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Based on interview, review of policies and procedures, and review of medical record documentation for 3 of 3 Medicare patients (Patients 34, 36, and 38), it was determined that the hospital failed to fully develop and implement P&Ps that ensured each Medicare beneficiary received the Important Message from Medicare as required.

Findings include:

1. The policy titled, "Important Message From Medicare" dated "Last Approved 06/2025" was reviewed and reflected:
* "Quorum facilities will comply with Centers for Medicare and Medicaid Services' (CMS) final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. The effective date of the final rule is July 2007."
* "The final rule requires hospitals to deliver a revised version of the Important Message from Medicare ... to inform Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights. Notice is required both for Original Medicare beneficiaries and for those enrolled in Medicare Advantage (MA) plans and other Medicare health plans subject to the MA regulations. The final rule also requires that the signed Important Message from Medicare or a copy is provided to each beneficiary or his or her representative within 2 calendar days of the day of discharge."
* "The hospital will comply by performing the following: Initial (On Admission) Delivery of the Important Message from Medicare (IM) The Important Message from Medicare may be given if the beneficiary is seen during a preadmission visit as long as the visit is not more than 7 calendar days in advance of the admission."
* "Registration personnel are responsible for the following ... Delivery of the Important Message from Medicare (IM) at or near admission, but no later than 2 calendar days following the date of admission."
* "A minimum of one Important Message will be issued to Medicare patients who stay 2 days or less. For Medicare patients staying more than 2 days, a minimum of 2 notices must be provided to each Medicare patient (unless patient is discharged within 2 days of receiving the initial IM). Copies of each IM that is issued to a patient must be placed on the patient's chart and maintained in the medical records."

2. During an interview conducted via email with the DQ on 08/04/2025 at 1443, the following information was provided:
* Regarding Patient 34, the DQ wrote, "... was admitted 5/1/2025 @ 2032 and was discharged 5/5/2025 @ 1349. [They] had an IMM given 5/5/2025 @ 1325, which was greater than wo [sic] days after [their] admission."
* Regarding Patient 36, the DQ wrote, "... was admitted to inpatient 6/1/2025 @ 0707. IMM was given 6/5/2025 which was greater than two days after [they were] admitted."
* Regarding Patient 38, an inpatient on the CCU, the DQ wrote, "Correct. This was a Medicare Advantage patient and ... did not receive an IMM."

Based on interview, and review of medical record documentation for 40 of 40 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40)), and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient was provided all required contact information of organizations whom they could contact to file a grievance.

The Interpretive Guidelines explain that "All patients, inpatient or outpatient, must be informed of their rights as hospital patients. The patient's rights include all of those discussed in this condition, as well as any other rights for which notice is required under State or Federal law or regulations for hospital patients. (See 42 CFR 482.11.) ... The hospital must establish and implement policies and procedures that effectively ensure that patients and/or their representatives have the information necessary to exercise their rights."

Findings include:

1. The policy titled, "Patient Rights and Responsibilities" dated "Last Approved 07/2022" was reviewed and reflected:
* "Copies of 'Patient's Rights and Responsibilities' are posted in patient care areas."
* "Each patient will be provided a list of names, addresses, and telephone numbers of patient advocacy groups, state authority or protection network when needed or requested."

The policy failed to explain how the hospital ensured that each patient, or when appropriate, the patient's representative (as allowed under State law), was informed of the patient's right to file a grievance with the State Agency as required.

2. The policy titled, "Patient Complaints and Grievances Policy" dated "Last Approved 12/2023" was reviewed and reflected:
* "The patient/patient representative shall be informed of whom to contact to file a complaint/grievance. This may be done via a variety of mechanisms ... Patient Handbook ... Business Office admission packet ... Patient Care Conferences ... Staff's knowledge of the complaint/grievance process ... Hospital internet web page."
* "The Medicare Beneficiary patient/patient representatives shall be informed of whom to contact to file a complaint/grievance or appeal if premature discharge, coverage decision, or qualities of care issues arise upon request."

The policy failed to explain how the hospital ensured that each patient, or when appropriate, the patient's representative (as allowed under State law), was informed of the patient's right to file a grievance with the State Agency as required.

