Prov Sacred Hrt Med Ctr & Childs Hosp.

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47565 . Based on observation, interview, and document review, the hospital failed to ensure that patients were provided care in a safe environment, free from self-harm. Failure to protect patients from self-harm places patients at risk for serious physical harm and death. Findings included: Failure to implement effective policies and procedures to care for suicidal patients, keep suicidal patients safe, and prevent patient elopement. Cross Reference: A-0144 Due to the severity of deficiency under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET. .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47565 . Item #1 Suicide Monitoring Based on observations, interviews, and record reviews, the hospital failed to appropriately monitor and prevent patient elopement for 1 of 1 patients reviewed (Patient #1). Failure to ensure care in a safe environment by monitoring and preventing the elopement of suicidal patients risks violation of patient rights, serious injury, or death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Suicide Screening and Risk Mitigation in Non-Psychiatric Departments,” PolicyStat ID 16083101, last approved 11/20/24, showed the following: a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider. b. All patients who are identified as low risk for suicide must have close observation. c. All patients who are identified as moderate risk must have a constant observer. d. All patients who are identified as high risk must not be left alone, and a 1:1 observer will be initiated. e. To decrease monitoring levels to close observation or no observation, a mental health professional, attending physician, or licensed provider must assess and document their recommendation for the reduced monitoring. f. The nurse will complete the C-SSRS daily shift screen for patients who were previously low, moderate, or high risk at least twice each calendar day. Document review of the hospital’s patient handout titled, “Patient Rights and Responsibilities,” last revised 01/13/25, showed that all patients have the right to receive care in a safe setting. 2. Investigator #1, Investigator #2, the Quality Assurance Registered Nurse (Staff #101), and the Director of Women’s and Children’s Services (Staff #102) reviewed Patient #1’s medical record. The review showed the following: a. On 02/25/25 at 7:15 PM, Patient #1 returned to the Emergency Department (ED) 2 hours after discharge from a previous hospitalization for an intentional overdose of 72 prescription fluoxetine (a medication used to treat depression) pills. At 8:16 PM, the Columbia Suicide Severity Rating Scale (C-SSRS) showed that the patient was at high risk for suicide. A 1:1 observer was initiated, and the provider was notified. On 02/26/25 at 9:50 AM, the patient was evaluated by a psychiatrist who documented that the patient needed around-the-clock supervision. On 02/26/25 at 7:41 PM, the patient was assessed by a pediatric hospitalist who admitted the patient and ordered a 1:1 observer. The patient was admitted to a dedicated behavioral health room with a 1:1 observer on the 3-South Pediatric unit on 02/26/25 at 8:21 PM. b. On 03/07/25 at 1:00 PM, the patient self-harmed by hitting their head against the wall and punching themselves in the face. On 03/10/25 at 12:15 PM, the patient ran past their 1:1 observer, out of the unit, and into an elevator where the patient began cutting their arm and neck with a tack before hospital staff stopped the patient. On 03/11/25 at 10:44 PM, the patient attempted to stab themselves in the eye after taking supplies from a cart. On 03/12/25, the patient was observed attempting to remove curtain hooks from the ceiling. On 03/13/25, the patient made statements of running away and self-harm, then punched themselves in the head and tried to stab themselves in the eye with a power plug. That same day, remote visual monitoring began and continued concurrently with the 1:1 observer. c. On 03/17/25, the patient made multiple statements about wanting to leave, attempted to walk out of their room, and when stopped by the nurse, they tried to grab items from the nurse’s pockets. The patient then threatened to jump from their bed. Later that same day, the patient unplugged their remote visual monitor and made statements of wanting to stab themselves in the eye, threatened to punch their 1:1 observer, and ended up spitting on their 1:1 observer. On 03/19/25, the patient was showering and was observed shoving a shower cap down their throat until they coughed it out. On 03/26/25, the patient was observed writing a note that stated they would make everyone think they were okay and not depressed, then hang themselves, cut their veins, or jump off a high building. d. On 04/04/25, documentation showed that the remote visual monitoring was discontinued; however, there was no evidence of a provider or mental health provider assessment or documentation of recommendations for the reduced monitoring. e. On 04/08/25, documentation showed that the 1:1 observation was discontinued; however, there was no evidence of a provider or mental health provider assessment or documentation of recommendations for the reduced monitoring. f. On 04/09/25, nursing notes showed that the