HospitalInspections.org

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by:

The facility failed to ensure two of 30 sampled patients (Patients 1 and Patient 2), were free from abuse (the improper treatment of a person), when Patient 1 and Patient 2 were physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.


This deficient practice resulted in EMT 1 and Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. Also, not reporting the incident to their chain -in- command (supervisors) had the potential harm to all ED patients, visitors, and staff. (Refer to A-0145)


The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:


1.The facility failed to follow manufacturer ' s recommendation of labeling the open and discard date of one of two sampled open glucose control solution (a liquid used to test the accuracy of blood glucose meters). This deficient practice has the potential to result in inaccurate blood glucose meter (a portable machine that's used to measure glucose in the blood) readings. (Refer to A-395)


2. The facility failed to ensure two of seven sampled employees completed their annual mandatory abuse and restraint training and maintained current certification of management of assaultive behavior (MAB – de-escalation training).

These deficient practices had the potential for the following:

A. patients getting physically abused,

B. patients on restraints, not monitored and/or provided less restrictive measures,

C. Patients with aggressive behavior harming others.

D. (Refer to A-397)


3. The facility failed to ensure one of 30 sampled patients (Patients 14) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure.


This deficient practice had the potential to compromise Patient 14's health and risk of infection due to dirty or compromised dressing. (Refer to A-398).


4. The facility failed to ensure fall precautions were executed for one of 30 sampled patients (Patient18). This deficient practice had the potential for Patient 18 to fall and fracture (break) bones, cause traumatic brain injury (damage caused by a blow to the head), and result in long term disabilities. (Refer to A-398).

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Emergency Services was met as evidenced by:

1. The facility failed to ensure Emergency equipment, including radiant warmers (equipment used to provide immediate access and warmth to newborn infants) and born-out-of-asepsis (BOA – unplanned out of-hospital

birth) kits, to stabilize newborns delivered in the ED, and were readily available. (Refer to A-1103)

2. The facility failed to ensure Diagnostic tests ordered STAT (right now), in the ED, were performed timely for one of thirty sampled patients (Patient 4). (Refer to A-1103)

3. The facility failed to ensure two of three crash carts had back boards (use as a surface to perform cardiopulmonary resuscitation (CPR) (emergency treatment done when someone breathing or heart stop) on patients in an emergency situation). (Refer to A-1103)


The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility ' s Governing Body failed to ensure:


1. Emergency department (ED) staff to de-escalate and manage violent patients in accordance with facility policy and procedure of "Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance" for two of 30 sampled patients (Patient 1 and 2). This deficient practice resulted in EMT 1, and Security Guard 1 responded by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients in October and November 2024 in consecutive month.


2.Staff to report abuse incidents between staff and patients for two of 30 patients (Patients 1 and 2) after patient 1 and patient 2 were physically assaulted in accordance with facility policy and procedure of "Reporting of Events Via Occurrence Reporting System." This deficient practice has the potential to put patients to further injury from the physical assault.


3.The contracted security service department abide with facility policy to assure Security Guard ' s (SG) competency of de-escalate and managing a violent patient. And SG1 and SG2 did not report to supervisor immediately after two of 30 sampled patients (Patients 1 and 2) were physically abused by EMT 1 and SG2 respectively. This deficient practice has the potential to inflict further injury to the patients from a physical assault.



Findings:

1. The Security Manager (SM) stated on 1/22/24 at 11:36 PM, that Patient 1, a 27 y/o female who presented to the Emergency Room on 10/09/24 with right shoulder pain was assaulted by Emergency Medical Technician (EMT 1).

The assault happened on 10/9/24 at around 4:00 AM. Patient 1 was in the ED (Emergency Department) lobby and was verbally aggressive to staff. Security Guard 1 (SG1), Security Guard 2 (SG2), and EMT 1 was with Patient 1 to deescalate (to decrease or reduce) the situation.
The Security Manager (SM) stated, Patient 1 spat at EMT1, and EMT 1 reacted by pushing security guard to the side and lunging towards Patient 1 and started punching Patient 1 ' s head area. SG1 and SG2 pulled EMT1 off Patient 1 to stop the attack. Patient 1 left the ED and the Police was called. Police came and arrested Patient 1 outside ED. Patient 1 was arrested because she made threats to harm the facility staff. SM added that a security report was not created. It was expected that the security staff complete a written security report after any unusual occurrence. EMT1 should not have assaulted Patient 1. Staff should never put hands on a patient. The expectation from security staff was to deescalate the situation.