3. The document titled, "Patient Rights and Responsibilities" with an identification number of "MC1002A/042825" was reviewed and reflected:
* "You have the right to ... Information on the availability of the grievance procedure and how to file a grievance pursuant to §92.7(b) ... "
* "You have the right to ... Lodge a concern with the state, whether you have used the hospital's grievance process or not." The "State Quality Improvement Organization" was listed, however, neither the State Agency nor its contact information was listed on the form.

The document failed to provide the State Agency's contact information as required. Additionally, the "Quality Improvement Organization," headquartered in Florida, did not have the most current address.

4. During a review of grievances with the DQ and the RM on 07/31/2025 beginning at 0930, the DQ confirmed that the State Agency's contact information was not listed on the Patient Rights and Responsibility form that was provided to all patients. Refer to Finding 3, the Patient Rights document provided to all patients.

Based on interview, review of medical record documentation for 7 of 9 patients (Patients 9, 19, 30, 31, 32, 36, and 37), and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital failed to fully investigate incidents and document follow up actions such as interviews, review of patient assessments, staff training, education provided, and/or corrective or remedial actions taken to prevent recurrence. The hospital failed to document whether abuse and/or neglect were ruled out.

The Interpretive Guidelines reflect:
* Investigate - The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
* Report/Respond - The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. The policy titled, "Patient Assessment, Reassessment and Plan of Care," with "Last Approved" date of "04/2019" was reviewed and reflected:
* "Initial and ongoing assessments will be performed and documented by the professional disciplines involved in the care of the patient according to their scopes of service and licensure."
* "Department-Specific Assessment & Reassessment Parameters ... Nursing - Emergency Department ... assess all patients presenting to the Emergency Department ... Patients will be reassessed ... Level I and Level II - upon arrival and every 5-15 minutes until 3 consecutive sets of normal then at least every 30 minutes ... Level III - upon arrival and at least every 90 minutes ... Level IV - upon arrival and at least every 4 hours ... Nursing - Medical /Surgical & Tele ... Admission Assessment by RN within 4 hours ... ongoing assessment ... every shift for Med/Surg and every 6 hours for Tele, or as the patient's condition warrants ... ICU and CVU patients are assessed as soon as possible after admission and are completed within 4 hours ... ongoing assessments conducted every 4 hours or as the patient's condition warrants ... Wound Care Assessment within 72 hours [Reassessment Time Frame] As determined by treatment and plan of care."

2. The policy titled, "Event Reporting Policy," with "Last Approved" date of "01/2019" was reviewed and reflected:
* "To track and trend processes at risk that impact patient safety by using a Patient Safety Evaluation System, Event Reporting System ('ERS')."
* "To analyze trends to prevent harm, improve patient safety, healthcare quality and healthcare outcomes."
* "Persons who witness, discover, or have direct knowledge of the event should be considered a witness for purposes of completing the EVENT REPORT form."
* "Additional Reportable Events ... Acquired Skin breakdown ... that occurred while patient/resident in facility ... or an existing wound present on admission which fails to respond to treatment and advances or worsens ... Fall of a Patient ... to include falls that were near miss events ... AMA (patient leaves Against Medical device) ... Delay of treatment, test or procedure which causes an adverse occurrence or injury either directly or indirectly ... Lost or damages patient belongings ... Healthcare associated infection, not present on admission causing harm, with hospitalization, increased LOS, moderate injury with treatment and interventions ... Patient, family or significant other Complaint."
* "Handling Occurrences ... When a reportable event occurs as described in Section I, take any and all immediate corrective actions necessary to prevent further harm to involved party or subsequent potential parties."
* "The RM will determine who should conduct investigation and involve appropriate personnel."
* An attached "Flowchart A" included the following: "RM investigates, directs corrective actions, assigns investigator and involved parties, evaluates and directs follow-up."
* An attached "Flowchart B" included the following: "RM investigates, directs corrective actions, assigns investigator and involved parties, evaluates and directs follow-up."

