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The facility failed to meet the regulatory requirements for the Condition of Participation at §482.12 Governing Body as evidenced by the following:

Based on interview and record review, the Governing Body failed to ensure one of one Advanced Care Provider (APP, health care professional, not a doctor, has advanced education and training) Physician Assistant (PA) 1 and one of one Attending Physician (Physician) 1 provided quality care to one of one sampled patients (Patient 3) when:

1. Neither PA 1 nor Physician 1 reviewed and took action on abnormal labs for one of one sampled patient (Patient 3).

2. PA 1 did not document a medical treatment provided to one of one sampled patient (Patient 3).

These failures resulted in Patient 3 return to the Emergency Department (ED) three days later in critical condition and death. ( Refer to A-049)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care, in compliance with the Condition of Governing Body.

Based on Interview and Record review, the Governing Body failed to ensure one of one Advanced Practice Provider (APP, health care professional, not a doctor, has advanced education and training) Physician Assistant (PA, advance practice provider) 1 and one of one Attending Physician (Physician) 1 provided quality care to one of one sampled patients (Patient 3) when:

1. Neither PA 1 or Physician 1 reviewed or acted on abnormal labs for one of one sampled patient (Patient 3).

2. PA 1 did not document a medical treatment provided to one of one sampled patient (Patient 3).

These failures resulted in Patient 3's return to the Emergency Department (ED) three days later in critical condition and death the following day.

Findings:

1. During a review of Patient 3's Emergency Documentation - MD, ED Physician Notes (Physician Notes), dated 12/6/24, the Physician Notes indicated PA 1 examined Patient 3. The Physician Notes indicated Patient 3 arrived at the hospital ED by private vehicle with Family Member (FM) 1. Patient 3 had a temperature of 102 degrees Fahrenheit (F, unit of temperature), which began 28 hours prior to coming to the ED, and associated symptoms of nausea and an earache. PA 1 ordered laboratory (lab) work for Patient 3.

During an interview on 1/27/25 at 12:11 p.m. with Chief Medical Officer (CMO), CMO stated Patient 3 had been brought to the ED on 12/6/24 by his mother with complaints of fever. PA 1 examined Patient 3. CMO stated PA 1 ordered a urinalysis (UA- laboratory test to analyze urine) to rule out a urinary tract infection. CMO stated the results of the UA ruled out an infection and PA 1 discharged Patient 1. CMO stated the UA was positive for bilirubin (a yellow-orange pigment produced when red blood cells are broken down. Bilirubin in the urine is considered abnormal and can indicate a problem with the liver). CMO stated the abnormal UA results were missed. CMO stated Patient 3 returned to the hospital's ED on 12/9/24 in septic shock (life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure), acute liver failure (life-threatening condition where the liver suddenly stops functioning properly), kidney failure (kidneys are no longer able to adequately filter waste products and excess fluid from the blood), and Disseminated Intravascular Coagulation (DIC- condition that causes abnormal blood clotting throughout the body's blood vessels). CMO stated Patient 3 expired (died) on 12/10/24.

During a review of Patient 3's Medical Record (MR), the UA laboratory results, dated 12/6/24 at 2:15 am, were noted to be abnormal in the following categories:

Specific Gravity (measures concentration of urine)... 1.028 (H) [high, normal 1.005-1.03]

Bilirubin (the presence of bilirubin is an important finding in the evaluation of liver function and a positive detection could be an indication of liver disease such as jaundice, cirrhosis or hepatitis) 2+ (A) [abnormal, (trace, normal less than 0.2)]

Ictotest (test for presence of bilirubin)... Positive (A), (Normal is Negative)

Blood... 2+ (A) (normal is 0, could indicate, bladder infection, kidney stones, kidney disease, or injury)

Protein (normal kidney function will filter out protein)...1+ (A) (normal trace or less than 0.2, could indicate kidney damage, diabetes (inability to utilize sugar), dehydration, fever, stress)

Urobilinogin (caused by breakdown of red blood cells)... 1+ (A) (normal trace, could indicate liver disease, biliary tract (aids in the digestion of fats) disorder, intestinal disorders, anemia)

Red blood cells (RBC)... 156 (H) (normal less than 6)

Bacteria... Trace (A) (normal is none, could indicate contamination of sample or infection)

All of the normal values displayed in black type and the abnormal values displayed in red type.

