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Based on document reviews and interviews, the Condition of Participation for Nursing Services was not met as evidenced by the hospital's failure to ensure that appropriate nursing assessment services and interventions were provided in the Behavioral Emergency Department, as evidenced by a significant change in a patient's condition which resulted in admission to the Intensive Care Unit due to medical decompensation for one (1) of ten (10) sampled patients presenting to the Emergency Department (Patient #1).

See A-0395, A-0396 and A-0397 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on document reviews and interviews, the hospital failed to ensure that appropriate nursing services and interventions were provided in the Behavioral Emergency Department ("BED"), which resulted in an admission to the Intensive Care Unit ("ICU") due to medical decompensation for one (1) of ten (10) sampled patients presenting to the Emergency Department ("ED") (Patient #1).

Findings:

The hospital's "Plan for the Provision of Patient Care, Nurse and Clinical/Ancillary Staffing Plan and Contingency Plan" policy, last revised 2/2022, states in part, "A Registered Nurse will supervise and evaluate the nursing care of each patient upon admission, when appropriate and on an ongoing basis in accordance with accepted standards of practice. Evaluation would include assessing the patient care needs, health status/condition and response to interventions".

The hospital's "Nursing Assessment, Reassessment & Documentation Guidelines" policy, last reviewed 2/2023, states in part, "It is the policy of Covenant Health to ensure nursing documentation for each patient is clear, accurate, and accessible. Complete documentation is an essential element of safe, quality, evidence-based nursing practice...Nursing staff will reassess the patient at regular time defined intervals and if the patient's condition changes...If one or more of the criteria are not within the defined limit or a difference exists from the current Registered Nurse initial or previous assessment, the abnormality is documented...".

"Documentation Guidelines for ED Observation Patients:
Up to the first 8 hours of the ED observation status, the ED RN/Clinical staff will do the following:
A. Carry out all ED observation orders
B. Continue to complete ED assessments and documentation per unit guidelines".

The hospital's "Skin and Pressure Injury Prevention and Treatment" policy, last reviewed 1/2021, states in part, "Nursing in collaboration with the health care team will assess, identify and manage skin integrity for all patients to prevent tissue damage and to promote wellness and holistic healing...".

The hospital's job description for the Vice President of Patient Care Services states, in part, "The Vice President, Patient Care Services, provides leadership and accountability for the execution of the system strategy for patient care services in each facility. This includes clinical quality, financial management, implementation of evidence-based practices, human resource management, regulatory readiness, and clinical education...Oversee clinical quality while assuring that each clinician understands the clinical priorities of the system and the entity".

The hospital's job description for the Clinical and Administrative Director of the Emergency Department ("ED RN Director") states, in part, "Fosters and develops excellence in nursing practice...Demonstrates and instructs staff in care delivery that preserves/protects patients autonomy, dignity and rights...Acts as a patient advocate...".

The hospital's job description for the ED Crisis /Behavioral Services Registered Nurse ("RN") dated 5/29/2019, states in part, "Assesses the need for services of other health care professionals to facilitate the delivery of care...Is aware of changing clinical status, anticipates problems and independently adapts plan of care to meet patient needs as clinical status changes...Evaluates effectiveness of plan of care, based on patient progress versus expected outcomes and independently revises plan or adjusts expected outcomes...Documents flow sheets, medication administration record and nurses notes all pertinent information, in a manner that is concise, thorough, legible and accurately reflects patient condition, care provided, response to care and conforms to SMRMC charting...".

On 5/8/2023 at 2:04 PM, Patient #1 was triaged in the ED after his/her Father/Guardian called 911, initially for a crisis situation. Upon further discussion, the identified issue by his/her Father/Guardian was that Patient #1 has not been eating or drinking and that he can no longer care for Patient #1 at home.

On 5/8/2023, ED Medical Doctor ("MD") #4 documented the following: "[Patient #1] is a 59 year-old who presented to the ED at St. Mary's Regional Medical Center on 5/8/2023, with/for Failure To Thrive and inability of the elderly father to provide needed care. The Differential Diagnosis include: intellectual disability, mood disorder, depression, anxiety, abandonment. The patient needs placement in either a Skilled Nursing Facility or a Group Home. This patient was admitted to ED observation for Failure to Thrive. Observation services are necessary to determine the patient's disposition. During this observation period therapeutic interventions will be performed and assessments of the patient's response to these interventions, performance of serial diagnostic studies and/or assessments that require the passage of time to allow decision making and appropriate treatment, and perform ongoing management while awaiting transfer for definitive care whether that be in house or transfer to another facility".

On 5/12/2023 2:56 PM, MD #1 documented, "...Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Renal failure, circulatory failure, sepsis"...at 2:03 PM, Patient #1 was admitted and sent to the Intensive Care Unit.

Previously on 4/27/2023, during a recent visit to the ED, nursing staff identified a wound on Patient #1. At that time, the assessment revealed pressure areas and a Stage II Ulcer on the buttocks.

Based on review of review of the patient medical record from 5/8/2023 to 5/12/2023 the following medical conditions were identified:

1. Skin Integrity / Wound Dressing / Powder - Based on the Skin and Pressure Injury Prevention and Treatment policy it states:
- Reposition patients with lateral positioning devices or pillows at least every 2 hours and as needed, even if patient on specialty support surface. Document time and position in ADL section of Electronic Medical Record ("EMR"). Document reason if patient not turned (i.e. patient off unit, up in chair, refused etc).
- Chair bound/fast patients reposition in chair at least every hour and as needed. Alternate with periods of bed rest to adequately off load ischial and sacral areas.
- Place patient on appropriate pressure redistribution surface based on individual facility standard equipment and available additional equipment (i.e. air mattress);
- Elbow/Heel protectors to offload or float heels off mattress using pillows or wedges; and
- Transparent Film or foam dressing to bony prominence's if patient unable to tolerate elbow/heel protectors to prevent shearing and change every three (3) days and as needed.

On 5/8/2023 at 6:42 PM, ED MD #4 ordered Micotin 2% Powder. This powder was to be applied twice a day to abdominal folds, bilateral groin folds and bilateral breast folds. A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- No documented evidence of nursing staff applying Micotin 2% Powder, per the MD order, on 5/8/2023, 5/9/2023, 5/10/2023, until 5/11/2023 at 11:38 PM, which is a duration of approximately eighty-one (81) hours.

A review of Patient #1's nursing documentation from 5/8/2023 to 5/12/2023 revealed the following:
- On 5/9/2023 at 4:16 PM, ED RN #5 removed a Mepilex dressing and applied a new Mepilex dressing to the Stage II Ulcer;
- On 5/10/2023 at 10:28 PM, the Mepilex dressing was removed but not reapplied until 5/11/2023 at 11:02 PM, which is a duration of twenty-four and 1/2 hours (24.5) hours with no dressing applied to Patient #1's Stage II Ulcer;
- There was no documented evidence of bed rest used as an alternative;
- There was no documented evidence that Patient #1 was repositioned every two (2) hours; and
- Nursing staff on the BED did not request a wound consultation to assist with Patient #1's pressure injuries.

On 5/12/2023 at 9:42 AM, after moving Patient #1 to the medical side of the ED, a wound consult was ordered by MD #1 which revealed the following:
- Moisture associated breakdown noted to buttocks/sacrum;
- Stage II Pressure ulcerations bilateral buttocks as well as suspected Deep Tissue Injury [DTI] to peri-wound;
- Contact dermatitis noted to torso with shearing bilateral buttocks and sacral area; and
- Abdominal and breast folds noted to have fungal component.

2. Nutrition - Due to admission diagnosis of Failure to Thrive ("FTT"), a Stage II Pressure Ulcer on the buttocks and the past history of not eating or drinking with a thirty (30) pound weight loss.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023, Patient #1 had Jello;
- On 5/9/2023, Patient #1 had refused all meals that day;
- On 5/10/2023, Patient #1 had eight (8) ounces of ice cream and half (½) of a protein drink;
- On 5/11/2023, Patient #1 had some peanut butter with crackers;
- From 5/8/2023 through 5/12/2023, Patient #1 only drank enough water to take his/her medications; and
- A nutritional consult was not ordered until 5/12/2023 after the patient left the BED.

