Memorial Hospital

“A Life Safety Code (LSC) survey was conducted at Memorial Hospital on 9/3/2025. An entrance conference was conducted on the morning of 9/3/2025 with the Chief Executive Officer (CEO) and Director of Maintenance to discuss the purpose of the LSC compliant and the survey process. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. A LSC exit conference was conducted on the afternoon of 9/3/2025, with the CEO and Director of Maintenance. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 29106 Based on observation during the walk-thru with the Director of Maintenance on the morning of 9/3/2025, the requirement for exit doors is not met. The doors at the end of the Med Surge corridors had thumb turn locks. Panic hardware is required. Replace the hardware.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 29106 Based on observation during the walk with the Director of Maintenance on the morning of 9/3/2025, the requirement for rated separation of the Emergency Electrical panels and Transfer switches from normal power panels is not met. The Emergency Electrical room and the normal power room did not have rated doors and frames installed. Submit an application to ARU to replace the doors and frames. Provide an application number in this plan of correction.”

“Gas Equipment - Other CFR(s): NFPA 101 Gas Equipment - Other List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 11 (NFPA 99) This Standard is not met as evidenced by: 29106 Based on observation during the walk thru of the facility with the Director of Maintenance on the morning of 9/3/2025, the requirement for med gas source room in relation to electrical devices is not met. The Electrical receptacles and switch are neither protected or located at a distance of 5’ above finish floor within the Med Gas room.”

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, the facility failed to provide emergency care necessary to meet the needs of its inpatients and outpatients based on: * 3 of 3 ER physicians reviewed had no delineated privileges to provide services at the hospital. * 3 of 3 ER physicians reviewed did not possess the required certifications required by the Medical Staff bylaws and the credentialing process. Cross refer to C0894”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 28422 Based on a review of facility documentation, personnel files and an interview with staff, the facility’s organizational structure failed to have a governing body or individual to implement policies to provide quality health care in a safe environment as evidenced by the following: * 1 of 1 respiratory therapists did not possess the certifications required by the facility’s job description for a respiratory therapist. * 2 of 3 surgical technicians did not possess the certifications required by the facility’s job description for a surgical technician. * 1 of 2 registered nurses that provided care in the med/surg unit, telemetry unit, emergency department, post-partum unit and larbor & delivery unit did not possess the certifications required by the facility’s job description for the same. * 1 of 1 registered nurse, first assist that provided care in the operating room did not possess the certifications required by the facility’s job description for a registered nurse, first assist. * 7 of 8 radiologic staff did not possess the certifications required by the facility’s various job descriptions for direct-care staff employed in the radiology department. Cross refer to C0962”

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, surgical procedures were not provided in a safe manner by qualified practitioners who had been granted clinical privileges by the governing body and also did not possess the certifications required by the credentialing department for their specific roles. * 1 of 1 general surgeon had no delineation of privileges and lacked certifications required by the credentialing department. * 2 of 3 OB-Gyn surgeons had privileges that had been granted in 2011 and lacked certifications required by the credentialing department. * 1 of 3 OB-Gyn surgeons had no delineation of privileges and lacked certifications required by the credentialing department. * 3 of 3 CRNAs (anesthesia providers) had no delineation of privileges and lacked certifications required by the credentialing department. Cross refer to C1142 Cross refer to C1145”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-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 coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 31690 Based on observation, interview, and record review, the facility failed to meet the Conditions of Participation for Infection Control as evidenced by, * The facility did not have an individual appointed to the role of Infection preventionist or infection control professional responsible for the infection prevention and control program. Cross refer to C1204 The facility failed to have an Infection Control program that adheres to nationally recognized infection prevention and control guidelines by: 1. The facility failed to ensure the temperature and humidity level were within acceptable ranges in the Operating Rooms, Scope Room, and Sterile Supply Room. 2. The facility failed to ensure that equipment that is sterilized for reuse is packaged according to the approved policy. 3. The facility failed to ensure that staff wore the appropriate surgical attire that provides a barrier between personnel and the patient. 4. The facility failed to ensure that provide a clean and sanitary environment to avoid sources and transmission of infection when disinfecting the blood glucose monitor. Cross refer to C1208”

“PERSONNEL CFR(s): (1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse specialist with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on site within the following timeframes: (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in paragraph (d)(1)(ii) of this section; or (ii) Within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met: (A) The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by CMS, under section 1820(b) of the Act. (B) The State has determined under criteria in its rural health care plan, that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH. (C) The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency. (2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if- (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient’s request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH’s bylaws or rules and regulations. (3) A registered nurse satisfies the personnel requirement specified in paragraph (d)(1) of this section for a temporary period if-- (i) The CAH has no greater than 10 beds; (ii) The CAH is located in an area designated as a frontier area or remote location as described in paragraph (d)(1)(ii)(A) of this section; (iii) The State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation on the issue of using RNs on a temporary basis as part of their State rural health care plan with the State Boards of Medicine and Nursing, and in accordance with State law, requesting that a registered nurse with training and experience in emergency care be included in the list of personnel specified in paragraph (d)(1) of this section. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of emergency services in the States. The letter from the Governor must also describe the circumstances and duration of the temporary request to include the registered nurses on the list of personnel specified in paragraph (d)(1) of this section; (iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this section, a CAH must submit documentation to the State survey agency demonstrating that it has been unable, due to the shortage of such personnel in the area, to provide adequate coverage as specified in this paragraph (d). (4) The request, as specified in paragraph (d)(3)(iii) of this section, and the withdrawal of the request, may be submitted to us at any time, and are effective upon submission. This Standard is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation, outside contract and an interview with staff, the facility failed to provide emergency care necessary to meet the needs of its inpatients and outpatients, as 3 of 3 emergency room physicians had no delineation of privileges and also did not possess the appropriate certifications as required of ER physicians by the facility’s Medical Staff Bylaws, Rules and Regulations, credentialing office or ER physician contract. Findings were: A document provided on 11-28-23 by staff #53 (authenticated with printed name, signature and date of staff #53) stated that the following certifications were required of ER physicians: * PALS (pediatric advanced life support) * ACLS (advanced cardiac life support) * ATLS (advanced trauma life support) Review of the facility’s contract with WEST TEXAS ACUTE CARE PHYSICIANS LLC (contracted by the facility to provide emergency room physicians) revealed the following: (beginning on) Page 1: “Recitals: A. District, a statutorily created Texas hospital district, is a political subdivision of the State of Texas and is charged with providing all necessary hospital and medical care for its needy inhabitants. District owns and operates a hospital (the “Hospitaf’) with an emergency room at the location set forth on Exhibit A attached hereto (the “ER”). B. Practice and District desire to enter into an agreement pursuant to which Practice will exclusively provide all emergency medicine physician staffing needs for the operation of the ER. C. In connection with the operation of the ER and provision of emergency medicine physician staffing, District requires the professional services of physicians (“Physicians”) who are qualified to provide emergency medical treatment and care for patients at the ER. D. Practice desires to arrange to provide for emergency medicine physician coverage of Professional Services ( as hereinafter defined) and Medical and Trauma Director services and District desires to engage Physicians of the Practice who are duly licensed, trained, qualified and experienced in furnishing the Professional Services to the ER’s patients (with all such individuals providing Services under this Agreement hereinafter referred to individually as a “Covering Provider” and collectively, the “Covering Providers”). 1. PRACTICE’S OBLIGATIONS. ... ( c) Practice Requirements. Practice shall ensure that the following minimum qualifications and requirements are satisfied: ... (iii) During the Term, the Medical and Trauma Director and each Covering Provider has or will obtain and shall maintain appropriate clinical privileges and credentialing as emergency medicine providers at the District.” Facility Bylaws, Rules and Regulations (last updated in 2004) stated the following: (beginning on) Page 7, Section 3: “SECTION 3. CONDITIONS AND DURATION OF APPOINTMENT A. Initial appointments and reappointments to the Medical Staff shall be made by the Governing Body. The Governing Body shall act on appointment, reappointment or revocation of appointments only after there has been a recommendation from the Medical Staff as provided in these Bylaws; provided that in the event of unwarranted delay (i.e., 60 days from the date of the application) on the part of the Medical Staff, the Governing Body may act without such recommendation on the basis of documented evidence of the applicant’s or staff member’s professional and ethical qualifications obtained from reliable sources other than the Medical Staff. B. All initial appointments for any applicant shall be to the Provisional Staff and shall be for twelve months. A member of any of the Provisional Staff may be reappointed for any additional twelve month period, but not more than one. C. Following the completion of a Provisional Staff appointment, appointments to the regular Courtesy Staff, Consulting Staff or the Active Medical Staff shall be for a period extending to the end of the current Medical Staff year of the Hospital, and reappointments shall be for a period of not more than two Medical Staff years. D. For the purposes of these Bylaws, the Medical Staff Year commences on the first day of January and ends on the last day of December each year. All appointments and reappointments will follow the procedure outlined in Article VI. E. Appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing body in accordance with these Bylaws.” (beginning on) Page 14: SECTION 9. EMERGENCY DEPARTMENT STAFF A. The Emergency Department Staff shall consist of those physicians who are admitted to the Medical Staff through the appointment process outlined in these Bylaws. Each member of the Emergency Department Staff shall first be appointed to the Provisional Staff and, upon satisfactory completion of the initial provisional period, shall be evaluated for advancement to the regular Emergency Department Staff. B. The members of the Emergency Department Staff shall receive privileges commensurate with the physician’s abilities. They may be granted those privileges held by members of the Active or Courtesy Staff, except to the extent limited by the Credentials Committee or explicitly by these Bylaws. C. Members of the Emergency Department Staff shall be assigned to and be monitored by the Chief of Staff or the ER Committee Chairman. They shall not be eligible to admit patients to the Hospital in their name unless granted this privilege explicitly after application. Members of this staff shall be able to treat hospital inpatients or outpatients who, on an emergency basis, require immediate care and may deliver necessary medical care until the patient’s attending physician can be contacted. Members of the Emergency Department Staff shall not be allowed to vote or hold office and are not required to attend staff meetings. They may be assigned to committees, but shall not serve as Chairman. D. Emergency Department Staff privileges are granted pursuant to a contractual agreement to provide physician coverage within the hospital’s emergency room. Such privileges shall be automatically terminated upon the expiration or termination of the contract or upon the termination or resignation of the physician employee from the contractor. Emergency Department Staff members whose privileges are terminated pursuant to this clause are not entitled to any right of appeal or other due process procedure provided for in these Bylaws.” (beginning on) Page 23 “Clinical Privileges SECTION 1. CLINICAL PRIVILEGES RESTRICTED A. Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the Governing Body, except as provided in Sections 2 and 3 of this Article VI.” The credentialing files for 3 ER physicians were reviewed (staff #17, #18, #19). None of the 3 physicians had delineated privileges to provide emergency services for the facility and none of the 3 physicians possessed the appropriate certifications as required of ER physicians by the facility’s Medical Staff Bylaws, Rules and Regulations or credentialing paperwork. * Staff #17 held current appointment as Provisional Status in Emergency Medicine effective 4-25-23 through 4-24-24. Staff #17’s ATLS certification had expired on 6-13-18. PALS and ACLS certifications had been obtained through an online testing company, which required no in-person, return demonstration of skills. * Staff #18 held current appointment as Active Status in Emergency Medicine beginning 3-3-19 and effective through 4-26-24. Staff #18 had no documentation of ATLS. PALS and ACLS certifications had been obtained through an online testing company, which required no in-person, return demonstration of skills. * Staff #19 held current appointment as Active Status in Emergency Medicine beginning 6-10-21 and effective through 4-26-24. Staff #19 had no documentation of ATLS. PALS and ACLS certifications had been obtained through an online testing company, which required no in-person, return demonstration of skills. Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, “No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements.” Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541. The above findings were confirmed with the facility CEO on 11-29-23, who concurred that the ER providers reviewed had no delineation of privileges nor were in possession of the certifications required by the credentialing office, the ER provider contract or facility Bylaws, Rules and Regulations.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 31690 Based on observation and staff interviews, the facility failed to maintain the proper temperature and humidity levels in each of the hospital operating/procedure rooms, scope room, and sterile supply room. Humidity levels outside accepted ranges have the potential to impact equipment integrity and functionality, promote microbial growth and can compromise the integrity of wrapped sterile instruments and supplies. Temperatures affect patient comfort and well-being. Thus, this deficient practice had the potential to affect the safety and well-being of any patient undergoing surgery in the hospital. Findings were: Facility policy NUR-OR-045, entitled Humidity and Temperature in the Operating Room, last revised 6/13/22, included the following: “...The humidity and temperature of the air supplied to all operating rooms will be monitored. The Maintenance Department will be notified should the humidity and/or temperature of the supplied air fall out of the recommended ranges. The Maintenance Department and Operating Room will take remedial actions as necessary and maintain appropriate documentation... Any deviations outside of the ranges will be recorded and reported to the Infection Control Committee quarterly...” Review of the Temperature and Humidity Logs for August 2023 thru October 2023 reflected that the temperature and humidity were out of range for each of the operating rooms, scope room, and sterile supply room for most days. During an interview on the afternoon of 11/27/23, Staff # 50, OR Director, verified the findings. When asked if she monitored the logs, she replied “no.” OR Acceptable ranges: Temperature: 68-73º F Humidity: 30%-60% OR#1: August 2023: Temperatures ranged from 64º to 67º F, no documented days were within the acceptable range. Humidity ranged from 61% to 67%, no documented days were within the acceptable range. OR#2: August 2023: Temperatures ranged from 59º to 76ºF, with 2 days being within the acceptable range. Humidity ranged from 55% to 76%, with 2 days being within the acceptable range. Scope Room: August 2023: Temperatures ranged from 63º to 66º F Humidity ranged from 38% to 72%, with 2 days being at 48% Sterile Supply Room: August 2023: Humidity ranged from 25% to 26% September and October 2023 temperature/humidity levels for each of the ORs, the Scope Room, and Sterile Supply Room were similar. The log sheet for each month included the following statement: “If any parameters are out of range, please contact maintenance at 4858.” There was documentation on most readings stating, “maintenance knows or maintenance called,” there was no corrective action had been taken to bring the levels within acceptable range. These findings were confirmed a final time in an interview with Staff #1, hospital CEO, and other administrative staff on the morning of 11/29/23 in the hospital conference room. A January 2015 joint statement from the Ambulatory Surgery Center Association (ASCA), American College of Clinical Engineering (ACCE), American Hospital Association (AHA), American Society for Healthcare Engineering (ASHE), American Society of Anesthesiologists (ASA), American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE), Association for Healthcare Resource & Materials Management (AHRMM), Association for the Advancement of Medical Instrumentation (AAMI), Association of perioperative Registered Nurses (AORN), Association of Surgical Technologists (AST), Health Industry Distributors Association (HIDA), and the International Association of Healthcare Central Service Materials Management (IAHCSMM) included the following: “ ...Relative humidity can impact the shelf life and product integrity of sterile supplies. Some products, such as biological indicators and chemical indicators used for sterilization monitoring and EKG electrodes used for patient monitoring, are very sensitive to humidity... Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly ...””

