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Based on medical record review, document review and interview with staff it was determined the hospital failed to maintain a safe environment for all patients during construction of the hospital. This failure resulted in the death of one (1) out of fifty-nine (59) (patient #1) patients who were admitted during a carbon monoxide leak. As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 02/01/22 at 10:00 a.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 02/3/22 at 5:02 p.m. (See Tag A 144).


The following interventions were implemented to resolve the IJ:

Carbon monoxide detectors will immediately be placed on all patient care areas and areas of construction.

All staff educated on notifiying the administrator or the Director of Nursing (DON) during business hours and the administrator on call after business hours of any gas smell.

The fire department and the gas company will be notified.

Patients will immediately be evacuated from the affected area and the smoke doors closed. Open exit door in affected area, fans will be placed facing the exit door.

Nursing supervisor will be responsible to turn off the gas. The Director of Maintenance or designee will re-educate the nurse supervisors. Maintenance or designee will be responsible to ensure the gas is off.

Nursing supervisor will notify the fire department, maintenance, CEO (or in their absence, the administrator on call). Maintenance will notify the gas company and HVAC company. CNO or designee to educate the Nursing Supervisors on this procedure.

Administrator on call will activate the command center.

Maintenance or designee will stay until the source or possible sources are identified and removed.

Patients will be held in a safe area until all possible sources are removed and all clear given. Patients will be assessed and monitored for signs and symptoms of possible carbon monoxide exposure.

Based on medical record review and staff interview it was determined the Director of Nursing failed to ensure assessments were completed on thirty-four (33) out of thirty-four (34) patients (Patients #2, 4, 6, 7, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 26, 27, 28, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 and 47), following a carbon monoxide leak on the North Hall of the facility. This failure has the potential for all patients to become ill and not receive proper treatment that may lead to their death. As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 02/01/22 at 10:00 a.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 02/3/22 at 5:02 p.m. (See Tag A 386).


The following interventions were implemented to resolve the IJ:

Carbon monoxide detectors will immediately be placed on all patient care areas and areas of construction.

All staff educated on notifiying the administrator or the Director of Nursing (DON) during business hours and the administrator on call after business hours of any gas smell.

The fire department and the gas company will be notified.

Patients will immediately be evacuated from the affected area and the smoke doors closed. Open exit door in affected area, fans will be placed facing the exit door.

Nursing supervisor will be responsible to turn off the gas. The Director of Maintenance or designee will re-educate the nurse supervisors. Maintenance or designee will be responsible to ensure the gas is off.

Nursing supervisor will notify the fire department, maintenance, CEO (or in their absence, the administrator on call). Maintenance will notify the gas company and HVAC company. CNO or designee to educate the Nursing Supervisors on this procedure.

Administrator on call will activate the command center.

Maintenance or designee will stay until the source or possible sources are identified and removed.

Patients will be held in a safe area until all possible sources are removed and all clear given. Patients will be assessed and monitored for signs and symptoms of possible carbon monoxide exposure.

Based on medical record review, interview with staff, and document review it was determined that the facility failed to ensure appropriate measures were taken to prevent, recognize, and respond to the accumulation of carbon monoxide (CO) in patient areas associated with the use of gas powered tools inside the facility. These failures contributed to a CO leak that ultimately caused the death of one patient (patient #1) out of forty-seven (47) medical records reviewed. This failure has the potential to cause harm to all patients.

Findings include:

Review of Patient #1's clinical record revealed the patient had an admitting diagnosis of acute on chronic respiratory failure. On 11/29/21, Registered Nurse (RN) #1's progress note revealed: "in to re assess pt. [patient] {patient was in their room} O2 [Oxygen] saturation in the 50s on NC (nasal canula). respiratory care and charge nurse notified. placed on no rebreather. 911 phoned ARRIVED AT 9:45 TAKEN TO [states the hospital the patient was transferred to] VIA EMS." On 11/29/21, the Respiratory Therapist (RT) note revealed: "RT called to patient room. Patient SaO2 [Arterial hemoglobin oxygen saturation] 54% on 5L/M (Liter per minute) O2 via high flow nasal cannula and respiratory rate 34. Patient placed on 100% O2 via non-rebreather at this time. Patient SaO2 increased to 88% on 100% O2, respiratory rate 30 and heart rate 92. Dr. called and 911 called at this time." It should be noted Patient #1's clinical record from the hospital the patient was transferred to was not in the clinical record and the Chief Nursing Officer (CNO) indicated their facility had not requested it.

