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Based on observation, document review, record review, policy review, video surveillance and interview, the Governing Body failed to function effectively and failed to ensure that hospital staff followed policies and procedures to provide oversight for the Conditions of Participation (CoP) of Patient Rights; Nursing Services; Physical Environment; Infection Control; and Surgical Services.

The cumulative effects of the Governing Body's systemic failures to function effectively resulted in multiple Immediate Jeopardy situations and inability to meet the required Hospital Conditions of Participation for Governing Body at 42 CFR 482.12, Patient's Rights at 42 CFR 482.13, Nursing Services at 42 CFR 482.23, Infection Control at 42 CFR 482.41, Physical Environment at 42 CFR 482.42 and Surgical Services at 42CFR 482.51.

Findings Include:

1. The Governing Body failed to ensure the hospital met the requirements for the Patient Rights Condition of Participation by failing to provide care in a safe setting free from abuse, neglect, and exploitation. (Refer to A0115)

2. The Governing Body failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for each patient. (Refer to A0385)

3. The Governing Body failed to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. (Refer to A700)

4. The Governing Body failed to ensure staff adhered to nationally recognized infection prevention and control guidelines and adhered to hospital policies and procedures for infection control and prevention such as proper hand hygiene, appropriate use of personal protective equipment, and inappropriate handling and/or storing of blood products and food handling. (Refer to A0747)

5. The Governing Body failed to ensure services were well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. (Refer to A0940)

Based on policy review, record review, and interview, the hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient's rights.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation.

Surveyors notified Staff Q, Chief Administrator Officer, on 12/07/23 at 1:35 PM, that an immediate jeopardy (IJ) existed related to 42 CFR 482.13 Patient Rights.

The hospital submitted a plan of removal (POR) on 12/12/23 at 9:36 AM. On 12/13/23 at 3:16 PM, the hospital was notified the written POR was accepted.

The POR included the following:

Oversight and Reporting: The Executive Sponsor will oversee the implementation, monitoring, and sustainment of the actions described in the plan of correction. Ongoing compliance will be reported through the Quality and Safety Committee of the Board of Directors. Once compliance is met, monitoring will continue through the continuous readiness program for sustainability.

Recognition of Potential Abuse Corrective Action: Effective 12/7/23 the use of Mental Health Protection Workers (MHPW) for assistance with patient transfers hospital-wide is halted until appropriate training and competency is completed. Beginning 12/8/23 the Physical Therapy Department developed training and competency validation related to safe patient transfers for Mental Health Protection Workers (MHPW). On 12/8/23 the SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication) titled "Behavioral Health Patient Transfers and Fall Algorithm" was sent electronically and discussed during shift huddles to [H2] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed. On 12/12/23 the SBAR titled "[H1] Fall Algorithm" was sent electronically and discussed during shift huddles to [H1] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed. Effective 12/7/23 nurses and behavioral health staff who were involved in the incident of alleged abuse received verbal coaching by the Chief Nursing Officer to review and ensure understanding of opportunities identified related to staff response, including an incomplete patient assessment, leaving the patient unattended, and the potential to cause injury or worsening of an injury sustained in a fall during the transfer of the patient during the event. Discussion also included the need to speak up and immediately intervene at the time of any activity which could cause harm. The remaining staff involved in the incident will receive the same verbal coaching and education before the start of their next scheduled shift. Beginning 12/11/23 Behavioral Health associates were assigned an Abuse, Neglect and Exploitation web-based training. Beginning 12/11/23 [H2] and [H1] employed associates, including department and hospital leadership, were assigned an Abuse, Neglect and Exploitation web-based training.

Recognition of Potential Abuse Monitoring for Sustainment/Reporting: Mental Health Protection Workers (MHPW) education completion will be validated by competency documentation. SBAR titled "Behavioral Health Patient Transfers and Fall Algorithm" during their next scheduled shift. [H2] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. SBAR titled "[H1] Fall Algorithm" during their next scheduled shift. [H1] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. The Chief Nursing Officer will validate and log the completion of verbal coaching with the seven staff members involved in the event. Behavioral Health associates will complete the web-based training by 12/15/23 or during their next scheduled shift. [H2] and [H1] employed associates will complete the web-based training by 12/31/23.

Recognition of Potential Abuse Evidence of Compliance: 12/7/23 Email communication.

MHPW safe patient transfer competencies. [H2] nursing staff roster to validate receipt and understanding of SBAR communication. [H1] nursing staff roster to validate receipt and understanding of SBAR communication. Log of Chief Nursing Officers verbal coaching with the seven staff. Web-based training roster.

Unwitnessed fall assessment Corrective Action: On 12/8/23 the SBAR titled "Behavioral Health Patient Transfers and Fall Algorithm" was sent electronically and discussed during shift huddles to [H2] nursing staff. The SBAR consists of information about what to do when a patient is found on the ground and how to safely assess and care for them. The fall algorithm specifically addresses unwitnessed falls, including patients who are unable to verbalize injury, and the care needed.

Unwitnessed fall assessment Monitoring for Sustainment/Reporting: Behavioral Health nursing associates will acknowledge the SBAR titled "Behavioral Health Patient Transfers and Fall Algorithm" during their next scheduled shift. [H2] nursing associates will acknowledge the SBAR by 12/31/23 or prior to their next scheduled shift. Completion of the post-fall assessment will be monitored through the post-fall auditing process.

Unwitnessed fall assessment Evidence of Compliance: [H2] BH nursing staff roster to validate receipt of SBAR communication. Post-fall audits.

Risk Investigation Corrective Action: On 12/7/23 the Abuse and Neglect - System policy was reviewed with all of the [Hospital] Risk Managers by the Risk Management Director via Google Meet. All Risk Managers attested to the policy review and have passed an education post-test.

Beginning 12/8/23 all [Hospital] Risk Management associates were assigned an Abuse, Neglect and Exploitation web-based training. On 12/7/23 the "Allegation of Associate Misconduct Process Flow" was reviewed with all the [Hospital] Risk Managers by the Risk Management Director via Google Meet. The expectation was set that all allegations of misconduct will follow the "Allegation of Associate Misconduct Process Flow." All Risk Managers attested to the policy review and have passed an education post-test. Beginning 12/7/23 a daily report of events categorized as behavioral will be sent to Risk Managers for review and correction of the classification in the Event Reporting System, if needed, to correctly identify and classify the nature of potential caregiver misconduct events. Education was completed on 12/7/23 about the expectation of reviewing the report by the Risk Management Director via Google Meet. All Risk Managers attested to the policy review and have passed an education post-test. On 12/7/23 a multidisciplinary team, including representation from Legal, Corporate Compliance, Quality, and Behavioral Health, was identified to review and validate the reports of potential caregiver misconduct weekly. The first meeting is scheduled for 12/12/23. On 12/7/23 the elements of an investigation of harm events were reviewed with all of the [Hospital] Risk Managers by the Risk Management Director via Google Meet. The elements of an investigation of harm include a medical record review, timeline of care, interviews and video surveillance. All Risk Managers attested to the process and have passed an education post-test.

Risk Investigation Monitoring for Sustainment/Reporting: Risk Managers have attested to the policy review and passed the education post-test with a score of 100%. All [Hospital] Risk Management associates will complete the web-based training by 12/15/23. An audit of abuse/neglect incidents in which a caregiver is alleged to have caused the abuse/neglect will be conducted for six months to ensure 100% compliance with policy. An account of caregiver abuse/neglect allegations will be presented to the Board of Directors' Quality and Patient Safety subcommittee every 2 months until 100% compliance with accurate classification and investigation is achieved. Beginning 12/12/23 the Risk Management Director or designee will lead the weekly meeting to review reported behavioral events. If an event is identified that had not been identified by Risk Management during their daily review, a risk manager will be assigned to begin an immediate investigation. The multidisciplinary team will meet until full compliance with accurate classification is achieved for 4 consecutive months. The Risk Management Director or designee will audit 10 harm events per month until 100% compliance of all applicable elements of an investigation are present and documented for 6 consecutive months. Then random audits will occur to ensure sustainment.

Risk Investigation Evidence of Compliance: Attestation and post-test results. Web-based training roster. Abuse/neglect incident audits. Board of Directors' Quality and Patient Safety meeting minutes. Multidisciplinary team meeting minutes. Harm event investigation audits.

Findings Include:

1. The hospital failed to provide/inform patients or patient's representative of Patient Rights in advance of furnishing patient care for 8 of 50 sampled patients. (Refer to Tag A0117)

2. The hospital failed to ensure that any patient and/or patient's representative was informed of the hospital's internal grievance process, including whom to contact to file a grievance. The hospital failed to ensure that as part of its notification of patient rights, the hospital must provide the patient and/or the patient's representative a phone number and address for lodging a grievance with the State Agency. The hospital failed to inform any patient that he/she may lodge a grievance with the State Agency directly, regardless of whether he/she had first used the hospital's grievance process. The hospital failed to follow its grievance process policy and failed to classify an allegation of abuse as a grievance. (Refer to Tag A0118)

3. The hospital failed to ensure the patients' right to receive care in a safe setting as required per 42 CFR §482.13(c)(2). (Refer to Tag A0144)


4. The hospital failed to ensure that 2 of 50 sampled patients were free from all forms of abuse and harassment. (Refer to Tag A0145)


5. The hospital failed to ensure the use of restraints was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient for 1 of 1 patient in restraints. (Refer to Tag A0168)


6. The hospital failed to ensure the monitoring of a patient for 1 of 1 patient in restraints as required per hospital policy. (Refer to Tag A0175)


7. The hospital failed to ensure that a physician or other licensed practitioner performed a face-to-face evaluation within one hour after the initiation of restraint when used for the management of violent behavior for 1 of 1 sampled patient in restraints. (Refer to Tag A0178)

Based on record review, policy review, document review and interview the hospital failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for each patient.

The cumulative effects of this deficient practice resulted in the continuance of an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation.

On 12/11/23 at 2:34 PM, Surveyors notified hospital administration (Staff Q, Chief Administration Officer) that an immediate jeopardy (IJ) existed related to 42 CFR 482.23 Nursing Services.

The hospital submitted a plan of removal (POR) on 12/12/23 at 9:36 AM. On 12/13/23 at 3:07 PM,
the hospital was notified the written POR was accepted.

The POR included but was not limited to the following:

Opportunity: Triage process
Corrective Action: Beginning 12/12/2023, the SBAR titled "ACS Initiation For Rapid Evaluation and Assessment" was sent electronically to St. Francis and St. Joseph
Emergency Department (ED) nursing associates, nursing support services, registration, Physicians, or LIPs, and will be discussed during department huddles. The SBAR includes education on the expectation that triage is initiated within 15 minutes of arrival. When the ED team cannot meet the 15-minute triage expectation, they should escalate to their leader or designee.
Monitoring for Sustainment/Reporting St. Francis and St. Joseph ED nursing
Associates, nursing support services, registration,
Physicians, and LIPs will acknowledge receipt of the SBAR titled "ACS Initiation for Rapid Evaluation and Assessment" by 12/22/23 or before their next scheduled shift. Audit a sample of 10 charts per day on each campus of patients who present to the emergency department with a chief complaint of Chest Pain, epigastric pain, Nausea/Vomiting, Arm Pain, Diaphoresis, Fatigue, or shortness of breath for triage completed within 15 minutes.
Date of Implementation: 12/12/2023 Evidence of Compliance: St. Francis and St. Joseph staff roster to validate receipt and understanding of SBAR communication.

Opportunity: Door to ECG time Corrective Action
Beginning 12/12/2023, the SBAR titled "ACS Initiation for Rapid Evaluation and Assessment" will be sent electronically to St. Francis and St. Joseph ED nursing Associates, nursing support services, registration, and Physicians, and LIPs and discussed during department huddles. The SBAR includes information about the AHA/ACC guidelines for Acute Coronary Syndrome (ACS). This SBAR was distributed to re-educate and obtain Associate attestation and establish the ACS criteria that would initiate a stat ECG to be completed and interpreted within 10 minutes in accordance with the AHA/ACC guidelines.
Monitoring for Sustainment/Reporting St. Francis and St. Joseph ED nursing associates, nursing support services, registration, and Physicians and LIPs will acknowledge receipt of the SBAR titled "ACS Initiation for Rapid
Evaluation and Assessment" by 12/22/23 or before their next scheduled shift. Audit a sample of 10 charts per day on each campus who present to the emergency department with a chief complaint of Chest Pain, Epigastric pain, Nausea/Vomiting, Arm Pain, Diaphoresis, Fatigue, or Shortness of Breath unless not deemed clinically necessary by the Physician or LIP.
Date of Implementation: 12/12/2023 Evidence of Compliance: St. Francis and St. Joseph staff roster to validate receipt and understanding of SBAR communication.

The hospital's plan of removal was not able to be validated prior to survey exit on 01/28/24 at 4:34 PM, and the Immediate Jeopardy remained in place.

Findings Include:

1. The hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care when the nursing staff failed to complete assessments as required, failed to notify physician of critical results and/or delay of care, failed to administer medication as ordered, failed to complete vitals as required, failed to document repositioning of patients at risk for skin break down every two hours or more frequently as ordered by the physician and failed to provide daily bathing as ordered. (Refer to A0395)

2. The hospital failed to ensure nursing care plans were kept current for each patient when nursing staff failed to followed the Patient Assessment and Reassessment, Nursing documentation guidelines, and Fall Risk policies of updating the patients interdisciplinary plan of care with interventions, short term goals, and long-term goals. (Refer to A0396)

Based on observation, document review, policy review, interview and review of the Life Safety Code (LSC) complaint investigation findings (KS00182852), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC). The hospital failed to ensure safe sleeping suites for patients, safe exit access, adequate hallway clearance, and appropriate removal of biohazard and trash collection.

The cumulative effect of this deficient practice places any patient, staff or visitor at the hospital at risk for serious injury, serious harm, serious impairment or death and resulted in three Immediate Jeopardies (IJ a situation in which the providers noncompliance with one or more requirements of participation caused or is likely to cause serious injury, harm, impairments or death to a patient).

The hospital administration was notified on 12/14/23 at 2:05 PM that three IJ's existed: 1. K232 - 2012 Edition National Fire Protection Association (NFPA) 101 LSC - Aisle, Corridor or Ramp Width, 2. K256 -2012 Edition NFPA 101 LSC - Sleeping Suites, and 3. K754 - 2012 Edition NFPA 101 LSC - Soiled Linen and Trash Containers.

The hospital submitted a plan of removal (POR) on 12/14/23 at 9:39 PM. On 12/15/23 at 1:28 PM the hospital was notified the written POR was accepted.

The POR included the followingbut is not limited to:

Tag K232

Opportunity: Obstructed Egress
Date of Implementation: 12/14/23
Corrective Action
On 12/14/23, unoccupied recliners and chairs were removed from the space and the tables and chairs were relocated to provide the required 48 inch exit access width.
On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage. These items were relocated to other appropriately rated separate locations.
On 12/15/23, an SBAR communication will be distributed through the hospital safety huddle that the egress corridor outside the POU cannot be used for storage.

Monitoring for Sustainment/Reporting
Observation audits of the POU to monitor for appropriate storage and required 48 inch exit access width will be conducted two times every 24 hours until there are no longer patients in the POU.
Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours.

Evidence of Compliance
POU observation audits POU egress corridor observation audits SBAR communication


K256

Opportunity: Sleeping Suites
Date of Implementation: 12/14/23
Corrective Action
Effective 12/14/23, admissions to the Psychiatric Observation Unit (POU) were halted. Patients currently in the POU will be moved to appropriate locations for continued care as soon as reasonably possible and no later than 12/18/23.
Until all patients are moved to appropriate locations for continued care, Consult 1 was secured and not available for patient care. On 12/15/23, the lock on the door will be exchanged to a new unique-key lock.
On 12/14/23, the room labeled "staff only" was updated on the life safety code plans with the correct name of the room. The shelves in the room labeled "staff only" were modified so no items could be stored closer than 18 inches to the ceiling or to the bottom of the sprinkler head.
On 12/14/23, the Director of Environmental Services was verbally notified and electronically communicated with by the Regional Safety Officer that waste containers greater than 64-gallons are not allowed in a room without a fire-rating of 1 hour. The waste container was immediately removed from the soiled hold room.
On 12/14/23, unoccupied recliners and chairs were removed from the space and the tables and chairs were relocated to provide the required 48 inch exit access width and ensure the emergency exit door is free of obstructions.
On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage.
On 12/14/23, the east and west 90-minute fire rated doors outside the POU were repaired and subsequently functioned correctly when drop tested.

Monitoring for Sustainment/Reporting

A daily report out of the Capacity Management System will demonstrate that no patients were placed in the POU after 12/14/23 at 1642.
A daily census report will demonstrate that there were no patients in the POU after 12/18/23. Observation audits of the POU to monitor for appropriate waste storage and required 48 inch exit access width will be conducted two times every 24 hours until there are no longer patients in the POU.
Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours.

Evidence of Compliance
Capacity Management Report with last admission to POU
Census reports each day
Completed maintenance work order for unique-key lock
Updated life safety code plans
Completed maintenance work order for rack modifications.
Copy of Email between the Regional Director of Emergency Management to the Director of Environmental Services
POU observation audits
POU egress corridor observation audits
Completed maintenance work order for the repair of the 90-minute fire rated doors.


Tag K754

Opportunity: Soiled Linen and Trash Containers
Date of Implementation: 12/14/23
Corrective Action
On 12/14/23, the egress corridor outside the POU was cleared of unused beds, unused equipment, and hazardous/soiled/combustible storage. Removal of these items ensures unobstructed access to the fire extinguisher and appropriate clearance of the fire sprinklers.

Monitoring for Sustainment/Reporting
Observation Audits of the egress corridor outside the POU to monitor for clear egress will be conducted two times every 24 hours.
Evidence of Compliance
POU egress corridor observation audits

The POR corrective actions to remove the immediacy for the three IJs were verified on 12/15/23 at 4:45 PM by Life Safety Code Surveyor.

Based on document review, record review, policy review, surveillance video, observation, and interview the hospital failed to ensure staff adhered to nationally recognized infection prevention and control guidelines and adhered to hospital policies and procedures for infection control and prevention such as proper hand hygiene, appropriate use of personal protective equipment, and inappropriate handling and/or storing of blood products and food handling.

The cumulative effect of this deficient practice places all patients, visitors, staff, and community at risk to contract and spread communicable diseases.

Findings Include:

1. The hospital failed to ensure hospital staff followed Infection Control policies and procedures, for 4 of 54 patient (Patient 7, 16, 21, and 48) records reviewed. (Refer to tag A0749)

2. The hospital failed to maintain a clean and sanitary environment. (Refer to tag A0750)

Based on record review, policy review, document review, staff and patient interviews, the hospital failed to ensure surgical services were provided in accordance with acceptable standards of practice when staff failed to follow policy and acceptable standards of practice to maintain safety, to provide supervision, and to prevent anesthesia medication administration errors.

The cumulative effect of this deficient practice places all patients at risk for physical injury and increased anesthesia related harm.

Findings Include:

1.The hospital failed to ensure staff followed policies and procedures to achieve and maintain patient care that meets the standards of medical practice and patient care. (Refer to A-0951)

Based on observations, document review, record review, policy review and interview, the Governing Body failed to ensure the hospital followed its policies and procedures. Failure of the governing body to provide oversight of the medical staff for the quality of care provided to patients places all patients at risk for inadequate medical care resulting in harm, further injury, ongoing pain, or death. The governing body must ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The governing body is responsible for the conduct of the hospital and this conduct includes the quality of care provided to patients.


Findings Include:


Review of the hospital's document titled, "MEDICAL STAFF BYLAWS: Governance and Credentialing Manual," dated 12/3/21, showed ...Establish, maintain, amend, and enforce Medical Staff Bylaws for the self- governance of the Medical Staff ...Develop clinical policy, monitor, evaluate, and improve the quality of care provided in associated hospital areas ...


Review of the hospital's document titled, "BYLAWS OF VIA CHRISTI HOSPITALS WICHITA, INC.," dated 9/10/15, showed..."System Policy" shall mean all policies, procedures, technical manuals, and other written guidance established, adopted, or issued from time to time by Ascension that are intended to apply to all organizations within the System, including without limitation, the Governance Authority Matrix ...


The hospital's Governing Body failed to ensure it protected: Patient's Rights; (refer to A-0115, A-0117, A-0118, A-0144, A-0145, A-0168, A-0175, and A-0178); Nursing Services; (refer to A-0385 and A-0395); Physical Environment; fire (refer to A-0700 and A-0709); Infection Control; (A-0747, A-0749, and A-0750); Surgical Services; (A-0940 and A-0951).


During an interview on 12/07/23 at 1:52 PM with Staff Q, Chief Administration Officer stated, "I feel like we are doing everything we can to keep patients safe at this time."


During an interview on 1/5/23 at 3:52 PM with E6, Chief Executive Officer (CEO), E6 stated that the video of a physician laughing at Patient 33 after they fell out of bed while restrained was disheartening.


During an interview on 1/5/23 at 8:01 AM Staff D, Director of Quality stated that the hospital has provided all they will be providing on investigations at this time.


During an interview on 01/08/24 at 10:02 AM, Staff T4, RN/Risk Manager, stated, "...I don't know what disciplinary action was done for the physician staff, we are not part of that process." Staff T4 stated that the hospital did not start an investigation into Patient 33's incident until surveyors requested the medical record on 12/11/23 at 1:29 PM.

Based on policy review, document review, record review, and interview, the hospital failed to ensure that services furnished under contract complied with all applicable conditions of participation and acceptable standards of practice as evidenced by the failure of a medical provider to provide a physical examination for 1 of 1 patient (Patient 33) that was brought to the Emergency Department (ED) for evaluation of a possible emergency medical condition, and failed to ensure acceptable standards of practice were followed for a 1 of 1 patient (Patient 33) that was placed in restraints. This deficient practice places any patient receiving services at the hospital at risk for serious injury or harm.


Findings Include:


Review of a policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA),"
revised 04/17/23, showed, " ...The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment, and when applicable, safe transfer of a patient...Standard for Medical Screening Examinations:


1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional.]


2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient ' s needs, and monitoring should continue until the individual is stabilized or admitted ..."


Review of a policy titled, "Patient Rights and Responsibilities," revised 01/21/22, showed, "
...Be treated in a dignified and respectful manner and receive care by competent personnel
...Receive care in a safe setting and be free from physical, verbal, emotional/psychological, and sexual abuse, and harassment ..."


