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Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by:

1. The facility's Governing Body failed to provide oversight to ensure patients receive complete emergency services, including maternal (the process of continuously observing a pregnant person's vital signs and physical indicators to assess their health and well-being during pregnancy, and as well as monitoring fetal health and uterine activity [tracking contraction -the tightening of the organ muscles where the unborn baby develops, which can be signs of labor]) and fetal monitoring (the process of tracking a baby's heart rate and other indicators during pregnancy to assess the baby's well-being and identify potential problems) for one (1) of 30 sampled patients (Patient 2), in accordance with the facility's policy regarding Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies) assessment standards.

This deficient practice had the potential for patients with pregnancy-related emergencies not to receive complete evaluations, placing patients at risk for undetected complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0063)


2. The facility's Governing Body failed to provide oversight to ensure emergency services were integrated and coordinated between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery Department (L&D, the hospital unit for pregnancy and childbirth emergencies) for one of 30 sampled patients (Patient 2), who was 32 weeks pregnant. Specifically, the facility failed to ensure L&D communicated results of obstetric evaluations, obtained physician order prior to transfer of Patient 2 back to the ED, performed nurse-to-nurse hand off (direct communication of patient status and care needs), and ensure ED staff received and acted on L&D findings by checking fetal heart tones (the process of tracking a baby's heart rate) after Patient 2 returned to the ED from L&D.

This deficient practice had the potential for patient transfers or discharges without necessary communication or documentation between departments to result in delayed or inappropriate treatment leading to patient harm and/or death. This deficient practice also placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0063)

3. The facility's Governing Body failed to provide oversight to ensure patient medical records were accurate and contained consultative evaluations (specialist reviews and findings), in accordance with the facility's medical staff rules and regulations, for one of 30 sampled patients (Patient 2).

This deficient practice had the potential for patient records not to reflect consultative findings or accurate risk assessments, which may lead to patient harm. This deficient practice also had the potential risk of not being able to address in a timely manner possible serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), or intrauterine demise (the baby dying before birth). (Refer to A-0063)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 26), was assessed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk and ensure appropriate interventions were implemented, in accordance with the facility's policy regarding patients at risk for elopement.

This deficient practice had the potential to place Patient 26 and other patients at risk of harm such as accidents or injury from being hit by a car, falling and breaking bones, and/or death. (Refer to A-0144)

2. The facility failed to ensure one of one sampled set of Emergency Exit double doors (Door #1), had a working alarm to notify staff of when the door was opened, which could impact 30 of 30 sampled patients, in accordance with the facility's policy regarding environmental rounds.

This deficient practice had the potential to place patients in harm when a functioning security system to alarm staff is not available and consequently may increase the risk patient elopement. (Refer to A-0144)

3. The facility failed to ensure staffed followed their "Sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) Utilization Policy," for one of 30 sampled patients (Patient 12), when staff was assigned to be a sitter for Patient 12 and at the same time was assigned to assist other patients thus unable to maintain a "line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)" of Patient 12.

This deficient practice had the potential for Patient 12 to injure self and/or others due to hospital staff not being able to maintain constant observation to ensure a safe environment. (Refer to A-0144)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by:

1. The facility failed to ensure that a registered nurse (RN, a licensed healthcare professional who has completed advanced training in nursing and passed a state licensing exam) supervised and evaluated nursing care for one (1) of 30 sampled patients (Patient 2). Specifically, the triage assessment (initial check to decide how urgent a patient's condition is) did not reflect the results of the C-SSRS (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), in accordance with the facility's policy regarding suicide (thoughts of ending one's own life) prevention.

This deficient practice had the potential to miss the opportunity to identify important risk factors and may delay the implementation. (Refer to A-0395)

2. The facility failed to develop an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 1) to address Patient 1's high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for delayed recognition and intervention of fall risks, which could result in additional falls and physical injury (such as broken bones [fractures] or head trauma [brain injury from a blow or impact]). It also had the potential to affect all patients admitted with fall risks who do not receive individualized care planning. (Refer to A-0396)

3. The facility failed to ensure staff followed their "Central Line: Insertion, Maintenance, and Care Policy" for one of 30 sampled patients (Patient 11), when staff incorrectly placed a CHG Foam disc patch (a hydrophilic foam disc dressing impregnated with Chlorhexidine Gluconate [CHG] used to prevent bloodstream infection) for Patient 11 with a PICC line (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period).

This deficient practice had the potential for Patient 11's PICC line to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper placement of CHG foam disc. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation for Medical Record Services was met, as evidenced by:

1. The facility failed to ensure medical records were accurately written or documented for one (1) of 30 sampled patients (Patient 2), in accordance with the facility's policy regarding suicide (thoughts of ending one's own life) prevention. Specifically, the triage assessment (an initial assessment to decide how urgent a patient's condition is) indicated "No suicidal risk," which did not reflect the results of the Columbia Suicide Severity Rating Scale (C-SSRS, a standard tool used be healthcare staff to evaluate suicidal thoughts and behaviors), which showed the patient answered "Yes" to having thoughts of dying and "Yes" to having thoughts of killing herself."

This deficient practice had the potential to result in patients with suicidal ideation (thoughts of ending one's own life) not being properly identified or monitored, leading to delayed or missed safety interventions. This could result in patients harming themselves or others. (Refer to A-0438)

2. The facility failed to ensure that medical record entries were properly documented, in accordance with facility's "Correction of Errors/Omission in Medical Records" policy and procedure, for five (5) of 30 sampled patients (Patient 1, Patient 3, Patient 4, Patient 7, and Patient 10). This was evidenced by the sitter documentation (sitter Observation Form, a monitoring tool used when staff provide continuous one-to-one observation of a patient) for Patient 1, and restraint documentation (Restraint Flowsheet, record used to monitor the safe application, release, and care of patients in restraints [any manual method, physical or mechanical device, material, or equipment used to restrict a patient's freedom of movement]) for Patients 3, 4. 7, and 10.

This deficient practice had the potential to cause miscommunication among healthcare providers and place patients at risk for medical treatment error (mistakes in care such as missed interventions, delays, or incorrect treatments). (Refer to A-0450)

3. The facility failed to ensure that one (1) of 30 sampled patient's (Patient 2), medical record contained the results of consultative evaluations and appropriate findings by clinical staff. Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term), considered a high-risk because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal stimulant drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

This deficient practice resulted in the discharge of Patient 2 to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without documentation of obstetric (pregnancy-related) consultation findings or confirmation of the baby's well-being. This deficient practice also had the potential risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-0464)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Emergency Services was met, as evidenced by:

1. The facility failed to ensure one (1) of 30 sampled patients (Patient 2), who presented to the Emergency Department (ED-hospital unit for urgent and life-threatening care) and Labor & Delivery (L&D-hospital unit for pregnancy and childbirth emergencies), received required assessments and physician examinations in accordance with the facility's policy and procedures, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department." Patient 2, was 32 weeks pregnant (about 8 months long, not yet full term), considered high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

In L&D, Patient 2 did not receive triage (an initial check to decide urgency of care), a Maternal-Fetal Triage Index (MFTI, scoring tool used to determine urgency of a pregnant patient's condition), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby's health], fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2's transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses).

When Patient 2 returned to the ED, staff did not check her (Patient 2) unborn baby's heart rate (fetal heart tones). Patient 2 later discharged to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without confirmation of Patient 2's own condition or the well-being of her (Patient 2) unborn baby.

This deficient practice had the risk of serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (The baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-1101)

2. The facility failed to ensure proper integrated communication between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery (L&D, hospital unit for pregnancy and childbirth emergencies) for one (1) of 30 sampled patients (Patient 2), 32 weeks pregnant (about 8 months long, not yet full term), considered a high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

Specifically, the facility failed to:

-Ensure L&D staff documented and communicated results of obstetric evaluations (such as triage [an initial check to decide urgency of care], vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating]), maternal or perinatal assessment (assessment of mother and baby's health), fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions).

-Ensure L&D staff obtained and communicated physician orders before transferring Patient 2 back to the ED.

-Ensure L&D staff provided nurse-to-nurse hand off (direct communication of patient status and care needs) when sending Patient 2 back to the ED.

-Ensure ED staff received and acted on L&D findings by checking fetal heart tones after Patient 2 returned from L&D.

-Ensure continuity of care so that maternal and fetal well-being was assessed and communicated before Patient 2 was discharged to a psychiatric facility (a healthcare institution that specializes in the diagnosis, treatment, and care of individuals with mental health disorders).

These deficient practices placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death). (Refer to A-1103)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the Governing Body (the facility's Board of Directors or equivalent leadership group legally responsible for hospital operations and patient safety) failed to provide oversight to ensure the facility's staff protects patients and provides safe and quality patient care. The Governing Body failed to:

1. Ensure patients receive complete emergency services, including maternal (the process of continuously observing a pregnant person's vital signs and physical indicators to assess their health and well-being during pregnancy, and as well as monitoring fetal health and uterine activity [tracking contraction -the tightening of the organ muscles where the unborn baby develops, which can be signs of labor]) and fetal monitoring (the process of tracking a baby's heart rate and other indicators during pregnancy to assess the baby's well-being and identify potential problems) for one (1) of 30 sampled patients (Patient 2), in accordance with the facility's policy regarding Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies) assessment standards.

This deficient practice had the potential for patients with pregnancy-related emergencies not to receive complete evaluations, placing patients at risk for undetected complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death).

2. Ensure emergency services were integrated and coordinated between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery Department (L&D, the hospital unit for pregnancy and childbirth emergencies) for one of 30 sampled patients (Patient 2), who was 32 weeks pregnant. Specifically, the facility failed to ensure L&D communicated results of obstetric evaluations, obtained physician order prior to transfer of Patient 2 back to the ED, performed nurse-to-nurse hand off (direct communication of patient status and care needs), and ensure ED staff received and acted on L&D findings by checking fetal heart tones (the process of tracking a baby's heart rate) after Patient 2 returned to the ED from L&D.