patient was found standing on the counter in their room and made statements of feeling isolated, lonely, and confined. The patient remained shut in the room with no call light or television remote and few personal belongings. g. Security footage showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:46 PM, security footage showed the patient on the 4th level of the hospital parking garage. Security reports showed that at 6:03 PM, security officers located the patient, and immediately after, the patient was observed jumping over the edge of the parking garage. The patient suffered non-survivable injuries and died 2 hours later in the hospital ED. 3. On 04/28/25 at 4:55 PM, Investigator #1 interviewed Staff #102. Staff #102 stated that the discussion to discontinue Patient #1’s 1:1 observation did not include the leadership of the unit. 4. On 04/28/25 between 3:25 PM and 4:15 PM, Investigator #1 interviewed pediatric nurses who were involved in Patient #1’s care (Staff #103, #104, and #105). Staff #103, Staff #104, and Staff #105 all stated that they were concerned about the discontinuation of Patient #1’s 1:1 observation and were not included in the decision-making process to discontinue the 1:1 observation. Staff stated that nursing staff and security staff implemented a door alarm to alert them if the patient attempted to exit their room. 5. On 04/30/25 at 9:30 AM, Staff #101 and Staff #102 confirmed the investigators’ findings of the missing provider or mental health professional assessments and documented recommendations for Patient #1’s reduced monitoring levels on 04/04/25 and 04/08/25. Item #2 Missing Child Alert Based on interviews, record reviews, and policy review, the hospital failed to implement policies and procedures to ensure staff notified security dispatch immediately following the discovery of a missing pediatric patient at high risk for suicide for 1 of 1 patients reviewed (Patient #1). Failure to activate emergency responses without delays puts patients at risk for physical and psychological harm, potential adverse outcomes, or death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Missing Child (previously known as Amber Alert),” PolicyStat ID 18044172, last approved 04/28/25, showed the following: a. The missing child alert system is a hospital-wide overhead page to alert staff of a potential missing or abducted child or actual missing or abducted child. b. Upon discovery of a missing child, staff will call the security dispatch number and identify that there is a missing child and the location. Security will notify the operator who will overhead page “Missing Child.” c. If a description of the missing child is available, the operator will overhead page the descriptors and a house-wide search will begin. d. All available staff throughout the hospital will immediately check all adjacent main hallways and exit areas to and from their department or unit. Staff will remain at the exits and observe for anyone who is accompanied by a child or anyone attempting to leave the building with a child. 2. The investigators reviewed the medical record of Patient #1. The review showed the following: a. On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit as a social admit while waiting for suitable placement with around-the-clock supervision. The patient had episodes of attempts at self-harm or actual self-harm on 03/07/25, 03/10/25, 03/11/25, 03/13/25, 03/17/25, and 03/19/25. b. On 03/10/25, the patient attempted to elope from the hospital. On 03/13/25 and 03/17/25, the patient made statements and threats of eloping from the hospital. c. On 03/26/25, the patient had written a suicide plan that stated they would make everyone think they were okay and not depressed, then hang themselves, cut their veins, or jump off a high building. 3. The investigators reviewed security documents and video of Patient #1’s elopement from the hospital. The review showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:34 PM, nursing staff noted that Patient #1 was not in their room. At 5:44 PM, 11 minutes later, a “Missing Child” alert was activated. At 5:46 PM, security footage showed Patient #1 on the 4th level of the hospital parking garage. At 6:03 PM, security officers located the patient in the garage and witnessed Patient #1 jump off the edge and fall from the 4th floor to the ground. The patient was transported to the ED and was pronounced dead 2 hours later. 4. On 04/28/25 at 4:25 PM, Investigator #1 interviewed a pediatric nurse (Staff #105). Staff #105 stated that multiple caregivers and other members of Patient #1’s treatment team would often take the patient for walks or to the gym without communicating this to the patient’s nurse. Staff #105 stated that the delay in activating the “Missing Child” alert occurred because 3-South pediatrics staff believed the patient was with another staff member, so they checked the unit before activating the alert. Item #3 Columbia Suicide Severity Risk Scale (C-SSRS) Based on interviews, record reviews, and policy review, the hospital failed to ensure staff completed focused nursing assessments for 4 of 8 patients who were identified to have suicidal ideation (SI) during their hospitalization (Patients #1, #2, #3, and #4). Failure to perform focused suicide risk assessments places patients at risk for inadequate monitoring, poor outcomes, physical harm, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Suicide Screening and Risk Mitigation in Non-Psychiatric Departments,” PolicyStat ID 16083101, last approved 11/20/24, showed the following: a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider. b. The nurse will complete the C-SSRS daily shift screen for patients who were previously low, moderate, or high risk at least twice each calendar day. 2. The investigators reviewed the medical records of 4 discharged and 4 current patients. The review showed the following: Patient #1 On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. A C-SSRS was completed at 8:16 PM and showed high risk for suicide. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit as a social admit while waiting for suitable placement with around-the-clock supervision. On 04/13/25 at 5:30 PM, the patient eloped from the hospital and ended their life by jumping off the 4th story of the hospital’s parking garage. Between the patient’s admission time and the time of their elopement from the hospital, the patient was missing 64 out of 92 C-SSRS screenings. Patient #2 On 04/18/25 at 10:31 PM, Patient #2 was admitted to the neurology unit after a suspected seizure. The patient was assigned a 1:1 observer for behavioral reasons. The patient did not receive an initial C-SSRS admission screening until 04/22/25 at 9:15 AM, when they scored low risk. On 04/27/25, the patient scored a moderate risk. Between the patient’s admission time and 04/29/25, the patient was missing 18 out of 21 C-SSRS screenings. Patient #3 On 03/14/25 at 3:59 PM, Patient #3 was admitted to the intensive care unit after a suicide attempt by intentional overdose. At 9:13 PM, the patient received their initial C-SSRS admission screening and scored as a high risk. Between the patient’s admission time through 04/29/25, the patient was missing 88 out of 88 C-SSRS screenings. Patient #4 On 04/18/25 at 1:55 PM, Patient #4 was admitted to the hospital for medical reasons. On 04/18/25 at 2:27 PM, the patient received their admission C-SSRS screening and scored as a moderate risk. Remote visual monitoring was initiated immediately and continued through 04/29/25. Between the patient’s admission time through 04/29/25, the patient was missing 1 out of 22 C-SSRS screenings. 3. At the time of the review, the Quality Assurance Registered Nurse (Staff #101) and the Director of Women’s and Children’s Services (Staff # 102) confirmed the missing C-SSRS screenings. Staff #102 stated that the hospital expects that patients at risk for suicidal ideation receive 2 daily C-SSRS screenings. Item #4 MD Assessment/Justification Based on interviews, record reviews, and policy review, the hospital failed to ensure providers assessed and documented their recommendation for downgrading suicidal monitoring for 2 of 8 patients who were identified to have suicidal ideation (SI) during their hospitalization (Patients #1 and #3). Failure to perform assessments and provide recommendations for downgrading monitoring places patients at risk for inadequate monitoring, poor outcomes, physical harm, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Suicide Screening and Risk Mitigation in Non-Psychiatric Departments,” PolicyStat ID 16083101, last approved 11/20/24, showed the following: a. The Columbia Suicide Severity Rating Scale (C-SSRS) screening tool will be completed on admission for all patients 12 and older by nursing staff or a licensed provider. b. All patients who are identified as low risk for suicide must have close observation. c. All patients who are identified as moderate risk must have a constant observer. d. All patients who are identified as high risk must not be left alone, and a 1:1 observer will be initiated. e. To decrease monitoring levels to close observation or no observation, a mental health professional, attending physician, or licensed provider must assess and document their recommendation for the reduced monitoring. Patient #1 2. Investigators reviewed hospital documents, security video, and the medical record for Patient #1. The review showed the following: a. On 02/25/25 at 7:15 PM, Patient #1 returned to the ED 2 hours after discharging from a previous hospitalization due to a suicide attempt by intentional overdose of fluoxetine. At 8:16 PM, the Columbia Suicide Severity Rating Scale (C-SSRS) showed that the patient was at high risk for suicide. A 1:1 observer was initiated, and the provider was notified. On 02/26/25 at 9:50 AM, the patient was evaluated by a psychiatrist who documented that the patient needed around-the-clock supervision. On 02/26/25 at 7:41 PM, the patient was assessed by a pediatric hospitalist who admitted the patient and ordered a 1:1 observer. On 02/26/25 at 8:21 PM, the patient was transferred to the 3-South pediatric unit. b. On 03/13/25, the patient made statements of running away and self-harm, and then punched themselves in the head and tried to stab themselves in the eye with a power plug. That same day, remote visual monitoring began and continued concurrently with the 1:1 observer. c. On 04/02/25, the last documented medical provider assessment, a pediatric hospitalist note showed that the plan was to continue suicide and self-harm