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Based on observation, interview, and record review, the facility's governing body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure oversight on the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) to ensure facility's policy and procedure was followed and that standard of care on patient safety was implemented for three of 30 sampled patients (Patients 1, 2, and 6) when:

1. Patient 1 presented on 8/30/24 to the ED for chest pain, did not receive triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), and Patient 1 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), 36 minutes after arrival to the ED, in the ED's waiting room by the first responder (Nurse Practitioner, NP 1). Patient 1 was not assessed, cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) was not initiated timely, and code blue (an overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) was not called when Patient 1 was found unresponsive.

2. Patient 2, who presented to the ED on 8/30/24 for chest pain, waited 26 minutes to receive a triage assessment after arrival to the emergency department, and 44 minutes to have a medical screening by a provider.

3. The facility's policy and procedure for chest pain was not implemented when Patient 6, who presented to the ED on 10/15/2024 for chest pain, was triaged by the Registered Nurse (RN) after registration (collecting demographic and insurance information) was completed by admitting receptionist 4 (AR 4, staff who performs admitting activities).

These deficient practices resulted in a reoccurrence of emergency department staff failing to follow policy and procedure, delay in life-saving measures, thus compromising Patient 6's safety and the potential to compromise safety for other patients who may present to the ED for chest pain.
Findings:

1. During a concurrent interview and record review on 10/18/24 at 3:20 p.m. with the Chief Operation Officer (COO), the governing body meeting agenda and minutes dated September 2024 were reviewed. The COO verified that the incident with Patient 1 occurred on 8/30/24 in which delayed care contributed to Patient 1's death was not documented on the agenda or the minutes that were presented to the governing body. The COO stated the incident, investigation, and plan of correction were discussed verbally with the governing body; however, the root cause analysis (RCA, a process for identifying the causal factors of a medical error that may result in a sentinel event) was not presented to the governing body. The COO further stated, the GB minutes and agenda does not have documentation on the Quality Assurance data (It involves assessing or evaluating quality; identifying problems or issues with care delivery and designing quality improvement activities to overcome them; and follow-up monitoring to make sure the activities did what they were supposed to) for the emergency department, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), MSE time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider), or review of emergency department policy and procedure such as "Chest pain protocol," or "Admission Triage to the Emergency Department," that was presented to the GB.

During a review of the facility's policy and procedure titled, "Chest Pain, Coronary Attack and Cardiopulmonary arrest," dated 2/2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol. The Emergency Department clerk shall inform the nursing staff that a patient has arrived for a medical screening exam. After triage, if the patient is able to come to the registration desk, the clerk will obtain the demographic information from the patient."

During a review of the facility's "Chest Pain Protocol," dated 11/2022, the Chest Pain Protocol indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."

During a review of the facility's "Governing Board Bylaws," dated 2/25/08, the bylaws indicated, "The purpose of the Governing Board is to recommend and implement Hospital policy, promote performance improvement, provide quality patient care, and provide for organizational management and planning of the Hospital."

2. During a concurrent interview and record review on 10/16/24 at 4:24 p.m. with the Director of ER/ICU (DCS), Patient 2's "Emergency Department Triage (document of a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait) Form," dated 8/30/24, was reviewed. The triage form indicated Patient 2 arrived to the emergency department (ED) on 8/30/24 at 8:06 p.m., with a chief of complaint of chest pain since 6 p.m. The triage form indicated Patient 2 received triage at 8:33 p.m., 27 minutes after arriving in the ED for chest pain. DCS stated Patient 2 should not have waited 27 minutes to received triage assessment.

During a review of Patient 2's "Conditions of Services (a general consent for medical screening, examination, and evaluation by a physician)," consent form dated 8/30/24 indicated Patient 2's signed the form on 8/30/24 at 8:08 p.m., 25 minutes prior to receiving triage assessment by a nurse.

During a review of Patient 2's "Order Chronology," undated, the order indicated, Patient 6 received the medical screening at 8:50 p.m., 44 minutes after the time of Patient 6' arrival (8:06 p.m.) to the emergency department for chest pain.

During a review of Patient 2's "Medical Screen Exam (MSE)," dated 8/30/24, the "MSE" indicated, Patient 6 have history of CVA (cerebral vascular accident or a brain attack, is an interruption in the flow of blood to cells in the brain), present with chief complaint of an episode of chest pain. The patient had an episode of chest pain that lasted for approximately 8 minutes started at 7:00 p.m ..."
During an interview on 10/18/2024 at 4:49 p.m., with the Director of Quality and Risk Management (DQRM), DQRM said the governing body (GB) reviews the facility's policies and procedure every three years and ultimately, the GB is responsible to ensure staff adhere to policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care. Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."
A review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

3. During a review of Patient 6's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 6 was admitted to the emergency department (ED) on 10/15/2024 at 12:48 p.m., for chest pain and abdominal pain.

During a review of Patient 6's "Medical Screen Exam (MSE)," dated 10/15/24, the "MSE" indicated that Patient 1 with "h/o (history) MI (myocardial infarction, a stroke, when blood supply to the brain is interrupted) presents ED (emergency department) for left-sided pain x (times) 4 days. Describes chest pain as constant, mild in severity, radiating to the left arm, pulsating in quality, similar to prior MI, and worse with movement of the left arm. Denies any trauma or injury. No alleviating or aggravating factors. Patient also experiencing left upper abdominal pain but denies nausea, vomiting, shortness of breath, or any other symptom."

During a concurrent observation, interview, and record review on 10/15/24 at 12:51 p.m. with Admitting Representative (AR) 4 in the registration area, Patient 6 was sitting in front of AR 4, and AR 4 was typing as she was speaking with Patient 2. After typing, AR 4 yelled to the triage nurse, who was sitting across the room "This patient has chest pain." The patient was directed by the triage nurse to come over and sit by the triage nurse. Review the electronic registration record with AR 4, indicated Patient 2's came from home, information on medical insurance, demographics (non-clinical data about a patient), and identification was entered on the registration screen.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, when a patient report that they are having chest pain the registration receptionist should only obtain identification, insurance should not be obtained until the patient is stable or family can provide. DPFS stated if the patient has been to the ER before, some information will be pulled from previous visits; however, medical insurance will require to be obtain each time the patient visits. DPFS stated it is important for patient with chest pain to be triage as soon as possible because there is protocol in place for the clinical team to do in a certain timeframe.

During an interview on 10/18/2024 at 4:49 p.m., with the Director of Quality and Risk Management (DQRM), DQRM indicated the governing body (GB) reviews the facility's policies and procedure every three years and ultimately, the GB is responsible to ensure staff adhere to policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care.
Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."

A review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

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

1. The facility failed to ensure one of 30 sampled patients (Patient 1's) POA (power of attorney, a legal authorization designated person to make decisions about another person's medical care) or next of kin (a person's closest living relative) was informed by a provider regarding the unanticipated outcome resulting from delay in care for Patient 1 that may have contributed to Patient 1's death in compliance to the facility's policy and procedure. This deficient practice may cause Patient 1's POA/next of kin to have increase emotional distress, confusion, and mistrust of the health care system. (Refer to A-131)

2. The facility failed to ensure five of 30 sampled patients (Patients 20, 23, 27, 29, 30) were provided information to formulate advance directives (legal documents that provide instructions for medical care and only go into effect if the patient cannot communicate their wishes). This deficient practice resulted in five patients not being able to communicate with the facility, what their wishes were, should they become incapacitated. (Refer to A-0132)

3. The facility failed to ensure one of 30 sampled patients (Patient 1), who presented to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, was triaged in a timely manner and receive necessary intervention to address Patient 1's medical condition.
This deficient practice resulted in 36 minutes after Patient 1 registered in the ED, was then found by a visitor in the ED waiting room, unresponsive (someone not reacting normally to touch, sound or other stimulation), which likely contributed to Patient 1's death. (Refer to A-0144)

4. The facility failed to ensure one of 30 sampled patients (Patient 1), when found to be unresponsive by the first responder (Nurse Practitioner, NP 1), was immediately assessed; cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) initiated and a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) called in a timely manner.
This deficient practice resulted in a delay in providing Patient 1 life-saving measures which may have contributed to Patient 1's death. (Refer to A-0144)

5. The facility failed to ensure one of 30 sampled patients (Patient 2), who presented to the ED for chest pain, did not have to wait 26 minutes to receive a triage assessment after arrival to the emergency department, did not wait 44 minutes to have a medical screening by a provider, and a diagnosis such as an EKG was completed in accordance with the facility policy and procedure. This deficient practice resulted in a delay in assessment and intervention to prevent cardiac arrest and death, compromising Patient 2's safety. (Refer to A-0144)

6. The facility failed to ensure one of 30 sampled patients (Patient 6), who presented to the ED for chest pain, receive triaged assessment prior to completing registration (collecting demographic and insurance information) by an admitting receptionist (staff who performs admitting activities), AR 4 in accordance with the facility's policy and procedure. This deficient practice resulted in a delay in assessment and intervention to prevent cardiac arrest and death, compromising Patient 6's safety. (Refer to A-0144)

7. The facility failed to ensure for one of 30 sampled patients (Patient 15), Patient 15's restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) order was obtained timely in accordance with the facility's policy and procedure.

This deficient practice had the potential to result in an inappropriate use of restraint and had the potential for Patient 15 to suffer from complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia {lack of oxygen], skin tear, etc. (Refer to A-0168)


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

Based on the interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 1), Patient 1's POA (power of attorney, a legal authorization designated person to make decisions about another person's medical care) or next of kin (a person's closest living relative) was informed by a provider of the unanticipated outcome resulting from Patient 1's delayed care that may have contributed to Patient 1's death.

This deficient practice resulted in Patient 1's POA/next of kin to not receive full disclosure and concerning reasons of Patient 1's unanticipated outcome and may lead to Patient 1's POA/next of kin to have increased emotional distress, confusion, and mistrust of the health care system.

Findings:

During a review of Patient 1's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, patient 1 was admitted to the emergency department (ED, is a hospital area staffed and equipped for the reception and treatment of persons requiring immediate medical care) on 8/30/24 at 8:30 a.m. Patient 1 demographic (non-clinical data about a patient, including: name, date of birth, address, phone number) and health insurance was obtained and documented on the face sheet.

During a review of Patient 1's "Physician Exam," note dated 8/30/24, the note indicated, "Patient (Patient 1) presented pulseless prior to triage, multiple rounds of high-quality CPR epinephrine were provided, patient was intubated ...After multiple rounds of CPR time of death was called at 2136 (9:36 p.m.)." The note indicated, "CC (chief of complaint) code Blue." The note indicated there was no EKG reading (left blank), and "diagnostic impression: cardiac arrest."

During a review of Patient 1's "ER Vital Signs & Nursing Intervention," report dated 8/30/24, the report indicated, "PT (Patient 1) BIB (brought in by) family member for CC (chief of complaint) of chest pain. Per admitting representative, (name of AR 1), PT (Patient 1) was not verbally responsive but was able to lift her hand for arm band placement and PT (Patient 1) was taken to wait room. Per security, PT (Patient 1) was placed onto waiting room chair by family member and left the ER (emergency room). PT (Patient 1) was found in waiting room unresponsive brought into ER to bed 2 immediately code blue initiated by (name of emergency room physician, MD 1) ..."

During an interview on 10/16/24 at 9:26 a.m. with Admitting Representative (AR) 1, AR 1 stated that on 8/30/24, Patient 1 was brought in by a family member and registered in the ED. AR 1 stated Patient 1's family member reported Patient 1 came in for chest pain. AR 1 stated he placed Patient 1's admitting packet in a bin for the triage nurse to pick up and triage Patient 1 as soon as possible. AR 1 further stated the ED got busy with the other patients that were coming in, and Patient 1 ended up in the ED waiting room. AR 1 stated, "I should have handed off to the triage nurse when the family member said chest pain." AR 1 verified that on 8/30/24, at 8:30 p.m. when Patient 1's family member reported that Patient 1 had chest pain, Patient 1 did not receive a triage assessment.

During an interview on 10/16/24 at 10:50 a.m., with triage nurse (RN) 2, who was the assigned triaged nurse on 8/30/24, from 6 a.m. through 6 p.m., RN 2 stated, "I was not notified by the admitting clerk (AR 1) that the patient (Patient 1) had chest pain." RN 2 verified Patient 1 was not triaged for chest pain which resulted in Patient 1 not having an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), vital signs not taken, and was not evaluated by the ED physician. Subsequently, Patient 1 was found unresponsive in the ED waiting room.

During a concurrent interview and record review on 10/16/24 at 4:12 p.m. with the Director of ED/ICU (DCS), Patient 1's electronic medical record (EMR, an electronic version of a patient's medical history, that is maintained over time), titled "Physician Exam," was reviewed. DICS confirmed that there was no disclosure of Patient 1 regarding the unanticipated outcome resulting from delay in care for Patient 1 that may have contributed to Patient 1's death.

During an interview on 10/16/24 at 5:27 p.m. with ED physician who treated Patient 1 on 8/30/24 (MD) 1, MD 1 stated although the nurses attempt to reach the family, he did not attempt to reach Patient 1's family/next of kin. MD 1 stated usually when there is critical incident or unusual death, he will notify the family.