3.a. During a review of incidents with the DQ and the RM on 07/31/2025 beginning at 0930, the following records were reviewed:

3.b. Regarding Patient 9: Patient 9 was admitted as an inpatient into the SCU on 06/13/2025 with an infestation of maggots in [their] wounds. An Event form and investigation reflected:
* "Description of Event ... Patient was brought up ... with [their] legs covered with maggots. They were falling out of [their] clothes when we undressed [them] and got [them] into [their] gown. [Patient] had been in ER since ... 6/12 and had not had any treatment to remove them. I understand [they] refused treatment ... did the same for us ... but ... should have remained in isolation in the ER until the majority of the maggots were removed instead of coming up to an inpatient floor and possible [sic] infecting other patient rooms. As of 6/14 ... the maggots are crawling out into the hallway. Also the patient stated in ER that [they] noticed the maggots approx [sic] 2 weeks ago and that makes their morphing into flies imminent."
* "Reviewer Comments" reflected: "Incident investigated. Per charting and interviews with staff, the pt refused to allow ED staff to address ... wounds and by extension, the maggots. Pt was alert and oriented and able to make decisions about ... care. Certainly there is room for improvement in terms of communication among the whole team to come up with a plan for transporting this patient to the inpatient side. Will follow up with charge nurse on duty."
* A second "Reviewer Comments" reflected: "reviwing [sic] concerns and protocols, will follow up with staff, ed and plant."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, further documentation on the event, such as which staff or witnesses were interviewed, which protocols were reviewed, with whom the reviewer spoke for follow up, or what was meant by "plant" was not included in the investigation report. Refer to Finding 2, the "Event Reporting Policy." It was unclear whether the situation had been resolved or not, or whether corrective actions were taken and any needed notification of other personnel for follow up had occurred to prevent recurrence of similar incidents. It was unclear whether abuse and/or neglect had been ruled out.

3.c. Regarding Patient 19: Patient 19 presented to the ED 07/18/2025 with complaints of foot pain and a "foot infection" and was subsequently admitted as an inpatient. An Event form and investigation reflected:
* "Description of Event ... 7/21 found open area on gluteal cleft. this [sic] was not present on 7/20, cna is [staff name] who had this pt yesterday and does everything extremely complete [sic] and said it was not there yesterday. pictures [sic] taken, waffle mattress placed on bed. also, [sic] no charting from MEWS on noc shift."
* "Patient Safety and Quality Information ... Risk Manager Comments ... 7.21.25: skin breakdown ... 7.28.25: Wound Care review complete."
* "Event Classification ... Deviation in GAPS reached the Patient but caused Minimal Temporary Harm ... Contributing Factors ... Procedures not followed ... When was harm assessed? Within 24 hours."
* "Reviewer Comments ... See follow up summary by ... wound care nurse ... No new onset pressure injury. Patient incontinent and immobile placing at risk for moisture skin damage. Charting documentation shows frequent repositioning and peri hygiene by care team. No deviations ... The patient was seen by wound care RN on 7/21/25 ... was noted to have an open area in gluteal cleft consistent with moisture associated dermatitis. A barrier cream was ordered. Patient was on waffle overlay and turning schedule. No indications of any pressure damage to skin."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, additional documentation on the event, such as whether staff or witnesses were interviewed, whether protocols were reviewed, and/or which "Procedures not followed," was not included in the investigation report. It was unclear when the last skin assessment occurred. The investigation included contradictory information. For instance, the Event Classification noted, "Deviation in GAPS reached the Patient but caused Minimal Temporary Harm ... Contributing Factors ... Procedures not followed," however, the reviewer comments noted "No deviations." It was unclear whether abuse and/or neglect had been ruled out, or what other specific "corrective actions" for the "procedures not followed" were taken, if any, to prevent recurrence.

