Wilson N Jones Regional Medical Center

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 33589 BASED ON record review and interview, the facility failed to ensure drugs are administered according to hospital policy when 2 of 20 patient records (Patient #1, and 19) who’s pain medication intervention was not effective in relieving the patient’s pain, did not document provider notification for adjustment considerations. FINDINGS The facility’s December 2023, last effective date “Medical Staff Rules and Regulations” required, “In general the medical record shall include the following: The patient’s response to care, treatment, ad services...” The facility’s June 2026, last revised date “Pain Management” Policy required, “PURPOSE To provide guidelines for the assessment, reassessment, and management of patients who are experiencing pain...To provide guidelines for aggressive and effective pain management at a level acceptable to the patient. To provide a mechanism for consistent documentation. POLICY Pain will be managed at the level reported by the patient without interpretation by the health-care provider. Pain will be defined as whatever the experiencing person says it is and whenever it occurs... Principle: At Sherman Medical Center, we believe no patient should suffer needlessly in pain. All patients have a right to pain relief... REASSESSMENT 1. Pain rating will be obtained at a minimum of once per shift or according to unit standards and / or more often as patient condition warrants. 2. Patients shall be reassessed within a reasonable amount of time depending on the route of pain relief interventions. 3. Documentation of reassessment will be made on the Daily Assessment... INTERVENTIONS 1. Collaborate with patient, significant other(s), and other disciplines to establish a goal for pain relief, and implement a plan to achieve that goal. Update plan of care as condition warrants. 2. Document all interventions and effectiveness of interventions in Daily Assessment pain tab 3. Educate patient and significant others when appropriate, regarding their roles in managing pain as well as the potential limitations and side effects of pain treatments. 4. Implement and instruct patient and significant other(s) on non-invasive methods of pain relief, encouraging patient control. o Distraction o Relaxing o Imagery o Laughter o Proper positioning and correct body alignment o Dimming lights and limiting noise o Physical comforts such as warm socks 5. Instruct patient to communicate his/her pain experience using the pain scale (0 = no pain - 10 = worse pain or facial/analog scale if possible) in order to correctly assess the effectiveness of therapeutic interventions employed to manage their pain. 6. Communicate to patients and significant others that pain management is an important part of care (consider personal, cultural, spiritual, and ethnic beliefs). 7. Administer analgesics in accordance with physician’s orders and document on MAR. 8. Notify physician of interventions that are not effective in relieving the patient’s pain...” Patient #1 was a 31-year-old female admitted on 5/24/2026 with a history of sickle cell pain crisis, Acute Vaso-occlusive episode, Leukocytosis, Reticulocytosis, and dehydration. She stated she had a Morphine allergy. She was admitted to medical surgical unit and medical management included rehydration with intravenous fluids, and multimodal pain management options as needed including Norco, and Dilaudid. During record review on 6/02/2026 of Patient #1’s pain assessment and interventions: 5/24/2026 15:30 PM Pain assessment: 10/10 Location: entire body Intervention: Norco 10/325 milligrams by mouth. 16:30 PM Reassessment response: no change. There was no documented provider notification that the pain medication was not effective in relieving the patient’s pain. 18:00 PM Pain assessment: 10/10 Location: entire body Intervention: Dilaudid 1 milligrams intravenously. 18:30 PM Reassessment response: no change. There was no documented provider notification that the pain medication was not effective in relieving the patient’s pain. 5/25/2026 00:30 AM Pain assessment: 10/10 Location: entire body Intervention: Dilaudid 1 milligram intravenously. 