Review of a policy titled, "Restraints and Seclusion Policy," revised 02/03/22, showed, "
...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient ..." The policy showed that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour after restraint initiation and must include the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient's condition at a minimum every 15 minutes, and document in the electronic medical record.


Review of a policy titled, "Code of Conduct- Behaviors that Undermine a Culture of Safety," revised 12/23/20, showed, " ...Other behaviors which impair the reasonable skill and safety of patients, due to mental or physical disabilities, alcohol and/or drug abuse, deterioration of skills due to the aging process, or lack of documenting patient care are also of our utmost importance. There are three types of behaviors that undermine a culture of safety that will be considered: A. Actions, B. Impairment, C. Non-compliance...It is expected that everyone will be treated with dignity and respect. There will be no toleration of unprofessional behavior...Violation of the Code of Behavior will be reported to the Professional Review Committee...Actions of Behaviors: Definition: an action that undermines a culture of safety occurs in varying degrees, which are classified into three levels of severity. Level III behavior is the most severe violation of this Policy and could result in immediate suspension. Any corrective action will be commensurate with the nature and severity of the disruptive behavior...Level II: A. Serious Non-compliance is defined as the failure to adhere to the laws, regulations, or policies governing [The Hospital] that: 1. Results in substantive harm or damage (or risk of substantive harm or damage) to the safety, rights, or welfare of the patient..."


Patient 33


Review of Patient 33's discharged medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in
4-point restraints for violent/aggressive behavior.


Review of a documented titled, "Prehospital Care Report Summary," by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33 ' s care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM.


Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses' desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses' station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At that time, Patient 33's feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort.


Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses' station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera /view.


At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses' station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33's left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses' desk watching patient, however no staff attempted to intervene with Patient 33's behavior or assess the patient.


Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, "Physical Examination Eye: Pupils are equal, round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal."


The documentation failed to show evidence of Patient 33's facial trauma, altered mental status, and failed to show evidence of a "plan of treatment" for Patient 33. Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33's eyes and listening to heart and lung sounds as documented.


Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33's movements had resulted in the patient's lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor.


At the time of Patient 33's fall, ~20 hospital staff were in the nurses' station and within line of site of the patient. Staff S2, Physician, got up from a chair behind the nurses' station, walked to edge of nurses' station, looked at Patient 33 on the floor, laughed and returned behind the nurses' station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33's fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed.


Video review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient's condition, possible injury, or change in condition.


Review of the hospital's incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33's medical record failed to show any documentation that a fall had occurred.


Review of an "ED Note-Physician," by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, "...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient's physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient's plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion ..." Review of the video footage failed to show evidence that hospital staff attempted non-physical interventions prior to using restraints and that Staff A6, Physician, ensured the safe and appropriate use of restraints to keep Patient 33 safe from harm as documented in the medical record.


Staff A6, Physician, failed to ensure that appropriate and safe application of restraints were followed by allowing Patient 33 to be restrained to a slide board instead of the bed. Review of the ED video showed that Staff A6, Physician at no time provided an actual physical examination of Patient 33.


Further review of the medical record showed that Staff A6, Physician, documented the "Face to Face" evaluation at 4:05 PM, prior to the completion of Patient 33 being placed in restraints.


Review of the medical record failed to show documented evidence that Staff A6, Physician, evaluated Patient 33's immediate situation, reaction to restraint interventions, medical and behavioral condition, and the need to continue/discontinue restraint after Patient 33 was placed in restraints.


Review of Patient 33's medical record failed to show documented evidence of a written order for restraints by a physician or other licensed practitioner as required per hospital policy and regulation requirements 42 CFR §482.13(e)(5).


During an interview on 12/07/23 at 1:52 PM with Staff Q, Chief Administration Officer stated, "I feel like we are doing everything we can to keep patients safe at this time."


During an interview on 1/5/23 at 8:01 AM Staff D, Director of Quality stated that the hospital has provided all they will be providing on investigations at this time.


During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED, and it was disheartening.


During an interview on 01/08/24 at 10:02 AM, Staff T4, RN/Risk Manager, stated, "...I don't know what discipline action was done for the physician staff, we are not part of that process." Staff T4 stated that the hospital did not start an investigation into Patient 33's incident until surveyors requested the medical record on 12/11/23 at 1:29 PM.


In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33's medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival by a QMP. Staff A6, Physician, failed to ensure that Patient 33 was properly restrained to ensure safety and prevent a fall while in restraints. Review of the video and medical record showed Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The hospital failed to ensure that Patient 33 was treated with dignity and respect as required per hospital policy as evidenced by Staff S2, Physician, laughing at Patient 33 when he sustained a fall.

Based on policy review, record review, and interview, the hospital failed to ensure it informed each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care for 8 of 53 sampled patients (Patient 1, 2, 4, 5, 9, 16, 26, and 33.) This deficient practice places any patient at risk of not understanding their individual rights as required per regulation requirements 42 CFR
§482.13(a)(1).

Findings Include:

Review of a hospital policy titled, "Admissions Consent Agreement," revised 02/26/14, showed, "...It is the responsibility of the Admissions management team to ensure the completed Admissions consent forms are either faxed directly into the document Imaging system or manually scanned into the system where they will be stored within the specified patient ' s electronicfolder indefinitely ...An "Admissions Consent Agreement" form shall be obtained for all patients receiving services from [The Hospital]...Acknowledgement of Receipt of Patient Rights and Responsibilities; Decreasing Your Risk of Infection; and Privacy, Payment, and Billing - Signature acknowledges my receipt of Patient Rights and Responsibilities; the Notice of Privacy Practice; Decreasing Your Risk of Infection; and Privacy, Payment, and Billing Information...Advance Directives - This section confirms that the patient has received general information about advance directives, as included in the Patient Rights & Responsibilities brochure, and that [The Hospital] will provide specific information and materials for a Living Will and/or Durable Power of Attorney upon request from the patient...All Ancillary areas should forward the original copy of the Admissions consent form to Admissions by day end of the day services were rendered by [The Hospital]. Admissions will be responsible for assuring these Admissions consent forms get appropriately scanned into the imaging system..."


Review of the medical record for Patients 1, 2, 4, 5, 9, 16, 26, and 33 failed to show evidence that the Admissions Consent Agreement containing acknowledgement of Patient Rights was received by the patient and/or a patient's representative and placed in the medical record as required per hospital policy.


During an interview on 11/29/23 at 12:58 PM, Staff B, Quality Manager, was asked if surveyors were provided the complete medical record for the sample patients requested. Staff B stated that each record requested "should be the complete medical record".

Based on policy review, document review, and interview, the hospital failed to ensure 50 of 50 sampled patients and/or patient's representative was informed of the hospital's internal grievance process, including whom to contact to file a grievance. The hospital failed to ensure that as part of its notification of patient rights, the hospital must provide the patient and/or the patient's representative a phone number and address for lodging a grievance with the State Agency. The hospital failed to inform any patient that he/she may lodge a grievance with the State Agency directly, regardless of whether he/she had first used the hospital's grievance process. The hospital failed to ensure that an allegation of abuse or neglect was classified as a grievance for 1 of 53 sampled patients (Patient 2.) This deficient practice places any patient at risk of not understanding their individual rights to file a grievance and with whom to contact to file a grievance as required per regulation requirements 42 CFR §482.13(a)(2) and places any patient at risk for not having an allegation of abuse or neglect thoroughly investigated and resolved.

Findings Include:

1. Failure to inform patients of right to file a grievance:

Review of a hospital policy titled, "Patient Rights and Responsibilities," revised 01/21/22, showed, "Per CMS' (Center for Medicare and Medicaid Services) Condition of Participation §482.13, a hospital must protect and promote each patient's rights ...[The Hospitals] have made a commitment as part of their mission to recognize and support patient rights, including the patient's right to ...Consult with a member of the Ethic Committee regarding any question or conflict by and among persons about your medical care...Patients and/or families are educated about basic patient rights in the following manner...Written information containing a copy of patients ' rights and patients ' responsibilities related to their rights is provided upon admission...Associates assist with conflicts, concerns, or complaints during the patient's stay..." The policy failed to include the patient's right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights.

Review of a document/brochure titled, "Patient Admission Information," dated 06/2019, showed, "...Patient rights and responsibilities; You have the right to ...Consult with a member of the Ethics Committee regarding any question or conflict by and among persons about your medical care...You are responsible for...Making your concerns and complaints known..." The brochure failed to include the patient's right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights.

Review of a hospital policy titled, "Grievance Resolution/Patient Feedback/Complaint Resolution," revised 08/24/23, showed, "...Each patient is provided with the Patient Rights and Responsibilities Brochure upon admission that includes information regarding how to file a grievance directly with the hospital as well as contact information for filing a grievance with the [State Agency]..." The brochure failed to include the patient's right to file a grievance, explanation of the grievance process, and the right to file a grievance directly with the State Agency, including the State Agency contact information with address and phone number, as one of its listed patient rights.

Review of medical records for all sampled patients (Patient 1 - 53), failed to show documented evidence that any patient was informed of the right to file a grievance, education on the process of filing a grievance, and the right to file a grievance directly with the State Agency, including the contact phone number and address for the State Agency.

During an interview on 12/05/23 at 10:45 AM, Staff A, Quality Manager was asked to review the hospital policy titled, "Patient Rights and Responsibilities," and the hospital's admission packet titled, "Patient Admission Information." After reviewing the policy and admission packet, Staff A was asked if a patient's right to file a grievance was listed as a patient right. Staff A refused to answer the question. Staff A was asked again to review the hospital policy and admission packet if he/she was unsure if the right to file a grievance was listed as a patient right.
Staff A refused to review the documents a second time and stated that he/she would refer the question to Staff A4, Consumer Experience Director, and stated, "[Staff A4] is the owner of that policy."

During an interview on 12/05/23 at 11:05 AM, Staff A4, Consumer Experience Director, was asked to review the hospital policy titled, "Patient Rights and Responsibilities." Staff A4 confirmed that the right to file a grievance was not listed as a patient right. Staff A4 was asked to review the listing of patient rights as printed in the hospital's admission brochure titled, "Patient Admission Information". Staff A4 confirmed the right to file a grievance was not listed as a patient right and stated, "I don ' t see it in that list [list of patient rights]." Staff A4 stated that it is a "patient's responsibility" to notify the hospital of a concern with care. Staff A4 also confirmed that the admission brochure failed to inform patients of the right to file a grievance directly with the State Agency and that language in the admission brochure never mentioned "grievance."

2. Failure to follow the hospital's grievance policy and procedure as required for an allegation of abuse and/or neglect:

Review of a hospital policy titled, "Grievance Resolution/Patient Feedback/Complaint Resolution," revised 08/24/23, showed, "...Grievances about situations that endanger the patient such as abuse or neglect are investigated immediately...The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Verbal responses are provided by authorized representatives and the interaction is documented on the Patient Concern Form by the authorized representative...acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days, as well as hospital contact information. If the investigation is not or will not be completed within 30 working days, the Consumer Experience Department or designee will inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible. The Consumer Experience Department coordinates with Department Leadership on the investigations of grievances. A letter is sent to patients and/or their representatives at the conclusion of all grievance investigations. The letter is sent by the Consumer Experience Department or designee following the receipt of the investigative findings, conclusions and actions from the involved departments' leadership...The response letter includes the name and contact information of the hospital's authorized representative, the steps taken on behalf of the patient to investigate the grievance, the results of the investigative process and date of completion...Ethic Consultation are available for problem-solving and conflict resolution...Definitions: ...Grievance - Grievances may be presented verbally or in writing...A grievance is an issue presented to any hospital employee, regarding the patient's care; abuse or neglect; issues related to the hospital's compliance with the [CMS] Hospital Conditions of Participation (CoPs) ...The following describes grievances for purposes of this policy: ...abuse or neglect, or the hospital's compliance with Medicare Conditions of Participation ..."


Review of Patient 2's discharged medical records showed a 60-year-old admitted for suicidal ideation (SI), threatening behavior, recent seizure (sudden, uncontrolled burst of electrical activity), and homelessness. Patient 2 suffered an unwitnessed fall on 08/23/23 at 4:38 PM that was recorded on hospital security footage. Patient 2 voiced an allegation that she was the victim of abuse by hospital staff after her fall.


Review of a document titled, "[H2] Grievance and Complaint Log," dated 03/01/23 - 11/27/23, showed an entry for Patient 2 as "received" on 09/07/23. The classification was documented as a "complaint" and the issue type and nature were documented as "behavioral issue." Case detail documentation showed the following, "... [Patient 2] admitted 2 weeks ago to [H2]. She presented in person to [H1] asking for follow up in regard to being 'mishandled physically' by security and nursing on 6W. If you could please call for further follow up. Thanks [House Supervisor]...Connected with patient regarding the message from House Sup. When I connected with the patient and informed her who I was she disconnected the call. I called her right back and this time she spoke with me and said that she has retained an attorney and would not provide me with any details about the incident. She asked if she could get the names of the security officers involved in this incident and the "nurses that instigated the incident". I informed her that I cannot provide her with this information myself and before I could say anything else she said "oh yes you will, this is public information" and disconnected the call. I tried calling her again but she disconnected the call once again." Further review showed the "complaint" was documented as "closed" on 09/08/23 at 6:51 PM (approximately 24 hours from time the "complaint" was received.)

Review of Patient 2's discharged medical record failed to show documented evidence of a hospital investigation upon an allegation of abuse as required per hospital policy. Further review of the medical record also failed to show documented evidence that the hospital followed its policy and grievance procedure, including providing a letter to Patient 2 with a response letter that provided the steps taken on behalf of the patient to investigate the grievance, the results of the investigation, and its date of completion.

During an interview on 12/06/23 at 9:20 AM, Staff A4, Consumer Experience Director, was asked why Patient 2's allegation of abuse was classified as a "complaint" versus a "grievance." Staff A4 stated, "As I'm looking at this [Grievance and Complaint Log], the reason why it was not classified as a grievance is because when my team connected with the patient by phone call to gather information and confirm her concerns, she disconnected the call and when we called back, she would not provide me any details about the incident." Staff A4 was asked why refusing to give information would prevent the hospital from performing an investigation or classifying the allegation as a grievance. Staff A4 reviewed the hospital policy and confirmed that a verbal accusation of abuse or concern of care is, by definition, a grievance and stated that Patient 2's allegation should have been classified as a grievance and not a complaint. Staff A4 stated that a grievance resolution letter was not sent to Patient 2 because the hospital incorrectly deemed her allegation as a complaint and not a grievance. Staff A4 confirmed that the hospital did not follow the proper grievance resolution procedure as required per hospital policy.

Based on policy review, document review, record review, surveillance video review, and interview, the hospital failed to ensure the patients' right to receive care in a safe setting as required per 42 CFR §482.13(c)(2). This deficient practice resulted in potential and/or actual harm for 12 of 50 sampled patients (Patients 38, 27, 2, 33, 24, 9, 31, 14, 54, 25, 52, and 42) and places any patient receiving services at this hospital at risk for serious injury, harm, or death.

Findings Include:

Review of a hospital policy titled, "Fall Risk," revised 03/21/23, showed the hospital uses the "Morse Fall Scale (0-24 Low risk; 25-44 Moderate; 45 or > High.) ...Critical thinking skills may place a patient in the "High Fall Risk" protocol at any time based on clinical judgement...Patients will be assessed using the Fall Risk Assessment every shift and at any time there is a change in the patient's condition...If a fall occurs a. assess the patient for injury and mental/physical of patient and compared to pre-fall assessment, b. Notify the physician of the fall, e ...notify family of the patient's fall..."

Review of a document titled, "Morse Interventions by Scale," showed the universal precautions for all patients include education regarding fall risk, orientation to room and call light upon admission. The document included precautions that staff are to follow including assess toileting needs, personal items and call light within reach, bed locked in low position and hourly rounding. For moderate Fall Risk Precautions in addition to the Universal Fall Precautions staff are to use a gait belt or lift equipment when mobilizing patients from bed or chair. High Fall Risk Precautions in addition to above Universal & Moderate Fall Precautions include, yellow High Fall Risk armband, gown, non-slip socks, and door sign in place. Patients are to be supervised when in the restroom or on bedside commode. Patient room placement near nurses' station, where available. The door to the patient's room should remain open when isolation status allows. Bed and chair exit alarms are to be activated. All inpatient medical beds currently have exit alarm capability.

Review of a hospital policy titled, "Patient Assessments and Reassessments," revised 08/17/23, showed that Registered Nurses (RNs) are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. The RN may delegate aspects of data collection to LPN, CNA, or Behavioral Health Tech. The RN must then analyze the data and set care priorities, formulate diagnosis, plan of care, and initiate referrals...Emergency Services: Initiation of assessment within 15 minutes for triage and completion of admission assessment within 30 minutes for Level 1 and 2; within three hours for Level 3, 4, and 5...Emergency Department: Content/Parameters: (not defined). Minimum Reassessment Timeframes: Focused reassessment minimally every hour and by specific need ...Operating Room: Content/Parameters: Defined by surgical checklist and perioperative assessment form. Minimum Reassessment Timeframes: Ongoing monitoring by CRNA (Certified Registered Nurse Anesthetist)/anesthesiologist..."

Review of the hospital policy titled, "Chest Pain Program" revised 10/24/2023 showed, "...Patients receive rapid evaluation for intervention to minimize acute coronary syndrome (ACS) morbidity and mortality...The program evaluated patients with signs and symptoms of chest pain or acute coronary syndrome. These signs include but are not limited to: ... arm pain...other non cardiac presentation especially in women. If these signs or symptoms are present, staff obtains a STAT electrocardiogram (ECG)..."

Review of a hospital policy titled, "CPG [Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain", revised 02/07/2023 showed, "In all patients who present with acute chest pain regardless of the setting, an ECG [electrocardiogram] should be acquired and reviewed for STEMI [ST Elevation Myocardial Infarction] within 10 minutes of arrival." Further review of the document showed, "Chest pain or chest pain equivalent will be referred to in these guidelines as "Chest pain" ... Regardless of the setting, an ECG should be obtained and interpreted within 10 minutes of arrival ..."

Review of hospital policy titled "Suicide Prevention" revision 11/07/22 showed "Policy: A. This policy is used to plan for care and management of a suicidal patient. Patients may be identified to be at risk of suicide either through patient-initiated statements/behaviors or through caregiver interactions. The intent of identifying a patient with suicide risk is to discern the imminent need for environmental safety measures to reduce the potential attempts and to activate level of care necessary to mitigate the overall risk and offer resources available in the community at large...C. Inpatient and non-inpatient non-behavioral health care setting that provide care to those at risk of harm e.g. emergency departments, intensive care units, medical-surgical units and other inpatient and outpatient locations: "Safer" environment.Remove objects from the room that can be used for self-harm and monitor the patient per patient observation orders while awaiting transfer to a higher level of care. Potential risks include but are not limited to those from ligature, sharps, harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags (for suffocation), oxygen tubing, bell cord, etc.

Review of a hospital policy titled, "Restraints and Seclusion Policy," revised 02/03/2022, showed, "...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient..." The policy stated that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour of restraint initiation and must include the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint. The use of restraints requires assessment/monitoring to be documented within one (1) hour of initiation, or more often as determined by the patient's condition. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient's condition at a minimum every 15 minutes, and document in the electronic medical record...RN will document they type of restraint used...The RN will document the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention...Immediately checks the patient to ensure that the restraints were properly and safely applied...Document the patient's response to and effectiveness of the restraint ...Assess/monitor/document the patient ' s condition in at least 1 hour, or more often as determined by the patient's condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient..."

The condition of a patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria. "...Training will be conducted...As part of orientation...On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients...Staff will be trained on the safe application of all types of restraint...Staff will be trained and demonstrate competency in monitoring the physical and psychological well-being of a patient who is restrained...include but not limited to respiratory and circulatory status, skin integrity, vital signs ..."

Review of a hospital fall log provided on 11/27/23, showed a total of 225 falls from 03/01/23 through 11/26/23 at Hospital 1 (H1- the above named hospital) and showed a total of 231 falls from 03/01/23 through 11/26/23 at Hospital 2 (H2 - an off campus hospital location).

Review of a document titled, "Nursing Staffing Matrix" undated showed, "Department Type: ICU: Day: 2:1 (2 patients to 1 Nurse) Night: 2:1 (2 patients to 1 Nurse)..."

Patient 38

Review of Patient 38's medical record showed a 74-year-old female that arrived to the ED at H1 via ambulance on 08/21/23 at 12:14 PM with complaints of worsening numbness to her left hand for the past 3 weeks. Patient 38 noticed that the pain has been radiating into her mid back and she doesn't feel she has been getting much relief. Patient 38 had a history of Chronic Obstructive Pulmonary Disease (disease of the airway), Hyperlipidemia (high levels of fats in blood), Chronic Kidney Disease (ineffective functioning of the kidneys), Hypertension (high blood pressure), and prediabetes.

The hospital failed to ensure nursing services provided a rapid and appropriate evaluation of Patient 38, including an ECG within 10 minutes of arrival per policy. ED Staff didn't complete the ECG until over 6 hours later and it showed ischemia (a condition in which blood flow (and thus oxygen) is restricted or reduced) to the heart muscle. At that time, the hospital staff sent the patient to the cardiac catheterization lab to initiate intervention to minimize acute coronary syndrome (ACS). Subsequently following the cardiac catheterization Patient 38 underwent an emergent Coronary Artery Bypass Graft (CABG). Following the procedure patient was moved to the Cardiac Intensive Care Unit with a balloon pump. Delay in ECG places all patients with potential cardiac issues at risk for receiving care in an unsafe setting. Patient 38 died 08/22/23 at 12:11 PM, 23 hours and 57 minutes after she presented in the Emergency Department.

Patient 27

Review of Patient 27's medical record showed a 76-year-old male admitted to H1 on 10/19/23 at 5:22 PM with a diagnosis of Urinary tract infection, Hypotension (low blood pressure), dehydration, Chronic Kidney Disease, Altered Mental Status (AMS). Patient 27 had a past medical history of right above/below the knee amputation (absence of leg), hypertension (high blood pressure), and diabetes type 2 (too much sugar in the blood).

Review of Patient 27's Morse Fall Risk on 10/19/23 at 11:31 PM showed a fall risk score of 20 [low fall risk]. Review of this assessment failed to identify patient had a secondary diagnosis which would have increased his score by 15 points and mental status fall risk Morse was scored as 0 however further documentation in the medical record showed patient forgets limitations increasing fall risk score by 15 which in turn would have been a score 50 indicating a high risk for falls.

