Aurora St Lukes Medical Center

“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 and interview, the facility failed to perform a comprehensive medical screening exam for 1 of 20 patients (Patient #1) in a total sample of 20 ED medical records reviewed. Findings Include: A review of Patient #1’s medical record from Hospital A revealed Patient #1 was a 49-year-old female who presented to Hospital A’s Emergency Department (ED) on 05/15/2026 at 2:51 PM with a chief complaint of arm laceration. Patient #1 stated she was stabbed with a knife on accident. C-SSRS (Columbia Suicide Severity Rating Scale)- initial screening was completed on 05/15/2026 at 3:00 PM with results of the evaluation being negative. A review of the “ED Provider Notes” from Hospital A on 05/15/2026 at 4:23 PM written by ED Physician Assistant (PA) K revealed, “ ... Patient... with complaint of laceration to the left forearm. My differential diagnosis includes but not limited to laceration ... Patient presents a linear laceration to the left forearm. Patient states that this was incidental because by her being startled by her child while cutting food at home ... During patient stay in the ED, local police presented and informed me that the patient will be chaptered, I am unsure of the specifics behind this ... Patient’s wound was anesthetized, cleaned, and well-approximated using 5 simple interrupted sutures... Disposition: Pt. is discharged home/self-care in stable condition.” A review of the “ED Timeline” from Hospital A on 05/15/2026 at 4:25 PM written by ED RN M revealed, “Pt. (Patient) left in PD custody.” There was no evidence of a mental health evaluation performed. A review of Patient #1’s medical record from Hospital B revealed Patient #1 arrived at Hospital B in police custody on 05/15/2026 at 5:04 PM. Patient #1 presented with complaint of suicidal ideation. Psychiatric evaluation completed on 05/15/2026 at 6:05 PM written by Physician N revealed, “... presented... on a CH. (Chapter) 51 after she reportedly cut herself with a knife while in the midst of an argument...” A review of “ED Note” from Hospital B on 05/15/2026 at 6:17 PM written by ED RN O revealed, “Patient presented to [Hospital B] on an Emergency Detention via [name of police department]. Per the Emergency Detention report, officers were dispatches (sic) for a woman who cut herself, unsure if intentional. Officers spoke with the patient’s daughter who advised her and her mother got into a verbal argument over last night issues. During the verbal fight, the patient ran at [daughter]. [Daughter] then restrained her mother by her arms. [Daughter] stated this is not like her mother and believed she was in a mental health crisis. [Daughter] told her mother she was leaving during the fight, which the patient stated, “I’m not going to make it without you.” [Daughter] then saw her mother with blood coming from her arm and her holding a knife. The patient said she would be fine and was driving herself to the hospital. The police located the patient at [Hospital A]. The patient denied intentionally cutting herself, but then advised (sic) in her mental health crisis, she cut herself intentionally but went too deep ... She doesn’t recall getting the knife or cutting herself ... Patient denies any current suicidal thoughts ... The patient is being discharged with outpatient resources.” During an interview on 06/17/2026 at 1:21 PM, ED PA K stated that Patient #1 came into the ED for repair of a laceration. ED PA K stated Patient #1 claimed the injury was an accident, and there was no mention of thoughts of suicide or self-harm. ED PA K stated the laceration was on the radial forearm edge, not near the wrist where attempts to self-harm are noted. ED PA K stated that in hindsight he should have put two and two together. ED PA K stated it didn’t register that the police would be taking Patient #1 to another hospital. ED PA K stated he did not ask the police officer any questions when he was told there was a Chapter 51 hold in place and was not aware that the police officer was taking Patient #1 to another hospital. During an interview on 06/17/2026 at 10:17 AM, Director of Quality B confirmed the above findings and stated Hospital A’s ED PA knew the patient was on a Chapter 51 hold but did not ask any questions and discharged the patient in police custody. “The PA should have inquired as to where the patient was going to be taken...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47413 Based on record review and interview, facility staff failed to provide a notice of patient rights in 3 out of 10 patients (Patients #7, 9, 10) medical records reviewed in a total universe of 10 patient medical records. Findings Include: A review of the hospital’s policy #2689 titled, “MW Region Patient Rights and Responsibilities” last revised 08/02/2024 revealed, “... A. Informing Patients of their Rights and Responsibilities During Hospital Admission... 1. During registration, the Patient Access or admitting team member will inform patients/Legal Decision-Makers of their rights and provide the patient/Legal Decision-Maker with a copy of Your Rights and Responsibilities as a Patient...” Review of Patient #7’s medical record revealed Patient #7 was admitted for a large ICH (intra-cranial hemorrhage- a life-threatening type of stroke that occurs when bleeding suddenly bursts into brain tissue, destroying brain cells and causing high pressure within the skull) on 05/14/2026. There was no evidence of patient rights being reviewed with or given to Patient #7. Review of Patient #9’s medical record revealed Patient #9 was admitted for a GI (gastro-intestinal) bleed and an EGD (esophagogastroduodenoscopy- a procedure to examine the lining of the esophagus, stomach, and the first part of the small intestine) on 06/12/2026. There was no evidence of patient rights being reviewed with or given to Patient #9. Review of Patient #10’s medical record revealed Patient #10 was admitted for a fall and back pain on 06/08/2026. There was no evidence of patient rights being reviewed with or given to Patient #10. During an interview on 06/16/2026 at 1:31 PM with Patient Access Manager P, she stated that if the patient does not have an active decision-maker or power of attorney, that the patient needs to sign that they received their rights.”