01:30 AM Reassessment response: No change. There was no documented provider notification that the pain medication was not effective in relieving the patient’s pain. During an interview on 6/02/2026 at 1:15 PM, Personnel #3 asked if they identified PRN pain medication follow up as an issue during the investigation. Personnel #3 stated it had been identified after I came. It is a new PI (Performance Improvement) project for us. During an interview on 6/03/2026 at 9:00 AM, Personnel #3 provided a timeline review. Personnel #3 stated providers were notified most of the time. The staff were providing her with other pain relief comfort measures. There were a few times the provider was not notified when the patient’s pain was not relieved. During record review of current patient paper records on 6/03/2026 ending at 13:02 PM, an interview was conducted with the navigator Personnel #1. Personnel #1 confirmed there was no provider notice documented for Patient #19 after the 14:00 PM reassessment with no change. Patient #19 was a 68-year-old female admitted on 5/29/2026 with hepatic encephalopathy, suspected sepsis with new onset of abdominal pain, fever, and declining mental status. Medical management included replete potassium, telemetry, Lactulose, Rocephin, Metronidazole, blood and urine cultures. Patient #19’s pain assessment and interventions: 5/30/2026 13:15 PM Pain assessment: 5/10 Location: abdomen Intervention: Tylenol 650 milligrams by mouth. 14:00 PM Reassessment response: No change. There was no documented provider notification that the pain medication was not effective in relieving the patient’s pain.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 33589 BASED ON record review and interview, the facility failed to ensure that all orders including telephone orders are authenticated promptly/timely by the ordering practitioner in accordance with the hospital policy when 3 of 20 patients records (Patient #1, 11, and 17) were found to have unauthenticated telephone orders that were not signed by the provider within the policy required timeframe of 48 hours. FINDINGS The facility’s December 2023, last effective date “Medical Staff Rules and Regulations” required, “All verbal and telephone orders shall be authenticated within forty-eight [48] hours by the prescriber or another practitioner that is responsible for the care of the patient and has privileges consistent with the orders written.” Patient #1 was a 31-year-old female admitted 5/24/2026 with a history of sickle cell pain crisis, Acute Vaso-occlusive episode, Leukocytosis, Reticulocytosis, and dehydration. She stated she had a Morphine allergy. She was admitted to medical surgical unit and medical management included rehydration with intravenous fluids, and multimodal pain management options including Norco, and Dilaudid as needed. During the record review on 6/02/2026 at 10:20 AM, Patient #1 had the following unsigned telephone orders: (1) 5/24/2026 21:30 PM Change Dilaudid dose to 1 milligram IVP (Intravenous) every 3 hours PRN (as needed). (3) 5/25/2026 13:30 PM Make Dilaudid PRN; 14:10 PM Change Dilaudid to 1 milligram IV every 2 hours as needed; AND 18:52 PM Change Dilaudid to 2 milligrams IV every 3 hours PRN. (4) 5/26/2026 05:07 AM Miralax 17 grams daily. 12:41 PM Narcan 0.4 milligrams IV x 1 as needed. 14:17 PM May apply compression stockings to arms and legs. 15:13 PM Apply moist heat packs to affected areas for 15 minutes, 3 times a day PRN. (1) 5/30/2026 07:56 AM Renew Dilaudid 2 milligram every 2 hours as needed. (1) 6/01/2026 01:00 AM May give Dilaudid IV or IM (intramuscular) 2 milligrams IV or IM every 2 hours PRN. During an interview on 6/03/2026 at 9:00 AM, Personnel #3 was asked at what point the providers have to sign telephone orders. Personnel #3 stated 48 hours. Personnel #3 was asked to verify Patient #1’s orders were not signed timely. Personnel #3 stated they were not. During record review of current patient paper records on 6/03/2026 ending at 13:02 PM, an interview was conducted with the navigator Personnel #3. Unsigned/unauthenticated telephone orders were found on multiple patient records (Patient #11, and 17). Personnel #3 confirmed the orders were not signed timely. Personnel #3 stated the providers are on for 7 days and then are off. Personnel #3 was asked what happens when a provider has a telephone order but is not on/scheduled for the next 7 days. Personnel #3 stated another provider can sign the order. Patient #11 was a 57-year-old male admitted on 5/29/2026 with hepatic cirrhosis with sever portal hypertension, splenomegaly, and ascites. Medical Management included paracentesis, cultures, and intravenous Albumin. Patient #11 had the following unsigned telephone orders: (1) 5/29/2026 21:30 PM May reinforce/change dressing to Abdomen, paracentesis site, cleanse with normal saline, pat dry, apply 4x4’s covered with abdomen pad. Change dressing as needed for drainage. (2) 5/30/2026 18:37 PM Tramadol 25 milligrams by mouth every 8 hours as needed. 