University of Utah Hospital and Clinics

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 39836 Based on interview and record review, it was determined that for 1 of 10 patients, the hospital did not obtain a physician order for a restraint when force was needed by the staff to administer a feeding through a feeding tube. (Patient identifier: 1) Findings include: 1. A review of patient 1’s medical record was completed on June 3, 2025, and revealed the following: Patient 1 was admitted to the hospital on December 18, 2024, and discharged on January 11, 2025, with diagnoses that included unspecified psychosis, Gastrostomy tube (G tube) feedings due to a history of intentional self-harm with lye ingestion, failure to thrive, and anorexia. At admission, Patient 1 weighed 39 kilograms (86 pounds) with a low body mass index (BMI) of 15.47 (according to the Centers for Disease Control and Prevention and the National Heart, Lung, and Blood Institute, the normal range for a female in her 20s is between 18.5 and 24.9). On December 24, 2024, at 9:16 AM, a physician wrote the following order: “If she does not complete each tube feed within 1 hour of scheduled mealtimes, staff will administer tube feed.” Note: Court documents showed that on April 5, 2022, the state of Wyoming granted legal guardianship to Patient 1’s parents and deemed her incompetent. Per an interview with Patient 1’s parents, they were aware and consented to the use of force to administer prescribed feedings if necessary. On December 24, 2024, at 11:50 PM, a registered nurse (RN 1) documented that after the one-hour time limit, the patient had not self-administered any of the ordered feeding. Per the physician’s order, the nurse attempted to initiate feeding, but staff had to “gently” hold Patient 1’s arms while the nurse administered the feeding to prevent the patient from grabbing the tubing or swinging arms to interfere with the feeding. On December 24, 2024, at 12:36 PM, a psychiatric technician (Psych Tech 1) documented that Patient 1 was given a specific amount of time to finish her feeding. Psych Tech 1 further stated that Patient 1 injected more water than formula into her G tube, and the staff needed to go “hands-on” to assist with the patient’s feeding. Patient 1 appeared to struggle and stated, “That is very traumatizing for them to do that to me.” 2. On June 2, 2025, at 7:07 AM, the surveyor interviewed RN 1. When RN 1 was asked about the nursing note she wrote on December 24, 2024, at 11:50 PM, she stated, “From what I remember, she never fought me or the team. We would hold her hands very softly. She was more vocal about issues with staff feeding her, but never abusive with staff.” On June 2, 2025, at 11:02 AM, the surveyor completed a second interview with Psych Tech 1. When asked to explain “hands on”, she stated that three staff members went in to finish administering Patient 1’s feeding, two staff members held the patient’s arms while the nurse fed the patient through her G-tube. The surveyor found no documented evidence that restraints had been ordered for Patient 1 at any time during her admission. On June 2, 2025, at 10:36 AM, an interview was conducted with Patient 1’s attending physician. He stated that Patient 1 had never been restrained during her admission. On June 3, 2025, at 2:15 PM, the surveyor interviewed the Chief Quality Medical Officer and the Accreditation Manager. Both stated that holding Patient 1’s arm to complete her feeding would not be considered a restraint. They both stated that restraining a patient to complete a medical procedure would not be considered a restraint. The Accreditation Manager used the example of a papoose board, a medical device that temporarily immobilizes an infant or child to facilitate completion of medical procedures, and it was not considered a restraint. 3. The hospital’s policy for Violent and Non-Violent Restraint or Seclusion of Patients was reviewed. Hospital policy describes restraints as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Centers for Medicare & Medicaid Services’ standardized interpretation of “Physical Holding” is as follows: Holding a patient in a manner that restricts the patient’s movement against the patient’s will is considered a restraint. This includes holds that some members of the medical community may term ‘therapeutic holds’. “Physical Holding for Forced Medications” is the application of force to physically hold a patient, in order to administer a medication against the patient’s wishes, and is considered a restraint. The use of force in order to medicate a patient, as with other restraints, must have a physician’s order.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 39836 Based on interviews and record review, it was determined that the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that involved all hospital departments and services. Specifically, the hospital failed to appropriately investigate and implement systematic improvements after a sentinel event led to a patient’s death. On 9/11/2024, a finding of Immediate Jeopardy (IJ) was identified in the area of 482.21 Quality Assessment and Performance Improvement Program. The hospital was notified of this finding on 9/11/2024 at 9:10 AM. The hospital submitted an IJ removal plan via email on 9/12/2024 at 2:15 PM, alleging removal as of 9/12/2024. The plan was accepted, and the hospital was notified at 3:28 PM on 9/12/2024. An onsite visit was conducted on 9/13/2024, and surveyors determined that IJ had been removed on 9/12/2024, based on the steps the hospital had implemented. The hospital was notified of the IJ removal at 12:40 PM on 9/13/2024. Findings include: The hospital’s quality assurance team failed to systematically analyze the root causes of a sentinel event and appropriately implement preventive actions. (Refer to tag A-283)”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 39836 Based on interview and record review, it was determined that the hospital failed to have an organized medical staff that was responsible for the quality of medical care provided to patients by the hospital. Specifically, the medical staff did not collaborate with the nursing staff to ensure that 1 out of 10 sampled patients were safe and appropriate for a non-medical unit. Additionally, emergency medical services (EMS) were not called in a timely manner for a patient’s change in condition. Findings include: The medical staff failed to be organized and accountable for the quality of medical care provided to patients. (Refer to Tag A-347)”

“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: 39836 Based on interview and record review, it was determined that the hospital failed to ensure that nursing services were furnished in a way that adequately met the needs of the patients. On 9/11/2024, an Immediate Jeopardy (IJ) finding was identified in the area of 482.23 Nursing Services. The hospital was notified of this finding on 9/11/2024 at 9:10 AM. The hospital submitted an IJ removal plan via email on 9/12/2024 at 2:15 PM, alleging removal as of 9/12/2024. The plan was accepted, and the hospital was notified at 3:28 PM on 9/12/2024. An onsite visit was conducted on 9/13/2024, and surveyors determined that IJ had been removed on 9/12/2024, based on the steps the hospital had implemented. The hospital was notified of the IJ removal finding at 12:40 PM on 9/13/2024. Findings include: The hospital failed to ensure all licensed nurses who provided services in the hospital adhered to the policies and procedures in initiating a rapid response and calling the provider timely with a patient’s change of condition. (Refer to tag A-395)”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 39107 Based on interview and record review, it was determined the hospital failed to have active hospital-wide programs for the surveillance, prevention, and control of Healthcare Acquired Infections (HAIs) and other infectious diseases, that demonstrated adherence to nationally recognized infection prevention and control guidelines. Specifically, the hospital failed to ensure systems were in place for the reporting of tuberculosis results to patients, staff, and the state health department. On 9/11/2024, a finding of Immediate Jeopardy (IJ) was identified in the area of 482.42 Infection Prevention and Control. The hospital was notified of this finding on 9/11/2024 at 9:10 AM. The hospital submitted an IJ removal plan on 9/12/2024 at 2:15 PM, via email alleging removal as of 9/12/2024. The plan was accepted and the hospital was notified at 3:28 PM on 9/12/2024. An onsite visit was conducted on 9/13/2024, and surveyors determined that IJ had been removed on 9/12/2024, based on the steps the hospital had taken. The hospital was notified of this finding at 12:40 PM on 9/13/2024. Findings include: The hospital failed to employ a sufficient system for identifying, reporting, investigating, and controlling infections and communicable diseases. (Refer to Tag A-749)”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45490 Based on interview and record review, it was determined that the hospital did not ensure a physicians order was in place for restraints for 1 of 10 sample patients. Specifically, the hospital did not ensure that a patient had a physician’s order for restraints timely after initiating restraints. (Patient identifier: 5) Findings include: Patient 5 was admitted to the hospital on 9/19/2023 with diagnoses that included liver transplant recipient, NASH (nonalcoholic steatohepatitis), and weakness. A review of patient 5’s medical record was completed on 9/18/2024. On 10/3/2023 at 12:00 AM, a registered nurse documented that they initiated restraints which included the left and right wrist as well as left and right ankle soft limb restraints. On 10/3/2023 at 5:10 AM, a physician wrote an order for the use of non-violent restraints on patient 5. The physician documented soft limb restraints on patients 5’s right wrist, left wrist, right ankle, left ankle, as well as mittens on his right and left hands. The restraint reason documented was “interference with medical treatment.” (It should be noted that the order for the additional restraints was placed approximately 5 hours after the restraints were initiated.) The hospital’s policy for Violent and Non-Violent Restraint or Seclusion of Patients was reviewed. Per the policy, an RN may identify the need and initiate the use of restraints with a patient and must obtain a physician’s verbal, telephone, or written order within 15 minutes of initiation. Any change in the form of restraint (addition or removal) requires discontinuing the existing order and placing a new order. On 9/10/2024 at 1:49 PM, an interview was conducted with the Informatics Quality Nurse (IQN). The IQN stated that they had searched through the patient’s record and were unable to locate a restraint order for the left and right ankle and wrist restraints closer to the time they were initiated on 10/3/2023 at 12:00 AM. The IQN stated the closest restraint order was dated 10/3/2023 at 5:10 AM. On 9/17/2024 at 10:35 AM, an interview was conducted with the Surgical Registered Nurse (SRN)1. SRN 1 stated that before increasing the level of restraints, a certified nursing assistant (CNA) would be used as a one-on-one for supervision. If the one-on-one was not sufficient, then they would initiate soft restraints. SRN 1 stated that they usually do not initiate restraints until they have physician orders. SRN 1 stated the nurses would typically get an order from the physician prior to initiating restraints. If that was not possible and restraints were initiated before an order is in place, then an order is usually obtained very quickly. SRN 1 stated that they were unsure of how quickly a restraint order should be received because they are able to get the orders almost instantly, but that they possibly have 1 hour to request the order. SRN 1 stated restraint orders are important because they physically restrain a person, and they need to be assessed to determine the safety and necessity.”

