Resolute Health Hospital

“A life safety code (LSC) full survey was conducted on site on 03/18/2026 & 03/20/2026. An entrance conference was held for the CEO, Associate Administrator, and Facility Director on 03/18/2026 to discuss the purpose of the LSC survey, and the survey process was 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 03/20/2026 in the hospital. In attendance was the Associate Administrator, Chief Nursing Officer, Director Accreditation & Regular Compliance, and Facility Directory. 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.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 35321 K341 - Fire Alarm System - Installation Findings: The surveyor observed, while accompanied by the Associate Administrator, Chief Nursing Officer, and Facility Director, during the hours of the survey from 11:30 am to 3:15 pm on 03/18/2026 and 9:45 am to 3:30 pm on 03/20/2026, that there were the following issues: 1) Based on observation, facility failed to provide a fire alarm strobe device in both the walk-in cooler and the walk-in freezer in the Dietary suite.”

“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: 35321 K500 - Building Services - Relative humidity and temperature records Findings: The surveyor observed, while accompanied by the Associate Administrator, Chief Nursing Officer, and Facility Director, during the hours of the survey from 11:30 am to 3:15 pm on 03/18/2026 and 9:45 am to 3:30 pm on 03/20/2026, that there were the following issues: 1) Based on review of the records, facility failed to implement a reliable storage/retrieval system for the relative humidity and temperature records in anesthetizing locations.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 35321 K712 - Fire Drills Findings: The surveyor observed, while accompanied by the Associate Administrator, Chief Nursing Officer, and Facility Director, during the hours of the survey from 11:30 am to 3:15 pm on 03/18/2026 and 9:45 am to 3:30 pm on 03/20/2026, that there were the following issues: 1) Based on review of the records, facility failed to document whether fire drill included the transmission of a fire alarm signal.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 35321 K914 - Electrical Systems - Maintenance and Testing Findings: The surveyor observed, while accompanied by the Associate Administrator, Chief Nursing Officer, and Facility Director, during the hours of the survey from 11:30 am to 3:15 pm on 03/18/2026 and 9:45 am to 3:30 pm on 03/20/2026, that there were the following issues: 1) Based on a review of the records, the facility failed to perform a comprehensive annual planned maintenance of the line isolation monitor system for the operating rooms, as verified by a third party.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46435 Based on interviews and record reviews, it was determined the facility failed to ensure each patient was informed of their rights in advance of furnishing or discontinuing care in accordance with the facility’s policy and procedures for 5 of 5 patients, (Patients #1, #2, #3, #4, and #5) reviewed for informed patient rights. Findings included: Record review of the facility’s policy, QM1017, titled “Patient Rights and Responsibilities,” Effective date 03/17/2014 with no Revision date, indicated the following, in part; “Patient Right” A. 2. The hospital informs the patient or the patient’s representative of the rights, in advance of furnishing or discontinuing patient care whenever possible”. “Process” A. Prior to admission, all patients admitted to Resolute Health will be given a copy of the Patient Handbook, which includes the Patient Rights and Responsibility. Additionally, a verbal explanation will be afforded if requested by patient. C. The patient will sign acknowledgment of receipt of the Patient Handbook on the “Consent for Treatment and Conditions for Admissions” Form during the admitting process. The Original form is retained in the patient’s medical record”. Record review on 3/3/26 at 1:00 PM for patients #1, #2, #3, #4 and #5 were reviewed specifically for pre-admission and admission documentation regarding Patient Rights and the patient signed acknowledgment for the receipt of patient rights and there were not signed acknowledgment receipt by the patient or patient’s representative for patient rights available as part of the Medical Records or made available to the survey team upon request. Interview on 3/3/26 at 1:00 PM with Staff #12 confirmed she could not find in the medical record where there is a signed acknowledgment from the Patient that they had received the Patient Rights and Responsibility or the Patient Handbook, although patients can see it during the admission process and they have access through the patient portal; if they have set up access to that system. Interview on 3/4/26 at 4:30 PM with Staff #31, stated; she has reviewed the process of admission which is electronic, via a digital pad given to the patient for input of patient information instead of paper forms. This system is a different system than the electronic medical records and she would like to have the person in charge of those systems and records speak on that process. Interview on 4/5/26 at 2:00 PM with Staff #38 indicated there were two different software systems that track patient information; one for admission information and one for medical information. These two systems do not combine information into the permanent medical record. Therefore, when anyone asks for the medical record, the only part of the record they receive is the medical portion and not the information that is contained in the admission software. Staff #38 stated this was an oversight and indicated they are already working on the process to have all patient information available in one record, so when a medical record is requested that it would have all patient information required, to be a complete medical record. This new process would include the signature page for the Patient Handbook which is where the patient acknowledges they have received the patient rights and responsibilities and that they understand them.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 26870 Based on observation, interview, and record review the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases. Specifically, observations of the facility revealed the following: 1.) The Intensive Care Unit area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 2.) The Medical Surgical Floor was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 3.) The Dialysis area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 4.) The Labor and Delivery area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 5.) The Neonatal Intensive Care Unit was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 6.) The Pre-Operative area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 7.) The Post Anesthesia Care Unit (PACU) was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 8.) Surgical Services area was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. 9.) A wheelchair alcove in the main lobby of the facility was unsanitary and unsafe in order to avoid the transmission of infection and communicable diseases. These deficient practices placed the patients’ health and safety at risk for the transmission of infections and/or communicable diseases. Findings included: Observations on 3/2/26 at 10:00 AM - 2:30PM of the facility with staff #36 revealed the following: 1.) Intensive Care Unit (ICU) A) Observations on the ICU floor, clean empty patient room 243 revealed a monitor in the patient room had a layer of dust like substance on the upper surface. An IV pole in the room had a dust like substance on the base of the pole. A recliner in the patient room, when opened, revealed a dusty appearance in the metal frame in the chair. B) Clean Supply room on the ICU floor, revealed there was debris on the floor. The clean supply room also contained blue bins which stored the clean supplies, in each of the blue bins was dust like particles and debris. In one blue bin, there were gauze pads that were open and loose with the dust particles. C) ICU Nourishment room revealed what appeared to be coffee spills on the floor. The counter tops had stains on the top of the counters. Picking up the coffee pot, there were coffee grounds and other debris on the “burner” of the coffee maker. Inside the microwave, revealed brown stains and food particles. D) Linen cart in the hallway, revealed cob webs behind the cart. E) Clean Equipment room revealed the bottom of the metal shelving had a clear plastic coating that was peeling and flaking off. There were blue plastic bins that appeared dusty and contained debris with clean supplies. There was a machine, EV1000, which contained dust on varying high surfaces. The floor had debris. F) Two alcoves in the ICU hallway, for nurses to chart, contained dusty keyboards. G) ICU Medication room revealed the handwashing sink had a splash guard, which was colored with a blackish grayish color around the caulking. The pill crusher was stained and had rust stained spots. There was debris where the pills were crushed. The medication Pyxis system inside the medication room had dust on the very top. There was a bulletin board in the medication room which also contained dust. H) Nurses Station revealed there was a dirty handwashing sink, a full trash can by the sink. There was a bulletin board with a compartment for markers, the compartment had a layer of dust. E) Dirty Soiled Utility Room revealed a large brown bin-stacked full of trash bags. Height of trash bags were taller then the height of the bin. 2.) Medical Surgical (Med/Surg) Floor A) Clean Equipment revealed a recliner that was identified as clean chair. There was a tear in the seem. When the recliner was open, the metal frame inside the chair was dusty. A bed side table that was identified as clean was also dirty. Another clean bed side table, when the drawer was opened, there was a brown residue inside the drawer. The bedside table was also missing laminate, exposing a wood, particle board. A 3rd bedside table had exposed wood at the corner. A clean Chair had rips in the vinyl. There was also an Oxygen tank standing loose. B) Staff Only-Room, had a sign stating “Clear Equipment”, there was dusty debris on the floor. A Chair seat was dusty. C) Walking down the med/surg floor, Patient Room 362, the outside door frame, dinged exposing wood. There was a Vital Sign Machine outside room 360, that had tape hanging from machine. There was another piece of tape holding a bag of “caps”. D) Clean Supply Room had a full trash can. The bottom of the metal shelves had a clear plastic, protective coating, which was peeling and flaking off. There was blue plastic bins that contained a dusty debris inside each blue bin. E) Medication Room, there was tape residue on cabinet door, with gray debris along the sticky edges. There was also a ceiling tile which had a hole. F) The Hallway area between patient rooms & garden elevators revealed an alcove which contained 6 wheel chairs. There was no signage stating whether the wheel chairs were clean or dirty. 2 out of the 6 wheel chairs had tears. The area was an open area which was accessible by staff, patients and visitors. G) Clean Patient Room 330 revealed in the patient bathroom, the shower seat had a brownish/reddish stain. The recliner in the clean patient room revealed the lever to recline the chair was dusty. Opening the recliner, revealed the inner metal frame to be dusty. The night stand beside the bed had crumbs on the surface. The window sill had dust/debris particles. There were chips/areas missing from the sheet rock. Around the wall/floor edges, there was debris and behind the furniture. H) A nurse was observed entering a patient room, leaving that room with out washing nor using hand sanitizer. The same nurse immediately entered another patient room, did not wash hands nor use hand sanitizer before or exiting the patient room. The same nurse then continued to enter another patients room. The nurse did not wash hands nor used hand sanitizer before or after entering the patients room. Interview with the nurse during the time of observations, confirmed hands were not washed nor used hand sanitizer before or after entering/exiting patient rooms. 3.) Dialysis A) Linen cart was not covered, exposing clean linen. The clean sink at the nurses station, the splash guard had a gray, dark brown color against the splash guard edge. B) Clean supply room revealed the bottom of the metal shelving had a clear plastic coating that was peeling and flaking off and there was dusty debris on the floor. 4.) Labor and Delivery A) Clean patient room, Labor and Delivery 7, revealed the monitor in the room was dusty behind the monitor as were the wires connected to the monitor. 5.) Neonatal Intensive Care Unit (NICU) A) Nursing Station at NICU 2, contained dust behind the keyboard. B) NICU-Clean Supply contained little blue bins to store clean supplies. Each blue bin contained dusty debris along with the clean supplies. C) Common area in lobby outside of the NICU revealed a full trashcan. Observations of the Peri-Operative area on 3/3/26 from 10:00amd through 12:30PM revealed: 6.) Pre-Op A) Clean patient room, Pre-Op 5, revealed the base of the stretcher bed was dusty. The surface behind the monitor screen was dusty, linen bag contained linen from the previous patient. B) Equipment Storage, 2 pairs of crutches were not tagged whether it was clean or dirty, leaning against clean, tagged crutches. C) Clear Equipment Storage had a recliner Chair, who’s seat was ripped-exposing the foam. Opening the chair, the inner metal frame was dusty. Patient Bathroom, the outside wall had damage which exposed the sheetrock. 7. ) PACU A) Clean Supplies & Medication room was combined. In the drawer of the medication room, the black bins were dusty. The floor was debris that was not swept. There was a full trash can at the medication room sink. B) in the clean supple area, the blue bins and shelves were dusty. C) Nourishment area, a utensil bin was a dusty reservoir where the untensils fall into. The ice/water machine had limestone deposits on the grate where the cup sits. D) Wheel chair storage area. Wheelchairs were not identified as clean or dirty. One wheel chair had a tear in the seat. 8.) Surgical Area A) (Operating Room) OR room #1, work station had missing laminate and a warped pull out shelf, exposing particle board. Above the door frame, was a crack in the wall. B) Stock location 3, contained a room of blue plastic bins containing supplies for surgical services. Each bin contained dusty debris. The bins were located on metal shelves. The bottom shelf had a clear protective plastic liner, that was peeling and flaking off. 9.) An alcove in the facility lobby, behind the stairs contained, that contained 5 wheel chairs. The wheel chairs were for patient or visitor use. There was no way to determine if the wheel chairs were clean or dirty. Observations revealed 3 of the 5 wheel chairs were torn. Interview on 3/2/26 with facility Staff (FS) #34 at the time of observations confirmed the above documented findings. Further interview on 3/3/26 at 1:36pm with Facility Staff (FS) #34 revealed that high infection disinfection is a problem with the facility and has to keep using reinforcement. Handwashing is also an issue and does audits every day. They even conduct survellience by using the camera system to watch staff to ensure they are practicing hand hygiene. Interview on 3/2/26 at 2:26pm with Facility Staff (FS)# 35 revealed his department is responsible for high dusting throughout the facility and the removal of trash. FS #35 stated that he monitors his staff’s work by walking around the hospital looking for issues. FS #35 confirmed that he does not have a method of tracking and trending, to monitor the staff’s work. He just walks the floors and uses a “walkie talkie”. He confirmed he is responsible for all the areas, just not the offices. Interview on 3/3/26 with Facility Staff (FS) #36 at the time of observations confirmed the findings. Record review of facility policy, titled Standard Precautions, last revised 05/23, states in part: A. Hand Hygiene. A. Perform hand hygiene ...before and after entering clean or empty rooms. E. Environmental Services. 1. Will provide all patient care in an environment that is cleaned to remove gross contaminations and disinfected to kill pathogens. a. Clean linen: store covered or in appropriately labeled clean equipment or utility room. F. Perform low-level disinfection on all non-critical patient equipment/surfaces I. Environmental Design 1. Maintain appropriate clean, soiled and sterile storage areas that are properly labeled. 4. Maintain surface (floors, cabinets, furniture) that are intact and able to be disinfected. Record review of facility policy titled Equipment Cleaning and Disinfection, last revised 12/19 states in part: 1. All equipment must be cleaned and disinfected immediately if visibly soiled, and immediately after use on patients with contact precautions. All clean equipment will be placed in the clean equipment room after it is cleaned, with A tag signifying clean, and use or dirty attach to it prior to leaving the room. 4. The equipment will be placed in the clean equipment room equipment that is not in the clean equipment room or tagged should be considered contaminated and cleaned before use. 5. Only equipment that has been cleaned and disinfected can be stored in the cleaned equipment area or clean utility room equipment that is not or cannot be cleaned immediately after use is placed in the soiled utility room or sent to a designated area. 7. Certain items will be cleaned on a daily basis, between patient use. These items include, wheelchairs, equipment, and stretchers. Equipment should be wiped down with the hospital approved disinfectant per manufacturers recommendations, by the staff member using the equipment after patient care. 9. Computers on wheels should be wiped with the hospital approved disinfectant by the nurse between patients should be cleaned at least once per shift.”

“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: 21935 Based on observation, staff interview, and review of facility policy, it was determined the facility failed to ensure that clean linen was stored in a manner that maintained its cleanliness and protected it from environmental contaminants to avoid sources and transmission of infection; and in accordance with the facility’s policy and procedures. Findings: 1. Observation: A. On March 03, 2026 at approximately 1:35pm, a tour of the central linen supply room (first floor, with direct access to the loading dock) revealed multiple bins containing clean linen that were not covered or otherwise protected from dust and environmental contaminants. Additional bins were observed with plastic coverings that were torn or had holes, resulting in exposure of the linen. B. The presence of spider webs in upper corner of the room, including behind the door leading to the loading dock, further indicated inadequate environmental control and housekeeping practice within the central linen supply room. 2. Staff Interview: A. On March 03, 2026, at approximately 1:45pm, staff #35 and staff #39 were interviewed in the central linen supply room. Both confirmed that the clean linen in this room was not adequately protected due to lack of proper covering or use of damaged coverings. B. Staff interviewed stated corrective actions would include removal and re-cleaning of affected linen, thorough high and low level cleaning of the room, and replacement of damaged coverings to ensure protection from contamination. 3. Policy Review: A Review of the facility’s policy titled, “Linen Storage” Policy FM-1096, last reviewed and approved May 20219 by the Quality Value Committee indicated, in part; 1) Clean linen carts are to covered prior to transport to patient care areas. 2) Linen carts not in use are to remain covered to prevent dust accumulation. 3) Clean linen is expected to be maintained in a manner that prevents contamination.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 33326 Based on record review, interviews, and observations, the facility failed to meet the conditions of participation of Emergency Services when, A.) The facility failed to follow the facility’s policy for events. The facility failed to implement and initiate an investigation and follow-up as soon as possible after an Event Report and complete within twenty-one business days of the time the event is submitted and failed to document why if unable to close. (Patients #4, 13, 14, 15, 16, and 17) B.) A patient requiring isolation precautions did not have the appropriate signage or PPE (personal protective equipment) available to prevent the spread of a MDRO (multiple drug-resistant organisms. (Patient #1) C.) The emergency room’s patient glucometer’s quality control solutions were expired, preventing the facility from testing the equipment and making them unavailable or erroneous in an emergency. D.) The Pediatric emergency room’s crash cart was not being checked daily, possibly creating a delay in providing an emergency resuscitation. These failures places patients at risk of possible delayed physical assessments, medical treatment, emergency resuscitation, and an increased risk of deteriorating conditions. Cross refers to: A1104”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 33326 Based on record reviews and interviews, the facility’s Emergency departments medical staff failed to ensure the established policies and procedures for the provision of emergency services were provided when, A.) The facilit’s medical staff failed to follow the facility’s policy for events. The facility failed to implement and initiate an investigation and follow-up as soon as possible after an Event Report and complete within twenty-one business days of the time the event is submitted and failed to document why if unable to close. (Patients #4, 13, 14, 15, 16, and 17) B.) A patient requiring isolation precautions did not have the appropriate signage or PPE (personal protective equipment) available to prevent the spread of a MDRO (multiple drug-resistant organisms.) Patient #1 was suspected of having an infectious disease and was not placed on isolation precautions. C.) The emergency room’s patient glucometers (used to check a patient’s blood sugars) quality control solutions were expired, preventing the facility from testing the equipment and making them unavailable or erroneous in an emergency. D.) The Pediatric emergency room’s crash cart was not being checked daily, possibly creating a delay in providing an emergency resuscitation. These failures places patients at risk of possible delayed physical assessments, medical treatment, emergency resuscitation, and an increased risk of deteriorating conditions. Findings include: A.) On the morning of 12/28/2025, in an administrative conference room, when asked for a copy of the facility’s incident reports, the facility provide a copy of the facility’s Risk reports. When asked for a copy of the facility’s incident reporting policy and procedures, the facility provided the Event reporting policy. Review of the facility provided policy “Event Reporting” (reviewed 08/09/2018) revealed the following: “II. PURPOSE: The purposes of this policy are to: A. Clarify and delineate the responsibilities of Hospital Staff Members, as defined in Section III. below, with respect to reportable events involving patients and/or visitors; B. Provide a system for promptly reporting and investigating reportable events and integrating risk reduction strategies into the patient safety activities; C. Comply with the requirements of applicable federal and state law and the standards of applicable accrediting organizations as they relate to reportable event requirements; D. Establish a process to validate documentation and investigation is conducted appropriately to the type and level of severity of reportable events; and E. Support a culture of shared accountability for the identification, reporting and management of reportable events that may impact the quality of care provided ... (1) The patient’s chart must: (a) Reflect all pertinent medical facts relating to the Reportable Event;... C. Department Director/Manager/Supervisor Responsibilities Each Department Director/Manager/Supervisor is responsible for: 1. Reviewing events that occur in their area, assigning severity, documenting the results of the review, and assigning or completing follow-up through the Hospital’s Occurrence Reporting System within 7 calendar days of event notice D. Hospital Patient Safety Officer or Designee Responsibilities The Hospital’s Patient Safety Officer is responsible for: 1. Providing leadership in all risk event functions/processes and ensuring that all staff is trained on this policy. 