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Based on interview and record review, the facility failed to ensure patient rights were provided for five of 32 sample patients, (Patients 2, 5, 13, 27, and 32), when:

1. For Patient 2, the patient or patient's representative was not informed of their patient rights in advance prior to providing care (Refer to A-0117).

2. For Patient 5, the consent to transfer to another facility was not signed by the patient or patient representative (Refer to A-0131).

3. For Patients 13, 27, and 32, the consent to surgery or special procedure was not completed by the physician/s (Refer to A-0131).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients seen at the facility, jeopardize their safety, and may cause delays in the provision of their care.

Based on interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented, for 12 of 32 sample patients (Patients 1, 2, 14, 15, 16, 17, 20, 22, 24, 25, 26, and 28), when:

1. For Patient 17, the Glucose (test used to indicate the amount of sugar in the blood) critical lab result was not reported to the physician (Refer to A-0398);

2. For Patients 1, 2, 14, 15, 16, 25, and 26, wound status and wound care provided were not assessed and documented as required (Refer to A-0398);

3. For Patient 14, Input and Output was not recorded at the end of the shift as required (Refer to A-0398);

4. For Patients 20, 22, 24, and 28, pain assessments and reassessments were not completed, pain medications were not administered, and pain management in the Emergency Room (ED) was not provided timely (Refer to A-0398).

The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to ensure the needs of patients in the Emergency Department were met in accordance with acceptable standards of practice when:

1. For Patient 10, staff did not provide a sepsis screening; and

2. For Patient 11, staff did not provide a triage examination in the Emergency Department (ED).

These failures had the potential to cause a delay in patient care and an adverse patient outcome.

Findings:

On January 2, 2025, at 11:27 a.m., a review of Patient 10's medical record and concurrent interview was conducted with the Registered Nurse Supervisor (RN Sup). A facility document titled, "Emergency Department Record," dated November 10, 2024, 4:11 a.m., was reviewed and indicated Patient 10 presented to the ED for generalized weakness, persistent cough, and shortness of breath. The document further indicated Patient 10 had a white blood count [test to measure the white blood cells in blood to determine infection] of 15.8 [normal 3.6-11.2].

A facility document titled, "Emergency Department Record," dated November 10, 2024, at 7:30 a.m., indicated, "...X-RAYS...CR Chest 1 View...Study Reason: Dyspnea...IMPRESSION...left upper consolidation with residual dense opacity concerning for residual pneumonia...Left lower lobe patchy opacities, may represent pneumonia and/or atelectasis..."

The review of Patient 10's record reflected no documented evidence Patient 10 received a sepsis screening.

An interview was conducted on January 2, 2025, at 11:45 a.m., with the Corporate Quality Officer (CQO). The CQO stated all patients over the age of 18, should be screened for sepsis in the ED, and if admitted, on the unit every shift.

An interview was conducted on January 2, 2025, at 11:55 a.m., with the RN Sup. The RN Sup stated there was no documented sepsis screenings in Patient 10's medical record for the date of service of November 10, 2024. The RN Sup further stated sepsis screening was not done in triage or in the ED, and it should have been per facility policy.

A review of the facility's Policy and Procedure (P&P) titled, "ADULT SEPSIS SCREENING AND PHYSICAN APPROVED NURSING SEPSIS PROTOCOL," dated May 2024, indicated, "...Registered Nurses to screen all adult patients...severe sepsis or septic shock and implement specified elements of the sepsis treatment bundle as indicated...All patients...will be screened for sepsis, severe sepsis, or septic shock in the Emergency Department, upon admission to all Inpatient units, every shift thereafter, and anytime there is a change in condition..."

2. On January 3, 2025, at 10:50 a.m., a review of Patient 11's record was conducted with the Clinical Nurse Manager (CNM).

The facility document titled, "ED Summary Report," indicated Patient 11 was admitted to the ED on January 1, 2025, at 6:12 p.m. The document further indicated, "Chief Complaint: Abdominal pain...35-week G1P0 [Gravida 1, indicates total number of pregnancies, Para 0, indicates a woman has never given birth] accompanied by mother, states she felt fluid leak, does not know if bag is ruptured..."

During review of Patient 11's medical record there was no documented evidence of triage documentation. There was no documented evidence Patient 11 was triaged when arrived at the ED on January 1, 2025.

On January 3, 2025, at 10:55 a.m., an interview was conducted with the Corporate Quality Officer (CQO). The CQO stated all patients seen in the ED should have a triage report in the electronic medical record.

A review of the facility P&P titled "Triage and Assessments of Patient's Using The Emergency Severity Index (ESI)", dated April 2023, was conducted. The P&P indicated, "...All patients presenting to the ED requesting emergency care will be initially triaged by a qualified RN or ED physician in a timely manner to determine priority of medical screen and care based on physical, psychosocial, and social needs..."

Based on interview and record review, the facility failed to implement its medical staff bylaws, rules and regulations, for one of 32 patients reviewed (Patient 27) when the final report for Patient 27's chest x-ray was not signed on time according to facility policy.

This failure had the potential to cause a delay in Patient 27's treatment.

Findings:

A review of Patient 27's medical record was conducted on December 31, 2024, at 11:09 a.m., with the Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The untitled facility document dated, December 28, 2024, was reviewed and indicated, "...DATE OF ADMISSION: 12/27/2024 [December 27, 2024]...CHIEF COMPLAINT: Abdominal pain...on hemodialysis [a medical treatment that filters waste and excess fluids from the blood when the kidneys are no longer able to do so.]..."