“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: 39836 Based on interviews and record review, the hospital did not adequately analyze and investigate adverse patient events and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Specifically, for 1 out of 1 sampled patient events that resulted in death, the hospital did not systematically analyze the causes of a sentinel event and appropriately implement corrective and preventive actions. (Patient identifier: 7) Findings include: An incident report classified as a serious event dated 3/24/2024, was reviewed and revealed the following: Patient 7, a 22-year-old female, was admitted on 1/26/2024, to an adult acute psychiatric unit to receive treatment for disorganized schizophrenia and methamphetamine dependence. Patient 7 had the following medical concerns develop during her admission: pleural effusion, generalized edema, refeeding syndrome, bilateral foot wounds, and acute kidney injury. Patient 7 decompensated quickly and ultimately passed away on 3/24/2024. The facility’s first review of the incident was documented on 4/22/2024. The facility review discussed concerns but ultimately documented that no deviation from the standards of care occurred. No corrective action was implemented by the hospital. The autopsy results were completed on 6/8/2024. Patient 7’s cause of death was documented as “refeeding syndrome, treatment resulted in ultimate death (toxic megacolon/natural causes).” The next facility review was on 8/7/2024, and identified the following concerns: “-Anticholinergic slow down gut motility effects of Clozapine (75 mg daily dose): 1. Consider preselecting stimulant laxatives like SENNA in the bowel regimen order set. 2. Should stimulant laxatives be considered for other anticholinergic meds? 3. Constipation & Diarrhea, in what situations when patients report both should we continue to administer senna, MiraLAX to patients? Are there criteria or tests we can do to confirm impaction that justifies continuing bowel regimen? -Toxic Megacolon sequela (a condition which is the consequence of a previous disease or injury), and actions related to updating orders with active bowel protocol. - Use of MEWS (Modified early warning signs) ... - Critical Thinking: “Do vitals need to happen more frequently in this patient?” Surveyors completed patient 7’s medical record review on 9/18/2024. They determined there were delays in the provider calling the emergency medical system (EMS) for transport to a higher level of care and in nursing staff calling the provider regarding the patient’s change in condition. Additionally, the facility’s policy was not followed by calling a rapid response for patient 7’s change in condition. On 8/28/2024 at 9:40 AM, an interview was conducted with the director of adult acute psychiatric care. He stated no training or policy changes had been made and that he felt policies had been followed appropriately. He stated the facility review did not find anything out of the standard of care. The director stated there was no time delay that could be seen, but communication could improve between physicians and staff. The director also stated patient 7’s autopsy results showed toxic megacolon, and that some education could be done on the medication Clozaril, which patient 7 was on (an anticholinergic medication that slows down gut motility). He further stated the hospital felt all interventions were appropriate. On 9/9/2024 at 2:50 PM, an interview was conducted with the senior patient safety clinical consultant (SPSCC). The SPSCC stated the event was labeled a serious safety event and marked as the highest level of harm. The SPSCC stated the hospital was not sure if there was a deviation in care. She stated that a rapid event investigation should have been completed (note: no documented evidence of this was provided). The SPSCC further stated some of their internal processes need improvement. As of 9/11/2024, there was no documented evidence of any corrective action being implemented. On 9/18/2024, a review of the policy titled Event Review Guidelines was completed. “b. Managers will review and respond to Permanent Harm, Death, or Serious Imminent Risk RLs (report and learn) within 2 business days.” On 9/18/2024, the hospital policy titled Defining and Investigating Patient Safety Events (formally known as Serious Safety Events) (formerly known as Sentinel Events) was reviewed. “Serious Safety Event: Serious safety events encompass both of the following: Events which require immediate investigation and response, as defined by patient safety, regulatory and accrediting agencies. Other events, or identified risks to patient safety, that may need immediate investigation and response.” It was determined that the quality assurance performance improvement program did not appropriately and timely investigate this event, including identifying system-wide causes, to prevent future sentinel events of this nature.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 39836 Based on interviews and record review, it was determined that the hospital did not ensure the medical staff was organized and accountable for the quality of medical care provided to patients. Specifically, the medical staff did not collaborate with the nursing staff to ensure that 1 out of 10 sampled patients were safe and appropriate for a non-medical unit. Additionally, emergency medical services (EMS) were not called in a timely manner for a patient’s change in condition. (Patient identifier: 7) Findings include: Patient 7’s record review was completed on 9/18/2024, and revealed the following: Patient 7 was a 22-year-old female admitted on 1/26/2024, to an adult acute psychiatric unit to receive treatment for diagnoses of disorganized schizophrenia and methamphetamine dependence. During patient 7’s admission on the psychiatric unit, patient 7’s medical history included a pleural effusion, generalized edema, refeeding syndrome, bilateral foot wounds, and acute kidney injury (AKI). Patient 7 decompensated quickly and ultimately passed away on 3/24/2024, at 1:46 PM. On 2/10/2024, at 8:00 PM, the following was documented in a nursing progress note, “ ...She (patient 7) had a visit today with her mom and mom called the unit afterwards and spoke with this author. Mom stated that she was concerned about swelling on her bilateral feet and lack of oxygenation on her toes ‘her toes were blue.’ Mom stated that patient complained of chest pain and patient had heart murmur when she was 17. Mom also stated that patient had swollen feet since she quit smoking. Her feet were assessed by this author and another nurse on the unit. Patient observed to have notable edema on bilateral feet with left feet (sic) more edematous than her right feet (sic) with open wound in between digits on bilateral feet. Her feet also had pustulent (sic) odor. Bilateral feet warm to touch and slightly red in appearance. On call provider paged ...” On 2/10/2024, at 9:33 PM, the following was documented in a nursing progress note, “Pt (patient) requested several towels and was observed bringing clothing and towels soiled with emesis to the laundry hamper. When asked what had happened, the pt stated, ‘I threw up.’ She endorsed feeling nauseous and received PRN (as needed) Zofran 4 mg ODT (orally disintegrating tablet). RN (registered nurse) checked with pt approximately one hour later, and pt endorsed still feeling nauseous and reported that she would like to take something else for the nausea ... At approximately 0400 (4:00 AM), pt’s roommate reported that the bathroom needed to be cleaned again. When staff came to pt’s door, (patient 7) was in the shower with the water running. Staff waited until pt exited the shower, and afterwards observed feces on the bathroom floor, on the toilet, and on the sink.” On 2/11/2024 at 1:49 PM, the following was documented in a nursing progress note, “ ... reported nausea/vomiting and diarrhea this morning at the start of shift. Emesis observed to be bile and undigested food, reported diarrhea not observed by staff. Provider notified of symptoms reported from previous shift and this morning and ordered labs to assess for GI (gastrointestinal) infection and contact precautions.” On 2/11/2024 at 9:49 PM, a nursing progress note stated, “ ...Patient was also given briefs to wear due to the frequency and urgency of their bowel movements today.” On 2/12/2024 at 11:25 AM, a psychiatric attending daily progress note stated, “The patient reported nausea, vomiting, and diarrhea yesterday morning and has had several observed episodes of emesis and diarrhea since then. Labs were ordered to assess for GI infection including a stool culture and the patient was placed on contact precautions.” On 2/13/2024 at 2:03 AM, a nursing progress note stated, “ ...She (patient 7) continues to endorse diarrhea and bowel incontinence and estimated that she had 3 loose stools today. Imodium (antidiarrheal) still being held at this time while GI testing is in process. Pt requested briefs as needed for incontinence.” On 2/14/2024 at 3:19 PM, a psychiatric attending daily progress note stated, “Staff report patient continues to endorse diarrhea but this has not been observed by staff.” On 2/15/2024 at 12:56 PM, a psychiatric attending daily progress note stated, “She (patient 7) reports that she thinks her body is sick - ‘the whole thing.’ She cannot localize any specific symptoms. She endorses feeling tired and that her entire body hurts. She denies nausea and a diffuse headache. She is encouraged to drink water and take some Tylenol which she agrees with. She has not had any vomiting or diarrhea in the last day ... She says the only thing her team can help with is more food as she is feeling more hungry ...” On 2/16/2024 at 7:44 AM, a psychiatric attending daily progress note stated, “She (patient 7) says she is feeling sick. She cannot localize any specific part of her body that is feeling unwell or any describe any symptoms but instead states, ‘I just don’t want to talk to you.’” On 2/23/2024 at 8:44 AM, it was documented in a nutrition 30-day screen note by a registered dietitian (RD), “Patient (patient 7) has had excessive intakes resulting in weight gain of 4.8 kg (4.8 kilogram=10.5 pounds) (11%) since admit weight of 43.3 kg (95.46 pounds). This is weight gain of 0.16 kg/day (0.35 pounds). This is considered clinically significant and not appropriate in respective time frame. Weight gain during admission is likely r/t (related to) medication (zyprexa) (antipsychotic) as well as high calorie high protein diet. Patient’s BMI (body mass index) of 20.03 is considered WNL (within normal limits). Pt would benefit from appropriate intakes to support weight stabilization during admission. Will continue to monitor pt’s weight, PO (by mouth) intake, and adjust nutrition care plan accordingly. Will follow up monthly per nutrition protocol. Available for additional consultation as needed.” There was no documented evidence of a dietary follow-up or an order for a dietary consult in patient 7’s medical record. On 3/1/2024 at 8:09 AM, a psychiatric attending daily progress note stated, “nursing noted facial swelling 3/1, patient appears to have rounder face than on admission and some peripheral edema in her left foot has been noted on dressing changes. Most likely secondary to weight gain during her admission (93>114lbs) but considering alternative pathologies and will check renal and liver function.” Note: Patient 7 was admitted weighing 93 pounds and weighed 118 on 3/24/2024. On 3/2/2024 at 5:21 PM, the following was documented in a physician progress note, “AKI (acute kidney injury): Cr (creatinine) and BUN (blood urea nitrogen-test kidney function) on 3/1 1.17 and 46 (Cr normal range: 0.57 - 1.11 milligrams (mg/deciliter (dl), BUN normal range: 8 - 24 mg/dL) respectively, patient’s face appears somewhat edematous which could also be c/w (consistent with) AKI. -Encourage PO (by mouth) hydration, order Gatorade -Avoid nephrotoxic medications (no NSAIDs) -UA (urinalysis) with microscopy to look for sediment, protein, etc to help ddx (differential diagnosis) of AKI -Repeat BMP (basic metabolic panel) on Monday AM.” On 3/2/2024 at 6:31 PM, it was documented in a nursing progress note, “Bilateral feet was assessed and observed to have generalized edema. Her face and eyes appeared puffy but she has not been complaining of pain. She continues to limp whenever she ambulates in the hallway.” On 3/5/2024 at 7:46 AM, the following was documented in a psychiatric attending daily progress note “The patient reports she is feeling sick and endorses nausea without vomiting as her only physical symptom ... She reports swelling in her legs, hands, and face that feels to be of the same severity as yesterday ... #. Peripheral edema of bilateral lower extremities, hands, and face #. Pleural effusions Worsening tissue edema noted over the past week (~2/27-3/5), medicine consulted and appreciate recs (recommendations). Likely most consistent with refeeding edema, continued to consider nephrotic syndrome though less likely with UA (urinalyses) without proteinuria (protein in the urine). Additionally evaluating for decompensated liver disease (less likely with a normal INR (international normalized ratio) and LFTs (liver function test)) and exam less consistent with CHF (congestive heart failure) on physical exam and bedside POCUS (point of care ultrasound) (though possible in the setting of stimulant use). Also continue to consider wet Beriberi (thiamine deficiency). - Medicine will continue to follow and consider a transfer to IMP (inpatient medical psychiatric), for closer monitoring and access to medical care as needed.” On 3/6/2024 at 7:20 AM, the following was documented in a medicine consult daily progress note, “ ...22 year old (sic) female with stimulant use disorder, and psychosis, who has gained about 30 pounds in the last month, with clear evidence of tissue edema, with pleural effusions, and facial/hand/leg edema. This generalized edema, in the absence of elevated intravascular pressure, most strongly is supportive of refeeding edema, given the clinical scenario of patient with severely limited PO (oral nutrition), and edema after gaining access to adequate nutrition. That said, nephrotic syndrome would also present similarly, with predominant facial edema. Appreciate psychiatry tream (sic) obtaining labs, to further evaluate for decompensated liver disease. Exam not suggestive of CHF, though difficult to rule out at this time, given patient at risk given stimulant use. Given adequate nutrition, doubt Wet Beriberi, but certainly is not ruled out. - daily weights - start low sodium diet - 20 mg daily torsemide (diuretic), at least for the next 3 days ... - we will follow closely at (acute psychiatric hospital unit), if patient’s needs progress past abilities of (acute psychiatric hospital unit), would be worth transferring to IMP for closer medicine consult availability (including on weekends), and radiology, etc.” There was no documented evidence internal medicine followed up on patient 7’s condition. There was no documented evidence of a low sodium diet being ordered in patient 7’s medical record. There was no documented evidence a dietary consult was ordered after diagnosis of refeeding syndrome. On 3/7/2024 at 9:20 PM, the following was documented in a nursing progress note, “This author noted an increased BNP (B-Type Natriuretic Peptide-test heart function) at a level of 418 (normal range: <=100 pg/mL). Provider was notified via page shortly after results were received. This evening when wound care is completed it is noted that pedal edema has worsened bilaterally and is worse on the left side, 3+ pitting. 2+ on the right side.” On 3/9/2024 at 7:23 PM, a nurse documented the following, “During the dressing, pitting edema +4 is noted in the Lt. (left) foot with severe tenderness in the whole foot as the patient reported. Edema is +2 in the Rt. (right) foot with mild tenderness.” On 3/24/2024 at 1:17 PM, it was documented in a Psychiatric discharge note, “weights remained stable with no evidence of LE (lower extremities) edema.” It was also documented, patient 7 had an, “EKG (electrocardiogram) from 3/4 showed QTc (corrected QT interval-time difference between waves in the heart’s electrical activity) of 452. EKGs obtained on 3/14 did show QTc ranging from 479-505 however poor quality EKGs given patient movement.” (QTc normal range: 360-460) There was no documented evidence in patient 7’s medical record the EKG was rechecked for accuracy. Additionally, there was no documented evidence from nursing staff that the edema had resolved. On 3/20/2024, 3/21/2024, 3/22/2024, and 3/23/2024, it was documented in nursing assessments that patient 7 had non-pitting facial edema, bilateral pedal edema, and bowel incontinence. Further review of patient 7’s medical record revealed that on the day of patient 7’s death (3/24/2024), an RN documented the patient experienced vomiting at 2:00 AM and that vital signs were abnormal throughout the morning. On 3/24/2024 at 1:17 PM, it was documented in a psychiatric discharge note that the physician was informed of the abnormal vital signs at 11:57 AM and arrived on the floor at 12:05 PM. On 9/18/2024, a review of the EMS report was completed. It was documented on the report that EMS was called at 12:50 PM and was at patient 7’s bedside at 1:08 PM; CPR was initiated at 1:18 PM. (Note: EMS was called 45 minutes after the physician evaluated patient 7.) On 8/26/2024 at 10:29 AM, RN4 was interviewed. RN4 stated psychiatrist 2 was told by nursing staff that patient 7’s whole body was swollen. RN4 stated that psychiatrist 2 replied, “she (patient 7) was not swollen.” RN4 stated that patient 7’s face was so swollen that it looked like she was squinting. RN4 was asked if patient 7’s swelling was ever resolved, and she replied as far as she remembered, the swelling was never resolved. RN4 stated that the staff was “pushing” to get patient 7 to the emergency room. RN4 stated there were many times when nursing staff felt disregarded and did not feel listened to. RN4 stated that the nursing staff agreed the incident should not have happened but did not know how to prevent it. RN4 stated the facility had been trying to “slip” patients in who should not be on psychiatric units because they have too many medical issues. RN4 stated that staff members do not feel they can appropriately care for patients with many medical problems. On 8/26/2024 at 2:30 PM, an interview was conducted with registered nurse 3 (RN3). RN3 was asked about patient 7’s admission. RN3 stated that patient 7 could not communicate appropriately about her medical state and that patient 7 would only give 1-word or 2-word answers. RN3 stated patient 7 was experiencing a lot of swelling and