3. Vital Signs - Patient #1 had a past medical history of high blood pressure ("BP") and on 5/8/2023 at 2:25 PM, ED MD #4 ordered vital signs to be taken every eight (8) hours. The accepted "normal" range for blood pressure is less than 120 systolic and less than 80 diastolic and a pulse of 60 to 100.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023 at 2:15 PM, BP was 149/104 with a pulse of 119 on admission to the BED;
- On 5/9/2023 at 8:00 AM, BP was 138/100 with a pulse of 98;
- On 5/10/2023 5:15 PM, BP 96/72 with a pulse of 110...Thirty three and a quarter (33.5) hours elapsed between vitals being taken;
- On 5/11/2023 at 8:41 AM, BP was 104/74 with a pulse of 116 ;
- On 5/11/2023 at 10:42 PM, BP was 86/59 with a pulse of 120 at 10:42 PM;
- On 5/12/23 at 7:40 AM, BP was 85/46 with a pulse of 109; and
- On 05/12/23 12:00 PM, BP was 90/65 with a pulse of 102.

The vitals taken, while Patient #1 was in the BED, were not in accordance with physician orders.

On 5/19/2023 at 9:48 AM, the ED MD Director was interviewed regarding Patient #1. He stated, in part, the following:
- Yes, I reviewed the ED course [for Patient #1]; and
- I went to [ED RN Director] and talked to her...I wanted to recognize the BED nurses for recognizing the signs of decompensation.

On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1. She stated the following:
- Today, we reviewed the chart again...the timeline is comprehensive and I have no concerns;
- Could we have moved faster, maybe, but nothing was missed;
- We have a 7:00 AM and 3:00 PM "bed meeting" where they alert me to high level issues;
- [ED RN Director] shared that a patient moved from the BED to the ED;
- I have an excellent nursing leader; and
- I trust that they are looking at, I don't go back and look...She is on top of everything.

On 5/24/2023 at 11:23 AM, an interview was conducted with ED RN #1, regarding Patient #1. She stated the following:
- Yes, I remember the patient;
- No, I was not made aware that Patient #1 had a pressure ulcer, I was only told he/she had redness on his/her back...on 5/12/2023, I found out;
- If someone had a high BP, I would call provider in the ED and report the medical finding and then they would give us direction and if I can't get hold of the provider, I would call the ED charge nurse and tell them I need them;
- We check BP once per shift;
- If someone has skin integrity problems, or doesn't want to eat or drink, we can't make them do anything on our unit;
- In our huddle (where the ED RN Director and ED Medical Director were present) on 5/11/2023 at 10:45 AM, I stated that Patient #1 shouldn't be in the BED, as my concerns were that he/she was not eating or getting up and toileting;
- On our unit, we don't do ins & outs (monitoring what the patients eat/drink and monitor bowel/bladder output);
- Leadership stated that they would "look into it"...several hours later, I didn't hear anything so I called numerous people, including Patient #1's provider (ED MD #2) and the ED Nurse Director that afternoon [5/11/2023];
- They stated later that day that because vital signs were stable, they were still "checking on it" and ultimately, Patient #1 was not approved to move into the medical side of the ED; and
- I didn't think about asking for laboratory blood tests ("labs"), I don't always think of that.

On 5/24/2023 at 12:11 PM, a telephone interview was conducted with ED RN #3, regarding Patient #1. He stated the following:
- Yes, I remember Patient #1;
- Initially, Patient #1 was appropriate for BED;
- Vitals were stable;
- I was not aware of a pressure area, no, that was definitely not shared with me. Ideally, it should have been reported to the MD and then do a re-check; and
- No, I don't recall notifying an MD, I could have missed it.

On 5/24/2023 at 12:19 PM a telephone interview was conducted with ED Technician #1, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- I don't recall his/her blood pressure;
- Yes, if there was something "off" with the BP, I would absolutely tell the nurse;
- Yes, I was aware he/she had a pressure area, as I was a part of a check with a nurse (RN #3 and RN #5) and both RN's were aware he/she had a stage II; and
- Patient #1 refused to move and eat.

On 5/24/2023 at 1:10 PM, a telephone interview was conducted with ED RN #5, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- No, he/she was not an appropriate BED patient;
- Maybe it was for convenience, but I don't know...It was actually a placement issue, so they said he/she is behavioral;
- I am sure I glanced at his/her BP, but in an ED there are some things that aren't a concern;
- We don't get super excited over a high BP;
- I wasn't aware of a pressure area, it was hard to visualize...When I put the next [Mepilex bandage] on, RN #3 was holding him/her;
- I didn't chart it but I did it, we are not the best at wound care documentation...I told the doctor that if he/she is going to continue not eating or drinking, he/she will need hydration and we are going to have do something; and
- I did not document that conversation.

On 5/24/2023 at 1:19 PM, an interview was conducted with the ED Nurse Director, regarding Patient #1 in the BED. She stated the following:
- Patient #1 was placed in the BED because he/she initially presented as needing a crisis evaluation;
- Patient #1 stayed in the BED because he/she didn't have any medical complaints and he/she was a bed search;
- It didn't really matter what side of the ED that Patient #1 was on;
- I was aware that Patient #1, during an ED visit on 4/27/2023, had a wound consultation for a pressure ulcer;
- I was at the huddle, along with the ED Medical Director, on the morning of 5/11/2023 where ED RN #1 presented her concerns;
- I talked to the medical provider, ED MD #2, and she did not feel [Patient #1] needed a higher level of observation;
- I got a call on Friday morning (5/12/2023) about 6:30 AM because [Patient #1] had a low BP, and was showing signs for decompensating; and
- I called the medical charge nurse and requested to move Patient #1 onto the medical side of the ED.

On 5/24/2023 at 1:54 PM, an interview was conducted with the ED Nurse Case Manager, regarding her involvement with Patient #1. She stated the following:
- Yes, I remember [Patient #1];
- He/she came in several times recently to the ED looking for skilled nursing placement;
- He/she went into the BED because it was clear he/she couldn't go home;
- On the morning of 5/12/2023, I saw Patient #1 in the medical side of the ED, as his/her room was right across from my desk;
- He/She looked so significantly different that I was concerned and I went to talk with his/her dad, who is his/her guardian;
- I then went to his/her provider [ED MD #1] and explained that he/she didn't look well;
- My recommendation was whether this was behavioral or not, we needed to medically intervene;
- He/she looked very ill and and was refusing to eat and drink and I hadn't heard about a conversation about hydration or nutrition;
- ED MD #1 stated he hadn't read the chart and would when he had time;
- At that point, I reached out to risk management due to my concerns;
- When I talked to [Risk Manager and ED Nurse Director], nobody had talked about hydration and nutrition;
- Nothing happened at that point, so I went to the ED Medical Director and explained my concerns;
- He then went to [ED MD #1] to discuss the case;
- I was very concerned and feel like I was blown off; and
- It shouldn't matter if he/she is behavioral or not, we still need to care for a patient's medical needs.

On 5/24/2023 at 2:25 PM, an interview was conducted with ED RN #4, regarding Patient #1. She stated the following:
- Yes, Patient #1 "rings a bell";
- Yes, he/she was appropriate at first, but as we continued to go through the week, it became apparent with him/her not eating or drinking, we were wondering if there are other things done like labs and hydration;
- During one of the shift changes, it was brought to my attention that he/she wasn't eating or drinking;
- Over the course of the previous twelve (12) hours, I was told he/she ate some ice cream;
- Over the course of the next twelve (12) hours, he/she had eight (8) ounces of ice cream and half (½) of an ensure;
- I was concerned and asked about getting labs;
- I don't remember asking a provider for labs but I asked during shift change;
- Information on Patient #1's pressure injury was passed on and I took off the Mepilex one night, but I did not put a Mepilex back on;
- I had suggested that maybe we should get labs because he/she wasn't eating or drinking, he/she was number one on our list; and
- I told everyone in huddle that I had concerns.

On 5/24/2023 at 3:24 PM, a telephone interview was conducted with ED MD #1, regarding Patient #1. He stated the following:
- Yes, I remember Patient #1;
- On the morning of 5/12/2023, I recall a time when the nurse case manager approached me with concerns and the patients' decline;
- Someone said they were concerned but I don't think there was an urgent need;
- Nobody asked me to go look at Patient #1 right away and I was approached in a less urgent manner to assess the case;
- Patient #1 was on my radar as someone who was not eating or drinking and I was thinking the behavioral team was going to admit him/her;
- His/Her behavior led to a medical condition;
- I am not sure how soon labs were done as I was busy with other things and [Patient #1] was on the list;
- I think they [BP's] were soft and they had been attributed to a lack of mobility...once I saw the chart, I went and did the work up;
- Yes, I think it was an isolated issue with BP's, as he/she wasn't eating or drinking, and dehydrated; and
- I don't remember the labs but I know he/she had developed acute renal insufficiency, then Patient #1 was moved to the ICU as soon as I realized he/she had an acute renal injury.

