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Based on observation, interview, and record review the hospital did not ensure staff provide a safe care environment to 2 of 2 patients when:

1. Patient 15 eloped and an unreasonable force (force that is unnecessary and excessive) was used by deploying a taser gun.
2. Patient 16 had a c-diff (a bacterium that can cause diarrhea and other intestinal conditions) and his bedside commode was not cleaned timely during his stay in the Emergency Department (ED).

As a result, Patient 15 sustained injury and was admitted to the hospital for 3 days, and Patient 16 had an unsafe and undignified environment.

Findings:

1. Patient 15 was admitted to the hospital on 6/28/24 with diagnoses which included fracture of right clavicle (collarbone) and psychosis (a symptom that caused a person to loose in touch with reality).

A review of Patient 15's Registered Nurse (RN) ED Notes dated 6/29/24 at 7:49 P.M., indicated " ...While I was discussing patient's next medication at bedside, patient was speaking with me calmly, then suddenly leapt out of bed and sprinted down the hallway past security and through the ambulance bay (area where ambulance park to unload patients) doors ...After he left the building, security ran after him through the hospital grounds."

An interview was conducted on 7/16/24 at 8:56 A.M., with the Emergency Department Manager (EDM) 2. The EDM 2 stated Patient 15 was a 5150 (involuntary 72 hour hold) patient who ran away and eloped in the ED on 6/29/24 at 7:40 P.M. The EDM 2 stated later that night, Patient 15 came back to the ED to retrieve his belongings. The EDM 2 further stated after Patient 15's arrival in the ED, Patient 15 ran away to elope again. Patient 15 was chased and tased with a taser gun by Security Agent (SA) 1. The EDM 2 stated Patient 15 sustained injury and was admitted to the hospital.

An observation of Patient 15's video recording was conducted on 7/19/24 at 1 P.M., with Regulatory 1 and the Senior Director of Facility Support Services (SDFSS). The video recording camera captured the ambulance area, part of the path going to ED entrance and the Front Street. On 6/29/24 at 9:51:27 P.M., Patient 15 arrived in the ED ambulance bay area, walked to the ED entrance pathway and disappeared on the camera recording. On 6/29/24 at 9:51:34 P.M., Patient 15 was captured by the video recording camera running from the ED entrance going to Front Street, was chased and the taser gun was deployed by the Security Officer. Patient 15 was tased on his back while running and fell to the ground at Front Street.

An interview was conducted on 7/19/24 at 1 P.M., with the SDFSS. SDFSS stated SA 1 tased Patient 15 on his back while running away. SDFSS stated it was not part of the policy deploy a taser gun to an eloping patient. SDFSS further stated that there was no reason to contain Patient 15 who was already outside the hospital building.

A review of hospital's policy and procedure titled, Use of Force last revised 3/7/22 indicated " ...III. Procedure: Department members are authorized to use only that amount of for that is objectively reasonable (reasonable force) to perform their duties ... S/A's (Security Agents) shall use de-escalation techniques and other alternatives practices that are consistent with their training before resorting to force ... V. Force Continuum/Matrix: B. Levels of Control ... 3. Third Level ... c. S/A's may utilize the TASER for subjects who have access to weapons ... VI. Unreasonable Force: Security members shall use only that force that is objectively reasonable. Unreasonable force is defined as the force that is unnecessary or excessive give the circumstances presented to S/As at the time the force is applied."

A review of hospital's policy and procedure titled, Taser - Conducted Energy Weapon (CEW) last revised 9/8/22 indicated " ...III. Procedure: The TASER is an intermediate weapon that is a handheld conductive energy weapon (CEW) used for controlling assaultive/high risk persons. The purpose of the TASER is to facilitate a safe and effective response and minimize injury to Subjects and Agents ...

2. Patient 16 was admitted to the hospital on 8/14/24 with diagnoses which included severe diarrhea (loose stool) and C-diff colitis (inflammation of colon caused by bacterium Clostridium Difficile) per History and Physical dated 8/14/24.

A review of Patient 16's room assignment indicated Patient 16 was assigned to room IRR09 (Emergency Department overflow area) on 8/15/24 at 12:24 A.M. until 8/16/24 at 6:57 P.M.

A review of Patient 16's stool output flowsheet indicated Patient 16 had 13 episodes of liquid stool and used bedside commode (portable toilet) throughout his stay in room IRR09 from 8/15/24 at 12:24 A.M., until 8/16/24 at 6:57 P.M.

An observation of room IRR09 was conducted on 9/17/24 at 11:35 A.M., with the SDN. Room IRR09 was an isolation glass room without a toilet inside the room.