The Director of Quality and Risk (DQR) stated on 1/23/25 at 11:00 AM that Emergency Department Manager (EDM) was onsite and aware of the incident of EMT1 physically assaulting Patient 1, and Patient 1 making threats to come back and harming staff. EDM did not notify the rest of leadership. There was a lack in notification and failing to follow chain of command. That situation should have been escalated (increase rapidly) to the House Supervisor and the Administrator on call. That way, a proper safety measure can be put in place in response to Patient 1 ' s threats to the facility.


During review of EMT1 ' s personnel file and interview with Human Resource Manager (HRM) on 1/23/25 at 1:27 PM, Record indicated that EMT1 has not completed Management of Assaultive Behavior (MAB) training. HRM stated that MAB is required for all ED EMT and nursing personnel.


2. During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24 around 7am, at the end of night shift, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM. SG1 was suspended only after finishing his shift. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor

immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible)


During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated Patient 2 came into ED after midnight and patient had blood on his face and mouth. Patient 2 was lying on the floor in the waiting area. SG2 and SG1 were trying to assist patient 2 to sit back on the chair. In a short while, SG1 accompanied Patient 2 outside the ED. SG2 stated after couple minutes, he heard some noise outside, he went outside the ED entrance and saw SG1 and Patient 2 were located at the junction of ED driveway and the City Street. Patient 2 was sitting on the ground and SG1 was standing next to Patient 2. When Patient 2 tried to stand up, SG1 punched Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident.


During an interview with Director of Quality and Risk (DQR) on 1/27/25 at 3:15 p.m., DQR stated the facility did conduct training to the ED staffs including ED and EMT after the 1st abuse incident that EMT 1 hit Patient 1; however, the security guards were not included in the training. Concurrently, DQR admitted that there was no reporting to chain of command immediately per facility policy regarding both abuse incidents that happened involving staffs physically assaulting the patients.


A record review, titled "incident report" dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated "someone hit me". SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ' s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ' s chin. SG1 fought back against Patient 2.

A review of the facility ' s policy titled, "Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ' dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ' s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate

and notify management of the situation. In an emergency, staff should call security and call a code Gray.

A review of the facility ' s policy titled, "workplace violence prevention plan", dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs.


A review of the facility ' s policy titled, "Medical staff chain of command" dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved.


A review of the facility ' s policy titled, "Reporting of Events Via Occurrence Reporting System" dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility's exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined.


3. A record review, titled "incident report" dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated "someone hit me". SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ' s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ' s chin. SG1 fought back against Patient 2.


During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated he observed SG 1 Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident.

During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible)

A review of the facility ' s policy titled, " Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance" dated 11/2024, indicated any act of intimidation, aggressive or violence behavior, or threat of violence will not be tolerated and should be reported immediately to employee ' s direct manager who will notify the House Supervisor, Security, and Administrator-On-Call as needed. And if any time a patient or visitor become physically threatening, staff should immediately disengage and leave the room.

Based on observation, interview, and record review, the facility failed to ensure two of 30 sampled patients (Patients 1 and Patient 2), were free from abuse (the improper treatment of a person), when Patient 1 and Patient 2 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.


This deficient practice resulted in EMT 1 and Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. Also, not reporting the incident to their chain -in- command (supervisors) had the potential harm to all ED patients, visitors, and staff.

On 1/23/2025, at 5:36 PM, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements have, caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality and Risk (DQR), Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Administrator (Admin), and Associate Chief Nursing Officer (ACNO).

The facility failed to ensure two of thirty sampled patients (Patient 1 and Patient 2) were free from all forms of abuse.

The facility failed to follow their policy and procedure resulted in EMT 1 and Security Guard 1 inappropriately responding by physically assaulting Patient 1 and 2 respectively after getting provoked by the patients. The facility did not follow their policy and procedure in dealing with the physical assault which happened.


The above-mentioned facility administrators were informed of the immediate jeopardy situation regarding the failure to ensure two of thirty sampled patients (Patient 1 and Patient 2) were free from abuse.