An interview and concurrent record review were conducted with the Medical Director for Radiology (MDR) on January 6, 2025, at 8:59 a.m. The undated untitled facility document was reviewed with the MDR. The document indicated, "...CR Chest 1 view...Current Study Date and Time: 12/28/2024 10:59 a.m. [December 28, 2024, at 10:59 a.m.]... preliminary report dictated by Resident: [Name of Resident 1] on 12/28/2024 at 11:39 a.m [December 28, 2024, at 11:39 a.m]...final report signed by: MDR on 12/30/2024 8:59 a.m. [December 30, 2024, at 8:59 a.m.]..." The MDR stated the final report was not signed on time. He further stated the final report should have been signed on December 29, 2024.

A review of facility's Policy and Procedure (P&P) titled, "Graduate Medical Education Residency Program," dated May 2018, indicated, "...exams will be dictated under the teaching attending on duty the following day, as designated by the attending schedule..."

A review of the facility's "Medical Staff Bylaws, and Rules and Regulation," revised June 25, 2024, indicated, "...Basic Responsibilities of medical staff membership Except for the honorary Medical Staff, the ongoing responsibilities of each member of the Medical Staff, including those who exercise temporary clinical privileges, include...abiding by the Medical staff and Governing body bylaws and the Medical Staff Rules and Regulations and other established rules and policies of the hospital..."

Based on interview and record review, the facility failed to ensure the patient or patient's representative were informed of their patient rights prior to providing care, for one of 32 sampled patients (Patient 2).

This failure resulted in Patient 2, and/or the patients' representatives, to not be informed of their rights as a patient, which could have lead to Patients 2's inability to effectively make decisions regarding their care and treatment.

Findings:

A review of Patient 2's record was conducted on January 02, 2025, at 3:05 p.m., with the Corporate Quality Officer (CQO). A facility document titled, "H&P," dated December 14, 2024, indicated Patient 2 was admitted to the facility on December 14, 2024, for wound debridement (a procedure that removes infected or dead tissue from a would to help it heal), and had a history of diabetes (disease where body cannot regulate blood sugar) and obesity. The Condition of Admission form was not signed, and indicated, "Pt [patient]unable to sign," was handwritten on the form. There was no documentation in the record that additional efforts had been made to provide the information on patient's rights to the patient, family, or surrogate.

An interview was conducted with the CQO on January 02, 2025, at 3:15 p.m. The CQO stated it was the facility's staff responsibility to provide the patients with the Conditions of Admission at the time of admission. The CQO further stated if the staff was not able to give the information on admission, the nurse should have made additional efforts to deliver the information during the patient's stay at the hospital. After reviewing the records, the CQO stated the patient's rights was not followed-up on after the initial admission process.

A review of the facility's policy and procedure titled, "CONDITIONS OF ADMISSION," dated April 2021, was conducted. The document indicated "...To ensure that a Conditions of Admission is signed for every patient...as to why there is no Conditions of Admissions signature...A Conditions of Admission is to be signed for every patient...When a patient is registered in the Emergency Room, the ED Patient Access Representative will obtain the signature on the Conditions of Admission (COA). When the Main Admitting Office is closed, the ED Patient Access Representative will obtain the signature on all Direct Admissions/Transfers in to the facility as well...If a signature is not obtained...a note will be entered into the [name of electronic medical record (EMR)] Registration notes...A Patient Access Representative will be assigned each day to review the report, call the nursing unit the patient is assigned to and check on condition of patient. If patient is able to sign the rep will visit the bedside to obtain the signatures, provide admission paperwork and assure account is updated appropriately with Emergency Contact/Next of Kin information..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for four of 32 sampled patients (Patients 5, 13, 27, and 32), when:

1. For Patient 5, the consent to transfer to another facility was not signed by the patient or patient representative.

2. For Patients 13, 27 and 32, the consent to surgery or special procedure was not completed by the physician.

These failures had the potential to cause a delay of care or transfer for patients 5, 13, 27, and 32, and may have caused harm to the patients.

Findings:

1. On January 3, 2025, at 11:05 a.m., an interview and concurrent record review of Patient 5's record was conducted with the Corporate Quality Officer (CQO). A facility document titled, "Emergency Department Record," dated December 26, 2024, indicated Patient 5 was seen in the Emergency Department (ED) for a mechanical fall and the patient was seven months pregnant.

A facility document titled, "History and Physical," dated, December 27, 2024, indicated Patient 5 was admitted to the facility for a right ankle fracture. The document further indicated Patient 5 was seven months pregnant.

A facility document titled, "Consultation," indicated "...The patient was being evaluated for an ankle fracture in the ED and seven months pregnant...in moderate to severe distress...Assessment...female with seven months pregnancy, waiting for ankle surgery. Due to staffing shortage in the OB department, I am advising the patient to be transferred to another facility because she will require continuous monitoring for the first six hours after surgery and thereafter NSTs (non-stress test) every four hours for the following 24 hours as well as tocolytics (drug to delay labor) for any possible contractions. Therefore, it is advisable that the patient be transferred to another facility that can monitor the baby continuously after surgery and NSTs prior to surgery for an hour..."