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 31690 Based on observation, interview, and record review the facility failed to ensure proper storage of vaccinations. Vaccinations were found in the nursing conference room refrigerator. This failure could result in contamination, decrease of stability, or effectiveness of the medication. Findings include: Observation on the morning of 11/28/23 in the nursing conference room reflected one opened vial of Tuberculin, Purified Derivative, Diluted Aplison 5TU/0.1ml, four prefilled syringes of Influenza Vaccine, Fluzone Quadrivalent 2023-2024 formula with the safety needle attached, two prefilled syringes Influenza Vaccine Fluzone Quadrivalent 2023-2024 formula with the manufacture stopper intact. Review of the Pharmacy policy # 09-01 “Medication Management-Storage”, Effective/Review Date: 4/14/22, reflected: “Medications may be stored only in authorized locations ...Medications shall be stored under the proper conditions of sanitation, temperature, light moisture, ventilation, organization, segregation, safety, and security ...” During an interview on the morning of 11/28/23, Staff #3 reported that “the medications should be kept in the medication refrigerator not in the staff refrigerator. The safety needles should not be put on until the time of use.” During an interview on the afternoon of 11/28/23, Staff #10 reported that medications should not be stored in the staff refrigerator. The stopper should not be removed from the medication and needle placed until immediately before administration.” During an interview on the afternoon of 11/29/23, Staff #4 reported that the medications had been in the staff refrigerator for “about a week.” Staff #3, Chief Operating Officer, verified these findings.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 28422 Based on a review of facility documentation, personnel files and an interview with staff, the facility’s organizational structure failed to have a governing body or individual to implement policies to provide quality health care in a safe environment, as staff employed in various roles throughout the hospital lacked certification required by their job descriptions. Findings were: * Staff #43 (respiratory therapist) was required by job description to hold various certifications, to include NRP (newborn resuscitation protocol). No documentation of current NRP certification was found in staff #43’s personnel file. * Staff #32 & #33 (surgical technicians/operating room technicians) were required by job description to hold current CPR certification. Staff #32 had no documentation of CPR certification. Staff #33 had CPR certification that had expired in July 2021. Staff #33 held CPR certification (obtained during the survey) that had been obtained online, with no in-person, return demonstration of skills. * Staff #45 & #46 (registered nurses that worked in med/surg, telemetry, emergency department, post-partum unit and labor/delivery unit) were required by job description to hold current CPR certification. Staff #46 held CPR certification that had been obtained online, with no in-person, return demonstration of skills. * Staff #52 (registered nurse that worked as a circulator and RN 1st assist) was required by job description to hold current CPR certification. Staff #52 held CPR certification (obtained during the survey) that had been obtained online, with no in-person, return demonstration of skills. * Staff members #35, #36, #37, #38, #39, #40, #41 and #42 that worked in the imaging department were required by their job description to hold current CPR. 7 of the 8 imaging department employees did not possess current CPR. Staff #35’s certification had expired June 2021. Staff #38’s certification had expired July 2022. Staff #42’s certification had expired December 2021. No CPR certifications were found for staff #36, #37, #39 or #40. Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, “No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements.” Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541. The above findings were confirmed with the facility CEO on 11-29-23, who concurred that the staff referenced above did not hold the certifications required by their job description.”

“PA, NP, & CLINICAL SPEC RESPONSIBILITIES CFR(s): The physician assistant, nurse practitioner, or clinical nurse specialist performs the following functions to the extent they are not being performed by a doctor of medicine or osteopathy: (i) Provides services in accordance with the CAH’S policies. This Standard is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, the facility failed to ensure that Nurse Practitioners provided services in accordance with the CAH’s policies. Findings were: Staff members #15 & #16, both Family Nurse Practitioners, were originally appointed to the medical staff on 8-19-19. Neither file contained any delineation of privileges. Both practitioners had identical letters in their files dated 4-26-22 that read: “We are pleased to inform you that in the regular meeting of the Board of Directors on April 25, 2022, the Board of Directors approved your application for reappointment to Active Status in Family Practice, Obstetrics, and Dermatology, with delineation of privileges as requested. Your privileges are effective until April 26, 2024.” The letter was signed by the individual serving as the CEO at the time the letter had been written. Additional, identical letters were found in both files dated 4-14-22 and read: “At a regular meeting of the District Medical Staff, [Staff #15 & #16] were granted privileges to round on inpatients at Seminole Memorial Hospital. They both will continue under the supervision of [staff #11]. These privileges will be approved annually by the Medical Staff and the Board of Directors. The letter was signed by the individual serving as Chief of Staff at the time the letter had been written. Facility Medical Staff Bylaws, Rules and Regulations (last updated in 2004) stated the following: (beginning on page 3) “1.9 The term “ALLIED HEALTH PERSONNEL” (AHP) means an individual, other than a licensed physician, dentist or podiatrist, whose patient care activities require that his authority to perform specified patient care services be processed through the usual Medical Staff channels delineating his or her qualifications, status, clinical duties and responsibilities including, but not limited to CRNAs, physician assistants, and psychologists. 1.10 The term “CLINICAL PRIVILEGES” or “PRIVILEGES” means the permission granted to a practitioner and AHPs by the Governing Body to render specific diagnostic, therapeutic, medical, dental, or surgical services.” (beginning on page 27) “SECTION 7. ALLIED HEALTH PERSONNEL A. PURPOSE 1. To describe the qualifications of Allied Health Professionals; 2. To establish the procedure for granting practice privileges for Allied Health Professionals; 3. To describe the responsibilities of Allied Health Professionals; B. QUALIFICATIONS Allied Health Professionals are non-physicians holding a license, certificate or such other legal credentials, if any, as required by Texas law, which authorizes the Allied Health Professionals to provide certain professional services. Such Allied Health Professionals are eligible for practice privileges in this hospital only if they: 1. Hold a license, certificate or other legal credential in a category of Allied Health Professionals which the Governing Body has identified as eligible to apply for practice privileges. 