On 1/24/2025 at 6:02 p.m., while onsite, the IJ was removed after verifying and confirming the facility's implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the following facility members: Chief Nursing Officer (CNO), Director of Quality and Risk (DQR), Chief Executive Officer (CEO), Administrator (Admin), and Associate Chief Nursing Officer (ACNO).

The IJ Removal Plan included the following:


1. On beginning 11/1/2024, the plan of action included that the ACNO provided written instructions to all house supervisors making rounds in the emergency department (ED), was increased to every three (3) hours with a rounding log created.

2. On 10/16/2024, the plan of action included all nursing staff are required to obtain mandatory management of assaultive behavior certification (MAB - de-escalation training), with training scheduled for February 2025.

3. On 12/11/2024, the plan of action included a re-education of all security guards on the facility ' s policy, Use of Force, with signed attestations that training was received.

4. On 12/11/2024, DQR completed a contract service evaluation for security services and required security company to correct deficiencies identified, including use of excessive force towards patients, failure to perform

appropriate de-escalation techniques, and inappropriate/unprofessional behavior, by 1/3/2025.

5. On 1/16/2025, DRQ met with security manager reviewed security services corrective action plan and made recommendations for security services.

6. On 1/24/2025, the house supervisor rounding log was revised to include the times of the rounds, the name of the ED charge nurse and the name of the security officer, and communication with both the charge nurse and security officer.

7. On 1/23/2025, the ACNO provided the list of expired licensure report to all house supervisors and nursing staff office, to ensure that facility staff with expired licenses or required certifications were not called to cover staffing needs. The report was provided to the nursing managers and directors weekly.

8. On 1/23/25, the hospital administrator and DQR reviewed the 2025 Security Post Orders and made revisions to the 2025 Post Orders, which included attestations from all the security officers indicating training was received, read and understood.

9. On 1/23/2025, facility administration created and initiated an educational tool regarding MAB training, Code Gray procedures, immediate reporting of unusual occurrences, and incident reporting system for all ED staff and security officers to complete within the first two hours of their shift, upon returning to duty.

10. On 1/24/2025, risk management specialist conducted one-to-one training with each security officer on incident reporting, including a completed a post-test.

Findings:

1. The Security Manager (SM) stated on 1/22/24 at 11:36 PM, that Patient1 who presented to the Emergency Room on 10/09/24 with right shoulder pain was physically assaulted by Emergency Medical Technician (EMT 1). The assault happened on 10/9/24 at around 4:00 AM. Patient 1 was in the ED (Emergency Department) lobby and was verbally aggressive to staff. Security Guard 1 (SG1), Security Guard 2 (SG2), and EMT 1 was with Patient 1 to deescalate (to decrease or reduce) the situation.

Security Manager (SM) stated, Patient 1 spat at EMT1, and EMT 1 reacted by pushing security guard to the side and lunging towards Patient 1 and started punching Patient 1 ' s head area. SG1 and SG2 pulled EMT1 off Patient 1 to stop the attack. Patient 1 left the ED and the Police was called. Police came and arrested Patient 1 outside ED. Patient 1 was arrested because she made threats to harm the facility staff. SM added that a security report was not created. It was expected that the security staff complete a written security report after any unusual occurrence. EMT 1 was sent home and terminated a month after this incident. EMT1 should not have assaulted Patient 1. Staff should never put hands on a patient. The expectation from security staff was to deescalate the situation.


The Director of Quality and Risk (DQR) stated on 1/23/25 at 11:00 AM that Emergency Department Manager (EDM) was onsite and aware of the incident of EMT1 physically assaulting Patient 1, and Patient 1 making threats to come back and harming staff. EDM did not notify the rest of leadership. There was a lack in notification and failing to follow chain of command. That situation should have been escalated (increase rapidly) to the House Supervisor and the Administrator on call. That way, a proper safety measure can be put in place in response to Patient 1 ' s threats to the facility.


During a concurrent review of EMT1 ' s personnel file and interview with Human Resource Manager (HRM) on 1/23/25 at 1:27 PM, Record indicated that EMT1 has not completed Management of Assaultive Behavior (MAB) training. HRM stated that MAB is required for all ED EMT and nursing personnel.

A review of the facility ' s policy titled, "Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ' dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ' s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate and notify management of the situation. In an emergency, staff should call security and call a code Gray.

A review of the facility ' s policy titled, "workplace violence prevention plan", dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs.