A facility document titled, "Daily Focus Assessment Report," dated December 27, 2024, at 11:31 a.m., indicated, "...Acute transfer order for ankle fracture repair for a 7 [seven] month gestation woman...Per house supervisor and COO, no OB service or staff available for pt's [patient's] needs pre and post surgery intervention; therefore, pt needs HLOC [higher level of care] for surgical intervention w [with]/OB services...Call made to [name of Doctor 1] to inquire on speaking to pt prior to CM [case management] obtaining transfer consent, no response, message left w/ [Name of Doctor 1] for further collab [collaboration] on transfer order..."

A facility document titled, "Daily Focus Assessment Report," dated December 27, 2024, at 5:30 p.m., indicated, "...pt [patient] accepted to [Hospital 2], by [Name of Doctor 2, IM (Internal Medicine)], [Name of Doctor 3, Ortho (Orthopedics)], [Name of Doctor 4, OB(Obstetrics)], [Name of Doctor 5, OB (Attending)]..."

A facility document titled, "Discharge Summary," dated December 28, 2024, indicated, "...Subsequently, we do not have OB department in full service here at our hospital. The patient (Patient 5) was transferred to [Hospital 2], which has OB and orthopedics. The patient was transferred there for further care and treatment..."

A facility document titled, "PATIENT'S REQUEST/REFUSAL/CONSENT TO TRANSFER," dated December 27, 2024, was reviewed. The document indicated, "...TRANSFER CONSENT...Signature of Patient or Legally Responsible Individual Signing on Patient's Behalf..." There was no documented evidence the consent for transfer was signed by the patient or the patient's representative..."

A review of the facility's Policy and Procedures titled, "EMTALA - TRANSFER POLICY," dated May 2023, was conducted. The document indicated, "...To establish guidelines for...providing an appropriate transfer to another facility of an individual with an emergency medical condition...Any transfer of an individual with an EMC (emergency medical condition) must be initiated...by written request for transfer from the individual or the legally responsible person acting on the individual's behalf..."

2a. On December 31, 2024, at 9:42 a.m., a review of Patient 13's medical record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated December 17, 2024, indicated Patient 13 was admitted to the facility on December 17, 2024, for shortness of breath and abdominal pain.

The facility document titled, "[Name of Facility] Consent to Surgery or Special Procedure," dated December 20, 2024, was reviewed. The document indicated, "...Insertion of Right Chest Tube...December 20, 2024,...time...12:30 p.m....Telephone consent from...daughter...two witnesses..." There was no documented evidence the physician reviewed the History and Physical, signed, dated or timed the consent prior to the procedure.

An interview was conducted on December 31, 2024, at 9:57 a.m., with the PSC. The PSC stated the physician should have signed the consent to surgery or special procedures. She further stated the physician can write in a provider note that the informed consent and risk and benefits were completed but he did not.

An interview was conducted on December 31, 2024, at 10 a.m., with the Cooperate Quality Officer (CQO) and the PSC. The PSC stated if the physician did not sign the informed consent per the policy, they could have documented the informed consent in the physician progress notes, however the physician did not document it in the electronic medical record (EMR). Further review of Patient 13's medical record, indicated there was no documented evidence the physician documented the informed consent and the risk and benefits in Patient 13's electronic medical record.

A review of the facility Policy and Procedure titled, "[Facility Name] Informed Consent," dated September 2024, was conducted. The document indicated, "...In every case where informed consent is required, the physician must note in the patient's medical record that informed consent was obtained...Informed Consent must be obtained prior to the procedure consent being signed, dated and timed by the patient..."

2b. A review of Patient 27's medical record was conducted on December 31, 2024, at 11:09 a.m., with Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The untitled facility document dated December 28, 2024, at 7:13 a.m., was reviewed. The document indicated Patient 27 was admitted to the facility on December 27, 2024, for abdominal pain and on hemodialysis [a medical treatment that filters waste and excess fluids from the blood when the kidneys are no longer able to do so] ..."

The facility document titled, "Authorization for consent to surgery or special diagnostic or therapeutic procedure," was reviewed with RN Sup. The document indicated, "... your physicians and/ or surgeons have recommended the following operation or procedure. Hemodialysis...Date...Time...Provider Signature..." There was no documented evidence the physician signed the hemodialysis consent prior to Patient 27's procedure.

There was no documented evidence the risks and benefits were explained to Patient 27 prior to the procedure.

An interview with the Chief Quality Officer (CQO) was conducted on December 31, 2024, at 11:21 a.m. The CQO stated the physician should have signed the consent for hemodialysis prior to the procedure.

An interview with RN Sup was conducted on December 31, 2024, at 11:23 a.m. The RN Sup stated there was no documentation on the chart that risks and benefits were explained by the physician to Patient 27. She further stated it was important to make sure the patient was aware of risks and benefits for any procedure.

2c. A review of Patient 32's medical record was conducted on January 3, 2024, at 2:17 p.m., with the Stroke Coordinator (SC). The facility document titled, "History and Physical," dated December 5, 2024, at 4:54 p.m., was reviewed. The document indicated Patient 32 was admitted to the facility on December 5, 2024, for ALOC [Altered level of consciousness (a change in a patient's awareness and alertness)].

