Burnett Medical Center

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 51278 Based on record review and interview, facility staff failed to provide 1 to 1 (1-1) nursing supervision per physician order for 1 of 1 patient (Patient #2) in a total sample of 10 inpatient medical records reviewed. Findings Include: A review of the facility policy titled, “Sitters,” last revised 01/18/2023, revealed, “When the need has been identified, a sitter shall be ordered by the primary nurse...The sitter shall be instructed on maintaining a safe environment:...Keep the patient in view at all times. Do not leave the patient unattended at any time.” Patient #2 was a 78-year-old female with a history of recurrent Laryngeal Cancer, unspecified Dementia, admitted to the hospital on 11/15/2025 because her husband could no longer care for her at home. Patient #2 was transferred on 11/24/2025 for treatment of a fractured hip. While hospitalized Patient #2 was to receive 1-1 supervision. Review of Misconduct Incident Report review submitted on 11/25/2025 at 3:47 PM revealed, RN (Registered Nurse) A was assigned care for Patient #2, upon arrival RN A found Patient #2 exiting bed. RN A reported that he walked with Patient #2 up and down the hallway, redirected her back to her room and stated Patient #2 returned back to bed. RN A stated Patient #2 was left alone so care could be provided to another patient. “Shortly thereafter (unknown specific timeframe) CNA (Certified Nursing Assistant) L entered room and observed Patient #2 toward the foot of the bed in an awkward position.” “CNA L reports that Patient was unable to reposition self to the head of the bed, appeared to be in pain and when asked if Patient #2 needed to use the bathroom nodded head “Yes.” “Patient #2 was unable to bear weight on left leg at this time.” 11/18/2025 at 11:35 AM, Pt. #2’s admission history and physical revealed, “She will require 1:1 sitter while inpatient.” 11/24/2025, “Inpatient Discharge Summary” at 10:29 AM by Physician J revealed an admitting diagnosis of Dementia and Laryngeal (Throat) cancer and a discharge diagnosis as the same with fall on 11/24/2025 resulting in a left hip fracture. Review of hospital course per this note revealed that Patient #2 when awake was frequently requiring 1:1 nursing care, communication was difficult as Patient #2 could not communicate in written format secondary to Dementia. “Unfortunately with her tendency to wander she did likely fall 11/24/2025 with discovery of a left hip fracture ...plan to pursue tertiary transfer for orthopedic care.” 11/24/2025, “Care Plan: Skin/Tissue Integrity-Adult” at 10:52 AM by RN A revealed, “Patient fell this morning unwitnessed; Patient has a fracture of the left hip from the fall. Patient is being discharged to a higher level of care to get the hip repaired from Ortho ...No sign of skin breakdown, no bruising noted yet from post fall.” A review of the multidisciplinary investigation team meeting minutes notes, held on 12/04/2025 at 9:00 AM as a follow up to Patient #2’s fall, revealed RN A was assigned 2 patients on 11/24/2025 which included Pt. #2 that required a 1-1 sitter. CMO (Chief Medical Officer) H said, “We would need to address how nurses are assigned and work on 1:1 care knowledge.” During an interview on 12/9/2025 at 2:45 PM RN A stated that upon arrival to his shift at 7:00 AM (on 11/24/2025) Patient #2 was restless and anxious, wanting to leave. RN A had been walking with Patient #2 up and down the hallway and was able to direct Patient #2 to bed, once Patient #2 was in bed RN A stated assistance was needed by another patient. RN A left the room. When RN A was asked how the lapse in 1-1 supervision contributed to Pt. #2’s injury, RN A stated, “She was a 1:1 and I had another patient.” RN A stated administration admitted this may have been a contributing factor and that they need to look into this process of assigning patients and those needing 1-1 supervision.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility staff failed to document notification of a physician and other appropriate care team members after a change in condition (fall) for 1 of 3 patients with falls (Patient #1) in a total of 10 medical records reviewed. Findings Include: A review of the facility’s policy titled, “Assessment and Reassessment” (no last revision date) revealed, “... Data collected shall be recorded in the nursing assessment record and shall be available to all those disciplines involved in the care of the patient...” A review of Patient #1’s medical record revealed Patient #1 was an 81-year-old who was admitted to the facility from 08/29/2024 through 09/03/2024 for respite care. Patient #1 was receiving home hospice services at the time of the hospital admission. A review of the nursing note documented in Patient #1’s medical record on 09/02/2024 at 6:46 AM revealed, “At 0520 (5:20 AM), pt had a fall and nursing staff responded immediately to find pt lying on the floor on her right side. Pt stated she did not hit her head, but her right hip was painful... Provider notified, no interventions at this time.” There was no evidence found in the medical record of documentation regarding notification of the telehealth provider or hospice, and no documentation regarding the outcome of those communications. During an interview on 10/29/2024 at 1:41 PM with Nurse Manager C, when asked about Patient #1, Nurse Manager C stated, “Staff contacted the provider using the Avel system (telehealth provider) after the fall occurred. The charge nurse contacted hospice and notified them of the patient’s fall.” During an interview on 10/30/2024 at 9:27 AM with Charge RN (Registered Nurse) K, when asked about if there was documentation in the medical record regarding contact with the [telehealth] provider or hospice after Patient #1’s fall, Charge RN K stated, “It should be detailed in my note.””

