Community Memorial Hospital

“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: 34337 Based on record review and interview, facility staff failed to ensure the quality of medical care provided to patients in 1 of 1 medical staff reviewed (Hospital Medical Staff). Findings include: Medical staff failed to identify and treat signs and symptoms of cardiogenic shock and failed to implement consultative recommendations for 1 of 1 patient (Patient #1). See tag A347.”

“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: 52395 Based on record review and interview, hospital staff failed to appropriately screen and implement interventions to prevent sepsis deterioration in 1 (Pt. #1) of 6 patients identified as high sepsis risk, failed to call a rapid response when criteria was met for 1 (Pt. #1) of 1 patient medical records reviewed, failed to notify the physician of abnormal vital signs in 1 (Pt. #1) of 17 medical records reviewed and failed complete a comprehensive admission assessment in 1 (Pt.#1) of 17 medical records reviewed. Failure to identify and respond to changes in condition may have contributed to Patient #1’s deterioration in status and subsequent cardiac arrest. Findings include: Facility staff failed to assess vital signs, failed to implement physican orders, failed to identify sepsis symptoms and failed to notify the physcian of abnormal findings according to policy and protocol. See tag A-395.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to follow their policy in responding to 1 of 6 patient grievances reviewed (Patient #1). Findings Include: A review of the facility policy #201 last reviewed 10/31/2024 titled, “[Facility Name] Patient Safety Patient Grievance Reporting and Investigation Policy,” revealed, “A grievance is a written or verbal Complaint...by a patient or the patient’s representative regarding the patient’s care...A grievance requires a written response to the patient in accordance with this policy...Procedure:...Handling of Grievances:..Centers for Medicare & Medicaid Services (CMS) guidelines mandate that Grievances be resolved within 7 days unless the Grievance is considered complex...Acknowledge Receipt of Grievancs via letter or phone call to the complainant within 7 calendar days...Draft a Grievance resolution letter to include the following:..Date of completion;...Writer’s name and phone number as the contact person;..Steps taken to investigate the Grievance..Investigation results (e.g., findings, what was done/will be done to avoid the issue in the future);...An apology notation...If final resolution is not met within 30 calendar days, continue to update complainant on a regular basis of investigation status and document.” On 05/06/2026 at 8:20 AM a review of Pt. #1’s safety event with Quality Director O revealed the facility had received a voicemail from Pt. #1’s family on 02/26/2026 expressing concerns over the care their son had received and requested answers. Ongoing review of this grievance revealed all requests for information regarding this grievance were initiated by the family. There was no evidence of a letter being sent to the complainant An interview was conducted with Pt. Relations Director P on 05/06/2026 at 11:40 AM. When Pt. Relations Director P was asked if it was correct that the complainant for Pt. #1 did not receive a formal letter acknowledging their complaint and did not receive a formal letter after 30 days that the investigation was ongoing, P stated, “Correct.””

