Woodland Heights Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48653 Based on record review and staff interview, the hospital staff failed to ensure that : A. Two (Patient # 1 and # 2) of 2 patients and/or their appointed representative were informed of the patient’s rights prior to furnishing care and treatment. The hospital staff failed to follow the “Patient Rights and Responsibilities” policy. (Cross Refer to Tag A0117) B. A properly executed informed consent was completed in 2 (# 2 and # 3) of 3 patient medical records reviewed. Also, the hospital failed to follow the “Informed Consent” policy. (Cross Refer to Tag A0131)”

“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: 48653 Based on record review and staff interview, the hospital’s nursing staff failed to: A. Develop, implement, and keep current, a nursing care plan for 1 (Patient # 2) of 1 patients that included documentation of the patient’s vital signs when the patient had a change in status and required a higher level of care. The nursing staff failed to follow the “Assessment of Patients” policy. (Cross Refer to Tag A0396) B. Administer a vasoactive medication per the physician’s order for 1 (Patient # 2) of 1 patient’s medical records reviewed. (Cross Refer to Tag A0405)”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s infection control program failed to: 1. Maintain a clean and sanitary environment to avoid sources and transmission of infection in 2 (Intensive Care Unit and Step-Down Unit) of 2 units of the hospital. (Cross Refer to Tag A0750) 2. Ensure adherence to infection prevention and control policies and procedures by hospital personnel when: 2a. Staff # 13 (Housekeeping) was unable to verbalize the hospital’s procedure for the cleaning and disinfection of a patient room which had been isolated for Clostridium Difficile (C-Diff) infection. 2b. Two (Patient # 1 and # 2) of 2 high-risk patients admitted from long-term care facilities were not placed in contact isolation after a known history of MRSA (Methicillin-Resistant Staphylococcus Aureus) infection. 2c. The hospital staff failed to follow “Contact Precautions” and “Management of Multi-Drug-Resistant Organisms (MRSA) Active Surveillance” policies. (Cross Refer to Tag A0776)”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital staff failed to ensure that 2 (Patient # 1 and # 2) of 2 patients and/or their appointed representative were informed of the patient’s rights prior to furnishing care and treatment. The hospital staff failed to follow the “Patient Rights and Responsibilities” policy. Findings include: A review of patient medical records was conducted with Staff # 5 and # 8 on 07/15/2025 at 9:00 AM. Patient # 1 Patient # 1 was admitted to the hospital on 05/07/2025 with a urinary tract infection and hypothermia. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. According to medical records, the patient had been declared mentally disabled by a court on 04/01/1968. The patient did not have a legal representative; however, the patient did have a next of kin. A review of the “Acknowledgement of Required Disclosures Form” revealed the following, “I acknowledge that I have received the following information prior to my procedure: -Patient Rights and Responsibilities in writing -Complaint/Grievance Process and Contact Information -CMS rights were verbally reviewed -The Center’s policy on Advance Directives -Advance Directive Forms, if requested -Disclosure of Physician Ownership and a list of physicians who have a financial interest or ownership in the center, if applicable. -Notice of Privacy Practices Form ....” A review of the patient’s “Acknowledgement of Required Disclosures Form” revealed Staff # 32 (Registration Clerk) documented the following on 05/07/2025 at 2:00 PM: “Pt unable to sign, no family” A review of the patient’s “Notice of Patients Rights and Responsibilities” Form revealed Staff # 32 (Registration Clerk) signed the form and documented the following on 05/07/2025 at 2:00 PM: “Pt unable to sign, no family”. The patient’s next of kin was not contacted, and there was no documentation to support that an attempt to contact the patient’s next of kin was made. There was no witness signature on the form. Patient # 2 Patient # 2 was admitted to the hospital on 04/24/2025 with lethargy, tachypnea (fast breathing), and fever. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. According to medical records, the patient had been declared mentally disabled by a court on 03/22/1979. The patient did have a Designated Legal Guardian. A review of “Acknowledgement of Required Disclosures Form” revealed the following, “I acknowledge that I have received the following information prior to my procedure: -Patient Rights and Responsibilities in writing -Complaint/Grievance Process and Contact Information -CMS rights were verbally reviewed -The Center’s policy on Advance Directives -Advance Directive Forms, if requested -Disclosure of Physician Ownership and a list of physicians who have a financial interest or ownership in the center, if applicable. -Notice of Privacy Practices Form ....” A review of the patient’s “Acknowledgement of Required Disclosures Form revealed Staff # 31 (Registration Clerk) documented the following on 04/24/2025 at 2:00 AM: “Pt unable to sign” A review of the patient’s “Notice of Patients Rights and Responsibilities” Form revealed Staff # 31 (Registration Clerk) signed the form and documented the following on 04/24/2025 at 12:00 AM: “Pt unable to sign”. The patient’s Designated Legal Guardian was not contacted, and there was no documentation to support that an attempt to contact the patient’s Designated Legal Guardian was made. There was no witness signature on the form. A review of the “Patient Rights and Responsibilities” policy with a date of 08/2023 revealed, “References and Citations: ...Woodland Heights Medical Center will make every endeavor to assure that the basic rights of all patients, regardless of age, sex, race, creed, national origin, or sources of payment, are preserved and protected. Respectfully, in providing care, the hospital and its staff have the right to expect behavior on the part of patients and their relatives and friends, which, considering the nature of their illness, is reasonable and responsible. PATIENT RIGHTS: Access to Care: Individuals regardless of age, race, creed, sex, national origin, or sources of payment for care, shall be accorded impartial to treatment or accommodations that are available or medically indicated. Respect and Dignity: The patient regardless of age, has the right to considerate, respectful care at all times and under all circumstances, with recognition of his personal dignity. Privacy and Confidentiality: The patient regardless of age, has the right, within the law, to personal and informational privacy, as manifested by the following rights .... Personal Safety: The patient regardless of age, has the right to expect safety insofar as the hospital practices and environment are concerned. The hospital supports the patient’s right to access protective services. Identity: The patient, regardless of age, has the right to know the identity and professional status of individuals providing service to him/her and to know which physician or other practitioner is primarily responsible for his/her care ...Communication: The patient, regardless of age, has the right of access to people outside the hospital by means of visitors and by verbal and written communication. When the patient does not speak or understand English, he/she will have access to an interpreter whenever possible. This is particularly true where language barriers are a continuing problem. Consent: The patient, regardless of age, has the right to reasonable informed participation in decisions involving his/her healthcare. To the degree possible, this should be based on a clear, concise explanation of his/her condition and of all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to recuperation, and the probability of success. The patient will not be subjected to any procedure without his/her voluntary, competent, and understanding consent or the consent of his/her legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed ....Refusal of Treatment: The patient may refuse treatment to the extent permitted by the law ....” An interview was conducted with Staff # 3 and # 5 on 07/15/2025 at 9:30 AM, and confirmed that the hospital staff were not contacting the legal representative or next of kin when providing and obtaining Patient’s Rights and Responsibilities and other required disclosures forms for patients with significant cognitive impairment.”

