Ascension SE Wisconsin Hospital

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 50644 Based on record review, observation and interview, the facility staff failed to ensure alcohol-based prepping solution (prep) was not pooled and allowed to dry per the manufacturer’s instructions for 4 of 5 patients (Patients #1, #2, #3, #11) prepped prior to a sterile procedure, resulting in a surgical fire with burns to Patient #1; and failed to perform a time out immediately prior to incision for 3 of 12 patients (Patients #3, #9, #11) in a total universe of 12 patients. Findings Include: The facility failed to minimize surgical fire risk and failed to ensure a time out was completed immediately prior to incision. See tag A-0951.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 50644 Based on record review, observation and interview, the facility staff failed to ensure alcohol-based prepping solution (prep) was not pooled and allowed to dry per the manufacturer’s instructions for 4 of 5 patients (Patients #1, #2, #3, #11) prepped prior to a sterile procedure, resulting in a surgical fire with burns to Patient #1; and failed to perform a time out immediately prior to incision for 3 of 12 patients (Patients #3, #9, #11) in a total universe of 12 patients. Examples of Surgical Prep: A review of facility policy #17063611 titled, “Fire Safety-Surgical Services and Procedural Areas, AW” last reviewed 3/6/2025 revealed, “...Prevention of fire hazards in the Surgical or Procedural Area include but are not limited to the following measures:...Follow the skin antiseptic manufacturer’s IFU for the recommended minimum dry time and allow the agent to dry completely before applying sterile surgical drapes. N. Alcohol-based skin prep solutions must be allowed to dry for at least 3 minutes before application of drapes. O. Accidental application of alcohol based skin prep solutions to drapes and hair should be avoided as these areas can take up to an hour to dry. 1. Ensure that solution soaked materials have been removed from the field prior to draping. P. Avoid pooling of flammable liquids and antiseptics. Q. For surgical procedures that involve the head or neck, use a water-soluble gel to cover the patient’s hair. Use of water-based ophthalmic lubricant in the patient’s eyes is recommended.” A review of “3M Duraprep Surgical-iodine povacrylex and isopropyl alcohol solution Solventum US LLC” (No date) revealed, “...To reduce the risk of fire, Prep Carefully:...do not drape or use ignition source until solution is completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair). Avoid getting solution into hairy areas...do not allow solution to pool remove solution-stained material from prep area...” A review of “ChloraPrep 26 mL [milliliter] applicator” IFU’s (no date) revealed, “Patient preoperative skin preparation...70% isopropyl alcohol...Do not drape or use an ignition source(e.g., cautery, laser) until the solution is completely dry for a minimum of three minutes on hairless skin and up to one hour in hair. Do not allow the solution to pool. Remove wet materials from the prep area...” A review of Patient #1’s medical record revealed that Patient #1 had a pacemaker placement performed by Electrophysiologist X on 3/15/2026 under MAC (monitoered anesthesia care) anesthesia. Patient #1 was brought to Cath Lab 1 at 11:44 AM by Cath Lab ST (Surgical Technician) I. Patient #1 was prepped with Duraprep by Cath Lab ST L at 11:44 AM and a grounding pad (placed when using electrocautery) was applied. At 11:52 AM a time out was completed which included the verification that “A flammable prep solution was utilized. The application site was dry before draping Fire Risk Assessment Complete: Score 3: High Risk.” The incision pocket was made at 12:02 PM on the left subclavian area. Cath Lab ST I documented at 12:09 PM, “Procedure delay due to fire under sterile drape. Patient hair caught fire. Contaminated sterile field, table break down all supplies discarded. Pocket covered with sterile raytex sponge and Tegaderm for sterility. Patient assessment performed.” After assessing Patient #1 for burns, patient was re-prepped and re-draped in order to clean and close the surgical site. Procedure ended at 12:51 PM and Patient #1 was transferred to the inpatient unit until he was rescheduled on 3/9/2026. During an observation on 3/11/2026 starting at 11:11 AM, observed the sterile supplies from Patient #1’s surgical fire incident. Observed pooled Duraprep (iodine and alcohol based prep solution) on the pillowcase by where Patient #1’s head/neck would have been. Observed iodine tinted drape towels from where Patient #1’s chest was squared off. Observed CO2 (carbon dioxide) tubing that was burned in half. Observed burned blue drape towels. There was pooling of wet, alcohol-based prep solution that served as an ignition source in the presence of a heat source (cautery), resulting in a surgical fire. During an observation on 3/11/2026 starting at 9:23 AM in Cath Lab 2, observed Patient #2 enter the Cath Lab for a cardiac catheter at 9:27 AM. Patient #2 was positioned supine on the Cath Lab table. Cath Lab ST I started prepping Patient #2 with ChloraPrep (alcohol and chlorahexidine prepping solution) on her left leg at 9:35 AM. Cath Lab ST I prepped from sheet to groin, then from mid-thigh to right below umbilicus. Prep was completed at 9:37 AM on the left leg and then the same process was followed on the right leg. Prepping finished at 9:39 AM. There was no evidence of a tuck towel or chucks pad placed under either thigh area to prevent pooling of ChloraPrep solution under the patient. The drape was then placed at 9:40 AM. Active pooling of the alcohol-based prep was observed upon drape placement and skin prep was present on bedding material that was underneath Patient #2. During an observation on 3/11/2026 starting at 1:35 PM in OR (Operating Room) 7, observed Patient #3 being prepared for robotic ventral hernia surgery. Patient #3 was positioned in supine position with arms tucked at her side and a grounding pad was placed on her right upper thigh. At 1:41 PM, observed OR RN (Registered Nurse) R start prepping Patient #3 with ChloraPrep prepping solution on her abdomen from nipple to pubis, bed sheet to bed sheet. There were no tuck towels used on either side of the abdomen to catch the excess ChloraPrep solution and when OR RN R was finished prepping, there was visible pooling of surgical prep on each side of Patient #3 on the material underneath her. During an observation on 3/12/2026 starting at 10:30 AM, observed Patient #11 being prepped for an Anterior Cervical Discectomy and Fusion by OR RN GG. OR RN GG clipped the neck area and scrubbed Patient #11’s chest up to his chin with chlorahexidine scrub. While prepping with alcohol, the sponge of alcohol was rubbed right along Patient #11’s beard line. Prepping was completed at 10:44 AM and draping starting at 10:47 AM not allowing a longer dry time for Patient #11’s beard or removing the alcohol prep from the