21:00 PM Add Magnesium to AM (morning) Labs on 5/31/2026. Patient #17 was a 66-year-old male admitted on 5/22/2026 after a fall at home with reported back pain. He has significant medical history and medical management. Patient #17 had the following unsigned telephone orders: (3) 5/29/2026 12:00 PM Glucerna 2 x / day with meals. Untimed Transfer to ICU (intensive Care Unit) due to A-Fib RVR (Atrial Fibrillation with rapid ventricular response); Amiodarone gtt (drip) no bolus; and 1 Liter Fluid Normal Saline Bolus. 22:40 PM Give 40 milligrams intravenous Lasix x 1 dose. (2) 5/30/2026 5:20 AM (Laboratory orders) BNP, CBC, BMP and Mag at 06:00. 8:00 AM Protonix 40 milligrams by mouth daily. Hold Zanax, Robaxin. (3) 5/31/2026 19:25 PM BMP Stat (laboratory). 03:30 AM Turn Amiodarone gtt (drip) off due to Sinus Bradycardia. 06:10 AM Stat Normal Saline 125 milliliters per hour; Daily CK levels (laboratory).”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 10135 Based on observation and interview, the facility failed to ensure proper air temperature controls in patient care areas were maintained and monitored in 2 of 3 units checked (Emergency department Medical Surgical unit). This deficient practice had the likelihood of affecting all patients on these units. Findings include: During observations on 11/12/2025 after 11:23 a.m. the following was found: Emergency department (ED) Trauma room #2 Thermostat setting was between 80-85 degrees Fahrenheit. The temperature taken at the thermostat was 65.1 degrees Fahrenheit. Bed level temperature was 67.2 degrees Fahrenheit. Eye level temperature was 66.3 degrees Fahrenheit. Exam room #1 Thermostat - no thermostat was in the room. Bed level temperature was 59.0 degrees Fahrenheit. Eye level temperature was 59.1 degrees Fahrenheit. Medication room Thermostat set at 70.0 degrees Fahrenheit. Temperature at the thermostat area was 59.1 degrees Fahrenheit. Eye level temperature was 59.1 degrees Fahrenheit. Staff #4 said the thermostat in the medication room also controlled the temperature in Room #1. Staff #’s 3 and 4 confirmed the temperatures. Interview with ED staff on 11/12/2025 after 11:23 a.m. revealed the following: “Sometimes the air temperature gets cool or too warm. When it gets that way they call plants operations. The HVAC system work correctly most of the time and there have been no recent problems or complaints from families. The exam room #1 near the ambulance doors gets cold and people complain if they are in that room. Hard to regulate the temperature in that room because the doors are constantly opening.” They “try not to place patients in that room.” “It’s cooler on the south end of the hall and warmer on the north end of the hall.” If they “place patients in Room #1, they complain about it being too cold and we have to give them a warm blanket.” “It gets very cold at the south end of the hall “and when they “put people in Room #1, they complain, and they have to give them a warm blanket.” Interview with Staff #4 on 11/12/2025 at 11:42 a.m., revealed that the south end of the ED was built in 1995 and was on a different air condition unit than the north side. Staff # 4 stated they don’t check room temperatures unless there is a complaint. There were problems regulating the temperature when changing to the winter settings. During the summer the chiller water temperature is set at 44 degrees Fahrenheit and the winter at 48.6 degrees Fahrenheit. The heating water temperature for the summer is at 120 degrees Fahrenheit and in the winter, it is set between 140-150 degrees Fahrenheit. Staff # 4 stated that the room temperatures were supposed to be set between 68 -72 degrees Fahrenheit. On 11/12/2025 after 11:45 a.m., the following was found: Medical Surgical unit Confidential interview with a staff member revealed that it was cold on the unit and that they couldn’t adjust the thermostats. The staff member stated the units were not blowing and they had received complaints from patients. The staff member stated they had turned in a work order last week. Room 276 Thermostat setting was at 73.3 degrees Fahrenheit. Temperature reading at the thermostat area was 60.4 degrees Fahrenheit. Bed level temperature was 59.7 degrees Fahrenheit. Eye level temperature was 60.8 degrees Fahrenheit. Staff #4 checked the fan blower, and it was off. When