This deficient practice had the potential for patient transfers or discharges without necessary communication or documentation between departments to result in delayed or inappropriate treatment leading to patient harm and/or death. This deficient practice also placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death).

3. Ensure patient medical records were accurate and contained consultative evaluations (specialist reviews and findings), in accordance with the facility's medical staff rules and regulations, for one of 30 sampled patients (Patient 2).

This deficient practice had the potential for patient records not to reflect consultative findings or accurate risk assessments, which may lead to patient harm. This deficient practice also had the potential risk of not being able to address in a timely manner possible serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), or intrauterine demise (the baby dying before birth).

Findings:

1. During a review of Patient 2's ED record titled, "History and Present illness, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation and abdominal discomfort (general stomach pain without a clear cause). The record also indicated an ultrasound (a scan that uses sound waves to see inside the body) confirmed Patient 2 was 32 weeks and 5 days pregnant.

During a record review of Patient 2's record titled, "ED physician Hand Off Note," dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2' L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).

During a concurrent interview and record review on 8/21/2025 at 12:08 p.m., with Interim SLD (Supervisor of Labor and Delivery), Patient 2's record "Triage (an initial check to decide urgency of care)," dated 8/17/2025, was reviewed. The record indicated Patient 2 was scratching, and kicking, and the Non-Stress Test (NST, is a noninvasive prenatal test that monitors the baby's heart rate in response to its own movements and contractions) monitor had to be physically held in place for 20 minutes, but the nurse was unable to hold the Toco transducer (Toco, the device used during an NST and other fetal monitoring to measure the timing and duration of uterine contractions detecting changes in abdominal wall tension). SLD confirmed that an NST was attempted; however, the reading was not completed.

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the SLD, Patient 2's L&D Emergency Room record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," was reviewed. SLD confirmed the following:
- No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented.
- No vital signs (temperature, blood pressure, heart rate, respiration rate, oxygen saturation, or pain score).
- No maternal or perinatal assessment
- No physical medical screening exam
-No provider orders to transfer Patient 2 back to the ED.
- No nurse-to-nurse hand-off report from the L&D nurse to the ED nurse

During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2's ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff checked fetal heart tones (the baby's heartbeat measured with a handheld Doppler device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available.

During a concurrent interview and record review with on 8/22/2025 with RN 13, Patient 2's "ED Physician Hand Off Note," dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby's well-being.

During a concurrent interview and record review on 8/22/2025 at 10:00 a.m. with RN 15, Patient 2's NST, was reviewed. RN 15 stated the reading was not clear as there were many missed spaces (gaps of no reading). RN 15 stated "from this reading, we cannot say for certain whether the patient is having contractions or not." RN 15 also stated "with this reading, there should be a repeat test done as the test is inconclusive."

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2's NST, was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 confirmed that when there was no fetal monitoring, vital signs, triage assessments, or physician medical screening exams completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death.

During a concurrent interview and record review of 8/21/2025 at 12:20 p.m. with the interim Supervisor of Labor and Delivery (SLD, a supervising nurse temporarily overseeing the childbirth unit), Patient 2's L&D Emergency Room record (8/17/2025 from 2:22 a.m. to 3:10 a.m.), was reviewed. SLD confirmed there was no documentation of vital signs (temperature, [body heat measurement, used to detect infection], heart rate [pulse, beats in one minute], blood pressure [force of blood against vessel walls], respiration rate [breaths per minute], oxygen saturation [percentage of oxygen in the blood], and pain assessment [patient's self-report pain rating], no Maternal-Fetal Triage Index (MFTI, an acuity scoring tool for pregnant patients), no maternal or perinatal assessment, no obstetric provider medical screening exam (MSE, a physician exam to identify emergency conditions), and no provider orders for transfer back to the Emergency Department (ED, urgent and life-threatening care unit).

During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA), the Governing Body's minutes (the official written record of a meeting held by a governing body) from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department," dated 12/15/2024, the P&P indicated, "(Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient's presenting complaint and condition. Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. The patient's physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage/Charge RN Responsibilities: Perform an assessment by identifying the patient's immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. Mercury) and proteinuria (a condition where excessive amounts of protein are present in the urine) greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation (the period of time during which a fetus [unborn baby] develops in the uterus, from conception to birth) admitted through Emergency Department requiring perinatal screening examination ..."

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept.," dated 4/26/2023, the P&P indicated, "Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient's health or fetus' (estimated gestational age >20 weeks) health in serious jeopardy ... Identify patient's immediate needs as follows; does the patient have any of the following: Pregnancy > 20 weeks gestation with or without pregnancy-related complaint ... Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE). The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ..."

During a review of the facility's policy and procedure (P&P) titled, "Antepartum Testing.," dated 10/27/2021, the P&P indicated, "To provide guidelines for the noninvasive determination of fetal well-being by observing the response of fetal heart rate to fetal movement or Nonstress Test (NST) ... The nurse will notify the physician of all abnormal test results and obtain follow-up orders, documenting actions and results ..."

During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board by-laws indicated, " The Governing Board is responsible for compliance with The Joint Commission ("TJC") standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital's goals, policies and programs ..."

During a review of the facility's "Quality Assessment/Performance Improvement Plan (QAPI) 2025," dated 6/25/2025, the plan indicated, " The (Name of the facility) Governing Board:
1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization.
2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained
3. Acts strategically to ensure the delivery of high-quality care and services.
4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.

2. During a record review of Patient 2's medical record titled, "ED physician Hand Off Note," dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note also indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim SLD (Supervisor of Labor and Delivery), Patient 2's L&D record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled, "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," was reviewed. SLD confirmed there was no documentation of triage, a Maternal-Fetal Index (MFTI, scoring tool used to determine urgency of a pregnant patient's condition), vitals signs, maternal or perinatal assessments, fetal monitoring, or a physician medical screening exam (MSE, a doctor's exam required to determine if an emergency condition exists). SLD further confirmed there was no physician order documented for transfer of Patient 2 back to the ED from L&D and no nurse-to-nurse hand-off between the L&D staff and the ED staff prior to the transfer of Patient 2 back to the ED.

During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2's ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby's heart rate (fetal heart tones, or FHTs- the baby's heartbeat heard with a handheld Doppler [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available.

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2's non-stress test (NST, test of baby's heart rate with movement or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with the interim Supervisor of Labor and Delivery (SLD, a supervising nurse temporarily overseeing the childbirth unit), Patient 2's ED record, dated 8/17/2025 through 8/21/2025, were reviewed. SLD confirmed there was no documentation that fetal heart tones (unborn babies heartbeat measured with a handheld Doppler device [a medical imaging device that uses high-frequency sound waves to create images]) were checked after Patient 2's return to the ED from L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA), the Governing Body's minutes (the official written record of a meeting held by a governing body) from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept.," dated 4/26/2023, the P&P indicated, "Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE)," and that documentation be included in the record ... "The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ..."

During a concurrent interview and record review with the Administration Manager (MA) on 8/22/2025 at 5:30 p.m. the Governing Body's minutes from July 2025 to March 2025 were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB has the responsibility for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department," dated 12/15/2024, the P&P indicated, " (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient's presenting complaint and condition. Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ..."

During a review of the facility's policy and procedure (P&P) titled, "Hand-Off/SBAR Communication, Patient," dated 5/22/2024, the P&P indicated, "To provide accurate information about patient's care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are "handed off' from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.

During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board by-laws indicated, "The Governing Board is responsible for compliance with The Joint Commission ("TJC") standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital's goals, policies and programs ..."

During a review of the facility's "Quality Assessment/Performance Improvement Plan (QAPI) 2025," dated 6/25/2025, the plan indicated, "The (Name of the facility) Governing Board:
1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization.
2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained
3. Acts strategically to ensure the delivery of high-quality care and services.
4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.

3. During a record review of Patient 2's medical record titled, "ED (Emergency Department, hospital unit for urgent and life-threatening care) physician Hand Off Note," dated 8/17/2025, indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The ED physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer of Patient 2 to L&D (Labor and Delivery, department that provides care for pregnant individuals during labor, childbirth, and the immediate after birth).

During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2's electronic medical record, was reviewed. RN 14 confirmed that Patient 2's L&D electronic record did not contain an obstetric provider medical screening exam (MSE, a doctor's exam to determine if an emergency condition exists), no physician's order to transfer Patient 2 back to the Emergency Department (ED-hospital unit for urgent and life-threatening care), and no nurse-to-nurse hand-off (verbal communication of patient information when responsibilities is transferred) between the L&D nurse and the ED nurse prior to Patient 2's transfer back to the ED.

During the same interview on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2's L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the interim supervisor of Labor and Delivery (SLD), Patient 2's Labor and Delivery Emergency Room (a hospital unit that handles urgent obstetric or pregnancy-related medical issues) record titled, "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., was reviewed. SLD confirmed that there was no documentation of triage (initial assessment to determine urgency of care), a Maternal-Fetal Triage Index (MFTI, tool used to score urgency for pregnant patients), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby's health], fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2's transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses).

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2's NST, was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During a concurrent interview and record on 8/22/2025 with RN 13, Patient 2's "ED Physician Hand-Off Note." dated 8/21/2025, was reviewed. The record indicated transfer to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed that Patient 2 was discharged without obstetric clearance (the medical evaluation of a pregnant patient to determine if their condition is an obstetric emergency and if it is safe for them to receive non-obstetric care) and the note did not reflect evaluation of fetal status (the process of assessing a fetus's health).