3.d. Regarding Patient 30: Patient 30 was admitted to CCU on 05/15/2024. An Event form and investigation reflected:
* "Description of Event ... "left elbow stage 3 reported by [staff member] to RM on 5/28/24."
* "Risk Manager Comments ... HAPI- Stage 3 elbow."
* "Event Classification ... Deviation in GAPS reached the Patient but caused no harm or Minimal Harm ... Contributing Factors ... Treatment Complexity"
* "Reviewer Comments ... Reviewing chart for areas of opportunity for education and process improvement. Will follow up with individual nurse as needed."
* "Patient Event Review Details ... Recommended Changes for Prevention ... escalate skin assessment refusal and turn refusals."
* "Reviewer Comments ... Patient ended up with an unstageable pressure injury to ... left elbow ... had very painful bilateral knees due to knee infections. IR drainage on 5/17/24 ... had confusion intermittently in charting. Charted by staff that [patient] did not want to move or turn, but they were turning [patient]. [Patient] was on CCU from 5/15-21. A wound was found on ... left elbow 5/19 PM."
* Additional "Recommended Changes for Prevention" noted: "Re-education to staff on 2 RN skin check and special attention to high-risk boney [sic] prominences. Please discuss with Wound Care if the Left Elbow was actually a cellulitis wound as Dr. ... called it in ... progress notes."
* Additional "Reviewer Comments" noted: "5/19/24 unstageable on left elbow ... Q2hr Turns were documented for the entire CCU stay. CCU has done a lot of work and education on this. A 2 RN skin assessment on admit was not done. Dr. ... mentioned the Left elbow was a cellulitic wound." Included in the additional reviewer comments were:
- "5/15-0100- Noc RN [RN 1] admit to ccu. Confused. No wounds, Q2hr turns & heels floated charted. No 2RN skin Check."
- "5/15- Day RN [RN2] No wounds. Q2hr turns & heels floated charted. Noc RN [RN1] No Wounds. 0600 1st time waffle boots are charted. Q2hr turns & heels floated charted."
- "5/16- Day RN [RN3] No wounds. Q2hr turns & heels floated charted. Noc RN [RN 4] notes patient will not eat. No wounds. 2 rn skin check, nurse unnamed. Q2hr turns & heels floated charted."
- "5/17- Day RN [RN 5] note reading that patient was asking not to be turned but turned at least q2 by rn [sic]. No wounds. Q2hr turns & heels floated charted. Noc RN [RN 4] No wounds. Q2hr turns & heels floated charted."
- "5/18- Day RN [RN 6] Nursing Note: 2RN skin check with [staff member] and Turned q2. No wounds. Q2hr turns & heels floated charted. Noc RN [RN 1] No wounds. 2 rn [sic] skin check, nurse unnamed. Q2hr turns & heels floated charted."
- "5/19- Day RN [RN 7] Noted patient isn't eating. Notes that there is a 'red pressure area in the patients [sic] LT heel' but that patient is in waffle boots. Q2hr turns & heels floated charted. Pictures of Left Elbow taken. Noc RN [RN 8] LT heel wound. Q2hr turns & heels floated charted."
- "5/20- Day RN [RN 9] LT elbow wound Q2hr turns & heels floated charted. Noc RN [RN 10] & ([RN 8] - LT elbow wound & LT heel wound) Q2hr turns & heels floated charted."
- "5/21- Day RN [RN 9] LT elbow wound Q2hr turns & heels floated charted. Noc RN [RN 10] - Q2hr turns & heels floated charted. transferred to MCU."
- "5/28 ... WC RN - Left elbow with wound 1.0 x 1.0 cm covered in yellow slough, unstageable pressure injury. Erythema circumfer [sic] about 2 cm. Recommend medihoney and optifoam. Right elbow with slight redness. Recommend optifoam, Right heel with reddish brown area with closed blister 4.0 x 1.0 cm. Consistent with DTI. Recommend optifoam, heel protector boots."
- "6/7- Dr. ... notes: 'L elbow cellulitis - Wound cx MSSA, R to penicillin. Changed abx to cefazolin 2 g q8h.'"