2. Initiating investigation and follow-up as soon as possible after an Event Report is submitted. Investigation and follow-up by the Patient Safety Officer will be completed within twenty-one business days of the time the event is submitted, and documented why if unable to close; ...” c. Data integrity and analysis; (1) The Patient Safety Officer or designee must conduct periodic analysis of all events based on appropriate categorizations (for example: severity, event type, locations and other factors). Focus should be directed to high-risk, problem-prone areas/events; (2) Trending and analysis of Reportable Events and Near Misses with communication via proper committee structures; (3) Documenting closure of all reported events from the prior month no later than the eighth calendar day of the following month, with the exception of those events that are under investigation.” During the patient’s medical records reviews, when asked what the A is, B.C.D.E priority designation was, Staff 12, Medical Staff Coordinator explained, A would be the least severe and E being the most severe. On 7/13/25, Patient #4 presented to the emergency room following an all-terrain vehicle roll over and was designated a trauma patient. Following an incident report review on 7/15/2025 04:27 pm, that had been designated a category D. PROTOCOL or POLICY NOT FOLLOWED, the initial quality risk reviewer sent the incident to ER (Emergency room) and PQ (physician quality) for review. The event was not closed and the reason for the delay was not documented. On 7/13/25, Patient #13 presented to the emergency room following a motorcycle accident at 60 mph with no helmet and designated a trauma patient. Following an incident report review on 7/15/2025 04:29, that had been designated a category D. CARE MGMT (management) EVALUATION OR ASSESSMENT ISSUE the initial quality risk reviewer sent to ER (Emergency Room) and PQ for further review. The interactions between the nurses and the physician were not documented in the patient’s medical record, and the event was not closed and the reason for the delay was not documented. On 9/23/2025, Patient #17, A 6-month-old infant, presented to the emergency room with cardiac resuscitation in progress. Following an incident report review on 9/25/25 at 3:31 pm, that had been designated a category E. PROF (professional)/CONDUCT-IMPROPER TECHNIQUE/ IGNORING STANDARDS, the initial quality risk reviewer sent to ER, PQ and CO (Clinical Operations) for further review. The interactions between the nurses and the physician were not documented in the patient’s medical record, and the event was not closed and the reason for the delay was not documented. On 10/23/2025, Patient #14 presented to the emergency room in respiratory distress and triaged as an ESI level 2 (emergent). The incident report had been designated a category C. Delay/Lack of Response to Patient Condition. The quality department received the incident on 11/08/2025; there was no information about the review. The interactions between the nurses and the physician were not documented in the patient’s medical record, and the event was not closed and the reason for the delay was not documented. On 10/23/2025, Patient #15 presented to the emergency room with respiratory distress and triaged as an ESI level 2 (emergent). The incident report had been designated a category C. Delay/Lack of Response to Patient Condition. The quality department received the incident on 11/08/2025; there was no information about the review. The interactions between the nurses and the physician were not documented in the patient’s medical record, and the event was not closed and the reason for the delay was not documented. On 12/10/25, Patient #16 presented to the emergency room in a hypotensive (low blood pressure) state and had been given Epinephrine (an emergency medication used to restore cardiac rhythm) by EMS in the field. The patient was triaged as an ESI 1 (critical). The incident report had not been given a category designation, Diagnosis - Delayed. The interactions between the nurses and the physician were not documented in the patient’s medical record, and the quality department received the incident on 12/11/2025; there was no information about the review. During an interview on the morning of 12/30/25, Staff #12, Medical staff coordinator stated, “I was previously an emergency room nurse; I review the medical records to see if there is an issue dealing with the quality of the care it will be sent to PQ (physician quality). We will have patients reporting questions about the billing; we wouldn’t forward those to the medical review board. We will send records to the specialist for that area. If there is a question concerning emergency department it will be sent to that department first and they will determine if there is a safety issue. We were scheduled to review the cases in November, but the specialist for the area was not available; we didn’t have one (a meeting) in December; the review is scheduled for January. We keep the findings confidential.” Staff #12 confirmed the reports did not indicate the conclusion or whether the event was closed. Staff #12 stated the conclusion of the risk events are not recorded or part of the patient record. During a teleconference call with Staff #16, Systems Emergency Medical director when asked if there is a procedure for escalating case reviews stated in part, “We monitor high risk cases. If we find concerns, we put them on a focused review. Any case that deals with the quality of care is at least sent to a medical review. If there is something more egregious, we will expedite the review. There is a more formalized process coming.” B.) An observation on 12/28/25 at 10:15 am, in the facility’s emergency department revealed a laboratory test was pending results for the patient in room #6; the patient had been admitted for loose stools and was pending the test results for Clostridium Difficle (a highly contagious bacteria that requires special patient isolation precautions). Further observation revealed the room did not have an isolation sign on the door to indicate the required precautions. During an observation and interview on the morning of 12/28/25 at 10:40 am, upon returning to room #6, the isolation equipment was still not in place. Staff # 8, RN confirmed she was the nurse for the patient in room #6. When asked why there was no isolation cart or signage on the room, Staff #8 stated, “I don’t usually work on this unit, I’m from the floor. I don’t know where they keep the carts.” When asked if there was an order for isolation precautions, Staff #8 stated, “No, it usually auto populates with an order if they have a history of an MDRO (multi drug resistant organism).” During an observation and interview on the morning of 12/28/25 at 10:45 am, at the emergency room nurse’s desk, Staff #2, Chief Nursing Officer confirmed the patient in room #6 was pending the results of the C. Difficle test and that the patient was required to be on contact isolation pending the results. When asked for the facility’s policy on C. Difficle precautions, the facility provided a standard contact precautions policy. Review of the facility provided policy “Guidelines for Patient with Multi-Drug-Resistant Organism” (dated 4/2022) reflected, “ ...b. Routine culturing of patients for MDRO is not recommended. Patients should be cultured under the following circumstances: i. when medically indicated ii. Roommate is newly found to be infected with MDRO. A culture will be taken to determine their colonization status and to determine if isolation precautions are indicated. Nursing should notify the patient’s physician ... g. In addition to Standard Precautions, Contact Precautions (or Contact Precautions Enhanced for C. diff) are recommended to reduce the opportunity for the transmission of MDRO to other patients, health care workers, and the environment (refer Standard &Transmission Based-Precautions policy). C.) An observation on 12/28025 at 10:30 am, during a tour of the facility’s emergency room revealed, the emergency room’s patient glucometer’s (2) two quality control solutions had expired on 12/11/2025, preventing the facility from testing the equipment and making them unavailable or erroneous in an emergency. During an interview on 12/28/25 at 10:30, Staff #6, Med Tech stated, “I try to test it twice a day. It only shows pass or fails, Laboratory sends us the strips and control solutions, they will have the expiration date on them. I’ve caught them before. We call the lab (laboratory) and they will bring us more. Staff #2 confirmed the solutions were expired and instructed the staff to retest after obtaining new testing solutions. Review of the facility provided document, “Roche Inform Glucose Control Solutions” (reviewed 9/12/2024) reflected, “Contains 2 levels of glucose control solution, 2.5 ml per vial, and one vial per level (gray top hypoglycemic range, white top hyperglycemic range). Storage and stability: Stable for 90 days after opening bottles or unopened until manufacturer’s expiration date, whichever occurs first. Check the expiration date and do not use if expired. Controls are stored at room temperature, do not freeze. Control solution can stain fabric, avoid drops on clothing. Seek immediate medical attention if the control is swallowed. Laboratory personnel will date controls with a 90 day expiration date and will replace them for patient care units.” D.) An observation on 12/28025 at 10:34 am, during a tour of the facility’s emergency room revealed, the Pediatric emergency room’s crash cart was not documented as having been checked on 12/12/25, 12/13/25,12/18/25, 12/27/25 and 12/28/25. The check did not include the inspection of the equipment located in the emergency cart; the check included supplies and medication expiration dates. Review of the facility’s incident reports reflected, the pediatric emergency cart was opened on 11/14/25 the laryngoscope’s batteries had exploded, and the scope was none functioning at that time. During a tour of the facility’s emergency room on 12/28025 at 10:34 am, Staff #2, CNO confirmed the pediatric cart had not been checked.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 21863 Based on a review of records, facility’s policies and procedures reviewed, and interviews conducted, the facility’s Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; the facility met the emergency needs of obstetric patients in accordance with acceptable standards of practice; and that the Hospital’s Conditions of Participation were met for; Nursing Services, Medical Records Services, and Emergency Services. Findings included: 1.) The facility’s Governing Body failed to ensure patient care and safety when Nursing Services failed to: a. Perform assessments and reassessments to ensure stabilization of Patient # 1, including vital signs prior to discharge in accordance with physician orders and the facility’s policies and procedures. b. Follow the facility’s policy and procedures for assessment and documentation of; Rhesus (Rh) factor evaluation (blood typing), intravenous device placement, patient vital signs, and post miscarriage blood loss monitoring. c. Follow the facility’s policy and procedures for performing fetal assessments and legal documentation for Twin fetuses delivered by Patient #1; Twin A and Twin B. As a result, the facility was not able to meet the requirements for the Condition of Participation, Nursing Services, and placed all patients in the facility at risk for the likelihood of harm. Refer to A-0392 for specific evidence of findings. 2.) The facility’s Governing Body failed to ensure medical records were complete, accurate, and documented by appropriate personnel in accordance with the facility’s policy and procedures when facility staff failed to ensure: a.) Patient assessments were completed, accurate, and documented by appropriate personnel caring for Patient #1 and her Twin fetuses (A and B) delivered. b.) Assessments and Legal documentation for both Twin fetuses A and B delivered by Patient #1 was accurate and/or completed by clinical staff present and not by other clinical staff; or non-clinical staff, that were not present. c.) Complete and accurate documentation of assessments, diagnostics, and treatments for Patient #1 provided by providers and nursing staff in accordance with facility policies, procedures and physician/provider orders. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Medical Record Services Refer to A-0450 for evidence of specific findings. 3.) The facility’s Governing Body failed to meet the emergency needs of obstetric patients in accordance with acceptable standards of practice; and in accordance with the facility’s policies and procedures for Patient #1, who presented to the facility’s emergency department (ED) pregnant with twins, in preterm labor, resulting in spontaneous abortion (miscarriage). Specifically, the facility failed to ensure the hospital’s emergency service/department was integrated with other departments of the hospital, specifically; the Obstetrics (OB) Labor and Delivery (L&D) department to ensure immediate availability of the full extent of its patient care resources to assess and render appropriate care for emergent OB/L&D patients. As a result, Patient #1 and her Twin fetuses delivered ,Twin A and Twin B, failed to receive appropriate obstetrics/gynecology (OB/GYN) emergency care through assessments, reassessments, testing, and diagnostics in accordance with established professional clinical practice guidelines/standard of care, and the facility’s policies and procedures. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Emergency Services and placed all patients in the facility at risk for the likelihood of harm. Refer to A-1103 for evidence of specific findings. 4.) The facility’s Governing Body failed to ensure the Quality Assessment/Performance Improvement (QAPI) program developed, implemented, and monitored the action plans identified for performance improvement measures from the Root Cause Analysis (RCA) completed on behalf of Patient #1 to verify compliance is sustained with regulatory requirements, and the facility’s policies and procedures to promote patient safety and quality of care. Specifically, the facility’s drafted Action Plan following a sentimental event, RCA meeting on 6/16/25, lacked evidence of final development, execution of the identified systemic issues across multiple departments involved including but not limited to; the Emergency Department (ED), Labor and Delivery (L&D), Nursing Services, Pastoral Care services, Health Informatics Management (HIM), Quality Management, and the House Supervisor (Administrator on Duty). There was no further coordination or leadership of the drafted action plans following the Human Resources (HR) interventions. Refer to A-0283 for evidence of specific findings. As a result of the Hospital’s failures to meet the Conditions of Participation for CFR §482.23-Nursing Services, CFR §482.24-Medical Records Services, and CFR §482.55-Emergency Services resulted in the facility’s inability to meet the Condition of Participation for CFR §482.12-Governing Body. 41048”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 21863 Based on records reviewed and interviews, the facility failed to ensure nursing services carried out their responsibilities; and followed facility policies and procedures to ensure patient care and safety. Specifically, Nursing Services failed to: 1. Perform assessments and reassessments to ensure stabilization of Patient # 1, including vital signs prior to discharge in accordance with physician orders and the facility’s policies and procedures. 2. Follow the facility’s policy and procedures for assessment and documentation of; Rhesus (Rh) factor evaluation (blood typing), intravenous device placement, patient vital signs, and post miscarriage blood loss monitoring. 3. Follow the facility’s policy and procedures for performing fetal assessments and legal documentation for Twin fetuses delivered by Patient #1; Twin A and Twin B. As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm. Refer to A-0392 for specific evidence of findings.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 21863 Based on record reviews and interviews, the facility failed to ensure the medical records were maintained that were complete, accurate, and documented by appropriate personnel in accordance with the facility’s policy and procedures. Specifically, the facility failed to ensure: 1.) Patient assessments were completed, accurate, and documented by appropriate personnel caring for Patient #1 and her Twin fetuses (A and B) delivered. 2.) Assessments and Legal documentation for both Twin fetuses A and B delivered by Patient #1 was accurate and/or completed by clinical staff present and not by other clinical staff; or non-clinical staff, that were not present. 3.) Complete and accurate documentation of assessments, diagnostics, and treatments for Patient #1 provided by providers and nursing staff in accordance with facility policies, procedures and physician/provider orders. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Medical Record Services Refer to A-0450 for evidence of specific findings. 41048”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 21863 Based on review of records, facility policy and procedures, and interviews, it was determined the facility failed to meet the emergency needs of obstetric patients in accordance with acceptable standards of practice; and in accordance with the facility’s policies and procedures for 1 of 1 patient reviewed (Patient #1) who presented to the facility’s emergency department (ED) pregnant with twins, in preterm labor, resulting in spontaneous abortion (miscarriage). Specifically, the facility failed to ensure the hospital’s emergency service/department was integrated with other departments of the hospital, specifically; the Obstetrics (OB) Labor and Delivery (L&D) department to ensure immediate availability of the full extent of its patient care resources to assess and render appropriate care for emergent OB/L&D patients. As a result, Patient #1 and her Twin fetuses delivered ,Twin A and Twin B, failed to receive appropriate obstetrics/gynecology (OB/GYN) emergency care through assessments, reassessments, testing, and diagnostics in accordance with established professional clinical practice guidelines/standard of care, and the facility’s policies and procedures. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Emergency Services and placed all patients in the facility at risk for the likelihood of harm. Refer to A-1103 for evidence of specific findings.