A review of the facility ' s policy titled, "Medical staff chain of command" dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved.


A review of the facility ' s policy titled, "Reporting of Events Via Occurrence Reporting System" dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility's exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined.



2. During an interview with Security Manager (SM) on 1/22/25 at 11:36 a.m., SM stated on 11/4/24 around 7am, at the end of night shift, he received a text message from security guard (SG1) stating that SG1 defended himself and punched Patient 2. SM stated SG1 completed his shift and did not report to any supervisor regarding the incident until he sent a text message to SM.


SG1 was suspended only after finishing his shift. During the interview with SM, he stated that SG1 should never hit a patient even when he was provoked by the patient. Also, they need to report to a supervisor immediately and the supervisor can inform SM to start investigating ASAP (as, soon, as, possible)


During an interview with SG2 on 1/23/25 at 9:51 am, SG 2 stated Patient 2 came into ED after midnight and patient had blood on his face and mouth. Patient 2 was lying on the floor in the waiting area. SG2 and SG1 were trying to assist patient 2 to sit back on the chair. In a short while, SG1 accompanied Patient 2 outside the ED. SG2 stated after couple minutes, he heard some noise outside, he went outside the ED entrance and saw SG1 and Patient 2 were located at the junction of ED driveway and the City Street. Patient 2 was sitting on the ground and SG1 was standing next to Patient 2. When Patient 2 tried to stand up, SG1 punched Patient 2 on his shoulder. SG2 stated he did not report what he observed to the supervisor since he was not involved in the incident.


During an interview with Director of Quality and Risk (DQR) on 1/27/25 at 3:15 p.m., DQR stated the facility did conduct training to the ED staffs including ED and EMT after the 1st abuse incident that EMT 1 hit Patient 1; however, the security guards were not included in the training. Concurrently, DQR admitted that there was no reporting to chain of command immediately per facility policy regarding both abuse incidents that happened involving staffs physically assaulting the patients.


A record review, titled "incident report" dated 11/6/24, indicated that an assault incident occurred at 11/4/24 at 2:10 am by SG1. Indicated that SG1 arrived in front of the ED at 2:10 am to give lunch breaks to the other staff and he saw SG2 trying to ask Patient 2 to get off the floor. SG1 saw Patient 2 face with blood and asked what happened. Patient 2 stated "someone hit me." SG1 accompanied Patient 2 outside the ED, and Patient 2 suddenly wrapped his arm around SG1 ' s neck; SG1 pushed Patient 2 away, then Patient 2 squared up and hit SG1 ' s chin. SG1 fought back against Patient 2.

A review of the facility ' s policy titled, "Patient Rights and Responsibilities", dated 3/2023, indicated that patient has the right to be free from all forms of abuse or harassment.


A review of the facility ' s policy titled, "Prevention and Management of Violence by a Patient or Visitor, Zero Tolerance ' dated approved 11/2022 (old version), indicated that Hospital procedure if patient or visitor becomes behaviorally escalated engage in de-escalation and limit setting as is appropriate to the patient or visitor ' s stage of escalation. If at any time a patient or visitor becomes physical threatening, staff should immediately disengage and leave the room if appropriate and notify management of the situation. In an emergency, staff should call security and call a code Gray.

A review of the facility ' s policy titled, "workplace violence prevention plan", dated 3/2024; indicated that Southern California Hospitals encourages all workforce members to report workplace violence to the hospital in accordance with established hospital policies and to see assistance and intervention from local emergency services or law enforcement when a violent incident occurs.


A review of the facility ' s policy titled, "Medical staff chain of command" dated 6/2022, indicated that Southern California Hospital is committed to providing safe quality patient care. Any healthcare professional who identifies a potential problem with respect to patient safety and /or quality, and unable to resolve it independently, is empowered to invoke the following procedures e.g. clinical chain of command until a satisfactory resolution is achieved.


A review of the facility ' s policy titled, "Reporting of Events Via Occurrence Reporting System" dated 12/24 indicated the purpose if to improve the quality of patient care and enhance patient, visitor and staff safety and reduce the facility's exposure to risk of financial loss ...an occurrence/event report is to be submitted through current Incident Reporting system on every occurrence/event involving a patient, visitor, physician, employee (staff or contract), or volunteer in any area or department of Southern California Hospital ... The responsibility for completing an Occurrence/Event/Risk report submission through the Occurrence Reporting System rests with any staff member (including physicians and agency/contract personnel who witnesses, discovers, or has the best knowledge of an occurrence as previously defined.

