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Based on review of medical records, hospital policies, incident reports, grievance reports, and staff interviews, it was determined the hospital failed to protect and promote patient rights. The hospital failed to ensure grievances were properly investigated, failed to ensure patients were cared for in a safe setting in 1 of 2 Patients (Patient #6) whose records were reviewed and required a 1:1 safety attendant and also for 1 of 1 patients (Patient #1) who had an unwitnessed fall and whose records were reviewed. The failure of the hospital to protect patients placed the health and safety of all patients at risk. Findings included:

Refer to A-0119 as it relates to the hospital's failure to properly investigate a grievance related to a patient death.

Refer to A-0144 as it relates to the hospital's failure to provide care in a safe setting.

The effects of these systemic failures impeded the hospital's ability to ensure all patients were cared for in a safe setting.

Based on policy review, medical record review, grievance log review, and staff interview, it was determined the hospital failed to ensure an investigation of a grievance was completed in 1 of 1 Patients (Patient #6) whose record was reviewed for a grievance related to the death of a patient. This had the potential to impact other grievances filed and investigated. Findings included:

A hospital policy titled "Patient Complaint and Grievance Program," approved 1/04/22, was reviewed. The policy stated, "Response to Grievance:...Grievances about situations that endanger the patient, such as claims of harm, abuse, or neglect, will be reviewed immediately and handed off to Risk Management (RM) for investigation." This policy was not followed. An example included:

Patient #6 was a 40 year old female identified on the grievance log as allegedly not having the 1:1 observation ordered. A code blue was called for Patient #6 at change of shift, this patient subsequently was transferred to ICU where she died a few hours later. Further information regarding the grievance and investigation was requested.

On 11/17/23 at 10:30 AM, the DON was asked who is responsible for the grievance process and she stated the Regional Manager of Patient Relations was responsible.

The closed grievance pertaining to the death of Patient #6 was reviewed with the ICU manager, Staff F. A letter from Staff F to the Regulatory Accreditation Coordinator was reviewed. The letter stated that "The code [for Patient #6] itself went very well...and no outlying concerns were found."

The timeline of the grievance investigation was also produced. One allegation in the hospital grievance investigation stated, "didn't have the 1:1 care or 15 min[minute] checks she [Patient #6] needed to be safe." This allegation was investigated with a chart review and stated, "Patient Safety Attendant at Bedside 9/22 through time in 9203 including checks to keep safe."

An interview was conducted with the Regional Manager of Patient Relations on 11/17/23, beginning at 11:30 AM. When asked to describe the grievance investigation process, she replied, "it gets investigated within 4 or 5 days with patient relations coordinator. The manager of the department leads the investigation and anyone else pertinent. We have a robust escalation process and then we involve the CNO and risk management and the service line Director. In this case [Patient #6] there was nothing to indicate escalation."

An interview with Staff F was conducted on 11/17/23, beginning at 10:05 AM. When asked about the meaning of the statement, "the code going well," she replied, "it meant we were there quickly, responded and transferred [Patient #6 to ICU]." When asked if she had seen the code sheet, she replied, "I have not." When asked if the code sheet should be a part of the medical record, she replied, "yes." When asked why the code sheet was not part of Patient #6's medical record, she stated, "I don't know, it's a human process, I wasn't there, it's a separate piece of paper."

Staff F was also asked if she saw the PSA, she stated "no." When asked how she could be certain Patient #6 did have every 15 minute checks, she replied "I knew there was a PSA in there...no, I didn't see the document."
There was no PSA flowsheet, which would have included documented 15 minute checks included in the medical record for Patient #6.

The hospital failed to ensure a complete investigation of a grievance was conducted regarding the death of Patient #6.

Based on review of medical records, policies, and staff interview, it was determined the hospital failed to ensure patient safety for 1 of 1 patients (Patient #1) who had an unwitnessed fall and whose records were reviewed. The hospital also failed to ensure patient safety for 1 of 2 Patients (Patient #6) whose records were reviewed and required a 1:1 safety attendant. This resulted in an unwitnessed fall without appropriate measures to mitigate future falls with ammended plans of care and a patient death which occurred during a 1:1 safety observation. This put all patients at risk for negative outcomes. Findings included:

1. A hospital policy dated 10/12/23, "Patient Falls Risk-SAHS" section "Risk Fall Assessment" stated a score between 11-14 was a moderate fall risk and interventions for moderate fall risk patients included a yellow wristband, nonskid socks, gait belt with transferring and ambulation, bed and chair alarm, and patient risk specific interventions. A score of more than 15 was a high risk and added precautions included, "Stay with ME", and the possibility of using personal sitter or video monitor sitter. The same hospital policy also stated in the section "Post Fall Guidelines", when there was an unwitnessed fall, "place an order for neuro checks every 2 hours for 24 hours" and "implement changes to fall prevention plan and document in the medical record and plan of care as appropriate."t
This policy was not followed. Examples included:

Patient #1 was a 65 year old female admitted to the hospital on 8/7/2023 with stroke diagnosis. Her medical record included a PT (physical therapy) note dated 8/10/23.

