White Rock Medical Center

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 28141 Based on record review, interview, and observation, the hospital failed to collect data and monitor the effectiveness of its post-operative surgical instrument cleaning procedures. Unaware that the hospital’s nonfunctional surgical instrument washer had been replaced by staff’s manual and mechanical cleaning procedures, the facility quality management failed to evaluate the effectiveness of its manual instrument reprocessing with objective measures and identify and address a potential lack of contaminant removal in quality and executive leadership committees between 02/12/2025 and survey initiation on 07/02/2025. Findings included: Observations on the hospital’s surgical unit on 07/02/2025 between 1330 and 1400 was conducted with Personnel A, B, D, E, and F in the hospital’s surgical suite. There were no surgeries at that time. The sterile processing department, identified by Personnel A as the post-operative cleaning and decontamination area for used surgical instruments, reflected three sinks with instructions for cleaning with enzymatic and detergent solutions. Additional instructions for cleaning parts of the endoscope (a tubular optical instrument used for examining, biopsy, or surgical procedures) and emergency eye wash procedures were also provided as pictorials on the wall. A gallon-sized plastic container identified by Personnel A as a cleaning chemical for surgical instruments had an opening date of 07/01/2025. The thermometer on one sink reflected a water temperature of 112.5-degree Fahrenheit. A surgical washer located in the area was identified by Personnel A as nonfunctional. A document titled “All Clean Test Washer Indicator Log Form” was dated 02/12/2025 and reflected Washer #1 had gone through the “All Clean Test” with “pass.” Personnel E stated at that time that quotes to repair the washer had been requested. Interviews Personnel A stated on 07/02/2025 at 1315 during an interview the instrument washer had been out of service for “four to five months” and instruments were “washed by hand ...two surgical cases ... 50 instruments just today.” When washing the instruments, staff followed the 3-sink-method. Personnel M stated during a telephone interview on 07/02/2025 at approximately 1325 that they notified administration in a February email that the washer had been broken. Quality Personnel C acknowledged during an interview on 07/02/2025 at 1545 that the last washer indicator test strip date was 02/12/2025, close to five months ago; Personnel C was asked how quality and administration were sure the washing and removal of contaminants on the surgical instruments was done correctly and effectively. There was no response. During an interview on 07/17/2026 approximately 1230, Quality Personnel C stated being unaware of the non-functional washer until survey initiation [07/02/2025]; action items after survey initiation included staff ordered test strips for the water, but “ ...I am not sure whether they had come in ...water temp logs have been created ...trying to find a vendor that sells the test strips.” Administrative Personnel E stated during a phone interview on 07/17/2025 at 1615 they created a purchase order in May 2025 after operating room staff notification. Administrative Personnel G was phone contacted on 07/17/2025 at 1610 and stated unawareness of the nonfunctional surgical washer until survey initiation on 07/02/2025. Record Review The latest hospital’s Quality Meeting minutes dated 03/18/2025 and Medical Executive Committee (MEC) minutes dated 04/17/2025 provided by hospital staff on 07/02/2025 did not reflect quality monitoring data of manual and mechanical cleaning due to a nonfunctional surgical instrument washer. MEC Committee minutes dated 04/17/2025 did not address a nonfunctional surgical instrument washer. Hospital provided email correspondence dated 05/23/2025 at 1140 reflected a purchase order was sent to a commercial supplier of sterilization and surgical products; three additional emails dated 05/28/2025, 06/09/2025, and 07/02/2025 (timed after survey initiation) requested updates on the original email. Temperature logs provided by the quality director on 07/18/2025 per email reflected temperature logs were initiated on 07/02/2025. Hospital Policy titled Surgical Instruments, Care and Cleaning - All Types, dated 12/2024, reflected the policy that “the cleaning, decontamination, and care of instruments will be evaluated in a quality management program ...will include monitoring of manual and mechanical cleaning ...” (p. 1).”

“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: 51905 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for two of twenty-four patients (Patient #1, #21). Patient #1 presented at eight (8) weeks of gestation with concern of a possible miscarriage and did not receive a complete obstetrical evaluation. Patient #21 presented for suture removal and abdominal pain and was denied a medical screening exam when requesting that the physician assess their abdominal pain. . See Tag 2406 .”

