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Based on interview, record review and policy review, the Governing Body failed to ensure professional oversight for staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standard (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed.

The severity and cumulative effect of this practice resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body and resulted in the hospital's failure to ensure quality health care and safety to all patients.

Based on interview, record review and policy review, the Chief Executive Officer (CEO) failed to ensure professional oversight for staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standard (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed.

These failures had the potential to affect the quality of care and safety for all patients.

Findings included:

Review of the hospital's untitled and undated document showed that all administrative leaders report to Staff EE, CEO.

Review of the hospital's policy titled, "Education," revised 04/2019, showed the hospital will provide educational opportunities for staff which will assist them to remain proficient and current in the healthcare field. General education programs will be offered to all hospital employees throughout the year. General nursing continuing education programs are identified each year by the nursing administration. Topics for presentation will be identified by a variety of sources including event reports and physician suggestions.

Review of the hospital's policy titled, "Abuse and Neglect," revised 04/2023, showed the Chief Nursing Officer (CNO) or Associate Vice-President (VP) of Clinical Services and Infection Prevention will report patient abuse/mistreatment by visitors as soon as possible to the BHS. Findings of the investigation are communicated to appropriate individuals and entities.

Review of the hospital's document titled, "Safety Event Manager," dated 10/29/23, showed:
- On 10/27/23 at 6:30 PM, Patient #22's ventilator (a machine that supports breathing) settings were changed, and a verbal order was placed under Staff Z's, Physician, name without his knowledge.
- At 9:15 PM, the ventilator settings order was noticed, and the ventilator was changed to the initial settings.
- The changed ventilator settings resulted in a "drastic" increase in work for breathing.
- The patient's prognosis was extremely poor, but the ventilator changes accelerated her death.
- Staff Z, recommended no significant ventilator changes were made without informing the physician. If changes were made, documentation was to be provided for why the changes were made. Verbal orders for significant, non-routine changes were not to be made under the physician's name without his/her knowledge.

Review of the hospital document titled, "Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to fine the root cause)," dated 01/04/24, showed:
- On 12/28/23, Patient #27 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) and sedated with an intravenous (IV, in the vein) drip of Versed (medication that causes you to sleep) and Fentanyl (medication for severe pain).
- Patient #27's IV tubing was accessed by a visitor with a needle he brought.
- The visitor made a deliberate attempt to withdraw medication from the patient's IV tubing.
- The patient became agitated and began thrashing.
- The nurse noticed blood and medication were dripping from the IV tubing from a puncture site.

During an interview on 01/24/24 at 11:00 AM, Staff EE, CEO, stated that he was responsible for the entire hospital. All senior leadership reported to him. He was responsible for ensuring staff were educated. He stated that education needed to be provided at a "broader level." The hospital had been too focused on the specifics of an event and had not recognized learning opportunities for others. The hospital needed to provide education to everyone to raise awareness and ensure meaningful education that included the whys of an event.

During an interview on 01/24/24 at 8:40 AM, Staff A, CNO, stated that there was no hospital-wide education provided in response to the events. She stated that she had not reported Patient #27's event to the BHS because she had not recognized the event as a visitor to patient abuse and had not anticipated the media response. During the interview, she recognized that Patient #27's event was a visitor to patient abuse.

During an interview on 01/24/24 at 1:00 PM, Staff C, Quality and Infection Prevention Executive Director, stated that Patient #27's event was not reported to the BHS because she had not viewed the event as a visitor to patient abuse. She had not expected media coverage. During the interview, she recognized that Patient #27 was abused by the visitor. She stated that there was no hospital-wide education provided in response to the events. She understood the necessity to educate all staff in response to events.

During a telephone interview on 01/24/24 at 11:35 AM, Staff Z, Physician, stated that education had only been provided to the respiratory therapists (RT) in response to Patient #22's event.

During an interview on 01/24/24 at 9:20 AM, Staff Y, Respiratory Department Director, stated that she provided one-to-one education for each RT, no education was provided to other staff.