The facility document titled, "Authorization for consent to surgery or special diagnostic or therapeutic procedure was reviewed with the SC. The document indicated, "... your physicians and/ or surgeons have recommended the following operation or procedure. Hemodialysis...Date...Time...Provider Signature..." There was no documented evidence the physician signed the hemodialysis consent prior to Patient 32's procedure.

There was no documented evidence the risks and benefits were explained by the doctor to Patient 32 prior to the procedure.

An interview with the SC was conducted on January 3, 2024, at 2:17 p.m. The SC stated there was no documentation on the physician notes or progress notes that risks and benefits were explained by the kidney doctor to the patient. The SC stated the kidney doctor should have explained the risks and benefits of hemodialysis to the patient. The SC stated it was important for the physician to explain the risks and benefits to the patient, "so they can receive informed care and make the proper decision."

A review of facility policy and procedure titled, "Informed Consent," dated September 2024, was conducted with RN Sup and CQO. The policy indicated, "...The hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures/complex procedures as outlined in the Informed Consent section and for special procedures as listed under Informed consent Special Requirements..."
















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Based on interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented for 12 of 32 sampled patients (Patients 1, 2, 14, 15, 16, 17, 20, 22, 24, 25, 26, and 28), when:

1. For Patient 17, the Glucose (test used to indicate the amount of sugar in the blood) critical lab result was not reported to the physician (Refer to A-0398);

2. For Patients 1, 2, 14, 15, 16, 25, and 26, wound status and wound care provided were not assessed and documented as required (Refer to A-0398);

3. For Patient 14, Input and Output was not recorded at the end of the shift as required (Refer to A-0398);

4. For Patients 20, 22, 24, and 28, pain assessments and reassessments were not completed, pain medications were not administered, and pain management for patients in the Emergency Room (ED) was not provided timely (Refer to A-0398).

These failures had the potential to impact the health, safety, and delay treatment of the patients.

Findings:

1. On January 3, 2025, at 11:02 a.m., a review of Patient 17's medical record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated November 11, 2024, indicated Patient 17 was admitted to the facility on November 11, 2024, for Diabetic Ketoacidosis (complication of diabetes which acid builds up in the blood to life threatening levels) and Sepsis (life threatening complication of infection).

A facility document titled, "[Name of Facility] Order management," dated November 14, 2024, at 12:37 a.m., was reviewed. The document indicated, "...comprehensive metabolic panel [a routine blood test that measures substances in the blood to provide information about the body's chemical balance]...once...collected..."

A facility document titled, "[Name of Facility] Results," dated November 14, 2024, was reviewed. The document indicated, "...collected November 14, 2024, 04:45 [4:45 a.m.]...glucose 477...reference...70-110mg/dL [milligrams per deciliter-unit of measurement]...result called to RN[Registered Nurse]...at 0752 [7:52 a.m.] on 11/14/24 0725 [November 14, 2024 7:52 a.m.]..."

During the review of Patient 17's medical record, there was no documented evidence the RN reported Patient 17's critical glucose lab result of 477 mg/dL to the physician.

An interview was conducted on December 31, 2024, at 11:11 a.m., with the PSC. The PSC stated the nurse did not document the notification to the physician. The PSC further stated the nurse did not document the critical lab result in the critical lab section of the electronic medical record.

A review of the facility's Policy and Procedure (P&P) titled, " [Facility Name] Critical Lab Values and Diagnostic Test Results Notification of," dated September 2024, was conducted and indicated, "...The responsible physician...will be notified as soon as possible, but no later than, 60 minutes...glucose (fasting)...< (less than 40 mg/dl or (greater than) 400mg/dl...Document responsible physician notification of the critical laboratory or diagnostic test result in the medical record..."

2a. A review of Patient 1's record was conducted on January 2, 2025, at 2:30 p.m., with the Corporate Quality Officer (CQO). A facility document titled, "History and Physical (H&P)," dated December 27, 2024, indicated Patient 1 was admitted to the facility on December 27, 2024, for coffee ground emesis (vomit indicative of internal bleeding that looks like coffee grounds), and melena (black tarry stool indicative of internal bleeding).

Continued review of Patient 1's medical record revealed an undated double sided facility document titled, "WOUND PROGRESS NOTES," which indicated side one was used to assess a patient's wound, and side two was used to place wound photos. There was no documentation on the form for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 1's name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement, and name of person taking the photo. There was no documented evidence the document was fully completed and that Patient 1's wounds were properly assessed.

An interview was conducted on January 3, 2025, at 2:44 p.m., with the CQO. The CQO stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have been clear so patient information could be read, indicating the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The CQO further stated the registered nurse did not follow the facility's policy and procedure.

2b. A review of Patient 2's medical record was conducted on January 2, 2025, at 3:05 p.m., with the CQO. A facility document titled, "H&P," dated December 14, 2024, indicated Patient 2 was admitted to the facility on December 14, 2024, for wound debridement (removal of dead tissue from a wound), and had a history of diabetes (disease where the body cannot regulate blood sugar) and obesity (overweight).