“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: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide adequate physician on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists. . Findings: 1. Record review of the on-call physicians’ schedule at Facility A: A. December 2024- 3 of 31 days did not have Cardiology on-call. B. January 2025- 13 of 31 days did not have Stroke on-call. C. January 2025- 13 of 31 days did not have Urology on-call. D. January 2025- 13 of 31 days did not have Gastroenterology on-call. E. February 2025- 9 of 28 days did not have Neurology on-call. F. February 2025- 9 of 28 days did not have Gastroenterology on-call. G. March 2025- 4 of 31 days did not have Orthopedics on-call. H. April 2025- 20 of 30 days did not have Upper Gastroenterology on-call. I. June 2025- 14 of 30 days did not have Neurosurgery on-call. . 2. Review of emergency services offered on Facility A’s website: A. Trauma and accidental injury treatment. B. Heart and Chest Conditions. C. Neurological Emergency Support. D. Respiratory and Infection Control. E. Digestive and Urinary Issues. F. Emergency Pediatric Services. G. Mental Health Crisis Support. . 3. Record review of Emergency Medical Treatment and Active Labor Act policy, Approved 10/2024: “ Procedure G. Physicians On-Call 1. The Hospital must maintain a list of physicians who are on-call for duty after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The list must include the names of individual physicians on call; names of groups or practices are not sufficient.” . Record review of Rules & Regulations of Medical Staff, Approved 11/2021: “Section 2: Admission and Discharge of Patients Standard Language 13 Call Obligation Emergency Department Call Staff Members, consistent with their granted Clinical Privileges, must participate in the on-call coverage of the emergency department or in other hospital coverage programs as determined by the Medical Executive Committee and the Governing Board, after receiving input from the appropriate clinical specialty. . Staff Members must be available on a rotational schedule, appropriate for that Member’s specialty, as periodically established by the Chief of Staff, to provide medical care or consultation to any patient in the emergency department who is found by the emergency physician on duty to require such care. It is the responsibility of the Physician on call in each specialty to be available to render such service in the emergency department as may be needed. If the Physician is unavailable for any reason, he or she shall secure a satisfactory alternate Physician from the medical staff to take call.” . 4. Interview: On 06/09/2025 at 11:57 A.M, an interview was conducted with the Director of Quality Staff D: Staff D was shown the emergency department on-call schedules for the past six months. Staff D indicated that the blanks present on the schedule meant that Facility A does not have coverage that day. . Staff D indicated that Facility A has anesthesia services, a cardiac catheterization laboratory, an intensive care unit, a medical-surgical unit, surgical services, operating rooms, orthopedic services, post-operative rooms, radiological services, and is a designated trauma center. .”

“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: 51905 . Based on observation, record review, and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for two of twenty-four patients (Patient #1, #21). Patient #1 presented at eight (8) weeks of gestation with concern of a possible miscarriage and did not receive a complete obstetrical evaluation. Patient #21 presented for suture removal and abdominal pain and was denied a medical screening exam when requesting that the physician assess their abdominal pain. . Findings: Medical Record: . Review of Patient #1’s medical record from Facility A: . 04/26/2025 Patient #1, Facility A . 1:20 P.M.: Patient #1, a 23-year-old woman of 8 weeks gestation, arrived at Facility A’s emergency department with a complaint of a possible miscarriage, abdominal pain, and spotting. . Past medical history: Gravida 4. Para 2. Abortions 1. . 1:35 P.M.: Patient #1 was triaged by a registered nurse and was deemed an acuity level two (2). (Per Emergency Department Triage Criteria policy 09/2023, acuity level 2 indicates “High risk conditions, major illness or injury; immediate life/organ threat and high liability risk, unstable vital signs; severe pain/distress which requires high resource intensity.”) . 2:00 P.M.: Urine analysis ordered. Urine pregnancy results are positive. . 2:18 P.M.: “US (ultrasound) OB (obstetric) <14 WK (week)” ordered. . 2:24 P.M.: Ultrasound order cancelled per “MD Discretion.” . 2:33 P.M.: Urine analysis positive for nitrites. Urine culture ordered per protocol. . 2.35 P.M.: Fetal heart tones ordered. Order cancelled: “Patient Left.” . 