Patient 3's "Physician Notes" dated 1/6/24 indicated PA 1 signed Patient 3's medical record on 12/6/24 at 4:35 a.m. and Physician 1 co-signed patient 3's medical record on 12/7/24 at 2:58 p.m.

During an interview on 1/28/25 at 3:06 p.m. with PA 1, PA 1 stated he did not remember seeing Patient 3's abnormal UA results.

During an interview on 1/28/25 at 1:19 p.m. with Physician 1, Physician 1 stated the medical records of patients seen by advanced practice providers are sent to physicians for a co-signature. Physician 1 stated the expectation was for the physician to review the MR before co-signing, but if many medical records were sent to him at once he would co-sign without reviewing the medical record. Physician 1 stated he co-signed Patient 3's medical record but he did not review Patient 3's medical record for 12/6/24 ED visit.

During an interview on 1/30/25 at 11:43 a.m. with CMO, CMO stated the expectation was for attending physicians to review a medical record before co-signing.

During a review of Patient 3's Discharge Summary, dated 12/10/24, the Discharge Summary indicated Patient 3 was a 4-year-old male previously healthy brought to the emergency room today (12/10/24) with jaundice (yellowing of skin and whites of the eyes, caused by high bilirubin levels, typically caused by a blockage of the bile duct, liver disease or excessive breakdown of red blood cells) for the past two days. Family reported Patient 3 started having fevers six days ago. Family brought Patient 3 to the ED here at (facility name) due to high fever of 104 degrees Fahrenheit (F) at home. On 12/6/24 PA 1 diagnosed Patient 3 with an ear infection and discharged Patient 3 home with an antibiotic. The urinalysis performed on 12/6/24, indicated 2+ bilirubin and 150 RBC. Two days ago, Family Members noticed Patient 3 was turning yellow and Patient 3 was itchy. Today (12/10/24), Patient 3's parents took Patient 3 to their primary care physician, Patient 3 was hypoxic (low levels of oxygen in body tissues) and jaundiced. PCP instructed Patient 3's parents to take him to the lab for blood draws and then to the ED. Patient 3's parents followed instructions and brought Patient 3 to the ED. In the ED, Patient 3 was noted to be hypotensive (low blood pressure) with systolic (upper number) in the "40's to 60's" (normal blood pressure range 92-107 over 50 to 64). Patient 3 was in liver and kidney failure. Patient 3 was too unstable to transfer to a higher level of care hospital by ground and the weather conditions prevented Patient 3 being airlifted to a higher level of care hospital. Medications were ordered to support Patient 3's low blood pressure, but the interventions were not successful. Patient 3's hemoglobin (protein contained in red blood cells that is responsible for delivery of oxygen to the tissue) continued to drop indicating significant bleeding with the abdomen (stomach) a likely source of the bleed. Multiple blood products were administered while monitoring the coagulation (blood clotting) parameters (levels) and hemoglobin. Patient 3's abdomen increased in size and became increasingly firmer. Patient 3's skin began to show signs of mottling (blotchy, discolored patches indicating decreased blood flow to all but vital organs, brain, heart, lungs). Patient 3's labs showed signs of continued decline. Patient 3 experienced periods of Pulseless Electrical Activity (PEA, potential lethal medical emergency). The facility initiated Cardiopulmonary Resuscitation (CPR, life-saving interventions) until the family members elected to stop the CPR. "[Patient 3] was declared dead at 6:50 A.M." Significant Findings included: "Acute [sudden] renal failure; Acute liver failure, Acute hypoxic respiratory failure; Shock; Disseminated intravascular coagulation [DIC, serious condition that causes abnormal blood clotting throughout the body's blood vessels]." Discharge Diagnosis/Plan Patient Discharge Condition Expired Discharge Disposition Morgue.

During a review of peer reviewed journal "UpToDate" the article titled "Patient Education: Blood in the urine (hematuria) in children (Beyond the Basics), dated 5/5/23, the article indicated, "If the child has hematuria and protein in the urine, further testing will be done. This includes blood and urine tests to evaluate the child's kidney function. The child's blood pressure will also be measured because high blood pressure is a common finding in children with kidney problems. The child may be referred to a pediatric nephrologist if the tests are abnormal."