2. Document their experience, background, training, judgement, and physical and mental health status with sufficient adequacy to demonstrate that any patient treated by them will receive care of the generally recognized quality established by the hospital. C. PROCEDURE FOR GRANTING PRACTICE PRIVILEGES An Allied Health Professional must apply and qualify for practice privileges. Applications for granting privileges, and renewal thereof, shall be submitted and processed in a parallel manner to that provided for practitioners, unless otherwise specified in the Medical Staff Rules and Regulations.” The above findings were confirmed in an interview with the CEO on 11-29-23.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 28422 Based on a review of facility documentation and interviews with staff, the facility failed to ensure that medical records were completed in a timely manner according to regulatory standards and facility requirements and to take the appropriate actions spelled out the in Bylaws, Rules and Regulations for outstanding delinquencies. Findings were: Medical record delinquency data was requested and provided to the surveyor by staff #5 during the survey. Staff #11’s data included (but was not limited to) the following: * H&P - 34 not completed and on the charts within 24 hours * Operative Reports - 10 not completed and on the charts within 24 hours * Records incomplete greater than 30 days after patient discharge - 1 Staff #12’s data included (but was not limited to) the following: * H&P - 17 not completed and on the charts within 24 hours * Operative Reports - 1 not completed and on the charts within 24 hours Staff #13’s data included (but was not limited to) the following: * H&P - 18 not completed and on the charts within 24 hours * Operative Reports - 6 not completed and on the charts within 24 hours Facility Medical Staff Bylaws, Rules and Regulations (last updated in 2004) state the following: (beginning on page 33) “SECTION 3. AUTOMATIC SUSPENSION A. A temporary suspension in the form of withdrawal of a practitioner’s admitting privileges, effective until medical records are completed, shall be imposed automatically after warning of delinquency for failure to complete medical records. History and physical including admitting diagnosis must be completed within twenty-four (24) hours from the time of patient’s admission. Patients scheduled for surgery must have history and physical and consultation completed. Operative reports must be recorded immediately or within twenty-four (24) hours from time of surgery. Final diagnosis must be recorded at time of discharge of patient. Post anesthetic evaluation must be recorded within forty-eight ( 48) hours following surgery. Outpatient surgery ( day surgery) post anesthetic evaluation must be recorded immediately prior to discharge of patient for proper anesthetic recovery by physician or certified registered nurse anesthetic (CRNA). Evaluation of patient by a physician prior to discharge of patient on all outpatient surgeries or procedures must be completed at time of discharge. Other portions of the medical records must be completed and signed by a responsible physician within thirty (30) days from date of discharge of patient. The Medical Record Director shall notify the physician in writing of his/her delinquent medical record status within twelve (12) hours after such notice. Any physician with delinquent history and physical, operative report and consultation report twenty-four (24) hours delinquent will be automatically suspended. When the patient is dismissed with other portions of the medical record incomplete, the attending practitioner will be notified by letter from the Director of Medical Records. Five days after such notice, any practitioner with delinquent medical records will be automatically suspended from all privileges except attending patients already hospitalized under his/her care. Unless within such five days he shall have completed his/her delinquent charts or secured a letter from the Chief of Staff that extenuating circumstances warrant deferring the suspension until next regular meeting of the Medical Staff Executive Committee who shall make a decision regarding suspension. Notice of automatic suspension shall be given by the Director of Medical Records to the Practitioner and appropriate departments of the hospital. Failure to complete medical records within 60 days after suspension shall be grounds for termination of the Medical Staff membership, which would require notice to the practitioner of his rights to a fair hearing procedure set out in the Medical Staff Bylaws.” (beginning on page 74) “II. MEDICAL RECORDS 1. The attending practitioner shall be responsible for the preparation of the complete and legible medical record for each patient. Its contents shall be pertinent and current. This record shall include identification data; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations, clinical laboratory and radiology services, and other provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis, condition on discharge; summary or discharge; summary or discharge note; and autopsy report when performed. 2. A complete admission history and physical examination shall be recorded within 24 hours after admission. This report shall include all pertinent findings from an assessment of all the systems of the body. If a complete history has been recorded and a physical examination performed within 7 days to the patient’s readmission to the hospital, the these reports may be used in the patient’s hospital medical record in lieu of a new admission history and physical examination, provide these reports were recorded by a member of the Memorial Hospital medical staff. In such instances, an interval admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded. 3. When the history and physical is not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be canceled, unless the attending practitioner states in writing that such delay would be detrimental to the patient. 4. Patients progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability. Progress notes shall be written at least daily on all patients or more frequently as condition warrants on critically ill patients and those where there is difficulty in diagnosis or management of the clinical problem. 5. Operative reports shall include a detailed account of the findings at surgery as well as the details of the surgical technique. Operative reports shall be written or dictated immediately following surgery and made a part of the patient’s current medical record. Any practitioner with undictated operative reports within 24 hours following the day of the operation shall be automatically suspended from operative privileges except for any inpatients who have already been scheduled for surgery. ... 