Based on observation, interview and record review, the facility failed to ensure its nursing staff to perform assessment and document restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every 2 hours in accordance to facility ' s policy and procedure of restraints on one of 30 sampled patients (Patient 17) for 12 hours (from 7 p.m. to 7 a.m.) on 1/16/2025, 1/17/2025 and 1/18/2025, consecutively for 3 nights.


This deficient practice had the potential to put Patient 17 at risk for skin break down and other injury due to lack of assessment and monitoring.


Findings:

During a review of Patient 17 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/26/2024, the H&P indicated, Patient 17 was admitted to the facility with diagnoses including failure to thrive (condition that adults involves, weight loss, fatigue and other physical decline), but not limited to Non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart), and sepsis (a body ' s overwhelming and life-threatening response to infection).


During a concurrent observation and interview on 1/22/2025 at 10:07 a.m. with Assistant Chief Nursing Officer (ACNO) at Patient 17 ' s room, Patient 17 was in bed with bilateral (both) soft wrists restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on. ACNO stated Patient 17 was on bilateral soft wrist restraints due to pulling lines.


During a review of Patient 17 ' s "physician order (orders written by physicians to direct care and treatment)," dated 1/16/2025, 1/17/2025, and 1/18/2025 the physician order indicated, there was need for bilateral wrists restraints due to pulling tube/lines and interfering with dressing, wounds, or devices.


During a concurrent interview and record review on 1/22/2025 at 10:35 a.m. with ACNO, Patient 17 ' s "Non-Behavioral restraints flowsheet (documentation of restraints use and assessment)," dated 1/16/2025, 1/17/2025, and 1/18/2025 was reviewed. The restraint flowsheet indicated Patient 17 ' s was on bilateral soft wrists restraints and there is no entry of assessment starting from at 8 p.m. on 1/16/2025 to 7 a.m. on 1/17/25, and 1/17/2025, and 1/18/2025 respectively. There was no assessment done from 7 p.m. to 7 a.m. (12 hours) consecutively for 3 days. ACNO stated that the assigned registered nurse should document and assess Patient 17 every two hours to check for skin for any injury, circulation, range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension), discoloration, and swelling while Patient 17 was on restraints. Patient 17 could be at risk for skin breakdown and injury due to lack of proper monitoring.


During a review of the facility ' s policy and procedure (P&P) titled, "Restraint", dated 3/2024, the P&P indicated, assessment by a trained and competent Registered Nurses (RN) in restraint application and management, as defined by the training requirements of this document, are done and documented at least every 2 hours for non-violent behavior restraint. Assessment by a responsible Licensed Independent Practitioner (LIP) shall occur as often as indicated by patient ' s condition, behavior, environmental considerations, and this policy.

Based on observation interview and record review, the facility failed to follow manufacturer ' s recommendation of labeling the open and discard date of one of two sampled open glucose control solution (a liquid used to test the accuracy of
blood glucose meters).

This deficient practice has the potential to result in inaccurate blood glucose meter (a portable machine that's used to measure glucose in the blood) readings.


Findings:


During a concurrent observation and interview, on 01/21/2025, at 3:18 p.m., It was observed that one of two open glucose control solution bottles in the acute rehab unit nurse station has no written open and discard dates. The registered nurse (RN3) confirmed that one of two open glucose control solution bottle has no written open and discard dates. RN3 stated that the facility follows manufacturer ' s guideline of labeling each of the glucose control solution bottle of its open and discard date once the bottle is open. It is the responsibility of the staff nurse to write the open and discard dates on the bottle. The solution expires 90 days after opening, and it needs to be tracked by nursing staff to ensure accurate results when testing a blood glucose meter.


A review of the glucose control solution manufacturer ' s recommendation titled "Nova Stat Strip Glucose Control Solution", REF 41743, indicated the following:

· Precautions: Use only for 3 months after first opening. When you open a new vial of control solution, count forward 3 months and write that date on the label of the control solution vial. Discard any remaining solution after the date you have written on the vial.

