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Based on record review, observations and interviews, the facility failed to maintain patients' Protected Health Information (PHI) for 2 (P (Patient) 27 and P28) of 2 (P27 and P28) patients. This failed practice can lead to direct inappropriate disclosure and an increased risk of misuse and breach of PHI.

The findings are:

A. Record review of facility's policy titled, "HIPAA37 [Health Insurance Portability and Accountability Act] Safeguards" dated 09/11/2021, stated "Policy: 1) [facility name] will maintain appropriate administrative, technical and physical safeguards to protect the confidentiality, integrity and accessibility of Protected Health Information, consistent with the requirements of these Policies and Procedures. 2) [facility name] must safeguard Protected Health Information form an intentional and unintentional use or disclosure that is in violation of these Policies and Procedures ... Procedure: 3) [facility name] workforce will take reasonable measures so that Protected Health Information on computer screens is not visible or accessible to unauthorized persons."

B. During an observation on 12/19/2023, at 7:54 am, of the emergency department, nursing area and triage, (the preliminary assessment of patients in order to determine the urgency of their need for treatment) the following PHI patient's information was revealed:

1) An unattended computer screen had P27's name, date of birth (DOB), age, gender, vaccines, allergies, room number, sepsis score, vitals, pain assessment, neurological (nervous system) assessment, respiratory assessment (appraisal of the patients respiratory system by a health care provider), and PRN (as needed) medication.

2) In an empty triage room, the following was revealed on a patient sticker sheet for P28: patient name, sex, DOB, medical record number, age, financial number and admission date and time.

C. During an interview on 12/19/2023, at 3:56 pm, with Staff (S) 13, Interim Nurse Manager, when asked if computers should be left on and unattended with patient information showing, S13 answered, "No, we are supposed to close or lock the computer as soon as we get up."

D. During an interview on 12/20/2023, at 8:15 am, with S3, Risk Manager, when asked what the policy is on securing electronic patient information, S3 answered, "If you are going to step away, you are supposed to lock your computer. We don't want any open computers with patient information."

E. During an interview on 12/19/2023, at 7:58 am, with S17, Registered Nurse (RN) when asked if patient stickers should remain in a triage room after the patient has been moved, S17 stated the patient stickers should be secured behind the nursing station when the patient has left the triage room.



49844

Based on record review and interview the facility failed to ensure that policies were being followed that related to pain management for 1 (P[patient] 24) of 3 (P24, P25, and P26) patients reviewed for pain assessments. This deficient practice could lead to patients pain not being addressed properly and care plans not being adjusted for pain.

The findings are:

A. Record review of facility's policy titled, "Pain Management" dated 12/27/2022 stated, "Purpose: To provide clinical guidance in facilitating the effective pain management of patients thereby enhancing their comfort, function, outcomes, and personal/family satisfaction. Pain management is an organizational priority. Policy:1) [Name of facility] recognizes the patient's right to the appropriate assessment, management and reassessment of pain. Caregivers from all disciplines will acknowledge, assess, and document, as appropriate, throughout the continuum of care the patient's self-report of pain or observable responses to pain utilizing cognitively and age appropriate pain scales. Patient descriptors of pain may include existence, nature, location, intensity, aggravators, and relievers [meaning patient's pain should be evaluated regularly while receiving care based on patients level of understanding and should be a detailed evaluation of the pain]. Pain is to be recognized as the 5th vial [sic] sign [in addition to blood pressure, temperature, pulse, and oxygen] and will be documented before and after pain medication and as indicated by the patient's care, treatment, and services. . . ."

B. Record review of P24's pain assessment and pain medication administration revealed:

1. Physician orders for: morphine (medication given for pain) 1 mg (milligram) every 2 hours as needed ordered 02/22/2022, at 9:34 AM, and oxycodone-acetaminophen (Percocet, medication given for pain) 5-325 mg every 4 hours as needed ordered 02/24/2022, at 7:52 AM.

2. On 02/23/2022, at 11:59 AM, P24 was given morphine 1 mg intravenously (through a catheter in the vein). The record did not contain any evidence P24's pain assessment at this time.

3. On 02/23/2022, at 12:29 PM, P24's pain level was reported (using a numeric rating on a scale of 1-10) at a level of 3 (mild pain) in the abdomen (stomach). No medication was administered at this time.

