HospitalInspections.org

The Condition of Participation for Patient Rights has not been met. The hospital failed to:


a. Ensure staff provided the level of supervision required (1:1, close supervision or line of sight supervision) to maintain safety based on an individualized risk assessment, failed to ensure a safe environment (unsecured needles, syringes, medications, personal belongings, and electric bed cords in the emergency department), and failed to ensure one patient received the necessary supervision for medication administration. Refer to A 144


b. Ensure a comprehensive investigation and physical examination was conducted following an allegation of sexual assault. Refer to A 145

Surveyor: Newton, Susan

Based on observation, clinical record reviews, interviews, review of hospital documentation, and review of hospital policies, for 5 of 10 patients reviewed for level of supervision (Patient 2, #3, #4, #28, #58), the hospital failed to ensure staff provided the level of supervision required (1:1, close supervision or line of sight supervision) to maintain safety based on an individualized risk assessment, failed to ensure a safe environment (unsecured needles, syringes, medications, personal belongings, and electric bed cords in the emergency department), and failed to ensure one patient (Patient #22) received the necessary supervison for medication administration. The findings include:


a. Patient #2 present to the Emergency Department (ED) after a medication overdose with the intent for self-harm.

The Columbia suicide severity rating scale (C-SSRS) dated 11/14/21 identified the patient was at low imminent risk for self-injury in the facility.

Observation in the ED's B POD on 11/15/21 at 10:30 AM identified Patient #2 on a stretcher in the room with multiple ligature points and medical equipment with the curtain partially closed. Observation Associate #2 was observed to be seated in a chair at the end of Patient #2's bed with her back to the patient.

Interview with Observation Associate #2 on 11/15/21 at 10:30 AM identified she was responsible for maintaining line-of-sight for 2 patients including Patient #2. Observation Associate #2 identified it was difficult to maintain line-of-sight for both patients and would occasionally turn her head to check on Patient #2.

Interview with Manager #5 on 11/15/21 at 10:30 AM identified Patient #2 should be observed at all times and Observation Associate #2 should not have her back turned to the patient.

The hospital's patient observation standards policy dated 11/7/19 directed line-of-sight observation is a level of continuous observation in which the patient is continually monitored by staff who will remain within the visual sight line and one staff observes no more than 4 patients. The policy further directs in settings other than psychiatric emergency services; patients are observed through continuous observation within one's visual line of site.

The hospital policy for levels of observation identified that a patient on 1:1 is continuously monitored by staff and remains within arm's length of the patient. Patients who are on line-of-sight supervision are continuously monitored by staff who will remain within visual sight line.

Review of the hospital policy for safety rounds identified line of sight means continually monitor within visual sight line not more than ten feet from the patient.

The Observation Associate job description identified the observation associate under the direction of the registered nurse maintains continuous visual contact and arm's length contact with the patient to ensure the patient's safety and dignity.

On 11/15/21 the hospital provided the Department with an action plan that identified all nurses and observation associates that worked in the hospital's main Emergency Department would be reeducated on the hospital's patient observation standards and audits would be conducted to ensure compliance.


b. Patient #3 presented to the ED with increased anxiety and homicidal ideations.

The psychiatric evaluation dated 11/15/21 identified that Patient #3 has thoughts of killing people, primarily his/her mother. Patient #3 made provocative statements asking what would happen if he/she left the hospital, the patient states he/she would be able to outrun security guards and sitters.

On 11/15/21 at 10:40 AM, Patient #3 was observed on a stretcher in his/her room (B POD) with the curtain partially closed. Observation Associate #4 was observed sitting in the hallway observing another patient in the hallway with his/her chair positioned so it was not possible to see the patient behind the partially closed curtain.

Interview with Manager #5 on 11/15/21 at 10:40 AM identified that the curtain should remain open to allow the Associate to maintain line of site supervision for patient safety. Manager #5 identified that all behavioral health patients are placed on minimum line-of-sight supervision for safety, or a higher level of observation based on assessment when they are not located in a behavioral health unit. Manager #5 identified that all of the crisis intervention unit beds were filled so the B section of the ED was being used as an overflow area.


c. Patient #4 present to the ED on 11/14/21 after an intentional medication overdose.

The Columbia suicide severity screen dated 11/14/21 identified Patient #4 was at high risk.

On 11/15/21 at 10:35 AM, Patient #4 was observed in a patient in room (B POD) with multiple ligature points and medical equipment. Observation Associate #3 was standing in the hallway with his back to Patient #4.

Interview with Observation Associate #3 identified he was assigned to maintain line-of-sight with two patients including Patient #4.

Interview with Manager #5 at the time of observation identified that Observation Associate #3 should maintain line-of-sight with Patient #4 at all times.


d. Patient #28 had a history of self-cutting and Major Depressive Disorder (MDD) and was admitted to the children's Emergency Department (ED) on 11/15/21 for a psychiatric evaluation.

The safety risk assessment identified that Patient #28 had current suicidal thoughts, wished to be dead, and had thoughts of a suicide method.

The clinical record identified standard environmental safety requirements that included to continue 1:1 and safety precautions while the patient remained in the ED. A sitter was initiated.

Observation on 11/16/21 at 10:05 AM identified an empty chair in the hallway facing towards Patient #28's ED room. Sitter #50 was noted sitting in a hallway chair with her back to Patient #28's room.

Interview with Sitter #50 on 11/16/21 at 10:05 AM identified that she was responsible for watching 2 patients that were directly in front of her. When asked who else required monitoring, Sitter #50 identified Patient #28. When asked who was watching Patient #28, Sitter #50 pointed to the empty chair and stated that "she left for a few minutes". When asked if she could visualize Patient #28, Sitter #50 replied "no".

Interview with Charge Nurse #20 on 11/16/21 at 10:50 AM identified that Patient #28 should have been in a sitter's line-of-sight. In addition, Charge Nurse #20 identified that the ED was short staffed to fulfill 1:1 and constant observation statuses for the number of patients in the ED, but per her assignment, every patient should have had a minimum of line-of-sight supervision.