On 5/25/2023 at 7:26 AM, an interview was conducted with ED RN #2, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- Yes, on 5/11/2023, his/her BP was low, and they [first shift] said he/she hadn't gotten out of the chair all day and wasn't taking in anything;
- I took Patient #1's BP, he/she was dehydrated, pulse was high and I knew I had to move Patient #1 to a bed to assess his/her skin integrity;
- I did contact the medical side of the ED to get him/her in a bed, but the charge nurse decided Patient #1 would stay in the BED;
- I contacted ED MD #3 and I told him Patient #1 is a mess, he/she hasn't eaten or drank in several days;
- I told him about the pressure injury, the vitals and that Patient #1 needed to be seen by him right away;
- He told me to take a picture of the wound; and
- No, he did not come over to see Patient #1.

On 5/25/2023 at approximately 8:00 AM, surveyors asked to speak with ED MD #3, and explained that he should have access to Patient #1's record to be able to speak to the evening of 5/11/2023. At approximately 8:15 AM, surveyors were told that ED MD #3 had no recollection of this visit for Patient #1. Surveyors then asked for his number to call him directly to verify.

On 5/25/2023 at 8:36 AM, an interview was conducted with ED MD #3, regarding Patient #1. He stated the following;
- I am starting to have a vague memory of this case;
- I probably told the nurse that I would come back and see the patient, but my shift ended at midnight;
- I was probably trying to do a bunch of stuff and I don't think I got around to seeing him/her, no, I didn't do it;
- I was managing a Non-ST-Elevation Myocardial Infarction [NSTEMI] transfer and I did not get back there [to the BED];
- I don't remember her [RN #2] talking about anything else except a rash; and
- I do not recall passing this information on to the incoming provider [ED MD #4].

On 5/25/2023 at 10:06 AM, an interview was conducted with ED Technician #2, regarding Patient #1's BP on 5/11/2023 at 10:42 PM, which was 86/59 with a pulse of 120 . She stated the following:
- Yes, I reported this to ED RN #2;
- I know Patient #1 hadn't been up and moving around and that he/she was refusing to eat and drink; and
- I take [vital signs] when I come on shift, unless the nurse tells us differently.

On 5/25/2023 at 10:16 AM, an interview was conducted with the ED Nurse Director, regarding Patient #1. She stated the following:
- Yes, the vital sign order is for every eight (8) hours for vitals;
- No, the vitals were not completed in accordance with the order;
- Yes, there is an expectation that if there is a pressure area that there would be a foam border dressing; and
- Per the job description, it is the expectation to have a care plan and it would include all pertinent issues.

Based on document reviews and interviews, it was determined the hospital failed to ensure that a nursing care plan was developed and updated for all identified patient issues for one (1) of ten (10) sampled patients presenting to the Behavioral Emergency Department ("BED") (Patient #1).

Findings:

The hospital's "Nursing Assessment, Reassessment & Documentation Guidelines" policy, last reviewed 2/2023, states in part, "It is the policy of Covenant Health to ensure nursing documentation for each patient is clear, accurate, and accessible. Complete documentation is an essential element of safe, quality, evidence-based nursing practice...Nursing staff will reassess the patient at regular time defined intervals and if the patient's condition changes...If one or more of the criteria are not within the defined limit or a difference exists from the current Registered Nurse initial or previous assessment, the abnormality is documented...".

The hospital's job description for the Vice President of Patient Care Services states, in part, "The Vice President, Patient Care Services, provides leadership and accountability for the execution of the system strategy for patient care services in each facility. This includes clinical quality, financial management, implementation of evidence-based practices, human resource management, regulatory readiness, and clinical education...Oversee clinical quality while assuring that each clinician understands the clinical priorities of the system and the entity".

The hospital's job description for the Clinical and Administrative Director of the Emergency Department ("ED RN Director") states, in part, "Fosters and develops excellence in nursing practice...Demonstrates and instructs staff in care delivery that preserves/protects patients autonomy, dignity and rights...Acts as a patient advocate...".

The hospital's "Emergency Department ("ED") Crisis /Behavioral Services Registered Nurse ("RN") Job Description" dated 3/29/2019, states in part, "Planning includes the development of a written plan of care that utilizes the data collected in the assessment process, incorporates the medical plan of care, demonstrates knowledge of resources available, sets priorities and establishes realistic outcomes and discharge planning...".

The hospital's "Skin and Pressure Injury Prevention and Treatment" policy last reviewed 1/2021, states in part, "A. Document wound information for all dressing applications and wound findings for all patients, in the Electronic Health Record ("EHR"). The wound is measured on admission, weekly, and when significant changes are seen in the wound. B. Unless otherwise ordered or contraindicated, RN will gently and partially lift pressure injury prevention border dressings for viewing of underlying skin condition(s) at a frequency of every shift. Dressing is then reapplied. C. Pressure Injury Prevention Protocols will be utilized to develop a patient care plan that is appropriate for the patient...".

On 5/22/2023, Patient #1's medical record was reviewed and revealed the following issues in relation to the required care plan:

During the patients stay in the BED from 5/8/2023 to 5/12/2023:
- The care plan was documented in the medical record only two (2) times;
- The care plan only contained one (1) issue and that was related to skin integrity;
- The care plan did not reflect the patient's goals and the nursing care to be provided to meet the patient's needs;
- There were no updates to this care plan documented in the medical record from 5/8/2023 to 5/12/2023; and
- This patient suffered from failure to thrive ("FTT") based on poor nutritional status.

Based on review of review of the patient medical record from 5/8/2023 to 5/12/2023 the following medical conditions were identified:
1. Skin Integrity / Wound Dressing / Powder - Based on the Skin and Pressure Injury Prevention and Treatment policy it states:
- Reposition patients with lateral positioning devices or pillows at least every two (2) hours and as needed, even if patient on specialty support surface. Document time and position in ADL section of Electronic Medical Record ("EMR"). Document reason if patient not turned (i.e. patient off unit, up in chair, refused etc).
- Chair bound/fast patients reposition in chair at least every hour and as needed. Alternate with periods of bed rest to adequately off load ischial and sacral areas.
- Place patient on appropriate pressure redistribution surface based on individual facility standard equipment and available additional equipment (i.e. air mattress);
- Elbow/Heel protectors to offload or float heels off mattress using pillows or wedges; and
- Transparent Film or foam dressing to bony prominence's if patient unable to tolerate elbow/heel protectors to prevent shearing and change every three (3) days and as needed.

On 5/8/2023 at 6:42 PM, ED Medical Doctor ("MD") #4 ordered Micotin 2% Powder. This powder was to be applied twice a day to abdominal folds, bilateral groin folds and bilateral breast folds. A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- No documented evidence of nursing staff applying Micotin 2% Powder, per the MD order, on 5/8/2023, 5/9/2023, 5/10/2023, until 5/11/2023 at 11:38 PM, which is a duration of approximately eighty-one (81) hours.

A review of Patient #1's nursing documentation from 5/8/2023 to 5/12/2023 revealed the following:
- On 5/9/2023 at 4:16 PM, ED RN #5 removed a Mepilex dressing and applied a new Mepilex dressing to the Stage II Ulcer;
- On 5/10/2023 at 10:28 PM, the Mepilex dressing was removed but not reapplied until 5/11/2023 at 11:02 PM, which is a duration of twenty-four and 1/2 hours (24.5) hours with no dressing applied to Patient #1's Stage II Ulcer;
- There was no documented evidence of bed rest used as an alternative;
- There was no documented evidence that Patient #1 was repositioned every two (2) hours; and
- Nursing staff on the BED did not request a wound consultation to assist with Patient #1's pressure injuries.

On 5/12/2023 at 9:42 AM, after moving to the medical side of the ED, a wound consult was ordered by MD #1 which revealed the following:
- Moisture associated breakdown noted to buttocks/sacrum;
- Stage II (partial thickness loss of dermis) Pressure ulcerations bilateral buttocks as well as suspected Deep Tissue Injury [DTI] to peri-wound;
- Contact dermatitis noted to torso with shearing bilateral buttocks and sacral area; and
- Abdominal and breast folds noted to have fungal component.

2. Nutrition - Due to admission diagnosis of FTT, a Stage II Pressure Ulcer on the buttocks and the past history of not eating or drinking with a thirty (30) pound weight loss.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023, Patient #1 had Jello;
- On 5/9/2023, Patient #1 had refused all meals that day;
- On 5/10/2023, Patient #1 had eight (8) ounces of ice cream and half (½) of a protein drink;
- On 5/11/2023, Patient #1 had some peanut butter with crackers;
- From 5/8/2023 through 5/12/2023, Patient #1 only drank enough water to take his/her medications; and
- A nutritional consult was not ordered until 5/12/2023, after the patient left the BED.