During a concurrent interview and record review on 8/22/2025 at 5:30 p.m. with the Administration Manager (MA),the Governing Body's minutes (the official written record of a meeting held by a governing body), from July 2025 to March 2025, were reviewed. The MA stated there were no discussions in the GB meetings regarding tracking and monitoring of Labor and Delivery Department performance. The MA also stated GB had the responsibility for providing oversight on overall quality of care and patient safety.

During a review of the facility's "Medical Staff General rules and Regulations (are a set of detailed operational standards, policies, and professional conduct guidelines for hospital medical staff)," dated 10/31/2020, the documents indicated, "Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician ... Patients shall be discharged only on a written order of the attending or alternate physician ...Medical Screening Exam (MSE): Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner, Registered Nurses functioning under Standardized Procedures) are authorized to perform the MSE ..."

During a review of the facility's policy and procedure (P&P) titled, "Hand-Off/SBAR Communication, Patient," dated 5/22/2024, the P&P indicated, "To provide accurate information about patient's care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are "handed off' from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.

During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board by-laws indicated, " The Governing Board is responsible for compliance with The Joint Commission ("TJC") standards, Title 22 licensure regulations, Medicare conditions of participation and Department of Public Health directives. The Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the CEO ... The Governing Board shall participate in and support an institutional planning process subject to review and approval by the General Partner, to periodically evaluate the Hospital's goals, policies and programs ..."

During a review of the facility's "Quality Assessment/Performance Improvement Plan (QAPI) 2025," dated 6/25/2025, the plan indicated, "The (Name of the facility) Governing Board:
1. Assumes full legal authority and responsibility for operations of the hospital, and has the overall responsibility of governance for the performance improvement activities within the organization.
2. Ensures that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained
3. Acts strategically to ensure the delivery of high-quality care and services.
4. Ensures that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.

Based on observation, interview and record review, the facility failed to:

1.a. Ensure one of 30 sampled patients (Patient 26) was assessed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk and ensure appropriate interventions were implemented, in accordance with the facility's policy regarding patients at risk for elopement.

This deficient practice had the potential to place Patient 26 and other patients at risk of harm such as accidents or injury from being hit by a car, falling and breaking bones, and/or death.

1.b. Ensure one of one sampled set of Emergency Exit double doors (Door #1), had a working alarm to notify staff of when the door was opened, which could impact 30 of 30 sampled patients, in accordance with the facility's policy regarding environmental rounds.

This deficient practice had the potential to place patients in harm when a functioning security system to alarm staff is not available and consequently may increase the risk patient elopement.

2. Ensure staff followed their "Sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) Utilization Policy," for one of 30 sampled patients (Patient 12), when staff was assigned to be a sitter for Patient 12 and at the same time was assigned to assist other patients thus unable to maintain a "line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)" of Patient 12.

This deficient practice had the potential for Patient 12 to injure self and/or others due to hospital staff not being able to maintain constant observation to ensure a safe environment.

On 8/22/2025 at 4:15 p.m., the survey team called an immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Manager Quality Risk Management (MQRM), Vice President of Quality Risk Management (VPQRM), and the Emergency Department Registered Nurse (RN).

The facility failed to ensure the following for the Emergency Department (ED):
-There was a working Emergency Exit door alarm near patient rooms 8, 9, and 10.
-Security or Engineering were accountable for maintaining the security system in the Emergency Department (ED)
-Risk assessment for elopement and interventions were implemented to prevent Patient 26 from leaving the ED.

These deficient practices had the potential to place Patient 26 and current patients at risk of elopement to suffer from harm and/or death.

During a review of Patient 26's "ED Note," dated 6/17/2025, the record indicated Patient 26 was brought to the facility's ED after being found wandering outside her apartment confused, incontinent (lost bladder control) of urine, and with a high alcohol level. The record further indicated Patient 26 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility's ED through a set of double doors with no alarm, was brought back into the ED and placed on right and left soft wrist restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), removed herself (Patient 26) from the restraints and eloped again. Patient 26 was brought back to the ED and was ultimately discharged after becoming sober (think and function without impairment). This incident prompted the survey team to investigate the ED door alarms. A set of emergency exit ED door alarms was found to not be working. Upon interviews with security and engineering, security stated that a log of when the doors were checked, was not kept, and both departments (security and engineering) stated it was the other department's (referring to either the security or engineering department) responsibility to check the ED doors.

On 8/22/2025 at 9:25 p.m., the IJ was removed in the presence of the CFO, CNO, VPQRM, and MQRM, after the facility submitted an acceptable IJ Removal Plan (IJRP, interventions to correct the deficient practice). The elements of the IJRP were verified and confirmed through observations, interviews, and record review. The acceptable IJRP regarding the emergency exit doors included the following: The Security Department shift supervisor would round and check all ED doors alarms daily and keep a log containing the officer's name, date, time, and disposition; door alarm log audits would be reported to Environment of Care (EOC) Committee monthly; alarm doors not working would be escalated to the Engineering Department immediately for repair; repairs would be tracked via work orders and reported to the monthly EOC." The ED door alarm was immediately fixed by the Engineering Dept to ensure the door alarmed, when opened. The acceptable IJRP regarding Elopement risk included an "Elopement Risk Assessment," which was created and implemented on 8/22/2025 for all patients in the Emergency Department and would be conducted during Triage; current and subsequent staff received training on the assessment form which included low, moderate, and high-risk interventions to implement.

Findings:

1.a. During a concurrent interview and record review on 8/21/2025 at 3:10 p.m. with Registered Nurse (RN) 2, Patient 26's "ED (Emergency Department, a hospital unit for urgent and life- threatening care) Note," dated 6/17/2025, was reviewed. The record indicated Patient 26 was brought to the facility's ED for "Evaluation of confusion ...She (Patient 26) was found to be confused and incontinent (involuntary loss) of urine." The record indicated Patient 26 denied a past medical history. The record also indicated at 4:25 p.m. (on 6/17/2025), "Patient (Patient 26) was found to have left her (Patient 26) room, exited the main ER (Emergency Department) and was on her way out of the building when she (Patient 26) was caught be security and brought to the emergency department. Patient is intoxicated (drunk, impaired function) and not clinically sober (can function) for discharge ..." The record further indicated at 4:45 p.m. (on 6/17/2025), "Patient (26) was found to have escaped her restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and was again attempting to leave the emergency department. She (Patient 26) was returned to her bed by security. Restraints were then placed again on her upper extremities. Patient remains intoxicated ..."

During a concurrent interview and record review on 8/21/2025 at 3:10 p.m. with RN 2, Patient 26's "Flowsheet Inquiry Report," dated 6/17/2025, was reviewed. The record indicated the following nursing notes about Patient 26's elopement attempts:

-On 6/17/2025 at 4:20 p.m., the record indicated "Pt (Patient 26) attempted to elope and left out of an emergency exit that did not sound. Pt was being incoherent (incomprehensible or unclear speech) and intoxicated towards staff and attempting to walk into traffic ..."

-On 6/17/2025 at 4:44 p.m., the record indicated "At approx. (approximately) 1620 (4:20 p.m.), pt (Patient 26) walked from ER bed 8 to bathroom with a steady gait ...RN was seated outside of bed 11 and saw pt walk out through the double doors. Double doors did not alarm. Pt found outside of ER on sidewalk, escorted back to ER bed 8 and placed on 2 pt (point) restraints (restraints applied to both wrists) for safety."

-On 6/17/2025 at 4:50 p.m., the record indicated that at "4:45 p.m., pt (Patient 26) again attempted to elope, removed herself from restraints and attempted to exit the building. She was safely received by security, RNs and ED tech in entrance to ED and compliant to come back to ED while she sobers up. Restraints reapplied..."

During the same concurrent interview and record review on 8/21/2025 at 3:10 p.m. with RN 2, Patient 26's "Physician Order Restraints," dated 6/17/2025, was reviewed. The record indicated Patient 26 had two orders, the first ordered at 4:25 p.m. and the second at 4:45 p.m., for soft wrist right and left restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for being impulsive (acting without forethought), trying to get out of bed, and unsteady.

During an interview on 8/22/2025 at 9:25 a.m. with Registered Nurse (RN) 7 , RN 7 stated the ED emergency exits were in the front and the back of the unit (the ED unit). RN 7 stated she heard the door alarms triggered before and had no experience with them being broken. RN 7 stated for patients trying to elope (the act of leaving a facility unsupervised and without prior authorization), interventions would be asking where the patient was going and assess (evaluate) the patient's orientation. RN 7 stated there was no assessment completed for elopement but would still document a note.

During a concurrent interview and record review on 8/22/205 at 10:03 a.m. with Registered Nurse (RN) 2, RN 2 stated there was no standard elopement assessment tool being completed by staff in the ED and staff would just write narrative notes about an event. RN 2 confirmed Patient 26 did not have an order for a sitter (a trained hospital staff member who provides constant, one-on-one supervision to a patient who is at high risk of falling, wandering, causing self-harm, or harming others) because the patient (Patient 26) was just really drunk and not aggressive, and the restraints were for personal safety, and would not necessarily warrant a sitter. RN 2 stated Patient 26 had the appropriate intervention, and a sitter was not needed because Patient 26 was not exhibiting behavioral issues such as trying to throw themselves out of bed.

During a review of the facility's policy and procedure (P&P) titled, "Sitter Utilization," dated 12/1/2021, the P&P indicated, "A physician's order is not needed for a sitter ...The following are patient presentations/conditions/behaviors that indicate a higher level of observation (constant or one-to-one) may be necessary to protect the patient ...A patient that actively attempts elopement or verbalizes desire for elopement."

