement assessed during Patient #14’s ER visit. RN Staff #7 was asked if the patient was assessed for any pregnancy-related complications during her ER visit. RN Staff #7 stated, “The only time the pregnancy was documented by the nursing staff was during her triage when she first got to the ER”. RN Staff #4 was asked if someone from the OB Department came down to monitor the baby. RN Staff #4 stated, “No”. RN Staff #4 was asked if the ER Department was monitoring OB patients to ensure the facility policy was followed and someone in the ER or from the OB department assessed the FHTs and fetal movement before the patient was discharged. RN Staff #4 confirmed there was no monitoring of OB patients who presented to the ER. Patient #23 Patient #23 was a 37-year-old female who presented to the ER on 5/09/2024 at 8:07 pm with complaints of, “pain at baby site, headache, and right leg pain”. Patient #23 was 16 weeks pregnant and referred to the ER by her OB Physician. Patient #23 was triaged by the RN and assigned an ESI 3-Urgent. She was assisted to the minor care area and placed in bed 10 on 5/09/2024 at 8:31 pm. Further review of the medical record revealed the patient rated her pain at an 8. No fetal heart tones were documented on admission. Patient #23 was medically screened by FNP #10 at 9:03 pm and found to not have an emergency medical condition. A review of the documentation by FNP #10 revealed the patient was examined on 5/09/2024 at 11:58 pm. The documentation of the examination by FNP #10 did not disclose that an assessment of the fetus had been completed. No fetal heart tones were documented during the patient’s ER visit. Patient #23 was diagnosed with an Upper Respiratory Infection, treated with antibiotics, and discharged home on 5/10/2024 at 12:03 am. Further review of the medical record revealed Physician #11 documented an attestation statement on 5/10/2024 at 3:38 am. This was 3 hours and 35 minutes after a high-risk OB patient left the ER. There was no documentation by FNP #10 that the patient was discussed with the attending physician before the patient was discharged. According to the American College of Obstetricians and Gynecologists (ACOG) pregnancy at age 35 or older is considered high risk. Some of the risks associated with advanced maternal age include: *Higher risk of pregnancy-related complications *Increased risk of chromosomal conditions in the baby *Greater likelihood of miscarriage *Higher rates of genetic defects *Certain pregnancy complications like high blood pressure or gestational diabetes. An interview was conducted with Registered Nurse (RN) Staff #9 on 7/17/2024 after 1:00 pm. RN Staff #9 was asked if Patient #23 was considered a high-risk OB patient. RN #9 confirmed Patient #23 was a high-risk OB patient due to her age and FHTs should have been assessed before the patient was discharged. RN Staff #9 confirmed no FHTs were documented during the patient’s ER visit on 5/09-5/10/2024. A review of the variance report with RN Staff #9 revealed Patient #23 was seen by Physician #15. RN Staff #9 confirmed Physician #15 did not document an examination of Patient #14 during the ER visit. A review of the facility policy, Policy Number ED.04.01.0005 with a revised date of 6/2024 was as follows: “SUBJECT: OBSTETRICAL PATIENT IN THE EMERGENCY DEPARTMENT POLICY STATEMENT It is the policy of Baptist Hospitals of Southeast Texas, Beaumont campus to provide a medical screening examination and treatment for all obstetrical patients that present to the Emergency Department. PROCESS 1. Upon presentation to the Emergency Department, the patient will be triaged by an Emergency Department Registered Nurse. 2. The triage Registered Nurse will determine whether the patient remains in the Emergency Department or will be sent to the Labor and Delivery department for further assessment. *If a patient remains in the Emergency Department, the treatment plan of the Emergency Department Physician will be followed. *If a patient is sent to the Labor and Delivery department, the Labor and Delivery The registered Nurse will assess the patient and will notify the obstetrician of the findings. 