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Based on record review, interview and policy review, the facility failed to provide appropriate treatment for a fracture.

See A144.

Based on record review, interview and policy review, the facility failed to ensure a patient received appropriate treatment for a hip fracture. This affected one (Patient #11) of three patients reviewed for fractures. The census was 73.

Findings include:

Record review revealed Patient #11 arrived to the emergency department (ED) on 03/14/25 at 5:13 AM via emergency medical services (EMS). EMS reported the patient was picked up from home with an altered mental status, a history of seizures and body jerking. EMS reported the patient was home with a relative and the home was poorly kept. Patient #11 was found on the floor at home, unresponsive for an unknown length of time. The patient presented uncooperative, intermittently arousable with sluggish pupils, a Glasgow Coma Scale (GCS) of seven out of 15 and a history of several abdominal surgeries. At 10:26 AM, after being stabilized in the ED, the patient was admitted to the Medical Intensive Care Unit (MICU). Pain assessment flow sheets were reviewed and staff was using the Critical Care Pain Observation Tool (CPOT) to assess Patient #11's pain as the patient was intubated. The highest pain score was four, with eight being the highest level of pain based on facial expressions, body movements, muscle tension and ventilator compliance. Pain assessment flow sheets were reviewed for the stay and there was no mention of hip pain during this encounter in the pain flow sheets.

On 03/31/25 the patient had an X-ray of the pelvis and right hip and due to Patient #11 complaining of pain. The results at 4:57 PM revealed there was an intertrochanteric fracture of the right hip. The fracture was angulated. There were no notes indicating care was provided for this fracture prior to discharge. The patient was discharged home in stable condition on 03/31/25 at 4:46 PM.

On 04/04/25 at 1:52 PM, Patient #11 returned to the ED, complaining hip pain and urinary frequency. Review of the ED nursing notes at 2:05 PM revealed the patient reported to the nurse that she had a fall a couple of days ago and has not been ambulating on her own. She also reported having pain where her sacral ulcer was and rated the pain to her right hip a nine on a one to ten scale. Imaging of the right knee, hip and femur was ordered at 2:12 PM and results revealed a right interochaneric femur fracture. At 2:15 PM, Patient #11 was administered Morphine 4 milligrams (mg) intramuscularly (IM) for pain and at 2:18 PM, Patient #11 denied pain. Consults with trauma surgery, orthopedic surgery and Internal medicine were placed. At 4:54 PM Rocephin (Antibiotic) intravenous was ordered. The patient was admitted on 04/04/25 at 4:50 PM.

Review of the orthopedic provider note, dated 04/04/25 revealed Patient #11 was recently admitted for encephalopathy as well as a fall on 03/14/25. On arrival the patient was intubated for respiratory protection. She stated that she had complaints regarding her right hip pain throughout her stay previous stay. On 03/31/25 X-rays of the right hip were taken which demonstrated a right hip fracture. The patient was discharged the same day without an orthopedic consult. The patient returned on 04/04/25 due to continued right hip pain and she denied pain elsewhere at this time. The provider noted the patient had previously had a left femur fracture status post intramedullary nailing in 2024.

On 04/04/25 at 3:30 PM the patient was evaluated by the Orthopedic Surgeon who noted Patient #11 had been admitted on 03/14/25 and was discharged on 03/31/25 after being found down for an unknown amount of time. She stated that she fell out of her bed onto the concrete floor. She does not remember the details of the event. She stated that she fell prior to her admission on 03/14/25 and had hip pain and after that she did not remember anything. During her hospital stay physical therapy worked with her and patient had right hip pain that continued during this time frame. No radiographic images were taken until 03/31/25, the day of her discharge and at that time the X-ray demonstrated a right intertrochanteric femur fracture. It is unclear why the patient was discharged that same day without any orthopedic evaluation. Surgery was sent for 04/05/25 to repair the fracture.

Review of the Operative Note dated 04/05/25 at 6:47 PM revealed the surgery was completed due to a displaced right subacute intertrochanteric femur fracture. A cephalomedullary nail was placed and there were no complications noted. The wound was irrigated with normal saline and there was no infection noted to the site by the surgeon.

Patient #11 was discharged in stable condition to a skilled nursing facility on 04/10/25 at 5:29 PM.