beard. Anesthesiologist II did not apply a water soluble barrier to Patient #11’s exposed beard. During an interview on 3/11/2026 at 10:12 AM with Cath Lab ST J, when asked if they use tuck towels or anything to prevent pooling of prep she stated, “What’s a tuck towel?” During an interview on 3/11/2026 starting at 10:12 AM, Cath Lab ST K stated, “No, we don’t use tuck towels or anything to prevent pooling of solution.” During an interview on 3/11/2026 at 1:28 PM, with OR Manager M and OR Director N, they stated that to prevent fires in the OR they compute a fire risk score in their charting and discuss that risk score during the time out. They stated that prep time is based on what kind of prep is being used but most of the preps they have are a 3 minute dry time and the staff time that before continuing on to draping the patient. OR Manager M and OR Director N stated that dripping of prep solution should be prevented by using chucks pads and removing them before draping. They stated that there should be no pooling of surgical prep. During an interview on 3/12/2026 at 12:30 PM, Anesthesia Medical Director JJ stated that their current practice does not include using a water-soluble gel to cover the patient’s hair for head and neck prepped procedures. A review of facility “Annual Fire Safety in Procedural Areas” education revealed no evidence of education completed in 2025. Quality Director DD confirmed this and stated, “There was a gap in assigning this education and it was missed in 2025.” Examples of Surgical Time Out: A review of facility policy #16336256 titled, “Universal Protocol and Time Out, AW” last revised 10/2/2024 revealed, “...Time Out (final verification): The Time Out is a deliberate pause in activity involving clear communication...among all members of the surgical/procedural team. The procedure is not started until any questions or concerns are resolved...A “Time out” is performed before any invasive procedure for which a consent is obtained or required...immediately prior to initiation of the proposed procedure...” A review of Patient #9’s surgical record revealed Patient #9 had a laminectomy performed by Surgeon HH on 3/5/2026. Patient #9 was brought to the OR at 7:27 AM and incision was made at 8:10 AM. A time out was performed at 7:58 AM (12 minutes prior to incision). During an observation on 3/11/2026 starting at 1:35 PM of Patient #3 who was having a ventral hernia repair done by General Surgeon V, observed OR RN R finish prepping Patient #3 and then ask the team to complete a time out. Patient #3 was not draped at this time and OR Manager M stepped in and told the team they needed to wait to complete the time out once the patient was draped and incision was ready to be made. During an observation on 3/12/2026 starting at 10:30 AM of Patient #11 who was having an Anterior cervical discretion and fusion by Surgeon HH, observed OR RN GG finish the prep on Patient #11 at 10:49 AM. Surgeon HH then asked to complete the time out when OR Manager M stepped in told them they can’t do the time out until they are completely draped and ready to make incision. Surgeon HH questioned, “Your not allowing me to do the time out until the towels are on? I don’t like to deviate from what I usually do.” During an interview on 3/11/2026 at 5:10 PM, OR Manager M stated that time outs should be done immediately before start of the procedure after draping is complete.”

“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: 34337 Based on record review, facility staff failed to perform a comprehensive Medical Screening Exam for 1 of 20 patients (Patient #1) in a total sample of 20 patient records reviewed. Findings include: Review of facility policy “Emergency Medical Treatment and Active Labor Act (EMTALA)” dated 4/15/2025 revealed “Standards for Medical Screening Examinations: ...2. The Medical Screening Examination extends until the point that the QMP (Qualified Medical Professional) determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient’s needs, and monitoring should continue until the individual is stabilized or admitted or appropriately transferred.” Per medical record review, Patient #1 presented to the hospital’s emergency department on 1/19/2026 at 10:07 AM in police custody for a manic episode and hand laceration, requiring medical clearance prior to entering either jail or a psychiatric facility. Review of Emergency Department (ED) nursing notes dated 1/19/2026 at 10:07 AM revealed “Lac (laceration) to R (right) palm - bleeding controlled.” Review of ED physician notes dated 1/19/2026 at 10:14 AM revealed Patient #1 “was reportedly found at his home breaking windows and had a laceration to his right hand.” The physical exam does not include documentation of the hand laceration. Review of ED nursing notes dated 1/19/2026 at 10:41 AM revealed “Integumentary: Skin location: Hand. Skin integrity: Abrasion; Edematous; Hematoma; Laceration.” There was no assessment or treatment of the laceration noted in the medical record. Patient #1 was discharged in police custody on 1/19/2026 at 12:23 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50643 Based on record review and interview, facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse in 3 of 4 caregiver misconduct allegations reviewed (Patient (Pt) #1, #2, #3) in a total of 4 caregiver misconduct allegations reviewed; and failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediately reporting in 1 of 1 abuse and neglect training reviewed (initial orientation), in a total of 1 abuse and neglect training reviewed. Findings include: The facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse. SEE TAG A-0145 The facility staff failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediately reporting. SEE TAG A-0145”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 50643 Based on record review and interview, facility staff failed to thoroughly investigate all patient complaints and grievances and protect patients from potential abuse in 3 of 4 caregiver misconduct allegations reviewed (Patient #1, #2, #3) in a total of 4 caregiver misconduct allegations reviewed; and failed to ensure that staff training for caregiver abuse and neglect addresses the process for immediate reporting in 1 of 1 abuse and neglect training reviewed (initial orientation), in a total of 1 abuse and neglect training reviewed. Findings Include: A review of the facility’s policy titled, “Patient Rights and Responsibilities” last revised 6/21/2024 revealed, “...Patients have the right, consistent with laws and regulations, to...be assured of reasonable safety within the care setting, including the right to be free from harassment, mental, physical, sexual, and verbal abuse, neglect, mistreatment, exploitation, humiliation, and retaliation...” A review of the facility’s policy titled, “Patient Complaints and Grievances” last revised 10/14/2022 revealed, “... If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action, then the complaint is a grievance for the purpose of these