“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: 47413 Based on record review and interview staff failed to follow-up on weight discrepancies in 4 of 5 patients (Patients #1, 2, 5, 6) with a weight discrepancy; failed to obtain daily weights in 5 of 5 patients (Patients #1, 2, 5, 6, 8) with daily weights ordered and failed to provide daily hygiene per unit standard in 6 of 10 patients (Patients #1, 2, 3, 6, 8, 9) in a total of 10 medical records reviewed. Findings Include: A review of the hospital’s document (no number) titled, “Unit Operations Guide: Unit: 11S...” last revised 11/03/2025 revealed, “... Nursing Assistant Responsibilities: Daily soap and water bath... Weights (Daily...); Daily Weights, Daily Bathing (when): Daily bed weights are to be completed by the night shift CNA (certified nursing assistant) during AM (morning) vitals... Daily bathing is to be completed by the day shift CNA at any time during the 0700-1530 (7:00 AM-3:30 PM) shift. If this is unable to be done during shift, then responsibility falls to PM shift CNA...” A review of the hospital’s policy #73355 titled, “Nursing Documentation Policy...” effective 06/12/2025 revealed, “... C. Plan of Care: ... The RN individualizes the plan of care for the patient by selecting the appropriate goals/outcomes and interventions for that patient...” Examples of failure to follow-up on weight discrepancy: A review of Patient #1’s medical record revealed he was admitted on 04/05/2026 for a GI (gasto-intestinal) bleed with an order for daily weights. Admission weight on 04/05/2026 revealed Patient #1 weighed 180 lbs (pounds). Review of the record revealed the following weights: -04/07/2026 at 5:00 AM: 194 lbs (14-pound weight gain from 04/05/2026) -04/09/2026 at 5:01 AM: 172 lbs (22-pound weight loss from 04/07/2026) -04/10/2026 at 4:44 AM: 166 lbs (6-pound weight loss from 04/09/2026) -04/16/2026 at 4:06 AM: 158 lbs -04/19/2026 at 5:44 AM: 170 lbs (12-pound weight gain from 04/16/2026) -04/21/2026 at 6:00 AM: 187 lbs (17-pound weight gain from 04/19/2026) -04/23/2026 at 4:04 AM: 194 lbs -04/24/2026 at 4:26 AM: 179 lbs (15-pound weight loss from 04/23/2026) There was no evidence in the medical record that staff re-checked Patient #1’s weight or notified the dietician or physician of the weight discrepancy. A review of Patient #2’s medical record revealed that Patient #2 was admitted on 03/25/2026 for weakness with an order for daily weights. Admission weight on 03/26/2026 revealed Patient #2 weighed 187 lbs. Review of the record revealed the following weights: -03/27/2026 at 4:47 AM: 196 lbs (9-pound weight gain from 03/26/2026) -04/01/2026 at 6:05 AM: 197 lbs -04/02/2026 at 6:00 AM: 181 lbs (16-pound weight loss from 04/01/2026) There was no evidence in the medical record that staff re-checked Patient #2’s weight or notified the dietician or physician of the weight discrepancy. A review of Patient #5’s medical record revealed Patient #5 was admitted on 04/29/2026 for leg weakness with an order for daily weights. Admission weight on 04/29/2026 revealed Patient #5 weighed 300 lbs. Review of the record revealed the following weights: -04/30/2026 at 1:00 PM: 308 lbs (8-pound weight gain from 04/29/2026) -05/01/2026 at 5:00 AM: 314 lbs (6-pound weight gain from 04/30/2026) -05/04/2026 at 10:43 AM: 288 lbs (26-pound weight loss from 05/01/2026) There was no evidence in the medical record that staff re-checked Patient #5’s weight or notified the dietician or physician of the weight discrepancy. A review of Patient #6’s medical record revealed Patient #6 was admitted on 05/01/2026 for right hip pain with an order for daily weights. Admission weight on 05/01/2026 revealed Patient #6 weighed 103 lbs. Review of the record revealed the following weights: -05/06/2026 at 6:00 AM: 100 lbs -05/07/2026 at 4:27 AM: 109 lbs (9-pound weight gain from 05/06/2026) -05/12/2026 at 4:06 AM: 125 lbs (16- pound weight gain from 05/07/2026) There was no evidence in the medical record that staff re-checked Patient #6’s weight or notified the dietician or physician of the weight discrepancy. During an interview on 06/17/2026 at 10:50 AM with RN (Registered Nurse) Manager W she stated that if there is a weight discrepancy, the patient should be re-weighed, and the discrepancy should be escalated to the dietician or physician. Examples of failure to obtain daily weights: A review of Patient #1’s medical record revealed an order, “Weigh Patient- Daily 04/06/2026 0600 (6:00 AM) Until Specified.” Review of Patient #1’s “Flowsheet History” revealed that staff did not record Patient #1’s weight on 04/08/2026, 04/11/2026, 04/13/2026, 04/17/2026, 04/18/2026, 04/20/2026, 04/25/2026 and 04/27/2026. A review of Patient #2’s medical record revealed an order, “Weigh... Daily 03/26/2026 0600 Until Specified.” Review of Patient #2’s “Flowsheet History” revealed that staff did not record Patient #2’s weight on 03/28/2026, 03/29/2026 and 03/30/2026. A review of Patient #5’s medical record revealed an order, “Weigh... Daily 04/30/2026 0600 Until Specified.” Review of Patient #5’s “Flowsheet History” revealed that staff did not record Patient #5’s weight on 05/02/2026, 05/03/2026, and from 05/05/2026-05/13/2026. A review of Patient #6’s medical record revealed an order, “Weigh... Daily 05/03/2026 