“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 completed in 2 (# 2 and # 3) of 3 patient medical records. Also, the hospital failed to follow the “Informed Consent” policy. A review of medical records was conducted with Staff # 5 and # 8 on 07/15/2025 at 1:30 PM. Findings include: Patient # 2 Patient # 2 was admitted to the hospital on 04/24/2025 with lethargy, tachypnea (fast breathing) and a fever. The patient arrived via ambulance from a state-funded living facility (Lufkin State School) where the patient resided. The patient had a history of severe cognitive impairment. According to medical records, the patient had been declared mentally disabled by a court on 03/22/1979. The patient did have a designated Legal Guardian. A review of Physician Progress Notes for patient # 2 revealed that Physician # 19 (hospitalist) documented the following. “Called by bedside nursing in light of tonic-clonic movements observed. Patient given multiple doses of Ativan with persistent tonic-clonic movements. Patient observed in respiratory distress with depressed mentation. Keppra increased with persistent tonic-colonic movements. Patient transferred to ICU. Arterial blood gas taken revealed hypoxia requiring 3L. Observed bedside using accessory muscles to breathe. Glasgow coma scale 3 with persistent seizures. Patient is endotracheal intubated. Propofol and Versed sedation administered. Low blood pressure observed. Right subclavian triple lumen catheter placed, right radial arterial line placed. Levophed ordered. Fosphenytoin IV bolus after IV fluid bolus given. Pulmonary critical care consultation in A.M. Neurology consultation in A/M ...” Physician # 19 placed an arterial line (an invasive catheter placed into an artery to continuously monitor blood pressures) and an endotracheal tube (a tube inserted into the trachea to assist with breathing) on 04/27/2025 at 4:04 AM. Physician # 19 placed an ultrasound-guided central venous catheter (a thin, flexible catheter inserted into a patient’s vein that extends into the large vein located directly above the heart) on 04/27/2025 at 4:05 AM. There was no informed consent signed for the procedures. There was no documentation that the patient’s legal guardian was contacted. There was no documentation detailing that an emergency existed in which informed consent could not be obtained prior to providing care/treatment to the patient. Physician # 19 failed to follow the hospital’s “Informed Consent” policy. Patient # 3 Patient # 3 was admitted to the hospital on 05/29/2025 with an acute kidney injury (AKI). The patient required hemodialysis treatment until kidney function could return to normal. A review of the “Disclosure and Consent-Cardiovascular System” form revealed that Physician # 33 placed a tunneled dialysis catheter for use in hemodialysis. The patient’s representative signed the consent and did not date or time the signature. Staff # 34 (Registered Nurse) witnessed the consent on 06/01/2025 at 11:15 PM. Physician # 33 did not sign the consent until the next day, 06/02/2025 at 12:49 PM. Physician # 33 did not document risks and benefits of the procedure in the progress or procedural note. A review of the hospital’s “Informed Consent” policy with a date of 12/2024 revealed, “POLICY: It is the policy of this facility that the patient, patient’s representative or surrogate must be given the opportunity to give an ‘informed consent’ prior to the administration of anesthesia by an anesthesiologist and prior to the performance of operative and/or invasive procedures, diagnostic or therapeutic procedures, or situations when it is deemed advisable to have a formal documentation of the patient’s consent for treatment. Written verification of the informed consent must be on the patient’s chart prior to the initiation of anesthesia or any of the above-stated procedures. 1.All patients admitted to our hospital must have an authorized for treatment sheet on their cart signed by the proper person, dated, and witnessed prior to a designated procedure. 2. Informed written consent for all procedures must be obtained prior to any invasive procedure. The informed consent process includes a discussion about potential benefits, risks, and side effects of the patient’s proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation. The physician will document the discussion of the aforementioned items by completing one or more of the following: A. Signing the informed consent B. Documenting the discussion in the History and Physical; C. Documenting the discussion in a progress note prior to the procedure. The purpose of a written consent form is to provide proof that there was a valid consent. The consent itself is not a substitute for the role of the physician in the informed consent process. A signed entry in the physician’s progress notes should be made documenting that informed consent was obtained and that the patient was made aware of and understands the risks and possible complications and agrees to the planned procedure, if the informed consent is not signed by the physician ....6. The following rules will apply with having an informed consent signed. A. the patient if an adult ...must sign the consent permit. B. There are possible exceptions: i. when there is an actual emergency and the patient cannot sign (critically ill or injuries are such that he/she cannot sign) ...iii.Where the patient has been declared legally incompetent or insane ...EMERGENCY CONSENTS: The treatment of a patient without a written consent is authorized when an emergency situation prevails. However, to determine when there is an emergency the following is helpful: 1. Determine whether the treatment is immediately required and necessary to prevent deterioration or aggravation of the patient’s condition. This may be a matter of first air od temporary medical care in lieu of surgery, or actual surgical or orthopedic procedure. Treat the emergency only. 2. Assess the possibilities of obtaining the written consent, weighed against the possibility the delay in acquiring the consent would jeopardize the health of the patient. 3. Obtain medical consultations as to existence of the emergency. It should be carefully charted and should include medical reasons for immediate treatment. 4. Consent by telephone when necessary in an emergency situation (where life or health of a patient is jeopardized) must be witnessed by two (2) people and a record kept with the chart as soon as possible to verify oral consent ...CONSENTS-LUFKIN STATE SCHOOL RESIDENTS: Lufkin State School residents will have consents completed as follows for specific procedures: 1. Permission from parents or legal guardian is required by Lufkin State School personnel prior to scheduling for elective procedures and/or hospital admission of the patient. A. Consent or permit will be witnessed by Lufkin State School representative(s) and forwarded to our hospital. B. If written permission is not forthcoming and/or the procedure becomes an emergency, telephone consent will be obtained when necessary and signed by 2 witnesses. 2. Emergency procedures for which consent cannot be immediately obtained will be handled as follows: If telephone consent cannot be obtained by the Lufkin State School physician, the physician performing the procedure may sign consent if deemed by him or her that is is a medical necessity to perform the life or limb saving procedure ...” An interview was conducted with Staff # 3 and # 5 on 07/15/2025 at 1:45 PM and confirmed the hospital staff were not obtaining proper consent prior to performing treatment and care on patients at the hospital. Staff # 3 and # 5 confirmed the hospital staff were not following the hospital’s Informed Consent policy.”