having difficulty walking. RN3 stated staff was expressing concerns to psychiatrist 2 about patient 7’s medical issues, such as the bilateral wounds on her feet and generalized edema with facial swelling. RN3 stated when psychiatrist 2 was asked to assess patient 7 by nursing, psychiatrist 2 stated, “I am not going to do that.” RN3 stated psychiatrist 2 eventually put in a consult with internal medicine the day psychiatrist 2 was scheduled to be off. RN3 stated they felt like patient 7 was being passed off to the next physician (psychiatrist 1). RN3 stated psychiatrist 1 followed up on psychiatrist 2’s plan to start patient 7 on Clozaril. RN3 further stated patient 7’s heart was checked before starting Clozaril and there were questions about the accuracy of the way the heart was checked. RN3 stated that a few days later, patient 7 was “not looking right.” RN3 further stated that the nursing staff felt like they were being “put off” and that patient 7’s medical concerns should have been addressed sooner. On 8/28/2024 at 1:00 PM, psychiatrist 1 was interviewed. Psychiatrist 1 stated on Sunday morning (3/24/2024), patient 7 started having abnormal vital signs; she was tachycardic (fast heart rate), with a blood pressure of 60 over 90. He stated patient 7 was clearly in discomfort and distress; her abdomen was distended, and she was not able to articulate what was wrong. He stated the decision was made to send patient 7 to the emergency room, and within 40 minutes, her status changed dramatically. Psychiatrist 1 stated his first impression was it was not an emergency. On 8/28/2024 at 2:41 PM, psychiatrist 2 was interviewed. Psychiatrist 2 stated she could not get much information out of patient 7 regarding her bowel movements. Psychiatrist 2 stated patient 7 had edema, but it was not sustained. Psychiatrist 2 stated she noticed the swelling 2 days before the internal medicine consult. (Note: the internal medicine consult occurred on 3/6/2024. Pedal edema was documented around 2/10/2024, and generalized edema was documented to have started around 2/27/2024-3/1/2024). On 9/5/2024 at 1:14 PM, psychiatric technician 1 (PT1) was interviewed. PT1 stated the psychiatric technicians are the ones who report patient bowel movements to the nurses. PT1 stated patient 7 never had any solid bowel movements, it was always watery diarrhea. PT1 stated a lot of nurses felt patient 7 should go to the main hospital. PT1 was asked if they had training on refeeding syndrome. PT1 stated he had no training on refeeding syndrome and was not aware patient 7 had refeeding syndrome.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39836 Based on interview and medical record review, it was determined that the hospital’s clinical staff did not ensure that care was evaluated and supervised for 1 of 10 patients. Specifically, nursing staff did not follow policy and procedures in initiating a rapid response and calling the provider timely with a patient’s change of condition. (Patient identifier: 7) Findings include: A medical record review for patient 7 was completed on 9/18/2024, and revealed the following: Patient 7 was a 22-year-old female admitted on 1/26/2024, to an adult acute psychiatric unit to receive treatment with diagnoses of disorganized schizophrenia and methamphetamine dependence. During patient 7’s inpatient psychiatric stay, patient 7’s medical diagnoses included pleural effusion, generalized edema, refeeding syndrome, bilateral foot wounds, and acute kidney injury. On 3/24/2024 at 2:10 AM, the following was documented in a nursing note. “Pt (patient) approached the nurses’ station at approximately 0200 (2:00 AM) and reported that she ‘just threw up.’ When RN (registered nurse) checked pt’s room, what appeared to be emesis was observed on the floor. Pt accepted offer for PRN (as needed) Zofran 4 mg ODT (orally disintegrating tablet) and pt’s floor was cleaned.” On 3/24/2024, patient 7’s vital signs were documented as follows: (Normal vital sign readings for reference: respirations: 12-18, heart rate 60-100, blood pressure 120/80-90/60, oxygen saturation 90%-100%) There was no documented evidence that vital signs were taken at 2:00 AM when patient 7 reported emesis (vomiting). At 10:24 AM: heart rate 144, respirations 42, blood pressure 108/79, oxygen saturation 96%. (There was no documented evidence nursing rechecked the abnormal vital signs until 11:55 AM.) At 11:55 AM: heart rate 145, respirations 42, blood pressure 96/43, oxygen saturation 82%. At 12:38 PM: heart rate 147, oxygen saturation of 94%, no recorded blood pressure or respirations. At 12:40 PM: heart rate 147, blood pressure 67/41, respirations 42, oxygen saturation 82%. There was no documented evidence patient 7 was placed on oxygen by facility staff when oxygen saturation dropped below the acceptable range. On 3/24/2024 at 1:17 PM, it was documented in a psychiatric discharge note that the physician was called at 11:57 AM, and arrived on the floor at 12:05 PM. The physician was called approximately an hour and a half after the first abnormal vital sign was documented. Surveyors requested the emergency medical services (EMS) report. A review of the EMS report was completed on 9/18/2024, and the following information was obtained: EMS was called at 12:50 PM, arrived at the patient at 1:08 PM, and cardiopulmonary resuscitation (CPR) was initiated at 1:18 PM. EMS documentation noted: “Arrived on scene and received report from the RN (registered nurse). Report stated Patient had been vomiting and tachycardic for the previous twelve hours. Patient vitals had been steadily dropping- Patient was poorly perfused and required oxygen. Patient had not been placed on oxygen prior to ...arrival. Patient vomit was red and brown and included small chunks· Patient pupils were fully dilated. Patient had an absent radial pulse - Patient was breathing. Patient was alert to painful stimuli only. Patient was non-verbal. EMS personnel called out to an ALS (advanced life support) unit for an assist. Patient was deteriorating quickly- Patient was rushed to the ambulance. Patient was being loaded in, a sternal rub was utilized and yielded no results. Patient carotid pulse was checked by EMS provider after it was seen that Patient chest was no longer rising and falling- Patient carotid pulse was absent. CPR was initiated. Huntsman Mental staff member accompanied EMS crew. Transport was Emergent 1039 with lights and sirens- ALS unit was canceled due to proximity to the hospital. CPR was continued during the entire transport. AED (automated external defibrillator) was pulled out and attached to patient. AED analyzed. No shock advised. IV (intravenous) not able to be established. CPR continued.” On 9/16/2024, the policy titled Response to Change in Patient Condition was reviewed. “Purpose: A. To describe which changes in patient condition would warrant a rapid response. B. To describe the rapid response process. Description: A. Criteria: the change in condition guidelines and criteria for implementation regarding if a patient exhibits any of the following: a. Significant changes in vital signs, including pulse oximetry b. Systolic blood pressure <80 or >200 c. Diastolic blood pressure <55 or > 100 d. Heart Rate <50 or >140 e. Temperature of 38.6 degrees Celsius or greater f. Respiratory rate <10 or >25 g. Pulse oximetry <90%... B. Response Process: 1. For all Code Blue events, follow the Code Blue procedure: call 9-911 first, call attending later ... 3. A Registered Nurse will promptly assess any patient when the patient, family, or staff member reports a concern about the patient’s condition. Based on that assessment, the nurse will implement one of the processes outlined in #4 ... 4. For non-Code Blue events that meet the criteria listed in A above: a. Contact the attending physician or designee. b. If a transfer is ordered, follow the transfer procedures: doctor-to-doc consult, arrange BLS (basic life support) or ALS (advanced life support) transport, fill out the EMTALA (emergency medical treatment and labor act) form, nurse-to-nurse consult, and notify the family ...” On 9/9/2024 at 1:29 PM, an interview was conducted with registered nurse 2 (RN2). RN2 stated they do not have a rapid response process. RN2 stated they call code blues. RN2 stated they call code blues for seizures, if a patient is unresponsive, or if the nurse needs more help. RN2 further stated that if vital signs were abnormal, depending on how abnormal they were, they should be rechecked, and then the provider should be called. RN2 stated there were no set parameters for calling the provider or calling a code blue; it was up to the nurse’s discretion. In an interview at 2:16 PM on 9/9/2024, with the clinical nurse coordinator (CNC) over the 2N and 2E units (patient 7 was admitted on the 2N unit), the CNC stated the psychiatric unit does not have a rapid response process and that their process was to call a “code blue.” The CNC was asked about the change in condition policy and if nursing staff followed that policy. The CNC stated staff should have rechecked vital signs and called the provider with the initial abnormal vital signs. There was no documented evidence that the nursing staff initiated a rapid response/code blue per protocol or called the physician timely to report the abnormal vital signs. Patient 7 decompensated quickly and ultimately passed away on 3/24/2024 at 1:46 PM.”