3. Vital Signs - Patient #1 had a past medical history of high blood pressure ("BP") and on 5/8/2023 at 2:25 PM, ED MD #4 ordered vital signs to be taken every eight (8) hours. The accepted "normal" range for blood pressure is less than 120 systolic and less than 80 diastolic and a pulse of 60 to 100.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023 at 2:15 PM, BP was 149/104 with a pulse of 119 on admission to the BED;
- On 5/9/2023 at 8:00 AM, BP was 138/100 with a pulse of 98;
- On 5/10/2023 5:15 PM, BP 96/72 with a pulse of 110...Thirty three and a quarter (33.5) hours elapsed between vitals being taken;
- On 5/11/2023 at 8:41 AM, BP was 104/74 with a pulse of 116 ;
- On 5/11/2023 at 10:42 PM, BP was 86/59 with a pulse of 120 at 10:42 PM;
- On 5/12/23 at 7:40 AM, BP was 85/46 with a pulse of 109; and
- On 05/12/23 12:00 PM, BP was 90/65 with a pulse of 102;

The vitals taken, while Patient #1 was in the BED, were not in accordance with physician orders.

On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1. She stated the following:
- Today, we reviewed the chart again...the timeline is comprehensive and I have no concerns;
- Could we have moved faster, maybe, but nothing was missed;
- We have a 7:00 AM and 3:00 PM "bed meeting" where they alert me to high level issues;
- [ED RN Director] shared that a patient moved from the BED to the ED;
- I have an excellent nursing leader; and
- I trust that they are looking at, I don't go back and look...She is on top of everything. On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1's stay in the BED from 5/8/2023 to 5/12/2023. She stated, "Today, we reviewed the chart again ...the timeline is comprehensive and I have no concerns. Could we have moved faster, maybe, but nothing was missed".

On 5/24/2023 at 12:11 PM a telephone was conducted with ED RN #3, regarding Patient #1. He stated the following:
- Yes, I remember Patient #1;
- Initially he/she was appropriate for the BED;
- I remember he/she was kind of a question of FTT or suicidal plan;
- I guess based on his/her accepting of food, there was that potential for problems;
- I was not aware of a pressure area; (RN #3 participated in a pressure ulcer dressing change for Patient #1)
- No, definitely not shared with me;
- Ideally, it should have been reported to the MD and then do a re-check; and
- I don't recall notifying an MD, I could have missed it.

On 5/24/2023 at 12:19 PM a telephone interview was conducted with ED Technician #1, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- I don't recall an issue with Patient #1's BP;
- Yes, I would absolutely tell the nurse about BP issues;
- He/she refused to move and he/she refused to eat;
- Yes, I was aware he/she had a pressure area;
- I was a part of a check of the pressure area with the nurses on duty (ED RN#3 and ED RN #5); and
- I was never told it was a stage II pressure ulcer.

On 5/24/2023 at 1:01 PM, a telephone interview was conducted with ED RN #5, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- Patient #1 was not appropriate for the BED;
- Patient #1 should have been on the medical side of the ED;
- Patient #1 was pretty much bed or chair bound;
- I didn't see a behavioral problem;
- Sometimes our ED is overwhelmed, so they need a bed;
- Patient #1 was resistant to do everything;
- I am sure I glanced at Patient #1's BP;
- In an ED, we don't get super excited over a high BP;
- I wasn't aware of a pressure area;
- I put the Mepilex on and I didn't chart that;
- We are not the best at wound care documentation;
- He/she didn't really eat that much;
- I told the doctor that if he/she is going to continue not eating, he/she will need hydration and we are going to have do something; and
- I did not document that conversation with the doctor.

On 5/25/2023 at 10:16 AM, an interview was conducted with the ED Nurse Director, regarding Patient #1. She stated the following:
- Yes, the vital sign order is for every eight (8) hours for vitals;
- No, the vitals were not completed in accordance with the order;
- Yes, there is an expectation that if there is a pressure area that there would be a foam border dressing; and
- Per the job description, it is the expectation to have a care plan and it would include all pertinent issues.

Based on document reviews and interviews, the hospital failed to assign the nursing care of patients to individuals who have the qualifications and expertise to meet the needs of the patients in one (1) of ten (10) sampled patients presenting to the Emergency Department ("ED") (Patient #1).

Findings:

The hospital's "Plan for the Provision of Patient Care, Nurse and Clinical/Ancillary Staffing Plan and Contingency Plan" policy, last revised 2/2022, states in part, "A Registered Nurse will supervise and evaluate the nursing care of each patient upon admission, when appropriate and on an ongoing basis in accordance with accepted standards of practice. Evaluation would include assessing the patient care needs, health status/condition and response to interventions".

The hospital's job description for the Vice President of Patient Care Services states, in part, "The Vice President, Patient Care Services, provides leadership and accountability for the execution of the system strategy for patient care services in each facility. This includes clinical quality, financial management, implementation of evidence-based practices, human resource management, regulatory readiness, and clinical education...Oversee clinical quality while assuring that each clinician understands the clinical priorities of the system and the entity".

The hospital's job description for the Clinical and Administrative Director of the Emergency Department ("ED RN Director") states, in part, "Fosters and develops excellence in nursing practice...Demonstrates and instructs staff in care delivery that preserves/protects patients autonomy, dignity and rights...Acts as a patient advocate...".

The hospital's job description for the ED Crisis/Behavioral Services Registered Nurse ("RN") dated 5/29/2019, states in part, "Assessment includes appropriate interviewing techniques, systematic physical assessment and interpretation of available data including : past medical history, current medical status, vital signs, lab work, x-rays and other diagnostic tests. It should encompass the financial, spiritual, psychological, physiological, social, and age appropriate needs of the patient, by providing preventative, curative, restorative, and supportive services with compassion and respect for everyone".

On 4/27/2023, during a recent visit to the ED, nursing staff identified a wound on Patient #1. At that time, the assessment revealed pressure areas and a Stage II Ulcer on the buttocks.

On 5/8/2023 at 2:04 PM, Patient #1 was triaged in the ED after his/her Father/Guardian called 911, initially for a crisis situation. Upon further discussion, the identified issue by his/her Father/Guardian was that Patient #1 has not been eating or drinking and that he can no longer care for Patient #1 at home.

On 5/8/2023, ED MD #4 documented the following: "[Patient #1] is a 59 year-old who presented to the ED at St. Mary's Regional Medical Center on 5/8/2023, with/for Failure To Thrive and inability of the elderly father to provide needed care. The Differential Diagnosis include: intellectual disability, mood disorder, depression, anxiety, abandonment. The patient needs placement in either a Skilled Nursing Facility or a Group Home. This patient was admitted to ED observation for FTT. Observation services are necessary to determine the patient's disposition. During this observation period therapeutic interventions will be performed and assessments of the patient's response to these interventions, performance of serial diagnostic studies and/or assessments that require the passage of time to allow decision making and appropriate treatment, and perform ongoing management while awaiting transfer for definitive care whether that be in house or transfer to another facility".

On 5/12/2023 at 7:40 AM, Patient #1 was moved from the Behavioral Emergency Department ("BED") to the medical side of the ED due to a Blood Pressure ("BP") of 86/72. Later in the day, laboratory blood tests ("labs") revealed that Patient #1 was in acute renal failure, dehydration and septicemia...and then transferred to the Intensive Care Unit.

On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1. She stated the following:
- Today, we reviewed the chart again...the timeline is comprehensive and I have no concerns;
- Could we have moved faster, maybe, but nothing was missed;
- We have a 7:00 AM and 3:00 PM "bed meeting" where they alert me to high level issues;
- [ED RN Director] shared that a patient moved from the BED to the ED;
- I have an excellent nursing leader; and
- I trust that they are looking at, I don't go back and look...She is on top of everything.

On 5/24/2023 at 11:23 AM, an interview was conducted with ED RN #1, regarding Patient #1. She stated the following:
- Yes, I remember the patient;
- No, I was not made aware that Patient #1 had a pressure ulcer, I was only told he/she had redness on his/her back...on 5/12/2023, I found out;
- If someone had a high BP, I would call provider in the ED and report the medical finding and then they would give us direction and if I can't get hold of the provider, I would call the ED charge nurse and tell them I need them;
- We check BP once per shift;
- If someone has skin integrity problems, or doesn't want to eat or drink, we can't make them do anything on our unit;
- In our huddle (where the ED RN Director and ED Medical Director were present) on 5/11/2023 at 10:45 AM, I stated that he/she shouldn't be in the BED, as my concerns were that he/she was not eating or getting up and toileting;
- On our unit, we don't do ins & outs (monitoring what the patients eat/drink and monitor bowel/bladder output);
- Leadership stated that they would "look into it"...several hours later, I didn't hear anything so I called numerous people, including the provider (ED MD #2) and the ED Nurse Director that afternoon on 5/11/2023;
- They stated later that day that because vital signs were stable, they were still "checking on it" and ultimately, Patient #1 was not approved to move into the medical side of the ED; and
- I didn't think about asking for labs, I don't always think of that.

