Pam Health Specialty Hospital of Oklahoma City

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure grievance information was correct for all patients and staff. Findings: A Review of “Patient Rights” poster observed in a hospital elevator documented the following: “You may also notify: Oklahoma Department of Health 1000 NE 10th Street Oklahoma City, OK 73117-1299 (405)271-6576” On 08/28/24 at 10:30 AM Staff A was shown the OSDH website which read in part: “Complaints against non-long-term care facilities may be filed... by calling (405) 426-8470... mailed... Oklahoma State Department of Health Medical Facilities 123 Robert S. Kerr Ave., Suite 1702 Oklahoma City, OK 73102-6406” On 03/16/26 at 9:09 am, Staff C stated the information on the poster to make a complaint with OSDH was not correct.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39648 Based on observation and interview, the hospital failed to ensure chemicals were stored out of reach of all public visitors of the hospital. Findings: During a tour of the facility 03/16/26 at 9:09 am, surveyors observed a bottle labeled glass and multi-surface cleaner on an overbed table in an unoccupied room. The door to the room was open and accessible to any patients who were ambulatory, to the public, and to staff. On 03/16/26 at 9:09 am, Staff C stated cleaning supplies should not be left in a room.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to maintain complete health records for three (Staff D, K, and L) of five clinical staff reviewed and four (Staff G, H, I, and J) of five medical staff reviewed. Findings: Staff G, H, I, and J A review of personnel files showed: 1. No proof of Measles, Mumps, Rubella (MMR) immunity, immunization, or declination. 2. No proof of Varicella immunity, immunization, or declination. 3. Signed attestation of immunity. Staff D A review of personnel files showed: 1. A failed respirator fit test on 09/26/24. 2. Respirator fit test was not completed on 06/09/25 due to “beard.” 3. No follow up testing documented. Staff K A review of personnel files showed: 1. No proof of immunization or declination of influenza documented. 2. A failed respirator fit test on 10/28/25 with a handwritten note that read, “Follow up testing required.” 3. No follow up testing documented. Staff L A review of personnel files showed: 1. No health screening evaluation. 2. No respirator fit test completion. 3. No proof of immunization or declination of influenza documented. Review of a policy titled “Employee Health Program” reviewed 12/29 of unknown year, stated employment health records must contain the following: 1. “Health Screening Evaluation” 2. “Evidence of immunity ... Measles... Mumps, Rubella ... Varicella ... titers ... immunization ... declination.” 3. “Respiratory Fit Testing - Clinical” 4. “Annually ... influenza vaccine ... or declination.” Review of a document titled, “Medical Staff Bylaws” dated 2024, section 2.6.3 showed conditions of continued medical staff membership included in part to “abide by ... all other lawful standards and polices of the Medical Staff and Hospital.” On 03/16/26 from 11:20 AM to 3:35 PM, Staff F stated: 1. Immunization records were usually in the medical staff personnel files. 2. Attestation of immunity did not equal proof of immunity. 3. Providers were credentialed to the hospital and agreed to follow hospital policy and procedures. On 03/16/26 at 11:20 AM, Staff M stated: 1. They did not document proof of MMR vaccination or immunization, but had the medical staff sign an attestation of immunity. On 03/16/26 at 1:00 PM Staff N stated all staff regardless of employment status were to have a completed health record. On 03/16/26 at 4:00 PM, Staff E stated: 1. There was no documentation of immunization, immunity, or signed declinations in Staff L’s personnel file. 2. All documentation available was provided. 3. The employee health records were lacking proper immunization documentation per facility policy.”

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 53719 Based on record review and interview, the hospital failed to ensure completion of transfer documentation for two (Pt #2 and Pt #5) of five patients reviewed. Findings: Review of the medical records showed patients admitted to the facility and were transferred to a higher level of care, did not show transfer documentation required by facility policy. Review of POLICY NUMBER: NSG 32: Memorandum of Transfer, revised 01/28/25, read in part: “The hospital may not transfer a patient with an emergency medical condition that has not been stabilized unless: a. The patient or a legally responsible person acting on the patient’s behalf ...requests transfer to another hospital in writing; b. A physician has signed a certification that includes a summary of the risks and benefits ...the medical benefits ... outweigh the increased risk to the patient.” “The medical record shall contain at a minimum: a. A brief description of the patient’s medical history and physical examination. e. Pertinent x-ray films and reports; and f. Any other pertinent information.” Pt #2 Review of the “Discharge Summary” showed the patient was inpatient at the facility from 11/25/25 until 01/29/26. Review of a physician note dated 01/29/26 with no time noted read in part, “[Pt #2] was noted to have drop in hemoglobin complicated by respiratory distress and failure requiring transferred [sic] to acute on 01/29. Discharge Condition & Disposition: transferred to acute ...Information Provided to the Patient and Family: Done. Discharge Follow Up: Transferred to acute.” Review of the Nursing Shift Assessment - LTCH note dated 01/29/2026 at 1:39 am read in part: “the patient required a higher level of care and was transferred out to acute care facility.” Review of the medical record did not show: 1. a signed physician certification form listing risks and benefits of transfer 2. documentation of medical history, diagnosis, or physical examination of the patient’s condition at the time of transfer 3. family notification of patient requiring transfer On 03/16/26 at 11:59 am, Staff E stated: 1. The patient was transferred to acute care after a change in medical status. 2. The MD ordered to send patient. 3. There was no formal consent on the chart from the patient and the staff only needed the order. Pt #5 Review of the Discharge Summary dated 03/17/26 with no time noted, showed the patient was inpatient at the facility from 02/4/26 until 02/17/26. Review of a physician note dated 02/17/26 with no time noted, read in part, “On 02/17/26, code blue was called. EMS notified. Patient was intubated. EMSA transported patient to [another facility] ...Discharge Condition & Disposition: Transfer to Acute Care One Time Now ... Discharge Follow Up: Follow up at [another facility].” Review of the medical record did not show: 1. a signed physician certification form listing risks and benefits of transfer 2. documentation of medical history, diagnosis, or physical examination of the patient’s condition at the time of transfer 3. code documentation 4. family notification of patient requiring transfer On 03/16/26 at 1:00 pm, Staff D reviewed the patient chart and stated: 1. There was no nursing note showing report was called. 2. There was only an order for transfer and there was no documentation of consent.”