it was adjusted the unit started blowing heat. Room 269 Thermostat was set at 58.0 degrees Fahrenheit. Temperature reading at the thermostat 73.9 degrees Fahrenheit. Bed level temperature was 74.4 degrees Fahrenheit. Eye level temperature was 74.1 degrees Fahrenheit. Air was barely blowing out the vent in the room. The blower was adjusted, but it was still not blowing. Room 270 Thermostat setting was over 85.0 degrees Fahrenheit. Temperature reading at the thermostat was 67.4 degrees Fahrenheit. Bed level temperature was 67.1 degrees Fahrenheit. Eye level temperature was 67.4 degrees Fahrenheit. The air blowing out of the vent in the room was 57.3 degrees Fahrenheit. The thermostat was calibrated. and the unit started blowing warm air. Room 271 Thermostat setting was over 80 degrees Fahrenheit. Temperature reading at Thermostat was 73.2 degrees Fahrenheit. Bed level temperature was 76.6 degrees Fahrenheit. Eye level temperature was 75.9 degrees Fahrenheit. The air blowing out of the vent in the room was 62.6 degrees Fahrenheit. The valves were adjusted, but cool air was still blowing from the unit. Room 272 Thermostat setting was over 84.0 degrees Fahrenheit. Temperature reading at thermostat area was 65.1degrees Fahrenheit. Bed level temperature was 66.2 degrees Fahrenheit. Eye level temperature was 66.0 degrees Fahrenheit. The air was barely blowing out of the vent in the room and when the temperature was taken it registered at 54.5 degrees Fahrenheit. When the blower valves were adjusted to an on position the unit immediately started blowing heat. Room 266 Thermostat setting was over 80.0 degrees Fahrenheit. Temperature reading at the thermostat was 68.0 degrees Fahrenheit. Bed level temperature was 66.7 degrees Fahrenheit. Eye level temperature was 67.8-68.0 degrees Fahrenheit. The air at the vent was taken as being 81.1 degrees Fahrenheit, but air was barely blowing out of the vent. The blower valve had to be adjusted by plant operations to get the unit to function. Staff #’s 3 and 4 confirmed the temperatures. Interview with Staff # 4 revealed that 2 weeks ago the motor to the pump which heat water to serve 2 Central North side went out and had to be repaired. The director stated that Room # ‘s 269 and 271 were going to be taken out of service because they needed HVAC actuators (controls airflow and temperature). Review of a facility’s policy revised 08/2025 and named “Maintaining a Safe, Functional Environment” revealed the following: “.1. Wilson N. Jones Regional Medical Center maintains ventilation temperature, and humidity levels for the care, treatment and services provided. All buildings and spaces within the hospital shall be constructed, maintained and monitored in accordance with AIA Guidelines for the Design and Construction of Health Care Plant Operations..” According to the American Institute of Architects (AIA) and associated standards adopted with ANSI/ASHRAE/ASHE Standard 170 gives the following on air temperatures: For patient rooms/general inpatient rooms: 70-75 degrees Fahrenheit and pharmacy 68-75 degrees Fahrenheit. The HVAC systems must be capable of maintaining any temperature set point within the specified range (and maintain it within a tolerance, often plus or minus 2 degrees Fahrenheit.”

“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 observation, record review, and staff interviews, Facility A failed to maintain a complete on-call list of available physicians to provide treatment necessary to stabilize one of 20 patients (Patient #3) with emergency medical conditions. The facility failed to provide an on-call cardiologist in a timely manner necessary to stabilize Patient #3’s emergency medical condition, which resulted in the patient’s decompensation. Refer to A2404 for additional information.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45521 Based on observation, record review, and staff interviews, Facility A failed to maintain a complete on-call list of available physicians to provide treatment necessary to stabilize individuals with emergency medical conditions for 1 of 20 patients (Patient #3). The facility failed to provide an on-call cath lab cardiologist in a timely manner necessary to stabilize Patient #3’s emergency medical condition, which resulted in the patient’s decompensation. Findings: A. Review of Patient #3’s Medical Record: A review of the document titled “Emergency Department Triage” on 01/04/2025 at 7:59 AM revealed the following: Patient #3 was transferred from Facility B via ambulance. Medication