1.b. During a concurrent observation and interview on 8/22/2025 at 9:41 a.m. with the Director of Security (DS), Chief Nursing Officer (CNO), and the Vice President Quality Risk Management (VPQRM), the survey team observed a set of Emergency Exit double doors alarms that was not working, The Emergency Exit double door (Door #1) led out to an open area of the hospital and to the street. This set of Emergency Exit doors was near Patient rooms 8, 9, and 10. DS stated he (DS) could not recall when the alarm was changed. DS stated rounding (method to check environmental safety conditions/concerns) was done once a week by engineering or security. DS stated a log was not kept that indicated findings. DS stated he (DS) would call engineering to fix the non-working alarm. DS stated it might be the whole system that's broken and not just the battery for the Emergency Exit doors.

During an interview on 8/22/2025 at 11:22 a.m. with Security Officer (SO) 1, SO 1 stated the responsibility to check the doors in the Emergency Department (ED), was by engineering. SO 1 stated he (SO 1) assisted the Engineering department by using a key to turn off the alarm. SO 1 stated if the alarms were not working, the engineering department would be notified right away. SO 1 stated if the door alarms were not working, a patient could get into an accident. SO 1 confirmed the set of emergency exit doors near Patient room 10, led to the street.

During an interview on 8/22/2025 at 11:43 a.m. with the Facilities Supervisor (FS), FS stated security was responsible for checking the integrity of the doors. FS stated he (FS) had not recently received any service tickets for the ED doors, except for today (8/22/2025). FS stated the batteries were replaced for the door alarm on 8/22/2025. FS also stated there was a monthly safety round and different areas were picked monthly.

During an interview on 8/22/2025 at 2:38 p.m. with Registered Nurse (RN) 2, RN 2 stated he (RN 2) was not aware that the ED door alarm near patient room 10, was not working. RN 2 stated he (RN 2) was aware of an incident when a patient (Patient 26) went through a set of doors in the ED, where the alarm did not go off, and did not know if repairs were made at that time.

During an interview on 8/22/2025 at 3:18 p.m. with the Chief Nursing Officer (CNO), CNO stated there was an alarm installed on the doors (Door #1) that was observed earlier, to prevent it from being left open. CNO was not aware that the door was not working until the observation with the survey team on 8/22/2025. CNO confirmed that the door alarm not working created a safety risk to patients on a hold or elopement risk.

During a review of the facility's "Repair Report," dated 6/1/2025-8/22/2025, the record indicated there was no service request for the ED doors (Door #1) on 6/17/2025 (when an ED patient eloped using Door #1 and the alarm did not sound).

During a review of the facility's "Safety Surveillance Rounds," dated 1/7/2025, the record indicated for the ED, the "Security Exit Alarm," was checked. The next check for ED security exit alarm was completed six months later on 7/1/2025.

During a review of the facility's policy and procedure (P&P) titled, "Environmental Rounds," dated 10/23/2024, the P&P indicated, "If conditions or hazards are identified during Environmental Rounds that pose immediate threat to life, health or safety, the situation must be immediately and appropriately addressed and reported to the Safety Officer."

2. During a review of Patient 12's "Face Sheet (a concise summary document containing key information about a person or entity, often used in healthcare)," dated 8/21/2025, the Face Sheet indicated Patient 12 was admitted to the facility unit on 7/25/2025 at 10:36 p.m.

During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/25/2025, the "H&P" indicated the following: Patient 12 was reportedly assisted by an Uber (transportation network) driver when Patient 12 was not talking and was in a confused state.

During a review of Patient 12's "Progress Notes ," dated 8/19/2025, the Progress Notes indicated the following: Patient 12 with "history of altered mental status (a change in a person's level of consciousness [a person's degree of wakefulness, alertness, and awareness of their surroundings], alertness, and cognitive function [the brain's ability to process information]) and remains confused."

During an interview on 8/19/2025 at 11:21 a.m. with Charge Nurse (CN 11), CN 11 stated the following: Confirmed there was another patient who was also confused and in the same room with Patient 12. Patient 12 was confused and was assigned a sitter (CNA 2) on that day (8/19/2025). CNA 2 was also assisting the other patient who was in the same room as Patient 12.

During a concurrent observation and interview on 8/19/2025 at 11:24 a.m. with Nurse Manager (NM 2) in Patient 12's room, CNA 2 went to assist the other patient in the shared room with Patient 12, and did not maintain "line of sight (a safety protocol where a designated, competent staff member maintains a direct, unobstructed view of a patient to ensure their immediate safety and to allow for prompt intervention if they become a risk to themselves or others)" of Patient 12. NM 2 stated the following: Confirmed CNA 2 was the sitter (healthcare professional who provides continuous supervision and support to patients in hospitals) for Patient 12 and was also assigned to assist with the other patient in the same room shared with Patient 12.

During an interview on 8/19/2025 at 11:46 a.m. with Registered Nurse (RN 11), RN 11 stated the following: Patient 12 was not assigned to RN 11 but knew that Patient 12 had a sitter due to being confused. RN 11 was assigned to the other patient (in the same room with patient 12) who was also very confused sometimes. CNA 2 was the main sitter for Patient 12 and watched both patients.

During an interview on 8/20/2025 at 2:22 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated the following: Confirmed on 8/19/2025 was assigned to Patient 12 as a sitter and also helping sometimes to assist the other patient in the same room. Patient 12 needed a sitter for safety concerns due to confusion. CNA 2 stated the other patient in the room was also confused on and off so that is why CNA 2 assisted the other patient. CNA 2 said "It is hard to watch both patients at the same time, I should focus on the patient who has an order for sitter. I can not see Patient 12 when I am assisting the other patient in the same room. Both patients are confused and can fall out of bed. For safety reasons there should be only one sitter for one patient. I do not decide or make the decision for sitter assignments."

During an interview on 8/20/2025 at 2:52 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated the following: Confirmed assigned to Patient 12 as a sitter today (8/20/2025) and assigned to assist with the other patient in the room. Confirmed both patients were still confused. CNA 2 said Patient 12 was confused, restless, and always wanted to get out of bed when awake. CNA 2 further stated "Not really safe to be watching both patients. Don't know if patient (Patient 12) is on Constant observations to maintain ['line of sight.']"

During an interview on 8/20/2025 at 3:23 p.m. with Registered Nurse (RN 3), RN 3 stated the following: Confirmed there was a sitter assigned to Patient 12 today (8/20/2025) for constant observation and line of sight. Patient 12 was confused and had a sitter for the past couple of days. RN 3 said the CNA who was assigned to be a sitter for Patient 12 was also watching the other confused patient in the same room. CNA 2 was helping watch both patients. RN 3 stated the set-up with the use of the sitter was a safety concern for patients. There was no line of sight for Patient 12 when CNA 2 helping the other patient. The confused patient (Patient 12) can fall from the bed.

During an interview on 8/20/2025 at 3:44 p.m. with Nurse Manager (NM 2), NM 2 stated the following: Confirmed Patient 12 had a sitter assigned for safety and was on a constant observation. NM 2 confirmed that with staff not following the sitter policy regarding constant observation and line of sight was a concern for Patient 12 when the assigned sitter for Patient 12 was busy assisting the other patient in the room. NM 2 further stated the current practice was a safety concern because confused patients can fall out of bed. NM 2 stated "Will educate staff on following sitter policy."

During a review of the facility's policy and procedure (P&P) titled, "Sitter Utilization Policy," dated December 2021, the "P&P" indicated "Purpose: To protect patients who exhibits behaviors consistent with altered mental status, and could contribute to risk of injury or decreased efficacy of clinical care. Policy: Two methods of observation are employed by a sitter to enhance the safety of patients. These methods of observation include: Constant observation and One-to-One Observation. Constant observation consists of staff member assigned to one or more patients where the staff member can directly observe the patient's activities at all times. This is also known as "line of sight," whereby the patient(s) is always within the staff's direct field of vision. Continuous direct visual observation will continue even when patients shower, change clothes, or use the bathroom. All attempts will be made to maintain the patient's privacy as much as possible; however, the safety of the patient must be the main concern.

Based on interview and record review, the facility failed to ensure that a registered nurse (RN, a licensed healthcare professional who has completed advanced training in nursing and passed a state licensing exam) supervised and evaluated nursing care for one (1) of 30 sampled patients (Patient 2). Specifically, the triage assessment (initial check to decide how urgent a patient's condition is) did not reflect the results of the C-SSRS (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), in accordance with the facility's policy regarding suicide (thoughts of ending one's own life) prevention.

This deficient practice had the potential to miss the opportunity to identify important risk factors and may delay the implementation of treatment and safety plans, which may result in harm for Patient 2.

Findings:

During a review of Patient 2's ED (Emergency Department, a hospital unit for urgent or life-threatening care) record titled, "History and Present illness," documented by ED physician (MD, a medical doctor) 1, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation (thoughts of ending one's own life).

During a concurrent interview and record review on 8/21/2025 at 10:16 a.m. with RN 14, Patient 2's ED record titled, "Emergency Department Triage (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) Report," dated 8/16/2025, was reviewed. The record indicated there were multiple cuts on Patient 2's wrists. However, the triage assessment indicated "Suicidal Risk: No." RN 14 stated the triage suicidal risk assessment did not include the results from the C-SSRS tool (Columbia Suicide Severity Rating Scale, a standardized tool used by healthcare staff to evaluate suicidal thoughts and behaviors), which indicated the following responses:

-"Have you wished you were dead or wished you could go to sleep and not wake up?" Patient 2's answer: "Yes."

-"Have you actually had any thoughts of killing yourself?" Patient 2's answer: "Yes."

-RN 14 stated the triage assessment should have reflected these results and should have indicated "Yes" for suicidal ideation.