In addition, tour of the children's ED on 11/16/21 at 10:00 AM identified the unit census was twenty-seven (27). Review of the Patient Suicide Risk level as of 11:13 AM identified that out of the twenty-seven (27) patients on the unit, nine (9) were determined to be high risk and required 1:1 monitoring per policy, and as of 11:33 AM eight (8) patients were determined to be high risk. Review of the sitter staffing schedule with the Charge Nurse on 11/16/21 at 11:45 AM identified that five (5) of the high risk patients were being observed in a cluster of two to three patients as the unit did not have enough staff to fulfill the 1:1 ratio.

Interview with the Clinical Program Director and Nurse Manager indicated that the behavioral health surge has resulted in a gap with sitters and several options are tried to obtain adequate staffing, however, they are not always able to accomodate this need.


e. Patient #58 was admitted to the children's ED on 11/14/21 for suicidal ideation.

Physician orders dated 11/14/21 directed the patient to be on line-of-sight supervision at all times for suicide risk.

Observation in Zone B on 11/15/21 at 10:50 AM noted PCT #1 completing vital signs on Patient #59 with the privacy curtain halfway drawn and Patient #58 not in line-of-sight. At 10:55 AM PCT #1 was observed to go back to the chair in the middle of the room and observed Patient #58.

Interview at that time with PCT #1 stated that line of sight means the patient is continually monitored within sight. The PCT stated that she had to take vital signs on Patient #59, so she did not see Patient #58 for a few moments.

Interview with RN #12 on 11/15/21 at 11:00 AM stated that if the PCT had to provide care to another patient she is to have someone else take over her duties of patient monitoring.


f. Tour of the children's ED on 11/16/21 at 10:25 AM identified that the resuscitation room was open and contained unsecured needles and syringes. Interview with Sitter #75 stated she was observing the patients in hallway #1 and #2 and stated that the door remains open should there be an emergency.


g. Patient #61 was admitted to the ED behavioral health unit on 11/10/21 with positive Suicidal Ideations (SI) in the context of polysubstance abuse and multiple psychosocial stressors.

Review of the psychiatric evaluation dated 11/10/21 identified the patient presented with positive Suicidal Ideations (SI). The patient was identified as a high suicidal risk and would be held overnight and re-evaluated in the morning.

Review of physician orders dated 11/15/21 directed the patient to be observed visually twice in 30 minutes around the clock.

P# 62 was admitted to the ED on 11/11/21 with making suicidal statements.

The History & Physical (H&P) dated 11/11/21 identified the patient was making suicidal statements, would be cleared medically, and transferred to the behavioral health unit of the ED for evaluation.

Review of physician orders dated 11/15/21 at 3:13PM directed to visually observe the patient twice in 30 minutes around the clock.

Observations on 11/16/21 at 11:00 AM during a tour in the ED behavioral health unit noted 6 beds including Patient #61's and #62's with the electrical cords either plugged in or lying on the floor. The cords were measured at 36 inches.

Interview with MHW #1 on 11/16/21 at 11:10 AM stated that the cords are to be locked up in the bed frame unless the beds are charging. MHW #1 stated that the electrical cords are checked on during the environmental rounds which are done every 15 minutes.

Interview with the Patient Services Manager for the Psychiatric ED Services on 11/17/21 at 9:40 AM stated that when the electrical cord to the bed is not in use, the cord is to be secured and locked within the bed frame for safety.


h. Tour of the Hospital's Crisis Intervention Unit (CIU) area of the ED on 11/16/21 at 9:45 AM identified that four (4) patients were in hallway beds (outside of the CIU) and Mental Health Worker (MHW) #5 was seated in the hallway observing the patients. The area was observed with unsecured lockers that contained patient's personal belongings. Also noted were multiple ligature risks. Interview with MHW #5 identified that the patient's required fifteen-minute observation checks. MHW #5 further identified that Patient #30 (hallway bed #2) was in the bathroom. Interview with Director #7 stated all patients in the hallway beds require line of site (in view at all times) observation because this area has ligature risks.

Review of Patient #30's clinical record identified the patient presented to the ED on 11/12/21 with a medication problem, since discharge on 11/8/21, has been without medications. Medication (methadone) was administered with a plan to discharge, however, the patient stated would "slit wrists" if discharged. A psychiatric consult was obtained on 1/12/21 (electronically signed 6:28 AM) and noted the patient had current suicide ideation. The psychiatric progress note dated 11/14/21 at 3:16 PM identified that the patient was placed in observation status in order to provide ongoing care in a safe environment. Interview with RN #19 on 11/16/21 at 9:45 AM stated the patient was being observed in the overflow hallway with a sitter. RN #19 requested to review the record to clarify the patient's prescribed level of monitoring, then was observed on the phone. RN #19 stated at 9:53 AM, the physician prescribed "standard observation".

Review of the clinical record failed to identify that an assessment was conducted to determine the change in observation status. Further, there was a discrepancy in the level of monitoring for the patients in the hallway overflow as MHW #5 stated the patients required 15-minute checks and the Director stated all patient's required line of sight at all times. Patient #30 was allowed to utilize the bathroom independently.


i. Tour of the Hospital's ED on 11/16/21 at 9:40 AM identified that five (5) patients were in hallway beds in POD D. Staff were not present in this area during tour. A vial of Heparin and a needle were observed in the bottom of the computer cart and Enoxapin 40 mg was observed on a bedside table. Subsequest to inquiry, the unsecured medications and needle were removed.


j. During tour of the hospitals main ED POD A on 11/16/21 at 9:10 AM, an unattended resuscitation room was noted to have unlocked supply carts (capability of locking) that contained syringes and scapels.


k. Patient #22 was admitted to the ED (YSC) on 11/14/21 with a diagnosis of hepatic encephalopathy, identified as not taking medications for 2 days, and was assessed as having confusion and decreased concentration.

Observation on 11/16/21 at 9:40 AM identified Patient #22 sitting upright in bed in an ED room. Patient #22 had a medication cup of pills and a small cup of liquid medication in front of him/her and there was no nurse with the patient. When asked what was in the cup, Patient #22 answered in another language. Continued observation identified the medication nurse was in the next room attending to another patient and did not have Patient #22 in sight.