2. During a concurrent interview and record review on 1/27/25 at 11:55 a.m. with Quality Patient Safety Program Manager (QPSPM) 1, Patient 3's medical record was reviewed. The "General Information [nursing notes] Textual Results" (GITR), dated 12/6/24, at 4:40 a.m. indicated Licensed Vocational Nurse (LVN) 1 documented, "bleeding from right nostril noted after swab for covid [sic- Corona Virus Disease: highly contagious virus] was done; pressure applied to the nose and ice pack administered; provider then placed a nasal sponge that stopped the bleeding." QPSPM 1 stated there was no note in the medical record from a provider regarding Patient 3's nosebleed or any interventions done to stop the bleeding.

During an interview on 1/28/25 at 3:06 p.m. with PA 1, PA 1 stated he did not remember placing a nasal sponge in Patient 3's nostril to stop a nosebleed.

During an interview on 1/29/25 at 7:50 a.m. with LVN 1, LVN 1 stated she did a COVID swab by placing the swab in each nostril and rotating the swab. LVN 1 stated the nosebleed started immediately. LVN 1 stated she tried to stop the bleeding by using a tissue to apply pressure and then applied an ice pack, but the bleeding did not stop. LVN 1 stated the provider [PA 1] was in the room and he made the decision to insert a nasal sponge to stop the bleeding. LVN 1 stated she believed the provider was [stated first name of PA 1].

During an interview on 1/29/25 at 1:27 p.m. with Emergency Department Medical Director (EDMD), EDMD stated his expectation was for ED providers to document every treatment, intervention, or phone call to patients for any care provided.

During an interview on 1/29/25 at 5:36 p.m. with Family Member (FM) 1, FM 1 stated she was in the ED room with Patient 3 on 12/6/24. FM 1 stated the nurse performed a nasal swab and Patient 3's nose began to bleed as soon as she removed the swab. FM 1 stated "the male doctor" put something in Patient 3's nose to stop the bleeding.

During an interview on 1/30/25 at 11:43 a.m. with Chief Medical Officer (CMO), CMO stated his expectation would be for a provider to make a note if a nasal sponge had to be placed in a patient to stop a nosebleed.

During an interview on 1/30/25 at 12:30 p.m. with Director of Quality (DQ), DQ stated PA 1 was the only APP on duty at the time Patient 3 had a nosebleed.

During a review of the hospital's "Supervisory Responsibility and Delegation of Services Practice Agreement [for] Physician Assistant (DSPA) (undated), the DSPA indicated, "The ED PA shall enter all clinical findings into the patient's chart through the computer hospital system."

During a review of the hospital's "Medical Staff Rules and Regulations" (MSRR) dated 12/2023, the MSRR indicated, "9. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each patient. This record shall include identification data, complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations; clinical laboratory; x-ray and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis; condition on discharge; follow-up and autopsy reports when available."

Based on interview and record review, the facility failed to complete the Advance Directive questionnaire form (legal document that states a person's wishes for medical care if they are unable to communicate their wishes) for six of 17 sampled patients (Patient 1, Patient 12, Patient 2, Patient 9, Patient 10, Patient 11). This failure had the potential to violate patients' rights to formulate an Advance Directive and for staff to be unaware of the patient's and/or legal representative's wishes for medical care.

Findings:

During a concurrent interview and record review, on 1/28/25 at 10:45 a.m. with Quality Patient Safety Program Manager (QPSPM) 2, Patient 1's "CONDITIONS OF ADMISSION-California Two-Part Form" (COA), dated 11/28/24, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a concurrent interview and record review, on 1/29/25 at 10 a.m. with QPSPM 2, Patient 12's COA, dated 1/24/25, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a concurrent interview and record review, on 1/29/25 at 1:10 p.m. with QPSPM 2, Patient 2's COA, dated 1/7/25, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a concurrent interview and record review, on 1/29/25 at 1:25 p.m. with QPSPM 2, Patient 9's COA, dated 12/30/24, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a concurrent interview and record review, on 1/29/25 at 1:30 p.m. with QPSPM 2, Patient 10's COA, dated 1/14/25, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a concurrent interview and record review, on 1/30/25 at 9:15 a.m. with QPSPM 2, Patient 11's COA, dated 12/3/24, was reviewed. The COA indicated, the "Compliance with Advance Directive Policies" was not completed. QPSPM 2 stated the form should not be blank and should have been completed on admission.