requirements... A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient ...regarding patient care... abuse or neglect...If the complaint cannot be resolved immediately by the associate, the associate will assist and assure the patient that the leader of the area where the patient is being treated will promptly be made aware of the complaint. If possible, the leader will immediately address the complaint... If the complaint is reported after the patient has been discharged, an associate may refer directly to the unit/department leader or designee to follow up on and manage. All complaints and grievances will be documented in the Salesforce Service Cloud as a patient feedback case. The department leader or designee will provide relevant documentation related to the grievance. This includes but is not limited to written statements of patients or persons involved. The unit/department leader or designee will assure the grievance has been assigned to the correct department(s) for appropriate follow up... Investigation should include review of medical records as well as interviews with associates, providers, and other department associates as appropriate that were involved or can offer input into the concern. Dept (department) leaders should be documenting when they make contact with others/who they contact/outcome of that follow up into the Follow-up Review Form to show actions they took to complete review...” A review of the facility’s policy titled, “Caregiver Misconduct and Injuries of Unknown Source Investigations and Reporting” last revised 4/28/2023 revealed, “...All caregivers providing services to patients in acute care facilities... must possess the knowledge and ability to identify and immediately report to the appropriate person all allegations of caregiver misconduct and injuries of unknown source...Any individual who becomes aware of an instance of suspected caregiver misconduct or allegation thereof or injury of unknown source shall immediately report the incident to the Charge Nurse, Department Supervisor/Manager/Director and/or Administrator-On-Call. The incident will be entered into the current reporting platform as applicable... Risk Management should be notified by providing the patient complaint number assigned to the incident, so support related to investigating the Incident can be provided. Risk Management will notify Human Resources and the [Facility name] Office of General Counsel of all reported incidents. When an individual becomes aware of the Incident and if the patient/client is physically located within an [Facility name] entity, a health care provider should immediately assess the patient/client and evaluate the nature of the allegation and/or extent of the reported injury... A thorough investigation may include... Collecting and preserving any physical evidence... Interviewing alleged victims and witnesses... Identifying any involved individuals... involving other regulatory authorities... Reviewing other related items such as staffing schedules, personnel files and the patient’s/client’s medical record... Documenting each step taken during the investigation, as well as the results of the investigation...” Review of Patient #2’s medical record revealed that Patient #2 was admitted to the 4th floor inpatient unit on 2/5/2025 with a chief complaint of shortness of breath and flu-like symptoms. Patient #2 was discharged on 2/7/2025 at 2:00 PM. Review of the facility Caregiver Misconduct Investigation of PCT A authored by Risk Manager J, and staff interviews revealed: · On 2/7/2025 at 7:09 PM, RN H sent an email to RN Manager G. “ ...(Patient #2) made a few complaints about (PCT A’s) behavior during our shift prior to being discharged. She stated that he said she was fine and specifically that ‘black don’t crack’... (PCT A) proceeded to ask her if she had children and how many she has... (PCT A) closed her room door to take her blood sugar and she told him to ‘leave the door open.’ (Patient #2) also stated that he asked if she wanted her sheets changed and she told him ‘No, they were just changed.’ According to the patient he came back two different times with clean linens... Both times he offered to change her sheets he offered to help her ‘get cleaned up’... (Patient #2) stated to me that she felt very uncomfortable and did not want him in her room again with the door closed. The patient was shortly after this conversation being discharged, so I informed (House Supervisor I) and told (Patient #2) to call me directly if anything happened again and I would be right there.” No further investigation, Adverse Event, or Complaint or Grievance were filed at the time of the report. · On 2/10/2025 (No Time) (2 days after Patient #2’s Complaint) RN Manager G investigated Patient #2’s complaint. RN Manager G attempted to contact Patient #2 one time which was unsuccessful, with no returned call. No Adverse Event, or Complaint or Grievance was filed. · On 2/10/2025 PCT A worked from 7:00 AM - 7:00 PM. · On 2/12/2025 (No Time) (4 days after Patient #2’s Complaint) RN Manager G had a coaching conversation with PCT A. PCT A denied Patient #2’s allegations. · RN M reported on 02/21/2025 at 10:01 PM that Patient #1 reported to RN M that after her previous admission (on 02/17/2025) someone who worked at the hospital contacted Patient #1 on her cell phone and sent 4 pictures of himself including a nude photo. Patient #1 showed RN M the photos, and RN M confirmed the pictures were of PCT A. · On 2/24/2025 at 1:13 PM (17 days after Patient #2’s Complaint) RN Manager G forwarded RN H’s email to Risk Management. · In an interview 02/25/2025 (no time) RN Manager G revealed, “(Manager G) came to writer’s office ...and reported he and (RN Assistant Manager B) were talking and recall a patient (Patient #3) from 2 weeks ago. (Patient #3) has mental health history and some confusion.” Per the interview with Manager G, (Patient #3) showed (Manager B) a piece of paper with a (phone) number that matched the same number of the phone used to send Patient #1 the pictures and a nude photo (of PCT A). Per interview with Manager G, just before discharge on 2/4/2025 Patient #3 told Manager G that a man had grabbed her breasts, but family refused an investigation at that time stating she was “confused” and “says things like that.” No further investigation, Adverse Event, or Complaint or Grievance was filed at the time of the report. · On 2/26/2025 (No Time) (19 days after Patient #2’s Complaint) Risk Management interviewed Patient #2 and learned that in addition to making Patient #2 feel uncomfortable with comments, PCT A also “was taking her blood sugar (and) he was running his had up/down her arm and leg” and PCT A offered to give Patient #2 a “bubble bath.” · A phone interview on 02/27/2025 (no time) with (Patient #3’s daughter), revealed that after discharge (Patient #3) informed her that a “male was touching her, wiping between her legs...” (Patient #3’s daughter) stated Patient #3 told her that the male associate did a “good job with the bath ...made it like