16. The patient’s medical record shall be complete at time of discharge, including progress notes, final diagnosis and ( dictated and transcribed) clinical resume. Where this is not possible, the patient’s chart will be available in a stated place in the medical record department for 30 days after discharge. If the record remains incomplete 30 days after all essential reports have been received and placed in the record, the practitioner shall be notified in writing that his admission privileges shall be suspended.” In an interview with staff #3 (COO), staff #3 stated that the physicians with delinquent medical records are notified weekly of them and are aware of them. In an interview with staff #1 (CEO), staff #1 was asked if any of the medical staff had been suspended for their medical delinquencies, as ordered in the Bylaws, Rules and Regulations. Staff #1 stated that he had not suspended any of the medical staff for delinquent medical records and didn’t have any intention of doing so. The above findings were confirmed in an interview with the CEO on 11-29-23.”

“DESIGNATION OF QUALIFIED PRACTITIONERS CFR(s): The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by-- (1) A doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (2) A doctor of dental surgery or dental medicine; or (3) A doctor of podiatric medicine. This Standard is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, the CAH failed to designate the practitioners who are allowed to perform surgery for its patients in accordance with its approved policies and procedures. Findings were: A document provided on 11-28-23 by staff #53 (authenticated with printed name, signature and date of staff #53) stated that the following certifications were required of OB-Gyn Surgeons: * PALS (pediatric advanced life support) * ACLS (advanced cardiac life support) * NRP (neonatal resuscitation program) The same document referenced above stated that the following certifications were required of General Surgeons: * ACLS (advanced cardiac life support) * ATLS (advanced trauma life support) Facility Medical Staff Bylaws, Rules and Regulations state the following regarding provider privileges: (beginning on page 7) “SECTION 3. CONDITIONS AND DURATION OF APPOINTMENT A. Initial appointments and reappointments to the Medical Staff shall be made by the Governing Body. The Governing Body shall act on appointment, reappointment or revocation of appointments only after there has been a recommendation from the Medical Staff as provided in these Bylaws; provided that in the event of unwarranted delay (i.e., 60 days from the date of the application) on the part of the Medical Staff, the Governing Body may act without such recommendation on the basis of documented evidence of the applicant’s or staff member’s professional and ethical qualifications obtained from reliable sources other than the Medical Staff. B. All initial appointments for any applicant shall be to the Provisional Staff and shall be for twelve months. A member of any of the Provisional Staff may be reappointed for any additional twelve month period, but not more than one. C. Following the completion of a Provisional Staff appointment, appointments to the regular Courtesy Staff, Consulting Staff or the Active Medical Staff shall be for a period extending to the end of the current Medical Staff year of the Hospital, and reappointments shall be for a period of not more than two Medical Staff years. D. For the purposes of these Bylaws, the Medical Staff Year commences on the first day of January and ends on the last day of December each year. All appointments and reappointments will follow the procedure outlined in Article VI. E. Appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing body in accordance with these Bylaws. F. Every application for staff appointment shall be signed by the applicant and shall contain the applicant’s specific acknowledgment of every Medical Staff member’s obligation to provide or arrange to provide for continuous care and supervision of their patients; to abide by the Medical Staff Bylaws and Rules and Regulations; and to accept committee assignments; and accept consultation assignments.” (beginning on page 22) “SECTION 3. REAPPOINTMENT PROCESS A. At least thirty days prior to the final scheduled Governing Body’s meeting in October the Executive Committee shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendation for reappointments to the Medical Staff and for the granting of clinical privileges for the ensuing period, and shall transmit its recommendations, in writing, to the Governing Body. This periodic appraisal shall occur every two years, unless the practitioner is requesting a change in clinical privileges. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented. B. Each recommendation concerning the reappointment and review for privileges shall be based upon, but not limited to, the following: 1. Current valid licensure and current DEA/DPS registration (if applicable); 2. Attendance at Medical Staff meetings and participation in staff affairs; 3. Continuing education and experience since prior appointment which qualifies applicant for privileges sought;” The credentialing files for 3 OB-Gyn Surgeons were reviewed (staff #11, #12, #14). * Staff #11 had been on staff with the facility since 1997 and the file contained current appointment through 8-29-25. A set of surgical privileges (approved in 2011) was found in the file. The file contained no documentation of PALS or ACLS certifications. NRP certification revealed an expiration date of 2-28-22. * Staff #12 had been on staff with the facility for an unknown amount of time (sheet with initial appointment date was marked “N/A”) and the file contained current appointment through 8-29-25. A set of surgical privileges (approved in 2011) was found in the file. Although the file contained documentation of PALS, ACLS and NRP certifications, they had been obtained online and no in-person, return demonstration of skills had been performed. * Staff #14 had been on staff with the facility since 8-24-21 and the file contained current appointment through 7-25-24. The file contained no delineation of surgical privileges. The file contained no documentation of PALS, ACLS or NRP certifications. The credentialing file for 1 General Surgeon was reviewed (staff #20). * Staff #20 had been on staff with the facility 5-19-20 and the file contained current appointment through 4-24-25. The file contained no delineation of surgical privileges. Although the file contained documentation of ACLS certification, it had been obtained online and no in-person, return demonstration of skills had been performed. Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, “No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements.” Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541. The above findings were confirmed in an interview with the CEO on 11-29-23.”