“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: 48653 Based on record review and staff interview, the hospital’s nursing staff failed to develop, implement, and keep current a nursing care plan for 1 (Patient # 2) of 1 patient’s that included documentation of the patient’s vital signs when the patient had a change in status and required a higher level of care. The nursing staff failed to follow the “Assessment of Patients” policy. Findings include: A review of medical records was conducted with Staff # 5 and # 8 on 05/16/2025 at 10:00 AM. Patient # 2 Patient # 2 was admitted to the hospital on 04/24/2025 with lethargy, tachypnea (fast breathing), and fever. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. On 04/27/2025 at 12:37 AM, the patient was found having uncontrollable seizures by Staff # 26 (Licensed Vocational Nurse). The patient received the following doses of Ativan to control the seizures: Ativan 4 mg (milligrams) IVP (intravenous push) at 1:29 AM by Staff # 27 (Registered Nurse) Ativan 2 mg IVP at 3:34 AM by Staff # 28 (Registered Nurse). Ativan is a powerful central nervous depressant that can cause respiratory depression and hypoventilation. Side effects can range from mild to severe, and life-threatening. The patient received a total of 6 mg of Ativan in a 2-hour window; no vital signs were documented during that time. The patient was transferred to the hospital’s ICU (intensive care unit) on 04/27/2025 at 3:24 AM. The patient had respiratory distress and required rapid intubation on 04/27/2025 at 4:04 AM. The following vital signs were documented on 04/27/2025: 04/27/2025 at 12:00 AM: “temp 98.6 F, pulse 96, respirations 22, blood pressure 111/70, oxygen saturation 91 %” The next vital signs were not taken again until 04/27/2025 at 4:21 AM, 4 hours and 21 minutes later: “pulse 92, respirations 12, blood pressure: 86/62, oxygen saturation 93%” There were no vital signs documented before or after the administration of IV (intravenous) Ativan. There were no vital signs taken before transferring the patient to another department of the hospital. There were no vital signs taken upon arrival to the hospital’s ICU. A review of the “Assessment of Patients” policy with a date of 12/2023 revealed, “POLICY: To be used on all inpatients, including 23-hour observation, admittance to ICU, Med/Surg, Gyn/Surg, and Step Down. To be completed within 8 hours of admission by the nursing care team ....Reassessment of Patients: Patients cared for in each treatment setting will be reassessed at regular intervals to ensure that care decisions remain appropriate. The time intervals for reassessments are defined in the following patient care departments. Patient reassessments are based on the anticipated length of stay, the complexity of the patient and the dynamics of the patient. In addition to the specified time intervals for reassessment, the patient will be reevaluated to determine response to specific treatment, or when a significant change occurs in the patient’s condition or diagnosis. Documentation of the reassessment becomes part of the patient’s permanent record ....” An interview with Staff # 3 and # 5 on 07/16/2025 at 2:30 PM confirmed the nursing staff did not take vital signs before or after administration of IV Ativan, a medication that has the potential to cause significant respiratory depression. The staff agreed that there should have been closer monitoring and vital signs documented for the patient.”

“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: 48653 Based on record review and staff interview, the hospital’s nursing staff failed to administer a vasoactive medication per the physician’s order for 1 (Patient # 2) of 1 patient’s medical records reviewed. Findings include: Patient # 2 Patient # 2 was admitted to the hospital on 04/24/2025 with lethargy, tachypnea (fast breathing), and fever. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. The patient required Levophed (also known as Norepinephrine Bitartrate, a vasoconstrictor that works by narrowing blood vessels, and stimulating the heart to increase blood pressure through peripheral vasoconstriction) for low blood pressure on 04/27/2025. The order for Levophed was placed by Physician # 19 and was as follows: “Levophed/NS (normal saline) 16MG(milligrams)/250 ML(milliliter) Premixed: Titrate for MAP (mean arterial pressure) between 65 to 75 mmHg (millimeters of mercury). Begin infusion at 0.05mcg/kg/min (micrograms per kilograms per minute). Increase by 0.02 mcg/kg/min every 3 min for between 65 and 75 mmHg to a maximum dose of 1 mcg/kg/min. Decrease by 0.02 mcg/kg/min every 10 minutes for between 65 to 75 mmHg ...” A review of the nursing documentation revealed the Levophed was infusing at a dose of 0.03mcg/kg/min from 04/28/2025 at 5:40 AM until 04/30/2025 at 6:00 PM. There was no titration of the drug occurring during this time. The following Mean Arterial Pressures (MAPs) were documented: 04/28/2025 “7:15 AM: 79 7:30 AM: 280 7:45 AM: 87 8:00 AM: 88 8:15 AM: 94 8:30 AM: 93 8:45 AM: 86 9:00 AM: 83 10:00 AM: 93 10:15 AM: 94 10:30 AM: 93 10:45 AM: 99 11:00 AM: 88 11:15 AM: 77 11:30 AM: 85 11:45 AM: 78 ....” The patient’s MAP remained above 75 mmHg for 3 hours and 15 minutes, and there was no rate change to lower the dose of the Levophed drip so that the patient’s MAP was maintained within the physician’s ordered parameters. The following MAPs were documented: 04/28/2025 “2:30 PM: 85 2:45 PM: 86 3:00 PM: 93 3:15 PM: 94 3:30 PM: 79 3:45 PM: 88 4:00 PM: 86 4:15 PM: 89 4:30 PM: 90 4:45 PM: 92 5:00 PM: 85 5:15 PM: 93 5:30 PM: 85 5:45 PM: 77” The patient’s MAP remained above 75 mmHg for 3 hours and 15 minutes, and there was no rate change to lower the dose of the Levophed drip so that the patient’s MAP was maintained within the physician’s ordered parameters. The following MAPs were documented: 04/29/2025 “6:00 PM: 99 7:00 PM: 101 8:00 PM: 94 9:00 PM: 93 10:00 PM: 88 11:00 PM: 85” 04/30/2025 “12:00 AM: 75 1:00 AM: 77 2:00 AM: 80 3:00 AM: no MAP taken 4:00 AM: no MAP taken 5:00 AM: no MAP taken 6:00 AM: 95” The patient’s MAP remained above 75 mmHg for 8 hours, and there was no rate change to lower the dose of the Levophed drip so that the patient’s MAP was maintained within the physician’s ordered parameters. There was no MAP documented between 2:00 AM and 6:00 AM on 04/30/2025. An interview was conducted with Staff # 5 and # 8 on 07/16/2025 at 2:00 PM. Staff # 5 confirmed the staff were not titrating the vasopressor to maintain the patient’s mean arterial pressure within the ordered parameters.”