On 5/24/2023 at 12:11 PM, a telephone interview was conducted with ED RN #3, regarding Patient #1. He stated the following:
- Yes, I remember [Patient #1];
- Initially, Patient #1 was appropriate for BED;
- Vitals were stable;
- I was not aware of a pressure area, no, that was definitely not shared with me. Ideally, it should have been reported to the MD and then do a re-check; and
- No, I don't recall notifying an MD, I could have missed it.

On 5/24/2023 at 12:19 PM a telephone interview was conducted with ED Technician #1, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- I don't recall his/her BP;
- Yes, if there was something "off" with the BP, I would absolutely tell the nurse;
- Yes, I was aware he/she had a pressure area, as I was a part of a check with a nurse (RN #3 and RN #5) and both RN's were aware he/she had a stage II; and
- Patient #1 refused to move and eat.

On 5/24/2023 at 1:10 PM, a telephone interview was conducted with ED RN #5, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- No, he/she was not an appropriate BED patient;
- Maybe it was for convenience, but I don't know...It was actually a placement issue, so they said he/she is behavioral;
- I am sure I glanced at his/her BP, but in an ED there are some things that aren't a concern;
- We don't get super excited over a high BP;
- I wasn't aware of a pressure area, it was hard to visualize...When I put the next [Mepilex bandage] on, RN #3 was holding him/her;
- I didn't chart it but I did it, we are not the best at wound care documentation...I told the doctor that if he/she is going to continue not eating or drinking, he/she will need hydration and we are going to have do something; and
- I did not document that conversation.

On 5/24/2023 at 2:25 PM, an interview was conducted with ED RN #4, regarding Patient #1. She stated the following:
- Yes, Patient #1 "rings a bell";
- Yes, he/she was appropriate at first, but as we continued to go through the week, it became apparent with him/her not eating or drinking, we were wondering if there are other things done like labs and hydration;
- During one of the shift changes, it was brought to my attention that he/she wasn't eating or drinking;
- Over the course of the previous twelve (12) hours, I was told he/she ate some ice cream;
- Over the course of the next twelve (12) hours, he/she had eight (8) ounces of ice cream and half (½) of a protein drink;
- I was concerned and asked about getting labs;
- I don't remember asking a provider for labs but I asked during shift change;
- Information on Patient #1's pressure injury was passed on and I took off the Mepilex one night, but I did not put a Mepilex back on;
- I had suggested that maybe we should get labs because he/she wasn't eating or drinking, he/she was number one on our list; and
- I told everyone in huddle that I had concerns.

On 5/25/2023 at 7:26 AM, an interview was conducted with ED RN #2, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- Yes, on 5/11/2023, his/her BP was low, and they [first shift] said he/she hadn't gotten out of the chair all day and wasn't taking in anything;
- I took Patient #1's BP, he/she was dehydrated, pulse was high and I knew I had to move Patient #1 to a bed to assess his/her skin integrity;
- I did contact the medical side of the ED to get him/her in a bed, but the charge nurse decided Patient #1 would stay in the BED;
- I contacted ED MD #3 and I told him Patient #1 is a mess, he/she hasn't eaten or drank in several days;
- I told him about the pressure injury, the vitals and that Patient #1 needed to be seen by him right away;
- He told me to take a picture of the wound; and
- No, he did not come over to see Patient #1.

On 5/25/2023 at 10:06 AM, an interview was conducted with ED Technician #2, regarding Patient #1's BP on 5/11/2023 at 10:42 PM, which was 86/59 with a pulse of 120. She stated the following:
- Yes, I reported this to ED RN #2;
- I know Patient #1 hadn't been up and moving around and that he/she was refusing to eat and drink; and
- I take [vital signs] when I come on shift, unless the nurse tells us differently.

A complete review of Patient #1's record revealed that there was no documented evidence that nursing personnel were assigned care related to:
- Vital Signs
- Skin Integrity
- Nutrition
- Hydration

On 5/25/2023 at 10:16 AM, an interview was conducted with the ED Nurse Director, regarding Patient #1. She stated the following:
- Yes, the vital sign order is for every eight (8) hours for vitals;
- No, the vitals were not completed in accordance with the order;
- Yes, there is an expectation that if there is a pressure area that there would be a foam border dressing; and
- Per the job description, it is the expectation to have a care plan and it would include all pertinent issues.

Based on document reviews and interviews, the hospital failed to ensure that medical records were accurately written for one (1) of ten (10) sampled patients presenting to the Emergency Department ("ED") (Patient #1).

Findings:

The hospital's "Nursing Assessment, Reassessment & Documentation Guidelines" policy, last reviewed 2/2023, states in part, "It is the policy of Covenant Health to ensure nursing documentation for each patient is clear, accurate, and accessible. Complete documentation is an essential element of safe, quality, evidence-based nursing practice...Nursing staff will reassess the patient at regular time defined intervals and if the patient's condition changes...If one or more of the criteria are not within the defined limit or a difference exists from the current Registered Nurse initial or previous assessment, the abnormality is documented...".

On 5/22/2023, Patient #1's medical record was reviewed and revealed the following:
- On 5/11/2023 at 10:23 AM, the Braden Scale was documented by Registered Nurse ("RN") #1;
- The documentation stated: activity - walks frequently; nutrition - excellent; friction and shear - no apparent problem;
- The total Braden Scale was twenty-three (23);
- The Braden Scale predicts Pressure Ulcer Risks and the higher numbers represent less likely to develop a pressure ulcer; and
- This documentation was completely different from other Braden Scale documentation for this patient on days prior and after.

On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1's stay in the Behavioral Emergency Department from 5/8/2023 to 5/12/2023. She stated, "Today, we reviewed the chart again...the timeline is comprehensive and I have no concerns. Could we have moved faster, maybe, but nothing was missed".

On 5/24/2023 at 11:23 AM, an interview was conducted with ED RN #1. She stated the following:
- The documentation of the Braden Scale on 5/11/2023 for Patient #1 was an error;
- I must have been thinking of another patient; and
- I did not amend the error in the medical record.

On 5/25/2023 at 10:16 AM, the ED RN Director was asked if there is an expectation that nursing staff amend any errors that are made in the medical record. She stated, "Yes".

Based on document reviews and interviews, the Condition of Participation for Emergency Services was not met as evidenced by the hospital's failure to ensure care was provided in accordance to accepted standards of care for one (1) of ten (10) sampled patients presenting to the Emergency Department (Patient #1).

Findings:

The hospital's "Bylaws Rules And Regulations Of The Medical Staff", last amended and restated by Medical Staff on 12/12/2022, states in part, "Each member of the Medical Staff shall: Provide his/her patient with care of the generally professionally accepted level of quality in the community and in a reasonably economical and efficient manner. Provide for continuous quality care for his/her patients...Patients Who Do Not Require Admission. Patients presenting themselves to the emergency department, but who do not require admission, should be accepted for any urgently needed emergency care by the appropriate active staff practitioner on call that day unless other suitable disposition is readily available. The active staff practitioner will be responsible for any urgent needs of that current health problem of that patient...".

The hospital's "Plan for the Provision of Patient Care, Nurse and Clinical/Ancillary Staffing Plan and Contingency Plan", last revised 2/2023, states in part, "The Chief Nursing Officer is responsible for the provision, monitoring, and evaluation of nursing care to ensure it is consistent with the mission of the hospital and is in accordance with hospital policies, acceptable standards of nursing practice, nursing service objectives, and nursing policies and procedures...The BED [Behavioral Emergency Department] is an area within our Emergency Department that provides specialized psychiatric assessment and treatment recommendations for people in acute need".

1. Physician Services

On 5/22/2023, Patient #1's medical record documentation of Emergency Department ("ED") visits between 4/26/2023 and 5/7/2023 were reviewed. This review indicated the following:

- On 4/26/2023 at 9:52 AM, Patient #1 arrived at the ED due to his/her's Father/Legal Guardian stating that Patient #1 was having diminished oral intake and lost 20 lb.; - Laboratory blood tests ("labs") revealed the Blood Urea Nitrogen ("BUN"): 26 MG/DL [Ref Range: 7 - 22] Creatinine: 1.08 MG/DL [Ref Range: 0.55 - 1.10] [These levels are valuable screening tests in evaluating renal disease]; and
- At 4:34 PM, he/she was discharged home with a diagnosis of shortness of breath, abdominal pain with an unspecified abdominal location and acute cystitis without hematuria.

