Altus Lumberton Hospital

“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: 10135 Based on interview and record review, the facility failed to meet the need of patients who presented to the emergency department (ED). This deficient practice was found in 5 of 20 sampled patients (Patient #’s 1, 4, 8, 10 and 15). The facility failed to: A. Ensure there was thorough a assessment and monitoring for a patient who presented with pseudo seizures. They failed to assess a patient prior to and after administration of a psychotropic medication and prior to discharge (Patient #1). Patient #1 was discharged 4 minutes after administration of a psychotropic medication. B. Ensure there were complete physician orders for a Cardene drip that was administered to a patient who presented with an elevated blood pressure (Patient #4). The facility failed to ensure there were dosage increments and timing intervals in the physician orders. C. Ensure staff reassessed vital signs before discharge on a pregnant female who presented with vaginal bleeding (Patient #8). D. Ensure staff reassessed a patient prior to discharge who was administered an antihistamine and pain medication. The staff discharged this patient 12 minutes after administering these medications (Patient #10). The facility failed to ensure physician’s orders were complete with the frequency on medications. E. Ensure staff provided a suicide risk assessment, physician’s order for 1:1 observations and documentation of monitoring on a patient who attempted suicide (Patient #15). Refer to tag A1101 for additional information.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the emergency department (ED) was organized in a manner to provide safe patient care in 5 or 20 sampled patients (Patient #’s 1, 4, 8, 10 and 15). The facility failed to: A. Ensure there was a thorough assessment and monitoring for a patient who presented with pseudo seizures. They failed to assess a patient prior to and after administration of a psychotropic medication and prior to discharge (Patient #1). Patient #1 was discharged 4 minutes after administration of a psychotropic medication. B. Ensure there were complete physician orders for a Cardene drip that was administered to a patient who presented with an elevated blood pressure (Patient #4). The facility failed to ensure there were dosage increments and timing intervals in the physician orders. C. Ensure staff reassessed vital signs before discharge on a pregnant female who presented with vaginal bleeding (Patient #8). D. Ensure staff reassessed a patient prior to discharge who was administered an antihistamine and pain medication. The staff discharged this patient 12 minutes after administering these medications (Patient #10). The facility failed to ensure physician’s orders were complete with the frequency on medications. E. Ensure staff provided a suicide risk assessment, physician’s order for 1:1 observations and documentation of monitoring on a patient who attempted suicide (Patient #15). This deficient practice had the likelihood to cause harm in all patients presenting to the emergency department. Findings include: Patient #1 Review of the ED record of Patient #1 revealed she was a 32-year-old female who presented on 07/18/2025 at 2:07 p.m. According to the registration entry form Patient #1 wrote the reason for her emergency visit was PNES (psychogenic non epileptic seizures). The onset of symptoms was at 10:00 a.m. on 07/17/2025. The triage assessment at 2:13 p.m., revealed Patient #1 presented with a chief complaint of psychiatric problems that she had for a day. There was a neuro category underneath the medical history which had seizures as an option, but it was not checked. Underneath the psych category anxiety, depression and panic attacks was selected. There was no documentation at this time that Patient #1 was anxious. At 2:37 p.m. Patient #1 had the following vital signs: blood pressure 130/89, pulse 82 respirations 18, pain 0 and oxygen saturation of 99 percent on room air. At 2:50 p.m. there was documentation “Waiting on ride prior to medication administration, patient aware.” Review of the “NURSING AND PHYSICIAN CHART” (medical screening) documentation at 2:52 p.m. by Staff #8 (Nurse practitioner) revealed that Patient #1 stated that she had pseudo seizures and had been jerking since last night. Patient #1 was documented as having dizziness and anxiety. Staff #8 (Nurse practitioner) documented that Patient #1 presented to “the ED for anxiety and pseudo seizures. No SI/HI (suicide ideation/head injury) reported by patient. Patient states she is managed by psychiatry and awaiting inpatient placement for behavior therapy. Discussed s/s that warrant return to ED. Welcomed to return for any new or worsening health concerns. All questions answered. Patient agrees with plan and verbalized understanding.” At 3:45 p.m. there was documentation that “This nurse at bedside verifying that patient has called her ride. Patient is actively crying and just shakes her head. Warm blanket provided. Patient then states, “I don’t know if he will be coming or not. He has not answered his phone.” This nurse informs patient that we have to wait until he gets here. Patient verbalized understanding at this time.” At 3:56 p.m. there was documentation that staff “followed up with patient regarding ride states “I think so, but I don’t know.” Pt educated on inability to give medication ordered prior to driver being obtained. Pt verbalized understanding” At 4:04 p.m., Staff #7 documented administering the anti-anxiety medication Lorazepam (Ativan) 2 milligrams intramuscularly. At 4:08 p.m. (4 minutes later), Patient #1 left the building with her family. There was no documentation of an intravenous access being started in the event of the emergency related to seizures. There was no documentation of an assessment prior to administration of the medication to justify usage. There was no documentation of vital signs immediately before administration nor after to monitor side effects of the medication. There was no documentation of continuous monitoring or assessment of Patient #1 for seizure activity. During an interview on 08/18/2025 after 12:33 p.m. Staff#1 confirmed the missing vital signs, psychotropic medication consent and there being nothing documented to show Patient #1 was checked for seizure activity. During an interview on 08/18/2025 after 12:33 p.m. Staff #2 said they had reviewed Patient #1’s record because of a complaint. The chart had been reviewed by a physician and he had found nothing wrong with the chart. The only fall out was with the missing vital signs before discharge. There had been no formal training done. There was just a one on one with the staff member. During an interview on 08/18/2025 at 2:06 p.m., Staff 7 revealed she was the nurse who had taken care of Patient #1. Staff #7 said Patient #1 complained of having pseudo seizures and showed her a plan on her cell phone. The plan had the patient’s name, current medications, diagnoses and it looked like something that was taken off of AI (artificial intelligence). Staff #7 said Patient #1 told the nurse practitioner (Staff #8) she was having pseudo seizures and was having one now. They did not see any signs or symptoms of her having seizures. When asked the reason for administering Ativan, Staff #7 said she really did not know for sure, she thought maybe it was for comfort measures. Staff #7 confirmed that she did not get vital signs on Patient #1 prior to leaving or before administering the medication. Staff #7 said she did not get vital signs because Patient #1 left with her family member. Staff #7 said she thought she talked to the nurse practitioner about it, but it was not documented. Staff #7 said their protocol was to hold the patients for 20 minutes after administration of medication and take vital signs. Staff #7 said hat this was her first patient with psychogenic seizures at this facility. Staff #7 said they do not have in- house neurology so they would send the patients out to a higher level of care. During an interview on 08/18/2025 at 2:34 p.m., Staff #8 confirmed she was the nurse practitioner that medically screened Patient #1. Staff #8 said Patient #1 was not actively having a seizure. Patient #1 said she had been shaking all day and wanted to stop and was having more anxiety. Patient #1 was told to get a ride home and that they would give her something to help her relax. Staff #8 said she did not consult with a neurologist because Patient #1 said she was under management of a physician and waiting placement. Staff #8 said Patient #1 did not present with anything neurological. When asked what they did when a patient presented with seizures, Staff #8 said they did a neurological workups, got seizure history, laboratory workups and electrocardiogram. Staff #8 said patients have to wait at least 15 minutes after receiving medication in the ED. If they do not wait, they have to sign an against medical advice (AMA) form. Staff #8 said she had not had a conversation with nursing about an AMA on Patient #1. During an interview on 08/18/2025 after 3:00 p.m. Staff #’s 1 and 2 confirmed they did not have a policy/procedure to address seizures. During an interview on 08/18/2025 at 4:11 p.m. Staff #4 pulled an undated “Case Scenario-Seizure Department of clinical education” form off the computer that they could use as a guide. Some of the criteria listed on the form were to: Perform Assessment. Underneath this category staff were to consider needed diagnostic procedures (i.e. CT, MRI, EEG, LP, Labs). Maintain airway, breathing and circulation. Provide supplemental oxygen (i.e. non-rebreather) Establish IV access for administration of crystalloid fluid/medications as needed. Prepare for /assist with medications as needed. Administer pharmacologic therapy as needed. Educate patient and significant others. Review of a facility’s policy named “Discharge Procedure” and effective 12/09/2019 revealed the following: “ ...PROCEDURE: 1. The patient will be assessed by a licensed RN to determine that the discharge criterion has been met ...” Review of a facility’s policy named “Discharge Criteria” and effective 12/09/2019 revealed the following: “ ...POLICY: The physician will determine the patient’s readiness for discharge when following criteria have been met: 1. Patient maintains stable vital signs ...” Patient #4 Review of the ED record on Patient #4 revealed she was a 47-year-old female who presented to the ED on 08/05/2025 at 5:13 p.m. and was given an emergency severity index of 2 (meaning Emergent). Patient complained of left face, arm and leg numbness, slurred speech and a headache. The initial vital signs were 275/153 (blood pressure), 108 (pulse), 18 heart rate,6/10 pain level and a 98 percent oxygen saturation rate on room air. Untimed Physician orders read: “aspirin 81 mg Oral Hydralazine 20 mg/1ml INJ ... Cardene 20mg/200ml INJ (nicardipine hydrochloride).” The orders were incomplete and did not have the frequency. There was another order of “aspirin 81 mg Oral -4 tablet(s) PO” The order was verbal, and it was placed at 5:39 p.m. At 5:50 p.m. Patient #4 was administered 4 tablets of Aspirin. At 5:56 p.m., Patient #4 had a blood pressure of 235/127. Another location in the chart showed the following documentation: “hydralazine 20 mg/1ml INJ*-10mgIVP” The order was verbal, and it was placed at 5:59 p.m. At 6:03 p.m., Patient #4 was administered a 10-milligram dose of the blood pressure medication Hydralazine. At 6:12 p.m., Patient #4 had a blood pressure of 221/112. At 6:21 p.m., Patient #4 had a blood pressure of 210/118. At 6:42 p.m., Patient #4 had a blood pressure of 219/111. At 6:51 p.m., a physician’s order was placed for “Cardene 20mg/200ml INJ (nicardipine hydrochloride)””20mg IV Medication Infusion at 25m/hr.. Titrate to a maximum of 15 mg/hr, SysBP>190, DiaBP>100” There was no instruction on dose increments or frequency of the titration. The titration order only gave the maximum amount nursing could titrate up to. At 7:01 p.m., Patient #4 had a blood pressure of 206/122. At 7:06 p.m. Patient #4 was started on the blood pressure drip Cardene. There was documentation that 20 mg- L Antecubital IV Medication infusion at 25cc/hr was administered. At 7:16 p.m., Patient #4 had a blood pressure of 209/119. At 7:27 p.m. Titrate 5 milligram per hour was documented. At 8:11 p.m. Patient #4 had a blood pressure of 175/111 and at 8:33 p.m. it was 179/105 At 8:34 p.m. Titrate 2.5 milligrams per hour was documented. There was no documentation to indicate as to if this was an increase or decrease back down to starting dose. At 9:00 p.m. Patient #4 had a blood pressure of 182/107 and 9:53 p.m. it was 214/127. At 9:53 p.m. Titrate 4 milligrams per hour was documented. At 9:59 p.m. Patient #4 was transferred