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 46812 Based on observation, staff interview, and review of maintenance records on 03/12/2024, Burnett Medical Center failed to construct, install, and maintain the building systems to ensure life safety to patients. The cumulative effects of the environment deficiencies result in the hospital’s inability to ensure a safe environment for all patients and staff. Findings include: The facility was found to contain the following deficiencies. 1. K131 Multiple Occupancies 2. K353 Sprinkler System - Maintenance and Testing 3. K362 Corridors - Construction of Walls 4. K521 HVAC 5. K908 Gas and Vacuum Piped Systems - Inspection and Testing Operations 6. K923 Gas Equipment - Cylinder and Container Storage As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET. See K-tags for details of the specific findings.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 41126 Based on observation, record review and interview the facility failed to ensure that crash carts containing emergency equipment and medications were maintained according to facility policy in 2 of 3 crash carts observed in 2 of 9 departments (Medical Surgical Unit and Emergency Department). Findings include: Medical-Surgical Department: Review of the facility policy titled, “Crash Cart Integrity” last reviewed 1/18/23 revealed, “Procedure: ...The Crash Cart Tag will be checked every day to ensure the cart is locked. ED (Emergency Department) and MS (Medical Surgical) will record the tag number of the Crash Cart on the daily checklist...Each Crash Cart will be checked by designated staff, restocked, and expirations checked every weekend and after each use...” On 3/12/2024 at 9:10 AM during a tour of the Med-Surg Department the Daily Checklist was reviewed. The checklist revealed the following dates had no documentation of a Crash Cart check and recording of the tag number; January 2024: 4,5,6,7,12,13,14 and February 2024: 5,12,13,14,15,17,18. The Checklist revealed the daily check of oxygen tanks was not performed on the following dates; January 2024: 4,5,6,7,11,19,31 and February 2024: 5,6,12,13,14,15,18, 25. On 3/12/2024 at 9:15 AM in an interview with Nurse Manager C, Manager C confirmed the missing documentation stating, “Of course that is supposed to be completed by nursing every day.” Emergency Department: On 3/12/2024 at 1:25 PM during a tour of the Emergency Department the emergency code cart had 2 Broselow Emergency tapes (a tape used as a quick reference in pediatric emergencies and provides pre-calculated emergency medications, airway and equipment sizes and defibrillator shock doses), both of which were out of date. One tape was dated 2007 and the other was dated 2011. The most current Broselow Emergency tape available is the 2023 updated version. In an interview on 3/12/2024 at 1:32 PM with Manager C when asked which of the two tapes were being used in pediatric emergencies stated, “I’m not sure which one is correct.” When asked if Manager C thought there should be an updated version in the code cart, Manager C stated, “Yes.””

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 41126 Based on observation, record review and interview, facility staff failed to ensure the emergency code cart was locked in 1 of 1 emergency code carts observed (Medical-Surgical unit) in a total of 4 code carts observed. Findings on the Medical Surgical unit: A review of facility policy titled, “Crash Cart Integrity” last reviewed 1/18/2023 revealed, “...The Crash Cart Tag will be checked every day to ensure the cart is locked...” On 3/12/2024 at 9:07 AM during a tour of the Medical Surgical unit accompanied by Medical/Surgical/Emergency Department Manager C, the emergency code cart, which contained emergency supplies and medications was found to be unlocked. When asked at that time if the code cart should be locked unless being used, Manager C stated, “Yes.” 43037”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 41126 Based on observation, interview and record review the failed to maintain refrigerators within in range as stated by facility policy and failed to report refrigerator temperatures out of range in 1 (Medical-Surgical) in 5 departments with refrigerators observed. Findings include: Review of the facility policy titled, “Refrigerators and Freezers- Dietary” dated 5/18/22 revealed, “Policy: Refrigerator temperatures shall be 40 degrees or colder...At any time time refrigerator or freezer is not within the acceptable range, it must be reported to the Maintenance Department immediately.” Observation on the Medical-Surgical unit on 3/12/2024 at 9:40 AM revealed a refrigerator at the nurses station which contained food items for patients; juices, sandwiches. Review of the document titled, “Med-Surg Department Daily Checklist” revealed the following dates where the refrigerator temperature was recorded above 40 degrees; January 2024: 1,2,3,7,8,9,10,11,14,15,18,20,21,22,26,28,29,30, 31 and February: 1,2,4,7,8,10,11,16,19,20,21,22,24,27,28, 29. There was no indication if the temperature had been adjusted and rechecked or if the out of range temperatures were reported to Maintenance. On 3/12/2024 at 9:40 AM in an interview with Nurse Manager C when asked if these out of temperature ranges had been reported to Maintenance per policy stated, “This is the responsibility of nursing. There is not a range reference on the checklist so I’m sure that they were not reported.””

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 46812 Based on observation, staff interview, and review of maintenance records on 03/12/2024, Burnett Medical Center failed to construct, install, and maintain the building systems to ensure life safety to patients. The cumulative effects of these deficiencies result in the hospital’s inability to ensure a safe environment for all patients and staff. Findings include: The facility was found to contain the following deficiencies. 1. K131 Multiple Occupancies 2. K353 Sprinkler System - Maintenance and Testing 3. K362 Corridors - Construction of Walls 4. K521 HVAC 5. K908 Gas and Vacuum Piped Systems - Inspection and Testing Operations 6. K923 Gas Equipment - Cylinder and Container Storage As a result of these deficiencies, 42 CFR 485.623(c) Life safety from fire was NOT MET. See K-tags for details of the specific findings.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 41126 Based on observation, interview and record review failed to ensure staff are documenting alcohol skin based preps are dry before applying drapes to the surgical patient per policy for 2 of 6 surgical records reviewed (Patient #8 & 9) in a total universe of 20 medical records reviewed. 