- On 4/27/2023 10:59 AM, Patient #1 arrived at the ED due to his/her family calling saying that the patient was seen in the ED yesterday and were hoping he/she would have been admitted because he/she continues to decline and is not able to take care of himself/herself;
- Patient #1 has bed sores, and has lost weight due to not eating much;
- The Provider stated that Patient #1 is not suicidal but does sound like he/she has some aspects of depression;
- The Provider stated that Patient #1 has not been eating well drinking well or taking care of himself/herself; and
- On 4/27/2023 at 5:24 PM, he/she was discharged home with a diagnosis of generalized abdominal pain and acute cystitis without hematuria.

- On 4/28/2023 at 7:40 AM, Patient #1 arrived at the ED due to not liking the taste of the antibiotic that was provided at a recent visit;
- The Provider did not suspect an acute medical illness that required extensive work-up or admission to the hospital; and
- On 4/28/2023 at 11:13 AM, he/she was discharged home with a new antibiotic.

- On 4/29/2023 at 3:30 PM, Patient #1 arrived at the ED due to concerns by the Father/Legal Guardian that he/she was not eating as much as usual and body aches;
- The Provider documented that Patient #1 was in today after multiple recent ED visits;
- Decrease in activity, in appetite, and had diarrhea over the last few days with left lower quadrant abdominal pain;
- Labs revealed BUN: 25 MG/DL [Ref Range: 7 - 22] and Creatinine: 0.83 MG/DL [Ref Range: 0.55 - 1.10]; and
- On 4/29/2023 at 9:23 PM, he/she was discharged home with a diagnosis of a urinary tract infection and abdominal pain.

- On 5/4/2023 at 10:45 AM, Patient #1 arrived at the ED due to concerns by the family and Father/Legal Guardian that he/she was only wanting to lay down and would not follow directions as usual. Father/Legal Guardian stated his concerns patient #1's actions are behavioral rather than physical and requested a psychiatric evaluation;
- Father/Legal Guardian stated that Patient #1 has also been refusing to eat or drink much;
- A psychiatric assessment was completed and it was determined that he/she does not require inpatient psychiatric hospitalization but would benefit from medication adherence and grief counseling;
- When cleared for discharge, family was upset stating that patient has not been eating or going to the bathroom but nursing stated that Patient #1 has both gone to the bathroom and eaten lunch while here on the unit and seen by both medical provider and psychiatric provider who approved discharge;
- Labs revealed BUN: 42 MG/DL [Ref Range: 7 - 22] Creatinine: 1.10 MG/DL [Ref Range: 0.55 - 1.10];
- The Provider reviewed the labs on 5/4/2023 at 1:29 PM, noting that the potassium was slightly low and had no comment on the BUN/Creatinine levels; and
- On 5/4/2023 at 1:58 PM, he/she was discharged home with a diagnosis of an adjustment disorder with depressed mood, intellectual disability, anxiety, hypokalemia,
and hypothyroidism.

- On 5/6/2023 at 3:21 PM, Patient #1 arrived at the ED due to concerns by the family that he/she has had a "gradual decline" over past six (6) months and are concerned that the recent behavioral evaluation was conducted with Father/Legal Guardian in the waiting room;
- Labs revealed BUN: 43 MG/DL [Ref Range: 7 - 22] Creatinine: 1.03 MG/DL [Ref Range: 0.55 - 1.10];
- The Psychiatrist documented that Patient #1 was brought in due to failure to thrive with recent weight loss due to decreased appetite and basic failure to care for self with prior diagnosis of intellectual disability...There is no suicidal ideation and no evidence of psychosis, hypomania, mania and no homicidal ideation and does not require inpatient care;
- The Provider documented that Patient #1 was re-evaluated by a psychiatric nurse practitioner and based on this re-evaluation after patient has been in the emergency department for greater than twenty-four (24) hours and has been managing to handle his/her own Activities of Daily Living, there seems to be no medical or psychiatric reason for further management in the emergency department and no justification for admission;
- The Provider also documented that vitals were notable for hypertension and tachycardia, he/she does have dry mouth that also smells slightly of ketones, which the Provider suspected this was secondary to poor oral intake, intravenous fluids and screening labs were ordered, labs returned showing evidence consistent with dehydration and mild hypokalemia...;
- Family begged hospital to continue to evaluate...The Provider spoke with the family again and after a lengthy conversation, family was told that there is no indication for admission for any management; and
- On 5/7/2023 at 6:56 PM, Patient #1 was discharged home with a diagnosis of dehydration and epigastric pain.

- On 5/8/2023 at 2:04 PM, Patient #1 was triaged in the ED after his/her Father/Guardian called 911, initially for a crisis situation. Upon further discussion, the identified issue by his/her Father/Guardian was that Patient #1 has not been eating or drinking and that he can no longer care for Patient #1 at home;
- The Provider documented that, "This patient will be admitted to ED observation for Failure to Thrive. Observation services are necessary to determine the patient's disposition. During this observation period we will perform therapeutic interventions and assess the patient's response to these interventions, perform serial diagnostic studies and/or assessments that require the passage of time to allow decision making and appropriate treatment, and perform ongoing management while awaiting transfer for definitive care whether that be in house or transfer to another facility".
- The Provider documented that, "Labs: ordered...Radiology: ordered...ECG/medicine tests: ordered".
- Patient #1 was placed in the Behavioral Emergency Department ("BED") due to stating that this was a crisis;
- While in the BED, the Provider documented on 5/9/2023 at 11:29 AM, "Patient has been seen and evaluated by the psychiatric nurse practitioner after [he/she] was presenting with [his/her] father for failure to thrive. The nurse practitioner yesterday did not feel that this was depression. Plan for re-evaluation today when [his/her] father is present with the nurse practitioner for further evaluation"...and documented on 5/9/2023 at 2:22 PM, "I just spoke with the social worker. The patient has been seen by the psychiatric nurse practitioner and does not meet criteria for inpatient treatment";
- On 5/10/2023 at 6:39 AM, ED MD #2 documented, "This patient was placed into ED observation status for falls/weakness. At the time of this evaluation with patient is not changed. The plan for continuing management is nursing home placement";
- On 5/11/2023 at 6:39 AM, ED MD #2 documented, "This patient was placed into ED observation status for falls/weakness. At the time of this evaluation with patient is not changed. The plan for continuing management is nursing home placement";
- On 5/12/2023 at 7:47 AM, Patient #1 was moved to the medical side of the ED, per ED RN #1's documentation stating, "Moved to ED due to failure to thrive";
- On 5/12/2023 at 12:00 PM, ED #1 documented that Patient #1 had soft blood pressures, has not been eating and drinking and Moved to medical ER. Does have stage II decubitus ulcer without evidence of cellulitis. Sepsis work-up initiated;
- Despite labs being ordered on 5/8/2023, no labs were done until 5/12/2023 at 12:16 PM, which revealed a BUN: 109 MG/DL [Ref Range: 7 - 22] Creatinine: 5.03 MG/DL [Ref Range: 0.55 - 1.10];
- On 5/12/2023 2:56 PM, MD #1 documented, "...Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Renal failure, circulatory failure, sepsis...".
- On 5/12/2023 at 2:03 PM, Patient #1 was admitted and sent to the Intensive Care Unit.

On 5/19/2023 at 9:48 AM, the ED MD Director was interviewed regarding Patient #1. He stated, in part, the following:
- Yes, I reviewed the ED course [for Patient #1]; and
- I went to [ED RN Director] and talked to her...I wanted to recognize the BED nurses for recognizing the signs of decompensation.

On 5/22/2023 at 2:48 PM, the Chief Medical Officer was interviewed by the MD Consultant Surveyor regarding Patient #1. He stated the following:
- Looking back, could we have acted more quickly? Again, you can Monday morning quarterback, but no, I don't see any issues, but in retrospect, yes;
- He/She wasn't eating or drinking much;
- I would imagine the folks thought it was his/her baseline; and
- He/She essentially had a kidney injury...dehydration did him/her in.

On 5/22/2023 at 2:48 PM, the MD Consultant Surveyor asked, "After four and a half days in your ED and then having the patient go to ICU, I would say that does not meet the standard of care for emergency medicine"? The Chief Medical Officer stated, "As would I".

