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Based on medical record review, surveyor observations, facility policy review, and patient and staff interview, the facility failed to ensure patients were free from the use of side rails as restraints. This affected three (Patient #22, Patient #24, and Patient #25) patients identified with all four side rails in use during the survey. The hospital census was 799.

Findings include:

1. Observation and interview during tour of the Cardiac Specialty Unit (3 Red) on 11/20/24 at 4:38 PM with Staff T revealed Patient #24 in Room 3330 in bed with four side rails up and no staff in the room. At this time Staff T verified patients should only have a maximum of three side rails up or it is considered a restraint. Staff T stated Patient #24 did not have an order for restraints.

Interview with Patient #24 on 11/20/24 at 4:45 PM revealed staff always keep four siderails up on the bed. The patient stated they keep the siderails up because staff does not want him getting out of bed on his own due to being hooked up to intravenous (IV) therapy. He also stated there was a bed alarm on his bed.

Review of the medical record for Patient #24 revealed the patient was admitted directly to the Cardiac Specialty Unit (3 Red) Room 3330 on 11/16/22 at 11:32 PM from a surrounding area emergency room for cardiogenic shock and transaortic valve replacement. Review of the orders revealed no orders for restraints. Review of the flow sheets revealed on 11/21/24 the patient care assistant (PSA) documented side rails up times four from 7:50 PM through 10:18 PM. The patient was discharged to home on 11/22/24.

2. Review of the medical record of Patient #25 revealed the patient was directly admitted from home on 11/19/24 with chest pain for expedited cardiology workup. Review of the physician orders revealed there was no order for restraints.

Observation and interview during tour of the Cardiac Specialty Unit (3 Red) on 11/20/24 at 4:38 PM with Staff T revealed Patient #25 with four siderails up o the bed. It was confirmed with Staff T at the time of the observation Patient #25 had all four siderails up.

3. Interview on 11/20/24 at 4:50 PM, Patient #22, a patient on 3 Red, stated any time she was in the bed staff consistently raised all four side rails. She stated the raised side rails made her feel claustrophobic, like she was a prisoner. The patient stated she began to sleep in the chair to prevent staff from raising the siderails.

Review of the medical record of Patient #22 revealed the patient was a direct admit to the Cardiac Specialty unit (3 Red) for electrophysiology evaluation on 11/08/24 at 6:54 PM.

Review of the safe environment flow sheet revealed on 11/09/24 at 12:05 AM and 2:05 AM all four siderails were up. The medical record lacked documentation of a physician order restraints.

Review on 11/26/24 of the policy titled "Use of Restraints," effective 03/10/2022, revealed side rails are a restraint if they are used to keep a patient from getting out of bed and/or if the side rails completely surround the patient when all of the segments are up including two full length or four half-length and cannot be lowered by the patient. If a restraint is used there must be a physician order that indicates the date and time of the order, restraint type, location of the restraint, duration, reason for the restraint, multidisciplinary teams members involved in discussion and evaluation of need, attempted alternatives prior to application, or in the event of renewal, the previous 24 hours and currently observed behaviors. A renewal restraint order should be obtained daily during rounding, not to exceed 30 hours. For violent restraints visual observation must completed and documented every 15 minutes. For nonviolent restraints the visual check needs to be completed and documented every two hours.

Based on medical record review, patient interview, and staff interview, the facility failed to ensure staff performed oral care during the hospital stay for three patients (Patient #3, Patient #22, and Patient #24). The hospital census was 799.

Findings include

1. Interview on 11/20/24 at 4:50 PM, Patient #22 reported staff has not provided mouth care since she has been hospitalized. A family member brought her toothbrush from home and family provides mouth care.

Review of the medical record of Patient #22 revealed the patient was a direct admit to the Cardiac Specialty unit (3 Red) on 11/08/24 at 6:54 PM.

Review of the daily cares flowsheet from admission to the day of discharge, on 11/22/24, revealed no oral care was performed by nursing staff.

2. Review of Patient #3's medical record with Staff P revealed the patient was admitted on 10/17/24 at 6:01 AM. . The hospitalist noted on 10/17/24 the patient was diagnosed with thrush and oral Nystatin was started. Further review of the medical record revealed there was no oral care offered or provided during the patient's stay. A bed bath was noted on 10/17/24 at 9:23 PM. The patient left against medical advice (AMA) on 11/24/2024 at 8:30 PM.

