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A. Based on a tour of the Emergency Department (ED), review of policy and procedure, medical record review, and interview with administrative staff, it was determined that a policy regarding the monitoring of the temperatures of refrigerators containing patient food was not implemented.

Findings include:

Reference: Policy and procedure titled "Temperature: Daily Refrigerator Temperature Documentation (Food & Nutrition) (Inspira Medical Center)" stated:
"I. POLICY
All food refrigerators containing patient food in the hospital are monitored for the daily temperature specification of 41° F [Fahrenheit] or below and above 32° and all food freezers containing patient food are monitored for the daily temperature of 0° F (-18° C [Celsius]) or lower.
II. RESPONSIBILITY
.....
2) All Non In-patient [sic] Units for patient food and Staff refrigerators: Departmental personnel [sic]
3) Temperatures are recorded on a verification log and any discrepancies will be reported immediately to the maintenance department for action.
III. PROCEDURE
.....
2. Departmental personnel are responsible for performing temperature checks for all clinics, staff refrigerators, and non-in-patient [sic] units on a daily basis when open. Department Director/Manager is responsible for completed logs.
3. Temperatures outside of the acceptable range are referred to the maintenance department for corrective action.
....."

1. During a tour of the Nutrition Area (B Side) in the ED on the morning of September 16, 2021, accompanied by Administrators #1 and #3, the following was observed:

a. The DAILY TEMPERATURE VERIFICATION LOG sheet for September 2021 on the door of the refrigerator containing patient food revealed:

(i) The freezer temperature documented for September 13 was entered as 10° - ten (10) degrees warmer than the minimum acceptable temperature, The ACTION TAKEN section of the form for this date did not contain an entry.

(ii) The refrigerator temperature documented for September 14 was entered as 32° - one (1) degree colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date did not contain an entry.

(iii) The refrigerator temperature documented for September 15 was entered as 30° - three (3) degrees colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date did not contain an entry.

(iv) The refrigerator temperature documented for September 16 was entered as 32° - one (1) degree colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date did not contain an entry.

b. On September 20, 2021, Administrator #3 stated that there was no evidence that any of the out of range temperatures were reported to the maintenance department.

2. During a tour of the Pediatric Area in ED on the morning of September 16, 2021, accompanied by Administrators #1 and #3, the following was observed:

a. The DAILY TEMPERATURE VERIFICATION LOG sheet for September 2021 on the door of the refrigerator containing patient food revealed:

(i) There were no freezer temperatures documented between September 1 and 15.

(ii) The staff member who entered the refrigerator temperature on September 5, did not enter his/her initials in the INITIALS section.

(iii) The refrigerator temperature documented for September 9 was entered as 30° - three (3) degrees colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date did not contain an entry.

(iv) The refrigerator temperature documented for September 10 was entered as 30° - three (3) degrees colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date did not contain an entry.

(v) There was no refrigerator temperature entered for September 14.

(vi) The refrigerator temperature documented for September 16 was entered as 25° - eight (8) degrees colder than the maximum acceptable temperature. The ACTION TAKEN section of the form for this date contained the entry: "Told ___ (first name)."

b. On September 20, 2021, Administrator #3 stated that there was no evidence that any of the out of range temperatures were reported to the maintenance department.

3. Administrator #3 agreed with the findings.

C# NJ00148206
B. Based on a tour of the Emergency Department (ED), review of policy and procedure, and interview with administrative staff, it was determined that a policy and procedure regarding the monitoring of suicidal patients was not implemented.

Findings include:

Reference: Policy and procedure titled "One to One (1:1) Criteria (NUR 1.03) ***INH [Inspira Health Network]***" stated:
"I. POLICY
A. To provide guidelines for the assessment and use of one to one (1:1) intervention for patients on suicide/behavioral health precautions.
.....
II. DEFINITION
One to one (1:1) - A specifically designated staff member will maintain constant observation of the patient at all times. Observation criteria per below table. a [sic] The staff member will intervene to prevent patient from harm and alert the patient's nurse as indicated.
Type of Patient
Suicidal/Homicidal
Observation Criteria
1:1 at arm's length
Protection for Patient
Remove all personal items from room
Provider Order Required
Yes
.....
IV. PROCEDURE
A. Hospital employees including non-licensed caregivers such as technicians or counselors
may implement the role of 1:1 under the supervision of the RN.
.....
C. Any licensed or non-licensed caregiver with established competency, including but not limited to, basic CPR may perform monitoring of the patient, and attend to the patient's personal needs under the supervision of the RN. Said employee shall function at their level of competency and within their scope of practice. Direction will be given by the RN, Nurse Supervisor or Nurse Manager to the staff person regarding the concerns warranting a 1:1 caregiver and caregiver expectations.
.....
F. Patient activities observed must be documented in the Patient Observation Record at least every fifteen minutes. Conduct room search at the time the patient is placed on Observation to check for a safe environment. (See Observation Record)
....."