“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: 39107 Based on staff interview, policy review, and record review, it was determined the hospital did not ensure it employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. Specifically, for 1 out of 11 sampled patients, the hospital did not report tuberculosis results or perform further evaluation to determine if a tuberculosis infection was latent or active, and the patient was admitted to the hospital 3 months later with active pulmonary tuberculosis. (Patient identifier: 6) On 9/11/2024, a finding of Immediate Jeopardy (IJ) was identified in the area of 482.42 Infection Prevention and Control. The hospital was notified of this finding on 9/11/2024 at 9:10 AM. The hospital submitted an IJ removal plan on 9/12/2024 at 2:15 PM, via email alleging removal as of 9/12/2024. The plan was accepted, and the hospital was notified at 3:28 PM on 9/12/2024. An onsite visit was conducted on 9/13/2024, and surveyors determined that IJ had been removed on 9/12/2024, based on the steps the hospital had taken. The hospital was notified of this finding at 12:40 PM on 9/13/2024. Findings include: 1. Medical Record Review A review of patient 6’s medical record was completed on 9/10/2024, and revealed the following: a) Computed Tomography Scan Patient 6 was referred to the hospital’s outpatient community clinic on 2/5/2024, for a computed tomography scan (CT scan). CT is an imaging technique that uses X-rays to create detailed images of the body. Under “Reason for Visit” in the medical record for patient 6, the reason listed for the imaging order was to monitor the patient’s known condition of, “Malignant neoplasm of floor of mouth.” A radiologist performed the CT scan on 02/05/2024 at 12:07 PM, and placed the results in the medical record at 2:15 PM. The radiologist noted that based on the review of the CT results, there was concern for active pulmonary tuberculosis. The radiologist further documented that the CT results were discussed with the physician who referred patient 6 for the CT scan on 02/05/2024 at 2:10 PM. On 02/08/2024 at 1:45 PM, the physician who referred patient 6 for the CT scan documented they had acknowledged the CT results. b) Laboratory Blood Test Results On 02/05/2024, the physician who referred patient 6 for the CT scan ordered an interferon-gamma releasing assay (IGRA) test for TB. This laboratory blood test detects both latent and active TB but cannot distinguish between them. The test was completed at 2:20 PM, at an outpatient clinic that was part of the same hospital system where the CT scan was performed. A positive result for the IGRA test was placed in the medical record on 2/07/2024 at 4:31 AM. No documented evidence was found in the medical record for follow-up to determine if the infection was latent or active, nor was there documented evidence that the hospital reported the suspected TB case to the state or local health department within 24 hours as required. c) Other Clinic Visits and Notes i) Patient 6 was seen in the hospital outpatient clinic on 2/15/2024, for a dietary consultation. There was no documented evidence that the CT scan result or the positive IGRA result were discussed during the visit on 2/15/2024. ii) A note was placed in the medical record by a registered nurse (RN) at 3:10 PM on 2/21/2024, stating that the TB test result was faxed to a confidential fax line for the out-of-state county health department where patient 6 resides. iii) A note was placed in the medical record by an RN at 3:37 PM on 2/21/2024, stating the RN called patient 6’s daughter to explain the TB test results. The RN documented they gave patient 6’s daughter the local health department’s phone number and stated that patient 6 should call their local health department for further instruction. Information obtained by surveyors from both the state health department and the out-of-state health department, where patient 6 resides, revealed neither of the departments were notified of the suspected TB case until 5/22/2024. No documented evidence was found in the medical record that patient 6 received further follow-up, evaluation, or treatment for TB between 2/5/2024 and 5/20/2024. d) Emergency Department and Inpatient Hospital Stay On 5/20/2024, patient 6 was seen in the outpatient clinic for a follow-up visit. A review of the medical record revealed that patient 6 was transferred directly from the outpatient clinic visit to a negative pressure emergency department room, admitted to the hospital with an admitting diagnosis of tuberculosis, and discharged from the hospital against medical advice (AMA) on 6/4/2024. The Emergency Department (ED) physician, who evaluated patient 6 on 5/20/2024, documented the following: “In the course of her workup was noted to have a lung nodule and then repeat imaging was concerning for possible tuberculosis. Seems that there was some difficulties with follow-up as patient lives in (name of state). Finally had a quaniferon (sic) test obtained back in February. Had not followed up until today when she was seen in ENT (Ear, Nose and Throat) clinic. Patient was cachectic and ill-appearing with respiratory distress and directed to present to the emergency department.” (Note: QuantiFERON Gold test is an IGRA test for tuberculosis.) Surveyors contacted the state health department and learned the state health department, as well as the out-of-state health department, were notified of patient 6’s tuberculosis case on 5/22/2024. Review of the hospital’s log of reported TB cases revealed that the hospital documented reporting positive sputum (collected for patient 6 on 5/21/2024) TB results to the health departments (in state and out-of-state) on 5/22/2024. On 6/7/2024, the attending pulmonary physician documented that before patient 6 was discharged, they contacted the state health department to coordinate patient 6’s ongoing TB therapy. 2. Policy Review A review of the hospital’s Communicable Disease Reporting, Care of Tuberculosis (TB) patients, and Critical Results - Radiology policies was completed on 9/10/2024. Per policy, hospital staff were to report suspected and confirmed TB cases within 24 hours and were to call the health department to arrange follow-up for patients with suspected and confirmed TB cases before the patient’s departure from an outpatient area. The hospital did not report the suspected TB case within 24 hours. The outpatient clinic did not arrange follow-up for the patient. Additionally, policies did not specify diagnostic criteria for TB, nor did policies specify which clinician or staff member would be responsible for contacting the health department to report suspected and confirmed tuberculosis cases. 3. Interviews a) Business Operations/Medical Records Support Specialist (OMRS) In an interview with a Business Operations/Medical Support Specialist (OMRS) on 8/28/2024, at approximately 11:00 AM, the OMRS was asked where in the medical record surveyors could find documentation that patient 6 was notified of the results of the TB lab tests. The OMRS looked through patient 6’s medical record and stated she could not find any documentation that the patient was notified of the positive TB result (CT and blood lab work with positive result on 2/5/2024) until 2/21/2024, via a phone call to patient’s daughter. b) Director of Patient Support On 08/28/2024, at approximately 12:30 PM, an interview was conducted with a director of patient support (DPS). Surveyors asked where in the medical record they could review documentation that patient 6 had received the results of the CT scan and laboratory blood test results. The DPS stated the hospital had verification that patient 6 had been informed of the test results due to an automatically generated note in the patient portal that indicated patient 6 had opened their patient portal account after the results had been uploaded to the portal. The DPS stated there was electronic confirmation in the patient portal that patient 6 had seen the results. The surveyors verified the reports indicated the following, “Extensive interval increase of multifocal consolidative and tree-in-bud opacities within the lung apices with multifocal regions of cavitation, concerning for active pulmonary tuberculosis” and the blood lab work results “QuantiFERON TB Gold Plus: Positive.” The surveyors asked if the patient portal had the ability to translate the results from English to Spanish for patient 6, who is Spanish speaking, and if the patient portal had the ability to comprehensively explain the implications of the results to patient 6 without a clinician available to clarify the results. The DPS stated she would check to see if the patient portal had translation ability and that she would provide surveyors with the information. No documented evidence or further information was received by surveyors regarding the patient portal. c) Hospital Epidemiologist (HE) and Infection Prevention and Control Technical Lead (IPCTL) - Interview 1 In an interview on 9/03/2024 at 9:36 AM, surveyors asked the hospital epidemiologist (HE) and infection prevention and control technical lead (IPCTL) if the hospital had specific policies on how the hospital monitors and reports TB results. The HE and IPCTL said the hospital follows the state’s reporting guidelines. The HE and IPCTL stated the TB lab result for patient 6 did not rise to a reportable level because the lab results from IGRA tests could be interpreted as being in the “latent” category. Surveyors asked about the note placed by a registered nurse which stated the results were faxed to the out-of-state health department on 2/21/2024, and the IPCTL stated she did not know why that was done. When surveyors asked if together both the lab test results and the results of the CT scan combined would be considered enough information to bring the TB results to the level requiring reporting to the state health department, the IPCTL stated that diagnosing TB is subjective and would be a clinical decision for a patient’s care team to make. Additionally, the HE and IPCTL stated the hospital uses an automated process to notify the state of positive TB test results through their medical records software program. d) Hospital Epidemiologist (HE) and Infection Prevention and Control Technical Lead (IPCTL) - Interview 2 In an interview on 9/03/2024 at 1:30 PM, the IPCTL and the HE stated that the automated system for reporting through their medical records software was only one of the ways the hospital reports TB results to the state. They stated that other ways include phone calls and faxes. They stated the hospital reports suspected cases of TB as well as confirmed cases. They stated that for patient 6 the hospital reported the case on 5/22/2024, as a suspected case while they waited for results of a sputum test (a test which takes time to grow the bacteria) to confirm the results. They stated when the sputum test results were confirmed on 6/7/2024, they reported the confirmed results to the state health department. When asked about whether the hospital should have reported the results of the CT scan and the lab tests that were conducted on 2/5/2024, the hospital epidemiologist stated, “With a large hospital system, it’s challenging for the infection control group to always know what’s going on” and that TB results are not definitive because interpreting the results includes taking into account a number of factors, like multiple clinical evaluations and tests. Additionally, she stated that clinicians have a responsibility to know the reporting requirements. When asked what would be appropriate after a