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, additional documentation on the event, such as whether the RNs caring for Patient 30 were full-time or part-time hospital employees, or whether they were contracted travel nurses was not included in the investigation report. The follow up did not include a review of nursing skin assessment qualifications, training, or competencies for those RNs who did not perform a skin assessment per protocol, i.e., a "2 RN skin assessment," or whether further education was required. The statement, "Will follow up with individual nurse as needed" was unclear as to which nurse(s) would be included in that follow up as 10 RNs, not including the WC RN, were involved in Patient 30's care. Of those 10, five RNs documented "No wounds" for the first four days prior to "Pictures of Left Elbow taken" on 05/19/2024. Additionally, there was no documentation or follow up regarding the delay in a WC RN assessment which occurred on 05/28/2024, nine days after the wound was first identified. Refer to Finding 2, the hospital's P&P and "Department-Specific Assessment & Reassessment Parameters" for Wound Care. Although the notes reflected a possible pre-existing "cellulitis wound," the notes failed to clearly reflect that a pre-existing condition existed, nor did they reflect that the left elbow "cellulitic" wound was communicated to nursing or had been included in Patient 30's plan of care. The investigation did not clearly determine whether a "HAPI" had been ruled out. For example, the WC RN notes reflected a left elbow with an "unstageable pressure injury," and that the "Right elbow [had] slight redness," therefore it was unclear whether the investigation determined that an exacerbation of a pre-existing condition occurred, or whether a "pressure injury" occurred during hospitalization. It was unclear whether abuse and/or neglect had been ruled out, or what other specific "corrective actions" for the "procedures not followed" other than "Re-education to staff on 2 RN skin check and special attention to high-risk" bony prominences to prevent recurrence. There were no notes as to when the "re-education" occurred, or which "staff" were included.

3.e. A second Event form and investigation regarding Patient 30's DTI to the R heel as described in Finding 3.d. was reviewed and reflected:
* "Description of Event ... Right heel DTI reported to RN ..."
* "Risk Manager Comments HAPI - R. Heel DTI."
* "Event Classification ... Deviation in GAPS reached the Patient but caused no harm or Minimal Harm ... Contributing Factors ... Procedures not followed."
* "Reviewer Comments ... Reviewing Patient Charts for areas of opportunity in education, processes and educated in 6/01 Weekly Update. Will follow up with individual nurses after review of charts. Will continue to follow up with Quality and Wound Care."
* "Patient Event Details ... Reviewer Comments ... Patient ended up with a DTI to ... right heel ... was very painful in both of ... knees. IR drainage 5/17 and washout of bilat knees 5/20 ... had intermittent confusion per notes and did not want to be turned. Notes from 5/25-28 noted that [patient] was refusing turns and heel floating. Also floating skin checks. Staff noted that they were educating [patient] regarding skin breakdown. Was on CCU 5/15-21, MCU 5/21-24, PCU 5/24 on. [sic] First noted the injury 5/26. Hospital staff tried to turn and educate patient. Patient was moving [themselves] around with [their] elbows and heels."

The hospital's investigation lacked similar follow up documentation as noted in Finding 3.d. For example, it was unclear whether what follow up occurred with "individual nurses" or when. It was unclear whether abuse and/or neglect had been ruled out.