4. On 02/24/2022, at 2:52 AM, P24 was given morphine 1 mg intravenously. The record did not contain any evidence P24's pain assessment at this time.

5. On 02/24/2022, at 8:09 AM, P24's pain level was reported at a level 10 (severe pain). P24 was given oxycodone-acetaminophen 5-325 mg by mouth. The record did not contain any evidence P24's pain assessment, to include location and description of pain, at this time.

6. On 02/24/2022, at 11:36 AM, P24's pain level was reported at a level 10. P24 was given morphine 1 mg intravenously. The record did not contain any evidence P24's pain assessment, to include location and description of pain, at this time.

7. On 02/24/2022, at 3:35 PM, P24's was given oxycodone-acetaminophen 5-325 mg by mouth. The record did not contain any evidence P24's pain assessment at this time.

8. On 02/25/2022, 7:55 AM, P24's pain level was reported at a level 6 (moderate pain). P24 was given oxycodone-acetaminophen 5-325 mg by mouth. The location of pain was documented as left arm. The record did not contain any documentation of P24's description of pain at this time.

C. During an interview on 12/20/2023, at 2:15 PM, with S (Staff) 21, intensive care unit supervisor, confirmed staff should be documenting a pain assessment when administering pain medications.

49844



Based on record review, observations and interviews the facility failed to perform accurate and daily checks of the crash cart (cart stocked with emergency medical supplies and medications) and defibrillator (device that applies an electric current to the heart) to ensure the supplies are not expired, damaged or unsafe. This deficient practice is likely to lead to infections, harm or death of all patients.

The findings are:

A. Record review of facility's policy titled "Patient Care - Crash Cart Maintenance," dated 10/28/22 stated, "Procedure: 1) Daily Crash Checks are to be completed on every workday and documented on the CRITICAL CARE - Crash Cart/Defibrillator - Daily Checklist [capitalized and underlined in policy] by the Charge Nurse or as designated by the unit.... c) Verify the following items are on the top or side of the crash cart: i) Checklists and forms, g) Verify that there are no expired items in or on cart."

B. During an observation and record review of the crash cart on 12/12/2023, at 10:40 am, of the [facility name] clinic revealed the following:

1) The cardiac unit crash cart "Crash Cart/Defibrillator Daily Checklist" was checked off on Tuesday 12/12/2023 for the following days 12/13/23, 12/14/23 and 12/15/23.

2) The "Crash Cart/Defibrillator Daily Checklist" showed the crash chart daily checks category: Checked by Initials: of S25, Tech, for the entire month of December 2023. This was front dated (days that have not yet happened) and days 12/12/2023 (S25 called off sick) and 12/13/2023 that S25 was not working (this is a normal day off).

3) One packet of Electrodes (carries electricity form an instrument to a patient for treatment) with an expiration date of 06/01/2023.

4) One packet defibrillation pads (an essential part of an automated external defibrillator to treat a sudden cardiac arrest emergency) with an expiration date of 11/11/2023

C. During an interview on 12/12/23, at 10:43 am, with S10, Imaging Manager, when asked who was responsible for performing daily crash cart. S10 stated it is alternated between two techs (S11 and S25). When asked about who had performed the daily crash cart checks this week (12/12/23), S10 stated, S25 had been out all week and S25 had completed the daily crash cart checks.

D. During an interview on 12/12/23, at 10:47 am, with S11, Tech, when asked who filled out the checklist on 12/12/2023, S11 answered, "S25." When asked how S25 could have filled it out when she is out sick, S11 replied "Not sure. I didn't check it today." When asked if the checklist had been done by S11 or double checked by S11 this month, S11 confirmed that she had not looked at the crash cart in the month of December.

E. During an observation on 12/19/23, at 7:50 am, of the Emergency Department Triage Room, it revealed three Intravenous (IV) Catheters (give medication or fluids straight into the bloodstream) with an expiration date of 11/27/23.

F. During an interview on 12/19/23, at 7:58 am with S17, Registered Nurse (RN), it was confirmed that the IV Catheters had expired.

Based on record review and interview the facility failed to re-assess patient's discharge based on changes in the patient's condition for 1 (P[patient]24) of 3 (P24, P25, and P26) patients reviewed for discharge planning. This deficient practice led to the patient being improperly discharged and patient being admitted to another hospital in less than 24 hours.