During a review of the facility's policy and procedure (P&P) titled, "Advance Health Care Directives," dated 11/21/2024, the P&P indicated, "Verify whether patient has executed an Advance Health Care Directive and document in electronic health record. 3) Inquire if patient desires assistance in completing an Advance Health Care Directives during this hospitalization and make appropriate referral to Spiritual Care Services in EHR."

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Use of Clinical Restraints [measures to keep someone under control or within limits]" for two of three sampled patients (Patient 13 and Patient 14) when restraints were not monitored timely. This failure had the potential to compromise the safety and comfort of Patient 13 and Patient 14 while on restraints.

Findings:

During a concurrent interview and record review on 1/30/25 at 8:55 a.m. with Quality Patient Safety Program Manager (QPSPM) 2, Patient 13's orders were reviewed. Patient 13's order for Restraints-Violent/Self Destructive-Adult (RVSDA) from 1/4/25, 1/5/25, 1/6/25 were reviewed. The RVSDA indicated, "Bilateral Wrists." Restraint monitoring (RM) dated 1/4/25, 1/5/25, 1/6/25 were reviewed and RM indicated there was documentation completed every two hours instead of every 15 minutes. QPSPM stated there was no documentation for restraint monitoring every 15 minutes and there should have been documentation.

During a concurrent interview and record review on 1/30/25 at 9 a.m. with QPSPM, Patient 14's orders were reviewed. Patient 14's order for Restraints-Non-Violent/Non Destructive (RNVB) from 1/6/25 for 1857 (6:57 p.m.) was reviewed. The RNVB indicated, "Bilateral Wrists." RM dated 1/6/25 was reviewed and RM indicated there was no documentation. QPSPM 2 stated there was no documentation for restraint monitoring for every 2 hours

During a review of the facility's P&P titled, "Use of Clinical Restraints," dated 10/27/21, the P&P indicated, "Non-Violent or Non-Self-Destructive Restraints Standard: a) Patients will be observed frequently. b) Monitoring and care must be documented in the patient's record at a minimum of every 2 hours, or more often based on the patient's assessment. . . 2) Violent or Self-Destructive (Behavioral) Restraints Standard: a) Patients will be observed frequently. b) Monitoring and care must be documented in the patient's record at a minimum of every 15 minutes, or more often based on the patient's assessment."

Based on interview and record review, the hospital staff failed to follow the facility policy and procedure (P&P) titled, "Use of Clinical Restraints," to obtain physician's orders (PO) for restraints for two of two sampled patients (Patient 1 and Patient 12). This failure resulted in a violation of Patient 1's and Patient 12's right to be free from unnecessary restraints.

Findings:

During a concurrent interview and record review on 1/28/25 at 10:45 a.m. with Quality Patient Safety Program Manager (QPSPM) 2, Patient 1's PO were reviewed. Patient 1's PO for "Restraints-Non-Violent/Non Destructive" (RNVB) dated 11/29/24 was reviewed. The RNVB indicated, "Bilateral Wrists" (restaints blace on both wrists). "Restraint" monitoring (RM) dated 11/29/24 was reviewed and the RM indicated "All four extremities". QPSPM 2 stated there was no PO and there should have been a PO for all four extremities.

During a concurrent interview and record review on 1/29/25 at 10 a.m. with QPSPM 2, Patient 12's PO were reviewed. Patient 12's PO for Restraints-Non-Violent/Non Destructive (RNVB) dated 1/25/25 at 7:40 p.m. to 1/27/25 at 7:46 p.m. was reviewed. The RNVB indicated, "Bilateral Wrists." The RM dated 1/25/25-1/27/25 was reviewed and RM indicated "Side rails x 4". QPSPM 2 stated there was no PO for siderails for 1/25/25-1/27/25 and there should be have been.

During a review of the facility's policy and procedure (P&P) titled, "Use of Clinical Restraints," dated 10/27/21, the P&P indicated, "a qualified nurse may apply restraints in response to an unanticipated event prior to obtaining a physician order. An order must be obtained as soon as possible after the patient placement [sic] in restraints."

Based on interview and record review facility failed to follow policy and procedure (P&P) on "Safe Discharge for High Risk Patients" when one of two sampled patient (Patient 15), who was homeless, was not provided with transportation upon discharge. This failure had the potential for Patient 15 to have unmet needs.

