Houston Methodist Sugarland Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 37322 Based on observation and interview during the tour of the emergency department (ED) on 06/30/2026 at 1100 revealed that 2 of 5 crash carts had not been consistently checked by personnel in the department to ensure that patient’s received care in a safe setting. The facility did not have sexual trafficking signs in 3 of 8 bathrooms in the ED. Findings Included: The facility policy “Emergency Cart” dated 09/23/2025, stated F. A licensed personnel member must verify and document the integrity of the emergency cart every 24 yours when the unit is open. G. A licensed personnel member must verify and document the presence and operational readiness of the defibrillator at minimum every shift or when unit is operational. Observation of the 2 of 5 ED carts on 06/30/2026 at 1100 revealed the emergency carts were not checked daily per hospital policy: Crash cart on the ambulatory side had missing checks on the following dates; 06/04/2026, 06/05/05, 06/08/2025 Second Cart: was missing cart checks on: 06/11/2026, 06/15/2026, 06/29/2026. Three (3) bathrooms out of eight (8) rooms were found not to have sexual trafficking signs posted. Rooms- M1729F, M1739T, M1622T Interview with nurse (ID#H) who validated the findings and stated the carts should be checked once a day. She also stated the signs in the bathrooms were just there.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to ensure an appropriate transfer for two (2) patients ( Patients ID # 12, #13 ). These two patients were discharged to police custody / CI Team for transport to a psychiatric facility. The facility failed to obtain an accepting physician and hospital; failed to complete a Memorandum of Transfer (MOT); and failed to send any medical records to the hospitals to which these patients were transported. Findings included : Review of facility policy titled “EMTALA & Patient Transfers,” last revised date 09/24/2024, showed: D. Appropriate Transfers: 2. The Hospital must arrange for an Appropriate Transfer if the Hospital does not have the Capability or Capacity to Stabilize or treat the individual’s Emergency Medical Condition, the individual requires a Higher Level of care, or the individual requests to be transferred. IV, DOCUMENTS : A. Medical Records: With respect to transfers, the Transferring Hospital will send to the receiving hospital a copy of all thee individuals medical records that are available at the time of Transfer and relevant to the Transfer and to the continuing care of the individual. Records that are unavailable at the time of transfer must be forwarded to the receiving physician and hospital as soon as possible. B. Memorandum of Transfer : The Hospital will provide a Memorandum of Transfer (MOT) for every individual who is transferred. The MOT will be signed by the Transferring Pshycian and Hospital administration. The MOT must contain the following information: 1. Patient’s full name, race,religion,national origin, age,sex, and any physical handicaps; 2. The Patient’s address, next of kin, and phone number if known; 3. The name, telephone numbers, and addresses of both the transferring and receiving physicians and hospitals; 4. The date and time the Patient first presented or was presented to the Transferring pshycian and transferring hospital; 5. The date and time on which the transferring physician secured a receiving physician; 6. The name date and time hospital administration was contacted in the receiving hospital. A copy of the MOT will accompany the individual being transferred. A copy of the MOT will be retained by both the transferring and receiving hospitals for five years from the date of Transfer, and filed separately from the medical record. ~~~~~~~~~~~~~~ During an interview on 12/19/2025 a 10:40 A.M with Staff-F, ED Manager, said the hospital recently implemented a new process for psychiatric patients who present with Suicidal ideation. She said “if patients are suicidal: the provider does a medical screening exam and medically clears them. We reach out to Sugar Land Crisis Intervention Team (CIT) if we believe the patients need an inpatient bed. The officer comes and interviews the patient, facilitates a Texana mental health evaluation; and obtains a psychiatric hospital bed .We discharge the patient to custody of the CIT officer. They transport the patient to psychiatric hospital.” Surveyors selected two (2) patients who had been discharged through the CI Team [Patients # 12, 13). Review of these clinical records with Staff-G, ED Manager, showed : Patient ID # 12: [Methodist Sugar Land record ] Patient ID # 12 was a 26-year-old female who presented voluntarily via private car to the ED on 8/5/2025: 8:38 AM: Arrival by car: arrival complaint: suicidal ideation 8:40 AM :Triage: Acuity level -2 MSE was initiated; patient was placed on suicide precautions, sitter in room. 9:44 AM- Discharge order written: NP (Staff ID -K) 9:54 AM: “Officer (Name), Sugar Land PD arrived and spoke to patient.” 