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

1. The facility adhere to the facility's complaint and grievance policy and procedure for 2 (two) of 3 (three) sampled patients (Patient 31 and Patient 32). Facility failed to follow the Grievance by failing to acknowledge, send the initial letter within 7 days, complete, and send the final letter for complaints filed by Patient 31 and Patient 32. (refer to A - 122).

2. The facility provided a safe care setting for one (1) of thirty-nine (39) sampled patients (Patient 1) when proper monitoring and reassessment every two hours according to facility's policy and procedure were not provided to Patient 1, who was placed in the emergency room waiting area. Patient 1 also still required medical screening examination (MSE - an exam performed by a qualified professional [MD] based on a patient's chief complaint to determine the emergency condition and its treatment) and a psychiatric evaluation according to triage nurse (Registered Nurse 1, RN 1) after being triaged as Emergency Severity Index (ESI) level 2 (a five-level emergency department [ED] triage algorithm that provides categorizing the patients into five groups from 1 [most urgent] to 5 [least urgent on the basis of acuity and resource needs). (refer to A - 144).

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the Condition of Participation for Patient's Rights were met.

Based on interview and record review, the facility failed to adhere to follow the complaint and grievance policy and procedure for 2 (two) of 3 (three) sampled patients (Patient 31 and Patient 32). Facility failed to follow the Grievance by failing to acknowledge, send the initial letter within 7 days, complete, and the final letter within 30 days for complaints filed by Patient 31 and Patient 32.

The failure resulted in delay in notifying Patient 31 and Patient 32's complaint status and final result of the grievance filed against the facility was delayed.

Findings:

During an interview with Director of Patient Experience (DPE) and Chief Patient Experience Officer (CPEO) on 9/21/2022 at 2:35 p.m., Grievance policy and procedure was reviewed. DPE stated, upon receipt of complaint, a patient advocate is assigned to the complaint. DPE stated, expectation for initial letter to be sent to complainant within 7 days, and a final letter with the results of the investigation is expected to be sent to complainant within 30 days.

A review of Patient 31's initial letter from the Office of the Patient Experience, dated 6/7/2022, indicated the facility received Patient 31's grievance letter, on 5/29/2022 (9 calendar days after concern was received by the facility).

A review of Patient 31's final letter from the Office of the Patient Experience, dated 8/9/2022, indicated results of the review of Patient 31 grievance letter submitted, on 5/29/2022 to the facility. (63 calendar days after the initial letter to Patient 31).

A review of Patient 32's initial letter from the Office of the Patient Experience, dated 3/31/2022, indicated The facility received Patient 32's grievance letter, on 1/24/2022 (66 calendar days after concern was received by the facility).

A review of Patient 32's letter from the Office of the Patient Experience, dated 5/3/2022, indicated concerns "Are still under review." Result still pending more than 30 days.

A review of Patient 32's final letter from the Office of the Patient Experience, dated 7/19/2022, indicated results of the review (110 calendar days after the initial letter to Patient 32). Patient 32's grievance letter was received by the facility, on 1/24/2022.

During an interview with DPE, on 9/22/2022 at 3:12 p.m., DPE stated, the facility's Grievance policy and procedure was not followed.

A review of facility policy and procedure titled "Management of Patient/ Family/ Visitor Complaint and Grievances Policy, HS 9417," revised date 4/2021, indicated a purpose of the policy, "To assure that patient, family and visitor complaints and grievances are identified and addressed." Policy and procedure indicated, "Patient complaints and grievances shall be responded to and resolved in a timely manner." Policy and procedure indicated, under Grievance Response:

A. If the grievance cannot be resolved immediately, the Office of Patient Experience, Patient Advocate, shall acknowledge receipt of the Grievance, in writing, within the first 7 days of receipt of the grievance.

B. The Office of Patient Experience, Patient Advocate will investigate and respond directly to the patient within 30 days of the time the grievance was filed.

