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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) was met, as evidenced by:

1. The facility failed to ensure the Emergency Department (ED) staff provided continues telemetry monitoring (real-time tracking of the heart's electrical activity through electrodes placed on the chest) and response to persistent, critical alarms, in accordance with the facility's policy regarding cardiac (heart) monitoring, for one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), based on clinical judgment.

This deficient practice regarding the lack of monitoring and response, delayed the recognition of Patient 1's deteriorating condition and hindered the facility's ability to evaluate and improve emergency care and may have contributed to Patient 1'death. (Refer to A-0063)

2. The facility failed to ensure the Emergency Department's (ED) Policy and Procedures aligned with current clinical practice for two of two reviewed ED's policy and procedure (Cardiac monitoring and emergency response documentation). The policy titled "Cardiac Monitoring (Adult)," dated 5/3/2022, indicated that monitor rhythm strip (a visual representation of a person's heart's electrical activity over time, essentially a graph of the heart's electrical signals) would be printed when a patient was placed on a cardiac monitor (initial strip, records the heart rate and rhythm), when telemetry (the automated process of measuring and transmitting data from remote locations for monitoring and analysis) was discontinued (final strip), or when there was a rhythm change (any variation in the heart's electrical activity, as detected by the monitor, that differs from the patient's initial or normal heart rhythm). The same policy also required registered nurses to carry assigned clinical communication devices to receive telemetry alarm alerts. However, these practices were not followed.

This deficient practice resulted in the governing body's inability to ensure that hospital staff adhered to the written policies for cardiac monitoring and emergency response documentation. This created the omission in required monitoring and documentation that impacted Patient 1's care and had the potential to affect the care for other ED patients. (Refer to A-0063)

3. The facility failed to ensure there was a written process for submitting work orders to Biomedical Engineering department (department involved in designing, developing, and maintaining medical devices, equipment, and systems), when telemetry equipment (a remote sensing system that automatically collects and transmits data from a distance) was suspected of malfunctioning. On 2/10/2025, following the discovery of Patient 1 unresponsive (not reacting or responding to communication) and concerns that telemetry (heart and oxygen monitoring's) alarms may not have functioned as expected, no work order (a formal document that initiates and manages a specific task or project, for maintenance, repairs, or operations) was placed to have the telemetry equipment evaluated.

This deficient practice resulted in the inability to ensure that a malfunctioning telemetry equipment was promptly identified, reported, and removed from use. The delay in sequestering and evaluating the telemetry unit used by Patient 1 resulted in a three-day gap (from 2/10/2025 date of incident through 2/13/2025), during which the equipment remained in use and could have affected other patients in the ED. (Refer to A-0063)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and staff response to persistent, critical alarms.

This deficient practice resulted in a delay in recognition and intervention during a deteriorating cardiopulmonary condition (a worsening of both the heart and lung's function, leading to a decline in overall health and potentially life-threatening situations) and may have contributed to Patient 1's death. (Refer to A-0144 IJ Tag)

The effect of this deficient practice resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assurance and Performance Improvement was met, as evidenced by:

1. The facility's Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team failed to measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment) and establish clear expectations for safety when the facility failed to:

1.a. Ensure implementation of an effective process to ensure Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) telemetry alarms (alerts triggered by a heart and oxygen monitoring to notify operators or users about unusual or abnormal events or conditions within a monitored system) were audible and responded to by staff. The facility did not have a system in place to alert staff to critical telemetry alarms when they were engaged with other patients. The telemetry system was not integrated with staff communication devices, such as phones or badges in accordance with the facility's "Cardiac Monitoring (supplies data about your heart rhythm)" policy and procedure. In addition, there were no staff assigned to continuously monitor the central telemetry (the display station showing vital signs for all monitored patients). This issue was not identified or corrected through the QAPI program before the incident involving one of 30 sampled patients (Patient 1).

This deficient practice resulted in Patient 1 being found unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025 and created a risk that other ED patients might not be promptly assessed when telemetry (real-time tracking of the heart's electrical activity through electrodes placed on the chest) alarms are not responded to by staff. (Refer to A-0286)

1.b. Ensure that the "Cardiac Monitoring" and "Code Blue (a medical emergency code signifying a cardiac [heart] or respiratory [ breathing] arrest, or other life-threatening situation) policies and procedures reflected the current Emergency Department (ED) practice.

This deficient practice resulted in the QAPI program not identifying that the policy for Cardiac Monitoring and Code Blue was not implemented as written, in the ED. This misalignment between ED practice and written policy resulted in incomplete and inconsistent documentation and responses during emergency events, which may place patients at risk of delayed or inadequate care. (Refer to A-0286)

1.c. Report a serious adverse event (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment), within 5 days, to the California department of Public Health (CDPH, department that works to protect the public's health) involving one of 30 sampled patients (Patient 1), in accordance with the facility's "National Crosswalk of Sentinel (a serious adverse event that results in patient death, permanent harm, or severe temporary harm) Events," policy and procedure when Patient 1 was found on 2/10/2025 at 8:40 p.m., disconnected from supplemental oxygen and cardiopulmonary monitor, unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain), and was pronounced dead at 8:57 p.m. on 2/10/2025. The facility reported the incident to CDPH on 3/5/2025 (23 days later).

This deficient practice delayed external regulatory review and the opportunity for oversight, which may affect patient safety when an investigation is not immediately undertaken to ensure corrective action plans are implemented and that the facility is taking strong enough steps to reduce the risk of a similar future event. (Refer to A-0286)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by:

1. The facility failed to ensure that one of 30 sampled patients (Patient 16), received treatment for self-reported pain during their (Patient 16's) stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), in accordance with the facility's policy regarding pain assessment and management.

This deficient practice had the potential for Patient 16 to experience increased pain and discomfort, worsening of Patient 15's condition, and delayed recovery from illness. (Refer to A-0395)

2. The facility failed to ensure one of 30 sampled patient's (Patient 27) Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screen, was completed in triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care), in accordance with the facility's policy regarding suicide (when someone harms themselves with any intent to end their life) risk screening, when Patient 27 was seen in the emergency department (ED) for overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended).

This deficient practice had the potential of failing to identify Patient 27's level of risk for suicide which can result in patient harm or even death. (Refer to A-0395)

3. The facility failed to ensure for one of 30 sampled patients (Patient 19), a plan of care (a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Heart Failure (also known as congestive heart failure, occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), was developed and implemented upon completion of assessment (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for not addressing Patient 19's care needs and risks, which may delay the implementation of necessary interventions resulting in complications such as kidney damage, irregular heartbeat, and cardiac arrest (when the heart stops beating). (Refer to A-0396)

4. The facility failed to ensure assessment and monitoring of a patient's condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes, for one of 30 sampled patients (Patient 26), while placed on violent restraints (bilateral wrist and ankle restraints- the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient's violent behavior poses an immediate danger to themselves or others. Example vest restraints and wrist restraints), as per facility's policy and procedure regarding restraints use.

This deficient practice had the potential for increased risk of injury (such as skin and circulatory [blood flow] impairment), psychological distress, and/or death. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by:

1. The facility failed to ensure that for one of 30 sampled patients (Patient 15), a complete pain assessment evaluation, was documented, in accordance with the facility's policy regarding pain assessment and management.

This deficient practice had the potential for Patient 15's pain to be inadequately managed, potentially leading to prolonged discomfort and overall negative impact on Patient 15's recovery process. In addition, incomplete pain assessment documentation had the potential to disrupt the continuity of care for Patient 15, making it difficult for other healthcare providers to understand Patient 15's pain level, response to interventions and delays the implementation of other alternative pain management strategies. (Refer to A-0449)

2. The facility failed to ensure the medical record for one of 30 sampled patients (Patient 1) contained complete documentation of a code blue event (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation). The "Code Narrator report (a tool that helps document and track key events during a code)" for Patient 1 lacked the required clinical elements including cardiac rhythm (the timing and pattern of the heart's electrical signals, which determine how the heart beats), timing of chest compressions (push on the person's chest in resuscitation), pulse checks (moments when medical staff checks for a heartbeat), and code team member roles, in accordance with the facility's code blue policy.

This deficient practice impeded the facility's ability to review what actions were taken during emergency, to understand how care was provided, and to identify ways to improve future emergency responses. (Refer to A-0450)

3. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 1) included a complete and authenticated documentation of care, as required by the Physician Assistant (PA, a healthcare professional licensed to practice medicine under physician supervision) 1's practice agreement, and the facility's medical staff rules and regulations. Specifically, the Emergency Department (ED) triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note, documented by PA 1, was not co-signed by a supervising physician, as required.

This deficient practice resulted in the medical record lacking documentation required to validate that the services provided by the PA 1 were reviewed by a supervising physician. The absence of a co-signature prevented confirmation that oversight was performed in accordance with the practice agreement and facility policy, which may have an impact on patient safety. (Refer to A-0450)

4. The facility failed to ensure that one of 30 sampled patients' medical records (Patient 9) were complete, containing documentation of justification for the continued use of restraints (the use of physical or mechanical devices to limit patient movement. Example wrist restraints), in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to compromise Patient 9's safety by allowing restraints to be applied without oversight and evaluation, increasing the risk of physical (example: skin breakdown [damage to the skin], circulatory issues [any condition such as tightly applied wrist restraints that impede blood flow]) and psychological harm (example: anxiety [a feeling of dread and uneasiness], trauma, etc.) to the patient (Patient 9). (Refer to A-0450)

5. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 1) included documentation from the physician (MD 1) who discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation). MD 1 did not record a physical assessment (a hands-on examination), clinical observations, or actions taken in response, in accordance with the facility's policy regarding medical records content.

This deficient practice resulted in an incomplete medical record and impaired the facility's ability to evaluate the care provided, ensure continuity of care (the consistent and coordinated management of a patient's treatment across shifts or providers), prevented a full understanding of the patient's condition during the emergency, and made it harder for the facility to review and improve its emergency procedures. (Refer to A-0464)

6. The facility failed to ensure that medical records for two of 30 sampled patients (Patient 9 and Patient 14) were complete, when:

6.a. Patient 9's medical records had no documentation of a physician's order for continuous cardiac (heart)monitoring (encompasses all methods of heart rate and rhythm (the pattern and regularity of the heart's beat) monitoring, including remote monitoring and often involves bedside displays), in accordance with the facility's policy regarding cardiac monitoring.

This deficient practice had the potential to compromise Patient 9's safety by delaying timely placement of Patient 9 on a cardiac monitor and potentially preventing timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 9. (Refer to A-0467)

6.b. Patient 14's medical record had no documentation of the following:

6.b.1. Physician's order for continuous cardiac monitoring was not placed by the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) provider, in accordance with the facility's policy regarding cardiac monitoring and policy on Rules and Regulations for the Professional Staff.

This deficient practice had the potential to compromise Patient 14's safety by delaying timely placement of Patient 14 on a cardiac monitor and/or not continuously monitoring Patient 14's heart rhythm potentially delaying timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 14. (Refer to A-0467)

6.b.2. No documentation of cardiac rhythm in the flowsheet assessment record despite Patient 14 being observed to be connected to a cardiac monitor, in accordance with the facility's policy regarding cardiac monitoring and documentation.

This deficient practice had the potential to compromise Patient 14's safety by preventing other healthcare providers not to be able to promptly recognize and respond to changes in the Patient 14's cardiac condition, leading to potential delays in necessary treatment and intervention. (Refer to A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Emergency Services was met, as evidenced by:

1. The facility failed to ensure that qualified medical personnel (QMP, a healthcare provider authorized by the facility to evaluate and treat emergency patients) fulfilled responsibilities to evaluate and document emergency care for one of 30 sampled patients (Patient 1), in accordance with the facility's policy regarding medical records content. Specifically, the physician (MD 1) who found Patient 1 unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025, did not document any clinical findings, assessments (medical evaluation of the patient's condition), or medical interventions (steps taken to treat the patient [Patient 1]).

This deficient practice resulted in the facility being unable to confirm whether timely and emergency care was provided. This omission limited the facility's ability to verify the care rendered during the critical event and prevented staff from fully understanding and evaluating the effectiveness of the emergency care provided. (Refer to A-1104)

2. The facility failed to ensure that emergency department staff documented in the Code Narrator (a tool that helps document and track key events during a code)" report regarding Patient 1's cardiac rhythm (pattern of the heart's electrical activity), time of pulse checks (moments when medical staff checks for a heartbeat), initiation of chest compressions (starting of manual pressing on the chest to restore circulation), or identification of responding team members during the code blue (a hospital-wide emergency called when patient is experiencing cardiac [heart] or respiratory arrest [stopped breathing]) on 2/10/2025.

This deficient practice impeded the facility's ability to assess the adequacy of the emergency response and limited the continuity of care (coordinated and consistent care among healthcare team members) by preventing post-event clinical evaluation, hindering quality assurance (a proactive approach to ensuring that services and amenities consistently meet or exceed established standards for excellence, guest satisfaction, and operational efficiency) processes, and restricted the facility's ability to identify areas for improvement in resuscitation (the act of reviving a patient from apparent death) practices. (Refer to A-1104)

3. The facility failed to ensure the annual educational requirements (the mandated training and continuing education that employees must complete each year to maintain their knowledge skills and compliance with regulatory standards) for three of 10 sampled Emergency Department (ED) employees (E2, E5 and E7), were completed, in accordance with the facility's annual educational requirements for employees and regulatory standards.

