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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.618 Emergency Services was out of compliance.

C-0880 The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients.

Based on document review and interviews, the facility failed to ensure suicidal patients were monitored by qualified staff for patient safety. Specifically, the facility failed to provide 1:1 (continuous) monitoring by qualified staff to ensure patient safety for three of four suicidal patients reviewed. (Patients #5, 6, and 9)

Findings include:

Facility policy:

The Care of the Patient with Suicidal Tendencies policy read, remove all dangerous items from the patient immediately. The following will be initiated when deemed necessary: Increased Observation, someone must be with the patient at all times. The nurse must determine the appropriate person to stay with the patient. The person may be a family member, friend, nurse, or hired sitter. Provides continuous observation to prevent self-harm. Document all information related to suicidal behavior and nursing interventions in the electronic chart. Document ongoing observations and safety checks every 15 minutes.

1. The facility failed to ensure suicidal patients were provided 1:1 monitoring by qualified staff while on suicide precautions for patient safety in the emergency department (ED).

A. Record Review

i. A review of Patient #5's medical record revealed the patient presented to the ED on 1/2/23 with feelings of hopelessness. Patient #5 also reported to ED staff she had thoughts of wishing she was dead in recent weeks, had thoughts to kill herself the week prior to presenting to the ED, refused to answer whether she had current thoughts to kill herself and was eventually transferred to a higher level of care for treatment of the mental health concerns. Further review of the medical record revealed no order was placed for 1:1 monitoring to ensure her immediate safety while in the ED, nor was there documentation revealing how the patient was determined to be safe without 1:1 monitoring.

ii. A review of Patient #6's medical record revealed the patient presented to the ED on 11/10/22 after ingesting an unknown amount of pills in a suicide attempt that morning. Patient #6 was eventually transferred to a higher level of care for treatment of the mental health concerns. Further review of the medical record revealed no order was placed for 1:1 monitoring to ensure the patient's immediate safety while in the ED, nor was there documentation revealing how it was determined the patient was safe without 1:1 monitoring. In addition, the medical record revealed that although the patient's husband was sitting with her in the room and the call light was documented within reach, there was no documentation showing evidence qualified staff provided 1:1 monitoring during Patient #9's visit.

iii. A review of Patient #9's medical record revealed the patient presented to the ED on 2/16/23 after ingesting pills in a suicide attempt. Patient #9 stated to ED staff she was unsure of why she took so many pills and presented with a flat affect (not expressing emotions in a way that other people might) while in the ED. Further review of the medical record revealed a provider order for 1:1 monitoring. Patient #9 was documented as being monitored by her parents in the ED. There was no documentation showing evidence that a qualified staff member provided 1:1 monitoring during Patient #9's ED visit.

B. Interviews

i. On 3/14/23 at 9:29 a.m., an interview with registered nurse (RN) #3 was conducted. RN #3 stated any patient who endorsed suicidal ideation was placed into the treatment room with the blinds open, and a family member sat with the patient.

ii. On 3/14/23 at 11:20 a.m., an interview with registered nurse (RN) #4 was conducted. RN #4 stated a patient who endorsed suicidal ideation was placed into the treatment room and had a family member sit with the patient if the family member felt safe to do so. RN #4 stated the call light was in the room to press if assistance was needed. RN #4 stated she had left the treatment room with a suicidal patient and a family member to monitor the patient in the past. RN #4 further stated she would not leave a family member in the treatment room with a suicidal patient if the patient had a specific plan of killing themselves. When asked, RN #4 was unable to discuss how she would identify whether the patient had a specific plan to harm themselves.

iii. On 3/15/23, at 3:14 p.m., an interview with director of nursing (DON) #1 was conducted. DON #1 stated when a patient presented to the ED with suicidal ideation, the patient had someone monitoring them at all times. DON #1 stated the facility had no safe room for patients at risk of self-harm, but utilized the call light in the treatment room to alert staff of any concerns or needs. DON #1 stated multiple people had monitored suicidal patients while in the ED, including clinic medical assistants, nursing students, nurse assistants, emergency medical technicians (EMT), and at times even family members. DON #1 further stated a patient was at risk of self-harming with items in the patient room if not monitored. DON #1 then stated staff at the facility had not completed any suicide education recently.