· Expiration: The expiration date is printed on the control vials. Once opened, solution stored as indicated will be stable for up to 3 months or until the expiration date, whichever comes first.

Based on interview and record review, the facility failed to ensure two of seven sampled employees (Emergency Medical Technician – EMT 1 and Registered Nurse – RN 9) completed their annual mandatory abuse and restraint training and maintained current certification of management of assaultive behavior (MAB – de-escalation training).

These deficient practices had the potential for employees to perform uncorrected practice for the following:

A. Patients getting physically abused,

B. Patients on restraints, not monitored and/or provided less restrictive measures,

C. Patients with aggressive behavior harming others.


Findings:


1. On 1/23/2025, at 1:27 PM, during concurrent interview with human resources manager (HRM) and director of education (Dir Ed), HRM stated upon hire, new Emergency Department (ED) employees attend hospital orientation, which included training in abuse, restraints, and de-escalation of aggressive behavior (MAB). HRM stated abuse, restraint and MAB training must be done annually.


Concurrently, during record review of personnel files for emergency medical technician (EMT)1 and registered nurse 9, HRM stated the following:

1. EMT1 ' s training for abuse, restraints, and MAB were not current: last abuse training on 7/2021, restraint training on 4/4/2023, and expired MAB training certificate on 9/2021.

2. Registered Nurse 9 training for abuse, restraints, and MAB were not current: abuse training on 11/2022, restraint training on 11/2022, and expired MAB training certificate on 10/2023.


A review of facility ' s job description for emergency medical technician (EMT), undated, indicated the following:

1. Primary duties included ensuring the safety of the patient.

2. Required qualifications included MAB training certificate, upon hire and recertification.


A review of facility ' s job description for Registered Nurse (RN) in the emergency department, undated, indicated the following:

1. Specialty training to provide prompt response and treatment for any patient presenting with any life-threatening, emergent, or urgent medical needs.

2. Required qualifications included MAB training certificate upon hire, and recertification.


A review of facility ' s Workplace Violence Prevention Plan, dated 3/2024, indicated the following:

1. This policy applies to all staff employed by the facility.

2. Purpose is to protect the safety and health of employees, medical staff, patients, and visitors from aggressive and violent behaviors.

3. High-risk areas for aggressive and violent behaviors included the emergency department.

4. The hospital leadership will provide effective training to employees who are reasonably anticipated to encounter aggressive and violent behaviors in the job, upon hire and annually.

5. Incidents of the use of physical force against an employee by a patient or a person accompanying a patient must be reported.

Based on observation, interview and record review, the facility failed to ensure:

1. One of 30 sampled patients (Patients 14) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure.This deficient practice had the potential to compromise Patient 14's health and risk of infection due to dirty or compromised dressing.

2. Fall precautions were executed for one of 30 sampled patients (Patient18). This deficient practice had the potential for Patient 18 to fall and fracture (break) bones, cause traumatic brain injury (damage caused by a blow to the head), and result in long term disabilities.


Finding:


1. During a review of Patient 14 ' s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/19/2025, the H&P indicated, Patient 14 was admitted to the facility with diagnoses including sepsis (a body ' s overwhelming and life-threatening response to infection), pneumonia (a lung infection that cause the air sacs in the lungs filling with fluid or pus that caused by bacteria, viruses, or fungi), and hypertension (chronic condition that blood pressure in the blood vessels is high).


During a concurrent observation and interview on 1/21/2025 at 2:50 p.m. with Interim Director Telemetry and Emergency Department (IDTED) in Patient 14 ' s room, Patient 14 was observed in bed, with an intravenous (IV) saline lock in her left hand. The IV dressing was observed to be blank with no date and no nurse ' s initial written on it. Concurrently, IDTED stated all nurses are expected to label the date and their initial on the IV dressing after changed. The IDTED also said, without labeling the date it could compromised the IV site for risk of infection.


During a review of the facility ' s policy and procedure (P&P) titled, "Intravenous Therapy - Initiation and Management of Peripheral Intravenous Line", dated 6/2023, the P&P indicated the dressing should be changed aseptically (a way that prevent infections) after 72 hours ... label the site with the date and initial.