During an interview on 06/26/25 at 12:40 PM, the Director of Quality stated the resident physician that ordered the X-ray did not view the results timely as the results went to their email inbox without timely recognition, review and/or action.

Review of the policy titled "Individuals Rights and Responsibilities", effective 05/15/25, revealed patients have the right to receive prompt, considerate, compassionate, dignified, and respectful care provided by qualified health care professionals. Patients also have the right to receive care in a safe and secure setting free from all forms of abuse, neglect, exploitation, or harassment. Patients also have the right to receive appropriate assessment and management of pain.

Based on record review, interview, and policy review, the facility failed to ensure the medical record contained documentation regarding two falls. This affected one (Resident #9) of four records reviewed for falls. The facility census was 50.

Findings include:

Review of medical record for Patient #9 revealed admission diagnoses of altered mental status, urinary tract infection (UTI), acute metabolic encephalopathy secondary to UTI, dislocated left shoulder, and hypotension.

Review of fall risk/interventions assessment completed on 04/17/25 revealed a score of 79.61 which indicated a high fall risk. Interventions on 04/17/25 included standard measures along with fall sign, socks, door open, bed alarm, and hourly visual checks. Patient had falls on 04/19/25 at 10:28 A.M. and 03:00 P.M.

Review of physician note dated 04/19/25 at 11:02 A.M. revealed the physician was asked to see the patient due to a fall. The patient was trying to get up from his chair and fell. Apparently he hit his head against the wall. The patient did have a bump at the back of his head. The patient's mental state appeared similar to what it was when seen earlier in the day. The patient was moving all four limbs. The physician wrote and order to check computerized tomography (CT) scan of head and X-ray of ribs emergently.

Review of CT scan of the head without contrast completed on 04/19/25 at 12:31 P.M. revealed head injury and patient on Eliquis (blood thinner) due to fall. CT scan revealed no acute intracranial abnormality.

Review of two view X-ray of the bilateral ribs on 04/19/25 at 12:35 P.M. revealed no evident displaced bilateral rib fractures.

Review of CT scan completed on 04/19/25 at 05:19 P.M. noted it was completed due to second fall with head injury today. CT scan revealed no acute intracranial abnormality.

Review of charting for 04/19/25 revealed no nursing note regarding the fall at 10:28 A.M. or any mention of the fall at 03:00 P.M.

Interview on 06/16/25 at 10:45 A.M. with Quality Specialist #200 revealed the facility could not locate any documentation in the medical record regarding the fall on 04/19/25 at 03:00 P.M. Quality Specialist #200 also verified the fall at 10:28 A.M. was only documented by the physician at 11:02 A.M.

Review of the policy titled "Falls Prevention Policy," dated 11/25/24, revealed when a patient experiences a fall the facility will complete a post fall assessment including vital signs and neuro checks and document description of the fall in the progress notes.

Based on record review, interview and policy review, the facility failed to ensure an appropriate medical screening examination was provided to a patient.

See A2406

Based on record review, interview and policy review, the facility failed to ensure an appropriate medical screening exam was provided to a patient. This affected one (Patient #5) of four pregnant patients whose records were sampled.

Findings include:

Review of the medical record for Patient #5 revealed she presented to the Emergency Department (ED) on 01/29/25 at 12:48 AM via emergency medical services (EMS) complaining of vaginal bleeding while pregnant, vomiting, and abdominal and back pain. She rated the pain a nine on a one to ten scale. The patient was triaged at an acuity level of four meaning "less urgent."

The triage note completed on 01/29/25 at 12:52 AM documented Patient #5 was eight weeks pregnant with abdominal pain, vaginal pain, and vaginal bleeding. At 12:53 AM, Patient #5's vital signs were temperature of 98.3 degrees Fahrenheit (F), pulse of 105, blood pressure 101/68, respirations of 18 and oxygen saturation of 100 percent on room air. Patient #5 rated her pain a nine on a one to ten scale. Review of the ED provider notes revealed Physician A assessed the patient at 12:54 AM and noted Patient #5 was eight weeks pregnant with a subchorionic hemorrhage, nausea, difficulty urinating and severe pain and tenderness in her abdomen (right lower and left lower quadrant and supra pubic areas) and low back. The provider documented "Patient states that it is hard for her to sit up because of pain." He documented Patient #5 was seen at another hospital a few hours prior but did not stay for laboratory or imaging results. Physician A documented Patient #5 was in acute distress.