Based on interview and record review, the facility failed to provide a safe care setting for one (1) of thirty-nine (39) sampled patients (Patient 1) when proper monitoring and reassessment every two hours according to facility's policy and procedure were not provided to Patient 1, who was placed in the emergency room waiting area. Patient 1 also still required medical screening examination (MSE - an exam performed by a qualified professional [MD] based on a patient's chief complaint to determine the emergency condition and its treatment) and a psychiatric evaluation according to triage nurse (Registered Nurse 1, RN 1) after being triaged as Emergency Severity Index (ESI) level 2 (a five-level emergency department [ED] triage algorithm that provides categorizing of patients into five groups from 1 [most urgent] to 5 [least urgent on the basis of acuity and resource needs).

These deficient practices resulted in the facility having no knowledge on the whereabouts of Patient 1 after exiting the ER waiting room, and Patient 1 returning to the ER, by emergency medical services (EMS) as a cardiac arrest and trauma patient after jumping off a parking structure near the hospital.

On 9/22/2022 8:11 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and called in the presence of the facility's Clinical Regulatory Affairs Director, Accreditation Specialist, Executive Director of Emergency department, Critical Care Director, Medical/Surgical Director and System Quality Improvement Coordinator, regarding facility's failure to provide a safe care setting for patient 1

On 9/24/2022 11:14 am, the IJ was removed after the facility submitted an acceptable IJ removal plan (interventions to correct the deficient practices). The elements of the acceptable IJ removal plan were verified and confirmed for the implementations while onsite by observation, interview, and limited record review. The IJ was removed in the presence of the facility's Executive Director of Emergency Department

The acceptable IJ removal plan was as follows:
In response to increased volume of patients presenting to our Emergency Department and to escalate concerns for all patients including emergency mental health and substance use presentations, ongoing process improvements have been developed and implemented. These include:
1. A modified reassessment process to ensure consistent, timely reassessment of our Emergency Department (ED) patients in the waiting room. This includes the addition of a second nurse (reassessment nurse) to supplement the triage nurse's reassessment duties. Once triaged, all patients are reassessed every 2 hours. The Electronic Medical Record (EMR) ED Reassessment Trigger will be monitored in real time by the triage nurse and the ED charge nurse. Active daily management is performed by the Administrative Nurse on Duty (AOD) who will support the Charge nurse in the oversight of this reassessment process as well as regular rounding in both treatment and waiting room space. Compliance reports have been designed and will be generated regularly for oversight by Executive Director and/or designee.
2. To supplement the triage and reassessment process, the facility will be adding "Reassessment Timer" to the facility's electronic health record as a visual cue to monitor completion of patient reassessment every 2 hours for the duration of the patient's Emergency Department stay.
3. After ED medical staff assessment of patients, psychiatric consultation will be done however to escalate concerns for all patients including emergency mental health and substance use presentations, the Triage nurse will activate the "secure chat" to connect the charge nurse, ED physician, and nurse to escalate care. (ED-HS 345, new added triaging process). Highest acuity patients (ESI scores) shall be preferentially placed in the treatment area considered most safe and appropriate, taking into consideration the environment and patient census at that time (ED-HS 345).

Findings:

A record review of Patient 1's Emergency Department (ED) Patient Care Timeline, indicated the following timeline for 8/15/2022 to 8/16/2022:
1. On 8/15/22 at 15:25 (3:25 p.m.), Patient 1 was dropped off by family member to emergency department (ED)
2. On 8/15/22 at 15:38 (3:38 p.m.), RN 1 triaged Patient 1 with ESI 2 acuity (patient very ill and high risk for requiring immediate care intervention ) and a chief complaint of psychiatric evaluation. The record indicated Patient 1 was COVID 19 + (positive), on 7/29/2022, and was anxious (an emotion characterized by a state of excessive worry, uneasy or nervousness), and had depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), not sleeping; lost 12 pounds and denied suicidal ideation (thoughts on killing oneself) and homicidal ideation (thought pattern characterized by the desire to kill another person or persons).
3. On 8/15/22 at 15:39 (3:39 p.m.), RN 1 triaged, obtained a set of vitals which was documented as: Blood Pressure (BP, normal values: 90/60 millimeters of mercury [mm Hg] to 120/80 mm Hg ): 149/92 mmHg (unit of measurement), Heart rate (normal values: 60 to 100 beats per minute [per min.]): 118, Respirations (resp., normal value 12 to 18 breaths per minute [per min.]): 16, SpO2 (a measurement of how much oxygen blood is carrying as a percentage of the maximum it could carry, normal value 95 % or higher on room air): 96 % on room air, temperature (temp., normal value 97.8°Fahrenheit [F] to 99.1° F): 98.1 F, and Pain score: 0 through verbal description. Patient 1 verbally stated weight was 175 pounds (lbs.). RN 1 also conducted a general assessment which included an infection risk assessment, a documentation of chief complaint and reason for ED visit, sepsis (infection) screening, foreign travel screening, weight measurement, history of allergy review, general physical appearance and patient behaviors, living conditions and immunization history. Also, home medications, ED abuse screening, fall risk assessment, and suicide risk using the Columbia-Suicide Severity Rating Scale (C-SSRS, a suicide screening tool involving a set of simple questions to assess the severity and immediacy of suicide risk with scoring as: 0 = No Suicidal Ideation, 1 = Wish to be Dead, 2 = Non-specific Active Suicidal Thoughts, 3=Active Suicidal). Patient 1 was assessed with a score of zero (0).
4. On 8/15/22 at 18:14 (6:14 p.m.), Medical Technician 1 (ED Tech 1, a non-licensed staff) obtained another set of vitals, documented as: BP 126/91 mmHg, heart rate 93 per min., resp 18 per min., temp. 97 F obtained via temporal (at the center of the forehead), SpO2 98 % on room air.
5. On 8/15/22 at 20:55 (8:55 p.m.), ED Tech 2 (a non-licensed staff) obtained a set of vitals documented as BP 119/84 mmHg, heart rate 84 per min., resp. 16 per min., SpO2 98 % on room air, pain score 1, and height and weight documented as: height: 5'7" (5 feet 7 inches) and weight 171 lbs / 15.3 ounces(oz).
6. On 8/15/22 at 23:00 (11:00 p.m.), ED Tech 3 (a non-licensed staff) obtained a set of vitals documented as: BP 131/85 mmHg, heart rate 80 per min., Resp 17 per min., SpO2 98 % on room air, and temp. 98.2 F.
7. On 8/16/22 at 00:03 (12:03 a.m.), RN 2 had roomed Patient 1 to TRI 01 (an ED room) (the facility's indication of Patient 1 being assigned a room).
8. On 8/16/22 at 00:32 (12:32 a.m.), RN 3 called Patient 1. Patient 1 did not answer.
9. On 8/16/22 at 00:53 (12:53 a.m., RN 3 called Patient 1. Patient 1 did not answer.
10. On 8/16/22 at 1:13 a.m., Patient 1 was called. Patient did not answer in ED waiting room, outside tent area, and ED valet area by RN 3.
11. On 8/16/22 at 1:14 a.m., RN 3 discharged Patient 1 from the system (facility's removal of patient from the electronic medical record).
12. On 8/16/22 at 3:39 a.m., Emergency Medical Services (EMS - an emergency service that when activated, provides urgent prehospital care for serious injuries and illness) brought Patient 1 by ambulance as a trauma patient s/p (status post (s/p) - a term used to refer to the condition of a patient after experiencing something) jumping off parking garage, Patient 1 was in cardiac arrest (a sudden unexpected loss of heart function, breathing and consciousness).
13. On 8/16/22 at 4:00 a.m., Patient 1 was pronounced dead in the ED.