Review of Patient #22's medication administration record identified the medications as Lactulose 30 mg, Synthroid 75 mcg, Nadolol 20 mg, Protonix 40 mg, Prednisone 2.5 mg, Rifaximin 550 mg, and Vitamins C & D.

Interview with RN #30 on 11/16/21 at 9:40 AM identified that she knew this patient for 2 days and that the patient was reliable which is why she felt comfortable leaving the medications. RN #30 identified that if she didn't feel the patient was reliable, she would not leave the medications.

The hospital's Medication Administration policy dated 4/28/21 identified that the individual administering the medication stays with the patient until the medication is taken.

Based on clinical record reviews, review of hospital documentation and interviews for one of two sampled Patients (Patients #75 and #76) who were reviewed for alleged sexual assault, the hospital failed to conduct a comprehensive investigation and physical examination. The findings include:

Patient #75 was admitted to the hospital on 10/30/2021 with a diagnosis a severe episode of a Major Depressive Disorder.

Physician's orders dated 10/30/2021 directed to conduct location and behavioral checks every fifteen minutes.

Patient #76 was admitted to the hospital on 11/1/2021 with a diagnosis of Depressive Disorder.

Physician's orders dated 11/1/2021 directed to conduct location and behavioral checks every fifteen minutes.

Patient #75 and Patient #76 were roommates on the child-psych inpatient unit.

A nurse's progress note dated 11/6/2021 identified that during bedtime, Patients #75 and #76 were observed in their room and were hugging each other. Both Patients were redirected, counseled for poor boundaries and Patient #76 was relocated to another room.

A nurse's progress note dated 11/8/2021, a late entry for 11/6/2021, identified that after Patient #76's room change, Patient #75 reported to the unit nurse that he/she was uncomfortable around Patient #76 and that Patient #76 touched him/her inappropriately multiple times in their room. He/she reported that Patient #76 would force kisses and hugs and rubbed his/her leg and genital area despite being told no. Additionally, Patient #75 reported scratches in the perineal area from Patient #76's nails and had a hickey on the abdomen. The nurse observed two faint pink markings on Patient #75's abdomen and one on the upper left chest. The Charge Nurse was immediately notified of the incident. The on-call physician and the Patient's responsible parties were notified.

The documentation failed to identify the actual time(s) of occurrence and/or documentation of an examination/assessment by a Nurse or Physician that evening.

A psychiatric physician progress note dated 11/7/2021 at 12:33 PM identified Patient #76 reported that on occasion Patients #75 and #76 would hug when no staff were around but denied any further touching or inappropriate behavior. A single seat plan was initiated.

A physician psychiatric progress note dated 11/7/2021 at 2:15 PM identified that the incident reported on 11/6/2021 was an emotional setback for Patient #75. Strategies to address painful feelings were developed.

Although Patient #75 was assessed by a physician the day after the incident, a physical exam was not conducted at that time to determine the extent of the patient's injuries.

Hospital documentation dated 11/8/2021 identified that the Unit Manager was notified on the evening of 11/6/2021 and directed the staff to obtain statements from the two nurses on the unit. Patient Relations was notified on the morning of 11/8/2021 at which time an investigation was initiated and the incident on 11/6/2021 was filed as a grievance. Referrals were made to the Department of Children and Families (DCF) and to the Detection, Admission, Reporting, and Treatment (DART) team.

A Physician's progress note dated 11/8/2021 at 1:47 PM identified Patient #75 was anxious and uncomfortable around Patient #76, which lead to intrusive thoughts of self-harm. Perseverating on staff telling him/her to forget about the incident was noted. Additionally, the patient reported that the inappropriate touching occurred multiple nights in a row and his/her delay in reporting was due to the fear of not being believed. A limited physical exam was conducted. Patient #75 required Hydroxyzine for anxiety related to the incident.

A DART consultation was conducted on 11/8/2021 at 4:30 PM that identified a superficial vertical linear abrasion to the right perineal area consistent with the patient's disclosure. Additionally, the patient reported distress due to the continued presence of Patient #76 on the unit. Safety concerns were discussed with staff to ensure minimal exposure.

Interview and review of the clinical record and hospital investigation with the Assistant Director of Patient Relations and the Unit Manager on 11/18/2021 at 10:30 AM identified that a review identified that patient location checks were documented as expected. Although statements were obtained from the unit nurses, statements from the other staff members (Counselors) on the unit were not obtained, and Patient #75 was not thoroughly interviewed at the time he/she reported the incident to determine the exact time the alleged assault occurred.

Interview, review of the clinical record and the hospital investigation on 11/19/2021 at 9:30 AM with the Director of Regulatory and the Unit Manager identified that although the patients were initially separated for inappropriate boundaries, there was no documentation in the clinical record that the patients were educated on the appropriate boundary expectations while on the unit. The Manager indicated that education is provided when issues are observed or noted. Additionally, the clinical record failed to identify that a nurse or physician conducted a thorough assessment/physical exam of Patient #75 on 11/6/2021 after the alleged assault was reported. The Manager indicated that a thorough assessment of the patient should have been conducted when the incident was reported to determine the extent of the patient's injuries.

Interview and review of the clinical record on 11/19/2021 at 1:30 PM with the Charge Nurse on duty on 11/6/2021 identified that hospital security was not notified of the alleged assault. Additionally, there was no documentation that the patient's responsible parties were asked if they wanted the local police to be notified.

Interview and review of the DART consultation with the physician who conducted the consult identified that the assessment and exam results were consistent with the patient's disclosure, and it was likely that the assault occurred.

The Hospital failed to ensure a timely assessment/physical exam of the patient after a sexual assault was reported. The hospital failed utilize all the means available to conduct a thorough investigation and/or failed to ensure the hospitals response to a reported sexual assault and investigation were conducted in accordance with the hospital's policy.

The Hospitals Immediate Response Algorithm directed a comprehensive investigation that included a thorough patient interview and physical exam within one hour of the reported incident, obtaining statements from staff, notification of hospital leadership. Additionally, the Algorithm directed leadership to obtain copies of related information and video footage if available. Explain to the Patient's guardians the right to call law enforcement. All information should be forwarded to Patient Relations within 24 hours.