an accident when he touched her privates.” Per (Patient #3) the male associate gave Patient #3 his telephone number to contact him after discharge (the number that was given to Patient #3 was the same number that sent the nude photos of PCT A to Patient #1). · Review of Pt #3’s medical record revealed PCT A documented assisting Pt #3 with a “bath” on 2/1/2025 and 2/2/2025. An interview was conducted on 4/29/2025 at 9:08 AM with Risk Manager J. When asked about the investigation timeline that Risk Manager J wrote for PCT A’s caregiver misconduct, Risk Manager J stated that when she received notification of the event on 2/24/2025, she entered an ERS (Event Reporting System), as it had not been done previously. Risk Manager J stated that the facility did not know about the case until Patient #1 reported it on 2/21/2025. Risk Manager J stated that based on the facility’s investigation, all information gathered from event details with Patient #1, Patient #2, and Patient #3 pointed to PCT A committing Caregiver Misconduct. Risk Manager J stated that the decision was made jointly by the Risk Department, HR, and General Council that there was substantiation of the allegations. Risk Manager J stated that PCT A was suspended on 2/24/2025, and terminated on 3/2/2025. Risk Manager J stated that PCT A did not work at the facility between 2/21/2025 and 3/2/2025. Review of the Caregiver Misconduct Investigation Report for PCT A, revealed that Patient #2’s complaint regarding PCT A was shared with the nurse on 02/07/2025 and staff did not immediately escalate to leadership and enter the complaint in the reporting system for follow up as per policy. Manager G was not informed of the complaint until 3 days later and there was no documented evidence of Manager G investigating Patient #2’s complaint as per policy, including interviewing the patient, staff, and witnesses. Patient #2 was not interviewed by staff until 02/26/2025 (19 days later), during which time it was discovered that 2 additional patients (Patient #1 and Patient #3) had come forward with caregiver misconduct and abuse allegations against PCT A. Review of PCT A’s schedule revealed that PCT A worked his full time schedule unrestricted between the dates of 2/7/2025 (the date Patient #2 complained) and 2/21/2025 (the date Patient #1 reported to facility staff that she had been contacted by PCT A and received a nude photo from PCT A.) An interview was conducted on 4/28/2025 at 2:10 PM with 4th Floor RN H. When asked about the email that RN H sent on 2/7/2025, RN H stated that before she sent the email, she reported the concern about PCT A’s inappropriate interaction with Patient #2 to House Supervisor I. RN H stated that she did not enter the concern into the ERS. RN H stated that she did not know if House Supervisor I took any immediate action on the concern, but that he instructed RN H to email RN Manager G, Assistant RN Manager B, and RN Lead F. RN H stated she then sent the email at the end of her shift. RN H told Patient #2 that she was going to report it to her Manager, and that Patient #2 agreed that was a good idea. An interview was conducted on 4/28/2025 at 2:30 PM with 4th Floor RN Manager G. RN Manager G stated that he recalled getting the email regarding Patient #2’s complaint dated 2/7/2025 sent by RN H, but that he was off duty (on a Friday evening at 7:09 PM) at the time, and did not see it until he was next on duty on Monday 2/10/2025. RN Manager G stated that he worked on investigating the case on 2/10/2025 and felt at the time that since Patient #2 had been discharged, there was no need to make changes in PCT A’s patient assignment. In a later interview on 4/30/2025 at 9:30 AM, RN Manager G stated that he attempted to contact Patient #2 once during the investigation, but never heard back from her. RN Manager G stated that he followed up with PCT A on 2/12/2025 regarding the reported interaction that made Patient #2 feel uncomfortable. RN Manager G stated that PCT A denied knowing that his interactions with Patient #2 were inappropriate or that it made Patient #2 feel uncomfortable. RN Manager G stated that he coached PCT A on interactions with patients, and told him that he should always ask patients if they feel comfortable having the door open/closed, patients have a right to refuse cares, and that refusal should be documented in the electric medical record. RN Manager G stated that he didn’t recall any further follow-up conducted at that time. RN Manager G stated he did not enter an ERS for the 2/7/2025 incident. An interview was conducted on 4/29/2025 at 12:10 PM with House Supervisor I. When asked about RN H coming to him on 2/7/2025 with a complaint of from Patient #2 about PCT A, House Supervisor I stated that at the time the information did not give him too much concern, and that Patient #2 was discharged about 2 hours after the report. House Supervisor I stated that he did not confront PCT A or enter an ERS, because he “did not have enough information to do so.” House Supervisor I stated that he instructed RN H to send the complaint in an email to RN Manager G, RN Lead F, and Assistant RN Manager B. A review of the facility training modules on 4/29/2025 at 11:35 AM revealed that all staff receive education yearly on “Abuse and Neglect” and “Annual Compliance.” Information in the modules included definitions of the “Vulnerable Adult, Sexual Abuse, and Verbal and Non-Verbal Harassment.” The modules also included Reporting responsibilities of every staff member, and that all staff should report suspected misconduct to their supervisors, and that staff “can enter an ERS.” No timelines for reporting were noted. An interview was conducted on 4/29/2025 at 11:55 AM with Education Specialist P who stated that there is no reference of the Caregiver Misconduct Policy in the Annual training. Education Specialist P stated that the Facility tends to be more reactive with training staff about Caregiver Misconduct when events take place, rather than offering broad proactive training.”