43264 Surgical Preparation: The facility policy, titled “Surgical Skin Preparation”, dated 05/12/2022, revealed: “...11. Chlorhexidine products and alcohol-based prep products...Allow prepping solution to COMPLETELY DRY prior to draping...12. If using Chlorhexidine product:...d. Allow the prepping agent to dry for a minimum of 3 minutes before drape application and cautery activation. Chlorhexidine preps contain alcohol which gives off flammable vapors while drying. To reduce the risk of fire, inspect the prepped area prior to draping to confirm dryness...” A review of Patient #8’s medical record revealed, patient had a “Cholecystectomy, Laproscopic” (Gallbladder removal) procedure performed on 01/29/2024. The “Site Preparation” electronic patient flowsheet, completed by Surgical Circulating RN O, revealed that the “Abdomen” was documented as the site to prep with “Chlorhexidine”, there was no documentation (no checkmark confirming yes or no) that the skin prep was dry before draping. A review of Patient #9’s medical record revealed, patient had a “Total Laproscopic Hysterectomy [removal of uterus and cervix], Bilateral Salpingo-oophorectomy [removal of ovaries and fallopian tubes], Cystoscopy [surgical instrument insertion into the bladder]” procedure performed on 02/06/2024. The “Site Preparation” electronic patient flowsheet, completed by Circulating RN KK, revealed that the “Abdomen” was documented as the site to prep with “Chlorhexidine”, there was no documentation (no checkmark confirming yes or no) that the skin prep was dry before draping. During an interview on 03/13/2024 at 1:41 PM, Surgical Circulating RN O confirmed that skin prep dry times for Patient #8 and Patient #9 should have been documented.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 41126 Based on observation, interview and record review the facility staff failed to ensure supplies and medications were not expired in 5 of 5 (Outpatient, Emergency Department, Medical-Surgical unit, Radiology, Therapy) hospital patient care departments in a total sample of 9 departments observed and failed to appropropriately store medications in 1 of 3 (Medical-Surgical unit) medication units observed. Findings on the Medical-Surgical unit include: Review of facility policy titled, “Blood Glucose Monitoring” dated 1/18/2023 revealed, “Procedure... Control solutions are good for 90 days. New bottles must be marked with date when opened...” On 3/12/2024 at 9:20 AM observation on the Medical Surgical unit revealed a glucose monitoring device with 2 control solutions. The control solution bottles had been opened, neither control solution bottle was dated. On 3/12/2024 at 9:20 AM in an interview with RN F, RN F stated, “We are supposed to put a sticker with the date when we open those. These do not have those stickers.” On 3/12/2024 at 9:30 AM during a tour of the Medical-Surgical unit the following supplies and medications were found to be expired; a tongue depressor with an expiration date of 4/30/2022 and an Aquacel dressing with an expiration date of 09/2021 from the Wound Care kit, a Ventolin 90 mcg (microgram) inhaler (aerosol bronchodilator) with an expiration date of October 2021 and a Combivent inhaler with an expiration date of 11/16/2020 on a shelf in the medication room, Folic acid 10 ml (milliliters) with an opened sticker of 02/24/2024 on the top of a cart, an unopened laryngeal mask airway with an expiration date of 02/28/2024 in the emergency code cart and an unopened 3-way luer lock-stopcock with an expiration date of 10/19/2023 in a cabinet at the nursing station. The findings were confirmed in an interview with Manager C on 03/12/2024 at 9:30 AM who stated the items should have been disposed of and replaced with new supplies. On 03/12/2024 at 9:40 AM during a tour of the Medical Surgical unit the following medications were found lying on a cart in the medication room; Fluticasone nasal spray 50 mcg (micrograms) with a sticker with a patient’s name who is no longer an inpatient, Sprivia hand held inhaler 18 capsules with no patient label, and a Ventolin albuteral inhaler with a sticker with a patient’s name who is no longer an inpatient. The following medications were found in the medication refrigerator; a nearly empty vial of White Faced Hornet Venom with an expiration date of 2/16/2024 and a nearly empty vial of Wasp Venom with an expiration date of 2/16/2023. The vials had a sticker with a patient’s name who is no longer an inpatient. On 3/12/2024 at 10:19 AM in an interview with Manager C, Manager C stated s/he did not know why those were there, but since they were expired they should be thrown out. On 3/12/2024 at 3:30 PM in an interview with RN E, RN E stated, “I don’t know why these meds are even here - two of those patients were discharged a while ago and I have no idea who the capsules belong to. They should have all been sent back to pharmacy.” Findings in the Emergency Department: On 3/12/2024 at 1:35 PM during a tour of the Emergency Department the following supplies and medications were found to be expired; two vials of sodium chloride 10 ml (milligrams) in the rapid sequence intubation kits with expiration dates of 1/3/2024, and a Pediatric blood culture bottle with an expiration date of 2/21/2024. The expired sodium chloride findings were confirmed in an interview with Pharmacist M on 3/12/2024 at 1:35 PM. Pharmacist M stated, “Our techs check for expirations every month, not sure how this got missed.” The expired blood culture bottle was confirmed on 3/12/2024 at 1:45 PM by RN K who stated, “We don’t see many kids.” Findings in the Therapy Department: On 3/13/2024 at 8:15 AM during a tour of the Therapy department the following cleaning supplies were found to be expired; Sani-HyperCide 32 ounces expiration date 8/2020, two Sani-24 germicidal spray with expiration dates of 9/22 and 6/21, Hydrogen peroxide 1 quart spray with expiration date of 8/21/2021. Findings were confirmed during the tour with Compliance Officer A. Findings in the Radiology Department: On 3/13/2024 at 12:10 PM during a tour of the Radiology Department a 50 ml (milliliter) bag of 0.9% Na CL (sodium chloride) was observed with an expiration date of 01/24. This finding was confirmed by Radiation Manager G at 12.20 PM on 3/13/2024. Findings in the Outpatient Department: On 3/13/2024 at 10:11 AM during a tour of the outpatient department an IV (Intravenous) start kit was observed with an expiration date of 7/12/2023, and 3 Tegaderm dressings were with expiration dates of 3/09/2023 and 11/09/2023. This finding was confirmed by Manager C at 10:15 AM on 3/13/2024. 43037”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 41126 Based on observation, record review, and interview, the facility failed to maintain a sanitary environment free of potential contamination to patients in 3 of 9 departments observed (Medical-Surgical, Therapy, Emergency Department). Findings include: Review of the facility policy titled, “Sanitary Environment Guidelines” dated 8/2/2021 revealed,”Supply and Storage Areas...Clean supplies and equipment are clean and free of spills, stains, tape and adhesive residue and are kept separate from dirty supplies and equipment....”Linen and waste...soiled reusable instruments that require high-level disinfection or sterilization are pre-cleaned and stored and transported in a covered biohazard container...” A review of facility policy titled, “Sanitary Environment Guidelines” dated 8/2/2021 revealed, “...