out to a higher level of care. During an interview on 08/19/2025 after 12:00 p.m., Staff #1 confirmed the medication administration and blood pressures. Staff #2 provided the following titration the information from their pharmacist: Review of an undated facility’s “Titratable Medications” policy revealed the following: Medication “nicardipine (Cardene)” Block Charting Y/N “Yes” Indications /Clinical Parameter “Hypertension/To maintain specified SBP goal” Recommended Starting Dose “5mg/hr” Recommended Dose Range “5-15 mg/hr” Titration Dose Increment “2.5 mg/hr” Titration Time Interval “Q 10 min” Maximum Dose per Protocol “15 mg/hr” Patient #8 Review of the ED record of Patient #8 revealed she was a 21-year-old female who presented on 08/10/2025 at 3:09 p.m. Patient #8 presented with complaints of a possible miscarriage. According to the triage assessment Patient #8 was triaged at 3:21 p.m. and there was documentation that the patient had complaints of slight spotting, and the bleeding was described as being dark red in color. The initial vital signs were taken at 3:22 p.m. and were documented as being 113/79 blood pressure, 79 pulse, 16 heart rate, 0 pain level and 100 percent oxygen saturation. A pregnancy test that was reviewed at 4:01 p.m. showed Patient #8 was positive for pregnancy. According to nursing documentation Patient #8 ‘s time of discharge home was 5:31 p.m., over 2 hours after presenting and the last set of vital signs. There was no documentation of vital signs prior to discharge. During an interview on 08/19/2025 after 9:00 a.m., Staff #1 confirmed there was no documentation of any other vital signs on the chart. Staff #1 said staff were supposed to take vitals every 2 hours unless ordered to be taken more often. Patient #10 Review of the ED record of Patient #10 revealed she was a 48-year-old female who presented on 08/14/2025 at 7:33 p.m. Patient #10 presented with complaints of seizures. There was nursing documentation at 7:45 p.m., that revealed that Patient #10 had a history of pseudo seizures and reported having 3 today. The initial vital signs were taken at 7:46 p.m. and were documented as being 150/87 blood pressure, 80 pulse, 16 heart rate, 8/10 pain level and 100 percent oxygen saturation. According to the medical screening exam signed off at 7:57 p.m., revealed Patient #10 had migraines, seizures and osteoarthritis. Patient #10 had sustained a fall and hit her hip and was now having hip and back pain. Physician orders were placed at 9:05 p.m. for the antihistamine Benadryl 25 milligrams orally and non-steroidal pain medication Toradol 30 milligrams intramuscularly. The physician’s order was missing the frequency or the reason for the medication. At 9:06 p.m. there was documentation that the physician was aware of allergy. Patient #10 stated that Toradol just makes her itch and was she was okay with taking it. At 9:10 p.m. the Benadryl and Toradol was administered and at 9:20 p.m. there was documentation that there was no reaction and there was a pain level of 0 out of 10. At 9:22 p.m., 12 minutes after being given the Benadryl and Toradol Patient #10 was discharged home form the hospital. There were no vital signs taken prior medication administration or before discharge. During an interview on 08/19/2025 after 9:00 a.m., Staff #1 confirmed there was no documentation of any other vital signs on the chart. Patient #15 Review of the ED record on Patient #15 revealed she was a 22-year-old female who presented on 04/18/2025 at 10:46 p.m. According to a triage assessment at 11:43 p.m. Patient #15 had a suicide attempt. Patient #15 had a history or traumatic brain injury and depression. According to documentation “Patient denies SI or HI. Witnessed by significant other, patient grabbed a kitchen knife and cut her left forearm...” The following interventions were checked to be completed: “Sitter at bedside, Belongings removed, Physician notified, Assess patient room for safety.” Review of the ED record revealed no physician’s order for Patient #15 to be put on observation or what type of supervison she required. Review of the chart revealed no suicide risk assessment nor a completed monitoring tool. Review of the ED record revealed Patient #15 was transferred to a higher level of care at 0025. During an interview on 08/19/2025 after 9:00 a.m., Staff #1 confirmed Patient #15 was on 1:1, but there was no documented risk assessment or monitoring tool completed. Staff #1 confirmed Patient #15 was transferred to another hospital for psychiatric care. Review of the facility’s undated policy named “Caring for Patients with Suicidal Ideations” revealed the following: PURPOSE: To protect the suicidal patient from harm. POLICY: ...2. A self-admitted patient that the staff has suspicions of possible suicidal tendencies: f. Notify the physician of any suicidal thoughts and obtain an order for suicide precautions ... 2. Ensure that precautions are taken to prevent the patient from harm in the event that his/her condition changes to a more serious state. a. The patient can become suicidal during the course of treatment and should be watched continuously. Review of the facility’s undated “SUICIDE RISK ASSESSMENT & CARE PLAN “revealed the following: “ ...This assessment /reassessment must be completed on any patient seen seeking or requiring treatment for emotional or behavioral(psychiatric) disorders in a general acute hospital (including inpatient care units, and the Emergency Department) ...” The assessment included some of the following interventions for patients: “ ...Low Lethality Risk Level ...Place patient on continuous observation. More than one patient may be observed at the same time as long as continuous observation is maintained ...” “High Lethality Risk Level ...Place patient on continuous 1:1 observation. Staff member may not observe more than one patient ...” Review of the undated policy named “Behavioral Health Monitoring Tool” revealed the following nursing duties: “ ...Patient placed in direct line of sight. Patient placed on q 15 min observation. Patient/family educated on need for precautions. Obtain MD Order for placement and removal of At Risk for Harm precautions. Document assessment & reassessments each shift an as needed in chart ...” Place this form with the chart to be scanned into medical records and send a copy with chart to accepting facility. Total time for 1:1 _____Hrs Min..””