provided was Heprin 1000 units per hour. Memorandum of Transfer from Facility B noted “ST-Segment Elevation Myocardial Infarction” (STEMI) as the patient’s problem, the patient needs a specialized Cardiologist. A medical screening examination was completed by Staff #1 at 8:11 AM and it was determined Patient #3 had an emergent medical condition. Patient #3 received multiple echocardiograms, labs were drawn, oxygen, morphine, and zofran were administered, a heparin and nitroglycerin drip were administered, vital signs were routinely cycled, and continuous telemetry monitoring was in place. A review of the document titled “Physicians Notes” by Staff # 1, MD, Emergency Medicine on 01/04/2025 at 8:19 AM revealed the following: “HPI[History of Present Illness]: Patient c/o mid-sternal chest pain developing with sharp constant that is radiating to middle back onset began 3hrs ago. Patient went to a stand-alone ED was seen by NP this morning and had an ECG that showed ST elevations on V2 andV3 leads with inferior ST depressions. I accepted patient for transport to this facility. Nurse reports that me that he took sildenafil this morning and that’s when he started having chest pain. Denies history of CAD. Patient reports pain is 5/10 and still having nausea. Pain now 5 /10. Pain was 8 /10.” ... A review of the document titled “Provider Note” by Staff # 1, MD, Emergency Medicine on 01/04/2025 at 8:35 AM revealed the following: “ECG [echocardiogram]performed here at 8:04 AM shows as elevations at V2 V3 mildly at V4 with slight ST depressions. At leads II and AVF. There is also ST elevations at I and mildly @ AVL. EKG shows sinus bradycardia. With heart rate of 57 bpm. Interventions at the other facility were started include heparin drip given two doses of nitroglycerin .4 sublingually. Aspirin patient has taken this morning is 324 mg PO[oral]. Patient also given 5mg of IV metoprolol. CBC, CMP, Trop, BNP[Labs], CXR[chest x-ray]ordered for the patient. I spoke to Staff # 2, who is the cardiologist on call for the cath lab and he stated to keep patient NPO[nothing by mouth], treat as NSTEMI (non-emergent) and he would take to cath lab at approx. 10am-11am. He advised me to keep on heparin drip. I ordered morphine 4mg IVP as well as zofran 4mg IVP. CMP remarkable for K 3.0. CBC unremarkable.” A review of the document titled “Physicians Notes” by Staff # 1, MD, Emergency Medicine on 01/04/2025 at 9:15 AM revealed the following: “Patient started on NTG[nitroglycerin] drip however stopped within 1 min of starting infusion as patient brady down to 28 beats pre minute. Patient immediately recovered heart rate to 57-60. B-type natriuretic peptide (BNP) 65.I called Staff # 2, MD-On-Call Cardiologist, and let him know about the situation.” ... A review of the document titled “Physicians Notes” by Staff # 1, MD, Emergency Medicine on 01/04/2025 at 9:56 AM revealed the following: “I texted Staff # 2 about patient’s brady down again to 28 shortly then coming back up. He advised dopamine however will hold off on the dopamine. Patient’s vitals are normal. He described feeling hot and is sweating. The house supervisor a RN called Staff# 2 and advised him about patient’s condition. Patient #3 was transferred from the emergency department to the catheterization lab at 10:08 AM to receive intervention. Patient # 3 waited from 7:59 AM to 10:08 AM to receive the cardiac intervention he required ( 2 hours 7 minutes). Patient #3 was diagnosed with a STEMI and admitted to the intensive care unit.” Summary: Patient # 3 was transferred from Facility B via ambulance for a “ST-Segment Elevation Myocardial Infarction” (STEMI) as the patient’s problem, the patient needed a specialized Cardiologist. Patient # 3 was accepted by Facility A. Staff # 1, ED Physician, spoke to Staff # 2, cardiologist on call for the cath lab, at approximately 8:35 AM. Staff # 2 said not to call a “STEMI code”, to treat the patient as a non-emergent STEMI. Nothing by mouth and continue the heparin drip. Staff # 2 said he would arrive between 10:00 and 11:00 AM. Staff # 1 communicated to Staff # 2, via voice call at 9:15 AM and via text at 9:56 AM, that the patient’s vital signs were deteriorating. Staff # 2, continued to give orders and say he’d be there at 10:00 AM. Despite Staff # 1, Staff # 8, and the Charge Nurse communicating to Staff # 2 about Patient #3’s deteriorating condition, Staff # 2 refused to acknowledge the patient’s deteriorating condition and postponed his arrival. Patient # 3 had waited two hours