2:47 P.M.: Patient #1 was seen by ED physician Staff A, and a medical screening exam was started. “Cardiovascular: Normal rate, regular rhythm, no murmur, gallop or edema Abdomen: Soft, non-distended, normal bowel sounds, no masses, non-tender Lungs: Clear to auscultation and percussion, non-labored respiration Musculoskeletal: Normal range of motion and strength, no tenderness or swelling Skin: Skin is warm, dry and pink, no rashes or lesions Neurologic: Awake, alert, and oriented X3, motor and sensory grossly intact, CNII-XII grossly intact Psychiatric: Cooperative, appropriate affect, normal mood.” . *3:10 P.M.: An image of the patient tracking board verifies Patient #1’s identity, chief complaint, attending physician, primary nurse, disposition, notes, and date. Within the notes section, it is documented, “pt (patient) not in room 1510 (3:10 P.M.).” . 4:14 P.M.: Physician notes, “Disposition Decision Time: 16:14 (4:14 P.M.) 04/26/2025. Patient left during Eval (evaluation): Eloped from Room.” . 5:01 P.M.: Nursing notes, “The patient left the Emergency Department without completion of treatment; patient was unaccompanied. Unable to locate patient. Patient paged three times with no response. Notified the ED physician and charge nurse of patient departure. Patient left without signing form prior to leaving. The patient eloped.” . “Clinical Impressions: First Trimester Pregnancy.” . Patient #1 presented with a complaint of possible miscarriage, abdominal pain, and spotting. Patient #1 was not provided with an ultrasound to evaluate and determine the existence or non-existence of the fetus. Facility A failed to provide a complete medical screening examination. . Review of Patient #21’s medical record from Facility A: . 01/18/2025 Patient #21, Facility A . 11:46 P.M.: Patient #21 arrived at Facility A’s emergency department with a follow-up request for suture removal and abdominal pain. . 11:50 P.M.: Patient #21 was triaged by Staff E. Staff E documented “Chief Complaint: ABDOMINAL PAIN and (RUQ abdominal pain and right Upper back pain). Onset. (1 months). (Suture removal on Right hand and forearm, laceration repair last 12/31/2024).” . 11:53 P.M.: Blood pressure 122/83. Heart rate 83. Respiratory rate 20. Oxygen saturation 100%. Pain 10/10. Staff A, documented a physical exam. “Appearance: Alert. Skin: (Right hand and right forearm wound dry clean and intact). Neuro: (Appears agitated).” . “PROGRESS AND PROCEDURES Course of Care: Patient is demanding Hydrocodone for their side pain. States the last doctor that saw him did not give him any pain medication and currently taking Hydrocodone belonging to his mom. When I told him that we need to do workup before prescribing Hydrocodone and may be given if indicated, he place his hand on his side pocket and appeared to be trying to pull something out of his pocket. Security guard was called. Suture has been removed by RN already. Patient is escorted by the security out of the building.” . 01/19/2025 . 12:00 A.M.: Staff F, physical assessment documentation. “Ambulatory to room. GENERAL / NEURO / PSYCH: Alert. Oriented X 4. Appears in no acute distress. RESPIRATORY: Respirations not labored. Breath sounds within normal limits. CVS: Normal sinus rhythm noted. Capillary refill less than 2 seconds. GI / GU: Abdominal tenderness. GI / GU: Abdominal tenderness in the right upper quadrant and right side of the abdomen (PAIN). Guarding present. Guarding present.” . 1:30 A.M.: Staff F nursing note states, “The patient left the Emergency Department without completion of treatment. The patient appears to be alert, oriented x4 and coherent. Notified the ED physician and charge nurse of patient departure. The patient left the Emergency Department ambulatory and via private vehicle.” . 1:56 A.M.: Staff F nursing notes states, “After the stitches were removed by RN and Tech, the patient was asking to see the physician again to ask about their abdominal pain. RN and Charge RN went to notify the Physician multiple times that the patient wished to see the physician again about their medical condition. The physician refused and said they would not go back to the patient room to see the patient. The patient was then made aware multiple times that the physician refused to see them again. The patient then walk out of the room with their phone camera on and as he was walking out toward the secretary desk said they had the conversation with the doctor in the room recorded on their phone and will record this whole incident. Security was notified. Incident report was filed by charge RN.).” . Diagnosis: Suture Removal Patient #21 presented with suture removal and abdominal pain. Patient #21 requested a physician assess their abdominal pain, which was a 10 out of 10. The physician refused to assess the patient, denying the request. Facility A failed to provide a medical screening examination. . Record review of Emergency Medical Treatment and Active Labor Act policy, Approved 10/2024: “Policy If an individual comes to the Emergency Department: A.The Hospital will provide an appropriate medical screening examination by a Qualified Medical Person within the capability of the Hospital’s Emergency Department to any individual seeking an examination; or if a representative acting on the individual’s behalf requests an examination or treatment for an emergency