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Based on records reviewed and interviews, the Condition of Participation (COP) for Governing Body was not met as evidenced by the failure of the Governing Body to ensure a thorough analysis and quality assurance review was conducted for an adverse event, and for the failure to ensure the quality of care was consistent with current standards of practice for 1 of 10 sampled patients.

Findings:

1. Condition: §482.21 Quality Assessment and Performance Improvement Program also known as A-0263 (QAPI). Based on records reviewed and interviews, the hospital's system for quality assurance failed to identify deficient practice and opportunities for improvement related to emergency services, adverse events, and medical record accuracy for 1 of 10 sampled cases. (Patient #1). Please see A0263 for details.

2. Standard: §482.24(c)(4)(iv) - Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia also known as A0465. Based on interviews and record reviews, the hospital failed to ensure the medical record was complete and accurate regarding documentation of complications for 1 of 10 sampled patients (Patient #1). Please see A0465 for details.

3. COP: §482.55 COP: Emergency Services also known as A-1100 Based on records reviewed and interviews, the Condition Participation for Emergency Services was not met as evidenced by the failure to ensure care was provided in accordance with current standards for 1 of 10 sampled patients presenting to the Emergency Department (ED) (Patient #1). Please see A-1100 for details.

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

Based on review of the hospital's grievance process, the hospital failed to ensure that the process clearly specified the time frame for response to the Grievant.

Finding:

The hospital's "Patient Grievance Procedure #HC-PA-2001", last revised 6/25/17, indicated that "resolutions of most grievances should be completed within seven business days of receipt but not more than 30 days. Upon resolution of a grievance, the Grievant will be provided with written notification of the decision that includes the contact person, steps that were taken on behalf of the patient to investigate the grievance, the results of the review and the date of the completion."

On 11/8/18, the hospital received a grievance involving Patient #18.

On 12/19/18, the surveyor requested to review the written notice provided to the patient. The surveyor was informed that they had closed the case on 12/6/18 and a written notice had not yet been provided to the patient (41 days after receipt of the grievance and 13 days after the case was closed).

The hospital's policy and procedure in relation to the time frame of the written notice was reviewed with the Chief Quality Officer, the Registered Nurse (RN) System Director for Risk, and the Patient Advocate on 12/19/18 at 4:14 PM. The surveyor was informed the the procedure was "vague" in relation to when the notice was to be provided to the Grievant.

Based on record reviews and interviews, the hospital failed to provide a written notice that contained the steps taken on behalf of the patient to investigate the grievance and/or the results of the grievance process for 2 of 4 patients who were involved in grievances filed (Patient #16 and Patient #17). In addition, the hospital failed to provide any notice to 1 of 5 patients who were involved in grievances filed (Patient #18).

Findings:

The hospital's "Patient Grievance Procedure #HC-PA-2001", last revised 6/25/17, indicated that "resolutions of most grievances should be completed within seven business days of receipt but not more than 30 days. Upon resolution of a grievance, the Grievant will be provided with written notification of the decision that includes the contact person, steps that were taken on behalf of the patient to investigate the grievance, the results of the review and the date of the completion."

1. On 10/31/18, the hospital received a grievance involving Patient #16.

The written notice, dated 11/16/18, did not contain the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

This finding was discussed and confirmed in an interview with the Chief Quality Officer, the Registered Nurse (RN) System Director for Risk, and the Patient Advocate on 12/19/18 at 3:45 PM.

2. On 11/7/18, the hospital received a grievance involving Patient #17.

The written notice, dated 11/29/18, did not contain the results of the grievance process.

This finding was discussed and confirmed in an interview with the Chief Quality Officer, the Registered Nurse (RN) System Director for Risk, and the Patient Advocate on 12/19/18 at 3:59 PM.

3. On 11/8/18, the hospital received a grievance involving Patient #18.

On 12/19/18, the surveyor requested to review the written notice provided to the patient. The surveyor was informed that they had closed the case on 12/6/18 and a written notice had not yet been provided to the patient (41 days after receipt of the grievance).