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 2's record and dated December 15, 2024, at 6:51 p.m., was reviewed. The document indicated side one was used to assess a patient's wound and side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2's name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement, and name of person taking the photo. There was no documented evidence the document was fully completed and that Patient 2's wounds were properly assessed.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 2's record and dated December 15, 2024, at 6:38 p.m., was reviewed. The document indicated side one was used to assess a patient's wound, and side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2's name, measuring device, anatomical location, patient identifier sticker, identification of site, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and Patient 2's wounds were properly assessed.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in patient 2's record and dated December 26, 2024, at 4:53 a.m., was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. There was no documentation for wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2's name, measuring device, patient identifier sticker, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and Patient 2's wounds were properly assessed.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 2's record and dated December 26, 2024, at 5:06 a.m., was reviewed. The document indicated side one was used to assess a patient's wound, and side two was used to place wound photos. There was no documentation of wound assessment on side one. On side two, there were two photos of the wound, however there was no documentation to show the measuring device, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and that Patient 2's wounds were properly assessed.

An undated double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 2's record was reviewed. The document indicated side one was used to assess a patient's wound, and side two was used to place wound photos. There was no documentation of a wound assessment on side one. On side two, there were two photos of the wound which were blurry and did not clearly show Patient 2's name, measuring device, patient identifier sticker, wound measurement and name of person taking the photo. There was no documented evidence the document was fully completed, and that Patient 2's wounds were properly assessed.

An interview was conducted on January 3, 2025, at 3:15 p.m., with the CQO. The CQO stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have been clear so patient information could be read, indicating the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The CQO further stated the registered nurse did not follow the facility's policy and procedure.

2c. On December 31, 2024, at 10:47 a.m., a review of Patient 14's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "H&P," dated December 8, 2024, indicated Patient 14 was admitted to the facility on December 8, 2024, for abdominal pain, localized numbness, tingling, weakness.

An undated double sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 14's record was reviewed. The document indicated side one was used to assess the patient's wound, side two was used to place wound photos. On side one there is a signature that is not legible and does not identify if the signature is a registered nurse. On side two, there were two photos of the wound. The photo on top was dated December 19, 2024, at 2300 (11 p.m.) the photo was missing the measuring tool and the body alignment tool. The second picture was missing the date and time. There was no documented evidence the document was completed, and that Patient 14's wounds were properly assessed.

An undated double sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 14's record was reviewed. The document indicated side one was used to assess the patient's wound, side two was used to place wound photos. On side one there is a signature that is not legible and does not identify if the signature is a registered Nurse. On side two, there were two photos of wounds. The photo on top was dated December 19, 2024, at 11 p.m., and the photo was missing the measuring tool, and the body alignment tool. The second picture was missing the measuring tool, and the body alignment tool. There was no documented evidence the document was fully completed, and that Patient 14's wounds were properly assessed.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 14's record and dated December 26, 2024, was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. On side two, there was one photo of a wound. The patient sticker was blurry and did not clearly show the patients name and physician information. The wound measuring tool, identification of site, and wound measurement were also missing. There was no documented evidence the document was completed, and Patient 14's wounds were properly assessed.

A double-sided facility document titled, ""WOUND PROGRESS NOTES," dated December 26, 2024, was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. On side two, there was three photos of different wounds. On each of the three pictures the wound measuring tool was missing. There was no documented evidence the document was fully completed, and Patient 14's wounds were properly assessed.

An interview was conducted on January 2, 2025, 11:34 a.m., with the PSC. The PSC stated the wound progress notes sheet should have been completed with the assessment of the wound and the photographs of the wound should have been clear, so patient information is legible, and indicated the date and time of when the photograph was taken, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The PSC further stated the registered nurse did not follow the facility's policy for wound documentation.

2d. On January 2, 2024, at 10:47 a.m., a review of Patient 15's medical record was conducted with the PSC. A facility document titled, "H&P," dated December 3, 2024, indicated Patient 15 was admitted to the facility on December 3, 2024, for shortness of breath.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in patient 15's record and dated December 27, 2024, was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. On side one there was a signature that was not legible and did not identify if the signature was a registered Nurse, and assessment of the wound was not documented. On side two, there was one photo of a wound. The photo was dated December 27, 2024, at 12:30 p.m., the photo was missing the measuring tool and the body alignment tool. There was no documented evidence the document was completed, and Patient 15's wounds were properly assessed.

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in patient 15's record and dated December 27, 2024, was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. On side one there was a signature that was not legible and did not identify if the signature was a registered nurse, and assessment of the wound was not documented. On side two, there was one photo of a wound, dated December 27, 2024, at 12:37 p.m., the photo was missing the measuring tool. There was no documented evidence the document was completed, and Patient 15's wounds were properly assessed.

An interview was conducted on January 2, 2025, at 3:08 p.m., with the PSC. The PSC stated the wound progress notes sheet should have been completed with the assessment of the wound and the photographs of the wound should have been clear, so patient information is legible, the size of the wound, the anatomical guide, and the signature of the nurse who took the photograph. The PSC further stated the registered nurse did not follow the facility's policy for wound documentation.

2e. On January 3, 2024, at 9:50 a.m., a review of Patient 16's record was conducted with the PSC. A facility document titled, "H&P," dated November 25, 2024, indicated Patient 16 was admitted to the facility on November 25, 2024, for shock, and acute hypoxic respiratory failure (AHRF, body fails to adequately oxygenate the blood).

A double-sided facility document titled, "WOUND PROGRESS NOTES," located in Patient 16's record and dated December 19, (no year) was reviewed. The document indicated side one was used to assess a patient's wound, side two was used to place wound photos. On side one the assessment was incomplete. On side two, there was one photo of a wound. The photo was not dated and timed and had no measurement tool. There was no documented evidence the document was completed, and Patient 16's wounds were properly assessed.