iv. On 3/15/23 at 4:20 p.m., an interview with medical provider (Provider) #2 was conducted. Provider #2 stated when a patient came into the ED with suicidal ideation, it was important to ensure the environment around the patient was safe inside the treatment room, the patient was on continuous monitoring, and suicide precautions were ordered. Provider #2 stated an order by the provider for 1:1 continuous monitoring by a qualified clinical staff member while in the ED was expected for patients who endorsed suicidal ideation. Provider #2 stated a non-clinical person such as a family member, friend of the patient, or someone not employed by the hospital was not appropriate to monitor the patient while in the ED. Provider #2 stated family members and family stressors might have posed as a trigger to a patient with suicidal ideation and it was important to remove any and all possible triggers around the patient. Provider #2 stated utilizing a clinical staff member to provide continuous monitoring of a patient with suicidal ideation was important to ensure patient safety and minimize the risk of self-harm behavior.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 Provision of Services was out of compliance.

C-1048 A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. Based on document review and interviews, the facility failed to ensure facility protocols were followed to assess for a potential infection. Specifically, the facility failed to ensure the Sepsis Alert protocol was completed per facility requirements for a patient with a suspected wound infection in one of one wound records reviewed (Patient #4). In addition, the facility failed to monitor patients per policy to ensure change of conditions did not occur in two of nine inpatient and observation status patient medical records reviewed. (Patients #2 and #4)

Based on document review and interviews, the facility failed to ensure facility protocols were followed to assess for a potential infection. Specifically, the facility failed to ensure the sepsis alert protocol was completed per facility requirements in a patient with a suspected wound infection in one of one wound records reviewed (Patient #4). In addition, the facility failed to monitor patients per policy to ensure change of conditions did not occur in two of nine inpatient and observation status patient medical records reviewed. (Patients #2 and #4)

Findings include:

Facility policies:

The Taking and Recording Vital Signs policy read, the purpose is to aid in diagnosis, treatment and to follow the progress of the patient. All patients admitted to the emergency room (ER) will have vital signs taken at least one time - on admission and thereafter will be 30 minutes prior to discharge. Any other vital signs will be done PRN as provider wishes.

The Sepsis Alert policy read, the purpose is to provide guidelines for appropriate and timely interventions for the care of patients with severe sepsis.

Procedure: A sepsis alert will be activated with a patient who presents to the ED with a known or suspected infection, plus two or more of the following criteria: heart rate greater than 90 beats per minute (BPM); respiratory rate greater than 20 breaths per minute; temperature greater than 100.4 degrees Fahrenheit; White blood cell count greater than 12,000 or less than 4000.

For the evaluation of a sepsis patient, the patient shall be stabilized, the suspected infection site should be identified, the patient should be placed on continuous cardiac monitoring, maintain adequate oxygen saturation and the ED physician or nurse practitioner will decide the further course of action.

Reference:

According to the Centers for Disease Control and Prevention (CDC), retrieved from https://www.cdc.gov/coronavirus/2019-ncov/videos/oxygen-therapy/Basics_of_Oxygen_Monitoring_and_Oxygen_Therapy_Transcript.pdf, an oxygen saturation of 95 to 100 percent is normal for healthy children and adults.

1. The facility failed to assess a patient for a potential infection according to facility protocol.

a. A review of Patient #4's medical record revealed the patient presented to the Emergency Department (ED) on 2/10/23 due to a skin tear wound on her lower left leg. Steri-strips were placed and the patient was discharged home.