“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 facility staff failed to ensure Intake and Output is measured as per physician orders in 1 of 5 medical records reviewed for Intake and Output (Patient (Pt) #1), failed to complete indwelling catheter care (Foley) assessments and interventions in 2 of 2 medical records reviewed for Foley care (Pt #1, #2); and failed to reassess and evaluate pain management needs for effectiveness in 3 of 10 medical records reviewed for pain assessments (Patient (Pt #1, #2, #3), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #17507191 titled, “Hospital Based Assessment & Documentation Policy” last revised 02/02/2025 revealed the following: - “Data collection/Reassessment is designed to evaluate the patient’s response to care and interventions and to determine if a change to the plan of care is warranted.” - “Additional data collection/reassessments are done when the patient’s diagnosis/condition warrants.” - “All entries are automatically timed and dated. Information should be entered following acquisition of data or when care is given.” - “Each discipline documents their interventions and the patient’s response to these interventions in the patient’s health care record.” Review of policy and procedure #16559148 titled, “Indwelling Urinary Catheter (Foley)” last reviewed 01/08/2025 revealed the following: - “Catheter care must be performed on a minimum of a daily basis. Care will also be completed as needed...” Review of policy and procedure #13867165 titled, “Pain Management Resource” last revised 06/21/2023 revealed the following: - “Assess the patient to identify the potential source of pain and implement appropriate non-pharmacological and/or pharmacological interventions.” - “Reassess following interventions...” - “Parental route (intravenous)-within 1 hour or as needed based on individual patient need and clinical condition.” - “Enteral route (oral)-within 2 hours or as needed...” - “Reassessment includes pain intensity/score, adverse effects, and sedation (for patients receiving opioid analgesics).” Pt #1: Review of Pt #1’s medical record revealed Pt #1 was admitted to the inpatient unit on 10/12/2024 at 9:48 AM with a diagnosis of Sepsis (infection of the blood stream) with Acute Renal Failure, Acute Kidney Injury, Metabolic Acidosis (too much acid in the body), and Generalized weakness; Pt #1 was discharged on 10/30/2025 at 9:15 AM. Review of Urology F’s physician progress note dated 10/12/2024 at 4:06 PM revealed, “Patient is a 75 y.o. (year old)...presents with h/o (history of) prostate cancer and obstructive uropathy (structural/functional issue with normal urine flow)...Pt has complicated GU (genitourinary) (reproductive and urinary systems) h/o s/p (status post) xrt (radiation treatment) for...prostate cancer.” Review of Pt #1’s physician orders dated 10/12/2025 at 9:53 AM revealed orders for Intake and Output to be measured “Every Shift” (the order was discontinued at discharge). Intake/Output: Review of Pt #1’s Intake flowsheet from 10/12/2025 through 10/19/2025 revealed there was no documentation of breakfast, lunch, and dinner intake on 10/13/2025, 10/14/2025, 10/15/2025. There was no documentation of breakfast and lunch intake on 10/16/2025, no documentation of lunch intake on 10/17/2025, and no documentation of dinner intake on 10/18/2025. Review of Pt #1’s Urine Output/Assessment flowsheets from 10/12/2025 through 10/19/2025 revealed there was no documentation of staff measuring urine output on 10/12/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/18/2025 and 10/19/2025. Genitourinary nursing assessments/Foley care interventions: Review of Pt #1’s GU nursing assessment flowsheet from 10/12/2025 through 10/19/2025 revealed the nursing assessments did not address Pt #1’s symptoms of urinary retention. Review of Pt #1’s GU flowsheet revealed on 10/13/2025 at 11:45 AM “Foley Catheter” was documented under GU interventions. Review of the nursing assessment flowsheets from 10/13/2025 through 10/19/2025 revealed there was no documentation of staff performing daily catheter care interventions as per policy. Pain assessments: Review of Pt #1’s pain medications revealed orders dated 10/13/2025 at 11:41 AM for Oxycodone 10 milligrams (mg) by mouth every 4 hours as needed and Morphine 2 mg intravenous every 4 hours as needed. Review of Pt #1’s Medication Administration Record (MAR) and nursing pain assessments revealed the following: -On 10/13/2025 Pt #1 was given Oxycodone for a pain level 6 out of 10 (moderate pain) at 2:18 PM, nursing staff did not complete a pain reassessment until 5:50 PM (3 hours and 44 minutes later); should be within 2 hours for oral medication as per policy. -On 10/18/2025 Pt #1 was given Morphine for a pain level of 8 out of 10 (severe pain) at 7:00 PM, nursing staff did not complete a pain reassessment until 10:06 PM (3 hours and 6 minutes later); should be within 1 hour for intravenous medication as per policy. -On 10/19/2025 Pt #1 was given Morphine for a pain level of 7 out of 10 (severe pain) at 2:26 AM, nursing staff did not complete a pain reassessment until 7:01 AM (4 hours and 35 minutes later); should be within 1 hour for intravenous medication as per policy. -On 10/19/2025 Pt #1 was given Oxycodone for a pain level of 5 out 10 (moderate) at 1:56 PM, nursing staff did not complete a pain reassessment until 9:10 PM (7 hours and 14 minutes later); should be within 2 hours for intravenous medication as per policy. Pt #2: Pain assessments: Review of Pt #2’s medical record revealed Pt #2 was admitted on 02/03/2025 at 3:57 PM for a prostate biopsy; Pt #2 was discharged on 02/05/2025 at 12:01 PM. Review of Pt #2’s pain medications revealed orders dated 02/03/2025 at 11:57 AM for Oxycodone 10 milligrams (mg) by mouth every 4 hours as needed. Review of Pt #2’s Medication Administration Record (MAR) and nursing pain assessments revealed the following: -On 02/03/2025 Pt #2 was given Oxycodone for a pain level 8 out of 10 (severe pain) at 10:59 PM, nursing staff did not complete a pain reassessment until 3:30 AM (4 hours and 31 minutes later); should be within 2 hours for oral medication as per policy. Pt #3: Review of Pt #3’s medical record revealed Pt #3 was admitted on 02/02/2025 at 4:28 PM with urinary retention and blood in urine with a concern for metastatic cancer; Pt #3 was an inpatient at the time of review. Foley care interventions: Review of Pt #3’s nursing flowsheets revealed a Foley catheter was placed on 02/02/2025 at 10:30 PM, there was no documentation of staff performing daily catheter cares on 02/03/2025 and 02/04/2025. Pain assessments: Review of Pt #3’s pain medications revealed orders dated 02/02/2025 at 5:02 PM for Morphine 2 mg intravenous every 4 hours as needed. Review of Pt #3’s Medication Administration Record (MAR) and nursing pain assessments revealed the following: -On 02/03/2025 at 2:47 PM Pt #3’s pain level was a 4 out of 10 (moderate), “Medication” was documented as an intervention on the Pain Assessment flowsheets, but Morphine was not given until 4:42 PM (1 hour and 55 minutes later). Nursing staff did not complete a pain reassessment until 6:42 PM (2 hours later) at which time Pt #3’s pain level was 7 out of 10 (severe pain). -On 02/04/2025 at 1:15 AM, Pt #3 was given Morphine for a pain level of 8 out 10 (severe), nursing staff did not complete a pain reassessment until 4:50 AM (3 hours and 5 minutes later). Per interview with Director of Nursing (DON) B and Nursing Manager C, while reviewing medical records beginning on 02/04/2025 at 12:55 PM, DON B and Manager C confirmed the findings and stated that staff should measure intake and output every shift and document the amounts including breakfast, lunch, and dinner on the Intake and Output flowsheets. DON B and Manager C stated that Foley catheter care should be completed at least daily as per policy and documented under the indwelling catheter flowsheet. Per DON B, staff should be completing the pain reassessments as per policy.