result that was inconclusive or showed suspected TB, the HE stated a bronchoscopy, or a sputum lab test was usually completed. When asked why that hadn’t been done after the results of the TB CT scan and lab results for patient 6 on 2/5/2024, the HE stated diagnosing TB is not as clear cut as some other diseases and that patients can have latent infections which can be activated or reactivated by many things, including cancer treatment. When asked if knowledge that a patient is undergoing cancer treatment should be used by the hospital in evaluating TB results, the HE and IPCTL stated that would be a clinical decision made by individual practitioners looking at their specific patient’s information. e) Radiologist An interview was conducted with a radiology resident on 9/3/2024, at approximately 1:00 PM. The radiology resident stated that if a CT scan showed results that looked like active TB, the process or next steps would be for the radiologist to call the referring provider from the ordering clinic and give them the information. The radiology resident stated that then the provider would call the patient and notify the health department after review. The radiology resident stated that the radiology department would not call the patient or notify the health department, and that would be a task the referring physician would oversee. f) Physician In an interview on 9/5/2024 at 10:02 AM, with a physician working in the hospital’s outpatient cancer clinic, the physician stated that if a patient had a CT scan showing active TB plus a positive IGRA lab test result, those results would alert her and generate a phone call from her to her clinic manager and the Infection Control Program to find out what to do next for treatment and reporting. (Note: Surveyors requested an interview with patient 6’s referring physician; however, hospital accreditation staff stated he was not available for interview.)”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 49678 Based on interview and record review, it was determined the hospital did not ensure patient discharge included transfer or referral of necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care. Specifically, for 1 of 11 sampled patients, the hospital’s home health referral and order did not include sufficient information to the home health agency regarding the wound care the patient would need at home. (Patient identifier: 9) Findings include: 1. Patient 9’s medical record review was completed on 9/12/2024, and revealed the following: Patient 9 was admitted to hospital on 5/19/2024, via Air Ambulance from an out-of-state hospital, with a diagnosis of Necrotizing Fasciitis. Patient 9 was discharged on 5/29/2024, with a discharge diagnosis of Groin Wound. The Home Health order dated 5/28/2024 at 12:13 PM, signed by the physician, included home health orders at discharge for: “clinical indications: post op deconditioning, nursing eval and drain care. Home Health services: Nursing, PT Eval and Treat.” The physician order for wound and drain care by home health was placed on 5/28/2024, and sent to the home health agency on 5/29/2024. The order included: “Drain Care: Home health nurse to remove JP (Jackson-Pratt type of wound drain) drains when output is less than 20cc in 48h period” and; “Wound Care: Apply interdry (type of dressing) to lateral aspects of scrotal skin twice per day. Home health nurse to remove incisional staples on 6/4/24.” This order did not specify enough information for the home health agency to provide focused and complete care for the patient, specifically wound care. The order did not include information regarding size of the wounds, orders for each individual wound type, the healing status of the wounds, or the number of wounds. Surveyors requested and reviewed Patient 9’s medical records from the out-of-state home health agency and out-of-state hospital. On 5/31/2024, a nurse from the out-of-state home health agency documented the following, “Patient was seen not admitted to Home Health services today as he required returning to the ED for concerns about his incision dehis (dehiscence) and degradation and no appropriate wound care orders or following provider locally for wound care management.” The out-of-state hospital medical record included a “History of Present Illness” note entered into the medical record by a physician at 11:58 PM on 5/30/2024, which stated that the patient was discharged to home health the day before and that the home health nurse directed him to the emergency department because the home health nurse was concerned about patient 9’s wounds. 2. A review of the hospital’s Discharge of Patients: Preparation & Discharge Time and Case Management discharge planning process policies was completed on 09/12/2024. Per policy, before discharge or as part of the discharge process, patients should be prepared and educated with the needs that will be necessary after discharge. Per policy, the hospital should have communicated specific discharge orders to the home health agency. The hospital was to provide a consistent process for discharge planning for patients identified as likely to suffer adverse health consequences upon hospital discharge. The hospital did not fully prepare the patient for a successful discharge as stated in their policies. The hospital did not ensure pertinent information was sent to the out-of-state Home Health agency to ensure patient 9 did not suffer adverse health consequences. 3. Interviews were conducted with hospital staff and the following information was obtained: a. On 08/27/2024 at 2:00 PM, an interview was conducted with a case management director. She stated home health agencies should be given all the information needed to understand each patient’s needs so the home health agency has an opportunity to accept the patient or not. b. On 09/03/2024 at 10:05 AM, an interview was conducted with a discharge nurse. The discharge nurse stated the information for the referrals to home health agencies and the orders for home health services were sent to the home health agency on or before the time the patient discharges form the hospital. She stated that all the information needed to continue care for the patient should be included in the referral and/or order. She stated the referral usually included the last few nursing notes for a patient in order for a home health agency to continue patient care upon discharge from the hospital. There was no documented evidence identified that the out-of-state home health agency received sufficient information in the orders necessary to provide the full level of care needed for patient 9.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45710 Based on observation, interview and record review, it was determined that the hospital failed to meet the requirements for EMTALA. Specifically, the hospital did not provide an appropriate medical screening examination (MSE) for 2 individuals who came to the emergency department and denied a transfer from an out-of-state hospital. (Patient Identifiers: 17, 21 and 22) Findings include: The hospital’s policies for emergency medical treatment and active labor act (EMTALA) stated that the hospital will adhere to the provisions of the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). The policy further states that it applies to any individuals who come to any Emergency Unit seeking emergency care or appear to a lay person observing them to be seeking emergency care. These individuals must be offered an appropriate medical screening examination (MSE) by a qualified medical person (QMP) to determine whether they are suffering from an emergency medical condition. No individual found to have an emergency medical condition shall be discharged or transferred until such condition is stabilized, except where transfer to another hospital is medically appropriate. Additionally, the policy states that the hospital would not refuse to accept the transfer of an individual for emergency care if the individual required specialized services unless the hospital lacks the capacity to treat the individual if the ambulance is en route to to the hospital or the hospital is on a diversionary status. 1. On 9/14/2023 at 9:30 PM, the hospital received a call from the transfer center requesting a transfer from an out-of-state hospital due patient 21 having a retinal detachment, an emergency medical condition. The emergency department physician was notified that the transfer was denied on 9/14/2023 at 10:48 PM despite having the capability to treat patient 21. 2. On 9/17/2023 at 2:42 AM, patient 17 was discharged from the hospital without receiving the appropriate crisis evaluation. On 09/17/2023 at the time of discharge, patient 17 became verbally aggressive to staff and was escorted out of the Emergency Department (ED) by security and the police while still having intravenous (IV) access. On 09/17/2023 at 3:00 AM, Patient 17 wandered back into the emergency room and was given graham crackers and a soda in order to remove the IVs. Both IVs were removed with no complications. No crisis evaluation occurred during patient 17 time in the ED. 3. On 09/08/2024 at 10:31 AM, patient 22 was brought to the hospital’s ambulance bay by a police officer, accompanied by two mobile crisis outreach team peer support specialists. Patient 22 was observed laying on the ground in the ambulance bay, while the two mobile crisis workers spoke with the charge nurse in sight of patient 22. Patient 22 was denied entry into the hospital. No MSE occurred. Refer to tag 2406 and 2409”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45710 Based on interviews, record review, and review of camera footage, it was determined that the hospital did not provide the proper medical screening to determine whether or not an emergency medical condition existed for a patient on hospital property. Specifically, a patient brought in by police who was lying on the ground in the Emergency Department’s ambulance bay was not examined by a person qualified by hospital bylaws or rules and regulations to determine whether or not an emergency medical condition existed. Additionally, the hospital did not provide a psychiatric evaluation prior to discharge for a patient who presented to the emergency department with suicidal ideation. (Patient Identifier: 17 and 22) Findings include: 1. Review of police report dated 9/6/2024 and interview with the reporting officer revealed patient 22 was released from a 3-week, court ordered, behavioral health unit on 9/4/2024. Patient 22’s boyfriend called police the following Friday, 9/6/2024. Police found patient 22 in a manic state, with disorganized thoughts. Police reported that at the time, patient 22 denied suicidal thoughts, homicidal thoughts, audio and visual hallucinations, and did not meet the requirements to be detained. Police were called out again on Sunday 9/8/2024. A review of a law enforcement report dated 9/8/2024 showed law enforcement responded at approximately 9:38 AM, to a residence where patient 22 was residing. Upon arrival the officers were met by 2 crisis workers and could hear yelling coming from the back yard. It was reported that patient 22 had taken 12 gabapentin and was responding to internal stimuli. A video taken by the mobile crisis workers was played for the officers that showed patient 22 raising her arms and praying loudly. The officers found patient 22 speaking loudly to herself in the back yard. When patient 22 was told that she would need to go to the hospital she became uncooperative tucking her arms under her body and screaming. The officers were able to get patient 