This deficient practice had the potential to compromise quality of patient care delivered by employees who may lack current knowledge and training necessary to provide effective treatment. (Refer to A-1110)

4. The facility failed to ensure Annual competencies (assessments and evaluations to determine if employees possess the necessary skills and abilities required for their positions) for one of 10 sampled Emergency Department staff member (E5), were completed as indicated by the facility's procedures regarding annual competency trainings.

This deficient practice had the potential to result in compromised patient safety and quality of care when healthcare professionals may not be equipped with the knowledge to provide safe, effective, and high-quality care to patients. (Refer to A-1110)

5. The facility failed to ensure that four of four sampled registered nurses (E2, E4, E6, and E8), working in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), fully met the written standardized emergency procedure (established protocols that define the actions, responsibilities, and practices that registered nurses must initiate based on patients' chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician [when no triage -the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) physician was available to perform a rapid medical exam [RME, a process in emergency departments that initiates testing and evaluation of patients while they are still in the waiting room, aiming to improve patient flow and reduce wait times]) requirements and competencies needed, to be authorized to perform standardized procedures in the facility's ED.

This deficient practice had the potential to compromise patient care and safety by increasing the risk of inadequate responses to emergency situations, leading to delays in treatment and ultimately adverse patient outcomes when employees do not possess the necessary competencies in accordance with the facility's policy regarding Standardized Emergency Registered Nurse procedures. (Refer to A-1112)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility's Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to:

1. Ensure the Emergency Department (ED) staff provided continues telemetry monitoring (real-time tracking of the heart's electrical activity through electrodes placed on the chest) and response to persistent, critical alarms, in accordance with the facility's policy regarding cardiac monitoring, for one of 30 sampled patients (Patient 1) who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]) based on clinical judgment.

This deficient practice regarding the lack of monitoring and response, delayed the recognition of Patient 1's deteriorating condition and hindered the facility's ability to evaluate and improve emergency care and may have contributed to Patient 1'death.

2. Ensure the Emergency Department's (ED) Policy and Procedures aligned with current clinical practice for two of two reviewed ED's policy and procedure (Cardiac monitoring and emergency response documentation). The policy titled "Cardiac Monitoring (Adult)," dated 5/3/2022, indicated that monitor rhythm strip (a visual representation of a person's heart's electrical activity over time, essentially a graph of the heart's electrical signals) would be printed when a patient was placed on a cardiac monitor (initial strip, records the heart rate and rhythm), when telemetry (the automated process of measuring and transmitting data from remote locations for monitoring and analysis) was discontinued (final strip), or when there was a rhythm change (any variation in the heart's electrical activity, as detected by the monitor, that differs from the patient's initial or normal heart rhythm). The same policy also required registered nurses to carry assigned clinical communication devices to receive telemetry alarm alerts. However, these practices were not followed.

This deficient practice resulted in the governing body's inability to ensure that hospital staff adhered to the written policies for cardiac monitoring and emergency response documentation. This created the omission in required monitoring and documentation that impacted Patient 1's care and had the potential to affect the care for other ED patients.

3. Ensure there was a written process for submitting work orders to Biomedical Engineering department (department involved in designing, developing, and maintaining medical devices, equipment, and systems), when telemetry equipment (a remote sensing system that automatically collects and transmits data from a distance) was suspected of malfunctioning. On 2/10/2025, following the discovery of Patient 1 unresponsive (not reacting or responding to communication) and concerns that telemetry (heart and oxygen monitoring's) alarms may not have functioned as expected, no work order (a formal document that initiates and manages a specific task or project, for maintenance, repairs, or operations) was placed to have the telemetry equipment evaluated.

This deficient practice resulted in the inability to ensure that a malfunctioning telemetry equipment was promptly identified, reported, and removed from use. The delay in sequestering and evaluating the telemetry unit used by Patient 1 resulted in a three-day gap (from 2/10/2025 date of incident through 2/13/2025), during which the equipment remained in use and could have affected other patients in the ED.

Findings:

1. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1's telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1's bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate (breathing patterns that deviate from the patient's normal breathing pattern). DRM confirmed the alarms continued until patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025.

During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system (the process of automatically collecting, transmitting, and analyzing data from remote sources to a central location for monitoring and control) in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed.

During an interview on 4/2/2025 at 3:46 p.m. with the ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person's blood) and all, but one cardiac monitor lead (provides different views of the heart's electrical activity), was disconnected. MD 2 also confirmed that Patient 1's oxygen tube was not in his (Patient 1) nose. MD 2 stated MD 1 checked Patient 1's pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse.

During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1's alarms because she (RN 1) was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient's care).

During an interview with the Administrator of Quality (AQ) on 4/4/2025 at 2:19 p.m., AQ stated that the telemetry alarm monitoring was not tracked before the incident involving Patient 1.

During an interview on 4/4/2025 at 5:15 p.m. with the Senior Vice President (SVP), SVP stated the governing body was responsible for patient safety and quality of care provide in the facility. The board's responsibility extends to oversight of the hospital's Quality Assurance and Performance Improvement (QAPI) program, which included conducting periodic review and ensuring patient safety.

During a review of the facility's "Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation," date 2024, the plan indicated, "The Board of Directors of (name of facility), the governing body, through its Quality and Health Improvement Committee ("QHIC"), oversees each hospital's Quality and Patient Safety Program ("Program"). The QHIC assures each hospital's executive and Professional Staff leadership develops the hospital's program consistent with the hospital's mission, vision and values. The hospital leadership is accountable to the QHIC to assure the planning and implementation, including establishing priorities for the Quality and Patient Safety Program with respect to the delivery of existing services and the implementation of new hospital services."

2. During an interview on 4/1/2025 at 2:05 p.m. with Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 5, RN 5 stated they were not required to print cardiac strips/telemetry strips (a recording of the heart's electrical activity over a specific period, typically 10 seconds) when placing a patient on the cardiac monitor unless there was an event or code (Code blue, a medical emergency code signifying a cardiac [heart] or respiratory arrest [stopped breathing], or other life-threatening situation). RN 5 stated the nurses do not carry phones. RN 5 also confirmed that ED never assigned a staff for monitoring the central cardiopulmonary monitor (a device used to continuously observe and record vital signs [VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] related to the heart function and respiratory [breathing] systems).

During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed.

During a concurrent interview and record review on 4/4/2025 at 2:05 p.m. with the Assistant Clinical Director (ACD) 2, the facility's Code Blue policy and procedure, dated 6/21/2021, was reviewed. The policy indicated staff should document on the "Code Blue Record" form found in Appendix C. ACD2 stated the ED no longer uses the paper Code "Blue Record" form and instead documents during codes using the electronic "Code Narrator" system. ACD 2 confirmed that the required documentation elements were the same in both the "Code Narrator" and the "Code Blue Record." However, the policy did not reflect the ED's current practice of using the "Code Narrator" instead of the paper form.

During an interview on 4/4/2025 at 5:06 p.m. with the Regional Senior Director Accreditation Regulation and Licensing (RSDAR), RSDAR confirmed that while the current "Cardiac Monitoring" (dated 5/3/2022) policy was applicable hospital-wide, including to the ED, practice in the ED did not reflect the current policy's requirements. Requiring printing of cardiac telemetry strips when patient was placed on the cardiac monitor (Initial Strip), when patient had telemetry monitoring discontinued (Final Strip), and use of phone to alert nurses for alarms, was not consistent with the written policy.

During a review of the facility's emergency department policy and procedure (P&P) titled, "Standard Emergency Registered Nurse Procedures," dated 10/21/2024, the P&P indicated, "Responsibilities: The Emergency Department is responsible for ensuring that this standardized procedure is accurate, relevant, and current. Maintenance: This policy and procedure shall be reviewed at least every three (3) years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statutes and current practice."

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/3/2022, the P&P indicated the following: The Emergency Department shall perform cardiac monitoring as needed, according to the physician's orders, and based on the patient's chief complaint and condition. Monitor rhythm strip(s) will be printed when: A patient is placed on the monitor (Initial Strip),A patient has telemetry discontinued (Final Strip), there is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient, alternative monitoring equipment is used, patient is placed back on telemetry monitoring, after alternative monitoring equipment use. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.). RNs will carry assigned clinical communication devices at all times except: When on breaks or meals."

During a review of the facility's policy and procedure (P&P) titled, "Code Blue Response- Adult Medical Center Campus," dated 6/21/2021, the P&P indicated, "Documentation: A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. Appendix C: Code Blue Record ..."

3. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1's telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1's bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate (breathing patterns that deviate from the patient's normal breathing pattern). DRM confirmed the alarms continued until patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025.

During an interview on 4/3/2025 at 5:35 p.m. with Charge Nurse (RN 9), RN 9 stated that if telemetry equipment was not functioning, staff could place a work order and Biomedical Engineering would typically respond the same day.

During an interview on 4/4/2025 at 1:40 p.m. with Biomedical Technician (BMT 2), BMT 2 stated that no work order had been placed on 2/10/2025 when the incident occurred. BMT 2 stated he (BMT 2) only learned about the alarm concern for Patient 1 in room ABC on 2/13/2025, while responding to an unrelated equipment issue in the ED. BMT 2 stated the ED supervisor informed him (BMT 2) at that time that the alarm in room ABC may not have gone off. BMT 2 stated that he (BMT 2) then sequestered the cardiac monitor and checked the central telemetry system. BMT 2 stated it was important for staff to place a high-priority work order when alarm issues were suspected.

During a concurrent interview and record review on 4/4/2025 at 1:50 p.m. with Biomedical Technician (BMT 1), the "Equipment and Case Information," containing work orders history, was reviewed. The document report indicated, on 2/13/2025, a work order was entered for a "scanner not working." On 2/18/2025, a separate work order was documented under type "Hazard/Recall/Safety," with a summary reading "Patient incident evaluation." BMT 1 confirmed that this second order was placed by the biomedical team.

During an interview on 4/4/2025 at 2:10 p.m. with the Administrator of Quality (AQ), AQ stated that the facility had no policy outlining when or how to place work orders, nor who was responsible. AQ provided a general guidance document titled "How to Report an Issue," but it did not contain specific instructions on reporting equipment issues or escalation procedures.

During an interview on 4/4/2025 at 5:15 p.m. with the Senior Vice President (SVP), SVP stated the governing body held responsibility for patient safety and oversight of the QAPI (Quality Assurance Performance Improvement, a data-driven, proactive approach to improving the quality of care and services) program, including ensuring that appropriate actions were taken in response to safety concerns.

During a review of the facility's policy and procedure (P&P) titled, "Southern California Regional Unusual Occurrence Reporting (UOR)," dated 5/3/2023, the P&P indicated, "To reduce risk for (facility name) members, employees, physicians, and visitors. To protect the organization against unplanned financial loss through risk Identification, analysis, evaluation, and corrective action for identified problems. To promote a safe environment for patients, visitors, physicians, and staff by identifying within a Just Culture environment the system problems/issues that contribute to unusual occurrences rather than focusing on individuals. Provisions/Procedures: If a medical device or equipment is involved in an event, it shall be taken out of service and maintained unaltered until turned over to the Risk Department or Clinical Technology."

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and staff response to persistent, critical alarms.

This deficient practice resulted in a delay in recognition and intervention during a deteriorating cardiopulmonary condition (a worsening of both the heart and lung's function, leading to a decline in overall health and potentially life-threatening situations) and may have contributed to Patient 1's death.

IJ Statement:

On 4/2/2025 at 5:38 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Senior Vice President (SVP), Chief Operating Officer (COO), Regional Senior Director, Accreditation, Regulatory& Licensing (RSDAR ), Administrator Quality Department (AQ), Director of Accreditation, Regulatory & Licensing (ARLD), Chief Nursing Executive (CNE), and Assistant Medical Group Administrator (AMA). The facility failed to ensure that Patient 1, who had a physician's order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and timely staff response to alarms. This deficient practice resulted in delay in recognizing a life-threatening cardiopulmonary (a problem with either the heart or lungs, or both, that could be fatal if not addressed quickly) emergency and contributed to Patient 1's death.

Patient 1 arrived in the Emergency Department (ED) on 2/10/2025 at 5:00 p.m. with symptoms including shortness of breath (difficulty breathing), chest discomfort, upper epigastric pain (abdominal pain), nausea (a feeling of sickness with an inclination to vomit), and coughing. Patient 1 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) as Emergency Severity Index (ESI, a 5-level triage algorithm used in emergency departments to quickly assess the acuity [severity] of a patient's condition and determine the resources needed for their care, prioritizing patients for treatment) as level 1, indicating a life-threatening condition. An electrocardiogram (EKG, a test that records the electrical activity of the heart, showing how it's beating and if there are any problems with its rhythm or function) indicated sinus tachycardia (a condition characterized by a heart rate faster than normal [over 100 beats per minute]) and ST elevation (a section of the heart muscle is potentially not getting enough oxygen, which can be a sign of a heart attack or other serious heart problem). At 5:28 p.m., a physician ordered continuous pulse oximetry (oxygen monitoring). Based on clinical risk, the ED staff also placed Patient 1 on continuous cardiac monitoring.

During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), the "Event History Report," for the telemetry system (the automated process of measuring and transmitting data from remote locations for monitoring and analysis), dated 2/10/2025, was reviewed. The telemetry system began displaying critical alarm messages beginning at 8:01 p.m. on 2/10/2025, Patient 1's bedside monitoring system generated multiple critical alarms over a span of 42 minutes. These alarms indicated:
-The oxygen saturation probe was either disconnected or not functioning properly,
-The device could not detect a pulse or oxygen readings,
-Patient 1's heart and breathing pattern were unstable,
-Cardiac electrodes were detached or malfunctioning,
-And, ultimately, that alarms were manually silenced by staff when Patient 1 was found unresponsive.