3. ED Physician shall have the discretion to notify and/or consult with other physicians as he/she deems necessary for the treatment of any Emergency Department patient. Unknown Gestational Age/No prenatal Care *If the patient has no prenatal care and does not know their gestational age (pregnancy not confirmed) they will be registered and treated in the ED until gestational dates are determined. * Gestational age will be determined by assessment from the ED provider OR an ultrasound. Patients Under 20 weeks of Gestational Age *Obstetrical patients less than 20 weeks gestation will be seen and treated in the ED. Fetal well-being should be determined as part of the treatment process via ultrasound and/or fetal heart tones and documented in the medical record. Patients Over 20 weeks of Gestational Age *If the patient is 20 weeks or greater with any of the following complaints they will be treated/medically cleared in the ED: * Chest pain or cardiac related complaint with abnormal vital signs * Shortness of breath with a SPO2 <90% * Stroke or stroke-like symptoms * Flu-like symptoms, covid-like symptoms, strep symptoms * Urgent physical injury * MVA *For any patient with the above complaints. the L&D department will immediately be notified of the patient’s arrival to the ED. The L&D nurse will come to the ED to perform fetal monitoring. If the patient requires additional OB monitoring they will be discharged to L&D for further evaluation once medically cleared in the ED. *If the patient is 20 weeks or greater with any other complaint than the ones listed above, the L&D department will be notified and the patient will be brought to the L&D. If the patient is cleared of pregnancy-related complaints, they may be sent back to the ED for further clinical evaluation for non-pregnancy related care. *If an obstetrical patient presents with any life-threatening injuries or instability of airway, breathing and/or circulation. this patient will be treated and stabilized in the emergency department, regardless of gestation.” 32143 Findings; Patient #27 A review of patient chart #27 revealed a 17 y/o pregnant female who came into the ED on 5/1/24 at 12:41 PM. The patient came in with a complaint of a seizure. The physician documentation stated per EMS she had a seizure while at school. The patient had experienced similar episodes in the past. A review of the physician orders revealed an order to check fetal heart tones (FHT) at 12:47 PM. There was no documentation that fetal heart tones were obtained or that the OB department was informed of the patient in the ED. A review of the ED physician notes dated 5/1/24 at 13:57 (1:57 PM) stated the ED physician had talked to a maternal-fetal medicine specialist in Houston, TX, regarding the patient’s condition. The specialist wanted to see the patient “now”, so the patient was discharged into the care of her family to take her to Houston. The ED physician felt she was stable and able to make the trip. An incident report was placed by nursing concerning the patient not getting any FHTs and was not seen by Labor & Delivery(L&D) on 5-13-24. A review of the report stated the ED called L&D stating they had a 36 wk 17 y/o patient who had a seizure at school. The L&D nurse asked if she should come to the ED and monitor the baby. The L&D nurse was told it was an “eclamptic” seizure and that she would be coming to L&D after she was screened by the provider. The L&D nurse called at 13:53 to check on the patient’s status and the ED nurse stated the physician was on the phone with the specialist in Houston. The L&D nurse called back to the ED at 14:50 (2:50 PM) and was informed the patient was discharged. The complainant stated per policy ED.04.01.005 obstetrical patient in the Emergency department and best practice for the pt’s gestation, needed to have fetal monitoring while she was down in the ED to assure fetal well-being.” A review of the incident report revealed Staff # 4 RN ED Director addressed the incident on 5-14-24 at 8:39 AM. Staff # 4 described the patient’s events in the ED but never addressed that the ED nurse did not document any information that the OB department was called, who they spoke to, what was the plan, and why the patient never got fht’s while in the ED. The ED nurse failed to follow physician orders. Staff # 9 RN OB Services addressed the incident report on 5/15/24 at 8:12 AM. Staff # 9 stated that she reviewed the chart and thought it was appropriate to keep the patient in the ED but felt there should have been better communication with L&D. Staff #9 reported due to the AWHONN and ACOG guidelines the baby should have been monitored for at least 30 minutes. Staff #9 was concerned that the baby went 75 minutes with no monitoring. The incident report revealed two different opinions from both departments. There was no documentation that the incident was resolved or that quality was working on a resolution. No information was provided that the nurses were counseled on failure to follow policy and physician orders. Patient #20 A review of patient #20’s ED chart stated presented to the ED on 7/11/24 at 12:08 PM. The patient reported she had