2. During an observation on 1/22/2025 at 10:30 AM, Patient 18 walked out of a room with a blanket that smelled of urine wrapped around her shoulders. At that time Patient 18 was screaming for someone to help her while walking to the nurses station, unassisted by staff. The nursing station was approximately 20 feet from Patient 18 ' s room. It was observed staff member took approximately 1 minute to notice Patient 18 had walked to the nurses station. LVN 1 then guided Patient 18 back to her room. Patient 18 had one yellow sock on her right foot and a pink band around her right wrist as she walked through the doorway to her room. There was no audible alarm blaring at this time.


During an interview on 1/22/2025 at 10:32 AM, LVN 1 stated Patient 18 had a pink bank around her wrist indicating Patient 18 has a conservator (a person appointed by a court-ordered arrangement to make decisions for another person). LVN 1 stated that a yellow band should be around her wrist indicating Patient 18 is at risk of falling; LVN 1 also said Patient 18 should have been wearing two slip resistant socks to reduce the risk of falling.

A record review of the document titled ' History and Physical ' (medical exam that includes a patient interview, physical exam, and documentation of findings of the exam) dated 1/13/2025 indicated Patient 18 had been admitted on 1/13/2025, for right lower extremity cellulitis (skin infection causing redness and swelling) and UTI (urinary tract infection, an infection of the bladder/urinary tract). The History and Physical indicated Patient 18 also had a history of bipolar (disorder sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), seizures (sudden uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and schizoaffective (mental illness disorder that can affect thoughts, mood, and behavior).


A record review of the document ' Flowsheets ' dated 1/21/2025, the Flowsheets indicated Patient 18 ' s Morse Fall scale (tool use to assess a patient ' s risk of falling) score was 50. The tool uses the 6 following factors relative to the patient that determine the risk for future falls: History of falling, secondary diagnosis (identification of possible illness), Ambulatory aid used such as a cane, Intravenous therapy (fluid given directly into the blood stream), Gait (manner of walking), Mental status (measure of a person ' s mental capacity such as mood and behavior).


A record review of the document titled ' Falls Prevention Policy ' number PAT.042 effective 9/24/2019, the Falls Prevention Policy indicated a fall is a sudden, unintentional descent, with or without injury to the patient resulting in the patient coming to rest on the floor, on or against some other surface, on another person, or on an object. It is only considered a fall when a patient attempts to stand or sit and falls into a bed, chair, or commode if the patient is injured. The Fall Prevention Policy indicated a nurse shall assess every patient for risk of falling every shift and as needed; Nurses should implement standard interventions (e.g. socks, band, signage) as well as individualized interventions such as help with toileting and ambulation to prevent falls according to the assessed level of the patient ' s fall risk using the Morse Fall scale as a reference. The Falls Prevention Policy indicated a score of greater than 45 represents a high fall risk; minimum fall prevention strategies should include patient wearing non-skid socks, signage, and patient ID band indicating the patient is at risk for falling. The Falls Prevention Policy indicted other measures to prevent falls according to the Morse Risk score: placing the patient close to the nurse station, place 3 side rails up, and a personal alarm if one is available.

Based on observation, interview and record review, the facility ' s Emergency Department (ED) failed to ensure the following:

A. Emergency equipment, including one of one radiant warmer (equipment used to provide immediate access and warmth to newborn infants) and one of one born-out-of-asepsis (BOA – unplanned out of-hospital birth) kits, to stabilize newborns delivered in the ED, and were readily available.

B. Diagnostic tests ordered STAT (right now), in the ED, were performed timely for one of thirty sampled patients (Patient 4).

C. Two of three crash carts had back boards (use as a surface to perform cardiopulmonary resuscitation (CPR) (emergency treatment done when someone breathing or heart stop) available for use on patients in an emergency situation).


These deficient practices had the potential for delays in emergency care and services to ED patients.

Findings:

A.

On 1/21/2025, at 1:21 PM, during initial tour of the Emergency Department (ED) with Administrator (Adm 2) and Director of Quality and Risk (DQR), registered nurse (RN) 1 stated walk-in patients in active labor are normally placed in room , where there is a crash cart for pediatric patients and other equipment for stabilizing the laboring woman and newborn. RN 1 stated the ED staff would call the on-call obstetrician (OB – physician who provides care during pregnancy, birth and after-birth period), and prepare the room with pediatric crash cart and warm blankets from the blanket warmer for the baby.

Concurrently, Pediatric crash cart was observed without a back board. RN 1 stated she did not know why there was no back board in the pediatric crash cart.

