Springfield Hospital

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 12112 Based on staff interview, record review and electronic communication, the CAH failed to provide health care services in accordance with written policies related to Patient Rights regarding the right to receive considerate and respectful care at all times and under all circumstances and the right to refuse treatment to the extent permitted by law for 1 applicable patient. (Patient #1) Findings include: Per record review, on 7/21/25 Patient #1 was brought to the Emergency Department (ED) by police after being found wandering the streets, appearing disorganized, unkempt and unable to answer questions reliably. When approached by ED staff s/he would shrink back fearfully and appear to be experiencing visual hallucinations. Patient #1 was diagnosed with severe malnutrition with muscle wasting; sepsis (infection) of the lower right leg; acute kidney disease and probable untreated schizophrenia (mental health condition) and was subsequently admitted to the hospital from the ED. On 7/22/25 a telepsychiatry evaluation was completed with recommendations for the initiation of olanzapine orally (antipsychotic medication used to treat mental health conditions to include schizophrenia). Other medications prescribed for treatment included intravenous antibiotics ceftriaxone 1 gram and vancomycin 1000 mg (milligrams), enoxaparin 30 mg injection (used to prevent blood clots), fosfomycin 3 Grams (an oral antibiotic for urinary tract infections), and sulfamethoxazole/trimethoprim 800/160 mg (also utilized for bacterial infections). During Patient #1’s hospitalization, their ability to have full mental capacity was identified to be an issue. Initial discharge plans included discharging Patient #1 to a psychiatric facility for further treatment for his/her schizophrenia. Patient #1 was being held on an involuntary status awaiting further determination by the Department of Mental Health (DMH); and was being followed by HCRS (mental health organization) staff who visited them and monitored the provision of services being provided by the CAH related to psychiatric interventions, treatment and pending services. While hospitalized, Patient #1 became suspicious of staff and frequently refused medication administration whether it was oral, intravenous or by injection. Per review of Patient #1’s MAR (medication administration record) there are multiple times nursing staff documented Patient #1’s refusal of medications. However, during a hospital visit made on the weekend of 7/26/25, an HCRS representative was informed by nursing staff of the challenges they were experiencing when attempting to administer prescribed medications. As a result, the nursing staff determined oral medications, specifically olanzapine could be administered if “they sneak” the medications into Patient #1’s coffee. Nursing staff confirmed with the HCRS representative how Patient #1 was being administered medications without the patient’s consent. The HCRS representative was further informed that eventually, Patient #1 became aware of the unauthorized administration and began to refuse coffee and/or food, continuing not to trust the staff. Subsequently, the HCRS representative brought this inappropriate forcing of medication to the CAH administration. The incidents of forced medications were confirmed by the surveyor during electronic communication with the HCRS representative on 4/13/26, who reconfirmed what s/he had been informed by nursing staff over the weekend of 7/26/25. The hospital eventually determined that Patient #1 was not a person who would harm themselves or others and the psychiatric hold was terminated. After slowly recovering from severe malnutrition and infections, Patient #1 was discharged to a rehab facility. Per review of the CAH policy Patient Rights and Responsibilities (last reviewed 10/08/2025) states “While you are a patient in the hospital, you have the right to: Make informed decisions regarding your care....refuse treatment to the extent permitted by law”.....and receive “.... respect for your personal privacy, dignity and comfort.” Because Patient #1 was not in a psychiatric facility where court ordered involuntary medications can be administered, the CAH staff failed to honor the patient’s right to refuse prescribed medications. Per interview on 3/25/26 at 1:45 PM, the Chief Nursing Officer (CNO) confirmed the ignoring of Patient #1’s rights when nursing staff intermittently forced medications during the first 4-5 days of hospitalization. At the time of the incident the CNO indicated the CAH was utilizing travelers (agency nurses used to fulfill nursing staff shortages) and identifying all involved in the practice of putting medication into the patient’s coffee was difficult to assess. The CNO further stated there was some “counseling” with nursing staff regarding the incidents, however, was unable to provide any formal documented re-training or formal update to Medication Administration policies and review of the patient’s right to refuse medication and/or treatment.