been at urgent care and was diagnosed with COVID. The patient reported she was 25 weeks pregnant, and her pulse rate was elevated. She was instructed by urgent care to come to the ED. A review of the physician’s notes revealed she was being evaluated by a nurse practitioner (NP). The NP put in an order for FHTs on 7/11/24 at 13:21(1:27 PM) and at 13:48 (1:48 PM) an order for an ultrasound “OB Limited”. A review of the chart revealed there were no FHTs performed. A review of the Diagnostic Imaging Report dated 7/11/24 revealed there was an ultrasound performed at 2:46 PM. The patient was 25 weeks pregnant and 5 days with a “fetal cardiac motion present at 144 bpm.” The patient was in the ER for 2 hours and 40 minutes before an FHT was detected and documented. There was no evidence that the NP or nurse called OB services and informed them of a patient in the ER who was more than 21 weeks pregnant for observation, according to policy. Patient # 28 A review of patient #28’s ED chart revealed she was received in the ED on 6/2/24 at 5:02 AM with a complaint of flank pain. The patient reported that she was 27 weeks pregnant and had been to another hospital 2 days prior and was told she had kidney stones. A review of the nurse’s notes revealed at 5:16 AM the nurse notified L&D and attempted to call in a report. The nurse documented, “Report to Labor and Delivery informed back pain is not a labor sign since pt has kidney stones and told must be cleared in ER first. 5:41 PM Focus assessment since L/D refused patient charge nurse, ERP, and house supervisor notified, pt moved to ED room and US order obtained.” There was no documented evidence that the house supervisor responded or attempted to investigate why an L&D nurse did not respond according to policy. A review of the chart revealed there was a physician order to obtain FHTs at 5:23 AM and OB ultrasound limited was ordered at 5:38 AM. There was no documentation that any FHTs were obtained prior to the ultrasound. The physician documented that the ultrasound for OB limited with FHTs was interpreted at 7:22 AM, 2 hours after the order was obtained. The ultrasound for the kidneys revealed no stones and the patient was admitted to the L&D at 10:00AM. A previous survey conducted by this surveyor on 2/13/24 revealed a maternal patient demise had occurred in October of 2023. The patient had previously been in the facility’s ED. The facility had performed a Root Cause Analysis concerning the patient’s visit and had identified that the patient never received FHTs in the ED. The facility revised its policy to read, “Patients Under 20 weeks of Gestational Age o Obstetrical patients less than 20 weeks gestation will be seen and treated in the ED. Fetal well-being should be determined as part of the treatment process via ultrasound and/or fetal heart tones and documented in the medical record. Patients Over 20 weeks of Gestational Age o If the patient is 20 weeks or greater with any of the following complaints they will be treated/medically cleared in the ED: * Chest pain or cardiac related complaint with abnormal vital signs * Shortness of breath with a SPO2 <90% * Stroke or stroke-like symptoms * Flu-like symptoms, covid-like symptoms, strep symptoms * Urgent physical injury * MVA For any patient with the above complaints. the L&D department will immediately be notified of the patient’s arrival to the ED. The L&D nurse will come to the ED to perform fetal monitoring. If the patient requires additional OB monitoring, they will be discharged to L&D for further evaluation once medically cleared in the ED. o If the patient is 20 weeks or greater with any other complaint than the ones listed above, the L&D department will be notified, and the patient will be brought to the L&D. If the patient is cleared of pregnancy-related complaints, they may be sent back to the ED for further clinical evaluation for non-pregnancy related care. o If an obstetrical patient presents with any life-threatening injuries or instability of airway, breathing and/or circulation. this patient will be treated and stabilized in the emergency department, regardless of gestation.” An interview was conducted 7/17/24 with staff # 3, #4, and #9. Staff #4 stated that she was aware there was a problem with pregnant patients 20 weeks or greater not being monitored for FHTs in the ER. Staff #4 stated that she had addressed her concerns on the incident reports and had meetings with the OB directors but stated it had not been followed through. Staff #4 confirmed no performance improvement on the incidents and no further follow-through. Staff # 9 confirmed there was no follow-up from the