medical condition for the individual; or it is apparent that the person needs an examination or treatment of a medical condition based on the individual’s appearance or behavior. The medical screening examination will include ancillary services routinely available to determine whether or not an emergency medical condition exists.” . “Procedure B Medical Screening Examination The hospital shall provide a medical screening examination to any individual who comes to the Emergency Department.” . Record review of Emergency Department Triage Criteria, Approved 09/2023: . “ESI Level 2- Emergent High risk conditions, major illness or injury; immediate life/organ threat and high liability risk, unstable vital signs; sever pain/distress which require high resource intensity.” . “ESI Level II - Emergent Standard: Those patients who present with evidence of an immediate threat of loss of life, limb or organ damage. A patient is critically ill and a delay in evaluation and care will compromise the patient’s outcome. The patient is in a high-risk condition, new onset on confusion, lethargy, or disorientation or new onset of severe pain and or distress.” . Record review of OB (obstetric) Ultrasound policy, Approved 02/2024: “Policy Prior to performing an OB ultrasound, we must obtain a recent positive pregnancy test. . Exceptions Prior recent scans showing pregnancy. Sent from an OB physician with h/o (history of) pregnancy.” . “Procedure Due to the different scanning parameters for an OB pelvic ultrasound vs (versus) a non-OB pelvic ultrasound we will need a positive pregnancy test prior to imaging the patient. . A urine pregnancy test should be administered due to the quick turn around time of the test. An HCG should be done to correlate the pelvic ultrasound results with the appropriate HCG results. . Due to the time delay on some HCG exam results we will not wait for the results of this exam prior to scanning the patient. The urine pregnancy test will be sufficient.” . Interviews: . An interview with ED Director, Staff C on 06/09/2025 at 11:01 A.M. was conducted. Staff C indicated, “Less than twenty (20) weeks gestation, triage like normal. Typically, they all (patients) receive an ultrasound. Ultrasound technicians are on call. Then they’re medically worked up.” “Greater than twenty (20) weeks go to triage, and the physician sees them there to see if they’re in active labor. If they are, we stabilize them and transfer them.” . An interview with ED RN Staff B on 06/10/2025 at 2:00 P.M. was conducted. Staff B indicated that they are a certified obstetrics nurse and has previously worked in labor and delivery. Staff B stated that all pregnant patients get ultrasounds once the pregnancy has been confirmed. When Staff B was asked about Patient #1 being ordered an ultrasound, and then the order being discounted. Staff B stated, “That I do remember. I ordered it thinking we would do it like usual, and (Staff A) said we’re not doing the ultrasound.” Staff B reports that the evaluation for a possible miscarriage is an ultrasound. Staff B indicated that signs and symptoms include bleeding, cramping, and, depending on the gestational age, fetal movement. . An interview with ED RN Staff F on 06/18/2025 at 7:59 A.M. was conducted. Staff F remembered patient #21. Staff F states that the patient arrived at Facility A for suture removal and complained of abdominal and back pain. Staff E indicated that the physician assessed Patient #21’s sutures; however, the patient requested to speak to the doctor regarding the stated pain. Staff F stated that both Staff F and the charge nurse on duty notified the physician several times of the patient’s request. Staff F indicated that the “doctor kept refusing to go back to see the patient.” . An interview with ED Physician Staff A on 06/18/2025 at 2:53 P.M. was conducted. Staff A indicates that any patient who comes to the emergency department with concerns of a miscarriage will receive a urine analysis, a quantitative serum HCG test, and an ultrasound. Staff A stated that all orders were cancelled by staff, including the ultrasound and fetal heart tones. Staff A states that if they put in orders they want them done, they are not sure why these orders were cancelled. When inquiring about Patient #21’s request for assessment, Staff A stated that the patient was a “security threat” and Staff A “did not have a chance to do a comprehensive evaluation.” . An interview with ED Physician Staff A on 08/13/2025 at 3:30 P.M. was conducted. Staff A explained how early fetal heart monitoring can be ordered. “Fetal heart tones (FHT) can be detected or monitored reliably by a handheld Doppler device by 10 to 12 weeks of gestational age. FHT can be detected earlier by Transvaginal US (ultrasound) by 5-6 weeks of GA (gestational age). By ACOG (American College of Obstetricians and Gynecologists) guideline, FHT by handheld Doppler should be used to confirm fetal viability after 12 weeks of GA and by Transvaginal US earlier if needed for viability or dating.” . Staff A explained when a provider would order fetal heart tones or an