On 5/24/2023 at 2:18 PM, ED MD #2 was interviewed regarding Patient #1. ED MD #4 was Patient #1's Provider from 6:30 AM to 3:30 PM on 5/10/2023 and 5/11/2023. She stated the following:
- I know that [Patient #1] was here and I took him/her in sign out a couple of mornings;
- He/She was here for placement;
- He/She was in the BED when I took care of him/her;
- I was not aware that he/she was not eating or drinking;
- I knew it [BP] was high but he/she had refused medications;
- I don't think he/she looked really sick and I would have treated if so; and
- He/She didn't strike me as any different than the other folks in the BED.

On 5/24/2023 at 3:24 PM, ED MD #1 was interviewed regarding Patient #1 and stated the following:
- Yes, I remember [Patient #1];
- He/She was on my radar as someone was not eating or drinking and I was thinking the behavioral team was going to admit him/her;
- His/Her behavior led to a medical condition;
- I don't know the exact timing of things, as I was busy with other things but [Patient #1] was on the list. I think [his/her BP's] were soft, which were attributed to lack of mobility...once I saw the chart, I went and did the work up;
- Someone said we are concerned, but I didn't think there was an urgent need...nobody asked me to go look at a patient right now...I was approached in a less urgent manner to assess the case;
- I think it was an isolated issue with the BP's as he/she wasn't eating or drinking;
- I think the [Nurse Case Manager] approached me and then the [ED MD Director] approached me and then put Patient #1 higher on the list; and
- I don't remember the labs, but I know he/she had an developed acute renal insufficiency.

On 5/24/2023 at 3:24 PM, a telephone interview was conducted with ED MD #1, regarding Patient #1. He stated the following:
- Yes, I remember Patient #1;
- On the morning of 5/12/2023, I recall a time when the nurse case manager approached me with concerns and the patients' decline;
- Someone said they were concerned but I don't think there was an urgent need;
- Nobody asked me to go look at Patient #1 right away and I was approached in a less urgent manner to assess the case;
- Patient #1 was on my radar as someone who was not eating or drinking and I was thinking the behavioral team was going to admit him/her;
- His/Her behavior led to a medical condition;
- I am not sure how soon labs were done as I was busy with other things and [Patient #1] was on the list;
- I think they [BP's] were soft and they had been attributed to a lack of mobility...once I saw the chart, I went and did the work up;
- Yes, I think it was an isolated issue with BP's he/she wasn't eating or drinking, and dehydrated; and
- I don't remember the labs but I know he/she had developed acute renal insufficiency and moved Patient #1 to the ICU as soon as I realized he/she had an acute renal injury.

On 5/25/2023 at approximately 8:00 AM, surveyors asked to speak with ED MD #3, and explained that he should have access to Patient #1's record to be able to speak to the evening of 5/11/2023. At approximately 8:15 AM, surveyors were told that ED MD #3 had no recollection of this visit for Patient #1. Surveyors then asked for his number to call him directly to verify.

On 5/25/2023 at 8:36 AM, an interview was conducted with ED MD #3, regarding Patient #1. He stated the following;
- I am starting to have a vague memory of this case;
- I probably told the nurse that I would come back and see the patient, but my shift ended at midnight;
- I was probably trying to do a bunch of stuff and I don't think I got around to seeing him/her, no, I didn't do it;
- I was managing a Non-ST-Elevation Myocardial Infarction [NSTEMI] transfer and I did not get back there [to the BED];
- I don't remember her [RN #2] talking about anything else except a rash;
- I do not recall passing this information on to the incoming provider [ED MD #4]; and
- ED MD #3 then asked surveyors what the Patient #1's vitals were at the time and after we told him, he stated, "There is no way I knew that. My recollection is that there is a rash, I don't remember anything else".

On 5/25/2023 at 9:33 AM, an interview was conducted with the ED MD Director regarding Patient #1. He stated the following:
- [The Nurse Case Manager] shared that she was very concerned about Patient #1, was really concerned, and had approached [ED MD #1] but he didn't really respond;
- I said to [The Nurse Case Manager] I will go talk to [ED MD #1]...I asked him to tell me about the patient, and he gave brief summary and that he hadn't been in yet, his morning was busy;
- Based on vitals, we felt we needed to do septic work-up, probably dehydration, intake has been poor but with those vitals we needed to do septic work up;
- The day before I don't recollect a lot, we do a brief huddle at 10:45 AM...and I think there was some confusion;
- It looked like he/she had a good day with eating some ice cream and having water;
- I had met him/her and the behavior was unchanged [saying he/she had to go to the bathroom, but didn't];
- There was a known pressure ulcer but he/she was resistant and the behavior was same, so no red flags, didn't seem like he/she was declining;
- We were working to get him/her into placement...and that night he/she deteriorated;
- We thought it was behavioral, that he/she was refusing to participate;
- In hindsight, it was a tough case...hard to see until vital signs changed;
- In retrospect, when a patient goes from behavioral to medical, we need to improve those cases; and
- Yes, things could have been in place sooner.

On 5/30/2023 at 1:59 PM, surveyors had a scheduled phone interview with ED MD #4, who was Patient #1's Provider from 9:00 PM on 5/11/2023 through 7:00 AM on 5/12/2023. He was called twice and never picked up or returned our calls.

2. Nursing Services

On 5/22/2023, Patient #1's medical record documentation of ED visits between 5/8/2023 and 5/12/2023 were reviewed. This review indicated the following:

On 5/8/2023 at 6:42 PM, ED MD #4 ordered Micotin 2% Powder. This powder was to be applied twice a day to abdominal folds, bilateral groin folds and bilateral breast folds. A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- No documented evidence of nursing staff applying Micotin 2% Powder, per the MD order, on 5/8/2023, 5/9/2023, 5/10/2023, until 5/11/2023 at 11:38 PM, which is a duration of approximately eighty-one (81) hours.

A review of Patient #1's nursing documentation from 5/8/2023 to 5/12/2023 revealed the following:
- On 5/9/2023 at 4:16 PM, ED RN #5 removed a Mepilex dressing and applied a new Mepilex dressing to the Stage II Ulcer;
- On 5/10/2023 at 10:28 PM, the Mepilex dressing was removed but not reapplied until 5/11/2023 at 11:02 PM, which is a duration of twenty-four and 1/2 hours (24.5) hours with no dressing applied to Patient #1's Stage II Ulcer;
- There was no documented evidence of bed rest used as an alternative;
- There was no documented evidence that Patient #1 was repositioned every two (2) hours; and
- Nursing staff on the BED did not request a wound consultation to assist with Patient #1's pressure injuries.

On 5/12/2023 at 9:42 AM, after moving Patient #1 to the medical side of the ED, a wound consult was ordered by MD #1 which revealed the following:
- Moisture associated breakdown noted to buttocks/sacrum;
- Stage II Pressure ulcerations bilateral buttocks as well as suspected Deep Tissue Injury [DTI] to peri-wound;
- Contact dermatitis noted to torso with shearing bilateral buttocks and sacral area; and
- Abdominal and breast folds noted to have fungal component.

Nutrition - Patient #1 had an admission diagnosis of Failure to Thrive, a Stage II Pressure Ulcer on the buttocks and the past history of not eating or drinking with a thirty (30) pound weight loss.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023, Patient #1 had Jello;
- On 5/9/2023, Patient #1 had refused all meals that day;
- On 5/10/2023, Patient #1 had ice cream (1 cup) mixed with a protein drink;
- On 5/11/2023, Patient #1 had some peanut butter with crackers;
- From 5/8/2023 through 5/12/2023, Patient #1 only drank enough water to take his/her medications; and
- A nutritional consult was not ordered until 5/12/2023, after the patient left the BED.

Vital Signs - Patient #1 had a past medical history of high blood pressure ("BP") and on 5/8/2023 at 2:25 PM, ED MD #4 ordered vital signs to be taken every eight (8) hours. The accepted "normal" range for blood pressure is less than 120 systolic and less than 80 diastolic and a pulse of 60 to 100.

A review of Patient #1's medical record from 5/8/2023 to 5/12/2023, nursing documentation revealed the following:
- On 5/8/2023 at 2:15 PM, BP was 149/104 with a pulse of 119 on admission to the BED;
- On 5/9/2023 at 8:00 AM, BP was 138/100 with a pulse of 98;
- On 5/10/2023 5:15 PM, BP 96/72 with a pulse of 110...Thirty three and a quarter (33.25) hours elapsed between vitals being taken;
- On 5/11/2023 at 8:41 AM, BP was 104/74 with a pulse of 116 ;
- On 5/11/2023 at 10:42 PM, BP was 86/59 with a pulse of 120;
- On 5/12/23 at 7:40 AM, BP was 85/46 with a pulse of 109;
- On 05/12/23 12:00 PM, BP was 90/65 with a pulse of 102; and
- The vitals taken while Patient #1 was in the BED, were not in accordance with physician orders.