The findings are:

A. Record review of facility's policy titled, "Discharge Planning Policy" dated 04/24/2023 stated, "Purpose: To provide an effective hospital-wide discharge planning process that focuses on the patient's goals and treatment preferences; includes the patient and his or her caregivers/support persons as active partners in the discharge planning for post-hospital care and reduces factors that may lead to an avoidable readmission. 1) Discharge planning is a responsibility for all hospital staff within each department. . ." Page 4 stated, "c) As part of the registered nurse's process to reassess patients, if the following circumstances occur, a case management consult will need to be completed to reassess the discharge plan.... i) Upon request of any individual for any reason ii) A change in the patient's medical stability. iii) A change in the patient's functional ability. iv) A change in social or financial status becomes apparent. v) A change in the ability of the caregiver to resume the previous level of care prior to admission. vi) A patient and/or the patient's representative changes their goals and/or treatment preferences. vii) A patient and/or the patient's representative changes the discharge plan. In response to the Case Management consult, the patient will be reevaluated within one business day of the consult with all pertinent documentation of the reassessment entered in the medical record."

B. Record review of facility's incident log revealed a fall was reported for P24 on 02/23/2022 at 3:36 PM. The description of the incident stated, "Patient has history of dementia [group of symptoms that affect memory and thinking] and is alert and oriented to name and date of birth only. Patient [P24] was placed in chair by physical therapy after working with them with call light in reach. Nurse went into room to round on patient and patient was found in [sic] the floor with complaints of pain to left arm. New skin tears to bilateral [both] arms. IV [intravenous catheter] had been pulled out. Nurse and PCT [patient care tech] helped patient out of [sic] floor and placed patient back into bed. . ."

C. Record review of P24's electronic health record revealed the following:

1. Review of physical therapy notes revealed P24 was seen by physical therapy on 02/23/2022 at 1:38 PM. Discharge recommendations at this visit stated, "Home with family, Home - community based therapy." Under "Fall History" it is stated, "None, Last 90 days" and under "Ambulation" it is stated that the patient walked 25 feet with a walker.

2. Review of X-ray results dated 02/23/2022, at 9:43 PM, revealed, "There is a mildly comminuted [broken in at least two places] and displaced [not aligning] fracture involving the left humeral neck [upper arm near shoulder joint]. No other convincing displaced fracture is identified. Glenohumeral [shoulder joint] alignment appears grossly intact, though dedicated shoulder radiographs may be beneficial in further evaluation."

3. Provider progress note dated 02/24/2022, at 7:46 AM, under "Assessment and Plan" stated "Left humeral fracture. Had a fall, from a sitting position, when she was pushing the table away from the bed and it skidded a little too much causing her to lose her anchor point on the table. Fell on her left side. Did not hit head, or lose consciousness, On my exam post fall, she was at her baseline mental status LUE (left upper extremity) sling [sic]"

4. Facility order for "OT [occupational therapy] eval [evaluation] and treat (evaluation and treatment)" dated 02/24/2022, at 7:50 AM. The order stated "Reason for Consult? New left humeral fracture that [patient] sustained on the afternoon of 2/23. Please evaluate"

5. Discharge summary dated 02/25/2022, at 12:34 PM, under "Brief History and Hospital Course by problem" stated, "On 2/23, [patient] had a fall, from a sitting position, when [patient] was pushing the table away from the bed and it skidded a little too much causing [patient] to lose [patients] anchor point on the table. Fell on [patients] left side. Did not hit head, or lose consciousness. And x-ray showed a left humeral fracture. Left upper extremity placed in sling [sic]. . . "Seen by physical therapy, recommended discharge home with home health care. . . Stable for discharge home"

6. Document titled, "Occupational Therapy Treatment Deferral Note dated 02/25/2022, at 12:50 PM, stated, "Reason for Treatment Deferral: Other (comment) (pt (patient) discharged from facility)"

7. Review of case management notes from 02/23/2022 to 02/25/2022 dated did not mention fall from 02/23/2022 and did not reveal any discussion on whether the discharge plan needed to be re-assessed.

