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Based on observation, interview, and document review the facility failed to provide care in a safe setting and failed to develop and implement a policy that protected patients from an alleged hospital staff abuser resulting in the potential for unsatisfactory outcomes including injury and/or death for all patients . Findings include:

See specific tag:

1. The facility failed to ensure a ligature-free environment for 1 of 3 patients (#30) with self-harm and/or suicidal ideation diagnosis and failed to ensure face masks were void of metal wires for 1 of 1 patients (#31) receiving psychiatric care in the behavioral unit with the diagnosis of potential self-harm and suicidal ideation resulting in the potential of self-harm or death, and the facility failed to ensure a self-harm free environment. See tag A-0144.

2. The facility failed to ensure a method was in placed to ensure that patients are free from all forms of abuse, neglect, or harassment. See tag A-0145.

Based on observation, interview, and document review the facility failed to ensure a ligature-free environment for 1 of 3 patients (#30) with self-harm and/or suicidal ideation diagnosis and failed to ensure face masks were void of metal wires for 1 of 1 patients (#31) receiving psychiatric care in the behavioral unit with the diagnosis of potential self-harm and suicidal ideation resulting in the potential of self-harm or death, and the facility failed to ensure a self-harm free environment. Findings include:

On 2/9/2022 at 0920 during a tour of the behavioral unit it was revealed four medical beds located in patient rooms #122 (1 bed), #121 (1 bed), and #116 (2 beds). The beds observed had functioning moveable side rails and all four beds were connected to an electrical source. Staff R, the manager of the behavioral unit was interviewed on 2/9/2022 at 0922. Staff R was queried if he knew that the beds posed a ligature risk to patients within the unit. Staff R replied, "We identified the risk last week during a safety audit."

On 2/9/2022 at 1000 during document review of patient #30 medical record, it was revealed the patient had been admitted to the facility for self harm and suicidal ideation. Patient #30 was located in room #116 bed #2. Staff Q, the Clinical Educator confirmed the findings on 2/9/2022 at 1002.

During the tour of the unit on 2/9/2022 at 0925, it was also revealed that 2 of 3 patients had masks with metal pieces located in the top of the masks posing a safety threat to patients. A document review of the medical records for patients revealed that one of those patients, #31, had a diagnosis of potential of self-harm and suicidal ideation. On 2/9/2022 an interview with staff R, the manager of the behavioral unit was conducted. Staff R was asked if was appropriate for psychiatric/behavioral patients to have a mask with metal wire in the mask. Staff R stated that he had no idea where those masks had come from as the unit only had masks without the wires.

Based on interview and record review, the facility failed to develop and implement policies relating to the protection of patients from an employee abuser resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

On 2/8/2022 at 1430, review of the medical record for Patient #1, the patient of concern, revealed he was a 66-year-old male who initially presented to the emergency department (ED) on 6/27/2021 with a chief complaint of altered mental status. Past medical history included: atrial fibrillation, smoking, hypertension (high blood pressure), Hepatitis C (a viral infection that attacks the liver and leads to inflammation), alcohol abuse and dependence, pulmonary embolism, COPD (chronic obstructive pulmonary disease-a disease of the lungs that restricts airflow and causes difficulty breathing), PVD (peripheral vascular disease (poor circulation), heart failure with reduced ejection fraction, gout, altered mental status, and stroke. Patient #1 stopped taking his anti-coagulant due to having blood in the urine and subsequently had a stroke as well as developed blood clots.

During his hospitalization, he was "found to have right lower extremity arterial occlusion not amenable to vascular intervention" and subsequently had a right below the knee amputation on 7/2/2021 that was consented to by his DPOA (durable power of attorney because of Patient #1's altered mental status.

Review of the initial nursing assessment revealed a Stage I pressure ulcer (superficial reddening of the skin) over the coccyx area. This deteriorated to a Stage II pressure ulcer (skin breaks open, wears away, or forms an ulcer) prior to discharge. Patient #1 was discharged on 7/11/2021 to an inpatient rehabilitation unit.

On 7/16/2021, he was re-admitted to the facility with altered mental status. It was noted that he was now having agitation and aggression toward staff that he had not had with his previous hospitalization. Additionally, he was noted to have underlying dementia. Patient #1 was started on Depakote and Zyprexa "with significant improvement." Physician notes indicate there was no pain in his stump (right leg) and there was no drainage. He was discharged 7/27/2021 back to inpatient rehabilitation.

Further review of the medical record revealed Patient #1 was re-admitted on 8/11/2021 with altered mental status and sepsis after he slumped over and was unresponsive at his doctor's office during a dressing change for his amputation site that had become infected and dehisced (split and re-opened). It was determined surgical intervention was not needed for the amputation site. Following antibiotics and diuresis, Patient #1 was discharged back to the inpatient rehabilitation unit on 8/20/2021.