Review of a "ED Note-Nursing" dated 10/20/23 at 6:37 AM, showed, " ... pt (sic) was alert, pleasant, confused, disoriented, bedbound due to recent rt (sic) AKA (Above Knee Amputation) and weakness...pt (sic) required frequent redirection and reorientation...including pt requiring reorientation after calling 911 from personal cell phone, pt (sic) believed he was driving a school bus and "needed help with the kids". Pt (sic) frequently removed monitor leads, bp (sic) cuff and nasal canula. Pt (sic) did not display the ability to reposition himself in bed, side rails x2 remained up to prevent fall...aprox (sic) 0414 staff from another department stated pt (sic) appeared to be out of bed, this RN went to pt (sic) room, pt (sic) was found at foot of bed, did not respond to his name, pt (sic) breathing was agonal, pulse was slow, weak. Code button was pressed, crash cart brought bedside. Compressions started at 0415. During code, at 0437 this RN spoke to family, during call [Return of Spontaneous Circulation] ROSC was achieved. Post code, report was called, CT [Computed Tomography] scan completed and pt (sic) was transferred to ICU. C-collar was placed during code, small abrasion noted to left lower leg, no other injuries noted."

Review of video footage dated 10/20/23 at 4:10 AM showed that an unidentified Staff entered Patient 27's room (5 minutes after documentation showed patient was found on the floor) further review of the video showed the unidentified Staff exiting the patient room at 4:15 AM. After what appears to be a visitor or patient in room next to Patient 27's room notified a staff member coming out of the CT room that Patient 27 needed assistance. An unidentified Staff entered the room at 4:10 AM. The nurse noted to exit room at 4:15 AM and retrieved crash cart. Further review of the video footage showed that Patient 27 had not been checked on by hospital staff from 10/20/23 at 2:00 AM until alerted by unknown visitor/patient at 4:10 AM.

Review of a document titled, "VCH SF: FY 2023 Daily Staffing Report", dated 10/19/23 into 10/20/23 at 7:00 AM showed a total of 6 RN's. Further review of the document showed multiple critical patients, three patients on ventilators and one patient on bi-pap.

During an interview on 11/08/23 at 4:00 PM, Staff D8, ED Manager stated that on 10/20/23 at approximately 4:00 AM there were 6 RN's and at minimum 36 patients. She went on to state that she was unsure of what the exact census was but the patient to nurse ratio was at least a 6:1 (6 patients to 1 RN). Emergency Nursing Association (ENA) standards are 4:1 (four patient to 1 RN).

Further review of the medical record showed that Patient 27 expired on 10/20/23 at 10:29 PM. The hospital failed to ensure that staff provided necessary supervision for Patient 27, who was confused, disoriented, and required frequent redirection. Ultimately, Patient 27 experienced an unwitnessed fall, and a visitor notified staff that Patient 27 needed assistance. Patient 27 coded and died following the fall.

Patient 2

Review of Patient 2's discharged medical records showed a 60-year-old admitted to H2 with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis was schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident (CVA- an interruption in the flow of blood to cells in the brain) without residual deficits.

Review of security video footage on the 6th floor west north hall of the Behavioral Health Unit at the Hospital 2 (H2 - off campus hospital location of H1) campus dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse's station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Registered Nurse (RN), Staff O4 RN, and unidentified staff member in gray shirt came out of the nursing station and walked down to Patient 2. Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurses' station, leaving the patient unattended. At 4:42 PM an unidentified male staff came into the hall and walked straight by Patient 2 without even looking at her. At 4:43 PM, Staff O4, Staff C4, Staff U3, Behavioral Health Technician (BHT) and an unidentified female staff member return to Patient 2 with a vitals machine and was observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT was observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2's face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers (MHPW) entered the hall and approached Patient 2. None of the staff standing around Patient 2 attempted to reposition her, she remained face down in a semi fetal position. Her body appeared to be heaving in a slight up and down motion. Staff Q4 and Staff R4, picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2's body hung limply, and she made no attempts to move or reposition herself. As Staff Q4 and Staff R4 picked her up, she was flipped over mid-air causing her wrists to cross over one another while dangling face-up. The MHPW's then carried Patient 2 by her wrists and ankles into a room.

The facility failed to initiate universal fall precautions including non-slip socks, which may have contributed to the patient's fall.

Review of Patient 2's medical record status post unwitnessed fall on 08/23/23 failed to show documented evidence that a post fall injury evaluation and neurological assessment were completed to include a Glasgow coma scale (measures the extent of impaired consciousness, in all types of acute medical and trauma events), any changes in eye opening, best verbal response and best motor response per hospital policy. The record failed to show a description of her level of consciousness, headache, pain, extremity movement and hand grasp.

Failure to assess the patient for injury following an unwitnessed fall and leaving the patient unattended on the floor places the patient at risk for further harm from unidentified potential injuries. Failure of staff to appropriately transfer a patient who had an unwitnessed fall has the potential to cause further injury and harm. These deficient practices create an unsafe care environment.

Patient 33

Review of Patient 33's medical record showed a 38-year-old male that arrived at the ED at H1 on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior.

Review of a documented titled, "Prehospital Care Report Summary," by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33's care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM.

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses' desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses'
station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At that time, Patient 33's feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses' station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view. Review of the medical record failed to show any nursing notes on Patient 33 to document interventions and application of restraints.

At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses' station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33's left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position.

Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses' desk watching patient, however no staff attempted to intervene with Patient 33's behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. This was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge. Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33's medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33's pupils and did not listen to heart or lung sounds as documented. Further review of the video showed that between time of arrival at 3:52 PM to 10:41 PM, Staff A6, Physician, never approached Patient 33 to perform a physical exam.

At 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33's movements had resulted in the patient's lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33's fall, 20 hospital staff were in the nurses' station and within line of site of the patient. Numerous staff pointed and laughed at Patient 33 while on the floor, restraints still attached to the slide board, laying on left side, on his shoulder with left arm behind him and left side of head on the floor. Staff S2, Physician, got up from a chair behind the nurses' station, walked to edge of nurses' station, looked at Patient 33 on the floor, laughed and returned behind the nurses' station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33's fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed. Further review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient's condition or possible injury. Review of the hospital's incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33's medical record failed to show any documentation that a fall had occurred.

Review of the "ED Triage Note," showed, " ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST [4:00 PM] by [Staff Z5, RN]." Staff Z5 documented the following vitals: Blood pressure 114/74, Pulse 104, Respiratory rate 16, and Oxygen saturation 94%. Review of the video footage showed these vital signs were obtained at 7:07 PM. Review of a document titled, "Alleged ED Caregiver Misconduct-Patient Timeline," undated, showed an interview with Staff Z5, RN. "...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs]..."

Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, "Physical Examination: Eye: Pupils are equal, round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal " The documentation failed to show evidence of Patient 33's facial trauma, altered mental status, and failed to show evidence of a "plan of treatment" for Patient 33.

Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33's eyes and listening to heart and lung sounds as documented.

During an interview on 12/0723 at 4:15 PM, Staff C5, stated that he has several concerns with staffing, the ED is expected to do more with less constantly. Staffing has been this way for multiple years. States people will continue to have adverse outcomes if they do not fix their staffing. States that some days staffing is unacceptable. States when staffing is bad, they try to go on diversion. States that managers rarely come in when they are short staffed. States he has absolutely had a bad outcome for short staffing.

Patient 24

Review of Patient 24's medical record showed an 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 has a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN).

Review of Patient 24's medical record showed a Morse Fall Risk score of 50 on 11/01/23 at 9:00 PM indicating high risk for fall.

Review of Patient 24's medical record showed a documented fall on 11/05/23 at 4:38 PM by staff L5, RN. Further review of the medical record showed an order for CT Head or Brain with and without Contrast on 11/05/23 at 4:36 PM (2 minutes prior to documented fall).

Review of an order dated 11/05/23 at 6:57 PM showed, "Order: Neurological Assessment High Risk for Injury... Order Details: 11/05/23 16:38:00 CST (4:38 PM), q1hr, 4, hr, Stop date 11/05/23 20:59:00 CST (8:59 PM)."

Review of Patient 24's medical record failed to show documented evidence of a Neurological Assessment between 4:38 PM and 6:38 PM every one hour as ordered. (2 of 4 assessments)

Review of an order dated 11/05/23 at 6:57 PM showed, "Order: Neurological Assessment High Risk for Injury... Order Details: 11/5/23 8:38:00 PM CST, q4hr, 20, hr, Stop date 11/6/23 4:59:00 PM CST."

Review of Patient 24's medical record failed to show documented evidence of a Neurological Assessment for the following dates/time:

From 11/05/23 at 9:10 PM to 11/06/23 at 2:19 AM (~5 hours)

From 11/06/23 at 2:19 AM to 11/06/23 at 9:00 AM (~7 hours)

During an interview on 12/12/23 at 1:25 PM, Staff L5, Registered Nurse (RN) stated that when Patient 24 fell, she hit the left side of her forehead and maybe hit the top of her head on something. Staff L5 stated that she was not present at time of fall. Staff L5 stated that Patient 24 had a small laceration to her forehead, was on a blood thinner, and that a large hematoma developed rather quickly.

Review of the medical record failed to show documented evidence nursing staff completed a full post fall assessment including but not limited to: vital signs, provider notification, and family notification.

During an interview on 12/12/23 at 12:35 PM Staff K5 stated that, she has noticed an increase in falls due to lack of staffing. She went on to state it is because staff cannot respond to the bed alarms soon enough, or staff do not know where the alarms are coming from, sometimes it comes to the nurses' phone and sometimes it does not because the bed's do not have the correct cords. In the Intensive Care Unit (ICU) we often have three patients and at times we are unable to leave a room to respond to an audible bed alarm.

Patient 9

Review of Patient 9's medical record showed a 63-year-old male, admitted to H1 on 11/18/23 at 11:41 PM with a diagnosis of sepsis (infection in the blood), cellulitis (bacterial skin infection), leukopenia (low white blood cells), alcohol intoxication, and hypokalemia (low potassium).

Review of Patient 9's Morse Fall Risk on 11/19/23 at 9:00 AM showed a fall risk score of 60 [high fall risk].

Review of "Environmental Safety Management," dated 11/19/23 at 9:00 AM, 8:08 PM, and 8:40
PM, showed, "...Personal items within reach...Supervision with toileting..."

Review of "Post Fall Information," dated 11/19/23 at 8:08 PM, documented that Patient 9's urinal was out of his reach, as required by "Environmental Safety Management."

Patient 31

Review of Patient 31's medical record showed a 73-year-old male that arrived at the ED at H2 via EMS on 10/06/23 at 10:59 PM with a diagnosis of Altered Mental Status of unknown onset. Patient 31 has a past medical history of diabetes mellitus and renal impairment. Patient 31 was then transferred to H1 on 10/12/23 at 11:59 PM for a higher level of care.

Review of Patient 31's medical record showed an initial Morse Fall Risk score of 50 on 10/07/23 at 5:35 AM indicating high risk for fall. Patient Morse Fall Risk score indicated high risk for fall throughout admission with discharge score on 10/19/23 at 9:25 AM with a score of 95 (high risk 45 and above).

Review of the medical record showed that Patient 31 had falls on the following dates: 10/08/23 at 4:15 AM at H2, 10/09/23 at 11:02 AM at H2, 10/16/23 at 7:25 AM at H1 and 10/16/23 at 4:03 PM at H1. (4 falls in 12 days)

Review of a document titled, "[Hospital 1] Incident Log" dated 03/01/2023 - 11/26/2023 showed, "...10/16/23 This RN (not RN caring for patient) heard a thud and then an "ow" coming from pt room in X. This RN does not see patient in bed or chair, then sees patient on floor near bed. This RN immediately calls RN who is caring for patient
(X) and notifies RN manager XX. Pt vitals taken - see chart. RN X notified of events. No bed exit/chair exit alarms going off at time of incident, all four rails of bed noted to be in up position also. No immediate/obvious injuries noted by this RN..."

Review of the medical record dated 10/15/23 at 8:00 PM showed that the following interventions were as required per facility Fall Bundle protocol: "... Exit alert on...Upper/Half length side rails for bed mobility..." Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall.

Review of the medical record dated 10/16/23 at 4:03 PM showed that the following interventions were in place per facility Fall Bundle protocol: "... Exit alert on ...Upper/Half length side rails for bed mobility..."Review of the facility incident log showed the bed exit/chair exit alarm not in place at time of fall.

Review of an order dated 10/08/23 at 4:15 AM stated, "Order: Neurological Assessment High Risk for Injury ...Order Details 10/8/23 4:15:00 AM CDT, q1hr, 4, hr, Stop date 10/8/23 8:29:00 AM CDT."

Review of Patient 31's medical record failed to show documented evidence of Neurological Assessment every 1 hour per orders between 10/08/23 at 4:15 AM to 10/08/23 at 8:29 AM.

Review of an order dated

Based on interview, record review, document review, and policy review the hospital failed to ensure that patients were free from abuse, mistreatment, neglect, and exploitation when they failed to ensure thorough investigations of all allegations of abuse, failed to report allegations of abuse to the state agency, and failed to show evidence that patients were protected during their investigation for 2 of 50 patients (Patient 2 and 33).

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation.

Findings Include:

Review of the hospital policy titled "Abuse and Neglect - System" Revised 07/17/23 showed, "...D. Patient/family Allegation of Provider Abuse/Neglect:

1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Examples of abuse include, but are not limited to physical, sexual, verbal/emotional, injury or intimidation of one patient by another..."

2. Any associate who witnesses or receives a report of alleged abuse or neglect from a patient/family, other patient, staff member, visitor, or other person should immediately notify the on-duty department leader and Risk Management.

3. The department leader and/or House Supervisor will ascertain the safety of the patient and initiate any needed interventions to maintain patient safety.

4. Risk Management initiates the Allegation of Associate Misconduct Process Flow and includes other departmental leaders in the investigation of the allegation.

5. Human Resources should be notified of the allegation of abuse as soon as possible to facilitate placing the associate on administrative leave until the investigation has concluded.

6. The associate's disposition at the close of an investigation will be determined in accordance with all applicable local, state, and federal laws..."

Review of a policy titled, "Patient Rights and Responsibilities," revised 01/21/22, showed, "...Be treated in a dignified and respectful manner and receive care by competent personnel...Receive care in a safe setting and be free from physical, verbal, emotional/psychological, and sexual abuse and harassment..."


Review of a policy titled, "Restraints and Seclusion Policy," revised 02/03/2022, showed, "...When restraints are in use, staff must monitor patient's condition at a minimum every 15 minutes, and document in the electronic medical record...RN will document they type of restraint used...The RN will document the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention...Immediately checks the patient to ensure that the restraints were properly and safely applied ...Document the patient's response to and effectiveness of the restraint...Assess/monitor/document the patient's condition in at least 1 hour, or more often as determined by the patient's condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient..."

Patient 2

Review of Patient 2's discharged medical records showed a 60-year-old admitted on 08/22/23 with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident (CVA- an interruption in the flow of blood to cells in the brain) without residual deficits.

Review of security video footage on the 6th floor west north hall of the Behavioral Health Unit at the Hospital 2 (H2 - off campus hospital location of H1) campus dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse's station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Registered Nurse (RN), Staff O4 RN, and unidentified staff member in gray shirt came out of the nursing station and walked down to Patient 2. Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurse's station, leaving the patient unattended. At 4:42 PM an unidentified male staff came into the hall and walked straight by Patient 2 without even looking at her. At 4:43 PM, Staff O4, Staff C4, Staff U3, Behavioral Health Technician (BHT) and an unidentified female staff member return to Patient 2 with a vitals machine and was observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT was observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2's face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers (MHPW) entered the hall and approached Patient 2. None of the staff standing around Patient 2 attempted to reposition her, she remained face down in a semi fetal position. Her body appeared to be heaving in a slight up and down motion. Staff Q4 and Staff R4, picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2's body hung limply, and she made no attempts to move or reposition herself. As Staff Q4 and Staff R4 picked her up, she was flipped over mid-air causing her wrists to cross over one another while to dangling face-up. The MHPW's then carried Patient 2 by her wrist and ankles into a room.

During an interview on 12/05/23 at 10:59 AM Patient 2 stated, "I was in my bed the whole day then I got up to go to the bathroom and by that time I felt like I might be having a seizure, so I went into the hallway. I don't remember some of it, but they were sprinkling water on my face." Patient 2 stated, her right arm was currently sore, and that hospital staff broke her hand. Patient 2 stated that one of the staff lost their grip on her hand, so they grabbed it and flung her onto the bed. the staff broke my hand, the guy was losing grip on one of my hands and he grabbed my hand again and they flung me onto the bed." Patient 2 stated that she reported the pain in her right hand to her nurse. Patient 2 stated "They taped my hand together knowing my hand was broke." Patient 2 stated that after she discharged from the facility, she went to the emergency room at another facility and her arm currently was in a cast or a sling due to the injury.

Review of Patient 2's hand X-rays after the fall revealed a 5th metacarpal, nondisplaced fracture of the hand (Boxer Fracture).

During an interview on 12/05/23 at 9:10 AM Staff T3 RN stated, "I did not witness [the initial incident] I was on lunch, when I came back, she [Patient 2] was on the floor. Staff T3 stated that the staff got vital signs, a blood sugar and MHPW's was called to get the patient back into bed. Staff T3 stated that Patient 2's oxygen saturation was good. I did not think she was having a seizure, at least she did not appear to be having a seizure. The doctor and the house manager were notified. Staff T3 stated that the protocol with finding someone on the floor, witness/unwitnessed fall is whoever finds the patient is able to complete the incident report and the incident would still be treated as a fall.

During an interview on 12/05/23 at 8:55 AM Staff U3 BHT stated that, ... If we are unable to deescalate a patient after multiple attempts or interventions, then the staff will call the "the guys up" or the mental health protection workers (MHPW). Patient 2 said she had a seizure, but she did not look like she had anything medical going on.

During a subsequent interview on 12/13/23 at 1:11 PM Staff U3 BHT stated, "regarding the incident with Patient 2 it did take us a long time to get to Patient 2." Staff U3 stated that Patient 2 has a habit of acting like she is falling. Staff U3 stated that the staff checked on her and she wouldn't get up off the floor. Staff U3 stated, "I flicked water in her face to startle her, sometimes if you flick water in their face, it will wake them." Staff U3 stated that she learned about flicking the water in their face, from a nurse.

Review of Staff T3 RN progress note dated 08/23/2023 at 7:02 PM showed, "On 08/23/23 at approximately 5:00 PM a peer came to the nurses' station to inform staff that patient is laying on the floor in the hallway patient will not respond verbally. Patient 2 vital signs were obtained and are within normal limits (WNL), no injuries observed by this staff. The patient is assisted to her bed by mental health protection workers (MHPW)s. A short time later pt (sic) comes out of her room to the nursing station to say that her "hand is broke." Staff H4 MD is notified, and orders received for x-ray of the patient's right hand.

Review of Patient 2 ' s Diagnostic Impression Right hand 2 views Xray dated 08/23/23 at 6:03 PM showed an acute nondisplaced transverse fracture of the proximal diaphysis of the right 5th metacarpal.

During an interview on 12/04/23 at 3:49 PM Staff H4, Medical Doctor (MD) stated that with boxer fractures we can consult occupational therapy and apply a wrist splint. Staff H4 stated, "I usually order a CT of head, a c-spine, and also there can be delayed injuries discovered later when the patient complains of pain that might not have been present on the initial assessment."

Review of Staff W3, Advanced Practice Registered Nurse, (APRN) progress note dated 08/25/23 at 4:41 PM showed on 08/24/23 "Patient 2 was having a difficult
morning. Today she is in bed, hyperventilating, crying, spitting into a basin. Sobbing "I will be good; I won't do it again." She [Patient 2] reports she was abused by security. "

Review of Staff W3, APRN's progress note dated 08/26/23 at 9:54 AM; "She [Patient 2] had seen a security guard and started to shake and become hysterical. Encouraged her to deep breathe and to go to her room if she becomes scared but that no one will hurt her on the unit. The patient is displaying symptoms of
post-traumatic stress disorder (PTSD) at this time. Did note bruise on the right side of her face by her eye. Eye is mildly swollen. She believes she was bruised when she had her seizure and the mental health workers were handling her."

During an interview on 12/04/23 at 3:05 PM Staff W3, APRN stated, "I remember Patient 2 being mad because security was being mean or rough with her on 08/23/23."

Review of Staff Y3, mental health worker's (MHW)/BHT progress note" dated 08/24/23 at 6:10 PM showed, "She [Patient 2] is loud, disorganized, moaning, repeats statements about MHPWs, says "Don't call the guys. I'll do whatever you want, just don't call the guys. I don't wanna be hurt no more!" Patient 2 whispers "Shh, they're out there!" Says I'll stay in my room and be quiet, just don't call the guys!" Complains of...MHPWs hurting her hand. Patient 2 stated, "...I had a seizure yesterday, they picked me up and turned me over, they didn't have to do that to me!!"

During an interview on 12/06/23 at 5:23 PM Staff Y3 MHW/BHT stated, "I've known [Patient 2] for many years." When asked if Patient 2 told her anything about being mishandled by "the guys" or the MHPW's injuring her hand? Staff Y3 stated "[Patient 2] did mention that to me, and I talked with someone who was there the day it happened, and the person reassured me nothing like that happened, the patient was handled very gently and there was no way she was injured then." Staff Y3 stated that as a BHT my responsibility in reporting abuse is to let the charge nurse know.

During an interview on 12/06/23 at 8:36 AM, Staff Q4, MHPW, who was seen in the video, criss crossing Patient 2's arms while lifting/moving the patient, stated that MHPWs offer to assist with lifting for mental health patients who pretend they can't walk. He stated that MHPWs do not do anything without the nurses approval and nursing staff present.

During an interview on 12/06/23 at 8:36 AM Staff Q4 MHPW stated, "going on 2 years, help with patient with escorting, lift to assist, help walker and wheelchair, medication assist we help. Lift assist overweight or mental health patients who pretend they can't walk, no walker or fall risk. We are trained with MOAB technique and use of force; MOAB teaches you to make sure that they not laying on stomach make sure that they on side or back to breathe and do what the nurse says. We try not to be aggressive with moving we try to help the patient. Weight and size manpower and aggression or are they hurt anywhere, you would have someone look at the footage and more than often the nurse has already seen the footage. We don't do anything without nurses' approval and her being present. That's how we were trained. She's not the lightest person and there was no lifting apparatus. We just try to make sure she's safe. Get her to the room as safely as possible."