Despite these numerous and escalating warnings, no staff responded to the alarms. The central telemetry station, which displays these alerts for staffing monitoring, was unattended, and no alerts were forwarded to nurses' communication devices as required by the facility's cardiac monitoring policy and procedures. At 8:40 p.m., Patient 1 was found unresponsive in their room. Patient 1's high-flow oxygen delivery system was not connected to Patient 1's nose, and cardiac monitoring leads (the electrical connections, or pairs of electrodes, that detect and display the heart's electrical activity, providing different "views" of the heart's activity) were disconnected, except one. Cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest [heart stop]) was started, and Patient 1 was intubated (insert a tube into a person or a body part, especially the windpipe for ventilation). However, Patient 1 remained in pulseless electrical activity (PEA, a condition where electrical signals are detected, but the heart is not pumping blood). Patient 1 was pronounced dead at 8:57 p.m.

On 4/3/2025 at 5:58 p.m., the IJ was removed in the presence of the Regional Senior Director, Accreditation, Regulatory & Licensing (RSDAR), Administrator of Quality (AQ), and Director of Accreditation, Regulatory& Licensing (ARLD). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview and record review. The IJ Removal Plan indicated:

-Responsible Parties for Oversight and Training: Assistant Clinical Directors (ACD) and Charge Nurses
1. Reeducation of Staff: Education was reassessed and reinforced beginning April 2, 2025, with focused instruction on alarm types, urgency, response expectations, and escalation protocols.
2. Refresher Training Implementation: Beginning April 2, 2025, mandatory in-person refresher sessions were conducted during pre-shift huddles on all shifts. Topics covered: Response to alarms
3. Staffing Enhancements for Central Monitor: Effective April 2, 2025, four dedicated monitor technicians were assigned to the central monitors located in Pods A, B, C, and D. Each technician completed a structured orientation, including roles, responsibilities, and clear escalation protocols for abnormal cardiac rhythms and pulse oximetry
4. Ongoing Monitoring and Accountability: A monitor technician is assigned to each pod during every shift to ensure continuous observation of patient data. Monitor technicians are responsible for real-time identification and escalation of abnormal readings to licensed and/or certified clinical staff. If the primary nurse is unavailable, the Charge Nurse will be notified
5. Infrastructure and Equipment Verification: All four ED pods are fully equipped to provide cardiac monitoring and pulse oximetry in every patient care room. On April 3, 2025, the central monitors were assessed and verified to be fully functional and calibrated, ensuring accurate alarm display and sound notification.

Cardiac Monitoring Procedures: Cardiac monitoring and/or pulse oximetry are initiated per physician order or under Standardized Emergency Registered Nurse Procedures Policy
Alarm Verification: Staff are responsible for confirming that audible alarms at the patient's bedside and central monitor are active and functional upon initiation of the monitor. This is documented on the monitoring log.
Escalation of Alarms: If the monitor technician is unable to reach the primary RN: The Charge Nurse will be notified
Red Alarm Response, red alarms are lethal arrhythmia (a condition in which the heart beats with an irregular or abnormal rhythm) this include asystole (also called "flatline" no heartbeat), ventricular fibrillation (V-fib, a a dangerous heart rhythm where the heart's lower chambers (ventricles) quiver or shake uncontrollably instead of beating normally, preventing the heart from pumping blood effectively), ventricular tachycardia (VT, a fast heartbeat that potentially leading to a dangerous lack of blood flow to the body), desaturation (a drop in the amount of oxygen in the blood), and apnea (brief stop in breathing): In the event of a red alarm, the monitor technician will immediately notify both the assigned RN and the physician.
Alarm Response Protocol: All staff are trained to respond to all alarm levels (red, yellow, blue). Upon any alarm, the monitor technician verbally notifies the assigned RN immediately.

Physician Education and Engagement:
Responsible: Chief of Emergency Department and Assistant Chiefs of ED
On April 3, 2025, all physicians and physician assistants were educated on the ED cardiac monitoring policy. Emphasis was placed on ensuring that orders for cardiac monitoring and pulse oximetry are promptly placed based on patient condition. Physicians were instructed to immediately respond to the red alarm when they are made aware

Emergency Staffing Coverage: In the event of multiple patients requiring resuscitation in the emergency department, the ACD and/or Charge Nurse will immediately: Assess staffing and reassign as needed. Maintain appropriate levels of nursing care and monitoring coverage.
Ongoing Monitoring: Daily audits will be conducted to verify alarm functionality. Verification of assessment and intervention when needed, as documented on the monitoring log.

Findings:

During a review of Patient 1's "ED (emergency department, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) Provider Notes," dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history which included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a review of Patient 1's "triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note," dated 2/10/2025, the note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1 (most urgent level requiring immediate life-saving intervention).

During a review of Patient 1's "Electrocardiogram (EKG, a diagnostic tool that records the heart's electrical activity), dated 2/10/2025 at 5:19 p.m., the report indicated sinus tachycardia (abnormal a heart rate that is faster than normal [heart rate over 100 beats per minute]), nonspecific T-wave abnormalities (irregularities in the heart's electrical cycle), and ST elevation (a possible sign of heart attack or heart muscle damage).

During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), Patient 1's telemetry event report, was reviewed. The telemetry event report (a report of monitor alerts), dated 2/10/2025, indicated starting at 8:01 p.m., Patient 1's bedside monitor generated multiple escalating alarms indicating critical deterioration as follows:

-"At 8:01:02 p.m., indicated, "Message Display: Sp02 Probe Off (oxygen sensor disconnected)"
-"At 8:01:21 p.m., indicated, "Message Display: Sp02 Pulse Search (cannot read)"
-"At 8:01:54 p.m., indicated, "Message Display: Sp02 Alarm (possible critical low oxygen level)"
-"At 8:02:03 p.m., indicated, "Message Display: Sp02 Unstable Pulse (irregular or changing heart rate)"
-"At 8:03:01 p.m., indicated, "Message Display: Irregular RR (respiratory rate)"
-"At 8:03:06 p.m., indicated, "Message Display: Check Electrodes (monitor leads disconnected or failing to detect signal)"
-"At 8:13:22 p.m., indicated, "Message Display: Sp02 Alarm"
-"At 8:13:23 pm., indicated, "Message Display: Check Electrodes"
-"At 8:142 p.m., indicated, "Message Display: Sp02 Alarm"
-"At 8:13:50 p.m., indicated, "Message Display: Alarms Silenced (alarm was silenced manually)"
-"At 8:13:58 p.m., indicated, "Message Display: Check Electrodes"
-"At 8:15:25 p.m., indicated, "Message Display: (Sp02) Alarm"
-"At 8:15:27 p.m., indicated, "Message Display: Check Electrodes"
-"At 8:19:52 p.m., indicated, "Message Display: SpO2 Alarm"
-"At 8:20:07 p.m., indicated, "Message Display: Check Electrodes"
-"At 8:24:39 p.m., indicated, "Message Display: Sp02 Alarm."
-"At 8:24:47 p.m., indicated, "Message Display: Check Electrodes"
-"At 8:43:40 p.m., indicated, "Message Display: (SpO2) Alarm."

During the same interview on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), the DRM confirmed the alarms continued until Patient 1 was found unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain) around 8:40 p.m.

During an observation and interview on 4/1/2025 at 2:05 p.m. with Director, Assistant Clinical Director (ACD) 2, in the emergency department at the central telemetry monitor (the central screen that displays patient heart and oxygen status), the ACD 2 confirmed that at the time of the incident, no staff were assigned to observe or respond to telemetry alarms at the central telemetry monitoring. ACD 2 stated the ED did not assign staff for central telemetry monitoring because this was not their practice.

During an interview on 4/2/2025 at 10:15 a.m. with Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed.

During a concurrent interview and record review on 4/2/2025 at 10:26 a.m. with Assistant Clinical Director (ACD 1), Patient 1's electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled "Orders," dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a physician order for continuous pulse oximetry monitor (monitoring of blood oxygen level via a finger probe), but no written order for telemetry. ACD 1 stated that telemetry monitoring was initiated based on ED protocol for patients presenting with chest pain and ST elevation.

During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with Assistant Clinical Director (ACD 1), Patient 1's "Code Narrator Report (a record of emergency response activity), dated 2/10/2025, was reviewed. The report indicated that a code blue (emergency cardiac arrest [when the heart stops beating] response) was initiated at 8:40 p.m. and Patient 1 did not regain a pulse (heartbeat) and was pronounced dead at 8:57 p.m. ACD 1 stated the terminal heart rhythm was pulseless electrical activity (PEA, a condition where the heart has electrical activity but is not pumping blood).

During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. MD 2 confirmed that the pulse oximeter and all, but one cardiac monitor lead was disconnected. MD 2 stated MD 1 checked Patient 1's pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse.

During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1's alarms because she was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient's care).

During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Director (MD) 7, MD 7 stated that any patient with ST elevation (a possible sign of heart attack or heart muscle damage) should be continuously monitored due to their high risk of cardiac deterioration.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/3/2022, the P&P indicated, "The Emergency Department shall perform cardiac monitoring as needed, according to the physician's orders, and based on the patient's chief complaint and condition. Documentation of cardiac rhythm, any changes in cardiac rhythm and anytime notification to the physician occurs, shall be recorded In KP Health Connect. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.)."

During a review of the facility's policy and procedure (P&P) titled, "Standardized Emergency Registered Nurse Procedures," dated 10/21/2024, the P&P indicated the following:
Requirements to be followed: Chest Pain
- Consider Oxygen via nasal cannula and Pulse oximetry
- Cardiac Monitor, when treatment room available

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team failed to measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment) and establish clear expectations for safety when the facility failed to:

1. Ensure implementation of an effective process to ensure Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) telemetry alarms (alerts triggered by a heart and oxygen monitoring to notify operators or users about unusual or abnormal events or conditions within a monitored system) were audible and responded to by staff. The facility did not have a system in place to alert staff to critical telemetry alarms when they were engaged with other patients. The telemetry system was not integrated with staff communication devices, such as phones or badges in accordance with the facility's "Cardiac Monitoring (supplies data about your heart rhythm)" policy and procedure. In addition, there were no staff assigned to continuously monitor the central telemetry (the display station showing vital signs for all monitored patients). This issue was not identified or corrected through the QAPI program before the incident involving one of 30 sampled patients (Patient 1).

This deficient practice resulted in Patient 1 being found unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025 and created a risk that other ED patients might not be promptly assessed when telemetry (real-time tracking of the heart's electrical activity through electrodes placed on the chest) alarms are not responded to by staff.

2. Ensure that the "Cardiac Monitoring" and "Code Blue (a medical emergency code signifying a cardiac [heart] or respiratory [ breathing] arrest, or other life-threatening situation) policies and procedures reflected the current Emergency Department (ED) practice.

This deficient practice resulted in the QAPI program not identifying that the policy for Cardiac Monitoring and Code Blue was not implemented as written, in the ED. This misalignment between ED practice and written policy resulted in incomplete and inconsistent documentation and responses during emergency events, which may place patients at risk of delayed or inadequate care.

3. Report a serious adverse event (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment), within 5 days, to the California department of Public Health (CDPH, department that works to protect the public's health) involving one of 30 sampled patients (Patient 1), in accordance with the facility's "National Crosswalk of Sentinel (a serious adverse event that results in patient death, permanent harm, or severe temporary harm) Events," policy and procedure, when Patient 1 was found on 2/10/2025 at 8:40 p.m., disconnected from supplemental oxygen and cardiopulmonary monitor, unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain), and was pronounced dead at 8:57 p.m. on 2/10/2025. The facility reported the incident to CDPH on 3/5/2025 (23 days later).

This deficient practice delayed external regulatory review and the opportunity for oversight, which may affect patient safety when an investigation is not immediately undertaken to ensure corrective action plans are implemented and that the facility is taking strong enough steps to reduce the risk of a similar future event.

Findings:

1. During a review of Patient 1's "ED (Emergency Department, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) Provider Notes," dated 2/10/2025, Patient 1's ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), Patient 1's telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1's bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate. DRM confirmed the alarms continued until Patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025.

During an observation and interview on 4/1/2025 at 2:05 p.m. with Assistant Clinical Director (ACD) 2, in the central telemetry monitor (the central screen that displays patient heart and oxygen status), the ACD 2 confirmed that at the time of the incident (2/10/2025), no staff were assigned to observe or respond to telemetry alarms at the central telemetry monitoring station. ACD 2 stated the ED did not assign staff for central telemetry monitoring because this was not their practice.

During an interview on 4/1/2025 at 2:15 p.m. with Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 5, RN 5 stated they were not required to print cardiac rhythm strips (test records the electrical activity of the heart) when placing patient on the monitor unless there was an event or code (a medical emergency code signifying a cardiac [heart] or respiratory arrest [stopped breathing], or other life-threatening situation). RN 5 stated the nurses do not carry phones. RN 5 also confirmed that the Emergency Department (ED) never assigned a staff for monitoring the central telemetry monitor.

During an interview on 4/2/2025 at 10:15 a.m. with Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed.

During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter and all, but one cardiac monitor lead was disconnected. MD 2 also confirmed that Patient 1's oxygen was not in his nose. MD 2 stated MD 1 checked Patient 1's pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse.

During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1's alarms because she (RN 1) was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient's care).