“MEDICAL STAFF - SELECTION CRITERIA CFR(s): 482.12(a)(6) [The governing body must] ensure that criteria for selection are individual character, competence, training, experience, and judgement. This Standard is not met as evidenced by: 40989 Based on document review and interview, the Governing Body failed to ensure the hospital followed the Medical Staff Bylaws, Rules, and Regulations when credentialing 2 (Nurse Practitioner #3 and #6) of 2 Nurse Practitioner (NP) files reviewed. A review the credential files for NP #3 and NP #6 was conducted with Director of Nurses Staff #2 on 1/18/2025 and 1/19/2025. Findings: NP Staff #3 A review of the credential file for NP #3 revealed a current medical staff appointment for 2/24/2023-2/24/2025. Further review revealed NP #3 failed to submit three letters of personal reference as required by the Medical Staff Bylaws, Rules, and Regulations. NP #6 A review of the credential file for NP #3 revealed a current medical staff appointment for 8/23/2024-8/23/2026. Further review revealed NP #6 failed to submit 2 of 3 letters of personal reference as required by the Medical Staff Bylaws, Rules, and Regulations. A review of the Medical Staff Bylaws, Rules, and Regulations adopted on January 17, 2025, was as follows: “ ...Section 7: Application Requirements and Initial Appointment: a. An applicant seeking appointments as an AHP/APP must apply as follows: 1) ... vii. References: The applicant submits three letters of reference, including at least one from a practicing physician, other than the Sponsoring Member, who has knowledge of the Applicant’s Current competence and conduct ...” An interview was conducted with DON Staff #2 on 2/18/2025 at 3:15 PM. DON Staff #2 was asked if NP #3 or NP #6 had letters of reference in the credential file. DON Staff #2 confirmed NP #3 did not submit any personal reference letters, and NP #6 only had one of the three required personal reference letters in the credential file.”

“Basis and Scope CFR(s): §482.1 Basis and scope. (a) Statutory basis. (1) Section 1861(e) of the [Social Security] Act provides that- (i) Hospitals participating in Medicare must meet certain specified requirements; and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals. . . . (b) Scope. Except as provided in subpart A of part 488 of this chapter, the provisions of this part serve as the basis of survey activities for the purpose of determining whether a hospital qualifies for a provider agreement under Medicare and Medicaid. This Condition is not met as evidenced by: 10135 Based on observation, interview and record review, facility failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services. Section 1861(e) of the Social Security Act defines hospital as: an institution that “. . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons...” The facility failed to ensure a minimum average daily in-patient census of 2 patients over the last 12 months from November 1, 2023-October 31, 2024. The calculated in-patient average daily census was 1.06. This deficient practice can affect all patients presenting to the facility for care. Findings include: During the entrance conference on 11/04/2024 at 1:05 PM, Staff #1 (Chief Nursing Officer and Administrator) of the facility stated they had two in-patients. During an observation of the “inpatient unit” on 11/04/2024 after 2:00 p.m., Patient #2 was the only patient on the unit. During an interview on 11/04/2024 at 3:00 p.m., Staff #1 (Chief Nursing Officer and Administrator) and Staff #2 confirmed that Patient #2 was the only in-patient on the unit. They also had Patient #3 who was an observation patient who left the facility at 11:21 a.m. on 11/04/2024. Review of the “HOSPITAL/CAH DATABASE WORKSHEET” completed by Staff #1 (Chief Nursing Officer and Administrator) on 11/04/2024 revealed there was three offsite emergency departments and a total of four in-patient beds. Some of the services listed that were not provided in-house or through contracts were anesthesia services, intensive care, nursery, pediatrics, obstetrics, surgery services, occupational therapy, physical therapy services, psychiatric, social services, acute renal dialysis and speech pathology services. Review of an unnamed facility report revealed from the months of November 2023-October 2024 the following total emergency room census: Facility #1 (main campus) 11, 571 visits Facility #2 (off-site) 6,704 visits Facility #3 (offsite) 6527 visits Facility #4 (offsite) 5679 visits Review of a monthly inpatient report on 11/05/2024 at 9:51 a.m. revealed the following average in-patient daily census: November 2023 - 1.70 December 2023- 1.81 January 2024- 1.77 February 2024- 1.72 March 2024- 1.13 April 2024- 1.03 May 2024- 0.81 June 2024- 1.83 July 2024- 1.00 August 2024- 0.97 September 2024- 1.33 The four inpatient bed capacity compared to the emergency room visits would not support emergency or unplanned admissions. During an interview on 11/04/2024 after 4:00 p.m.., Facility #1 ED Staff # 13 (licensed vocational nurse) and Staff #5 (registered nurse) stated they transferred most of their patients out to Facility #5 and 6. During an interview on 11/05/2024 at 9:51 a.m., Staff #1 (Chief Nursing Officer and Administrator) confirmed the numbers on the reports and stated that she receives the monthly report from the finance department. Staff #1 (Chief Nursing Officer and Administrator) confirmed the services they did not provde and stated that if the services were needed by an in-patient they would have to be transferred to another facility. During an interview on 11/06/2024 after 8:33 a.m., Facility #2 ED Staff #15 (registered nurse) stated they transferred most of their patients out to Facility #5 and 6. Review of the facility’s unnamed reports of discharges, admission days, inpatient midnight census totals for the timeframe of November 1, 2023- October 31, 2024, revealed there was a total midnight census of 386 which calculated out to be an average daily census of 1.06. During an interview on 11/05/2024 after 10:00 a.m., and 11/12/2024 at 10:48 a.m., Staff #1 (Chief Nursing Officer and Administrator) confirmed the accuracy of the numbers in the unnamed reports.”