10:42 AM: “Pt was taken to Hospital B under custody of police.” ED Course: 8/8/2025 (time 11:07 PM)- NP (Staff ID-K): Medical Decision Making: patient presenting with suicidal ideation and attempt on Sunday ... Patient states she “attempted to cut her throat with a box cutter. “... “Patient is medically cleared by NP provider. Charge nurse notifies Sugarland PD. Plan of care discussed with patient/ family --patient / family agreed to plan. Patient is stable and non-toxic. Patient was taken to Hospital B under police custody.” Continued review of the medical record failed to show: a) Memorandum of Transfer (MOT) to include physician certification and summary of risk/benefit of transfer; and no acceptance from a receiving hospital. b) No documented communication between Methodist hospital staff and Hospital-B [the facility that was obtained via CIT process & was the location where patient was transported following discharge]. C) No evidence that any medical record or clinical information was sent or taken to Hospital-B. During an interview on 12/19/2025 at 1 PM with Staff-G, ED Manager, he verified the above-listed information was not in Patient’ ID # 12’s medical record. HOSPITAL-B Medical Record : Patient ID # 12 Review of Hospital-B medical record for Patient ID #12 showed: -She arrived at Hospital-B on 8/5/2025 at 12:15 PM - She was brought in by police; had Emergency Detention Order (EDO) Sugar Land police. (but signed in voluntarily) -Patient ID # 12’s admission assessment (8/5/25 at 0240) showed “she was actively suicidal with a plan. Tried to hang herself this past weekend...Numerous superficial cuts to right/left forearms and right/left thighs” -She was assessed at being high risk for suicide and placed on suicide precautions. -Sugar Land PD-EDO, dated 8/5/25, 9:21 AM, showed: “5. Name, address, relationship to the above-named person who reported or observed recent behaviors, acts, attempts/threats.: Methodist employee (name) has also witnessed these behaviors.” During an interview on 1/8/2026 at 8:40 AM with Hospital-B Quality staff, he verified Patient ID # 12 was brought in by Sugar Land PD on 8/5/2025. He had been asked earlier to email an EDO, if there was one. Quality Staff said the patient had signed in voluntarily, so he had not looked at the EDO until requested by this surveyor. He said he saw a reference in the EDO to a “Methodist employee (name).” He said “this was curious, as this patient came in directly from a police officer to our facility. We had no idea Methodist was involved.” He verified there was no MOT from Methodist Sugar Land, no clinical information sent from Methodist, and no documented communication from Methodist. ~~~~~~~~~~~~~ Patient ID # 13: [Methodist Sugar Land record ] Patient ID # 13 was a 30-year-old male presented voluntarily via private car to the ER on 8/8/2025: 2110: Arrival by car: arrival complaint: suicidal ideation 2111” MSE initiated 2111: Triage: Acuity level -2 2113: ED RN Note: “patient coming into ED due to suicidal ideation. He is planning to cut his wrist.” Patient ID # 13 was placed on suicide precautions, sitter in room. 12- lead EKG obtained Multiple laboratory tests were ordered and resulted: -Complete blood count (CBC) -Comprehensive metabolic profile (CMP) -Blood alcohol level (BAL) -Urine drug screen (UDS) [positive for opioids & cannabis] -Acetaminophen level -Salicylate level -Creatine kinase-total (CPK) 8/9/2025 (time 0030): MD discharge order written. 8/9/22025 (time 0150) Staff-ID-L, MD notes: “ED Course: suicidal ideation. Medical Decision Making: 30-year-old history of bipolar & medically cleared; police consulted, Texana interview, Discharged into police custody. Patient agreeable and voluntary. 8/9/2025 (0045): Patient ID # 13 discharged to Sugar Land police department.” Further review of the record showed: -No Memorandum of Transfer (MOT) to include physician certification and summary of risk/benefit of transfer; and no acceptance from a receiving hospital. -No documented communication between Methodist hospital staff and Hospital-A [the facility that was obtained via CIT process & was the location where patient was transported following discharge]. -No evidence that any medical record or clinical information was sent or taken to Hospital-A. During an interview on 12/19/2025 at 1 PM with Staff-G, ED Manager, he verified the above-listed information was not in Patient’ ID # 13’s medical record. ~~~~~~~~~~~~~~~~~~ HOSPITAL-A Medical Record : Patient ID # 13 Review of Hospital-A medical record for Patient ID #13 showed: -He arrived at Hospital-A on 8/9/2025 at 2:05 AM - He was brought in on Emergency Detention Order (EDO) Sugar Land police. - Patient ID # 13’s admission assessment (8/9/25 at 0240) showed “patient walked inside Methodist Hospital and stated he wanted to cut & kill himself.” - He was assessed for being at risk for suicide and immediately placed on suicide precautions & aggression /homicide precautions. -EDO, dated 8/9/25, 1206 AM, showed: “5. Name, address, relationship to the above-named person who reported or observed recent behaviors, acts, attempts/threats.: Houston Methodist Sugar Land Hospital: Registered Nurse (name). “ During an interview on 1/8/2026 at 8:40 AM with Hospital A Quality Staff, she verified Patient ID # 13 was brought in by EDO by law enforcement on 8/9/25. There was no MOT from Methodist Sugar Land, no clinical information sent from Methodist, and no documented communication from Methodist.”