An interview was conducted on 9/17/24 at 11:40 A.M., with Charge Nurse (CN) 1. CN 1 stated room IRR09 was an isolation room without a toilet. CN stated for a patient with C-Diff, a bedside commode will be used by the patient. CN 1 stated the stool in the bedside commode would be emptied in the red biohazard trash in the room. CN 1 stated the EVS would empty the trash and clean the room. CN 1 further stated the cleaning and emptying of the bedside commode and the emptying of the red biohazard trash was not being documented in the chart.

A review of hospital's policy and procedure titled, Standard and Transmission based precaution policies last reviewed 3/2024 does not specify guidelines on c-diff patients, assignments of room without toilet, the use of BSC and its emptying and cleaning guidelines.

Based on interview and record review the hospital did not implement their current policies and procedures on abuse allegation for 1 of 1 patient (Patient 18). The nursing staff did not follow the protocol when Patient 18 made an allegation of physical abuse.

This failure had the potential for Patient 18's well-being and at risk for further abuse.

Findings:

Patient 18 was admitted to the hospital on 8/21/24 with diagnoses which included Failure to thrive (a decline in weight loss and decreased appetite) per History and Physical dated 8/21/24.

A review of Adult Protective Services (APS) report completed on 8/22/24 indicated at 9 P.M. " ...The daughter of CLT (Client) was still present and from her account of the situation, her and CLT (Client) say that nurse [Name of Nurse] had pushed CLT back into the bed when she touched his shoulder suggesting he should sit down ... The daughter of the CLT then requested the nurses create an APS case ..."

An interview was conducted on 9/5/24 at 11:01 A.M., with the Emergency Department Manager (EDM) 2. The EDM 2 stated she received a report of an allegation of abuse when RN 1 took care of patient 18. The EDM 2 further stated that the report indicated RN 1 pushed Patient 18 back in bed in an aggressive manner. The EDM 2 stated she then reported to Senior Risk Manager (SRM) about the allegation of abuse. The EDM 2 further stated, it was then they made the decision that the allegation of abuse did not happen. The EDM 2 stated, she reported it to SRM and thought that was enough. The EDM 2 was not aware that the decision had to be made in conjunction with hospital leadership.

An interview was conducted on 9/12/24 at 11:30 A.M. with the Director of Regulatory (DR). The DR stated the EDM 2 and the SRM were the 2 leadership that made the decision right after the incident that the physical abuse allegation did not happen. The DR stated the allegation of abuse was presumed to have been discussed during the leadership meeting the following day at 10 A.M. The DR further stated she could not provide the evidence of discussion and the leadership determination on the allegation of physical abuse incident.

An interview was conducted on 9/13/24 at 9:28 A.M., with SRM. The SRM stated she received a call from the EDM 2 who reported to her that EDM 2 had conducted her investigation and determined her finding. The SRM further stated agreed with EDM 2's decision and did not take any further action.

A review of hospital policy and procedure titled Abuse Screening, Assessment and Reporting last revised date 11/24/20 indicated "Procedure: I. For allegations of abuse/neglect ... B. The Nurse Manager/Department Manager/Nursing/Physician Supervisor shall: 2. ...Risk and supervisor will coordinate to inform the following: i. Executive Leadership ... ii. UC San Diego Health Security; iii. House Supervisor; Patient's attending physician; and iv. Patient Experience ... 3. In conjunction with those listed above, determine whether it is necessary to relieve the employee(s) involved in the incident of their duty (ies) and place the party (ies) on the investigatory leave of absence pending the completion of all investigations and//or summary suspension."

Based on interview and record review the hospital did not ensure patient needs and treatments were met for 4 of 4 patients (Patient 13, Patient 14, Patient 17 and Patient 31) when:

1. Patient 13's vital signs and pain assessment were not reassessed within 4 hours after the ED triage in the ED waiting area per policy.
2a. Patient 13's pain level was not reassessed after Morphine (pain medication) Intravenous (IV) was given.
2b. Patient 14's pain level was not reassessed after Oxycodone (pain medication) tablet was given.
2c. Patient 17's pain level was not reassessed after Tylenol tablet (pain medication) was given.
3. Patient 31's neurological assessment (a medical evaluation of a patient's nervous system) was not done in a timely manner per physician's order.

This failure had the potential to affect the patients' care and well-being.

Finding:

1. Patient 13 was admitted to the hospital on 12/27/23 for diagnoses which included hydroureteronephrosis (swelling of kidney caused by obstructing kidney stone on flow of urine) and forniceal rupture (leak of urine to the surrounding tissue of the kidney) per ED Provider Notes dated 12/27/23.