Review of Patient #1's clinical record (from the hospital the patient was transferred to and obtained by the State Agency Program Manager) from 11/29/21 through 12/02/21 revealed the patient was brought to the Emergency Department by Cabell County Emergency Medical Squad (EMS) on 11/29/21 with respiratory distress and altered mental status. When EMS arrived at the facility and went to Patient #1's room, their CO detectors alarmed. They notified staff and the fire department and quickly removed the patient from the scene. Patient #1 was placed on a non-rebreather mask and then switched to continuous positive airway pressure (both are methods to provide extra oxygen to the patient). Lab results from the facility (that accepted the patient via transfer) revealed the patient's CO (Carbon Monoxide) level at 10:29 a.m. was 2.5. This level exceeded the levels indicated normal for a non-smoker [patient's record revealed they are a non-smoker]. On 12/02/21, a document titled "Death Summary," written by the patient's physician. States in part: "Date of death: 12/02/21, Primary discharge diagnosis: Acute hypoxic respiratory failure and carbon monoxide poisoning ...Time of death: 2120 [9:20 p.m.]."

A review of The Centers for Disease Control and Prevention The National Institute for Occupational Safety and Health (NIOSH) titled, "Carbon Monoxide" states in part, "NOT allow the use of or operate gasoline-powered engines or tools inside buildings or in partially enclosed areas unless gasoline engines can be located outside away from air intakes. Use of gasoline-powered tools indoors where CO from the engine can accumulate can be fatal...Use personal CO monitors where potential sources of CO exist. These monitors should be equipped with audible alarms to warn workers when CO concentrations are too high."

A review of current standards for workplace carbon monoxide by The Occupational Safety and Health Administration (OSHA) The NIOSH recommended exposure limit (REL) for CO is 35 ppm. It should be noted after the fire department arrived and began to ventilate the north hallway the CO level was increasing to 60 ppm.

Review of a letter sent to the facility on March 18, 2021, from the State Agency Life Safety Division states in part. "The plans submitted on February 19, 2021 for the new single-story building addition for a new dialysis suite as well as renovation to provide four (4) new patient beds plus two dialysis beds to regular patient beds have been reviewed for [states name of facility] The plans appear acceptable and construction may begin...Renovated areas must be isolated from occupied areas during construction using airtight barriers and exhaust overflow shall be sufficient to maintain negative air pressure in the construction zone. Air quality requirements at areas not being renovated should be maintained at existing levels. Precautions must be taken always to maintain patient safety and health standards."

A review of an untitled document from a local fire department obtained by the State Agency Program Manager states in part: "Dispatched on 11/29/21 at 9:52 a.m. arrived 11/29/21 at 10:07 a.m. Station 800 dispatched as mutual aid for station 200 for CO detection at Encompass of Huntington. Engine 804 enroute with lights and sirens, arrived on scene with Chief 201, 832. Established command. Mountaineer gas response requested by 201. EMS supervisor on scene and advises fire department units that during an EMS 911 call for a patient with difficulty breathing. The EMS crew portable CO detectors activated, alerting EMS crew of dangerous CO levels. EMS crew advised dispatch and activated fire response and EMS supervisor. 800 and 200 units enter facility with portable CO and gas detector. When entering hallway of initial alarm activation fire department portable detector alerted 800 and 200 units of increasing CO level at 60 ppm [parts per minute]. Facility staff management immediately notified. Staff and patients immediately evacuated from area. 800/200 immediately closed off north hall using the fire doors. The remainder of the building is cleared, and the patients are sheltering in place. The fire department units don appropriate PPE [personal protective equipment] and continue investigation of CO source. CO source was found to be gasoline fueled power equipment being operated inside construction area of patient corridor inside the facility ... After approximately 90 minutes of ventilation the CO levels show 0 ppm. Determined the patient corridor safe and staff/patients can re-enter. Fire department units advise building maintenance supervisor to not restart construction operations due to increase safety concern and hazard to staff and patients. Scene cleared at 11:52 a.m."