On 2/20/23 at 5:54 p.m., Patient #4 presented to the ED with complaints of shortness or breath and increased swelling in her lower extremities. According to the Nursing Note, Patient #4 and her family were concerned for a possible infection of the wound due to increased redness and increased tenderness. At this time, Patient's #4 vital signs were assessed which included a pulse of 92 and a respiratory rate of 22.

At 5:55 p.m., registered nurse (RN) #3 completed a sepsis screening. RN #3 documented there was not a suspected or known infection which resulted in sepsis criteria not being met.

This was in contrast to the sepsis alert policy which read a suspected infection should have been included in the assessment. Additionally, Patient #4's vital signs met criteria for a sepsis alert.

b. On 3/15/23 at 3:14 p.m., an interview was conducted with the director of nursing (DON) #1. DON #1 stated if a patient or family member reported a suspected infection, she would expect nursing staff to look at the wound and let the doctor know the concern.

Patient #4's record was reviewed with DON #4. DON #4 stated the patient's suspected infection along with her respiratory rate and pulse would have triggered the criteria for sepsis to be met. DON #4 further stated RN #3 should have documented the suspected infection rather than documenting none reported.

DON #4 stated it was important to identify a suspected infection early in order to treat the potential infection and provide a better outcome for the patient.

2. The facility failed to ensure vital signs were assessed in accordance with facility policy and providers' orders.

a. Review of Patient #4's medical record revealed the patient arrived to the facility on 2/20/23 for treatment of shortness of breath and swelling of both feet. On 2/20/23 at 8:10 p.m., a provider order was created which instructed vital signs to be assessed every four hours while awake.

i. On 2/20/23 at 8:30 p.m., Patient #4's blood pressure (BP) was documented at 109/27. In addition, Patient #2's oxygen saturation level (O2 sat) was documented at 82% on room air. According to the CDC, a normal O2 sat ranged from 95-100%. There was no vital sign reassessment taken to reassess the blood pressure and the low O2 sat level until 11 ½ hours later on 2/21/23 at 8:00 a.m., which revealed a BP of 103/61 and an O2 sat of 94% on room air. In addition, there was no evidence if staff was unable to reassess Patient #4's vital signs because of the patient being asleep.

Further review of the medical record revealed the final set of vital signs were assessed 8 ½ hours later on 2/21/23 at 4:30 p.m. Patient #4 was then discharged one hour and fifteen minutes later on 2/21/23 at 5:45 p.m.

This was in contrast with the provider's order which instructed to assess vital signs every four hours while awake. This was also in contrast with the Taking and Recording Vital Signs policy which instructed staff to take vital signs 30 minutes before discharge.

b. Review of Patient #2's medical record revealed the patient was admitted 12/09/22 with diagnosis of physical deconditioning and was ordered to have daily vital signs assessed. On 12/10/22 the physician changed the order to vital signs every eight hours.

i. Patient #2's vital signs were documented on 12/11/22 at 7:44 p.m. and were not rechecked until approximately 12 hours later on 12/12/22 at 8:20 am. There was no evidence if staff was unable to reassess Patient #2's vital signs because of the patient being asleep. Additionally, from 12/12/22 through discharge on 12/22/23 vital signs were only documented twice daily despite a physician order for every 8 hours from 12/10/22.

c. On 3/15/23 at 3:06 p.m., an interview with registered nurse (RN) #4 was conducted. RN #4 stated vital signs were a measurement of how well the body was working and included assessment of heart rate, blood pressure, oxygenation level, temperature, respirations and pain level. RN #4 stated vital signs were expected to be assessed in accordance with a provider order. RN #4 further stated the risk of not assessing vital sings in accordance with a provider order was that a patient could be at risk for developing a medical condition such as sepsis or a cardiac event if the blood pressure increased or decreased.

d. On 3/15/23 at 10:48 a.m., an interview with the Director of Nursing (DON) #1 was conducted. DON #1 stated she expected the nursing staff to assess vital signs in accordance with the doctor's orders. She said the importance of assessing vital signs was to monitor for a potential decline in the patient and a potential change in condition.