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50646 Based on record review and interview, nursing staff failed to develop, and keep current, a nursing care plan and a fall risk care plan that reflected the patient’s goals and needs, and failed to obtain and document telemetry strip monitoring for 1 (Patient #1) of 10 patient records reviewed. Findings Include: Pt. #1 was admitted to the facility on 06/03/2024 with seizures. Pt. #1 had a history of hypertension, previous stroke with residual right sided sensory deficit and seizure disorder. Pt. #1 suffered from confusion and agitation during their hospitalization and left against medical advice (AMA) on 06/05/2024 at 10:00 PM. Development of nursing care plan Review of the facility’s policy ID 14776656, “Interdisciplinary Patient Assessment & Documentation,” dated 11/27/2023 revealed: “The admission navigator history and initial plan of care should be completed within 24 hours. Initial interdisciplinary referrals are generated, based on assessment data/risk screens. ...The plan of care should be developed, when possible, in conjunction with the patient/family. A care plan has individualized patient priorities, expected outcomes with target dates, and appropriate interventions. B. When the plan of care has been developed, the healthcare team implements it. Each discipline documents their interventions and the patient’s response to these interventions in the patient’s health care record.” Review of Pt.#1 medical record revealed no evidence of a nursing care plan throughout Pt.# 1’s hospitalization (greater than 24 hours). Development of fall prevention interventions: Review of the facility’s policy ID 16439940, “Fall Prevention,” dated 08/01/2024 revealed: “Patients who score 45 or higher on the Morse Fall Scale (scoring for patients at risk for falls) are considered “high-risk” for falls ...Using a bed or chair alarm for patients who are unable to, choose not to, or may forget to follow safety directions.” Review of the facility’s policy ID 16517032, “Safety Management of Clinical Alarms,” dated 03/01/2024 revealed: “Clinical associates must assure that all alarms are set to activate at appropriate settings for each patient and are sufficiently audible with respect to distances and competing noise within the unit.” Review of Pt. #1’s Adult Patient Care Summary admission sheet completed by RN O on 06/04/2024 at 11:30 AM revealed a Morse Fall Risk Score of 45 (high risk) on admission and 60 at 4:00 PM. Ongoing review of Pt. #1’s medical record revealed a bed alarm was initiated and fall risks were reviewed with the patient on 06/04/2024 at 11:30 AM. There was no documentation evident on 06/05/2024 of Morse Fall Risk, fall prevention or any documentation around whether bed alarm was on or off and what the fall risk care plan interventions were for Pt. #1. Review of Physical Therapy Evaluation 06/04/2024 1:30 PM revealed, “Patient safety/Precautions: Bed and Chair Alarm. Assessment: Cooperative and pleasant, cognition, mobility, and speech appear at baseline ... Pt was left in the room with a chair alarm on and a call button within reach ...Discontinue acute care PT due to baseline mobility/ambulation level.” Review of Occupation Therapy Evaluation 06/04/2024 1:46 PM revealed that Pt. #1 needed help with set up for feeding, bathing and dressing. “Pt was left in the room with a bed alarm on and a call button within reach.” Evaluation 06/05/2024 2:02 PM revealed, “Pt with significant improvements this date. Goals met. No further skilled OT intervention is recommended at this time. Subjective: More Alert; Self Care: Showered prior to meeting. Pt was left in the room with a bed alarm off and a call button within reach.” During an interview on 09/03/2024 at 1:47 PM with Patient Care Tech D when asked how a patient is identified as a fall risk Patient Care Tech D stated they look at the fall score in the computer, get it in report, see it on the tips board and see that the patient is in a yellow grown which indicates they are a fall risk. When asked how often patients are rounded on Patient Care Tech D stated, “I round every 2 hours at a minimum but I try and round more frequently if I am able. The RN rounds on the odd hours and I round on the even hours.” When asked about the expectation around call light and alarm response times s/he stated that they try and respond immediately. If they are unavailable because they are assisting someone else they request that the RN working with the patient be notified to assist. During Interview on 09/04/2024 at 8:30 AM with Quality Coordinator M when asked if the care plan was found in the medical record s/he stated, “No we could not find any.” When asked if it should be in the record Quality Coordinator M stated, “Yes it should be in the chart.” During an interview on 09/04/2024 at 08:52 AM, Medical Manager RN I stated, “Expectations around charting did not change during down time (a period during which computers were not available and charting was done manually).” S/he stated it was a challenge during down time for all staff to know exactly where to chart as the organization tried to improve forms. They had utilized their twice daily huddles with staff to inform them about downtime documentation forms to utilize for charting. Medical Manager RN I stated, “Charting definitely improved by the end of downtime but it still could have been better.” Lack of Telemetry Documentation: Review of facility’s policy ID 13282525, “Care of the Patient Requiring Telemetry Care” dated 06/06/2023 revealed, “A rhythm strip will be obtained, interpreted..., and documented on admission, transfer with a change in level of care, every shift, and with a change in baseline rhythm...Assessment of rhythm and any necessary interventions are documented.” Review of Pt. #1’s medical record revealed on 06/04/2024 07:00 AM that telemetry monitoring was ordered. Ongoing review of Pt. #1’s medical record revealed no telemetry strip documentation was completed on 06/05/2024. An interview was conducted with Telemetry Tech G 09/03/2024 at 1:40 PM. When asked what the process is around telemetry S/he stated that the order comes in and they admit the person on the monitor. The RN or PCT places the box and electrodes on the patient. The telemetry tech runs the first strip on the patient. They also run strips if there are any irregular rhythms. The nurse caring for the patient runs a strip every shift and does the interpretation of the strip. The nurse also does an interpretation of irregular rhythm strips that the tech places in a basket for them. Those strips are all scanned into the patient’s medical record. During an interview with Nurse Manager RN I and Patient Care Supervisor C on 09/04/2024 at 08:52 AM, both stated telemetry should be documented once a shift by the RN with interpretation of the strip documented in the chart. During an interview on 09/04/2024 at 10:00 AM with RN P when asked how often telemetry strips needed to be documented RN P said once a shift they need to run strips and document on the rhythm.”