(Facility name) shall provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. All areas of the hospital must be clean and sanitary...” A review of facility policy titled, “Cleaning Patient Room-Discharge/Transfer” dated 5/8/2022 revealed, “...Damp dust overbed tables...with a hospital-approved germicidal solution...” Emergency Department: On 3/12/2024 at 1:04 PM during a tour of the Emergency Department accompanied by Manager C, round holes approximately 1/2 centimeter in diameter were found in the walls in rooms 2, 3, 4, 5 & 6. When asked about the holes, Manager C stated that there may have been something hanging on the walls which was removed and left the holes. When asked if the holes should be filled in because they could be an infection control risk, Manager C stated, “Yes, I’ll ask them to do that right away.” Therapy Department: On 3/13/2024 at 8:15 AM during a tour of the Therapy Department a portable whirlpool, covered with a sheet, and a hydrocollator (thermostatically controlled liquid heating device designed to heat packs in water), considered clean equipment, were observed in the dirty utility room. In an interview on 3/13/2024 at 8:30 AM with Physical Therapy Assistant X, Assistant X confirmed that both pieces of equipment are used on patients and are stored after cleaning. 43037 Medical/Surgical Department: On 3/12/2024 at 10:11 AM during a tour of the Medical Surgical department accompanied by Manager C, the dirty utility room was found to have a hopper (type of sink for disposal of clinical waste) directly adjacent to a handwashing sink. In an interview with Manager C at this time Manager C stated that there used to be a splash guard separating the hopper disposal unit and the handwashing sink but it kept falling off. When asked if Manager C agreed there should be a splash guard, Manager C stated, “Yes.” On 3/12/2024 at 10:22 AM during a tour of the Medical Surgical department accompanied by Registered Nurse D, the patient shower room was found to have 2 blue hard plastic bed pans on the floor next to the bathtub. In an interview with Registered Nurse D if the bed pans were single patient use or multi-patient use, Registered Nurse D stated, “I’m not sure.” When asked if the bed pans were clean or dirty, Registered Nurse D stated, “They should be clean, but they are on the floor.” On 3/12/2024 at 10:28 AM during an interview with Registered Nurse D, Registered Nurse D stated, “I found out about the bed pans. They are disposable and should have been thrown away.” On 3/12/2024 at 10:28 AM during a tour of the Medical Surgical unit accompanied by Registered Nurse D, a tour of empty room #107 revealed the overbed tray contained pens, a nail file, toothpicks, nasal spray and cough drops. When asked if room #107 was supposed to be a clean room ready for a new patient, Registered Nurse D stated, “Yes. I guess the housekeeper did not clean that tray from the last patient.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures. This Standard is not met as evidenced by: 43264 Based on observation, interview and record review the facility failed to provide staff training and education related to cleaning products and procedures for blood and body fluids spills for all clinical facility staff in a total 9 departments, the facility failed to provide staff training and education related to cleaning procedures for the Controlled Substance Waste Management System (Smart Sinks) for 2 of 2 departments (Medical Surgical unit & Emergency Department) in a total of 9 departments observed. Findings include: A review of facility policy, titled “Infection Prevention and Control Program”, dated 05/20/2022, revealed: “...Elements of the Infection Prevention and Control Program shall include:...Implementing policies and procedures to reduce the likelihood and spread of infections...Communicating and educating staff, patients and visitors regarding infection control processes. Infection control processes for the Environment of Care...” During an interview on 03/12/2024 at 3:30 PM with Infection Control RN V, when asked about training for staff who are expected to have contact with blood or other potentially infectious materials on blood borne pathogen standards, RN V stated “staff get annual training in healthstream [electronic competency-based training].” During observations on 03/13/2024 at 9:20 AM with EVS (Environmental Services) Manager DD on the Medical Surgical unit, observed 3 blood and body fluid spill kit bags in the dirty utility/housekeeping closet on the Medical Surgical unit and also observed 2 blood and body fluid spill kit boxes in a cupboard behind the Medical Surgical unit nurse’s station. During an interview on 03/13/2024 at 9:24 AM, EVS Manager DD stated that he/she is not sure where all of the spill kits are located in the facility departments and he/she has never ordered these kits - he has only been in the manager role for “one year.” During an interview on 03/13/2024 at 9:25 AM with EVS LL, when asked about using the blood and body fluid spill kits located in the dirty utility/housekeeping closet, EVS LL stated “I don’t know what those kits are for.” During an interview on 03/13/2024 at 9:28 AM with Nurse Manager C, when asked about the blood and body fluid spill kits in the cupboard by the Medical Surgical unit nurse’s station and the process for cleaning up spills, Manager C stated that if the spill is “containable, nursing will clean up - if a large spill, then we call housekeeping for help.” Nurse Manager C stated that the kits in the dirty utility/housekeeping closet on the Medical Surgical unit “should be thrown away” as the kits by the nurse’s station are the ones that are to be used. During an interview on 03/13/2024 at 9:55 AM with Emergency Department (ED) Registered Nurse (RN) AA, when asked the process for blood and body fluid spills, RN AA stated “We call housekeeping for assistance.” When asked if there are any blood and body fluid spill kits stored in the ED, he/she thought there were kits somewhere in the ED but wasn’t sure where. ED nursing staff started looking for blood and body fluid spill kits in ED and found 3 spill kits in Trauma Room #7. A review of the facility’s “Bloodborne Pathogens and Standard Precautions, Clinical” yearly healthstream staff training module revealed that there was no competency-based training related to blood and body fluid spills. On 03/13/2024 at 3:40 PM, EVS Manager DD and Quality Assurance Manager H confirmed there is no facility policy/procedure for staff to reference regarding blood and bodily fluid spills. 41126 Findings on the Medical Surgical unit and Emergency Department: Review of the Manufacturers Directions for Use for the “Smart Sink” revealed, “Cleaning the Smart Sink...it is recommended to perform routine cleaning in accordance with your facility policies and procedures.” On 3/12/2024 at 9:40 AM during a tour of the Medical Surgical unit a Controlled Substance Waste Management System called a “Smart Sink” was observed in the medication room. The unit had a large opening used to dispose of used medications that was visibly caked with a gray substance. On 3/12/2024 at 2:35 PM during a tour of the Emergency Department the same Controlled Substance Waste Management System called a “Smart Sink” was observed on a counter in the nurses station. The unit had a large opening used to dispose of used medications that was visibly caked with a gray substance. In an interview on 3/13/2024 at 10:00 AM with Pharmacy Manager L when asked about the care and maintenance of these Smart Sinks, Manager L stated, “ To be honest I have no idea how to maintain or care for these units. My tech takes care of emptying them when they are full but I do not truly understand anything about that unit.” When asked about cleaning the obvious gray matter from the opening Pharmacy Manager L stated, “I see what you mean but we do not have a policy on cleaning those units.””

