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Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) complaints/grievances reviewed, the hospital failed to ensure that the process for resolving grievance was followed, as required.

Findings include:

1. On 2/13/2024, the hospital's policy titled, "Complaint and Grievance" (6/2022) was reviewed and indicated, " ... Grievance: A formal or informal written or verbal complaint that is made to the organization by a patient ... Grievance Process: Any complaint that cannot be resolved in a timely manner will be resolved through the grievance process ... Grievance Resolution: 1. The Patient Experience Department, in consultation with the Department of Risk Management, is responsible for the submission of response letter .... 2. The patient will receive a written acknowledgement of the complaint within 7 days ... 3. The written resolution will include the following elements: Identification of a contact person for follow-up; Steps taken during the investigation; Results of the investigation and any actions taken; Date of completion ..."

2. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital's ED for possible fluid overload. On 11/28/2023 at 11:25 PM, Pt. #2 was admitted to E527. On 12/2/2023 at 4:36 AM. Pt. #2 was transferred from E527 to E405. Pt. #2 was discharged on 12/2/2023.

3. On 2/13/2024, Pt. #2's grievance to the hospital was reviewed. On 12/3/2023 at 11:53 AM, Pt. #2 sent an email to E #21 (House Operations Administrator/Nursing Supervisor) that indicated, "Good Morning, (E #21), My name is (Pt. #2). I was admitted to East 527 for period of six days. During that stay, the housekeeping regiment was almost non-existent. And as if you know that evening, a mouse was running around my room, Before I release any video of the mouse running around, and the total disregard for cleanliness in that room, I would like to know what your plans are to alleviate this problem ... Feel free to contact me at any time to tell me what the hospitals intentions are to rectify the situation ..."

- There was no written response provided to Pt. #2 regarding the following: Identification of a contact person for follow-up; Steps taken during the investigation; Results of the investigation and any actions taken; and Date of completion.

4. On 2/15/2024 at approximately 2:00 PM, E #23 (Director of Regulatory) stated that a written response was not provided to Pt. #2's grievance.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #9) clinical records reviewed for violent restraints the hospital failed to ensure every 15-minutes monitoring was documented and assessed while on violent restraints as required.

Findings include:

1. On 02/15/2024 at approximately 2:05 PM, the hospital's policy titled, "Restraints and Seclusion" dated 01/18/2021 was reviewed and included, " ...Violent Restraint: Emergency measure, violent and/or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others ...A 1:1 sitter order is required for all patients immediately upon initiation of violent restraints ...and must document Q15 minutes checks on the ...observation flowsheet ..."

2. On 02/15/2024 at approximately 10:30 AM, Pt. #9's clinical record was reviewed. Pt. #9 was admitted to the emergency room with a diagnosis of major depressive disorder on 01/05/2024 at 11:56 AM.

- Pt. #9's ED physician order dated 01/05/2024 at 7:32 PM, included, "Violent Restraints/Self-Destructive -Four Point Hard Restraints for 4 hours." The one-hour face-to-face evaluation included clinical justification for behavioral restraint: violent and/or destructive behavior towards self and other; criteria to discontinue restraints: patient non longer at risk of preventing medical or surgical healing; RN to monitor according to patient care policy; Attestation: ...completed a face-to-face assessment of this patient."

- Pt. #9's restraints flowsheet documentation included: 01/05/2024: 19:00 [7:00 PM] initiation of four-point restraints, Locking Left Upper extremity, Locking Right Upper Extremity, Locking Left Lower Extremity, and Locking Right Lower Extremity. At 1959 [7:59 PM] Restraints continued to be used: Yes; Right, left - Upper and Lower Extremity: Continued - checked-off as Yes.
- On 01/05/2024, at 2010 [8:10 PM] Restraints Discontinued. Pt. #9's restraints flowsheet lacked the documentation of every 15-minute monitoring while on four-point hard restraints for violent behavior (total of 70 minutes).

3. On 02/15/2024 at approximately 2:30 PM, the ED Nurse Manager (E #5) was interviewed. E #5 stated the documentation was not completed by the sitter. E #5 stated anytime there is a violent restraints in the emergency department, they arrange for a sitter at the bedside, so the sitter did not document the every 15-minutes monitoring for this patient in the flowsheet.

A. Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for nursing admission assessments, the hospital failed to ensure that respiratory assessment was completed, as required.

Findings include:

1. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital's ED for possible fluid overload. The clinical record included the following:

- On 11/28/2023 at 9:15 AM, the attending physician's notes indicated, " ... Assessment and Plan: chronic Hypoxemic Respiratory Failure, COPD (Chronic Obstructive Pulmonary Disease) ... (Pt. #2) ... presents with shortness of breath ... Physical Exam: Pulmonary ... Respiratory distress present ... wheezing ..."