“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: 43037 Based on record review and interview, facility staff failed to document two nurse skin checks at admission and failed to reposition patients per policy to prevent skin breakdown in 1 of 10 medical records reviewed (Patient #1). Findings include: A review of facility policy #14493095, “(Facility System Name) Pressure Injury Prevention Bundle (Hospital Names) Best Practice Guidelines”, last revised 5/9/2023 revealed, “...Skin Assessment:...Head to toe minimum q (every) 24 hours, 2nd nurse skin check on admission, OR (Operating Room) cases lasting > 4 hours, Unit to unit transfers...Keep Turning:...Reposition q 2 hours while in bed, Reposition q 1 hour while sitting in chair, Offload heels...Keep Turning: Change position frequently with early ambulation: Turn all patients with limited mobility/no mobility at least every 2 hours...” A review of Patient #1’s medical record revealed Patient #1 was admitted to the facility on 3/22/2024 with complaints of weakness, fatigue, poor oral intake and dizziness. Patient #1 was found to be in mixed obstructive/cardiogenic shock (shock caused by the obstruction of blood flow and dysfunction of the heart) and required transfer to Other Hospital O for a higher level of care which occurred within the first 4 hours of Patient #1’s admission. Patient #1 was then transferred back to this facility on 3/25/2024 for continued hospitalization until discharge on 4/2/2024. An interview was conducted with Patient #1’s adult child on 5/23/2024 at 11:19 who stated that Patient #1 had multiple pressure ulcers on his/her coccyx which were discovered sometime after returning home on 4/2/2024. Patient #1’s adult child also stated the discharge paperwork did not include information for the presence or treatment of Patient #1’s pressure ulcers. Patient #1’s adult child also stated nobody verbally advised them of Patient #1’s pressure ulcers upon discharge. A review of Patient #1’s medical record “Integumentary” daily nursing assessment revealed no skin integrity issues were documented upon admission to the facility on 3/22/2024 (facility charts by exception--assessments documented only if not within normal limits). There was no documentation of a second nurse skin check. A skin check with 2nd nurse participation was documented upon arrival to Other Hospital O on 3/22/2024 at 1:00 AM without mention of any wounds or concerns. A review of “Integumentary” admission and daily nursing assessment revealed no documented skin check with second nurse participation was completed upon re-admission to this facility on 3/25/2024. Daily skin assessments from 3/25/2024 through 4/1/2024 do not include any documentation of skin breakdown, bedsores or wounds. Skin assessment dated 4/2/2024 at 8:49 AM revealed, “...Skin location: Coccyx, Skin location orientation: Mid, Skin Integrity: Abrasion, Skin Color: Erythemia (redness of the skin which occurs with skin injury)...Type of Wound: Pressure ulcer...Pressure Injury Properties: Date first assessed/Time first assessed: 4/2/2024 8:54 AM...Dressing Status: Clean, Dry, Intact, Dressing changed: New, Staging: Stage I, State of Healing: Early...Wound Assessment: Fragile...Dressing: Foam...10:15 PM: Skin Location: Coccyx...Skin Integrity: Abrasion, Skin Color: Erythemia, Skin Condition/Temp: Warm...” A review of “Braden Scale - For Predicting Pressure Sore Risk” scoring tool revealed Risk Factors include Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction and Shear. Total scores indicate risk as follows: “Severe Risk: Total score < 9; High Risk: Total score 10-12; Moderate Risk: Total score 13-14; Mild Risk: Total score 15-18.” Risk Factor for Mobility reveals, “Mobility: Ability to change and control body position. Score/Description: 1. Completely Immobile - Does not make even slight changes in body or extremity position without assistance. 2. Very Limited - Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited - Makes frequent though slight changes in body or extremity position independently. 4. No limitations - Makes major and frequent changes in position without assistance...” Nursing documentation of Patient #1 Braden assessment scores as follows: 3/25/2024 - 3 assessments recorded. Overall scores of 17, 19 and 16 (mild risk). Mobility scores of 3, 3, and 3 (slightly limited). 3/26/2024 - 2 assessments recorded. Overall scores of 16 and 15 (mild risk). Mobility scores of 2 and 2 (Very Limited ...unable to make frequent or significant changes independently). 3/27/2024 - 2 assessments recorded. Overall scores of 15 and 15 (mild risk). Mobility scores of 2 and 2 (Very limited). 3/28/2024 - 2 assessments recorded. Overall scores of 15 (mild risk) and 12 (high risk). Mobility scores of 2 and 2 (Very limited). 3/29/2024 - 2 assessments recorded. Overall scores of 12 (high risk) and 15 (mild risk). Mobility scores of 2 (very limited) and 3 (slightly limited). 3/30/2034 - 2 assessments recorded. Overall scores of 15 (high risk) and 14 (moderate risk). Mobility scores of 3 and 3 (slightly limited). 3/31/2024 - 2 assessments recorded. Overall scores of 16 (mild risk) and 12 (high risk). Mobility scores of 3 and 3 (slightly limited). 4/1/2024 - 2 assessments recorded. Overall scores of 12 (high risk) and 16 (mild risk). Mobility scores of 3 and 3 (slightly limited). Braden scale documentation indicates risk for pressure injuries for patient #1 of “high risk” at times with bed mobility assessed 7 times over a 1 week period as “very limited” (inability to make significant changes in position independently). A review of Physical Therapy Scoring tool revealed, “...Scoring 1 - Total/Assist of 2 (or unable); 2 - A lot (modA (moderate assist) or maxA (maximum assist)); 3 - A little (minA (minimum assist)); 4 - None (no physical assist, ind (independent) or SBA (stand by assist))...” A review of Physical Therapy Note dated 3/25/2024 at 2:17 PM revealed, “...How much help from another person do you currently need...1. Turning from your back to your side while in a flat bed without using bedrails? 3; 2. Moving from lying on your back to sitting on the side of a flat bed without using bedrails? 3; 3. Moving to and from a bed to a chair (including a wheelchair)? 2; 4. Standing up from a chair using your arms (e.g., wheelchair, or bedside chair)? 2; 5. To walk in hospital room? 1; 6. Climbing 3-5 steps with a railing? 1...” A review of repositioning schedule revealed no documentation was found that indicated Patient #1 was repositioned by staff or that staff assisted repositioning every two hours. Inconsistent documentation of Patient #1 “self” repositioning found. An interview was conducted with Registered Nurse (RN) J on 5/28/2024 at 2:15 PM. When asked how a patient’s skin is assessed on admission or transfer, RN J stated that 2 nurses check skin and both sign off on the nursing assessment. When asked how often patient’s skin is assessed, RN J stated, “I assess my patient’s skin every day and I update the patient and family on wound care and the plan for healing.” When asked how repositioning is documented in a patient’s record, RN J stated that there is a “turning schedule” that should be documented on every 2 hours. An interview was conducted with Wound Care Nurse (RN) K on 5/28/2024 at 2:28 PM. When asked which patients are seen by Wound Care, RN K stated that he/she gets notified to consult on a patient and that there would be no consult conducted unless it was requested and ordered by a physician. RN K stated that they often write wound care orders for patients in-house, and then the physicians will copy and paste these orders into the discharge summary and discharge instructions at discharge. There is no evidence this occurred in this case, as the Discharge Summary does not contain information or instructions regarding wound care. When asked if repositioning should be always be documented in the repositioning schedule, RN K stated, “Yes.