and seven minutes for the on-call doctor, Staff # 2, to arrive and provide stabilizing treatment. Staff # 2 failed to follow the facility’s “Rules and Regulations” page 10 subsection b stating “An on-call physician must respond when there is a request to help determine if an emergency medical condition exists or to help stabilize a patient.” B. A review of the documents for Facility A titled “On-Call Physician schedule for the ED” for the last six months revealed the following: 1. October 2024 - 6 of 31 days did not have a Gastroenterologist available on-call. 2. November 2024 - 11 of 30 days did not have a Gastroenterologist available on-call. 3. December 2024 - 4 of 31 days did not have a Gastroenterologist available on-call. 4 of 31 days did not have a Surgeon on-call. 4. January 2025 - 21 of 31 days did not have a Colorectal provider available on-call. 5. February 2025 - 2 of 28 days did not have a Gastroenterologist available on-call. 23 of 28 days did not have a Colorectal provider available on-call. C. Review of Facility A’s Rules and Regulations Policy: February 2019. Approved revision September 2022, page 9 and 10, Section 1, subsections b, e and f: F. On Call Roster and Coverage 1. Call Coverage Requirements b. An on-call physician must respond when there is a request to help determine if an emergency medical condition exists or to help stabilize a patient. The request may come from anyone designated by WNJ as qualified to perform a medical screening exam either in the ED or Labor and Delivery (“L&D”). WNJ has designated the following practitioners as qualified to perform a medical screening exam: Physicians, Nurse Practitioners, Certified Nurse Midwifes, Physician’s Assistants and ED and L&D Registered Nurses (“attending clinician”). The attending clinician has the final decision-making authority if the on-call physician and attending clinician disagree about the on-call physician’s need to respond. e. Except for cardiologists as provided in Article II. F. 1. f., below, the on call physician will respond by phone within twenty (20) minute of being contacted by the ED and, when requested, must be physically available to see an ED patient within thirty (30) minute of the initial contact by the ED. f. Cardiologists must return pages and phone calls from the ED within ten (10) minutes and, when requested by the ED, cardiologists must be physically available to see an ED patient within thirty (30) minutes of the initial contact by the ED. D. Staff Interviews: An interview with the ED Physician, Staff #1, MD, Emergency Medicine on 03/19/2025 at 11:30 AM revealed the following: The patient appeared to me to be having a STEMI; you’re a nurse, so if I tell you that this patient is in dire need of medical attention, this would be that patient. “I felt that he was having some emergent medical disease; something was happening to him, whether it was a STEMI or not. When I reviewed the EKG, it appeared to be a STEMI to me. I labelled it as STEMI. And just for further clarification on your part, when I did call, the interventional cardiologist on-call, he felt that it was not. The cardiologist said to treat the patient as an NSTEMI and not activate the code STEMI.” The troponin level was 109 which is considered critical. A troponin level indicates that the cardiac muscle is suffering from ischemia, and the troponin, which are proteins in the cardiac muscle, are being leaked into the bloodstream. So the higher they are, the more destruction there has been of the muscle. Staff # 2 was notified by Staff # 1: twice by voice call, and once by text that the patient’s vital signs were deteriorating. Stagg # 2 gave orders and said he’d be there at 10:00 AM. As per Staff # 1: “A cardiologist, when requested to come to the facility, should be at the bedside in 30 minutes. Also, the patient should be in the cath lab within an hour. That’s the standard of care”. An interview with Staff # 8, Emergency Department RN, on 03/20/2025 at approximately 9:08 AM revealed the following: “I remember the patient arrived from Facility B with a heparin drip. We obtained an EKG, contacted Staff #2, the MD on call for the Cath Lab, and sent the results. The Emergency room doctor believed it was a STEMI. Staff # 2 said it was not a STEMI and that it should not be called to the Cath Lab. Staff # 2 was called a couple of times with updates. The patient was in the ER for about 2-2.5 hours before the Cath Team took him. I never saw Staff # 2 in the ER. This is my understanding of what happened.””