The Condition of Participation for Nursing Services has not been met. The hospital failed to:

a. Ensure staffing was adequate to ensure patients received the necessary supervision in accordance with policy. Refer to A 392

b. Ensure 3 of 10 patients (#66, #94 and #106) had wound assessments completed in accordance with the hospital's policy, failed to ensure 2 of 8 patients (#14 and #32) had fall interventions in place, failed to ensure 2 of 3 patients (#6 and #84) had pain assessed timely or notified the physician when pain was not relieved, and failed to implement infection control practices for 1 of 3 patients (#24) reviewed for isolation precautions in the Emergency Department. Refer to A 395

c. Ensure 2 of 10 patients (#84 and #93), had comprehensive plan of care to address the patient's pain. Refer to A 396

d. Ensure 1 of 3 patients (#22) had supervised medication administration and for 2 of 5 patients (#40 and #41), failed to ensure medication was administered per physician's orders. Refer to A 405

e. Ensure for 1 of 3 patients (#22) were monitored during blood administration in accordance with hospital policy. Refer to A 410

Based on observation, clinical record reviews, hospital documentation, interviews, and policy review for 6 of 9 patients reviewed for level of supervison, (Patient #28 and 5 others), the hospital failed to provide sufficient numbers of staff to ensure that 1:1 monitoring, close supervision, or line-of-sight supervision was provided to patients in accordance with hospital policy. The findings include:

a. Patient #28 had a history of self-cutting and Major Depressive Disorder (MDD) and was admitted to the children's Emergency Department (ED) on 11/15/21 for a psychiatric evaluation.

The safety risk assessment identified that Patient #28 had current suicidal thoughts, wished to be dead, and had thoughts of a suicide method.

The clinical record identified standard environmental safety requirements that included to continue 1:1 and safety precautions while patient remains in the ED. A sitter was initiated.

Observation on 11/16/21 at 10:05 AM identified an empty chair in the hallway facing towards Patient #28's ED room. Sitter #50 was noted sitting in a hallway chair with her back to Patient #28's room.

Interview with Sitter #50 on 11/16/21 at 10:05 AM identified that she was responsible for watching 2 patients that were directly in front of her. When asked who else required monitoring, Sitter #50 identified Patient #28. When asked who was watching Patient #28, Sitter #50 pointed to the empty chair and stated that "she left for a few minutes". When asked if she could visualize Patient #28, Sitter #50 replied "no".

Interview with Charge Nurse #20 on 11/16/21 at 10:50 AM identified that Patient #28 should have been in a sitter's line-of-sight. In addition, Charge Nurse #20 identified that the ED was short staffed to fulfill 1:1 and constant observation statuses for the number of patients in the ED, but per her assignment, every patient should have had a minimum of line-of-sight supervision.

The hospital policy for levels of observation identified that a patient on 1:1 is continuously monitored by staff and remains within arm's length of the patient. Patients on line-of-sight supervision are continuously monitored by staff who will remain within visual sight line.


b. Tour of the children's ED on 11/16/21 at 10:00 AM identified the unit census was twenty-seven (27). Review of the Patient Suicide Risk level as of 11:13 AM identified that out of the twenty-seven (27) patients on the unit, nine (9) were determined to be high risk and required 1:1 monitoring per policy, and as of 11:33 AM eight (8) patients were determined to be high risk.

Review of the sitter staffing schedule with the Charge Nurse on 11/16/21 at 11:45 AM identified that five (5) of the high risk patients were being observed in a cluster of two to three patients as the unit did not have enough staff to fulfill the 1:1 ratio. The Charge Nurse provided bed numbers of the five patients who required 1:1 supervision but did not provide the names of the patients.

Interview with the Clinical Program Director and Nurse Manager indicated that the behavioral health surge has resulted in a gap with sitters and several options are tried to obtain adequate staffing, however, they are not always able to accomodate this need.


41683

Based on observation, clinical record reviews, staff interviews, and policy review for 3 of 10 sampled patients reviewed for alteration in skin integrity (#66, #94 and #106), the hospital failed to ensure that wound assessments were completed in accordance with the hospital's policy, failed to ensure 2 of 8 patients (#14 and #32) had fall interventions in place, failed to ensure 2 of 3 patients (#6 and #84) reviewed for pain management were reassessed and/or that pain was addressed pain in a timely manner, and failed to implement infection control practices for 1 of 3 patients (#24) reviewed for isolation precautions in the Emergency Department (ED). The findings include:


a. Patient #66 was admitted to the Emergency Department (ED) on 11/15/21 with an altered mental status.

Review of the ED provider note dated 11/16/21 noted increased confusion, hallucinations, and difficulty walking.

Observation on 11/16/21 at 10:05 AM noted Patient # 66 lying in bed with a large bandage to the lower left extremity. The bandage was observed to be heavily stained with blood. Observations at 10:19AM noted the patient's legs were covered with a sheet with bloody drainage that soaked through.

Interview with RN #13 on 11/16/21 at 10:05 AM stated that the patient sustained skin tears last evening while kicking his/her legs in the bed and hit the side rails of the bed.

Review of the clinical record and interview with RN #12 on 11/16/21 at 10:25 AM noted that there was no documentation of the patient hitting his/her legs and sustaining injuries and there should have been. RN #12 stated that after the incident the areas were to be assessed, a treatment initiated, and then documented in the clinical record.


b. Patient #94 was admitted to the hospital on 11/15/21 with an altered mental status and was COVID-19 positive.

The admission nursing note dated 11/15/21 at 6:11 PM noted that a two (2) RN skin assessment was completed, a suspected DTI (deep tissue injury) to the left buttocks was observed and a wound consult was placed.

Nursing notes dated 11/16/21 at 10:56 AM noted the patient was assisted with turning and repositioning every 2 hours with pillows, had a DTI to the left buttocks, barrier cream was applied, and a skin care consult was placed.

Nursing notes dated 11/17/21 at 6:41 AM noted the patient had a DTI to the left buttocks and barrier cream was applied.