During a review of the facility's policy and procedure (P&P) titled, "Adverse Event Reporting, DHS," dated June 2019, the P&P indicated, "Disclosure of Adverse Event to Patient or Patient's representative: The patient, or the party responsible for the patient, must be notified by the patient's physician and the designated representative from the facility concerning the nature of the adverse event. The Patient or the Patient's responsible party (Representative) must be informed about the adverse event by the time the report is made to the DHS."

Based on interview and record review, the facility failed to ensure for five of 30 sampled patients (Patients 20, 23, 27, 29, and 30), Patients 20, 23, 27, 29, and 30 were provided information on how to formulate an Advance Directive (AD, a legal document indicating patient preference on end-of-life treatment decisions) upon admission to the facility.

This deficient practice had the potential to result in Patients 20, 23, 27, 29, and 30 to not be able to formulate an AD which may violate the patients' rights and wishes for treatment and medical care, should they become incapacitated.

Findings:

1. During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/3/2024, the H&P indicated, Patient 20 was admitted to the facility with a chief complaint of unstable angina (a type of chest pain).

During a concurrent interview and record review on 10/18/2024 at 9:08 a.m. with the Information System Director (ISD), the ISD verified Patient 20's "Advance Directive Acknowledgement/Flow Chart," dated 8/2/2024, indicated Patient 20 did not have an AD (Advance Directive, a legal document indicating patient preference on end-of-life treatment decisions). The form further indicated that there was no AD brochure (a booklet that gives you information about a product or service) or additional information on AD provided to Patient 20 upon admission to the facility.

During a concurrent interview and record review on 10/18/2024 at 9:58 a.m., the DPFS stated the Admission Department would ask the patient upon admission for an AD. The DPFS stated when a patient had no AD, the Admission department would provide the AD brochure, and a social worker referral would be initiated to provide the patient on information on how to formulate an AD. The DPFS verified Patient 20's record indicated the patient had no AD. The DPFS stated an AD brochure should have been provided.

During a review of the facility's policy and procedure (P&P) titled, "CALIFORNIA HEALTHCARE DECISIONS LAW (Formerly- "Patient Self Determination Act"), approve date on 6/2022, the P&P indicated, "(name of the facility) shall provide written information at all time of admission/registration, to each patient describing...A patient's right under California law to accept it or refuse medical treatment and the right to formulate and revoke Advance Directive; and ...Admission Representative Treatment is life sustaining. A brochure designed for this purpose shall be provide to the patient... Provide patient with Patient's Rights Brochure as required by the ACT. As part of the hospital admission process ...If an Advance Directive had not been completed ...If patient has further questions, refer them to Social Services."

2. During a concurrent interview and record review on 10/16/2024 at 4:25 p.m., with charge nurse from telemetry (CN) 1, CN 1 verified Patient 23's "Advance Directive Acknowledgement form," dated 9/29/2024, Patient 23 did not have an AD and was not provided the following: an AD brochure (a booklet that gives you information about a product or service) and a social services referral for AD to explain and/or discuss AD to the patient.

During a review of Patient 23's face sheet (a patient's demographic information, an insurance policy overview, and/or a law enforcement information sheet), dated 9/30/24, the record indicated Patient 23 was admitted for chest pain.

During an interview on 10/18/2024 at 12:30 p.m., with the Director of Patient Financial Services (DPFS), the DPFS stated during patient registration and/or admission, the admitting representative (AR) was trained to provide patients with AD brochure. The DPFS stated the AR staff do not have access to enter referrals to social services, for assistance with AD.

During a review of facility's policy and procedure (P&P) titled, "CALIFORNIA HEALTHCARE DECISIONS LAW (Formerly- "Patient Self Determination Act") approve dated in 6/2022, the P&P indicated, "(name of the facility) shall provide written information at all time of admission/registration, to each patient describing...A patient's right under California law to accept it or refuse medical treatment and the right to formulate and revoke Advance Directive; and ...Admission Representative Treatment is life sustaining. A brochure designed for this purpose shall be provide to the patient... Provide patient with Patient's Rights Brochure as required by the ACT. As part of the hospital admission process ...If an Advance Directive had not been completed ...If patient has further questions, refer them to Social Services."

3. During a concurrent interview and record review on 10/17/2024 at 3:09 p.m. with the Director of Education (DSD), the DSD verified Patient 27's "Advance Directive Acknowledgement form," dated 10/1/2024, Patient 27 did not have an AD and was not provided the following: an AD brochure (a booklet that gives you information about a product or service) and a social services referral for AD to explain and/or discuss AD to the patient.

During an interview on 10/18/2024 at 12:30 p.m., with the Director of Patient Financial Services (DPFS), the DPFS stated during patient registration and/or admission, the admitting representative (AR) was trained to provide patients with AD brochure. The DPFS stated the AR staff do not have access to enter referrals to social services, for assistance with AD.

During a review of facility's policy and procedure (P&P) titled, "CALIFORNIA HEALTHCARE DECISIONS LAW (Formerly- "Patient Self Determination Act") approve dated in 6/2022, the P&P indicated, "(name of the facility) shall provide written information at all time of admission/registration, to each patient describing...A patient's right under California law to accept it or refuse medical treatment and the right to formulate and revoke Advance Directive; and ...Admission Representative Treatment is life sustaining. A brochure designed for this purpose shall be provide to the patient... Provide patient with Patient's Rights Brochure as required by the ACT. As part of the hospital admission process ...If an Advance Directive had not been completed ...If patient has further questions, refer them to Social Services."

4. During a concurrent interview and record review on 10/17/24 at 4:08 p.m. with the Director of Education (DSD), the DSD verified Patient 29's "Advance Directive Acknowledgement form," dated 10/3/2024, Patient 29 did not have an AD and was not provided social services referral for AD to explain and/or discuss AD to the patient.

During an interview on 10/18/2024 at 12:30 p.m. with the Director of Patient Financial Services (DPFS), the DPFS stated during patient registration and/or admission, the admitting representative (AR) was trained to provide patients with AD brochure. The DPFS stated the AR staff do not have access to enter referrals to social services, for assistance with AD.

During a review of facility's policy and procedure (P&P) titled, "CALIFORNIA HEALTHCARE DECISIONS LAW (Formerly- "Patient Self Determination Act") approve dated in 6/2022, the P&P indicated, "(name of the facility) shall provide written information at all time of admission/registration, to each patient describing...A patient's right under California law to accept it or refuse medical treatment and the right to formulate and revoke Advance Directive; and ...Admission Representative Treatment is life sustaining. A brochure designed for this purpose shall be provide to the patient... Provide patient with Patient's Rights Brochure as required by the ACT. As part of the hospital admission process ...If an Advance Directive had not been completed ...If patient has further questions, refer them to Social Services."

5. During a concurrent interview and record review, on 10/17/2024 at 5:45 p.m. with the Director of Education (DSD), the DSD verified Patient 30's "Advance Directive Acknowledgement form," dated 10/3/2024, Patient 30 did not have an AD and was not provided the following: an AD brochure (a booklet that gives you information about a product or service) and a social services referral for AD to explain and/or discuss AD to the patient.

During an interview on 10/18/2024 at 12:30 p.m. with the Director of Patient Financial Services (DPFS), the DPFS stated during patient registration and/or admission, the admitting representative (AR) was trained to provide patients with AD brochure. The DPFS stated the AR staff do not have access to enter referrals to social services, for assistance with AD.

During a review of facility's policy and procedure (P&P) titled, "CALIFORNIA HEALTHCARE DECISIONS LAW (Formerly- "Patient Self Determination Act") approve dated in 6/2022, the P&P indicated, "(name of the facility) shall provide written information at all time of admission/registration, to each patient describing...A patient's right under California law to accept it or refuse medical treatment and the right to formulate and revoke Advance Directive; and ...Admission Representative Treatment is life sustaining. A brochure designed for this purpose shall be provide to the patient... Provide patient with Patient's Rights Brochure as required by the ACT. As part of the hospital admission process ...If an Advance Directive had not been completed ...If patient has further questions, refer them to Social Services."

Based on observation, interview, and record review, for three of 30 sampled patients (Patients 1, 2, and 6), the facility failed to:

1.a. Ensure Patient 1, who presented to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, was triaged in a timely manner and receive necessary intervention to address Patient 1's medical condition.

This deficient practice resulted in 36 minutes after Patient 1 registered in the ED, was then found by a visitor in the ED waiting room, unresponsive (someone not reacting normally to touch, sound or other stimulation), which likely contributed to Patient 1's death.

1.b. Ensure Patient 1, when found to be unresponsive by the first responder (Nurse Practitioner, NP 1), was immediately assessed; cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) initiated and a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) called in a timely manner.

This deficient practice resulted in a delay in providing Patient 1 life-saving measures which may have contributed to Patient 1's death.

2. Ensure Patient 2, who presented to the ED for chest pain, was triaged and medically screened by a provider timely in accordance with the facility's policy and procedure.

This deficient practice resulted in a delay in Patient 2's assessment and necessary intervention for chest pain that could negatively affect Patient 2's safety and may cause for the patient to suffer from cardiac arrest (heart attack) and/or death.

3. Ensure Patient 6, who presented to the ED for chest pain, was triaged prior to completing the registration requirement (collecting demographic and insurance information) by an admitting receptionist (AR 4, staff who performs admitting activities), in accordance with the facility's policy and procedure.

This deficient practice resulted in a delay in Patient 6's assessment and provision of timely and necessary intervention for chest pain, which could negatively affect Patient 6's safety and may cause for the patient to suffer from cardiac arrest (heart attack) and/or death.

On 10/16/2024 at 3:15 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Operating Officer (COO) and the Director of Quality & Risk Management (DQRM).

The IJ was related to the facility's failure to ensure that Patient 1, who presented to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), medically screened by a provider, received a diagnostic test such as an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), and provided needed interventions prior to completing the ED registration (collecting demographic and insurance information) and ensure Patient 1 was not send to the ED waiting room. These deficient practices resulted in Patient 1 being found by the visitor, 36 minutes after registration, in the ED waiting room unresponsive, which likely contributed to Patient 1's death.

In addition, the facility's failure to ensure that Patient 1, when found to be unresponsive by the first responder (Nurse Practitioner, NP 1), was assessed; cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) was initiated and a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) was called. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 1's death.

On 10/18/2024 at 5:40 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: Chair of the governing board, Chief Operational Officer (COO), Chief Nursing Officer (CNO), Director of Quality and Risk Management (DQRM), Director of ER/ICU (DCS), and Director of Patient Financial Services/Admitting (DPFS).

The IJ Removal Plan indicated the following:

-From September 3, 2024, to September 10, 2024, all ED registration Staff were educated on Policy T-1 "Registration of the Patient Information Triage," and Policy T-4 "Admission Triage to the Emergency Department"

-ED Staff was instructed on expectations regarding triage and chest pain during the staff meeting on September 10, 2024.

-On October 17, 2024, staff (provider, nurse, or clerk) were instructed to go to the waiting area to call for a patient and visualize the waiting area.

-On October 17, 2024, Policy T-1 "Registration of the Patient Information Triage," and Policy T-4"Admission Triage to the Emergency Department" were revised to clarify the information needed for quick registration.
-On October 18, 2024, the triage/registration area was reconfigured to relocate the triage nurse to the second desk in the current registration area. Security will direct patients to the registration desk in the new ER Admitting/Triage area. The triage nurse sitting next to the registration desk will be able to visualize the ER entrance and hear the patient's presenting concern (reason the patient wants to be seen in the ER). The ER Admitting Rep. will verbally inform the Triage nurse of the presenting concern. An ER RN is assigned as a second triage RN to cover breaks and assist if needed. The triage nurse will communicate the status of any patients to the second triage nurse using SBAR. The second triage nurse will hand off his/her assigned patients to one of the ED nurses in the main treatment area using SBAR when relieving the Triage nurse or assisting in triage.

-The second registration desk was relocated to the ER waiting area for the second ER Admitting Rep. to perform post triage/post MSE registration and observe the entire ER waiting area. The second registration clerk will be able to call for assistance, initiate calling a code blue, and initiate CPR for assistance for patients requiring prompt medical attention.

-When a second ER Admitting Rep. is not available (Midnight to 6:00 a.m. or during breaks), a CNNNA, EMT or other BLS certified personnel will remain in the ER waiting area to observe the patients, call for assistance, initiate calling a code blue, and initiate CPR if required. There is a phone for the second ER Admitting Rep. or CNNNA or EMT or BLS person to call for help/code blue. A "Code Blue / Help" call button will be installed in the waiting area to call for assistance no later than October 25, 2024. ER Staff, ER Provider, House Supervisor, and RT will respond to the code blue per the current practice. ER Admitting Reps. currently maintain BLS certification and are able to initiate CPR.

-On October 18, 2024, ED staff, ER Admitting Reps. and provider staff were instructed on the revised workflow.

-On October 18, 2024 all ED staff, ER Admitting Reps. and providers were instructed to follow BLS guidelines for the assessment of an unresponsive patient.

-On October 18, 2024, the ED Medical Director instructed the ED providers on the revised workflows, and assessment guidelines.