On 1/22/2025, at 2:10 PM, during interview with director of education (Dir Ed) and nurse educator (NEd)2, NEd2 stated crash carts should have a backboard included. NEd2 stated the nurses, in every unit, should be checking the crash carts daily to make sure that emergency equipment, including back boards are included in the crash carts.

Concurrently, during record review of the Crash Cart Inventory, NEd2 stated she did not know why the back board was not indicated on the crash cart inventory.

On 1/23/2025, at 1:12 PM, during telephone interview with DQR and facility ' s emergency on-call OB, OB stated emergency equipment needed in the ED for a laboring woman getting ready to deliver an infant included a radiant warmer to keep the baby warm after childbirth and a born-out-of-asepsis (BOA – unplanned out of-hospital birth) kit, which contains supplies for emergency deliveries, including bulb syringe, sterile gloves, sterile towels, umbilical cord clamps, and a scalpel.

Concurrently, DRQ stated the facility ' s radiant warmer was not in the hospital, because it was out for service. DRQ stated she found a BOA kit, in central supply, which should have been stocked in the ED.

A review of facility ' s Crash Cart/AED – Inspection, Maintenance, Exchange policy, dated 3/2024, indicated the following:

1. The emergency crash carts will be immediately available in each patient care areas.

2. The crash carts shall be checked daily, in each unit, by licensed personnel, and documented on a checklist log (Ambu bag, O2 cylinder, Defib, Suction, Backboard, pharmacy) to verify the integrity of the crash cart and to ensure that all equipment is available and functioning.

3. Central supply will verify the existing components on the crash cart and replacement items will be pulled.

4. The crash cart will be inspected for completeness, cleanliness and functionality by central supply.

B.

On 1/24/25, at 3:21 PM, during concurrent interview with nursing educator (NEd)2 and record review of Patient 4 ' s medical record review, NEd2 stated the following:

1. Face sheet (a document that summarizes a patient ' s key information in their medical record) was admitted to the facility on 11/14/2024, with a diagnosis, which included ventilator (breathing machine) dependent.

2. Nursing Triage note, dated 11/14/2024, indicated patient ' s chief complaint was to replace patient ' s gastrostomy tube (G-tube – a small tube surgically inserted into the stomach through the abdomen) replacement.

3. ED physician note, dated 11/14/2024, indicated patient came from a nursing home with a clogged g-tube and ordered computed tomography (CT scan – a noninvasive medical procedure that uses X-rays to create a detailed cross-sectional images of the body) and chest X-ray to find the g-tube ' s position and check for infection.


Concurrently, during record review of Patient 4 ' s physician orders, dated 11/14/2024, NEd2 stated, at 10:55 AM, ED physician ordered a STAT chest x-ray and CT of patient ' s abdomen and pelvis, but the STAT chest x-ray and CT of the abdomen and pelvis was not done until 1410 – not done STAT (within one hour).

During review of the facility ' s STAT Turnaround Time policy, dated 1/24/2025, indicated the following:

1. All stats print automatically in the emergency department.

2. Delays in meeting the stat turnaround time of one hour can cause delays in patient care.

C.During a concurrent observation and interview on 01/21/2025 at 1:45 p.m. of the emergency department (ED) with the Director of Quality and Risk (DQR), it was observed that two of three (crash cart 15 and pediatric crash cart) did not have a back board. DQR stated that crash cart should have back board.


During an interview on 01/21/2025 at 2:09 p.m. with the register nurse (RN1), RN1 stated that each crash carts should have a back board. Back board is used as back support to patient receiving chest compression during code blue.


During an interview on 1/22/2025 at 2:10 p.m. with the nurse educator (NED2), NED2 stated that each crash cart should have a back board. Backboard is not part of the facility ' s crash cart checklist (a tool used by staff that ensures all necessary emergency medications, equipment, and supplies are readily available on a crash cart), but it should be.


A review of the facility ' s policy titled , "Crash Cart and AED Inspection, Maintenance, Exchange, dated 3/2024 indicated the crash carts shall be checked daily, in each unit, by licensed personnel, and documented on a checklist log (Ambu bag, O2 cylinder, Defib, Suction, Backboard, pharmacy) to verify the integrity of the crash cart and to ensure that all equipment is available and functioning.