A review of the internal investigation revealed the hospital felt the risk for a future carbon monoxide leak subsided when construction was temporarily halted. The facility failed to recognize other patient rooms that could be affected in the future. Documentation states in part "Equipment malfunction contributed to this? Unknown event. Equipment misuse contributed to event? Unknown." No training was conducted with the staff for signs and/or symptoms of a carbon monoxide poisoning. The facility also failed to re-educate staff on conducting a head-to-toe assessment or a focused assessment during a carbon monoxide leak.

A joint interview conducted on 01/31/22 at 3:30 p.m. and 02/01/22 at 4:00 p.m. with the Chief Nursing Officer (CNO), Director of Quality and Risk Management, Facility Maintenance Supervisor, and the General Supervisor for the contracted construction company revealed the facility failed to ensure all areas of the hospital were checked to determine the source of a carbon monoxide leak which occurred on 11/29/21 inside the building before allowing patients to return to the area. The leak was detected by ambulance personnel transferring patient #1 to a higher level of care due to acute illness. No windows or doors were opened during the use of the gas-powered saw to allow for airflow, until after the EMS alerted us that their carbon monoxide alarms were alarming.

An interview was conducted on 02/01/22 at 11:25 a.m. with the Receptionist. The Receptionist stated he/she was informed of a CO leak the morning it occurred when he/she was working. The Receptionist stated he/she had developed a headache during that time. The Receptionist stated he/she didn't leave the area nor was he/she asked to evacuate. The Receptionist stated the maintenance worker came to the lobby and checked the CO levels and they were okay. The Receptionist stated then he/she felt safe staying. The Receptionist stated he/she had no knowledge of any patients getting sick, other than the patient who was taken out of the facility. The Receptionist said he/she had no knowledge of any staff becoming ill because of the CO leak.

An interview was conducted on 02/01/22 at 8:25 p.m. with the CNO and the DQRM. They stated CO detectors were not located in any patient hallway before the leak occurred and the fire department recommend they place CO detectors on the units. They stated after the incident, one (1) CO detector was placed on the North Hall, between Rooms 116 and 117, and one (1) was placed on the West Hall outside Room 129. They stated no detector was placed in the South Hall (another patient hall). It further revealed the hospital does not have a policy on Carbon Monoxide or the use of gas-powered tools indoors.

An interview was conducted on 02/02/22 at 11:15 a.m. with the Plant Operations Director (POD). The POD stated CO detectors were not located on the patient halls before the CO leak. The POD stated detectors were placed on the North and West Halls after the leak. He/she stated no CO detector was placed on the South Hall until the date of this interview. He is unaware of a personal CO alarm on the plumbers body.

An interview was conducted on 02/03/22 at 8:50 a.m. with the POD. The POD stated he/she did not know the construction contractors had gasoline power saws in use. The POD stated he/she makes rounds of the facility once a day but had not made rounds of the North Hall yet on the date and time the CO leak occurred. The POD stated the person in charge of construction makes rounds daily also, but he/she doesn't know if his/her rounds had been made yet that day.

An interview was conducted on 02/03/22 at 9:30 a.m. with the General Supervisor of the construction company contracted to do the construction work that was being conducted during the leak. He/she stated that at the time of the CO leak a gas generated saw was being used by a plumber in the construction area on the North Hall, he was aware of the use of the saw and allowed it to be used. The plumber was not wearing a CO personal alarm. He/she stated the saw was in use between 8:15 to 8:30 and the time the FD arrived (after EMS arrived at approximately 9:45). The General Supervisor stated as soon as he/she was told by the POD about the leak he/she told the POD to shut down construction, which the POD did immediately. The General Supervisor concurred this could have been a source of CO. The General Supervisor stated he/she met with all construction staff that day, before any construction area resumed work, and told them no gas-powered equipment was allowed to be used inside the building. It should be noted the hospital is updating the interior of the hospital to increase the needs of patients who are disabled in accordance with the Americans with Disabilities Act (ADA). At the time of the incident the hospital had a permit for construction.

Review of floor plans for the facility's first floor, provided to the surveyor by the General Supervisor of the contracted construction company, revealed Patient #1's room on the North Hall was five (5) rooms away from the construction area where the gas-powered saw was being used. The distance from Patient #1's room to the construction area (as measured by the POD) was sixty-six (66) feet, five (5) inches.