Review of the clinical record and interview with RN #14 on 11/17/21 at 11:45 AM noted that although the patient was admitted with a DTI on 11/15/21, the wound had not been measured according to hospital policy. RN #14 stated that they had ordered a consult for the wound nurse but that can take up to 48 hours before it is completed. RN #14 further stated that on admission a complete assessment including measurements are to be completed by nursing.

Review of the Pressure Injury Assessment Policy identified pressure injuries are assessed and documented on admission and the documentation is to include measurements including length, width, and depth.


c. Patient #106 was admitted on 10/14/21. A Braden Risk score on 10/15/21 at 4:00 AM identified the patient's score was 18 indicating the skin assessment was within defined limits.

Review of a nursing skin/ wound consult documentation dated 11/9/21 at 8:50 AM identified that Patient #106 was first assessed for a pressure injury on 11/9/21 at 8:37 AM. The assessment identified a new coccyx Deep Tissue Pressure Injury (DTPI) with a purple base, non -blanching peri-wound intact with blanching with measurements of 6 centimeters long, 3 centimeters wide and a depth of 0 centimeter.

A plan of care note dated 11/14/21 identified Patient #106 had a Deep Tissue Injury (DTI) wound to coccyx, barrier cream was applied, and indicated that Wound Care was consulted.

Review of Patient #106's consult orders identified a RN order/request for Inpatient Consult to Wound nurse dated 11/14/21 at 10:56 AM and a second Inpatient consult for Wound nurse order dated 11/17/21 at 11:21 AM.

Review of Patient #106's clinical records with RN #14 on 11/17/21 at 11:17 AM failed to identify documentation the patient was assessed by the Wound Nurse between 11/14/21 and 11/17/21 as requested by the registered nurse.



d. Review of Patient #14's clinical record dated 11/16/21 at 9:47 PM identified the patient scored 45 points on the Morse Fall Risk assessment (above 45 = high fall risk) and scored 60 points on 11/17/21 at 1:57 PM.

Review of Patient #14's enhanced safety measures documentation dated 11/16/21 at 9:47 PM indicated the patient's bed alarm was set to the on position.

Observation of Patient #14 during tour of the Heart and Vascular step-down unit on 11/17/21 at 10:35 AM with Manager #10, Manager #11, and MD #8 identified that Patient #14 had signage posted at the entrance to the patient's room identifying the patient as a fall risk. The patient was observed lying in bed and the bed alarm was inactive and according to the Manager, the alarm should have been on.


e. Patient #32's diagnoses included Gastro-Intestinal (GI) bleed secondary to duodenal bleeding ulcer with hemorrhagic shock.

On 11/10/21 at 12:45 PM the patient was transferred from the Medical Intensive Care Unit (MICU) to the medical unit.

A fall risk assessment identified that the patient was oriented only to self and was bedbound. The fall risk assessment identified that the patient was at risk for falls with a plan of care to maintain the fall prevention program which included to keep the bed in lowest position and utilize a bed alarm.

Review of a nurse's note dated 11/11/21 at 3:30 AM identified that the patent was found on the floor laying sideways. The note identified that the fall was unwitnessed. The patient was assessed with no physical signs of injury, was examined, and underwent a CT scan with no injuries identified.

Review of the post fall investigation with RN #9 on 11/15/21 at 11:00 AM identified that while doing rounds the patent was found on the floor, and the bed alarm was not sounding. RN #9 stated that RN # 0 was assigned to care for the patient and although he checked on the patient prior to his break, he failed to ensure that the patient's bed alarm was set to the on position prior to leaving the patient.

RN #9 identified that RN #10 was reeducated on the use of bed alarms.



f. Review of Patient #6's clinical record identified the patient underwent a surgical procedure on 11/12/21.

A physician's order dated 11/12/21 at 8:00 PM directed to administer Oxycodone 10 milligram (mg) every three (3) hours as needed. An additional order dated 11/12/21 at 8:00 PM directed to administer Oxycodone 5mg every three (3) hours as needed.

Review of Patient #6's medication administration record and flowsheet with Patient Safety Coordinator #1 and Registered Nurse (RN) #18 identified that from 11/13/21 at 7:02 PM to 11/15/21 at 12:47 PM on Patient #6 received seven (7) doses of oxycodone.

Review of pain reassessment documentation identified that pain reassessments were completed 2-6 hours after the administration of oxycodone. Patient #6's assessment failed to identify documentation that the patient was asleep or off the unit one hour after after the administration of analgesics.

An interview with RN #18 on 11/16/21 at 4:05 PM identified that it was the practice to reassess a patient's pain as close as possible to one hour of administering a pain medication.


g. Review of the clinical record identified that on 11/16/21 at 10:49 AM, Patient #84 reported pain as a 10 out of 10 (score 1-10 with 10 being the worst possible pain) and oxycodone 20 mg was administered. The record identified that the patient's pain level was reassessed at 12 noon and at that time the patient reported pain as an 8 out of 10.

Further review of Patient #84 clinical record failed to identify that the physician was notified that the patient's pain was not relieved with pain medication.

Interview with Registered Nurse #8 on 11/16/21 he indicated that at 12 noon he did not offer any other pain medication to the patient and he did not inform the physician that the pain medication was not effective. RN#8 also indicated that it was his understanding that the patient's acceptable pain goal was between 3 to 4 on a scale of 1 to 10.

Review of the clinical record and interview on 11/16/21 at 2 PM with the Nurse Manager indicated that RN#8 failed to identify that any alternative non-pharmaceutical measures were offered to the patient to address the patient's pain.

Review of the facility's Pain Assessment and Management Policy directed pain is reassessed and documented with change of status, as clinically relevant, and after any interventions. The Policy further indicated that if at the time or reassessment the patient is sleeping, the patient is not awoken and sleeping is documented as an observation, and if the patient is off the unit staff documents that the patient is off the unit.


h. Review of Patient #24's clinical record identified that Patient #24 had rhinovirus and was on contact and droplet precautions.

Observation on 11/16/21 at 10:20 AM identified Patient #24's room had a droplet precaution sign at the door. RN #3 was observed entering the room wearing only a surgical mask for Personal Protective Equipment (PPE) and did not don any additional PPE.