3.f. Regarding Patient 31: Patient 31 was admitted to CCU on 05/17/2024 for Afib RVR and hyponatremia. An Event form and investigation was reviewed and reflected:
* "Description of Event ... Sacral pressure ulcer stage 1 noted."
* "Risk Manager Comments HAPI - stage 2 - pressure ulcer."
* "Event Classification ... Deviation in GAPS reached the Patient but caused no harm or Minimal Harm ... Contributing Factors ... Procedures not followed."
* "Recommended Changes for Prevention ... Educate staff on ensuring patients turn and documenting turns. Educate staff that once a patient has a PI they [sic] patients needs staff [sic] of [sic] the 'back' as much as possible."
* "Reviewer Comments ... 5/21/24 Stage 2 Pressure ulcer ... Admit 5/17 to CCU." Additional reviewer comments included:
- "[RN 8] - 5/17 0500: Braden score 17 'Low Risk' (Assist pt to turn Q2, encourage mobility, CCU bed). No skin breakdown noted. No turns charted. No 2RN Skin check."
- "[SM 11] - 05/17 0830: BS 16. No other changes. First turn @ 1030 Ind-lt, 1239 Ind-back, 1845 bath."
- "[RN 7] - 5/17: No changes. 2000-RT Heels skin check (not 2RN), 22 LT heels, 00 Back Heels, 0330 LT heels, 06 Back Heels."
- "[SM 11] - 5/18 0800: Abrasion on left foot, second toe noted. No other changes. 0736- LT, heels, skin check (not 2 RN), 09 Ind-back, 1112 RT heels, 1255 back, 1351 RT heels, 1716 LT heels."
- "[RN 8] - 5/18-19:15: BS 17. No other changes. Not [sic] turns documented."
- "[SM 11] - 5/19 0800: Stage 1 HAPI on coccyx. Note: 'Patient educated on the importance of repositioning every two hours.' Wound care consult and Riskconnect entered. 0752 LT heels skin check (not 2RN), 1015 RT heels skin check (not 2RN), 12 LT heels, 142 RT, 16 Ind-back, 1713 LT."
- "[SM 12] - 5/19 2000: no changes. Note: 'Patient able to boost self in bed and assist with turns' 19 ind-back, 2006 RT heels, 22 ind back heels, 0001 LT heels, 02 RT heels, 04 LT heels, 06 RT heels."
- "[SM 11] - 5/20 0800: no changes. 0845 walk, 1030 LT heels, 1308 walk, 1420 LT heels, 1607 RT heels, 1800 walk."
- "[RN 1] - 5/20 2000: No changes. 20 LT heels, 22 RT heels, 00 LT heels, 02 RT heels, 04 LT heels, 06 RT heels."
- "[SM 11] - 5/21: 0930 RT skin check (not 2rn)."
- "[SM 13] - 5/21 1141: 'Patient seen for skin and wound evaluation. [Patient 31] admitted 1 for Afib RVR and hyponatremia. Hx Meth use, ETOH, PE, Afib, heart failure, cardiomyopathy. Coccyx is very reddened, some non blanchable. Area approx 1 x 1 x 0.1 cm. Consistent with stage 2 pressure injury ... cannot tolerate the head of the bed down due to severe heart failure. Recommend strict turn q2h and desitin. Notified MD of all findings and recommendations."
- "5/22- f/u with [SM 11] ... says patients c/o not being turned the night before HAPI discovery."
* "Patient Review Details" noted, "Patient was admitted for Afib RVR and hyponatremia. [Patient] has a history of drug use and heart failure. [Patient] does not tolerate the head of the bed down due to respiratory distress. [Patient] can move but does not do it on his own. [Patient] needs direction and encouragement. No turns were charted NOC shift 5/18 into 5/19. [Patient] acquired a stage 2 pressure injury and it was noted 5/19 by day shift. [Patient] is on a CC bed and documented as independent in turns. This patient was educated by many staff members and turned, and ... would scoot ... back to center. This patient was non compliant with repositioning."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, additional documentation on the event, such as whether the RNs caring for Patient 30 were full-time or part-time hospital employees, or whether they were contracted travel nurses was not included in the investigation report. The follow up did not include a review of nursing skin assessment qualifications, training, or competencies for those RNs who did not perform a skin assessment per protocol, i.e., a "2 RN skin assessment," or whether further education was required. The only interview noted was by SM 13 who spoke with SM 11, but the investigation does not say whether this was to obtain more information or to provide education. It was unclear whether SMs 10, 11, 12, and 13 were RNs or other direct care staff because only initials were used in the report; there were no credentials or roles noted. There were no notes about interviews with RN 8, SM 11, or SM 12 about 2 RN skin checks, or why turns were not charted, i.e., missed q2h turns, per the reviewer comment, on 05/17/2024, 05/18/2024, or 05/19/2024. It was unclear whether abuse and/or neglect had been ruled out.