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (4) Use objective measures to evaluate its organizational processes, functions and services. This Standard is not met as evidenced by: 43037 Based on record review and interview, the facility failed to maintain performance improvement projects based on data driven and ongoing audits for 1 of 1 quality assessment and performance improvement program in a total sample of 1 quality assessment and performance improvement programs reviewed. Findings: A review of facility policy titled, “Quality Improvement Policy” last reviewed 3/26/2022 revealed, “...All Department Quality Goals are aligned with (Facility name) Organizational Goals and Strategic Plan. New goals are set October of each Fiscal Year and are evaluated quarterly. Goal is for each department to have 2-3 goals aligned with the organizational goal...Department/Service Performance Improvement Information will be submitted to the Quality Manager by Department Managers on a quarterly basis. These reports shall include data collected and trended over time, if possible, and compared to benchmarks from recognized sources whenever possible; and the Director’s analysis of the data, with an action plan and follow-up, as indicated. Other performance improvement activities undertaken by the department of service shall also be included in the report submitted/presented by the Quality Improvement Manager to the Board of Directors...” A review of facility document shared by Quality Assurance Director H outlining FY (Fiscal Year) 2024 Quality Improvement projects for each hospital department revealed 23 hospital based departments were listed for FY 2024 (October 1, 2023-September 30, 2024). 1 department (Rehabilitation) had 3 Quarter 1 goals, 12 departments had 2 Quarter 1 goals. 9 departments had 1 Quarter 1 goal and 1 department (Dietary) had no Quarter 1 goals listed. Of the departments that had Quarter 1 goals, 18 departments had updated most, but not all of their Quarter 1 goals with “Goal met” or “Goal not met”. 5 departments did not update Quarter 1 goals. Quarter 2 goals were not written at all for 5 departments. On 3/13/2024 at 12:26 PM an interview was conducted with Quality Assurance Director H. When asked to describe the facility’s QAPI program, Director H stated that s/he has only been at the facility since September 1, 2023 and that the program had no director for some time prior to that date. Director H stated that Chief Nursing Officer B, who is Director H’s boss is giving Director H “bits and pieces” of the job a little at a time. Director H states s/he is not completely “in charge” of the Quality Department yet and gave an example of not having clarification of whether or not monitoring of contracted services for quality is part of his/her job. Director H states that they are trying to rebuild the QAPI program as it should be, but they are “not there yet.” When asked if the departments were to write at least 2 goals per department, Director H stated, “We wanted to set up at least 1 goal for Quality for each department. We are not yet at our scope or number we want.” When asked how priorities are set for performance improvement activities, Director H stated, “Department Managers just pick what they want and that is not how it should be.” When asked if managers understood what kind of goals should be written, Director H stated, “No.” When asked why all departments did not participate in setting goals for Quarter 2, Director H stated that they should have, but some did not. When asked what actions are taken if improvement or participation did not occur, Director H stated, “Nothing is done for not meeting goals or if improvement is not shown.” When asked to share how data is used to monitor effectiveness and safety of services and quality of care, Director H stated, “Safety Zone (on-line program to report incidents, errors and near misses) is going live soon and we are teaching leaders how to use it. The orange paper incident reports will be gone.” On 3/13/2024 at 10:30 AM in an interview with Rehab Manager Y when asked about current Quality projects in the department, Manager Y stated that they use the evaluations that patients complete at the end of their therapy to look for areas for improvement. When asked for specific examples Manager Y was not able to name any.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 41126 Based on record review and interview the facility failed to complete death information checklists per facility policy on 2 of 4 expired patients (Patient #12 & 13) in a total of 4 expired patients reviewed. Findings include: Review of the facility policy titled, “Organ, Tissue and Eye Donation” dated 1/18/2023 revealed, “Procedure: ...Documentation of denied consent, unsuitable donors and consent/disclosure forms for donation shall be noted in the patient’s medical chart for all deaths...Document on the appropriate record of death checklist...” Review of Patient # 12’s medical record revealed an Emergency Room arrival at 7:29 AM on 4/16/2023 for unresponsiveness. Resuscitation efforts were unsuccessful and the patient expired at 7:36 AM on 4/16/2023. Review of the facility form “Record of Death Checklist” revealed no documentation under the following headings: Funeral Home, Autopsy, Coroners Case, In consultation with Organ/Tissue organization the decedent is or is not a suitable donor, Next of Kin, Belongings taken by___. Review of the facility form “Mandatory Death Reporting” revealed no documentation under the following headings: Hospital Contact Name, OPO (Organ Procurement Organization) Contact Name, Appropriate for Donation, Not Appropriate for Donation, Do you or the Patient’s Family want to speak to a representative from the Recovery Agency.” Review of Patient #13’s medical record revealed an Emergency Room arrival at 1:39 AM on 8/21/2023 for chest pain. The patient became unresponsive while waiting for transfer and resuscitation efforts were unsuccessful. The patient expired at 4:22 AM on 8/21/2023. Review of the facility form “Record of Death Checklist” revealed no documentation under the following headings: Autopsy, Coroners Case, In consultation with Organ/Tissue organization the decedent is or is not a suitable donor, staff signature. Review of the facility form “Mandatory Death Reporting” revealed no documentation under the following headings: Appropriate for Donation, Not Appropriate for Donation, Do you or the Patient’s Family want to speak to a representative from the Recovery Agency. There was no evidence of these queries being addressed elsewhere in the patient’s medical record. On 3/13/2024 at 3:00 PM in an interview with Nurse Manager C, Manager C confirmed the findings and stated, “I would expect every query on these forms to be completed.””

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to establish a process for prompt resolution of patient grievances, failed to establish a grievance committee to review and respond to grievances and failed to have the governing body involved in the grievance process in 1 of 1 hospital grievance programs reviewed. Findings Include: Review of Facility policy last revised 10/26/2023 titled, “Customer Service Recovery Program,” revealed, No documented process of how a grievance is made, no evidence of what a grievance or complaint is, no time frames or process of how grievances are investigated and no evidence of how the governing body is involved or how grievances are incorporated into the facility quality program. In an interview with Quality Assurance Manager H on 3/12/2024 at 10:15 AM, when asked how complaints and grievances are handled, Manager H said, “We treat everything the same.” When asked how are complaints or grievances made, Manager H stated, “I take the information anyway it comes to me.” When asked how are complaints and grievances followed up on, Manager H stated, “The current policy doesn’t have a specific date, but I have a working time frame of 14 days, that is my personal goal. Each one is different. We don’t have a separate policy on complaints and grievances, we use our customer feedback policy.” When asked if there was a grievance committee that reviewed and resolved grievances, Manager H stated, “We are working to establish a grievance committee, don’t currently have one.””