“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: 34337 Based on record review and interview, facility staff failed to identify clinical escalation of cardiogenic shock based on diagnostic findings and failed to implement medical recommendations for 1 of 1 patient presenting with cardiogenic shock (Patient #1) in a total sample of 17 patients reviewed. Findings include: Per medical record review, Patient #1 presented to the Emergency Department (ED) with nausea, vomiting and abdominal pain. An ECG was resulted at 6:50 AM: ECG 12-lead... “EKG Diagnosis: Sinus Tachycardia (fast heart rate)...**Acute MI/STEMI*** Abnormal ECG When compared with ECG of 11-Feb-2024 15:03, QRS duration has decreased, Acute Septal infarct is now Present” A repeat ECG revealed: “ECG 12 lead in Process: Collected 12/25/2025 09:46 AM... EKG Diagnosis: Sinus Tachycardia... consider pulmonary disease, pericardial effusion or normal variant ST elevation consider Inferolateral injury or acute infarct ***Acute MI/STEMI*** Abnormal ECG when compared with ECG of 25 Dec-2025 06:31, No significant change was found” Review of Patient #1’s medical record revealed the following out of range laboratory results on 12/25/2025 at 7:00 AM: elevated WBC (14.2), elevated BUN (27), elevated creatinine (1.53), hyponatremia (130), low Chloride level (94), low CO2 (19), and elevated anion gap (17) indicating metabolic acidosis. An elevated Troponin (test indicating heart muscle damage) of 67 was resulted on 12/25/2025 at 8:46 AM. Review of Patient #1’s “Admission History & Physical” filed on 12/25/2026 at 11:56 AM by Hospitalist N revealed, “In the ED, he was found to be influenza positive. Because he reported feeling presyncope, EKG and high sensitivity cardiac troponin were obtained with concern subsequently raised for pericarditis/myocarditis after obtaining these studies... Will obtain formal echocardiogram to further evaluate suspicion of pericardial fluid seen on point-of-care studies performed in the emergency department.” Patient #1 was admitted as an inpatient on 12/25/2025 at 11:43 AM. A review of Patient #1’s admission physician orders by Hospitalist N on 12/25/2025 at 11:37 AM, revealed a consult to cardiology. Review of Patient #1’s ultrasound on 12/25/2025 at 11:57 AM revealed an ejection fraction of 22% (critical measurement to evaluate how efficiently the heart is working - normal range is 50%-70%). Review of Patient #1’s “Cardiology Consultation” on 12/25/2025 filed at 3:37 PM by Cardiologist BB revealed recommendations for cardiac MRI, low dose beta blocker, heparin drip, and strict I/O’s. “ ... I/O’s: No intake or output data in the 24 hours ending 12/25/2025 15:22...” Review of Patient #1’s medical record did not include orders for a cardiac MRI, heparin drip or I/O’s. A review of Patient #1’s medical record inpatient timeline for 12/25/2025 revealed the following: 11:43 AM: Arrival to unit 11:57 AM: Echocardiogram (ultrasound of the heart) ordered -EF (Ejection Fraction-blood flow) 22% “...There is severe left ventricular systolic dysfunction (left side of heart not working properly)...” 1:21 PM: Flow sheet- Tachycardic (fast heart rate). 2:33 PM: Flow sheet- Provider notification: tele monitoring page, waiting for response. 2:39 PM: back pain “4” Tylenol 1000 mg given, no reassessment. 3:52 PM: BP 104/72, Pulse 143, Resp 23, Temp 96.5 F, SpO2 87% 3:56 PM: rechecked SpO2 93% on 2 L O2. 4:35 PM: BP 152/77, Pulse 132, Resp 23, Temp 96.8 F, SpO2 95% (on 2 L o2). 5:36 PM: BP 100/60, Pulse 147, Resp 20, Temp 97.7 F, SPO2 not documented., Chest pain “4.” 5:31 PM: Tele monitoring order placed by charge nurse. 5:37 PM: EKG revealed flutter Pericarditis. 5:39 PM: Flow sheet “change in status” “page” waiting response.” 5:39 PM: EKG completed for chest pain (Ventricle rate 155, atrial rate 156) “Sinus tachycardia ...abnormal EKG.” 0.4 mg Nitro SL (sublingual-under the tongue for chest pain) tablet 5:42 PM: RRT (Rapid Response Team) called to bedside. 