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 12112 Based on observation and confirmed by staff interview, the CAH failed to ensure patient equipment in the Emergency Department (ED) and floors and ceiling in the Surgical Operating Rooms (OR) and ante-rooms were properly maintained. Findings include: 1. A tour of the ED on 10/29/24 at 10:30 AM was conducted to examine the condition of stretcher mattresses utilized by patients during the provision of care and services. Although multiple stretcher mattresses had been replaced, a stretcher in room #14 noted to have torn edges on the foot rest and on sides of the stretcher mattress; in room #15 the stretcher mattress had tears on the upper edge. Per the Association for the Health Care Environment states in a report dated 2/29/2017 states: “Cleaning and disinfecting all patient care areas is essential to preventing healthcare-acquired infections.....Damaged covers cannot be properly cleaned and may allow bodily fluids and pathogens to penetrate the mattress core “ The Director of Quality, Risk & Compliance confirmed at the time of observation, the damaged noted to the mattresses. 2. During a tour of the Surgical suites accompanied by the nurse manager for Surgical Services on 10/29/24 at 2:25 PM observations in OR #2 noted a horizontal crack in the flooring sidewall/baseboard near the entrance to the OR. The crack extended approximately 6-8 feet in length. The special non-porous flooring extends and adheres to the wall for approximately 4-5 inches. Although floors in operating rooms must be seamless in order to prevent probability of contamination, having a broken surface/crevices decreases the integrity of the environmental surface permitting dirt and particles in the crack. 3. Within one of the OR ante-rooms above a scrub sink (presently not in use) 2 holes were observed covered in red duct tape, one on the ceiling and the second on the wall above the sink. The nurse manager stated the 2 holes were the result of an outside vendor installing equipment to correct a problem “....with the air handlers and humidity”. S/he further stated the company who installed the equipment had removed their equipment when their repair was not effective, thus leaving the 2 holes. The ceiling hole creates the potential for exposure to the Surgical Services environment to possible dust and moisture intrusion. Contact made on the morning of 10/31/24 the Director of Quality, Risk and Compliance confirmed the noted environmental concerns had been identified during Environmental Rounding in May, 2024, however no Work Orders were created to make the repairs.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 12112 Based on record review and confirmed by staff interview, there is a failure by the CAH (Critical Access Hospital ) to ensure policies are reviewed and updated at least biennially. Findings include: During the course of reviewing CAH policies on 10/29/24 it was identified there are departments within the hospital that have not updated and/or reviewed their specific policies for greater than 2 years to include: Annual Program Review last approved 1/14/2015 (the management plans for the environment of care); Fire Doors last approved 7/14/2020; Housekeeping policies: Cleaning of Discharge Unit last approved 12/4/2017; Cleaning services and schedule of services last approved 9/8/2020; Sequence for cleaning of patient rooms last approved 7/20/21 and Elevator Safety last approved 4/26/2019. Per interview on the afternoon of 10/30/24 the Director of Quality, Risk & Compliance confirmed although efforts have been made in multiple departments to update policies & procedures, there are many departments who require reinforcement and guidance by the CAH professional health care staff and advisory to assist these departments in reviewing and updating policies & procedures.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 12112 Based on observation and interview the CAH (Critical Access Hospital) failed to ensure the Emergency Department’s (ED’s) environment maintained patient safety as evidenced by failing to secure a supply room that contained sharps and other healthcare supplies that could be accessed by any passerby. Findings include: During a tour of the ED on 5/21/24 at approximately 10:15 AM with the ED Nurse Manager and the Assistant Director of Nursing, a supply room located in the hallway near beds 7, 9, 10, & 11 was noted to be open and unsecured allowing anyone to access. This hallway was a high traffic area for which patients, visitors, and staff moved about in the ED. Some of the items found in the store room were, “Pedialyte (oral electrolyte solution for children), Chlorox Bleach wipes, Hibiclens solution 32 oz (antibacterial cleansing solution), germicidal surface wipes, 20g IV catheters (needles used to put in IV’s), 22g IV Catheters, 18g IV catheters, Butterfly 21G (needles used to draw blood), Butterfly 23G, Normal saline flushes (syringes containing sodium chloride commonly used to flush IV’s), RX destroyer formula (material used to destroy medications), and “Gallant disposable prep razors”. Per interview at that time with the ED Nurse Manager, S/He confirmed that the supply room was open and “never” locked and anyone could access.