1. Review of the medical record of Patient #7 revealed:

a. The REASON CODE section of an OBSERVATION RECORD form, dated 6/24/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", and "SUICIDAL BEHAVIORS."

(i) There were no entries made on the form between 2300 (11:00 PM) and 2400 (12:00 AM) indicating that the patient was being observed on a 1:1.

b. The REASON CODE section of an OBSERVATION RECORD form, dated 6/25/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", "SUICIDAL BEHAVIORS" and "OTHERS: (SPECIFY) Safety."

(i) There were no entries made between 1800 (6:00 PM) and 2245 (10:45 PM) indicating that the patient was being observed on a 1:1.

c. The REASON CODE section of an OBSERVATION RECORD form, dated 6/26/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", "SUICIDAL BEHAVIORS" and "OTHERS: (SPECIFY) Safety."

(i) There were no entries made between 0015 (12:15 AM) and 1800 (6:00 PM) indicating that the patient was being observed on a 1:1.

d. The REASON CODE section of an OBSERVATION RECORD form, dated 6/27/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", and "SUICIDAL BEHAVIORS."

(i) There were no entries made between 0315 (3:15 AM) and 0700 (7:00 AM) indicating that the patient was being observed on a 1:1.

e. The REASON CODE section of an OBSERVATION RECORD form, dated 6/29/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", and "SUICIDAL BEHAVIORS."

(i) There were no entries made between 0030 (12:30 AM) and 0115 (1:15 AM) indicating that the patient was being observed on a 1:1.

f. The REASON CODE section of an OBSERVATION RECORD form, dated 7/9/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", and "SUICIDAL BEHAVIORS."

(i) There were no entries made between 0830 (8:30 AM) and 0900 (9:00 AM) indicating that the patient was being observed on a 1:1.

(ii) There were no entries made between 1245 (12:45PM) and 1330 (1:30 PM) indicating that the patient was being observed on a 1:1.

g. The REASON CODE section of an OBSERVATION RECORD form, dated 7/10/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", "SUICIDAL BEHAVIORS" and "OTHERS: (SPECIFY) Safety."

(i) There were no entries made between 0030 (12:30 AM) and 0130 (1:30 AM) indicating that the patient was being observed on a 1:1.

h. The REASON CODE section of an OBSERVATION RECORD form, dated 7/11/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", and "SUICIDAL BEHAVIORS."

(i) What appears to have been entries in the "Code" and "Initials" boxes between 1700 (5:00 PM) and 1945 (7:45 PM) were heavily scribbled over making them illegible.

i. The REASON CODE section of an OBSERVATION RECORD form, dated 7/16/21, included the entries: "ELOPEMENT RISK", "FALL PREVENTION", "SUICIDAL BEHAVIORS" and "OTHERS: (SPECIFY) Safety."

(i) There were no entries made between 0015 (12:15 AM) and 0100 (1:00 AM) indicating that the patient was being observed on a 1:1.

C# NJ00148206
C. Based on a review of the medical record of one patient (#1) who was discharged from the emergency department, review of policy and procedure, and interview with administrative staff, it was determined that a discharge policy was not implemented:

Findings include:

Reference: Policy and procedure titled "Discharge Referral Procedure (ER.11) *IHN [Inspira Health Network]* stated: ".....
III. PROCEDURE
.....
b. Nurse carries out the following:
.....
* RN/LPN [Registered Nurse/Licensed Practical Nurse] finalizes chart, electronically signing his/her name, date and time of discharge, patient disposition, appropriate charge sheets, if applicable and any other pertinent information. (i.e. valuables returned, etc.)

1. Review of the medical record of Patient #1 revealed:

a. An "Admit-Discharge-Transfer Forms" sheet stated:
"Valuables/Belongings ED [emergency department] Entered On: 8/30/2021 18:30 [6:30 PM]EDT
Performed On: 8/30/2021 18:29 [6:29 PM] EDT by _______, _______ (Surname and first name)
Valuables/Belongings ED
ED Clothing: Pants, Shirt, Shoes, Socks
Patient Placed in Gray Gown: Yes
Location Patient Belongings: shelf 6
....."
The entries were electronically signed by the writer at 18:29 [6:29 PM] EDT.

b. There was no documentation in the medical record that the patient's belongings were returned to him/her prior to discharge.