During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Director (MD) 7, MD 7 stated that any patient with ST elevation (a possible sign of heart attack or heart muscle damage) should be continuously monitored due to their high risk of cardiac deterioration.

During an interview with the Administrator of Quality (AQ) on 4/4/2025 at 2:19 p.m., AQ stated that the telemetry alarm monitoring was not tracked before the incident involving Patient 1.

During an interview on 4/4/2025 at 4:12 p.m. with the Administrator of Quality (AQ), AQ confirmed there were no prior quality improvement projects addressing alarm response time or telemetry monitoring before the incident (incident involving Patient 1 being found disconnected from the cardiac monitor and found unresponsive).

During a review of the facility's "Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation," date 2024, the plan indicated, "The purpose of this Plan is to provide the mechanism for improving hospital quality and safety and to ensure ...collaborative approach to deliver safe, effective, efficient, equitable, patient centered, and timely care within a quality assurance and performance improvement (QAPI) framework. The activities in this plan are essential to achieving the strategic plan ...This plan informs the improvement processes for patient outcomes, reducing and preventing medical errors, and applying remediation strategies in response to system or process failures ...Ensure the actual and potential hazards associated with high risk procedures, processes, and patient care populations are identified, assessed, and controlled in a way that demonstrates continuous improvement and moves the organization toward high reliability and the ultimate objective of ensuring our patients are free from unnecessary harm. Design, construct, operate, and maintain a safe environment of care as well as evaluate, purchase, and utilize equipment and products in a way that promotes the efficiency and effectiveness with which safe healthcare is provided."

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/3/2022, the P&P indicated, "The Emergency Department shall perform cardiac monitoring as needed, according to the physician's orders, and based on the patient's chief complaint and condition. Documentation of cardiac rhythm, any changes in cardiac rhythm and anytime notification to the physician occurs, shall be recorded In KP Health Connect. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.)."

2. During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed.

During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director in the Emergency Department, (ACD)1, Patient 1's electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled, "Code Narrator Report (a documentation system that allows nurses to efficiently document the details during an emergency resuscitation)," dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a pulseless electrical activity (PEA, the heart electrical signals are working but the heart is not pumping blood). ACD 1 confirmed that Patient 1's heart rhythm was not documented in the report.

During the same interview on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 further stated that during a code (Code Blue, emergency cardiac arrest [when the heart stops beating] response), each time a pulse was checked, the corresponding cardiac rhythm (the pattern and regularity of the heart's beat, influenced by the heart's electrical system) should be documented. ACD 1 confirmed the Code Narrator report also lacked the time chest compressions were started and stopped, and the specific roles of the code team members were not indicated. ACD 1 confirmed that these documentation elements were required as part of the code record and emphasized the importance of documenting time-stamped clinical actions during a code event.

During a concurrent interview and record review on 4/4/2025 at 2:05 p.m. with Assistant Clinical Director (ACD) 2, the facility's Code Blue policy and procedure, dated 6/21/2021, was reviewed. The policy indicated staff should document on the "Code Blue Record" form found in Appendix C. ACD2 stated the ED no longer uses the paper Code "Blue Record" form and instead documents during codes using electronic "Code Narrator" system. ACD 2 confirmed that the required documentation elements are the same in both the "Code Narrator" and the "Code Blue Record." However, the policy does not reflect the ED's current practice of using the "Code Narrator" instead of the paper form.

During an interview on 4/4/2025 at 5:06 p.m. with the Regional Senior Director Accreditation Regulation and Licensing (RSDAR), RSDAR confirmed that while the current "Cardiac Monitoring," policy, dated 5/3/2022, was applicable hospital-wide, including in the ED, the practice in the ED did not reflect the current policy's requirements. Requiring printing of cardiac telemetry strips when patient was placed on the monitor (Initial Strip), when patient had telemetry discontinued (Final Strip), and use of phone to alert nurses for alarms, were not consistent with the written policy.

During a review of the facility's "Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation," date 2024, the plan indicated, "The purpose of this Plan is to provide the mechanism for improving hospital quality and safety and to ensure ...collaborative approach to deliver safe, effective, efficient, equitable, patient centered, and timely care within a quality assurance and performance improvement (QAPI) framework ...Leadership is responsible for: Implementing changes in existing processes to improve the quality of the care provided ...Establishing quality of care and patient safety metrics, which can be monitored through the hospital's ...Ensuring that staffing resources are available, trained and competent to appropriately meet the needs of the patients served ...The Patient Safety and Risk Management Committees strive to reduce risk, improve patient safety and quality outcomes in the delivery of health services across all settings of care. These two committees work in tandem to monitor the effectiveness of the corrective actions taken in response to an adverse or sentinel event to ensure that the risk reduction strategies achieve the expected results."

During a review of the facility's emergency department policy and procedure (P&P) titled, "Standard Emergency Registered Nurse Procedures," dated 10/21/2024, the P&P indicated, "Responsibilities: The Emergency Department is responsible for ensuring that this standardized procedure is accurate, relevant, and current. Maintenance: This policy and procedure shall be reviewed at least every three (3) years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statutes and current practice."

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/3/2022, the P&P indicated the following: The Emergency Department shall perform cardiac monitoring as needed, according to the physician's orders, and based on the patient's chief complaint and condition. Monitor rhythm strip(s) will be printed when: A patient is placed on the monitor (Initial Strip),A patient has telemetry discontinued (Final Strip), there is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient, alternative monitoring equipment is used, patient is placed back on telemetry monitoring, after alternative monitoring equipment use. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.) RNs will carry assigned clinical communication devices at all times except: When on breaks or meals."

During a review of the facility's policy and procedure (P&P) titled, "Code Blue Response- Adult Medical Center Campus," dated 6/21/2021, the P&P indicated, "Documentation: A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. Appendix C: Code Blue Record ..."

3. During a review of Patient 1's "ED (emergency department) Provider Notes," dated 2/10/2025, Patient 1's ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1's telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1's bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate breathing patterns that deviate from the patient's normal breathing pattern) DRM confirmed the alarms continued until Patient 1 was found unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025.

During an interview on 4/4/2025 at 2:42 p.m. with the Administrator of Quality (AQ), AQ confirmed the incident involving Patient 1 was reported to California Department of Public Health (CDPH, department that works to protect the public's health) after the completion of the Corrective System Analysis (CSA, a systematic process for identifying, analyzing, and addressing system failures) was finalized. AQ confirmed that the incident involving delayed response to alarm for Patient 1 was on 2/10/2025, but the facility reported the incident to CDPH on 3/5/2025 (23 days later).

During a review of the facility's policy and procedure (P&P) titled, "National Crosswalk of Sentinel Events," dated May 2024, the P&P indicated, "Adverse events or series of adverse events that cause/result in death or serious disability lasting > (more than) 7 days or present on discharge from an inpatient health care facility. 'Serious disability' is a physical or mental impairment that substantially limits one or more of the patient's major life activities, the loss of bodily function, or the loss of a body part. Requires report to CDPH within 24 hours if urgent threat or 5 days if not urgent."

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

1. Ensure that one of 30 sampled patients (Patient 16), received treatment for self-reported pain during their (Patient 16's) stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), in accordance with the facility's policy regarding pain assessment and management.

This deficient practice had the potential for Patient 16 to experience increased pain and discomfort, worsening of Patient 15's condition, and delayed recovery from illness.

2. Ensure one of 30 sampled patient's (Patient 27) Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screen, was completed in triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care), in accordance with the facility's policy regarding suicide (when someone harms themselves with any intent to end their life) risk screening, when Patient 27 was seen in the emergency department (ED) for overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended).

This deficient practice had the potential of failing to identify Patient 27's level of risk for suicide which can result in patient harm or even death.

Findings:

1. During a review of Patient 16's Emergency Department (ED) Physician Progress Note," dated 4/1/2025, the note indicated that on 4/1/2025, Patient 16 presented to the ED complaining of left lower abdominal pain for the past couple of days.

During a review of Patient 16's flowsheet (a tool used to track and document patient data over time, typically in a structured format) titled, "Pain Management-Assessment, "dated 4/1/2025, the flowsheet indicated the following pain assessment was documented on 4/1/2025:

-At 9:04 a.m., Patient 16's Pain score (self-reported) was 8/10 (8/10 on a 0-10 pain scale is considered very strong pain that is difficult to bear, making it hard to engage in normal activities; (0: No pain; 1-3: Mild pain, often described as nagging or annoying, but not significantly interfering with daily activities; 4-6: Moderate pain, which can interfere with daily activities; 7-10: Severe pain, which can be disabling and interfere with normal activities;10: The worst pain imaginable) localized in the abdomen. No acceptable level of pain, character of pain, duration, aggravating factors, alleviating factors, and pain interventions, were recorded.
-At 9:47 a.m., Patient 16's pain level was documented 7/10 (strong pain). Acceptable level of pain was documented 7/10.
-At 1:31 p.m., Patient 16's pain level was documented 9/10 (Pain that is very hard to tolerate). Acceptable level of pain was documented 5/10

During a concurrent interview and record review on 4/3/2025 at 3:05 p.m. with registered nurse (RN) 8, RN 8 reviewed Patient 16's "Pain Management" flowsheet, dated 4/1/2025 and the "Medication Administration Record (MAR), dated 4/1/2025. RN 8 stated that Patient 16 did not receive pain relieving medication during their (Patient 16) stay in the Emergency Department (ED) on 4/1/2025 from 9:02 a.m. through 2:35 p.m. (time of Patient 16's discharge). RN 8 also said that the expectation for the nurse was to assess the patient's pain, address the concerns, and collaborate with the physician by requesting a pain medication order (if pain is significant and requires a medication order).

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 3/21/2022, the P&P indicated that, "Acute pain - is pain of short duration and the cause is usually known (i.e. Injury or surgical intervention). It generally disappears when healing occurs. Acute pain may be associated with objective physical signs ... Most often there are NO physical signs directly related to pain. The patient's subjective (self) report of the presence of pain is all that is needed to initiate treatment ... 4.2. Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan.
4.3. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment and defined criteria based on patient condition, age, and ability to understand during Emergency department visit and at the time of admission to inpatient.
4.4. The patient will be reassessed as to patient's response to pain through the following: Evaluation and documentation of response to pain interventions, including pain medication administration. The patient will be reassessed for pain scale or level of pain within 60 minutes (within one hour) of pain medication administration.
Progress toward pain management goals including functional ability, i.e. ability to take deep breaths, tum in bed, walk with improved pain control ... 4.5 Patients have the right to be treated for pain and receive treatment in a timely manner.
5.2. Ongoing Pain Management: a. Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge
5.5 Documentation: Pain will be recorded as part of the initial admission patient assessment or as appropriate to the setting with every full set of vital signs ... g. The functional pain goal (patient's acceptable level of pain) will be documented every shift.

2. During a review of Patient's 27 "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/11/2024, the H&P indicated that Patient 27 was brought to the Emergency Department with chief complaint of overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended). The H&P also indicated Patient 27 was picked up from the street and brought in by ambulance for ingestion of unknown substance and bizarre behavior. Preliminary urine toxicology (a urine drug screen ) indicated Patient 27 was positive for methamphetamines (a highly addictive drug with potent central nervous system [comprise of the brain and the spinal cord- a long tube-like structure that extends downwards form the base of the brain] stimulant [speeds up the body's functions] properties). The H&P further indicated that Ativan (a drug used to treat anxiety [a feeling of fear and uneasiness] disorders) and 2 liters of normal saline (a solution of 0.9% sodium chloride in water) was administered to Patient 27.

During a concurrent interview and record review on 04/04/2025 at 11:42 a.m. with the patient safety officer (PSO), Patient 27's medical record titled, "Patient Care Timeline," dated 10/11/2024 at 6 :42 p.m. to 10/12/2024 at 8:17 a.m., was reviewed. The patient's (Patient 27) Patient Care Timeline record did not indicate that a Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screening assessment was completed during triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care).

During the same interview on 4/04/2025 at 11:42 a.m. with the patient safety officer (PSO), the PSO stated that the triage nurse did not complete a C-SSRS screening assessment tool. PSO also said that Patient 27 was oriented to person and place and was seen in the ED for overdose. PSO added that patients who arrive in the ED with chief complaint of overdose must be screened for suicide (when someone harms themselves with any intent to end their life) risk. Furthermore, there was no documentation from the triage nurse as to why a C-SSRS screen was not completed.

During a review of the Policy and Procedure titled "Management of Patients Who Are a Danger to Self or Others or Are Gravely Disabled (a condition where a person, due to a mental health disorder, is unable to provide for their basic needs, such as food, clothing, or shelter. This can also include an inability to seek necessary medical care or ensure their personal safety)." (Policy No.: SC.QRM.PCS.023), with revised date of 3/12/2018, the document indicated the following:
Provisions and Procedures for the Emergency Department & Labor and Delivery (L&D) Triage
Initial Suicide Risk Screen
o During the triage and/or admitting process, the Registered Nurse (RN) shall complete a suicide risk screening using the C-SSRS on any of the following patients age ten (10) years and older.
o Patients who present with a behavioral health related primary complaint.
o Patients exhibiting signs/symptoms of self-harm.
o Patients who are identified with risk factors for suicide; and/or whenever the nurse's clinical judgment determines a risk screen is appropriate.
o For patients age nine (9) years and under who present with suicidal thoughts and behavior, follow policy and procedures as outlined below in collaboration with parent/guardian.

Based on interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 19), a plan of care (a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Heart Failure (also known as congestive heart failure, occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), was developed and implemented upon completion of assessment (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for not addressing Patient 19's care needs and risks, which may delay the implementation of necessary interventions resulting in complications such as kidney damage, irregular heartbeat, and cardiac arrest (when the heart stops beating).