During an interview on 01/23/24 at 3:05 PM, Staff R, Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that she had spoken with the ICU staff regarding the event with Patient #27. No education was provided to staff outside of the ICU. She did not know why the event was not reported to the BHS.

Based on interview, record review and policy review, the hospital failed to ensure staff were educated related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standards (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed.

The severity and cumulative effect of this practice resulted in the hospital's non-compliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights and resulted in the hospital's failure to ensure quality health care and safety to all patients.

Based on interview, record review and policy review, the hospital failed to provide staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standards (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed.

These failures had the potential to affect the quality of care and safety for all patients.

Findings included:

Review of the hospital's policy titled, "Education," revised 04/2019, showed the hospital will provide educational opportunities for staff which will assist them to remain proficient and current in the healthcare field. General education programs will be offered to all hospital employees throughout the year. General nursing continuing education programs are identified each year by the nursing administration. Topics for presentation will be identified by a variety of sources including event reports and physician's suggestions.

Review of the hospital's policy titled, "Abuse and Neglect," revised 04/2023, showed the Chief Nursing Officer (CNO) or Associate Vice-President (VP) of Clinical Services and Infection Prevention will report patient abuse/mistreatment by visitors as soon as possible to the BHS. Findings of the investigation are communicated to appropriate individuals and entities.

Review of the hospital's document titled, "Safety Event Manager," dated 10/29/23, showed:
- On 10/27/23 at 6:30 PM, Patient #22's ventilator (a machine that supports breathing) settings were changed and a verbal order was placed under Staff Z's, Physician, name without his knowledge.
- At 9:15 PM, the ventilator settings order was noticed, and the ventilator was changed to the initial settings.
- The changed ventilator settings resulted in a "drastic" increase in work for breathing.
- The patient's prognosis was extremely poor, but the ventilator changes accelerated her death.
- Staff Z recommended no significant ventilator changes were made without informing the physician. If changes were made, documentation was to be provided for why the changes were made. Verbal orders for significant, non-routine changes were not to be made under the physician's name without his/her knowledge.

Review of the hospital document titled, "Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause)," dated 01/04/24, showed:
- On 12/28/23, Patient #27 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) and sedated with an intravenous (IV, in the vein) drip of Versed (medication that causes you to sleep) and Fentanyl (medication for severe pain).
- Patient #27's IV tubing was accessed by a visitor with a needle he brought.
- The visitor made a deliberate attempt to withdraw medication from the patient's IV tubing.
- The patient became agitated and began thrashing.
- The nurse noticed blood and medication were dripping from the IV tubing from a puncture site.

During an interview on 01/24/24 at 11:00 AM, Staff EE, Chief Executive Officer (CEO), stated that education needed to be provided at a "broader level." The hospital had been too focused on the specifics of an event and had not recognized learning opportunities for others. The hospital needed to provide education to everyone to raise awareness and ensure meaningful education that included the whys of an event.

During an interview on 01/24/24 at 8:40 AM, Staff A, CNO, stated that there was no hospital-wide education provided in response to the events. She stated that she had not reported Patient #27's event to the BHS because she had not recognized the event as a visitor to patient abuse and had not anticipated the media response. During the interview, she recognized that Patient #27's event was a visitor to patient abuse.

During an interview on 01/24/24 at 1:00 PM, Staff C, Quality and Infection Prevention Executive Director, stated that Patient #27's event was not reported to the BHS because she had not viewed the event as a visitor to patient abuse. She had not expected media coverage. During the interview, she recognized that Patient #27 was abused by the visitor. She stated that there was no hospital-wide education provided in response to the events. She understood the necessity to educate all staff in response to events.

During a telephone interview on 01/24/24 at 11:35 AM, Staff Z, Physician stated that education had only been provided to the respiratory therapists (RT) in response to Patient #22's event.

During an interview on 01/24/24 at 9:20 AM, Staff Y, Respiratory Department Director, stated that she provided one-to-one education for each RT, no education was provided to other staff.

During an interview on 01/23/24 at 3:05 PM, Staff R, Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that she had spoken with the ICU staff regarding the event with Patient #27. No education had been provided to staff outside of the ICU. She did not know why the event was not reported to the BHS.