A review of the facility's P&P titled, "Skin and Wound Care," dated May 2024, was conducted. The document indicated, "...All patients admitted to the hospital will be assessed...for any skin impairment and pressure injury...Photographs...Wound photos should be included in the medical record to support documentation....All photographs of wounds...are to be posted on the on the Wound Progress Notes form...Labeling on the photo will include...Patient's name and medical record number...Location or site...Date and time of photograph...Healthcare provider's initials...Orientation Guide (Align to Body Stick figure)...measuring device or tools used within the photo...Documentation...Initial Nursing Assessment will include documentation of skin assessment, Braden Scale score, and any skin impairment or injuries upon admission, and every shift in the wound flowsheet..."

2f. A review of Patient 25's medical record was conducted on December 31, 2024, at 9:40 a.m., with the Registered Nurse Supervisor for Intensive Care Unit (RN Sup). The facility document titled, "History and Physical," dated December 26, 2024, at 8:52 p.m., indicated, "...Admission date: 12/26/2024 [December 26, 2024] ...Chief Complaint ... Intractable right foot pain ...History of present illness ...severe left lower extremity Peripheral Artery Disease (PAD) [a common condition in which narrowed arteries reduce blood flow to the arms or legs.], hypertension [HTN] (high blood pressure)..."

A review of an untitled document dated December 27, 2024, at 8:00 p.m., indicated, "...12/27/2024 20:00 [December 27, 2024, at 8 p.m.]...Pts [Patient's] right foot is swollen and red, a small ulcer [an open sore or lesion that develops on the skin or mucous membrane] on the right big toe that has been there for 1[one] month..."

During the record review, there was no documented evidence of Patient 25's wound assessments on December 28, 2024, and December 30, 2024.

A review of Patient 25's medical record and concurrent interview was conducted on December 31, 2024, at 9:40 a.m., with the RN Sup. The RN Sup stated there were no other wound assessments after the initial assessment on December 27, 2024. The RN Sup stated the nurses are supposed to be documenting wound assessments every shift. The RN Sup further stated it is important to do wound assessments "so we can monitor the wound and the progression of the wound."

2g. A review of Patient 26's medical record was conducted on December 31, 2024, at 10:28 a.m., with RN Sup. The facility document titled, "History and Physical," dated December 28, 2024, indicated, "...Admission date/time: 12/28/2024 20:37 [December 28, 2024, at 8:37 p.m.]...chief Complaint...painful bump on neck...History of present illness...DM [diabetes mellitus] [a chronic disease that affects how the body regulates blood sugar levels], hypothyroidism [a condition where the thyroid gland doesn't produce enough thyroid hormone]..."

A review of a facility untitled document dated December 29, 2024, at 8 a.m., was conducted with the RN Sup. The document indicated, "...12/2/2024 08:00 [December 27, 2024, at 8 a.m.]...Abcess in the neck, dressing clean dry and intact..."

During the review of Patient 26's medical record there was no documented evidence of wound assessments on December 30, 2024.

On December 31, 2024, at 10:28 a.m., a review of Patient 26's medical record and a concurrent interview was conducted with the RN Sup. The RN Sup stated there were no wound assessments documented on December 30, 2024. The RN Sup stated the nurses are supposed to document wound assessments every shift. The RN Sup further stated it is important to do wound assessments "so we can monitor the wound and the progression of the wound."

A review of the facility policy titled, "Skin and wound care," revised May 2024, was conducted. It indicated, "Documentation...Initial nursing assessment will include documentation of skin assessment, Braden scale score, and any skin impairment or injuries upon admission, and every shift in the wound flow sheet..."

A review of the facility's P&P titled, "Skin and Wound Care," dated May 2024, was conducted. The document indicated, "...All patients admitted to the hospital will be assessed...for any skin impairment and pressure injury...Photographs...Wound photos should be included in the medical record to support documentation....All photographs of wounds...are to be posted on the on the Wound Progress Notes form...Labeling on the photo will include...Patient's name and medical record number...Location or site...Date and time of photograph...Healthcare provider's initials...Orientation Guide (Align to Body Stick figure)...measuring device or tools used within the photo...Documentation...Initial Nursing Assessment will include documentation of skin assessment, Braden Scale score, and any skin impairment or injuries upon admission, and every shift in the wound flowsheet..."

3. On December 31, 2024, at 10:47 a.m., a review of Patient 14's record was conducted with Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated December 8, 2024, indicated Patient 14 was admitted to the facility on December 8, 2024, for abdominal pain, localized numbness, tingling, weakness.

A facility document titled, "Order Management," dated December 8, 2024, was reviewed. The document indicated, "...Intake and output [I&O, the measurement of fluids and food that enters and exits the body] every shift...Start 12/8/2024 [December 8, 2024]...Stop date 12/21/2024 [December 21, 2024]..."

During a review of Patient 14's medical record there was no documented evidence of I&O's on December 26, 2024, for the p.m. shift (7a.m. to 7p.m.), December 28, 2024, for the p.m. shift, and December 30, 2024, for the p.m. shift.