Findings:

During a review of Patient's 19 "History and Physical (H&P, a formal and complete assessment of the patient and the problem," dated 04/02/2025, the H&P indicated that Patient 19 had a past medical history of diabetes (a condition where the body doesn't produce enough insulin [regulates sugar levels in the bloodstream] that leads to high blood sugar levels), heart failure and asthma (a respiratory disease characterized by inflammation and narrowing of the airways, leading to difficulty breathing, wheezing, and chest tightness) and was transferred to the hospital for shortness of breath (difficulty breathing) and congestive heart failure exacerbation (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling).

During a concurrent interview and record review on 04/03/2025 at 2:43 p.m. with the Quality Coordinator (QC) 1, Patient 19's medical record titled, "Manage Plan," undated, was reviewed. Patient 19's Manage Plan record did not indicate heart failure as part of Patient 19's plan of care (POC). QC 1 stated that the admitting nurse failed to identify and develop a heart failure POC. QC 1 added that the nurse should have initiated and developed the plan of care since heart failure was one of the reasons of Patient19's hospitalization. QC 1 further said the plan of care tracks and monitors a patient's progression and helps determine the need for intervention.

During a review of the facility's Policy and Procedure (P&P) titled, "Patient Assessment, Reassessment and Plan of Care" (Policy No.: 2120), with revised date of 10/17/2022, the P&P indicated the following:

Plan of Care:
-Upon completion of the assessment, a plan of care will be developed by all health care team members, in consultation with the patient/family as appropriate and possible.
-Care, treatment, and services are planned to ensure that they are appropriate to the patient's needs.
-Development of a plan for care, treatment, and services is based on the data from the assessments and reassessments of patient's needs and/or changes in condition.
-The plan of care will be reviewed daily in consultation with appropriate members of the heath care team and the patient/family. The plan of care will be revised as necessary and appropriate to the patient's condition and according to the patient's comprehension of disease-specific information and the ongoing assessment process.

Based on interview and record review, the facility failed to ensure assessment and monitoring of a patient's condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes, for one of 30 sampled patients (Patient 26), while placed on violent restraints (bilateral wrist and ankle restraints- the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient's violent behavior poses an immediate danger to themselves or others. Example vest restraints and wrist restraints), as per facility's policy and procedure regarding restraints use.

This deficient practice had the potential for increased risk of injury (such as skin and circulatory [blood flow] impairment), psychological distress, and/or death.

Findings:

During a review of Patient's 26's "ED (Emergency Department) Provider Notes," dated 10/14/2024, the record indicated that Patient 26 presented in the emergency department with depression (a mental disorder that can impact how you feel, think, and act) and suicidal thoughts (having abstract thoughts about ending one's life). While waiting for the psychiatric evaluation (a comprehensive assessment conducted by a psychiatrist to evaluate a person's mental health), Patient 26 became very combative and violent requiring sedation (the administration of a sedative drug to produce a state of calm or sleep) and restraints (the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient's violent behavior poses an immediate danger to themselves or others).

During a review of Patient's 26's "Order History," dated 10/17/2024, the Order History record indicated that a medical order to place patient on bilateral (both side) wrist and ankle violent restraints (the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient's violent behavior poses an immediate danger to themselves or others. Example: vest restraints and wrist restraints), was entered on 10/17/2024 at 5:35 p.m., and was discontinued at 9:05 p.m.

During a concurrent interview and record review on 04/04/2025 at 11:30 a.m. with the patient safety officer (PSO), Patient 26's medical record titled, "Restraint Flowsheet," dated 10/17/2024, was reviewed. The PSO stated that the Restraint Flowsheet record had no documentation of assessment and monitoring regarding Patient 26's condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) from 7:15 p.m. to 9:00 p.m. on 10/17/2024.

During the same interview on 4/04/2025 at 11:30 a.m. with the patient safety officer (PSO), PSO said that per hospital policy, patients on violent restraints should be monitored and assessed every 15 minutes. The last assessment by nurse was at 7:00 p.m. which indicated the continued use of bilateral wrist and ankle restraint. PSO further stated that the order to discontinue restraint was not until 9:00 p.m. In addition, there was missing documentation of assessment and monitoring of patient's condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes from 7:15 p.m. to 9:00 p.m. on 10/17/2024.

During a review of the Policy and Procedure (P&P) titled, "Restraint Use" (Policy No.: SC.QRM.PCS.024), with revised date of 3/19/2018, the document indicated the following:
Assessment, monitoring, and documentation of all restraint types:
-Registered Nurses (RN) are responsible for the assessment, monitoring and provision of care for patients in restraints. The use of restraint (including drugs or medication used as restraint as well as physical restraint) must be documented in the patient's plan of care.

-Patient assessment by staff who have observed, examined or interacted directly with the patient will occur every 15 minutes for violent, self-destructive restraints and every 2 hours for non-violent, non-self-destructive restraints.

-Assess the patient every at least every 15 minutes and as needed to determine continued need for restraints. Assessment must include Behavior/mental status; Physical comfort; Circulation.

-Assess at least every two (2) hours. Assessment must include Nutritional needs (food/meal); Hydration needs; Elimination needs; ROM (Range of Motion) Restraints released and reapplied, one limb at a time.

Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 15), a complete pain assessment evaluation was documented, in accordance with the facility's policy regarding pain assessment and management.

This deficient practice had the potential for Patient 15's pain to be inadequately managed, potentially leading to prolonged discomfort and overall negative impact on Patient 15's recovery process. In addition, incomplete pain assessment documentation had the potential to disrupt the continuity of care for Patient 15, making it difficult for other healthcare providers to understand Patient 15's pain level, response to interventions and delays the implementation of other alternative pain management strategies.

Findings:

During a review of Patient 15's "Emergency Medicine Provider Note," dated 4/1/2025, the note indicated that Patient 15 came to the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) complaining of tingling (a sensation like pins and needles) in the left arm for two days, and pain in the right upper shoulder and cramping in the left rib cage.

During a review of Patient 15's medical record (MR) titled, "Patient Care Timeline," dated 4/1/2025 at 10:20 a.m. to 4/1/2025 at 3:33 p.m., the MR indicated that on 4/1/2025 at 10:23 a.m., Patient 15's pain level was assessed to be 3/10 (a pain level of 3/10 on a 0-10 pain scale is considered mild to noticeable pain), localized at the right shoulder. The MR also indicated that the acceptable level of pain (stated by Patient 15), was not documented.

During a concurrent interview and record review on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, Patient 15's "Pain Assessment" documentation, dated 4/1/2025, was reviewed. RN 8 reviewed Patient 15's "Pain Assessment" documentation on 4/1/2025, and stated the following:

-At 10:23 a.m.: Patient 15's recorded pain level was documented as 3/10 (0: No pain, 1-3: Mild pain, ranging from barely noticeable to distracting but manageable. At level 3, the pain is noticeable and distracting, but you can still function, 4-6: Moderate pain, interfering with daily activities, 7-10: Severe pain, disabling and interfering with the ability to perform daily tasks), localized at right shoulder. No documentation of Patient 15's acceptable level of pain, character (type of pain. Example: throbbing, sharp pain, dull, or aching), duration (the length of time a patient experiences pain), and pain aggravating factors (any elements that intensify or worsen pain. Example: movement), alleviating factors (things that help reduce or eliminate pain. Example: rest), and intervention was recorded.

-At 12:50 p.m.: Patient 15's pain level was documented 3/10, localized at right shoulder. No documentation of Patient 15's acceptable level of pain, character, duration, and pain aggravating factors, alleviating factors, and intervention was recorded.

-At 1:27 p.m.: Patient 15's pain level was recorded 3/10, acceptable pain level was documented 3/3; localized at left arm, described as throbbing and aching; intermittent in duration, aggravated by activity, and alleviated by rest and medication. Documented intervention was recorded as "Care and Medication."

-At 2:42 p.m.: Patient 15's pain level was recorded as 2/10, localized at left arm, continuous in duration. No record of acceptable pain level, character of the pain, aggravating and alleviating factors, and interventions were documented.

-At 3:04 p.m.: no documentation of Patient 15's pain level, acceptable level of pain, character, aggravating factors, alleviating factors, and intervention.

During the same interview on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, RN 8 stated that pain assessment was performed with each set of vital signs (VS, physiological measurements that indicate a person's basic bodily functions and overall health status [typically every 2 hours, unless indicated otherwise] and as needed.

During the same interview on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, RN 8 stated that a full/complete pain assessment (which includes patient's pain level, acceptable level of pain, aggravating factors, etc.) should be documented to ensure effective pain management.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 3/21/2022, the P&P indicated that, "Acute pain - is pain of short duration and the cause is usually known (i.e. Injury or surgical intervention). It generally disappears when healing occurs. Acute pain may be associated with objective physical signs ... Most often there are NO physical signs directly related to pain. The patient's subjective (self) report of the presence of pain is all that is needed to initiate treatment ... 4.2. Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan.
4.3. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment and defined criteria based on patient condition, age, and ability to understand during Emergency department visit and at the time of admission to inpatient.
4.4. The patient will be reassessed as to patient's response to pain through the following: Evaluation and documentation of response to pain interventions, including pain medication administration. The patient will be reassessed for pain scale or level of pain within 60 minutes (within one hour) of pain medication administration.
5.2. Ongoing Pain Management: a. Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge
5.5 Documentation: Pain will be recorded as part of the initial admission patient assessment or as appropriate to the setting with every full set of vital signs ... g. The functional pain goal (patient's acceptable level of pain) will be documented every shift.

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

1.a. Ensure the medical record for one of 30 sampled patients (Patient 1) contained complete documentation of a code blue event (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation). The "Code Narrator report (a tool that helps document and track key events during a code)" for Patient 1 lacked required clinical elements including cardiac rhythm (the timing and pattern of the heart's electrical signals, which determine how the heart beats), timing of chest compressions (push on the person's chest in resuscitation), pulse checks (moments when medical staff checks for a heartbeat), and code team member roles, in accordance with the facility's code blue policy.

This deficient practice impeded the facility's ability to review what actions were taken during emergency, to understand how care was provided, and to identify ways to improve future emergency responses.

1.b. Ensure that the medical record for one of 30 sampled patients (Patient 1) included a complete and authenticated documentation of care, as required by the Physician Assistant (PA, a healthcare professional licensed to practice medicine under physician supervision) 1's practice agreement, and the facility's medical staff rules and regulations. Specifically, the Emergency Department (ED) triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note, documented by PA 1, was not co-signed by a supervising physician, as required.

This deficient practice resulted in the medical record lacking documentation required to validate that the services provided by the PA 1 were reviewed by a supervising physician. The absence of a co-signature prevented confirmation that oversight was performed in accordance with the practice agreement and facility policy, which may have an impact on patient safety.

2. Ensure that one of 30 sampled patients' medical records (Patient 9) were complete, containing documentation of justification for the continued use of restraints (the use of physical or mechanical devices to limit patient movement. Example wrist restraints), in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to compromise Patient 9's safety by allowing restraints to be applied without oversight and evaluation, increasing the risk of physical (example: skin breakdown [damage to the skin], circulatory issues [any condition such as tightly applied wrist restraints that impede blood flow]) and psychological harm (example: anxiety [a feeling of dread and uneasiness], trauma, etc.) to the patient (Patient 9).

Findings:

1.a. During a review of Patient 1's "ED (emergency department) Provider Notes," dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD)1, Patient 1's electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled, "Code (Code Blue- a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation) Narrator Report (a tool that helps document and track key events during a code)," dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a pulseless electrical activity (PEA, the heart electrical signals are working but the heart is not pumping blood). ACD 1 confirmed that Patient 1's heart rhythm was not documented in the Code Narrator report.

During the same interview on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 further stated that during a code, each time a pulse was checked, the corresponding cardiac rhythm (the timing and pattern of the heart's electrical signals, which determine how the heart beats) should be documented. ACD 1 confirmed the report also lacked the documentation of the time chest compressions (the act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation) were started and stopped, and the specific roles of the code team members were not indicated as well. ACD 1 confirmed that these documentation elements were required as part of the code record and emphasized the importance of documenting time-stamped clinical actions during a code event.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue Response- Adult Medical Center Campus," dated 6/21/2021, the P&P indicated, "To provide guidance for the development of a standardized level of care provided to the adult patient experiencing a cardiac and/or respiratory arrest ... All those involved in the Code Blue situation respond in accordance with the American Heart Association Basic Life Support and Advanced Cardiovascular Life Support guidelines ... An accurate, chronological documentation record will be completed and submitted as part of the legal medical record for the patient in all Code Blue situations ... A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. A Code Blue Evaluation Form will be completed during the debriefing critique of the code and forwarded to the Quality Department."

During a review of the "American Heart Association (a non-profit organization dedicated to fighting heart disease and stroke through research, education, and advocacy)" Guidelines, dated 2020, the Guideline indicated providers are expected to document the patient's condition before, during, and after a resuscitation attempt, including time of arrest, interventions (such as CPR [Cardiopulmonary Resuscitation- An emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped] and Defibrillation- a medical procedure using electrical shocks to restore a normal heart rhythm), response to treatment, and names and roles of responders. This documentation is essential for legal, clinical, and quality assurance (a proactive approach to ensure establishments consistently deliver high-quality service and amenities, meeting or exceeding established standards) purposes.