During an interview on 12/13/23 at 12:52 PM, Staff R4, MHPW stated that MHPWs were never taught how to lift patients. Staff R4 stated that MHPWs get called a couple of times a week to help with lifting patients. Staff R4 stated that it should be an RN that tells MHPWs how to lift or transfer a patient. If a patient accused a staff member of abuse, the house supervisor would be notified, and the facility would separate the patient from he accused staff member. Then the alleged incident would be investigated by risk management. The investigation could include a video review and staff interview. Staff C2 stated "let me refer to the Abuse/Neglect policy..."let me pull it up." The policy states, "that any action taken on a suspected abuse, or neglect to be clearly noted in medical record in suspected abuse neglect or exploitation." "I'm speaking from a general nursing unit perspective. If a patient said they'd been hit or abused, then it would be documented." Staff C2 stated that notifying law enforcement, adult protective services and KDHE would be handled post investigation by the risk management team. Staff C2 stated that she is always notified of an abuse investigation. Staff C2 stated "I don't recall being notified of an abuse allegation. Staff C2 stated that as far as an appropriate transfer like a certified nursing assistant (CNA) or nurse would complete, I wouldn't expect that from the MHPW staff members.

During an interview on 12/06/23 at 2:20 PM with Staff C, Director of BHU, stated, "...they would have been trained for face up. That's a big thing. We don't want anyone face down. From what you're describing, and without seeing the video, I can't say that's an approved technique. Typically, if nursing staff present, we would do an appropriate transfer to bed. But in my experience there are patients that are not compliant with what we're trying to do. But that's not at the risk of the safety of the patient. They're taught to avoid close physical contact to avoid getting spit on or hit. Transfers are not necessarily, like I would not expect a MHPW to know how to properly transfer a patient. If their role is...they're not in a clinical setting or the only time I would expect them to get involved in a transfer from floor to bed, there should have been some reason staff called them to transfer. There would have been a history for the patient. I know they're trained to keep patients safe and face up. I'm trying to not make assumption without video in front of me..." (this staff was on vacation at this time).

During an interview on 12/06/23 at 10:27 AM, Patient 2 was handled by hospital staff. He stated that there was opportunity for improvement and education.
Nursing staff failed to intervene or prevent MHPW's from moving Patient 2 in a way that could cause serious injury or worsening of an injury sustained in her fall.

During an interview on 12/06/23 at 11:46 AM, Staff S4, RN/Risk Manager, stated that she reviewed the video footage of Patient 2's fall on 08/30/23 and had concerns that Patient 2 could have received an injury or worsening of an injury by the way she was picked up and that Patient 2 was treated without dignity by hospital staff. Staff S4 stated that she did not make a report of ANE on behalf of Patient 2 because of the lack of documentation. S4 confirmed that the video indicated Patient 2's treatment was consistent with abuse, neglect, and exploitation (ANE).

During an interview on 12/06/23 at 1:18 PM, Staff T4, RN/Director of Risk of Management, stated he reviewed the security footage of Patient 2's fall. Risk gets involved in safety reporting events that are entered, may get a phone call from the house mgr. I don't recall exactly when I got involved. PreSert meeting is not available (protected by Patient Safety Organization).T4 refused to answer the following question: "Did you have concerns with regarding the way the staff carried the patient back to the bed and did it looked like a potential risk for harm to the patient? T4 responded to the following question: "Do you feel the hospital did what should have been done?" by saying, "I think there was opportunity for us to do things
differently. Staff T4 was asked if he had a concern on how Patient 2 was treated by hospital staff and if it could have put Patient 2 at risk for harm. Staff T4 stated, "I think there was opportunity for us to do things differently."

The hospital failed to complete a thorough investigation by failing to recognize the incident seen in the video footage as potential abuse. The hospital failed to protect all patients from further potential abuse by failing to adequately investigate allegations of abuse regarding improper use of transfer techniques of a patient that had the potential to resulted in bodily harm or have other adverse outcomes including death. The video footage was review by the hospitals leadership team and the hospital failed to implement corrective actions of involved staff members seen in video footage and failed to report and provide a summary of their investigation to the state agency.


Patient 33

Review of Patient 33's discharged medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior. Review of a documented titled, "Prehospital Care Report Summary," by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33's care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM.

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses' desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses' station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At that time, Patient 33's feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses' station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view.

Review of Patient 33's medical record failed to show any nursing notes or documented interventions and application of the restraints.

At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses' station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33's left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position.
Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses' desk watching patient, however no staff attempted to intervene with Patient 33's behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. 7:07 PM was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge.

Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33's medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33's pupils and did not listen to heart or lung sounds as documented.

The video showed that between time of arrival at 3:52 PM to 10:41 PM, Staff A6, Physician, never approached Patient 33 to perform a physical exam.

Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33's movements had resulted in the patient's lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor.

At the time of Patient 33's fall, About 20 hospital staff were in the nurses' station and within line of site of the patient. Numerous staff pointed and laughed at Patient 33 while on the floor, restraints still attached to the slide board, laying on left side, on shoulder with left arm behind him and left side of head on the floor. Staff S2, Physician, got up from a chair behind the nurses' station, walked to edge of nurses' station, looked at Patient 33 on the floor, laughed and returned behind the nurses' station and sat down. At 7:25 PM, an unidentified RN responded to Patient 33's fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed.

During an interview on 01/08/24 at 12:45 PM with Staff D8, Emergency Manager of ED showed the corrective action plan for primary nurse involved in the incident with Patient 33. Staff Z5 was ultimately the nurse assigned to the patient and responsible for the fall, therefore the decision was made to discipline the primary nurse. The ED manager went on to say that the employee stated she was only laughing at the irony of the situation and that her intention was not to laugh at the patient. She went on to say that Chaplain services came in to do Compassionate Care training with ED staff and to date not all ED employees have received the training and that she as the ED manager is supposed to be scheduling the remaining staff. At the time of this interview this has not been completed."

Video review from 7:25 PM to 10:41 PM, showed that Staff S2, Physician, never approached Patient 33 to perform a physical exam to assess patient's condition or possible injury after the fall. Review of the hospital's incident log showed that Patient 33 sustained a fall while in restraints on 11/21/23, however review of Patient 33's medical record failed to show any documentation that a fall had occurred.

Review of the "ED Triage Note," showed, " ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST
[4:00 PM] by [Staff Z5, RN]." Staff Z5 documented the following vitals: Blood pressure.

Review of the video footage showed these vital signs were obtained at 7:07 PM.
Review of a document titled, "Alleged ED Caregiver Misconduct-Patient Timeline," undated, showed an interview with Staff Z5, RN. "...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs] .."

Review of an ED physician note dated 11/21/23 at 3:55 PM, signed by Staff A6, Physician, showed, "Physical Examination Eye: Pupils are equal,
round and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm Respiratory: Lungs are clear to auscultation (listening to lungs), respirations are non-labored, breath sounds are equal" The documentation failed to show evidence of Patient 33's facial trauma, altered mental status, and failed to show evidence of a "plan of treatment" for Patient 33.

Although the medical record showed documentation of a physical assessment, review of the video footage failed to show that Staff A6 ever approached Patient 33 to complete a physical assessment that included assessment of Patient 33's eyes and listening to heart and lung sounds as documented.

Review of an "ED Note-Physician," by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, "...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient s physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient's plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion..." Review of the video footage failed to show evidence that hospital staff attempted non-physical interventions prior to using restraints and that Staff A6, Physician, ensured the safe and appropriate use of restraints to keep Patient 33 safe from harm as documented in the medical record.

During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED, and it was disheartening.

In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33's medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival, including vital signs and a nursing assessment. Staff A6, Physician, failed to ensure that Patient 33 was properly restrained to avoid injury. The hospital staff failed to provide ongoing monitoring of a patient in restraints as required per the facility "Restraints and Seclusion" Policy, including 15-minute monitoring with required documentation, and failed to ensure the safety of a patient to prevent a fall. Review of the video and medical record showed nursing staff and Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall. The hospital failed to ensure that Patient 33 was treated with dignity and respect as required per hospital policy titled, "Patient Rights and Responsibilities" as evidenced by staff and providers laughing at Patient 33 when he sustained a fall.

Based on policy review, document review, and security video review, the hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 1 of 1 patients (Patient 33) reviewed with restraints. This deficient practice violated the Patient 33 rights and places any patient receiving services at this hospital at risk for serious injury and harm.

Findings Include:

Review of a policy titled, "Restraints and Seclusion Policy," revised 02/03/2022, showed, "...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient..."

Review of Patient 33's medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation).

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses station at 3:58 PM. At 4:00 PM, Staff E8, RN, arrives with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. At 4:11 PM, staff completed the process of restraining Patient 33 arms and legs to the slide board.

Further review of the security footage showed that Patient 33 remained restrained to the slide board until 7:24 PM when he sustained a fall and an unidentified nurse removed Patient 33's restraints at 7:25 PM.


Review of Patient 33's medical record failed to show documented evidence of a written order for restraints by a physician or other licensed practitioner as required per hospital policy and regulation requirements 42 CFR §482.13(e)(5).

Based on policy review, record review, and security video review, the hospital failed to ensure the condition of a patient in restraints was monitored at intervals required by hospital policy for 1 of 1 (Patient 33) patients reviewed with restraints. This deficient practice places any patient in restraints at risk for injury and harm.

Findings Include:

Review of a policy titled, "Restraints and Seclusion Policy," revised 02/03/2022, showed, "...The use of restraints requires assessment/monitoring to be documented within one (1) hour of initiation, or more often as determined by the patient's condition. Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient's condition at a minimum every 15 minutes, and document in the electronic medical record ...RN will document they type of restraint used...The RN will document the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Describe the impact of the intervention ...Immediately checks the patient to ensure that the restraints were properly and safely applied...Document the patient's response to and effectiveness of the restraint...Assess/monitor/document the patient's condition in at least 1 hour, or more often as determined by the patient's condition, and: Check skin integrity, body alignment, and circulation and sensation to affected limbs...Offer the patient the following every two (2) hours while awake: Repositioning/Range of motion of the restrained limbs; Fluids/nourishment; Hygiene/Elimination...Document any injuries incurred by the patient..."


Review of Patient 33's medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 was noted be combative towards staff and placed in 4-point restraints (restraints applied to both arms and both legs).

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed... At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At that time, Patient 33's feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view.

Review of Patient 33's medical record failed to show any nursing notes or documented interventions and application of the restraints per hospital policy.

At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses' station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33's left hand, however, did not apply a blood pressure cuff or obtain vitals. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses' desk watching patient, however no staff attempted to intervene with Patient 33's behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. Further review of the video and medical record failed to show evidence that Staff Z5 performed a restraint assessment. At 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33's movements had resulted in the patient's lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor. At the time of Patient 33's fall, about 20 hospital staff were in the nurses' station and within line of site of the patient. At 7:25 PM, an unidentified RN responded to Patient 33's fall and released the patient restraints from the slide board. Patient 33 was assisted by staff onto the bed.

In summary of the ED video footage from time of Patient 33's arrival at 3:52 PM to 10:41 PM, and review of Patient 33's medical record showed the hospital failed to provide ongoing monitoring of a patient in restraints as required per facility policy [Restraints and Seclusion] and failed to ensure Patient 33 was properly restrained to avoid falls and injury.

Based on document review, policy review, and security video review, the hospital failed to ensure a patient in restraints was assessed face to face by a physician or other licensed practitioner after the initiation of the intervention as required per hospital policy for 1 of 1 (Patient 33) patient reviewed with restraints. This deficient practice resulted in Patient 33 suffering a fall and places any patient receiving services at this hospital at risk for serious injury and harm.

Findings Include:

Review of a policy titled, "Restraints and Seclusion Policy," revised 02/03/22, showed, "...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for care of the patient..." The policy showed that a restraint order for violent/self-destructive behavior requires a face-to-face evaluation by a physician or other licensed practitioner within one (1) hour after restraint initiation and must include the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue the restraint.

Documentation of any injuries incurred by the patient is required. When restraints are in use, staff must monitor patient's condition at a minimum every 15 minutes, and document in the electronic medical record.


Review of Patient 33's medical record showed a 38-year-old male, arrived at the ED on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in facial injury. Patient 33 received a CT of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 was noted be combative towards staff and placed in restraints.

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. Staff A6, Physician, walked up to nurses' desk and watched numerous staff and security working to restrain Patient 33, and then walked away 15 seconds later. At 4:04 PM, Staff A6, approached and stood at nurses' station while two security staff and two RNs continued to hold patient. At 4:06 PM, Staff A6, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At 5:54 PM, Staff A6, Physician approached Patient 33 with an unidentified staff member and appeared to look at the patient's facial injury. Patient 33 continued to be restrained to the slide board. Staff A6, laughed and walked away 30 seconds later.

Review of an "ED Note-Physician," by Staff A6, Physician, dated 11/21/23 at 4:05 PM, showed, "...Document Subject: Face to Face...At this time, patient has become combative towards nursing staff. Due to this, will place patient in restraints to protect himself and others. I have evaluated the patient and attest to the following: Non-physical interventions were tried and were ineffective or not viable; The patient was an imminent risk of physically harming him/herself or others, including staff; The patient attempted to physically harm him/herself or others; The patient's physical and psychological status has been reviewed with staff; Rationale for restraint/seclusion use has been discussed with the patient, and alternative coping skills identified and discussed; The patient's plan of care and or treatment plan has been evaluated; The patient is physically safe in restraint; Continue restraint/seclusion..."


Staff A6, Physician, failed to ensure that appropriate and safe application of restraints were followed by allowing Patient 33 to be restrained to a slide board instead of the bed. Review of the ED video showed that Staff A6, Physician at no time provided a physical examination of Patient 33.

Further review of the medical record showed that Staff A6, Physician, documented the "Face to Face" evaluation at 4:05 PM, prior to the completion of Patient 33 being placed in restraints.

Review of the medical record failed to show documented evidence that Staff A6, Physician, evaluated Patient 33's immediate situation, reaction to restraint interventions, medical and behavioral condition, and the need to continue/discontinue restraint after Patient 33 was placed in restraints.

Review of a document titled, "Alleged ED Caregiver Misconduct-Patient Timeline," undated, showed a hospital interview with Staff A6, Physician. "...Interview [Staff A6], Primary physician...He does remember this patient ...He puts them in restraints right away. He remembers ordering this. He then gives Geodon so that imaging can be done. The restraints are left in place and he gives the nurse instructions that when the Geodon takes effect and the patient gets back from CT you can remove the restraints. He did not give instruction to continue restraints for the patient. He was surprised to learn that the patient was still in restraints after he left." Review of the security video showed that Staff A6, Physician was at Patient 33's bedside after returning from CT and remained in restraints.

Based on policy review, record review, and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 22 of 50 patients when the nursing staff failed to:

1. Complete assessments as required. (Patients 38, 2, 33, 4, 5, 7, 23, 24, 25, and 31)

2. Notify physician of critical results and/or Delay of Care (Patients 6, 3, 7, and 24)

3. Administer medication as ordered. (Patient 6 and 2)

4. Complete vitals as required. (Patients 2, 3, 15, 16, 20, 23, 24, 25, 26, 29, 30, and 46)

5. Document repositioning of patients at risk for skin break down every two hours or more frequently as ordered by the physician. (Patients 4, 5, 7, 9, 22, 24, 25, and 31)

6. Provide daily bathing as ordered. (Patients 1, 4, 5, 7, 8, 24, 25, and 31)

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious
impairment or death.

Findings Include:

1. Assessments:

Review of a hospital policy titled, "Patient Assessments and Reassessments," revised 7/29/20, showed that Registered Nurses (RNs) are responsible for initial patient assessments in all care settings where nursing care is provided. The registered nurse is responsible for performing the assessment processes. Nurses must document an assessment with "a change of shift or hand off; when there are significant changes in patient condition (requires provider notification); undesired response occurs (requires provider notification)..." Nursing initial assessments and reassessment requirements and time frames showed the following:

Behavioral Health Initial Assessment: Initiation of assessment within 15 minutes for triage assessment and completion of admission assessment within 24 hours.

Behavioral Health Reassessment: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per adult admission assessment criteria in EHR (Electronic Health Record); Systems review per admissions assessment criteria and flow sheet. Minimum Reassessment Timeframes: Every shift;

As indicated by need focused reassessment; Vital signs minimally every 8 hours.

Med Surg Initial Assessment: Initiation of assessment within one (1) hour and completion of admission assessment within 24 hours.

Routine Adult Med Surg Patients: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per adult admission assessment criteria in EHR; Systems review per admissions assessment criteria and flow sheet. Minimum Reassessment Timeframes: Every shift; As indicated by need focused reassessment; Vital signs minimally every shift.

Post-Surgical Adult: Content/Parameters: Initial vital signs, pain assessment; Collection and review of data per post-operative orders and adult admission assessment criteria if it's a new admission. Minimum Reassessment Timeframes: Vital signs and focused assessment every 15 minutes x 4, every 30 minutes x 2, every hour x 4, then every 4 hours for 36 hours; As indicated by need focused reassessment; Every 12 hours, at the start of each nurse shift or by specific need.

Critical Care Initial Assessment: Initiation of assessment within one (1) hour and completion of admission assessment within 24 hours.

Critical Care: Content/Parameters: Initial vital signs, pain assessment, baseline physiological status before collection and review of data per Adult Admission criteria; System review per Adult Admission Assessment criteria. Minimum Reassessment Timeframes: Every 4 hours minimum for the ICU (Intensive Care Unit); Start of each shift; As indicated by need focused reassessment.

Emergency Services: Initiation of assessment within 15 minutes for triage and completion of admission assessment within 30 minutes for Level 1 and 2; within three hours for Level 3, 4, and 5.

Emergency Department: Content/Parameters: (not defined). Minimum Reassessment Timeframes: Focused reassessment minimally every hour and by specific need.

Operating Room: Content/Parameters: Defined by surgical checklist and perioperative assessment form. Minimum Reassessment Timeframes: Ongoing monitoring by CRNA (Certified Registered Nurse Anesthetist)/anesthesiologist.

Post Anesthesia Care Unit: Initiation of assessment immediately upon admission to unit.

Post Anesthesia Care Unit: Content/Parameters: Physiological and mental status, pain level; Data collected by criteria defined on PACU (Post Anesthesia Care Unit) flow sheet. Minimum Reassessment Timeframes: Every 15 minutes until stable and specific focused reassessment per departmental policy.

Review of the hospital policy titled, "Patient Assessments and Reassessments", revised 08/17/2023 showed, "...Emergency Services...Initiation of Assessment Within...15 minutes for triage assessment..."

Review of the hospital policy titled, "Chest Pain Program" revised 10/24/2023 showed, "...Patients receive rapid evaluation for intervention to minimize acute coronary syndrome (ACS) morbidity and mortality...The program evaluated patients with signs and symptoms of chest pain or acute coronary syndrome. These signs include but are not limited to: ...arm pain...other non-cardiac presentation especially in women. If these signs or symptoms are present, staff obtains a STAT electrocardiogram (ECG)..."


Review of a hospital policy titled, "CPG [Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain", revised 02/07/2023 showed, "In all patients who present with acute chest pain regardless of the setting, an ECG [electrocardiogram] should be acquired and reviewed for STEMI [ST Elevation Myocardial Infarction] within 10 minutes of arrival." Further review of the document showed, "Chest pain or chest pain equivalent will be referred to in these guidelines as "Chest pain" ...Regardless of the setting, an ECG should be obtained and interpreted within 10 minutes of arrival..."

Review of a hospital policy titled, "Fall Risk", revised 03/21/23 showed, "...b. Patients will be assessed using the Fall Risk Assessment every shift and at any time there is a change in the patient's condition... F. If a fall occurs, a.
Assess the patient for injury and mental/ physical status of patient and compare to pre-fall assessment. b. Notify the physician of the fall. c. Notify House Manager. d. Implement necessary measures to decrease risk of fall. e. With patient permission, notify family of the patient's fall. f. Complete and submit ERS (Event reporting system) report. g. Initiate Post-Fall Assessment IPOC in Electronic Medical Record (EMR)..."

Patient 38

Review of Patient 38's medical record showed a 74-year-old female that arrived to the ED at Hospital 1 (H1) via ambulance on 08/21/23 at 12:14 PM with complaints of worsening numbness to her left hand for the past 3 weeks. Patient 38 noted that the pain has been radiating into her mid back and she doesn't feel she has been getting much relief. Patient 38 had a history of Chronic Obstructive Pulmonary Disease (disease of the airway), Hyperlipidemia (high levels of fats in blood), Chronic Kidney Disease (ineffective functioning of the kidneys), Hypertension (high blood pressure), and prediabetes.

Review of Patient 38's "Prehospital Care Report Summary" (Emergency Medical Service - EMS report) dated 08/21/23 documented, EMS was dispatched at 11:36 AM, "Dispatch Reason...Chest Pains." The report documented "pt (patient) complains of pain to left hand and arm that began approximately 20 minutes ago. Pt reports pain is sharp in nature and rated pain at 9/10. Pt reports she has chronic pain and the pain has been intermittent over the last 6 months..."

Further review of the "Prehospital Care Report Summary" revealed an Abnormal, 12-Lead 1, electrocardiogram (ECG) dated 08/21/23 at 11:59 AM that showed Sinus rhythm, and "Widespread ST-T abnormality may be due to myocardial ischemia [MI - occurs when the blood flow through one or more of your coronary arteries is decreased)." Manual interpretation by the EMS professional documented "NRS no ST elevation or ectopy"

The "Prehospital Care Report Summary" documented, Patient 38 transferred to facility bed in "[H1] er triage" EMS handoff report was given to Staff C5, RN at 12:11 PM.

Review of the hospital policy titled, "Patient Assessments and Reassessments", revised 08/17/2023 showed, "...Emergency Services...Initiation of Assessment Within...15 minutes for triage assessment..."

Patient 38 waited in the triage waiting area from 12:14 PM through 1:10 PM. Patient 38's documented triage time showed 1:10 PM (54 minutes after arrival).

The medical record showed that nursing staff failed to initiate a triage assessment within 15 minutes of patient arrival to the emergency department as required per facility policy.

The nursing staff's failure to initiate a triage assessment within 15 minutes caused a delay in recognition of Patient 38's acute coronary syndrome (ACS - any condition brought on by a sudden reduction or blockage of blood flow to the heart. ACS is most often caused by plaque rupture or clot formation in the heart's arteries. Symptoms may include heart attack-like chest pressure, chest pressure while resting or doing light activity, or sudden heart stoppage. This condition is treatable if diagnosed quickly).

