Crescent Medical Center Lancaster

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 28637 Based on observation, record review and interviews, the facility failed to establish and enforce a clearly explained procedure for submitting a patient’s or a patient representative’s written or verbal grievance to the hospital. The findings include: The facility provided pamphlet, “Know Your Rights” distributed to patients instructed the patients to call an inactive phone number for assistance with filing a complaint or grievance. This failure could result in delays for patients and/or their representatives to have their concerns addressed. Findings included: During an observation, interview and record review on 04/01/2026 at 12:50 PM with Staff A and Staff B, a pamphlet titled, “Know Your Rights”, identified by Staff A as the same pamphlet provided to patients and families, was reviewed. The back of the pamphlet included a Section titled, “Your Responsibilities as a Patient” and included a paragraph titled, “Patient Advocate”. The paragraph reflected, “Please contact the hospitals Patient Advocate for any issues that arise while you are a patient, or after discharge. They will assist you in resolving the issue or assist with filing a complaint or a grievance. [phone number].” On 04/01/2026 at or around 12:55 PM, when asked whether the phone number was working, Staff A stated it was. Staff B dialed the number from her cell phone via speaker and “We’re sorry, the number you reached is not in service” was heard from her phone. Staff A left the room stating he was going to check on the situation and Staff B stated she was not aware the number was not working properly. She stated the number should be routed to Staff A’s office and he was responsible for checking voicemail messages. She stated the facility had recently had flooding issues within the administrative office areas that required the phone lines to be unplugged then reset and she was not sure whether that may have affected anything. Staff A returned and stated he had directed staff to make changes to the pamphlet immediately. Record review of the facility’s policy titled, Patient Rights-Complaint/Grievances, dated revised 08/2025, reflected the following: “PURPOSE: To implement and maintain a formal grievance and complaint resolution process ...Policy: A. Upon admission, patients will be given information on the complaint/grievance process in the Patient Rights and Responsibilities ...”.”

“A life safety code (LSC) complaint survey was conducted on site on 09/10/2025. An entrance conference was held for the hospital’s chief nursing officer and the director of quality on the morning of 09/10/2025 to discuss the purpose of the LSC survey and the survey process were explained. Instructions were provided on writing plans of correction. 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. An LSC exit conference was conducted on 09/10/2025 in the hospital. In attendance were the chief nursing officer and the director of quality. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 51905 . Based on observation and interviews, Facility A failed to provide an acceptable level of safe and quality supplies in two (2) of two (2) emergency department trauma rooms. This failure created a risk that supplies needed for immediate patient care could be ineffective or unsafe for use. . Observation: . On 08/12/2025 at 11:00 A.M., a tour of Facility A’s emergency department was conducted with the Chief Nursing Officer, Staff A. During the inspection of the unit’s trauma rooms, multiple supplies were found to be expired. Many of the items were respiratory-based, such as endotracheal tubes and inline suctioning kits. All expired items found were removed from the cabinets and airway kits. Respiratory therapists were witnessed replenishing the airway kits with new unexpired supplies in real time. . Supplies found to be expired included: . One (1) Quickflash Radial Artery Catheterization Expired 11/30/2024 One (1) Universal Bite Block Expired 01/1025 Three (3) Ballard Closed Suction System for Adults 14FR T-Piece Expired 09/29/2024 Two (2) Ballard Closed Suction System for Adults 14 FR T-Piece Expired 05/23/2025 One (1) LMA Unique Silicone Cuff - Cuff Pilot Size 5 Expired 06/28/2022 One (1) LMA Unique Silicone Cuff - Cuff Pilot Size 4 Expired 07/28/2022 One (1) LMA Unique Silicone Cuff - Cuff Pilot Size 4 Expired 03/15/2025 One (1) LMA Unique Silicone Cuff - Cuff Pilot Size 4 Expired 06/28/2024 Two (2) LMA Unique Silicone Cuff - Cuff Pilot Size 3 Expired 06/28/2022 One (1) LMA Unique Silicone Cuff - Cuff Pilot Size 2.5 Expired 06/28/2021 One (1) Arrow EZ-IO Needle and Stabilization Kit 15mm/15ga Expired 02/28/2025 One (1) ClearLink System Continu-flo Solution Set Expired 02/08/2025 One (1) L-370 Hotline 3 Fluid Warming Set 2.4m Expired 07/19/2025 One (1) Emergency Cricothyroidectomy Kit 6.0omm Expired 02/21/2022 One (1) Adult Colorimetric CO2 Detector >15kg Expired 04/08/2025 One (1) Disposable Patient Circuit Kit with Exhaust Collector and PEEP Value Expired 04/30/2023 One (1) Bougie Endotracheal Tube Introducer 15FR Expired 11/18/2023 One (1) Drager Thermo Trace Expired 07/28/2025 One (1) ClearLink System Secondary Medication Set Expired 07/00/2024 One (1) Siemens Multistix 10SG Reagent Strips for Urinalysis Expired 07/31/2023 . Interview: . On 08/12/2025 at 11:45 A.M., Chief Nursing Officer, Staff A indicated that there is no policy for supplies management as it pertains to expiration dates. Staff A was asked to verify that the supplies collected from the two (2) trauma rooms had expired. Staff A stated, “Yes, they are expired. We just went through our inventory, too. I have Respiratory addressing this and restocking now. There will be corrective actions for those who signed off on the (unexpired) items in stock.” .”