0600 Until Specified.” Review of Patient #6’s “Flowsheet History” revealed that staff did not record Patient #6’s weight on 05/04/2026, 05/09/2026, 05/10/2026 and 05/11/2026. A review of Patient #8’s medical record revealed an order, “Weigh... Daily 06/07/2026 0600 Until Specified.” Review of Patient #8’s “Flowsheet History” revealed that staff did not record Patient #8’s weight on 06/07/2026. During an interview on 06/17/2026 at 10:51 AM with RN Manager W, she stated that if there is a physician order for daily weights that staff need to follow the order. Examples of failure to provide daily hygiene per unit standard: A review of Patient #1’s medical record revealed an admission from 04/05/2026-04/28/2026. Review of Patient #1’s “Flowsheet History” revealed that Patient #1 received a “Soap/Water bath” 14 days and “Hair Washed” 1 day in his 23-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #1 was only provided “Perineal care and Catheter care.” A review of Patient #2’s medical record revealed an admission from 03/25/2026-04/02/2026. Review of Patient #2’s “Flowsheet History” revealed that Patient #2 received a “Soap/Water bath” 3 days and “Hair Washed” 1 day in her 8-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #2 was only provided “Perineal care and Catheter care.” A review of Patient #3’s medical record revealed an admission from 04/14/2026-04/22/2026. Review of Patient #3’s “Flowsheet History” revealed that Patient #3 received a “Soap/Water bath” 1 day and “Hair Washed” 0 days in her 8-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #3 was only provided “Perineal care and Catheter care.” A review of Patient #6’s medical record revealed an admission from 05/01/2026-05/12/2026. Review of Patient #6’s “Flowsheet History” revealed that Patient #6 received a “Soap/Water bath” 7 days and “Hair Washed” 0 days in her 11-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #6 was only provided “Perineal care and Catheter care.” A review of Patient #8’s medical record revealed an admission from 06/06/2026-06/09/2026. Review of Patient #8’s “Flowsheet History” revealed that Patient #8 received a “Soap/Water bath” 1 day and “Hair Washed” 0 days in her 3-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #8 was only provided “Perineal care and Catheter care.” A review of Patient #9’s medical record revealed an admission from 06/12/2026-current (at the time of survey). Review of Patient #9’s “Flowsheet History” revealed that Patient #9 received a “Soap/Water bath” 2 days and “Hair Washed” 0 days in his current 5-day hospitalization. Review of the “hygiene flow sheets” revealed all other days a soap/water bath was not provided and that Patient #9 was only provided “Perineal care and Catheter care.” During an interview on 06/17/2026 at 10:50 AM with RN Manager W, she stated that a daily “soap and water” bath should be “asked and offered” to every patient, and that hair washing is separate from the soap and water bath. She stated, “Bathing is part of the daily routine.””

“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: 50644 Based on record review and interview, the facility failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 7 patients (Patient #1) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed. Findings Include: A review of the facility’s policy titled, “MW Region EMTALA (Emergency Medical Treatment and Labor Act)” last revised 12/09/2024 revealed, “...b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to transfer that:...agrees to accept the Transfer...Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient’s medical record...” A review of Patient #1’s medical record revealed Patient #1 was a 42 year old male who presented to Hospital A’s Emergency Department (ED) on 07/27/2025 at 9:55 AM with a chief complaint of suicidal ideations. Further review of Patient #1’s “ED Nursing Notes” on 07/27/2025 at 2:00 PM written by ED RN (Registered Nurse) X revealed, “...Ride arranged per pt [patient] request to go to [Hospital B].” A review of the “ED Provider Notes” on 07/27/2025 at 2:01 PM written by ED Physician’s Assistant (PA) Y revealed, “...After being informed of discharge, patient requested assistance with transportation. He states that he wants to go to a specific facility where he has gone in the past. After further research, this facility is apparently [Hospital B]. We did not advise or suggest that this patient go to [Hospital B], he has made this decision on his own following discharge.” There was no evidence of an appropriate transfer being initiated, no evidence Hospital B was notified or accepted Patient #1 for transfer, and no evidence of physician to physician communication completed. During an interview on 08/13/2025 at 2:59 PM, Safety Manager V confirmed the above findings and stated [ED RN X] “went against the plan of care.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47413 Based on record review and interview, facility staff failed to appropriately transfer a patient receiving care in the ED (Emergency Department) to another facility in 1 of 9 patients (Patient #1) who were transferred in a total universe of 20 patient medical records reviewed. The facility failed to appropriately transfer a patient receiving care in the ED to another facility. See Tag A-2409.”