incidents since the policy was changed and updated. Staff #9 confirmed the policy was changed due to an incident with a maternal death after the patient had been in the facility for treatment. The facility discovered through a root cause analysis that pregnant patients were not being monitored for FHTs. Staff in the ED and OB department were educated on the policy change. There was no data to reveal that the practice change, was monitored by the department or through quality. Staff # 3 confirmed that the quality department had not followed through with the incident reports for failure to monitor the pregnant patient’s FHTs. The quality department had no data, analysis of the data, or follow-through.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 32143 Based on review and interview, the facility failed to provide a written acuity plan for staffing, ensure a registered nurse was always on duty, and represent the psychiatric unit in the staffing advisory or effectiveness committee meetings in 5 of 5 (adolescent, adult, acute adult, geriatric, and child) patient behavioral units. Refer to Tag A0392”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 32143 Based on review and interview, the facility failed to provide a written acuity plan for staffing, ensure a registered nurse was always on duty, and represent the psychiatric unit in the staffing advisory or effectiveness committee meetings in 5 of 5 (adolescent, adult, acute adult, geriatric, and child) patient behavioral units. An acuity system identifies the amount of nursing care needed for each patient on a unit based on the level of intensity, nursing care, and tasks needed for each patient. The system allocates resources based on patients’ needs, not according to raw patient numbers. An acuity tool allows each nurse to score his or her patients, based on acuity, for the upcoming shift and can report this information to the charge nurse, who then assigns patients before the shift change. The handoff report between RNs allows each to validate patients’ current acuity and care needs. The psychiatric unit may have a patient that requires a 1:1 observation that would require one staff member to one patient at arm’s length, a line of sight that requires a staff member always to keep the patient within their line of sight, a patient that required restraint and needs observation, or the patient needs extensive medical care. There was no acuity plan to show how the staffing would be increased, how many staff would be required, or when to decrease staffing levels. The current staffing plan allows for person-dependent decisions instead of process decisions on increasing or decreasing staffing needs due to patient acuity. A review of the policy and procedure “Nursing Organization Plan Providing Patient Care” revision date 7/23 revealed on page 16 under “Delivery of Care Methodology”, “ ... An assessment is made at the beginning of each shift by the nurse manager or nurse in charge utilizing shift reports and patient acuity tool in order to assign the most appropriate staff to meet the identified patient needs ...BEHAVIORAL HEALTH (Page 19 of 22) Adolescent Unit -Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I: I 0 Adult Unit-Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I: I 0 Acute Unit-Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:8 Geropsych Unit - Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:9 Children’s Unit- Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:5. In Behavioral Health tech staff is utilized to monitor patient/environmental safety and to report identified needs to the RN, thus Psych Techs are added in response to patient monitoring needs. The Staffing Coordinator and/or Nursing Supervisors/Directors may adjust staffing levels up or down as called for by change in complexity of patient needs, or census. Reports are maintained in Kronos for each nursing unit reflecting numbers actual staffing and are available at any time for director review. Monday through Friday nursing directors huddle with the staffing coordinators to review staffing needs for the day and or weekend Nursing directors are notified when there is a staffing variance. Whenever there is a staffing Variance the Staffing Variance Algorithm will be utilized.” An interview was conducted with Staff # 7 on 5/8/24. Staff # 7 reported that the behavioral unit had their own house supervisors, and they would make decisions concerning staffing needs due to patient acuity. Staff #7 confirmed the acuity level was decided by the house supervisor when she was not there. A review of the Nursing Advisory Council policy and procedures