An interview was conducted on January 2, 2025, 11:34 p.m., with the PSC. The PSC stated the nursing staff did not document the output on the following dates; December 26, 2024, the p.m. shift, December 28, 2024, p.m. shift, and December 30, 2024, p.m. shift. The PSC further stated the nursing staff should have completed and documented the shift totals for the Input and Output for each day at the end of shift.

A facility document titled, "Intake and Output (I&O) monitoring Policy," dated December 2024, was reviewed. The document indicated, "...Intake and output documentation will be charted and recorded every shift and totaled at the end of the twenty-four (24) hours with in the Electronic Medical Record (EMR)...Accurately measure and record all fluid output, including urine, stool, vomitus and drainage from mounds...Document the time and type of fluid intake and output on the designated I&O chart..."

4a. On January 2, 2025, at 10:45 a.m., an interview and review of Patient 20's record was conducted with Clinical Nurse Manager (CNM).

The facility document titled, "Vital Sign Report," dated December 29, 2024, through December 31, 2024, indicated, "...Assess Date/Time: 12/29/24 [December 29, 2024] 12:28 [p.m.]...Pain Score 4..."

The facility document titled, "History and Physical," dated December 29, 2024, at 2:30 p.m. indicated, "...patient presents to the ER for evaluation of right flank pain. Patient states...right flank pain since this morning...rates it from a 2-4/10 dull ache that comes and goes...Pain: scale: Numeric: 4...Assessment/Plan: #flank pain, right side...Tylenol 500mg prn [as needed] for pain..."

An untitled facility document indicated "...Order Inquiry..ACETAMINOPHEN...start date 12/29/24 [December 29, 2024] 15:19 [3:19 p.m.] Q6HPRN [every six hours as needed]..."

The facility document titled, "Medication Administration Record," dated December 29, 2024, indicated "...ACETAMINOPHEN [500mg] Oral every 6 [six] hours as needed...indication: Pain...Last Administered..."

The facility document titled, "Daily Assessment Inquiry," dated December 29, 2024, through December 30, 2024, at 3:30 p.m., indicated, "...Pain Location...Pain Scale...Pain Score..."

On January 2, 2025 at 11 a.m., the CNM stated the medication administration record indicated Tylenol as needed was ordered for Patient 20, however, was never given to the patient. The CNM stated Patient 20 verbalized pain four out of ten but did not receive any medication. The CNM stated Patient 20 was only assessed for pain the one time on December 29, 2024, at 12:28 p.m. and pain should have been reassessed daily.

4b. On January 2, 2025, at 2:15 p.m., an interview and review of Patient 22's medical record was conducted with the CNM.

An untitled facility document indicated "Pain Score...Abdomen generalized...12/30/24 0006 [December 30, 2024, at 12:06 a.m.] 10...0224 [2:24 a.m.] 10...0239 [2:39 a.m.] 4...0901 [9:01 a.m.] 9...1606 [4:06 p.m.] 8...2018 [8:18 p.m.] 8..."

The facility document titled, "History and Physical," dated December 30, 2024, at 5:39 a.m. indicated, "...came to ED for abdominal pain for the last 3 [three] days. The patient says the pain radiates to [their] back. She says nothing helps with the pain...Assessment/Plan: #Gallstone Pancreatitis [DEFINE]...Dilaudid and Ketorolac given in the ED..."

An untitled facility document indicated, "...Med Admin PRN [as needed]...Hydromorphone... administration...12/30/24 [December 30, 2024]... 09:03 [9:03 a.m.]...1606 [4:06 p.m.]...2019 [8:19 p.m.]...12/31/24 [December 31, 2024] 00:54 [12:54 a.m.]..."

An interview was conducted on January 2, 2025, at 2: 20 p.m., with the CNM. The CNM stated if pain medications are given, the expectation would be for pain to be reassessed within an hour for oral medications, and 15 minutes for IV medications. The CNM stated for a pain score of nine, the expectation would be to offer pain medications. The CNM stated Patient 22 received pain medication on December 30, 2024, at 9:03 a.m., but the pain was not reassessed according to the facility policy. The CNM further stated Patient 22 received pain medication again on December 30, 2024, at 4:06 p.m. but pain was not reassessed according to policy.

4c. On January 2, 2025, at 2:45 p.m., an interview and review of Patient 23's medical record was conducted with CNM.

The facility document titled, "History and Physical," dated December 29, 2024, at 9:38 p.m. indicated, "...presents to ER for evaluation of abdominal distension...currently complaining of abdominal pain, shortness of breath, and back pain..."

The facility document titled "Vital Sign Report," indicated "...Pain Score Detail...12/29/24 [December 29, 2024] 21:30 [9:30 p.m.]...pain score: 9...23:37 [11:37 p.m.] Pain Score: 9...12/30/24 [December 30, 2024] 00:37 [12:37 a.m.] Pain Score: 7...14:21 [ 2:21 p.m.] Pain Score: 8..."

The facility document titled, "Medication Administration History Report," indicated "...Scheduled...Hydrocodone-Acetaminophen...once...admin Dt/Tm [date/time] 12/29/24 23:37 [December 29, 2024, at 11:37 p.m.]...PRN...Morphine...every 4 [four] hours as needed...intravenous...admin Dt/Tm 12/30/24 03:28 [December 30, 2024, at 3:28 a.m.]...admin Dt/Tm 12/30/24 14:21 [December 30, 2024, at 2:21 p.m.]..."