Findings:

1. During a review of Patient 1's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 1 was admitted to the emergency department (ED, is a hospital area staffed and equipped for the reception and treatment of persons requiring immediate medical care) on 8/30/24 at 8:30 a.m. Patient 1's demographic (non-clinical data about a patient, including: name, date of birth, address, phone number) and health insurance was obtained and documented on the face sheet.

During a review of Patient 1's "ER Vital Signs & Nursing Intervention," report dated 8/30/24, the report indicated, "PT (Patient 1) BIB (brought in by) family member for CC (chief of complaint) of chest pain. Per admitting representative, (name of AR 1), PT (Patient 1) was not verbally responsive but was able to lift her hand for arm band placement and PT (Patient 1) was taken to wait room. Per security, PT (Patient 1) was placed onto waiting room chair by family member and family member left the ER (emergency room). PT (Patient 1) was found in waiting room unresponsive brought into ER to bed 2 immediately code blue initiated by (name of emergency room physician, MD 1) ..."

During a review of Patient 1's "Physician Exam," note dated 8/30/24, the note indicated, "Patient (Patient 1) presented pulseless prior to triage, multiple rounds of high-quality CPR epinephrine were provided, patient was intubated ...After multiple rounds of CPR time of death was called at 2136 (9:36 p.m.)." The note indicated, "CC (chief of complaint) code Blue." The note indicated there was no EKG reading (left blank), and "diagnostic impression: cardiac arrest."

1.a. During an interview on 10/16/24 at 9:26 a.m. with Admitting Representative (AR) 1, AR 1 stated that on 8/30/24, Patient 1 was brought in by a family member and registered in the ED. AR 1 stated Patient 1's family member reported Patient 1 came in for chest pain. AR 1 stated he placed Patient 1's admitting packet in a bin for the triage nurse to pick up and triage Patient 1 as soon as possible. AR 1 further stated the ED got busy with the other patients that are coming in, and Patient 1 ended up in the ED waiting room. AR 1 stated, "I should have handed off to the triage nurse when the family member said chest pain." AR 1 verified that on 8/30/24, at 8:30 p.m. when Patient 1's family member reported that Patient 1 had chest pain, Patient 1 did not receive a triage assessment.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, "(Name of AR 1) should have alerted the triage nurse that Patient 1 has chest pain because for chest pain there is protocol in place for the clinical team to do in certain timeframe."

During an interview on 10/16/24 at 10:50 a.m., with triage nurse (RN) 2, who was the assigned triaged nurse on 8/30/24, from 6 a.m. through 6 p.m., RN 2 stated, "I was not notified by the admitting clerk (AR 1) that the patient (Patient 1) had chest pain." RN 2 verified Patient 1 was not triaged for chest pain which resulted in Patient 1 not having an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), vital signs not taken, and was not evaluated by the ED physician. Subsequently, Patient 1 was found unresponsive in the ED waiting room.

During a review of the facility's policy and procedure (P&P) titled, "Admission Triage to the Emergency Department," dated 2/2023, the P&P indicated, "When the patient presents to the registration desk, the clerical staff will immediately notify the triage nurse of the patient's arrival. No financial information is to be obtained until the medical screening is completed."

During a review of the facility's P&P titled, "Chest Pain, Coronary Attack and Cardiopulmonary arrest," dated 2/2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol. The Emergency Department clerk shall inform the nursing staff that a patient has arrived for a medical screening exam. After triage, if the patient is able to come to the registration desk, the clerk will obtain the demographic information from the patient."

During a review of the facility's P&P titled, "Chest Pain Protocol," dated 11/2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation measures the amount of oxygen in the blood). Stat (Immediately) 12 Lead EKG (Electrocardiogram, measures the electrical activity of the heart). Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."

1.b During a concurrent interview and record review on 10/15/2024 at 4:45 p.m. with the Director of Quality and Risk Management (DQRM) and the Supervisor of Security Services (SS), the facility's surveillance video of the ED entrance, which had views of the entrance to the waiting room and the entrance to the ED treatment area, dated 10/30/24 from 8:21 p.m. through 9:09 p.m., was reviewed. The DQRM verified the following was seen on the surveillance video:

- At 8:21 p.m., Patient 1's family member entered the ED entrance and spoke to the security who was situated at the ED entrance. The security brought a wheelchair and left the wheelchair at the exit.

-At 8:22 p.m., Patient 1's family member came back and retrieved the wheelchair.

-At 8:25 p.m., the family member wheeled Patient 1 into the ED treatment area. The DQRM stated this was when Patient 1 was registered, the registration desk was located inside the room of where the treatment area was.

-At 8:32 p.m., 7 minutes after Patient 1's arrival to the ED, Patient 1 was wheeled from the registration desk to the waiting room by the patient's family member. Patient 1's family member was seen exiting the ED less than a minute later.

-At 9:08 p.m., 36 minutes after Patient 1's arrival to the ED, a visitor was seen talking to the ED nurse practitioner (NP) 1 in the hallway by the waiting room entrance. The DQRM stated the visitor was telling NP 1 to check on a patient (Patient 1) who was unresponsive. NP 1 was seen entering the ED waiting room, and within 2-3 seconds, NP 1 exited the ED waiting room.

-At 9:09 p.m., RN 4 wheeled out of the ED waiting room Patient 1 to the treatment area. Patient 1's upper torso was slumped to one side of the wheelchair and her (Patient 1) head was pointed down to the ground. One of Patient 1's arm was dangling about two inches from the ground.

The DQRM confirmed a code blue (a hospital emergency code that indicates a patient is in critical condition and needs immediate medical attention) was not called in the waiting area. The DQRM stated Patient 1 was taken into the ED treatment area to start CPR (Cardiopulmonary resuscitation, an emergency treatment that is done when someone's breathing or heartbeat has stopped).

During an interview on 10/16/24 at 10:00 a.m. with the ED Nurse Practitioner (NP) 1, NP 1 stated, when she (NP 1) entered the ED waiting room, Patient 1's cell phone was on the floor by the patient's feet, and the patient (Patient 1) was slumped over. NP 1 stated she (NP 1) did not assess and check Patient 1 for a pulse (the number of times the heart beats per minutes by palpating in the wrist area or in the neck). NP 1 further stated, she (NP 1) left the room to put on gloves and to call for help.

During an interview on 10/17/24 at 9:40 a.m. with Registered Nurse (RN) 4, RN 4 stated after receiving report, that there was a patient (Patient 1) in the ED waiting room unresponsive, RN 4 entered the ED waiting room. RN 4 stated he (RN 4) determined that Patient 1 was unresponsive because Patient 1 was not moving and was not reacting. RN 4 stated he (RN 4) did not assess Patient 1 for a pulse and did not call a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]). RN 4 confirmed CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) was not started until Patient 1 was wheeled into the ED treatment area and placed on the gurney. RN 4 could not recall how long it took to transfer Patient 1 from the waiting room to the treatment room's gurney and when CPR was started. RN 4 further confirmed that it was unknown as to when did Patient 1 became unresponsive.

During a concurrent interview and record review on 10/18/24 at 10:30 a.m. with the Director of Emergency/ICU (DCS), the facility's policy and procedure (P&P) titled, "Code Blue," dated November 2022, was reviewed. The P&P indicated, "Staff who discovers the patient, shall call for help and initiate CPR/BLS ... Primary Advance Cardiac Life Support (ACLS) Registered Nurse (RN) (Telemetry ACLS RN/ICU - ER RN) assesses patient's overall status -ensures CPR/BLS is started, places patient on monitor, delivers defibrillation per ACLS guidelines, delegates I. V. medications, recording to other ACLS RNs. (House Supervisor, Director, another ACLS RN), delegates preparing and assisting with intubation to Respiratory Therapist or ACLS RN and coordinates the CODE BLUE process." The DCS stated, staff did not follow the policy, they should have followed the process.

During a review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "If a victim is unconscious/unresponsive, with absent or abnormal breathing (i.e., only gasping), the healthcare provider should check for a pulse for no more than 10 s and, if no definite pulse is felt, should assume the victim is in cardiac arrest. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions, early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia."

2. During a concurrent interview and record review on 10/16/24 at 4:24 p.m. with the Director of ER/ICU (DCS), Patient 2's "Emergency Department Triage (document of a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait) Form," dated 8/30/24, was reviewed. The triage form indicated Patient 2 arrived at the emergency department (ED) on 8/30/24 at 8:06 p.m., with a chief of complaint of chest pain since 6 p.m. The triage form indicated Patient 2 received triage at 8:33 p.m., 27 minutes after arriving in the ED for chest pain. DCS stated Patient 2 should not have waited 27 minutes to receive triage assessment.

During a review of Patient 2's "Conditions of Services (a general consent for medical screening, examination, and evaluation by a physician)," consent form dated 8/30/24, the form indicated Patient 2 signed the form on 8/30/24 at 8:08 p.m., 25 minutes prior to receiving triage assessment by a nurse.

During a review of Patient 2's "Order Chronology," undated, the order indicated, Patient 2 received the medical screening at 8:50 p.m., 44 minutes after the time of Patient 2's arrival (8:06 p.m.) to the emergency department for chest pain.

During a review of Patient 2's "Medical Screen Exam (MSE, a preliminary assessment that a patient receives when a patient presents in the Emergency Department)," dated 8/30/24, the "MSE" indicated, Patient 2 had history of CVA (cerebral vascular accident or a brain attack, is an interruption in the flow of blood to cells in the brain), presented with chief complaint of an episode of chest pain. The patient had an episode of "chest pain that lasted for approximately 8 minutes started at 7:00 p.m."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care. Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."
During a review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

3. During a review of Patient 6's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 6 was admitted to the emergency department (ED) on 10/15/2024 at 12:48 p.m., for chest pain and abdominal pain.

During a review of Patient 6's "Medical Screen Exam (MSE)," dated 10/15/24, the "MSE" indicated that Patient 1 with "h/o (history) MI (myocardial infarction, a stroke, when blood supply to the brain is interrupted) presents ED (emergency department) for left-sided pain x (times) 4 days. Describes chest pain as constant, mild in severity, radiating to the left arm, pulsating in quality, similar to prior MI, and worse with movement of the left arm. Denies any trauma or injury. No alleviating or aggravating factors. Patient also experiencing left upper abdominal pain but denies nausea, vomiting, shortness of breath, or any other symptom."

During a concurrent observation, interview, and record review on 10/15/24 at 12:51 p.m. with Admitting Representative (AR) 4 in the registration area, Patient 6 was sitting in front of AR 4, and AR 4 was typing as she was speaking with Patient 2. After typing, AR 4 yelled to the triage nurse, who was sitting across the room "This patient has chest pain." The patient was directed by the triage nurse to come over and sit by the triage nurse. A Review the electronic registration record with AR 4, indicated Patient 2's came from home, information on medical insurance, demographics (non-clinical data about a patient), and identification was entered on the registration screen.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, when a patient report that they are having chest pain the registration receptionist should only obtain identification, insurance should not be obtained until the patient is stable or family can provide. DPFS stated if the patient has been to the ER before, some information will be pulled from previous visits; however, medical insurance will require to be obtain each time the patient visits. DPFS stated it is important for patient with chest pain to be triage as soon as possible because there is protocol in place for the clinical team to do in a certain timeframe.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care. Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."

During a review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 15), Patient 15's restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) order was obtained timely in accordance with the facility's policy and procedure.

This deficient practice had the potential to result in an inappropriate use of restraint and had the potential for Patient 15 to suffer from complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia {lack of oxygen], skin tear, etc.

Findings:

During review of Patient 15's History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/28/2024, the H&P indicated Patient 15 was admitted to the facility with a chief complaint of Gastric Outlet Obstructions (inability of food and/or water to properly exit from the stomach because of mechanical blockage)

During a concurrent interview and record review on 10/17/2024 at 12:15 p.m. with the Information System Director (ISD), the ISD verified Patient 15's "Restraint ( Flowsheet," indicated Patient 15's soft wrist bilateral restraint was initiated on 10/6/2024 at 7:00 a.m.

During the same interview and record review on 10/17/2024 at 12:15 p.m., the ISD verified Patient 15's "Order Detail" indicated a physician's telephone order as follows:

-On 10/06/2024 at 2:37 p.m., restraint soft wrist - left restraint for Non-Violent and Non-Self Destructive; and,

-On 10/06/2024 at 2:37 p.m., restraint soft wrist - right restraint for Non-Violent and Non-Self Destructive.

The ISD verified Patient 15's soft wrist bilateral (left/right) restraint were initiated on 10/6/2024 at 7 a.m., and the restraint order was obtained on 10/6/2024 at 2:37 p.m. (7 hours and 37 minutes after Patient 15 was put on soft wrist bilateral restraint).