On 5/22/2023 at 2:38 PM, an interview was conducted with the Vice President of Patient Care Services, regarding Patient #1's stay in the BED from 5/8/2023 to 5/12/2023. She stated the following:
- Today, we reviewed the chart again...the timeline is comprehensive and I have no concerns;
- Could we have moved faster, maybe, but nothing was missed;
- We have a 7:00 AM and 3:00 PM "bed meeting" where they alert me to high level issues;
- [ED RN Director] shared that a patient moved from the BED to the ED;
- I have an excellent nursing leader; and
- I trust that they are looking at, I don't go back and look...She is on top of everything.

On 5/24/2023 at 11:23 AM, an interview was conducted with ED RN #1, regarding Patient #1. She stated the following:
- Yes, I remember the patient;
- No, I was not made aware that Patient #1 had a pressure ulcer, I was only told he/she had redness on his/her back...on 5/12/2023, I found out;
- If someone had a high BP, I would call provider in the ED and report the medical finding and then they would give us direction and if I can't get hold of the provider, I would call the ED charge nurse and tell them I need them;
- We check BP once per shift;
- If someone has skin integrity problems, or doesn't want to eat or drink, we can't make them do anything on our unit;
- In our huddle (where the ED RN Director and ED Medical Director were present) on 5/11/2023 at 10:45 AM, I stated that he/she shouldn't be in the BED, as my concerns were that he/she was not eating or getting up and toileting;
- On our unit, we don't do ins & outs (monitoring what the patients eat/drink and monitor bowel/bladder output);
- Leadership stated that they would "look into it"...several hours later, I didn't hear anything so I called numerous people, including Patient #1's provider (ED MD #2) and the ED Nurse Director that afternoon on 5/11/2023;
- They stated later that day that because vital signs were stable, they were still "checking on it" and ultimately, Patient #1 was not approved to move into the medical side of the ED; and
- I didn't think about asking for labs, I don't always think of that.

On 5/24/2023 at 12:11 PM, a telephone interview was conducted with ED RN #3, regarding Patient #1. He stated the following:
- Yes, I remember Patient #1;
- Initially, Patient #1 was appropriate for BED;
- Vitals were stable;
- I was not aware of a pressure area, no, that was definitely not shared with me. Ideally, it should have been reported to the MD and then do a re-check; and
- No, I don't recall notifying an MD, I could have missed it.

On 5/24/2023 at 12:19 PM a telephone interview was conducted with ED Technician #1, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- I don't recall his/her BP;
- Yes, if there was something "off" with the BP, I would absolutely tell the nurse;
- Yes, I was aware he/she had a pressure area, as I was a part of a check with a nurse (RN #3 and RN #5) and both RN's were aware he/she had a stage II; and
- Patient #1 refused to move and eat.

On 5/24/2023 at 1:10 PM, a telephone interview was conducted with ED RN #5, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- No, he/she was not an appropriate BED patient;
- Maybe it was for convenience, but I don't know...It was actually a placement issue, so they said he/she is behavioral;
- I am sure I glanced at his/her BP, but in an ED there are some things that aren't a concern;
- We don't get super excited over a high BP;
- I wasn't aware of a pressure area, it was hard to visualize...When I put the next [Mepilex bandage] on, RN #3 was holding him/her;
- I didn't chart it but I did it, we are not the best at wound care documentation...I told the doctor that if he/she is going to continue not eating or drinking, he/she will need hydration and we are going to have do something; and
- I did not document that conversation.

On 5/24/2023 at 1:19 PM, an interview was conducted with the ED Nurse Director, regarding Patient #1 in the BED. She stated the following:
- Patient #1 was placed in the BED because he/she initially presented as needing a crisis evaluation;
- Patient #1 stayed in the BED because he/she didn't have any medical complaints and he/she was a bed search;
- It didn't really matter what side of the ED that Patient #1 was on;
- I was aware that Patient #1, during an ED visit on 4/27/2023, had a wound consultation for a pressure ulcer;
- I was at the huddle, along with the ED Medical Director, on the morning of 5/11/2023 where ED RN #1 presented her concerns;
- I talked to the medical provider, [ED MD #2], and she did not feel [Patient #1] needed a higher level of observation;
- I got a call on Friday morning (5/12/2023) about 6:30 AM because [Patient #1] had a low BP, and was showing signs for decompensating; and
- I called the medical charge nurse and requested to move Patient #1 onto the medical side of the ED.

On 5/24/2023 at 1:54 PM, an interview was conducted with the ED Nurse Case Manager, regarding her involvement with Patient #1. She stated the following:
- Yes, I remember [Patient #1];
- He/she came in several times recently to the ED looking for skilled nursing placement;
- He/she went into the BED because it was clear he/she couldn't go home;
- On the morning of 5/12/2023, I saw Patient #1 in the medical side of the ED, as his/her room was right across from my desk;
- He/She looked so significantly different that I was concerned and I went to talk with his/her dad, who is his/her guardian;
- I then went to his/her provider [ED MD #1] and explained that he/she didn't look well;
- My recommendation was whether this was behavioral or not, we needed to medically intervene;
- He/she looked very ill and and was refusing to eat and drink and I hadn't heard about a conversation about hydration or nutrition;
- ED MD #1 stated he hadn't read the chart and would when he had time;
- At that point, I reached out to risk management due to my concerns;
- When I talked to [Risk Manager and ED Nurse Director], nobody had talked about hydration and nutrition;
- Nothing happened at that point, so I went to the ED Medical Director and explained my concerns;
- He then went to [ED MD #1] to discuss the case;
- I was very concerned and feel like I was blown off;
- It shouldn't matter if he/she is behavioral or not, we still need to care for a patient's medical needs.

On 5/24/2023 at 2:25 PM, an interview was conducted with ED RN #4, regarding Patient #1. She stated the following:
- Yes, Patient #1 "rings a bell";
- Yes, he/she was appropriate at first, but as we continued to go through the week, it became apparent with him/her not eating or drinking, we were wondering if there are other things done like labs and hydration;
- During one of the shift changes, it was brought to my attention that he/she wasn't eating or drinking;
- Over the course of the previous twelve (12) hours, I was told he/she ate some ice cream;
- Over the course of the next twelve (12) hours, he/she had eight (8) ounces of ice cream and ½ of an ensure.
- I was concerned and asked about getting labs;
- I don't remember asking a provider for labs but I asked during shift change;
- Information on Patient #1's pressure injury was passed on about and I took off the Mepilex one night, but I did not put a Mepilex back on;
- I had suggested that maybe we should get labs because he/she wasn't eating or drinking, he/she was number one on our list; and
- I told everyone in huddle that I had concerns.

On 5/25/2023 at 7:26 AM, an interview was conducted with ED RN #2, regarding Patient #1. She stated the following:
- Yes, I remember Patient #1;
- Yes, on 5/11/2023, his/her BP was low, and they [first shift] said he/she hadn't gotten out of the chair all day and wasn't taking in anything;
- I took Patient #1's BP, he/she was dehydrated, pulse was high and I knew I had to move Patient #1 to a bed to assess his/her skin integrity;
- I did contact the medical side of the ED to get him/her in a bed, but the charge nurse decided Patient #1 would stay in the BED;
- I contacted ED MD #3 and I told him Patient #1 is a mess, he/she hasn't eaten or drank in several days;
- I told him about the pressure injury, the vitals and that Patient #1 needed to be seen by him right away;
- He told me to take a picture of the wound; and
- No, he did not come over to see Patient #1.

On 5/25/2023 at 10:06 AM, a phone interview was conducted with ED Technician #2, regarding Patient #1's BP on 5/11/2023 at 10:42 PM, which was 86/59 with a pulse of 120. She stated the following:
- Yes, I reported this BP to ED RN #2;
- I know Patient #1 hadn't been up and moving around and that he/she was refusing to eat and drink; and
- I take [vital signs] when I come on shift, unless the nurse tells us differently.

On 5/25/2023 at 10:16 AM, an interview was conducted with the ED Nurse Director, regarding Patient #1. She stated the following:
- Yes, the vital sign order is for every eight (8) hours for vitals;
- No, the vitals were not completed in accordance with the order;
- Yes, there is an expectation that if there is a pressure area that there would be a foam border dressing; and
- Per the job description, it is the expectation to have a care plan and it would include all pertinent issues.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.