St David’s Medical Center

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 31974 Based on review of documents and staff interview, the facility failed to ensure the policies and procedures governing medical care provided in the emergency services or department are established and are a continuing responsibility of the medical staff when policies and procedures for reassessment and documentation of vital signs for 1 of 10 patients reviewed (Patient #2) were not implemented for patient #2 in the emergency department at risk of indicators of current health condition, assessment of interventions, and abnormal vitals signs not being monitored or observed. Findings were: Review of the facility provided policy titled “Emergency Department Assessment Reassessment” effective 9/2023 reflected in part, “ ...Any patient awaiting a medical screening exam, regardless of location, will be reassessed at a minimum of hourly and more frequently based upon the acuity assigned. Before receiving a medical screening exam, the Triage Acuity level and the chief complaint will determine the depth of assessment. Once the medical screening exam is begun, the patient’s reassessment will be based upon acuity, orders, treatments, interventions, or changes in the patient’s medical Patients assigned a triage acuity level 1, 2, or 3 (using a 5-level triage system such as ESI or CTAS) will receive a detailed nursing assessment. Patients assigned a triage acuity level 4 or 5 will minimally receive a focused nursing assessment unless screened and discharged from the Emergency Screening Program ... Triage Acuity Levels (Beveridge): Level 1 Resuscitation Level 2 Emergent Level 3 Urgent Level 4 Semi-Urgent Level 5 Non-Urgent Reassessment - A periodic re-evaluation process based on the patient’s chief complaint, acuity, condition, and symptoms or treatments. The frequency of reassessment performed for patients during their treatment may be determined by the patient’s chief complaint, acuity, condition, symptoms, treatments, and orders. Reassessment may be documented in the form of a detailed nursing assessment or a focused assessment ... Guidelines for the reassessment of patients who have received a Medical Screening Exam (some patient conditions may warrant variations from the timeframes below): Triage Level 1 Every 15 minutes or until condition is stabilized Triage Level 2 Every 60 minutes Triage Level 3 Every 120 minutes Triage Level 4 At triage and prior to discharge Triage Level 5 At triage and prior to discharge Vital signs - Usually refer to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and /or hemodynamic compromise. A pain scale may also be included for those patients with pain as a component of their presenting complaint. Vital signs, including pulse oximetry and pain scale, should be monitored when initial vital signs are abnormal and /or as the patient’s condition warrants ...” Review of Patient #2’s medical record reflected in part, “ED Physician Note 3/31/26 0226: “ ...51-year-old with a past medical history of endometriosis, chronic back pain who presented to the ED for flare of thoracolumbar pain with radiating burning/numbness around torso and feeling of spasms in lower extremities. Difficulty getting comfortable ...Urinalysis not consistent with UTI, no hematuria, CT of thoracolumbar spine shows multilevel degenerative changes without high grade neural foraminal stenosis. Feeling better after medications given in ED. Given ED return precautions, advised to follow up with PCP/pain management, and discharged to home 3/31/26 0637 ...” Timeline in ED for Patient #2: 3/31/26 2:02 am Arrived at “walk in” 2:34 am Triaged 2:34 am Vitals: Pulse Ox: 98, BP 146/92, O2 delivery: room air, Temp 37.2, Pulse 97, Respiratory Rate 18 2:03 am Seen by provider (greet time) 2:51 am To imaging (CT) l-spine and t-spine 2:45 am IV placed 2:45 am Labs drawn 3:04 am Methocarbamol 1500 mg po administered 3:04 am Toradol 30 mg IM administered; pain rated at 10. 3:04 am Lidocaine patch 3:19 am Reassessment of pain: 10 6:08 am Dilaudid 1 mg IV, indication: pain rated at 8 6:38 am pain rated at 4. 7:09 am Zofran 4 mg po, indication: nausea from Dilaudid Nurses’ Note 3/31/26 0717: “Pt left ED a&ox4 (alert and oriented x 4), gcs (Glascow Coma Scale) 15, rr (respiratory rate) even, unlabored, pt states she is not driving.” Note: There was no documentation found for reassessment of pain after 3:19 am until the administration of Dilaudid at 6:08 for pain rated at 8. . Vitals were taken at 02:34 am during triage and were not taken or documented again throughout stay in ED or prior to discharge. During an interview on the morning of 6/2/26 Staff #2 confirmed Patient #2 was triaged as a Level 3. She stated the ED uses an ESI score of 1-5, 1 being the highest acuity, 5 being the lowest. (Emergency Severity Index is a 5-level algorithm used in emergency departments to triage patients based on both their medication acuity and expected resource needs.). Staff #2 confirmed the ED did not reassess the patient every 120 minutes and vital signs were not monitored after initial vitals signs were abnormal, per policy and procedure.