During an interview and record review on 10/17/2024 at 2:41 p.m. with the ISD, the ISD stated, Patient 15's "Nursing Notes," dated 10/6/2024 at 7:00 a.m., indicated Patient 15 was confused, unable to answer questions, pulling at the foley catheter (a flexible tube that drains urine from the bladder into a collection bag) and nasogastric tube (NGT, a tube inserted through the nose, down the throat, and esophagus, and into the stomach). Patient 15 was placed on bilateral soft wrist restraint. The ISD verified there was no clinical documentation that the physician was notified of Patient 15's restraint application on 10/6/2024 at 7 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Guidelines," approve dated 11/2022, the P&P indicated, " ...Obtains a physician/LIP order prior to using medical restraints. If the physician/LIP is unavailable, restraints may be applied by registered nurse who has successfully demonstrated competence in restraint assessment and application. A telephone order from the physician/LIP shall be obtained as soon as possible, within 2 hours after the initiation of the intervention."

Based on interview and record review, the facility failed to meet the Condition of Participation for QAPI (Quality Assessment & Performance Improvement, a data driven and proactive approach to quality improvement) as evidenced by:

1. The facility failed to ensure the QAPI (Quality Assessment & Performance Improvement) Committee implement an effective plan of correction that ensured staff adherence to the facility's "Admission Triage to the Emergency Department" and "Chest Pain, Coronary Attack, and Cardiopulmonary Arrest" policy and procedure for three of 30 sampled patients (Patients 1, 2, and 3) after two incidents that occurred on 8/30/24 and a reoccurrence of the deficient practice on 10/15/24.

This deficient practice resulted in a reoccurrence of emergency department staff failing to follow policy and procedure, causing a delay in life-saving measures, and compromising Patient 6's safety and the potential to compromise the safety of other patients who present to the ED for chest pain. (Refer to A- 0283)

2. Based on interview and record review, the QAPI (Quality Assessment and Performance Improvement) failed ensure that adverse patient events are tracked, analyzed for causes, and implement preventive actions and mechanisms to ensure patient safety. There was no implementation of an effective preventative measures to prevent reoccurrence of delay in care for Patient 6, who presented to the ED on 10/15/24 for chest pain, did not receive triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait) prior to completing registration (collecting demographic and insurance information) by an admitting receptionist (staff who performs admitting activities), AR 4.

This event occurred after the incident of Patient 1, who presented to the ED on 8/30/24 for chest pain, who also did not receive triage assessment in a timely manner thus causing a delay in intervention that likely contributed to Patient 1's death.

This deficient practice resulted in a reoccurrence of emergency department staff failing to follow policy and procedure, which had the potential to cause delay in life-saving measures, thus compromising Patient 6's safety and the potential to compromise safety for other patients who also present to the ED with chest pain. (Refer to A-0286)

3. The facility failed to ensure the QAPI (Quality Assessment and Performance Improvement) department adhered to the facility's "Quality and Patient Safety Plan" to develop a root cause analysis (RCA, a process for identifying the base or contributing causal factors that underlie variations in performance associated with adverse events, sensitive events, or near misses) as part of the proactive risk assessment to report to the GB (Governing Body).

This deficient practice resulted in a reoccurrence of ED not following the facility's policy and procedure to assess and treat patients presenting to the ED for chest pain, which may result in a delay in life-saving measures for patients arriving to the ED with chest pain. (Refer to A- 0308)

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

Based on interview and record review, the facility failed to ensure the QAPI (Quality Assessment & Performance Improvement) Committee implemented an effective plan of correction (describes the actions the facility will take to correct deficiencies and specifies the date by which those deficiencies will be corrected) that ensured staff adherence to the facility's "Admission Triage to the Emergency Department" and "Chest Pain, Coronary Attack, and Cardiopulmonary Arrest" policy and procedure for three of 30 sampled patients (Patients 1, 2, and 3) after two incidents that occurred on 8/30/24 and a reoccurrence of the deficient practice on 10/15/24 when:

1. Patient 1 presented on 8/30/24 to the emergency department (ED, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, did not receive triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), a medical screening by a provider, and diagnostic test such as an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), and needed interventions. In addition, when Patient 1 was found, 36 minutes after arrival to ED, unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.) by the first responder (Nurse Practitioner, NP 1), NP 1 did not assess Patient 1 for responsiveness or check for pulse (the number of times the heart beats per minutes by palpating in the wrist or in the neck area); NP1 did not start CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest); and NP 1 did not call a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]).

This deficient practice had the potential to compromise overall patient safety for patients arriving in the ED resulting in delayed assessments and implementation of emergent interventions and also had the potential to cause patient death.


2. Patient 2, who presented to the ED on 8/30/24 for chest pain, waited for 26 minutes to receive a triage assessment after arrival to the emergency department, and waited 44 minutes to have a medical screening by a provider.

This deficient practice had the potential to result in delayed implementation of emergent interventions which may lead to patient death.

3. Patient 6, who presented on 10/15/24 to the ED for chest pain, did not receive triage assessment prior to completing registration (collecting demographic and insurance information) by an admitting receptionist (staff who performs admitting activities).

This deficient practice had the potential to result in delayed implementation of emergent interventions which may lead to patient death.

Findings:

1. During a concurrent interview and record review on 10/17/24 at 8:48 a.m. with the Director of Quality and Risk Management (DQRM), DQRM stated staff did not enter the incident of Patient 1, who came into the ED on 8/30/24 for chest pain and died due to delay in care, into the facility internal, "Incident Manage Portal (IMP)s." DQRM stated that when incidents were reported to the IMP, leaders such as the chief nursing officer (CNO), manager, and directors of appropriate units and quality performance (a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality) would be alerted to the incident, respond to the incident report, and would be able to follow up. DQRM confirmed that the facility started investigation on 9/3/24, 4 days after Patient 1's death.

During a concurrent interview and record review on 10/18/24 at 4:49 p.m. with the Director of Quality and Risk Management (DQRM), the facility's QAPI meeting minutes from 2/16/24 to 5/2024, were reviewed. The minutes did not have reports for the emergency department performance improvement, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), or MSE (Medical Screening Exam) time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider) or review of ED's policies and procedures.

DQRM stated in March 2024, the Director for QAPI resigned and the Manager for QAPI also resigned in May 2024. DQRM stated there was no report from QAPI to the governing body since last year, September 2023, and there had been no data collected on the ED's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements). DQRM stated the 4th quarter (October, November, and December) of 2023 should have been reported to GB. DQRM further stated the Ed throughput was not reported; "it absolutely should have been reported out." DQRM stated, "Throughput is one of those things, basic things that we reported out. It is important so that we can improve creating certain quality of care." DQRM verified that the GB was responsible for ensuring the QAPI department reports data collected from the ED's throughput to the GB.

During a concurrent interview and record review on 10/18/24 at 3:20 p.m. with the Chief Operation Officer (COO), the governing body meeting agenda and minutes dated September 2024, were reviewed. The COO verified that the incident with Patient 1 occurred on 8/30/24 in which delayed care contributed to Patient 1's death was not documented on the agenda or the minutes that were presented to the governing body. The COO stated the incident, investigation, and plan of correction were discussed verbally with the governing body; however, the root cause analysis (RCA, a process for identifying the causal factors of a medical error that may result in a sentinel event) was not presented to the governing body.

The COO further stated, the GB minutes and agenda did not have documentation on the Quality Assurance data (It involves assessing or evaluating quality; identifying problems or issues with care delivery and designing quality improvement activities to overcome them; and follow-up monitoring to make sure the activities did what they were supposed to) for the emergency department, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), MSE time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider), or review of emergency department policy and procedure such as "Chest pain protocol," or "Admission Triage to the Emergency Department," that was presented to the GB.

During a review of the facility's "Quality and Patient Safety Plan 2023-2024," the plan indicated, "The Quality and Risk Management Director shall continuously collect relevant patient safety data from internal and external sources ...At least once each quarter, the Quality and Risk Management Director shall assemble relevant patient safety data from internal and external sources and report it to the Quality Council/Patient Safety Committee ... The Quality Council/Patient Safety Committee shall conduct a proactive risk assessment of high-risk processes identified in the alerts or by the Director. This assessment shall include various steps such as identifying specific process steps with undesirable variations, reviewing confidential data, conducting root cause analyses, redesigning processes, and implementing measurement strategies to assess effectiveness."

During a review of the facility's policy and procedure (P&P) titled, "Incident Management Policies and
Procedures," dated June 2019, the P&P indicated, "A report will be entered in the Incident Management Portal (IMP) on every unusual occurrence involving a patient or visitor in any area of the hospital. This includes any programs or services provided in facilities outside of the immediate hospital grounds. The IMP system is used as part of the facilities integrated Risk and Process Assessment and Improvement (PA&I) Program. Risk Management as part of the PA&I Program, functions to identify and reduce facility liability and to identify, evaluate and reduce the risk of patient injury associated with care. Any occurrence involving a patient or visitor which is not consistent with the regular hospital routine, regardless of whether or not there was an apparent injury or other damage. defined above. It is the responsibility of the Risk Manager or designed staff to screen, report, investigate and follow-up on occurrences."

2. During a concurrent interview and record review on 10/16/24 at 4:24 p.m. with the Director of ER/ICU (DCS), Patient 2's "Emergency Department Triage (document of a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait) Form," dated 8/30/24, was reviewed. The triage form indicated Patient 2 arrived at the emergency department (ED) on 8/30/24 at 8:06 p.m., with a chief of complaint of chest pain since 6 p.m. The triage form indicated Patient 2 received triage at 8:33 p.m., 27 minutes after arriving in the ED for chest pain. DCS stated Patient 2 should not have waited 27 minutes to receive triage assessment.

During a review of Patient 2's "Conditions of Services (a general consent for medical screening, examination, and evaluation by a physician)," consent form dated 8/30/24, the form indicated Patient 2 signed the form on 8/30/24 at 8:08 p.m., 25 minutes prior to receiving triage assessment by a nurse.

During a review of Patient 2's "Order Chronology," undated, the order indicated, Patient 2 received the medical screening at 8:50 p.m., 44 minutes after the time of Patient 2's arrival (8:06 p.m.) to the emergency department for chest pain.

During a review of Patient 2's "Medical Screen Exam (MSE, a preliminary assessment that a patient receives when a patient presents in the Emergency Department)," dated 8/30/24, the "MSE" indicated, Patient 2 had history of CVA (cerebral vascular accident or a brain attack, is an interruption in the flow of blood to cells in the brain), presented with chief complaint of an episode of chest pain. The patient had an episode of "chest pain that lasted for approximately 8 minutes started at 7:00 p.m."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care. Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."
During a review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

3. During a review of Patient 6's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 6 was admitted to the emergency department (ED) on 10/15/2024 at 12:48 p.m., for chest pain and abdominal pain.

During a review of Patient 6's "Medical Screen Exam (MSE)," dated 10/15/24, the "MSE" indicated that Patient 1 with "h/o (history) MI (myocardial infarction, a stroke, when blood supply to the brain is interrupted) presents ED (emergency department) for left-sided pain x (times) 4 days. Describes chest pain as constant, mild in severity, radiating to the left arm, pulsating in quality, similar to prior MI, and worse with movement of the left arm. Denies any trauma or injury. No alleviating or aggravating factors. Patient also experiencing left upper abdominal pain but denies nausea, vomiting, shortness of breath, or any other symptom."

During a concurrent observation, interview, and record review on 10/15/24 at 12:51 p.m. with Admitting Representative (AR) 4 in the registration area, Patient 6 was sitting in front of AR 4, and AR 4 was typing as she was speaking with Patient 2. After typing, AR 4 yelled to the triage nurse, who was sitting across the room "This patient has chest pain." The patient was directed by the triage nurse to come over and sit by the triage nurse. A Review the electronic registration record with AR 4, indicated Patient 2's came from home, information on medical insurance, demographics (non-clinical data about a patient), and identification was entered on the registration screen.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, when a patient report that they are having chest pain the registration receptionist should only obtain identification, insurance should not be obtained until the patient is stable or family can provide. DPFS stated if the patient has been to the ER before, some information will be pulled from previous visits; however, medical insurance will require to be obtain each time the patient visits. DPFS stated it is important for patient with chest pain to be triage as soon as possible because there is protocol in place for the clinical team to do in a certain timeframe.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Scope of Services: Emergency Department," dated February 2023, the P&P indicated, "To provide a consistently high level of quality care to members of the community and any other person requiring emergency care. Offer services and programs which address and meet the full spectrum of needs of the patients and their families ...Upon presentation to the Emergency Department each patient is triaged by a registered nurse or physician prior to demographic or financial information being obtained."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain, Coronary Attack and Cardiopulmonary Arrest," dated February 2023, the P&P indicated, "Upon presentation of the patient at the Emergency Department, the nurse on duty will triage the patient so that the patient can be placed on a cardiac bed immediately. No patient will be turned away or delayed at the desk for clerical information or financial reasons. Notify the Emergency Department doctor of the patient's arrival and condition without delay. Follow chest pain protocol and emergency orders/ protocol."

During a review of the facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated November 2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures. Vital Signs are taken and recorded including temperature and 02 Saturation. Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs. Oxygen is started by nasal cannula at 2-3 Liters/Minute, if not already on. Connect patient to a monitor and obtain rhythm strip. Notify MD and carry out cardiac admission order accordingly. Administer medication as ordered for chest pain."

During a review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "The goals in patients presenting to the ED or office with acute chest pain are: identify life-threatening causes; determine clinical stability; and assess need for hospitalization versus safety of outpatient evaluation and management...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion (e381)."