A review of Patient 13's Patient Care Timeline (PCT) indicated that on 12/27/24 at 4:43 P.M., Patient 13's vital signs and pain assessment which included Blood Pressure (BP) 186/110 (normal BP 120/80) and abdominal pain level of 9 out of 10 (10 being the highest pain level). Per the same PCT, there were no evidence of documentation that staff provided intervention. Patient 13's PCT also indicated that the next pain assessment done was on 12/27/24 at 10:35 P.M., which was 6 hours after the initial assessment was done and the vital signs were assessed on 12/27/24 at 11:30 P.M., which was 7 hours after the initial assessment.

An interview and record review were conducted on 5/1/24 at 1 P.M., with the Emergency Department Manager (EDM) 1. The EDM reviewed the PCT and flowsheet of pain assessment. The EDM stated the expectation for patients that were triaged and asked to wait in the ED lobby's waiting room was to be reassessed every 4 hours. The EDM 1 acknowledged that Patient 13's vital signs were not taken, and pain assessment was not done after 4 hours from the time of the initial assessment.

A review of hospital policy and procedure titled, Triage last revised 8/2022 indicated " ...Procedure: II. E. Patients placed in waiting area following triage will have a focused re-assessment performed and documented a minimum of every 4 hours."


2a. Patient 13 was admitted to the hospital on 12/27/23 with diagnoses which included hydroureteronephrosis (swelling of kidney caused by obstructing kidney stone on flow of urine) and forniceal rupture (leak of urine to the surrounding tissue of the kidney) per ED Provider Notes dated 12/27/23.

A review of Patient 13's Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 12/27/24 at 10:35 P.M., Patient 13 was given Morphine 4 mg (milligram) IV. There was no documentation that pain level was reassessed after Morphine was given.

A record review and interview were conducted on 9/18/24 at 10:38 A.M., with the Senior Director of Nursing (SDN). The SDN reviewed Patient 13's MAR and Pain Assessment flowsheet. The SDN stated Patient 13's MAR indicated Patient 13 was given Morphine 4 mg IV on 12/27/24 at 10:35 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 13's pain level after pain medication was given.

A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated " ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient's pain to determine the effectiveness of the pain management strategies ... B. IV, IM, subcutaneous and epidural/peripheral nerve infusion/intrathecal analgesics: approximately 15-45 minutes following administration ..."

2b. Patient 14 was admitted to the hospital on 4/24/23 with diagnoses which included abdominal pain status post oocyte retrieval (procedure that removes eggs from an ovary to enable fertilization outside of the body) per History and Physical dated 4/24/23.

A review of Patient 14's Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 4/24/23 at 8:21 P.M., Patient 14 was given Oxycodone (Roxicodone) tablet 10 mg (milligram. There was no documentation that pain level was reassessed after Oxycodone was given.

A record review and interview were conducted on 9/18/24 at 11:20 A.M., with the Senior Director of Nursing (SDN). The SDN reviewed Patient 14's MAR and Pain Assessment flowsheet. The SDN stated Patient 14's MAR indicated patient was administered with Oxycodone (Roxicodone) tablet 10 mg on 4/24/23 at 8:21 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 14's pain level after pain medication was given.

A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated " ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient's pain to determine the effectiveness of the pain management strategies ... A. PO, PR, and gastric tube analgesics: approximately 45-75 minutes following the administration ..."

2c. Patient 17 was admitted to the hospital on 8/17/24 with diagnoses which included bilateral foot pain per ED Provider Notes dated 8/17/24.

A review of Patient 17's Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 8/17/24 at 2:09 P.M., Patient 17 was given Acetaminophen (Tylenol) 975 mg table. There was no documentation that pain level was reassessed after Oxycodone was given.

A record review and interview were conducted on 9/17/24 at 2:19 P.M. with the Senior Director of Nursing (SDN). The SDN reviewed Patient 17's MAR and Pain Assessment flowsheet. The SDN stated Patient 17's MAR indicated patient was administered with a pain medication Acetaminophen (Tylenol) 975 mg tablet on 8/17/24 at 2:09 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 14's pain level after pain medication was given.

A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated " ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient's pain to determine the effectiveness of the pain management strategies ... A. PO, PR, and gastric tube analgesics: approximately 45-75 minutes following the administration ..."