An interview was conducted on January 2, 2025 at 2:50 p.m., with the CNM. The CNM stated the patient's pain was not reassessed according to the facility's policy. The CNM stated the patient was not given pain medication on December 30, 2024, until 2:21 p.m., despite having orders for IV morphine.

4d. A review of Patient 28's medical record was conducted on January 3, 2025, at 10:15 a.m., with the Stroke Coordinator (SC). The untitled facility document, creation date, November 27, 2024, at 9:38 p.m., was reviewed. The document indicated, "...Arrival Date: 11/27/2024 [ November 27, 2024]...Chief Complaint: Assault...reports to the ER for the evaluation of an alleged assault. Patient states she was assaulted on Sunday. She was hit twice on the left side of her ribs...she states the rib pain has been getting progressively worse as time passes. Patient denies shortness of breath, nausea, vomiting, diarrhea, constipation, sick contact, and any other symptoms..."

A review of facility document titled, "[Name of Facility] Triage Report," dated November 27, 2024, at 8:29 p.m., was conducted with the SC. It indicated, "... pt [patient] brought in by ems [Emergency Medical Services] for c.o. [complaint of] left rib pain after she got hit on Sunday by a stick. Patient states pain is getting worse...Pain assessment Score:10..."

The untitled facility document, creation date, November 27, 2024, at 9:38 p.m., was reviewed with the SC. The document indicated, "...Provider contact time: 11/27/2024 21:25...she states the rib pain has been getting progressively worse as time passes...Physical Exam Narrative...chest: + tenderness along the anterior aspect of the left side of the chest...Abdomen: soft, non-distended, non-tender. No guarding no rebound No masses..." At this time the SC stated MD1 did not order any pain medicine for Patient 28 right away. SC further stated there was no documentation that pain was referred to provider when patient did not get a pain medication order right away.

A review of facility document titled, "Medication Administration History Report," was conducted with the SC. The document indicated, "...Ordering Provider: [ Name of NP]...Start Date: 11/27/2024 22:37 [November 27, 2024, at 10:37 p.m.]... Ketorolac 60 mg/2 ml...order does:30 mg/1 ml Frequency: once Route: intramuscular...Admin Dt/tm [Administration Date/time]: 11/27/2024 22:42 [November 27, 2024, at 22:42 p.m.]...Verified by [ Name of Licensed Vocational Nurse]..."

On January 3, 2024, at 11:05 a.m., an interview with the Emergency Room Manager (ERM) was conducted. The ERM stated Patient 28 should have received pain medicine within an hour of arrival to the ED.

A review of facility's policy and procedure (P&P) titled "Pain Management," revised September 2024, indicated "...Patients have the right to main management...Treatment is to be provided in a timely manner...Patients will be routinely reassessed for pain during the initial daily shift assessment, upon change of condition, after procedures known to cause pain, with new complaints, and as needed...Inpatients shall receive treatment for any active pain issue...if a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15- 60 minutes following treatment (depending on the type of intervention)..."







50304

Based on interview and record review, the medical staff failed to be continuously responsible for the policies and procedures governing medical care provided to patients, when Emergency Department (ED) staff failed to document medical screening evaluations (MSE) in the Electronic Medical Record (EMR) for two of 32 patients reviewed (Patient 4 and 12).

These failures had the potential to result in a delay of patient care and adverse outcomes.

Findings:

A. On January 3, 2025, at 10:30 a.m., Patient 4's medical record was reviewed with the Corporate Quality Officer (CQO).

A review of the facility document titled "[Name of Facility] Triage Report," indicated Patient 4 arrived in the emergency room on December 17, 2024, at 1:52 p.m., for a chief complaint of uterine contractions. Patient 4's delivery due date was February 10, 2025.

A review of the facility document titled, "OB Department Daily Staffing Sheet," dated December 17, 2024, morning shift 7 a.m. to 7 p.m., and night shift 7 p.m. to 7 a.m., indicated there was no post-partum [following childbirth] nurses scheduled.

During further review of Patient 4's medical record, the CQO stated when a pregnant person comes into the ED, they would be sent to the obstetrics (OB) department [a dedicated obstetrics unit for expected mothers] for evaluation, but at this moment the OB is short staffed due to pending closure of the unit and OB patients are being seen in the ED only. The CQO stated she could not locate any physician notes for Patient 4. She further stated any patient seen in the ED should be seen and evaluated by a physician. There was no documented evidence Patient 4 received a Medical Screening Evaluation (MSE).

B. On January 3, 2025, at 11:24 a.m., a review of Patient 12's medical record was conducted with the Clinical Nurse Manager (CNM).

The facility document titled, "ED Summary Report," indicated Patient 12 was admitted to the ED on January 1, 2025, at 6:22 p.m. The document further indicated "Chief Complaint: Miscarriage...BIBA [Brought in by ambulance] Patient CO [complained of] abd [abdominal] cramping and vag [vaginal] bleeding..."

During the review of Patient 12's medical record, there was no documented evidence of ED physician notes. There was no documented evidence Patient 12 received a Medical Screening Exam (MSE) while in the emergency room on January 1, 2025.

A review of the facility's Policy and Procedure titled, "EMTALA-MEDICAL SCREENING AND STABILIZATION POLICY," dated April 2023, indicated, "...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to determine whether or not an EMC [Emergency Medical Condition] exists...to any individual, including pregnant woman having contractions..."