6:05 PM: CODE BLUE (heart stopped beating) called, CPR (cardiopulmonary resuscitation) started and continued using ACLS guidelines, Lucas device (automatic compression) used during code. 7:42 PM: Ambulance arrival for transport 7:52 PM: Transferred to facility #2 using Lucas device. Time of Death: 9:19 PM at facility #2 Review of Patient #1’s “Hospital Cardiogenic Shock/ECMO (Extracorporeal Membrane Oxygenation - life-support therapy for patients with severe, life-threatening heart or lung failure) Referral Intake Review” on 12/25/2025 on 6:57 PM by RN DD, ECMO Coordinator: “History of Present Illness: Influenza A, myocarditis... Coded on floor. Was ST (sinus tachycardia - fast heart rate) most of the day in 120-130’s, shock most of the day. IABP (intra-aortic balloon pump) will be emergently placed at bedside. Pt. actively coding again.” During an interview on 5/6/2026 at 11:00 AM with ED MD Y, when asked about the STEMI notification on the EKG, ED MD Y stated, “it was not a STEMI pattern, and we compared it to the previous EKG and there was no change.” ED MD Y stated “This patient could have pericarditis or myocarditis, no ischemia and was tachy (fast heart rate), the bedside ultrasound showed pleural effusions and had inflammatory markers so that is why I recommended admission.” During an interview on 05/05/2026 at 2:05 PM when asked about the recommendations from cardiology, Hospitalist N stated he ordered the beta blocker to start at 9 PM that night and didn’t think the patient needed a heparin drip (fast acting blood thinner) so he ordered Lovenox (alternate blood thinner). During an interview on 05/06/2026 at 1:19 PM, Patient Safety Officer Q and Quality Assurance Director O stated that the facility is developing an algorithm for persistent tachycardia and presented a case on 5/5/2026 to grand rounds on atypical cardiogentic shock. Officer Q and Director O went on to state this case “did go to peer review and the standards of care were met....and on March 9th it was reviewed by the complaints and grievance committee and identified that there was no actual or potential harm.” There was no additional information provided as to how the conclusion was made that there was no actual or potential harm, or information regarding the reasons corrective actions were identified despite the internal review conclusion that all standards of care were met.”

“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: 52395 Based on record review and interview, hospital staff failed to appropriately screen and implement interventions to prevent sepsis deterioration in 1 (Patient #1) of 6 patients identified as sepsis risk out of 17 medical records reviewed and failed to implement sepsis protocol for 1 (Pt. #1) of 6 patients in a total sample of 17 patient medical records reviewed, failed to call a rapid response when criteria was met for 1 (Pt. #1) of 1 rapid responses reviewed, failed to notify the physician of abnormal vital signs in 1 (Pt. #1) of 17 medical records reviewed and failed to complete a comprehensive nursing admission assessment in 1 (Pt.#1) of 17 medical records reviewed. Findings Include: Review of the facility’s policy, “Inpatient RN [Registered Nurse] 4 Hour Telemetry Protocol Order,” # 4992 last review date:12/19/2025 revealed, “Purpose statement: To permit authorized personnel to initiate timely and necessary care for patients presenting for telemetry monitoring pending provider orders... authorized personnel... Registered Nurse... Protocol 1. Place patient on telemetry for up to four hours. 2. Notify provider with any NEW onset dysrhythmia 3. Notify provider for heart rate greater than 120 or less than 50...” Review of the facility’s standards of care, “[Facility Name] Inpatient Acute Care Standards of Nursing Care,” approved on 5/14/2025 revealed, “These standards have been created to set the minimum standard of nursing care that all patients will receive while admitted to an inpatient acute care unit. ...Admission: Full Assessment, Vital Signs (Includes Temp, Pulse (heart rate, RR (respiratory rate), BP (blood pressure) and SPO2 (pulse ox- percentage of oxygen in blood): Upon arrival ... Documentation: Document a Smart text “RN IP admission note P2” on arrival.” Review of the facility’s policy, “Nursing Inpatient Admission Work,” #1925, last review date 04/24/2025 revealed, “RN...responsibilities: 1. Upon patient arrive [sic] to the inpatient area: b. evaluate the patient for immediate physical and safety needs...c. Obtain vital signs...3. Complete Head-to-toe Assessment...d. Document an admission note...” Review of the facility’s “Rapid Response Team Policy, “#2811 last reviewed date on 03/22/2025 revealed, “...Procedure A. Activate a Rapid Response... when any of the following criteria are present...1. a. Respiratory rate <8 or >28... b. Heart Rate <70 or > 130... other acute changes in urine output <50 ml in 4 hours...” Review of the facility’s policy, “MCU Admission Policy. “#2623, last review date on 10/21/2025 revealed, “Description: The modified care unit provides individualized care with the level of observation appropriate for the acutely ill patient...Type of patients to be admitted: 1. Patients requiring close observation appropriate to the acute phase of illness or recovery from acute illness... 