On 8/24/2021, Patient #1 was found to be in cardiac arrest at the rehabilitation facility. EMS (emergency medical services) was able to shock him with a return of a heartbeat. On arrival to the ED, he was intubated and he remained in critical condition. He was admitted to the facility with diagnoses which included: cardiac arrest and severe anoxic-ischemic encephalopathy (lack of oxygen caused severe brain damage). Prognosis was listed as grim. Attempts were made to contact family members as there was "no hope for survival." Patient #1 was pronounced dead on 8/25/2021 at 1235.

As a result of the above findings and during for review of the Condition of Participation for Patient Rights, facility policy titled "Physical Assault or Other Allegations of Misconduct Involving a Patient-Investigating Allegation and Notification" effective 11/3/2020 was reviewed on 2/10/2022 at 1000. Policy states, "Inpatient and outpatient allegations of physical or other misconduct will immediately be reported to the entity leader... Entity leader must immediately inform the Risk Manager or Risk on-call representative, and the designated Human Resources partner... At that time, determination of next steps will be made. Collectively, this team will determine next steps to include: The patient's attending physician or on call provider should be contacted as well to determine potential care needs. Security Services should be contacted and informed of allegation and need to assist with the interview process... In events involving vulnerable adults or pediatric patients, consideration must be given for whether reporting to outside agencies are mandated... Formulate plan for investigation... An investigation should be initiated when: An allegation of physical or other misconduct involving a patient is made... When necessary, the accused team member will be immediately removed from the care of the patient making the allegation... For the initiation of an investigation surrounding allegations involving non-employed privileged providers, the entity Vice President for Medical Affairs and/or the medical staff office will be consulted."

On 2/10/2022 at 1130, Staff I was queried as to what the facility response would be if a staff member was accused of assaulting a patient to which he stated they would be immediately removed from patient care. When shown the above referenced policy, Staff I agreed that changes needed to be made to the policy.

Based upon interview and document review the facility failed to track and keep records of contracted staff for Covid vaccination and exemption for all individuals actively working in the confines of the facility according to the QSO Memorandum 22-07 All resulting in the potential for spread of Covid within the facility to patients. Findings include:

1. The facility failed to track and keep records of all contracted staff for the vaccination and exemption status of all contracted staff employees. (See tag A-0792)

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 resulting in the potential for poor patient outcomes, up to and including death, for all patients served by the facility. Findings include:

On 2/8/2022 at 1015 upon arrival to the facility, it was observed that construction was occurring around the Main and Emergency Department (ED) entrances to the building. During survey, between 2/8/2022 at 1015-2/10/2022 at 1545, construction workers were visualized inside and outside the hospital. Construction workers were visualized in hallways, the cafeteria, and in the elevators intermingling with hospital staff, patients and/or visitors, and other vendors.

On 2/10/2022 at 0947, Senior Director of Facilities Staff X stated the process was to compile a comprehensive list of all contractors and vendors to corporate and that corporate would send out communication to these companies regarding the COVID vaccination policy. The facility required an attestation to be signed by each company and to be sent directly to corporate verifying that all staff in the company were vaccinated for COVID-19. Following the attestations, a weekly review would be conducted for follow-up on who had returned the attestation and who had not. Staff X further stated that all attestations were to have been returned no later than 1/27/2022 and that "conformity is mandatory."

On 2/10/2022 at 1015, review of facility policy titled "Immunization Guidelines for Team Members" effective 1/24/2022 was completed. Policy states, "Non-employed team member: an individual who is not employed by a (corporate name) entity but who works or provides services on behalf of (corporate name) or on behalf of another organization. May also be referred to as a non-employee..." A table follows with immunization and screening requirements. Following the table, there is an asterisk with the following note. "Non-employed team members (contractors/vendors) working in non-healthcare settings (facilities where clinical care/services are not delivered), will follow the Virtual and Remote team member vaccine requirements)." The Virtual and Remote Team Member recommendation regarding COVID-19 in the table above indicates the COVID-19 vaccine is "recommended."
There is no where in the policy that speaks of contracted services and/or vendors other than that asterisk note and there is no mention of attestation by outside contractors or vendors. Additionally, the policy does not address any clinical precautions that should be taken for employees that have been exempted from receiving the COVID-19 vaccine.

On 2/10/2022 at 1118, Vice President of the Medical Group and Quality Staff I admitted in regards to the COVID-19 vaccination policy that no checks had been done as to whether attestations had been signed or not. He stated the facility felt the individual companies would be responsible for their own employees and record keeping and the employer would sign an attestation that all employees were vaccinated. He stated the hospital did not keep each vendors records. Staff I further stated that the asterisked note in the vaccination policy was only for contracted/vendor staff who were not coming into the building "such as snow removal." If a contractor/vendor was entering the building, a vaccine was required.