“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: 40989 Based on record review and interview the hospital failed to ensure Emergency Services met the needs of 5 (Patients #1, #2, #3, #12, and #13) of 5 patients reviewed as exhibited by (AEB); A. Three (3) of 5 (Patient #1, #2, and #3) patient medical records reviewed were assessed and reassessed for pain levels in the Emergency Department (ED). B. Two (2) of 5 (Patients #12 and #13) patient medical records reviewed had vital signs assessed and documented every 2 hours and at time of discharge. C. Two (2) of 2 Providers (Physician #17 and Nurse Practitioner #3) gave clear and direct orders on cleaning and irrigating wounds before nursing staff implemented treatments in 2 of 5 (Patients #1 and #13) patient medical records reviewed. This deficient practice had the likelihood to cause harm to all patients who presented to the Emergency Department. Refer to Tag A1101”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 40989 Based on record review and interview the hospital failed to ensure Emergency Services were organized in a manner to provide complete and accurate patient assessments and complete physician orders as exhibited by (AEB); A. Three (3) of 5 (Patient #1, #2, and #3) medical records reviewed were assessed and reassessed for pain levels in the Emergency Department (ED). B. Two (2) of 5 (Patients #12 and #13) medical records reviewed had vital signs assessed and documented every 2 hours and at time of discharge. C. Two (2) of 2 Providers (Physician #17 and Nurse Practitioner #3) gave clear and direct orders on cleaning and irrigating wounds before nursing staff implemented treatments in 2 of 5 (Patients #1 and #13) patient medical records reviewed. This deficient practice had the likelihood to cause harm to all patients who presented to the Emergency Department. Findings: Patient #1 Patient #1 was a 31-year-old male who arrived at the hospital on 10/20/2024 at 1:21 PM with a chief complaint of a head laceration. He was transported to the hospital in a private vehicle. Registered Nurse (RN) Staff #5 performed a focused triage assessment at 1:23 PM. There was documentation that the patient was hit in the head by a deer feeder and the patient’s pain level was of 10/10. (The pain scale is a numeric scale ranging from 1-10 with 10 being the worst pain)”. Blood Pressure- 147/113 (normal is 120/80), Temperature- 98.5 Fahrenheit, Heart Rate- 111 (normal adult heart rate is 60-100), Respirations- 18, Oxygen saturation of 96%, and Pain level of 10/10. (The pain scale is a numeric scale ranging from 1-10 with 10 being the worst pain)”. Physician #17 wrote an order for Norco 5-325 (pain medication) milligrams (MG) 1 tablet on 10/20/2024 at 1:36 PM. Norco 5-325 mg. It was administered orally at 1:43 PM by RN Staff #5. RN Staff #5 documented a reassessment of the pain medication at 2:57 PM that read, “no reaction”. RN Staff #5 failed to document a reassessment of the patient’s pain score. This was 1 hour and 14 minutes after the medication was administered. Physician #17 wrote orders on 10/04/204 at 1:36 PM to clean and irrigate the patient’s wound. The order failed to give a specific solution to clean and irrigate the wound. Licensed Vocational Nurse (LVN) Staff #13 documented the wound was cleaned and irrigated at 2:12 PM but failed to document the solution used. RN Staff #5 documented on 10/04/2024 at 2:56 PM the patient’s Blood Pressure was 153/108, Heart Rate was 80, Respirations were 16, and oxygen saturation was 99%. There was no temperature or pain reassessment documented at this time. A review of the discharge note dated 10/20/2024 at 2:57 PM by RN Staff #5 was as follows: “Disposition: Discharge: The patient was discharged with family. At discharge, the patient’s status had improved. The patient was in good condition. The patient was considered stable. On a 0 to 10 pain scale, the patient’s pain was unable to be determined ...The patient departed the facility on 10/20/2024 at 2:57 PM ...” An interview was conducted with RN Staff #5 on 11/05/2024 at 2:30 PM. RN Staff #5 was asked after pain medication was administered, when was the pain level reassessed. RN Staff #5 stated, “It depends on how it was given.” RN Staff #5 was asked if Patient #1’s pain level was reassessed after the pain medication was administered or when the patient was discharged. RN Staff #5 stated, “Well, I didn’t document it I guess”. RN Staff #5 was asked if the physician was notified of the patients elevated blood pressure before he was discharged. RN Staff #5 replied, “No he was not but I think this patient’s high blood pressure was from pain.” An interview was conducted on 11/05/2024 after 2:30 PM with RN Staff #5 and NP #3. RN Staff #3 was asked how did she know what solution to clean and irrigate the wound with if the physician failed to give a clear