-On 11/28/2023 at 11:25 PM, Pt. #2 was admitted to E527. The registered nurse admission assessment on 11/28/2023 lacked documentation of the required respiratory assessment.

2. On 2/14/2023, the hospital's policy titled, "Admission Assessment and Further Reassessment Process" (12/2019) was reviewed and included, "... Registered Nurse (Admission Assessment)... This assessment should include appropriate physical observation and/or examination procedures and documenting... of data..."

3. On 2/13/2024 at approximately 2:30 PM, findings were discussed with E #9 (5 East Patient Care Manager). E #9 stated that the nursing admission assessment lacked the required respiratory assessment.

B. Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) clinical records reviewed for intake and output monitoring, the hospital failed to ensure that the registered nurse followed the documentation guidelines.

Findings include:

1. On 2/13/2024, the clinical record for Pt. #2 was reviewed. On 11/27/2023 at 12:10 PM, Pt. #2 walked into the hospital's ED for possible fluid overload. On 11/28/2023, Pt. #2 was admitted to E527. On 11/30/2023, a physician's order to monitor strict intake and output every eight hours was placed for Pt. #2. The clinical record lacked documentation that intake and output were measured every-eight hours on 12/1/2023 and 12/2/2023.

2. On 2/14/2024, the hospital's policy titled, "Documentation Guidelines" (9/2019) was reviewed and include, "RN (Registered Nurse) Documentation... Assure that... intake/outputs are charted... as ordered..."

3. On 2/13/2024 at approximately 2:30 PM, findings were discussed with E #9 (5 East Patient Care Manager). E #9 stated that documentation for intake and output monitoring on 12/1/2023 and 12/2/2023 were missing.





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c. Based on document review and interview, it was determined that for 3 of 3 (Pt. #1, Pt. #5, and Pt. #6) clinical records reviewed for pain assessment and re-assessment, while in the emergency department, the hospital failed to ensure the pain level was assessed, re-assessed after medication administration, and documented as required.

Findings include:

1..On 02/13/2024 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought into the ED (Emergency Department) with a chief complaint of hit and run on 12/24/2023, at 4:03 PM. Pt. #1's clinical record included the following:

- The ED Physician Assistant (MD #1) Rapid Assessment note dated 12/24/2023 at 4:22 PM, included, " ...(Pt. #1) driver wearing seatbelt, no loc [loss of consciousness], notes head injury ...denies neck, chest or abdominal pain ...pain in the right hand and wrist ...patient [Pt. #1] medically screened and orders initiated ...to be placed in WR [waiting room] for further treatment ..."

-The ED arrival and triage nurse (E #15) note dated 12/24/2023 at 4:24 PM, included, " ...patient [Pt. #1] arrived to triage via EMS [emergency medical services] sp [status post] MVA with laceration to face and right-hand injury. Pt. [Pt. #1] was restrained driver with airbag deployment, denies loss of loc [level of consciousness] or neck pain ...no altered mental status ...eye opening response ...best motor response ...verbal response ...infection screening - no history of isolation ...Triage Acuity: 2 ..."

-Pt. #1's medication administration record included the administration of Acetaminophen (Tylenol) 1000 mg [milligram] on 12/24/2023 at 20:00 [8:00 PM] and the administration of Norco [analgesic] 1 tablet on 12/25/2023 at 12:52 AM."

- Pt. #1's nursing flowsheet dated 12/24/2023 at 4:33 PM through 12/25/2023 3:24 PM, was reviewed and lacked documentation indicating patient assessment for pain screening, reassessment after medication administration.

2. On 02/15/2024 at approximately 10:45 AM, Pt. #5's clinical record was reviewed. Pt. #5 was admitted to the emergency room with a chief complaint of chest pain and shortness of breath on 02/12/2024 at 7:23 AM.

-Pt. #5's triage nurse notes at 7:27 AM, included, "Vital signs: Temperature: 97.7 (normal 98.4); Heart Rate: 132 (Normal 60-100); Respiration: 22 (Normal 16-18); Blood Pressure: 134/88 (normal 120/80), oxygen saturation: 97 percentage (normal 98-100). Triage Acuity Level -2."

-Pt. #5's clinical record from 02/12/2024 8:00 AM through 02/13/2024 11:00 AM, lacked the assessment and documentation of scoring of chest pain assessment throughout Pt. #5's stay in the ED.

3. On 02/15/2024 at approximately 11:00 AM, Pt. #6's clinical record was reviewed. Pt. #6 was admitted to the emergency room with a chief complaint of seizures on 02/11/2024 at 11:46 AM.