Based on document review, medical record review and interview with staff it was determined the Director of Nursing failed to ensure assessments were completed on thirty-four (34) out of thirty-four (34) patients (Patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35) following a carbon monoxide (CO) leak on the North Hall of the facility. This failure has the potential for all patients to be at risk for CO poisoning that may ultimately cause their death.

Findings include:

On 02/03/22, surveyors were provided a spreadsheet of all patients located on the North Hall on 11/29/21, when a CO leak occurred. The spreadsheet included the dates and times of assessments completed following the CO exposure. The spreadsheet revealed the facility did not assess those patients at the time the leak was detected and at least every four (4) hours for twenty-four (24) hours. A review of the medical records for patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 35 reveald no head to toe or focal nursing assessment. It should be noted in an interview with the Chief Nursing Officer on on 02/03/22 at 3:30 p.m. an expectation that assessments of patients after a carbon monoxide should be assessed at least every four (4) hours for twenty-four (24) hours. (See last interview in deficient practice).

A review of the American Nurses Association defines an assessment for a carbon monoxide leak as placing the patient in fresh air, a pulse oxemetry reading, monitor for confusion, monitor vital signs, monitor any underlying health issue, [heart and lung diagnosis], assess for headache, dizziness, weakness, and palpitations, monitor the lungs for rales or wheezing. Monitoring should occur every hour for two (2) hours and then every four (4) hours for twenty-four (24) hours if the patient has no symptoms. The extended monitoring is due to the possibility of a delayed reaction of symptoms.

A review of the Amercian Nurses Association defines a head to toe assessment as conducting a neurological exam, mental status, cardiovascular exam, muscular skeletal exam, circulatory exam, pulmonary exam and spiritual exam. A focused assessment would include the area of body that is affected. Example chest pain would include listening to the heart for any murmurs, gallops or clicks. The patient would also be asked to rate their pain.

Review of the medical record for patient #2 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 6:00 p.m. temperature 99.1 Fahrenheit, pulse 96, blood pressure 132/86, respirations 18, and oxygen saturation 97%.

Review of the medical record for patient #3 revealed no head to toe or focal nursing assessment and no wound assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 6:57 p.m. pulse 85 and oxygen saturation 94%. 11/29/21 at 9:41 p.m. pulse 63, and blood pressure 133/66.

Review of the medical record for patient #4 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. Vital signs on 11/29/21 at 5:30 p.m. pulse 61, oxygen saturation 96%. 11/29/21 at 7:08 p.m. Temperature 99.0 Fahrenheit.

Review of the medical record for patient #5 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #6 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #7 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/03/21. Vital signs on 11/29/21 at 6:40 p.m. temperature 97.6 Fahrenheit, pulse 79, respirations 18, blood pressure 170/81, and oxygen saturation 96%.

Review of the medical record for patient #8 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. On 11/29/21 at 10:17 a.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 94%.

Review of the medical record for patient #9 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. On 11/29/21 at 9:48 p.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 99%.

Review of the medical record for patient #10 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. On 11/29/21 at 9:42 p.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 95%. Vital signs on 11/29/21 at 6:47 p.m. blood pressure 116/49.

Review of the medical record for patient #11 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 12/01/21. On 11/29/21 at 6:37 p.m. a nursing note was completed that states in part, "refused meds all day felt nauseated." Vital signs on 11/29/21 at 8:24 p.m. Temperature 98.2 Fahrenheit, pulse 77, respirations 16, blood pressure 113/69, and oxygen saturation 96%.

Review of the medical record for patient #12 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. On 11/29/21 at 7:00 a.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 97%.

Review of the medical record for patient #13 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. On 11/29/21 at 5:58 a.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 96%.

Review of the medical record for patient #14 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. On 11/29/21 at 7:58 p.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 97%. Vital signs on 11/29/21 at 2:30 p.m. blood pressure 104/63. 11/29/21 at 3:07 p.m. pulse 107.

Review of the medical record for patient #15 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 10:31 p.m. temperature 98.7 Fahrenheit, pulse 102, respirations 16, blood pressure 121/74, and oxygen saturation 97%.

Review of the medical record for patient #16 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #17 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 7: 22 p.m. blood pressure 118/71.