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A Teams Conference was held on 2/10/2022 at 1400 with facility administration to discuss the vaccination status of contracted staff. The facility is currently under renovation with many contracted staff present and in the hallways with clinical staff. On 2/10/2022 at 1420, Staff Y, the Chief Operations Officer and Corporate Senior Vice President explained that contracted companies were provided an attestation to be returned to the corporate offices that states it is the contracted companies' responsibility to keep track of vaccinations and exemptions. Staff X, the Senior Director of Facilities was asked to provide attestations and list of all contracted companies and attestations. Staff X stated, "What do you want me to do? Shut down all of the contractors?"

On 2/10/2022 at 1435, three contracted employees were interviewed for vaccination status. Staff BB was questioned about vaccination status. Staff BB stated he had three vaccinations for Covid. Staff CC stated he was not vaccinated and had not applied for exemption status. Staff DD stated he was triple vaccinated for Covid.

On 2/10/2022 at 1525 it was revealed that an attestation had not been submitted by contracted company A of staff BB and staff CC. On 2/11/2022 at 1645 information was provided that contracted company B was also without an attestation.

Based on interview and document review, the facility failed to meet the emergency needs of the patient by having a nurse available to triage according to professional standards of practice resulting in the potential of poor patient outcomes up to and including death for all patients served by the facility. Findings include:

During the initial tour of the emergency department (ED) on 2/8/2022 at 1050, Triage Nurse Staff C stated she worked closely with a nurse technician who "triages and reports to the nurse." When Staff C was asked to clarify, she stated, "The nurse technician will ask patients why they are coming to the ED and assign an ESI (emergency severity index level-acuity). Then they will let the nurse know they are working with."

On 2/8/2022 at 1055, ED Manager Staff B stated the "more experienced" nurse technicians were given triage training which included assigning ESI levels.

On 2/8/2022 at 1110, ED Nurse Technician Staff E was queried as to what job duties she performed when working in triage to which she stated, " I get vital signs, ask why the patient is here and assign an acuity, and take patient's back to a room..." Staff E stated she had completed a competency regarding triage which included assignment of ESI levels.

Review of the job descriptions for nurse technicians on 2/8/2022 at 1500 revealed the position was not specific to the ED. Education level required was for "high school diploma or equivalent." No mention of triage is mentioned in the job description.

Review of facility policy titled "Assignment of Patients-Emergency Department" last revised 5/2016 and last reviewed 6/29/2021 states, "1. A triage assessment will be started by ED staff upon patient arrival to department. 2. The patient is assigned and escorted to a room according to the severity of their illness or injury and a patient history and physical assessment will be done..."

On 2/10/2022 at 0900 a request was made for the employee file of Staff E. On 2/10/2022 at 1500, a document for ESI (Emergency Severity Index) testing was presented. On the top of the document it stated, "remediated = passing." No further competencies were presented for review prior to exit. On 2/11/2022 at 1645, a file was sent via email for competencies for staff E. Staff E completed 3 ED competencies on 2/8/2022 and 10 ED competencies on 2/11/2022 after the start of the EMTALA survey. The ESI testing was documented as being completed on 2/8/2022 at 1441 after being interviewed by surveyors.

On 2/10/2022 at 1415, ED Medical Director Staff J was queried as to if he was aware nurse technicians were triaging patients in the ED. Staff J stated, "In certain circumstances when we have increased patient flow and shortage of staff, the nurses are necessary to care for the patients and we do use nurse technicians to triage. Our most experiences nurse technicians have been trained... I understand that it is not in their job description; however, this only a rare occurrence. Our preference is to have a nurse, but that is not always possible."

Based on observation and interview, the facility failed to ensure Emergency Treatment and Labor Act (EMTALA) signs in waiting areas and in the ambulance receiving area were present and/or likely to be noticed by all individuals that presented to the emergency department resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 2/8/2022 at 1015 on entrance to the Emergency Department (ED), it was noted there was construction occurring around the ED entrance. Looking around the waiting area, it revealed there was no signage present for EMTALA in any areas of the ED waiting room. This was confirmed by Registration Staff D on 2/8/2022 at 1025 and later by ED Manager Staff B on 2/8/2022 at 1035.

On 2/8/2022 at 1042, visualization of the ambulance receiving area revealed an EMTALA sign that was present on the backside of the wall and next to the door that the patient and emergency personnel would be entering, making it impossible to read without turning 180 degrees to see it. At the time of discovery, Staff B stated the flow of traffic had just been changed because of the construction and now the sign was not easily visualized upon entry.