The hospital's policy and procedure in relation to the timing of the written notice was reviewed with the Chief Quality Officer, the Registered Nurse (RN) System Director for Risk, and the Patient Advocate on 12/19/18 at 4:14 PM. The surveyor was informed the notice had not been provided to the patient yet because of "busyness".

Based on records reviewed and interviews, the Condition of Participation (CoP) for Quality Assurance Performance Improvement (QAPI) was not met as evidenced by the hospital's Quality Assurance program's failure to identify deficient practice and opportunity for improvement related to emergency services, adverse events, and medical record accuracy for 1 of 10 sampled cases.

Findings:

1. The hospital's Quality Assurance process failed to ensure a thorough review and analysis of an adverse event was completed timely and in accordance with current standards for 1 of 10 sampled cases reviewed. The hospital failed to provide evidence to indicate that its QA process identified medical record documentation disparities regarding a nurse repositioning a patient, or an immediate nurse assessment related to that patient's response to the repositioning, Please see A-0286 for details.

2. The hospital failed to ensure the disparities between the documented physician assessment of a patient's cervical and thoracic spine and acceptable standards of practice for such assessments were sufficiently reviewed in order to identify process improvements to improve health outcomes, please see A-1100 for details.

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

Based on records reviewed and interviews, the hospital's Quality Assurance process failed to ensure a thorough review and analysis of an adverse event was completed timely and in accordance with current standards for 1 of 10 sampled cases reviewed (Case #1).

Finding:
1. The hospital failed to provide evidence to indicate that its QA process identified medical record documentation disparities regarding a nurse repositioning a patient, or an immediate nurse assessment related to that patient's response to the repositioning.

2. The medical record for Patient #1 contained documentation of physician assessment techniques related to cervical spine assessment and the conduction of full range of motion assessment for a cervical spine injury which was inconsistent with the standard of care for treatment of known cervical spine injured patients. The medical record also lacked documentation of an incident nurse treatment and repositioning of patient #1 which resulted in a significant change to the patient. The hospital failed to provide any evidence to indicate that the QA Committee had identified the areas of an inaccurate medical record and care inconsistent with standards of practice as areas in need of QA review and follow up.

Based on interviews and record reviews, the hospital failed to ensure the medical record was complete and accurate regarding documentation of complications for 1 of 10 sampled patients (Patient #1).
Finding

On 1/10/19 at 1:25 PM in an interview with RN #5 (day nurse) the nurse stated she "wasn't clear regarding Patient #1's c-spine precaution orders, questioned it, so she made Patient #1 strict c-spine precautions until she could get clarification ...had c-collar on ...Patient #1 did speak of an increase in his/her numbness in BLE [both lower extremities]" on her initial nurses assessment.

On 1/7/19 at 08:28 AM while conducting an interview with a family member, the surveyor was informed that the family member was present when the charge nurse entered Patient #1 room and began to change the position of Patient #1 from flat to a head and upper body elevated position. The family member stated that he/she told the nurse he/she thought the ED physician said Patient #1 was supposed to stay flat because no x-rays of the back had been done yet. The family member reports that the nurse continued to elevate the head of the bed for Patient #1 despite his/her screaming and the family member reported the nurse's response was, "the doctor ordered him to be sat up" ...
The medical record did not contain any documentation of this incident or any evidence of an assessment for a change of condition due to the sudden increase in severe pain except for a Neurosurgical note which stated " Thursday eve pt admitted by trauma service ...placed/forced into a 45-degree position by the staff, which caused an acute loss of all motor function at that time, in addition to causing a tremendous amount of pain to the patient (this per patient and [family member]). Apparently staff told the patient he 'had to get to 45 degrees despite the pain' and he lost all movement since that time."

Based on records reviewed and interviews, the Condition Participation for Emergency Services was not met as evidenced by the failure to ensure care was provided in accordance with current standards for 1 of 10 sampled patients presenting to the Emergency Department (ED) (Patient #1).

Finding:

It is a standard practice for all patients who seek care through the Emergency Department (ED) of a hospital to receive a thorough evaluation/assessment, stabilizing treatment, and discharge to home or to previous living environment in a stable condition, admission to the hospital for continuing treatment, or transfer to another hospital for further treatment that the hospital is unable to provide. The complete medical screening exam, including tests and consults along with findings and the medical decision related to stabilizing treatment, admission, and/or discharge should be documented in the record.