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 21863 Based on a review of documentation and interviews, the facility’s Quality Assessment/Performance Improvement (QAPI) program failed to ensure corrective action plans identified in the Root Cause Analysis (RCA) were developed, implemented, and monitored to track performance improvement measures and verify compliance is sustained with regulatory requirements, and the facility’s policies and procedures to promote patient safety and quality of care. Specifically, the facility’s drafted Action Plan following a sentimental event, RCA meeting on 6/16/25, lacked evidence of final development, execution of the identified systemic issues across multiple departments involved including but not limited to; the Emergency Department (ED), Labor and Delivery (L&D), Nursing Services, Pastoral Care services, Health Informatics Management (HIM), Quality Management, and the House Supervisor (Administrator on Duty). There was no further coordination or leadership of the drafted action plans following the Human Resources (HR) interventions. Findings included: Review of the facility’s incident report dated 6/6/25 for Patient #1 documented a complaint/grievance reported by Patient #1 by email from her Emergency Department (ED) visit the early morning hours of 6/3/25, due to premature labor of twins at 18 weeks gestation. Patient #1 indicated the person who greeted her did not recognize the emergent situation; telling her she couldn’t possibly be in labor. Then a nurse placed her in a wheelchair indicating she would be going to Labor and Delivery (L&D). As they started heading to L&D, they were told the L&D department refused her because she was not 20 weeks gestation and was taken back to ED and placed in a room. The nurse called for the ED physician to come to the room in which the ED physician assessed, consulted with L&D OB physician, Staff #24, and both determined Patient #1 was in premature labor and advised the nurse caring for her to take her to L&D. The nurse began to head upstairs with Patient #1 and was again told that L&D would not accept her because she was under 20 weeks pregnant according to their “algorithm.” Patient transferred back to the bed in the ED room and Twin A was born and was inside the Amniotic Sac. The L&D OB arrived bedside and advised Patient #1 that twin B was breech, but with a little push, she would be able to deliver Twin B. The sac of Twin A was ruptured and the umbilical cords were both cut and the twins were placed on a table nearby while the placenta was delivered by the OB. The nurse wrapped the twins and handed them to the patient where she and her husband held them until they no longer saw movement or a heartbeat which was approximately 20-30 minutes. Patient #1 and family present indicated at no point did anyone ever assess the Twins (A and B). The incident report further documented, 6/8/25; leadership and the Patient Safety Officer (PSO) was involved. Charge nurses had been directed to follow physician orders despite nursing requests. Further comments documented upon review of Patient #1’s medical record, there was limited documentation until after 7:00 AM when the OB nurse came down to the ED and completed the paperwork and charted in Patient #1’s record what she “had been told had happened because the ED nurse did not know how to document the events.” Notarized written statements about the events that occurred were received along with the Texas Family Code discussing the definition of being born alive. The Director of ED (Staff #19) commented on 6/16/25 the following: Instruction was given to the charge nurses to follow physician orders regardless of what the OB nurses state. The ED RN was at bedside and followed the guidance of the ED provider and the L&D physician. The ED does “not have training or competencies on Apgar scores nor are ED nurses well versed in the rules and regulations regarding miscarriages.” A binder was provided, but “complicated to follow and should be handled by OB.” The Director ED, Staff #19) indicated a meeting for 6/16/25 to discuss further and “come up with a plan,” to prevent this type of incident from happening again. The incident was closed on 10/19/25, without further interventions documented; or a follow up letter sent to Patient #1 due to legal counsel obtained. Review of the preliminary/draft RCA revealed Causation #1: Assessment not performed on either infant. Surveyors confirmed this causation through review of Patient #1’s medical record dated 6/3/25 including her statement; and staff interviews completed. Findings of Causation #1: -Lack of knowledge assessing APGAR Scores -ED Nurse stated she was not trained to conduct APGAR Scores. Causation #2: Continuum of Care Findings of Causation #2 -Poor communication among staff or team members. Surveyors confirmed this causation through review of Patient #1’s medical records dated 6/3/25 including her statement; and staff interviews completed. Action Plan: Re-education around OB and ED requests L&D and ED determine need for assistance with imminent delivery and call OB ER Code. Provide APGAR scoring training, completion date 11/1/2025. Review of the Ethics report dated 7/11/25 revealed a report made through the hotline for Ethical concerns regarding Patient #1 and the Twin fetuses A and B that were delivered on 6/3/25: - There were no immediate assessments completed for the Twin fetuses A and B. - Documentation was done several hours after delivery of Twin fetuses A and B by a nursing staff who was not present at delivery. - There were modifications to the medical record regarding APGAR scores of the Twin fetuses A and B that were not accurate and completed by non-clinical staff. These allegations were verified by surveyors through review of Patient #1’s medical records dated 6/3/25 including her statement; and staff interviews completed. Interview on 11/18/25 at 11:35 with the CMO (Staff #36), and Interim PSO (Staff #3) present, stated the following: Recommendations included a physician peer review meeting that was completed 9/17/25 to ensure the standard of care was met. It was identified that there were “systemic issues;” with “escalating things and communicating.” It was recommended that communication occur with the “group physicians; to be educated,” and that “formal processes” be communicated with the nurses. Interview with the Interim PSO, Staff #3, on 11/18/25 at 11:40 AM, stated there had been a “Quality Summitt” for nurse training completed, and “education was happening” however, there was “not true tracking at this time, for compliance or a percentage completed” for review or verification. Interim PSO, Staff #3, further confirmed there was not documentation or evidence specifically related to Nursing education for, “fetal assessments-Apgar Scores.” There was no documentation or evidence specifically related to “OB alerts.” PSO, Staff #3 stated this event was serious, with safety concerns and the facility’s current “interim leadership” was addressing the identified issues. On 11/24/25 at 9:15 AM, the Interim PSO, Staff #3, stated there had not been loop closure after the RCA meeting and further recommendations that were discussed. The draft RCA documentation was “gone, was not in the dashboard,” and there was “no folder” with everything that had been drafted or completed. She further stated another PSO (staff #31) who assisted the prior PSO (Staff #32) provided the draft RCA copy that had been sent to in an email and provided to the surveyors for review. Interview on 11/20/25 at 3:00 PM with the Patient Safety Officer (PSO), Staff #31 indicated the following: He works at another facility (sister facility B) and he assisted with support to the facility’s PSO, Staff #32 with completing a Root Cause Analysis (RCA) regarding Patient #1 because Staff #31 was new to her role without a lot of experience. He attended the RCA with PSO, Staff #32, as a resource. The Interim PSO, Staff #3, was the primary mentor/ for PSO, Staff #32. The RCA meeting included the CMO virtually (on teams), ED staff, L&D staff, leadership, HIM staff, Staff #4, the Associate Administrator (Staff #4) was present and was not sure if “education” was present. He and PSO, Staff #32 were the only PSO’s present. PSO, Staff #31 stated, we went through the timeline to figure out what actually occurred from the beginning; initial presentation to the ER (Emergency Room), and the communication with L&D, and post discharge communication that occurred with the family. The departments appeared cooperative in the meeting with compassion in regard to the unfortunate outcome for the patient and family. We reminded the departments of what the reasoning behind the RCA meeting was for. Part of the scope of the RCA was addressing what was documented in the EMR and scanned into the EMR. There were opportunities identified with the documentation that were “atypical.” Communication with ED and L&D “opportunities” discussed. PSO, Staff #31 was asked if facility policies were reviewed in the RCA? He responded that he “came in, in the last minute” and printed out DHS policies, and our policies through “our system, [sister facility],” this facility’s policies and it was identified, “policies needed to be reviewed.” PSO, Staff #31 was asked about Nursing assessments being addressed and he responded, that “we looked at the triage process and the care provided in the ED and the communication between the different departments with getting assistance for ED from L&D. The physician’s quality side went to Peer Review for review. Chaplain assistance and involvement was reviewed.” PSO, Staff #31 was asked what the next step was after the identified concerns, and he responded, “my involvement was just attending the meeting to help facilitate and guide the meeting.” Once the opportunities are identified, then an Action Plan is developed; with follow-through after that. Additionally, from there, PSO, Staff #32, “was going to schedule a meeting for an Action Plan and ensure it get’s implemented by Directors and leadership.” Typically, within 14 days of having the RCA Meeting, an Action Plan is developed, and then within 21 days, submitted to home/corporate office, which includes the timeline and action plan. PSO, Staff #31 was asked what training is provided to complete an RCA? He responded, the training was “On the job training.” Try to have the new PSO help another experienced PSO for 1 or 2 RCA’s, attend a few meetings to see how the process is. Then they are monitored by the experienced PSO a few times. PSO, Staff #31 said that PSO, Staff #32 did reach out and asked for assistance and guidance for this specific case and she would give me updates, especially once Patient #1 obtained legal counsel. Interview on 11/24/25 at 9:30 AM with the facility’s Director of Accreditation and Regulatory Compliance, Staff #5, stated that the implementation and monitoring of Action Plans was not solely the responsibility of the facility’s PSO. It falls onto the specific Directors over those specific departments involved. In this case it was a team effort, and the Directors; CNO, ED Director, and L&D Director received the complaint allegations within the facility’s Incident Reporting system, “MIDAS.” Staff #5 confirmed and stated the Human Resources (HR) part was handled with the immediate issues identified that included disciplinary actions and employment separations; but the clinical part was not handled appropriately across the departments. At this time, Staff #5 said the facility is going to “start from scratch; clinically and go forward with ED and L&D” action plans. 41048”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41048 Based on records reviewed and interviews, the facility failed to ensure nursing staff met the needs of patients by performing and documenting complete and accurate assessments for 1 of 1 patient (Patient #1) reviewed who presented to the facility’s emergency department pregnant with twins, in preterm labor, resulting in a complete spontaneous abortion (miscarriage). Specifically, the facility failed to ensure nursing staff: 1. Performed assessments and reassessments to ensure stabilization of Patient # 1, including vital signs prior to discharge in accordance with physician orders and the facility’s policies and procedures. 2. Followed the facility’s policy and procedures for assessment and documentation of; Rhesus (Rh) factor evaluation (blood typing), intravenous device placement, patient vital signs, and post miscarriage blood loss monitoring. 3. Followed the facility’s policy and procedures for performing fetal assessments and legal documentation for Twin fetuses delivered by Patient #1; Twin A and Twin B. These deficient practices have the potential to result in harm to all patients receiving care in the facility. Findings included: Record review of Patient #1’s clinical electronic medical record (EMR) revealed that she was a 25-year-old pregnant female with monochorionic diamniotic twins [Mono/Di twins are identical twins who share a single placenta (monochorionic) but have separate amniotic sacs (diamniotic) in the womb], at 18 weeks gestationally [full terms is considered 40 weeks], arriving to the facility’s Emergency Department (ED) on 6/3/2025 at 3:55 AM with chief complaint of abdominal cramping and determined to have an Emergency Severity Index (ESI) of 2. Further review Patient #1’s disposition revealed Patient #1 had a miscarriage of Twin A and Twin B. Review of Patient #1’s Electronic Medical Record revealed a scanned notarized statement provided by Patient #1 from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented her statement of the events, in part (summarized): - On 6/3/25 at approximately 03:50 AM, In Room 16, ED Registered Nurse (RN), Staff #30, requested Patient #1 to undress in a gown and that she needed her arm for vital signs when she reported to Staff #30 that she couldn’t move her arm as she was holding the fetus in place from being delivered and was in excruciating pain.Staff #30 asked for the ED provider to come into the room. - Another ED RN Staff (unknown) placed a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). - ED provider, Staff #23, arrived; assessed Patient #1, stating “let me make some phone calls,” and asked for a doppler. - Patient #1 stated that they planned to move her upstairs to Labor & Delivery (L&D) as a doppler study was performed in which she was not verbally given the numerical results or any results. - Twin A was delivered right after, where she laid between Patient’s legs; still kicking in her amniotic sac that had not ruptured. At this time, L&D on call doctor, Staff #24, arrived at bedside and assumed care. - L&D doctor, Staff #24, told Patient #1 that Twin B was breech and asked her to push, then Twin B was delivered with her amniotic sac ruptured during delivery. - Patient #1 reported the infants were placed on a “cold, silver tray unattended” by L&D doctor, Staff #24. - L&D doctor, Staff #24, performed internal exam and abdominal massage to check for the placenta. He performed an ultrasound; patient stated she was told her uterus was empty. - The placenta was delivered after fundal massage lasting approximately 7 seconds and was bright red in color. - The fetuses were placed left of her feet without an assessment. - Patient #1 held both infants after ED RN/Staff # 30 wrapped them in towels where Patient observed a beating heart for both Twins due to their translucent skin described as a rate between 80-100 beats per minute. - L&D doctor/Staff #24 instructed ED RN/Staff #30 to administer Cytotec 200mcg. - L&D doctor/Staff #24 informed Patient #1 there would be a birth and death certificate for each twin, and he would return with the paperwork. - Patient reported approximately 20 minutes alone with the babies when during this time the heart rates ceased to no observable heartbeat, they became cold to the touch and their bodies darkened with no voluntary movement. - L&D provider, Staff #24, later returned and asked about obstetric history, prior appointments, weight, and MFM [maternal-fetal medicine] involvement. - L&D doctor, staff #24, stated that if Patient wanted to be discharged rather than admitted upstairs, and if vital signs were stable, Patient could be discharged home. - Patient #1’s father enters the room who is a neonatologist physician for this facility and Patient asked L&D doctor/Staff #24 about the gender(s) of the fetuses. There is a brief discussion between L&D doctor/Staff #24, and Patient #1’s father who indicated the likelihood of them both being girls. This is the first time that L&D doctor, Staff #24, “acknowledged the babies; up until this point, no medical observation or evaluation has been performed by [L&D doctor/Staff #24]. This includes but doesn’t limit: a pulse check, color, assessment to check for any signs of life, and negligence of two born-alive twin girls.” - The Chaplain/Staff #34 arrived for comfort and prayer indicated he does not usually work at this facility as unsure of the details of Post Mortem care as far as the disposition of the newborns. - ED RN/Staff #30 comes in for paperwork for disposition of the newborns. She indicated we can do a funeral home or dispose of them. She was unsure of the procedures of what either means, but would attempt to obtain more information. - L&D RN/Staff #25 comes in to have the parents sign a few additional signatures that were missed. - At approximately 08:00 AM on 6/3/2025, Patient #1 reported she was still soaked in fluids and blood; requested assistance. - Patient #1 self-ambulated about 200 feet to bathroom; reported passing 8 blood clots approximately 4 inches each. - Patient stated no repeat vital signs were taken prior to discharge. Review of Patient #1’s EMR revealed a scanned notarized statement provided by Patient #1’s spouse from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented his statement of the events, in part (summarized): On 6/3/25 at approximately 04:00 AM, his wife, Patient # 1, was in Room 16 of the ER [Emergency Room], and he stayed just outside the room with their son because his mom was screaming in pain. ER Dr/Staff #23 comes out of the room when Patient #1’s spouse asked her “what’s happening” and she responded, “We have heart beats but we are going to lose them.” Patient #1’s spouse goes into the room and observes Patient #1 in a hospital gown, laying on the bed with an IV and repeatedly saying, “I’m sorry, I’m sorry.” - Twin A was already delivered, still in the amniotic sac and attached to the placenta. Twin B was crowning, also in the sac. - L&D doctor, Staff #24, attempted multiple times to pull Twin B out by the legs; when unsuccessful, he stated: “The baby is breech and the head is stuck. I need you to push.” - Patient #1 pushed, and Twin B was delivered. - L&D doctor, Staff #24, cut open Twin A’s sac and clamped/cut both umbilical cords. - The Twins were placed on a metal tray while the physician focused on delivering the placenta. - Patient #1’s spouse witnessed Twin A display voluntary movement: Raised left arm above head, kicked left leg, arched back in a stretching motion when he reported this to L&D doctor (staff #24). L&D doctor (staff #24) responded sarcastically: “Yeah, they do that.” - Patient’s spouse realized both infants were alive on a cold table “waiting to die” without comfort or support. - After placenta delivery, Nurse staff #30 wrapped both infants in towels and asked if the parents wanted to hold them. - Patient #1’s spouse observed: Translucent but well-formed bodies, visible heartbeats, chest rise/fall and subtle movement. - L&D doctor (staff #24) stated that because this was a live birth, the parents would receive a birth certificate and a death certificate, likely on the same document. Record review of the Emergency/Urgent care, ED Triage Part 1 Entered On: 06/03/2025 04:20 AM Performed On: 06/03/2025 04:18 by ED RN (Staff #30) revealed the following: -“ED Triage HW; Chief Complaint: pt reports to ed via pov [privately own vehicle] with cc [chief complaint] of cramping pt is 18 weeks pregnant with twins ob dr [obstetrics physician named.] -Vital signs were documented as follows: Systolic Blood Pressure: 125 mmHg, Diastolic Blood Pressure: 62 mmHg, Heart Rate: 78 bpm, Best Eye Opening Response: Spontaneously, Best Motor Response: Obeys simple commands, Best Verbal Response: Oriented, Respiratory Rate: 22 breaths/min (HI), SpO2: 97 %, Oxygen Delivery: Room air, Glasgow Coma Total Score: 15, Height: 165 cm (Converted to: 5 ft 5 in, 64 .96 in), Weight: 55 kg (Converted to: 121.254 lb), Dosing BMI: 20, Dosing BSA-Mosteller: 1.59 m2, Pain Present: Yes actual or suspected pain, Mode of Arrival : Car. There was no documentation of a patient temperature taken. - ED screening Staff #30 documented on the ED triage Part 1, Patient #1 was given an emergency severity index (ESI) of 2 by staff #30. Pregnancy Status: Yes - ED Triage Assess Baby Deliver Last 12 Mo: No. Recent Travel: No travel inside or outside the country within last 30 days Infectious Exposure Symptoms: Abdominal pain” - ED Screening/history adult entered by staff #30 on 06/03/2025 04:23 AM; ED Arrival Details ED Visit Result of Injury: No. Pain assessment was documented by staff #30 at 04:18 AM on 6/3/2025 as “10 = worst possible pain”. Review of the “Emergent/Urgent Care, ED Note-Physician” dated 6/3/2025 and authored/authenticated at 7:39 AM, by ED physician (Staff #23) indicated the following, in part: History of present illness: Patient #1 is “18 weeks gestation with mono Di twins who presents for evaluation of lower abdominal pain/cramping and sensation of impending passage of fetus. Patient ports that she has had abdominal pain for the past [blank]” Physical exam: Vital signs: 6/3/25 at 04:18 AM, Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. There was no temperature documented. Further physical exam for GU: (Genitourinary exam) documented, “visible amniotic sac bulging through vaginal introitus. RN [ED-Registered Nurse/Staff #30] as chaperone at bedside.” The “Medical Decision Making” section documented: “Baby A 0.142 kg, Baby B 0.137.” “Test considered, but not ordered: CBC.” “Diagnostics/diagnostics results: No results in the past 36 hours.” “Impression/Plan: 1. Miscarriage 003.9 Patient education: Managing Pregnancy Loss, Miscarriage.” “Patient discharged in stable condition.” Review of the “Consultation Notes, Consult Note EMR” created on 6/3/2025 at 4:56 AM by OB/GYN, MD/Staff #24 indicated the following, in part: Chief complaint: “pt reports to ed via pov with cc of cramping pt is 18 weeks pregnant with twins” [OB physician named]. Physical exam: Vital signs: 6/3/25 at 04:18 AM, Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. There was no temperature documented. Lab results: Hematology, chemistry last 36 hrs. = 0 Diagnostics results: radiology - last 36 hrs. = 0 (no results in the past 36 hours) Diagnostics - non-radiology = 0 (no qualifying data) - GU: “normal external genitalia. On initial exam by ER physician, membranes were bulging through vagina, and when I [staff #24] arrived in the ED, twin A was passing vaginally, and then twin B passed after a push from the mother. The placenta was expelled within 2-3 minutes, and appears to be a complete mono-di placenta with 2 cords. The fetal sex on both infants is somewhat ambiguous. Dr. [Patient #1’s father, who is a neonatologist MD at this facility] came in to be with his daughter, [Patient #1], and his opinion is that the fetuses are both female. Light but consistent bleeding was occurring, and mother was given Cytotec 200 mcg buccally [Cytotec (misoprostol) is commonly used to help manage miscarriages, particularly missed or incomplete miscarriages, by inducing uterine contractions to expel pregnancy tissue]. Re-exam after about 20 minutes revealed minimal bleeding”. - Assessment/plan: “Complete spontaneous abortion of mono-di twin gestation at 18 weeks. Discussed with [Patient’s outpatient OB Physician], who agrees with plan to discharge patient from ED after 1-2 hours of observation, if she is not bleeding heavily and “vitals are stable.” He would like to see her for F/U in a few days. Discussed disposition of fetuses and placenta, and they prefer to send them to pathology of disposition, and not have them go to a funeral home, which is acceptable under Texas law if the fetuses weight less than 350 gm.” The consultation note was signed on 6/3/2025 at 05:51 AM by Obstetrician (Staff #24). Review of the record “ED disposition” entered on 6/3/2025 at 09:01 AM revealed the following: - Patient #1 was discharged. - The Vital signs section listed: Pain present: No actual or suspected pain, Height 165 cm, Weight 55kg, Dosing BMI: 20, Dosing BSA-Mosteller: 1.59 m2. No further vital signs documented. - ED mode of Discharge: ambulatory, ED disposition: discharge, Mode of transportation: private vehicle, ED discharged: home, ED condition: good, Accompanied by discharge: Spouse. Discharge comments: “gcs [Glasgow coma scale] 15, pt given dc instructions, medication education and follow up information, piv [peripheral intravenous] removed intact and pt ambulated out” Review of the record “ED patient Depart Summary” on 6/3/2025 at 09:01 AM revealed: - Patient #1 was provided with a visit summary and patient education package. This included a visit summary indicating arrival time on 6/3/2025 at 3:46 AM and discharge time on 6/3/2025 at 8:50 AM. - The patient education “Managing pregnancy loss; Miscarriage” - Major tests and procedures: no information was documented. Final review of Patient #1’s full and complete EMR revealed there was no evidence documented of the following: 1.) No vital signs taken, assessed, or documented within the record other than one set of vital signs documented on 6/3/25 at 04:18 AM that indicated Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. 