Based on interview and record review, the QAPI (Quality Assessment and Performance Improvement) failed ensure that adverse patient events are tracked, analyzed for causes, and implement preventive actions and mechanisms to ensure patient safety. There was no implementation of an effective preventative measures to prevent reoccurrence of delay in care for Patient 6, who presented to the ED on 10/15/24 for chest pain, did not receive triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait) prior to completing registration (collecting demographic and insurance information) by an admitting receptionist (staff who performs admitting activities), AR 4.

This event occurred after the incident of Patient 1, who presented to the ED on 8/30/24 for chest pain, who also did not receive triage assessment in a timely manner thus causing a delay in intervention that likely contributed to Patient 1's death.

This deficient practice resulted in a reoccurrence of emergency department staff failing to follow policy and procedure, which had the potential to cause delay in life-saving measures, thus compromising Patient 6's safety and the potential to compromise safety for other patients who also present to the ED with chest pain.

Findings:

During a concurrent interview and record review on 10/17/24 at 8:48 a.m. with the Director of Quality and Risk Management (DQRM), the DQRM stated the incident regarding Patient 1, who came to the ED for chest pain, had died due to contributing events of delay in care, was not reported through the facility's internal reporting system, "Incident Manage Portal (IMP)s." The DQRM stated the incidents reported through the IMP, would be responded and followed up by the facility leaders (the chief nursing officer (CNO), manager, and directors of appropriate units and quality performance [a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality] department). The DQRM confirmed that Patient 1's incident was investigated on 9/3/24, 4 days after Patient 1's death.

During a concurrent interview and record review on 10/18/24 at 4:49 p.m. with the Director of Quality and Risk Management (DQRM), the facility's QAPI meeting minutes from 2/16/24 to 5/2024, were reviewed. The minutes did not have reports for the emergency department performance improvement, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), or MSE (Medical Screening Exam) time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider) or review of ED's policies and procedures.

During a concurrent interview and record review on 10/18/24 at 3:20 p.m. with the Chief Operation Officer (COO), the governing body meeting agenda and minutes dated September 2024, were reviewed. The COO verified that the incident with Patient 1 occurred on 8/30/24 in which delayed care contributed to Patient 1's death, was not documented on the agenda or the minutes that were presented to the governing body. The COO stated the incident, investigation, and plan of correction were discussed verbally with the governing body; however, the root cause analysis (RCA, a process for identifying the causal factors of a medical error that may result in a sentinel event) was not presented to the governing body. The COO further stated, the GB minutes and agenda does not have documentation on the Quality Assurance data (It involves assessing or evaluating quality; identifying problems or issues with care delivery and designing quality improvement activities to overcome them; and follow-up monitoring to make sure the activities did what they were supposed to) for the emergency department, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), MSE time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider), or review of emergency department policy and procedure such as "Chest pain protocol," or "Admission Triage to the Emergency Department," that was presented to the GB.

Based on interview and record review, the facility's governing body failed to ensure the QAPI (Quality Assessment and Performance Improvement) department adhered to the facility's "Quality and Patient Safety Plan" to develop a root cause analysis (RCA, a process for identifying the base or contributing causal factors that underlie variations in performance associated with adverse events, sensitive events, or near misses) as part of the proactive risk assessment to report to the GB.

This deficient practice resulted in a reoccurrence of ED not following the facility's policy and procedure to assess and treat patients presenting to the ED for chest pain. (Cross reference A-0286)

Findings:

During a review of Patient 1's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 1 was admitted to the emergency department (ED, is a hospital area staffed and equipped for the reception and treatment of persons requiring immediate medical care) on 8/30/24 at 8:30 a.m. Patient 1's demographic (non-clinical data about a patient, including: name, date of birth, address, phone number) and health insurance was obtained and documented on the face sheet.

During a review of Patient 1's "Physician Exam," note dated 8/30/24, the note indicated, "Patient (Patient 1) presented pulseless prior to triage, multiple rounds of high-quality CPR epinephrine were provided, patient was intubated ...After multiple rounds of CPR time of death was called at 2136 (9:36 p.m.)." The note indicated, "CC (chief of complaint) code Blue." The not indicate there is no EKG reading (left blank), and "diagnostic impression: cardiac arrest."

During a review of Patient 1's "ER Vital Signs & Nursing Intervention," report dated 8/30/24, the report indicated, "PT (Patient 1) BIB (brought in by) family member for CC (chief of complaint) of chest pain. Per admitting representative, (name of AR 1), PT (Patient 1) was not verbally responsive but was able to lift her hand for arm band placement and PT (Patient 1) was taken to wait room. Per security, PT (Patient 1) was placed onto waiting room chair by family member and left the ER (emergency room). PT (Patient 1) was found in waiting room unresponsive brought into ER to bed 2 immediately code blue initiated by (name of emergency room physician, MD 1) ..."

During a concurrent interview and record review on 10/15/24 at 4:45 p.m. with the Director of Quality and Risk Management (DQRM) and Supervisor of Security Services (SS), the surveillance video of the ED's entrance, which had views of the entrance to the waiting room and entrance to the ED treatment area, dated 10/30/24 from 8:21 p.m. through 9:09 p.m., was reviewed. DQRM verified the following seen on the surveillance video:

At 8:21 p.m., Patient 1's family member entered the ED entrance and spoke to the security who was situated at the entrance. The security brought a wheelchair and left the wheelchair at the exit.

At 8:22 p.m., Patient 1's family member came back and retrieved the wheelchair.

At 8:25 p.m., the family member wheeled Patient 1 into the ED treatment area. DQRM stated this was when Patient 1 was registered, the registration was located inside the door to the treatment area.

At 8:32 p.m., 7 minutes after Patient 1's arrival, Patient 1 was wheeled from the registration desk to the waiting room by the family member. The family member was seen exiting the ED less than a minute later.

At 9:08 p.m., a visitor was seen talking to the ED nurse practitioner (NP) 1 in the hallway by the waiting room entrance. DQRM stated the visitor was telling NP 1 to check on a patient (Patient 1) who was unresponsive. NP 1 was seen entering the waiting room, and within 2-3 seconds, NP 1 exited the waiting room.

At 9:09 p.m., Patient 1 was wheeled out of the waiting room by RN 4. Patient 1's upper torso was slumped to one side of the wheelchair and her head was pointed down to the ground. One of Patient 1's arm was dangling about two inches from the ground. DQRM confirmed a code blue was not called. DQRM stated Patient 1 was taken into the ED treatment area to start CPR.

During an interview on 10/16/24 at 9:26 a.m. with Admitting Representative (AR) 1, AR 1 stated that on 8/30/24, when Patient 1 was brought in by family, he (AR 1) completed the registration process, "the family member provided all the information," which included asking for identification, demographic, and insurance information. AR 1 confirmed that at this time Patient 1 was sitting in the wheelchair beside the family member. AR 1 stated that the family member requested to leave Patient 1 by the registration desk to wait because she (AR 1) was afraid that Patient may stand up and fall. AR 1 stated he (AR 1) placed Patient's admitting packet in a bin. AR 1 further stated he got busy with other patients coming in, and Patient 1 ended up in the waiting room. AR 1 stated, "I should have handed off to the triage nurse when the family member said chest pain." AR 1 verified that on 8/30/24, at 8:30 p.m., when Patient 1's family member reported that Patient 1 had chest pain, Patient 1 did not receive a triage assessment.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, "(Name of AR 1) should have alerted the triage nurse that Patient 1 has chest pain because for chest pain there is protocol in place for the clinical team to do in certain timeframe."

During an interview on 10/16/24 at 10:50 a.m. with triage nurse (RN) 2, who worked in the ER on 8/30/24 from 6 a.m. through 6 p.m., RN 2 stated, "I was not notified by the admitting clerk that the patient had chest pain." RN 2 verified that Patient 1 did not receive a triage assessment, instead was sent to the waiting room, as a result Patient 1 did not have an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), did not have vitals taken, and was not assessed by the ER physician prior to Patient 1 being found, nonresponsive in the waiting room by another patient.

During an interview on 10/16/24 at 10:00 a.m. with the ED Nurse Practitioner (NP) 1, NP 1 stated, when she (NP 1) entered the waiting room, Patient 1's cell phone was on the floor by Patient 1's feet, and Patient 1 was slumped over. NP 1 stated, "She (Patient 1) looks as if she is not breathing." NP 1 stated she (NP 1) did not assess and check Patient 1 for a pulse. NP 1 further stated, she (NP 1) left the room to put on gloves and to call for help.

During an interview on 10/17/24 at 9:40 a.m. with Registered Nurse (RN) 4, RN 4 stated after receiving report that there is a patient in the waiting room unresponsive, RN 4 enter the waiting room. RN 4 stated he determine that Patient 1 was unresponsive because Patient 1 was not moving and not reacting. RN 4 stated he did not assess Patient 1's for a pulse and did not call a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]).

RN 4 confirmed CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) was not started until Patient 1 was wheeled into the ED treatment area and placed on the gurney. RN 4 could not recall how long it took to transferred Patient 1 from the waiting room to the treatment room's gurney and thus when CPR was started. RN 4 further confirmed that Patient 1 was found unresponsive with unknown time when Patient 1 became unresponsive.

During a concurrent interview and record review on 10/18/24 at 3:20 p.m. with the Chief Operation Officer (COO), the governing body meeting agenda and minutes dated September 2024, were reviewed. The COO verified that the incident with Patient 1 occurred on 8/30/24 in which delayed care contributed to Patient 1's death, was not documented on the agenda or the minutes that were presented to the governing body. The COO stated the incident, investigation, and plan of correction were discussed verbally with the governing body; however, the root cause analysis (RCA, a process for identifying the causal factors of a medical error that may result in a sentinel event) was not presented to the governing body.

The COO further stated, the GB minutes and agenda does not have documentation on the Quality Assurance data (It involves assessing or evaluating quality; identifying problems or issues with care delivery and designing quality improvement activities to overcome them; and follow-up monitoring to make sure the activities did what they were supposed to) for the emergency department, such as the emergency department's throughput (tracks ED arrival to ED departure for patients admitted to the facility from the ED used to analyze ED operations and identify workflow improvements), MSE time frame (tracking patient time of arrival to the ED to the time they received a medical screening exam by a provider), or review of emergency department policy and procedure such as "Chest pain protocol," or "Admission Triage to the Emergency Department," that was presented to the GB.

During a review of the facility's Quality and patient Safety Plan 10223-2024," the plan indicated "At least once each quarter, the Quality and Risk Management Director shall assemble relevant patient safety data from internal and external sources and report it to the Quality Council/Patient Safety Committee. The report shall contain pertinent information related to the type, severity, frequency, and impact of Adverse Events, Sentinel Events, Near Misses, and Hazardous Conditions, along with any remedial actions taken... The Quality Council/Patient Safety Committee shall conduct a proactive risk assessment of high-risk processes identified in the alerts or by the Director. This assessment shall include various steps such as identifying specific process steps with undesirable variations, reviewing confidential data, conducting root cause analyses, redesigning processes, and implementing measurement strategies to assess effectiveness."

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 ensure one of 30 sampled Patients (Patient 1), Patient 1, when found to be unresponsive by the first responder (Nurse Practitioner, NP 1), receive assessment; CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest); and that a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) was called in a timely manner.

This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 1's death (Refer to A-0395)

2. The facility failed to ensure one of 30 sampled patients (Patient 19) was reassessed (reevaluate) for chest pain after Nitroglycerin (medication used primarily to relief chest pain) was given. This deficient practice had the potential to result in delayed intervention needed when the medication's effectiveness was not assessed. This deficient practice may also result to complications such as extremely low blood pressure and may lead to damage in the brain and other vital organs. (Refer to A-0395)

3. The facility failed to ensure one of 30 sampled patient's (Patient 19) vital signs (VS, measurement of body temperature, heart rate, rate of breathing, blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]), oxygen saturation [percentage of oxygen in the blood] and level of pain) was obtained in accordance with the facility's policy and procedure regarding reassessment. This deficient practice had the potential to result in the timely provision of necessary interventions which could lead to worsening of patient's condition such as stroke (when blood flow to the brain is disrupted, causing brain damage or death), heart attack, etc. (Refer to A-0395)

4. The facility failed to ensure seven of 30 sampled patients' (Patients 16, 22, 23, 25, 27, 28, and 29's) pain was assessed in accordance with the facility's policy and procedure regarding pain assessment.
This deficient practice had the potential to result in Patients 19, 16, 22, 23, 25, 27, 28, and 29's delayed treatment and may cause worsening of pain that can lead to psychological distress due to unmanaged pain. (Refer to A-0395)

5. The facility failed to ensure one of 30 sampled patients (Patient 1), who presented to the emergency department (ER, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), a medical screening by a provider, and diagnosis such as an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), and needed interventions prior to completing a registration (collecting demographic and insurance information), instead of being sent to wait in the waiting room.

This deficient practice resulted in Patient 1 being found by the visitor, 36 minutes after registration in the waiting room unresponsive, which likely contributed to Patient 1's death. (Refer to A-0398)

6. The facility failed to ensure two of three sampled patients (Patients 4 and 5), Patients 4 and 5, Heart rate (HR, heartbeat per minutes) alarm, Respiration (RR, breath per minute) alarm, and Apnea (stop breathing) alarm was not turned off in compliance with the facility's policy and procedure.