Review of the medical record for patient #18 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 7:21 p.m. temperature 97.7 Fahrenheit, pulse 65, respirations 18, blood pressure 144/77, and oxygen saturation 97%.

Review of the medical record for patient #19 revealed no head to toe or focal nursing assessments were completed from 11/28/21 through 11/30/21. Vital signs on 11/29/21 at 7:18 p.m. temperature 98.8, pulse 83, respirations 18, blood pressure 104/70, and oxygen saturation 97%.

Review of the medical record for patient #20 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. Vital signs on 11/29/21 at 8:33 p.m. temperature 97.5 Fahrenheit, pulse 65, respirations 16, blood pressure 137/67, and oxygen saturation 95%.

Review of the medical record for patient #21 revealed no head to toe or focal nursing assessments were completed from 11/27/21 through 11/30/21. Vital signs on 11/29/21 at 7:24 p.m. temperature 97.5 Fahrenheit, pulse 72, respirations 15, blood pressure 146/81, and oxygen saturation 95%.

Review of the medical record for patient #22 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/07/21. Vital signs on 11/29/21 at 8:07 p.m. temperature 98.1 Fahrenheit, pulse 87, respirations 16, blood pressure 117/73, and oxygen saturation 99%.

Review of the medical record for patient #23 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/10/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #24 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 11/30/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #25 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/06/21. A nursing note completed on 11/30/21 at 1:30 p.m. stated in part: "To remove staples and (unable to read) f/u (follow-up) appointment." Vitals signs on 11/29/21 at 7:09 a.m. temperature 97.9 Fahrenheit, pulse 74, respirations 16, blood pressure 127/66, and oxygen saturation 96%.

Review of the medical record for patient #26 revealed no head to toe or focal nursing assessments were completed from 11/24/21 through 12/01/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #27 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. On 11/29/21 at 8:12 a.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 99%. On 11/29/21 at 7:31 p.m. an oxygen saturation level was completed and the patient had an oxygen saturation level of 98%.

Review of the medical record for patient #28 revealed no head to toe or focal nursing assessments were completed from 11/19/21 through 11/29/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #29 revealed no head to toe or focal nursing assessments were completed from 01/14/22 through 01/22/22. No vital signs documented on 11/29/21.

Review of the medical record for patient #30 revealed no head to toe or focal nursing assessments were completed from 12/23/21 through 12/30/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #31 revealed no head to toe or focal nursing assessments were completed from 01/04/22 through 01/08/22. No vital signs documented on 11/29/21.

Review of the medical record for patient #32 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #33 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #34 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. No vital signs documented on 11/29/21.

Review of the medical record for patient #35 revealed no head to toe or focal nursing assessments were completed from 11/29/21 through 12/17/21. No vital signs documented on 11/29/21.

An interview was conducted on 02/03/22 at 3:30 p.m. with the Chief Nursing Officer (CNO). The spreadsheet was referenced. The CNO acknowledged the patients listed above did not have vital signs or assessments documented for the date and time of the CO exposure nor for the time following the exposure. The CNO stated it was possible that during the chaos surrounding the CO leak, assessments were not done and/or documented. The CNO concurred that, especially after a disaster, vital signs, neurological checks and assessments should occur immediately and at more frequent intervals with the minimum of every four (4) hours for at least twenty-four (24) hours. The CNO also concurred the hospital does not have a policy on assessments following a CO leak, but would expect vital signs to be done at the time of the discovery and if no symptoms at least every four (4) hours.

Based on observation and staff interview it was determined the facility failed to provide a safe environment for all patients and staff. This failure has the potential for all patients to be adversely affected.

Findings include:

Observation on 01/31/22 between 4:00 p.m. and 5:30 p.m. revealed there were water-stained ceiling tiles by the nursing station, in the corridor by the storage room near the Chief Nursing office, the Respiratory therapy room, two (2) at each entrance to occupational therapy, in the corridor by the activity room, by the exit in the dining room, in the corridor by Room 111 and in the corner of Room 127.

These findings were verified on 01/31/22 at 4:00 p.m. and 02/01/22 at 11:00 a.m. with the Facility Maintenance Supervisor at the time of discovery and again with the Chief Nursing Officer and the Director of Quality and Risk Management at the time of exit on 02/02/22 at 4:00 p.m.