During an interview on 8/19/2025 at 11:34 a.m. with the Nurse Manager of ED (NM, a nurse in charge of supervising nurses and operations in the department) 1 , NM1 stated the expectation was for all patients presenting with suicidal ideation to have the Columbia (C-SSRS) tool completed at triage and the results documented in the record. This would allow the patient's suicide risk to be properly evaluated and interventions (such as psychiatric consults [a meeting with a psychiatrist- a medical practitioner specializing in the diagnosis and treatment of mental illness], sitter assignment [one-to-one staff assigned to observe a patient at all times], or increased observation [closer monitoring by staff]), could be initiated.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Prevention," dated 9/23/2020, the P&P indicated, "To identify individuals at risk for suicide and to decrease the risk of suicidal death. To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients ... The patient will be screened for suicide risk at the point of entry, or at any time during the course of hospitalization if their psychiatric condition changes or if suicidal ideation is expressed ... The Emergency Department (ED) Triage Registered Nurse (RN) determines suicide risk initially by completing the Columbia-Suicide Severity Rating Scale (C-SSRS) ...must be documented."

Based on interview and record review, the facility failed to develop an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 1) to address Patient 1's high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for delayed recognition and intervention of fall risks, which could result in additional falls and physical injury (such as broken bones [fractures] or head trauma [brain injury from a blow or impact]). It also had the potential to affect all patients admitted with fall risks who do not receive individualized care planning.

Findings:

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/12/2025, the "H&P" indicated, Patient 1 was 92 years old, with known history of dementia (a group of symptoms affecting memory, thinking and social abilities). The H&P further indicated Patient 1 had been recently discharged after an admission for generalized weakness (a feeling of muscle fatigue or lack of strength that affects multiple muscle groups) with worsening confusion. At readmission, Patient 1 was described as "severely agitated (extremely emotional upset and restless)" and "combative (eager to fight or resist)," requiring admission for further evaluation.

During a concurrent interview and record review on 8/19/2025 with the Emergency Department (ED, hospital unit for urgent and life-threatening care) Nurse Manager (NM, a supervising nurse responsible for managing unit staff and care planning) 1, Patient 1's medical record (MR, the official chart of a patient's care) document titled, "Daily Assessment Inquiry," dated from 7/12/2025 through 7/17/2025, was reviewed. The MR indicated that Patient 1 was assigned a fall risk score using the Morse Falls Scale (a standardized tool that predicts the likelihood of patient falling; scores of 0-24 = no risk, 25-50 = low risk, and 51 or greater = high risk for falls). Patient 1' scores were as follows:

- On 7/12/2025: 100 (high fall risk)
-On 7/13/2025: 70 (high fall risk)
-On 7/14/2025: 115 (high fall risk)
-On 7/15/2025: 110 (high fall risk)
-On 7/16/2025: 110 (high fall risk)

During the same interview and record review on 8/19/2025 with NM1, Patient 1's "Care Plan," initiated on 7/12/2025, was reviewed. The care plan did not include any interventions or goals addressing Patient 1's high risk for falls. NM 1 confirmed that there was no documented care plan addressing Patient 1's high risk of fall, despite Patient 1's prior fall history and consistently high fall risk scores. NM 1 stated there should have been a care plan initiated for fall risk under these circumstances.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care Documentation, Interdisciplinary," dated 9/1/2022, the P&P indicated the following: Purpose: To provide guidelines in completing the Interdisciplinary care plan to ensure that each patient has a completed care plan period ...The Interdisciplinary plan of care should include: A. The RN initiates the Interdisciplinary plan of care after completion of the initial assessment. The plan of care is initiated within 12 hours of patient's admission ...B. The Interdisciplinary plan of care will be updated every shift and as patient condition indicates.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Management, Mobility and Ambulation" dated 5/26/2025, the P&P indicated the following: Assessment and Reassessment. 1. The patient's fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient falls. 2. Evidence-based fall risk interventions will be implemented based upon an age-appropriate fall risk assessment tool.

Based on observation, interview, and record review the facility failed to ensure staff followed their "Central Line: Insertion, Maintenance, and Care Policy" for one of 30 sampled patients (Patient 11), when staff incorrectly placed a CHG Foam disc patch (a hydrophilic foam disc dressing impregnated with Chlorhexidine Gluconate [CHG] used to prevent bloodstream infection) for Patient 11 with a PICC line (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period).

This deficient practice had the potential for Patient 11's PICC line to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper placement of CHG foam disc.

Findings:

During a review of Patient 11's "Face Sheet (a concise summary document containing key information about a person or entity, often used in healthcare)," dated 8/13/2025, the Face Sheet indicated Patient 11 was admitted to the facility unit on 7/18/2025 at 4:35 p.m.

During review of Patient 11's "History and Physical (H&P)," dated July 2025, the "H&P" indicated the following: Patient 11 with a history nonhealing right foot infection and right foot underlying osteomyelitis (infection of the bone tissue).

During a concurrent observation and interview on 8/19/2025 at 11:29 a.m. with Nurse Manager (NM 2) in Patient 11's room, Patient 11's PICC (Peripheral Inserted Central Catheter, is a intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) line to the right upper arm was observed with a CHG foam disc incorrectly placed underneath the transparent dressing at the PICC insertion site. The CHG foam disc placed underneath the transparent dressing did not allow the catheter to rest within the slit of the disc. NM 2 stated the following: Confirmed CHG foam disc was improperly placed and would educate staff on proper placement of CHG foam disc.

During an interview on 8/19/2025 at 11:46 a.m. with Registered Nurse (RN 11), RN 11 stated the following: Confirmed assigned to Patient 11 for the day (8/19/2025). RN 11 stated "did not do the last dressing change for patient (Patient 11) and it was done by some one else." RN 11 said "will change patient's (Patient 11) PICC line dressing because the CHG foam disc is improperly placed. Improper placement of the CHG foam disc could be a risk for infection."

During an interview on 8/21/2025 at 3:31 p.m. with Registered Nurse (RN 13), RN 13 stated the following: RN 13 was a PICC line nurse and confirmed RN 13 placed PICC line for Patient 11. RN 13 said it was important to properly place the CHG foam disc underneath the transparent dressing making sure the PICC line catheter was resting within the slit of the CHG foam disc. RN 13 further said, If not properly placed, it could lead to the possibility of staff who changes the PICC line dressing to pull out the PICC by accident and a risk for infection can happen too.

During a review of the facility's policy and procedure (P&P) titled, "Central Line: Insertion, Maintenance, and Care Policy," dated April 2024, the "P&P" indicated "Purpose: To serve as guidelines concerning the safe initiation and care of central lines (central venous catheters [CVCs] or central venous access devices [CVADs]). Types of central lines include non-tunneled catheters (short-term catheters), peripherally inserted central catheter (PICCs), tunneled catheters (long-term catheters) and implanted ports (Port-A¿Cath and Power Ports). Policy: E. Always use Chlorhexidine gluconate (CHG) impregnated sponge on all central lines, unless contraindicated (i.e. allergy). Ensure proper application of CHG impregnated sponge at the insertion site, white foam side next to skin. Do not lay CHG impregnated sponge on top of catheter hub. B. Dressing Change: F. Apply CHG impregnated sponge following manufacturer's instructions."

During a review of the facility's manufacturer's instructions titled, "Aegis CHG-Impregnated Foam Disc" the manufacturer's instructions indicated "Aegis is a hydrophilic foam disc dressing impregnated with chlorhexidine gluconate (CHG) that supports clinical best practices and professional guidelines for reducing CLABSI (Central Line Associated Blood Stream Infection) and CRBSl (Catheter Related Blood Stream Infection). It absorbs exudate and inhibits or kills microorganisms on the dressing's surface. How to apply: Step 3 Ensure the Aegis disc makes 360° contact with the skin around the catheter. Additionally, the catheter should rest upon the slit portion of the disc."

Based on interview and record review, the facility failed to ensure medical records were accurately written or documented for one (1) of 30 sampled patients (Patient 2), in accordance with the facility's policy regarding suicide (thoughts of ending one's own life) prevention. Specifically, the triage assessment (an initial assessment to decide how urgent a patient's condition is) indicated "No suicidal risk," which did not reflect the results of the Columbia Suicide Severity Rating Scale (C-SSRS, a standard tool used be healthcare staff to evaluate suicidal thoughts and behaviors), which showed the patient answered "Yes" to having thoughts of dying and "Yes" to having thoughts of killing herself."

This deficient practice had the potential to result in patients with suicidal ideation (thoughts of ending one's own life) not being properly identified or monitored, leading to delayed or missed safety interventions. This could result in patients harming themselves or others.

Findings:

During a review of Patient 2's ED (Emergency Department, a hospital unit for urgent and life-threatening care) record titled, "History and Present illness," documented by ED physician (MD, a medical doctor) 1, dated 8/16/2025, the record indicated Patient 2 presented to the Emergency Department with suicidal ideation (thoughts of ending one's own life).

During a concurrent interview and record review 8/21/2025 at 10:16 a.m. with RN 14, Patient 2's ED record titled, "Emergency Department Triage (initial check to decide how urgent a patient's condition is) Report," dated 8/16/2025, was reviewed. The triage assessment indicated "Suicidal Risk: No." RN 14 stated that the assessment should have reflected the results of the C-SSRS, which indicated:

-"Have you wished you were dead or wished you could go to sleep and not wake up?" Patient 2's answer: "Yes."
-"Have you actually had any thoughts of killing yourself?" Patient 2's answer: "Yes."
-RN 14 confirmed that the documentation in the triage assessment was inaccurate and inconsistent with the C-SSRS results.