During an interview on 12/07/23 at 11:33 AM, Staff X4, PA (Physician Assistant) stated she was not present during triage but had she been aware of the patient's radiating pain, she would have ordered a STAT (immediate) ECG and labs. Staff X4 went on to state that after viewing the ECG obtained by EMS, she would have definitely ordered a STAT ECG.

The medical record failed to show that the ED staff completed an ECG within 10 minutes of Patient 38's arrival as required by hospital policy, CPG Clinical Practice Guidelines] for TJC [The Joint Commission] Chest Pain"] for patients presenting with signs and symptoms of ACS and failed to show rapid evaluation and intervention to minimize ACS morbidity and mortality as required per facility policy.

Review of Patient 38's medical record documented Staff K8, MD, ordered an initial ECG at 6:35 PM. Staff completed initial ECG 53 minutes after order at 7:28 PM (7 hours, 14 minutes after arrival to emergency department). Staff K8, MD, ordered a repeat Stat (immediate) ECG at 7:41 PM due to an abnormal initial ECG. ED staff completed the ECG 25 minutes later at 8:04 PM. The repeat ECG unequivocally showed, "ST Elevation Myocardial Infarction."

The nursing staffs' failure to provide a rapid and appropriate evaluation of Patient 38, including an ECG within 10 minutes of arrival, per policy, resulted in a treatment delay to minimize the effects of acute coronary syndrome.

Review of The American College of Cardiology (ACC), American Heart Association (AHA) and the European Society of Cardiology have all recommended a door to balloon (D2B) time of 120 minutes from the first medical contact or 90 minutes from the patient presentation to the first balloon inflation.

Further review of Patient 38's medical record showed patient arrived at the cardiac catheterization lab on 08/21/23 at 9:17 PM (about 9 hours after arrival to the ED) with a finding of a critical 99% thrombotic left main lesion with probable blood clot. At 11:15 PM (about 11 hours after arrival to the ED), Patient 38 was transferred to the operating room for an emergent coronary artery bypass graft surgery. Patient 38 received two grafts to restore blood flow around the blocked heart arteries and a balloon pump to help the heart pump more blood. Following the surgery Patient 38 transferred to the cardiothoracic intensive care unit and the record showed she was hemodynamically unstable until her death.

Patient 38 died on 08/22/23 at 12:11 PM, 23 hours and 57 minutes after she presented in the Emergency Department.

During an interview on 12/07/23 at 4:15 PM, Staff C5, RN (Registered Nurse) stated that he thinks that ECGs, labs, radiology, etc. are getting missed due to the lack of staffing. Staff C5 stated that the hospital policy states door to ECG time is 10 minutes. Staff C5 went on to state he obtains an ECG on patients with arm pain especially if it radiates and especially women over the age of 40. Staff C5 stated that Patient 38 did not have an ECG due to patient EMS brought her in for hand pain that radiated up into her back and in triage she said she had been taking gabapentin for nerve pain that has been going on for years and requested to be admitted for pain control.


Patient 2

Review of Patient 2's discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits.

Review of Patient 2's nursing admission assessment dated 08/22/23 at 6:31 PM showed Staff T3 RN staff failed to document a cardiovascular or gastrointestinal assessment.

Review of nursing shift assessments from 08/22/23 - 08/29/23 showed no documented evidence of a cardiovascular or gastrointestinal assessment.

Failure to complete a head-to-toe assessment places patients at risk for deterioration of current illness, ineffective management of care needs and other adverse outcomes.

Review of security video footage dated 08/23/23 at 4:38 PM showed; Patient 2 exited a room wearing regular socks without traction and fell to the floor, landing face down. At 4:39 PM, an unidentified patient walked past Patient 2 and then went to the nurse's station and pointed down the hall to where Patient 2 was laying on the floor. At 4:40 PM, three staff members Staff C4, Staff O4, and Staff U3 came out of the nursing station and walked down to Patient 2.

Without assessing Patient 2, all three staff members left the patient laying on the floor and walked back to the nurse's station, leaving Patient 2 laying on the floor unattended. At 4:43 PM, Staff O4, Staff C4, Staff U3 and unidentified staff member return to Patient 2 with a vitals machine and can be observed obtaining a blood pressure, oxygen saturation, and temperature. Staff U3 BHT is observed bending over Patient 2 and flicked a colorless liquid from a cup onto Patient 2's face. At 4:45 PM, Staff Q4 and Staff R4 Mental Health Protection Workers entered the hall and approached Patient 2. Without attempting to reposition the patient, who remained facedown her stomach in a semi fetal position, body appeared to be heaving in a slight up and down motion. The workers picked Patient 2 up by her wrists and ankles, from a face down position. Patient 2's body hung limply, and she made no attempts to reposition herself or otherwise move. As the staff picked her up by her wrists and ankles, Patient 2's wrists were crossed over one another and she was flipped mid-air to dangle face-up. Patient 2 was then carried into a room by her wrist and ankles.

Review of Patient 2 medical record on 08/23/23 failed to show documented evidence that the Staff T3 RN conducted a post fall injury evaluation and neurological assessment including a Glasgow coma scale (measures the extent of impair consciousness in all types of acute medical and trauma events), any changes in consciousness, headache, pupil response, etc. The nursing staff failed to assess airway, breathing, circulation, activate the rapid response team, assess injury to cervical spine and assist patient to move using safe handling practices.

Further review of Patient 2's medical record dated 08/23/23 showed the nursing staff failed to complete vital signs and the post fall neurological assessment at least hourly for 4 hours. Failure of the nursing staff to conduct and document continued observation of Patient 2 at least every 4 hours for 24 hours status post unwitnessed fall could result in missing signs/symptoms of a head injury.

During an interview on 12/06/23 at 2:20 PM Staff C2, Director of Behavioral health unit (BHU) stated that regarding our fall policy if it is determined to be a fall, we would start with an assessment by a nurse. The staff would complete a post fall debriefing, notify the house supervisor, complete the Morse fall risk scale, and update the plan of care. Staff C2 stated that with an unwitnessed fall sometimes patients with behaviors will put themselves on the floor but that does not mean we should dismiss it. Staff C2 stated that the post fall debriefing is a form that is used hospital wide not just for psychiatric units. The Post fall form includes a fall risk assessment, obtaining vital signs and updating the care plan.


Patient 33

Review of Patient 33's medical record showed a 38-year-old male that arrived at the Emergency Department (ED) on 11/21/23 at 3:53 PM with a diagnosis of alcohol intoxication and nasal fracture. Patient 33 was brought to the ED by ambulance after a fall resulting in a facial injury. Patient 33 received a CT (computed tomography) scan (a type of x-ray procedure used to produce images of the inside of the body) of head/face/spine that showed nasal fractures and was treated with one dose of Geodon (an antipsychotic medication that may be used to treat agitation). Patient 33 had a fall while in 4-point restraints for violent/aggressive behavior.

Review of a documented titled, "Prehospital Care Report Summary," by Emergency Medical Services (EMS), dated 11/21/23 showed a clinical presentation of Patient 33 with severe alcohol intoxication, trauma injury to nose with clotting blood and dry blood from nose down face and over chest, and altered mental status. Patient 33's care was transferred to [The Hospital] at 3:54 PM and handoff report given to a registered nurse at 3:58 PM.

Review of ED surveillance video on 11/21/23 from 3:52 PM to 10:41 PM, showed Patient 33 was brought into the ED at 3:52 PM by EMS, accompanied by six hospital security personnel. Patient 33 was transferred to an ED bed at 3:54 PM, taken down the hall out of camera view and returned to the ED hallway in front of the nurses' station at 3:58 PM. Patient 33 appeared to be agitated and resistive to security staff that were observed holding Patient 33 down to the bed by the upper arms and wrists. At 4:00 PM, Staff E8, RN, arrived with 4-point hard restraints (locking restraints used only in cases of dangerous/aggressive behavioral patients at risk of injuring self or others). Staff A6, Physician, walked up to nurses' desk and watched as numerous staff and security worked to restrain Patient 33, and then walked away 15 seconds later. Staff E8, RN, placed a plastic, flexible slide board underneath patient and with the assistance of another RN and security, applied restraints to Patient 33's arms which were secured to the slide board instead of the bed. At 4:04 PM, Staff A6, Physician, approached and stood at nurses' station while two security staff and two RNs continued to hold patient while Staff F8, RN, appeared to administer an injection medication. At 4:06 PM, Staff A6, Physician, walked away as staff continued to hold Patient 33 while restraining Patient 33 to slide board. At 4:11 PM, staff completed process of restraining Patient 33's arms and legs to the slide board. At that time, Patient 33's feet were observed hanging over the foot of the bed. Staff failed to pull patient up in bed to ensure safe placement and comfort. Medical staff walked away and left Patient 33 unattended except for security staff standing at nurses' station observing patient. At 4:15 PM, Patient 33 was resting quietly. At 4:26 PM, Staff A6, Physician, approached resting patient, tapped Patient 33 on the upper left arm, and walked away three seconds later. At 4:28 PM, Staff Z5, RN, and another unidentified staff member, wheeled Patient 33 down the hall and out of camera view.

Review of Patient 33's medical record failed to show any nursing notes or documented interventions and application of the restraints.

At 4:38 PM, Patient 33 returned and was placed in ED hallway in front of nurses' station. Patient 33 continued to be restrained to the slide board and was resting quietly. At 4:54 PM, Staff F8, RN, attached oximetry probe to Patient 33's left hand, however, did not apply a blood pressure cuff or obtain vitals. Patient 33 continued to rest quietly until 5:18 PM. From 5:18 PM to 7:06 PM, Patient 33 was resting with intermittent bouts of waking in which he would thrash upper and lower extremities against restraints and was making attempts to raise himself to a sitting position. Multiple hospital staff members were observed walking past patient and an unidentified staff member was observed leaning against nurses' desk watching patient, however no staff attempted to intervene with Patient 33's behavior or assess the patient. At 7:07 PM, Staff Z5, RN, approached Patient 33 and applied a blood pressure cuff and obtained a blood pressure. 7:07 PM was the first and only evidence of vitals being obtained on Patient 33 (three hours and 15 minutes after arrival at the ED) from admission through discharge.

Review of the medical record showed that Staff Z5, RN, documented the vitals as being obtained as part of a triage assessment at 4:00 PM. Although Patient 33's medical record showed that Staff A6, Physician, documented a physical assessment at 3:55 PM, review of the video footage showed that Staff A6 never approached the patient and did not assess Patient 33's pupils and did not listen to heart or lung sounds as documented.

Further review of the video showed at 7:21 PM, Patient 33 woke up and began resisting restraints, thrashing arms and legs, and made vigorous attempts to sit up while being restrained to the slide board. Patient 33's movements had resulted in the patient's lower extremities extending past the foot of the bed. At 7:24 PM, Patient 33 was successful at sitting up and fell out of the bed to the floor.

Review of the "ED Triage Note," showed, " ...ED Triage Adult Entered On: 11/21/2023 19:09 CST [7:09 PM] Performed On: 11/21/2023 16:00 CST [4:00 PM] by [Staff Z5, RN]." Staff Z5 documented the following vitals: Blood pressure 114/74, Pulse 104, Respiratory rate 16, and Oxygen saturation 94%.

Review of the ED video at 4:00 PM, showed that Staff Z5, RN, approached Patient 33's bedside and assisted other staff members with placing a slide board under patient. At 4:01 PM, Staff Z5 walked away from Patient 33. Staff Z5 did not assess Patient 33 and did not obtain vitals at 4:00 PM as documented in the medical record.

Review of a document titled, "Alleged ED Caregiver Misconduct-Patient Timeline," undated, showed an interview with Staff Z5, RN. " ...She says she charts at the end of her shift and back times the information which is why the triage note was entered for 1600 [4:00 PM] and the 1600 [4:00 PM] VS [vital signs] were actually 1900 [7:00 PM] VS [vital signs] ..."

Review of Patient 33's medical record failed to show documentation that Patient 33 had a fall during his hospitalization. The medical record failed to show evidence that nursing staff or Staff S2, Physician, performed a post fall evaluation on Patient 33 to assess for injury and mental/physical status of the patient compared to pre-fall status.

In summary of the ED video footage from time of arrival at 3:52 PM to 10:41 PM, and Patient 33's medical record, the hospital failed to ensure Patient 33 received a physical assessment upon arrival, including vital signs and a nursing assessment. The hospital staff failed to provide ongoing monitoring of a patient in restraints as required per the facility "Restraints and Seclusion" Policy, including 15-minute monitoring with required documentation, and failed to ensure the safety of a patient to prevent a fall. Review of the video and medical record showed nursing staff and Staff S2, Physician, failed to provide a post fall assessment of Patient 33 or assess for change in condition and/or injury after a fall.

The failure of the hospital to ensure that nursing staff used appropriate application of restraints, provided ongoing monitoring and assessment of a patient, and followed best practices to protect and prevent a patient from harm, places patients at risk for serious injury.

During an interview on 1/5/23 at 3:52 PM with Staff E6, Chief Executive Officer (CEO) stated that he saw the video of the incident in the ED and it was disheartening.


Patient 4

Review of Patient 4's medical record showed a 75-year-old female, admitted to H1 on 04/30/23 at 9:30 PM with left distal third spiral tibial shaft fracture (complex broken leg). Patient reported she tripped at home and fell on her left side. Patient 4 underwent surgical repair of the fracture on 05/03/23 at 10:15 AM.

Review of an order dated 05/03/23 at 11:32 AM, showed, "Neurovascular Assessment Lower Extremity ... q4hr (every 4 hours) for 48hrs (48 hours) ... stop 05/05/23 at 11:59 AM."

Review of Patient 4's medical record failed to show documented evidence that nursing staff conducted any neurovascular assessment on Patient 4's lower extremity as ordered. Failure to perform neurovascular checks as ordered has the potential for the nurse to miss symptoms of compromised blood flow or nerve damage to the ted limb.


Patient 5

Review of Patient 5's medical record showed an 83-year-old female that was transferred to H1 via EMS on 07/28/23 at 5:46 PM after an elective hip surgery with a diagnosis of hypotensive episodes post-operative and concern for sepsis due to unclear infection source. A Computed Tomography Scan (CT) was concerning for duodenal abnormality (Duodenal disease can include inflammatory lesions, strictures, and fistulas, and long-standing disease increases the risk of duodenal cancer).

Review of an order dated 07/28/23 at 10:29 PM, showed, "Penlight Pupil Check q12hr, ...observe for purulent discharge/infiltrates. For worsening peripheral eye infiltrates, consult ophthalmology to evaluate."

Review of Patient 5's medical record showed the nursing staff failed to document Penpoint pupil checks as ordered on 08/02/23, 08/06/23, and 08/07/23. Failure of the nursing staff to document Penpoint pupil checks as ordered places the patient at risk for unrecognized neurological impairment.

Review of Patient 5's medical record showed the nursing staff failed to document evidence of these assessments for the following dates/shift:

08/02/23: Respiratory assessment (night shift). 08/02/23: Cardiovascular assessment (night shift). 08/06/23: Cardiovascular assessment (day shift). 08/06/23: Respiratory assessment (day shift). 08/07/23: Pain assessment (night and day shift). 08/10/23: Respiratory assessment (night and day shift).

Failure of the nursing staff to conduct and document respiratory, cardiovascular, and pain assessments as ordered places the patient at risk for unrecognized patient decline or death. Review of the medical record showed nursing staff failed to document a reassessment with change of shift as required per facility policy, "Patient Assessments and Reassessments."


Patient 7

Review of Patient 7's medical record showed a 40-year-old female that presented to the Emergency Department (ED) on 11/14/23 at 8:12 PM, via Emergency Medical Services (EMS) with Altered Mental Status (AMS) and an elevated heartrate of 144 [60-100] beats per minute. Past medical history included Diabetes Mellitus type 2 (high blood glucose), Chronic Kidney Disease Stage III (moderate kidney damage), and visual blindness. Further review of the medical record showed a patient representative for Patient 7 reported fever and increased confusion at home. Patient 7 was admitted on 11/15/23 at 10:08 AM with a diagnosis of Diabetic Keto Acidosis (DKA) (condition where blood contains excessive acids) and headache.

Review of an order dated 11/19/23 at 8:43 PM, showed, "NIH (National Institutes of Health) Stroke Scale (tool used to measure impairment caused by a stroke) BID (twice daily)".

Per the NIH website, the Stroke Scale Severity rating: 0 = no stroke; 1-4 = minor stroke; 5-15 = moderate stroke; 15-20 = moderate/severe stroke; 21-42 = severe stroke.

Review of Patient 7's medical record showed an initial NIH assessment was completed 11/20/23 at 12:30 AM (~ 4 hours after order) with a score of 27 [severe stroke]. Further review showed only one NIH assessment was completed on 11/21/23, 11/22/23, 11/24/23, 11/25/23, and 11/26/23. Failure of nursing staff to conduct and document NIH assessment as ordered placed the patient at risk for unrecognized neurological decline.


Patient 23

Review of Patient 23's medical record showed a 37-year-old that arrived at the ED at H1 via ambulance on 11/02/23 at 11:47 PM with a diagnosis of seizure disorder, alcohol withdrawal, chronic alcohol abuse and hypokalemia (high potassium). Patient 23 was admitted on 11/03/23 at 1:54 AM to the intensive care unit.

Review of an order dated 11/03/2023 at 2:01 AM showed, "Neurological Checks, q4hr (every four hours) ..."

Review of Patient 23's medical record showed nursing staff failed to document evidence of a neurological check on 11/10/23 between 12:00 AM and 6:02 AM (6 hours and 2 minutes). Failure of nursing staff to conduct and document neurological checks as order places the patient at risk for unrecognized neurological decline.

Review of an order dated 11/03/23 at 6:24 PM showed, "Order: Restraint Initiate Non-Violent Behavior...Order Details: Interfering with medical care devices, soft limb...Evaluate patient, replicate restraint continue phase if indicated."

Review of Patient 23's medical record showed nursing staff failed to document evidence of hourly extremity and skin assessments for the following dates/times:

11/04/23: 2:00 PM and 6:00 PM
11/05/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM
11/06/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM
11/07/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM
11/08/23: 12:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM
11/09/23: 2:00AM, 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM
11/10/23: 12:00AM, 2:00AM, 4:00AM and 6:00AM

Failure of nursing staff to conduct and document extremity and skin checks as ordered while Patient 23 was restrained places patient at risk for unrecognized skin breakdown and impaired neurovascular functioning.


Patient 24

Review of Patient 24's medical record showed an 88 year old female admitted on 11/01/23 at 12:46 PM to the ED at H1 via private vehicle with a diagnosis of elevated blood pressure and toe pain. Patient 24 had a history of Coronary Artery Disease (CAD) (damage to major blood vessels), Degenerative Joint Disease (DJD), dementia, Coronary Artery Bypass Grafting (CABG) (heart bypass surgery), Diabetes Mellitus (DM) (high blood glucose), hyperlipidemia (high cholesterol), and Hypertension (HTN).

Review of an order dated 11/02/23 at 8:52AM showed, "Order: Penlight Pupil Check...Order Details:...q12hr Observe for purulent discharge/ infiltrates. For worsening peripheral eye infiltrates..."

Review of Patient 24's medical record failed to show Nursing Staff documented evidence of Penlight Pupil Check every 12 hours as ordered on the following dates:
11//09/23, 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23 and 11/21/23 (17 of 40 assessments). Failure of nursing staff to conduct and document pupil checks as ordered places the patient at risk for unrecognized neurological impairment.

Review of an order dated 11/05/23 at 6:57 PM showed, "Order: Neurological Assessment High Risk for Injury... Order Details: 11/05/23 16:38:00 CST, q1hr, 4, hr, Stop date 11/05/23 20:59:00 CST (8:59 PM)."

Review of Patient 24's medical record failed to show documented evidence of a Neurological Assessment between 4:38 PM and 6:38 PM every one hour as ordered (2 of 4 assessments).

Review of an order dated 11/05/23 at 6:57 PM showed, "Order: Neurological Assessment High Risk for Injury... Order Details: 11/5/23 8:38:00 PM CST, q4hr, 20, hr, Stop date 11/6/23 4

Based on policy review, document review, and interview the hospital failed to ensure nursing care plans were kept current for each patient when nursing staff failed to followed the Patient Assessment and Reassessment, Nursing documentation guidelines, and Fall Risk policies of updating the patients interdisciplinary plan of care with interventions, short term goals, and long-term goals for 2 of 50 Patients reviewed (Patient 2 and 15). This deficient practices has the potential to place patients at risk for deterioration of current illness, ineffective management of care needs and other adverse outcomes.


Findings Include:

Review of hospital policy titled "Patient Assessment and Reassessment" revised 08/17/2023 showed, "...Interdisciplinary plan of care (for admitted patients). Each admitted patient will have a comprehensive, integrated, multidisciplinary plan of care, which is developed from the initial patient assessment. This plan of care will include, at minimum, physician, and nursing components. Initial patient assessments provide the baseline of the patient at the time of admission. From these assessments, the needs of the patient are identified, and the plan of care is developed.

A. The plans of care focus on: 1. Immediate needs. The RN assessment results in a listing of patient problems, needs or nursing diagnoses. 2. The patient's needs for education regarding the diagnosis, treatment, and continuing
management of health care problems and the maintenance of health; and discharge planning.

B. RNs are expected to review the plan of care at least daily.

C. Updates or modifications to the plan of care occur whenever there is: 1. A significant change in the patient's condition or status 2. At specified time intervals, to include: b. Nurses, at least daily; and c. Other support staff with each observation..."

Review of the hospital policy titled, "Nursing Documentation Guidelines," revised 03/01/2023, POLICY: The main purpose of the medical record is to accurately and adequately document a patient's health history, including past and present illness(es) and treatment(s), with emphasis on the events affecting the patient during the current episode of care. The Documentation Guidelines outline how to appropriately provide nurse documentation in the electronic health record (EHR).

IPOC (Interdisciplinary Plan of Care): IPOCs are suggested based on assessment findings. Suggested IPOCs must be accepted and personalized (goals, indicators, interventions) based on the individual needs of the patient.

Proceed to: ... Review current care plan and implement additional fall prevention strategies. ... Provide fall prevention information (Tool 3J).

Review of hospital policy titled, "Fall Risk," revised 03/21/23 showed, "F. If a fall occurs... g. Initiate Post-Fall Assessment Interdisciplinary plan of care (IPOC) in Electronic Medical Record (EMR)."