-Pt. #6's triage nurse notes at 12:18 PM, included, "Patient (Pt. #6) is having grand mal seizures. (Pt. #6) brought from home by EMS (Emergency Medical Services) for AMS (altered mental status) and hyperglycemia (high blood glucose levels, above 125) ; Vital Signs: Heart Rate: 113; Respiration: 26; Blood Pressure: 117/62; and oxygen saturation: 95 percentage. Triage Acuity Level -2."

-Pt. #6's clinical record from 02/11/2024 11:46 AM through 02/13/2024 11:00 AM, lacked the assessment and documentation of pain scoring and assessment throughout Pt. #6's stay in the ED.

4. On 02/15/2024, the hospital's policy titled, "Pain Assessment" dated 05/21/2019, was reviewed and included, " ... Approved self-report tools include: Numeric Rating Scale 0-10 (recommended for ages 12 and older) ...Initial assessment for all patients ...a comprehensive pain assessment should be conducted upon admission ...a comprehensive pain assessment includes: location, characteristics (type/quality of pain) intensity, onset, duration, aggravating and relieving factors ...conduct a focused pain assessment in an ongoing fashion and as part of routine care ...Patients can expect to receive prompt, safe and effective pain management ...pain relief is an important part of the treatment ...Reassessment after pain treatment is a cornerstone to effective and safe pain management ...reassessment is dependent on the intervention and is timed ...PO [per orally] at least 60 minutes following administration ..."

5. On 02/15/2024 at approximately 1:30 PM, hospital's ESI [emergency severity index] handbook's screenshot, was reviewed and included, " ...ESI Triage Algorithm ... Emergency severity index: Level 1: Requires immediate life-saving intervention; Level 2: Consider severe lethargy, high risk situation; Level 3: Danger zone check vitals; Level 4 and Level 5: monitor for different resources that are needed ...Triage nurses should assign ESI level 2 if the patient reports a pain rating 7/10 or greater and triage nurse's subjective and objective assessment confirms that the patient's pain requires interventions that are beyond the scope of triage. The triage nurse concludes that it would be inappropriate for this patient to wait and would assign this patient to the last open bed."

6. On 02/14/2024 at approximately 11:14 AM, the ED Registered Nurse (E #16) was interviewed. E #16 stated that in general pain assessment must be done upon initial nursing assessment, while admitting the patient in the ED. E #16 stated that the pain level is re-assessed after administration of pain medication. E #16 stated that she (E #16) does not recall administering Norco (analgesic) to patient (Pt. #1) and perhaps, forgot to assess and re-assess the pain level scores.

7. On 02/14/2024 at approximately 12:30 PM, the Triage Nurse (E #15) was interviewed. E #15 acknowledged that pain must be assessed and documented, before and after administration of medication.

8. On 02/14/2024 at approximately 1:30 PM, the ED Nurse Manager (E #5) was interviewed. E #5 stated that anytime patients with triage level 2, that requires immediate care, pain level scoring must be assessed. E #5 stated that in-general pain scoring must be assessed before administration of pain medication and 30 minutes to an hour after administration of medication.

Based on documentation review and interview, it was determined that for 3 of 7 patients' rooms (E507, E563, and E559) observed in 5 East Medical Surgical/Telemetry Unit, the hospital failed to ensure that equipment inside the patient's rooms were maintained, as required.

Findings include:

1. On 2/13/2024 between approximately 10:40 AM through 12:30 PM, an observational tour of the hospital's 5 East (Medical-Surgical-Telemetry Unit) was conducted. During the tour, three of the seven rooms observed (E507, E563, and E559) did not have thermostat covers.

2. On 2/16/2024, the hospital's document titled, "Environment of Care Management Plan Utility Systems" (2023) included, "... The program is also designed to assure effective preparation of staff responsible for the use and for the maintenance and repair of the equipment...Inspecting, Maintaining, and Testing of Utility Systems... Plant Operations maintains a current documented inventory of all of the utility system... This inventory includes all equipments maintained by (Name of the Hospital)..."

3. On 2/14/2024 at approximately 9:20 AM, an interview was conducted with E #17 (Director of Plant Operations). E #17 stated that the thermostat cover protects the metal strip that controls the thermoregulation of the room. E #17 stated that the thermostat inside the patient's rooms should be covered.

A. Based on document review, observation, and interview, it was determined that for 2 of 2 (Room #4 and Room #14) ED rooms observed for cleaning and disinfection, the hospital failed to ensure that the high and low dusting was completed to avoid infection.