ultrasound. “FHT by handheld Doppler alone vs formal US depends of clinical context, GA and goals for the evaluation. FHT: can be obtained on all OB (obstetrics) patients to provide reassurance in patients with GA >=10-12 weeks GA, provided fetal viability and IUP (intrauterine pregnancy) was done by prior imaging and patient has no abdominal pain, vaginal bleeding or trauma. TV (transvaginal) OB US is preferred if, GA <10-12 weeks GA, if fetal viability is in question or was not confirmed previously, r/o(rule out) ectopic pregnancy, or suspect pregnancy complications ie. (for example) decreased fetal movement, threatened abortion, amniotic fluid leak, subchorionic hemorrhage or placental abruption. Combined FHT and US can be ordered in patient with anxiety about fetal well-being, FHT at bedside followed by US evaluation.” . Staff A explained why fetal heart tones were ordered for Patient #1. “Although fetal heart tone (FHT) detection by handheld Doppler is typically reliable only after 10-12 weeks of gestational age, it may be attempted earlier in the Emergency Department as part of an initial maternal-fetal assessment, particularly in symptomatic patients when gestational age has not yet been confirmed by formal transvaginal ultrasound. While fetal cardiac activity may occasionally be detected by 8 weeks, (since the fetal heart is formed and beating by this time), absence of audible tones at this stage should not be interpreted as fetal demise. In this case, FHT was ordered while awaiting transvaginal OB ultrasound and laboratory results to expedite care, provide potential early reassurance, and document timely fetal viability assessment in a patient with first-trimester bleeding and a history of prior miscarriage.” . An interview with the Director of Quality, Staff D on 08/13/2025 at 3:30 P.M. was conducted. Staff D was asked what time Patient #1 left Facility A. In an interview with Staff A, they stated Patient #1 eloped at 3:10 P.M. However, it is documented in Patient #1’s chart that they eloped at both 4:14 P.M. and 5:01 P.M. Staff D states, “I reviewed the patient chart as well and I can see on the track board in a comment section there is a comment at the patient is not in room at 15:10 (3:10 P.M.). As there are various reasons that a patient may not be in the room the team made attempts to locate the patient. Documented at 17:01 (5:01 P.M.) they had been unable to locate the patient and had paged the patient three time with no response and determined at that point that the patient eloped. Attempting to locate the patient is normal practice before documenting disposition. Unfortunately, there is not any documentation of the times of the three attempts to verify disposition time.” . Staff D provided an image of the tracking board that shows Patient #1’s identity, chief complaint, attending physician, primary nurse, disposition, notes, and date. Within the notes section, it is documented, “pt (patient) not in room 1510 (3:10 P.M.).””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 37325 Based on record review and interview the facility failed to make the hospital record of 9 of 9 (Patients #2, #3,#4,#5,#6, #7, #8, #9, and #10) Patients medical records readily available. Findings included: Based on a list of medical records requested from the hospital that had not been fulfilled compiled on 01/28/25 by Personnel #4. The hospital received a request for medical records for Patient #2 from a law firm on 06/24/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #4 from a law firm on 06/30/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient#7 from the patient on 08/23/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient#10 from the patient on 08/23/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #5 from a law firm on 09/08/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #8 from a law firm on 10/01/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #6 from disability services on 10/09/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #3 from the patient on 11/14/24. The request has not been fulfilled as of 01/28/25. The hospital received a request for medical records for Patient #9 from the patient on 12/30/24. The request has not been fulfilled as of 01/28/25. During an interview on 01/28/25 at 09:50 AM Personnel #4 stated there were 594 request for medical records that had not been fulfilled as of 01/28/25. Personnel #4 stated the facility sold in October of 2023. The facility was to have access to the medical records through the electronic medical records provider for one year. On 05/31/24 the facilities access to the medical records was terminated by the previous owners, three months early. Personnel #4 stated the hospital currently does not have access to the medical records. The hospital’s policy titled Release of Patient Information approved 12/23 reflected...”G. Access to Health Care Information. Information from the Hospital...Within 15 days of the request, the Hospital will comply with a request or notify the patient that the requested information does not exist or cannot be found...””