The note stated Patient #1 had "impaired gait, impaired balance, decreased endurance, decreased strength, decreased mobility." Patient #1's record included a POC which required observation levels for activities which included, "sitting (static): Close supervision, sitting (dynamic): close supervision, standing (static): contact guard, Standing (dynamic): Minimum assistance."

Patient flowsheet indicated patient was a fall risk and required fall wrist band, call light within reach, non-skid footwear, and side rails up.

Patient #1's record included fall risk documentation. Her fall risk scores ranged from moderate to high fall risk. There were no additional fall risk interventions documented when Patient #1 changed from a moderate to a high fall risk on 8/12/23 at 7:40 PM.

Patient #1's record included a PT note from 8/10/23 at 4:02 PM which stated Patient #1 was found unattended on the commode and, "states she had been there an hour trying to have a BM but unsuccessful. [Patient #1] crying and c/o [complains of] pain and that her LEs [lower extremities] were numb. Pt [patient] required min/mod [minimum/moderate] assist to stand and take several small steps with a walker to transfer to bed." There were no changes made to Patient #1's POC after she was discovered sitting on the commode alone for an extended period of time despite being a fall risk.

Patient #1's record also included a "Post Fall Nursing note" on 8/10/23 at 11:58 PM which stated, "Patient was found on ground after being put on commode by previous shift, patient states she fell and denied hitting her head." The note stated Patient #1 was not wearing non-skid socks. There were no additional safety precautions documented after Patient #1's fall.

Additionally, patient #1's medical record documented neuro checks were completed every 4 hours. Hospital policy on unwitnessed falls required an order for neuro check every 2 hours.

Staff G, Patient #1's day shift RN, was interviewed on 11/17/23 beginning at 11:15 AM. Staff G stated Patient #1 was up and down on the commode as she was trying to have a BM and she was in close contact with doctor about bowel regime. When asked about usual care for patients who used the commode, Staff G stated, "I usually stay with her on the commode, either me or the CNA, I know I would not leave her on the commode." When asked if she remembered putting Patient #1 on the commode, Staff G stated, "I do not remember putting her on the commode." When asked if Patient #1 was able to get on the commode herself , Staff G stated, "we told her she needs to call but I am not sure what happened."tWhen asked if she remembered Patient #1 getting up by herself that day, she said, "no." Staff G stated Patient #1's fall precautions included "bed alarm would be on, call light on, remote next to her and her husband was in and out". Staff G did not mention non-skid socks on patient during shift.

Staff H, the RN who found Patient #1 after her fall, was interviewed on 11/17/23 at 11:50 AM. When asked what happened leading up to the fall she stated, "I went to check on her after receiving report and I found her on the ground around 7:30 PM. She was set up on the commode and I believe she had tried to get up." When asked if Patient #1 knew who put her on the commode, Staff H stated, "I believe she said the nurse."tStaff H stated, "She didn"t tell me how long but I know from report she was put on the commode. Report starts at 7:00 PM and ends around 7:30 PM. I called people in and we did an assessment and contacted the doctor." When asked if anything changed in Patient #1's POC after the fall, Staff H reported there was a post fall assessment.

The day shift CNA, Staff J, was also interviewed 11/17/23 beginning at 12:07pm. Staff J reported she was giving report on a different patient when she heard someone fell and ran to see who it was, and it was the patient [Patient #1]. Staff J stated apparently [Patient #1] was on the commode and, "I don't remember who put her on the commode - if it was me or the nurse."tWhen asked what was usually done for patients using the commode, Staff J stated she would usually stay with the patient, but Patient #1 had been on the toilet many times and her husband had been there all day. When asked what was done with the bed alarm when a patient was using the commode, Staff J reported it was turned off.

The hospital failed to ensure Patient #1 was provided care in a safe setting.

2. A policy titled "Medical Record Documentation" was reviewed. Under "Content of the Medical Record," it stated, "Relevant observations;...The patient's response to care, treatment, and services provided;...Documentation of complications."