Patient 2

Review of Patient 2's discharged medical records showed a 60-year-old admitted with chief complaint of suicidal ideation (SI), threatening, recent seizure (sudden, uncontrolled burst of electrical activity), and homeless. The admitting diagnosis is schizoaffective disorder (chronic condition with hallucinations or delusions, and mood disorder symptoms such as mania and depression) and status epilepticus (seizure activity with 5 minutes or more of continuous clinical or recurrent seizure activity) with a past medical history (PMH) of gastroesophageal reflux disease (GERD - stomach acid repeatedly flows back into the mouth and stomach), hyperlipidemia (elevated levels of fats or lipids in the blood), migraine headaches (severe throbbing pain), chronic pancreatitis (inflammation of the pancreas) and Cerebrovascular accident ( CVA- an interruption in the flow of blood to cells in the brain) without residual deficits.

Review of Patient 2's "History and Physical," dated 08/23/23 at 4:19 PM showed a diagnosis of status epilepticus on 08/21/23 with a known history of seizures.

Review of Patient 2's "Interdisciplinary Plan of Care (IPOC)" dated 08/22/23 failed to show a plan of care initiated that focused on Patient 2's problem with increased risk for seizure like activity. The plan of care did not include any
interventions to implement seizures precautions that would keep the patient safe and reduce the risk for harm.

During an interview on 12/14/23 at 10:21 AM, Staff CC, Director of Behavioral health unit stated that if staff knew a patient had a seizure disorder noted, or other medical condition the expectation would be to include the medical condition in the plan of care.

During an interview on 12/05/23 at 4:23 PM Staff O4, RN house supervisor (day shift) for 6 west was asked if a patient with a known history of seizure would require seizure precautions. Staff O4 RN stated, "I guess but on a psychiatric floor it is tricky, but we do have the mats we can put on the side of the bed to prevent a fall out of the bed or something like that."

During an interview on 12/05/23 at 10:59 AM, Patient 2 stated "on 08/23/23, I was in my bed the whole day then I got up to go to the bathroom and by that time I felt like I might be having a seizure, so I went into the hallway. I don ' t remember some of it, but they were sprinkling water on my face." Patient 2 stated her "right arm is sore, the staff broke my hand, the guy was losing grip on one of my hands and he grabbed my hand again and they flung me onto the bed."

Review of Staff T3, RN progress note dated 08/23/23 at 7:02 PM showed, "On 08/23/23 at approximately 5:00 PM a peer came to the nurses' station to inform staff that [Patient 2] is laying on the floor in the hallway patient will not respond verbally, vital signs obtained and are within normal limits (WNL) no injuries observed by this staff."

Further review of Patient 2's medical record showed that nursing staff failed to follow the hospitals fall risk policy and did not initiate the Post Fall assessment IPOC. The nursing staff failed to include interventions, measurable goals and outcomes that address Patient 2's safety needs post fall.

During an interview on 12/14/23 at 11:19 AM, Staff T3, RN stated that the plan of care is completed when the patient first admits, and the nurse can update it whenever new problems are identified.

During an interview on 11/29/23 at 3:00 PM Staff V2, RN stated, "I would add the fall IPOC to the patient's plan of care."

During an interview on 12/06/23 at 2:20 PM, Staff CC Director of Behavioral health unit (BHU) stated that regarding our fall policy if it is determined to be a fall, we would start with an assessment by a nurse. The staff would complete a post fall debriefing, notify the house supervisor, complete Morse fall risk scale, and update plan of care.


Patient 15

Review of Patient 15's current medical records show an 88-year-old admitted with chief complaint of increased agitation and confusion over the last few weeks. The admitting diagnoses included aggressive behavior and altered mental status with a past medical history (PMH) of anemia (not having enough healthy red blood cells to care oxygen to the body ' s tissue), atrial fibrillation (an irregular and often very rapid heart rhythm), benign essential hypertension (mild to moderate high blood pressure that has no identifiable cause), coronary artery disease (CAD- caused by plaque buildup in the wall of the arteries that supply blood to the heart), hearing loss, hiatal hernia (stomach protrudes up into the chest) with gastroesophageal reflux disease (GERD- stomach acid flows back into the mouth and stomach), hyperlipidemia, pericardial effusion (buildup of extra fluid in the space around the heart), major depressive disorder (MDD - persistent feeling of sadness and loss of interest) and prediabetes.

Review of Patient 15's "Braden Assessment" dated 11/27/23 showed a Braden skin assessment score of 13 indicating a moderate risks for skin integrity. The Braden assessment scale measures sensory perception, activity, mobility, moisture, nutrition, and friction. The Braden scale score ranges: low risk score (19-23), mild to moderate risk score (13-18) high risk score (10-12) and a severe score is (less than 9).

The facility failed to update Patient 15's plan of care with new problem to include at risk for impaired skin integrity.

Review of Patient 15's "Nutrition ADLs" from 11/14/23 to 11/21/23 showed the patient consistently had poor oral intake; less than 50% per meal for greater than 3 days.

Review of Patient 15's interdisciplinary plans of care failed to show initiation of a nursing care plan to include inadequate nutritional intake less than 50% placing the patient at risk for dehydration and malnutrition.

Based on policy review, document review and interview, the hospital failed to ensure that life safety from fire requirements were met for all patients, visitors, and staff at the hospital.

The cumulative effects of this deficient practice resulted in three Immediate Jeopardies (IJ - a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death). (Refer to Life Safety Code Tags K754, K232, and K256)


Findings Include:

On 12/07/23 between the hours of 9:15 AM and 9:45 AM the following observations were made:

Observation of the Psychiatric Observation Unit (POU) suite revealed that based on the size of the suite, two compliant exits from the POU suite are required. One of the two provided exits is obstructed by furniture and lockers. This exit is labelled as the Emergency Exit. When interviewed Staff A5, RN stated this is the exit they would use in the event of an emergency requiring evacuation. Patient census at the time of observation was 6.

Observation of the POU suite revealed that patients are being housed in a suite not designed for sleeping. Patients were observed sleeping in chairs and on the floor. Sleeping rooms and beds are not provided.

Observation of the POU suite revealed that patients may be restrained to a bed in the "Consult 1" room. It was observed that the "Consult 1" room is not equipped with smoke detection as required. Staff interview revealed that this room is used for restraining patients and/or sleeping patients.

Observation of the POU suite revealed that rooms within the suite are being used for purposes other than their intended use. The "Staff Only" room is used as a storage room for patient belongings, miscellaneous equipment, sleeping mats, ect. Storage was observed stacked higher than allowed and within 18 inches of the ceiling and sprinkler heads. The room labeled "Staff Only" is indicated as a "restraint room" on the 2023 Life Safety Code Plans. This room is designed as a psych anti ligature room not a storage room.

Observation of the "Soiled Hold" room inside the POU suite revealed that over 64 gallons of waste were contained in the room without a fire rating of 1 hour. Storage consisted of waste, bio-hazard waste, soiled linens, mop bucket and mop heads.

Observations of the POU suite revealed that the emergency exit door is impeded by tables and chairs and lockers reducing the exit access width to less than required. The size of the suite requires two exits be provided. One of the two required exits is obstructed.

Observation of the egress corridor outside the POU suite revealed excessive storage in the egress corridor outside of the POU emergency exit door. Signage is in place stating, "Do not block".

Observation of the egress corridor outside the Psychiatric Observation Unit (POU) suite revealed excessive obstructive storage throughout the egress corridor. This egress corridor could be used by patients, staff, and visitors within smoke compartments (SC), SC-L.2, SC-L.3, SC-L.6, and SC-L.7. It should be noted that smoke compartment SC-L.7 contains the cafeteria so additional staff and visitors could be affected by this obstructed egress corridor. Storage consists of unused beds, unused equipment, combustibles, trash, laundries, and soiled linens. Beds were observed stacked two deep on one side of the corridor. Full clean and soiled linen carts were observed on one side of the corridor blocking a fire extinguisher cabinet and multiple signs stating, "No Storage by order of the Fire Marshal." Full and soiled linen carts were filled and stacked within 18 inches of the ceiling and fire sprinklers.

On 12/12/23 between the hours of 12:45 PM and 2:00 PM the following observations were made:

Observation of the facility's 2023 Life Safety Code Plans revealed that the corridor outside the POU is a designated egress corridor and is referenced as such on the facility's 2023 Life Safety Code Plans. This egress corridor is accessible to other smoke compartments. This egress corridor takes occupants to the tunnel system beneath/adjacent to the hospital.

Observation of the facility's 2023 Life Safety Code Plans revealed that the POU suite is designed and designated as a "patient- care, non-sleeping suite". However, based on interview of both patients and staff, patients are held within the POU suite for 48+hours or until evaluated and released by a psychiatrist.

Observation of the egress corridor outside the POU suite revealed storage outside the emergency exit door from POU suite. Signs posted on door, "Do not block this door. Emergency Exit."

Observation of the egress corridor outside the POU suite revealed Hazardous/Soiled/Combustible storage in the corridor outside the emergency exit from the POU suite. Over approximately 20 full linen carts lined the egress corridor.

Observation of the egress corridor outside the POU suite revealed unused beds, two deep, restricting egress beyond the 90-minute fire rated doors in the tunnel.

During an interview on 12/13/23 at 9:48 AM, when asked about the storage in the egress corridor, Staff M5, EVS (Environmental Services) stated "My shift is 5:00 AM-1:30 PM, I am the only one who works with the linen. The carts are in hallway because it is where Linen King delivers and picks ups the carts, since there is not enough room in the Linen Room. I am the only person that has access to this room besides security and supervisor after 1:30 PM."

The facility failed to ensure proper storage of unused beds, unused equipment, combustibles, trash, laundries, and soiled linens. Continued observation of the space revealed continuous storage of these items exceeding the allowable quantities. The time frame of the storage does not equate to "in-use". These items are all being stored in the basement west egress corridor.

Based on document review, record review, policy review, review of surveillance video, observation, and interview the Hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines and hospital policies and procedures for infection control and prevention when staff failed to perform proper hand hygiene, use appropriate personal protective equipment, inappropriately handled and/or stored blood products and use appropriate food handling for Hospital 1 and Hospital 2 through multiple observations on numerous patient care areas of unidentified direct care staff throughout both facilities.

This deficient practice has the potential to place all patients, visitors, staff, and the community at risk to contract and spread infectious and/or communicable diseases.


Findings Include:

Review of a hospital policy titled, "Hand Hygiene" revised 06/19/19, showed, "All members of the health care team will comply with current Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. A. Indications for hand washing and hand antisepsis: 1. When entering the patient care area/before patient contact. 2. When exiting the patient care area/after patient contact... 4. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. 5. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 6. If hands will be moving from a contaminated body site to a clean body site during patient care. 7. After glove removal... C. Hands should be washed with soap and water in the following situations: 1. When hands are visibly dirty or contaminated with blood or other body fluids..."

Review of a hospital policy titled, "Standard and Isolation Precautions," revised 10/23/20, showed, "...2. The type of Personal Protective Equipment (PPE) used during patient care is determined by the nature of the healthcare worker (HWC) - patient interaction and the extent of anticipated blood body fluid, or pathogen exposure...a. Gloves: worn when there is the possibility of hand contact with blood or body fluids, mucous membranes, non-intact skin, or when performing vascular access procedures, phlebotomy procedures, and when handling contaminated items or surfaces. b. Gowns: worn if contact with blood or bodily fluids may occur. c. Mask: worn when there is potential contact with respiratory secretions and sprays of blood or bodily fluids...d. Face shield/eye protection (goggles): full coverage eye protection is worn during aerosol generating procedures (AGP) and other patient-care activities that are likely to generate splashes or sprays of blood or other body fluids to prevent exposure of mucous membrane of the mouth, nose, and eyes to patient's body fluids...1. Contact/Contact Plus Precautions: used to reduce the spread of microorganisms (germs) by direct (patient to patient) or indirect (HCWs hands or patient care equipment to patient) contact ...c. PPE: the HCW is required to wear gloves and gown for contact with the patient and/or the environment of care. 2. Droplet Precautions: are implemented for patients with suspected or confirmed respiratory viral illnesses to reduce the risk of diseases that are spread through microorganisms (germs) transmitted by respiratory droplets that travel short distances as a patient coughs, sneezes, or talks. Pediatric droplet precautions are a combination of droplet and contact precautions used for all pediatric respiratory illnesses ...b. PPE: requires the HCW wear a mask prior to fully entering the patient's room...d. N-95 mask/Powered Air Purifying Respirator (PAPR), or Controlled Air Purifying Respirator (CAPR), and eye protection are indicated when performing...open suctioning of airways...3. Airborne Precautions are used for patients known or suspected to be infected with microorganisms (germs) transmitted person-to-person by the airborne route...b. N95/PAPR or CAPR is required of the HCW when caring for patients in Airborne Precautions...10. Communication...a. Place appropriate Isolation Precautions sign on door. Do not remove sign until room has been cleaned by Environmental Services...Documentation: Per authority statement, an order for specific required isolation will be generated to reflect isolation precaution status..."

Review of a hospital policy titled, "Infection Prevention and Control Program" revised 02/03/22, showed, "...The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable disease and provide primary leadership in the following activities: ...g. Mitigate risks associated with patient infections present upon admission...i. Mitigate risks contributing to healthcare-associate infections...All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations ...Department director/manager will...Monitor associate compliance with infection prevention and control policies and procedures, including but not limited to appropriate use of personal protective equipment, engineering controls, work practice controls, and hand hygiene practices..."

Review of a hospital policy titled, "Infection Control Guidelines for Patient Care Areas and Clinical Support Areas - Work Instruction" revised 07/22/19, showed, "...1. All body fluids / substances should be considered potentially infectious materials. Standard Precautions should be instituted for all patients regardless of their diagnosis...3. Personal Protective Equipment (PPE) is to be removed and discarded prior to leaving the patient room (exception: N95 mask or PAPR for Airborne Precautions should be removed after exiting the room) ... 4. Duration of precautions...a. For most conditions, precautions will continue for duration of illness or until dismissal...6. Ensure that necessary PPE is readily accessible...c. Patient Care...1. Complete Infectious Disease Screening in the Electronic Medical Record on all patients admitted to the nursing unit. Assess all patients for presence of an infectious disease or condition requiring transmission based precautions...2. Implement evidence-based practice measures to prevent hospital acquired infections...d. Patient Care Environment ... 1. Maintain a clean and sanitary environment. All staff are responsible for ensuring high standards of cleanliness regarding patient care equipment, medical devices, and the environment of care...g. Linen...1. Clean linen should be stored in a covered cart or within a cabinet...o. Food and Drink ... 6. Staff may only eat in clean designated areas. Covered drinks should be in a designated area of the unit. Food and drink is not allowed in areas where work involving exposure or potential exposure to blood or other potentially infectious material may occur or where the potential for contamination of work surfaces exists, i.e. where specimens are placed, stored or processed...c. Isolation Precautions...2. If the patient's behavior (e.g. wandering) or health status poses a significant risk of disease transmission, room isolation precautions may be necessary)...a. Patient Care...1. During triage, assess patients for presence of infectious disease or condition requiring isolaton precautions...c. Masks should be work when there is a suspicion that a patient may have an airborne transmissible disease (e.g. TB, varicella) or droplet transmissible (e.g. influenza, pertussis, meningitis)..."

Review of a hospital policy titled, "Housekeeping Procedures, Patient / Residential Room Cleaning" issued 02/01/22, showed, "...Isolation Discharge Room Cleaning Procedure...Equipment:...Gloves and other PPE in accordance with posted standard precaution signs...Procedure: 1. Put on appropriate PPE and follow proper hand hygiene protocol..."


Patient 7

Review of Patient 7's medical record showed a 40-year-old female that presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 11/14/23 at 8:12 PM. Patient 7 was admitted inpatient on 11/15/23 at 10:08 AM with diagnoses of pharyngitis (inflammation of back of throat) and altered mental status (AMS) (change in normal mental function).

During an observation on 11/30/23 at 1:47 PM, Staff J3, Patient Care Technician (PCT), entered Patient 7's room with "Contact Precaution Plus" signage. Staff J3 failed to perform hand hygiene on entrance and failed to don required Personal Protective Equipment (PPE) (gown and gloves) and proceeded to assist Patient 7 with her bedding and adjusting a pillow, potentially contaminating her scrubs and her hands. Staff J3 then proceeded to exit the room without washing hands and entered another patient room without performing hand hygiene upon entrance or exit. Staff J3, with potentially contaminated hands, then walked down the hall to the Nourishment Room. She obtained food and a utensil from the Nourishment Room and returned to Patient 7's room. Without donning PPE, performing hand hygiene, or applying PPE, Staff J3 opened the food container and handed it to Patient 7. Staff J3 then exited the room without washing hands with soap and water as required per hospital policy.

During an interview on 11/30/23 at 1:53 PM, Staff J3 stated that Patient 7 was on Contact Precautions for C-diff (Clostridium difficile - a germ that causes diarrhea and inflammation of the colon) and stated that those precautions included hand hygiene, gloves, and gown and acknowledged that she did not follow infection control policy. Upon acknowledging that she had violated infection control policy, Staff J3 continued down the hall and failed to wash her hands.

During an interview on 11/30/23 at 4:00 PM, Staff E, Infection Control, stated that C-diff requires, "Contact Precautions Plus" and includes mandatory glove and gown use and requires hand hygiene upon entering room and washing hands with soap and water upon exiting. Staff E stated that failure to follow required contact precautions could lead to spread of a highly contagious bacterial infection to other patients, staff, or visitors.

Review of a document titled, "Active Isolation Line List", provided by the hospital on 11/30/23 at 3:35 PM, showed that Patient 7 was on Contact Plus Precautions with an isolation start date and time of 11/15/23 at 11:47 AM.

Review of Patient 7's medical record failed to show documented evidence of an isolation order to reflect isolation precaution status as required per hospital policy.


Review of a document titled, "Active Isolation Line List," provided by the hospital on 12/05/23 at 11:42 AM, showed Patient 7 as a Clostridium difficile (C. diff) patient on contact plus precautions (infection control prevention guidelines used in cases of C-diff that includes the following: upon entrance - perform hand hygiene, put on and tie gown, cover cuffs with gloves. To exit - remove gloves, remove gown, wash with soap and water).


Patient 16

Review of Patient 16's medical record showed a 72-year-old male admitted to Hospital 2 (H2 - an off-campus hospital location) Behavioral Health Unit on 11/22/23 with diagnoses of COVID-19 (severe acute respiratory infection), confusion and weakness.

During an observation at on 11/27/23 at 12:20 PM, showed Contact Droplet signage on Patient 16's door. Staff S, PCT, was observed sitting in room with door shut with a surgical mask under her chin, not covering her nose or mouth. Staff S, PCT, failed to follow infection prevention guidelines by failing to wear PPE appropriately for a COVID-19 patient as required per facility policy.


Patient 21

Review of Patient 21's medical record showed a 29-year-old female that presented to the ED on 09/21/23 at 1:01 PM and was admitted inpatient on 09/21/23 at 10:44 PM, with diagnoses of atrial flutter with 2:1 block (heart murmur centered in upper chambers of heart causing irregular heart rhythm), lightheadedness, and sepsis (infection in blood stream).

Review of a document titled, "Active Isolation Line List", showed Patient 21 positive for CRE (Carbapenem-resistant Enterobacterales (CRE) are a serious threat to public health. Infections with CRE are difficult to treat and have been associated with mortality rates of up to 50% for hospitalized patients) on 11/22/23 as a fourth patient identified as contracting hospital acquired CRE.

Review of Patient 21's medical record failed to show documented evidence of an Infectious Disease Screening or screening of the patient for condition requiring transmission-based precautions upon patient admission as required per facility policy.


Patient 48

Review of Patient 48's medical record showed a 46-year-old male that presented to the ED on 01/01/24 at 8:06 PM with a chief complaint of suicidal ideation (thoughts about ending one's own life) and psychosis (severe medical condition where thoughts and emotions are affected, and patients have trouble differentiating between real and what is not real). Further review of the medical record showed that Patient 48 was positive for COVID-19 on 01/01/24 at 11:28 AM.

During an observation at H2 on 01/02/24 at 3:40 PM, showed Patient 48 moving around a closed unit of the ED, Zone 2 (an area in the ED that is locked to prevent patient elopement) without a mask covering the mouth and nose. Observation of the nursing care area failed to show PPE present including gown, face shields, or N95 masks for staff use and failed to show signage present on Patient 48's door identifying isolation precaution as required per facility policy.

During an interview on 01/02/24 at 3:40 PM, Staff Q6, RN, confirmed that Patient 48 was not to be out of his room without wearing a mask.

During an observation on 11/27/23 at 11:00 AM at H1, an unidentified staff member was observed starting an IV (intravenous - a device placed into a vein and used to administer medications) on an unidentified patient with a partially ungloved hand. This same staff was then observed touching the Computer on Wheels with a dirty gloved hand. No hand hygiene was observed after direct patient contact.

During an observation on 11/27/23 at 11:12 AM at H1, an unidentified RN was observed starting an IV on a patient in the ED. Unidentified RN then observed removing IV after unsuccessful placement and, without removing or changing gloves and without performing hand hygiene, proceeded to touch computer on wheels in patient care area with contaminated gloves.

During an observation on 11/27/23 at 11:15 AM at H1 Emergency Department Room 42, a food tray of uneaten food was observed on top of a dirty linen cart. Staff were unsure if the patient had refused the food tray or not.

During an observation on 11/27/23 at 11:49 AM at H1, a housekeeping staff member was observed touching cleaning items on environmental services (EVS) cart and without changing gloves or performing hand hygiene, placed contaminated gloved hands onto top of dietary cart containing patient meal trays being delivered by dietary services staff member.

During an interview on 11/30/23 at 1:41 PM at H2, Staff K3, Touchpoint Patient Services Manager stated that she manages the culinary ambassadors and they put the food trays together and deliver to patients. The expectations are to wash hands prior to taking a cart to the floor. The expectations is for the staff to foam in and foam out, verify the patient, and go over the meal with the patient. The staff are to follow signage on the doors of isolation rooms and put on proper PPE. They are not to go into rooms with "blue/purple" airborne or COVID rooms. We leave trays in rooms. They receive annual blood borne pathogens education and upon hire. They are to only place the food tray on the bedside table and are to never leave their food cart unattended.

During an interview on 11/30/23 at 2:02 PM at H1, Staff L3, Touchpoint Assistant Director Food Nutritional Services stated that it is the expectation that hand hygiene is always performed when preparing, touching, serving or handling of any foods. Gloves are always to be worn during food handling and tray preparation. There is no exception this is the expectation. I usually do rounds to observe twice daily on staff.

During an observation on 11/29/23 at 1:30 PM at H1, Staff N2, RN, and O2, RN, were observed in the Emergency Department (ED) performing wound care with no gloves and failed to perform hand hygiene after patient contact.