22 in handcuffs and carry her to the police vehicle after she refused to walk. The police officer reported that patient 22 had hallucination and delusions while in transport. On 9/8/2024 at 10:31 AM, patient 22 was brought to the hospital’s ambulance bay by a police officer, accompanied by two mobile crisis outreach team peer support specialists. Patient 22 was denied entry into the hospital for examination. On 9/17/2024 at 10:05 AM, camera footage of the ambulance bay from 10:00 AM to 10:36 AM on 9/8/2024, was reviewed with a hospital security officer present. A police vehicle was observed to pull into the ambulance bay at 10:31 AM. At 10:32 AM hospital personnel, identified as the charge nurse by the hospital security officer, exited the Emergency Department (ED) with other medical personnel and spoke with an unidentified man and woman. While hospital staff were speaking to the unidentified man and woman, the driver of the police vehicle was observed to remove a person from the back of the vehicle. The person immediately fell to the ground and remained on the ground until the unidentified man and woman walked to the police vehicle and helped the police officer return the person on the ground to the vehicle. The police vehicle left the ambulance bay at 10:36 AM followed by a car driven by the unidentified woman that was seen speaking with the charge nurse. The police report further revealed that upon arriving at the University of Utah, patient 22 refused to exit the vehicle and stated that the officer would have to carry her. The officer moved patient 22’s feet outside the door. The officer then put their arms under patient 22. At that time, patient 22 dropped all of their weight on the officer’s arms, fell to the ground, and hit their head on the pavement. Patient 22 then refused to sit up and continued to lay on the ground stating that she would not go in. After being denied entry to the hospital, patient 22 refused to get back in the car and used her legs to block the officer from placing her back in the vehicle. One of the crisis workers was able to help the officer place patient 22 back in the car. The police officer reported that during the car ride to the alternate hospital, patient 22 experienced disorganized thoughts, talked about Buddha, Jesus, the Latter Day Saints church, being raped and her property being stolen. Review of an ED record dated 9/8/24 showed that patient 22 presented to alternate hospital’s ED with law enforcement at 11:09 AM, with an emergency application for involuntary commitment. Patient 22’s diagnoses included unspecified psychosis not due to a substance, a history of schizophrenia, and possible substance abuse. Review of the alternate hospital’s ED record also revealed that at admission to the alternate hospital, patient 22 started rambling about being kidnapped by serial killers many years ago and forced to drink gasoline, while babies were raped in front of her. The ED physician noted “no evidence of substance abuse, she is cooperative but is very disorganized with delusions”. A crisis evaluation found patient 22 to be manic, with hyper-religious and hyper-sexual delusions and paranoia. Patient 22 remained in the ED on observation for psychiatric instability for approximately 54 hours while awaiting placement at a inpatient psychiatric facility. Patient 22 received multiple doses of atypical antipsychotic medication and exhibited marked improvement but continued to show some indications of mania. Patient 22 was transferred to a psychiatric facility on 9/10/2024 at 8:20 PM. On 9/17/2024 at 2:24 PM, an interview was conducted with the police officer who transported patient 22 to the hospital. She stated that on the morning of 9/8/2024, she arrived in the hospital’s ambulance bay at approximately 10:25 AM, followed by two mobile crisis peer support specialists in their own car. The officer further stated the patient was agitated, irritable, and refusing to leave the car. The officer was trying to get patient 22 out of the car when patient 22 stated, “My legs don’t work”, and dropped all her weight on the officer’s arms. Patient 22 then fell to the ground hitting her head. The officer stated she stayed with patient 22 because she was in her custody, while the mobile crisis peer support specialist spoke with the charge nurse, who had come out into the ambulance bay. The officer stated the charge nurse told the mobile crisis peer support specialist that the hospital would not let them in because the hospital was on non-trauma divert and that they would need to take the patient to a different hospital. The officer continued; “I have never had a charge nurse refuse while I was on the property.” On 9/17/2024 at 2:13 PM, an interview was conducted with the mobile crisis support manager. She stated that the peer support specialist followed the police officer into the ambulance bay. The crisis support manager stated the crisis support specialists got out of the car to go speak with the charge nurse and give a “hand off” (report of the patient’s history and presentation). As they approached the door, the charge nurse came out into the ambulance bay and told them they would have to take the patient to another hospital that the hospital was only accepting trauma patients. At that time the patient was lying on the ground next to the police car and the peer support specialist mentioned this to the charge nurse who still would not allow the patient to enter the hospital. On 11/25/2024 at 9:00 AM, an interview was conducted with the charge nurse on duty on the morning of 9/8/2024. When asked about the incident involving patient 22 she stated, “we made the decision to turn them away because we were on non-trauma divert not realizing at the time that since that patient was already on premises that she should have been brought in.” On 9/17/2024 at 10:50 AM, an interview was conducted with the University of Utah hospital’s assistant director of capacity management. When asked specifically about what the process was when a police officer brought a patient in via the ambulance bay while on divert, he stated, “...the patient should receive a basic medical screening exam.” The hospital’s capacity management guidelines were reviewed and included the following: “...1. Non-Trauma Divert - All ED ambulance traffic and ED to ED Transfer Center patients’ traffic is stopped. ED walk ins and Transfer Center direct admit patients still accepted ...” In summary, University of Utah hospital did not provide patient 22 with a medical screening to determine whether an emergency medical condition existed. 46232 2. Review of patient 17’s ED record showed she presented to the hospital emergency department on 09/16/23 at 1:42 PM, with Suicidal Ideation and a plan for suicide. The family reported the patient had been clean from heroin and methamphetamine (street drugs) but was concerned about recent use. The family reported the patient had been eating strange foods, shoving things in her ears and nose, and was an unreliable historian. On August 28, 2024, at 12:43 PM, an interview was conducted with a family member of the patient. The family member stated patient 17 had been unsafely discharged from the ED, in their pajama pants, cotton blouse and flip flops in close to freezing temperatures. Review of patient 17’s ED record showed that on 09/16/23 at 3:46 PM, an ED provider documented that patient 17 was reported by family to have suicidal ideations, and had been inserting objects into her ears and nose. The patient had a documented history that was significant for anxiety and depression, oppositional defiant disorder, and substance abuse with possible relapse. The provider’s documented psychiatric examination showed the patient was inattentive and non-communicative with inappropriate affect and judgment with memory impairment. Crisis staff were contacted with plans to evaluate the patient when they were able. At 2:55 PM, a nurse documented that the patient exited the exam room, repeatedly screaming profanities (“fuck you”) at staff, instructing them not to touch her, and reporting she was in pain. At 2:56 PM, the ED provider completed a face to face evaluation and documented patient 17 was aggressive, agitated, and combative, and at 3:00 and 3:01 PM, provider documentation, nursing notes and emergency medical technician notes showed the patient attempted to leave, continued to yell and scream at staff, attempted to drink her blood from a syringe, and was posturing toward staff, aggressive and threatening, presenting possible physical harm. Hospital staff required both police and security to assist while the patient was chemically restrained with droperidol and versed, and physically restrained in 4-point (both arms and both legs) hard restraints. The restraint ordering physician documented the reason for restraint was “Danger to Self and Others” and the patient was subsequently blue sheeted (placed on a psychiatric hold for safety) by the ED physician. The patient remained in restraints for approximately two hours before she was removed at 5:01 PM. At 11:21 PM, an ED provider documented patient 17 had been signed out to another provider and needed a crisis evaluation when they were able to appropriately participate. On 09/17/23 at 12:30 AM and 2:10 AM, the crisis worker attempted to talk to with patient 17, but the patient was not cooperative during both encounters. During the crisis worker’s second attempt to evaluate the patient, the patient stood up, raised her voice at the crisis worker, and the crisis worker exited the patient’s room due to the patient’s escalation. At 2:30 AM, nursing documented that the ED provider voided the blue sheet, the patient’s belongings were returned by security, and at 2:39 AM, the patient began yelling and became verbally aggressive. Nursing documented that the ED provider approved the patient could leave, the patient was escorted out of the ED by security and police, with two IVs still in place. At 2:44 AM, the discharging ED Physician Assistant (PA) documented: “Signout was received on this 37-year-old female with a history of methamphetamine and heroin use for psychosis. Patient did require chemical restraints by previous team...Urinalysis is positive for benzodiazepines, opiates, stimulants, methadone. Awaiting crisis evaluation ...The patient refused to talk to crisis (worker) on several accounts without success....She told me that she was sober for the last 7 years. Stated that she wanted Subutex, lithium, Depakote. She states she does not know when she last had these medications. Informed the patient that we could provide resources for outpatient substance use. I asked crisis (worker) to provide outpatient resources. The patient declined.” The patient was documented by nursing staff as “eloped.” Review of patient 17’s ED record showed that at 3:00 AM, nursing documented that the patient returned inside the hospital and was wandering around in the waiting area of the ED. The nurse removed the patient’s IVs. There was no documentation that attempts were made to evaluate the patient when she returned to the ED. There was no documented evidence that Patient 17 received a psychological assessment by the crisis worker to determine if they were psychiatrically stable and safe to discharge. On 09/10/24 at 1:21 PM, the hospital accreditation staff member confirmed by email that there was no psychological assessment by the crisis worker for patient 17 during their ED stay from 09/16/23 through 09/17/23. On 09/10/24 at 9:01 AM, an interview was conducted with the discharging ED provider. The ED provider stated when a