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3. A review of Patient 31's admission record indicated Patient 31 was admitted to the facility on 8/25/24 with medical diagnoses of anterior communicating aneurysm (Acom - narrowing of part of a brain), and hypertension (high blood pressure).

Review of Patient 31's physician order dated 9/12/24 indicated Patient 31 was to have neurological assessment (NA - checking patient's mental status) every four hours.

An interview was conducted with Patient 31 on 9/13/24 at 2:54 P.M., inside his room. Patient 31 stated he has not seen his licensed nurse since 9 A.M. Patient 1 further stated his physician advised him that his mental status will be frequently checked by nursing staff.

A concurrent interview and record review of were conducted with Registered Nurse (RN) 2 on 9/13/24 at 2:57 P.M. Per the electronic neurological assessment flow sheet, Patient 31's neurological assessment was last documented on 9/13/24 at 7 A.M. RN 2 stated, she should have recorded Patient 31's assessment at 11 A.M to accurately document Patient 31's mental status. There was no evidence of documentation Patient 31's neurological assessment was done every four hours per physician order.

An interview was conducted with the Unit Manager (UM) on 9/13/24 at 3:02 P.M. The UM stated she expects RN's to implement neurological assessment per physician's order and RN's should have documented on time to address changes that may have happened. The UM further stated RN 2 should have assessed Patient 31 on 9/13/24 at 11:00 A.M. and should have documented her findings on Patient 31's neurological assessment form.

Review of the facility's policy titled, Patient Treatment and Medication Orders dated, 5/24/24, indicated," ...X. Medication and treatments should be administered as ordered by prescribers ...."

Based on interview and record review the facility did not perform the 3rd day Utilization Review (UR - a systematic process of reviewing medical necessity, patient care, and service usage) after the initial UR for 1 or 1 patient (Patient 11) per policy. As a result, Patient 11's admission status was not corrected timely.

Findings:

Patient 11 was admitted to the hospital on 4/15/24 for diagnoses that included fall and left leg pain per History and Physical dated 4/16/24.

A review of Patient 11's admission status order dated 4/16/24 at 5:35 P.M., indicated "Inpatient Admission".

A review of Patient 11's InterQual (a tool used to determine patient's appropriate status and level of care) indicated that Patient 11 had an initial InterQual review on 4/16/24 and it indicated the criteria status was not met. The following InterQual review was on 4/21/24 and had indication the criteria status was not met.

An interview was conducted on 9/11/24 at 3:37 P.M., with the Care Management Chief Administrative Officer (CMCAO). The CMCAO stated the InterQual review should have been done on Day 3 after the initial InterQual review on 4/16/24. The CMCAO stated the InterQual review should have been done to ensure appropriateness of Patient 11's ordered admission status. The CMCAO acknowledge Patient 11's InterQual review was not done on Day 3.

A review of hospital's policy and procedure titled, Clinical Determination of Appropriate Patient Status last revised 5/24/24 indicated," ...Procedure: IV: Inpatient Status: C. Acute inpatients will have a documented InterQual clinical screening criteria review according to the following requirements: 3. Follow up or continued stay reviews must be completed by hospital day 3, then no less frequently than every third day, for patients located in a unit other than a critical care unit."

Based on interview and record review the facility did not inform and provide Medicare Outpatient Services Courtesy Notice (MOSCN) to 1 of 1 patient (Patient 11) when Patient 11's admission status was changed from Inpatient to Outpatient. This failure had affected Patient 11's discharge disposition and discharge plan.

Findings:

Patient 11 was admitted to the hospital on 4/15/24 for diagnoses that included fall and left leg pain per History and Physical dated 4/16/24.

A review of Patient 11's admission order status indicated that Patient 11 had 7 admission order status changed within 11 days. The document further indicated that Patient 11 had a change of admission status from Inpatient to Outpatient in a bed three times on 4/16/24 at 5:14 P.M, 4/22/24 at 1:37 P.M., 4/24/24 at 1:35 P.M.

A review of Patient 11's Electronic Medical Record indicated that Patient 11 was not provided with MOSCN on 4/16/24 at 5:14 P.M., and on 4/24/24 at 1:35 P.M. The MOSCN would have,"...notify you [patient] that the status of your current hospital stay is being changed from inpatient to outpatient services."

An interview was conducted on 9/11/24 at 3:30 P.M., with the Patient Access Director (PAD). The PAD stated the MOSCN was a document provided to patients to notify them of their admission status change from inpatient to outpatient. Patient 11 was provided with the MOSCN once on 4/22/24.

A review of hospital's policy and procedure did not indicate the process on providing the Medicare Outpatient Services Courtesy Notice.