“REPORTING ADVERSE REACTIONS AND ERRORS CFR(s): §482.23(c)(5) - There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital’s staff failed to recognize and report medication errors that resulted in patient harm to 2 (Patient # 1 and # 2) of 2 patients. The hospital staff failed to follow the “ID and Color-Coded Armband Policy”, “Medication Reconciliation Policy”, and “Assessment of Patients Policy”. During a review of medical records with Staff # 6, and # 8 on 07/15/2025 at 9:00 AM, the following was revealed, Patient # 1 Patient # 1 was admitted to the hospital on 05/07/2025 with urinary tract infection and hypothermia. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. The patient had a known medication allergy to Rocephin (also known as Ceftriaxone- an antibiotic used to treat bacterial infections). A review of the patient’s medical record revealed the following allergies were documented by Staff # 16 (Registered Nurse): “NSAIDS, ASPIRIN, ERYTHROMYCIN, AZITHROMYCIN, AZTREONAM, CEFTIRAXONE SODIUM”. A review of the patient’s medication administration record revealed Staff # 17 (Nurse Practitioner) ordered “Ceftriaxone IVP 1 Grams” on 05/07/2025 while the patient was in the hospital’s emergency room. Further review of the patient’s medication administration record revealed Staff # 16 (Registered Nurse) administered Ceftriaxone 1-gram IVP (intravenous push) on 05/07/2025 at 3:09 PM despite the patient’s known allergy to the antibiotic. Staff # 16 (Registered Nurse) did not document the application or confirmation of the patient’s allergy armband as required in the hospital’s “ID and Color-Coded Armband Policy”. On 05/08/2025 at 5:17 AM, Staff # 23 (Registered Nurse) documented, “Spoke with Physician # 19 about blotchy redness seeming worse and pt receiving Rocephin in ER yesterday afternoon. Order received and carried out”. Physician # 19 ordered the following medications for the patient’s rash, “Methylprednisolone Sodium 125mg (milligrams) IVP” and “Benadryl 50mg/ml (milligrams per milliliters) IVP”. Staff # 23 (Registered Nurse) who identified the medication error that occurred in the Emergency Room did not report the error for further follow-up and investigation. Patient # 2 04/24/2025 Admission Patient # 2 was admitted to the hospital on 04/24/2025 with lethargy, tachypnea (fast breathing), and fever. The patient arrived via ambulance from a state-funded living facility where the patient resided. The patient had a history of severe cognitive impairment. The patient had a PEG (percutaneous gastrostomy tube) in place for feedings and medication administration. A review of the patient’s home medication list from 04/24/2025 revealed the following home medications and doses: “-Keppra (a medication used to prevent seizures) 1,500 mg (milligrams) in the morning and 1,750 mg at bedtime via PEG tube” A review of the patient’s medical record revealed Staff # 25 (Registered Nurse) reviewed the patient’s home medication on 04/24/2025 at 5:57 PM. Staff # 25 copied the medication list from a previous hospital admission occurring earlier in 2025 and did not contact the patient’s living facility for an updated list. The medication list included the following medication and doses, “-Keppra 750 mg orally twice a day. -Levetiracetam (also known as Keppra) 250mg orally twice a day.” A review of the patient’s medication administration record (MAR) revealed the patient received the following medication and doses: 4/24/2025 Keppra 750 mg (milligram) given orally at 9:07 PM Keppra 500 mg IV (intravenous) given at 9:59 PM 04/25/2025 Keppra 750 mg given orally at 12:03 PM Keppra 750 mg given orally at 10:23 PM 04/26/2025 Keppra 750 mg given orally at 11:14 AM Keppra 750 mg given orally at 10:30 PM 04/27/2025 Keppra 500 mg IV(intravenous) given at 1:34 AM Keppra 1000 mg given orally at 8:43 AM Keppra 1000 mg given orally at 9:22 PM The patient received a significantly lower dose of Keppra while in the hospital compared to his home dose due to an inaccurate home medication list documented by Staff # 25. Also, the route for the medication order was incorrect, as the patient had a PEG tube for feedings and medications. On 04/27/2025, the patient was found having uncontrollable seizures by Staff # 26 (Licensed Vocational Nurse). The patient received the following doses of Ativan to attempt to control the seizures. Ativan 4 mg IVP (intravenous push) at 1:29 AM by Staff # 27 (Registered Nurse) Ativan 2 mg IVP at 3:34 AM by Staff # 28 (Registered Nurse). Ativan is a powerful central nervous depressant that can cause respiratory depression and hypoventilation. Side effects can range from mild to severe and life-threatening. The patient received a total of 6 mg of Ativan in a 2-hour window. The patient had respiratory distress and required rapid intubation on 04/27/2025 at 4:04 AM. The patient’s admission medication reconciliation was not done until 04/29/2025 at 8:21 AM by Physician # 24, 5 days after admission. The patient received a significantly lower dose of Keppra compared to the home dose from 04/24/2025 to 04/27/2025 due to an incorrect home medication list, and Physician # 24 failing to complete the medication reconciliation on admission. As a result, the patient had uncontrollable seizures, received high doses of Ativan, and required rapid intubation secondary to respiratory distress. The medication errors were not reported by hospital staff for further follow-up and investigation. 05/17/2025 Admission Patient # 2 was admitted to the hospital from a long-term care facility on 05/17/2025 due to complaints of tachycardia (high heart rate), hypotension (low blood pressure), and fever. The patient’s home medications were reviewed by Staff # 29 on 05/17/2025 at 1:01 PM. The following medication was listed on the patient’s home medication: “Phenytoin 200mg every night” Phenytoin is a medication used to treat and prevent seizures. A medication reconciliation was completed by Physician # 24 on 05/17/2025 at 5:35 PM and included the following orders: “Phenytoin 200 mg daily via PEG tube Phenytoin 300 mg every night via PEG tube” The medication was administered at the following times: 05/17/2025 Phenytoin 200 mg given at 9:46 PM via PEG Phenytoin 300 mg given at 9:55 PM via PEG 05/18/2025 Morning dose not given due to critical phenytoin level of 20.4 resulted at 3:10 AM Phenytoin 200 mg given at 9:01 PM via PEG 05/19/2025 Phenytoin 200 mg given at 9:33 AM via PEG On 05/19/2025 at 2:49 PM, the patient’s phenytoin level was critical at 22.1 due to the patient receiving 2 doses of phenytoin after a critical result of 20.4 on 05/18/2025. The medication errors were not reported by hospital staff for further follow-up and investigation. A review of the hospital’s “ID and Color-Coded Armband Policy” with a date of 08/2024 revealed, “PURPOSE: A clearly defined method of communicating the patient’s identification by utilizing two identifiers on the white patient identification (ID) armband and identifying any risk factors or special needs by standardizing the use of color-coded armbands that support safe patient care ....The following chart presents the meaning of each color coded arm band used in inpatient and outpatient settings: Red with white stripes: Allergy band-write all allergies in the white area, for patients with 4 or more medication allergies, write ‘see medical chart’ to obtain the full list of allergies ....Color-coded Hospital Armbands: It is during the initial assessment that risk factors associated with medication allergies, falls, latex allergies, DNR status, limb alert, blood bank identification or EMS arrivals are clearly identified and the proper color-coded armband is placed on the patient’s arm immediately. If for any reason, that band has to be removed during the patient’s hospital stay, it must be replaced immediately, and the medication allergies or other risks are reviewed by the nurse providing care and the patient again prior to replacing any armband back on the patient. For patients with 4 medication allergies, the words “see medical chart” will be written on the allergy band. It is the responsibility of the nurse providing care to continually assess and reassess the patient’s medical condition, including the confirmation of the patient’s medication allergies. Because this is an interdisciplinary process, it is important to identify who has the responsibility for applying and removing the color-coded bands, how this information is documented, and how it is communicated ....The following procedures have been established to remove any uncertainty in these processes: ...The application or confirmation of the armbands will be documented in Medhost EDIS and GE Centricity ....” A review of the hospital’s policy, “Medication Reconciliation Policy” with a date of 072023 revealed, “Nursing Instructions: Admission: 1. Initiate Medications Reconciliation Admission/Discharge Orders on admission. 