“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: 46010 Based on observation, interview, and record review, the facility failed to implement an effective infection prevention program. The facility failed to: 1. ensure Neonatal ICU staff moved dirty equipment to a dedicated cleaning space prior to disassembly/cleaning of patient care equipment such as GE Care Station Isolettes. 2. ensure the humidity water was changed every 7 days per manufacturer specifications for Neonatal ICU Care Station Isolettes. 3. establish a process to ensure equipment contaminated in isolation rooms would he handled in a manner to prevent cross-contamination and transfer of microorganisms to other staff, patients or surfaces. 4. ensure that the facility competency-based checkoff training for staff cleaning of the GE Care Station Isolettes followed established infection control policies and manufacturer specifications. Findings included: Observation in the 3rd Floor Neonatal Intensive Care Unit (NICU) on 6/4/24 at 10:30 am. Unit Secretary Staff ID # 66 showed surveyor and leadership team where she had cleaned the GE Care Station Isolette. She showed a clinical bed space, adjacent to Isolation Room 337A, with a sink and counter space, immediately outside of Isolation Room 337A. There was Patient ID #3 noted to be in the room with isolation signage on the door. The sink utilized for equipment cleaning process was located outside Room 337A and other clinical patient rooms and was noted to be the sink utilized to wash hands for staff who exited the isolation room and adjacent patient rooms. Interview with Unit Secretary Staff ID # 66 on 5/4/24 at 11:00 am. She verbalized that cleaning and disinfecting neonatal ICU isolettes is a part of her role on the unit. She verbalized there was no dedicated space for cleaning that has been designated by the facility. She verbalized that she used the “purple wipes” and pointed to the “Super Sani Cloth” wipes for cleansing. She stated that units which required “deep cleansing” which she identified as units with visible soiling or staining from blood, dried milk, etc would have removable components “soaked in water in a basin” prior to cleansing. She verbalized there was not a process in place to identify if the Isolette had been in an isolation room prior to cleansing and there were no differences to cleaning process based on patient’s isolation status. Interview with NICU Nurse Manager Staff ID #59 on 6/4/24 at 2:30 pm. She reviewed the GE CareStation User Manual. She confirmed the facility unit based staff, were performing Isolette changes every 2 weeks or at discharge (if sooner). She was not aware that the manufacturer recommendations for changing the water reservoir were to be performed weekly (every 7 days). She confirmed this was not being completed. She reviewed the user manual for GE Carestation Isolettes. This included maintenance, cleaning and disinfection manufacturer recommendations. She confirmed that the removable parts of the Isolette such as tubing management grommets, canopy seals, porthole gaskets and fan had instructions to soak. She was unable to confirm what they should be soaked in, the dwell time for soaking and what/if they should be rinsed prior to drying and re-installation. She confirmed the facility does not have a dedicated space where devices are relocated to for the cleansing and disinfection process. She provided a competency checklist which was used by facility unit-based education staff for verifying competency of staff who perform these roles. She confirmed the facility did not have a procedural policy for cleaning and disinfecting Isolette units. She confirmed the competency checklist did not follow the manufacturer recommendations seen in the IFU (Instructions for Use). Interview with Infection Control Practitioner Staff ID # 70 on 6/4/24 at 3:15 pm. She confirmed there was no infection control audits or observations related to cleansing and disinfecting of equipment in the NICU that she was aware of. She was asked infection control process related to cleansing of medical equipment and devices. She stated that infection control recommends that the staff follow manufacturers recommendations. She stated that each piece of equipment has its own “IFU” (Instructions for Use). She stated that they should utilize products based on recommendations. She stated that proper “contact time” is an important part of the efficacy for different products. She confirmed that soiled equipment cleaning/disassembly should not be occurring in clinical areas. In addition, she reviewed the NICU Giraffe Omnibed Cleaning Checklist with surveyor. She confirmed there was no instructions or information related to