Documentation in Patient #1's medical record indicated he/she presented to Hospital #1's ED by Emergency Medical Services (EMS) on 10/4/18 at approximately 11:08 AM after sustaining a fall with loss of consciousness at a physician's office. The medical record denoted that patient #1 arrived with spinal immobilization by EMS using a rigid cervical collar and a long spinal immobilization board. The medical record contained documentation from a nurse (prior to Patient #1's arrival) stating that Patient #1 had a known fracture of the 4th Thoracic Vertebrae in the spine and the right leg reported as worse than normal.

On 10/4/18 at 12:17 PM the Emergency Room physician documented in the medical record, "Chief complaint of fall. History of present illness: Patient comes to the ER with a complaint of falling forward. Patient was at his/her spinal surgeons office; he was bending forward, felt light headed and fell onto his/her head. Patient claims he/she has numbness to the right abodomen, and down the right leg. Patient unsure if he/she lots of consciousness, but does have neck pain and back pain. He/she was recently diagnosed with a herniated disks in the C-spine (cervical spine or neck) and a compression fracture of T4 (thoracic spine vertebrae #4) ... Physical Exam, Head: Normocephalic, atraumatic; Neck: Supple, trachea midline, no tenderness, no JVD (Juglar Vein Distention) , no carotid bruit (Vascular Murmur) ... Back: Nontender, normal range of motion, Musculoskeletal: Normal strength, no tenderness, no swelling, no deformity, decreased range of motion of the right leg, decreased sensation to the right leg ..."

On 10/4/18 at 12:40 PM a Cat Scan (CT) of the Head and neck (Cervical spine) was conducted and the ED physician contacted the on-call Trauma physician after CT results which indicated a skull fracture and a small fracture with fragments to one of the neck vertebrae (bones) was obtained. In interview with the surveyor on 1/11/2019 the ED physician stated that "Patient #1 was kept c-spine (neck) precautions with cervical collar;" the ED physician stated that he "contacted Trauma after CT results at 1:15 PM and his (the ED physician) shift ended at 2:00 PM. Patient #1's care was considered in hands of Trauma. The medical record contained documentation from the ED physician which stated, "Impression and plan diagnosis, Skull fracture, facial laceration, C-spine facture."

On 10/4/18 at 3:30 PM the Surgeon covering Trauma services, assessed Patient #1 and documented in the medical record "[Patient #1 ] complains of tingling and numbness from his/her chest down to his/her feet but reports no problems moving any of his/her extremities ... Neck: 'Supple, full range of motion; Musculoskeletal: no muscle pain , no bone pain, no joint pain...Chronic back pain ... No gross deformity of extremities. All extremities with full range of motion; Neurologic: no headache, no sensory changes." This documentation indicated that the physician had the patient move his/her head and neck in every possible way to determine that the patient had "full range of motion" and this is contrary to the standard of care for a patient with a known cervical fracture.

There was no evidence in the medical record that any diagnostic testing or evaluation of Patient #1's existing T4 fracture to determine if any exacerbation of that fracture existed from the fall which resulted in loss of consciousness, a skull and neck fracture was completed prior to or upon admission. Additionally, the medical record contained an admission order that stated, "HOB 45 Degrees" (Head of Bed elevated to 45 degrees) with no mention of spinal precautions. However, this would be inconsistent with the standard of care given that there is no evidence of an assessment of the existing T4 fracture after the fall, and no mention of the stability of the cervical fracture as seen on the CT scan performed on 10/4/18. There was no admission order in the medical record to denote that Patient #1 was to be on spinal precautions. The failure to conduct an assessment of a known spinal fracture in the presence of a change in sensation and a fall which resulted in another spinal fracture is inconsistent with the standard of care.

On 1/10/19 at 1:25 PM in an interview with RN #5 (day nurse) the nurse stated she "wasn't clear regarding Patient #1's c-spine precaution orders, questioned it, so she made Patient #1 strict c-spine precautions until she could get clarification ...had c-collar on ...Patient #1 did speak of an increase in his/her numbness in BLE[both lower extremities]" on her initial nurses assessment.

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