2. Patient’s name, medical record number, DOB, and room number must be documented. 3. Document the patient’s height and allergies ....5. Document disposition of all medications brought with the patient. 6. Document the source of the patient’s medication information. Record name of pharmacy or person providing the information, if different from the patient. 7. Pre-admission medications will be documented by the physician or admitting nurse. Documentation will include the name, strength, dose, form, and frequency of the medication. 8. Document the date and time the medication was last taken ...10. Orders from the physician will be received for each medication to be continued or held. This is to occur at the time of admission assessment and not left for review by the physician on the next visit. No medication should be dispensed until this process has occurred ....15. These orders must be transcribed and noted in the area designated as “Admission Reconciliation”. Transcription includes transferring the order the Pharmacy. 16. Do not process these orders if the form is not complete. 17. Pre-admission medications and medications ordered on admission must be reviewed by pharmacy prior to administering. The patient’s pre-admission medications and all ordered medications must be listed in Micromedex. The nurse assigned primary care of the patient AND an additional nurse must review Micromedex report for interactions prior to administration of medications, with the exception of emergent medications. 18. Essential medications include, but are not limited to, insulin, vasoactive medications, antiarrhythmics, seizure medications ....The Micromedex report must be printed, dated, timed, and signed by the nurse assigned primary care of the patient AND an additional nurse reviewing the report. The Micromedex report is placed in the patient’s chart and made a permanent part of the medical record ....PHYSICIAN INSTRUCTIONS: Admission: 1. Review the patient’s pre-admission medication list. The review should include, but is not limited to: appropriateness of the medication, strength, form, frequency, and dosing; medication/medication interactions, medication/food interactions, contraindications, disease process, patients renal clearance, known allergies, and past ADRs. 2. For each medication, mark ‘yes’ to continue the medications in the hospital or ‘no’ to hold the medications. 3. If a medication will be continued by you are changing the strength, form, frequency, or schedule for medication, mark ‘no’ and write an order for the medication on a separate Physician’s Order form ....PHARMACY INSTRUCTIONS: 1. Review medications ordered to be given while the patient is in the hospital. This review should include the patient’s pre-admission medications and medications ordered on admission. The review should include, but is not limited to: appropriateness of the medication, strength, form, frequency, and dosing, medication/medication interactions, medication/food interactions, contraindications, disease process, renal clearance, known allergies ....2. A pharmacist must document the reconciliation process in the pharmacy information system. Placing medications on the patient’s profile will represent medication reconciliation and clarification of variances as occurred ...4. Recommend appropriate changes to medications and collaborate with the physician to ensure that the ordered medications are accurate, safe, and appropriate for the patient ....” A review of the hospital’s “Assessment of Patients” policy with a date of 12/2023 revealed, “POLICY: To be used on all inpatients, including 23-hour observation, admittance to ICU, Med/Surg, Gyn/Surg, Step Down. To be completed within 8 hours of admission by the nursing care team. PROCEDURE: ...Nursing Assessment/Reassessment Criteria ...2. Assessment and Reconciliation of Medications: a. Reconciliation begins at the time the patient enters the organization and continues throughout the continuum of care involving nurses, physicians, and/or pharmacists. The physician is responsible for reconciling medications taken during the hospital stay and has access to active medications at all times through the computer system. i. A complete list of medications will be obtained/documented in the medical record on admission, or as soon as possible ....Departmental Assessments/Screenings: ...PHARMACY: The pharmacist will assess medication orders for each patient by reviewing each order upon receipt and prior to dispensing the medication. This review includes: Assuring the order is complete, clear, and accurate. Screening for drug interactions, patient drug allergies, appropriateness of dose, frequency, indication, and route of administration, and duplication of drug interactions, allergies, and duplicate therapy. Verification of the order with the prescriber/patient primary nurse and/or recommendation of modification to the order when indicated by the Pharmacist’s assessment. Identification and investigation of suspected adverse drug reactions ....The pharmacist routinely monitors the therapy of all patients. This includes serum electrolyte levels for patients receiving certain electrolytes, and therapeutic serum drug levels for patients receiving certain drugs ...” An interview was conducted with Staff # 2 and # 5 on 07/15/2025 at 4:00 PM which confirmed the hospital staff were not recognizing and reporting adverse drug reactions and medication errors for further follow-up and investigation. An interview with Staff # 30 (Director of Pharmacy) was conducted on 07/16/2025 at 1:00 PM. Staff # 30 was asked if Keppra and Phenytoin were medications that could be crushed and given via PEG tube. Staff # 30 explained it was not the preferred way and it would depend on if the tablets or capsules were extended release or not. Staff # 30 was asked why the patient was not given a liquid version of Keppra that went into the PEG tube. Staff # 30 said, “normally we would try to order the liquid version for the patients with PEG tubes”.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s biomedical engineering staff failed to ensure 27 of 27 Mindray Bedside Monitors had a current PM (preventative maintenance) sticker. Findings include: During a tour of the hospital’s ICU (intensive care unit) and SDU (step down unit) on 07/15/2025 at 2:00 PM, the surveyor observed 27 of 27 patient rooms with Mindray Bedside Monitors that had no PM sticker. There was no documentation on the monitors that informed the clinical staff of when preventative maintenance had been performed on the monitors. Mindray Bedside Monitors are medical devices that are used to continuously monitor a patient’s vital signs. These monitors provide real-time data on the patient’s condition. They are crucial for tracking a patient’s health status and enabling timely clinical decisions. A review of the hospital’s “Bedside Tele-Packs Mindray Report” printed on 07/15/2025 revealed the monitors were newly installed on 10/01/2024 with preventative maintenance performed on 10/01/2024 during installation. The biomedical team failed to place PM stickers on every monitor after preventative maintenance had been performed. An interview with Staff # 11 was conducted on 07/15/2025 at 3:00 PM in the hospital’s ICU hallway. Staff # 11 stated, “The PMs have been completed by the Mindray technicians when the monitors were installed. The Mindray technicians did not place a sticker on the monitors once PM had been completed”.”