patient arrived with suicidal ideation, they were triaged and brought into the psychiatric section of the ED. The ED provider stated patients were evaluated by a qualified medical personal to determine their medical needs. The ED provider stated that all psychiatric patients underwent a screening exam, and if necessary, they met with the crisis worker to determine whether they needed to be admitted to a psychiatric facility or discharged with a safety plan. The ED provider stated as a provider they were able to go in and assess the patient if they no longer posed a threat to themselves or others. The ED provider stated the patient had the choice to do things or not and they were not able to force anything upon the patient. On 11/25/24 at 10:33 AM, a second interview was conducted with the discharging ED provider. The ED provider stated they were able to see patient 17 had been blue sheet at 3:00 PM. The ED provider stated it had been reported that patient 17 was inserting foreign objects but patient 17 never expressed this to them while under their care. The ED provider stated that according to their documentation, they were unable to determine why the blue sheet had been voided. However, at the time of discharge, patient 17 had the appropriate indicators to determine they were safe to leave. Patient 17 left without their after-visit summary (includes discharge instructions). On 09/10/24 at 10:02 AM, an interview was completed with the nurse who discharged Patient 17 on 09/17/23. The nurse stated they remembered patient 17 had been restrained during day shift, but during their shift, patient 17 was just sitting in bed. The nurse stated that Patient 17 requested a prescription for certain medications, and the provider informed the patient that they could not prescribe them. That was when Patient 17 escalated and wanted to leave since they were not helping her. The nurse stated patient 17 had the right to decide if she wanted to leave or not. The nurse stated patient 17 denied suicidal ideation, and the provider cleared her to be discharged since she was not a harm to herself. The nurse stated they remembered patient 17 was yelling and screaming while the police escorted them out of the ED. On 09/13/24 at 1:29 PM, an interview was done with an ED crisis worker. The crisis worker stated a behavioral health intake was completed to determine a patient’s suicide risk when they met with a patient. The intake consisted of gathering robust information about the patient’s past medical history and family history. The crisis worker stated there were times when patients were not willing to meet with the crisis workers. The crisis worker stated just because a patient was not responding to them did not mean they were not having a mental health crisis. The discharging provider indicated awareness of the blue sheet process for the patient, placing the patient on a psychiatric hold. The blue sheet documented that the patient had been aggressive and had attempted to drink blood from a syringe. Two attempts made by the social worker to conduct a psychiatric assessment were unsuccessful due to the patient’s lack of cooperation and escalation. The provider also indicated that the patient was safe to leave, even though the 30 minutes prior to the patient’s exit from the ED, the patient had stood up and raised her voice with the social worker causing the social worker to leave the patient’s room, and later became aggressive and required police and security to escort the patient out of the ED with IVs still in place.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 19354 Based on interview and record review, it was determined that the hospital refused to accept the appropriate transfer of one of 22 sampled patients when patient 21, diagnosed with a retinal detachment (a medical emergency of the eye that can lead to vision loss if not treated promptly), required the specialized capabilities of the recipient hospital. The hospital had available space and qualified personnel for the treatment of patient 21’s emergency medical condition (EMC). Additionally, the hospital was the closest recipient hospital that could provide the necessary stabilizing treatment, and when the patient transfer was refused, the patient required three additional transfers subsequently delaying treatment of his EMC. Findings include: 1. The hospital’s Emergency Medical Treatment and Labor Act policy was requested and reviewed. The policy stated that hospital would not refuse to accept the transfer of an individual for emergency care if the individual required specialized treatment unless the hospital lacked the capacity to treat the individual, if an ambulance en route or if the hospital, was on a diversionary status. Review of a local ambulance report showed that on 09/14/23 at 5:22 PM, the ambulance was dispatched to patient 21 for an injury of the eye and orbit causing a visual disturbance. Patient 21 reported to Emergency Medical Services (EMS) personnel that he had distorted vision in his right eye due to a hole in the retina causing liquid to leak, and could not see through the right eye at night. Patient 21 was transported to Hospital A Emergency Department (ED). Review of Patient #21’s ED record from Hospital A showed the patient arrived to the ED on 09/14/23 at 5:57 PM with complaints of loss of vision to the right eye and a history of retinal detachment to the left eye with surgical repair. Upon examination, patient 21 reported he began having visual changes in the medial (inner) field of vision in the right eye two days prior. He was examined by an optometrist at that time and was recommended to come to the ED. The patient reported that his vision became worse throughout the day (09/14/23), which prompted him to come to the ED. An ultrasound of the eye by the ED physician showed a right eye retinal detachment on the lateral (outside) portion of the retina. The ED physician contacted two ophthalmology physicians at the University of Utah, and “after some discussion” it was decided that “they cannot accept the patient...due to capacity.” Review of call center documentation for patient 21 showed that on 09/14/23 at 9:29 PM, the ED physician at Hospital A called the call center at the University of Utah requesting transfer of patient 21 to ophthalmology specialty. The call center documented three attempts to the ophthalmologist on call before contact was made. At 9:48 PM a return call was made from the call center to the ED physician at Hospital A. Documentation included that Hospital A’s ED physician reported that the patient was homeless, had a history of retinal detachment of the left eye that was repaired in 2022, and that the patient presented with a retinal detachment on the right side “tonight.” “Per [the University of Utah ophthalmologist on call] this pt (patient) does not need to come to the emergency dept (department), he can be seen as outpatient for surgery....” Additional documentation from the call center at 10:18 PM showed: “[Ophthalmology resident] call back and asked that “I”’ call the admin physician on call to ask if we should continue with transfer or not.” “Advised [admin physician] of the clinical story and what our attending [ophthalmologist on call] had already told [Hospital A’s ED physician].” “Per [admin physician] we need to tell [Hospital A’s ED physician] that our ED does not have capacity for this pt [(patient) tonight and we cannot accept them at this time.” At 10:48 PM. the call center documented “Calling to reconnect with [Hospital A’s ED physician] that the ophthalmologist reported to let [Hospital A’s ED physician] know “...that we cannot take this pt (patient) tonight due to capacity in the ED and hospital.” Review of the University of Utah’s website showed a link to the Moran Eye Center. The Moran Eye Center indicated that they provided immediate and specialized treatment to preserve eyesight, including retinal detachment. During non-business hours or evenings, weekends and holidays, patients with immediate eye issues should proceed to the Emergency Room at the University of Utah. The diversionary log dated 09/14/23 showed the hospital was not on a diversionary status. Review of the bed count log for 9/14/2023 showed the following: The acute medical unit had a capacity of 36 with a census of 35; The medical unit had a capacity of 40 patients with a census of 38; The neuro acute care unit had a capacity of 37 with a census of 35. Review of the bed count log for 9/15/2023 showed the following: The acute medical unit had a capacity of 36 with a census of 35; The medical unit had a capacity of 40 patients with a census of 38; The neuro acute care unit had a capacity of 37 with a census of 32. The hospital central logs for the ED were requested and reviewed. Patient 21 was not admitted to the hospital on or around 9/14/2023. On 11/27/2024 at 3:45 PM, the on-call resident ophthalmologist was interviewed. The on-call resident ophthalmologist stated that the attending ophthalmologist was contacted for retinal concerns, that retinal detachments were not emergent, and that the patient could be seen in the clinic in one or two days. On 9/3/2024 at 12:08 PM, the on-call ophthalmologist was interviewed. The ophthalmologist was asked to explain interhospital transfers. The ophthalmologist stated the hospital would receive a telephone call from the hospital transfer center. Whether or not to admit depends on whether the patient’s condition is urgent or emergent. For patients who need to be seen emergently, the hospital would discuss the case with the physician at the transferring hospital. Furthermore, the ophthalmologist stated the decision to accept the transfer would depend on the hospital’s staffing and whether the hospital had the means to provide the care. It was stated that not every retinal detachment required urgent care, and the decision to admit would depend on how long the retina had been detached, the status of the other eye, if the patient had a place to stay after the transfer, and the patient’s means to receive aftercare support. On 11/27/2024 at 4:00 PM, the Chief Medical Officer was interviewed and stated that she had been told that the patient had been “stabilized.” She further stated that the ED was at capacity on 9/14/2024 with patients waiting for a bed to be available on other units. Due to the University of Utah’s refusal to accept Patient 21, he was transported by helicopter from Hospital A to Hospital C. The University of Utah was 235 miles from the referring hospital whereas Hospital C was 292 miles from the transferring hospital. Record review of the medical record from Hospital C showed that Patient 21 arrived in the ED on 9/15/2023 at 2:24 AM. It was documented that patient 21 was homeless and uses methamphetamine, with reports of a previous retinal detachment in the left eye. An ophthalmologist examined the patient and confirmed the patient had a detached retinal and recommended transfer and surgical repair since there was no retina specialists on call at Hospital C. The University of Utah was recommended, however, when the transfer center was contacted, they informed Hospital C that the patient had already been declined and that the Chief Medical Officer (admin physician) was involved in that decision. During the patient’s course of care in the ED, the patient reported that his vision was slowly getting worse, and the patient was subsequently transported by air to Hospital D at 8:51 AM. The patient was transferred to Hospital D by air, and subsequently transferred to Hospital E by air, before the patient received treatment for his EMC.”