A policy titled "Code Blue Response," approved 4/4/23, stated, "Recording and Documentation: The Code Blue Record --BO-1427 is to be used during resuscitation. The code blue sheets are located on a clipboard on the crash cart. The Code Blue Record must be reviewed and signed by the Code Blue Team...Both original and rewrite will become part of the patient's chart...A copy should be made and left with the chart...The original Code Blue Record should be faxed or tubed to medical records to be scanning[sic] into the patient EMR." These policies were not followed. An example included:

Patient #6 was a 40 year old female who initially presented to the ED at St. Alphonsus Nampa on 9/16/23 with complaints of nausea, vomiting, pain, and weakness. Patient #6 had a medical history which included polysubstance abuse, depression, anxiety, and multiple psychiatric evaluations with inpatient admits. Patient #6 was transferred to St. Alphonsus in Boise on 9/19/23 for a neuropsychology and psychiatry evaluation. Patient #6 was placed in the Medical Surgical unit and refused IV hydration, a nasogastric tube or IV medications.

Patient #6's medical record included a psychiatrist evaluation note signed and dated 9/22/23. The physician note stated Patient #6 was not competent to make her own decisions and her DNR status was changed to full code and suicide precautions were initiated. A Patient Safety Attendant order was initiated on 9/22/23 at 1:17 PM to provide 1:1 observation.

Patient #6's medical record included a nursing note signed and dated on 9/23/23 at 7:25 PM. The nursing note stated, "1:1 sitter at bedside for patient safety...several episodes of emesis continued throughout the day shift...Sitter notified nursing staff of pt change at shift change. Pt blue upon assessment. No palpable pulse. Code blue called. CPR initiated. Code team took over from here. ICU nurse hand off."

A request was made to the DON, Staff L, on 11/16/23 at 10:00 AM for the PSA flow sheet for Patient #6 as well as the Code Blue Record for Patient #6.

At 1:00 PM on 11/16/23, the ICU Supervisor, Staff K, stated the PSA flow sheet and Code Blue Record was still unable to be located for Patient #6.

A request was made to speak to the RN attending to Patient #6 on 9/23/23. Surveyors were informed this RN was out of the country and unable to be contacted.

A request was made to speak to the PSA observing Patient #6 on 9/23/23. Staff A was interviewed on 11/16/23 beginning at 1:15 PM. Staff A confirmed they sat near the foot of the bed in Patient #6's room during their shift on 9/23/23 beginning at 3:00 PM. Staff A stated Patient #6 was lying on her back with her head slightly elevated. Staff A stated her face was able to be observed. When asked to describe the events leading up to the Code Blue, Staff A stated, "she was laying in bed with a blank stare, the heart monitor started beeping, I touched her arm and there was no response. I yelled out the hall to come here and a nurse called a Code Blue." Staff A stated they did not recall who took the flow sheet at that point.

Patient #6's medical record included a nursing note which stated, "Pt [Patient #6] arrived to floor @2008 [8:08 PM]...pt [Patient #6] remained hemodynamically unstable...Central line placed...Shortly after pts [Patient #6] BP became unreadable, Unable to find pulse, code called at 2118 [9:18 PM]."

Patient #6's medical record included a Code Blue Record from 9/24/23 at 2:02 AM which documented rescue medications administered at 2:02 AM and 2:07 AM. The Record was signed by a Team Lead RN and Critical Care RN. There was no further documentation on this Code Blue Record.

A Nursing Note on 9/24/23 stated, "soft code around 0200, pressures dropped and pulses became weak and thready. MD at bedside, see code sheet."

The NP attending Patient #6 upon her arrival to the ICU was interviewed on 11/17/23 beginnning at 8:30 AM. She was asked about the term "soft code" documented by the RN. She stated, "I don't know that term." The attending NP was asked about the prognosis of Patient #6 when she arrived to ICU and she stated, "by the time she got to us she was in cardiogenic shock, hypovolemic shock and septic shock. I was unsure if family knew so I called brother and they came to bedside..." Patient #6 expired at 4:26 AM on 9/24/23. Family had returned home prior to TOD.

The medical record for Patient #6 was incomplete. The Code Blue Record for 9/23/23 as well as the PSA flow sheet for 9/23/23 was requested again on 11/17/23 prior to exit. No documentation for Patient #6's Code Blue Record or the PSA flowsheet was provided.

There was no documentation confirming Patient #6 was provided a 1:1 safety observer as ordered. Additionally, there was no documentation of what life saving interventions were performed during Patient #6's medical emergency.

Based on policy review, medical record review, and staff interview, it was determined the complete medical record was not available for 1 of 2 Patients (Patient #6) whose records were reviewed and required a 1:1 safety attendant. This had the potential to interfere with complete care and investigation of a patient who coded and died during a 1:1 safety watch. Findings included:

Refer to A-0438, as it relates to the failure of the hospital to ensure medical records were complete and accurate.

The effects of this systemic failure impeded the hospital's ability to completely investigate the death of a patient who was on a 1:1 safety watch.