revealed the council was a committee responsible for “the development, ongoing monitoring, and evaluation of the Baptist Hospital Staffing Plan ... The council consists of 60 % direct care registered nurses. Each nurse has one vote and is selected by their peers who provide direct care during at least 50% of their work time. “Behavioral Health Services was one of the units to be represented on the council. the staffing committee or council approach typically involves direct care nurses (e.g., representatives from various clinical areas) and leadership (e.g., management, infection control, quality, education) collaborating to develop staffing plans to guide patient care assignments. A review of the nursing advisory council meeting minutes for 8/23, 1/17/24, and 3/12/24 revealed there was no nursing representation from the behavioral health unit. An interview with Staff # 4 and 7 on 5/8/24 confirmed that Staff # 7 was the behavioral unit representative. Staff #7 was the unit director that was making all the staffing decisions for the unit and was not elected by her peers. Staff #7 confirmed she had not attended all the meetings and was unsure which ones she had attended. Staff #7 stated that she did talk to her staff about staffing. An interview was conducted with staff # 16, 17, and 18 on 5/8/24. Staff #16, 17, and 18 all confirmed that they were never informed of any staffing committee, nor have they been asked to vote for a peer to represent them. Staff #18 stated she was not aware there were any meetings. Staff #16 reported she had been left on the unit with patients by herself and felt it was “very unsafe.” Staff #16 stated that she had to go several times a week, to a closed room for the IDT meetings, and had to leave the mental health techs on the floor alone with no supervision. Staff #16 stated that she had voiced her concerns about unsafe staffing but there was always some type of retaliation. Staff #17 stated she had been alone as the only nurse with just techs for many shifts. Staff #17 stated that she had to ask for other nurses to come to her unit to assist in emergencies leaving their unit short. Staff #17 stated the house supervisors are always busy and unable to assist with lunch breaks or any break in general. Staff #17 stated they must eat at the desk quite often and not get any breaks. Staff #17 stated she did not feel comfortable expressing her concerns due to retaliation. A review of the matrix/grid revealed that the minimal nursing staff from 1-5 children was 1 RN. A review of the staffing sheet revealed there was only 1 RN assigned to the child unit from 4/1/24 to 5/7/24 and 2 nurses when the census increased to 6 patients on 5/2/24 and 5/3/24. There was no documentation if the nurse got a meal break or who covered for the nurse. There was no information on the number of admissions, discharges, or who covers for the nurse when attending the treatment team meetings. A review of the staffing schedule for the geriatric unit revealed the RN had an MHT’s and an LVN from 5/4/24 through 5/6/24 but no documentation covered for the RN during meal breaks. The RN must always supervise the LVN and MHT’s. According to the Texas Nurse Association, “Safe staffing is more than a number. It is the right number of nurses and the right match of nurse and patient characteristics that makes staffing “safe.” It is the right number of nurses and the appropriate workload. It is the right number of nurses and the right kind of resources to support the nurse in the particular environment. It is the right number of nurses and the right kind of culture - one that supports collaborative, interdisciplinary practice and encourages nurses to identify and report problems and barriers to providing care.” 47892 An interview was conducted with staff # 9, 10, and 11 on 5/8/24. Staff #9, 10, and 11 all confirmed that they were never informed of any staffing committee, nor have they been asked to vote for a peer to represent them. Staff #10 and 11 stated they were unaware there were any meetings or even what nurse staffing committee meetings are. Staff #10 and 11 stated they feel the staffing ratio of 1 nurse to 8 patients was “very unsafe.