Interview with RN #3 on 11/16/21 at 10:30 AM identified that she was not aware that Patient #24 was on contact precautions and would have donned a gown, and gloves in addition to the surgical mask if she was aware. RN #3 identified there should have been both a contact precaution sign and droplet precaution sign outside Patient #24's room to identify what type of PPE should be worn prior to entering the room.

The hospital's contact precautions policy directed a contact precautions sign will be displayed outside of the patient's room and healthcare workers will wear gloves and gowns upon entering the room.


41683

Based on clinical record review and interview for 2 of 10 patients reviewed for pain (Patients #84 and #93), the hospital failed to develop a comprehensive plan of care to address the patient's pain. The findings includes:


a. Review of the clinical record identified that on 11/16/21 at 10:49 AM, Patient #84 reported pain as a 10 out of 10 (score 1-10 with 10 being the worst possible pain) and oxycodone 20 mg was administered. The record identified that the patient's pain level was reassessed at 12 noon and at that time the patient reported pain as an 8 out of 10.

Further review of Patient #84 clinical record failed to identify that a care plan was initiated to address the patient's acceptable pain level or interventions identified to address the pain.

Interview with Registered Nurse #8 on 11/16/21 he indicated that at 12 noon he did not offer any other pain medication to the patient and he did not inform the physician that the pain medication was not effective. RN#8 also indicated that it was his understanding that the patient's acceptable pain goal was between 3 to 4 on a scale of 1 to 10.

b. Patient #93 was admitted to the hospital on 9/15/21 for wound evaluation and Suicidal Ideations (SI).

Review of the History and Physical (H&P) dated 9/15/21 identified the patient had paraplegia and had multiple wounds including extensive necrotic and deep pressure wounds to the buttocks and heels. The H&P further identified that the patient was refusing care and treatments for wounds, refusal of medication, and refusal to turn and reposition.

Review of the clinical record and interview with RN #9 on 11/17/21 at 1:50 PM identified that although the clinical record documented the patient's refusals for treatment, repositioning and medication, there was no care plan in place to address the patient's needs for wound care or refusal of treatments and repositioning. RN #9 stated that developing a plan of care and addressing the patient's issues were overlooked.

Based on clinical record review, interview, observation and policy review for 1 of 3 patients receiving medications (Patient #22), staff failed to supervise the medication administration and for 2 of 5 patients reviewed for titratable medications (Patient #40 and #41), the hospital failed to ensure medication was administered per physician's orders. The findings include:


a. Patient #22 was admitted to the ED on 11/14/21 with a diagnosis of hepatic encephalopathy and identified as not taking medications for 2 days. Patient #22 was assessed as having confusion and decreased concentration.

Observation on 11/16/21 at 9:40 AM identified Patient #22 sitting upright in bed in an ED room. Patient #22 had a medication cup of pills and a small cup of liquid medication in front of him/her and there was no nurse with the patient. When asked what was in the cup, Patient #22 answered in another language. Continued observation identified the medication nurse was in the next room attending to another patient and did not have Patient #22 in sight.

Review of Patient #22's medication administration record identified the medications as Lactulose 30 mg, Synthroid 75 mcg, Nadolol 20 mg, Protonix 40 mg, Prednisone 2.5 mg, rifaximin 550 mg, and Vitamins C & D.

Interview with RN #30 on 11/16/21 at 9:40 AM identified that she knew this patient for 2 days and that the patient was reliable which is why she felt comfortable leaving the medications. RN #30 identified that if she didn't feel the patient was reliable, she would not leave the medications.

The hospital's Medication Administration policy dated 4/28/21 identified that the individual administering the medication stays with the patient until the medication is taken.


b. Patient #41's history and physical dated 11/11/21 identified a diagnosis of acute respiratory failure with hypoxia and required respiratory support on a ventilator.

The physician's order dated 11/14/21 directed fentanyl 0.5 mcg/kg/hr continuous infusion, titrate by 0.25 mcg/kg/hr every 2 minutes to titrate to Richman Agitation Sedation Scale (RASS) goal -1 to). Minimum frequency of titration goal parameter assessment every 4 hours and/or pre/post dose changes.

Review of the flowsheets dated 11/16-11/17/21 identified the RASS goal was assessed on 11/16/21 at 8:00 PM and not assessed again until 11/17/21 until 4:00 AM (eight hours later).

Interview with Manager #14 on 11/17/21 at 10:30 AM identified that the RASS should be assessed every 4 hours and with any dose change and documented in the medical record.


c. Patient #40's history and physical dated 11/11/21 identified a diagnosis of hypocemix/hypercarbic respiratory failure.

The physician's order dated 11/16/21 directed dexmedetomidine (precedex) 0.2 mcg/kg/hr, titrate by 0.1 mcg/kg/hr no more frequently than every 30 minutes for RASS -1 to 0. Minimum frequency of titration goal parameter assessment every 4 hours and/or pre/post dose changes.

Review of the flowsheet dated 11/17/21 identified Patient #40's RASS score at 12:00 AM was -1 (goal), the RASS score was -2 when reassessed at 2:00 AM, 3:00 AM, 4:00 AM, 5:00 AM, and 6:00 AM. The RASS score at 7:00 AM was -1 (goal).

Review of the medication administration record (MAR) identified Patient #40 received precedex 0.4 mcg/kg/min continuous without rate change on 11/17/21 from 12:00 AM-7:00 AM.

Interview with Manager #14 on 11/17/21 at 11:00 AM identified based on the documented RASS of -2 from 2:00 AM through 6:00 AM, the nurse missed an opportunity to adjust the precedex to meet the RASS goal of -1 to 0 per the physician order.

The intravenous continuous infusion policy dated July 2021 identified frequency of monitoring during drug administration is at baseline (prior to) and 15 minutes after each dose change. If goal is reached, the assessment will occur at minimum every 4 hours or as clinically relevant.

Based on observation, interview, clinical record review, and review of hospital policy for 1 of 3 patients (Patient #22) reviewed for blood administration, the hospital failed to ensure a patient receiving blood was being monitored per hospital policy. The findings include:

a. Patient #22 was admitted to the ED on 11/14/21 with a diagnosis of hepatic encephalopathy. Review of the history and physical dated 11/15/21 identified the patient had altered mental status caused by acute metabolic encephalopathy.