At 12:56 AM, Physician A documented "all labs and everything that was done" at the prior hospital was reviewed. Physician A's documenation of "medical decision making: included "[At] this point in time, there is really nothing further to do for her; since she is pregnant, we ncannot really do a whole lot of medications and we cannot do a CT scan....". Physician A did not believe this to be an acute intra-abdominal issue. Physician A documented they would check for COVID and flu and then try to symptomatically help her and discharge her back home. Physician A documneted the medical screening examination for Patient #5 considered "Problem List This Visit: Abdominal pain, vaginal bleeding, back pain, nausea, difficulty urinating[.] Differential Diagnosis: Viral illness, threatened miscarriage[.]
Diagnoses Considered but Do Not Suspect: None[.] Pertinent Comorbid Conditions: None."

At 12:58 AM. the COVID/influenza testing returned a positive result for COVID-19. Between 1:00 AM and 1:05 AM, Patient #5 was administered acetaminophen, Reglan (treats GERD) and metaclopramide, an anti-nausea medication. The medical record reflected that Patient #5 was discharged home on 01/29/25 at 1:52 AM with prescriptions for cough medication and muscle relaxing medication. The medical record did not contain documentation of further reassessment of Patient #5's abdominal pain or abnormal vital signs, nor did the record contain documentation of consultation with the on-call OB/GYN physician or further diagnostic testing pertaining to her complaints of vaginal bleeding and abdominal pain associated with early pregnancy.

Within 12 hours of discharge, on 01/29/25, Patient #5 called EMS for ongoing abdominal pain and went into cardiac arrest enroute to the hospital. Patient #5 underwent an emergent exploratory laparotomy with evacuation of hemoperitoneum and evidence of a left ruptured ectopic pregnancy. She had a.ruptured ectopic pregnancy requiring massive transfusion and was sent to the intensive care unit (ICU) for stabilization. On day four post-op, Patient #5 suffered a cerebellar herniation and had cessation of reflexes. Patient #5 did not regain neurologic function and was sent to a skilled nursing facility. Patient #5 was subsequently transferred to another hospital where she was declared brain dead and eventually died on 04/20/25.

During an interview on 06/12/25 at 12:00 PM, the ED Nurse Manager verified the medical record lacked documentation of any further treatment prior to the discharge of Patient #5.

During an interview on 06/12/25 at 12:26 PM, the Director of Quality stated Physician A declined to answer questions of the State Agency on advice of his legal counsel.

Review of the policy titled "Emergency Medical Treatment & Active Labor Act (EMTALA)", effective 03/21/24, revealed the policy applies to all Medicare-participating Bon Secours Mercy Health (BSMH) hospitals that have an emergency department on or off of the hospital's main campus, and any hospital-based urgent care center that qualifies as a Dedicated Emergency Department (DED). The policy ensures that individuals seeking examination and/or treatment will receive a Medical Screening Examination (MSE) by a physician or qualified medical personnel to determine if the patient has an emergency medical condition (EMC) and if so provide stabilizing treatment and/or an appropriate transfer to another facility. An appropriate MSE is one that is sufficient to determine with reasonable clinical confidence whether a patient has an EMC. A patient has an EMC if their medical condition manifests itself by acute symptoms of sufficient severity (severe pain) such that the absence of immediate medical attention could be expected to result in placing the health of the individual in serious jeopardy. An individual with an EMC is considered stabilized when no material deterioration of the individuals condition is likely, within reasonable medical probability.

Review of the policy titled "Obstetrical Patient Flow for Pregnant Women Presenting for Care in the Emergency or OB Department", effective 04/28/25, revealed for pregnant patients presenting at a BSMH location without Obstetrical Services with an obstetrical complaint and delivery is not imminent, they should transfer the patient to an appropriate facility as directed by patient's obstetrician or an accepting facility. The policy directed that patients less than 20 weeks gestation be evaluated in the ED, and the ED provider may consult the OB provider to evaluate the obstetrical concern.