3.g. Regarding Patient 32: Patient 32 underwent cardioversion on 05/24/2024 and suffered a burn. An Event form and investigation was reviewed and reflected:
* "Description of Event ... patient received cardioversion, 3 shocks. When I was removing the pad for ... left upper back, I noticed a small square area of skin disruption, did not look like friction or skin tearing, appeared to be a possible burn as it was just under the top of the gel part of the pad. I alerted [RN] in CCU the next morning around 0900 as when I returned from lunch the patient had been transferred and I had 2 new patients to see. I notified [RN, their] primary nurse of this burn and asked [RN] to ensure treatment and dressing. [RN] stated [they] were on it."
* "Risk Manager Comments ... skin integrity- burn possible."
* "Event Classification ... Deviation in GAPS reached the Patient but caused no harm or Minimal Harm ... Contributing Factors ... Treatment Complexity."
* "Skin Integrity/Pressure Ulcer Details ... Burn ... Stage/Category II ... square disruption of top layer of tissue ... Device Involved in Pressure Ulcer ... Other Type of Device ... shock pads."
* "Patient Event Review Details ... Reviewer Comments ... Unfortunately this nurse was contacted by voicemail and never got to evaluate patient before [they] discharged. Nothing was charted under skin assessments or notes by [patient's] primary nurses after the ED. No evaluation or assessment can be verified by this nurse."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, the investigation focused on the follow up actions of the floor RN, however, there was no documentation on the procedure itself, or whether protocols for cardioversion were followed per hospital policy. There was no follow up regarding correct electrode placement, whether energy levels were verified, or whether the cardioversion equipment was checked, and the Preventive Maintenance schedule for the device followed. It was unclear whether any witnesses were interviewed, and whether any corrective personnel actions were taken to prevent recurrence, and therefore there was no assurance that similar incidents/events involving other patients would not recur.

3.h. Regarding Patient 36: Patient 36 was on SSU for surgery on 06/03/2025. An Event form and investigation was reviewed and reflected:
* "Description of Event ... Patient came to SSU to be staged for surgery (partial amputation of left 5th toe). Upon arrival to SSU, it was noted that patient's IV in LFA was reddened and infiltrated. Patient had been receiving Q12hr Vancomycin through that IV ... RN in MCU had been asked in phone report about location and status of the IV but did not state that there was any issue with the IV and couldn't find how long the IV had been in place. IV was dc'd with tip intact and another IV started in LFA - 22g with US guidance. We rolled the patient from side to side to change the patient's gown and found 2 wadded draw sheets, a pillow case, and a urine soaked chux and draw sheet. There were multiple crumbs in the bed along with the scent of syrup. The patient did not eat breakfast this morning and had been NPO since midnight. A skin tear was also noted on the patient's right buttocks - patient stated that that [sic] had been there for a while. Patient also had a dressing to the RFA that the patient stated was covering a skin tear. Patient's skin integrity did not appear to be a high priority with this patient with large amounts of linens, urine soaked linens, and an infiltrated IV."
* "Risk Manager Comments ... 6.4.25: IV infiltrate ... "
* "Event Classification ... Deviation in GAPS reached the Patient ..."
* "Reviewer Comments ... Deferring to inpatient floor manager for staff follow up."
* "Patient Event Review Details ... Notified manager of RN ... to discussed [sic] IV infiltrate and provide education if appropriate as [RN] floated to MCU from another unit. Discussed bedding, skin hygiene and saturated with [sic] linens with CNA who oversaw care. [CNA] reports ... cannot remember the exact time [patient] was toileted but ... did urinate in a urinal prior to transferring off unit. Urine output was documented in I/O flowsheet within the hour of [patient] transferring. [CNA] unfortunately states ... did not inspect ... linens the am before ... transfer. [CNA] apologized and says ... will be better about this going forward and reports it had been a busy day on the unit. Skin tears are being documented and followed with weekly photos."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, there was no documentation whether the medical record was reviewed for the following information:
- date/time when the infiltrated IV was placed;
- date/time when the IV was last assessed;
- date/time of last skin assessment; or
- date/time of last bedding change.
There was no documentation on whether any direct care RNs had been interviewed about the quality of patient care regarding skin care assessments, skin tears, patient hygiene and nutrition (meals). The report noted that someone spoke with the CNA regarding care, but it is unclear whether any RNs, who are responsible for managing the care of the patient, were provided feedback and/or education. It was unclear whether any corrective personnel actions were taken to prevent recurrence, and therefore there was no assurance that similar incidents/events involving other patients would not recur. It was unclear whether abuse and/or neglect had been ruled out.