2.) No temperature taken to rule out infection. 3.) No documentation for placement of a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). 4.) No documentation or evidence of a doppler assessment completed for Patient #1. 5.) No documentation or evidence of an immediate assessment completed for Twin A and Twin B upon delivery by staff present. 6). No documentation or evidence of Rh factor evaluation to determine the need for RHIG (Rh Immune Globulin), a crucial medication (RhoGAM) given to Rh-negative pregnant individuals after delivery/miscarriage. 7.) No documentation or evidence of nursing assessments or observations for blood loss surveillance monitoring post-spontaneous abortion other than one documented note by the OB/GYN MD at 20 minutes. Record review of the Nursing flowsheet Assessment- Obstetrics/Gynecology (OB/GYN) authored by Labor and Delivery (L&D) Registered Nurse (RN), Staff #25, on 6/3/2025 revealed the following: At 04:15 AM, the APGAR score (newborn assessment based on breathing effort, heart rate, muscle tone, reflex to stimulation, and color. See below for additional details) for Twin A at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.142 kilograms (kg). Gender: unknown At 04:16 AM, the APGAR score for Twin B at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.137 kg. Gender: unknown Review of L&D RN, Staff #25’s Timesheet documentation for 6/3/25 indicated she was scheduled from 6:45 AM to 7:15 PM and clocked in at 6:42 AM on 6/3/25 which was after Patient #1 delivered Twin A and Twin B at 4:15 AM. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin A, who was born “First on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. - The document had a parents’ signature space that was not signed or dated. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin B, who was born “Second on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. - The document had a parents’ signature space that was not signed or dated. Record review of scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled with a handwritten “Twin A” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The form was incomplete, with only some sections of the form completed: Patient reference was partially completed, prenatal care, source of prenatal care, HIV test, obstetric procedures, onset of labor, method of delivery, child health information, maternal morbidity, abnormal conditions of the newborn, and “was infant transferred within 24 hours of delivery?”. All other sections of this form were left incomplete. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:15 AM) and source of payment for delivery. - Child’s Health Information documented birth weight as 0.142 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. Record review of the scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled, with a handwritten “TWIN B, VAG [Vaginal]” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:16 AM). - Only 3 sections of this form were completed: patient reference (partially), pregnancy history and child health information. All other sections left incomplete. - Child’s Health Information documented birth weight as 0.137 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. 10135 Interview conducted on 11/18/2025 at 9:37 AM with Obstetrics L&D doctor/Staff #24 stated the following, in part: On 6/3/25 he was the OB hospitalist on duty when he received a call from ED DR (Staff #23) that Patient #1 was “23 weeks pregnant,” had a prolapsed membrane through the vagina and a “heartbeat” could be seen. He was later told by the L&D nurse that the patient was 18 weeks, and he went down to see her in ED. - When he got to the ED the patient told him she was 18 weeks and when he checked Patient #1 the amniotic membrane was bulging. Baby #1(A) was out (delivered), membrane ruptured and then Baby #2(B) was out (delivered). Both babies looked less than 500 grams and when he first looked at the babies there was no spontaneous movement or heart beats noticed. - He said there was not an L&D/OB nurse in the room with him. The ED nurse was the only one there with him. The ED nurse brought in a delivery tray which did not include a soft cloth, and he had to place the babies on a sterile towel. - He said the patient was definitely less than 23 weeks pregnant and the babies weighed less than 300 grams, which were weighed by the ED nurse. - He said the hospital’s policy for pregnancies is for 20 weeks and under, the patient is to be seen in the ED first and then moved to the L&D unit if needed. - He said it would have been better if an L&D OB nurse was with him during delivery or for Patient #1 to have been sent to L&D unit because the L&D nurses were used to dealing with fetal demise and they have the necessary supplies. - He said Baby A was placed on the bed between Patient #1’s legs when he arrived and then Baby B was delivered. Baby A was moved over to a counter on a towel. Further interview with L&D doctor/Staff #24 was asked if he assessed the babies and his response was that he did not see any signs of life, and he only spent about 15 seconds looking at the babies between deliveries. He said that he did not feel or check for a heartbeat. - He said the mother or father said they saw the babies moving. - He said 22 or 23 weeks is the limit on fetal viability based on studies. Interview on 11/18/25 at 10:33 AM, L&D- RN/Staff #25 stated the following, in part; She normally worked 7:00 AM to 7:00 PM as an L&D RN and normally took care of the bereavement paperwork. Staff #25 stated on 6/3/25 she was told there was a demise in the ED and for her to look over the paperwork. She went to the ED between 9-10 AM and looked at the paperwork. She had mom, Patient #1, fill out the lab sheet and burial information. The forms were originally filled out by the RN present at birth (Staff #30) without an RN signature as witnessed on them. Staff #25 said she had the mom re-sign the forms so she could witness them close to the time she arrived to the ED. Staff #25 said a couple hours later, around noon, she started documenting in Patient #1’s medical record. Staff #25 stated that the ED nurse, Staff #30, had placed the twins in one container, so she took them to the triage in the L&D unit and placed them in separate containers and weighed Twin A as being 0.142 kilograms and Twin B as 0.137 kilograms. L&D RN, Staff #25 stated she charted the APGAR score in Patient #1’s record as being zero “0” for both Twin A and Twin B with the APGAR score based on OB/GYN, MD/Staff #24’s notes that indicated the babies were “still born.” Staff #25 stated that she and the chaplain (Staff #35) called OB/GYN, MD/Staff #24 to verify the information. The ED RN (staff #30) was also called and reported that the dad of the Twins said he saw the babies move, but she had not. Further interview with L&D-RN/Staff #25 confirmed she did not document in the patient’s medical record where she obtained this information from, and stated she now knows she should have done that. Staff #25 said technically anyone with healthcare license could assess APGAR scores. Staff #25 was asked if anyone told her to change the APGAR score in the patient’s medical record and she responded, “no.” Staff #25 said prior to her documentation on 6/3/25 around noon, there was no APGAR scores documented within Patient #1’s record for Twin A and Twin B. Staff #25 (L&D-RN) said no matter what the patient complaint was in the ED, fetal heart tones were supposed to be done for pregnancies of 10-12-weeks. They could be done by doppler. Interview on 11/18/25 at 5:20 PM with ED RN, Staff #30 indicated the following, in part; Staff #30 (ED RN), revealed she worked the 7:00 PM to 7:00 AM shift on 06/03/2025. Patient #1 was brought in a wheelchair into the ED by the house supervisor and presented in severe pain. Patient #1 said she was 18 weeks pregnant with twins and was having them. Staff #30 (ED RN), said she took Patient #1 to a room, helped her into bed and checked her vaginal area. Staff #23 (ED Physician) came into the room with the ultrasound and realized Patient #1 needed to go to the L&D unit since Patient’s amniotic sac was hanging out. They were informed by an L&D Charge Nurse that they were not taking the patient because she was under 20 weeks pregnant. Staff #30 (ED RN), said she had the patient in a wheelchair ready to take her up to the unit when the call came in. She took Patient #1 back into the room and waited on Staff #24, L&D Hospitalist to come down. Staff #30 (ED RN), said she left the room to get needed supplies for Staff #24 L&D Hospitalist, and it took 5-10 minutes. Staff #30 (ED RN) said baby 1(A) was hanging out of Patient #1. When baby 1(A) was delivered the baby was placed on a sterile drape at the end of the bed. A couple of minutes later baby 2(B) was delivered and placed on the drape on the bed. The placenta was delivered 5-10 minutes after the babies. The babies were handed to each one of the parents to hold. Staff #30 (ED RN) said she left the room to get Cytotec for bleeding for the patient. They let the parents be alone with the twins and she checked them periodically to make sure there was no postpartum bleeding. Staff #30 (ED RN) said the product of conception paperwork and containers were brought down by the house supervisor. Staff #30 (ED RN) said she discussed the paperwork with the family after they were done bonding. She then took the babies to weigh them. After this it was change of shift and they called L&D to complete the paperwork. Staff #30 (ED RN) confirmed she did not complete the APGAR scores on the two twins stating she did not have the education or training to assess APGAR scores. Staff #30 (ED RN), said no OB alert was called because of maternal hemorrhaging and the fetus not being viable. Since then, they had changed their protocol to call an OB alert for anyone coming in with a delivery less than 20 weeks. 21863 Interview on 11/18/25 at 11:35 with the CMO (Staff #36), and Interim PSO (Staff #3) present, stated the following: It was identified that there were “systemic issues;” with “escalating things and communicating.” It was recommended that communication occur with the “group physicians; to be educated,” and that “formal processes” be communicated with the nurses. Interview with the Interim PSO, Staff #3, on 11/18/25 at 11:40 AM, stated there had been a “Quality Summitt” for nurse training completed, and “education was happening” however, there was “not true tracking at this time, for compliance or a percentage completed” for review or verification. Interim PSO, Staff #3, further confirmed there was not documentation or evidence specifically related to Nursing education for, “fetal assessments-Apgar Scores.” There was no documentation or evidence specifically related to “OB alerts.” PSO, Staff #3 stated this event was serious, with safety concerns and the facility’s current “interim leadership” was addressing the identified issues. Review of the facility policy, Emergency Department Standards of Nursing Practice and Documentation, last reviewed/revised 09/2020 indicated the following, in part: Review of the Emergency Department Standards of Nursing Practice and Documentation, ED 1004, last revised 09/2020, indicated the following, in part; Triage: Initial Patient Assessment B. Initial vital signs will be taken to include: Temperature: 1. For adult all patients Patient Reassessment A. Patient contact will be minimally one hour. B. Reassessment may include, but is not limited to: 1. Patient’s current condition/status 2. Vital signs 3. Performed interventions C. Patient condition reassessment times are as follows unless warranted more frequently based on clinical presentation: 2. Level 2- minimally every 2 hours D. Reassessment of vital signs 1. Vital signs may be retaken or reported as individual elements (e.g. heart rate, respirations, or temperature only) depending on clinical presentation 2. Temperature will be reassessed within 1 hour of receiving medication to reduce fever, and prior to discharge disposition. F. Performed interventions 1. Medications and response to medications 2. Pain rating reassessment will be completed within 1 hour after medication intervention for pain and prior to discharge disposition. Documentation B. All patients will have vital signs repeated prior to admission, transfer, or discharge with abnormal findings reported to the physician C. All procedures and interventions with patient’s response will be documented. Routine Discharge From Hospital B. Patients are reassessed prior to discharge. This includes a recent set of vital signs, response to medications or treatments given, as well as reassessment of chief complaint. F. Documentation by the ED RN will include discharge reassessments, education, method of transport, and anyone accompanying patient from our facility. Record review of the facility policy and procedure entitled: RHIG, Policy # LB-BB-TS-26, effective 05/24/24, revealed the following information, in part: III. Policy A.) Pregnant Rh Negative or Weak D/Partial D Rh Positive females are suitable candidates. B.) Patient has a negative antibody screen for Anti-D. C.) When mom is known or discovered to be Weak D/Partial D, Transfusion Requirements “RHIG Candidate” and “Use D negative RBCs” shall be placed in the patient’s profile. D.) The Blood Bank Lead/Supervisor will ensure RHIG is given to appropriate candidates following review of the Patient Typing and Comments report. IV. Indications for Use B.) Miscarriage, trauma, abortion, inv Record review of the facility policy and procedure entitled: Obstetrical Patient to the ED Department, Policy # CO- 2.036, effective date: 03/24 revealed the following, in part: B.) Medical Screening (MSE) 1.) facility provides a medical screening examination to all patients presenting for obstetrical evaluation, testing or services within the capabilities of the Obstetrical Unit and the ancillary services routinely available to the Obstetrical Emergency Department (OBED), including the use of on-call physicians. a.) Patients 20 weeks gestation or greater, with obstetrical presentations (other than for scheduled procedures) will receive a MSE in the OBED. b.) Patients fewer than 20 weeks gestation will receive a MSE by a QMP in the in the DED. 2.) The emergency department physician will assess patients presenting with emergency trauma and/or medical conditions and the location of further assessment and treatment will be at the medical discretion of the emergency department physician. a.) An emergency department record will include at last name, date of birth, time of presentation, estimated gestation and presenting complaint noted. b.) If the patient is transferred to another inpatient area, document mode of transport, personnel accompanying patient, departure and arrival time, any medically relevant observations, vital signs, and interventions. C.) Assessment and MSE Guidelines 1.) The OB RN (QMP) will perform an assessment on all presenting patients, including the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Laboring Coping Algorithm if appropriate, and assign an evaluation priority rating using the AWHONN Maternal Fetal Triage Index (MFTI)/ 2.) The OB RN (QMP) will complete an evaluation including an objective assessment of data, then will confirm and document the MFTI priority rating and review with the Delivering Clinician. b.) For patients with a MFTI priority rating 2 (Urgent) For obstetrical patients presenting with the complaint of decreased fetal movement, and/or < 34 weeks gestation complaining of spontaneous rupture of membranes (SROM) or spotting, the QMP may elect to follow the Exhibit in this policy. IV. EXHIBIT Exhibit A - Guidelines for Care of the Obstetrical Patient Presenting to the Obstetrics Unit for Triage and Medical Screening Examination receiving a MFTI (Maternal fetal triage index) Priority rating of 2 (Urgent) To provide guidance for the evaluation of obstetrical patients presenting to the obstetrical unit with the complaint of A) decreased movement, and/or B) < 34 weeks gestation complaining of spontaneous rupture of membrane (SROM) or spotting and receiving a Maternal Fetal Triage Index (MFTI) priority rating of 2. B.) Less than 34 Weeks Gestation with Detectable, Uterine Contractions: Obstetric patients < 2cm and < 80% effaced and the Fetal Fibronectin (fFN) results are negative, the patient may be discharged home after consultation with a Delivering Clinician by phone. A Delivering Clinician may also elect to order a transvaginal ultrasound. If fFN is unavailable, serial SVEs should be performed a minimum of two hours apart with no change in cervical dilatation (remaining < 2cm) effacement (remaining < 80%) or station. The patient should be evaluated in the OB ED for a minimum of 3hours. C.) Less than 34 Weeks Gestation Complaining of Spontaneous Rupture of Membranes (SROM) or Spotting Obstetric patients < 34 weeks gestation presenting with the complaint of SROM, leaking fluid, or spotting, a Delivering Clinician may order a Sterile Vaginal Exam, SVE, and the verification of intact membranes by use of amniotic fluid specific biomarker test or rapid immunoassays tests designed to detect amniotic fluid proteins in cericovaginal fluid. If the results are negative, the patient may be discharged home after consultation with a Delivering Clinician by phone. The patient should be observed in the OB ED a minimum of 2 hours prior to discharge. Record review of the facility policy and procedure entitled: Maternal Program Plan, Policy #1029, effective date: 04/24 revealed the following, in part: I.) Medical Conditions that elevate pregnancy risk: 2.) Obstetric: f.) Multiple Gestations “ Di-Di Twins “ Mo-Di Twins “ Triplets g.) Term Premature Rupture of Membranes h.) Preterm Premature Rupture of Membranes i.) Preterm Labor Management j.) Fetal Demise J. Triage, Stabilization and Transfer Resolute Baptist Hospital provides care for the pregnant patients with the capability to detect, stabilize, and initiate management of unanticipated maternal-fetal or maternal problems that occur during the antepartum, intrapartum, or postpartum period until the patient is stable enough to be transferred to a higher level of neonatal and/or maternal care. An OB patient who presents with no prenatal care and exhibits extremely high-risk conditions that contribute to Severe Maternal Morbidity and Mortality (SMM), (e.g. severe maternal hypertension, Placenta accrete Spectrum), require a collaborative approach with maternity team to determine if the patient is eligible for delivery at our facility or for transfer to a higher level of care. RBH has a written hospital preparedness and management plan for patients with placenta accreta spectrum disorder who are undiagnosed until delivery, including educating hospital and medical staff who may be involved in the treatment and management of placenta accreta spectrum disorder about risk factors, diagnosis, and management. The team will make the decision for the most appropriate location for delivery if imminent and/or transfer to a higher-level of Obstetrical Care. The team may consist of the Obstetrician and/or Family Medicine, Intensivist, and leadership representatives from Labor & Delivery, Surgical Services, Adult Intensive Care, Neonatal Intensive Care, Pharmacy, Laboratory Services, Blood Bank (with ability to meet the requirements of the Massive Transfusion Protocol), Respiratory Services, Radiology, and any additional provider/discipline requested by the Obstetrician, Family Medicine Physician or Intensivist. Consults available are MFM, Cardiology, Urology, General Surgery, and other credentialed providers as necessary. Patients with diagnosis that elevate the pregnancy risk may deliver at our facility if deemed appropriate after an MFM evaluation. Record review of the facility policy and procedure entitled: Fetal Demise/ Perinatal Bereavement, Policy # LD 1007, effective date: 11/24 revealed the following, in part: I. PURPOSE To outline the process of the care of neonates after death and the provision of emotional and spiritual support to the bereaved family. II. DEFINITION(S) A.) Perinatal Loss: Loss experienced by parent(s) and/or family at any time from conception through the neonatal period (28 days of life). B.) Live Birth: By legal definition, the infant is live born, regardless of gestational age, if he/she shows any sign of life at or sometime after birth. If there are any signs of life after delivery (breathing, beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles), whether or not the umbilical cord has been cut or the placenta is attached, this event is a live birth. C.) Stillborn/Fetal Death/Fetal Demise: None of the signs of life are present at or after birth. D.) Miscarriage/Spontaneous Abortion: Loss of pregnancy < 350 grams. E.) Neonatal Death: Live born infant that expires within the first 28 days following birth. F.) Reportable Death: Any situation meeting criteria that requires Justice of the Peace report. (See Postmortem Disposition Form Attachment A) G.) Certificate of Fetal Death: Form required for a delivery weighing 350 grams or more, or if the weight is unknown, a fetus aged 20 weeks or more as calculated from the start date of the last normal menstrual period to the date of delivery results in a fetus that shows no evidence of life. H.) Birth Certificate and Death Certificate: If there are any signs of life after delivery (breathing, beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles), whether or not the umbilical cord has been cut or the placenta is attached, this event is a live birth. A Certificate of Birth must be filed, even if the infant lives for only a very short period of time, regardless of the weight or length of gestation or the infant’s chances of survival. If the infant dies after delivery, a standard death certificate must also be filed. IV. PROCEDURE C.) Delivery Room Record: An electronic Delivery Room Record is completed for all fetuses. If live birth, place newborn and pediatrician copies in the newborn chart. If fetal demise/stillborn, place all copies in mother’s chart. D.) Documentation: The nurse caring for the family documents a complete physical assessment for infant: 1.) Fetal demise/stillborn infant: Complete the Nonviable/Stillborn Assessment (Attachment B). 