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 12112 Based on interviews, record and policy review the CAH failed to ensure care was provided in accordance with written policies and procedures regarding the use of chemical and physical restraints for 1 applicable patient (Patient #11). Findings include: Per review of nursing triage notes from 2/01/24 at 09:50, Patient #11 arrived at the ED via ambulance accompanied by police. The patient had come to the ED after calling 911 numerous times. Upon arrival the patient was “praying and yelling” at the EMS squad and not able to communicate effectively with the ED staff. Per review of nursing progress notes from 2/01/24, at 09:43 AM, “Lorazepam (anti-anxiety medication) IM (intramuscularly) 2 mg (milligrams) given” in right ventral gluteus (bottom) ...at 09:53 AM, “Diphenhydramine (antihistamine) IM 50 mg given” in right ventral gluteus ...at 09:53 AM “Lorazepam IM 2 mg given” right anterior thigh. Review of “Medication Orders” reveals these medications were ordered; however, there was no indication and/or documentation in the record as to why these medications were given. Per interview on 5/22/24 at 2:03 PM with an ED provider, S/He stated that S/He does not use “chemical restraints” and that if a patient was hallucinating and/or violent they would treat the patient’s symptoms with medications to ensure safety. At 10:00 AM a nursing progress note states, “Patient yelling and fighting with the police and EMS staff as well as hospital staff. Patient attempted to be calmed down with a staff hold. Patient continues to yell, scratch, bite towards the staff as well as attempting to throw (him/her-self) off stretcher. ED physician ordering 4 point locked restraints.” Review of the physician’s “General Orders” dated 2/01/24 reveal, “Restraints protocol (4 point locked)” were ordered at 10:58. There was no documentation in the record of an order for the physical hold noted above. A providers note, from 2/01/24 [signed at 17:41] states that Patient #11, “was found extremely anxious and aggressive ...Multiple de-escalation attempts were performed without avail. Intramuscular medications were given to treat agitation with little to no improvement. 4 point restraint was then placed after patient started biting ...self and attempting to bite and scratch ED personnel ...Patient reassessed at the bedside after 4-point restraints were removed.” There was no documentation in the record that a face-to-face evaluation of the patient was done by a provider within 1 hour of the application of the restraints. Per interview on 5/23/24 at 1:38 PM with the ED Nurse Manager, S/He confirmed that a physical hold is a restraint, that a physician’s order is required, and that there was no order documented in the record for Patient #11. S/He stated that when Ativan (Lorazepam), Haldol (antipsychotic medication), and Benadryl were used for a patient with behaviors that are violent or self-destructive those medications were considered chemical restraints. At 3:21 PM the Nurse Manager further confirmed that there was no documentation in the record that a face to face was done by a provider within one hour of restraint application for Patient #11 per the hospital policy. The Restraint and Seclusion Policy-Approved 12/14/2021, states for “ Violent or Self Destructive Restraint and/or Seclusion-Patients may be subject to Restraint and/or Seclusion, including medications used as a restraint, in emergency situations where their behavior is violent or self-destructive and jeopardizes the immediate safety of the patient, a staff member, or others, and less restrictive methods of managing the behavior would be ineffective ... MD, DO, PA-C or APRN responsibilities...Issuing an order, or declining to issue an order ...Completing a face to face evaluation ...within one (1) hour of the initiation of Violent or Self-Destructive Restraint and/or Seclusion ...Definitions...Drug used as a Restraint means where a drug is used to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patients’ condition ...Restraint means any manual method, physical or mechanical device, material, or equipment that involuntarily immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ...Methods of Restraint and Applications of Restraint...Physical Hold...A Physical Hold involves holding a patient in a manner that restricts the patient’s movement against the patient’s will. This is considered a restraint.””