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40989 Based on document review and interview the hospital failed to ensure that informed consent for psychotropic medications was completed and properly executed before the administration of psychotropic medications in 3 (Patient #2, #4, and #7) of 5 (Patient #2, #3, #4, #6, and #7) patient charts reviewed. The hospital also failed to follow its policy, Policy #BHC.08.00.0005. Findings: On 11/30/2023 at 1:30 PM, medical records were reviewed with Staff #1, #15, and #16. A review of the psychotropic medication consent document showed the initial statement to be: “This patient has received a complete explanation of _______________(blank to specify medication/dosage) completed by staff ...” At the bottom of the page was a statement that read, “I have received a complete explanation of the psychoactive medication(s) in writing.” Patient #2 Patient #2 was a 41-year-old female admitted to the hospital on 11/25/2023. A review of the medication orders and informed consents were as follows: 11/24/2023 at 3:09 PM, Zyprexa (antipsychotic) 5mg by mouth every 6 hours as needed for agitation. Patient #2 received 1 dose of this medication between 11/24/2023 and the survey exit date of 11/30/2023. The consent did not document the dosage of the medication. 11/24/2023 at 3:09 PM, Vistaril (antihistamine used for anxiety) 25mg by mouth every 6 hours as needed for anxiety. Patient #2 received 7 doses of this medication between 11/24/2023 and the survey exit date of 11/30/2023. The consent did not document the dosage of the medication only the name of the medication. 11/24/2023 at 3:09 PM Trazadone (antidepressant) 50 mg by mouth at bedtime as needed. Patient #2 received 4 doses of this medication between 11/24/2023 and the survey exit date of 11/30/2023. The consent did not document the dosage of the medication only the name of the medication. 11/28/2023 at 11:56 AM Trazadone (antidepressant) 100 mg by mouth at bedtime. Patient #2 received 1 dose of this medication between 11/24/2023 and the survey exit date of 11/30/2023. The consent did not document the dosage of the medication only the name of the medication. 11/29/2023 at 10:11 AM, Trazadone (antidepressant) 150 mg by mouth at bedtime. Patient #2 received 2 doses of this medication between 11/24/2023 and the survey exit date of 11/30/2023. The consent did not document the dosage of the medication only the name of the medication. An interview was conducted with Staff #15 and #16 on 11/30/2023 at 2:30 PM. Staff #16 was asked if the informed consent for Trazadone should have had the medication dosage listed on the consent. Staff #16 stated, “Yes, it should. It says to list the medication and the dosage on the consent form.” Staff #16 was asked which dosage of Trazadone did the signed informed consent apply to. Staff #16 stated, “There should have been a new consent each time the medication was increased but I can see that was not completed either. I do not know, but it would have to be for the order that was written on November 24th because the change in tie dosages was not made until November 28th and again on November 29th. There should have been new consents signed by Patient #2 every time the dosage was increased. The staff know that anytime the medication is increased it can change the patient’s thought process and a new consent has to be completed.” 11/25/2023 at 12:57 PM, Abilify (antipsychotic) 5 mg by mouth daily. Patient #2 received 2 doses of this medication. 5 mg was given by mouth on 11/25/2023 at 2:44 PM and 11/26/2023 at 8:03 AM. 11/26/2023 at 9:53 AM, Abilify (antipsychotic) 10 mg by mouth daily. Patient #2 received 3 doses of this medication. 10 mg was given by mouth on 11/27/2023 at 8:03 AM, 11/28/2023 at 8:02 AM, and 11/29/2023 at 8:33 AM. Staff #16 confirmed there was no signed informed consent for the administration of Abilify in the patient’s medical record before the medication was administered on 11/25/2023 and 11/26/2023. Staff #16 confirmed Patient #2 received 5 doses of the antipsychotic medication, Abilify, without a signed informed consent from the patient. Staff #16 confirmed only one consent was signed by the patient on 11/30/2023. There was no dosage documented on the informed consent. The informed consent was signed and dated by Patient #2 and signed by a witness but there was no time documented when the consent was signed. Patient #4 Patient #4 was a 56-year-old female admitted to the facility on 11/29/2023. A review of the medication orders and informed consents were as follows: 11/29/2023 at 12:26 PM Risperidone (antipsychotic) 1mg by mouth twice a day. The informed consent was signed and dated by Patient #4 on 11/29/2023 at 3:50 PM. Patient #4 received 3 doses of this medication. The nurse failed to document the dosage of medication on the informed consent. 11/29/2023 at 12:26 PM Haldol (antipsychotic) 5mg by mouth every 6 hours as needed for agitation. The informed consent was signed and dated by Patient #4 on 11/29/2023 at 3:53 PM. The nurse failed to document the dosage of medication on the informed consent. 