order. RN Staff #5 stated, “Well he told me to use saline”. RN Staff #5 was asked if she placed a verbal order in the computer for clarification. RN Staff #5 stated, “No I did not but there is a drop-down item that allows them to add to the order for what they want. They can free text whatever they want in that area but they never do we just always use saline”. NP #3 confirmed he was unaware that was an option for some orders. Patient #12 Patient #12 was a 24-year-old female who presented to the ED on 11/03/2024 at 6:31 PM complaining of a tooth problem. A triage assessment was completed at 6:45 PM by RN Staff #19 and the vital signs were documented as a blood pressure of 139/70, pulse of 67, respirations of 18, temperature 98.1 degrees Fahrenheit, oxygen saturation 100% on room air and a pain level of 8/10. The provider assessment was completed at 6:45 PM and orders were placed for Bicillin LA 1,200,000 units (an antibiotic) intramuscular (IM ) and Toradol (pain medication) 60 mg IM. The medication was administered by LVN #13 at 6:50 PM. A review of the discharge disposition documented on 11/03/2024 at 6:55 PM by LVN #13 revealed Patient #12 was discharged 5 minutes after the administration of the IM medications. Further review revealed there were no vital signs documented at discharge. LVN Staff #13 documented the patient’s pain level was a 5/10. In an interview with the Director of Nurses (DON) Staff #2 on 11/05/2024 after 10:00 AM. DON Staff #2 confirmed there were no documented vital signs at discharge or if the patient had a reaction to the IM injection of the antibiotic administered by LVN #13. Patient #13 Patient #13 was a 28-year-old male who arrived at the facility on 11/02/2024 at 11:07 AM with a head laceration. A triage assessment was completed at 11:09 AM by RN Staff #6. The vital signs were documented as a blood pressure of 151/98, a pulse of 92, respirations of 15, temperature of 98.2 degrees Fahrenheit, oxygen saturation of 96% on room air, and a pain level of 8/10. The provider assessment was at 11:09 AM and NP #3 gave orders to cleanse and irrigate the wound at 12:18 PM. NP #3 failed to order a solution to cleanse and irrigate the wound. RN Staff #5 documented that the wound was “gently scrubbed” at 12:36 PM but failed to document the solution the wound was irrigated with. Also, NP #5 gave an order for Morphine (pain medication) 4mg IM. The morphine was administered by LVN Staff #13 on 11/02/2024 at 12:29 PM. The next pain assessment was documented at 1:35 PM to be a 5/10. This was the same time the patient was discharged. There was no documentation of a vital signs reassessment at the time of discharge. In an interview on 11/05/2024 after 11:00 AM, DON Staff #2 confirmed vital signs should have been assessed and documented at discharge. A review of the facility policy titled, “Pain Management” P&P #: NUR.07 was as follows: “PURPOSE: To assure that patients receive an assessment and management of their pain consistent with the scope of care, treatment, and service provided by the organization in its various care settings. POLICY: Patients have the right to pain management. It is the policy of Altus Lumberton Hospital to do the following: 1. Conduct an appropriate assessment and/or reassessment of a patient’s pain consistent with the scope of care, treatment, and service provided in the specific care setting in which the patient is being managed. 2. Require that methods used to assess a patient’s pain are consistent with the patient’s age, condition, and ability to understand 3. Assess the patient’s response to care, treatment, and service implemented to address pain. 4. Treat the patient’s pain or refer the patient for treatment ... EMERGENCY DEPARTMENT Routine Reassessment If no pain issues were identified during the initial assessment, then no routine reassessment is required. If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain ... ...Reassessment Following Treatment for Pain If a treatment intervention for pain is provided, then the response to that intervention must be assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15 - 60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the time of discharge or transfer ...” A review of the facility policy titled, “Patient Assessment and Care Planning”, P&P #: NUR.09 was as follows: “ ...POLICY: This is an organization-wide document. As such, it applies to all settings in which patient care, treatment, and service are provided requiring the assessment of patient care needs. ASSESSMENTS / REASSESSMENTS Each clinical discipline shall define - in writing - the scope and content of screening, assessment, and reassessment information that it collects. The depth and frequency of collecting this information depends on the patient’s needs; scope of care, treatment, and service provided in a particular care setting; and