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 51738 Based on a review of facility documents, medical records, and interviews, the facility failed to follow policies and procedures governing medical care provided in the emergency department by: A. Not obtaining patient, family member, or witness signatures on the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” forms for 2 of 20 patients (#14 and #16), and B. Not obtaining patient, family member, or witness signatures on discharge instructions for 1 of 20 patients (patient #1). Findings were: A: A review of the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” form, partially reveals: Page 1: “Page 9: “I, the undersigned, as the Patient or Patient Representative ...have read, and fully and completely understand this Conditions of Admission and Consent for Inpatient Care ...and that I have signed ...knowingly, freely, voluntarily ...” On the bottom of Page 9 there is a “Patient/Patient Representative Signature” box, a checkbox “Patient is Unable to Sign” and signature boxes for a “Witness Signature and Title”, and “Additional Witness Signature and Title”. A review of facility policy titled, “PARA.PP.PTAC.038 Procedure for Registration Forms and Signatures” (Revised: 05/01/2024) reveals in part: “Policy: The Patient Access Department obtains signatures on all registration forms ... The Consent form is signed upon the first registration ... The Consent should be obtained for each account within the episode of care ... Documentation requirements when a patient is unable to sign: A physician or a licensed clinical person should document a medical reason why the patient is unable to provide a signature, within the medical record. The documentation should include the physician’s or licensed clinical person’s signature and title including the last and first name ... The witness signature area, when signed with a second witness signature and title, indicates a patient’s inability to sign with a representative not present ... Guidelines for witness signatures and titles: In the event a patient, a legally authorized individual, or a family member is medically unable to sign, two staff members can act as a witness on the consent form. The two witnesses may be registration and clinical staff. A witness’s signature includes a staff member’s full first name, last name and title ... Special Note: If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency.” A review of the Conditions of Admission and Consent for Inpatient and/or Surgical Care” form for patient #14 and #16 partially reveals that “UTS [Unable to Sign]” is written in all of the signature and initial boxes on pages 1 - 8. For patient #14, on page 9, “UTS” is written in the “Patient/Patient Representative Signature” box and the box “Patient is Unable to Sign” is checked. There is an electronic “Witness Signature and Title”, but the same patient access representative signed on the “Additional Witness Signature and Title” line. For Patient #16, on page 9 “UTS” is written in the “Patient/Patient Representative Signature” box but the box “Patient is Unable to Sign” is not checked. There is an electronic “Witness Signature and Title”, but there is no signature on the “Additional Witness Signature and Title” line. A review of the medical records for patients #1, #14, and #16 reveals: Patient #1: Date of Service (DOS): 12/28/2025. Diagnosis: Cellulitis. Significant past medical history: Right leg cryoablation on 12/23/2025; Hypertension; rheumatoid arthritis. On 12/26/2025 - patient #1 began having redness, warmth, pain, and swelling of right lower leg. Surgeon sent patient to the Emergency Department (ED) to rule out a DVT (Deep Vein Thrombosis, i.e. blood clot). Ultrasound (US) performed showed no evidence of a DVT. Discharged home with antibiotics. Patient #14: (DOS): 12/30/2025. Diagnosis: Anxiety, suicidal ideation (SI) per family report. Significant past medical history: anxiety, depression. Presented to ED on 12/30/2025 via ambulance after taking 8 Seroquel. Medically cleared and transferred to psychiatric facility. Patient #16: (DOS): 1/5/2026. Diagnosis: SI, Overdose (OD). Significant past medical history: anxiety, depression. Sent to ED for medical clearance prior to inpatient psychiatric treatment. Patient #16 took 7 Restoril the previous night. Medically cleared and transferred to psychiatric facility. A further review of the medical records for patients #14 and #16, reveals there is no documentation of a medical reason why the patients are unable to provide a signature on their consent forms. In interviews conducted during the review of medical records on the afternoon of 2/4/2026, Staff #1, Director of Quality, and Staff #2, Quality Coordinator, acknowledged that staff did not follow facility policies