2.) Live births, regardless of weight or gestational age, are admitted and their assessment is completed in the hospital EHR. Record review of the facility policy and procedure entitled: Standards of Practice: Newborn, Policy #Nrsy 1004, effective 05/24, revealed the following information, in part: Standard I: Nursing Practice C.) Transitional care practices include a complete history and assessment. Initial assessment and interventions occur concurrently following delivery. Standard IV: Professional Responsibility and Accountability B.) Legal accountability extends to the: Nurse practice acts. Parameter of professional practice established by professional organizations. Institutional standards. Legislative changes that affect practice. Policies, procedures, and protocols within the practice environment. Standard V: Utilization of Nursing Personnel Nursing care for women and newborns is conducted in practice settings that have qualified nursing staff in sufficient numbers to meet patient care needs. Sufficient nursing personnel are scheduled to meet patient care requirements. Many variables are considered in determining both the number and type of nursing staff needed. Among these variables are those related to the patient, practice, organization, and personnel. 47892”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 21863 Based on record reviews and interviews, the facility failed to ensure the medical records were complete, accurate, and documented by appropriate personnel in accordance with the facility’s policy and procedures for 1 of 1 patient reviewed (Patient #1) for a complaint regarding inaccurate medical records. Specifically, the facility failed to ensure: 1.) Patient assessments were completed, accurate, and documented by appropriate personnel caring for Patient #1 and her Twin fetuses (A and B) delivered. 2.) Assessments and Legal documentation for both Twin fetuses A and B delivered was accurate and/or completed by clinical staff present and not by other clinical staff; or non-clinical staff, that were not present. 3.) Complete and accurate documentation of assessments, diagnostics, and treatments provided by providers and nursing staff in accordance with facility policies, procedures and physician/provider orders. Findings include: Record review of Patient #1’s clinical electronic medical record (EMR) revealed that she was a 25-year-old pregnant female with monochorionic diamniotic twins [Mono/Di twins are identical twins who share a single placenta (monochorionic) but have separate amniotic sacs (diamniotic) in the womb], at 18 weeks gestationally [full terms is considered 40 weeks], arriving to the facility’s Emergency Department (ED) on 6/3/2025 at 3:55 AM with chief complaint of abdominal cramping and determined to have an Emergency Severity Index (ESI) of 2. Further review Patient #1’s disposition revealed Patient #1 had a miscarriage of Twin A and Twin B. Review of Patient #1’s Electronic Medical Record revealed a scanned notarized statement provided by Patient #1 from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented her statement of the events, in part (summarized): - On 6/3/25 at approximately 03:50 AM, In Room 16, ED Registered Nurse (RN), Staff #30, requested Patient #1 to undress in a gown and that she needed her arm for vital signs when she reported to Staff #30 that she couldn’t move her arm as she was holding the fetus in place from being delivered and was in excruciating pain. Staff #30 asked for the ED provider to come into the room. - Another ED RN Staff (unknown) placed a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). - ED provider, Staff #23, arrived; assessed Patient #1, stating “let me make some phone calls,” and asked for a doppler. - Patient #1 stated that they planned to move her upstairs to Labor & Delivery (L&D) as a doppler study was performed in which she was not verbally given the numerical results or any results. - Twin A was delivered right after, where she laid between Patient’s legs; still kicking in her amniotic sac that had not ruptured. At this time, L&D on call doctor, Staff #24, arrived at bedside and assumed care. - L&D doctor, Staff #24, told Patient #1 that Twin B was breech and asked her to push, then Twin B was delivered with her amniotic sac ruptured during delivery. - Patient #1 reported the infants were placed on a “cold, silver tray unattended” by L&D doctor, Staff #24. - L&D doctor, Staff #24, performed internal exam and abdominal massage to check for the placenta. He performed an ultrasound; patient stated she was told her uterus was empty. - The placenta was delivered after fundal massage lasting approximately 7 seconds and was bright red in color. - The fetuses were placed left of her feet without an assessment. - Patient #1 held both infants after ED RN/Staff # 30 wrapped them in towels where Patient observed a beating heart for both Twins due to their translucent skin described as a rate between 80-100 beats per minute. - L&D doctor/Staff #24 instructed ED RN/Staff #30 to administer Cytotec 200mcg. - L&D doctor/Staff #24 informed Patient #1 there would be a birth and death certificate for each twin, and he would return with the paperwork. - Patient reported approximately 20 minutes alone with the babies when during this time the heart rates ceased to no observable heartbeat, they became cold to the touch and their bodies darkened with no voluntary movement. - L&D provider, Staff #24, later returned and asked about obstetric history, prior appointments, weight, and MFM [maternal-fetal medicine] involvement. - L&D doctor, staff #24, stated that if Patient wanted to be discharged rather than admitted upstairs, and if vital signs were stable, Patient could be discharged home. - Patient #1’s father enters the room who is a neonatologist physician for this facility and Patient asked L&D doctor/Staff #24 about the gender(s) of the fetuses. There is a brief discussion between L&D doctor/Staff #24, and Patient #1’s father who indicated the likelihood of them both being girls. This is the first time that L&D doctor, Staff #24, “acknowledged the babies; up until this point, no medical observation or evaluation has been performed by [L&D doctor/Staff #24]. This includes but doesn’t limit: a pulse check, color, assessment to check for any signs of life, and negligence of two born-alive twin girls.” - The Chaplain/Staff #34 arrived for comfort and prayer indicated he does not usually work at this facility as unsure of the details of Post Mortem care as far as the disposition of the newborns. - ED RN/Staff #30 comes in for paperwork for disposition of the newborns. She indicated we can do a funeral home or dispose of them. She was unsure the procedures of what either means, but would attempt to obtain more information. - L&D RN/Staff #25 comes in to have the parents sign a few additional signatures that were missed. - At approximately 08:00 AM on 6/3/2025, Patient #1 reported she was still soaked in fluids and blood; requested assistance. - Patient #1 self-ambulated about 200 feet to bathroom; reported passing 8 blood clots approximately 4 inches each. - Patient stated no repeat vital signs were taken prior to discharge. Review of Patient #1’s EMR revealed a scanned notarized statement provided by Patient #1’s spouse from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented his statement of the events, in part (summarized): On 6/3/25 at approximately 04:00 AM, his wife, Patient # 1, was in Room 16 of the ER [Emergency Room], and he stayed just outside the room with their son because his mom was screaming in pain. ER Dr/Staff #23 comes out of the room when Patient #1’s spouse asked her “what’s happening” and she responded, “We have heart beats but we are going to lose them.” Patient #1’s spouse goes into the room and observes Patient #1 in a hospital gown, laying on the bed with an IV and repeatedly saying, “I’m sorry, I’m sorry.” - Twin A was already delivered, still in the amniotic sac and attached to the placenta. Twin B was crowning, also in the sac. - L&D doctor, Staff #24, attempted multiple times to pull Twin B out by the legs; when unsuccessful, he stated: “The baby is breech and the head is stuck. I need you to push.” - Patient #1 pushed, and Twin B was delivered. - L&D doctor, Staff #24, cut open Twin A’s sac and clamped/cut both umbilical cords. - The Twins were placed on a metal tray while the physician focused on delivering the placenta. - Patient #1’s spouse witnessed Twin A display voluntary movement: Raised left arm above head, kicked left leg, arched back in a stretching motion when he reported this to L&D doctor (staff #24). L&D doctor (staff #24) responded sarcastically: “Yeah, they do that.” - Patient’s spouse realized both infants were alive on a cold table “waiting to die” without comfort or support. - After placenta delivery, Nurse staff #30 wrapped both infants in towels and asked if the parents wanted to hold them. - Patient #1’s spouse observed: Translucent but well-formed bodies, visible heartbeats, chest rise/fall and subtle movement. -L&D doctor (staff #24) stated that because this was a live birth, the parents would receive a birth certificate and a death certificate, likely on the same document. Record review of the Nursing flowsheet Assessment- Obstetrics/Gynecology (OB/GYN) authored by Labor and Delivery (L&D) Registered Nurse (RN), Staff #25, on 6/3/2025 revealed the following: At 04:15 AM, the APGAR score (newborn assessment based on breathing effort, heart rate, muscle tone, reflex to stimulation, and color. See below for additional details) for Twin A at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.142 kilograms (kg). Gender: unknown At 04:16 AM, the APGAR score for Twin B at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.137 kg. Gender: unknown Review of L&D RN, Staff #25’s Timesheet documentation for 6/3/25 indicated she was scheduled from 6:45 AM to 7:15 PM and clocked in at 6:42 AM on 6/3/25 which was after Patient #1 delivered Twin A and Twin B at 4:15 AM. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin A, who was born “First on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. -The document had a parents’ signature space that was not signed or dated. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin B, who was born “Second on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. - The document had a parents’ signature space that was not signed or dated. Record review of scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled with a handwritten “Twin A” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The form was incomplete, with only some sections of the form completed: Patient reference was partially completed, prenatal care, source of prenatal care, HIV test, obstetric procedures, onset of labor, method of delivery, child health information, maternal morbidity, abnormal conditions of the newborn, and “was infant transferred within 24 hours of delivery?”. All other sections of this form were left incomplete. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:15 AM) and source of payment for delivery. - Child’s Health Information documented birth weight as 0.142 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. Record review of the scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled, with a handwritten “TWIN B, VAG [Vaginal]” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:16 AM). - Only 3 sections of this form were completed: patient reference (partially), pregnancy history and child health information. All other sections left incomplete. - Child’s Health Information documented birth weight as 0.137 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. Review of the “Emergent/Urgent Care, ED Note-Physician” dated 6/3/2025 and authored/authenticated at 7:39 AM, by ED physician (Staff #23) indicated the following, in part: History of present illness: Patient #1 is “18 weeks gestation with mono Di twins who presents for evaluation of lower abdominal pain/cramping and sensation of impending passage of fetus. Patient ports that she has had abdominal pain for the past [blank]” Physical exam: Vital signs: 6/3/25 at 04:18 AM, Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. There was no temperature documented. Further physical exam for GU: (Genitourinary exam) documented, “visible amniotic sac bulging through vaginal introitus. RN [ED-Registered Nurse/Staff #30] as chaperone at bedside.” The “Medical Decision Making” section documented: “Baby A 0.142 kg, Baby B 0.137.” Impression/Plan: 1. Miscarriage 003.9” Patient education: Managing Pregnancy Loss, Miscarriage. Review of the “Consultation Notes, Consult Note EMR” created on 6/3/2025 at 4:56 AM by OB/GYN, MD/Staff #24 indicated the following, in part: - GU: “normal external genitalia. On initial exam by ER physician, membranes were bulging through vagina, and when I [staff #24] arrived in the ED, twin A was passing vaginally, and then twin B passed after a push from the mother. The placenta was expelled within 2-3 minutes, and appears to be a complete mono-di placenta with 2 cords. The fetal sex on both infants is somewhat ambiguous. Dr. [Patient #1’s father, who is a neonatologist MD at this facility] came in to be with his daughter, [Patient #1], and his opinion is that the fetuses are both female. Light but consistent bleeding was occurring, and mother was given Cytotec 200 mcg buccally [Cytotec (misoprostol) is commonly used to help manage miscarriages, particularly missed or incomplete miscarriages, by inducing uterine contractions to expel pregnancy tissue]. Re-exam after about 20 minutes revealed minimal bleeding”. - Assessment/plan: “Complete spontaneous abortion of mono-di twin gestation at 18 weeks. Discussed with [Patient’s outpatient OB/MD], who agrees with plan to discharge patient from ED after 1-2 hours of observation, if she is not bleeding heavily and “vitals are stable.” He would like to see her for F/U in a few days. Discussed disposition of fetuses and placenta, and they prefer to send them to pathology of disposition, and not have them go to a funeral home, which is acceptable under Texas law if the fetuses weight less than 350 gm.” The consultation note was signed on 6/3/2025 at 05:51 AM by Obstetrician (Staff #24). Final review of Patient #1’s full and complete EMR revealed there was no evidence documented of the following: 1.) No vital signs taken, assessed, or documented within the record other than one set of vital signs documented on 6/3/25 at 04:18 AM that indicated Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. 2.) No temperature taken to rule out infection. 3.) No documentation for placement of a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). 4.) No documentation or evidence of a doppler assessment completed for Patient #1. 5.) No documentation or evidence of an immediate assessment completed for Twin A and Twin B upon delivery by staff present. 6.) No documentation of an ultrasound performed by L&D doctor/Staff #24. 7). No documentation or evidence of Rh factor evaluation to determine the need for RHIG (Rh Immune Globulin), a crucial medication (RhoGAM) given to Rh-negative pregnant individuals after delivery/miscarriage. 8.) No documentation or evidence of nursing assessments or observations for blood loss surveillance monitoring post-spontaneous abortion other than one documented note by the OB/GYN MD at 20 minutes. 10135 Interview conducted on 11/18/2025 at 9:37 AM with Obstetrics L&D doctor/Staff #24 stated the following, in part: On 6/3/25 he was the OB hospitalist on duty when he received a call from ED DR (Staff #23) that Patient #1 was “23 weeks pregnant,” had a prolapsed membrane through the vagina and a “heartbeat” could be seen. He was later told by the L&D nurse that the patient was 18 weeks, and he went down to see her in ED. - When he got to the ED the patient told him she was 18 weeks and when he checked Patient #1 the amniotic membrane was bulging. Baby #1(A) was out (delivered), membrane ruptured and then Baby #2(B) was out (delivered). Both babies looked less than 500 grams and when he first looked at the babies there was no spontaneous movement or heart beats noticed. - He said there was not an L&D/OB nurse in the room with him. The ED nurse was the only one there with him. The ED nurse brought in a delivery tray which did not include a soft cloth, and he had to place the babies on a sterile towel. - He said the patient was definitely less than 23 weeks pregnant and the babies weighed less than 300 grams, which were weighed by the ED nurse. - He said the hospital’s policy for pregnancies is for 20 weeks and under, the patient is to be seen in the ED first and then moved to the L&D unit if needed. - He said it would have been better if an L&D OB nurse was with him during delivery or for Patient #1 to have been sent to L&D unit because the L&D nurses were used to dealing with fetal demise and they have the necessary supplies. - He said Baby A was placed on the bed between Patient #1’s legs when he arrived and then Baby B was delivered. Baby A was moved over to a counter on a towel. Further interview with L&D doctor/Staff #24 was asked if he assessed the babies and his response was that he did not see any signs of life, and he only spent about 15 seconds looking at the babies between deliveries. He said that he did not feel or check for a heartbeat. - He said the mother or father said they saw the babies moving. - He said 22 or 23 weeks is the limit on fetal viability based on studies. Interview on 11/18/25 at 10:33 AM, L&D- RN/Staff #25 stated the following, in part; She normally worked 7:00 AM to 7:00 PM as an L&D RN and normally took care of the bereavement paperwork. Staff #25 stated on 6/3/25 she was told there was a demise in the ED and for her to look over the paperwork. She went to the ED between 9-10 AM and looked at the paperwork. She had mom, Patient #1, fill out the lab sheet and burial information. The forms were originally filled out by the RN present at birth (Staff #30) without an RN signature as witnessed on them. Staff #25 said she had the mom re-sign the forms so she could witness them close to the time she arrived to the ED. Staff #25 said a couple hours later, around noon, she started documenting in Patient #1’s medical record. Staff #25 stated that the ED nurse, Staff #30, had placed the twins in one container, so she took them to the triage in the L&D unit and placed them in separate containers and weighed Twin A as being 0.142 kilograms and Twin B as 0.137 kilograms. L&D RN, Staff #25 stated she charted the APGAR score in Patient #1’s record as being zero “0” for both Twin A and Twin B with the APGAR score based on OB/GYN, MD/Staff #24’s notes that indicated the babies were “still born.” Staff #25 stated that she and the chaplain (Staff #35) called OB/GYN, MD/Staff #24 to verify the information. The ED RN (staff #30) was also called and reported that the dad of the Twins said he saw the babies move, but she had not. Further interview with L&D-RN/Staff #25 confirmed she did not document in the patient’s medical record where she obtained this information from, and stated she now knows she should have done that. Staff #25 said technically anyone with healthcare license could assess APGAR scores. Staff #25 was asked if anyone told her to change the APGAR score in the patient’s medical record and she responded, “no.” Staff #25 said prior to her documentation on 6/3/25 around noon, there was no APGAR scores documented within Patient #1’s record for Twin A and Twin B. Staff #25 (L&D-RN) said no matter what the patient complaint was in the ED, fetal heart tones were supposed to be done for pregnancies of 10-12-weeks. They could be done by doppler. Interview on 11/18/25 at 5:20 PM with ED RN, Staff #30 indicated the following, in part; Staff #30 (ED RN), revealed she worked the 7:00 PM to 7:00 AM shift on 06/03/2025. Patient #1 was brought in a wheelchair into the ED by the house supervisor and presented in severe pain. Patient #1 said she was 18 weeks pregnant with twins and was having them. Staff #30 (ED RN), said she took Patient #1 to a room, helped her into bed and checked her vaginal area. Staff #23 (ED Physician) came into the room with the ultrasound and realized Patient #1 needed to go to the L&D unit since Patient’s amniotic sac was hanging out. They were informed by an L&D Charge Nurse that they were not taking the patient because she was under 20 weeks pregnant. Staff #30 (ED RN), said she had the patient in a wheelchair ready to take her up to the unit when the call came in. She took Patient #1 back into the room and waited on Staff #24, L&D Hospitalist to come down. Staff #30 (ED RN), said she left the room to get needed supplies for Staff #24 L&D Hospitalist, and it took 5-10 minutes. Staff #30 (ED RN) said baby 1(A) was hanging out of Patient #1. When baby 1(A) was delivered the baby was placed on a sterile drape at the end of the bed. A couple of minutes later baby 2(B) was delivered and placed on the drape on the bed. The placenta was delivered 5-10 minutes after the babies. The babies were handed to each one of the parents to hold. Staff #30 (ED RN) said she left the room to get Cytotec for bleeding for the patient. They let the parents be alone with the twins and she checked them periodically to make sure there was no postpartum bleeding. Staff #30 (ED RN) said the product of conception paperwork and containers were brought down by the house supervisor. Staff #30 (ED RN) said she discussed the paperwork with the family after they were done bonding. She then took the babies to weigh them. After this it was change of shift and they called L&D to complete the paperwork. Staff #30 (ED RN) confirmed she did not complete the APGAR scores on the two twins stating she did not have the education or training to assess APGAR scores. 