“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: 47413 Based on record review and interview, facility staff failed to follow their hospital policy to appropriately transfer a patient receiving care in the ED (Emergency Department) to another facility in 1 of 9 patients (Patient #1) who were transferred in a total universe of 20 patient medical records reviewed. Findings Include: A review of the facility’s policy titled, “MW Region EMTALA (Emergency Medical Treatment and Labor Act)” last revised 12/09/2024 revealed, “ ... b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to transfer that: ... agrees to accept the Transfer ... Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient’s medical record ...” A review of Patient #1’s medical record revealed that Patient #1 was a 58-year-old male with a history of diabetes, depression and suicidal ideation who presented to Hospital A on 03/19/2025 at 1:38 PM for shoulder pain and depression. Patient #1 was discharged from Hospital A in stable condition on 03/19/2025 at 9:08 PM via cab arranged by Hospital A staff to Hospital C. Patient #1 presented to Hospital C on 03/19/2025 at 9:46 PM for depression. During an interview on 04/29/2025 at 12:41 PM with ED Manager E, when asked about Patient #1, ED Manager E stated, “It was the patient’s request to go to [Hospital C]. He told [ED RN I] this information. [Patient #1’s] disposition should have been to transfer instead of discharge based on his request to go to [Hospital C].””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50646 Based on record review and interview, the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 8 patients (Patient #1), and failed to document risks of transfer for 4 of 8 patients (Patients #3, 4, 5, 6) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed. Findings include: The facility staff failed to appropriately transfer patients receiving care in the Emergency Department. See Tag A-2409.”

“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: 50646 Based on record review and interview, the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 8 patients (Patient #1), and failed to document risks of transfer for 4 of 8 patients (Patients #3, 4, 5, 6) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed. Findings include: Review of Facility Policy #19290, “[Facility] EMTALA (Emergency Medical Treatment and Labor Act)” dated 12/09/2024 revealed: ...D. Stabilization, Transfer, or Discharge 1. Transfer or Discharge of a Patient: A physician or QMP [Qualified Medical Personnel] may discharge or Transfer a Stable patient from the hospital to a Recipient Hospital for ongoing care if the following are met: a) The physician or QMP documents that an appropriate MSE [Medical Screening Exam] has been completed and : 1. The patient does not suffer from an EMC [Emergency Medical Condition]; or 2. The patient had an EMC, but the physician or QMP has determined with reasonable clinical confidence that the patient has been Stabilized and has reached the point where the patient’s continued care, including diagnostic work-up, treatment, and/or other follow-up care could reasonably be performed in another setting ...Unstable Patient Transfers: ...A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form ... A representative of the Recipient Hospital must confirm prior to Transfer ...” A review of Patient #1’s medical record revealed Patient #1 was a 21 year-old who presented to Hospital A’s ED on 01/15/2025 at 9:15 PM for a self-inflicted wrist laceration, in police custody, under a Chapter 51 hold (involuntary psychiatric hold). Patient #1 was discharged into police custody on 01/15/2025 at 11:20 PM to be transported to Hospital B. There was no evidence found that a transfer form was completed, no evidence Hospital B was notified and accepted the transfer, and no physician-to-physician handoff completed. Review of Emergency Department Practitioner Note written by Physician Assistant F, dated 01/15/2025 at 11:26 PM revealed: “[Patient #1] is a 21 year old female who presents to the ED under a Chapter 51 hold for evaluation ...Patient will be discharged to [Hospital B] under a Chapter 51 hold.” During an interview on 02/26/2025 at 07:35 AM, ED RN (Registered Nurse) G stated that he never called and talked to Hospital B regarding Patient #1. During an interview on 02/26/2025 at 09:12 AM, Physician Assistant F stated that since Patient #1 came in with the police and Patient #1 was medically cleared that a transfer form was not needed, and Patient #1’s disposition could be selected as, “discharged.” Physician Assistant F stated that he never called and talked to a physician at Hospital B. Review of Patient (Pt.) #3’s ED medical record revealed Pt. #3 was a 34-year-old male who arrived in the ED on 01/15/2025 at 6:28 PM with a chief complaint of Suicidal Ideation. Pt. # 3 was transferred to receiving hospital on 01/15/2025 at 11:25 PM. A review of Pt. #3’s transfer form revealed no risks of transfer were documented. Review of Pt. #4’s ED medical record revealed Pt. #4 was a 44-year-old female who arrived in the ED on 01/19/2025 at 7:59 PM with a chief complaint of Suicidal Ideation and intentional overdose. Pt. #4 was transferred to a psychiatric hospital on 01/20/2025 at 12:45 AM. A review of Pt. #4’s transfer form revealed no risks of transfer were documented. Review of Pt. #5’s ED medical record revealed Pt. #5 was an 89-year-old female who arrived in the ED on 01/22/2025 at 05:15 AM, with a chief complaint of falling at home with a diagnosis confirmed of a right femur fracture and a prolonged QT interval [an extended duration of the electrical depolarization and repolarization of the heart’s ventricles (lower chambers). Pt. #5 was transferred to accepting facility via ambulance transfer on 01/22/2025 at 7:55 AM. A review of Pt. #5’s transfer form revealed no risks of transfer were documented. Review of Pt. #6’s ED medical record revealed Pt. #6 was a 27-year-old female who arrived in the ED on 02/05/2025 at 11:42 AM, with a chief complaint of Suicidal Ideation and Bipolar. Pt. #6 was transferred to a psychiatric hospital on 02/05/2025 at 9:30 PM. A review of Pt. #6’s transfer form revealed no risks of transfer were documented. During an interview on 02/26/2025 at 3:00 PM, when asked about the expectation for documentation of risks of transfer, Quality Director B stated it was the expectation that all sections of the transfer form be completed.”