“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 program failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in 2 (Intensive Care Unit and Step-Down Unit) of 2 units of the hospital. Findings include: During a tour of the hospital’s Intensive Care Unit (ICU) and Step-Down Unit (SDU) with Staff # 5, # 6, and # 12 on 07/15/2025 at 1:20 PM, the following infection control issues were identified: Intensive Care Unit (ICU) There were 4 large holes in the wall of room ICU-01. The holes were not patched, and there was drywall exposed which could not be adequately cleaned and disinfected. There was an IV (intravenous) pump in room ICU-01 that was not covered with a clear, plastic bag to identify the pump as “clean”. Staff # 12 confirmed the IV pump should have been covered with a clear, plastic bag to identify it as “clean”. The air duct on the ceiling in room ICU-01 was covered in a thick layer of dust buildup. The air duct was directly over the patient’s hospital bed. There were 15 wooden nightstands in ICU rooms 01 through 15. The nightstands had raw, exposed wood that could not be adequately cleaned or disinfected. There was a build-up of dust, dirt, and rust on the wheels and handles of the nightstands. There were privacy curtains in ICU rooms 01 through 15. The privacy curtain in every ICU room had expired according to the hospital’s Infection Prevention Plan, which requires the curtains to be changed 6 months after installation. The cabinets in the ICU rooms were broken and had exposed raw wood that could not be adequately cleaned and disinfected. Every ICU room had damaged cabinets with exposed raw wood. The bedside table in room ICU-03 was dirty. There was an unknown brown substance on the mirror and pull-out compartment of the bedside table. There was a build-up of dust, dirt, and an unknown brown and orange substance on the COW (computer on wheels) located in the hallway between rooms ICU-01 and ICU-03. The keyboard located on the COW was also covered in dust, dirt, and an unknown flaky white substance. The Life-Pak 15 defibrillator located on top of the emergency code cart was covered in a thick layer of dust and dirt. The Sonosite ultrasound machine was covered in a thick layer of dust. A Sonosite ultrasound machine is used in critical care areas to assist with sterile bedside procedures. There was a large stretcher in the hallway of the ICU that had a build-up of dust and dirt on the bottom portion of the stretcher. The anteroom located outside the negative pressure isolation room was used as a storage room, and the isolation carts were covered in a thick layer of dust. There was clutter and no room to move around in the anteroom. The Clean Supply room had large blue bins that had an accumulation of dust, dirt, and other unknown debris inside. There was a large brown and orange stain on the racks where sterile patient supplies were used. The metal supply carts had wheels that were covered in rust, dirt, and an unknown black substance. The floor of the clean supply room had a buildup of an unknown brown and orange substance. The patient nutrition refrigerator had hair, dirt, and dust inside the door and on the shelves. There were expired condiments in the refrigerator door that expired on 03/02/2025. The medication refrigerator was stored on a large black plastic pallet. There was a large build-up of dust, dirt and unknown black substance located under the pallet. There was a sterile medication preparation area on top of the medication refrigerator that was labeled, “sterile product preparation only”. The preparation area was covered in dust. The inside of the cabinet doors and shelves where sterile supplies were stored had a build-up of an unknown black substance. The desk of the nurses’ station had multiple areas of damage where raw wood was exposed. There were areas where the paint had peeled off and was missing. The desk could not be adequately cleaned and disinfected. Step-Down Unit (SDU) The emergency code cart in the Step-Down Unit was covered in dust. The Life-Pak defibrillator’s screen was also covered in dust. The sheets located on the patient bed in SDU room 01 had large holes which exposed the mattress underneath. The room was considered clean and ready for a patient. The blanket warmer had a thick build-up of dust on the top. There were privacy curtains in SDU rooms 01 through 12. The privacy curtain in every SDU room had expired according to the hospital’s Infection Prevention Plan, which requires the curtains to be changed 6 months after installation. A review of the hospital’s “Infection Control Plan” with a date of 09/2024 revealed, “PURPOSE: A. To define the Infection Prevention and Control Program, its goal, objectives, authority, and responsibilities. B. To outline processes used to determine and evaluate healthcare associated infections (HAI’s) among patients, healthcare workers, visitors, and others in the healthcare environment. This policy states the determination of HAI’s type of surveillance used, data source, patient sources, and reporting of analysis. C. To identify process improvement opportunities, plan intervention activities, implement the action plan, and evaluate plans for effectiveness. D. To integrate the Infection Prevention and Control Program into all disciplines, services, and settings throughout Woodland Heights Medical Center .... PROGRAM GOALS: A. To prevent or limit acquisition and transmission of infections within the hospital. B. Infection Control addresses prioritized risks and uses surveillance methodologies to minimize, reduce, or eliminate the risk of infections. C. Incorporate evidence-based practice and CDC recommendations for prevention of Healthcare Associated Infections into policy and practice within the facility as they relate to: 1. Reduction of Healthcare Associated Infections in selected units ...2. Reduction of Surgical Site Infections ...3. Reduction of Multi-drug Resistant Organisms (MDROs) ...4. Enhancement of hand hygiene practice throughout the facility with a compliance goal of 95%....5. Re-education of policy and skills evaluation for safe insertion practice ... D. Limiting unprotected exposure to pathogens ... E. Limiting the risk of transmission of infections associated with the use of medical equipment, devices and supplies ...” An interview was conducted with Staff # 5 and Staff # 12 on 07/15/2025 at 3:00 PM, which confirmed there were significant infection control issues in the hospital’s ICU and SDU.”