During an interview on 11/29/23 at 3:31 PM H1, Staff NN, Wound Care RN, and Staff O2, Wound Care RN, stated that glove use is required with any patient contact and failure to do so would be a direct violation of facility infection control policies and would pose a risk of infection to patients.

During an observation on 11/29/23 at 1:41 PM at H1, two unidentified staff members were observed handling blood specimens without gloves and placed blood specimens on a computer without performing hand hygiene.

During an observation in the Coronary Intensive Care Unit (CICU) on 11/27/23 at 12:01 PM at H1, an unidentified RN was seen providing oral suctioning for a patient on contact precautions. The unidentified RN failed to don appropriate gown as required for contact precautions per facility policy. The unidentified RN then removed gloves and exited room failing to perform hand hygiene.

During an observation in the Medical Intensive Care Unit (MICU) on 11/27/23 at 12:08 PM at H1, Staff W7, DO, was observed in a patient room that was in contact/airborne precautions. Staff W7, exited room and removed N95 mask, holding it in ungloved hands while speaking with other staff in hallway. Staff W7 threw mask in trash after approximately 1 minute and then proceeded to touch non-disposable stethoscope and white coat without performing hand hygiene.

During an observation on 11/27/23 between 12:18 PM and 12:40 PM showed multiple hospital staff in contact precaution rooms, including patients with positive cases of COVID-19, Methicillin-Resistant Staphylococcus Aureus (infection that is resistant to some antibiotics) (MRSA), and Hepatitis C (viral infection that causes liver swelling), without wearing required PPE, failed to wear face masks appropriately, and failed to perform hand hygiene when exiting patient rooms. Staff C, RN, confirmed that patient rooms observed were under contact precautions for COVID-19, MRSA, and Hepatitis C.

During an observation on 11/27/23 at 12:18 PM at H2, Staff E2, Radiology Student, was observed walking out of an ED room wearing contaminated gloves and holding contaminated linens. Staff E2 was then observed putting the contaminated linens in adjacent room, grabbed papers and carried them with the contaminated gloved hands. Staff E2 failed to perform hand hygiene.


Review of Patient 29's medical record showed a 64-year-old male admitted to H2 Behavioral Health Unit on 11/29/23 with an admitting primary diagnosis of Pneumonia.

During initial tour on 11/27/23 at 12:35 PM at H2 with Staff C and Staff D2 on Floor 7 East, also known as 7PI [Psychiatric Intermediate], this surveyor observed patient 29's room to have an unidentified patient sitter and a telesitter [mobile video monitoring device] present in the room. Patient door was identified with a contact precautions placard on door. No personal protective equipment [PPE] was observed. Sitter was in chair next to patient at window. Door to room closed. The unidentified patient sitter did not have appropriate PPE on while sitting next to the patient, as required per facility policy.


During tour on 11/28/23 at 11:05 AM at H2, Patient 16's room now empty and being cleaned. Staff C2, Director of BHU, stated that the patient was discharged this AM The patient had a diagnosis of COVID which is why he was on contact precautions on 11/27/23. Housekeeping was observed throughout cleaning process via in room camera transmitting to the nurses station. Housekeeping staff was observed wearing gloves but no other PPE. When cleaning the bed, for example, the cleaning occurred from the inside out. The center of the mattress to the edge of the mattress, thus causing the clothing being worn by housekeeping staff to come in contact with the uncleaned portion of the mattress and railing. Cleaning then continued to the inside of the railing, with housekeeping staff leaning over and coming in full contact with the outside of the railing. The outside of the railing was the last contact surface to be cleaned on the bed. Cleaning continued throughout the room with some surfaces cleaned more thoroughly than others.

During an observation on 11/28/23 at 11:05 AM at H2, 7 East Psychiatric Intermediate Unit, observation continued in the nourishment room. During observation the refrigerator, microwave, sink, ice maker, and refreshment cart, were dirty. A stained incontinence cloth was being used as tablecloth. The nourishment cart lacked organization, the second shelf of the cart had multiple zip lock bags and cup lids that were uncovered. The third shelf had a bath basin filled with zip lock bags of sweeteners, cleansing wipes, and paper and plastic bags.

Review of refrigerator log for 11/2023 showed there were 6 times (11/01/23, 11/10/23, 11/21/23, 11/22/23, 11/29/23, and 11/30/23) that a temperature was not recorded. Further review of the temperature log showed 4 days where the refrigerator temperature log was out of range. There were three days 11/03/23, 11/17/23, and 11/18/23 where the temperature range was below 34 degrees. There was one day 11/08/23 where the temperature was above the recommended temperature of 41. The thermostat regulator but was malfunctioning on 7 days where the nursing staff was unable to clear the minimum or maximum temperature range. There was no documented evidence of actions taken to correct improper temperatures or the thermostat malfunction.

During an observation on 11/28/23 at 11:06 AM at H2, 7 East Psychiatric Intermediate Unit (PIU) showed Staff R, RN, exiting Patient 30's room and she did not remove her gloves, Staff R walked down the hall and went to another area of the unit, exchanged something and came back to the room with the same gloves on. Staff R failed to remove gloves and perform adequate hand hygiene.

During an interview on 11/28/23 at 4:59 PM, Staff R, RN stated that she has been with this hospital since September 2023, and she has been a nurse for over 4 years. Staff R stated that with Contact precautions the staff would only need to wear gloves, the staff would only wear a gown if there was drainage or a chance for staff to encounter bodily fluids. Staff R stated that with Droplet precautions the staff would wear gloves, gown, and masks. When asked specifically about Patient 30, Staff R stated that Patient 30 is in just contact precaution, and that she did his dressing change for his surgical incision, and it was not draining. Staff R stated, "So, I didn't think I needed to wear an isolation gown. If his wound was draining or I anticipated encountering other bodily fluid, then I would have worn an isolation gown and the other necessary PPE's." Staff R stated that staff normally take off the plastic isolation gowns in the brown paper trash bag room and will wash their wash their hands in the sink in the patient rooms. Staff R stated that the trash is usually emptied after meals, with gown changes, or changing the patients briefs and we take it with us to the soiled utility room and discard.

During an observation on 11/28/23 at 11:59 AM at H2, in room 613 had a strong odor of urine, the bed was disheveled, and the linen thrown on the floor and in the plastic chair. The failure to maintain a clean environment has the potential to place the patient at risk for infection.

During an observation on 11/28/23 at 12:25 PM at H1, Staff P, RN, was assisting with a sterile procedure in a contact precaution room that requires use of gown and gloves. Staff P was not wearing proper PPE (gown) as required per hospital policy.

During an observation on 11/29/23 at 1:35 PM at H1, an unidentified housekeeping staff member was observed emptying trash and changing trash bag without donning gloves. The unidentified housekeeping staff member was then observed touching her personal cell phone without performing hand hygiene as required by hospital policy.

During an observation on 11/29/23 at 1:38 PM at H1, an unidentified ED, RN was seen coughing into open hand and then touched computer on wheels without performing hand hygiene as required by hospital policy.

During an observation on 11/29/23 at 1:45 PM at H1, an unidentified physician was seen touching an unidentified patient for assessment without gloves as required by hospital policy.

During an observation on 11/29/23 at 1:41 PM at H1, one unidentified RN and one unidentified paramedic observed in the ED handling blood specimens without gloves. The unidentified paramedic was seen placing the blood specimens on computer on wheels without performing hand hygiene or donning gloves as required by hospital policy.

During an observation in H1's ED on 11/29/23 at 1:46 PM, an unidentified RN was observed walking out of an unidentified patient room with a mask under her chin and without gloves. The unidentified patient was in contact/droplet precautions. The unidentified RN failed to wear the mask appropriately and failed to perform hand hygiene before entering or exiting the patient room as required by hospital policy.

During an observation on 11/29/23 at 1:46 PM at H1, Staff J2, Physician, Staff K2, Physician Assistant (PA) student and another unidentified provider were seen exiting patient room 6041 without performing hand hygiene as required by hospital policy.

During an interview at the time of the observation, Staff K2 stated that all staff must "foam in and foam out" (hand hygiene) when entering and exiting a patient room. Staff K2 stated that failing to perform hand hygiene places patients and others at risk for the spread of infection and other blood borne pathogens. Staff K2 acknowledged he failed to perform hand hygiene when exiting a patient's room but did not explain why he failed to follow hospital policy.

During an observation on 11/29/23 at 1:52 PM, at H2, Staff M2, RN, performed direct patient care and then failed to perform hand hygiene when exiting the patient room as required by hospital policy.

During an interview at the time of the observation, Staff M2 stated that she did not perform hand hygiene when exiting the patient room as required by hospital policy because she did not touch the patient. She went on to state she only had the patient sign a document with her personal pen and then placed the pen back in her pocket.

During an observation on 11/29/23 at 2:52 PM at H2, Staff D3, RN was observed walking out of a patient room wearing a surgical face mask and gloves. The patient's door showed an Airborne and Contact Precaution sign and an N-95 box tape to door. Staff D3 failed to don proper PPE for an Airborne Contact Precaution patient as required by hospital policy.

During an interview at the time of the observation, Staff D3, RN, stated that the unidentified patient had a diagnosis of COVID-19. Staff D3 went on to state that Airborne and contact precautions require the staff to wear googles, gown, gloves and N-95 mask. Staff D3 stated, "I have been working here for about a month, I'm a traveler. Hand hygiene is in and out of rooms washing hands for 45 seconds, after contact with patient or body fluids and always between patients. So you don't spread germs."

During an observation on 12/05/23 at 10:49 AM at H1, an RN entered an unidentified patient's room who was on contact/droplet precautions. During an interview at the time of the observation, the unidentified RN stated that the patient was positive for COVID-19 and was on a ventilator (machine to help individuals breathe). The unidentified RN failed to don appropriate PPE and failed to perform hand hygiene prior to entering or upon exiting the patient room as required by hospital policy.

During an observation on 12/05/23 at 10:49 AM at H1, Pediatric Intensive Care Unit (PICU) an unidentified RN was seen providing direct patient care to a patient in contact/droplet isolation precautions with no gown or gloves. An unidentified RN identified the patient had a diagnosis of Respiratory Syncytial Virus (RSV - contagious infection of the respiratory tract). There were no accessible PPE available at the entrance of the patient's door for staff members as required by hospital policy.

During an observation on 12/05/23 at 11:03 AM at H1, ED showed an unidentified RN starting an IV on an unidentified patient. During the procedure, the RN ' s gloves were contaminated with the patient's blood. The RN failed to remove and discard the contaminated gloves or perform hand hygiene as required per hospital policy. The RN then attempted to clean the bloody gloves with a cotton ball and retrieved laboratory specimen tubes from a clean supply cart sitting adjacent to the nurse. The RN passed the laboratory tubes to another RN who took the tubes without wearing gloves. Both RNs failed to put on and remove gloves and failed to perform appropriate hand hygiene as required by hospital policy.

During an observation 12/05/23 at 11:07 AM at H1's, ED an unidentified male RN was observed holding blood specimens with contaminated gloves. The unidentified RN placed blood specimens on computer at nursing station where open drinks were present before placing specimens in bag for transport to laboratory.

During an observation on 01/02/24 at 10:28 AM at H1, Staff, U7, Certified Registered Nurse Anesthetist (CRNA) was observed giving IV medications and then touching computer without donning gloves or performing hand hygiene as required by hospital policy.

During an interview on 11/27/23 at 4:07 PM at H2, Staff E, Director of Infection Control, stated that the hospital had observed and identified areas for improvement in infection control, specifically cleaning of equipment, hand washing and hand hygiene, and room cleaning. Staff E was unable to identify when deficiencies in infection control became an issue and stated, "it has been ongoing."

During an interview on 11/28/23 at 11:06 AM at H2, Staff C2, Director of Behavioral Health, stated that personal protective equipment (PPE) is stored in the Ante Room, and staff should put on and take off PPE in the Ante room. The staff try to keep patients in isolation near the Ante Room but if the staff are not able to do that then they will put on the PPE in the Ante Room then walk down the hall to the room.

During an interview on 11/29/23 at 1:50 PM, Staff Z2, Phlebotomist, stated, "...You use hand hygiene going in and out of rooms and if you don't it spreads germs to everyone." During an observation leaving room 501, Staff Z2 exited room pushing cart with no hand hygiene noted as required by hospital policy.

During an interview on 11/29/23 at 3:00 PM at H2, Staff T2, Chief Nursing Officer (CNO), stated that it is the expectation for all employees to follow infection control practices and that every staff member should, "foam in and foam out" when entering or exiting a patient room. He stated that failure to perform hand hygiene increases the risk of patient infection.





During an interview on 11/29/23 at 3:21 PM, with Staff E, Infection Control, and Staff R2, Environmental Services (EVS) Director, Staff E stated that after every isolation, there is a terminal clean completed. Staff E stated that the expectation for staff is to keep the room clean with no trash on the floor, even while patient is in isolation. Staff R2 stated that the process is the same for most isolation terminal cleans but they change the chemicals depending on what the patient is on isolation for. Staff R2 stated that EVS dons appropriate PPE prior to entering room and stated that the expectation is for EVS is to bag equipment if it needs to be transported to another location for cleaning, or to clean it while in room. Staff R2 states they get the page for the terminal clean which states what type of clean needs to be completed. Staff R2 stated that if there is confusion on what terminal cleaning policy to follow, EVS is required to go ask staff on unit to ensure proper cleaning is completed. Staff R2 also stated that EVS is required to put on gloves when emptying any trash at the facilities.







During an interview on 12/04/23 at 2:37 PM, with Staff T2, CNO, Staff Q, Chief Administrator Officer, and Staff E, Infection Control, Staff Q stated th

Based on observation, interview, policy and document review the hospital failed to provide an adequate clean and sanitary environment for all patients currently at this hospital receiving dietary services. This deficient practice effects all patients receiving dietary services at this hospital and has the potential to place them at risk for food borne infection, or other adverse outcomes.

Findings Include:

Review of hospital policy titled "Infection Prevention and Control Program" revised 02/03/22 showed "Policy; 4. The infection control officer(s) is responsible to identify, investigate, report, prevent and control infections and communicable diseases and provide leadership in the following activities: e. Maintain a sanitary hospital environment. f. Develop and implement infection control measures related to healthcare workers. Healthcare workers, for infection control purposes, includes all hospital associates, medical staff, contract workers, (e.g. agency nurses, environmental staff, facilities staff etc.), and volunteers...k. Monitor compliance with all policies, procedures, protocols and other infection control program requirements...2. All areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations...14. Environmental Services/ Touchpoint; a. Maintain a clean and sanitary environment free of risk of infection...

Review of hospital document titled "Food Storage Chart" undated showed "Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1. Dry Storage...30 days. Oil, 60 days, Syrup, Peanut butter, 6 Months, or the manufacturer's expiration date, if sooner...Honey ...Rice, pasta, flour, dehydrated potatoes, sugar; Within 1 Year of delivery, or the manufacturer's expiration date, if sooner, All unopened canned, carton boxed, or bottled goods, Spices; Refrigerated Storage; ...4 days Unused portions of foods prepared on site that are reheated for service, such as rice, vegetables, soups, gravies and meat sauces...7 days Cheese - all cheeses except hard cheese (14 days),...30 days; Salad dressings, mayonnaise, tartar sauce, Cake icing (shortening based) ...60 days; Ketchup, BBQ, Tabasco, steak sauce, mustard, horseradish, relish, pickles, natural peanut butter, Sauces - chocolate, caramel, strawberry..."

Review of hospital policy titled "Production, Purchasing, Storage" revised 12/2017 showed "Subject: Food Handing Guidelines (HACCP); Preparation of Produce; Wash hands and wear disposable gloves when handling raw produce or ready to eat foods ...Inspect all produce for damage. Discard severely damaged produce or remove damaged areas plus one inch beyond damaged area. If damaged area can not be removed without contaminating the remainder of product, discard product. Prepare produce using clean, sanitized utensils, sanitized cutting board, work areas and sinks...

During an observation on 11/28/23 at 11:32 AM, of the kitchen area located in the basement, showed food debris and trash on the sticky floor. Opened personal drinks were located in the cooking area. Cooking pots and pans on a large rolling stainless-steel cart had visible food debris on cart and in on cooking pans. Cutting boards were stacked on stainless steel shelf with visible food debris. A stainless-steel cart had food debris and a spray bottle labeled sanitizer with a box of food service plastic cups. A stainless steel coffee maker and stainless-steel tea dispenser had visible food debris, liquid smeared on the dispenser handles with visible debris. On a shelf below the coffee and tea dispenser was a plastic container with a brown liquid substance at bottom of container labeled regular. The stainless steel shelf was visibly soiled with food debris and there was one large white safety and sanitation dispenser for plastic film and foil that had visible food debris and opened plastic replacement filters. The next shelf below had visible food debris on containers next to a spray bottle and red bucket labeled Kleen-Pail sanitizer. The bucket had brown liquid half way up the bucket.

On a rolling stainless steel cart was a large plastic container with several brown spotted bananas with no label and large plastic container of red grapes with no label. A clear plastic container with red lid that was visibly dirty had what appeared to be a white chocolate chips with no label. There was a clear plastic container with an open red lid with chocolate chips, and an open baking soda box with a best if used by July 22, 2023 date. There was a stainless-steel container with visible food debris containing multiple knifes with visible food debris on them. There was also an opened used container of peanut sauce with approximate ¼ used on the lower shelf of stainless-steel counter showing refrigerate after opening, there was no date of when the peanut sauce was opened. The microwave had visible food debris on door and button controls and visible food debris under and around microwave.

During an observation on 11/28/23 at 11:39 AM of Kitchen refrigerator located in basement, showed, a used bottle of salsa 1/3 full, with plastic saran wrap attached to upper part of bottle that had a hospital sticker label that showed a good thru date of 11/23/23. There was sliced yellow cheese in plastic bag with use by date of 11/21/23 and what appeared to be white and purple frosting in plastic bags that was undated.

During an observation on 11/28/23 at 11:41 AM in the Kitchen walk in cooler located in the basement showed:

1. A "Garlic in Oil" container with a hospital sticker label good thru date of 10/28/23 and manufacture best by showed 09/23/23.
2. An opened rice vinegar with hospital sticker label good thru date of 09/29/23.
3. A container of ham base with hospital sticker label good thru date of 10/22/23,
4. A container of chipotle base with hospital sticker label good thru date of 10/22/23.
5. A container of horseradish sauce with hospital sticker label good thru date of 10/08/23.
6. A container of sweet and sour sauce with hospital sticker label good thru date of 11/20/23
7. A container of Worcestershire sauce with hospital sticker label of good thru date of 09/02/23
8. A container of Dijon mustard with hospital sticker label of good thru date of 09/08/23.
9. A container of vinegar with hospital sticker label of good thru date of 09/02/23.
10. A container of Mayonnaise with hospital sticker label of good thru date of 11/19/23
11. A stainless steel container with partially covered black beans with hospital sticker good thru date of 11/23/23.
12. A stainless steel container of gravy with a crusty top partially opened with hospital sticker label good thru date of 12/01/23.
13. A clear container of sausage patties partially covered with hospital sticker label good thru date of 11/30/23
14. A plastic bag of cooked rice with a hospital sticker label with good thru date of 11/27/23.
15. A covered plastic container of cooked pasta with hospital sticker label good thru date of 11/24/23.
16. A partially covered stainless steel container of cooked pasta with hospital sticker label of good thru date of 11/24/23.
17. A stainless steel container of chicken gravy with hospital sticker label of good thru date of 11/27/23.
18. A box of celery with stalks that have brown film down the entire stalk, wilted brownish yellow leaves with date of 11/08/23 on box.
19. A box of 1/8 shred lettuce 4/5 lbs. bags with best used by date of 11/25/23 showing brownish wilted lettuce in bags.
20. A bag labeled "Fresh Thyme" dated 09/29/23 showed wilted brownish sprags of thyme.
21. A bag labeled "Fresh Mint" dated 11/10/23 showed wilted shriveled up brownish green leaves.
22. A bag labeled "Fresh Oregano" dated 11/15/23 showed condensation in bag with shriveled up brownish leaves.
23 A bag labeled "Fresh Sage" dated 10/30/23 showed shriveled up brownish leaves.

During an observation at Hospital 2 (H2 - an off-campus hospital location) on 11/29/23 at 8:15 AM, Staff HH, Cook was handling food without gloves. Staff HH, cook, stated "I'm making Chinese food today for lunch."

During an observation at H2 on 11/29/23 at 8:15 AM Staff II, Cook was only wearing one glove while handling food.

During an interview on 11/28/23 at 11:32 AM Staff U, Food Service Director, stated "We will do better and get it cleaned up. I will throw away all the expired food."

During an interview on 11/28/23 at 11:40 AM with Staff V, Head Chef, stated "we just got behind throwing food away with expiration dates since it was over the weekend."

During an interview on 11/29/23 at 9:20 AM, Staff V Executive Chef, was asked about his understanding of the hand hygiene policy, stated, "staff should change their gloves and wash their hands whenever they change task or walk away from your station." Staff V Executive Chef stated, "the staff are expected to wash their at least three times or every half hour." Staff V stated that if an employee is observed no following hand hygiene guideline the employee will first get a verbal warning, if the behavior continues then it would be a written write up. When asked about what the risks are regarding staff following proper hand hygiene Staff V stated, "the patients are risk for developing a food borne illness."

During an interview on 12/14/23 at 9:56 AM Staff DD, RN CNO (Chief Nursing Officer) stated, "I have not been downstairs to the kitchen, but I expect it to be clean and sanitary with expired food to be removed."

Based on document review, record review, staff and patient interview, the hospital failed to ensure staff followed policy and procedure to achieve and maintain patient care that meets the standards of medical practice and patient care for 3 of 8 patients surgical records reviewed (Patients 54, 39, and 42). This deficient practice has the potential to place patients at risk for physical harm during surgical procedures.


Findings Include:

Patient 54

Review of Patient 54's medical record revealed the patient was seen on 01/19/23 for outpatient surgery at Hospital 2 [H2 - an off-campus hospital location] for a planned Esophagogastroduodenoscopy [EGD] [a test to examine the lining of the esophagus, stomach, and the first part of the small intestine, the duodenum] and a Colonoscopy [a test to examine the entire colon, large intestine, and rectum].

Review of the pre anesthesia note dated 01/19/23 at 1:07 PM by Staff K6, Anesthesiologist, included history of "seizure + CVA [Cardiovascular accident] 2001 left side loss of sensation uses cane." Problem list included "morbid obesity" [129.4 kg or 285lbs] and "chronic neck pain, coronary artery disease, enlarged heart."