This deficient practice has the potential for critical change in vital signs that may go unnoticed, if the heart rate drops significantly or if Patient 4 or Patient 5 stop breathing, the absence of an alarm could delay necessary interventions, potentially leading to severe complications which can compromise Patient 4 and Patient 5 safety. (Refer to A-0398)

7. The facility failed to ensure for one of 30 sampled patients (Patient 20), the facility's policy and procedure (P&P) for chest pain was implemented when, Patient 20's electrocardiogram (EKG or ECG, test that measures the electrical activity of the heart) was not completed timely.

This deficient practice had the potential to result in Patient 20's delayed treatment that could have a negative effect on Patient 20's provision of care which could lead to the patient's deterioration of condition and/or death. (Refer to A-0398)

8. The facility failed to ensure for one of two sampled Emergency Cart (Emergency Cart 2, mobile cart unit stocked with emergency medical equipment, supplies, and drugs use by medical personnel for life threatening emergency), Emergency Cart 2, was checked daily for clean equipment when, Emergency Cart 2's suction machine (medical device to clear the airway of secretions or obstructions like mucus or saliva), was not readily available for use and had a green tag labeled "Dirty."

This deficient practice had the potential to result in an emergency equipment not readily available for use when needed which could delay the provision of necessary care and may compromise patient safety. This deficient practice also had the potential to result in bacterial contamination due to a dirty equipment in the crash cart. (Refer to A-0398)

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

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

1. Ensure one of 30 sampled Patients (Patient 1), Patient 1, when found to be unresponsive by the first responder (Nurse Practitioner, NP 1), receive assessment; CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest); and that a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]) was called in a timely manner.

This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 1's death

2.a. Ensure one of 30 sampled patients (Patient 19) was reassessed (reevaluate) for chest pain after Nitroglycerin (medication used primarily to relief chest pain) was given. This deficient practice had the potential to result in delayed intervention needed when the medication's effectiveness was not assessed. This deficient practice may also result to complications such as extremely low blood pressure and may lead to damage in the brain and other vital organs.

2.b. Ensure one of 30 sampled patient's (Patient 19) vital signs (VS, measurement of body temperature, heart rate, rate of breathing, blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]), oxygen saturation [percentage of oxygen in the blood] and level of pain) was obtained in accordance with the facility's policy and procedure regarding reassessment. This deficient practice had the potential to result in the timely provision of necessary interventions which could lead to worsening of patient's condition such as stroke (when blood flow to the brain is disrupted, causing brain damage or death), heart attack, etc.

3. Ensure seven of 30 sampled patients' (Patients 16, 22, 23, 25, 27, 28, and 29's) pain was assessed in accordance with the facility's policy and procedure regarding pain assessment.

This deficient practice had the potential to result in Patients 19, 16, 22, 23, 25, 27, 28, and 29's delayed treatment and may cause worsening of pain that can lead to psychological distress due to unmanaged pain.

Findings:

1. During a review of Patient 1's "face sheet (a document that gives a patient's information at a quick glance)," undated, the "face sheet" indicated, patient 1 was admitted to the emergency department (ED, which is a hospital area staffed and equipped for the reception and treatment of persons requiring immediate medical care) on 8/30/24 at 8:30 a.m. Patient 1 demographic (non-clinical data about a patient, including: name, date of birth, address, phone number) and health insurance were obtained.

During a review of Patient 1's "Physician Exam," note dated 8/30/24, the note indicated, "Patient (Patient 1) presented pulseless prior to triage, multiple rounds of high-quality CPR epinephrine (adrenaline, medication used to treat low blood pressure and slow heart rate and allergic reaction) were provided, patient was intubated (tube inserted into the windpipe to help with breathing)... After multiple rounds of CPR, the time of death was called at 2136 (9:36 p.m.)." The note indicated, "CC (chief of complaint) code Blue." The note also indicated there is no EKG reading (left blank) and "diagnostic impression: cardiac arrest."

During a review of Patient 1's "ER Vital Signs & Nursing Intervention" report dated 8/30/24, the report indicated, "PT (Patient 1) BIB (brought in by) family member for CC (chief complaint) of chest pain. Per admitting representative (name of AR 1), PT (Patient 1) was not verbally responsive but was able to lift her hand for armband placement, and PT (Patient 1) was taken to the waiting room. Per security, PT (Patient 1) was placed on a waiting room chair by a family member and left the ER (emergency room). PT (Patient 1) was found in the waiting room unresponsive and brought into the ER to bed 2 immediately, code blue initiated by (name of emergency room physician, MD 1) ..."

During a concurrent interview and record review on 10/15/24 at 4:45 p.m. with the Director of Quality and Risk Management (DQRM) and Supervisor of Security Services (SS), the SS provided and played the surveillance video of the ED's entrance, which has views of the entrance to the waiting room and entrance to the ED treatment area, dated 10/30/24 from 8:21 p.m. through 9:09 p.m., was reviewed. DQRM verified the following seen on the surveillance video:

At 8:21 p.m., Patient 1's family member entered the ED entrance and spoke to the security who was situated at the entrance. The security brought a wheelchair and left the wheelchair at the exit.

At 8:22 p.m., Patient 1's family member came back and retrieved the wheelchair.

At 8:25 p.m., the family member wheeled Patient 1 into the ED treatment area. DQRM stated this is when Patient 1 was registered, the registration is located inside the door to the treatment area.

At 8:32 p.m., 7 minutes after Patient 1's arrival, Patient 1 was wheeled from the registration desk to the waiting room by the family member. The family member was seen exiting the ED less than a minute later.

At 9:08 p.m., a visitor was seen talking to the ED nurse practitioner (NP) 1 in the hallway by the waiting room entrance. DQRM stated the visitor is telling NP 1 to check on a patient (Patient 1) who is unresponsive. NP 1 seen entered the waiting room, and within 2-3 seconds, NP 1 exited the waiting room.

At 9:09 p.m., Patient 1 was wheeled out of the waiting room by RN 4. Patient 1's upper torso was slumped to one side of the wheelchair and her head was pointed down to the ground. One of Patient 1's arm was dangling about two inches from the ground. DQRM confirmed a code blue was not called. DQRM stated Patient 1 was taken into the ED treatment area to start CPR.

During an interview on 10/16/24 at 10:00 a.m. with the ED Nurse Practitioner (NP) 1, NP 1 stated, when she enters the waiting room, Patient 1's cell phone was on the floor by patient 1's feet, and Patient 1 was slumped over. NP 1 stated she did not assess and check Patient 1 for a pulse (the number of times the heart beats per minutes by palpating in the wrist area or in the neck). NP 1 further stated, she left the room to put on gloves and to call for help.

During an interview on 10/17/24 at 9:40 a.m. with Registered Nurse (RN) 4, RN 4 stated after receiving report that there is a patient in the waiting room unresponsive, RN 4 enter the waiting room. RN 4 stated he determine that Patient 1 was unresponsive because Patient 1 was not moving and not reacting. RN 4 stated he did not assess Patient 1's for a pulse and did not call a code blue (overhead page that alerts staff a patient is in possible life-threatening distress requiring lifesaving procedure [resuscitation]).

RN 1 confirmed CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating to increase chances of survival after cardiac arrest) was not started until Patient 1 was wheeled into the ED treatment area and placed on the gurney. RN 4 could not recall how long it took to transferred Patient 1 from the waiting room to the treatment room's gurney and thus when CPR was started. RN 1 further confirmed that Patient 1 was found unresponsive with unknown time when Patient 1 became unresponsive.

During a concurrent interview and record review on 10/18/24 at 10:30 a.m. with the Director of Emergency/ICU (DCS), the facility's policy and procedure (P&P) titled, "Code Blue" dated November 2022 was reviewed. The P&P indicated, "Staff who discovers the patient, shall call for help and initiate CPR/BLS ... Primary Advance Cardiac Life Support (ACLS) Registered Nurse (RN) (Telemetry ACLS RN/ICU - ER RN) assesses patient's overall status -ensures CPR/BLS is started, places patient on monitor, delivers defibrillation per ACLS guidelines, delegates I. V. medications, recording to other ACLS RNs. (House Supervisor, Director, another ACLS RN), delegates preparing and assisting with intubation to Respiratory Therapist or ACLS RN and coordinates the CODE BLUE process." The DCS stated, staff did not follow the policy, they should have follow this process ... GROUND FLOOR Code Blue: Personnel from Emergency Department shall bring the Crash Cart."

A review of the American Heart Association CPR & First Aid guideline provided by the facility titled, "Adult Basic and Advance Life Support," dated 2021, the guideline indicated, "If a victim is unconscious/unresponsive, with absent or abnormal breathing (i.e., only gasping), the healthcare provider should check for a pulse for no more than 10 s and, if no definite pulse is felt, should assume the victim is in cardiac arrest. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions, early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia.

2. During a review of Patient 19's, "Emergency Department Triage Form," dated 7/27/24, the triage form indicated, Patient 19 presented to the Emergency Department (ED) with a chief complaint of abdominal pain x (times) 2 days, constipation, and chest pain.

2.a. During a concurrent interview and record review on 10/17/2024 at 4:51 p.m. with the Information System Director (ISD), the ISD verified Patient 19 had a physician's order, dated 07/27/24 at 6:54 p.m., of Nitroglycerin 0.4 milligram (mg, metric unit of measurement, used for medication dosage and/or amount) 1 tablet to be given sublingual (under the tongue) every 5 minutes times (x) 3 as needed for chest pain, if not relieved call the physician.

In the same interview and record review on 10/17/2024 at 4:51 p.m., the ISD verified Patient 19's, "Order detail -Administrations" which indicated Patient 19 received Nitroglycerin 0.4 mg via sublingual on 7/27/24 at 7:17 pm.

Subsequently, on 10/17/2024 at 4:51 p.m., the ISD further verified that Patient 19's "ER: Vital Signs & (and) Nursing Interventions and Procedures," dated 7/27/24, had no documentation of Patient 19's follow-up reassessment of vital signs (VS) and pain assessment after the patient received nitroglycerin for chest pain.

During a concurrent interview on 10/18/2024 at 10:41 a.m., with Registered Nurse 7 (RN 7), RN 7 stated the patient should be reassessed after 5 minutes of giving the nitroglycerin to know if additional dose was needed as indicated in the physician's order. RN 7 further stated the patient's reassessment was important after giving the nitroglycerin because it could cause for the patient's blood pressure to drop.

In the same interview on 10/18/2024 at 10:41 a.m., with RN 7, RN 7 verified Patient 19's "ER: Vital Signs & Nursing Interventions and Procedure," indicated VS were not assessed after 5 minutes of administration of Nitroglycerin at 7:17 p.m. RN 7 stated Patient 19's next VS was taken at 11:30 p.m. (4 hours after the patient was given nitroglycerin).

During a review of the facility's policy and procedure (P&P) titled, "Standards of Care Scope of Service," date approved in 2/2023, the P&P indicated, "Reassessment with vital signs also occurs after all narcotic, cardiac, vasoactive or other medication which may have an effect on a vital sign, following all procedures which may affect a patient's condition..."


2.b. During a concurrent interview and record review on 10/17/2024 at 4:16 p.m. with the Information System Director (ISD), the ISD verified Patient 19's "Emergency Department Triage Form," indicated that on 7/27/2024 at 6:15 p.m., Patient 19 was triaged (process of sorting and prioritizing patients for care) for a chief complaint of abdominal pain for 2 days, constipation, and chest pain. Patient 19 was assigned a triage level of 2, emergent (Level 2, emergent refers to patients who require rapid medical intervention for a condition that could pose a threat to life and or limb. Emergent condition include chest pain).

In the same interview and record review on 10/17/2024 at 4:16 p.m., with the ISD, the ISD verified Patient 19's vital signs (VS) on triage (7/27/2024 at 6:15 p.m.) were: Temperature 98.6 Fahrenheit (F), HR 103 (heart rate), RR 18 (Respiration), BP 180/97 (Blood Pressure), 96% O2 Saturation (measures the amount of oxygen in the blood).

Subsequently, on 10/17/2024 at 4:16 p.m., the ISD verified Patient 19's "ER: Vital Signs & (and) Nursing Interventions and Procedure" which indicated that the next set of Patient 19's VS were taken at the following dates and times:

- On 7/27/2024 at 11:30 p.m., Patient 19's VS were 98.6 F, HR 96, RR 20, BP 155/95, and 97% O2 sat; and,

- On 7/28/27 at 2:55 a.m., Patient 19's VS were 97.0 F, HR 72, RR 20, BP 135/82 and 98% O2 Sat.


During an interview on 10/17/24 at 4:16 p.m. with the Director of Critical Services (DCS), the DCS stated Patient 19 was triaged as Level 2, emergent. The DCS stated Patient 19's vital signs should had been checked every 30 minutes to 60 minutes until stable as indicated in the facility's policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Admission Triage To The Emergency Department (Triage)," dated 2/2023, the P&P indicated, "II. EMERGENT (PATIENTS REQUIRING RAPID PHYSICIAN ATTENTION) ...EMERGENT refers to patients who require rapid medical intervention for a condition that could pose a threat to life and or limb. Emergent conditions include, but are not limited to: ...Chest pain ...ANY OTHER SUSPECTED LIFE THREATENING SITUATION Vital signs in this category should be every 30-60 minutes or less until the patient is stabilized."