3.i. Regarding Patient 37: Patient 37 was on SSU for surgery on 06/03/2025. An Event form and investigation was reviewed and reflected:
* "Description of Event ... Patient ... with history of acute myelogenous leukemia, status post bone marrow transplant in 2017 with possible graft-versus-host disease. The patient has 5 Leiden deficiency, hemochromatisis, diabetes mellitus, transient ischemic attack, and colon cancer status post colostomy. Patient was admitted 05/20/25 with bilateral pneumonia, respiratory failure, and septic shock. Patient initially required ventilatory and pressor support due to pneumococcal bacteremia. Patient has had significantly altered mental status, throughout [their] stay. Information collected from patient chart. Wound Care RN's received wound care consultation on 6/5/25 and patient was seen by wound care RN on 6/5/25. Patient had areas of redness on bilateral buttocks that were red, but blanchable. There was an area on the right buttock that had non-blanchable redness. Patient was seen for follow wound care on 6/12/25 after Wound Care RN was notified that skin was open, reddened, and flaky. Patient was seen by Wound Care RN's [sic] again on 6/18/25 for follow up. Upon assessment on 6/18, patient had open wound that had a pink and red wound bed, with dry flaky skin and pink peri-wound. This wound is consistent with an evolving, deep tissue injury."
* "Immediate & Remedial Actions Taken ... Patient was assessed multiple times by Wound Care RN's [sic] and patient was consistently turned - on a turning schedule. Patient was on CCU bed or hospital bed with waffle overlay. It was documented that patient heels were consistently floated, and that patient was turned side to side. Patient had barrier cream ordered and was used which is an appropriate intervention. Multiple, two RN skin checks were documented in patient chart per CCU nurses and areas of redness to the coccyx were documented. Per, [sic] documentation in chart, SCU RN reported patient was on waffle overlay on 5/29/25 at 1730 on the unit. Hospitalists were notified of findings and recommendations. Nursing staff was provided education on turns to offload and alleviate pressure."
* "On 5/28/25 there was a period between 1004 and 1530 in the CCU where the patient appeared to be in the chair for 7 hours and 26 minutes per documentation under ADLs in the patient chart. A small area of blancheable redness to the buttocks was first documented on 5/28/25 in the Critical Care Unit at 212. Being in a chair for an extended period, of time, coupled with low blood pressures and multiple patient comorbiditities, including mental status and respiratory failures, are all potential contributing factors to the patient's pressure injury."
* "Event Description ... Patient was found to have a wound consistent with a deep tissue injury that was evolving. Apparent cause form was completed and appropriate team members notified."
* "Skin Integrity/Pressure Ulcer Details ... Red and flaky skin above coccyx and open wound with red wound bed. Areas of purple hue/discoloration consistent with DTI evolving. Red coccyx first noted in CCU on 5/28 per RN documentation in chart."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, it was not clear whether "two RN skin checks" were consistently performed, or whether q2h turns occurred between the time that Patient 37 was admitted on 05/20/2025, and the time that "A small area of blancheable redness to the buttocks" was first documented on 05/28/2025, an approximately 8-day time period. Additionally, it was unclear whether the "right buttock," left buttock, bilateral buttocks, or coccyx evolved into a DTI, as the notes failed to accurately describe which "reddened" area became "open, reddened, and flaky." Although the patient had a "waffle overlay" on "5/29/25 at 1730," the notes don't reflect when this overlay was first implemented. It is also unclear when the hospitalists were notified of findings. It was unclear whether any corrective personnel actions were taken to prevent recurrence, and therefore there was no assurance that similar incidents/events involving other patients would not recur. It was unclear whether abuse and/or neglect had been ruled out.

4. During the incident/adverse event review with the DQ and the RM on 07/31/2025 beginning at 0930, the DQ confirmed Findings 3.b. - 3.i. The DQ confirmed that the investigations lacked documented actions and follow up in accordance with hospital P&Ps and CMS standards. Regarding Finding 3.b., the DQ acknowledged that the outcome of the investigation was not clearly documented. Regarding Finding 3.c., the DQ acknowledged it was unclear when the last skin assessment had occurred. Regarding Findings 3.d, 3.e., 3.f. and 3.g., the DQ acknowledged that it was unclear what follow up occurred with nursing or other staff. Regarding Finding 3.h., both the RM and the DQ acknowledged that the investigation did not clearly reflect whether the medical record review included review of the date/time of the infiltrated IV start, the date/time of the last IV assessment prior to infiltration, the date/time of the last skin assessment, the date/time of the last bedding change, or what education, if any was provided to direct care staff.