41048 Interview conducted on 11/17/2025 at 1:15 PM with H.I.M supervisor (staff # 10) stated the following, in part: - She was approached by her supervisor for a request to produce live birth certificates for Patient #1’s miscarriage of twins and death certificates in order to “bury the babies.” - the HIM department couldn’t provide the birth certificate because the state form requires a documented APGAR score to process. - the APGAR score was not present in the medical record. - She received “push back” from the facility’s CEO and direct supervisor to produce the records. - Based on their request, her department proceeded with the request for the birth certificates. - She explained that she and her team filled out the form with inaccurate APGAR scores that weren’t in the medical record based on the “parents statements.” - She explained that she and her team found suitable scores to use in the state form by doing an internet search. There had to be a number and “zero doesn’t work.” We tried “1,” and it didn’t work. - She also stated that the fetuses never had or were given medical records numbers. In order to get a birth certificate there needs to be a medical record. - She stated that they scanned the required forms into Patient #1’s medical record including a form called “Medical Data Worksheet for Childbirth Certificate” which had “estimated” APGAR scores using the information the parents put in their statements. - Weeks later several people were fired including her supervisor. - She received a disciplinary action for the “falsification” and felt it was not warranted because she was told to do it by her supervisor and the hospital’s CEO. Record review of the facility policy and procedure entitled: Obstetrical Patient to the ED Department, Policy # CO- 2.036, effective date: 03/24 revealed the following: B.) Medical Screening (MSE) 1.) facility provides a medical screening examination to all patients presenting for obstetrical evaluation, testing or services within the capabilities of the Obstetrical Unit and the ancillary services routinely available to the Obstetrical Emergency Department (OBED), including the use of on-call physicians. a.) Patients 20 weeks gestation or greater, with obstetrical presentations (other than for scheduled procedures) will receive a MSE in the OBED. b.) Patients fewer than 20 weeks gestation will receive a MSE by a Qualified Medical Person/Personnel (QMP) in the Dedicated ED (DED). 2.) The emergency department physician will assess patients presenting with emergency trauma and/or medical conditions and the location of further assessment and treatment will be at the medical discretion of the emergency department physician. a.) An emergency department record will include at last name, date of birth, time of presentation, estimated gestation and presenting complaint noted. b.) If the patient is transferred to another inpatient area, document mode of transport, personnel accompanying patient, departure and arrival time, any medically relevant observations, vital signs, and interventions. C.) Assessment and MSE Guidelines 1.) The OB RN (QMP) will perform an assessment on all presenting patients, including the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Laboring Coping Algorithm if appropriate, and assign an evaluation priority rating using the AWHONN Maternal Fetal Triage Index (MFTI). (See reference article by Ruhl, Scheich, Onokpise, & Bingham, 2015.) 2.) The OB RN (QMP) will complete an evaluation including an objective assessment of data, then will confirm and document the MFTI priority rating and review with the Delivering Clinician. b.) For patients with a MFTI priority rating 2 (Urgent) For obstetrical patients presenting with the complaint of decreased fetal movement, and/or < 34 weeks gestation complaining of spontaneous rupture of membranes (SROM) or spotting, the QMP may elect to follow the Exhibit in this policy. Record review of the facility policy and procedure entitled: Fetal Demise/ Perinatal Bereavement, Policy # LD 1007, effective date: 11/24 revealed the following: I. PURPOSE To outline the process of the care of neonates after death and the provision of emotional and spiritual support to the bereaved family. II. DEFINITION(S) A.) Perinatal Loss: Loss experienced by parent(s) and/or family at any time from conception through the neonatal period (28 days of life). B.) Live Birth: By legal definition, the infant is live born, regardless of gestational age, if he/she shows any sign of life at or sometime after birth. If there are any signs of life after delivery (breathing, beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles), whether or not the umbilical cord has been cut or the placenta is attached, this event is a live birth. C.) Stillborn/Fetal Death/Fetal Demise: None of the signs of life are present at or after birth. D.) Miscarriage/Spontaneous Abortion: Loss of pregnancy < 350 grams. E.) Neonatal Death: Live born infant that expires within the first 28 days following birth. F.) Reportable Death: Any situation meeting criteria that requires Justice of the Peace report. (See Postmortem Disposition Form Attachment A) G.) Certificate of Fetal Death: Form required for a delivery weighing 350 grams or more, or if the weight is unknown, a fetus aged 20 weeks or more as calculated from the start date of the last normal menstrual period to the date of delivery results in a fetus that shows no evidence of life. H.) Birth Certificate and Death Certificate: If there are any signs of life after delivery (breathing, beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles), whether or not the umbilical cord has been cut or the placenta is attached, this event is a live birth. A Certificate of Birth must be filed, even if the infant lives for only a very short period of time, regardless of the weight or length of gestation or the infant’s chances of survival. If the infant dies after delivery, a standard death certificate must also be filed. IV. PROCEDURE C.) Delivery Room Record: An electronic Delivery Room Record is completed for all fetuses. If live birth, place newborn and pediatrician copies in the newborn chart. If fetal demise/stillborn, place all copies in mother’s chart. D.) Documentation: The nurse caring for the family documents a complete physical assessment for infant: 1.) Fetal demise/stillborn infant: Complete the Nonviable/Stillborn Assessment (Attachment B). 2.) Live births, regardless of weight or gestational age, are admitted and their assessment is completed in the hospital EHR. Review of the Emergency Department Standards of Nursing Practice and Documentation, ED 1004, last revised 09/2020, indicated the following, in part; Triage: Initial Patient Assessment B. Initial vital signs will be taken to include: Temperature: 1. For adult all patients Patient Reassessment A. Patient contact will be minimally one hour. B. Reassessment may include, but is not limited to: 1. Patient’s current condition/status 2. Vital signs 3. Performed interventions C. Patient condition reassessment times are as follows unless warranted more frequently based on clinical presentation: 2. Level 2- minimally every 2 hours D. Reassessment of vital signs 1. Vital signs may be retaken or reported as individual elements (e.g. heart rate, respirations, or temperature only) depending on clinical presentation 2. Temperature will be reassessed within 1 hour of receiving medication to reduce fever, and prior to discharge disposition. F. Performed interventions 1. Medications and response to medications 2. Pain rating reassessment will be completed within 1 hour after medication intervention for pain and prior to discharge disposition. Documentation B. All patients will have vital signs repeated prior to admission, transfer, or discharge with abnormal findings reported to the physician C. All procedures and interventions with patient’s response will be documented. Routine Discharge From Hospital B. Patients are reassessed prior to discharge. This includes a recent set of vital signs, response to medications or treatments given, as well as reassessment of chief complaint. F. Documentation by the ED RN will include discharge reassessments, education, method of transport, and anyone accompanying patient from our facility. APGAR Score: https://www.ncbi.nlm.nih.gov/sites/books/NBK470569/ Apgar scoring is indicated in all newborn infants at 1 and 5 minutes and should be documented in the clinical record. In infants scoring <7, expanded Apgar score recording is encouraged by the American College of Obstetrics and Gynecology and the American Academy of Pediatrics as a method of monitoring response to resuscitation. There are 5 parts to an Apgar score. Each category is weighted evenly and assigned a 0, 1, or 2 value. The components are then added to give a score recorded 1 and 5 minutes after birth. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is deemed low in full-term and late preterm infants, at 5 minutes, when an infant has a score of <7, Neonatal Resuscitation Program guidelines recommend continued recording at 5-minute intervals up to 20 minutes. The score is calculated using the following assessment: -Breathing effort If the neonate is not breathing, the respiratory score is 0. If respirations are slow and irregular, weak, or gasping, the respiratory score is 1. If the neonate is crying vigorously, the respiratory score is 2. -Heart rate The heart rate is evaluated with a stethoscope or an electrocardiogram and is the most critical part of the score in determining the need for resuscitation. If there is no heartbeat, the heart rate score is 0. If the heart rate is <100 bpm, the heart rate score is 1. If the heart rate is >100 bpm, the heart rate score is 2. -Muscle tone In inactive neonates with loose and floppy muscle tone, the score for muscle tone is 0. In neonates demonstrating some tone and flexion, the score for muscle tone is 1. In neonates in active motion with a flexed muscle tone that resists extension, the muscle tone score is 2. -Grimace response or reflex irritability in response to stimulation In a neonate with no response to stimulation, the reflex irritability response score is 0. A neonate grimacing in response to stimulation has a reflex irritability response score of 1. In a neonate who cries, coughs, or sneezes on stimulation, the reflex irritability response is 2. -Color Most infants will score 1 for color even at the 5-minute, as peripheral cyanosis is common among normal infants. If the neonate is pale or blue, the score for color is 0. If the infant is pink, but the extremities are blue, the score for color is 1. If the neonate is entirely pink, the score for color is 2.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 21863 Based on records reviewed and interviews, the facility failed to ensure the hospital’s emergency service/department was integrated with the other departments of the hospital, specifically; the Obstetrics (OB) Labor and Delivery (L&D) department to ensure immediate availability of the full extent of its patient care resources to assess and render appropriate care for an emergency OB/L&D patients affecting 1 of 1 patient reviewed (Patient #1) who presented to the facility’s emergency department (ED) pregnant with twins, in preterm labor, resulting in spontaneous abortion (miscarriage). As a result, Patient #1 and her Twin fetuses delivered ,Twin A and Twin B, failed to receive appropriate obstetrics/gynecology (OB/GYN) emergency care through assessments, reassessments, testing, and diagnostics in accordance with established professional clinical practice guidelines/standard of care, and the facility’s policies and procedures. These deficient practices have the potential to result in harm to all patients receiving care in the facility. Findings included: Record review of the facility policy and procedure entitled: Obstetrical Patient to the ED Department, Policy # CO- 2.036, effective date: 03/24 revealed the following: B.) Medical Screening (MSE) 1.) facility provides a medical screening examination to all patients presenting for obstetrical evaluation, testing or services within the capabilities of the Obstetrical Unit and the ancillary services routinely available to the Obstetrical Emergency Department (OBED), including the use of on-call physicians. a.) Patients 20 weeks gestation or greater, with obstetrical presentations (other than for scheduled procedures) will receive a MSE in the OBED. b.) Patients fewer than 20 weeks gestation will receive a MSE by a QMP in the in the DED. 2.) The emergency department physician will assess patients presenting with emergency trauma and/or medical conditions and the location of further assessment and treatment will be at the medical discretion of the emergency department physician. a.) An emergency department record will include at last name, date of birth, time of presentation, estimated gestation and presenting complaint noted. b.) If the patient is transferred to another inpatient area, document mode of transport, personnel accompanying patient, departure and arrival time, any medically relevant observations, vital signs, and interventions. C.) Assessment and MSE Guidelines 1. The OB RN (QMP) will perform an assessment on all presenting patients, including the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Laboring Coping Algorithm if appropriate, and assign an evaluation priority rating using the AWHONN Maternal Fetal Triage Index (MFTI). (See reference article by Ruhl, Scheich, Onokpise, & Bingham, 2015.) 2. The OB RN (QMP) will complete an evaluation including an objective assessment of data, then will confirm and document the MFTI priority rating and review with the Delivering Clinician. b.) For patients with a MFTI priority rating 2 (Urgent) For obstetrical patients presenting with the complaint of decreased fetal movement, and/or < 34 weeks gestation complaining of spontaneous rupture of membranes (SROM) or spotting, the QMP may elect to follow the Exhibit in this policy. IV. EXHIBIT Exhibit A - Guidelines for Care of the Obstetrical Patient Presenting to the Obstetrics Unit for Triage and Medical Screening Examination receiving a MFTI (Maternal fetal triage index) Priority rating of 2 (Urgent) To provide guidance for the evaluation of obstetrical patients presenting to the obstetrical unit with the complaint of A) decreased movement, and/or B) < 34 weeks gestation complaining of spontaneous rupture of membrane (SROM) or spotting and receiving a Maternal Fetal Triage Index (MFTI) priority rating of 2. B.) Less than 34 Weeks Gestation with Detectable, Uterine Contractions: Obstetric patients < 2cm and < 80% effaced and the Fetal Fibronectin (fFN) results are negative, the patient may be discharged home after consultation with a Delivering Clinician by phone. A Delivering Clinician may also elect to order a transvaginal ultrasound. If fFN is unavailable, serial SVEs should be performed a minimum of two hours apart with no change in cervical dilatation (remaining < 2cm) effacement (remaining < 80%) or station. The patient should be evaluated in the OB ED for a minimum of 3hours. C.) Less than 34 Weeks Gestation Complaining of Spontaneous Rupture of Membranes (SROM) or Spotting Obstetric patients < 34 weeks gestation presenting with the complaint of SROM, leaking fluid, or spotting, a Delivering Clinician may order a Sterile Vaginal Exam, SVE, and the verification of intact membranes by use of amniotic fluid specific biomarker test or rapid immunoassays tests designed to detect amniotic fluid proteins in cericovaginal fluid. If the results are negative, the patient may be discharged home after consultation with a Delivering Clinician by phone. The patient should be observed in the OB ED a minimum of 2 hours prior to discharge. Record review of the facility policy and procedure entitled: OB Emergency Response, Policy # LD 1040, effective date: 04/24 revealed the following: Purpose: This policy is designed to encourage recognition of patient clinical deterioration and/or provide guidance in the event of an obstetrical emergency that would require assistance to optimize patient outcomes. The development of a rapid response team is a patient safety initiative promoted by the American College of Obstetricians and Gynecologists, the Institute for Healthcare Improvement, the American Medical Association, The Joint Commission, the Agency for Healthcare Research and Quality and the Association of Women’s Health, Obstetric and Neonatal Nurses. The premise underlying rapid response systems is that in crises, patient outcomes can be optimized with a timely response that matches resources (appropriate crisis team personnel and equipment) to new patient needs. The team is summoned with a single call, saving time for the front-line caregiver (who might otherwise issue sequential stat pages) and eliminating personnel and equipment delay. Policy: Patient care emergencies may occur at any time in any setting; particularly the inpatient setting. Many emergencies are preceded by a period of instability during which timely interventions may help avoid further deterioration. It is important that obstetric staff prepare themselves by assessing potential emergencies, establishing early warning systems, designating specialized first responders, conducting emergency drills and debriefing staff after actual events to identify strengths and opportunities for improvement. When the need arises, a member of the OB team or a provider may request or initiate the response: 1.) OB staff will initiate an “OB Emergency” by calling “5555”. This will be announced overhead to initiate an OB rapid response. The response team will respond to the patient emergency and roles will be assigned by an OB team member (usually the L&D charge nurse) 2.) The response should be documented on the Rapid Response Treatment form (RRT) and turned into the OB Director 3.) If appropriate, the OB staff will debrief utilizing the ACOG debriefing tool. IV. Team Consists of the following members: 1. Anesthesia 2. Charge Nurse 3. Respiratory therapy 4. NICU Nurse 5. Surgical Tech 6. ICU Nurse 7. ED Nurse 8. House Officer 9. OB Physician Others may be requested as necessary: 1. OB director 2. Labor and Delivery Manager 3. NICU Manager 4. Laboratory 5. Pastoral Care 6. Postpartum Nurse 7. Neonatologist/Neonatal Nurse Practitioner Record review of the facility policy and procedure entitled: Maternal Program Plan, Policy #1029, effective date: 04/24 revealed the following: I.) Medical Conditions that elevate pregnancy risk: 2.) Obstetric: f.) Multiple Gestations Di-Di Twins Mo-Di Twins Triplets g.) Term Premature Rupture of Membranes h.) Preterm Premature Rupture of Membranes i.) Preterm Labor Management j.) Fetal Demise J. Triage, Stabilization and Transfer Resolute Baptist Hospital provides care for the pregnant patients with the capability to detect, stabilize, and initiate management of unanticipated maternal-fetal or maternal problems that occur during the antepartum, intrapartum, or postpartum period until the patient is stable enough to be transferred to a higher level of neonatal and/or maternal care. An OB patient who presents with no prenatal care and exhibits extremely high-risk conditions that contribute to Severe Maternal Morbidity and Mortality (SMM), (e.g. severe maternal hypertension, Placenta accrete Spectrum), require a collaborative approach with maternity team to determine if the patient is eligible for delivery at our facility or for transfer to a higher level of care. RBH has a written hospital preparedness and management plan for patients with placenta accreta spectrum disorder who are undiagnosed until delivery, including educating hospital and medical staff who may be involved in the treatment and management of placenta accreta spectrum disorder about risk factors, diagnosis, and management. The team will make the decision for the most appropriate location for delivery if imminent and/or transfer to a higher-level of Obstetrical Care. The team may consist of the Obstetrician and/or Family Medicine, Intensivist, and leadership representatives from Labor & Delivery, Surgical Services, Adult Intensive Care, Neonatal Intensive Care, Pharmacy, Laboratory Services, Blood Bank (with ability to meet the requirements of the Massive Transfusion Protocol), Respiratory Services, Radiology, and any additional provider/discipline requested by the Obstetrician, Family Medicine Physician or Intensivist. Consults available are MFM, Cardiology, Urology, General Surgery, and other credentialed providers as necessary. Patients with diagnosis that elevate the pregnancy risk may deliver at our facility if deemed appropriate after an MFM evaluation. Credentialed Obstetrician /Family Medicine, Anesthesiologist, and the Intensivist will make a collaborative decision to transfer critically ill patients to the Intensive Care Unit (ICU) within the facility or suggest transport for critical patients, patients with complications that require a higher level of care such as gestational ages under 32 weeks. Interview on 11/17/25 at 12:42 PM, Staff #17 (ED RN) stated the following: We have an algorithm we follow for OB patients presenting to the ED. If the patient is over 20 weeks, we notify L&D, and if the patient is under 20 weeks and in Labor, the ED physician will see the patient first for medical clearances. If the patient walks in, we try to determine the gestation by the information given by the mother during the triage process. Fetal heart tones are taken by ultrasound. We do not have fetal monitoring in the ED. The L&D nurse would have to bring a monitor downstairs to assess the baby. The ED physician would consult with the L&D OB hospitalist, and they would determine together if the patient would be sent to L&D. If there was a true emergency, then an OB emergency or OB Alert would be