“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: 45521 Based on observations and interviews, the facility failed to provide a safe setting for patients when they failed to secure sharps in the Emergency Department (Trauma Room # 1, Room 5B, Room 6, and hallway) that were toured on the morning of 12/10/2024. The findings include: Observation: Observations made during the afternoon of 12/10/2024 during a tour of the Emergency Department with Staff # 9, Director of Nursing, revealed the following: Trauma Room 1: Twenty-four pieces of Pro Vent syringes were in an unsecured lower cabinet against the wall to the right when entering the room. They were observed on the top shelf, the second tray from the left. A syringe and a scalpel were found in an unsecured top drawer to the left of the sink. On the counter to the right of the sink was an open tray with five blunt-tipped syringes and three pieces of Vacuette Evo protect. One pro vent syringe was observed in an unsecured middle top drawer to the right of the sink. As you walk into the room to the right, there is an unsecured top drawer. It is the third drawer from the right. 11 pieces of Vacuette Evo protect, four 20 gauge/one-inch syringes, and four 25 gauge/5/8 syringes were observed. An unsecured suture cart was under the disposable gloves on the wall to the right. No key could be found for the cart. In the cart, it was observed that there were three pieces of 25 gauge/5/8 syringes, 16 pieces of 27 gauge/1.5-inch syringes, and nine laceration trays. The unsecured chest tube cart was to the right of the suture cart in Trauma Room 1, which had one chest kit, one Jet Vac-Pediatric, and one Jet Vac-Pediatric. Room 5 has two beds, 5A and 5B. The curtain was pulled closed for the patient in 5A’s privacy. On 5B side: In an unsecured top drawer, the farthest right drawer from the sink, two pieces of 20 gauge/1 inch syringes and an ABG Pro Vent syringe were observed. One laceration tray was observed at the entrance of ED Room 6 in an unsecured top drawer in a cabinet to the right. In the hallway to the ICU to the right is a bank of lower cabinets, and in the unsecured first cabinet to the right, eight pieces of ABG Pro Vent syringes were observed. See photos uploaded into ACTS and a part of the ROC. Policy: A review of the policy titled “REFERENCE: PHAR 01.28, Medication Procurement & Storage” provided by Staff # 9 revealed that this policy is for the Pharmacy and has no content related to sharps storage in the Emergency Department. Interview Interview with Staff # 9, Chief Nursing Officer, on 12/10/2024 at approximately 4:15 PM revealed the following: I emailed you the only policy I can find about storing medication and sharps. I know there is a safety concern about the syringes found in unlocked cabinets and drawers. I don’t know how to stop this from happening. Summary: No policy was found according to Staff # 9 per request for a policy on sharps in the ED.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45521 Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on record review and interviews, the facility failed to complete a medical screening examination (MSE) for one of the twenty-one patients (Patient #2) whose records were reviewed (Patient #2). Patient #2 presented to the facility with a chief complaint of a single seizure. Patient # 2 arrived for his first visit to the facility on 10/21/2024 at 1:54 PM and was discharged at 4:56 PM. Patient #2 returned to the facility Emergency Department on the same day at 5:35 PM, after having another seizure. The ED physician did not initiate a medical screening exam for the return visit. Refer to A2406 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45521 Based on record review and interviews, the facility failed to complete a medical screening examination (MSE) for one of the twenty-one patients whose records were reviewed (Patient #2). Patient #2 presented to the facility with a chief complaint of a single seizure. Patient #2 arrived for his first visit to the facility on 10/21/2024 at 1:54 PM and was discharged at 4:56 PM. Patient #2 returned to the facility Emergency Department on the same day at 5:35 PM, after having another seizure. The ED physician did not initiate a medical screening exam for the return visit. The findings include: A review of the Hutchins Fire Rescue report completed on 10/21/2025 revealed they were dispatched to medical emergency services. Upon arrival, a 21-year-old male was found “sitting upright on the floor of an 18-wheeler sleep cab.” Patient #2 was placed on continuous monitoring and transported to Facility A for evaluation. Patient #2, a 21-year-old male, presented to the facility on 10/21/2025 at 1:54 PM with a chief complaint of a single seizure that was witnessed and lasted minutes. It was also noted that the patient lost consciousness and was incontinent. The medical record indicated Patient #2 had no prior history of seizures. A medical screening exam (MSE) was initiated at 1:51 PM. A CBC [complete blood count], CMP [complete metabolic panel], CPK [creatine kinase] [ blood labs], urine analysis (UA), UA drug screen, and a CT (computerized tomography) of the brain were completed at the facility. The physical exam revealed no abnormalities. Patient # 2 was discharged and departed the facility via private vehicle on 10/21/2024 at 16:56. No discharge diagnosis could be found in the patient’s medical chart for his initial visit. A review of the document titled “Progress and Procedures” completed by Staff # revealed, “after the patient was discharged but prior to leaving the hospital, he had another seizure. Discussed with neurology who recommended loading the patient with Keppra and admission for further testing.” Abnormal test results included high glucose 129, total protein 8.3, albumin 5.1, and a urine analysis which revealed bacteria. Patient # 2 arrived back at the facility on 10/21/2024 at 5:35 PM via private vehicle after a second seizure. Staff #1, DO, ED Medical Director, did not treat this arrival as a separate event and continued using Patient #2’s medical chart from his first visit on 10/21/2024. A separate medical screening exam was not completed. Staff # 1, DO, ED Medical Director, continued to use the patient’s chart from the prior visit. Staff #1 made a note regarding the patient’s return to the hospital and then continued with documentation in the medical record. Neurology was consulted and recommended administering the medication Keppra and admitting the patient to the facility for additional testing. Seizure precautions were started. Policy A review of the document titled “ER 03.04, EMTALA Guideline” revealed the following: page. 1, bullet # 5, “Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not.” The facility failed to initiate a medical screening exam for Patient # 2 upon his arrival on his second visit on 10/21/2024 at 5:35 PM. Interviews: An interview with [Staff # 1], DO, Medical Director, on 12/10/2024 at approximately 2:30 PM revealed the following related to Patient #2’s first visit to the emergency department: “The patient had a single seizure witnessed by the girlfriend. There were no acute findings, and the patient was “Discharged home to follow up with a neurologist.” Additionally, Staff #1, DO reported the following regarding the patient’s second visit, “After discharge, he [the patient] had another seizure; he now met the criteria for admission for further testing and workup. CT was done and documented in the original medical screening from Visit # 1, approximately 5 minutes earlier. “To me, the way I think of MSE [medical screening exam], like if I’ve just seen them, I didn’t consider an MSE. The chart and the MSE was the same as the first time. I started an addition to the chart in the second paragraph.””

“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: 27128 Based on interview and record review the hospital failed to ensure there was an ongoing evaluation of wounds along with daily skin assessments for 1 of 1 patient (Patient #1) The patient was admitted to the hospital with a sacrum wound. The wound deteriorated during the patient’s admission to the hospital, and the patient acquired several additional wounds. Findings included: Hospital A Patient #1 was an 82-year-old male who was admitted to the hospital on 10/07/2023 with a past medical history significant for congestive heart failure, hypertension, type-2 diabetes, osteoarthritis and suspected dementia who presents to the hospital with dyspnea on exertion, short of breath and lower extremity swelling. Imaging studies confirmed bilateral pleural effusions and pulmonary edema. Patient #1 was admitted with a sacral wound. During the patient’s admission, the nursing notes reflected that there was only one wound on the patient’s sacrum. There were no measurements or photos of the wound. There were no additional wounds noted. A physician’s order for a Wound Care Consult was requested by the provider on 10/07/2023 for a stage II wound on Patient #1’s sacrum. The wound care nurse did not assess Patient #1 throughout the patient’s entire admission to the hospital. On 10/27/2023 Patient #1 was transferred to a local acute care hospital (Hospital B) at the request of the patient’s family. Hospital B A skin assessment was completed at Hospital B on 10/27/2023. The following wounds were identified: Skin/wounds: Wounds present on admission on 10/27/2023. Wound 10/27/23 Buttocks-Pressure injury stage 3. Wound 10/27/23 Buttocks-Right buttocks DTI (Deep Tissue Injury). Wound 10/27/23 Chest-Mid chest wound. Wound 10/27/23 Elbow Posterior; Right elbow dry wound. Wound 10/27/23 Forearm Anterior; Distal; Left wrist unstageable pressure injury. Wound 10/27/23 Left; Plantar left heel DTI. Wound 10/27/23 Upper Arm Anterior; Right right upper arm hematoma. There were photos of each of the wounds that were identified. During an interview on 02/13/2024 at 12:25 PM with Personnel #2 Wound Care Nurse she confirmed that measurements were not documented for Patient #1’s wounds during his admission. She stated that there should have been measurements documented and photos taken of all wounds. She stated she never received the provider’s wound consult order. Pressure Ulcer Injury Prevention Program dated 05/2022. “...The patient shall be assessed: Whenever there is a change in the patient’s cognition or functional ability. At least every 24 hours by a Registered Nurse. The assessment of care and treatment needs of the patient shall be ongoing throughout the patient’s hospital stay. Nursing staff shall take pictures (per protocol and with facility-approved camera) of a patient’s pressure injuries initially and throughout the patient’s hospitalization. Pictures shall be dated and timed, and placed in the patient’s medical record... At least weekly, the pressure ulcer (injury) wound shall be assessed and documented. This is will be performed by a physician, advanced practice nurse, physician assistant, certified wound care specialist, or designated Wound Care nurse...””