“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: 29972 Based on record review and interview staff failed to initiate a nursing care plan with interventions and goals to address patient’s care needs related to skin in 1 of 10 medical records reviewed (Patient (Pt) #1); and failed to update and revise the nursing care plan with appropriate interventions and goals to reflect patient’s care needs related to falls 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 #23908 titled, “Nursing Documentation” last revised 12/13/2023 revealed, - “The plan of care is comprised of age and gender/sex-appropriate assessments, screenings, diagnoses/patient problems, goals/outcomes, and patient interventions and is documented in the EHR (Electronic Medical Record).” - “All inpatients will have an individualized plan of care initiated within 24 hours of admission and documented in the medical record.” - “Care plans can have multiple components/phases. The nurse will initiate only those phases appropriate to the patient’s condition.” - “The RN (Registered Nurse) individualizes the plan of care for the patient by selecting the appropriate goals/outcomes and interventions for that patient.” - “The RN may update the plan (s) by adding or deleting or revising outcomes/goals or interventions.” - “Nursing plans of care are initiated based on patient needs, medical diagnosis...” Review of “Attachment F: Adult-Post Fall Management Procedure” last revised 10/18/2024 revealed, - “b. Implement/modify risk for falls plan of care as appropriate...” Review of Pt #1’s medical record revealed Pt #1 was admitted to the inpatient hospital unit on 11/23/2024 at 5:30 PM and received surgery on 11/25/2024 for a Small Bowel Obstruction due to an incarcerated incisional hernia; Pt #1 was discharged home on 12/03/2024 at 12:17 PM. Review of Pt #1’s “Evaluation Post Fall” dated 12/01/2024 at 11:11 AM, revealed Pt #1 had an unwitnessed fall in the bathroom on 12/01/2024 at 11:01 AM. Per documentation, Pt #1 “turned around to flush and got tangled in her Vac (wound vac) cord...” Review of Pt #1’s Care Plan Event log revealed a care plan was opened for “At Risk for Falls” on 11/23/2024 at 4:30 PM. Review of the Care Plan Event log dated 12/01/2024 (after the fall on 12/01/24 at 11:01 AM) revealed there was no documentation that staff updated/revised the At Risk For Falls Care Plan in response to Pt #1 falling. Review of the Care Plan Event log dated 12/02/2024 revealed there was no documentation of nursing staff reviewing Pt #1’s Risk for Falls Care Plan and progress to goal. Per interview with Director of Nursing (DON) C on 02/19/2025 at 2:42 PM, DON C stated that if a patient falls, nursing staff should update/revise the Care Plan before the end of the shift. DON C stated that this should be documented and reviewed in the Care Plan Event Log. DON C Stated that Care Plans should be reviewed by nursing staff every shift. DON C was unable to provide documentation of nursing staff updating/revising Pt #1’s Care Plan post fall on 12/01/2024, and reviewing/updating the Risk for Falls Care Plan on 12/02/2024. Review of Physician (surgery) progress note dated 12/01/2024 at 11:36 AM (post op day 6) revealed Pt #1 had an open repair of incisional hernia with mesh placement on 11/25/2024. Per surgery progress note, “robotic incisions well approximated with dermabond. Midline incision is covered with prevena vac (wound vac)...There is noted area of blistering lateral to VAC dressing...” Review of Pt #1’s orders revealed an Inpatient Consult to Wound Care Medical Provider ordered on 12/01/2024 at 2:55 PM. Review of Pt #1’s Inpatient Wound Care Consult Note dated 12/02/2024 at 4:24 PM revealed, “(Pt #1) had a prevena vac in place which was removed on POD #7 (Post Operative Day) leaving a large superficial open wound from what appears to be a deflated blister...TRX (treatment): adaptic followed by ABD abd (abdomen) tape, change daily and prn (as needed) to prevent moist dressing...” Review of Pt #1 nursing flowsheets revealed a “Wound Abdomen Right Distal Blister” was “First Assessed” on 12/01/2024 at 3:04 PM. Per nursing assessment, the Wound Bed was “Pink;Red”, “Hydrogel” Topical Agent applied and a dressing was placed. Review of Pt #1’s Care Plan Event log for 12/01/2024 through 12/03/2024 (discharge), there was no documentation of staff opening a skin/wound Care Plan to address Pt #1’s skin concerns. Per interview with Director of Nursing (DON) C on 02/19/2025 beginning at 3:30 PM, DON C confirmed nursing staff did not open a skin/wound Care Plan. DON C stated that nursing staff should open a nursing Care Plan for skin if there are wounds and skin concerns that require monitoring and treatment.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) to another facility in 1 of 10 Patients (Patient #1) transferred in a total universe of 20 medical records reviewed. Findings include: The facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) to another facility. See Tag A-2409”