D. Record review of P24's records from an outside hospital revealed "ED [emergency department] Provider Note" dated 02/26/2022 at 11:08 AM under the history stated, "[Patient] brought from home where [patient] lives w/ [with] [daughter]. Hx [history] obtained from daughter as patient doesn't know why [patient] is here. Was discharged from [facility name] yesterday after hospitalization for acute chole [inflammation of the gallbladder] and placement of GB [gastro-biliary] drain [remove bile from stomach], complicated by a fall and resulting humerus fx [fracture] and compression fx of L1 [lumbar spine 1]. They [family] are unable to provide the level of care [patient] needs, as [patient] can't walk or toilet." Under medical decision making it stated, "Diagnosis management comments: Unsuccessful discharge, needs higher level of care per family. Will admit for SNF [skilled nursing facility] placement."

E. During an interview on 12/20/2023, at 2:30 PM, with S(staff)22, Case Management it was asked if physical therapy and occupational therapy consults are normally completed before discharge planning is completed. S22 confirmed the consults would be done prior to discharge.

F. During an interview on 12/20/2023 at 2:40 PM with S24, Occupational Therapist, it was confirmed that an order for occupational therapy would be completed prior to discharge because discharge recommendations are provided by the service. It was asked if re-assessment would be completed if a patient falls. S24 stated, "Yes, any change in status like a fall or surgery would require a new order and a re-assessment."

Based on observation, record review and interview, the facility failed to meet the Condition of Participation to ensure a transfer consent was obtained and failed to arrange for appropriate transportation that presented to the Emergency Department. This failed practice can lead to poor outcomes related to patients not being evaluated when seeking medical care.

The findings are:

A. The facility failed to obtain transfer consents and failed to arrange for appropriate transportation. Refer to tag A-2409.

49844


Based on record review, and interview the facility failed to appropriate transfer patients for 2 (P [patient] 16, 18) of 22 (P1-P22) patients reviewed for appropriate transfers by:
1. Failing to provide a summary the risks of transfer for P16.
2. Failing to provide appropriate transfer for P16
2. Failing to obtain a transfer consent for P18.

These deficient practices are likely to lead to physical, mental, and psychological harm to all patients.

The findings are:

Failed to provide appropriate transport:

A. Record review of policy titled "EMERGENCY DEPARTMENT - EMTALA (Emergency Medical Treatment and Active Labor Act) - Corp - ED" dated 03/19/2019 revealed Section 4.8. "Order the transfer through the use of appropriate personnel, supplies, and equipment" and 4.8.1. "The patient will not be transferred to another hospital by private automobile."

B. Record review of P16's medical record revealed P16 was transferred to an outside hospital. An untitled transfer form dated 07/09/23, at 11:52 PM under "section A" 'Transport Mode' is 'POV (Patients Own Vehicle).' Under "Transport service" it stated "None." The record did not contain any documented risks given to the patient/family regarding transferring the patient in their own vehicle. No evidence of an AMA (Against Medical Advice) form was found.

C. During an interview on 12/20/2023 at 11:58 AM, with S1, Quality Manager, confirmed there was not consent for transferring a patient in their own vehicle.

D. During an interview on 12/20/2023 at 11:58 AM, with S1, when asked for a policy regarding patients being transferred in their own vehicle, S1 stated "there is no policy".

E. During an interview on 12/20/2023 at 2:59 PM, with S22, Emergency Department Charge Nurse, stated that patients transferred to other hospitals in a private vehicle would have to sign out AMA.

Failure to obtain consent:

F. Record review of policy titled "EMERGENCY DEPARTMENT-EMTALA (Emergency Medical Treatment and Active Labor Act)- Corp - ED" dated 03/19/2019 Sections 4.9. "A transfer form must be completed at time of transfer" and 4.9.2 "Complete all sections of the form."

G. Record review of P18's medical record revealed P18 signed a form titled "CONSENT AND ASSESSMENT FOR TRANSFER" Signed on 07/14/2023 at 5:26 AM, failed to specify what the patient was consenting to.

1. Box 1 stated "CONSENT TO TRANSFER: I agree and consent to be transferred"

2. Box 2 stated "REFUSE TREATMENT / REQUEST TRANSFER: I refuse to consent to further medical examination and treatment offered to me and request to transfer."

3. Box 3 stated "REFUSAL TO TRANSFER I understand the physician believes it is in my best interest to be transferred however I refuse to be transferred. I request to continue receiving treatment at ______."

4. All three boxes remain unmarked.

H. During an interview on 12/20/2023 at 10:40 AM with S4 Assistant Chief Nursing Officer, confirmed "It's not clear what this patient consented to because it is not marked."