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 12112 Based on interviews and policy review the CAH failed to ensure the policies for restraints/seclusion and EMTALA were reviewed and updated biennially. Findings include: 1.) Per review, the CAH’s “Restraint/Seclusion Policy” was implemented on “2/1/2002” and was last approved on “12/14/2021”. There was no documentation that shows this policy has been reviewed and/or updated since this time. Per interview on 5/23/24 at 3:10 PM with the Quality/Improvement/Risk Manager, S/He stated that the hospital’s Director of Quality left the hospital in December and that “Quality was on hold” since that time. The interim Chief Nursing Officer (CNO) stepped in to manage the quality program; however, it was at a very broad level. S/He confirmed that the CAH was aware that the restraint/seclusion policy should have been reviewed and updated and it was not done. 2.) The EMTALA (Emergency Medical Treatment and Labor Act) requires hospitals with Emergency Departments (ED) to provide a Medical Screening Examine (MSE) to any individual who comes to the ED and requests such an exam, and prohibits hospitals with an ED from refusing to examine and treat an individual with an emergency medical condition. Per review of the CAH policy Patients Seeking Care in the Emergency Department last approved on 1/15/2020, was insufficient, outdated (must be reviewed biannually) and did not reflect the necessary requirements/components necessary for the CAH ED to maintain compliance with EMTALA requirements. ED staff confirmed this was the only policy available.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 12112 Based on staff interview and record review, there was a failure of the CAH to ensure the QA/PI (Quality Assurance/Performance Improvement) was ongoing and comprehensive involving all hospital departments. Findings include: Per interview on 5/23/24 at 2:15 PM staff identified to be part of QA/PI confirmed due to staff changes in December 2023, “Quality was on hold”. Staff further stated for the past 5-6 months any CAH QA/PI activities stopped functioning leaving only limited guidance to re-establish the QA/PI program. Staff confirmed the QA/PI program was not ongoing or comprehensive as required. However, it was noted a interim QA/PI consultant had been contracted 1 day per week to assist QA/PI staff in the redevelopment of the program.”

“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: 12112 Based on interview, medical record and document review, it was determined that in 1 of 20 medical records reviewed of patients who presented to the hospital emergency department requesting medical services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide stabilizing treatment to Patient #1. Findings include: 1. See findings cited at 42 CFR 489.24 (d) (1-3)”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 12112 Based on staff and family interview and record review, it was determined that the Critical Access Hospital (CAH) failed to provide,within the capabilities of the staff and facilities available, stabilizing treatment for an emergency medical condition prior to discharge and /or transfer for 1 of 20 applicable patients (Patient #1). Findings include: On 10/15/23 at 6:45 AM Patient #1, age 80, with past medical history to include Atrial Fibrillation (cardiac arrhythmia), hypertension (elevated blood pressure) and congested heart failure (heart does not pump blood well) arrived via ambulance to the Springfield Hospital Emergency Department with a chief complaint of significant back pain which radiated down both legs. Symptoms began during the night and reports difficulty walking. Patient complained of being cold and shaky. Patient #1 confirmed s/he has a history of back pain but confirmed present pain symptoms was higher up in his/her back and more severe. Pain was rated as a “10/10”. Patient #1 was alert and oriented. B/P was elevated 150/102 (via cuff); HR 76; temp 97.6. After initial assessment, the ED Provider #1 ordered CBC (complete blood count) with Differential; Urine analysis; clotting studies and a CT scan (a computed tomography medical image). The CT scan was performed without contrast due to Patient #1’s poor kidney function. An infusion of 1000 cc of normal saline was administered and Ketorolac (a non-steroidal anti-inflammatory drug) for pain was administered