precautions. d. On 04/04/25, documentation showed that the remote video monitoring was discontinued; however, there was no evidence of a provider or mental health provider assessment and no documentation of recommendations for the reduced monitoring. e. On 04/08/25, a pediatric psychiatrist’s note showed that the patient acknowledged that they lacked the full ability to manage their suicidal and self-harm thoughts and behaviors without restrictive measures and close supervision around their triggers. The provider documented that the patient’s family was not able to provide appropriate supervision of the patient, and the plan was to continue pursuing long-term residential treatment. f. On 04/08/25, documentation showed that the 1:1 observation was discontinued; however, there was no evidence of a provider or mental health provider assessment and no documentation of recommendations for the reduced monitoring. Nursing staff and security staff implemented a door alarm to alert them if the patient attempted to exit their room. g. Security footage showed that on 04/13/25 at 5:30 PM, the patient walked off the unit and entered the elevator. At 5:34 PM, nursing staff noted that Patient #1 was not in their room, and after an 11-minute delay, a “Missing Child” alert was activated. At 5:46 PM, security footage showed Patient #1 on the 4th level of the hospital parking garage. At 6:03 PM, security officers located the patient in the garage and witnessed Patient #1 jump off the edge and fall from the 4th floor to the ground. The patient was transported to the ED and was pronounced dead 2 hours later. Patient #3 3. Medical record review showed that on 03/14/25 at 3:59 PM, Patient #3 was admitted to the intensive care unit after a suicide attempt by intentional overdose. At 9:13 PM, the patient received their initial C-SSRS admission screening and scored as a high risk. No mitigating interventions were initiated until a 1:1 observation order was placed for impulsive behavior on 03/17/25 at 10:33 AM. On 03/18/25 at 8:12 AM, the 1:1 observer was pulled for other duties and did not resume until 7:00 PM that same day. There was no evidence of a provider or mental health provider assessment, and no documentation of recommendations for the reduced monitoring. On 03/22/25 at 8:45 AM, the 1:1 observer was discontinued, and remote visual monitoring was started. There was no order for the downgrade, no evidence of a provider or mental health provider assessment, and no documentation of recommendations for the reduced monitoring. On 03/24/25 at 3:35 PM, the 1:1 observer order was discontinued by a nurse. 4. On 04/30/25 at 9:30 AM, the Quality Assurance Registered Nurse (Staff #101) and the Director of Women’s and Children’s Services (Staff #102) verified the missing provider assessments and documentation.”

“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: 43837 . Based on interview, review of hospital policies and procedures, and document review, the hospital failed to implement policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to ensure patients receive a comprehensive medical screening examination (MSE) by a qualified medical professional risks poor health outcomes, injury, and death. Findings included: The hospital failed to provide evidence that 1 of 25 patients received medical screening examinations when they presented for emergency care. Cross Reference Tag #2406 .”

“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: 43837 . Based on interview, review of hospital policies and procedures, and document review, the hospital failed to implement policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 25 patients who presented for emergency care. Failure to ensure patients receive a comprehensive medical screening examination (MSE) by a qualified medical professional risks poor health outcomes, injury, and death. Findings included: 1. Review of the hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA), number 14592163, effective date 11/14/23, showed that a physician, advanced registered nurse practitioner (ARNP), or physician’s assistant (PA) provides an appropriate medical screening examination to all individuals seeking emergency services. 2. Medical record review for the index patient showed that the patient arrived via ambulance on 07/28/24 at 11:21 PM, with a chief complaint of rectal bleeding and dizziness. The ambulance run sheet showed that the patient had stated that he had been drinking alcohol and smoking marijuana, and had “Mexies” (fentanyl) in his pocket. The ambulance run sheet showed that the patient was alert and oriented to person, place, time, and situation with a heart rate of 102, blood pressure of 149/54, and respiratory rate of 16 at 10:57 PM. Emergency Department (ED) triage notes showed that the patient arrived by ambulance with complaint of rectal bleeding associated with dizziness. Security was notified for a safety search in triage at 11:21 PM, but at 11:22 PM, the patient refused a safety search and was escorted out by security. There was no documentation of a medical screening examination (Patient #18). 3. On 09/05/24 at 1:45 PM, during medical record review, the Director of the ED (Staff #1) verified that there was no documentation of a medical screening examination completed for Patient #18. .”