Based on policy review, medical record review, and staff interview, it was determined the complete medical record was not available for 1 of 2 Patients (Patient #6) whose records were reviewed and required 1:1 observation for safety. This had the potential to interfere with complete care and investigation of the patient who coded and died. Findings included:

A policy titled "Medical Record Documentation" was reviewed. Under "Content of the Medical Record:" it stated, "Relevant observations;...The patient's response to care, treatment, and services provided;...Documentation of complications."

A policy titled "Code Blue Response," approved 4/4/23, stated, "Recording and Documentation: The Code Blue Record --BO-1427 is to be used during resuscitation. The code blue sheets are located on a clipboard on the crash cart. The Code Blue Record must be reviewed and signed by the Code Blue Team...Both original and rewrite will become part of the patient's chart...A copy should be made and left with the chart...The original Code Blue Record should be faxed or tubed to medical records to be scanning[sic] into the patient EMR." These policies were not followed. An example included:

Patient #6 was a 40 year old female who initially presented to the ED at St. Alphonsus Nampa on 9/16/23 with complaints of nausea, vomiting, pain, and weakness. Patient #6 had a medical history which included polysubstance abuse, depression, anxiety, and multiple psychiatric evaluations with inpatient admits. Patient #6 was transferred to St. Alphonsus in Boise on 9/19/23 for a neuropsychology and psychiatry evaluation. Patient #6 was placed in the Medical Surgical unit and refused IV hydration, a nasogastric tube or IV medications.

Patient #6's medical record included a psychiatrist evaluation note signed and dated 9/22/23. The physician note stated Patient #6 was not competent to make her own decisions and her DNR status was changed to full code and suicide precautions were initiated. A Patient Safety Attendant order was initiated on 9/22/23 at 1:17 PM to provide 1:1 observation.

Patient #6's medical record included a nursing note signed and dated on 9/23/23 at 7:25 PM. The nursing note stated, "1:1 sitter at bedside for patient safety...several episodes of emesis continued throughout the day shift...Sitter notified nursing staff of pt change at shift change. Pt blue upon assessment. No palpable pulse. Code blue called. CPR initiated. Code team took over from here. ICU nurse hand off."

A request was made to Staff L on 11/16/23 at 10:0 AM for the PSA flow sheet for Patient #6 as well as the Code Blue Record for Patient #6.

At 1:00 PM on 11/16/23, Staff K stated the PSA flow sheet and Code Blue Record was still unable to be located for Patient #6.

A request was made to speak to the RN attending to Patient #6 on 9/23/23. Surveyors were informed this RN was out of the country and unable to be contacted.

A request was made to speak to the PSA observing Patient #6 on 9/23/23. Staff A was interviewed on 11/16/23 beginning at 1:15 PM. Staff A confirmed they sat near the foot of the bed in Patient #6's room during their shift on 9/23/23 beginning at 3:00 PM. Staff A stated Patient #6 was lying on her back with her head slightly elevated. Staff A stated her face was able to be observed. When asked to describe the events leading up to the Code Blue, Staff A stated, "she was laying in bed with a blank stare, the heart monitor started beeping, I touched her arm and there was no response. I yelled out the hall to come here and a nurse called a Code Blue." Staff A stated they did not recall who took the flow sheet at that point.

Patient #6's medical record included a nursing note which stated, "Pt [Patient #6] arrived to floor @2008 [8:08 PM]...pt [Patient #6] remained hemodynamically unstable...Central line placed...Shortly after pts [Patient #6] BP became unreadable, Unable to find pulse, code called at 2118 [9:18 PM]."

Patient #6's medical record included a Code Blue Record from 9/24/23 at 2:02 AM which documented rescue medications administered at 2:02 AM and 2:07 AM. The Record was signed by a Team Lead RN and Critical Care RN. There was no further documentation on this Code Blue Record.

A Nursing Note on 9/24/23 stated, "soft code around 0200, pressures dropped and pulses became weak and thready. MD at bedside, see code sheet."

The NP attending Patient #6 upon her arrival to the ICU was interviewed on 11/17/23 beginnning at 8:30 AM. She was asked about the term "soft code" documented by the RN. She stated, "I don't know that term." The attending NP was asked about the prognosis of Patient #6 when she arrived to ICU and she stated, "by the time she got to us she was in cardiogenic shock, hypovolemic shock and septic shock. I was unsure if family knew so I called brother and they came to bedside..." Patient #6 expired at 4:26 AM on 9/24/23. Family had returned home prior to TOD.

The medical record for Patient #6 was incomplete. The Code Blue Record for 9/23/23 as well as the PSA flow sheet for 9/23/23 was requested again on 11/17/23 prior to exit. No documentation for Patient #6's Code Blue Record or the PSA flowsheet was provided.

The hospital failed to ensure the medical record for Patient #6 was complete which led to the inability of the hospital to properly investigate the grievance regarding the death of the patient.