“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: 29963 Based on record review and interview, facility staff failed to appropriately transfer a patient receiving care in the Emergency Department to another facility in 1 of 10 Patients (Patient #1) who were transferred in a total universe of 20 Patient medical records reviewed. Findings Include: A review of facility policy #19290 “AAH EMTALA (Advocate Aurora Health Emergency Medical Treatment and Active Labor Act),” last revised 04/24/2024 revealed, “ ... D. Stabilization, Transfer, or Discharge 1. Transfer or Discharge of a Patient: A physician or QMP (Qualified Medical Professional) may discharge or Transfer a Stable patient from the hospital to a Recipient Hospital for ongoing care if the following are met: a) The physician or the QMP documents that an appropriate MSE (Medical Screening Exam) has been completed and (1) The patient does not suffer from an EMC (Emergency Medical Condition); or (2) The patient has an EMC, but the physician or QMP has determined with reasonable clinical confidence that the patient has been Stabilized and has reached the point where the patient’s continued care, including diagnostic work up, treatment and or other follow-up care could reasonable by performed in another setting... 3. Unstable Patient Transfers: An unstable patient may be transferred if hospital staff provide stabilizing treatment for the patient’s EMC within the Capacity and Capabilities of the Hospital and sections a-d below are met: a) A physician certifies the transfer ... (1) Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form ... (b) Recipient Hospital: A representative of the Recipient hospital must confirm prior to Transfer that: (1) The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and (2) Hospital staff should document any communication with the Recipient Hospital, including the date and the time of the Transfer request, and the name of the person accepting the Transfer in the patient’s medical record. (3) A Medicare participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department, is required to accept an appropriate transfer ...” A review of a blank hospital form titled, “Patient Transfer Documentation” revised 08/23 revealed, “1. Section 1. Physician Certification (Physician complete section 1 ...1. Diagnosis: 2. Reason(s) for Benefits of Transfer 3. Transfer Risks 4. Accepting Facility/Hospital has agreed to accept this patient transfer and has the available space and qualified personnel for the treatment of the patient. 5. Mode/Level of Care for transfer ...” A review of Patient #1’s ED medical record, “History” written by ED PA (Physician Assistant) L on 08/29/2024 at 2:57 PM revealed, “[Patient #1] is a 55-year-old (fe/male) presenting to the emergency department in police custody on a Chapter 51 hold (involuntary detention-initiated when a person is a danger to themselves or others) after making suicidal statements. Patient was arrested overnight and had a blood alcohol of 0.09 when (s/he) left the police station this morning. They were called to (his/her) house several hours later when (his/her) counselor alerted police that (s/he) was making suicidal statements about shooting (himself/herself) with a gun. With police present (s/he) was discussing (his/her) plan for suicide by cop. Patient admits to drinking additional alcohol this morning but is unable to quantify. (S/he) reports (s/he) recently lost his son, which triggered (his/her) depression and (his/her) thoughts that (s/he) no longer wishes to be alive. (S/he) denies any attempt to kill (him/herself) today. (S/he) answers by saying “I wish I had means to do that.” (S/he) denies any physical complaints ... Patient is a 55-year-old with complaint of suicidal ideation and alcohol intoxication in need of medical clearance in police custody. My differential diagnosis includes but is not limited to metabolic derangement, alcohol intoxication, electrolyte abnormality, overdose attempt among others. Medical clearance unremarkable with exception to high alcohol level. The patient was cleared for discharge into police custody for transfer to Milwaukee County [Hospital #2].” A review of Patient #1’s “ED timeline” from [Hospital #1], from 08/29/2024 at 2:46 PM through 08/29/2024 at 4:59 PM revealed, “2:46 PM: Patient arrived in ED at 2:46 ... 2:50 PM: Provider contact with patient ... 4:30 PM: Discharge Disposition Selected ... 4:42 PM: Departure Condition: Mobility at Departure: Ambulatory. Patient teaching: discharge instructions reviewed; Follow-up care reviewed; Patient verbalized understanding. Departure Mode: in police custody ... 4:59 PM: Patient discharged.” A review of Patient #1’s medical record revealed, there was no “Patient Transfer Documentation” completed by ED PA L when Patient #1 was discharged from Hospital A. ED PA L discharged Patient #1 from the facility in police custody under a Chapter 51 hold. The findings were confirmed with ED Manager J, who stated, “There was no transfer form completed, the provider did not call the facility to talk to a provider who accepted [Patient #1].” During an interview on 10/09/2024 at 3:20 PM with ED MD N who stated, “All patient transfers, including Chapter 51 patients in police custody require a phone call from doctor to doctor. Patients cannot be transferred unless a physician accepts the care.””

“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: 47413 Based on interviews and record review, facility staff failed to recheck a potassium level after IV (intravenous) potassium was completed per facility policy in 1 (Patient #1) of 10 patients; failed to provide a complete nursing handoff report for 1 (Patient #1) of 10 patients; failed to administer an insulin drip per physician order and facility policy for 1 (Patient #1) of 10 patients; and failed to assess and monitor for changes in condition in 1 (Patient #1) of 10 patients in a total sample of 10 medical records reviewed. Findings include: Staff failed to recheck a potassium level after IV potassium was completed per facility policy and failed to assess and monitor for changes in condition. See tag A-0395. Staff failed to provide a complete nursing handoff report and failed to administer an insulin drip per physician order and facility policy. See tag A-0405.”