4. Complex cardiovascular and neurological patients (MI (heart attack), CHF (congestive heart failure), Pacemaker, cardiovascular surgeries, cardiovascular diagnostic procedures... “ 6. Patients unable to be managed elsewhere due to the need for: a. close observation appropriate to patient condition...” Review of the facility’s “Sepsis Adult Inpatient Flowchart” dated 12/14/2014 revealed, “Confirmed or suspected infection plus at least two of the following signs and symptoms: Temperature >100.9 or < 96.8 F (degree Fahrenheit), HR (heart rate) >90 bpm (beats per minute), Respiratory Rate > 20, WBC >12,000: Yes Infection + 2 SIRS = Sepsis...Ensure: Vital sign assessment every 1-2 hours x4, then reassess... Is there is organ dysfunction or tissue hypoperfusion?... Organ dysfunction or tissue hypoperfusion: At least one sign?... Renal Urine output < 05 ML/KG/hr... Labs and Tests: Renal Creatinine > 2.0...if yes = Severe Sepsis...” A review of Patient #1’s sepsis screen on 12/25/2026 revealed: 05:54 AM: BP 119/89, Pulse 139, Resp 24, Temp 98.8 F 05:56 AM: “ED Triage Notes:...sick since Sunday with what he describes is coughing/ Headache/ fever (flu symptoms) ...” 6:02 AM: “Sepsis Screen Confirmed or suspected infection “No” SIRS variables “none noted “,[sic] positive sepsis screen: “NO” 6:24 AM CBC with Diff resulted: WBC 14.2 e3/uL [Ref Range: 4.0-10.0] 11:08 AM “ED Notes: Nursing Admission Handoff Report, Admitting Diagnosis: Viral myocarditis ... Influenza A, AKI (acute kidney injury), vomiting ...” 1:17 PM: “Sepsis screen: Confirmed or suspected infection “No” SIRS variables “none noted “,[sic] positive sepsis screen: “NO” Per the facility’s sepsis protocol and policies, Patient #1’s labs and vitals met the criteria for further workup and treatment of sepsis. Review of Patient #1’s admission physician orders by MD N on 12/25/2025 at 11:37 AM, revealed multiple orders for medications to treat nausea and pain, orders for fluid and electrolyte replacement, lab and imaging tests and a consult to cardiology. MD N ordered, “Notify Provider: Systolic BP less than 90 or greater than 180, Heart rate greater than 120 or less than 40, Respiratory rate greater than 24 or less than 8. Pulse Oximetry routine every 8 hours.” During an interview on 5/5/2026 at 9:36 AM with ED RN L when asked how patients are screened for sepsis, ED RN L stated, “It starts in triage if there is a suspected infection. If there is suspected infection triage nurse would flag yes, then if they meet criteria for heart rate, respiratory rate or fever, they would also flag yes. The WBC is usually the last component and the primary nurse should be doing that once it is resulted.” When asked about how the next RN knows if they need to complete the sepsis screen, ED RN L stated, “EPIC flags it so is shows up yellow until it is completed, if it is past due, it is red, which alerts us that it still needs to be done.” During an interview on 05/5/2026 at 12:53 AM with ED Manager M when asked what the criteria is for SIRS, ED Manager M stated, “They follow what is in EPIC...temperature greater than 100 or less than 96.8, pulse greater than 90, respiratory rate greater than 20, and WBC greater than 12.” A review of Patient #1’s vital signs that met rapid response criteria revealed: 05:54 AM Pulse 139 07:24 AM Pulse 142 and Resp 41 08:08 AM Pulse 136 09:02 AM Pulse 135 Resp 29 09:46 AM Resp 27 11:43 PM-3:52 PM (none) 3:52 PM Pulse 143, SpO2 87% 4:00 PM BP Pulse 132 A review of Patient #1’s medical record nursing assessments flow sheet revealed: The first set of vital signs on MCU was taken at 3:52 PM (4 hours and 9 mins after arrival): BP 104/72, Pulse 143, Resp 23, Temp 96.5 F, SpO2 87% and 2 L of O2 were