3. During a concurrent interview and record review on 10/16/2024 at 4:12 p.m. with the Information System Director (ISD), the ISD verified Patient 16's "Emergency Department Triage Form," dated 10/9/2024, indicated Patient 16 was triaged (a process that prioritizes patients based on urgency of medical needs) on 10/9/2024 at 12:44 a.m. with a chief complaint of chest pain x (times) 1 week and numbness (loss of feeling or sensation in an area of your body) on BLE (bilateral lower extremities, refers to both lower limbs of the body).

In the same interview and record review on 10/16/2024 at 4:12 p.m., the ISD verified Patient 16's vital signs (VS) on triage (10/9/2024 at 12:44 a.m.) was: Temperature 97.3 Fahrenheit (F), Pulse rate of 60, Respiration rate of 20, Blood Pressure of 167/80, O2 saturation of 99%. The ISD verified Patient 16's pain was not assessed.

During a concurrent interview and record review on 10/16/2024 at 4:31 p.m. with ISD, the ISD verified Patient 16's "ER Vital Signs & Nursing Interventions and Procedure-Re-Assessment/Intervention/Responses," dated 10/9/2024 at 2:30 a.m., indicated Patient 16 had been having pain and cramps on both legs with a pain score of 9 out of 10 pain scale (pain score of 7-10 was considered severe pain). The ISD stated Patient 16's initial pain assessment was done on 10/9/2024 at 2:30 a.m. (2 hours and 46 minutes after Patient 16 was triaged).

During an interview on 10/16/2024 at 4:27 p.m. with the Director of Critical Services (DSC), the DSC stated pain assessment should be included when the patient was triaged and should have been documented in the triage form when patient presented to the ED with pain.

During a review of facility's policy and procedure (P&P) titled, "Vital Sign Protocol," revised in 07/2024, the P&P indicated, "1.2 Routine vital signs consist of: a. Blood pressure b. Pulse c. Respiration d. Temperature e. Pain Scale."

During a review of facility's policy and procedure (P&P) titled, "Chest Pain Protocol," date approved in 11/2022, the P&P indicated, "Purpose...To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures ...Document...Time of onset, the location, duration and type of pain (pressure, piercing, burning) utilizing a pain scale of 1 to 10 ..."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," date approved on 08/2023, the P&P indicated, "All patients will be assessed for pain at regular intervals with vital signs and with each new report of pain...It is the responsibility of all hospital employees to facilitate the pain relieving process and expedite interventions needed to keep patients comfortable by reporting patient complaints of pain to the nursing staff and/or physician."

4. During a concurrent interview and record review on 10/16/2024 at 4:10 p.m. with telemetry charge nurse (CN) 1, CN 1 verified Patient 22's emergency department (ED) "Triage note," dated 10/3/2024, indicated Patient 22's chief complaint was headache after a fall (an event which results in a person coming to rest inadvertently on the ground or another lower level). CN 1 stated there was no documented evidence Patient 22 was assessed for pain during triage (the process of sorting and categorizing patients based on the severity of their injuries, and the order in which patients require care and monitoring).

Concurrently, during an interview on 10/16/2024 at 4:10 p.m., with the Director of Critical Services (DCS), the DCS stated when a patient was being triaged, the triage nurse should assess the patient for pain.

During a review of the facility's policy and procedure (P&P) titled, "Vital Sign Protocol," revised in 07/2024, the P&P indicated, "1.2 Routine vital signs consist of: a. Blood pressure b. Pulse c. Respiration d. Temperature e. Pain Scale."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," date approved in 08/2023, the P&P indicated, "All patients will be assessed for pain at regular intervals with vital signs and with each new report of pain...It is the responsibility of all hospital employees to facilitate the pain relieving process and expedite interventions needed to keep patients comfortable by reporting patient complaints of pain to the nursing staff and/or physician."

5. During a concurrent interview and record review on 10/16/24 at 4:25 p.m. with telemetry charge nurse (CN) 1, CN 1 verified Patient 23's emergency department (ED) "Triage note," dated 9/29/24, chief complaint was chest pain for two hours.
In the same interview and record review on 10/16/24 at 4:25 p.m., CN 1 verified Patient 23 had a physician's order, dated 9/29/24, for aspirin (medication for pain) 81 milligrams (mg) by mouth once. CN 1 stated Patient 23's "Medication Administration Record," dated 9/29/24, indicated Patient 1 was given aspirin 81 mg at 9:20 p.m.
Furthermore, on 10/16/24, at 4:25 p.m., CN 1 verified Patient 23's "ED Vital Signs, Nursing Interventions and Procedures form," dated 9/29/24, CN 1 stated Patient 23's pain was not reassessed after aspirin was given, at 9:20 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," dated 8/2023, the P&P indicated the following:

1. Pain assessment and management program was implemented in accordance with established guidelines by the regulatory and professional organizations.
2. All patients will be assessed for pain at regular intervals, with vital signs and with each new report of pain.
3. All patients will be re-assessed and documented for pain, after pain relieving interventions.
4. Medications for pain, administered by IV, will be reassessed in 30 minutes.
5. Medications for pain, administered by mouth, will be reassessed in 60 minutes.

6. During a concurrent interview and record review on 10/17/2024, at 11:44 a.m. with the Director of Education (DSD), Patient 25's ED Vital Signs, Nursing Interventions and Procedures form, dated 9/30/24, DSD stated patient was in the ED with a 5150 hold (a section of California Welfare and Institutions Code that allows for the involuntary psychiatric hospitalization of an adult experiencing a mental crisis) and was transferred to another facility with an inpatient psychiatric unit. During patient's stay in the ED from 9/30/24 to 10/1/24, patient was not assessed for pain on 10/1/24 with vital signs at 6:30 a.m., 7:22 a.m., 9:42 a.m., and prior to being transferred to another facility.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," dated 8/2023, the P&P indicated the following:

1. Pain assessment and management program was implemented in accordance with established guidelines by the regulatory and professional organizations.
2. All patients will be assessed for pain at regular intervals, with vital signs and with each new report of pain.
3. All patients will be re-assessed and documented for pain, after pain relieving interventions.
4. Medications for pain, administered by IV, will be reassessed in 30 minutes.
5. Medications for pain, administered by mouth, will be reassessed in 60 minutes.

7. During a concurrent interview and record review on 10/17/24 at 3:09 p.m. with the Director of Education (DSD), the DSD verified Patient 27's emergency department (ED) "Triage note," dated 10/1/2024, Patient 27's chief complaint was abdominal pain for ten hours. The DSD stated there was no documented evidence Patient 27's pain was assessed during triage (the process of sorting and categorizing patients based on the severity of their injuries, and the order in which patients require care and monitoring).

During a review of facility's P&P titled, "Vital Sign Protocol," revised in 07/2024, the P&P indicated, "1.2 Routine vital signs consist of: a. Blood pressure b. Pulse c. Respiration d. Temperature e. Pain Scale."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," date approved in 08/2023, the P&P indicated, "All patients will be assessed for pain at regular intervals with vital signs and with each new report of pain...It is the responsibility of all hospital employees to facilitate the pain relieving process and expedite interventions needed to keep patients comfortable by reporting patient complaints of pain to the nursing staff and/or physician."

8. During a concurrent interview and record review, on 10/17/2024, at 3:55 p.m., with the Director of Education (DSD), the DSD verified Patient 28's emergency department (ED) "Triage note," dated10/1/2024, indicated Patient 28's chief complaint was lower abdominal cramps. The DSD stated there was no documented evidence Patient 27's pain was assessed during triage (the process of sorting and categorizing patients based on the severity of their injuries, and the order in which patients require care and monitoring).
Concurrently, during an interview on 10/17/2024, at 3:55 p.m., with the Director of Critical Services (DCS), the DCS stated when a patient was being triage, the triage nurse should assess the patient for pain.
During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," dated 8/2023, the P&P indicated the following:

-Pain assessment and management program was implemented in accordance with established guidelines by the regulatory and professional organizations.

-All patients will be assessed for pain at regular intervals, with vital signs and with each new report of pain.
-All patients will be re-assessed and documented for pain, after pain relieving interventions.

-Medications for pain, administered by IV, will be reassessed in 30 minutes.

-Medications for pain, administered by mouth, will be reassessed in 60 minutes.

During a review of the facility's policy and procedure (P&P) titled, "Vital Sign Protocol," dated 7/24, the P&P indicated the following:
-Routine vital signs (VS) included blood pressure, pulse, respirations, temperature, and pain scale.
-Routine VS in the emergency department (ED) is every two hours.

During a review of the facility's P&P titled, "Standards of Care/Scope of Service," dated 2/2023, the P&P indicated the following: Staff requirements included current state licensure, basic life support certification, and Advance Cardiac Life Support certification.

-Every ED patient can expect to receive triage on admission, nursing care based on the assessment of their needs, the provision of a safe environment, and initiation of immediate treatment for emergencies.

- Reassessment of the patient is ongoing and done with vital signs, after all narcotic and cardiac medications, which may have an effect on the patient's vital signs.

9. During a concurrent interview and record review on 0/17/24 at 4:08 p.m. with the Director of Education (DSD), the DSD verified Patient 29's emergency department (ED) "Triage note," dated10/3/2024, Patient 29's chief complaint was abdominal pain for one week. The DSD stated there was no documented evidence Patient 29's pain was assessed during triage (the process of sorting and categorizing patients based on the severity of their injuries, and the order in which patients require care and monitoring).

Concurrently, during record review of Patient 29's ED physician notes and physician orders, dated 10/3/24, DCS stated physician ordered morphine sulfate 2 milligrams (mg) intravenous (IV -into the vein) medication, once, for pain at 7:31 a.m.

During a review of Patient 29's medication administration record, dated 10/3/24, DCS stated patient 29 received pain medication at 8:37 a.m. During review of patient's 29's ED Vital Signs, Nursing Interventions and Procedures form, dated 10/3/24, DCS stated patient was not assessed for pain prior to and after pain medication, morphine sulfate 2 mg IV was administered.

During interview with Director of Critical Services (DCS), DCS stated during triage (the process of sorting and categorizing patients based on the severity of their injuries, and the order in which patients require care and monitoring) in the ED, the triage nurse should assess the patient for pain.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management Guidelines," dated 8/2023, the P&P indicated the following:

-Pain assessment and management program was implemented in accordance with established guidelines by the regulatory and professional organizations.

-All patients will be assessed for pain at regular intervals, with vital signs and with each new report of pain.
-All patients will be re-assessed and documented for pain, after pain relieving interventions.

-Medications for pain, administered by IV, will be reassessed in 30 minutes.

-Medications for pain, administered by mouth, will be reassessed in 60 minutes.

During a review of the facility's policy and procedure (P&P) titled, "Vital Sign Protocol," dated 7/24, the P&P indicated the following:
-Routine vital signs (VS) included blood pressure, pulse, respirations, temperature, and pain scale.
-Routine VS in the emergency department (ED) is every two hours.

During a review of the facility's P&P titled, "Standards of Care/Scope of Service," dated 2/2023, the P&P indicated the following:-Staff requirements included current state licensure, basic life support certification, and Advance Cardiac Life Support certification.

-Every ED patient can expect to receive triage on admission, nursing care based on the assessment of their needs, the provision of a safe environment, and initiation of immediate treatment for emergencies.

- Reassessment of the patient is ongoing and done with vital signs, after all narcotic and cardiac medications, which may have an effect on the patient's vital signs.

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

1. Ensure one of 30 sampled patients (Patient 1), who presented to the emergency department (ER, area in the hospital staffed and equipped for the reception and treatment of persons requiring immediate medical care) for chest pain, received a triage assessment (a quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait), a medical screening by a provider, and diagnosis such as an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), and needed interventions prior to completing a registration (collecting demographic and insurance information), instead of being sent to wait in the waiting room.

This deficient practice resulted in Patient 1 being found by the visitor, 36 minutes after registration in the waiting room unresponsive, which likely contributed to Patient 1's death.

2. Ensure two of three sampled patients (Patients 4 and 5), Patients 4 and 5, Heart rate (HR, heartbeat per minutes) alarm, Respiration (RR, breath per minute) alarm, and Apnea (stop breathing) alarm was not turned off in compliance with the facility's policy and procedure.

This deficient practice has the potential for critical change in vital signs that may go unnoticed, if the heart rate drops significantly or if Patient 4 or Patient 5 stop breathing, the absence of an alarm could delay necessary interventions, potentially leading to severe complications which can compromise Patient 4 and Patient 5 safety.

3. Ensure for one of 30 sampled patients (Patient 20), the facility's policy and procedure (P&P) for chest pain was implemented when, Patient 20's electrocardiogram (EKG or ECG, test that measures the electrical activity of the heart) was not completed timely.