“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 Control Professional (Staff # 12) failed to ensure adherence to infection prevention and control policies and procedures by hospital personnel when: A. Staff # 13 (Housekeeping) was unable to verbalize the hospital’s procedure for the cleaning and disinfection of a patient room which had been isolated for Clostridium Difficile (C-Diff) infection. B. Two (Patient # 1 and # 2) of 2 high-risk patients admitted from long-term care facilities were not placed in contact isolation after a known history of and positive test for infections with multidrug-resistant organisms (MDROs). C. The hospital staff failed to follow “Contact Precautions”, “Management of Multi-Drug-Resistant Organisms (MRSA) Active Surveillance”, and “Assessment of Patients” policies. Findings include: A. During a tour of the hospital’s ICU (Intensive Care Unit) on 07/15/2025 at 2:00 PM, the surveyor observed Staff # 13 (housekeeping) cleaning a patient room. Staff # 13 was asked to verbalize what Clostridium Difficle was and if there was a different process for the cleaning and disinfection of a room which was under contact isolation. Staff # 13 was unable to verbalize how a contact isolation room would be cleaned and did not know what Clostridium Difficile was. Clostridium Difficile (C-Diff) is a highly contagious bacterial infection that leads to inflammation of the colon. C-Diff is spread through contact with contaminated feces and can survive on surfaces and objects for extended periods, making it easy to transmit to other individuals. Proper hand hygiene with soap and water is imperative in preventing the spread of C-Diff. Alcohol-based hand sanitizers do not kill the bacteria. B. A review of patient medical records for Patient # 1 and # 2 was conducted on 07/15/2025 at 9:00 AM with Staff # 5 and # 11. Patient # 1 Patient # 1 was admitted to the hospital from a long-term care facility on 05/07/2024 with hypothermia and urinary tract infection (UTI). A review of the history and physical completed by Physician # 18 on 05/07/2025 at 4:09 PM revealed, “Plan:1. UTI and possible sepsis, he presented with hypotension and hypothermia with neutropenia, urine analysis consistent with UTI history of pseudomonas UTI with multidrug resistance ....” There was no order placed for contact precautions to be implemented. There was no nursing documentation to provide evidence that contact precautions were implemented to prevent the spread of the infectious organism to hospital staff, patients, or visitors. Patient # 2 04/24/2025 admission Patient # 2 was admitted to the hospital from a long-term care facility on 04/24/2025 due to sepsis and pneumonia. On 04/27/2025, the patient had a sputum culture test positive for gram-positive cocci methicillin-resistant staphylococcus aureus. Isolation precautions were not implemented until 05/03/2025 at 2:26 PM, 6 days after the patient tested positive for a multi-drug-resistant organism (MDRO). 05/17/2025 admission Patient # 2 was admitted to the hospital from a long-term care facility on 05/17/2025 due to complaints of tachycardia (high heart rate), hypotension (low blood pressure), and fever. A review of Physician # 24’s History and Physical completed on 05/17/2025 at 5:17 PM revealed, “ ....He received over 3 weeks of antibiotic therapy for severe sepsis due to MRSA aspiration pneumonia and UTI cultures positive for MDR Enterococcus, Morganelli, and MDR Pseudomonas. Repeat sputum culture is growing MRSA ...” There was no order placed for contact precautions to be implemented. There was no nursing documentation to provide evidence that contact precautions were implemented to prevent the spread of the infectious organism to hospital staff, patients, or visitors. A review of the Centers for Disease Control (CDC), “Management of Multidrug-Resistant Organisms in Healthcare Settings” revealed, “ ....Infection Control Precautions: Since 1996 CDC has recommended the use of Standard and Contact Precautions for MDROs ‘judged by an infection control program to be of special clinical and epidemiologic significance.’ ....Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganism, which are transmitted by direct or infect contact with the patient or the patient’s environment..” C. A review of the hospital’s “Contact Precautions” policy with a date of 08/2023 revealed, “INTRODUCTION: In addition to Standard Precautions, Contact Precautions are to be used for patients known or suspected to be infected, or colonized with epidemiologically important microorganisms. These microorganisms can be transmitted by direct contact with the patient, or through indirect contact with the patient’s environment. POLICY: 1. In order to reduce the risk of transmission of microorganisms, Contact Precautions will be routinely practiced by all Hospital personnel whenever indicated. The following strategies for Contact Precautions as recommended by the Centers for Disease Control (CDC) must be adhered to in order to protect patients and personnel. A. Use Contact Precautions for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. B. For specific recommendations for use of Contact Precautions for colonization or infection with MDROs, “Management of Multi-Drug Resistant Organisms,” or go to the MDRO guideline: www.cdc.gov/ncidod/dhgp/pdf/as/mdroGuideline2006.pdf. SPECIFIC REQUIREMENTS: I. Patient Placement: A. In acute care hospitals, 1. Place patients in a single-patient room when available ....II. Use of Personal Protective Equipment (PPE) A. Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close proximity to the patient. 2. Don gloves upon entry into the room or cubicle. B. Gowns. 1. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle ....IV. Patient Care Equipment and Instruments/Devices: A. Handle patient-care equipment and instruments/devices according to Standard Precautions. B. In the hospital setting, Use of disposable noncritical patient care equipment or patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient ....Environmental Measures: A. Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection with a focus on frequently touched surfaces and equipment in the immediate vicinity of the patient ....” A review of the hospital’s “Management of Multi-Drug Resistant Organisms (MRSA) Active Surveillance” policy with a date of 08/2023 revealed, “DEFINITIONS: Multi-Drug Resistant Organisms are common bacteria (germs) that have developed a resistance to multiple types of antibiotics (i.e., MRSA, etc) ....B. Multidisciplinary program: 1. Implement and maintain a multidisciplinary program to improve adherence to CDC and WHO-Recommended Practices for hand hygiene and Standard/Transmission-based Precautions (i.e., Pharmacy, Lab, Housekeeping, Nursing, Physicians, Education, Etc.). C. 1. Implement and maintain communication systems to notify receiving health-care workers when known patients with MRSA are admitted/transferred so that infection control precautions may be initiated promptly ....B. Contact Precautions: All Patients known to be infected or colonized or who have a history of significant infection or colonization of MRSA should be placed in Contact Isolation ....Enhanced Surveillance: 2. Implement active surveillance cultures for target MRSA from patients in at-risk populations (at-risk populations to be determined by targeted MRSA Surveillance Data). High Risk Populations: Obtain surveillance cultures at the time of admission from areas of skin breakdown and draining wounds. In addition, include the following sites according to target MRSA: anterior nares, throat, and perirectal or perineal area. Surveillance cultures may be repeated at the time of patient discharge or transfer until transmission has ceased or as per recommendation of the Infection Control Committee ....3. Admitted from long-term care or rehab facilities ....” A review of the hospital’s “Assessment of Patients” policy with a date of 12/2023 revealed, “POLICY: To be used on all inpatients, including 23-hour observation, admittance to ICU, Med/Surg, Gyn/Surg, Step Down. To be completed within 8 hours of admission by the nursing care team. PROCEDURE: ...Nursing Assessment/Reassessment Criteria ...3. During the admission process, all patients will be screened for symptoms or diagnosis of potentially infectious conditions and placed in the appropriate isolation. When the initial nursing assessment screening process identifies a patient with a diagnosis or history of Methicillin-Resistant Staphylococcus Aureus (MRSA), the nurse will place the patient in contact isolation ....” An interview was conducted with Staff # 5, # 6, and # 12 on 07/15/2025 at 4:00 PM, which confirmed the hospital staff did not follow infection control policies and procedures when housekeeping staff were unable to verbalize cleaning and disinfection processes, and nursing staff failed to screen for and implement contact precautions on high-risk patients.”