“A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 03/12/2024. Burnett Medical Center was found to be NOT in substantial compliance with the following applicable regulations for Critical Access Hospital participation in Medicare-Medicaid: 42 CFR Subpart 485.623 - Condition of Participation: Physical Environment was NOT MET 42 CFR Subpart 485.623(d)(1) - Life safety from Fire was NOT MET NFPA 101 (2012 edition) - Life Safety Code was NOT MET The original single story slab-on-grade building, with a crawl space below for mechanical equipment, was approved and built in the 1950’s, 1960’s, 1970’s and classified as Type II (0,0,0) Unprotected Noncombustible. A single story slab-on-grade building Hospital/ Clinic expansion was approved in 2008 and classified as Type II (1,1,1) Protected Noncombustible. The original hospital is separated from the 2008 Hospital/Clinic Expansion building by a 2-hour fire barrier. The facility was surveyed as one (1) building, classified as Type II (0,0,0) Unprotected Noncombustible. The building is protected throughout with an NFPA 13-automatic sprinkler system. There is an exit access corridor smoke detection system. Additional smoke detectors are located in various use areas. The facility has an emergency generator that provides power to the emergency loads. Occupancy Note: The attached Rural Health Clinic was not part of this Critical Access Hospital (CAH) survey, as it is separated from the CAH by a two-hour fire-rated occupancy separation barrier. The attached Skilled Nursing Facility (SNF) was not part of this CAH survey, as it is separated from the CAH by a two-hour fire-rated occupancy separation barrier. Burnett Medical Center is licensed for 17 beds, with a census of 5 inpatients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. Six (6) federal deficiencies of the Life Safety Code were cited.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility did not provide two-hour rated building separations in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.1.3, 19.1.3.3, 8.3.4.2, & 8.3.5. This deficient practice could affect an undetermined number of patients, staff, and visitors. Findings include: On 03/12/2024 at 2:24 pm, observation above the ceiling at the Skilled Nursing Facility fire doors revealed a 4-inch round scab patch attached to the two-hour rated barrier, separating the hospital from the Skilled Nursing Facility, that was not protected in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019. The scab patch was attached with one screw and fire caulking. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1, 9.7.1.1, & 9.7.5; NFPA 13 (2010 edition) Section 6.2.7; and NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.2.1.1, 5.2.4.1, 13.2.7.1, & 13.3.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 03/12/2024 at 10:23 am, record review of sprinkler system inspections revealed that the facility did not document monthly visual inspections of the wet system gauges and valves. 2. On 03/12/2024 at 1:54 pm, observation in the kitchen storage and just outside the kitchen storage door, revealed three sprinkler head escutcheon rings were missing, thereby not completing the sprinkler assembly listing. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility did not provide corridor walls forming a barrier to limit the transfer of smoke as required in NFPA 101 (2012 edition) Section 19.3.6.2. This deficient practice could affect an undetermined number of patients, staff, and visitors. Findings include: On 03/12/2024 at 2:20 pm, observation above the ceiling near the 2-hour rated fire barrier in the staff corridor hallway revealed a 2-inch unsealed penetration in the gypsum wall above the ceiling that would not resist the passage of smoke. The corridor in this area is adjacent to the PT/OT room. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 46812 Based on record review and interview, the facility did not ensure fire and smoke dampers were maintained in accordance with NFPA 101 (2012 edition) Sections 19.5.2.1 and 9.2.1; NFPA 90A (2012 edition) Sections 5.4.8.1 and 5.4.8.2; NFPA 80 (2010 edition) Sections 19.4.1 and 19.4.1.1; and NFPA 105 (2010 edition) Section 6.5.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: On 03/12/2024 at 11:33 am, record review revealed that the facility had no record at the time of the survey of when the last fire & smoke damper functional testing was completed. Staff stated they were in the process of compiling an inventory of all dampers in the building to provide the vendor that will do the inspection. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 46812 Based on record review and interview, the facility failed to maintain the medical gas system in accordance with NFPA 99 (2012 edition) Sections 5.1.14, 5.1.14.4.4, 5.1.14.4.5, 5.2.13 and 5.2.14. This deficient practice could affect an undetermined number of patients, staff, and visitors. Findings include: On 03/12/2024 at 12:25 pm, review of maintenance records of building systems revealed that there was no record of annual inspection of the central supply system for medical oxygen gas with reserve supply and periodic testing of related alarm systems. Staff stated the system had been inspected, but there were issues getting the report from the vendor. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility failed to store oxygen cylinders in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.4 and 8.7; and NFPA 99 (2012 edition) Sections 5.1.3.3.2 and 11.3.1. This deficient practice could affect an undetermined number of patients, staff, and visitors. Findings include: On 03/12/2024 at 1:10 pm, observation in the med gas room revealed two (2) H-sized medical air cylinders and three (3) H-sized nitrogen cylinders was not properly secured or chained. This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff DD and Staff HH.”

“DISCHARGE PLANNING CFR(s): A Critical Access Hospital (CAH) must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from the CAH to post-discharge care, and reduce the factors leading to preventable CAH and hospital readmissions. This Condition is not met as evidenced by: 44431 Based on record review and interview the facility failed to complete a discharge planning evaluation for 2 of 11 patients (Patient #1 and Patient 7); failed to provide a handoff between the surgeon and the hospitalist completing the discharge for 1 of 11 patients (Patient #1); failed to follow and implement physician orders prior to discharge for 1 of 11 patients (Patient #1); failed to identify those patients likely to suffer adverse health consequences and provide a follow up phone call and transitional care management appointment per policy for 1 of 11 patients (Patient #1); and failed to provide correct and effective discharge instructions for 2 of 11 patients discharged (Pt. #1 and Pt. #7) out of 11 medical records reviewed. Findings Include: The facility failed to identify those patients likely to suffer adverse health consequences upon discharge and provide a follow up phone call and transitional care management appointment per policy. See tag C 1404 The facility failed to complete a discharge planning evaluation for Pt. #1 and Pt. #7. See tag C 1406 The facility failed to assess its discharge planning process and implement an action plan based on findings. See tag C 1422 The facility failed to follow physician orders at discharge; failed to provide a handoff between the surgeon and the hospitalist completing the discharge; and failed to provide patients with the necessary medical information for post-surgical care at the time of discharge. See tag C 1430”