placed as an intervention. There is no no evidence of physician notification of patient condition (abnormal vital signs). There was no evidence of an initiation of a rapid response when Pt. #1 met the rapid response criteria according to facility protocol. Telemetry 4 hours standing orders were not initiated when patient arrived to unit. During an interview on 05/5/2026 at 11:37 AM with MCU Manager N when asked what needs to be done when a patient is admitted to MCU from the ED, MCU Manager N stated, “Admission note, vital signs, assessment and screenings.” When asked why this wasn’t done on Patient. #1 she stated, “It should have been, I followed up with the nurse.” During an interview on 05/06/2026 at 08:19 AM with RN X (who admitted Pt. #1). When asked why Patient #1’s vitals weren’t taken on admission and were taken over 4 hours after admission, RN X stated that he attempted to get vitals but the patient was getting an ECHO. When asked why the MD wasn’t notified of the abnormal vitals or if the doctor should have notified of Patient #1’s need for oxygen or drop in pulse ox he stated, “I don’t know.” When asked if a patient that has an active source of infection, elevated WBC and elevated HR should flag for sepsis, RN X stated, “I think so.” RN X stated, “I paged the MD for orders but he didn’t get back to me.” When asked why he didn’t follow the 4-hour tele protocol, RN X stated, “I forgot we could do that.” RN X stated that later in the afternoon, he couldn’t remember the time, the C.N.A obtained vital signs and the patient was diaphoretic (sweaty) so he called the charge RN and she helped get an EKG and call the rapid response. Patient #1 had felt faint and started seizing at 5:42 PM (approximately 6 hours after admission to the inpatient unit) and an RRT was called that turned into a code blue. Patient #1 was given CPR, intubated (tube in throat to help breath artifically). Resuscitation attempts continued until Patient #1 was transported to a higher level of care at 7:42 PM for suspected cardiogenic shock and treatment of ECMO (Extracorporeal Membrane Oxygenation-advanced life support for life threatening heart and lung failures). Patient #1 was pronounced dead at 9:19 PM.”

“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: 29972 Based on record review and interview, staff failed to perform pain assessments/reassessments and provide effective pain interventions to ensure pain management needs are met in 1 of 10 medical records reviewed (Patient (Pt) #1); and failed to evaluate vital signs prior to discharge as per policy in 1 of 10 medical records reviewed (Pt #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #2671 titled, “Patient Care Services Pain Assessment, Reassessment Policy” last reviewed 02/20/2024 revealed: 1. “Pain assessment is done based on patient’s clinical presentation and as appropriate for the care setting.” 2. “Appropriate follow up and treatment is done based on the needs of the patient and appropriate for the care setting.” 3. “Pain assessment/reassessment is done:...prior to and following pharmacological (medications) or non-pharmacologic interventions.” 4. “Reassess pain in a timely and comprehensive manner appropriate to circumstances prior to and following every intervention and with each new complaint/report of pain.” 5. “Document assessment, reassessment and management of pain in the electronic health record (EHR).” Review of the Discharge procedure approved by the Enterprise Clinical Practice Collaborative on 05/14/2025 revealed, “Vital signs will be completed within 2 hours of the patient leaving the unit for discharge to ensure no change in status.” Vital sign evaluation: Review of Pt #1’s medical record revealed she was admitted to the inpatient unit on 07/29/2025 at 4:52 PM, for pain management post surgery for total hysterectomy (removal of ovaries and uterus) and ventral hernia (protrusion of abdominal tissue or organ through a weakness or gap in the abdominal wall) repair; Pt #1 was discharged on 07/30/2025 at 11:13 AM. Review of Pt #1’s vital signs (VSs) documented on 07/30/2025 (day of discharge) revealed: -At 10:01 AM: Pulse Oxygenation (PO) 97% -At 9:48 AM: Temperature 99.0 degrees Fahrenheit (F). -At 7:26 AM: Blood Pressure (BP) 109/60 (normal 120/80); Temperature 99.5 F; Pulse 118 (normal 60-100); Respiratory