“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: 33589 Based on record review and interview, the facility failed to ensure each patient was informed of the patient’s rights (or when appropriate, the patient’s representative as allowed under State law), citing 7 of 7 patients (Patient #12, #13, #14, #15, #16, #17, and #18) were not informed of the patient’s rights including the mechanism to report patient complaints. FINDINGS Patient #12, #13, #14, #15, #16, #17, and #18 were not informed of the patient’s rights including the mechanism to report patient complaints. The signed consent form used on 7/14/2024 for each of the patients did not include the required patient rights and complaints information. During record review and interview on 7/16/2024 ending at 2:15 PM, Personnel #2 reviewed the records and confirmed the rights/complaint information was not included on the signed consent form for each patient. After record review revealed the form being used on 7/14/2024 with patients did not contain the patient rights and complaint information, Personnel #2 provided an updated form that included Rights and Complaints information that could be implemented.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 33589 Based on record review and interview, the facility failed to ensure each patient was informed of the patient’s rights (or when appropriate, the patient’s representative as allowed under State law), citing 7 of 7 patients (Patient #12, #13, #14, #15, #16, #17, and #18) were not informed of the patient’s rights including the mechanism to report patient complaints/grievances. FINDINGS Patient #12, #13, #14, #15, #16, #17, and #18 were not informed of the patient’s rights including the mechanism to report patient complaints/grievances. The signed consent form used on 7/14/2024 for each of the patients did not include the required patient rights and complaints/grievance information. During record review and interview on 7/16/2024 ending at 2:15 PM, Personnel #2 reviewed the records and confirmed the rights/complaint information was not included on the signed consent form for each patient. After record review revealed the form being used on 7/14/2024 with patients did not contain the patient rights and complaint information, Personnel #2 provided an updated form that included Rights and Complaints information that could be implemented.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 33589 Based on record review and interview, the facility failed to ensure the incident reporting system was engaged to document all incidents with evaluation, follow-up, and corrective actions, citing 11 of 11 patients did not have incident reports documented to show the deviation of intended intervention/care. 5 of 5 patients (Patient #1, #2, #3, #4, and #5) did not have Troponin results as ordered; AND 6 of 6 patients (Patient #6, #7, #8, #9, #10, and #11) did not have Potassium results as ordered. FINDINGS Patient #1, #2, #3, #4, and #5 had Troponin (lab work) ordered with no result. Patient #6, #7, #8, #9, #10, and #11 had Potassium (Lab work) ordered with no timely result. During an interview on 7/16/2024 at 9:10 AM, Personnel #1 stated was asked about both Troponin and CMP labs. Personnel #1 stated we had issues with lab reagents on 6/12/2024. The troponin and potassium labs were effected. The results were delayed until reagents could be secured. During an interview on 7/16/2024 ending at 10:17 AM, Personnel #2, #3, and #4 were present. Personnel #2 stated only one Potassium was not resulted. It was for a outpatient surgery that was scheduled. The patient did not have pre-op labs and they wanted a potassium prior to going into surgery. Due to reagent issues, the lab could not result it by that time and due to proximity and pick up they could not result within the hour if it was sent to the reference lab. The Surgeon decided to cancel for that day. There were no other potassiums without result. They were asked for a list of un-resulted potassiums. A stack of 5 patients (2 STAT orders, 3 Routine orders) with potassium orders that could not be resulted at the time of the order was provided. Personnel #2 stated later in the day results were completed after reagent was secured. They were asked for documentation of the incidents. They stated there were no incident reports completed. The facility’s April 2024 revised “Occurrence_ Incident Reporting” policy required, “a confidential, non-punitive, systems-based approach to the identification and reporting of incidents and near misses...comfortable in reporting all incidents and near misses...leaders of the organization are responsible for fostering such an environment through their personal example and by establishing mechanisms that support effective responses to actual occurrences..Unintentional Unsafe Acts Are unintended acts, either of omission or commission, or an act that does not achieve its intended outcome...Incident: An unintended event, unexpected or out of the ordinary, no matter how trivial, that could have harmed or did harm to a patient. A clinical incident is an occurrence inconsistent with the accepted professional standards of patient care, or routine organizational policies and procedures...Hazardous Condition: Any set of circumstances (exclusive of the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome...Adverse Events: Are events that may result from acts of commission or omission such as administration of the wrong medication, FAILURE to make a TIMELY diagnosis or INSTITUTE THE APPROPRIATE THERAPUTIC INTERVENTION, adverse reactions or negative outcomes of treatment...An occurrence report is completed whenever there is an event involving a patient, which is: 1. Inconsistent with the accepted routine operation of the hospital, regardless of outcome. 2. Inconsistent with the routine care of a patient, regardless of outcome. 3. An unusual or unexpected response by the patient to standard treatment or medical intervention.””