IV at 7:45 AM with patient reporting to nurse at 8:30 AM only experiencing “slight improvement”. Per review of the CT scan report read by remote radiologist noted Patient #1 had small bilateral pleural effusions (build up of fluid between the tissues that line the heart and lungs) and a “...peripherally calcified splenule (a small benign nodule of a healthy spleen).... versus hematoma left upper quadrant”. Upon review of the WBC (White blood cell count) ED Provider #1 states: “Unclear etiology of symptoms. S/he does have a mildly elevated white count but no focal source of infection.” .....WBC was 13.9 (normal is 4.5 -11.0) with elevated Neutrophils 81 % (part of WBC noted to help fight infections, normal is 40-70 and elevates with possible infection). Lymphocytes (a component of WBC associated with the immune system) was decreased to 5 (normal count is 15-20). At 10/15/23 at 1:05 PM Patient #1 was discharged to home accompanied by family. Instructions were provided and Patient #1 indicated s/he understood to return to ED if an elevated temperature occurred and was reminded to stay hydrated. 10.50 hours later, on 10/15/23 at 11:58 PM Patient #1 returns to the ED via ambulance. Chief complaint is back pain which has become increasingly worse. Patient #1 also demonstrated a change in mental status, now acting confused. Per the CAH Clinical Report-Nurses states: “ Appears in pain and anxious. The patient is disoriented to person and situation.”. Upon arrival Patient #1’s temperature was 100.1. After initial assessment by ED provider #2 a repeat WBC; a head CT due to Patient #1’s decline in orientation and a CT of pelvis and lumbar spine was ordered. Once again, Patient #1 is medicated with Ketorolac 15 mg via intravenous push. The head CT results noted “no acute intracranial process” and the CT of the pelvis/abdomen showed no acute process but reconfirmed significant degenerative disc disease of the spine. The redrawn WBC results demonstrated an increase of WBC from 13.9 to 18.6; Neutrophils increased to 95 and lymphocytes had dropped to 2. Again Patient #1’s kidney function prevented a contrast material to be used during the CT scans to assist the radiologist in obtaining better views of the patient’s body. At the second ED visit on 10/15/23 ED Provider #2 diagnosed the patient with “Acute nontraumatic lumbar back pain associated with disc herniation in the lumbar spine. No radiculopathy (pinching of the nerves at the root often due to narrowing of the space in the spine) or neurological deficit”. On the morning of 10/16/23 Provider #2 reported off to Provider #3 who resumed care for Patient #1. Upon review of Patient #1’s record and discussion with family, Provider #3 states within Clinical Report-Physician/Midlevels documents “ I had considered the possibility of further imaging, MRI of the lumbar spine. Patient stated that s/he absolutely would not be able to tolerate this. We are concerned about the slight increase in her/his white blood cell count from 14-18 from her/his visit yesterday.” Despite the recognized concern for the increased white blood cell count, further work-up using the CAH’s Sepsis (a potentially life-threatening condition) Protocol was not considered. The Sepsis Protocol provides guidelines for healthcare providers which can facilitate the rapid identification and effective treatment of sepsis. Implementation of the Sepsis Protocol can include drawing Blood cultures and lactate levels. However, neither Provider #2 or Provider #3 chose to evaluate the source of the elevated WBC or screen Patient #1 further to identify symptoms of a possible infection. Per interview during the screening of this initial complaint on 5/7/24, Provider #2 informed the Surveyor, testing for lactate was not considered because the equipment that performs the blood analysis was not functioning. Per interview on 5/7/24 at 4:30 PM the Director of Laboratory Services denied the main analyzer was non-functioning and the CAH has a back up analyzer. “...it is always available”, confirming an initial lactate measurement could have been performed. Per interview on 5/21/24 at 1:05 PM Provider #3 acknowledged the elevated WBC, the fact it had “...gone up...it was worrisome”. Despite concerns, Provider #3 discharged Patient #1 home with family. Per interview on 5/21/24 at 3:30 PM the nurse who discharged Patient #1 on the morning of 