Findings:

During a concurrent interview and record review on 1/30/25 at 11:20 a.m. with Quality Patient Safety Program Manager (QPSPM), Patient 15's Discharge Summary Note dated 1/15/25 was reviewed. Patient 15's Discharge Summary Note indicated Reason for Admission. Patient 15 was recently hospitalized for Chronic Obstructive Pulmonary Disease (COPD, ongoing lung condition caused by damage to the lungs, such as by smoking). Patient 15 was discharged four (4) days ago but returned to the hospital today (1/14/25). Patient 15's Discharge Summary Note indicated Intent to Admit 1/14/25 at 2:55 a.m. Cardiac telemetry (remote heart monitoring, COPD exacerbation (worsening). Patient 15's Discharge Summary Note indicated Discharge to Shelter. Patient 15's Admit, Discharge, Transfer Forms, dated 1/25/25, indicated DC (discharge) Information Disposition (location) Shelter. Right Click on Box to View Reference Text: No. QPSPM 2 stated there was no documentation if Patient 15 was picked up by family or if the hospital provided Patient 15 transportation to the shelter.

The California Department of Public Health All Facility Letter (AFL) 19-01, dated 1/4/19, indicate" "Effective January 1, 2019, SB [senate bill] 1152 (Chapter 981, Statutes of 2018) requires GACHs [General Acute Care hospital} ...to include within their discharge policies a written homeless patient discharge planning policy and process ...SB 1152 requires hospitals to document all of the following prior to discharging a homeless patient ...Hospital offered transportation to the discharge destination ..."

During a review of the California Hospital Association document titled Discharge Planning California Hospital Discharge Planning for Homeless Patients, dated 2019, the document indicated "H. Transportation The hospital must offer the homeless patient transportation to his/her post-discharge destination, if that destination is within 30 minutes or 30 miles of the hospital."

During a review of the facility's policy and procedure (P&P) titled, "Safe Discharge for High Risk Patients," dated 12/28/2018, the P&P indicated, "The hospital will offer the homeless patient transportation to his/her post-discharge destination as identified in the discharge plan."

Based on interview and record review, the hospital failed to:

1. Ensure medical records (MR) were reviewed by an attending physician prior to being co-signed for two of two sampled patients (Patient 3 and Patient 4). This failure resulted in abnormal labs not being reviewed and acted upon for Patient 3 who returned to the Emergency Department (ED) three days later in critical condition and expired.

2. Ensure an Advanced Practice Provider (APP- health care professional licensed to perform medical tasks that are usually done by a doctor, but the provider is not a doctor) documented a medical treatment provided to one of one sampled patient (Patient 3). This failure resulted in an inaccurate medical record and had the potential for medical symptoms not to be correlated with laboratory results.

3. Follow its policy and procedure (P&P) titled, "Interprofessional Plan of Care" for three of three sampled patients (Patient 5, Patient 6, and Patient 7). This failure resulted in care plans not being developed or implemented for admitted patients being held in the Emergency Department (ED) and had the potential for unmet care needs.

Findings:

1. During an interview on 1/27/25 at 12:11 p.m. with Chief Medical Officer (CMO), CMO stated Patient 3 had been brought to the ED on 12/6/24 by his mother with complaints of fever. Physician Assistant (PA - advanced practice provider) 1 examined Patient 3. CMO stated PA 1 ordered a urinalysis (UA- laboratory test to analyze urine) to rule out a urinary tract infection. CMO stated the results of the UA ruled out a urinary infection and PA 1 discharged Patient 1. CMO stated the UA was positive for bilirubin (yellow-orange pigment produced when red blood cells are broken down. Bilirubin in the urine is considered abnormal and can indicate a problem with the liver). CMO stated the abnormal UA results were missed. CMO stated Patient 3 returned to the hospital's ED on 12/9/24 in septic shock (life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure), acute liver failure (life-threatening condition where the liver suddenly stops functioning properly), kidney failure (kidneys are no longer able to adequately filter waste products and excess fluid from the blood), and Disseminated Intravascular Coagulation (DIC- condition that causes abnormal blood clotting throughout the body's blood vessels). CMO stated Patient 3 expired (died) on 12/10/24.