what products should be used for cleaning, no contact or dwell time, no instructions for what agent should be used for “soaking” removable plastic parts and dwell time for soaking, etc. Record Review of the facility’s “Standard and Transmission-Based Precautions” policy, last reviewed 02/26/2024, stated “ ...Policy 1. Standard Precautions: All healthcare providers and healthcare personnel shall practice standard precautions in the care of all patients. Standard precautions apply to (1) blood; (2) all body fluids, secretions and excretions except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of micro-organisms from both recognized and unrecognized sources of infection in healthcare settings ....d) Patient care equipment ... ii. Reusable patient care equipment should be cleaned and reprocessed according to manufacturer guidelines between patient uses ... v. Soiled equipment should be handled in a manner which prevents cross contamination to the skin, mucous membranes, and clothing; and transfer to microorganisms to other patients or surfaces.” Record Review of the facility’s “Infection Prevention and Control Program Plan CY 2024”, last reviewed 1/17/2024, stated “5.7 Responsibilities of the Hospital Epidemiologist and the Infection Prevention and Control staff shall include, but not limited to, the following: ...5.7.3 Establish a process for ongoing review and evaluation of all aseptic, isolation, sterilization, disinfection, food safety, and sanitation practices. This shall also include the evaluation of equipment and supplies used for sterilization, disinfection, cleaning, and decontamination processes.” It further stated “ ...6.3.3 The following are IPC activities which have been selected for implementation during this year: 6.3.3.1 Process surveillance activities: ...6.3.3.1.4 Appropriate cleaning and disinfection of reusable patient care equipment requiring high-level disinfection and sterilization (semi-critical and critical equipment). 6.3.3.1.5. Appropriate cleaning and disinfection of non-critical patient care equipment.” Record Review of the manufacturer’s GE Giraffe OmniBed Carestation User Manual provided by Nursing Director Staff ID # 58 stated “Chapter 7: Maintenance, Cleaning and Disinfection. The following schedule lists the minimum frequencies for cleaning and disinfection. Water Reservoir. Minimum frequency Every 1 week. The humidity reservoir should be cleaned and disinfected weekly and when humidity use is discontinued. ... Cleaning and Disinfecting Method Recommendations. The following table indicates which ports may be cleaned or disinfected with each method. Method: Wipe with a disinfecting cloth. Parts: All components with the exception of the tubing management grommets, porthole gaskets, and canopy seals. Method: Soak. Parts: Tubing management grommets, canopy seals, porthole gaskets and fan. Method: Steam sterilize. Parts: Water Reservoir Method: Wipe. Parts: All device surfaces and components to remove visible debris prior to disinfection.” It further stated “Preparing to Clean and Disinfect the Device. To prepare the device for cleaning and disinfecting: 1. Gather PPE per clinical protocol. 2. Obtain recommended solutions. 3. Move the device to a work area where youhave adequate space to completely disassemble parts. Note: All parts to ne cleaned and disinfected, included rail mounted options, should be placed in an area separate from the area where clean parts are placed.4. Put on PPE per clinical protocol ...” Record Review of the facility’s “Giraffe Omnibed Cleaning Checklist”, undated, stated “Process: 1. Choose correct cleaning solution 2. Ensure all residue has been removed from the inner and outer isolette 3. Spray and wipe the outside of the isolette, moving from top to bottom. Allow appropriate soak time for cleaning solution 4. Partially raise the top of the bed 5. Clean the inside cover 6. Once finished cleaning the inside cover, raise the roof completely 7. Remove and soak all plastic bumpers (4 large portholes, 2 long, 8 small corner pieces) 8. Clean the inside and outside of the two side panels, ensuring to separate the interior wall from the outer wall. Allow for appropriate soak time. Once finished, lower the side panels 9. Clean and lower the end panel, allowing for appropriate soak time 10. Clean and remove the following base pieces, allowing for appropriate soak time. Make sure the place the clean pieces in a clean location: 11. Mattress 12. Clear mattress base 13. Bed warmer (make sure to unplug) 14. Catch tray 15. First base 16. Second base 17. Third base (make sure to appropriately release the spring clips) 18. Fourth base 19. Remove and clean the spindle, allowing for appropriate soak time 20. Clean the main base, allowing for appropriate soak time 21. Replace the spindle 22. Clean the soaking plastic items and allow to air dry while reassembling the bed 23. Rebuild the base, making sure the pieces lock into place 24. Raise the sidewalls (x3) 25. Remove and clean the water reservoir and container, allowing for appropriate soak time 26. Clean the