including “Guidelines for witness signatures and titles” found in facility policy titled, “PARA.PP.PTAC.038 Procedure for Registration Forms and Signatures”. B: A review of policy “Patient Discharge from the Emergency Department (Revised: 9.2024)” partially reveals: “5. EMR [electronic medical record] instructions will be prepared by the ED Physician and reviewed with the patient and/ or family, in the patient’s primary language, by the nurse ...6. Have patient or family member sign that they understand the instruction. Witness the signature and date ...8. The signed copy is included with the patient’s medical record.” A review of the medical record for patient #1 reveals that there is not a signed copy of the discharge instructions included in her medical record. A review of the discharge instructions provided to patient #1 reveal that there is no patient signature on the “Patient Signature Page”.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45521 Based on record review and interviews, the facility failed to comply with 42 CFR §489.24a, Special responsibilities of Medicare hospitals in emergency cases, by not providing a complete medical screening examination (MSE) for one of 20 sample records (Pt#1) reviewed. Facility A failed to obtain a chest X-ray and/or blood tests to determine if Patient #1 had an emergency medical condition related to respiratory illness. Patient #1 presented to Facility B after an unresolved complaint of a cough and fever where Facility B assessed Patient # 1 and completed a chest X-ray. Patient #1 was diagnosed with pneumonia and treated with antibiotics. Based on record review and interviews, the facility failed to comply with 42 CFR §489.24(e)(1)-(2) Special responsibilities of Medicare hospitals in emergency cases, in one of 20 sample records (Pt#1) reviewed. The hospital failed to ensure Patient #1 was appropriately transferred to Facility B when they failed to ensure Facility B had capacity to treat Patient #1, failed to secure an accepting physician and failed to ensure medical records were sent to Facility B. Refer to A2406 for additional information. Refer to A2409 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45521 Based on record review and interviews Facility A failed to obtain a chest X-ray and/or blood tests to determine if Patient #1 had an emergency medical condition related to treatment for a respiratory illness. Patient #1 presented to Facility B after an unresolved complaint of a cough and fever where Facility B assessed Patient # 1 and completed a chest X-ray. Patient #1 was diagnosed with pneumonia and treated with antibiotics. Facility A: A review of the document titled “Emergency Provider Report” by Staff #1A, MD, ED Physician on 06/27/2025 at 23:23 revealed the following: A 10-month-old male arrived with his mother to Facility A. Patient #1 was picked up from daycare with a temperature above 100°F. The mother also reported discharge from his eyes. The mother denied congestion, vomiting, or diarrhea. Patient # 1’s past medical history included a tube that is needed for feeding the patient thin liquids Vital signs revealed tachycardia with a heart rate of “160’s-170’s”, and oxygen saturation was 96% on room air. Patient # 1 temperature was not documented. Patient # 1 was noted as “well nourished,” and “his nasogastric tube was not in place. He had an increased respiration rate with an impaired ability to breathe, subcostal retractions, intermittent grunting, and intermittent wet cough. There were coarse lung sounds in the lower right base and occasional wheeze.” The abdomen was noted as soft. Facility B: A review of the documentation titled “Physician ED Documentation” page 32 by Staff # 1B, MD, Emergency Department, and Staff # 2B, MD, Emergency Department on 06/28/2025 at 02:42 revealed the following: The patient’s chief complaint was pulling out nasogastric tube on 6/27/2025 and had increased oral feeding fever, cough and left eye drainage. Tylenol, 140 mg, rectally was provided on 06/28/2025 at 00:18. Augmentin 384 mg oral. was provided by Staff # 3B, RN, Emergency Department at on 06/28/2025 at 03:26. Physical Exam: Vital signs during triage: Temperature: 39.2 °C (102.6F)-rectal, heart rate: 167 beats per minute, blood pressure: 96H/83, respirations: 60 breaths per minute, SpO2: 96%, and weight: 9.260kg. The patient was noted to be, “tachycardic (increased heart rate), with normal distal pulses and an increased respiratory rate. Abdominal breathing and crackles were present in both lungs. The crackles were greater in the right lung than in the left lung.” Patient #1 was suctioned, and a chest X-ray was completed. The chest X-ray revealed pneumonia in the right lobe, and Augmentin was provided. Difficulty breathing and fever improved during the Emergency Department stay. The nasogastric tube was replaced. Discharge instructions with a follow-up, instructions to return to the Emergency Department if needed, and a prescription for