Rate (RR) 20 (normal 12-20). Review of Pt #1’s VS documentation for BP, RR, and Pulse (which was out of normal parameters), revealed there was no documented evidence that nursing staff evaluated VSs within 2 hours of discharge (11:18 AM) to ensure there was no change in status as per hospital procedure. Pain Management: Review of Pt #1’s Pre-Operative History and Physical (H&P) conducted by Physician D (attending physician) on 07/24/2026 at 2:00 PM revealed, “Indication for surgery--45 year old...with a history of uterine fibroids with pelvic pain and urinary frequency.... “H&P revealed that Pt #1 has a history of opioid (narcotic) dependence on maintenance agonist therapy (medication to reduce cravings), anxiety, Bipolar Disorder, and chronic pain. Pt #1 is on Suboxone (medication to treat dependence on opioid drugs). Per Physician D’s documentation, “CHIPS (Inpatient Pain Service) referral placed per recommendation. (Pt #1) reports with her last surgery she took Dilaudid postoperatively with adequate pain control.” Review of Pt #1’s Pre-Operative History and Physical (H&P) conducted by Physician E on 07/01/2025 at 10:45 AM revealed, “(Pt #1)....presents to the Preoperative Clinic for further evaluation prior to her scheduled hysterectomy and hernia procedure...She has a history of opioid use disorder, maintained on Suboxone and monitored by her psychiatrist...Risk Factors for Difficult to Manage Postoperative Pain: History of Opioid/Substance Use Disorder...Recommendations: Consider CHIPS (Inpatient Pain Service) consultation for recommendations...CHIPS was consulted post operatively after her previous abdominal surgery 5/24.” There was no documented evidence of the physician consulting with CHIPS for recommendations. Review of Pt #1’s Discharge Summary dated 07/30/2025 at 10:11 AM revealed Physician D documented, “(Pt #1)...admitted to PACU (Post Anesthesia Care Unit) after uncomplicated surgery. Initially with difficulty due to bladder pain and feeling need to defecate (have bowel movement)....high doses of IV (intravenous) Dilaudid needed to control pain. Due to this difficulty, she was admitted for pain control. When dosed with Dilaudid PO she would be comfortable and able to sleep, otherwise agitated, verbally aggressive and unhappy with plan of care. Her Dilaudid was titrated from 2 mg q (every) 4 hours to 4 mg q 3 hours, to 4 mg q 2 hours for pain relief.” Review of Pt #1’s Medication Administration Record (MAR) revealed the following orders for Hydromorphone (Dilaudid) (narcotic pain medication): -On 07/29/2025 at 5:20 PM Dilaudid (Opioid/Narcotic) order for 2 mg (milligrams) tablet PO (by mouth) every 4 hours PRN (as needed) for severe pain (Pain Score 7-10). On 07/29/2025 at 8:00 PM the Dilaudid order was changed to 4 mg tablet PO every 3 hours PRN and on 07/30/2025 at 2:39 AM Dilaudid was changed to 4 mg tablet PO every 2 hours as needed for severe pain. Review of Pt #1 nursing Pain assessment flowsheets and orders revealed: -On 07/29/2025 at 6:22 PM Pt #1’s pain score was a 9 out of 10 (severe pain) and was given Dilaudid 2 mg PO, there was no documented evidence of nursing staff performing a pain reassessment until 9:11 PM (2 hours and 49 minutes later) at which time Pt #1’s pain score was a 10 out of 10. -On 07/29/2025 at 9:24 PM Pt #1 was given Dilaudid 4 mg PO for severe pain, the pain reassessment at 10:24 PM indicated Pt #1’s pain continued to be a 10 out of 10, the pain management interventions documented were “Pain management plan reviewed with patient,” there was no documented evidence of adjusting or adding additional pain interventions to address the Dilaudid 4 mg not addressing the pain. A pain reassessment was not performed until 12:31 AM (2 hours and 7 minutes later) at which time Pt #1 was given Dilaudid 4 mg PO; nursing staff did not complete a pain reassessment until 3:04 AM (2 hours and 33 minutes later) and Pt #1 continued to complain of severe pain with a pain score of 9 out of 10. -On 07/30/2025 at 4:25 AM Pt #1’s pain continued to be severe with a pain score of a 8 out of 10, there was no documented evidence of nursing staff providing a pain intervention until 9:13 AM (4 hours and 48 minutes later) at which time Pt #1 was given Dilaudid 4 mg PO for severe pain (no pain assessment documented). -Pt #1’s Dilaudid orders were changed