interior of the drawer, allowing for appropriate soak time 27. Sign the “cleaned by” label and adhere to the bed “ Cleaner: Meets Cleaning Guidelines Does Not Meet Guidelines Signature: ________________________ Date: __________________ Validator Signature: ________________ Date: __________________””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to nursing adhered to facility discharge policy and professional nursing standards of practice: *Two (2) patients were discharged without nursing communicating / providing specific infection prevention discharge information (Patient ID # 1, 8 ). This deficient practice posed a significant risk for the spread of MDRO and COVID infections to other persons exposed to these patients post-discharge. Findings included: TX00492261 Review of the above listed complaint intake showed allegations that Patient ID # 1 was transferred to a nursing home without the hospital communicating the presence of multiple MDRO infections. Allegations included this oversight placed Patient # 1’s nursing home roommate, other immunocompromised patients, and staff at risk for at risk for contracting MDRO infections. ~~~~~~~ Review of facility policy titled “Discharge Planning,” revised date 09/19/2023, showed : Responsible of Nursing included “ completes all appropriate paperwork for discharge and/or transfer to post-acute care facility.” Review of Texas Administrative Code (TAC) Title 22: Examining Boards; Part 11: Texas Board of Nursing; Chapter 217- Rule 11: “ Standards of Nursing Practice” showed: ...D. Accurately and completely report and document the client’s status...”. Patient # 1: Review of the medical record of Patient # 1 with Staff ID-E, RN/PI Specialist showed he was a 69 year old male admitted on 1/13/2024 . Record review of facility policy “Infection Prevention & Control Program Plan”, date reviewed 1/17/2024 : Table 2: ‘Quick Guide for Inpatient Transmission Based Precautions ( Infection/Isolation/ duration) showed 3 columns tabled: ‘Suspected / confirmed infection;’ ‘Isolation (precaution type)’; Discontinue Isolation.” Table 2 was the reference document used when reviewing Patient # 1’s medical record / lab results. On 3/28/2024 the clinical record of Patient # 1 was reviewed with Staff-L, Infection Preventionist. She explained that specific isolation precautions and duration of precautions depended on the bacteria / isolate and date identified. Facility used Table 2 (of facility Infection Control Plan) as a reference to determine precautions and duration of isolation. ~~~~~~~~~~~~ Review of Patient ID # 1’s lab specimen culture results showed: - 1/14/2024: [ sputum culture results]: Acinetobacter calcoaceticus- Acinetobacter- baumannii complex .” This organism is multi-drug resistant.”Application of criteria in Table 2 for discontinuation of isolation showed “CONTACT” isolation for this gram negative organisms should be continued.- 1/15/2024 [ right nares culture results]: Methicillin-resistent staphlocossus-aureus PCR : detected. Table 2 showed CONTACT isolation should be continued unless one negative culture or wound is healed. - 1/27/2024 [ sacral wound culture results]: 3 organisms detected: Klebsiella pneumoniae; Escherichia coli; Proteus mirabilist. All 3 organisms are multi-drug resistant.” - 2/1/2024 [ thigh wound culture results] : 2 organisms: Klebsiella pneumoniae ( multi-drug resistant) ; Enterococcus raffinosus (Vancomycin resistant) Staff-L , Infection Preventionist, said that based on the MDRO culture results and dates, Patient #1 should have remained on CONTACT precautions post-discharge. ~~~~~~~~~~~~ During interviews conducted on 3/28/2024 on Brazos Tower-6 with three (3) RN staff ID# G, H, I : they described the process for transferring a patient from their unit to a nursing home. Their descriptions were consistent with facility policies. All three (3) RNs said if a patient was transferred with active MDRO infections and required CONTACT precautions post-transfer: this would be included in the verbal report to the nursing home. They all 3 said Contact Precautions and MDRO would be specifically documented. Additional review of Patient #1’s medical record with Staff -E, showed a Nursing Note dated 2/24/2024 at 9:54 AM read: “report called to Mariam RN Supervisor. Complete report done including past medical history, ICU stay...” This documentation did not include mention of the active MDRO infections and the need to for CONTACT Precautions to be continued at the nursing home. This was verified by Staff-E, PI Specialist. Patient # 8: Record review on 3/28/2024 of Patient #8’s medical record with Staff -E, PI Specialist, showed this patient was admitted on 2/19/2024. Review of his laboratory test results showed he tested positive for COVID on 2/22/2024. He was discharged home on 2/23/2024. Staff-E was unable to locate documentation that Patient # 8 had been provided education or information related to COVID and precautions to follow post-discharge. Staff-E said she would expect COVID education to be included in the “After Visit Summary” and it was not.”