amoxicillin-clavulanate (Augmentin) 600 mg-42.9 mg/5 mL oral liquid, 3.4 mL, PO (oral), twice a day for 5 days, were provided to the mother of Patient #1. Vital signs during discharge on 06/28/2025 at 03:22 by Staff # 3B, RN, Emergency Department page 53: Temperature: 99.1F, heart rate: 125 beats per minute, blood pressure: 91/50, respirations: 40H breaths per minute, SpO2: 92% on room air, and weight: 9.260kg. Policy: A review of the Policy titled “EMTALA - Definitions and General Requirements. Last approved 07/2024, page 3 revealed the following: “A. General Requirements Any hospital with an emergency department will provide to any individual who “comes to the emergency department” an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual’s ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the hospital’s DED or elsewhere on the hospital’s campus. EMTALA requires the hospital to do the following: 1. Provide an appropriate MSE to the individual within the capability of the hospital’s emergency department to determine whether or not an EMC exists. 2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer. 3. Not delay examination and/or treatment in order to inquire about the individual’s insurance or payment status. 4. Accept appropriate transfers of individuals with EMCs if the hospital has the specialized capabilities not available at the transferring hospital and has the capacity to treat the individuals. 5. If a patient presents to the ED and decides to leave prior to triage, prior to examination or against medical advice (“AMA”) following the MSE, the hospital should obtain or attempt to obtain in writing a waiver of right to a medical examination, an informed refusal of examination, or leaving AMA. An appropriate transfer should be offered to a patient who refuses examination or treatment. The appropriate forms are located on HCA’s Intranet.” The facility failed to follow its own policy when an X-ray was not completed to determine treatment for Patient # 1’s respiratory illness. Interviews: 1. An interview with Staff 1A, MD, Emergency Department, on 08/20/2025 at approximately 2:02 PM revealed the following. The mother arrived with her child, complaining of a cough. She told me the baby has a NG (nasogastric) tube that he pulled out During the physical assessment, I told the mother I was concerned that the baby might have aspirated and would require pediatric inpatient care. I told her I would start the evaluation workup here and order a transfer. 2. An interview with Patient #1’s mother, on 8/25/2025 at approximately 3:56 PM, revealed the following: Staff #1, MD, Emergency Department told me that they don’t have anyone to do an X-ray for my son, and there were no pediatric staff at the hospital.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45521 Facility A: Based on record review and interviews, the facility did not appropriately transfer in one of 20 sample records (Pt#1) reviewed when they failed to ensure Facility B had the capacity to treat Patient #1, failed to secure an accepting physician, and failed to ensure medical records were sent to Facility B. Facility A Chart Review: On 06/27/2025 at 23:23, Patient # 1 had difficulty breathing, grunting, and a wet cough, which indicated respiratory distress. Staff #1A, the Emergency Department MD, noted that Patient #1 would require transfer and admission to a pediatric hospital. Patient #1 left Facility A with his mother and arrived at Facility B on 06/28/2025 at approximately 02:53. Transfer for Patient #1, would require Emergency Medical Services trained in basic life support to ensure medical management of his respiratory condition. Facility A failed to acquire acceptance from a physician at Facility B. Additionally, Facility A failed to send Patient # 1’s medical record to Facility B and to complete a Memorandum of Transfer. Facility A was aware that Patient #1 was being taken to Facility B and failed to ensure an appropriate transfer was completed. Facility B: Chart review: A review of Patient # 1’s chart revealed no communication from Facility A related to a transfer. Facility B did not receive a request for acceptance from Facility A for Patient # 1. Additionally, no medical record was received at Facility B for Patient # 1. Policies: A review of the Policy titled “EMTALA - Definitions and General Requirements,” Last approved on 07/2024, Section E. Transfer Obligations of Each Hospital, subsections 2-5: “2. A transfer to another medical facility will be appropriate in those cases in which the receiving hospital can provide medical treatment within its capacity that can minimize the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; and the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to provide such care. 3. The transferring hospital must send the medical records related to the EMC along with any history, preliminary diagnosis, results of diagnostic studies or telephone reports, and other medical records pertinent