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 43037 Based on record review and interview the facility staff failed to provide necessary information at discharge to the patient and patient’s family regarding the follow up care and treatment of an identified pressure ulcer, a referral for physical/occupational therapy, and the need for supplemental oxygen in 1 of 10 medical records reviewed (Patient #1). Findings include: A review of Patient #1’s medical record revealed Patient #1 was admitted to the facility on 3/22/2024 with complaints of weakness, fatigue, poor oral intake and dizziness. Patient #1 was found to be in mixed obstructive/cardiogenic shock (shock caused by the obstruction of blood flow and dysfunction of the heart) and required transfer to Other Hospital O for a higher level of care which occurred within the first 4 hours of Patient #1’s admission. Patient #1 was then transferred back to this facility on 3/25/2024 for continued hospitalization until discharge on 4/2/2024. Note that due to a cyberattack on this facility and others in the hospital system nation-wide on 5/8/2024, the facility is unable at this time to provide copies of Patient #1’s “After Visit Summary”, a document provided to all patients upon discharge outlining all discharge instructions including, but not limited to those for medications, follow up appointments, scheduled therapy, wound/dressing care and illness information. Oxygen needs at Discharge An interview was conducted with Complainant A on 5/23/2024 at 11:19 AM. Complainant A stated Patient #1 never used oxygen during the day, but required the use of oxygen at night when going to bed. A review of Patient #1’s medical record “Internal Medicine...History and Physical” dated 3/25/2024 at 1:22 A.M. revealed, “...Assessment and Plan...Supplemental O2 (oxygen) to maintain SPO2 (saturation of peripheral oxygen - amount of oxygen in blood) 88-92%...” A review of Patient #1’s medical record “Internal Medicine Discharge Summary” dated 4/2/2024 at 11:15 PM revealed “...On 3-4 L (liters) O2 (oxygen) NC (nasal canula) at baseline...” No documentation of need for oxygen upon discharge. Plan of Care note dated 4/2/2024 at 11:56 PM revealed, “(Patient #1) was discharged home with (Complainant A) @ 10:00 PM. (Patient #1’s) original discharge at 8:00 PM was delayed due to a lack of an oxygen tank needed for discharge. (Patient #1’s) family retrieved one and (Patient #1/Complainant A) were provided discharge teaching, and left using (Patient #1’s) own wheelchair from home.” No documentation was found related to the patient’s home oxygen orders at admission. No documentation of a change in oxygen needs was found. No order for a change in oxygen use was found in Patient #1’s discharge summary. No documentation found of a discussion with Patient #1 or family member regarding need for an oxygen tank for use at discharge. Due to the cyberattack, unable to verify instructions received by Patient #1 in their After Visit Summary. An interview was conducted with Case Management Manger M on 5/28/2024 at 3:09 PM. When asked how patients and family members get information regarding discharge plans, Manager M stated that every situation is unique. Patients may refuse to have family members included in discussions of plans, and if the patient does not have an activated POAH (power of attorney for healthcare) there may not be a need to discuss discharge plans with family members. Manager M stated that there must be an order to fax to oxygen supply agencies when a patient is going home on O2 (oxygen) or if they have home O2 and the required needs change. Pressure Injury care and treatment after discharge An interview was conducted with Patient #1’s adult child on 5/23/2024 at 11:19 who stated that Patient #1 had multiple pressure ulcers on his/her coccyx which were discovered sometime after returning home on 4/2/2024. Patient #1’s adult child also stated the discharge paperwork and verbal instructions did not include information for the presence or treatment of Patient #1’s pressure ulcers. Daily skin assessments for patient #1 from 3/25/2024 (admission) through 4/1/2024 do not include any documentation of skin breakdown, bedsores or wounds. Skin assessment dated 4/2/2024 at 8:49 AM revealed, “...Skin location: Coccyx, Skin location orientation: Mid, Skin Integrity: Abrasion, Skin Color: Erythemia (redness of the skin which occurs with skin injury)...Type of Wound: Pressure ulcer...Pressure Injury Properties: Date first assessed/Time first assessed: 4/2/2024 8:54 AM...Dressing Status: Clean, Dry, Intact, Dressing changed: New, Staging: Stage I, State of Healing: Early...Wound Assessment: Fragile...Dressing: Foam...10:15 PM: Skin Location: Coccyx...Skin Integrity: Abrasion, Skin Color: Erythemia, Skin Condition/Temp: Warm...” Patient #1 was discharged on 4/2/2024 (same day the pressure injury was first documented). Due to the inability to access Patient #1’s After Visit Summary, there is no evidence that information was provided at discharge related to follow-up care for patient #1’s stage 1 pressure injury to the coccyx. Physical Therapy (PT)/Occupational Therapy (OT) needs at discharge A review of Patient #1’s medical record revealed History and Physical dated 3/25/2024 at 1:22 AM, “...PT/OT (Physical Therapy/Occupational Therapy) consults...” Physical Therapy Evaluation dated 3/26/2024, “...Discharge Recommendations:...Recommend continued multidisciplinary therapy after hospital stay...Assessment: (Patient #1) is a 80 y.o. (year old) male/female admitted with acute B (bilateral) PE (pulmonary embolism) s/p (status post) systemic tPA (medication used to dissolve blood clots and restore blood flow) at (other hospital), now transferred back...Presents below functional baseline, limited by severe deconditioning, dyspnea with minimal activity, impaired endurance and balance...Will benefit from skilled PT intervention in order to progress mobility as tolerated...Plan: PT m-f (Monday-Friday)...” Occupational Therapy note dated 3/28/2024 at 8:49 AM revealed, “...Discharge recommendations:...Recommend continued multidisciplinary therapy after hospital stay...” Internal Medicine Progress Note dated 3/26/2024 at 12:16 PM revealed, “...Decreased Functional Mobility:...HHC (Home Health Care) and therapy referrals sent and pending...” Internal Medicine Progress Note dated 4/1/2024 at 7:49 AM revealed, “...Plan...Family agreed to take the patient home with home PT/OT. Social worker working on arranging home health...” Internal Medicine Discharge Summary dated 4/2/2024 at 11:15 PM revealed, “...Forward to PCP (Primary Care Physician): PCP to do:...Other Issues Requiring O/P F/U (Outpatient follow up): Charged with home health PT/OT due to continued functional impairment requiring assistance...Decreased Functional Mobility:...Due to the prolonged hospital stay (Patient #1) was able to continue to work with PT and OT and was able to achieve functional status that permitted him/her to go home with home health care, PT, OT...” Due to the inability to access Patient #1’s After Visit Summary, there is no evidence of orders sent to or received by PT, OT or home care agencies. There was no documentation in the social work note indicating that the referral for services had been made and identifying the agency that would provide services.”