During an interview on 8/19/2025 at 11:34 a.m. with the Nurse Manager of ED (NM, a nurse in charge of supervising nurses and operations in the department)1, NM1 stated the expectation was for all patients presenting with suicidal ideation to have the Columbia (C-SSRS) tool completed at triage, and the results documented in the record accurately. This ensured the patient's suicide risk level was clearly identified and interventions (such as psychiatric consults [a meeting with a psychiatrist- a medical practitioner specializing in the diagnosis and treatment of mental illness], sitter assignment [one-to-one staff assigned to observe a patient at all times], or increased observation [closer monitoring by staff]), could be initiated.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Prevention," dated 9/23/2020, the P&P indicated, "To identify individuals at risk for suicide and to decrease the risk of suicidal death. To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients ... The patient will be screened for suicide risk at the point of entry, or at any time during the course of hospitalization if their psychiatric condition changes or if suicidal ideation is expressed ... The Emergency Department (ED) Triage Registered Nurse (RN) determines suicide risk initially by completing the Columbia-Suicide Severity Rating Scale (C-SSRS) ...must be documented ..."

Based on interview and record review, the facility failed to ensure that medical record entries were properly documented, in accordance with facility's "Correction of Errors/Omission in Medical Records" policy and procedure, for five (5) of 30 sampled patients (Patient 1, Patient 3, Patient 4, Patient 7, and Patient 10). This was evidenced by the sitter documentation (sitter Observation Form, a monitoring tool used when staff provide continuous one-to-one observation of a patient) for Patient 1, and restraint documentation (Restraint Flowsheet, record used to monitor the safe application, release, and care of patients in restraints [any manual method, physical or mechanical device, material, or equipment used to restrict a patient's freedom of movement]) for Patients 3, 4. 7, and 10.

This deficient practice had the potential to cause miscommunication among healthcare providers and place patients at risk for medical treatment error (mistakes in care such as missed interventions, delays, or incorrect treatments).

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/12/2025, the "H&P" indicated, Patient 1 was 92 years old, with known history of dementia (a group of symptoms affecting memory, thinking and social abilities). The H&P further indicated Patient 1 had been recently discharged after an admission for generalized weakness (a feeling of muscle fatigue or lack of strength that affects multiple muscle groups) with worsening confusion (change in a person's ability to think, focus, and be aware of their surroundings). At readmission, Patient 1 was described as "severely agitated (extremely emotional upset and restless)" and "combative (eager to fight or resist)," requiring admission for further evaluation.

During a concurrent interview and record review on 8/19/2025 at 2:00 p.m. with the Emergency Department (ED, hospital unit for urgent and life-threatening care) Nurse Manager (NM, a supervising nurse responsible for managing unit staff and care planning)1, Patient 1's "Sitter Observation Form," dated 7/12/2025, was reviewed. The form contained two different time entries for the same 15-minute observation period, with scribbling-out errors and overwritten initials. NM 1 confirmed this was not an appropriate documentation.

During a review of the facility's policy and procedure (P&P) titled, " Correction of Errors/ Omission in Medical Records," dated 6/22/2022, the P&P required staff to correct errors by drawing a single line through the error, labeling it as "errors," and including the date, time, and staff authentication. Scribbling or obliterating entries was not permitted.

2. During a review of Patient 3's medical record (MR) document titled, "ED Physician Hand Off Note (a real-time, written document that summarizes patient information and the care plan for another physician or healthcare team)," dated 7/12/2025, the note indicated Patient 3 was verbally aggressive and placed in restraints.

During a record review of Patient 3's "Restraint Flowsheet," dated 6/8/2025, the staff were instructed to document restraint release every 2 hours using a key: check mark (?) = done, star (*) =see notes, R = Refused. At 8:00 a.m., staff wrote "NA" instead of using the required key.

During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that documentation should follow the key, and that "NA" was not appropriate to use.

During a review of the facility's policy and procedure (P&P) titled, " Correction of Errors/ Omission in Medical Records" dated 6/22/2022, the P&P indicated, "Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry."

3. During a review of Patient 4's "History and Physical (H&P)," dated 5/31/2025, the "H&P" indicated Patient 4 was admitted for shortness of breath (difficulty breathing) and hypoxia (low oxygen in the blood). On arrival, oxygen saturation (percentage of oxygen in the blood) dropped below 80s. Patient 4 became altered (confused) and unresponsive (not reacting) and went into cardiopulmonary arrest (heart and breathing stopped). The patient was resuscitated (reviving using emergency life-saving measures), and admitted to the ICU (Intensive Care Unit, hospital unit for critical ill patients).

During a concurrent interview and record review on 8/22/2025 at 1:40 p.m. with RN 2, Patient 4's "Restraint Flowsheet," dated 5/30/2025, was reviewed. The Flowsheet contained entries marked "NA" at 12:30 a.m. and at 1:30 a.m. instead of using the facility-approved key (check mark (?) = done, star (*) =see notes, R = Refused). RN 2 confirmed this did not follow policy.

During a review of the facility's policy and procedure (P&P) titled, " Correction of Errors/ Omission in Medical Records" dated 6/22/2022, the P&P indicated, "Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry."

4. During a review of Patient 7's "H&P," dated 5/17/2025, the record indicated Patient 7 had shortness of breath, lived in a boarding care home (a group living environment providing daily care), and had mental impairment (reduced ability to think, reason, or remember). Patient 7 was in respiratory distress (severe difficulty breathing that threatens life) and referred to ED.

During record review of patient 7's "Restraint Flowsheet," dated 5/16/2025, the Flowsheet indicated restraint releases at 8:00 p.m., 10:00 p.m., and 12:00 a.m. were marked "NA" instead of using the required documentation key (check mark (?) = done, star (*) =see notes, R = Refused).

During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that documentation should follow the key, and that "NA" was not appropriate to use.

During a review of the facility's policy and procedure (P&P) titled, " Correction of Errors/ Omission in Medical Records," dated 6/22/2022, the P&P indicated, "Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry."

5. During a review of Patient 10's "H&P," dated 5/15/2025, the record indicated Patient 10 was found unresponsive, responded to Narcan (a medication that rapidly reverse opioid [a class of drug used to reduce moderate to severe pain] overdose), and was admitted to the ED with glucose (blood sugar) greater than 900. Patient 10 required chemical (medications used to control dangerous behavior) and physical restraints.

During record review of Patient 10's "Restraint Flowsheet," dated 5/15/2025 - 5/16/2025, entries at 2:00 p.m., and 4:00 p.m., contained straight line and scribbles in areas where staff should have documented checks for food, fluids, and range of motion (ROM, gentle exercises that move a patient's joints). Instead of using the required documentation key , the entries were unclear.
During an interview on 8/22/2025 at 1:48 p.m. with the ED charge nurse (RN, Registered Nurse, a licensed healthcare professional trained to supervise care) 2, RN 2 confirmed that not using the key (check mark (?) = done, star (*) =see notes, R = Refused) and scribbles were not acceptable documentation.

During a review of the facility's policy and procedure (P&P) titled, " Correction of Errors / Omission in Medical Records" dated 6/22/2022, the P&P indicated, "Each correction or addition to a medical record shall be dated, timed, and authenticated by the individual making the entry. Initials are acceptable for the purpose of authentication, provided the initials are legibly written so that they clearly identify a particular individual. Only the individual who made the original entry in a medical record is authorized to properly correct that entry ...Draw a single line through the discovered error (do NOT scribble over it, erase it; tear the incorrect portion off, "X" it out, or otherwise obliterate the incorrect entry). Do not use White Out. Write the word ERROR either in the margin or at the end of the line containing the incorrect entry, followed by the time, date, and proper authentication of the individual making the correction. Note the correct information in close proximity to the original entry, if possible. Where the correction requires more space than is available near the original entry, record the correct information in a new entry in the medical record or in an addendum to the medical record. The correct information must be separately authenticated, timed, and dated."

Based on interview and record review, the hospital failed to ensure that one (1) of 30 sampled patient's (Patient 2), medical record contained the results of consultative evaluations and appropriate findings by clinical staff. Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term), considered a high-risk because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal stimulant drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

This deficient practice resulted in the discharge of Patient 2 to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without documentation of obstetric (pregnancy-related) consultation findings or confirmation of the baby's well-being. This deficient practice also had the potential risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death).

Findings:

During a record review of Patient 2's medical record titled, "ED (Emergency Department, hospital unit for urgent and life-threatening care) physician Hand Off Note," dated 8/17/2025, indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The ED physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer of Patient 2 to L&D (Labor and Delivery, department that provides care for pregnant individuals during labor, childbirth, and the immediate after birth).

During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2's electronic medical record, was reviewed. RN 14 confirmed that Patient 2's L&D electronic record did not contain an obstetric provider medical screening exam (MSE, a doctor's exam to determine if an emergency condition exists), no physician's order to transfer Patient 2 back to the Emergency Department (ED-hospital unit for urgent and life-threatening care), and no nurse-to-nurse hand-off (verbal communication of patient information when responsibilities is transferred) between the L&D nurse and the ED nurse prior to Patient 2's transfer back to the ED.

During the same interview on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2's L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the interim supervisor of Labor and Delivery (SLD), Patient 2's Labor and Delivery Emergency Room (a hospital unit that handles urgent obstetric or pregnancy-related medical issues) record titled, "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., was reviewed. SLD confirmed that there was no documentation of triage (initial assessment to determine urgency of care), a Maternal-Fetal Triage Index (MFTI, tool used to score urgency for pregnant patients), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby's health], fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2's transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses).