to the patient’s presenting EMC and the written informed consent or certification required for the transfer. Test results that become available after the individual is transferred should be telephoned to the receiving hospital, and then mailed or sent via electronic transmission consistent with HIPAA provisions on the transmission of electronic data 4. All transfers must be effected through qualified personnel and appropriate transportation equipment including the use of necessary and medically appropriate life support measures during the transfer. The ED physician has the responsibility for medical decision-making regarding appropriate mode of transportation, equipment needed and qualified personnel for the transport.” Facility A failed to follow its own policy. Facility A failed to communicate with Facility B to ensure there was space available for Patient # 1 at Facility B. Facility A failed to provide Patient # 1’s medical chart to Facility B. Facility A failed to document appropriate transportation for Patient # 1. Interviews: 1. An interview with Staff 1A, MD, Emergency Department, on 08/20/2025 at approximately 2:02 PM revealed the following. ...During the physical assessment, I told the mother I was concerned that the baby might have aspirated and would require pediatric inpatient care. I told her I would start the evaluation workup here and order a transfer. I understood the patient was seen at Facility B and offered to transfer the patient there. The mother said she was going to leave and try another hospital. At this point, the mother told me she lost her insurance and was afraid of the cost of going to Dell. I told her my primary concern was for the patient. The mother was annoyed with me and left before I reached my desk to call Dell. 2. An interview with Staff 2A, RN, Emergency Department on 08/19/2025 at approximately 2:27 PM: I was in the triage area with the mother, patient, and the physician. She asked why we could not take care of her child here, and it was explained that while we have a Labor and Delivery Department, we do not have a pediatric unit. She was advised to take the patient to the pediatric specialist. I heard the physician call ahead to Facility B. The mother took the patient and left AMA.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 30250 Based on a review of documents and interview, the facility failed ensure that nurses who provide services in the hospital must adhere to the policies and procedures of the hospital, as evidence by failing to consistently implement policies related to pressure injuries and wound documentation. Findings included: Facility Policy entitled “Pressure Injury Prevention” (Last Revised 3/5/2025) stated in part, “PURPOSE: Outline expectations for risk assessment, physical assessment, application of interventions, and documentation for the prevention of pressure injuries. TOOLS: Adult patients ? 18 years of age will be assessed using the Braden II scale o AT RISK = score ? 18 POLICY: SKIN RISK AND PHYSICAL SKIN ASSESSMENT: 1. All patients will be assessed for pressure injury risk level using a standardized, evidence based risk assessment tool. 2. A full physical skin assessment must be routinely performed on all patients. 3. Skin risk and physical assessment will occur at the following intervals: a. Upon admission; b. Once per shift ... PROCEDURE STATEMENTS: 1. Skin risk assessment will be documented ...for each patient. 2. Ongoing skin assessments will be as follows: a. For patients determined ...AT RISK (per risk scale), skin assessments are completed with daily, comprehensive patient assessments ... 3. Skin assessment changes and presence of any skin alterations or wounds will be documented in the EHR for all patients ...” Facility Policy entitled “NE1 Wound Assessment Tool” (Revised 10/5/2022) stated in part, “POLICY: DEFINITION: A standardized, evidence based skin and wound assessment tool used to assess patients who have been admitted with or develop skin injuries. This method and tool is primarily focused on pressure injury/ulcer) assessments and follow up through discharge .... PROCEDURE: A. All patients receive a head-to-toe skin inspection. The inspection is done on admission and at least once per shift. B. Patient’s nurse or wound care team member takes a digital image of skin injury that is caused by pressure on admission, occurrence, and at the discretion of the clinician, prior to discharge (beginning with stage 1 pressure injuries/ulcers) ... D. Pressure injuries/ulcers will be photographed using iMobile shared device, GE Media Manager Application, and the NE1 Tool ... 2. Peel off NE1 Wound Assessment Tool from the adhesive backing. 3. Frame the tool around the wound, placing it at the 12 o’clock position .... 