This finding was verified on 11/20/24 at 11:56 AM by Staff P during the medical record review.

3. Review of Patient #24's medical record revealed the patient was admitted directly to the Cardiac Specialty Unit (3 Red) on 11/16/22 at 11:32 PM for cardiogenic shock and transaortic valve replacement. The patient was discharged home on 11/22/24. Review of the flow sheets revealed there was no oral care provided or offered except for on 11/17/24.

This finding was verified on 11/21/24 at 12:15 PM by Staff F during medical record review.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure Emergency Department personnel provided an appropriate medical screening examination which included a magnetic resonance imaging (MRI) scan and a neurosurgery consult to determine if a medical emergency condition existed in a patient prior to transfer to another emergency department (ED). (A2406)

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure Emergency Department personnel provided an appropriate medical screening examination which included a magnetic resonance imaging (MRI) scan and a neurosurgery consult to determine if a medical emergency condition existed in a patient prior to transfer to another emergency department (ED). This affected Patient #1. The census was 799.

Findings include:
The medical record revealed Patient #1 revealed the patient had a history of herniated disks and was instructed if she experienced severe back pain and incontinence of stool or urine, she should go to the nearest ED to be evaluated for cauda equina syndrome, is a serious medical emergency that occurs when the nerve roots at the base of the spinal cord are compressed. The only way to determine if this condition exists is by performing an MRI. The patient presented to a local ED on 10/26/24 for complaints of back pain, numbness of the left lower extremity, and fecal incontinence. The patient was then transferred to this ED at 3:02 PM. The history and physical at this ED revealed Patient #1 was transferred for MRI and a neurosurgery evaluation.

An ED triage transfer note stated the patient reported chronic issues with back but today woke up with fecal incontinence. The patient reported to staff she had never done this in the past. At 3:06 PM, the patient rated her pain a six on a zero to ten scale. A physician order at 3:13 PM requested a neurosurgeon consult. At 3:14 PM the ED provider note revealed medical decision making included the patient will be hospitalized, a MRI will be ordered and neurosurgery notified. At 3:29 PM an order was placed to admit the patient to the facility's Medical Observation unit. A peripheral intravenous (IV) access was placed in the patient's right antecubital at 4:07 PM. According to the Medication Administration Record (MAR), the patient was medicated with Morphine 4 milligram (mg) IV at 4:15 PM. The patient rated her pain an eight on a zero to ten scale at the time she was medicated. Review of the neurological assessment at 4:45 PM revealed the patient had numbness in her left lower extremity. At 4:59 PM the bed previously ordered in the Medical Observation unit was discontinued. At 5:00 PM an order was placed to discontinue the IV and discharge the patient. At 5:50 PM a physician ordered for the patient to be transferred to an outside hospital. The patient was discharged at 6:12 PM. The medical record lacked documentation the MRI or neurosurgery consult was obtained prior to transferring the patient.

The neurosurgeon, Staff AA, was interviewed on 11/20/24 at 12:21 PM. He stated he was not willing to do a work-up, which included a MRI, on a patient whose surgeon was in town. Staff AA stated he did not see the patient while she was in the ED and he arranged for the transfer via phone.

Review of the facility policy titled "Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA)," effective 02/10/22, defined an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any body organ or part. The policy defines medical screening examination as the process required to reach, with reasonable clinical competence, the point at which it can be determined whether or not an emergency medical condition exists. Such screening must be done within the hospital's capability and available personnel, including on-call physicians. The medical screening examination is an ongoing process, and the medical record must reflect continued monitoring based on the patient's needs until it is determined whether or not the individual has an emergency medical condition and, if he/she does, until the patient is either stabilized or appropriately transferred. Screening is to be conducted to the extent necessary by physicians and/or other qualified medical personnel to determine whether an emergency medical condition exists. Under stabilizing treatment, the policy states if an individual is determined to have an emergency medical condition, the patient will be provided treatment to stabilize the individual's emergency medical condition within the capability of it's ED (including routinely available ancillary services). Stabilized means an individual has, within reasonable clinical confidence, reached the point where continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient. If the individual's emergency medical condition cannot be stabilized within the capabilities of the hospital, an appropriate transfer should be made.

Staff A was interviewed on 11/26/24 at 3:45 PM. confirmed an MRI was not performed in order to determine if a medical emergency condition existed prior to the patient being transferred to another facility.