A review of Patient 1's Emergency Department Service Report, dated 8/16/2022 at 3:39 a.m., indicated Patient 1 presented in the ED a, "Cardiac Arrest and Trauma (EMS reports pt jumped off parking garage. Asystole [no pulse or no heartbeat] entire time en route to ED)." Under history, the record indicated, "Found by passerby after jumping off parking structure near hospital. No pulse and respiration."

During hospital tour of the ED and interview with Clinical Nurse Educator (CNE), on 9/20/2022 at 11:16 a.m., CNE stated Medical Doctors (MDs) evaluates ESI 2 and ESI 3 sometimes in the presence of RN when patient has been roomed or sent back to waiting room awaiting treatment orders and room/bed placement. ESI 2 patients were usually given a bed depending on the current census of the ED.

During an interview, on 9/20/2022 at 2:08 p.m., RN 1 stated Patient 1 was brought to the ED for concern related to anxiety (an emotion characterized by a state of excessive uneasiness, tension worried thoughts and physical changes like increased blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), weight loss, not eating or sleeping and COVID - 19 infection (an infectious disease caused by the SARS-CoV-2 virus). RN 1 stated that Patient 1 was scored as zero (0) on C-SSRS based on the answers to screening questions. A C-SSRS 0 score indicates the Patient 1 did not meet criteria for suicide ideation. RN 1 stated Patient 1 was rated ESI 2 based on history obtained from Patient 1's family, their expressed concern as well as RN 1's clinical judgement and believing Patient 1 would benefit from a psychiatric evaluation. RN 1 stated ED physicians, who assess the patients would place orders for consult for a psychiatrist to come see the patients. RN 1 stated Patient 1 was, "Calm, and cooperative, but also guarded and quiet." RN 1 stated Patient 1 was placed in the waiting room.

During an interview, on 9/20/2022 at 2:08 p.m., RN 1 stated patients in the ED waiting room must get assessments every two hours. RN 1 stated staff members who may include ED Trauma technicians (ED Techs), RNs, or care partners (certified nursing assistants who provide basic care to patients including taking vital signs and helping with activities of daily living) usually take a repeat set of vital signs every two hours on ED patients in the waiting room. Reassessments were done if patients presented with changes in vital signs, behavioral or physical changes, however Patient 1 was calm and sitting quietly in the ED. Patient 1 had no notable physical or behavioral changes. RN 1 stated she last saw Patient 1 around, on 8/15/2022 at 11 p.m., at end of RN 1's shift, in the ED waiting room. RN 1 stated she remembered Patient 1, because Patient 1 had asked for a blanket. RN 1 stated vital signs was done by ED Tech 3, on 8/15/2022 at 11:00 p.m., which was the last known staff who had contact with Patient 1 before readmission as a cardiac arrest trauma patient a few hours later.

During an interview, on 9/21/2022 at 3:04 p.m., ED tech 4 stated vital signs for patients in the ED waiting room were done every two hours (hrs.) by ED techs. ED techs report any changes to RN or charge RN on shift.

During a record review of Patient 1's medical record with Clinical Nurse Educator (CNE), RN nurse informatics (RN-NI 1), and Quality Improvement Coordinator (QIC), on 9/22/2022 at 8:32 a.m., Patient 1's medical record had no MSE which could have placed the psychiatric evaluation order for Patient 1 to assess and confirm real status of the ESI 2 for Patient 1.

During an interview with Clinical Nurse Educator (CNE), RN nurse informatics (RN-NI 1), and Quality Improvement Coordinator (QIC) and concurrent record review of Patient 1's electronic medical records, on 9/22/2022 at 1:38 p.m., CNE stated a licensed practitioner (RN) has to do all reassessments every two hours on patients in the ED waiting room. Quality Improvement Coordinator (QIC) stated Patient 1's reassessment was not done by an RN. QIC stated reassessments involves more than taking a set of vitals, it involves an evaluation of the patient as a whole and will be done by an RN.