The physician's order dated 11/16/21 at 6:47 AM directed to administer 1 unit of red blood cells over two hours for a hemoglobin of less than 7.

Clinical record review with RN #3 on 11/16/21 at 10:30 AM identified an initial set of vital signs was done at 8:39 AM, the blood was started at 8:45 AM at 125 ml/hr, and a second set of vital signs was done at 9:31 AM, 46 minutes after initiation of the blood transfusion.

Interview with RN #3 identified she obtained a baseline set of vital signs, cross checked the blood with another nurse, hung the blood, set a timer for 15 minutes on her phone to obtain the next set of vital signs and left the room to assist another patient. RN #3 identified the alarm sounded while she was busy in the other patient's room and returned to Patient #22's room approximately 20 minutes after the blood was hung and obtained a second set of vital signs and documented them in the medical record as she obtained them.

Interview with Manager #5 on 11/16/21 identified an initial set of vital signs should be obtained within 30 minutes prior to the initiation of the transfusion and a second set of vitals 15 minutes after the initiation of the transfusion.

The hospital blood policy directs to monitor the patient for the first fifteen minutes for signs of a transfusion reaction and document vital signs within 10-20 minutes from initiation of transfusion.

The Condition of Participation for Physical Environment has not been met.

Based on observations throughout the hospital, interviews, and policy reviews, the hospital failed to ensure that a sanitary environment was maintained.

Please see A701

Based on observations throughout the hospital, interviews, and policy reviews, the hospital failed to ensure that a sanitary environment was maintained. The findings include:

a. Observation of the Emergency Department (ED) on 11/15/21 at 9:30 AM identified resuscitation room 1 and resuscitation room 2 had soiled floors with large dust balls in the corners and heavy dust on surfaces including open storage bins used for resuscitation supplies. Interview with Manager #4 on 11/15/21 at the time of observation identified environmental services staff does clean the resuscitation rooms between patients to wipe clean the high touch surfaces and any equipment used with hospital approved disinfectant but it is difficult for the environmental services staff to have access to the resuscitation rooms to do heavy cleaning because they are frequently in use.

b. Observation at on 11/16/21 at 9:45 AM in the emergency department identified the patient bathroom in the chest pain pod with soiled floors, and pink mold on the shower curtain and shower stall floor.

c. Observation of the medication room in the chest pain pod identified a bag containing a breast pump on the counter. Interview with Manager #5 at the time of the observation identified that the breast pump appeared used but clean and based on additional contents of the bag belonged to an employee. Manager #5 identified that personal belongings should not be stored in the medication room.

d. Observation on 11/16/21 at 9:50 AM in the emergency department identified dirt and heavy dust on the floor in the chest pain assessment area. Further observation identified large balls of dust on the manual resuscitator hanging on a hook in the area. Interview with Manager #5 at the time of observation identified that daily rounds are done to ensure all emergency equipment is available and in good order and it should have been identified that manual resuscitator needed to be replaced. Manager #5 immediately discarded the manual resuscitator and replaced it with a new one. Interview with Environmental Services Supervisor #2 on 11/16/21 at 9:55 AM identified that the chest pain pod is cleaned every shift by a member of the environmental services department. Environmental Services Manager #1 was unable to provide an explanation for why the area was not clean.

e. Observation on 11/15/21 at 9:30 AM in Resuscitation Room #1 identified an endotracheal tube that expired in 2/10/21 and three adult colormetric CO2 detectors that expired on 9/24/21. Interview with Manager #4 on 11/15/21 at 9:30 AM identified that materials management staff checks for outdated supplies daily while restocking.

f. A tour of the surgical areas (YSC) was conducted on 11/15/21. Observations on 11/15/21 at 9:52 AM and 10:14 AM and on 11/16/21 at 9:21 AM and 9:40 AM noted a buildup of dust and debris on several horizontal surfaces in operating/procedure rooms in the surgical/radiology departments to include monitors, door closures, wall boards and equipment towers. Interview with the Manager of Operating Room (OR) Support Services on 11/15/21 at 10:14 AM noted the OR had its own designated cleaning staff to clean ORs between cases and to provide terminal cleaning to OR suites. Interview with Procedural Manager #1 on 11/16/21 at 9:40 AM noted the radiology department had designated environment staff to clean the radiology department between cases and at the end of the day. The hospital policy entitled Environmental Cleaning of Operating and Procedure Rooms Standard Operating Procedure directed to damp dust all horizontal surfaces prior to bringing in case carts, supplies, instruments, and equipment (lights, furniture, booms, equipment etc.) into the room for the first scheduled case of the day. The hospital policy entitled Cleaning and Disinfecting of Reusable Medical Equipment identified reusable medical equipment is to be cleaned and disinfected when removing from a patient room or between patients. Equipment shall be disinfected after each use using a hospital approved disinfectant wipe.

g. Tour and observation of Operating Room (OR) suites (SRC) was conducted with Registered Nurse (RN#2) on 11/15/21 at 10:50 AM. During observation dust built-up was noted on the Robotic machine which were located inside OR #18 and OR #14. Interview with RN #2 on 11/15/21 at 10:50 AM identified that daily terminal cleaning is performed for surgical suites and robotic machines should be cleaned during room cleaning. Review of the facility environmental cleaning of Operating and Procedure Rooms standard Operating Procedure guidelines indicated that terminal cleaning included cleaning all exposed surfaces using EPA-registered hospital approved disinfectant wipes.

h. Observations during a tour of the ED on 11/15/21 at 10:15AM noted on the A side of the Emergency Department the WOW carts, intubation cart, ultrasound machine, vital signs machine, and cast cutter machine heavily soiled with dust and debris on the legs and base of the equipment.