“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: 47413 Based on interviews and record review, facility staff failed to recheck a potassium level after IV (intravenous) potassium was completed per facility policy in 1 (Patient #1) of 10 patients and failed to assess and monitor for changes in condition (blood sugars) in 1 (Patient #1) of 10 patients in a total sample of 10 medical records reviewed. Findings include: A review of Patient #1’s medical record revealed Patient #1 presented to the facility’s Emergency Department on 04/09/2024 at 9:06 AM with a chief complaint of nausea, chest heaviness and a headache. Patient #1’s history and physical revealed Patient #1 had a history of Type 1 Diabetes Mellitus. Further review of the medical record revealed Patient #1’s blood sugar was checked on 04/09/2024 and resulted high at 345 mg/DL (milligrams per deciliter; normal limits for persons with Type 1 diabetes is 80-130 mg/DL before meals) at 12:22 PM. Patient #1’s potassium level was found to be low, and potassium supplementation was ordered to be completed prior to the administration of insulin. Patient #1 was admitted to the inpatient unit on 04/09/2024 at 4:33 PM where his/her condition declined and was transferred to the ICU on 04/09/2024 at 6:50 PM with a diagnosis of Diabetic Ketoacidosis and a blood sugar critically high at greater than 600 mg/DL. A review of the facility order set titled, “ED DKA (Diabetic Ketoacidosis) Insulin Infusion” revealed, “Potassium Supplements and follow up labs: potassium CHLORIDE 20mEq (milliequivalents)/100mL (milliliters) IVPB (intravenous piggy back) premix: Potassium: recheck potassium level within 2 hours after total dose of supplements completed...Nursing Orders: Check Metered Blood Glucose (blood sugar): Routine, PRN (as needed), For suspected signs of hypoglycemia, hyperglycemia ...” A review of the facility’s policies revealed that there were no policies or protocols in place in the Emergency Department to ensure critically high blood sugars are followed up on outside of following medical staff order sets. A review of Patient #1’s medical record revealed that “potassium CHLORIDE 20mEq/100mL IVPB premix” was started on 04/09/2024 at 12:34 PM and was completed on 04/09/2024 at 2:30 PM. Review of the medical record revealed Patient #1’s potassium level was not checked again until 5:32 PM, over 3 hours after the potassium infusion was completed. A review of “History of Present Illness” written on 04/09/2024 at 2:53 PM by Endocrine MD L revealed, “...patient presented to the ED this morning with several symptoms in setting of having pump issue supplies. Patient reports administering [his/her] basal insulin prior to arriving to ED, but [s/he] couldn’t remember the dose. Our team was consulted close to 3 pm and most recent labs notable for BG (blood glucose) 345 ... This suggests patient is going into DKA, and DKA protocol insulin gtt (drip) ordered...Addition: noted change in patient’s condition per chart review after our consultation; patient now in florid (fully developed) DKA and admitted to the ICU. DKA protocol gtt as ordered was not started until [about] 3 hours later ...” Review of Patient #1’s medical record revealed: “Lab Ordered: ... POCT (point of care testing) METERED BLOOD GLUCOSE” was ordered on 04/09/2024 at 3:51 PM by Endocrinology PA P. A review of Patient #1’s medical record revealed there was no evidence additional blood sugars were checked in the Emergency Department past 04/09/2024 at 12:22 PM when Patient #1’s blood sugar resulted at 345 mg/DL. Further review of the medical record revealed the next documented blood sugar result was from a lab draw on 04/09/2024 at 5:32 PM and resulted as 615 mg/DL (no time noted when lab was drawn). A review of “Focus Note” on 04/09/2024 at 6:40 PM revealed, “On call hospitalist notified of change in patient status around 1814 (6:14 PM). STAT was called for increased work of breathing and confusion. Patient admitted for Type 1 DM with hyperglycemia (high blood sugar) 2/2 (secondary to) not using Omnipod pump due to non working controller. Patient started on IVFs (intravenous fluids), electrolyte supplementation and IV ceftriaxone (antibiotic). Insulin gtt was not initiated. Endocrinology was consulted in the afternoon. Recommended initiation of IV insulin DKA protocol. Patient arrived on [Inpatient unit] around 1630 (4:30 PM). Nursing staff noted worsening confusion, increased work of breathing ... A/P (Assessment/Plan): Worsening DKA ... Dispo: Transferring to [ICU] for ongoing case ...” During an interview on 06/27/2024 at 1:02 PM with ED RN N, when asked about rechecking a potassium level after the potassium infusion was finished, ED RN N stated, “I believe that it should be rechecked after the infusion is done.” An interview was conducted on 06/28/2024 at 2:23 PM with Director of Quality S. When asked to confirm Patient #1’s potassium level recheck, Director of Quality S stated, “Potassium Supplementation completed 4/9/24 at 1430 (2:30 PM); Potassium level rechecked 4/9/24 at 1732 (5:32 PM). During an interview on 06/28/2024 at 2:23 PM with Director of Quality S, when asked about policies on assessing patients in DKA, Director of Quality S stated, “Confirming there’s not a policy on assessing DKA and nurses would follow the order set.