During a review of the facility's emergency department policy and procedure (P&P) titled, "Nursing initial Assessment and Re-Assessment Documentation," dated 5/3/2023, the P&P indicated, "Nursing Interventions - will be documented on appropriate flowsheets in KPHC, as applicable, otherwise, the RN will document in the ED Notes section to ensure that interventions are documented. Patient care status updates and other general information pertaining to patient care will also be documented in the ED Notes section, unless otherwise specified."

1.b. During a concurrent interview and record review on 4/2/2025 at 2:03 p.m. with the Patient Safety Officer (PSO, a staff member responsible for monitoring and promoting safety practices), Patient 1 's medical record documented by Physician Assistant (PA 1) titled, "ED Provider Triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) Note," dated 2/10/2025, was reviewed. The record indicated that the note had not been co-signed (formally reviewed and signed by another provider, in this case, a supervising physician). PSO confirmed that the note was not co-signed by a supervising provider.

During an interview on 4/4/2025 at 10:15 a.m. with the Assistant Area Medical Director (MD) 7, MD 7 stated that the Physician Assistant (PA, a licensed healthcare professional who works under the supervision of a physician, providing medical care and performing a range of diagnostic and treatment tasks) who is working in the triage area were supervised by physicians and that the entire PA note was expected to be reviewed and co-signed by a supervising physician.

During a review of Physician Assistant (PA) 1's Practice Agreement, dated 4/27/2023, the Practice Agreement indicated: "According to California law, a PA may perform medical services if the following requirements are met: 1) The PA renders the services under the supervision of a licensed physician and surgeon. Supervising Physicians shall be available in person or by electronic communication at all times when the PA is performing medical service. The supervising physician shall review, countersign, and date within 24 hours the admitting history and physical of any hospitalized patient completed by the physician assistant."

During a review of the facility's "Rules and Regulations of the Professional Staff," dated 2023, the Rules and Regulation indicated, "Complete Medical Record: The attending practitioner(s) shall be responsible to assure that a complete, legible, dated and authenticated medical record is prepared for each patient accepted for care by the Hospital. This record shall be in such form and shall contain such information as the Executive Committee and Hospital Administrator shall jointly prescribe. Entries in the medical record may be electronic or hard copy."

2. During a review of Patient 9's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 2/11/2025, the H&P indicated that Patient 9 was admitted with a chief complaint of altered mental status (AMS, a change in a person's normal mental function, encompassing alterations in consciousness [temporary changes in a person's awareness and perception of the world, often accompanied by shifts in behavior], cognitive function [includes ability to learn, recall events, decision-making, etc.], behavior, or alertness, ranging from mild confusion to coma [a prolonged state of unconsciousness where a person is unresponsive to their environment, unable to wake, and does not react to stimuli like pain, sound, or light]).

During a review of Patient 9's medical record (MR) titled, "Order History(a record of all the physician's orders [instructions] for a patient's treatment, including medications, tests, procedures, and other care directive), dated 2/10/2025, the MR indicated that on 2/10/2025 at 9:59 p.m., an order for nonviolent, bilateral (both) wrist restraints (physical restraints designed to limit a patient's movement, typically used for medical or surgical purposes, to prevent harm to themselves or others, or to ensure the integrity of medical equipment, while not intended to address violent or aggressive behavior), was placed by the emergency department (ED) physician.

During a review of Patient 9's medical record (MR) titled, "Documentation Flowsheet (for restraints assessment)," dated 2/10/2025, the MR indicated the following:
-On 2/10/2025 at 10:00 p.m., bilateral wrist restraints were applied to Patient 9. The MR also indicated that the clinical justification for restraint use was documented as the patient (Patient 9) pulling tubes and lines (which refers to the patient attempting to remove medical devices such as intravenous [IV, through the vein] lines or catheters, posing a risk to their safety or treatment efficacy].
-On 2/10/2025 at 11:00 p.m. and at 1:00 a.m., justification (the patient's behavior that warranted the use of the restraints) for the bilateral use of wrist restraints was not documented.

During an interview on 4/3/2025 at 2:06 p.m. with registered nurse (RN) 8, RN 8 stated the following: "We document the justification in the restraint assessment to indicate the reason for keeping the patient in restraints. When there is no reason to keep the patient in restraints, patient should not be in restraints."

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 9/2022, the P&P indicated the following:
5.8. Assessment, monitoring, and documentation of all restraint types:
5.8.2. Patient assessment by staff who have observed, examined or interacted directly with the patient will occur every 2 hours for non-violent, non-self-destructive restraints.
5.8.4. A description of the patient's behavior or symptom(s) that warranted the use of the restraint and the patient's condition.

Based on interview and record review, the facility failed to ensure that medical record for one of 30 sampled patients (Patient 1) included documentation from the physician (MD 1) who discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation). MD 1 did not record a physical assessment (a hands-on examination), clinical observations, or actions taken in response, in accordance with the facility's policy regarding medical records content.

This deficient practice resulted in an incomplete medical record and impaired the facility's ability to evaluate the care provided, ensure continuity of care (the consistent and coordinated management of a patient's treatment across shifts or providers), prevented a full understanding of the patient's condition during the emergency, and made it harder for the facility to review and improve its emergency procedures.

Findings:

During a review of Patient 1's "ED (emergency department) Provider Notes," dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a review of Patient 1's "triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note," dated 2/10/2025, the triage note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity [severity] and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1 (most urgent level requiring immediate life-saving intervention).

During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person's blood) and all, but one cardiac monitor lead (provides different views of the heart's electrical activity), was disconnected. MD 2 stated MD 1 checked Patient 1's pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse.

During a concurrent interview and record review on 4/2/2025 at 11:30 a.m. with Informatic staff member (IN, staff member responsible for managing the hospital's electronic medical records system) 1, Patient 1's physician notes, was reviewed. IN 1 confirmed that MD 1, the physician who found Patient 1 unresponsive on 2/10/2025, did not enter a note in Patient 1's medical record (a collection of written or digital documents that contain information about a patient's health, diagnoses, treatments, and other medical history). IN 1 confirmed that there was no documentation describing what MD 1 observed, what was assessed, or whether any actions or instructions were given to staff.

During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director and Ancillary Chief of Staff (MD 7), MD 7 stated that physicians were expected to document all patient encounters before the end of their shift. MD 7 stated that when a physician discovers a patient unresponsive, the expectation was to record a note with observations and actions taken. This information was necessary to ensure other healthcare staff can understand the event and provide consistent, informed care. MD 7 confirmed that such documentation was essential for communication between medical teams and supports safe and effective care.

During a review of the facility's policy and procedure (P&P) titled, "Medical Records Content-Medical Staff," dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overseeing the patient's hospital care) is required to complete a medical record that includes a history of the present illness (a summary of symptoms and their development), physical examination(a hands-on evaluation of the patient 's condition), progress notes (written updates on clinical status), and final findings (the physician's conclusions based on treatment and outcomes). The policy also states that current records should be completed within 24 hours.

Based on observation, interview and record review, the facility failed to ensure that medical records for two of 30 sampled patients (Patient 9 and Patient 14) were complete, when:

1. Patient 9's medical records had no documentation of physician's order for continuous cardiac (heart)monitoring (encompasses all methods of heart rate and rhythm (the pattern and regularity of the heart's beat) monitoring, including remote monitoring and often involves bedside displays), in accordance with the facility's policy regarding cardiac monitoring.

This deficient practice had the potential to compromise Patient 9's safety by delaying timely placement of Patient 9 on a cardiac monitor and potentially preventing timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 9.

2. Patient 14's medical record had no documentation of the following:

2.a. Physician's order for continuous cardiac monitoring was not placed by the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) provider, in accordance with the facility's policy regarding cardiac monitoring and policy on Rules and Regulations for the Professional Staff.

This deficient practice had the potential to compromise Patient 14's safety by delaying timely placement of Patient 14 on a cardiac monitor and/or not continuously monitoring Patient 14's heart rhythm potentially delaying timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 14.

2.b. No documentation of cardiac rhythm in the flowsheet assessment record despite Patient 14 being observed to be connected to a cardiac monitor, in accordance with the facility's policy regarding cardiac monitoring and documentation.

This deficient practice had the potential to compromise Patient 14's safety by preventing other healthcare providers not to be able to promptly recognize and respond to changes in the Patient 14's cardiac condition, leading to potential delays in necessary treatment and intervention.

Findings:

1. During a review of Patient 9's medical record (MR) titled, "Emergency Department (ED) Physician Note," dated 2/10/2025, the MR indicated the following: Patient (Patient 9) presented to the facility's ED with altered mental status (AMS, a change in a person's normal mental function, encompassing alterations in consciousness [temporary changes in a person's awareness and perception of the world, often accompanied by shifts in behavior], cognitive function [includes ability to learn, recall events, decision-making, etc.], behavior, or alertness, ranging from mild confusion to coma [a prolonged state of unconsciousness where a person is unresponsive to their environment, unable to wake, and does not react to stimuli like pain, sound, or light]) and agonal breathing (an abnormal, often labored breathing pattern characterized by shallow, gasping breaths or snorting sounds, that can occur during the early stages of cardiac arrest [when the heart stops beating] or near death). The MR further indicated that:

-Patient 9 was found with acute respiratory failure (a life-threatening condition where the lungs suddenly fail to adequately oxygenate the blood or remove carbon dioxide, leading to hypoxia [low oxygen levels]) and was intubated (the medical procedure of inserting a tube into the airway to help with breathing).
-Patient 9 was also found with hypoglycemia (low blood sugar, life threatening condition), requiring continuous medication administration
-Patient 9 also had persistent hypotension (a condition in which blood pressure is abnormally low) requiring multiple pressors (medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs]).

During a review of Patient 9's medical record (MR) titled, "Order History, a record of all the physician's orders [instructions] for a patient's treatment, including medications, tests, procedures, and other care directive), dated 2/10/2025, the MR indicated that on 2/10/2025, there was no order placed for continuous cardiac monitoring for Patient 9 on 2/10/2025 during Patient 9's stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention). This information was verified by registered nurse (RN 8) during an interview on 4/3/2025.

During concurrent interview and record review on 4/3/2025 at 1:57 a.m. with Registered Nurse (RN) 8, Patient 9's medical record (MR) titled, "Vital Signs Flowsheet (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), dated 2/10/2025, was reviewed. The MR indicated that Patient 9's heart rhythm (rate) was monitored and documented in Patient 9's Vital Signs flowsheet. RN 8 stated the following:

-"In our Emergency Department (ED), placing patients on a cardiac monitor is a standard of practice and is done at the nurse's discretion. Typically, patients classified as ESI 3 (Emergency Severity Index level 3, indicating patients who require urgent care but are not in immediate danger) and higher (ESI 2 and ESI 1, indicating more critical needs) are required to be on a cardiac monitor, especially if they are receiving certain medications that may affect cardiac function, such as antiarrhythmics or other drugs that can cause changes in heart rhythm (such as pressors, medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs])."

-"I (RN 8) typically place my patients on a cardiac monitor, particularly when their clinical presentation warrants it. Regarding documentation, I do document any abnormal heart rhythms in a patient chart, but I do not typically document a normal heart rhythm."

During an interview on 4/4/2025 at 10:02 a.m. with Assistant Area Medical Director for Hospital Services (MD 7), MD 7 stated that the flow of orders should be from the doctor to the nurse. If the nurse recognized that a patient required cardiac monitoring or if the nurse had already placed a patient on a cardiac monitor, the nurse should approach the physician and notify them (the physicians) to obtain an order (for cardiac monitoring). MD 7 then said that a continuous cardiac monitoring required a physician to place an order for it. MD 7 further stated that "if a patient was to be admitted to a telemetry (a specialized ward where patients receive continuous electronic monitoring of their vital signs, particularly heart rhythm and rate, allowing healthcare providers to track and respond to any changes remotely) unit, the patient should also be monitored in the ED."

During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: "Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor and [document] the heart rate and rhythm of the patient."

During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following regarding cardiac monitoring orders: "There are doctors that do place orders for cardiac monitoring at times, but the majority of doctors don't."

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (ADULT)," dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility's commitment to ensure patient safety through appropriate care delivery interventions. 4.1. Cardiac Telemetry Monitoring - Cardiac Telemetry monitoring is an intervention to continuously monitor the cardiac rhythm and any associated changes in rate and/or characteristics. Cardiac Telemetry monitoring is utilized throughout multiple patient care units with 24-hour visualization by competent healthcare personnel. 5.1.1 A physician's order is required for telemetry monitoring/cardiac monitoring and discontinuation.

During a review of the facility's policy and procedure (P&P) titled, "Standardized Emergency Registered Nurse procedures," dated 10/2024, the P&P indicated the following: 4 .... Altered Level of Consciousness (Altered Mental Status, AMS) ...Place patient on a cardiac monitor when treatment room is available ...
During a review of the facility's employee document titled, "Nursing Expectations, Norms, and Workflows," dated 8/2023, the document indicated the following: Patients who are presenting with a cardiac, respiratory, and neurological complaint are to be placed on a cardiac monitor.

During a review of the facility's Rules and Regulations for the Professional Staff (Rules and Regs), dated 2023, the Rules and Regs indicated the following: Medical Records: 1. The attending practitioner(s) shall be responsible to assure that a complete ...medical record is prepared for each patient accepted for care by the Hospital ...xiv. Medications, assessments, and treatments are ordered ...