During a review of Patient 3's MR, the UA laboratory results, dated 12/6/24 at 2:15 am, were noted to be abnormal in the following categories:
Specific Gravity (measures concentration of urine) ... ...1.028 (H) [high, normal 1.005-1.03]

Bilirubin (the presence of bilirubin is an important finding in the evaluation of liver function and a positive detection could be an indication of liver disease such as jaundice, cirrhosis or hepatitis) ?? ... ...2+ (A) [abnormal, (trace, normal less than 0.2)]

Ictotest (test for presence of bilirubin) ?? ... ...Positive (A), (Normal is Negative)
Blood ... ...2+ (A) (normal is 0, could indicate, bladder infection, kidney stones, kidney disease, or injury)

Protein (normal kidney function will filter out protein) ?? ... ...1+ (A) (normal trace or less than 0.2, could indicate kidney damage, diabetes (inability to utilize sugar), dehydration, fever, stress)

Urobilinogin (caused by breakdown of red blood cells) ... ...1+ (A) (normal trace, could indicate liver disease, biliary tract (aids in the digestion of fats) disorder, intestinal disorders, anemia)

Red blood cells (RBC) ... ...156 (H) (normal less than 6)

Bacteria ... ...Trace (A) (normal is none, could indicate contamination of sample or infection)
All normal values displayed in black type and abnormal values displayed in red type.

The "Emergency Documentation - MD" dated 1/6/24 indicated PA 1 signed the MR on 12/6/24 at 4:35 a.m. and Physician 1 co-signed the MR on 12/7/24 at 2:58 p.m.

During an interview on 1/28/25 at 3:06 p.m. with PA 1, PA 1 stated he did not remember seeing Patient 3's abnormal UA results.

During an interview on 1/28/25 at 1:19 p.m. with Physician 1, Physician 1 stated MRs of patients seen by APPs are sent to physicians for a co-signature. Physician 1 stated the expectation was for the physician to review the MR before co-signing, but if many MRs were sent to him at once he would co-sign without reviewing the MR. Physician 1 stated he co-signed but did not review Patient 3's medical record for 12/6/24 ED visit. Physician 1 stated he co-signed but did not review Patient 4's medical record for 12/9/24 ED visit.

During a review of Patient 4's MR, the "Emergency Documentation - MD" dated 1/9/24 indicated Family Nurse Practitioner (FNP- advanced practice provider) 1 signed the MR on 12/10/24 at 3:24 p.m. and Physician 1 co-signed the MR on 12/10/24 at 6:11 p.m.

During an interview on 1/30/25 at 11:43 a.m. with CMO, CMO stated the expectation was for attending physicians to review a medical record before co-signing.

During a review of the hospital's "Supervisory Responsibility and Delegation of Services Practice Agreement [for] Physician Assistant (DSPA) (undated), the DSPA indicated, "All charts [medical records], whether the patient was treated according to protocol. . . or under the supervising physician's patient-specific order, and which include a drug order, shall be reviewed and co-signed by the supervising physician within 72 hours of the encounter, as specified by regulation."

During a review of the hospital's "Medical Staff Rules and Regulations" (MSRR) dated 12/2023, the MSRR indicated, "9. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each patient. This record shall include identification data, complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations; clinical laboratory; x-ray and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis; condition on discharge; follow-up and autopsy reports when available."

2. During a review of Patient 3's "Emergency Documentation - MD" dated 12/6/24 indicated PA 1 completed the provider documentation, assessments, and orders for Patient 3.

During a concurrent interview and record review on 1/27/25 at 11:55 a.m. with Quality Patient Safety Program Manager (QPSPM) 1, Patient 3's medical record was reviewed. The "General Information [nursing notes] Textual Results" (GITR) dated 12/6/24 at 4:40 a.m. indicated Licensed Vocational Nurse (LVN) 1 documented, "bleeding from right nostril noted after swab for covid [sic- Corona Virus Disease: highly contagious virus] was done; pressure applied to the nose and ice pack administered; provider then placed a nasal sponge that stopped the bleeding." QPSPM 1 stated there was no note in the medical record from a provider regarding Patient 3 nosebleed or any interventions done to stop the bleeding.

During an interview on 1/28/25 at 3:06 p.m. with PA 1, PA 1 stated he did not remember placing a nasal sponge in Patient 3's nostril to stop a nosebleed.

During an interview on 1/29/25 at 7:50 a.m. with LVN 1, LVN 1 stated she did a COVID swab by placing the swab in each nostril and rotating the swab. LVN 1 stated the nosebleed started immediately. LVN 1 stated she tried to stop the bleeding by using a tissue to apply pressure and then applied an ice pack, but the bleeding did not stop. LVN 1 stated the provider was in the room and he made the decision to insert a nasal sponge to stop the bleeding. LVN 1 stated she believed the provider was [stated first name of PA 1].