to increase the dosing frequency on 07/30/2025 at 2:39 AM to every 2 hours, however there was no indication that the nursing staff increased frequency of Dilaudid administration as per physician orders. Pt #1 was given one 4 mg tablet of Dilaudid between 2:39 AM and 9:13 AM despite documentation of Pt #1 consistently complaining of severe pain and the continued dose and frequency of Dilaudid not being effective. Review of Physician D’s Post Operative Rounding Note dated 07/30/2025 at 9:57 AM revealed, “(Pt #1) reports difficulty with pain control...” Per interview with Physician D on 03/18/2026 at 1:37 PM, Physician D stated that Pt #1’s surgery was originally scheduled for a day procedure but due to the amount of Dilaudid needed to control her pain in PACU, the decision was made to keep Pt #1 overnight for pain control. Physician D stated that as a result of Pt #1’s history of opioid addiction, Pt #1 required more pain medications than average for effective pain management. Per interview with Director of Acute Care Services H on 03/18/2026 beginning at 1:30 PM, Director H stated staff should be performing a pain assessment prior to giving a PRN pain medication and staff should conduct a pain reassessment within one hour after giving an oral PRN pain medication to ensure the intervention was effective. Director H stated that staff should assess vital signs within 2 hours of discharge as per procedure.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 52395 Based on record review and interview, the facility failed to obtain acceptance from a receiving facility and failed to document risks and benefits of transfer for 1 of 7 patients (Patient #1) transferred from the Emergency Department (ED) in a total of 20 patient ED records reviewed. Findings Include: A review of the facility’s policy titled, “Patient Care Services Management of Patient Transfers Policy” last reviewed 01/20/2025, states “V. B.1. After assessing the patient’s condition and determining the appropriateness and necessity for transfer or upon patient request for transfer, the treating physician will discuss transfer risks and benefits with the patient/family to obtain patient/family consent. 2. The transferring physician will contact a physician at the receiving facility for acceptance of transfer. 3. After securing an accepting physician and accepting facility for transfer, the transferring RN and physician must all report to the receiving facility communicating the reason for the transfer, the patient’s condition at the time of transfer, available history, observation of signs or symptoms, preliminary diagnosis, and results of any tests.” A review of Patient (Pt.) #1’s medical record revealed Pt. #1 arrived to the ED on 12/22/2025 at 9:22 AM for an intentional overdose of an unknown amount of pills. Further review of the medical record revealed at 5:14 PM, Pt. #1 was transferred to a behavioral health facility accompanied by law enforcement. There was no documented evidence found in the medical record of an accepting physician, notification to the receiving facility, or nurse to nurse report. A review of Pt. #1’s “Physician’s Certificate of Transfer-EMTALA” on 12/22/2025 at 4:47 PM revealed, “...Accepting hospital: [Hospital B]...Accepting provider: none needed...” Further review revealed, “RN Documentation Report given to” was blank. The documented risks and benefits of transfer were not specific to Patient #1’s condition. During an interview with ED Medical Director E on 1/26/2026 at 9:15 AM, when asked if someone needed to be transferred to (BH) Behavioral Health, he stated that they would typically ask for the Behavioral Health Liaison to help get things started. If it was determined they need to be admitted to inpatient, they would call and do an MD to MD conversation to ensure that they are willing to accept the patient. When asked if a patient comes in for medical clearance would they still need an accepting physician if they were going to be transferred, ED Medical Director E stated, “yes, they will need a MD to MD and an RN to RN before they transfer.” ED Medical Director E stated, “we dropped the ball on this one...” During an interview on 01/26/2026 at 1:30 PM, ED Manager F stated, “It was unfortunate because it was a new RN and a new charge RN and it just slipped through the cracks.””