Findings include:

1. On 02/15/2024 at 11:55 AM, the hospital's environmental services vendor policy titled, "Emergency Room Cleaning" dated 10/01/2023, was reviewed and included, " ...Procedure: Follow enhanced Discharge Cleaning Procedures ...high dust and disinfect vertical surfaces including doors, walls ...switches, IV [intravenous] poles etc. 6. Disinfect horizontal surfaces including bed side tables, ledges, sink surfaces, dispensers, etc ..."

2. On 02/13/2024 between approximately 10:00 AM through 12:45 PM, an observational tour of the hospital's emergency department (ED) was conducted along with ED Nurse Manger (E #5). During the tour following was observed:

-At approximately 10:30 AM, the two (2) ED Rooms - Room #14 and Room #4 were checked for cleaning, disinfection, and dusting. Both Room #14 and Room #4, were empty with no patients and cleaned by the housekeeping staff, however, there were dust found on the overhead light, over the medication cart, over the supply cart, and on the thermostat covers.

3. On 02/13/2024 at approximately 11:30 AM, the Housekeeping Staff (E #6) was interviewed. E #6 stated that she (E #6) was cleaning the rooms quickly after patient discharge and was not focusing on the doing high and low dusting.


B. Based on observation, document review, and interview, it was determined that for 2 of 2 (E #4/Safety Attendant and E #8/ED Registered Nurse) observed for infection control practices, the hospital failed to ensure the staff adherence to dress code policy while working in the patient care area.

Findings include:

1. On 02/13/2024 between approximately 10:00 AM through 12:45 PM, an observational tour of the hospital's emergency department (ED) was conducted along with ED Nurse Manager (E #5). During the tour the following was observed:

-At approximately 10:50 AM, the ED Registered Nurse (E #8) was seen getting ready with the paperwork for blood administration at the nurses station and had artificial fingernails approximately 2-inches long.

-At approximately 11:10 AM, the Safety Attendant (E #4) was seen with artificial fingernails approximately 2-inches long, conducting one-to-one patient monitoring at the bedside in the ED hallway.

2. On 02/15/2024 at approximately 2:00 PM, the hospital's policy titled, "Dress Code and Uniform Requirements" dated 11/4/2019 was reviewed and included, " ...Fingernails shall be clean, trimmed, and at a length that does not interfere with the job. Fingernails may not exceed one-quarter (1/4) inch in length. Based on CDC (Centers for Disease Control and Prevention) guidelines do not wear artificial fingernails or extenders when having direct contact with patients."

3. On 02/13/2024 at approximately 10:55 AM, the ED Registered Nurse (E #8) was interviewed. E #8 stated that the infection control education and training was provided annually. E #8 denied that E #8 was wearing artificial fingernails. E #8 stated "I have to hurry up to give blood for the patient."

4. On 02/13/2024 at approximately 11:00 AM, the ED Nurse Manager (E #5) was interviewed. E #5 acknowledged that the fingernails were artificial and more than 2-inches long, and should not have been worn as part of the staff uniform policy in emergency department. E #5 stated that it causes cross contamination, and infection prevention concerns.

5. On 02/13/2024 at approximately 11:15 AM, the ED Safety Attendant (E #4) was interviewed. E #4 acknowledged wearing artificial fingernails that were approximately two (2) inches and stated that they would be removed as soon as the shift was over.









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C. Based on observation, document review, and interview, it was determined that for 1 of 5 patients' (Pt. #3) in isolation precautions observed, the hospital failed to ensure that the procedure for preventing infection was followed, as required.

Findings include:

1. On 2/13/2024 between approximately 10:40 AM through 12:30 PM, an observational tour of the hospital's 5 East (Medical-Surgical-Telemetry Unit) was conducted. During the tour, five patients were in isolation precautions (E523, E527, E529, E545, and E569). One of the five rooms (Pt. #3 in E523) did not have a room signage to indicate that Pt. #3 was in contact isolation.

2. On 2/13/2024, the hospital's policy titled, "Isolation Patients" (12/1/2023) was reviewed and included, "... to ensure proper implementation of precautions and isolation techniques... to prevent the spread of healthcare associated infections... Types of Isolation... Contact-MDRO (multi-drug resistant organism)... Isolation Responsibilities... It is the responsibility of the primary nurse to ensure appropriate isolation is ordered, signs are hanging up... outside of the patient's room..."

3. On 2/13/2024, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted on 2/10/2024 for chest pain. On 2/10/2024, Pt. #3 had a physician's order to place Pt. #2 on contact isolation for MDRO (multi-drug resistant organism).

4. On 2/13/2024 at approximately 11:00 AM, findings were discussed with E #9 (5 East, Patient Care Manager). E #9 stated that the room should have a signage to indicate that Pt. #3 is in contact isolation. E #9 stated that the signage is important to ensure that anyone going inside Pt. #3's room is aware of necessary precautions to take to prevent spread of infection.