“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: 38532 . Based on observation, interview, and document review, the hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse accountable for the quality of nursing care provided to its patient’s places patients at risk for inconsistent or inadequate care, adverse outcomes, and death. Findings included: 1. The hospital failed to ensure that Providence Sacred Heart Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the services and the quality of the patient care provided by nursing services. Cross Reference: A0386 .”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 38532 . Based on interview and document review, the hospital failed to ensure that Providence Sacred Heart Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the service and the quality of the patient care provided by nursing services. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death. Findings included: 1. Document review of the hospital’s organizational chart titled, “Inland Northwest Washington Organizational Chart,” no date, showed the following: a. Departments including Acute Care, Critical Care/Telemetry, Emergency Services, Trauma Services, and Women & Children’s report through the Sacred Heart Chief Nursing Officer included: b. Perioperative Services report through the Chief Operating Officer (Staff #517) for Holy Family Hospital (a separately licensed and certified hospital). c. Transplant Services and the Heart Institute report through the Chief Medical Officer for Inland Northwest Service Area (Staff #514). d. Cardiovascular Procedural Services and Perioperative Services-Director report to the Executive Director of Perioperative Services (Staff #518). Staff #518 reports to the Chief Operating Officer at Holy Family Hospital (Staff #517) (a separately licensed and certified hospital). Document review of the Transplant Hospital’s organizational chart titled, “Organizational Chart,” no date, showed that Transplant services and staff report through the Chief Medical Officer (Staff #514). 2. On 07/10/24 at 9:00 AM, Surveyor #5 interviewed the Clinic Nurse Manager (Staff #505) related to oversight and administrative structure for the Transplant Program. At this time, Staff #505 stated that the outpatient clinics were under oversight of Providence Medical Group, and she reported to the Transplant Program Director (Staff #513) who was employed by Providence Medical Group and reported to the Chief Medical Officer (#514). She stated that the Transplant program oversight was provided by the Chief Medical Officer Staff (#514). Staff #505 verified there was no contract or agreement as they were all Providence Employees. 3. On 07/10/24 at 11:00 AM, Surveyor #5 and the Sacred Heart Medical Center Chief Nursing Officer (Staff #514) reviewed the Inland Northwest Washington organizational chart provided to the Surveyor and the Transplant Hospital organizational chart and discussed oversight of Nursing Services by staff providing care to patients at Sacred Heart Medical Center and Children’s Hospital (PSCMC) including the Transplant Program. 4. At the time of the review, Staff #514 verified that the Transplant Program nursing staff are employees of PSCMC, but that the Transplant Program Manager (Staff #513) is an employee of Providence Medical Group, and oversight of Providence Medical Group is provided by the Chief Medical Officer (CMO) who is the CMO for the Service Area. Staff #514 stated that Staff #513 evaluated the nursing care by staff providing care at the Transplant Center. Staff #514 verified that he was not on the organizational chart reporting or oversight structure for the transplant hospital. Surveyor #5 found no evidence that Sacred Heart Medical Center and Children’s Hospital operated with one nursing service hospital-wide under the direction of one Registered Nurse. 5. On 07/11/24 at 10:00 AM, during interview with Staff #514, Surveyor #5 noted that organizational chart showed that Perioperative Services reported through the Chief Operating Officer (Staff #517) at Holy Family Hospital a separately licensed and certified hospital. 6. At this time, Staff #514 verified that Perioperative Services at Sacred Heart Medical Center and Children’s Hospital (Preoperative, Intraoperative, and Postoperative Services/Care), Cardiac Cath Lab, Interventional Radiology, Electrophysiology lab, and Endoscopy report up through the Chief Operating Officer at Holy Family Hospital (a separately licensed and certified hospital). Surveyor #5 found no evidence that Sacred Heart Medical Center and Children’s Hospital operated with one nursing service hospital-wide under the direction of one Registered Nurse. 7. On 08/01/24 at 12:00 PM, during interview with Surveyor #5, Staff #514 verified that the organizational chart provided to the Surveyor showed organizational flow for the Inland Northwest Washington service area which included Sacred Heart Medical Center and Children’s Hospital, St Lukes Rehabilitation Medical Center, and Holy Family Hospital. Staff #514 stated that the Chief Executive Officer (Staff #519) provided oversight for the Inland Northwest Washington Service area. .”