This deficient practice had the potential to result in Patient 20's delayed treatment that could have a negative effect on Patient 20's provision of care which could lead to the patient's deterioration of condition and/or death.

4. Ensure for one of two sampled Emergency Cart (Emergency Cart 2, mobile cart unit stocked with emergency medical equipment, supplies, and drugs use by medical personnel for life threatening emergency), Emergency Cart 2, was checked daily for clean equipment when, Emergency Cart 2's suction machine (medical device to clear the airway of secretions or obstructions like mucus or saliva), was not readily available for use and had a green tag labeled "Dirty."

This deficient practice had the potential to result in an emergency equipment not readily available for use when needed which could delay the provision of necessary care and may compromise patient safety. This deficient practice also had the potential to result in bacterial contamination due to a dirty equipment in the crash cart.

Findings:

1. During a review of Patient 1's "Face sheet (a document that gives a patient's information at a quick glance)," undated, the "Face sheet" indicated, Patient 1 was admitted to the emergency department (ED, is a hospital area staffed and equipped for the reception and treatment of persons requiring immediate medical care) on 8/30/24 at 8:30 a.m. Patient 1 demographic (non-clinical data about a patient, including: name, date of birth, address, phone number) and health insurance was obtained and documented on the face sheet.

During a review of Patient 1's "Physician Exam," note dated 8/30/24, the note indicated, "Patient (Patient 1) presented pulseless prior to triage, multiple rounds of high-quality CPR epinephrine were provided, patient was intubated ...After multiple rounds of CPR time of death was called at 2136 (9:36 p.m.)." The note indicated, "CC (chief of complaint) code Blue." The not indicate there is no EKG reading (left blank), and "diagnostic impression: cardiac arrest."

During a review of Patient 1's "ER Vital Signs & Nursing Intervention," report dated 8/30/24, the report indicated, "PT (Patient 1) BIB (brought in by) family member for CC (chief of complaint) of chest pain. Per admitting representative, (name of AR 1), PT (Patient 1) was not verbally responsive but was able to lift her hand for arm band placement and PT (Patient 1) was taken to wait room. Per security, PT (Patient 1) was placed onto waiting room chair by family member and left the ER (emergency room). PT (Patient 1) was found in waiting room unresponsive brought into ER to bed 2 immediately code blue initiated by (name of emergency room physician, MD 1) ..."

During an interview on 10/16/24 at 9:26 a.m. with Admitting Representative (AR) 1, AR 1 stated that on 8/30/24, when Patient 1 was brought in by family, AR 1 completed the registration process, "the family member provided all the information," which included asking for identification, demographic, and insurance information. AR 1 confirmed that at this time Patient 1 was sitting in the wheelchair beside the family member. AR 1 further stated that the family member requested to leave Patient 1 by the registration desk to wait because she was afraid that Patient may stand up and fall. AR 1 stated he placed Patient's admitting packet in a bin that the triage nurse would pick up and reviewed as soon as possible. AR 1 further stated they got busy with other patients coming in, and Patient 1 ended up in the waiting room. AR 1 stated, "I should have handed off to the triage nurse when the family member said chest pain." AR 1 verified that on 8/30/24, at 8:30 p.m. when Patient 1's family member reported that Patient 1 had chest pain, Patient 1 did not receive a triage assessment.

During an interview on 10/16/24 at 9:41 a.m. with the Director of Patient Financial Services/Admitting (DPFS), the DPFS stated, "(Name of AR 1) should have alerted the triage nurse that Patient 1 has chest pain because for chest pain there is protocol in place for the clinical team to do in certain timeframe."

During an interview on 10/16/24 at 10:50 a.m. with triage nurse (RN) 2, who worked in the ED on 8/30/24 from 6 a.m. through 6 p.m., RN 2 stated, "I was not notified by the admitting clerk that the patient (Patient 1) had chest pain." RN 2 verified that Patient 1 did not receive a triage assessment, instead was sent to the waiting room, as a result Patient 1 did not have an EKG (an electrocardiogram, a test to record the electrical signals in the heart and show how the heart is beating), did not have vitals taken, and was not assess by the ED physician prior to Patient 1 being found, nonresponsive in the waiting room.

During a concurrent interview and record review on 10/16/24 at 4:12 p.m. with the Director of ED/ICU (DCS), Patient 1's electronic medical record (EMR, an electronic version of a patient's medical history, that is maintained over time), titled "Physician Exam," was reviewed. DICS confirmed that there was no disclosure of Patient 1 regarding the unanticipated outcome resulting from delay in care for Patient 1 that may have contributed to Patient 1's death.

During an interview on 10/16/24 at 5:27 p.m. with ED physician (MD 1) who treated Patient 1 on 8/30/24, MD 1 stated although the nurses attempt to reach the family, he did not attempt to reach Patient 1's family/next of kin. MD 1 stated usually when there was critical incident or unusual death, he will notify the family.
During a review of the facility's policy and procedure (P&P) titled, "Adverse Event Reporting, DHS," dated June 2019, the P&P indicated, "Disclosure of Adverse Event to Patient or Patient's representative: The patient, or the party responsible for the patient, must be notified by the patient's physician and the designated representative from the facility concerning the nature of the adverse event. The Patient or the Patient's responsible party (Representative) must be informed about the adverse event by the time the report is made to the DHS."

2. During a concurrent observation and interview on 10/15/2024 at 12:13 p.m., with Registered Nurse (RN) 9 inside Patient 4's room, the bedside telemonitor (a system that continuously monitors patient heart rate, respiratory rate, and/or oxygen saturations while automatically transmitting information) was observed to have a displayed of a red "X." RN 4 stated that "X" indicated the heart rate alarm was off.

During a concurrent observation and interview on 10/18/2024 at 12:15 p.m. with RN 5 and the Director of ED/ICU (DCS), the central telemonitor at the nurse station was observed under Patient 4 and Patient 5's heart rate, respiration, and apnea alarm showed a green light on the word "off," and a red "X" next to the respiration and heart rate monitor display.

During a concurrent interview and record review, on 10/18/24 at 9:23 a.m. with the Biomedical Engineer (BM), the photos taken of the telemonitor that displayed Patient 4 and Patient 5's respiration and apnea alarm were reviewed with the BM. BM stated the red "X" on the monitor by the heart rate and respiration indicated, "The alarm is not functioning."

During a review of Patient 4's "History and Physical (H&P)," dated 10/7/24, the "H&P" indicated Patient 4 "presented to the hospital with severe abdominal pain located in the epigastric (upper middle area of the abdomen) area then radiates all over the abdomen for the last 4 to 5 days, sharp continuous 10 out of 10 intensity getting worse over time increased by eating drinking decreased by rest, was found to have small-bowel obstruction (a partial or complete blockage of your small intestine). The plan is to admit Patient 4 to the ICU (intensive care unit in a hospital ward reserved for serious circumstances). Surgery has been consulted."

During a review of Patient 5's "History and Physical (H&P)," dated 10/13/24, the "H&P" indicated that Patient 5's medical history includes "history of systemic hypertension (high blood pressure in the arteries that carry blood from the heart to the body's tissues), AFib (Atrial fibrillation, an irregular and often very rapid heart rhythm), and h/o (history of) bleeding peptic ulcer (a lesion in the lining of the digestive tract) who presents with (family member) for evaluation of worsening generalized weakness and decreased p.o. (oral intake). "

During a review of the facility provided operational manual titled, "Dyna Scope 7000 System Version 07 Series Central Monitor: DS-7700 System," dated 2013, the operational manual indicated, "When the alarm is suspended, make sure to check the patient's condition frequently. When the alarm is suspended, all alarm function will become ineffective even if the alarm for individual parameter is set to ON. Also. the alarm event will not be stored as recall. If the upper/lower alarm limit of the individual parameter is set to OFF. or if arrhythmia alarm is set to OFF. alarm will not function even if the alarm for individual parameter is set to ON. Be cautious when setting them OFF. The alarm for the parameter not selected for the "HR/PR Alarm Source" (ECG/SpO2/BP) on the bedside monitor will be set to OFF on this unit. Ex. If SpO2 is set as the HR/PR alarm source on the bedside monitor, HR alarm will be OFF on this unit. Even if alarm ON/OFF setting or threshold is changed, it will automatically tum OFF after 3 seconds ... Set ON/OFF of alarm and upper and lower alarm limit for each parameter. Sets the lower alarm limit. The lower limit will be turned OFF when a value below the range is selected. In this case, alarm will not generate. Sets the upper alarm limit. The upper limit will be turned OFF when a value above the range is selected. In this case, alarm will not generate. Automatically sets the limits corresponding to the current value. If the upper or lower limit is OFF, the limits will remain to be OFF."

During a review of the facility's policy and procedure (P&P) titled, "Patient Clinical Alarm," dated November 2022, the P&P indicated, "Clinical Alarm System: defined by Joint Commission as " ... any alarm that is intended to protect the individual receiving care or alert the staff that the individual is at increased risk and needs immediate assistance would be within the scope of this definition." "Examples might include cardiac monitor alarms, apnea alarms, abduction alarms ... Clinical Alarm Fatigue: Alarm is intended to alert caregivers of potential patient problems, but if they are not properly managed, can compromise patient safety. Numerous alarms and the resulting noise tend to desensitize staff and cause them to ignore alarms or even disable them. Clinical Alarm (Medical Equipment/Device Alarm) Evidence-Based Safety Guidelines: All hospital staff and medical staff who use medical equipment shall check alarm settings prior to device use to ensure they are appropriate and that audible alarms will be clearly discernable relative to ambient and competing noise. At no time shall hospital staff or medical staff bypass, shut off or adjust medical equipment alarm volumes to a level that cannot be readily heard when the alarm activates. Medical equipment alarms shall be immediately responded to by the hospital staff member and/or physician assigned to or treating the patient ... equipment alarm volumes to a level that cannot be readily heard when the alarm activates. Medical equipment alarms shall be immediately responded to by the hospital staff member and/or physician assigned to or treating the patient. nonfunctioning alarm must be removed from use and sent to Bio medical Engineering for repair."

3. During a review of Patient 20's "Emergency Department Triage Form," dated 8/2/2024, the triage form indicated Patient 20 was presented to the Emergency Department (ED) with a chief complaint chest tightness x (times) 3 days.

During a concurrent interview and record review on 10/18/24 at 9:08 a.m., with Information System Director (ISD), the ISD verified Patient 20's "Emergency Department Triage Form" indicated Patient 20 was triage (a process used to prioritize patients for care or treatment based on the urgency of needs) for a chief complaint of chest tightness times (x) 3 days categorized Patient 20 to triage level of 3 Urgent (Patients requiring further evaluation in treatment area as soon as possible) on 8/2/2024 at 1:18 p.m.

During a concurrent interview and record review on 10/18/24 at 10:35 a.m., with Registered Nurse 7 (RN 7), RN 7 verified Patient 20 was triage on 8/2/2024 at 1:18 p.m., and Patient 20's EKG was completed on 8/2/24 at 2:57 pm (1 hour and 39 minutes after the patient was triaged for chest tightness). RN 7 stated Patient 20's EKG should have had been completed right away because the patient came in with chest pain. RN 7 stated the nurses should initiate EKG as every minute and seconds counts as the patient could be suffering from a heart attack and could die.

During a review of facility's policy and procedure (P&P) titled, "Chest Pain Protocol," dated 11/2022, the P&P indicated, "To ensure that patients presenting themselves with chest pain and/or signs of coronary symptoms are treated quickly and promptly, according to the criteria set forth by the American Heart Association, and Core Measures...Stat 12 Lead EKG. Obtain MD orders for additional EKG if subsequent chest pain occurs."

The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines," dated 11/30/2021, indicated, "The goals in patients presenting to the ED or office with acute chest pain are...The 12-lead ECG, which should be acquired and interpreted within 10 minutes of arrival to a medical facility."

4. During a concurrent observation and interview, on 10/15/2024 at 3:16 p.m., with Charge Nurse 1 (CN1) , two crash cart (Emergency Carts 1 and 2) were observed on the Telemetry unit (special unit where patients cardiac activity and other vital signs are monitored) Emergency Cart 2 had a suction machine on top of the crash cart with a green tag "Dirty" attached. CN 1 stated, crash carts were checked daily, and suction machine should not have a "Dirty" tag.

During an interview on 10/17/2024 at 10:43 a.m., with the Perioperative Supervisor (SPD), the SPD stated, suction machines were to be sanitized in the unit using Sani-Cloth (disinfection wipes) and should not have a "Dirty" tag attached to the machine.

During a review of the facility's policy and procedure (P&P) titled, "Crash Cart" approved in 7/2019, the P&P indicated, "All Crash Carts shall be stocked and available for emergency use in all assigned patient care areas of the hospital ...Check all equipment on the top and side of Crash Cart to make sure that everything is ready and available."

During a review of the facility's P&P titled, "Cleaning, Disinfection and Sterilization" revised in 12/2022, the P&P indicated, "Hospital and Equipment Cleaning - Guidelines. EQUIPMENT- Suction machine...WHO - Sterile Processing Department. HOW - Nursing will take soiled equipment to soiled utility room...Nursing will drop off equipment once daily to the SPD. Clean with approved germicidal...and will re-stock per par level..."