“DISCHARGE PLANNING PROCESS CFR(s): The CAH’s discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to follow it’s discharge planning policies and procedures to identify those patients likely to suffer adverse health consequences upon discharge and failed to provide a follow up phone call and transitional care management appointment per policy for 1 patient (Pt. #1) out of a total of 11 discharge records reviewed. Findings Include: Review of facility document, dated 08/23/2023 titled, “[Facility Name] Transitional Care Management (TCM) flow diagram,” revealed, “Patient ready for discharge---was the patient discharged after hours/wkend---yes--Charge nurse contacts ER (Emergency Room) HUC (Health Unit Coordinator) to schedule patient appt (appointment) within 7 days---RN schedules appt as TCM appointment---RN enters information on patient’s exit care----RN highlights date/time of TCM appointment and provides to patient along with Exit Care---RN provides patient education re: f/u (follow up) phone call with RN and TCM appointment with provider.” Review of facility policy last reviewed 01/18/2023 titled, “Assessment and Reassessment,” revealed, “Each patient admitted to the institution shall receive a complete head-to-toe assessment...Discharge planning: Factors include discharge location, follow-up needs....Discharge planning shall be initiated at the time of admission and shall be reassessed continuously throughout the patient’s hospital stay.” Review of Facility Internal Investigation and Root Cause Analysis completed on 10/10/2023 as a result of Patient #1’s event revealed, “A transitional care management (TCM) appointment should be made within 7 days of discharge, this was not done. No post discharge phone call follow ups were done by nursing staff- the process is to call patients within 48 business hours following discharge.” Pt. #1 was admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy and discharged home on 09/24/2023 (Sunday). Review of Pt. #1’s medical record revealed no evidence of a 48 hour post discharge phone call, no evidence of a TCM appointment scheduled and no evidence of a completed discharge planning evaluation pre-discharge. This was confirmed during an interview with Manager B on 11/02/2023 at 1:05 PM. Review of Pt. #1’s Emergency Department (ED) Medical Record revealed Pt. #1 returned to the ED on 10/2/2023 at 12:04 AM with increased weakness. Family reported patient has become increasingly weak over the last week, being unable to walk or stand, decreased appetite, increased pain at incision site. Sepsis screen was positive, signs of organ dysfunction present and subtle mental status changes. Skin on lower abdomen/pelvic region is hot to touch, firm, and red. Several purple blister-like areas noted to lower abdomen. Foul, yeasty odor and white/yellow discharge noted from incision site. Pt. was transferred by air to a higher level of care and died of MRSA (staph infection resistant to antibiotics) and necrotizing fasciitis (flesh eating bacteria infection) on 10/04/2023, 12 days after their surgical procedure. On 11/02/2023 at 11:40 AM in an interview with Social Services Manager I, I stated, “The doctors and or nurses screen the patient and then we get a referral, we don’t have an automatic referral to social services...we try to plan on Friday for the weekend discharges, if there is a need then we would call that following Monday.” On 11/02/2023 at 1:05 PM in an interview with Manager B, when asked how Pt. #1’s discharge needs were addressed- when they were admitted on 09/22/23 (Friday) and discharged 09/24/23 (Sunday), B stated, “They were discharged before social services or UR (Utilization Review) came back on Monday.””

“DISCHARGE PLANNING EVALUATION CFR(s): (1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-CAH care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to provide a discharge planning evaluation for 2 patients (Pt. #1 and Pt. #7) out of a total of 11 discharge records reviewed. Findings Include: Review of facility policy last reviewed 02/04/2022 titled, “Patient Rights and Responsibilities,” revealed, “Every patient...shall receive...information about the patient’s illness, course of treatment, and prognosis for recovery in terms the patient can understand...Every patient shall have the opportunity to participate to the fullest extent in planning for his or her care and treatment.” Review of Pt. #1’s medical record revealed no evidence of a discharge planning evaluation being completed. This was confirmed during interview with Manager B on 11/02/2023 at 1:05 PM. Review of Pt. #7’s medical record revealed no evidence of a discharge planning evaluation being completed. This was confirmed during interview with CNO (Chief Nursing Officer) M on 11/21/2023 at 2:00 PM. On 11/02/2023 at 1:05 PM in an interview with Nurse Manager B, B stated, “We don’t have a specific policy for the discharge planning evaluation.” On 11/02/2023 at 3:59 PM in an interview with Nurse Manager B, when asked if there was a discharge needs assessment completed for Pt. #1, Manager B stated, “(She/He) didn’t have one, you are correct.””

“DISCHARGE PLANNING CFR(s): (7) The CAH must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to assess it’s discharge planning process in 1 of 1 discharge processes reviewed and failed to implement appropriate interventions upon recognition of deficient practices, in 1 (Pt. #1) of 1 Sentinel Events reviewed. This deficient practice has the potential to impact all patients receiving care at this facility. Findings Include: Review of facility policy last reviewed 03/26/2022 titled, “Sentinel Events Policy & Procedure,” revealed, “It is the policy of [Name] Medical Center to identify and respond appropriately to all sentinel events...Once identified, each sentinel event will be followed by a thorough and credible root cause analysis, development of an action plan designed to implement improvements to reduce risk, implementation of the improvements, and monitoring the effectiveness of those improvements....Action Plan: The action plan is the product of the root cause analysis and identifies the strategies that [Facility] intends to implement in order to reduce the risk of similar events occurring in the future. It will address responsibility for implementation, oversight, pilot testing as appropriate, time lines and strategies for measuring the effectiveness of the actions.” Patient #1 was a 68 year old admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy (removal of the reproductive organs) and discharged home on 09/24/2023 (Sunday). On 10/02/2023 at 12:04 AM (10 days after surgery) Pt. #1 presented to the ED (Emergency Department) with severe abdominal pain and was diagnosed with sepsis (life threatening complication of infection). Pt. #1 was transferred to a higher level of care and died on 10/04/23. On 11/02/2023 at 12:05 PM in an interview with Compliance and Medical Practice Staff C, C stated, “This is the only adverse event we’ve had in the last 6 months and we are treating it like a sentinel event. We are working through the RCA (Root Cause Analysis).” When asked what has changed, Staff C stated, “We are still working through this, it isn’t closed, we discussed this with medical staff on 10/31/2023 and what we can safely do here, we are looking at our systems and processes, this case is also being reviewed externally and we have a phone call scheduled with external peer review and our surgeon on 11/06/2023. Our next multidisciplinary meeting regarding this event is scheduled for 11/6/2023 at 12:30 PM.” On 11/21/2023 at 2:05 PM in an interview with RN O, when asked what processes have changed or education provided, O stated, “I haven’t been told much except that state was here because [Pt. #1] passed away, I don’t know any specifics or what happened, just what I’ve heard from other nurses, not anything from my manager.” During an interview on 11/21/2023 at 3:30 PM with Compliance Officer C, when asked what action steps have been implemented following the 11/06/2023 Root Cause Analysis Meeting, C stated, “Nothing additional, we are still working through action steps, it’s been busy with the EPIC (Electronic Health Record) conversion.” On 11/21/2023 a review of the facility action plan document last updated 11/06/2023 revealed action steps were identified and nothing further has been implemented, no dates have been assigned for completion of interventions or monitoring of changes made. On 11/22/2023 at 2:45 PM in an interview with CNO N when asked what the last review of the discharge planning process revealed, CNO N stated, “We couldn’t find any documentation of a discharge planning assessment being completed, I know we’ve done them, but don’t remember when.””