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2's NST, was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During a concurrent interview and record review on 8/22/2025 with RN 13, Patient 2's "ED Physician Hand Off Note," date 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby's well-being.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department," dated 12/15/2024, the P&P indicated, "In no event shall the provision of emergency services and care be based upon, or affected by, the person's race, ethnicity, religion, national origin, citizenship, age, gender identity or expression, sexual orientation, pre-existing medical condition, physical or mental disability, insurance status, economic status, or the ability to pay for medical services. (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient's presenting complaint and condition. Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. The patient's physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage /Charge RN Responsibilities: Perform an assessment by identifying the patient's immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. mercury and proteinuria greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation admitted through Emergency Department requiring perinatal screening examination ..."

During a review of the facility's "Medical Staff General rules and Regulations (are a set of detailed operational standards, policies, and professional conduct guidelines for hospital medical staff)," dated 10/31/2020, the documents indicated, "Each patient shall be the responsibility of a member of the Medical Staff. The physician shall be responsible for the medical care and treatment, for the prompt completeness, pertinence and accuracy of the medical record, for necessary special instructions, and for transmitting information pertaining to the condition of the patient to the referring practitioner and to the patient and/or relatives of the patient. Whenever these responsibilities are transferred to another physician, a note covering the transfer of responsibility shall be entered as an order and be documented in the progress notes of the medical record and the transferring physician shall personally notify the receiving physician ... Patients shall be discharged only on a written order of the attending or alternate physician ... A medical record will be created and maintained for each patient receiving services from (Name of the facility) for the purpose of: Providing continuing care for the patient at HPMC and at other health care facilities and health care providers ...Serving as a method of communication between health care providers serving the patient. Providing a historical record of tests, treatments, and interventions for the patient. Medical Screening Exam (MSE): Physicians and other authorized personnel (Physician Assistant, Nurse Practitioner, Registered Nurses functioning under Standardized Procedures) are authorized to perform the MSE ..."

During a review of the facility's policy and procedure (P&P) titled, "Hand-Off/SBAR Communication, Patient," dated 5/22/2024, the P&P indicated, "To provide accurate information about patient's care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are "handed off' from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 30 sampled patients (Patient 2), who presented to the Emergency Department (ED-hospital unit for urgent and life-threatening care) and Labor & Delivery (L&D-hospital unit for pregnancy and childbirth emergencies), received required assessments and physician examinations in accordance with the facility's policy and procedures, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department." Patient 2, was 32 weeks pregnant (about 8 months long, not yet full term), considered high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

In L&D, Patient 2 did not receive triage (an initial check to decide urgency of care), a Maternal-Fetal Triage Index (MFTI, scoring tool used to determine urgency of a pregnant patient's condition), vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating), maternal or perinatal assessment [assessment of mother and baby's health], fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions). L&D staff also did not obtain a physician order for Patient 2's transfer back to the ED or provide a nurse-to-nurse hand-off (direct communication of patient information between nurses).

When Patient 2 returned to the ED, staff did not check her (Patient 2) unborn baby's heart rate (fetal heart tones). Patient 2 later discharged to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems) without confirmation of Patient 2's own condition or the well-being of her (Patient 2) unborn baby.

This deficient practice had the risk of serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (The baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death).

On 8/22/2025 at 4:09 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), VP Quality Risk Management (VPQRM), Manager of Quality Risk Management (MQRM), and the Charge Nurse Emergency Department (RN 2). The facility failed to protect the health and safety of a pregnant patient (Patient 2). Patient 2 was 32 weeks pregnant (about 8 months along, not yet full term) and was considered a high-risk pregnancy (a pregnancy with conditions that increase the chance of serious complications for the mother or baby) because she had an active urinary tract infection (bladder or kidney infection), no prenatal care (regular pregnancy check-ups), and a positive drug screen for cocaine (a powerful and stimulant drug that can harm the pregnancy) and methamphetamine (stimulant drugs that can harm the pregnancy).

During a record review of Patient 2's emergency department (ED) medical record titled, "History and Present Illness," dated 8/16/2025, the record indicated Patient 2 walked into the ED and reported suicidal ideation (thoughts of harming herself) and abdominal discomfort (nonspecific stomach pain). The record indicated an ultrasound (imaging technique that uses high-frequency sound waves to generate images) confirmed that Patient 2 was 32 weeks pregnant (about 8 months, not yet full term).

During a record review of Patient 2's medical record titled, "ED physician Hand Off Note," dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer to Labor and Delivery (L&D, the hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review with Registered Nurse (RN 14) on 8/21/2025 at 10:40 a.m., Patient 2' L&D electronic medical record, was reviewed. RN14 confirmed that there was no documented evidence that the obstetrician reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim Supervisor of Labor and Delivery (SLD), Patient 2's L&D Emergency Room record, dated from 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," was reviewed. SLD confirmed the following:

- No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented.
- No vital signs were documented, including temperature (body heat measurement, used to detect infection), heart rate (pulse, beats in one minute), blood pressure (force of blood against vessel walls), respiration rate (breaths per minute), oxygen saturation (percentage of oxygen in the blood), and pain assessment (patient's self-report pain rating).
- No focused maternal or perinatal assessment (evaluation of the health of mother and baby) was documented.
- No obstetric provider medical screening exam (MSE, a physician examination to determine emergency conditions in pregnancy), was documented.
- No provider orders were issued to transfer Patient 2 back to the ED.
- No hand-off report (report patient care information, authority, and responsibility from one healthcare provider to another during a shift change or patient transfer) from the L&D Registered Nurse (RN) 1 to the ED nurse, was documented.

During a concurrent interview and record review with SLD on 8/21/2025 at 12:55 p.m., Patient 2's ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby's heart rate (fetal heart tones, or FHTs- the baby's heartbeat heard with a handheld Doppler, [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available.

During a concurrent interview and record review on 8/22/2025 with RN 14, Patient 2's "ED Physician Hand Off Note," dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric (branch of medicine that deals with mental health issues) rehabilitation facility. RN 14 confirmed Patient 2 had been transferred.
During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2), in the L&D emergency room, Patient 2's NST, was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 stated when there is no fetal monitoring, vital signs, triage assessments, or physician medical screening exams (initial evaluation provided to determine if a patient has an emergency medical condition) completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death.

On 8/22/2025 at 9:24 p.m. the IJ was removed in the presence of the CFO, CNO, VPQRM, and MQRM, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan included: Creation of an algorithm (a step-by-step instruction designed to solve a problem or accomplish a task) for "Triage of Pregnant Patients in the Emergency Department," to help ensure patients presenting to the Emergency Department (ED) and L&D received appropriate treatment. A tool, "ED to L&D Intake Form," was created to identify high-risk pregnant patients presenting to the ED and to ensure all pregnant patients 20+ weeks of gestation receive a complete assessment, vital signs, and medical screening examinations in the ED. ED and L&D current staff were educated on the "Triage of Pregnant Patients in the Emergency Department" and the "ED to L&D Intake Form." All subsequent staff would be educated by the department leader (director, manager, supervisor, charge RN) or designee prior to shift. The "ED to L&D Intake Form" would be used as a handoff tool when transferring pregnant patients 20+ weeks of gestation from ED to L&D. The "Triage of Pregnant Patients in the Emergency Department," outlined that patients who were 20+ weeks of gestation would be sent to L&D for fetal heart rate monitoring. Once the patient is in L&D, an MFTI and MSE would be conducted in triage. L&D staff would place "discharge to ED" order in CPOE (the account number will not carry over to ED- a new account number for ED is needed) and document discharge destination in Centricity to ensure that there is a physician order if/when sending patient back to the ED. Thirty random monthly audits would be conducted to ensure: All patients presenting to L&D receive an MFTI and MSE. The expectation is 100% compliance; all non-compliance will be coached and/or lead to disciplinary action. All patients discharged to the ED would have a doctor's order.

Findings:

During a concurrent observation and interview with Certified Nurse Assistant (CNA, a healthcare professional who provides direct, hands-on care to patients under the supervision of a license nurse) 4 on 8/19/2025 at 11:10 a.m. in the Emergency Department (ED, hospital unit for urgent and life-threatening care), Patient 2 was repositioning herself back and forth in a recliner chair, eventually settling into a fetal position (a position in which someone lies in a curved shape with legs and arms bent and close to the body) in a recliner chair. CNA 4 stated that Patient 2 was pregnant and under one-to-one observation (a practice where a designated healthcare professional stays in continuous, close proximity to a patient to ensure their safety) for suicidal ideation (thoughts of self-harm or ending one's life). CNA 4 stated they (referring to healthcare staff) had been assigned to observe Patient 2.

During a review of Patient 2's ED record titled, "History and Present illness, dated 8/16/2025, the record indicated Patient 2 arrived in the ED reporting suicidal ideation and abdominal discomfort (general stomach pain without a clear cause). The record also indicated an ultrasound (a scan that uses sound waves to see inside the body) confirmed Patient 2 was 32 weeks and 5 days pregnant.

During a record review of Patient 2's record titled, "ED physician Hand Off Note," dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming lasting approximately 1-3 minutes and then resolving. The note indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14, Patient 2' L&D electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).
During a concurrent interview and record review on 8/21/2025 at 12:08 p.m., with Interim SLD, Patient 2's record "Triage (an initial check to decide urgency of care)," dated 8/17/2025, was reviewed. The record indicated Patient 2 was scratching, and kicking, and the Non-Stress Test (NST, is a noninvasive prenatal test that monitors the baby's heart rate in response to its own movements and contractions) monitor had to be physically held in place for 20 minutes, but the nurse was unable to hold the Toco transducer (Toco, the device used during an NST and other fetal monitoring to measure the timing and duration of uterine contractions detecting changes in abdominal wall tension). SLD confirmed that an NST was attempted; however, the reading was not completed.