called. The OB hospitalist, L&D nurse, and NICU personnel are supposed to respond and come to the ED. L&D personnel would assist with the delivery and the baby. NICU would assist with the baby once delivered. The patient is then transferred to the L&D department. This was the way an OB Emergency should be, but we, in the ED department, get pushback from the L&D nursing staff on patients less than 20 weeks, even after the ED physician consulted with the OB hospitalist. The OB nursing staff will tell us no the patient is not coming to L&D, even though the physicians ordered that the patient be admitted to L&D. We have reported this practice to my director multiple times, and my director has had meetings with the L&D director, but nothing has changed. We still struggle with receiving help for patients less than 20 weeks of gestation. Interview on 11/17/25 at 12:42 PM at 1:08 PM, Staff #18 (ED RN) stated the following: If an OB patient walks in, in labor, registration and the triage nurse would notify us in the back that the patient was in labor. We get the patient back to the room, and an OB Emergency is called. The L&D nurse and the OB hospitalist are to respond and come down to the ED department. We only deliver in the ED if it is an absolute emergency. For patients who are not in labor, the ED physician determines if it is a medical condition or if there is a complaint with the baby. We use an algorithm to decide which patients go up to L&D and which patients stay in the ED. If the patient is less than 20 weeks of gestation, the patient will stay in the ED unless the ED physician consults the OB hospitalist and they decide the patient needs to go to L&D for further observation. The L&D nurses believe that if the patient is less than 20 weeks, the delivery should be done in the ED. This algorithm was started a little over a year ago for patients in active labor and for postpartum hemorrhage or non-viable delivery. The algorithm was implemented to ensure that the L&D nursing staff would come down and help us. Staff #18 further stated there continues to be instances where the L&D nursing staff have said “no, they were not taking the patient in L&D.” Staff #18 (ED RN) was asked if she knew of any incidents that had occurred when she responded; this just happened to a 19-week pregnant mother who delivered in the ED, and it was a fetal demise. The L&D nursing staff would not accept the patient even though the OB hospitalist spoke with the ED physician and wanted the patient to be admitted. Interview on 11/17/25 at 1:35 PM, Staff #19 (ED Director) said an algorithm was created with the OB Director (Staff #22) to assist staff in the ED and in L&D with how to manage OB patients. This algorithm helps staff to determine which pregnant patients stay in the ED, and which pregnant patients go upstairs to the L&D ED. If the patient is 20 weeks or over and their complaint is OB-related, they will go to the L&D ED. If a pregnant patient is 20 weeks or under, they will be seen in the ED no matter what. The ED physician will medically screen the patient, and then he will consult with the OB hospitalist. They decide what is best for the patient. If it is determined patient needs to go to L&D, then the patient should go to L&D. Staff #19 (ED Director) was asked about the incident that occurred on 6/03/2025 with Patient #1 and she stated that they have had a lot of pushbacks, though, from the L&D nursing staff, even after the physicians decided together to admit the patient to L&D. Staff #23 was the ED physician on 6/3/25, and consulted with Staff #24 the OB hospitalist. They both determined Patient #1 needed to go to L&D. Staff #23 (ED physician) informed the nurses that Patient #1 was coming up stairs, but the L&D nurse called down and would not receive the patient. Staff #23 (L&D hospitalist) had to come to the ED to see the patient. Patient #1 was never transported upstairs to L&D. The L&D nurse never came down to the ED. Staff #24 (L&D hospitalist) and Staff #30 (ED RN) delivered the babies. Staff #19 (ED Director) stated she believed that this is a “cultural problem”. There is no support from L&D services for ED. L&D nursing staff are basing their decision on the below 20 weeks in the Algorithm. OB emergencies are called for any patient who is delivering a baby in the ED. In August or September, we have had a couple of deliveries for which the L&D nurse would not come down to help after an OB emergency was called. Interview on 11/17/25 at 2:59 PM, RN shift supervisor for L&D, Staff #20, stated the following: When a patient is in active labor, they are greeted in the Emergency department and go through registration. The patients are either triaged in the ED or sent to the L&D unit. When they are sent to the L&D unit, the ED nurse calls them and speaks to the L&D nurse to get an assigned room. The ED staff escorts the patient, or they send staff down to get the patient. L&D supervisor, Staff #20 stated they used an algorithm to determine where the patient goes. If the patient is over 20 weeks pregnant and having contractions they are sent up to the L&D unit, put on a monitor and medically screened. If the patient is less than 20 weeks pregnant, they go to the ED based on the professional practice standards and the viability of the baby. Staff #20 further stated, if there were other patient concerns; the ED physician and the OB physician discuss. There is an OB hospitalist present 24/7 at the hospital that can go down to the ED if needed. If the patient is in imminent delivery they may come up to the unit and that depends on how busy the unit was, and the hospitalist determination. L&D, Staff #20 denied ever overriding the physician’s order to have a patient transferred to the L&D unit or denying a patient because of “staffing.” Interview on 11/17/25 at 3:16 PM, RN for L&D, Staff #21, stated the following for a patient presenting to the hospital in active labor: If the patient was over 20 weeks pregnant with signs and symptoms they were seen by a nurse in the ED. The ED calls them, and the patient is sent up or the L&D or staff go and get them. They obtain height, weight, and allergies and place the patient on a monitor. After the assessment the physician is notified. If the patient was less than 20 weeks pregnant, they were assessed and cleared by the ED. If their condition was urgent, they were sent to the OB unit. The OB hospitalist and ED physician talk and decide if the patient needs to be transferred. The patient is “wheeled to the unit only if census allowed.” Interview on 11/17/25 at 3:26 PM with the RN Director of L&D, Staff #22 stated the following: Their processes were based on the fetus’s viability on a rule in Neonatology, and their fetal demise gestational policy. If the patient was over 20 weeks pregnant and in active labor the ED physician and the OB hospitalist would discuss it, and the patient was brought to L&D for triage and evaluation. If the patient was less than 20 weeks pregnant and in active labor, they were triaged in the ED and medically screened. The ED physician then consults with the OB hospitalist. If L&D staff were needed in the ED, they can call an ED emergency. The process for an ED emergency has been in place since before she came to OB in June 2023. L&D Director, Staff #22, stated there were no instances of denying patients coming to the L&D unit. L&D Director, Staff #22, stated the L&D doctor, Staff #24 was told by the ED physician, Staff #23, that Patient #1 was “25 weeks pregnant.” The ED physician (Staff #23) and the OB hospitalist (Staff #24) talked and decided the patient needed to come to the L&D unit. They later found out somehow that Patient #1 was 18 weeks pregnant, and the OB hospitalist (Staff #24) went downstairs to the ED to see the patient. When staff #22 was asked if an OB emergency was called for Patient #1, she stated “no”. When asked if an OB emergency had been called since then (6/3/25), she stated “yes”. Record review of Patient #1’s clinical electronic medical record (EMR) revealed that she was a 25-year-old pregnant female with monochorionic diamniotic twins [Mono/Di twins are identical twins who share a single placenta (monochorionic) but have separate amniotic sacs (diamniotic) in the womb], at 18 weeks gestationally [full terms is considered 40 weeks], arriving to the facility’s Emergency Department (ED) on 6/3/2025 at 3:55 AM with chief complaint of abdominal cramping and determined to have an Emergency Severity Index (ESI) of 2. Further review Patient #1’s disposition revealed Patient #1 had a miscarriage of Twin A and Twin B. Review of Patient #1’s Electronic Medical Record revealed a scanned notarized statement provided by Patient #1 from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented her statement of the events, in part (summarized): -On 6/3/25 at approximately 3:45 AM, Patient #1 presented to the facility’s ED in “excruciating pain” with difficulty talking. Patient #1’s husband informed the “greeter” that she was almost 18 weeks pregnant with twins and that she was in labor. The greeter responded, “no, that’s not possible.” The greeter went back to talk to someone which felt like an “eternity” as Patient #1 was laboring in the hospital ER lobby in physical and emotional distress. Patient #1 called her dad, a neonatologist who has medical rights at this facility at 03:47 AM after arriving to the facility and spoke to him for 47 seconds. A nurse then came with a wheelchair and stated Patient #1 was going to Labor & Delivery (L&D). -Another unidentified staff member instructed the nurse to take her to room 16 in the ED - Approximately 03:50 AM, In Room 16, ED Registered Nurse (RN), Staff #30, requested Patient #1 to undress in a gown and that she needed her arm for vital signs when she reported to Staff #30 that she couldn’t move her arm as she was holding the fetus in place from being delivered and was in excruciating pain. Staff #30 asked for the ED provider to come into the room. - Another ED RN Staff (unknown) placed a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). - ED provider, Staff #23, arrived; assessed Patient #1, stating “let me make some phone calls,” and asked for a doppler. - Patient #1 stated that they planned to move her upstairs to L&D once again as a doppler study was performed in which she was not verbally given the numerical results or any results. - Twin A was delivered right after, where she laid between Patient’s legs; still kicking in her amniotic sac that had not ruptured. At this time, L&D on call doctor, Staff #24, arrived at bedside and assumed care. - L&D doctor, Staff #24, told Patient #1 that Twin B was breech and asked her to push, then Twin B was delivered with her amniotic sac ruptured during delivery. - Patient #1 reported the infants were placed on a “cold, silver tray unattended” by L&D doctor, Staff #24. - L&D doctor, Staff #24, performed internal exam and abdominal massage to check for the placenta. He performed an ultrasound; patient stated she was told her uterus was empty. - The placenta was delivered after fundal massage lasting approximately 7 seconds and was bright red in color. - The fetuses were placed left of her feet without an assessment. - Patient #1 held both infants after ED RN/Staff # 30 wrapped them in towels where Patient observed a beating heart for both Twins due to their translucent skin described as a rate between 80-100 beats per minute. - L&D doctor/Staff #24 instructed ED RN/Staff #30 to administer Cytotec 200mcg. - L&D doctor/Staff #24 informed Patient #1 there would be a birth and death certificate for each twin, and he would return with the paperwork. - Patient reported approximately 20 minutes alone with the babies when during this time the heart rates ceased to no observable heartbeat, they became cold to the touch and their bodies darkened with no voluntary movement. - L&D provider, Staff #24, later returned and asked about obstetric history, prior appointments, weight, and MFM [maternal-fetal medicine] involvement. - L&D doctor, staff #24, stated that if Patient wanted to be discharged rather than admitted upstairs, and if vital signs were stable, Patient could be discharged home. - Patient #1’s father enters the room who is a neonatologist physician for this facility and Patient asked L&D doctor/Staff #24 about the gender(s) of the fetuses. There is a brief discussion between L&D doctor/Staff #24, and Patient #1’s father who indicated the likelihood of them both being girls. This is the first time that L&D doctor, Staff #24, “acknowledged the babies; up until this point, no medical observation or evaluation has been performed by [L&D doctor/Staff #24]. This includes but doesn’t limit: a pulse check, color, assessment to check for any signs of life, and negligence of two born-alive twin girls.” - The Chaplain/Staff #34 arrived for comfort and prayer indicated he does not usually work at this facility as unsure of the details of Post Mortem care as far as the disposition of the newborns. - ED RN/Staff #30 comes in for paperwork for disposition of the newborns. She indicated we can do a funeral home or dispose of them. She was unsure of the procedures of what either means, but would attempt to obtain more information. - L&D RN/Staff #25 comes in to have the parents sign a few additional signatures that were missed. - At approximately 08:00 AM on 6/3/2025, Patient #1 reported she was still soaked in fluids and blood; requested assistance. - Patient #1 self-ambulated about 200 feet to bathroom; reported passing 8 blood clots approximately 4 inches each. - Patient stated no repeat vital signs were taken prior to discharge. Review of Patient #1’s EMR revealed a scanned notarized statement provided by Patient #1’s spouse from her ED visit dated 6/3/25, that was received by the facility on 6/6/25 that documented his statement of the events, in part (summarized): -On 6/3/25 at approximately 3:45 AM, Patient #1 presented to the facility’s ED in “excruciating pain” with difficulty talking. Patient #1’s husband informed the male “greeter” that she was almost 18 weeks pregnant with twins and that she was in labor. The greeter responded, “That’s not possible.” Patient #1’s spouse stated, “Well that’s what is happening here, can you please get someone?” and then he left to get someone. Patient #1’s spouse assisted her into a chair and went to park the car. -He returned after parking the car, having a brief conversation with Patient #’1 father; to his wife still in the lobby of the hospital’s ED where they continued to wait another minute or two before a male showed up with a wheelchair. -Patient #1 was assisted into the wheelchair and in process of being taken to L&D when another unknown staff yelled out, “Wait she stays back here” in ED/ER [Emergency Room], and was taken to room 16 in the ER. -Approximately 04:00 AM, Patient # 1 was in Room 16 of the ER, and he stayed just outside the room with their son because his mom was screaming in pain. ER Dr/Staff #23 comes out of the room when Patient #1’s spouse asked her “what’s happening” and she responded, “We have heart beats, but we are going to lose them.” Patient #1’s spouse goes into the room and observes Patient #1 in a hospital gown, laying on the bed with an IV and repeatedly saying, “I’m sorry, I’m sorry.” - Twin A was already delivered, still in the amniotic sac and attached to the placenta. Twin B was crowning, also in the sac. - L&D doctor, Staff #24, attempted multiple times to pull Twin B out by the legs; when unsuccessful, he stated: “The baby is breech and the head is stuck. I need you to push.” - Patient #1 pushed, and Twin B was delivered. - L&D doctor, Staff #24, cut open Twin A’s sac and clamped/cut both umbilical cords. - The Twins were placed on a metal tray while the physician focused on delivering the placenta. -Patient #1 and L&D doctor, Staff #24 had a brief discussion about how he needed to communicate with his wife about “what was happening” because she felt like he was not communicating and “seemingly annoyed,” he responded, “Well you need to deliver the placenta, or I need to give you anesthesia.” -Patient #1 told the L&D doctor, “No, you will not give me anesthesia, I get angry with that. Can’t you just assist in pushing by massaging my stomach or something.” -The L&D Doctor, Staff #24 then reached into Patient#1’s vagina as she screamed, stating in an appeared annoyed voice, “I’m trying to see if the placenta is in your uterus or vagina.” He discovered it was in the vagina and said, “you need to push.” - Patient #1’s spouse witnessed Twin A display voluntary movement: Raised left arm above head, kicked left leg, arched back in a stretching motion when he reported this to L&D doctor (staff #24). L&D doctor (staff #24) responded sarcastically: “Yeah, they do that.” - Patient’s spouse realized both infants were alive on a cold table “waiting to die” without comfort or support. - After placenta delivery, Nurse staff #30 wrapped both infants in towels and asked if the parents wanted to hold them. - Patient #1’s spouse observed: Translucent but well-formed bodies, visible heartbeats, chest rise/fall and subtle movement. - L&D doctor (staff #24) stated that because this was a live birth, the parents would receive a birth certificate and a death certificate, likely on the same document. - The Chaplain/Staff #34 arrived for comfort and prayer, stating “we are young, and could always make other babies.” The Chaplain, Staff #34 informed us that we need to decide for the “paperwork” if we need a funeral home or have the hospital take over care and disposal of the babies; and if we wanted to use a funeral home, we needed to know which one. Record review of the Emergency/Urgent care, ED Triage Part 1 Entered On: 06/03/2025 04:20 AM Performed On: 06/03/2025 04:18 by ED RN (Staff #30) revealed the following: -“ED Triage HW; Chief Complaint: pt reports to ed via pov [privately own vehicle] with cc [chief complaint] of cramping pt is 18 weeks pregnant with twins ob dr [obstetrics physician named.] -Vital signs were documented as follows: Systolic Blood Pressure: 125 mmHg, Diastolic Blood Pressure: 62 mmHg, Heart Rate: 78 bpm, Best Eye Opening Response: Spontaneously, Best Motor Response: Obeys simple commands, Best Verbal Response: Oriented, Respiratory Rate: 22 breaths/min (HI), SpO2: 97 %, Oxygen Delivery: Room air, Glasgow Coma Total Score: 15, Height: 165 cm (Converted to: 5 ft 5 in, 64 .96 in), Weight: 55 kg (Converted to: 121.254 lb), Dosing BMI: 20, Dosing BSA-Mosteller: 1.59 m2, Pain Present: Yes actual or suspected pain, Mode of Arrival : Car. There was no documentation of a patient temperature taken. - ED screening Staff #30 documented on the ED triage Part 1, Patient #1 was given an emergency severity index (ESI) of 2 by staff #30. Pregnancy Status: Yes - ED Triage Assess Baby Deliver Last 12 Mo: No. Recent Travel: No travel inside or outside the country within last 30 days Infectious Exposure Symptoms: Abdominal pain” - ED Screening/history adult entered by staff #30 on 06/03/2025 04:23 AM; ED Arrival Details ED Visit Result of Injury: No. Pain assessment was documented by staff #30 at 04:18 AM on 6/3/2025 as “10 = worst possible pain”. Review of the “Emergent/Urgent Care, ED Note-Physician” dated 6/3/2025 and authored/authenticated at 7:39 AM, by ED physician (Staff #23) indicated the following, in part: History of present illness: Patient #1 is “18 weeks gestation with mono Di twins who presents for evaluation of lower abdominal pain/cramping and sensation of impending passage of fetus. Patient ports that she has had abdominal pain for the past [blank]” Physical exam: Vital signs: 6/3/25 at 04:18 AM, Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. There was no temperature documented. Further physical exam for GU: (Genitourinary exam) documented, “visible amniotic sac bulging through vaginal introitus. RN [ED-Registered Nurse/Staff #30] as chaperone at bedside.” The “Medical Decision Making” section documented: “Baby A 0.142 kg, Baby B 0.137.” “Test considered, but not ordered: CBC.” “Diagnostics/diagnostics results: No results in the past 36 hours.” “Impression/Plan: 1. Miscarriage 003.9 Patient education: Managing Pregnancy Loss, Miscarriage.” “Patient discharged in stable condition.” Review of the “Consultation Notes, Consult Note EMR” created on 6/3/2025 at 4:56 AM by OB/GYN, MD/Staff #24 indicated the following, in part: Chief complaint: “pt reports to ed via pov with cc of cramping pt is 18 weeks pregnant with twins” [OB physician named]. Physical exam: Vital signs: 6/3/25 at 04:18 AM, Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. There was no temperature documented. Lab results: Hematology, chemistry last 36 hrs. = 0 Diagnostics results: radiology - last 36 hrs. = 0 (no results in the past 36 hours) Diagnostics - non-radiology = 0 (no qualifying data) - GU: “normal external genitalia. On initial exam by ER physician, membranes were bulging through vagina, and when I [staff #24] arrived in the ED, twin A was passing vaginally, and then twin B passed after a push from the mother. The placenta was expelled within 2-3 minutes, and appears to be a complete mono-di placenta with 2 cords. The fetal sex on both infants is somewhat ambiguous. Dr. [Patient #1’s father, who is a neonatologist MD at this facility] came in to be with his daughter, [Patient #1], and his opinion is that the fetuses are both female. Light but consistent bleeding was occurring, and mother was given Cytotec 200 mcg buccally [Cytotec (misoprostol) is commonly used to help manage miscarriages, particularly missed or incomplete miscarriages, by inducing uterine contractions to expel pregnancy tissue]. Re-exam after about 20 minutes revealed minimal bleeding”. - Assessment/plan: “Complete spontaneous abortion of mono-di twin gestation at 18 weeks. Discussed with [Patient’s outpatient OB Physician], who agrees with plan to discharge patient from ED after 1-2 hours of observation, if she is not bleeding heavily and “vitals are stable.” He would like to see her for F/U in a few days. Discussed disposition of fetuses and placenta, and they prefer to send them to pathology of disposition, and not have them go to a funeral home, which is acceptable under Texas law if the fetuses weight less than 350 gm.” The consultation note was signed on 6/3/2025 at 05:51 AM by Obstetrician (Staff #24). Review of the record “ED disposition” entered on 6/3/2025 at 09:01 AM revealed the following: - Patient #1 was discharged. - The Vital signs section listed: Pain present: No actual or suspected pain, Height 165 cm, Weight 55kg, Dosing BMI: 20, Dosing BSA-Mosteller: 1.59 m2. No further vital signs documented. - ED mode of Discharge: ambulatory, ED disposition: discharge, Mode of transportation: private vehicle, ED discharged: home, ED condition: good, Accompanied by discharge: Spouse. Discharge comments: “gcs [Glasgow coma scale] 15, pt given dc instructions, medication education and follow up information, piv [peripheral intravenous] removed intact and pt ambulated out” Review of the record “ED patient Depart Summary” on 6/3/2025 at 09:01 AM revealed: - Patient #1 was provided with a visit summary and patient education package. This included a visit summary indicating arrival time on 6/3/2025 at 3:46 AM and discharge time on 6/3/2025 at 8:50 AM. - The patient education “Managing pregnancy loss; Miscarriage” - Major tests and procedures: no information was documented. Final review of Patient #1’s full and complete EMR revealed there was no evidence documented of the following: 1.) No vital signs taken, assessed, or documented within the record other than one set of vital signs documented on 6/3/25 at 04:18 AM that indicated Blood Pressure (B/P) of 125 mmHG (Systolic) over 62 mmHG (Diastolic), Heart Rate of 78 bpm, SpO2/Pulse Oximetry of 97% saturation, Respiratory Rate was blank, and a Dosing BMI of 20 documented. 