“ADMINISTRATION OF ANESTHESIA CFR(s): The CAH designates the person who is allowed to administer anesthesia to CAH patients in accordance with its approved policies and procedures and with State scope-of-practice laws. (1) Anesthesia must be administered by only-- (i) A qualified anesthesiologist; (ii) A doctor of medicine or osteopathy other than an anesthesiologist; including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (iii) A doctor of dental surgery or dental medicine; (iv) A doctor of podiatric medicine; (v) A certified registered nurse anesthetist (CRNA), as defined in Sec. 410.69(b) of this chapter; (vi) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter; or (vii) A supervised trainee in an approved educational program, as described in §§ 413.85 or 413.86 of this chapter. This Standard is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, the facility failed to designate anesthesia providers in accordance with its approved policies and procedures and current standards of practice. Findings were: A document provided on 11-28-23 by staff #53 (authenticated with printed name, signature and date of staff #53) stated that the following certifications were required of CRNAs (certified registered nurse anesthetists): * BLS (basic life support) * ACLS (advanced cardiac life support) Facility Medical Staff Bylaws, Rules and Regulations (last updated in 2004) stated the following: (beginning on page 3) “1.9 The term “ALLIED HEALTH PERSONNEL” (AHP) means an individual, other than a licensed physician, dentist or podiatrist, whose patient care activities require that his authority to perform specified patient care services be processed through the usual Medical Staff channels delineating his or her qualifications, status, clinical duties and responsibilities including, but not limited to CRNAs, physician assistants, and psychologists. 1.10 The term “CLINICAL PRIVILEGES” or “PRIVILEGES” means the permission granted to a practitioner and AHPs by the Governing Body to render specific diagnostic, therapeutic, medical, dental, or surgical services.” (beginning on page 27) “SECTION 7. ALLIED HEALTH PERSONNEL A. PURPOSE 1. To describe the qualifications of Allied Health Professionals; 2. To establish the procedure for granting practice privileges for Allied Health Professionals; 3. To describe the responsibilities of Allied Health Professionals; B. QUALIFICATIONS Allied Health Professionals are non-physicians holding a license, certificate or such other legal credentials, if any, as required by Texas law, which authorizes the Allied Health Professionals to provide certain professional services. Such Allied Health Professionals are eligible for practice privileges in this hospital only if they: 1. Hold a license, certificate or other legal credential in a category of Allied Health Professionals which the Governing Body has identified as eligible to apply for practice privileges. 2. Document their experience, background, training, judgement, and physical and mental health status with sufficient adequacy to demonstrate that any patient treated by them will receive care of the generally recognized quality established by the hospital. C. PROCEDURE FOR GRANTING PRACTICE PRIVILEGES An Allied Health Professional must apply and qualify for practice privileges. Applications for granting privileges, and renewal thereof, shall be submitted and processed in a parallel manner to that provided for practitioners, unless otherwise specified in the Medical Staff Rules and Regulations.” Credentialing files for 3 CRNAs were reviewed (staff #21 - #23). * Staff #21 held current appointment with the facility through 1-23-25. No delineation of privileges was found. * Staff #22 held current appointment with the facility through 1-23-25. No delineation of privileges was found. Although current certifications for BLS and ACLS were present, they had been obtained online and had no documentation of in-person, return demonstration of skills. * Staff #23 held current appointment with the facility through 11-27-24. No delineation of privileges was found. Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, “No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements.” Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541. The above findings were confirmed in an interview with the CEO on 11-29-23.”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 31690 Based on record review and interview the facility failed to ensure that the individual that is responsible for infection prevention and control is appointed by the governing body. Findings were: Review of the governing body, board meeting, minutes reflected no appointment of Staff #4 as Infection preventionist or infection control professional responsible for the infection prevention and control program. During an interview with Staff #2, COO, she reported that she could not find any appointment of the infection preventionist in the past minutes.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 31690 Based on observation, interview, and record review the facility failed to ensure that the infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources of transmission of infection by: 1. The facility failed to ensure the temperature and humidity level were within acceptable ranges in the Operating Rooms, Scope Room, and Sterile Supply Room. 2. The facility failed to ensure that equipment that is sterilized for reuse is packaged according to the approved policy. 