5. Use guidelines on the tool to assist with wound evaluation. Always use professional judgement and consult appropriate medical professionals as needed ....” Review of documentation revealed the following: Review of the medical record for Patient #1 revealed the following: · For all Braden Skin Assessments performed from 07/24/25 through 08/18/25, the patient scored less than 18, which according to the Braden II scale places the patients at risk for pressure injuries (“Pressure Injury Prevention” policy). · Skin assessments from 07/20/25 to 07/23/25 include documentation regarding a surgical incision sites, and an abrasion to the right posterior foot. · Skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) included no documentation for any “skin alteration”. · The first skin assessment that references a pressure injury to the scrum occurs on 07/25/25 at 2130 which includes documentation of a wound care consult. Skin Assessments are adequately documented on 07/26/25, 08/5/25 at 08:15, 08/7/25 at 08:38, 08/8/25 to 08/13/25, 08/15/25 at 07:50, and 08/16/25 to 8/18/25. · 07/27/25 - 0700 No documentation of sacral wound. No PM Skin assessment. · 08/05/25 - 20:40 - “present, exists.” · 08/06 /25 - 19:30 - “present, exists”. · 08/07/25 - 20:00 - “present, exists”. · 08/14/25 - 08:00 - “present, exists” · 08/15/25 - 20:30 - “present, exists” Based on medical record review, Patient #1 did sustain a pressure injury while inpatient. Once identified a wound consult was place and this pressure injury was treated and addressed. However, it does appear the skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) included no documentation for any “skin alteration”, at this time Patient #1 had a sizable surgical incision on their back that was not assessed or documented. On at 07/25/25 at 2130, a sacral wound was noted on the skin assessment. It is unclear why for over 24 hours, the skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) indicated no skin alterations. It appears that skin assessments were not performed in a consistent manner due Patient #1’s surgical incision not being noted on the skin assessments completed on 07/24/25 (1420 and 2020) and 07/25/25 (0900). Also, after the sacral injury was noted on 07/25/25 at 2130 one shift skin assessments was missing (07/28/25 Evening shift) and several skin assessments only documented “present, exists” with no details of the skin issue indicated. Review of medical records for 9 current inpatients at the time of the survey revealed 4 patients were missing shift skin assessments and/or did not have details of the skin issue documented: · Patient #4 had a pressure injury to the sacrococcyx identified on 08/14/25. The shift skin assessment on 08/18/25 at 2200 only documented “present, exists” with no details of the skin issue indicated. · Patient #7 had an abdominal incision noted on 08/12/25. On 08/12/25 no day shift skin assessment was documented. The skin assessment on 08/15/25 at 1400 only documented “present, exists” with no details of the skin issue indicated. · Patient #8 had a pressure injury to the sacrococcyx identified on 08/18/25. The skin assessment on 08/17/25 at 2200 only documented “present, exists” with no details of the skin issue indicated. · Patient #9 had a sheering injury to the back noted on 08/15/25. The skin assessment on 08/18/25 at 2200 only documented “present, exists” with no details of the skin issue indicated. Review of Wound Photos for Patient #1 revealed the NE1 Wound Assessment Tool not used per policy for sacral wound photos taken by on 7/25/25, 7/28/25, 7/30/25, 8/7/25, 8/8/25, and 8/11/25. · 07/25/25 - 20:11-Photo of Coccyx Pressure Injury- NE1 Wound Assessment Tool not used · 07/28/25 - 10:11-Two Photos of Above Pressure Injury - NE1 Wound Assessment Tool not used · 07/30/25 - 9:22- Photo of Buttock/Coccyx Pressure Injury-NE1 Wound Assessment Tool not used · 08/07/25 - 15:05 - Photo of Buttock/Coccyx Pressure Injury-NE1 Wound Assessment Tool not used · 08/08/25 - 11:57-Photo of Buttock Pressure Injury- NE1 Wound Assessment Tool not used · 08/11/25 - 11:21-Photo of Sacral Pressure Injury- NE1 Wound Assessment Tool not used Review of medical records for 9 current inpatients at the time of the survey with pressure injuries revealed 4 patients had wound photos that did not use the NE1 Wound Assessment tool, per facility policy: · Patient # 3 had a pressure injury to the coccyx identified on 08/08/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool. · Patient # 4 had a pressure injury to the sacrococcyx identified on 08/14/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool. · Patient #6 had a pressure injury to the sacrum identified on 08/12/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool. · Patient #8 had a pressure injury to the sacrococcyx identified on 08/18/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool. Based on the above findings, the facility nursing staff was not documenting pressure injuries and wounds in a manner consitent with their policies, “Pressure Injury Prevention” and “NE1 Wound Assessment Tool” (Revised 10/5/2022). The above findings were verified on 08/19/25 with staff member #4.”