2.) No temperature taken to rule out infection. 3.) No documentation for placement of a 20 gauge Intravenous (IV) in the left Antecubital Fossa (AC). 4.) No documentation or evidence of a doppler assessment completed for Patient #1. 5.) No documentation or evidence of an immediate assessment completed for Twin A and Twin B upon delivery by staff present. 6). No documentation or evidence of Rh factor evaluation to determine the need for RHIG (Rh Immune Globulin), a crucial medication (RhoGAM) given to Rh-negative pregnant individuals after delivery/miscarriage. 7.) No documentation or evidence of nursing assessments or observations for blood loss surveillance monitoring post-spontaneous abortion other than one documented note by the OB/GYN MD at 20 minutes. Record review of the Nursing flowsheet Assessment- Obstetrics/Gynecology (OB/GYN) authored by Labor and Delivery (L&D) Registered Nurse (RN), Staff #25, on 6/3/2025 revealed the following: At 04:15 AM, the APGAR score (newborn assessment based on breathing effort, heart rate, muscle tone, reflex to stimulation, and color. See below for additional details) for Twin A at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.142 kilograms (kg). Gender: unknown At 04:16 AM, the APGAR score for Twin B at 1 minute was 0 (zero) and at 5 minutes was 0. Neonate Outcome: Fetal death. Birth Weight 0.137 kg. Gender: unknown Review of L&D RN, Staff #25’s Timesheet documentation for 6/3/25 indicated she was scheduled from 6:45 AM to 7:15 PM and clocked in at 6:42 AM on 6/3/25 which was after Patient #1 delivered Twin A and Twin B at 4:15 AM. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin A, who was born “First on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. - The document had a parents’ signature space that was not signed or dated. Record review of the medical record scanned document labeled “Verification of Birth Facts”, no date or time stamp, revealed the following, in part; - The document indicated the Legal Name given for Twin B, who was born “Second on 6/3/2025 at 4:15 AM, as a Female.” The parents’ names were listed and additional demographics. - The document had a parents’ signature space that was not signed or dated. Record review of scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled with a handwritten “Twin A” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The form was incomplete, with only some sections of the form completed: Patient reference was partially completed, prenatal care, source of prenatal care, HIV test, obstetric procedures, onset of labor, method of delivery, child health information, maternal morbidity, abnormal conditions of the newborn, and “was infant transferred within 24 hours of delivery?”. All other sections of this form were left incomplete. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:15 AM) and source of payment for delivery. - Child’s Health Information documented birth weight as 0.142 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. Record review of the scanned document titled “Medical Data Worksheet for Child’s Birth Certificate”, labeled, with a handwritten “TWIN B, VAG [Vaginal]” on the right upper corner, revealed the following, in part; - The document indicated, “This form to be completed by hospital staff.” - The form was handwritten without an author’s name, signature, time stamp, or date. - The Patient reference section had the name of Patient #1, medical record number, newborn name (Baby Girl), date and time of birth (6-3-25, 4:16 AM). - Only 3 sections of this form were completed: patient reference (partially), pregnancy history and child health information. All other sections left incomplete. - Child’s Health Information documented birth weight as 0.137 grams. Obstetric estimate of gestation (completed weeks): 18. Child’s sex documented as, Female. An APGAR score of “3” at 5 minutes, and “4” at 10 minutes. Interview conducted on 11/18/2025 at 9:37 AM with Obstetrics L&D doctor/Staff #24 stated the following, in part: On 6/3/25 he was the OB hospitalist on duty when he received a call from ED DR (Staff #23) that Patient #1 was “23 weeks pregnant,” had a prolapsed membrane through the vagina and a “heartbeat” could be seen. He was later told by the L&D nurse that the patient was 18 weeks, and he went down to see her in ED. - When he got to the ED the patient told him she was 18 weeks and when he checked Patient #1 the amniotic membrane was bulging. Baby #1(A) was out (delivered), membrane ruptured and then Baby #2(B) was out (delivered). Both babies looked less than 500 grams and when he first looked at the babies there was no spontaneous movement or heart beats noticed. - He said there was not an L&D/OB nurse in the room with him. The ED nurse was the only one there with him. The ED nurse brought in a delivery tray which did not include a soft cloth, and he had to place the babies on a sterile towel. - He said the patient was definitely less than 23 weeks pregnant and the babies weighed less than 300 grams, which were weighed by the ED nurse. - He said the hospital’s policy for pregnancies is for 20 weeks and under, the patient is to be seen in the ED first and then moved to the L&D unit if needed. - He said it would have been better if an L&D OB nurse was with him during delivery or for Patient #1 to have been sent to L&D unit because the L&D nurses were used to dealing with fetal demise and they have the necessary supplies. - He said Baby A was placed on the bed between Patient #1’s legs when he arrived and then Baby B was delivered. Baby A was moved over to a counter on a towel. Further interview with L&D doctor/Staff #24 was asked if he assessed the babies and his response was that he did not see any signs of life, and he only spent about 15 seconds looking at the babies between deliveries. He said that he did not feel or check for a heartbeat. - He said the mother or father said they saw the babies moving. - He said 22 or 23 weeks is the limit on fetal viability based on studies. Interview on 11/18/2025 at 8:40 AM with the ED physician (Staff #23) stated the following, in part regarding Patient #1 presenting to the ED on 6/3/25: Patient #1 was definitely less than 20 weeks gestation. The patient was brought back to room 216 in the ED. A Doppler of fetal heart tones was not done because the delivery of the babies had already started. The patient had a bulge in her vagina when she checked her. Patient #1 needed to go directly to L&D and she discussed this with OB L&D physician (Staff #24), and we agreed that the patient needed to go to L&D. The Nurse in L&D told the charge nurse “no,” that Patient #1 was not coming to L&D. ED Physician (Staff #23) then called OB L&D Physician (Staff #24) and told him that if Patient #1 was not going up to L&D, that he needed to come down to the ED. Once L&D Physician (Staff #24) arrived, he took over care of the patient telling me; “he was good and could handle the patient.” ED physician (Staff #23) returned to care for other patients in the ED leaving L&D Physician (Staff #24) and ED RN (Staff #30) in the room with Patient #1 when the babies were delivered. ED Physician (Staff #24) stated an OB emergency was never called. In addition, she was reluctant to call an OB emergency after this incident, because of such “backlash from the L&D nursing staff. The last OB emergency call was a missed AB [abortion/miscarriage] because the patient was hemorrhaging.” ED Physician (Staff #24) was asked if she had told L&D Physician (Staff #24) that the babies were “25 weeks and she said that Patient #1 was “less than 20 weeks; I never told [L&D Physician (Staff #24)] that this patient was 25 weeks.” ED Physician (Staff #24) was asked about death certificates, and she stated ED doesn’t have anything to do with the death certificates; typically, the primary care physician signs the death certificate. Interview on 11/18/25 at 10:33 AM, L&D- RN/Staff #25 stated the following, in part; She normally worked 7:00 AM to 7:00 PM as an L&D RN and normally took care of the bereavement paperwork. Staff #25 stated on 6/3/25 she was told there was a demise in the ED and for her to look over the paperwork. She went to the ED between 9-10 AM and looked at the paperwork. She had mom, Patient #1, fill out the lab sheet and burial information. The forms were originally filled out by the RN present at birth (Staff #30) without an RN signature as witnessed on them. Staff #25 said she had the mom re-sign the forms so she could witness them close to the time she arrived to the ED. Staff #25 said a couple hours later, around noon, she started documenting in Patient #1’s medical record. Staff #25 stated that the ED nurse, Staff #30, had placed the twins in one container, so she took them to the triage in the L&D unit and placed them in separate containers and weighed Twin A as being 0.142 kilograms and Twin B as 0.137 kilograms. L&D RN, Staff #25 stated she charted the APGAR score in Patient #1’s record as being zero “0” for both Twin A and Twin B with the APGAR score based on OB/GYN, MD/Staff #24’s notes that indicated the babies were “still born.” Staff #25 stated that she and the chaplain (Staff #35) called OB/GYN, MD/Staff #24 to verify the information. The ED RN (staff #30) was also called and reported that the dad of the Twins said he saw the babies move, but she had not. Further interview with L&D-RN/Staff #25 confirmed she did not document in the patient’s medical record where she obtained this information from, and stated she now knows she should have done that. Staff #25 said technically anyone with healthcare license could assess APGAR scores. Staff #25 was asked if anyone told her to change the APGAR score in the patient’s medical record and she responded, “no.” Staff #25 said prior to her documentation on 6/3/25 around noon, there was no APGAR scores documented within Patient #1’s record for Twin A and Twin B. Staff #25 (L&D-RN) was asked about “OB emergency’s process, procedures, and/or policy; and she said that when OB emergencies were called for deliveries outside of the L&D unit, a NICU provider, NICU charge nurse, L&D hospitalist, ED doctor and L&D charge nurse responded to the OB emergency. Staff #25 (L&D-RN) further stated there was “no policy” on what the procedures were. Staff #25 (L&D-RN) stated that no matter what the patient complaint was in the ED; fetal heart tones were supposed to be done for pregnancies of 10-12-weeks. They could be done by doppler. Staff #25 (L&D-RN) was asked about the staffing on the L&D unit and she responded that it is not what she liked sometimes. Patients receiving magnesium drips should be 1 to 1 and sometimes they would have 2 patients, and 1 delivery. Interview on 11/18/25 at 5:20 PM with ED RN, Staff #30 indicated the following, in part; Staff #30 (ED RN), revealed she worked the 7:00 PM to 7:00 AM shift on 06/03/2025. Patient #1 was brought in a wheelchair into the ED by the house supervisor and presented in severe pain. Patient #1 said she was 18 weeks pregnant with twins and was having them. Staff #30 (ED RN), said she took Patient #1 to a room, helped her into bed and checked her vaginal area. Staff #23 (ED Physician) came into the room with the ultrasound and realized Patient #1 needed to go to the L&D unit since Patient’s amniotic sac was hanging out. They were informed by an L&D Charge Nurse that they were not taking the patient because she was under 20 weeks pregnant. Staff #30 (ED RN), said she had the patient in a wheelchair ready to take her up to the unit when the call came in. She took Patient #1 back into the room and waited on Staff #24, L&D Hospitalist to come down. Staff #30 (ED RN), said she left the room to get needed supplies for Staff #24 L&D Hospitalist, and it took 5-10 minutes. Staff #30 (ED RN) said baby 1(A) was hanging out of Patient #1. When baby 1(A) was delivered the baby was placed on a sterile drape at the end of the bed. A couple of minutes later baby 2(B) was delivered and placed on the drape on the bed. The placenta was delivered 5-10 minutes after the babies. The babies were handed to each one of the parents to hold. Staff #30 (ED RN) said she left the room to get Cytotec for bleeding for the patient. They let the parents be alone with the twins and she checked them periodically to make sure there was no postpartum bleeding. Staff #30 (ED RN) said the product of conception paperwork and containers were brought down by the house supervisor. Staff #30 (ED RN) said she discussed the paperwork with the family after they were done bonding. She then took the babies to weigh them. After this it was change of shift and they called L&D to complete the paperwork. Staff #30 (ED RN) confirmed she did not complete the APGAR scores on the two twins stating she did not have the education or training to assess APGAR scores. Staff #30 (ED RN), said no OB alert was called because of maternal hemorrhaging and the fetus not being viable. Since then, they had changed their protocol to call an OB alert for anyone coming in with a delivery less than 20 weeks. Interview on 11/18/25 at 11:52 AM with RN L&D shift supervisor (Staff #26) indicated the following, in part; On 6/3/25 she was the night shift supervisor on for 6/3/25. She is the last nurse on the unit to take on patient care. They always try to have two nurses in the room during delivery. L&D RN (Staff #26) was asked about the process/procedure for when ED calls to L&D to have a patient transferred. L&D RN (Staff #26) said the ED calls up to L&D and gives patient details, and they follow the algorithm to see if the patient meets criteria. If the patient is over 20 weeks pregnant, she is stabilized and cleared in the ED first before transferring. If the patient is under 20 weeks there is a doctor-to-doctor conversation. When L&D RN (Staff #26) was asked if she remembered any incidents where they could not receive a patient because they were too busy or had insufficient staffing, she replied, “No, I have never witnessed that.” L&D RN (Staff #26) was asked about Patient #1 from 6/03/2025 when she was denied transfer from the ED to L&D. L&D RN (Staff #26) stated she was in a room helping another nurse when another [named] nurse received a call and was told an 18-week pregnant female was coming up. L&D RN (Staff #26) said the “algorithm was not followed.” L&D RN (Staff #26) stated that she told the nurse, “let me call the doctor.” Just as she said that, OB doctor, Staff #24, called her and asked if the patient with 25-weeks twins were up on the unit, and she told him that she only knew about an 18-week pregnant female with twins. OB Doctor, Staff #24, then told her that he was going down to the ED. L&D RN (Staff #26) said she was expecting to hear back from OB Doctor, Staff #24, to offer help, but she never saw or talked to him again. Later, in the early AM the house supervisor (Staff #36) was looking for a pathology slip for the twins. She told the house supervisor they did not have pathology paperwork. He was shown the bereavement binder and given copies of each form. RN L&D shift supervisor (Staff #26) was asked about calling OB emergencies and who was supposed to respond. She said anyone available in the OB, possibly anesthesia, physician and she believed NICU staff responded. When OB goes, they normally take a delivery pack with them. RN L&D shift supervisor (Staff #26) was asked if an OB emergency had been called where they were unable to respond, and she replied “no.” RN L&D shift supervisor (Staff #26) said they used the algorithm to determine criteria. If the mom is less than 20 weeks the ED gets heart sounds, stabilizes and uses an ultrasound to determine gestation age. If the mom is less than 20 weeks the OB hospitalist talks to her or lets her know about the patient. Normally the doctor goes down to the ED and handles it, and she does not hear anything else if they do not come to the unit. RN L&D shift supervisor (Staff #26) said that even if they are understaffed, they cannot say the patient cannot come to the unit. They have to find a spot because they are considered a smaller ED within the hospital. RN L&D shift supervisor (Staff #26) said they try to stick to the algorithm when accepting patients to the unit. Interview on 11/18/25 at 12:45 PM with the L&D Clinical Manager (Staff #29) indicated the following, in part; She was responsible with staffing, and their staffing ratio was normally 1:2 depending on the status of the patients. Staffing was reviewed and verified with L&D Clinical Manager (Staff #29) for the overnight shift, 06/02/2025 (7 PM) into the morning of 06/03/2025 (7 AM) that revealed there was 1 charge RN, 3 RNs, and a scrub tech. The unit had a total patient census of 4 patients, and the acuity level of those patients was 1:1, 1:2, 1:2 and 1:2. On the morning of 6/3/25, the ED director called her and asked for someone to help with the paperwork for Patient #1 and RN/Staff #25 went down to the ED and helped with the paperwork. L&D Clinical Manager (Staff #29) stated that when an OB alert is called, the NICU team, L&D charge nurse/or assigned nurse, house supervisor, OB hospitalist and scrub tech respond. Interview on 11/20/25 at 4:00 PM with RN/House Supervisor (HS), (Staff #36) indicated the following: He was the HS on duty on 6/3/25 when he received a call from registration to take Patient #1 to L&D. While on the way, he received a call from the L&D shift supervisor (Staff #26) stating that she was told Patient #1 was 25 weeks and coming to L&D, but that the patient was 18 weeks and needed to stay in the ED; and that the OB Doctor (Staff #24) was on his way down to the ED. HS, Staff #36, stated there was quit a bit of going back and forth with “pushback from L&D,” and he was trying to just make an “exception” to the 20 weeks since the patient was pregnant with twins and in active labor. HS, Staff #36, said he later received a call that Patient #1 had a miscarriage, and the ED staff needed some help with the paperwork; to “figure out what to do; what’s the process?” HS, Staff #36 said he tried to get assistance from the L&D nurse who gave him some paperwork and stated, “We’re really busy, call if any questions.” HS, Staff #36 said he called the part time Chaplain, (Staff #34) since the full-time Chaplain usually helped out with the paperwork. HS, Staff #36 was asked about a policy for OB patients related to gestational determination and he responded, “not aware of” but that typically, “20 weeks was the cut off” but there can be an “exception to the rule. The ED physician is the most highest authority person” and we should “do what’s best for the patient.” Typically an L&D nurse will come down to the ED when asked, but in this case they reported to me that L&D was “overwhelmed, we’re slammed;” and I relied on what they were telling me when the L&D nurse stated that they “can’t leave the unit.” HS, Staff #36 stated that for the Fetal Demise Form for a non-viable or still born; and the Birth Certificate are left to the L&D nursing staff and Chaplain to assist in completion since they were the “experts” and it was in their “wheelhouse.” HS, Staff #36 stated he did not complete an incident report or “memorialize” the events that occurred with Patient #1 on 6/3/25 because he did not know of any issues or concerns until they “came up later.” He was not part of any Performance Improvement (PI) plan(s), and no one asked him; although he stated he “offered suggestions but did not hear anything back and nothing was done;” that he was aware of. HS, Staff #36 stated he has not seen or been part of any education provided in response to the concerns identified regarding Patient #1. He only saw a form that had a change on it regarding the weight of fetus was changed from 500 grams to 350 grams. HS, Staff #36 was asked about any OB alerts/OB codes called and he indicated that he has “not heard an OB code; or that aware of. Have not drilled on it.” HS, Staff #36 said they conduct codes and drills for; “Fire, Heart, Sepsis, Trauma, Hemorrhagic Patient, Mass [blood] Transfusion, but not OB codes or drills.” Interview on 11/18/25 at 11:35 with the CMO (Staff #36), and Interim PSO (Staff #3) present, stated the following: A Root Cause Analysis (RCA) meeting was completed with the recommendations that included a physician peer review meeting that was completed 9/17/25 to ensure the standard of care was met. It was identified that there were “systemic issues;” with “escalating things and communicating.” It was recommended that communication occur with the “group physicians; to be educated,” and that “formal processes” be communicated with the nurses. Interview with the Interim PSO, Staff #3, on 11/18/25 at 11:40 AM, stated there had been a “Quality Summitt” for nurse training completed, and “education was happening” however, there was “not true tracking at this time, for compliance or a percentage completed” for review or verification. Interim PSO, Staff #3, further confirmed there was not documentation or evidence specifically related to Nursing education for, “fetal assessments-Apgar Scores.” There was no documentation or evidence specifically related to “OB alerts.” PSO, Staff #3 stated this event was serious, with safety concerns and the facility’s current “interim leadership” was addressing the identified issues.”