the goals of a particular program or course of treatment. Information collection activities may vary between settings. Information obtained during initial screens or assessments may indicate the need for further assessment or reassessment. At a minimum, the need for collecting this information shall be determined by the care, treatment, and services sought, the patient’s presenting condition(s), and whether the patient agrees to the recommended care, treatment, or service ... ATTACHMENT A SUMMARY OF EACH DISCIPLINES SCOPE OF ASSESSMENT & REASSESSMENT ... Nursing: Assessment Time Frame Emergency-Within 30 minutes of receipt into treatment area ... Reassessment Time Frame Minimum time frames are noted below: Emergency Care *Every two hours and upon transfer/discharge ...” 10135 Patient #2 Review of an Emergency department (ED) record on Patient #2 revealed he was a 57-year-old male who presented to the emergency room on 11/02/2024 at 5:27 a.m.. Patient #2 presented with complaints of back and flank pain. Review of the record revealed the first set of vital signs were taken at 5:45 a.m. on 11/02/2024. Patient #2 had a blood pressure of 130/66, temperature of 99.8 degrees Fahrenheit, heart rate 100, respirations 17, oxygen saturation 95 percent and a pain level of 10/10 (meaning the worst level of pain). A focused assessment was performed at 5:46 a.m. by Staff #18 (Registered nurse). There was documentation that Patient #2 had bilateral flank pain, pain radiating to bilateral feet, and a headache. There was documentation that the severity of the pain was severe and at an 8 (0-10 scale). There was no documentation in the record to indicate this was a medical screening and if it was deemed that Patient #2 had an emergency medical condition. A physician’s order was written on 11/02/2024 at 6:43 a.m. for the pain medication Morphine 4 milligrams intravenous push. It was administered at 7:00 a.m.. There was no documentation of an assessment of what the pain level was before or after the dose of Morphine. Another physician’s order was written on 11/02/2024 at 8:13 a.m. for the pain medication Morphine 4 milligrams intravenous push. It was administered at 8:33 a.m. There was no documentation of an assessment of what the pain level was before or after the dose of Morphine. A physician’s order was written to admit Patient #2 to inpatient status at 8:55 a.m. on 11/02/2024. The next documented pain assessment was over 4 hours after the one taken at 5:46 a.m. Patient #2’s pain level at 10:16 a.m. was at a severity level of 5 out of 10. During an interview on 11/05/2024 at 12:00 p.m., Staff #1 (Chief Nursing officer/Administrator) stated that the assessment at 5:46 a.m. was the medical screening and that there was no documentation written to indicate it was or any notation of the existence of an emergency medical condition. Staff #1(Chief Nursing officer/Administrator) confirmed the lack of pain assessments on Patient #2. Patient #3 Review of an ED record on Patient 3 revealed she was a 65-year-old female who presented to the emergency room on 11/03/2024 at 10:10 p.m.. Patient #3 presented with complaints of chest pain. The vital signs were documented as a blood pressure of 153/73, pulse 73, respirations 15, temperature 98.2 degrees Fahrenheit, oxygen saturation 97 percent on room air and a pain level of 5 out of 10. The providers assessment was at 10:18 p.m., There was documentation that Patient #3 had complaints of chest pain that started 3 hours before presenting to the ED. The pain was sudden, unchanged since onset, intermittent, involved substernal area, aching and radiated to the left shoulder and arm. Patient #3 had moderate pain and had a history or coronary artery disease. At 10:27 p.m., Patient #3 was administered a chewable aspirin 81 milligrams. A set of vitals was taken again at 11:00 p.m., but there was no documentation of the pain level or if the aspirin was effective. The next assessment of pain by nursing was over 6 hours later at 4:22 a.m. when the pain level was described as being 0 out of 10. During an interview on 11/05/2024 after 12:00 p.m., Staff #1 (Chief Nursing officer/Administrator) confirmed the lack of pain assessments on Patient #3. Review of a facility’s policy titled “Pain Management “with an effective date of 12/09/2019 revealed the following: “..EMERGENCY DEPARTMENT ...Routine Reassessment If no pain issues were identified during the initial assessment, then no routine reassessment is required. If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity of the patient’s pain. ,,,Reassessment Following Treatment for Pain If a treatment intervention for pain is provided, then the response to that intervention must be assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15-60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the time of discharge or transfer ...””

“MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(2) [The bylaws must:] (2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure the Medical Staff Bylaws included a statement of privileges that allowed 1 of 1 (Nurse Practitioner #3) to complete a Medical Screening Exam in 5 of 18 (Patient #9, #13, 15, #18, and #21) patient medical records reviewed. Also, the facility failed to follow the policy titled, “EMTALA”. Findings: A review of medical records was completed with Director of Nurses (DON) Registered Nurse (RN) Staff #2 on 11/05/2024 after 10:00 AM. The review revealed the following. Patient #9 Patient #9 was a 69-year-old female who presented to the Emergency Department (ED) on 11/02/2024 at 7:02 PM with a finger laceration. She was triaged by Registered Nurse (RN) #19 on 11/02/2024 at 7:17 PM and taken to ED Room #01. The MSE was completed by Nurse Practitioner (NP) #3 on 11/02/2024 at 8:03 PM. Patient #9 was examined, treated, and discharged home by NP #3. Patient #9 departed the facility on 11/02/2024 at 8:31 PM without having an MSE from a qualified medical provider. Patient#13 Patient #13 was a 28-year-old male who presented to the ED on 11/02/2024 at 11:07 AM with a chief complaint of head laceration. He was triaged by RN #6 on 11/02/2024 at 11:09 AM and taken to ED Room #6. The MSE was completed by NP #3 on 11/02/2024 at 11:13 AM. Patient #13 was examined, treated, and discharged home NP #3. Patient #13 departed the facility on 11/02/2024 at 1:35 PM without having an MSE from a qualified medical provider. Patient #15 Patient #15 was a 79-year-old female who presented to the ED on 11/01/2024 at 7:12 PM with a chief complaint of a laceration to the right lower leg. She was triaged by RN #18 on 11/01/2024 at 7:15 PM and taken to ED Room #6. The MSE was completed by NP #3 on 11/01/2024 at 7:22 PM. Patient #15 was examined, treated, and discharged home by NP #3. Patient #15 departed the facility on 11/01/2024 at 8:36 PM without having an MSE from a qualified medical provider. Patient #18 Patient #18 was a 24-year-old male who presented to the ED on 11/04/2024 at 12:26 PM with a chief complaint of abdominal pain. He was triaged by RN #5 on 11/04/2024 at 12:29 PM and taken to ED Room #4. The MSE was completed by NP #3 on 11/04/2024 at 12:26 PM. Patient #18 was examined, treated, and discharged home by NP #3. Patient #18 departed the facility on 11/04/2024 at 2:28 PM without having an MSE from a qualified medical provider. Patient #21 Patient #21 was a 65-year-old female who presented to the ED on 11/04/2024 at 8:58 PM with a chief complaint of left shoulder pain, right elbow pain, right knee pain, and laceration to her lip after a fall at her home. She was triaged by RN #21 on 11/04/2024 at 9:15 PM and taken to ED Room #4. The MSE was completed by NP #3 on 11/04/2024 at 9:41 PM. Patient #21 was examined, treated, and discharged home by NP #3. Patient #21 departed the facility on 11/04/2024 at 11:15 PM without having an MSE from a qualified medical provider. A review of the Medical Staff Bylaws & Rules and Regulations revised January 2023 was as follows; “ ...A. Admission and Discharge of Patients ... B: Emergency Services: 1. The Medical Director shall have overall responsibility for emergency care for patients. The Hospital provides first aid and referral for emergencies. a ... b ... c ... d. The policies and procedures governing emergency medical care shall be established by and shall be a continuing responsibility of the Medical Staff. e ... f. Medical Screening examinations will be performed by qualified RN’s under the supervision of a qualified Member of the Medical Staff ...” A review of the facility policy titled, “EMTALA”, with an effective date of December 9, 2019, was as follows: “PURPOSE: To ensure that Lumberton Hospital LLC. complies with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA’) and associated regulations (42 U.S.C.1395dd and 42C.F.R. 489.20.-24). To be in compliance with Texas Licensing Regulation 133.163. POLICY: It is the policy of the Altus Lumberton Hospital that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act (“’EMT ALA”), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated there under ... PROCEDURE: MEDICAL SCREENING EXAMINATION: All patients who come to Altus Lumberton Hospital for emergency medical treatment shall receive an appropriate Medical Screening Examination (MSE). Neither the MSE nor necessary stabilizing treatment shall be delayed in order to inquire about an individual’s method of payment, and insurance status, or in order to obtain prior authorization ... 1 ... 2 ... 3 ... 4. Personnel Qualified to Perform the Exam a) Qualified Medical Person at Emergency Department means physician in the hospital ...” An interview was conducted with Nurse Practitioner (NP) #3 on 11/05/2024 after 11:00 AM. NP #3 was asked if he completed the MSE on the ED patients. NP #3 stated, “Yes, I do”. An interview was conducted with Chief Nursing Officer (CNO) Staff #1 on 11/06/2024 after 10:00 AM. CNO Staff #1 was asked who was considered a qualified RN as stated in the Medical Staff Rules and Regs dated 2023. CNO Staff replied, “I would say that refers to Nurse Practitioners”. CNO Staff #1 was asked if the Medical Staff Rules and Regs defined a Qualified RN. CNO Staff #1 confirmed the Medical Staff Rules and Regs did not define a qualified RN. A review of the Governing Body meeting minutes dated January 2024 revealed the Medical Staff Bylaws & Rules and Regulations had been reviewed but there was no approval of the revised rules documented. In an interview on 11/06/2024 after 10:00 AM with CNO Staff #1, CNO Staff #1 was asked if the Medical Staff Bylaws & Rules and Regs had been approved. CNO Staff #1 stated, “No, this is all I have. I do not have anything saying they were approved. CNO Staff #1 confirmed 5 of 18 (Patients #9, #13, 15, #18, and #21) patients reviewed had received an MSE by a non-qualified individual”.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 40989 Based on observation, document review, and interview the facility failed to ensure the required signage (per Section 1867 (a)(1)(N)(iii) of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX) was posted conspicuously for all patients entering the Emergency Department (ED) for health care services. Findings: A tour of Facility #2 was conducted on 11/06/2024 at 8:33 AM with Registered Nurse (RN) Staff #15. While observing the main lobby of the Emergency Room (ER) at Facility #2, the surveyor did not observe the required signage posted in the patient waiting area. An interview was conducted with the Chief Nursing Officer (CNO), Administrator Staff #1 on 11/06/2024 after 9:00 AM. Staff #1 confirmed Facility #2 failed to display the required signage specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX).”