“DISCHARGE PLANNING CFR(s): (b) Standard: Discharge of the patient and provision and transmission of the patient’s necessary medical information. The CAH 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, postdischarge 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: 44431 Based on record review and interview the facility failed to follow and implement physician orders upon discharge and failed to provide a handoff between the surgeon and the discharging hospitalist for 1 of 11 patient records reviewed (Patient #1), and failed to provide 2 of 11 patients (Pt. #1 and Pt. #7) with the necessary medical information for post-surgical care upon discharge out of a total 11 discharged records reviewed. Findings Include: Review of facility policy last reviewed 01/08/2023 titled, “Discharge a Patient,” revealed, “The patient...shall be involved in the discharge process. A physician’s order shall be required prior to discharge...Discharge instructions ordered by the physician shall be completed...Preparation: Verify the patient’s discharge orders..Complete home care form and/or discharge instructions..collect medications and prescriptions for instruction in self-administration...Teach procedures, medications....Explain and write activity restrictions, diet, and when to call the physician...Review the discharge instructions, including medications to be taken at discharge, to the patient and or family.” Review of facility document titled, “[Facility] Medical Staff Rules and Regulations for acute care,” no effective date, revealed, “C. A qualified Practitioner shall be responsible for the general medical condition, care and treatment of each patient in the Medical Center. This shall include the responsibility for prompt completion and accuracy of the medical record, necessary special instruction, and the condition of the patient to referring Practioners...Whenever these responsibilities are transferred to another Practitioner, a note covering the transfer of responsibilities shall be entered into the medical record.” Pt. #1 was admitted to the hospital on 09/22/2023 (Friday) following surgery for a total abdominal hysterectomy (removal of the reproductive organs) and discharged home on 09/24/2023 (Sunday). Not following Physician Orders: Review of Pt. #1’s post op (after surgery) orders on 09/22/2023 revealed, “Post Op Antibiotic...Cephalexin 500 mg QID (4X a day) X 7 days (urine was cloudy) suspect UTI (urinary tract infection). Start date of 9/22/23 and end date of 9/29/23. UA (Urine Analysis) + Urine for culture tomorrow AM.” Review of Pt. #1’s discharge instructions on 09/24/2023 revealed Pt. #1 was not discharged home on an oral antibiotic. Further review of the medical record revealed no evidence of the urine culture being obtained prior to discharge per order, and no evidence that Pt. #1 was discharged with the ordered oral antibiotics. On 11/02/2023 at 4:20 PM, when Manager B was asked if the order for the urine culture was missed, Staff B stated, “Correct.” On 11/21/2023 at 11:30 AM in an interview with Hospitalist M when asked why wasn’t the antibiotic that was ordered post op continued at discharge, M stated, “I didn’t think the antibiotic was warranted, but was considered. In hindsight it was the wrong decision. I’m not sure the antibiotic chosen would have made a difference.” No handoff between the surgeon and the Hospitalist who completed the discharge for Patient #1: Further review of the medical record revealed no instructions for post op wound care were ordered by Surgeon H and no documentation of a handoff being completed between Surgeon H and Hospitalist M. When asked how the handoff from surgery to the inpatient unit happens, Hospitalist M stated, “Historically surgery refers to family medicine, they report off to us usually, but not always...we have a good working relationship. I don’t remember getting a handoff from the surgeon on this patient. We’ve worked together for 25 years...if I had known the history, in hindsight I should have had [Pt. #1] use a cotton towel under [their] pannus [stomach fold], to keep the air on it. They really should call us with the incision into the pannus if we need to treat it differently.” On 11/21/2023 at 1:00 PM in an interview with Surgeon H, when asked about the process for handing off a patient from surgery to hospital service, Surgeon H stated, “The process is to work with family physicians....I give PO [Phone orders] and relinquish care to family medicine. My usual practice is to call the Doctor assuming care, not sure what my reason was not to. I usually call, but can’t remember in this case. Typically the hospitalist discharges the patient, but I’m available on Saturday and Sunday by phone if needed.” When asked if there has been any further discussion about this event, H stated, “We had a meeting with a lot of physicians, it was critiqued with peer review, I’m pretty sure we will do things from that.” Post-surgical discharge instructions not provided: Patient #1: A review of Pt #1’s discharge instructions dated 9/24/2023 revealed that there were no discharge instructions present indicating what wound/incision care should be completed after discharge, activity/lifting restrictions, diet or what signs and symptoms of infection to report or when to call the physician. This was confirmed in an interview during record review with Nurse Manager B on 11/02/2023 at 1:05 PM. On 11/21/2023 at 11:30 AM in an interview with Hospitalist M when asked why Pt. #1 didn’t receive specific discharge instructions, Hospitalist M stated, “I don’t trust checklists...I don’t remember getting a handoff from the surgeon on this patient...If I had know the history....I didn’t give specific instructions or anything on signs/symptoms of infection.” When asked who is responsible for giving the discharge instructions to patients at discharge, M stated, “Typically nursing gives the discharge instructions, We are a small hospital, we didn’t see it coming, it surprised us and we feel terrible.” Patient #7: Pt. #7 was admitted to the hospital on 09/05/2023 (Tuesday) for a total abdominal hysterectomy and discharged home on 09/07/2023 (Thursday). Review of Pt. #7’s discharge instructions revealed Pt. #7 had the same procedure as Pt. #1 and received the same discharge instructions as Pt. #1. Pt. #7’s discharge instructions did not include instructions for wound care or for signs and symptoms of infection or when to seek medical attention. This was confirmed in an interview during record review on 11/21/2023 at 2:00 PM with CNO O. On 11/21/2023 at 1:45 PM in an interview with Charge Nurse P, when asked who is responsible for ensuring the patient has the right discharge instructions, P stated, “Not sure who is responsible, but typically it’s laid out in the discharge instructions and when to call the provider if symptoms get worse and it is dependent case by case.” On 11/21/2023 at 2:05 PM in an interview with RN O (Discharging RN for Pt. #1) when asked why there were not discharge instructions provided to Pt. #1 for incision care and signs and symptoms of infection, RN O stated, “There should be. We provided diet, activity and discharge instructions to the patient, a copy is in the chart.” When O was asked why the oral discharge instructions given to Pt. #1 weren’t documented, O stated, “It’s hard when we’re busy to get the charting done with phones, call lights, and we’re busy with hands on care...could be a lot better if we had more time.” A review of discharge instructions given to other patients with same/similar surgery (Patient #11) revealed that there were detailed discharge instructions available that list instructions and signs and symptoms of infection and when to seek medical attention.”