10/16/23 at 10:18 AM confirmed Patient #1 was unsteady and had difficulty getting into his/her vehicle. The elderly family member who was attempting to assist the patient but was unable to transfer Patient #1 from wheelchair to the car due to Patient #1’s inability to support his/herself and ongoing pain symptoms with generalized weakness. The CAH had failed to provide appropriate screening and stabilizing treatment for Patient #1 over the course of the 2 ED visits. Subsequently, after Patient #1’s second ED discharge on 10/16/23 at 10:18 AM and due to Patient #1’s rapid health decline, once home family contacted Patient #1’s PCP. Family was informed to get Patient #1 to Dartmouth Hitchcock Medical Center (DHMC) immediately. Within approximately 2-3 hours Patient #1 was admitted to DHMC. Upon arrival at DHMC Patient #1’s temperature had increased to 103 F; pulse elevated to 150, WBC was now at 19 with the noted “left shift” (when a WBC count increases and immature Neutrophils also increase, a possible bacterial infection may be present as noted in a “left shift”). Lactate level was 4.0 (a laboratory test that can reflect infection). Patient #1 was diagnosed with Sepsis. Blood cultures drawn identified MSSA (Methicillin-resistant Staphylococcus aureus). Further testing noted a large abscess in the left iliopsoas muscle (muscle that connects the inner hip to the spine) and osteodiscitis (a spinal infection that develops between the discs in the spine) of L-3 & L-4. Patient #1 was treated urgently with antibiotics among other interventions to stabilize his/her critical condition and required hospitalization for further intensive treatment. Per the Annals of Emergency Medicine Infectious Disease/American College of Emergency Physician/ Policy Statement (July 2021) states “Early Care of Adults with Suspected Sepsis in the Emergency Department and Out of Hospital Environment” notes: “Sepsis is a major cause of hospital death in the United States.....makes sepsis and septic shock one of the highest mortality conditions treated in the ED....Sepsis care may be the most consequential during the earliest phase of treatment....” In addition, the policy statement further indicates “ Clinicians should use multiple clinical laboratory findings to detect sepsis and guide care....recommend collecting blood cultures as early as feasible...” Although the CAH ED was capable of drawing blood cultures, and despite Patient #1’s presentation, this procedure was not performed, eliminating an opportunity for further detection and screening for the diagnosis and emergent treatment of a bacterial infection resulting in acute sepsis. Per interview on 5/7/24 at 11:10 AM during initial screening of this complaint the ED Medical Director upon review of both ED admission records for Patient #1 confirmed “In retrospect, more could have been done for this patient”. The MD further acknowledged the “left shift” being identified during both admissions to the ED and noted blood cultures would have been “ ...a good idea”. Per National Institute of Health (NIH) National Library of Medicine/Journal of Clinical Laboratory Analysis September/2013 states “Combination of White Blood Cell Count and Left Shift Level Real-timely reflects a course of Bacterial Infection: Left shift indicates that an abundant Neutrophils are consumed at the site of bacterial infection....”. The CAH outdated policy Patient Seeking Care in the Emergency Department last updated on 1/15/2020 states “A Medical Screening Exam is defined by law to mean a medical history, a physical examine and diagnostics evaluation sufficient to determine if an emergent medical condition exists.” There was a lack of diagnostic evaluation and appropriate stabilization of the individual who arrived twice to the ED seeking treatment for an emergent medical condition but was twice discharged prior to receiving necessary intervention, resulting in critical symptoms of sepsis warranting acute intervention.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 45670 Based on a walkthrough of the premises on 11/7/23 with the Director of Engineering, survey activities determined that: It could not be determined if the hydraulic passenger elevator is provided with a sprinkler within 24 inches of the sprinkler pit, as required for a total protection sprinkler system by the Vermont Elevator Rules and ASME A17.1 (2013).”