“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: 49344 . Based on record review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department for Patient #3 to determine whether or not an emergency medical condition existed. Findings: Patient #3 was a 3-year-old, male with autism, non-verbal who presented to the emergency department on 03/24/24 at 4:40 PM with complaints of “fevers and vomiting for 1 day. Symptoms started with upper respiratory symptoms, cough, congestion for 2 days. Parents report that he has vomited 5-6 times and is not tolerating water even. Parents deny any obvious illness exposure.” The ED log documented an ESI Level 3 (the ESI (Emergency Severity Index) is a triage tool used in emergency departments to categorize patients based on the severity of their conditions and the resources they are expected to need. ESI levels range from 1, most urgent, to 5, least urgent). The patient was discharged home on 3/24/2024 at 6:49 PM with a diagnosis of “Viral intestinal infection, unspecified”. A review of the medical record revealed a Medical Screening Exam was conducted on 3/24/24 by Staff #9 PA (Physician Assistant) at 5:35 PM. The medical screening exam revealed the following: “Constitutional: Well-developed, well-nourished child who is awake, alert, cooperative with no acute distress. Constitutional: The patient appears in no acute distress, alert Eyes: Pupils: equal, round, and reactive to light, Conjunctiva: normal ENT: TM’s are normal, Nose: nasal drainage, that is minimal and is seen coming from both nares, that is clear. Mouth: is normal, Posterior pharynx: is normal. Respiratory: the patient does not display signs of respiratory distress, Respirations: normal, Breath sounds: are normal, clear throughout. Cardiovascular: Rate: normal, Rhythm: regular, Heart sounds: normal Abdomen/GI: Bowel sounds normal, Palpation: abdomen is soft and non-tender, in all quadrants. Skin: rash, is not appreciated. A review of the Physician Assistant orders and results revealed the following: Flu A/B Sofia (Within Normal Limits) COVID-19 AG (Within Normal Limits) Strep A Assay W-Opti (Within Normal Limits) Zofran IM 2mg” A review the medical record of the Emergency Room Nurse’s documentation revealed the following vital signs for Patient #3. “3/24/2024 5:04 PM: Blood pressure was not obtained. Pulse: 170 Respirations: 32 Temperature 99 Oxygen Saturation 100% Room Air 3/24/2024 6:49 PM Blood pressure was not obtained. Pulse: 138 Respirations: 29 Temperature was not obtained. Oxygen saturation: 100% on Room Air” Patient #3 was discharged by Staff #9, PA, on 03/24/24 at 6:45 PM. The Discharge Assessment documented the following: “Patient awake and alert. Discharge instructions given to patient, instructed on discharge instructions, follow-up, and referral plans. Medication usage demonstrated understanding of instructions medications; Prescriptions are given x1.” A review of the “Discharge Disposition/Summary” revealed the following: Discharge: Home Condition: Improved Diagnosis: Viral intestinal infection, unspecified Follow-up: Private physician, 2-3 days Prescriptions: Ondansetron 4mg Oral tablet, disintegrating” A review of the facility policy titled; “Pediatric Trauma Assessment and Resuscitation” dated 01/2023 revealed: “...4. Obtain a complete set of vital signs including respiration rate, pulse oximetry, and blood pressure. Use cardiac monitoring whe patients’ injuries necessitate monitoring. Continuing to reassess all vitals as needed. 5. Reference nationally recognized guidelines including ATLS, TNXX, ENPC, PALS, Broselow Tape, and Harriet Lane Handbook for all pediatric/infant age group standards of care....” Based on the guidelines from various pediatric care courses and references, including PALS (Pediatric Advanced Life Support), the Harriet Lane Handbook, a normal heart rate range for a 3-year-old child typically is between 70 and 110 beats per minute (bpm) at rest. Further review of the medical record revealed there was no complete blood count (CBC) to assess for leukocytosis indicative of sepsis, a comprehensive metabolic panel (CMP) to evaluate renal function and electrolyte balance disrupted by hypovolemia from vomiting, or a urinalysis to detect ketones suggesting severe dehydration or urinary tract infection (UTI). Also, screening tests for sepsis C-reactive protein (CRP), procalcitonin, and blood cultures were not ordered. There was no electrocardiogram (ECG) performed to rule out significant arrhythmias like supraventricular tachycardia (SVT) as the cause of tachycardia. PA #9 did not assess oral intake and hydration status PO challenge. A PO challenge is a medical test where a person swallows (orally takes) a specific substance, usually a food or medication, under controlled conditions to ensure safety and to observe how the person’s body responds to the substance, helping doctors diagnose and manage potential blockages or related issues in the digestive tract. Failure to perform this PO challenge could have warranted further investigation. There were no imaging studies performed. An abdominal series or CT scan could have assisted in ruling out intraabdominal conditions such as bowel obstruction, appendicitis, or ileus. Patient #3 presented to Hospital #2 on 03/25/2024 at 3:55 PM. A review of the medical record revealed a CT with contrast of abdomen and pelvis was ordered. A computed tomography (CT) scan is a medical imaging procedure that uses X-ray images taken from various angles around the body. The CT scan results in the medical record noted “fluid-filled loop of small bowel in the lower abdomen which is distended with fecilization. Question chronic partial small bowel obstruction versus chronic ileus... a large amount of stool throughout the colon with stool-like material in the distal ileum-constipation vs partial small bowel obstruction 2/2 bezoar vs meckel’s diverticulum.” Patient #3 was then transferred to pediatric Hospital #3 on 03/26/2024 with post operative report dated 03/27/24 revealing the patient had an “intestinal obstruction” with procedures performed. “Laparoscopy” Abdomen/peritoneum/omentum/diagnostic and Enterotomy Exploration or foreign body removal.” A review of Hospital #3’s “Discharge Summary” revealed “During admission, the patient was on IV pain medications with an NGT (nasal gastric tube) to LIWS (low intermittent wall suction). The patient underwent Gastroview protocol with contrast reaching the rectum within 21 hours. However, due to persistent bilious NGT output and no BM ’ s the decision was made to proceed to the OR. The patient was taken to the OR with the surgeon on 3/27/2024 for exploratory laparoscopy with enterotomy for bezoar removal. The patient tolerated the procedure well and was admitted post-operatively for NGT management, pain control, monitoring for complete return of bowel function, and advancement of diet.” An interview with Staff #12, Emergency Room Physician on 5/7/2024 at 11:01 AM in the Emergency Department stated, “The one thing that I would have done is an oral challenge to make sure that the child could tolerate water before discharging. If they cannot tolerate anything by mouth, it would prompt me to do other diagnostic testing. I wouldn’t have discharged the patient without the oral challenge though.” An interview with Staff #13, Emergency Room Physician and supervisor of Staff #9, PA, on 5/07/2024 at 11:20 via telephone call stated: “After hearing the scenario, I would have done an oral challenge to ensure the patient could tolerate fluids before discharging home. As far as diagnostic testing such as blood work and x-rays, it would have been determined based on the oral challenge.””