Review of progress note dated 01/19/23 at 5:25 PM by Staff M7, Surgeon, revealed "During the EGD [shortly after duodenal biopsy was performed], while in the left lateral recumbent position, patient rolled backwards on the stretcher and slid slowly onto the floor. The bed rail was down in order for accommodate the position of the endo cart. His head and neck were supported by CRNA [Certified Registered Nurse Anesthetist] and did not hit the floor. The scope was withdrawn from the patient and the exam was aborted. The patient was lifted back onto the bed with assistance of additional staff members. He remained hemodynamically stable [blood pressure and heart rate] throughout. The gastroscope was reinserted for a quick examination to ensure no trauma or bleeding had occurred. Upon awakening, patient was assessed by anesthesia and myself. . ."

Review of anesthesia record dated 01/19/23 "free notes" by Staff V7, CRNA, revealed at "16:28 [4:28] PM Filling additional propofol [a short acting intravenous anesthetic] syringe. Standing at pyxis [a drug supply management machine]. Surgeon and scrub started to yell for help. When turning to assist, patient was rolling backwards on bed from force of surgeon advancing scope. Bed rail on back of patient was not in place. Scrub indicated that this is for the scope to be able to reach patient for procedure. Immediately protected patient's head and held it securely as he started to roll off the bed. Assisted patient in guided fall to floor. Notified [Staff K6] of current situation at 1629 [4:29 PM]. Discontinued propofol gtt [drip] after patient stabilized on floor." "Transport at 16:57 [4:57] CRNA VSS (vital signs stable) upon PACU [post anesthesia care unit] arrival. Patient neurologically intact. Able to move hands and feet. Denies numbness/tingling in extremities. Patient stated he did have a headache that was increasing. [Staff K6] notified of patient status. Will continue to follow up as indicated."

Review of note from Staff M7, Surgeon, on duodenum biopsy report dated 01/22/23 revealed "I believe that the polyp in the stomach is contributing to the iron deficiency anemia. I have requested my procedure scheduler reach out to you to schedule another EGD so that I can remove the polyp."

Review of document titled "Staff Meeting - February 2023" revealed "Patient Safety Changes: Remember on Endoscopy cases either the scrub or RN is to remain on the backside of the patient at all times if the bedrail is down. NO EXCEPTIONS."

During a telephone interview on 01/05/24 at 9:18 AM, Staff M7, Surgeon, stated "We had just started and he had woken up and started moving around. He was under sedated. I don't know what happened, why he was waking up, but he woke up, rolled over and slid off the bed in the middle of my exam. It was like a slow roll and not fast with a thump. So, the way the bed is set up, the tower is positioned behind the bed then the patient on the bed and endoscopist behind patient on the other side. So, me, on one side, the tower is on the other side. I guess you could say the tower caught his fall. So, rather he slid off bed and wedged between the bed and the tower. But he eventually ended up on the floor...oh the other thing, the CRNA used both hands to catch his head, so his head never hit the floor. Obviously, we ended the procedure and got him off the floor. It took quite a few of us. We got him back up. Obviously, the procedure didn't proceed...Since that procedure [colonoscopy] not done, it was rescheduled."

During an interview on 01/05/24 at 11:15 AM Staff V7, CRNA, stated..."Usually there's someone on that side of the cart. I had turned to go to the pyxis to get more propofol. The surgeon had shoved the scope and there was no one behind the patient and the patient started to roll and I ran over and assisted patient to floor...he was under a total IV [intravenous] anesthetic...he was completely sedated. Not conscious of his surroundings...Typically, in these cases, there's a roll behind patient. There was no roll. The scrub went to surgeon's side without placing bedrail up...he rolled into the endoscopy cart. That's probably what gave me time to get over there and help him down and support his head and neck."

During an interview on 01/04/24 at 11:34 AM Staff J7, Certified Surgical Technician [CST] stated..."doing the EGD portion of it and surgeon, [Staff M7] was wanting to take biopsies. I've done specialty GI [gastroenterology] for the past 3 years...I had positioned the patient so we could go from the EGD to the colonoscopy and [surgeon] was complaining that biopsy forceps weren't going down scope the way [surgeon] wanted and [surgeon] wanted me on the other side of the patient bed. I refused and [surgeon] was getting irritated. So finally, I went over and the patient's arm which I will usually position in front of them so it will counterbalance weight and it had been moved on their side and was falling off. The patient was a large patient...but I saw him starting to go and I actually went over the bed with the patient and had a hold of his neck and his body. He fell into the cart. It was up next to the bed. It blocked him and it was moving backwards, and I was lowering him to the ground as best I could. The CRNA was assisting as well. The surgeon wanted to continue, and anesthesia said no. That's what stuck out to me was [surgeon] wanted to continue. No bleeding. He said he was sore. As far as I know, he wasn't hurt. We woke him up completely in the room. The anesthesiologist [Staff K6] came in room and did neuro check. I believe patient even went up for imaging..."

During an interview on 01/05/24 at 10:58 AM, Patient 54 stated that when he woke up they told him he fell. After he complained of his head hurting, a CT [computed tomography - imaging used to detect injury] scan was done. He confirmed he was not awake during the EGD. He was told he rolled off the table, but no one knew why. The pain in his head and back along with the bruising on his hip and back lasted for weeks but he did not know what to do about it. He stated he did not receive any pain management after the fall. No one called to follow up with him regarding the incident.

The facility did not provide evidence of investigation regarding this incident. The incident log documented a recap of events with a designation of "E - Mild Harm."

During an interview on 01/04/24 at 1:40 PM with Staff S6, RN Director of Surgical Services stated that the following measures have been implemented. "If a person has to leave and the rail needs to be down, then someone else has to assist or they call another scrub in...Unfortunately, that doctor was new to us. She doesn't come to this facility anymore. We just had a short period of time when a different GI [gastrointestinal] group was coming here. Now they're not." When asked if there were policy changes Staff S6 responded "I would call it more of a workflow change."

The hospital failed to provide any policy and procedure that addressed safety precautions related to gurney size, safety straps or adequate staffing in surgical suite to monitor patient safety. Patient 54 fell from the gurney in the middle of a procedure while sedated causing pain and bruising to patient's head, hip and back. Patient 54 had to reschedule both the EGD and Colonoscopy, the EGD was repeated for polyp removal not completed and the colonoscopy which was not done at all. This resulted in additional anesthesia exposure and increased risk to a patient with history of multiple cardiac diagnoses as well as risk for aspiration or pneumonia.


Patient 39

Review of Patient 39's medical record revealed the patient was seen on 11/20/23 for outpatient surgery at H2 for a planned Laparoscopic Cholecystectomy [a procedure to remove the gallbladder].

Review of Preop Allergy List dated 11/17/27 at 10:07 AM completed by Staff RN, included "Anectine - [succinylcholine chloride is a skeletal muscle relaxant for IV administration indicated as an adjunct to general anesthesia] Reaction - Severe."

Review of Pre-Anesthesia record dated 11/20/23 at 6:30 AM by Staff K6, Anesthesiologist, anesthesia history included "patient's history: pseudocholinesterase deficiency, [a rare disorder that makes you sensitive to certain muscle relaxants - succinylcholine - used during general anesthesia] delayed emergence separate from pseudo choline...Severe reaction to: Anectine""

Review of Anesthesia Record page 3 dated 11/20/23 revealed a time listing that includes the following "7:12 . . . chart review; 7:19 intubated; 7:34 surgery start; 8:15 surgery stop." "Free Notes" by Staff J6, CRNA revealed "8:41 - Delayed waking up. Case discussed with [Staff K6, anesthesiologist]. Decision to continue sedation for prolonged wake up made. Awaiting further instruction for post op care. 8:53 - Sedation with propofol gtt determined, will remain on ventilator in PACU. 9:07 - Patient remains paralyzed, decision to go to PACU on propofol gtt awaiting reversal of NMB [neuromuscular blockade aka anesthesia]. Report given to RN. Patient remains of[sic] 30 mcg/kg/min of propofol. MDA [medical doctor of anesthesia] aware."

Review of Anesthesia Record dated 11/20/23 revealed the following drugs utilized between the surgical stop time of 8:15 AM and transfer to PACU at 9:07 AM.

8:19 AM Sugammedex 200 mg IV [to reverse sedation]

8:30 AM Naloxone .4 mg IV [to reverse sedation]

8:32 AM Naloxone .4 mg IV

8:51 AM Phenylephrine .1 mg IV [treat hypotension, low blood pressure, during anesthesia]

Review of Medication Record dated 11/20/23 revealed the following Propofol [anesthetic] detail following transfer to PACU.

9:03 AM Propofol 30 mcg/min

9:55 AM Propofol 35 mcg/min

12:00 PM Propofol Discontinued

Review of Assessment Notes dated 11/20/23 revealed the following:

10:45 AM moves 4 extremities voluntarily or on command [continued status from this point on]

12:00 PM can maintain greater than 92% O2 Sat [Oxygen saturation] on room air

12:00 PM Extubated

1:10 PM 2 person assist with ambulation

1:10 PM left extremities; active movement with decreased strength

2:10 PM 1 person assist with ambulation

2:45 PM left extremities; active movement with decreased strength

Review of Document titled Surgical Services Safety Huddle Notes dated January 2024, the following Action Item was included, "Anesthesia Timeout will go into effect 1/5/2024"

Review of Document titled "Ascension Via Christi Surgical Services, Anesthesia Time Out - SBAR" [situation, background, assessment, recommendation] revealed the instruction to "Implement the Anesthesia Time Out for AVC [Ascension Via Christi] Wichita hospitals...in any procedural areas requiring anesthesia services." The SBAR instructs that the anesthesia time out should be led by the anesthesia attending or designee, documented by the RN circulator and be completed while patient is awake with review of name, date of birth, procedure, allergies, type of anesthesia plan and any other relevant anesthesia concerns.

During an interview on 01/05/24 at 10:29 AM with Staff J6, [CRNA], stated..."When ready for induction, hook up to monitors, call to anesthesia and we'll be told to proceed, generally. Then we'll proceed. Generally, they'll [anesthesiologist] be in the room but it doesn't occur all the time. Anesthesiologists will put a note in chart essentially past medical history, allergies, and I'll review that chart prior to induction." Staff J6, CRNA verbalized knowledge of contraindications of succinylcholine being pseudocholinesterase deficiency, [a rare disorder that makes you sensitive to certain muscle relaxants - succinylcholine - used during general anesthesia]...Staff J6 stated "Upon wake-up patient didn't have amount of twitches I would normally experience. Weakness. I called [Staff K6, Anesthesiologist] We devised plan that we would continue to sedate on propofol and remain intubated and when she...would be extubated." Staff J6, CRNA, acknowledged allergies were listed on patient's chart, including Anectine [another name for Succinylcholine]. Staff J6 verbalized that some items in the precheck list are prepopulated and appear in a different format on the monitor utilized during surgery, smaller and boxed in, but would include anesthesia history. Staff J6 stated "there's a possibility that when I was reading this chart, I was asked a question. Perhaps I went back to the more bold part here. [referring to another section of chart]" Staff J6 stated that the anesthesiologist was not present during induction or throughout the procedure until he [Staff J6] contacted Staff K6, Anesthesiologist. Inquiry as to whether Staff K6 was contacted prior to induction, Staff J6 stated "I attempted but called the wrong anesthesiologist. The surgeon was coming into the room and so I went ahead. Mornings are very rushed. Sometimes I am gathering induction meds prior to the anesthesia record getting completed. I believe that is where part of the fail safe could have occurred. I prepared the succinylcholine prior to knowing [patient's allergy]. So, in addition to the anesthesia time out, I have made it my practice to not pull up any induction meds prior to reading the chart fully. I think it was muscle memory that made me push that. I have also started seeing my own patients. I felt after this incident it was important to start putting things into my own hands."

During an interview on 01/03/24 at 1:15 PM with Staff K6, Anesthesiologist, stated..."My job is to make sure patients are adequately worked up and ready to have anesthesia in surgery. Then to deal with any complications that might arise. There's only one [anesthesiologist] at a time here at [H2]. I have CRNAs that are in the surgery. They maintain airway, anesthesia, supply any supplemental medications, [pain or neuromuscular] or reversal agents. I am not required to be in the room, but I am. For the colonoscopies, EGD's, I don't necessarily go in for those, and those are short. It can be challenging to get to all of them. For general, I always go to the room. Someone gives me a call and says ""we're about to go to sleep in whatever the room is and I go back."" I try to check on the cases as they're going and check in. Making sure they're on time, no issues and anything needed help managing or issues with. . . Succinylcholine...No. That's a big no no. It's a contraindication...I honestly don't know why she was given that drug. No. I wasn't notified that they were in the room or the case was started. That's our protocol to get a call prior to induction...In endoscopy, I don't have them call. But with general, they'll call. It's a rare occasion [when they don't]. I allow them [CRNA's] leeway and breadth. Normally I don't pick induction drugs for them to use. But most of the time, I allow them to operate within the fullest extent of their training." Staff K6, CRNA found out Succinylcholine had been given "when the CRNA [Staff J6] called me and she wasn't waking up. After the case was over. I asked if he [Staff J6] gave succinylcholine. I reminded him [Staff J6] of it, the Pseudocholinesterase Deficiency." Staff K6 stated "They started doing an anesthesia time out to review allergies. So, it is an extra step prior to induction."

During an interview on 01/04/24 at 4:13 PM with Staff K6, Anesthesiologist, stated..."I'll be honest [Staff J6] didn't give me a satisfactory answer. When he [Staff J6] called me, I asked him [Staff J6] about the allergy list he [Staff J6] said "I guess I missed it.""

During an interview on 01/03/24 at 3:45 PM with Staff N6, RN, stated that she participated in Patient 39's care in PACU. Allergies are listed in patient's charts. They wear an allergy bracelet, put on in pre-op. "Doctor [Staff K6] said keep her intubated until she was not paralyzed anymore and was ready to be extubated...maybe about 2 hours, maybe a little longer."

During an interview on 01/03/24 at 3:54 PM with Staff L6, RN, stated that she participated in Patient 39's care in PACU Phase II where the patient has to be oriented to person, place, time and event and able to hold a conversation. Staff L6 remembered that patient "did complain that one of her sides still felt numb." Asked about leadership or manager addressing the incident... "collectively we all talked about it. But not leadership."

During an interview on 01/04/24 at 10:30 AM with Staff H6, RN, stated that anesthesiologists are "sometimes" in the operating room during induction but "they don't have to be. Most of them [CRNA's] will call when they're doing induction or I'll ask them to call. During an interview on 01/04/24 at 10:04 AM with Staff I6, CST [Certified Scrub Technician], stated..."it wasn't recognized until the case was over. We go over patient, allergies, what we're doing, fire risk, any concerns... in surgical time out. Usually, the anesthesiologist shows up after the patient is asleep. I don't know the policy, but this new group, it seems the anesthesiologist is in the room after the induction. The other group was in the room before induction."

During an interview on 01/04/24 at 3:51 PM with Staff G6, Surgeon, stated "I was not aware until recovery. Dr. [Staff K6] told me ""she inadvertently got succinylcholine. She's on a ventilator in recovery and I'm going out to talk to family now."" She came for follow up in 2 weeks. We discussed it. It upset me. We discussed it quite a while. She was upset, understandably. I apologized. I don't know how I could have prevented it but...it's really not an allergy it's a deficiency. She could still have a bad outcome, but not an allergic reaction...but until 6 months to a year, it seems they've [anesthesiology group] gone more to a medical supervision model...I know that they allow CRNA's to do induction without anesthesiologists in room. Now they get them intubated and then anesthesiologist comes in. If he had been at bedside, it wouldn't have happened. Time out typically occurs before incision. Everything else is already done. I'm all about perfect outcome. When I look retrospectively, had he been in there, this wouldn't have happened. They see them before, and then roll them back. Exactly. I don't know [if anesthesiologist's notes are being read] With 2 people, it can get lost. Having both of them in the room is better always. Then there's accountability."

The facility did not provide evidence of investigation regarding this incident. The incident log documented a "brief overview" of events with a designation of "D - No Harm."

During an interview on 01/04/24 at 1:40 PM with Staff S6, RN Director of Surgical Services stated, "we're working on an anesthesia stop, review patient name, date of birth, allergies..." Staff S6 stated "...believe they call the anesthesiologists before induction. If the physician wants to be in there." Staff S6 stated that there are around 8 anesthesiologists that rotate, setting their own schedules. Approximately ten to twelve CRNA's rotate.

Patient was identified to have pseudocholinesterase deficiency and allergy to Anectine. The facility failed to provide any policy and procedure that addressed safety precautions related to allergy review by the anesthesia provider prior to intubation resulting in Patient 39 remaining intubated for an additional 3.75 hours after surgery was complete increasing risk for complications, aspiration or pneumonia and induced temporary paralysis to patient.


Patient 42

Review of Patient 42's medical record revealed the patient was seen on 12/28/23 for outpatient surgery at H2 for a planned Cystoscopy with Transurethral Resection of Bladder Tumor [utilizes a long thin tool with a camera on it to find the bladder tumor and cut it out].

Review of Assessment form dated 12/26/23 revealed patient with weight of 121 kg [266 lb]; history of tobacco use; daily alcohol use.

Review of Anesthesia Records Pre-Anesthesia note dated 12/28/23 revealed patient with a history that included: Coronary Artery Disease, Complex sleep apnea syndrome, Dyspnea [shortness of breath], coronary artery bypass surgery, hypertension, ADD/AHA stage C heart failure [Structural heart disease with prior or current symptoms of heart failure]. Patient's airway had Mallampati classification: IV (hard palate only) [indicates the highest classification indicating the most difficult airway to intubate].

Review of Anesthesia Record page 3 dated 12/28/23 revealed a time listing that included the following: 8:16 Orotracheal Intubation Grade 2a [partial view of glottis]; Difficulty with intubation: No; Traumatic: Yes - laceration to upper lip and near base of tongue; CRNA - 1 attempt; Anesthesiologist - 1 attempt; 8:30 - Surgery start; 8:40 - Surgery Stop; "Free Note" at 8:56 - Examined the soft palate and noted laceration to right side. Will attempt to stop bleeding with nasal pledgets and Afrin but feel an ENT evaluation will be needed. Asked charge to call on-call ENT. 8:56 - Laceration inside mouth clotted after intubation, no issues with bleeding during the case. Once patient was reversed, gas off, and started to swallow, bleeding resumed prior to extubation of ETT [endotracheal tube]. Bleeding not slowing, patient re-sedated for airway protection and ENT [Ear, Nose, Throat] called for consult. 9:27 - Using videoscope, Afrin-soaked pledgets [compress or pad] were applied to laceration. 9:28 - Afrin administered to laceration using cotton administrators by Dr. [Staff K6]. 9:34 - Reevaluation of laceration with videoscope. Bleeding continued. Reapplied Afrin and pledgets. Will wait for ENT evaluation. 10:13 - ENT in room. 10:15 - Notified wife of soft palate laceration. Discussed with her the plan to treat. 10:25 - patient out of room. 10:40 - Emergence from anesthesia. Extubated Awake. 10:44 - Transport to PACU. Patient stable, awake and following commands, swallowing and breathing without issue, no bleeding noted at handoff.

Review of Operative Document dated 12/28/23 at 1:38 PM revealed a diagnosis and repair of right soft palate laceration with a complex closure of right soft palate laceration...1.5 x 1 cm right soft palate laceration posterior and medial to the right maxillary alveolar ridge.

Review of Anesthesia Record dated 12/28/23 revealed the following anesthesia drugs utilized between the first surgical stop time of 8:40 AM and transfer to PACU at 10:44 AM.

8:40 AM Sugammedex 200 mg IV [to reverse anesthesia]

8:58 AM Ephedrine 10 mg IV [treat hypotension - low blood pressure - during anesthesia]

9:00 AM Ephedrine 10 mg IV

9:03 AM Glycopyrrolate .2mg IV [decrease saliva]

9:28 AM Propofol 50 mg [anesthesia]

10:13 AM Propofol 50 mg

10:15 AM Propofol 50 mg

Review of Assessments dated 12/28/23 pain documented at 11:22 AM at level 3 - location mouth; 12:22 at level 3 - location throat. 1:15 - able to maintain oxygen level on room air. 2:04 - able to drink fluids.

Review of Personnel File for Staff L7, showed clinical privileges approved for 12/01/23 to 03/31/25 "Granted with supervision" in all categories.

During an interview on 01/05/24 at 2:20 PM, Staff L7, CRNA stated that because they are new, having graduated mid-November, the anesthesiologists are in the operating room [OR] for all inductions. The anesthesiologist, [Staff K6], was not in the OR until the intubation got more "challenging" and came in to assist. "Once airway was secured, we noticed more bleeding. It was clear the laceration occurred during my attempt...active bleeding stopped once airway was secured. When waking up and he started moving his mouth, then it was really bleeding. [Staff K6] made the decision to consult ENT [ear, nose, throat] when the bleeding wasn't stopping...The patient was obese with a long tongue...The [supply] person is working on getting brand removed. It's more rigid and pointier..."

During an interview on 01/04/24 at 4:13 PM, Staff K6, Anesthesiologist stated "CRNA had a difficult time getting in place and was using a different ET [endotracheal] tube. 7.5 tube had been auto substituted and the point comes to a sharper point and it's more rigid. She tried once and then I took a second look and placed it. He was a large guy, doesn't extend neck well. Sleep apnea. Redundant tissue. It happened in part, because of the ET tube. We notified [supply staff] and asked them to remove them from stock. It was a recent change and suppliers; we get no say in the stock. Took opportunity to instruct CRNA about ET tubes. She was brand new. It started bleeding again after case. I attempted pledgets [wad of absorbent cotton]. I knew someone else would have to come in. Dr. [ENT] put some stitches in. I called him [patient] yesterday. He was mostly concerned about his foley [catheter]." Staff K6 stated that he had never had a patient require sutures before or have a laceration that large.

The facility did not provide evidence of investigation regarding this incident. The incident log documented a recap of events with a designation of "E - Mild Harm."

Review of document titled Submit a Product Failure, dated 01/04/24 revealed that a product failure notification was submitted to the manufacturer of the ETT used during intubation for Patient 42.

Patient was identified at risk for challenging intubation in pre-anesthesia assessment. The facility failed to provide any policy and procedure that addressed safety precautions or staff supervision when a new CRNA is orienting. This failure caused the patient to have prolonged anesthesia with known health factors increasing cardiac failure risk, risk for aspiration or pneumonia as well as pain in throat and mouth.