2.a. During a review of Patient 14's medical record (MR) titled, "Emergency Department (ED) Patient Care Timeline," dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), the MR indicated the following:

-On 4/1/2025, at 11:38 p.m., Patient 14 arrived in the ED complaining of abdominal pain.
-On 4/1/2025, at 11:43 a.m., Patient 14 was triaged (a patient has been sorted and prioritized for treatment based on the urgency of their condition), given Emergency Severity Index (ESI) level of 3 (urgent condition, but the patient is stable).
-On 4/1/2025 at 11:50 a.m., Patient 14 was reassessed to ESI level of 2 (considered high-risk and should not be left unattended for any length of time).
-On 4/1/2025 at 12:02 p.m., an ED provider was assigned to Patient 14.
-On 4/1/2025 at 12:12 p.m., Patient 14 was moved to a room.

During an observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, a remote cardiac monitor (a device that enables nurses and other healthcare staff to continuously monitor the cardiac rhythms of multiple patients from a central location, providing real-time data on heart rates and rhythm abnormalities) located at the nurses' station, was observed. The monitor displayed multiple patients' various vital information, including the heart rhythm, heart rate, blood pressure, respirations, and SpO2 (peripheral oxygen saturation, refers to the percentage of hemoglobin in your blood that is carrying oxygen, as measured by a pulse oximeter).

During the same observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, Patient 14's cardiac rhythm was observed to be irregular (as displayed on the cardiac monitor), with a heart rate ranging from 116-126 beats per minute (bmp). Not all patients were observed to be displaying cardiac rhythms on the monitor.

During an interview on 4/2/2025 at 1:58 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following: "The doctor and the nurse work together to assess whether the patient needs to be connected to a cardiac monitor. If they determine that monitoring is necessary, the physician can then place an order for cardiac monitoring to ensure continuous observation of the patient's heart rhythm and vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Cardiac monitoring depends on a chief complaint and the assessment of the patient."

During an observation on 4/2/2025 at 2:35 p.m., Patient 14 was observed in the room (located in the ED), lying on a gurney, connected to a cardiac monitor.

During a concurrent interview and record review on 4/3/2025 at 11:02 a.m., with Registered Nurse (RN) 8, Patient 14's "Emergency Department (ED) Patient Care Timeline," dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), was reviewed. RN 8 stated that Patient 14s "ED Patient Care Timeline" had no documentation indicating whether Patient 14 was placed on a cardiac monitor during Patient 14's stay in the ED. RN 8 also said that Patient 14's medical record contained no documentation of the physician 's order for continuous cardiac monitoring.

During a review of Patient 14's History and Physical (H&P, a comprehensive assessment performed by a healthcare provider that includes a thorough medical history and a physical examination), dated 4/1/2025, the H&P indicated that Patient 14 had past medical history (PMH, previous illnesses, surgeries, and medication) of atrial fibrillation (AFib, a common type of arrhythmia [irregular heartbeat] where the heart's upper chambers [atria] beat chaotically and too quickly, potentially leading to blood clots, stroke [clot in the brain], heart failure [(the heart can't pump enough blood to meet the body's needs, often due to a weakened or stiffened heart muscle], and other heart-related complications), heart failure and pulmonary hypertension (a condition characterized by high blood pressure in the arteries of the lungs, making the right side of the heart work harder to pump blood through the lung). The H&P also indicated that Patient 14 was admitted to the facility with a diagnosis of acute hypoxemic respiratory failure (a condition where the lungs are not effectively delivering enough oxygen to the blood, leading to low oxygen levels in the blood).

During an interview on 4/3/2025 at 1:57 a.m. with Registered Nurse (RN) 8, RN 8 stated the following:

-"In our Emergency Department (ED), placing patients on a cardiac monitor is a standard of practice and is done at the nurse's discretion. Typically, patients classified as ESI 3 (Emergency Severity Index level 3, indicating patients who require urgent care but are not in immediate danger) and higher (ESI 2 and ESI 1, indicating more critical needs), are required to be on a cardiac monitor, especially if they are receiving certain medications that may affect cardiac function, such as antiarrhythmics or other drugs that can cause changes in heart rhythm [such as pressors, medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs])."

-"I typically place my patients on a cardiac monitor, particularly when their clinical presentation warrants it."

During an interview on 4/4/2025 at 10:02 a.m. with the Assistant Area Medical Director for Hospital Services (MD 7), MD 7 stated that, "The flow of orders should be from the doctor to the nurse. If the nurse recognizes that a patient requires cardiac monitoring or if the nurse has already placed a patient on a cardiac monitor, the nurse should approach the physician and notify them (the physicians) to obtain an order." MD 7 then said that a continuous cardiac monitoring requires a physician to place an order for it, "If a patient is admitted to a telemetry (a specialized ward where patients receive continuous electronic monitoring of their vital signs, particularly heart rhythm and rate, allowing healthcare providers to track and respond to any changes remotely) unit, the patient should also be monitored in the ED."

During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: "Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor the heart rate and rhythm of the patient."

During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following regarding cardiac monitoring orders: "There are doctors that do place orders for cardiac monitoring at times, but most doctors don't.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (ADULT)," dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility's commitment to ensure patient safety through appropriate care delivery interventions. 4.1. Cardiac Telemetry Monitoring - Cardiac Telemetry monitoring is an intervention to continuously monitor the cardiac rhythm and any associated changes in rate and/or characteristics. Cardiac Telemetry monitoring is utilized throughout multiple patient care units with 24-hour visualization by competent healthcare personnel. 5.1.1 A physician's order is required for telemetry monitoring/cardiac monitoring and discontinuation.

During a review of the facility's employee document titled, "Nursing Expectations, Norms, and Workflows," dated 8/2023, the document indicated the following: Patients who are presenting with a cardiac, respiratory, and neurological complaint are to be placed on a cardiac monitor.

During a review of the facility's the Rules and Regulations for the Professional Staff (Rules and Regs), dated 2023, the Rules and Regs indicated the following: Medical Records: 1. The attending practitioner(s) shall be responsible to assure that a complete ...medical record is prepared for each patient accepted for care by the Hospital ...xiv. Medications, assessments, and treatments are ordered ...

2.b. During a review of Patient 14's medical record (MR) titled, "Emergency Department (ED) Patient Care Timeline," dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), the MR indicated that Patient 14 arrived to the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) on 4/1/2025 at 11:38 p.m. complaining of abdominal pain. The MR also indicated that Patient 14 was moved to a room in the ED at 12:12 p.m. on 4/1/2025.

During an observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, a remote cardiac monitor (a device that enables nurses and other healthcare staff to continuously monitor the cardiac rhythms of multiple patients from a central location, providing real-time data on heart rates and rhythm abnormalities) located at the nurses' station, was observed. The monitor displayed multiple patients' various vital information, including the heart rhythm, heart rate, blood pressure, respirations, and SpO2 (peripheral oxygen saturation, refers to the percentage of hemoglobin in your blood that is carrying oxygen, as measured by a pulse oximeter). Patient 14's cardiac rhythm was observed to be irregular (as displayed in the cardiac monitor), with a heart rate ranging from 116-126 beats per minute (bmp).

During an interview on 4/2/2025 at 1:58 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following: "The doctor and the nurse work together to assess whether the patient needs to be connected to a cardiac monitor. If they determine that monitoring is necessary, the physician can then place an order for cardiac monitoring to ensure continuous observation of the patient's heart rhythm and vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Cardiac monitoring depends on a chief complaint and the assessment of the patient."

During an observation on 4/2/2025 at 2:35 p.m., Patient 14 was observed in the room in the ED, lying on a gurney, connected to a cardiac monitor.

During a concurrent interview and record review on 4/3/2025 at 11:02 a.m. with Registered Nurse (RN) 8, Patient 14's "Emergency Department (ED) Patient Care Timeline," dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), was reviewed. RN 8 stated that Patient 14's "ED Patient Care Timeline" had no documentation indicating whether Patient 14 was placed on a cardiac monitor during Patient 14's stay in the ED.

During further review of Patient 14's medical record (MR) titled, "Documentation Flowsheet-Vital Signs, (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.),, the MR indicated that no cardiac rhythm (heart rate and pattern) was documented under the space allocated for documentation of cardiac rhythm, which is called "Monitored Cardiac Rhythm (section in the medical record where continuous heart rhythms of the patient being monitored are recorded)" and "Cardiac Rhythm Interval Monitoring (involves tracking and documentation the time intervals of different rhythms to assess for any irregularities or changes in the patients' heart function over time)."

During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: "Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor and document the heart rate and rhythm of the patient."

During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated that current practice for cardiac monitoring documentation requirements included documentation of the patient's cardiac rhythm on the patient's comprehensive assessment flowsheet at least once a shift and/or when there was a change in the heart rhythm.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (ADULT)," dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility's commitment to ensure patient safety through appropriate care delivery interventions. 5.6. Documentation in electronic medical record:
5.6.1 Rhythm and rate, as required by unit standards

Based on interviews and record review, the facility failed to:

1. Ensure that qualified medical personnel (QMP, a healthcare provider authorized by the facility to evaluate and treat emergency patients) fulfilled responsibilities to evaluate and document emergency care for one of 30 sampled patients (Patient 1), in accordance with the facility's policy regarding medical records content. Specifically, the physician (MD 1) who found Patient 1 unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025, did not document any clinical findings, assessments (medical evaluation of the patient's condition), or medical interventions (steps taken to treat the patient [Patient 1]).

This deficient practice resulted in the facility being unable to confirm whether timely and emergency care was provided. This omission limited the facility's ability to verify the care rendered during the critical event and prevented staff from fully understanding and evaluating the effectiveness of the emergency care provided.

2. Ensure that emergency department staff documented in the Code Narrator (a tool that helps document and track key events during a code)" report regarding Patient 1's cardiac rhythm (pattern of the heart's electrical activity), time of pulse checks (moments when medical staff checks for a heartbeat), initiation of chest compressions (starting of manual pressing on the chest to restore circulation), or identification of responding team members during the code blue (a hospital-wide emergency called when patient is experiencing cardiac [heart] or respiratory arrest [stopped breathing]) on 2/10/2025.

This deficient practice impeded the facility's ability to assess the adequacy of the emergency response and limited the continuity of care (coordinated and consistent care among healthcare team members) by preventing post-event clinical evaluation, hindering quality assurance (a proactive approach to ensuring that services and amenities consistently meet or exceed established standards for excellence, guest satisfaction, and operational efficiency) processes, and restricted the facility's ability to identify areas for improvement in resuscitation (the act of reviving a patient from apparent death) practices.

Findings:

1. During a review of Patient 1's "ED (emergency department) Provider Notes," dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history which included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a review of Patient 1's "triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note," dated 2/10/2025, the note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1, the most urgent level requiring immediate life-saving intervention.

During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person's blood) and all leads, but one cardiac monitor lead (provides different views of the heart's electrical activity), was disconnected. MD 2 stated MD 1 checked Patient 1's pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse.

During a concurrent interview and record review on 4/2/2025 at 11:30 a.m. with the Informatic staff member (IN, staff member responsible for managing the hospital's electronic medical records system) 1, IN 1 confirmed that MD 1, the physician who found Patient 1 unresponsive on 2/10/2025, did not enter a note in Patient 1's medical record (a collection of written or digital documents that contain information about a patient's health, diagnoses, treatments, and other medical history). IN 1 verified that MD 1 did not document Patient 1's clinical condition, and physical examination (a hands-on examination of patient's body by a healthcare provider), interventions, or the timeline of events related to the incident.

During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director and Ancillary Chief of Staff (MD 7), MD 7 stated that all physicians were expected to complete documentation for any patient encounters by the end of their shift. MD 7 stated that when a physician discovers a patient unresponsive, it was standard practice to document the findings and action taken. MD 7 further stated that such documentation was necessary to ensure that care was coordinated, and that other clinical staff understand the patient's condition. MD 7 confirmed that documentation of significant events was essential for communication among medical professionals and supports safe and effective care delivery.

During a review of the facility's policy and procedure (P&P) titled, "Medical Records Content-Medical Staff," dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overall care of the patient during hospitalization) was required to complete a medical record that included: a history of the present illness (a summary of patient's current symptoms and the timeline of their development), physical examination findings (a hands-on evaluation of the patient 's condition), progress notes (written documentation of the patient's status and response to treatment), and final findings (a summary of diagnoses and care conclusion). The policy also indicated that current records should be completed within 24 hours.

2. During a review of Patient 1's "ED (emergency department) Provider Notes," dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance, from home, with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival.

During a review of Patient 1's "Code Narrator Report (a tool that helps document and track key events during a code)," dated 2/10/2025, the Code Narrator Report indicated that a code blue (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation) was initiated at 8:40 p.m. on 2/10/2025. However, the report did not include documentation of when chest compressions (starting of manual pressing on the chest to restore circulation [blood flow]) began, Patient 1's cardiac rhythm (the timing and pattern of the heart's electrical signals, which determine how the heart beats) during the event, the timing of pulse checks (moments when medical staff checks for a heartbeat), or the identity and assigned roles of the team members who responded to the emergency.

During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD)1, ACD 1 confirmed that the Code Narrator Report lacked documentation of critical information such as the cardiac rhythm, pulse checks, and timing of chest compressions. ACD 1 sated, "This information should be part of the code documentation."

During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director (MD 7), MD 7 validated that documentation during a code was necessary to understand what interventions were performed and when. MD 7 stated this type of documentation was expected for all code blue responses to help ensure accurate evaluation of care and support informed clinical decision-making.