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the SLD, Patient 2's L&D Emergency Room record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," was reviewed. SLD confirmed the following:

- No Maternal-Fetal Triage Index (MFTI, tool to identify urgency of care for pregnant women) level documented.
- No vital signs (temperature, blood pressure, heart rate, respiration rate, oxygen saturation, or pain score).
- No maternal or perinatal assessment
- No physical medical screening exam
-No provider orders to transfer Patient 2 back to the ED.
- No nurse-to-nurse hand-off report from the L&D nurse to the ED nurse

During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2's ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff checked fetal heart tones (the baby's heartbeat measured with a handheld Doppler device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available.

During a concurrent interview and record review with on 8/22/2025 with RN 13 , Patient 2's "ED Physician Hand Off Note," dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby's well-being.

During a concurrent interview and record review on 8/22/2025 at 10:00 a.m. with RN 15, Patient 2's NST, was reviewed. RN 15 stated the reading was not clear as there were many missed spaces (gaps of no reading). RN 15 stated "from this reading, we cannot say for certain whether the patient is having contractions or not." RN 15 also stated "with this reading, there should be a repeat test done as the test is inconclusive."

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2's NST, was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During the same interview on 8/22/2025 at 10:14 a.m. with the L&D charge nurse (CN 2), CN 2 confirmed that when there was no fetal monitoring, vital signs, triage assessments, or physician medical screening exams completed, the absence of these assessments could result in serious complications for both Patient 2 and her unborn baby, including preterm labor (going into labor before 37 weeks of pregnancy), eclampsia (a life-threatening medical emergency occurring during pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal health problems that could have resulted in disability or death.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department," dated 12/15/2024, the P&P indicated, "(Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient's presenting complaint and condition. Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. The patient's physical, psychological and social needs are assessed as appropriate based on the presenting complaint and based on patient condition changes ... All patients seeking care will receive a medical screening exam (MSE) by a qualified provider in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ... Patients shall not be discharged without the direction of a physician ... Triage /Charge RN Responsibilities: Perform an assessment by identifying the patient's immediate needs as follows: Uterine contractions or pain greater than 20 weeks gestation ...Symptoms of urinary tract infections/pyelonephritis ...Preeclampsia (BP systolic greater or equal to 140 or diastolic greater or equal to 90 mm. Mercury) and proteinuria greater than 20 weeks gestation ...OB patients greater than 20 weeks gestation admitted through Emergency Department requiring perinatal screening examination."

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept.," dated 4/26/2023, the P&P indicated, "Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient's health or fetus' (estimated gestational age >20 weeks) health in serious jeopardy... Identify patient's immediate needs as follows; does the patient have any of the following: Pregnancy > 20 weeks gestation with or without pregnancy-related complaint ... Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE). The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department."

During a review of the facility's policy and procedure (P&P) titled, "Antepartum Testing.," dated 10/27/2021, the P&P indicated, "To provide guidelines for the noninvasive determination of fetal well-being by observing the response of fetal heart rate to fetal movement or Nonstress Test (NST) ... The nurse will notify the physician of all abnormal test results and obtain follow-up orders, documenting actions and results."

Based on interview and record review, the facility failed to ensure proper integrated communication between the Emergency Department (ED, hospital unit for urgent and life-threatening care) and the Labor and Delivery (L&D, hospital unit for pregnancy and childbirth emergencies) for one (1) of 30 sampled patients (Patient 2), 32 weeks pregnant (about 8 months long, not yet full term), considered a high-risk pregnancy because she (Patient 2) had an infection, no regular pregnancy checkups (prenatal care), and a positive drug screen for cocaine (an illegal drug that can harm pregnancy) and methamphetamine (an illegal stimulant drug that can harm pregnancy).

Specifically, the facility failed to:

-Ensure L&D staff documented and communicated results of obstetric evaluations (such as triage [an initial check to decide urgency of care], vital signs (temperature [body heat], blood pressure [pressure of blood in blood vessels], heart rate [beats per minute], respiration rate [breaths per minutes], and oxygen saturation [oxygen carried in the blood], pain assessment [patient self-report pain rating]), maternal or perinatal assessment (assessment of mother and baby's health), fetal monitoring (non-stress test [NST, test of baby's heart rate with movement] or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), or a medical screening (MSE- a required doctor's exam to find emergency conditions).

-Ensure L&D staff obtained and communicated physician orders before transferring Patient 2 back to the ED.

-Ensure L&D staff provided nurse-to-nurse hand off (direct communication of patient status and care needs) when sending Patient 2 back to the ED.

-Ensure ED staff received and acted on L&D findings by checking fetal heart tones after Patient 2 returned from L&D.

-Ensure continuity of care so that maternal and fetal well-being was assessed and communicated before Patient 2 was discharged to a psychiatric facility (a healthcare institution that specializes in the diagnosis, treatment, and care of individuals with mental health disorders).

These deficient practices placed Patient 2 and her unborn baby at risk of undetected serious complications, including preterm labor (going into labor before 37 weeks of pregnancy), fetal distress (dangerous changes in the baby's heart rate or oxygen levels), intrauterine demise (the baby dying before birth), and severe maternal complications (serious health problems that could cause disability or death).

Findings:

During a record review of Patient 2's medical record titled, "ED physician Hand Off Note," dated 8/17/2025, the note indicated Patient 2 had episodes of agitation (a condition in which a person is unable to relax and be still) and screaming, lasting approximately 1-3 minutes and then resolving. The note also indicated the episodes could represent contractions (tightening of the organ muscles where the unborn baby develops, which can be signs of labor). The physician consulted the on-call obstetrician-gynecologist (OB-GYN, a doctor that specializes in pregnancy, and women's reproductive health), who directed transfer to L&D (Labor and Delivery, hospital unit for pregnancy and childbirth emergencies).

During a concurrent interview and record review on 8/21/2025 at 12:20 p.m. with the Interim SLD (Supervisor of Labor and Delivery), Patient 2's L&D record, dated 8/17/2025 from 2:22 a.m. to 3:10 a.m., titled, "OB Triage (obstetric triage, the preliminary assessment of pregnant to determine urgency)," was reviewed. SLD confirmed there was no documentation of triage, a Maternal-Fetal Index (MFTI, scoring tool used to determine urgency of a pregnant patient's condition), vitals signs, maternal or perinatal assessments, fetal monitoring, or a physician medical screening exam (MSE, a doctor's exam required to determine if an emergency condition exists). SLD further confirmed there was no physician order documented for transfer of Patient 2 back to the ED and no nurse-to-nurse hand-off between the L&D staff and the ED staff prior to the transfer of Patient 2 back to the ED.

During a concurrent interview and record review on 8/21/2025 at 12:55 p.m. with SLD, Patient 2's ED electronic medical record, dated 8/17/2025 through 8/21/2025, was reviewed. SLD confirmed that there was no documented evidence that staff assessed the baby's heart rate (fetal heart tones, or FHTs- the baby's heartbeat heard with a handheld Doppler [produce imaging through sound waves] device). SLD stated that fetal heart tones should have been obtained in the ED because a Doppler was available.

During a concurrent interview and record review on 8/22/2025 at 10:14 a.m. with charge nurse (CN 2) in L&D emergency room, Patient 2's non-stress test (NST, test of baby's heart rate with movement or fetal heart tones [baby's heartbeat measured with a handheld Doppler device-small imaging monitor]), was reviewed. CN 2 confirmed the NST was "inconclusive" and should have been repeated with proper repositioning and continuous monitoring until a reliable result was obtained.

During a concurrent interview and record review on 8/21/2025 at 10:40 a.m. with Registered Nurse (RN) 14 , Patient 2's Labor and Delivery electronic medical record, was reviewed. RN 14 confirmed that there was no documented evidence that the obstetrician (a doctor who specializes in caring for women during pregnancy and childbirth) reviewed or interpreted the incomplete non-stress test (NST, a test that was used to measure the baby's heart rate in response to its own movements).

During a concurrent interview and record review on 8/22/2025 with RN 13 , Patient 2's "ED Physician Hand Off Note," dated 8/21/2025, was reviewed. The record indicated Patient 2 would be transferred to a psychiatric rehabilitation facility (specialized facility designed to help individuals with persistent or severe mental health problems). RN 13 confirmed Patient 2 had been transferred. RN 13 also confirmed the transfer occurred without obstetric physician clearance or documentation of the baby's well-being.

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Emergency Dept.," dated 4/26/2023, the P&P indicated, "Pregnant patients greater than 20 weeks gestation with pregnancy-related complaints will be sent to Labor and Delivery for evaluation by an obstetrician for their medical screening exam (MSE)," and that documentation be included in the record ... "The Labor and Delivery department will be notified of the patient and ED staff will transport the patient to the Labor and Delivery Department ..."

During a review of the facility's policy and procedure (P&P) titled, "Triage, Assessment and Reassessment Standards, Labor and Delivery Department," dated 12/15/2024, the P&P indicated, " (Name of the facility) triage assessment is based on the use of the MFTI that is based on the patient's presenting complaint and condition. Triage assessments are done to determine the patient's need for care, the type of care required and the need for further assessment. Patients are assigned a triage priority level at the completion of the initial triage assessment by the triage RN using the MFTI scale ...All patients will receive medical screening and stabilization. No patient will be re¿directed to another facility for care prior to completion of this process ..."

During a review of the facility's policy and procedure (P&P) titled, "Hand-Off/SBAR Communication, Patient," dated 5/22/2024, the P&P indicated, "To provide accurate information about patient's care, treatment or service, and their current conditions with any recent or anticipated changes when responsibilities are "handed off' from one care provider to another, in permanent and/or temporary situations. To provide a framework for effective communication among members of the healthcare team in order to ensure consistency of communication and continuity of treatment, through a standardized approach of giving and receiving information across the care continuum ... Document hand-off in EHR under the Hand-off tab including lunch relief or changes in assignment on the same unit.