11/29/2023 at 12:26 PM Vistaril 25 mg by mouth every 6 hours as needed for anxiety. The informed consent was signed and dated by Patient #4 on 11/29/2023 at 3:54 PM. The nurse failed to document the dosage of medication on the informed consent. 11/29/2023 at 12:26 PM Trazadone (Antidepressant/Sedative) 50mg at bedtime as needed for sleep. The informed consent was signed and dated by Patient #4 on 11/29/2023 at 3:53 PM. The nurse failed to document the dosage of medication on the informed consent. 11/30/2023 at 6:06 AM Valporic Acid (Depakene) 250mg by mouth three times a day. The informed consent was signed and dated by Patient #4 on 11/29/2023 at 3:50 PM. Patient #4 received 5 doses of this medication. The nurse failed to document the dosage of medication on the informed consent. Patient #7 Patient #7 was a 32-year-old male admitted to the facility on 11/01/2023. A review of the medication orders and informed consents were as follows: 11/01/2023 at 4:26 PM Trazadone 50mg by mouth at bedtime as needed for sleep. The informed consent was signed and dated by Patient #7 on 11/01/2023 at 5:26 PM. Patient #7 received 5 doses of this medication. The nurse failed to document the dosage of medication on the informed consent. 11/01/2023 at 4:26 PM Haldol 5mg by mouth 3 times a day as needed for agitation. The informed consent was signed and dated by Patient #7 on 11/01/2023 at 5:36 PM. There was no witness signature or signature of the person who explained the risks and benefits of the medication to the patient. There was no documentation of the dosage of medication on the informed consent. 11/01/2023 at 4:26 PM Lorazepam 2mg by mouth 3 times a day as needed for agitation. The informed consent was signed and dated by Patient #7 on 11/01/2023 at 5:36 PM. The nurse failed to document the dosage of medication on the informed consent. 11/01/2023 at 4:26 PM Vistaril 25mg by mouth 3 times a day as needed for anxiety. The informed consent was signed and dated by Patient #7 on 11/01/2023 at 5:36 PM. Patient #7 received 4 doses of this medication. The nurse failed to document the dosage of medication on the informed consent. 11/02/2023 at 4:40 PM Invega (antipsychotic) SR 9mg by mouth at bedtime. Patient #7 received 1 dose of this medication on 11/02/2023 at 8:53 PM. 11/03/2023 at 3:31 PM Invega Sustenna 156mg Intramuscular 1 time dose. Patient #7 received one dose of this medication on 11/03/2023 at 8:54 PM. Staff #15 confirmed in an interview on 11/30/2023 after 2:00 PM that Patient #7 gave verbal consent on 11/02/2023 at 8:30 PM for the administration of Invega. It was also confirmed there was no dose documented on the consent. Staff #15 stated, “There should be two separate consents for this medication. One for the oral medication and one for the IM injection. They know this. I guess we will have to get on this now and re-educate the staff regarding this problem.” A review of the facility Policy # BHC.08.00.0005 with a review date of 5/21 was as follows: “ ...SUBJECT: PHARMACY STANDARDS: PSYCHOACTIVE DRUGS: INFORMED CONSENT ... DEFINITIONS ... Psychoactive medication means a medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness. Psychoactive, education includes the following categories: (a) Antipsychotic or neuroleptics (b) Antidepressants; (c) Agents for control of mania or depression; (d) Antianxiety agents; (e) Sedatives, hypnotics, or other sleep-promoting drugs, and (f) Psychomotor stimulants PROCESS STANDARDS To facilitate the attainment of Outcome Standards: A. Informed medication consent must be obtained for each individual medication, not by medication class. Any time the medication regimen is altered in a way that would result in a significant change in the risks or benefits for the patient, an explanation of the change is to be provided to the patient and/or the patient’s legally authorized representative. The explanation is to include the notification of the right to withdraw consent at any time ... E. The form titled Consent to treatment with psychoactive medication is to be utilized for documenting the explanation and patient consent. In addition, the nurse is to provide the patient or the legally authorized representative with written medication instruction specific to the prescribed medication ...” Staff #15 and Staff #16 confirmed the medication dose should be documented on the informed consent and each time the medication dosage was changed there should have been a new informed consent completed. Staff #15 also confirmed the medication dosage was not properly documented on the informed consent in 3 (Patient #2, #4, and #7) of 5 (Patient #2, #3, #4, #6, and #7) patient charts reviewed.”