During interview with Clinical nurse educator (CNE), RN nurse informatics (RN-NI 1), and Quality Improvement Coordinator (QIC) and concurrent record review of Patient 1's electronic medical records, on 9/22/2022 at 1:38 p.m., CNE confirmed that after the 15:39 hrs. (3:39 p.m.) triage vital signs, the next set of vitals was done at 1814 hrs. (6:14 p.m.) approximately 2 hrs. and 35 minutes later. CNE confirmed that all vital signs were done by ED techs except the triage assessment. No assessments or reassessments are performed by licensed staff on Patient 1 during his 8/15/2022 visit.

A record review of the facility policy and procedure titled, "Triage - Emergency Department ED 365," revised date 2/2022, indicated under patient evaluation after a patient had been triaged and sent to the waiting room, Patients will be reassessed every 2 hours or more as necessary."

Based on interview and record review, the facility failed to complete neuro (nerve and nervous system) assessment (evaluation of level of alertness, sensory function, cognition, mood and affect, and thought content) every 4 (four) hours for 1 (one) of 4 (four) sampled patients (Patient 16). Patient 16 had an order for neuro checks (assessment) every four hours after a stroke (a medical emergency and occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).

This deficient practice had the potential for harm if Patient 16 had a had a change in mental status (assessment of current mental capacity through evaluation of general appearance, behavior, any unusual or bizarre beliefs and perceptions [e.g., delusions, hallucinations], mood, and all aspects of cognition [e.g., attention, orientation, memory]) and required timely treatment.

Findings:

A review of Patient 19's History and Physical, dated 9/12/2022 and signed 9/14/2022, indicated Patient 14 was admitted to the facility, on 9/14/2022 with history of syncopal episodes (fainting, or passing out) and presented to facility for Transcatheter aortic valve replacement (TAVR; minimally invasive heart procedure to replace a thickened aortic valve [controls the flow of blood out from the heart to the rest of the body] that can't fully open) consideration.

A review of Patient 19's orders, dated 9/15/2022, indicated a physician order for neuro checks, interval of every 4 (four) hours.

A review of Patient 19's Progress Note, dated 9/20/2022, indicated Patient 19 had a code stroke (term used to prioritize the assessment and care of a patient presenting with signs and symptoms concerning for stroke) on 9/15/2022, slurred speech and facial droop. Progress note indicated, plan for neuro checks every 4 (four) hours.

During a concurrent interview and record review on 9/21/2022 at 9:55 a.m., with Registered Nurse 4 (RN 4), Patient 19's medical record was reviewed for neuro checks. RN 4 stated, neuro check was completed on 9/20/2022 at 8:00 a.m., with following neuro check completed on 9/20/2022 at 9:02 p.m. RN 4 stated, neuro check was ordered every 4 (four) hours and were not completed on 9/20/2022 for 12 p.m., 4 p.m., and 8 p.m. RN 4 stated, important to completed neuro checks to note changes in Patient 19's neuro status.

During a concurrent interview and record review, on 9/22/2022 at 2:07 p.m., Registered Nurse -Nurse Informatics 1 (RN-NI1), Patient 19's medical record was reviewed. RN-NI 1 stated, order for neuro check every 4 hours was active from initial order on 9/15/2022 at 5:23 p.m. until Patient 19 was discharged to another facility on 9/22/2022 at 11 a.m.

A review of facility's policy titled, "Assessment of Patients, HS 1310", effective date 2/1995, revised Date 2/2020, indicated a purpose, "To comprehensively assess and document the initial admission assessment of all patients, and to ensure that each patient's physical, psychological spiritual, cultural, nutritional, and social status needs are assessed continuously while receiving care at [facility]." The policy indicated, "The registered nurse (RN) is responsible for performing all nursing assessment/ reassessment processes." The policy indicated, "Additional reassessments will be done and documented according to the following: ... E. Physician orders."