3. The facility failed to ensure that staff wore the appropriate surgical attire that provides a barrier between personnel and the patient. Findings were: 1. Based on observation and staff interviews, the facility failed to maintain the proper temperature and humidity levels in each of the hospital operating/procedure rooms, scope room, and sterile supply room. Humidity levels outside accepted ranges have the potential to impact equipment integrity and functionality, promote microbial growth and can compromise the integrity of wrapped sterile instruments and supplies. Temperatures affect patient comfort and well-being. Thus, this deficient practice had the potential to affect the safety and well-being of any patient undergoing surgery in the hospital. Facility policy NUR-OR-045, entitled Humidity and Temperature in the Operating Room, last revised 6/13/22, included the following: “...The humidity and temperature of the air supplied to all operating rooms will be monitored. The Maintenance Department will be notified should the humidity and/or temperature of the supplied air fall out of the recommended ranges. The Maintenance Department and Operating Room will take remedial actions as necessary and maintain appropriate documentation... Any deviations outside of the ranges will be recorded and reported to the Infection Control Committee quarterly...” Review of the Temperature and Humidity Logs for August 2023 thru October 2023 reflected that the temperature and humidity were out of range for each of the operating rooms, scope room, and sterile supply room for most days. During an interview on the afternoon of 11/27/23, Staff # 50, OR Director, verified the findings. When asked if she monitored the logs, she replied “no.” OR Acceptable ranges: Temperature: 68-73º F Humidity: 30%-60% OR#1: August 2023: Temperatures ranged from 64º to 67º F, no documented days were within the acceptable range. Humidity ranged from 61% to 67%, no documented days were within the acceptable range. OR#2: August 2023: Temperatures ranged from 59º to 76ºF, with 2 days being within the acceptable range. Humidity ranged from 55% to 76%, with 2 days being within the acceptable range. Scope Room: August 2023: Temperatures ranged from 63º to 66º F Humidity ranged from 38% to 72%, with 2 days being at 48% Sterile Supply Room: August 2023: Humidity ranged from 25% to 26% September and October 2023 temperature/humidity levels for each of the ORs, the Scope Room, and Sterile Supply Room were similar. The log sheet for each month included the following statement: “If any parameters are out of range, please contact maintenance at 4858.” There was documentation on most readings stating, “maintenance knows or maintenance called,” there was no corrective action had been taken to bring the levels within acceptable range. These findings were confirmed a final time in an interview with Staff #1, hospital CEO, and other administrative staff on the morning of 11/29/23 in the hospital conference room. A January 2015 joint statement from the Ambulatory Surgery Center Association (ASCA), American College of Clinical Engineering (ACCE), American Hospital Association (AHA), American Society for Healthcare Engineering (ASHE), American Society of Anesthesiologists (ASA), American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE), Association for Healthcare Resource & Materials Management (AHRMM), Association for the Advancement of Medical Instrumentation (AAMI), Association of perioperative Registered Nurses (AORN), Association of Surgical Technologists (AST), Health Industry Distributors Association (HIDA), and the International Association of Healthcare Central Service Materials Management (IAHCSMM) included the following: “ ...Relative humidity can impact the shelf life and product integrity of sterile supplies. Some products, such as biological indicators and chemical indicators used for sterilization monitoring and EKG electrodes used for patient monitoring, are very sensitive to humidity... Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly ...” 2. The facility failed to ensure that equipment that is sterilized for reuse is packaged according to the approved policy. Observations on the afternoon of 11/28/23 in the surgical sterile supply room revealed the following: Ring Forceps/Sponge Stick clamp, sterilized on 10/19/23, in the package with the clamp closed. Tenaculum forceps, sterilized on 10/18/23, with the forceps tip closed. Curved Mayo Scissor, sterilized on 11/21/23, with the scissors closed. Straight Mayo Scissor, sterilized on 10/6/23, with the scissors closed. During an interview on the afternoon of 11/28/23, Staff #50, OR Director, stated “these instruments should be open when sterilized, not closed.” Facility Policy “NUR-OR-099, Entitled Sterilization in Perioperative Settings, last reviewed: 7/21/22, included the following: “...Items should be prepared and packaged so sterility can be achieved and maintained to the point of use. Instruments should be held open and unlocked...” 3. The facility failed to ensure that staff wore the appropriate surgical attire that provides a barrier between personnel and the patient. Observations on the afternoon of 11/29/23 in the surgical area revealed Staff #23, CRNA, at the head of the patient having a Cesarean section’s stretcher. The CRNA was wearing an Adidas sweatshirt over his operating room attire. There was no barrier over the sweatshirt. During an interview with Staff #50, OR Director, she reported that this was not proper surgical attire. Facility Policy “NUR-OR-014, Entitled Attire in the Operating Room (OR), last reviewed: 5/20/22, included the following: “Surgical attire provides a barrier between personnel and patient and between patient and personnel, through which contamination may pass...All personnel entering sei-restricted and restricted areas of the surgical suite shall be in operating room attire. Operating room attire consists of standard multi-use fabric or limited-use non-woven pant suits...All reusable attire shall be laundered after each use, by a laundry facility approved and monitored by Seminole Memorial Hospital. OR attire shall be stored in an enclosed cupboard...””