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47413 Based on interview and record review, the facility staff failed to provide a complete nursing handoff report for 1 (Patient #1) of 10 patients and failed to administer an insulin drip per physician order and facility policy for 1 of 10 patients reviewed (Patient #1) in a total sample of 10 patients reviewed. Findings include: A review of Patient #1’s medical record revealed Patient #1 presented to the facility’s Emergency Department on 04/09/2024 at 9:06 AM with a chief complaint of nausea, chest heaviness and a headache. Patient #1’s history and physical revealed Patient #1 had a history of Type 1 Diabetes Mellitus. Further review of the medical record revealed Patient #1’s blood sugar was checked on 04/09/2024 and resulted high at 345 at 12:22 PM. Patient #1’s potassium level was found to be low, and potassium supplementation was ordered to be completed prior to the administration of insulin. Patient #1 was admitted to the inpatient unit on 04/09/2024 at 4:33 PM where his/her condition declined and was transferred to the ICU on 04/09/2024 at 6:50 PM with a diagnosis of Diabetic Ketoacidosis and a blood sugar critically high at greater than 600 mg/DL (milligrams per deciliter; normal limits for persons with Type 1 diabetes is 80-130 mg/DL before meals). A review of the facility’s policy titled, “KAPS (Keep All Patients Safe)” last revised 05/2024 revealed, “ED (Emergency Department) RN (Registered Nurse) to call inpatient RN for all areas listed below ... Insulin drip and blood sugar checks...” A review of the facility’s policy titled, “Region Medication Administration” last revised 09/18/2023 revealed, “ ... Medication Timing: Medications not listed as time-critical care are considered non time-critical. These medications may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours ...” A review of the facility’s policy titled, “Region Time Critical Medications” last revised 05/31/2023 revealed that insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion was not listed as a time sensitive medication and would be considered a non-time-critical medication. A review of “History of Present Illness” written on 04/09/2024 at 2:53 PM by Endocrine MD L revealed, “...patient presented to the ED this morning with several symptoms in setting of having pump issue supplies. Patient reports administering [his/her] basal insulin prior to arriving to ED, but [s/he] couldn’t remember the dose. Our team was consulted close to 3 pm and most recent labs notable for BG (blood glucose) 345 [mg/DL] ... This suggests patient is going into DKA, and DKA protocol insulin gtt (drip) ordered...Addition: noted change in patient’s condition per chart review after our consultation; patient now in florid (fully developed) DKA and admitted to the ICU. DKA protocol gtt as ordered was not started until [about] 3 hours later ...” A review of Patient #1’s medical record revealed that “Care Handoff: Report given to floor” was completed on 04/09/2024 at 3:32 PM. A review of Patient #1’s medical record revealed, “04/09/2024 at 3:51 PM: Orders Placed [by Endocrinology PA P] ... insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion ...” A review of the medical record revealed, “Manage Orders: insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion” was acknowledged on 04/09/2024 at 4:39 PM by Inpatient RN M. Further review of the medical record revealed that insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion was not started until 04/09/2024 at 6:38 PM, three hours after it was ordered. A review of “Focus Note” on 04/09/2024 at 6:40 PM revealed, “On call hospitalist notified of change in patient status around 1814 (6:14 PM). STAT was called for increased work of breathing and confusion. Patient admitted for Type 1 DM with hyperglycemia (high blood sugar) 2/2 not using Omnipod pump due to non working controller. Patient started on IVFs (intravenous fluids), electrolyte supplementation and IV ceftriaxone (antibiotic). Insulin gtt was not initiated. Endocrinology was consulted in the afternoon. Recommended initiation of IV insulin DKA protocol. Patient arrived on [Inpatient unit] around 1630 (4:30 PM). Nursing staff noted worsening confusion, increased work of breathing ... A/P (Assessment/Plan): Worsening DKA ... Dispo: Transferring to [ICU] for ongoing case ...” An interview was conducted on 06/27/2024 at 1:02 PM with ED RN N. When asked about the report given to the inpatient unit, ED RN N stated that s/he did not know there was an order for an insulin drip placed and did not report that to the inpatient nurses. An interview was conducted on 06/25/2024 at 1:35 PM with Endocrine MD L. When asked about Patient #1’s insulin drip, Endocrine MD L stated, “Our expectation is that the drip needs to be started when it is ordered, no matter where it is ordered. In patients with DKA, it is better to start treatment sooner than later.” During an interview on 06/25/2024 at 2:20 PM with Manager of Quality B, when asked about order acknowledgement, Manager of Quality B stated, “The expectation is when orders are placed by a doctor, staff are expected to follow through with those orders.” An interview was conducted on 06/25/2024 at 2:30 PM with Inpatient RN M. When asked about the report s/he received, Inpatient RN M stated, “No I did not see the order, and I did not get a report about an insulin drip.” During an interview on 06/25/2024 at 4:10 PM with Inpatient Manager C, when asked about order acknowledgement, Manager C stated, “If you are reviewing and releasing your orders and you acknowledge them, you should have a plan to address the orders.””