During a review of the facility's policy and procedure (P&P) titled, "Medical Records Content-Medical Staff," dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overseeing the patient's hospital care) was required to complete a medical record that includes a history of the present illness (a summary of symptoms and their development), physical examination (a hands-on evaluation of the patient 's condition), progress notes (written updates on clinical status), and final findings (the physician's conclusions based on treatment and outcomes). The policy also indicated that current records should be completed within 24 hours.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue Response- Adult Medical Center Campus," dated 6/21/2021, the P&P indicated, "To provide guidance for the development of a standardized level of care provided to the adult patient experiencing a cardiac (heart stops beating) and/or respiratory arrest (stopped breathing) ... All those involved in the Code Blue situation respond in accordance with the American Heart Association Basic Life Support and Advanced Cardiovascular Life Support guidelines ... An accurate, chronological documentation record will be completed and submitted as part of the legal medical record for the patient in all Code Blue situations ... A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. A Code Blue Evaluation Form will be completed during the debriefing critique of the code and forwarded to the Quality Department."

During a review of the "American Heart Association (AHA, a non-profit organization dedicated to fighting heart disease and stroke through research, education, and advocacy)" Guideline, dated 2020, the AHA Guideline indicated providers are expected to document the patient's condition before, during, and after a resuscitation attempt, including time of arrest (cardiac/respiratory arrest), interventions (such as CPR [Cardiopulmonary Resuscitation- An emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped] and Defibrillation a medical procedure using electrical shocks to restore a normal heart rhythm), response to treatment, and names and roles of responders. This documentation is essential for legal, clinical, and quality assurance purposes.

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

1. Ensure the annual educational requirements (the mandated training and continuing education that employees must complete each year to maintain their knowledge skills and compliance with regulatory standards) for three of 10 sampled Emergency Department (ED)employees (E2, E5 and E7) were completed, in accordance with the facility's annual educational requirements for employees and regulatory standards.

This deficient practice had the potential to compromise quality of patient care delivered by employees who may lack current knowledge and training necessary to provide effective treatment.

2. Ensure Annual competencies (assessments and evaluations to determine if employees possess the necessary skills and abilities required for their positions) for one of 10 sampled Emergency Department staff member (E5), were completed as indicated by the facility's procedures regarding annual competency trainings.

This deficient practice had the potential to result in compromised patient safety and quality of care when healthcare professionals may not be equipped with the knowledge to provide safe, effective, and high-quality care to patients.

Findings:

1.a. During a concurrent interview and record review on 4/4/2025 at 3:45 p.m. with the Assistant Clinical Director (ACD 1), Employee 2's (E2) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. ACD 1 stated that E 2's file was missing a completed rhythm recognition web-based (involves using the internet and online platforms to deliver educational content and training programs) training for 2024 (the process of identifying and interpreting various heart rhythms which is essential for effective patient care in emergency settings) that was required for ED nursing staff to be completed annually.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/2022, the P&P indicated that: 5.4. Registered Nurses' (RN) education and Competency: ...Newly hired and/or transferring RNs ...be accountable for completing annual competency validation on rhythm strip (test records the electrical activity of the heart) recognition and proper use of monitoring equipment ...

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department (ED) Scope of Service," dated 5/2023, the P&P indicated the following: "Inservice/Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ..."

1.b. During a concurrent interview and record review on 4/4/2025 at 4:20 p.m. with the Assistant Clinical Director (ACD 1), Employee 5's (E5) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. E5's file contained no record of rhythm recognition web-based training completed in 2024 and was also missing EMTALA (the Emergency Medical Treatment and Labor act, a federal law that requires hospitals to provide emergency medical treatment to patients regardless of their ability to pay or insurance status) training for 2024. ACD 1 stated that these two educational trainings (Rhythm Recognition and EMTALA) were required for the emergency staff to be completed annually to demonstrate staff competencies as required by the facility.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department (ED) Scope of Service," dated 5/2023, the P&P indicated the following: "Inservice/Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ..."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA)," dated 5/15/2023, the P&P indicated the following: 5.17.2 Training and education on EMTALA requirements will be provided to ED staff during new employee orientation and annually.
During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," dated 5/2022, the P&P indicated that: 5.4. RN education and Competency: ...Newly hired and/or transferring RNs ...be accountable for completing annual competency validation on rhythm strip recognition and proper use of monitoring equipment ...

1.c. During a concurrent interview and record review on 4/4/2025 at 4:26 p.m. with the Assistant Clinical Director (ACD 1), Employee 7's (E7) annual mandatory education requirements for the emergency department (ED) nursing personnel, were reviewed. E7's file indicated that 2023-2024 Abuse (any intentional or unintentional harm caused to a patient by a caregiver, whether through physical, emotional, or financial means) Assessment and Reporting (to prohibit and be free from all forms of abuse which includes verbal, mental, physical, sexual, exploitation, neglect and harassment during any episode of patient care) web-based training, was missing. The ACD 1 stated that Abuse Assessment and Reporting training should be done every 2 years and was a mandatory educational requirement for the ED nursing staff.

During a concurrent interview and record review on 4/4/2025 at 4:27 p.m. with the Assistant Clinical Director (ACD 1), Employee 7's (E7) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. E7's file contained no record of EMTALA (the Emergency Medical Treatment and Labor Act, a federal law that requires hospitals to provide emergency medical treatment to patients regardless of their ability to pay or insurance status) web-based training for 2024. ACD 1 stated that EMTALA educational training was a required annual education for the emergency staff to be completed every year to demonstrate staff competencies as required by the facility Emergency Department unit.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights: Protection from Abuse, Exploitation, Neglect, and Harassment," dated 11/2023, the P&P indicated the following: "Train: All employees receive abuse training upon hire and ongoing training by the end of the second calendar year from when the employee last completed training. The training/education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA)," dated 5/15/2023, the P&P indicated the following: 5.17.2 Training and education on EMTALA requirements will be provided to ED staff during new employee orientation and annually.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department (ED) Scope of Service," dated 5/2023, the P&P indicated the following: " ...Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ..."

2. During a concurrent interview and record review on 4/4/2025 at 4:20 p.m. with the Assistant Clinical Director (ACD 1), Employee 5's (E5) annual competencies (refer to the measurable knowledge, skills, abilities, and behaviors that employees need to perform their jobs successfully, assessed and verified on an annual basis) for 2024, were reviewed. E5's file lacked E5's annual competency check-off list and skills validation for the year 2024. The ACD 1 stated that E5 was a traveler nurse, (registered nurse [RN] who accepts temporary nursing assignments in various locations and typically, traveler nurses come through an agency [contracted services] and do not stay longer than a year). The ACD 1 then said that competencies and skill checks, as well as annual performance evaluations, were not conducted for traveler nurses in the Emergency Department (ED).

During the same interview on 4/4/2025 at 4:21 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 said that Employee 5's (E5) start date at the facility was 8/23/2023 (this indicated that E5 Had been working as a travel nurse at the facility for more than one year since 2023).

During an interview on 4/4/2025 at 5:23 p.m. with the Director of Clinical Education (DCE), the DCE stated that a traveler nurse that extends their assignment beyond one year must go through the unit's regular annual competency check-off list and skills validation to ensure that they are up to date with the latest practices and protocols relevant to their role. The DCE also said that additionally, all traveler nurses were expected to complete any mandated web-based learning modules, which provide important training and updates on policies, procedures, and clinical practices.

During a review of the facility's policy and procedures (P&P) titled, "Emergency Department (ED) Scope of Service," dated 5/2023, the P&P indicated the following: " ...Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ..."

Based on interview and record review, the facility failed to ensure that four of four sampled registered nurses (E2, E4, E6, and E8), working in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), fully met the written standardized emergency procedure (established protocols that define the actions, responsibilities, and practices that registered nurses must initiate based on patients' chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician [when no triage -the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) physician was available to perform a rapid medical exam [RME, a process in emergency departments that initiates testing and evaluation of patients while they are still in the waiting room, aiming to improve patient flow and reduce wait times]) requirements and competencies needed, to be authorized to perform standardized procedures in the facility's ED.

This deficient practice had the potential to compromise patient care and safety by increasing the risk of inadequate responses to emergency situations, leading to delays in treatment and ultimately adverse patient outcomes when employees do not possess the necessary competencies in accordance with the facility's policy regarding Standardized Emergency Registered Nurse procedures.

Findings:

During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated that standardized emergency procedures (pre-defined, consistent protocols and guidelines designed to ensure a coordinated and effective response to a variety of emergencies) allowed registered nurses in triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) to place orders to initiate pre-established, presenting chief complaint-based physician orders for patients waiting for an Emergency Department (ED) physician evaluation. The ACD 2 then stated that ED Registered Nurses must pass the testing scenarios and pass the ESI (Emergency Severity Index) triage test, which was a five-level algorithm used to categorize patients based on the severity of their condition and urgency of their need for medical care. The ACD 2 also said that regarding annual competency testing for the standardized procedures, no specific frequency had been assigned to it.

During a concurrent interview and record review on 4/4/2025 at 3:31 p.m. with the Assistant Clinical Director (ACD 1), the facility's current roster of registered nurses (RNs) authorized to perform standardized procedures (effective as of 2/2/2024), was reviewed. The ACD 1 stated that the list of registered nurses (dated 2/2/2024) contained a few names of registered nurses who no longer work at the facility.

During the same interview on 4/4/2025 at 3:31 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 stated that competencies for standardized procedures were included among the annual mandatory competencies and demonstrated Employee 2's (E2) 2024 competency summary, where the ACD pointed to the Standardized Nursing Protocol policy, documented to be verbally validated by the Assistant Clinical Director (ACD 2). The ACD 1 also said that no initial competency scenario-based testing (which demonstrates understanding of the goals, scope and limitations of utilizing Emergency RN Standardized Procedures) was found in E 2's file.

During an interview on 4/4/2025 at 3:40 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 then demonstrated Employee 2's (E2) annual scenario-based testing competency with a perfect score, dated 4/12/2024. The ACD 1 verified that E2's testing competency results contained no record of being reviewed and approved by one the following:

1. Rapid Medical Exam provider
2. Full-time physician on shift for that day
3. Chief of Emergency medicine

During a concurrent interview and review on 4/4/2025 at 3:50 p.m. with the Assistant Clinical Director (ACD 1), Employee 4's (E4) personnel file, was reviewed. The E4's file contained no initial competency (scenario-based testing with results, which should be reviewed and approved by the Director of the Emergency Department). The E4's file contained 2024 scenario-based testing with results, but had no record of the reviewer (annual testing competency results should be reviewed and approved by one the following):
1. Rapid Medical Exam provider
2. Full-time physician on shift for that day
3. Chief of Emergency medicine.

During a review of Employee 6's (E6) personnel file, no initial and annual (for year 2024) scenario-based testing with results (reviewed and approved), were found in E6's personnel file. This information was confirmed by the Assistant Clinical Director (ACD 1) on 4/4/2025 at 3:55 p.m.

During a concurrent interview and record review on 4/4/2025 at 4:15 p.m. with the Assistant Clinical Director (ACD 1), Employee 8's (E8) personnel file, was reviewed. E8's personnel file contained no initial and annual (for year 2024) scenario-based testing with results reviewed and approved, in accordance with the facility's policy. ACD 1 stated that E8 was an Assistant Clinical Director (ACD) and has held this position since 2022; therefore, E8 did not require any competency testing based on the employment position.

During an interview on 4/4/2025 at 4:25 p.m. with the Assistant Clinical Director (ACD 1), the ACD reviewed the facility's current roster of registered nurses (RNs) authorized to perform standardized procedures (effective as of 2/2/2024), and stated that all four employees (E2, E4, E6, and E8) were listed on the roster as RNs currently authorized to perform standardized procedures in the Emergency Department.

During an interview on 4/4/2025 at 5:05 p.m. with the Administrator of Quality (AQ), the AQ stated that the Emergency Department leadership was ultimately responsible for the implementation of policies and procedures related to Standardized Procedures for the Emergency Department Registered Nurse.

During a review of the facility's policy and procedure (P&P) titled, "STANDARDIZED EMERGENCY REGISTERED NURSE PROCEDURES," dated 10/21/2024, the P&P indicated the following:

1.1. Emergency Department Registered Nurses who have demonstrated competency in the use of standardized orders may initiate standardized orders based on patients' chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician.

2.1. Emergency Department Registered Nurses who are functioning independently and demonstrated successful completion of the following education, training and experience: ...
a. An initial competency of scenario-based testing which demonstrates understanding of the goals, scope and limitations of utilizing Emergency Registered Nurse Standardized Procedures. The results of every Registered Nurse's competency testing shall be reviewed and approved by the Director of the Emergency Department.
b. Annual competency testing shall demonstrate the Emergency Registered Nurses understanding of the goals, scope and limitations of utilizing Emergency Registered Nurse Standardized Procedures. The results of every Registered Nurse's competency testing shall be reviewed and approved by the following:
1. Rapid Medical Exam provider
2. Full time physician on shift for that day
3. Chief of Emergency medicine

2.4. Access to list of nurses who are approved to use Standardized Procedures: A current roster of Registered Nurses who have been competency validated to perform presenting complaint based standardized procedures will be available for review.

2.6. Validation and management of Registered Nurses authorized to perform Standardized Procedures: A written record of initial and on-going competency will be maintained in the employee personnel file in the Emergency Department.

2.7. Situations to remove authorization to perform Standardized Procedures:
a. Quality and judgment concerns will be reviewed with the Registered Nurse as needed and on an annual basis.
b. Expiration of Annual competency
c. Failure of competency testing.
If a nurse has his or her authorization to perform Standardized Procedures revoked, their name will be promptly removed from the approved list in the department and with the Nurse Director.