i. Observation on the B side of the ED noted in the main stockroom for supplies the shelving was heavily soiled with dust and debris. The bins that held the supplies had dust and debris within them. Observations of the Trauma Room 1 and 2 noted dust balls moving about the floor, the WOW cart legs and wheels soiled with heavy debris in the wheels and the windows to the supply cabinets marred with white film. Observation of the B side nursing station noted the walls to be heavily soiled with dried liquids and debris. Interview with the Assistant Director for EVS on 11/15/21 at 1PM stated that equipment is to be cleaned after a patient leaves the room. The Assistant Director stated that general cleaning outside of patient rooms is to be done every shift and the Techs do most of the room cleaning due to time restraints and getting the room cleaned before another patient enters the room. The Assistant Director stated that there is a grey area on who is to clean the equipment in the Emergency Department, but they have recognized the issue and are looking into how to resolve the issue.

j. Observations during a tour of Celentano 3 unit on 11/17/21 at 1:50 PM noted the patient refrigerator soiled with dried on liquid and particles of food on floor of refrigerator. Further observations noted 4 WOW carts and 2 vital signs machines lower legs and wheels heavily soiled with dust and debris. Interview at that time with RN (Nurse Manager) # 9 stated the last time the carts had been cleaned was in the summer by EVS. RN # 9 stated that the nurse's wipe down the surface area, screen, and keyboards frequently.

k. Observations during a tour of 5 West Verdi unit on 11/17/21 at 11:15 AM noted the trim on walls in the hallway heavily dusty, the 4 WOW carts and 2 Vital signs carts were heavily soiled with dust and debris on the legs and wheels of the equipment. The shelves of the life pack cart were heavily soiled with dust and 2 patient lifts were noted to be dusty and debris on the base of the equipment. Interview with RN # 10 (Nurse Manager) at that time stated that nursing wipes down the keyboards, workspace, and equipment, but EVS is to do the legs and wheels of the carts. RN #10 stated that she was not aware the last time EVS cleaned the equipment.

l. Observations during a tour of the ED (SRC) on 11/15/21 at 09:45 AM and at various times throughout the day the surveyor, accompanied by the Director of Facility Engineering, observed that the occupant load within the two (2) smoke compartments exceeded the requirements of thirty (30) square feet per patient the aggregated areas of corridors, patient rooms, treatment rooms, lounge or dining areas, and other similar areas on each side of the horizontal exits, not meeting the requirements of section 19.2.2.5.11 of NFPA 101. i.e; the result of all treatment and exam rooms within the emergency department being occupied, patients in wheelchairs, stretchers, and chairs were placed against the exit access corridor walls throughout the entire emergency department impacting the means of egress, general aisles, passageways, corridors and exit discharges not meeting the minimum requirements of the referenced LSC standard.

m. Observations during a tour of the ED (YSC) on 11/15/21 at 11:00 AM and at various times throughout the day the surveyor, accompanied by the Director of Facility Engineering, observed that the occupant load in the B-Pod and CIU exceeded the requirements of thirty (30) square feet per patient the aggregated areas of corridors, patient rooms, treatment rooms, lounge or dining areas, and other similar areas on each side of the horizontal exits, not meeting the requirements of section 19.2.2.5.11 of NFPA 101. i.e; the result of all treatment and exam rooms within the emergency department being occupied, patients in wheelchairs, stretchers, and chairs were placed against the exit access corridor walls and against egress doors impacting the means of egress, general aisles, passageways, corridors and exit discharges, not meeting the minimum requirements of the referenced LSC standard.

n. Observations during a tour of the ED CIU (YSC) on 11/15/21 at 11:45 while accompanied by the Director of Facility Engineering observed patient rooms with excessive graffiti on the walls along with holes and damaged wall coverings. Interview with Director of Engineering on 11/15/21 stated the unit is overpopulated and at times cannot get into the rooms to make repairs as needed.

o. Tour and observation of Operating Room (OR) suites (YSC) was conducted with Facility staff on 11/17/21. During observation dust built-up was noted in L+D OR #2. Interview with facility staff on 11/17/21 identified that daily terminal cleaning is performed for surgical suites. Review of the facility environmental cleaning of Operating and Procedure Rooms standard Operating Procedure guidelines indicated that terminal cleaning included cleaning all exposed surfaces using EPA-registered hospital approved disinfectant wipes.

p. Observations on 11/15/2021 at 9:30 AM and times throughout the day on the YNPH psychiatric in-patient floors/units identified hard plastic soap dispensers used throughout the areas that were not designed for use in a psychiatric/ institutional standard and could be utilized as a weapon if broken and/or a means of self-harm.

q. Observations on 11/15/2021 at 9:30 AM and times throughout the day on the YNPH psychiatric in-patient floors/units identified that the facility failed to maintain a clean and sanitary environment i.e., patient room floors under beds, behind beds and along the side of the bed throughout the facility were debris laden up to and including patient trash, food debris and soiled linen.

r. Observations on 11/15/2021 at 10:45 AM and at times throughout the day identified that the facility ceilings in the (YSC) Central Sterile Department were lay in tiles that were not designed and or proper for the semi restricted areas of the department i.e. perorated, regular, serrated and or textured not designed for a semi restricted space and, not maintaining an easily cleanable surface.

s. Observations on 11/15/2021 at 10:45 AM and at times throughout the day identified that the facility (YSC) Central Sterile Department failed to maintain separation and negative ventilation from construction i.e. the separation wall had been dislodged from it installation and had gaps that would allow infiltration of construction dust, and the required negative air fan ductwork to the exterior of central sterile was torn and dumping exhausted air into the construction site making the construction area positive to the department. Subsequent to this observation it was immediately corrected.

t. Observations on 11/15/2021 at 10:45 AM and at times throughout the day identified that the facility (YSC) Central Sterile Department had open ceiling tiles with extension cords run into the ceiling to the construction area not maintaining an integral ceiling assembly

u. Observations on 11/15/2021 at 10:45 AM and at times throughout the day identified that the facility (YSC) Central Sterile Department failed to maintain the required exhaust ventilation above the front of the steam sterilizers i.e., exhaust vents in the exhaust trough in front of the steam sterilizers were closed off with red duct tape not maintaining the system as designed.

v. Observations on 11/16/2021 at 1:30 PM of the dietary department (SRC) identified that the dietary department exhaust hood above the stoves was grease laden and had not been inspected or cleaned (quarterly) as required by NFPA 96, "Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations", section 8-3 and Table 8-3.1.