During an interview on 1/29/25 at 1:27 p.m. with Emergency Department Medical Director (EDMD), EDMD stated his expectation was for ED providers to document every treatment, intervention, or phone call to patients for any care provided.

During an interview on 1/29/25 at 5:36 p.m. with Family Member (FM) 1, FM 1 stated she was in the ED room with Patient 3 on 12/6/24. FM 1 stated the nurse performed a nasal swab and Patient 3's nose began to bleed as soon as she removed the swab. FM 1 stated "the male doctor" put something in Patient 3's nose to stop the bleeding.

During an interview on 1/30/25 at 11:43 a.m. with Chief Medical Officer (CMO), CMO stated his expectation would be for a provider to make a note if a nasal sponge had to be placed in a patient to stop a nosebleed.

During an interview on 1/30/25 at 12:30 p.m. with Director of Quality (DQ), DQ stated PA 1 was the only APP on duty at the time Patient 3 had a nosebleed.

During a review of the hospital's "Supervisory Responsibility and Delegation of Services Practice Agreement [for] Physician Assistant (DSPA) (undated), the DSPA indicated, "The ED PA shall enter all clinical findings into the patient's chart through the computer hospital system."

3. During an interview on 1/30/25 at 10 a.m. with Emergency Department Director of Nursing (EDDN), EDDN stated ED registered nurses (RN) are not required to complete care plans unless the patient had been admitted to the hospital and held in the ED for more than four hours.

During a concurrent interview and record review on 1/30/25 at 12:39 p.m. with Quality Patient Safety Program Manager (QPSPM) 1, Patient 5's medical record was reviewed. The History and Physical (H&P) dated 1/3/25 indicated Patient 5 was a six-week-old infant who was brought to the ED for cough, congestion, and retractions (skin around the ribs, nostrils, or under the breastbone pull inward indicating the infant was having difficulty breathing). The Physician Order (PO) dated 1/3/25 at 6:03 p.m. indicated Patient 5 was admitted to the hospital with a diagnosis of Respiratory Syncytial Virus (RSV- may mimic cold-like symptoms but can be severe). The location history indicated Patient 5 was transferred from the ED to the pediatric unit on 1/4/25 at 12:10 a.m. (6 hours later) QPSPM 1 stated there was no care plan in Patient 5's medical record while he was in the ED.

During a concurrent interview and record review on 1/30/25 at 12:52 p.m. with QPSPM 1, Patient 6's medical record was reviewed. The H&P dated 1/1/25 at 2:29 p.m. indicated Patient 6 was brought to the ED with complaints of lower back pain and left leg pain with paresthesia (abnormal sensation of tingling, prickling, burning, or numbness in the skin). The PO dated 1/1/25 at 2:05 a.m. indicated Patient 6 was admitted to the hospital. The location history indicated Patient 6 was transferred from the ED to the Medical/Surgical unit on 1/1/25 at 9:40 a.m. (7 1/2 hours later). QPSPM 1 stated there was no care plan in Patient 6's medical record while he was in the ED.

During a concurrent interview and record review on 1/30/25 at 1 p.m. with QPSPM 1, Patient 7's medical record was reviewed. The H&P dated 1/3/25 at 11:33 p.m. indicated Patient 7 was brought to the ED with complaints of "about 3 days of cough, 2 days of rhinorrhea [runny nose], and 1 day of progressive shortness of breath." The PO dated 1/3/25 at 4:02 p.m. indicated Patient 7 was admitted to the hospital. The location history indicated Patient 7 was transferred from the ED to the Pediatric unit on 1/1/25 at 3:05 a.m. (11 hours later). QPSPM 1 stated there was no care plan in Patient 7's medical record while he was in the ED.

During a review of the hospital's P&P titled, "Interprofessional Plan of Care" dated 1/26/22, the P&P indicated, "The Interprofessional Plan of Care is a guideline for the healthcare team to assess and reassess the progress of the patient. This plan of care will list the active clinically relevant patient problems, goals/outcomes and interventions individualized for the patient throughout the stay from admission to discharge and communicate and coordinate care among disciplines. Procedure: 1. Developing the Interprofessional Plan of Care (POC) a. The interprofessional plan of care (POC) will be initiated within 4 hours of admission by the RN [registered nurse]."