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Based on staff interview, medical record review, and the review of facility policy and procedure, it was determined that the facility failed to ensure the protection and promotion of patient rights.

Findings include:

1. The facility failed to follow policy and procedure regarding contraband and illegal items. (Refer to Tag A-0144)

2. The facility failed to ensure that the protocol for screening for abuse and neglect was followed. (Refer to Tag A-0145)

Cherry Hill Campus
C#NJ00143610

Based on staff interview, review of one (1) out of one (1) Medical Record (#CH1), and review of facility policies and procedures, it was determined that the facility failed to ensure that the policies and protocols on securing and reporting contraband items is followed resulting in contraband items being available for use.

Findings include:

Reference #1: Facility policy titled, "Identification and Disposition of Contraband and Controlled Items" states, "...Contraband is any illegal item/substance a patient may have in his/her possession..... Management of Contraband ...2. Contraband should immediately and safely separated from the individual who possesses the items. The contraband shall be secured. Security shall safeguard any illegal contraband until it is turned over to law enforcement. 3. Security personnel will take possession of all unidentified or suspected illicit substances. All suspected controlled dangerous substance (CDS) shall be turned over to the appropriate law enforcement agency..... 4. Clinical staff shall complete documentation in the medical record for any destruction/disposition of contraband items..... 6. The patient will be notified by security regarding the disposition of contraband to law enforcement....."

Reference #2: Facility policy titled, "Management of Patient Belongings/Valuables" states, "...Valuables: Possessions not essential to maintaining the patient's quality of life while admitted to the hospital..... Articles, such as, knives, guns, drugs, and smoking materials are not accepted. Law enforcement shall be contacted if any weapons or drugs are brought into the hospital....."

Reference #3: Facility policy titled, "Patient & Room Search" states, "...If hospital associates have reason to believe that an individual(s) entering the hospital or during the hospital stay, possess an item that could cause harm to the individual or to others and/or that could interfere with treatment, the hospital associate will contact security..... When any member of the healthcare team... believes a patient still possesses contraband, a patient search will be completed....."

1. On 4/21/2021 the medical record of Patient #CH1 was reviewed. Patient #CH1 presented to the facility Emergency Department (ED) on 3/20/21 at 4:08 PM, with complaint of a bilateral foot infection. The following was noted:

a. At 9:13 PM, a note written by Staff #CH28, an ED nurse, stated, "Walked into patients room to draw labs; the patient had an [sic] used syringe on [patient's] lap, also [the patient] had empty Fentanyl bags on the floor of the room, on [the patient's] bed and in [the patient's] wallet. [Staff #CH28] notified [ED Physician] and called security, had pt's belongings taken by security and the pt was placed in green scrubs....."

b. On 3/21/21 at 12:36 AM, a note written by Staff #CH29, an Intensive Care Unit (ICU) nurse, stated, "Pt stated [the patient] wanted to leave AMA (Against Medical Advice) because [the patient] is in pain and stated [the patient] is not getting proper treatment at the hospital..... Security called for belongings. As patient was getting [the patient's] stuff together [the patient] found bags of heroin in [the patient's] belongings and snorted them. Code gray called. Pt AAOx3 [awake, alert & oriented x3], still insisted on leaving and was escorted out of the hospital by security....."

2. An interview with Staff #CH16 on 4/22/2021 at 12:00 PM confirmed the above findings and that the facility did not follow policy and protocol in searching the patient's belongings, documenting the handling of the contraband, and notifying law enforcement in the ED and in the ICU.

This finding resulted in an Immediate Jeopardy (IJ) on April 26, 2021 at 9:55 AM. The IJ template was provided to Staff #CH16 at 9:55 AM, and a removal plan was requested. A removal plan was provided by the facility on April 27, 2021 at 5:04 PM and was accepted on April 27, 2021 at 5:13 PM.

On April 28, 2021, an on-site survey was conducted. The facility took the following steps to remove the immediacy of the IJ: a policy review was conducted and the facility determined the need for reinforcement with staff to improve compliance. The facility provided education to ED staff, ICU Clinical Nurses, Patient Care Technicians (PCT), ED providers, Intensivists and Security Officers, regarding the policy outlining the process expectations for identification and disposition of contraband and controlled items.

It was determined the IJ removal plan was successfully implemented and the IJ was removed on April 28, 2021.

Cherry Hill Campus
C#NJ00143610

Based on staff interview, review of one (1) out of two (2) Medical Records (#CH11), and review of facility policies and procedures, it was determined that the facility failed to ensure an abuse and neglect screening is performed on a patient under the age of eighteen (18) with a history of sexual assault, alcohol use, drug use, and attempted suicide.

Findings include:

Reference #1: Facility policy titled, "Child Abuse" states, "...PURPOSE ...Children under the age of 18 receiving care at [Health System] will be assessed for abuse and neglect..... All associates and caretakers have a responsibility to report abuse per policy and regulation. Nursing will assess for abuse during the initial RN (registered nurse) assessment process....."

Reference #2: Facility policy titled, "Management of the Mental/Behavioral Health Patient in the Emergency Department" states, "...1. Patients presenting with BH (behavioral health) care needs have the right to receive care from qualified healthcare professional(s) in a safe environment..... 3. Patients, licensed providers, and staff collaborate to develop the patient's plan of care and agreed upon behaviors. 4. It is crucial that all members of the ED (emergency department) team document assessment findings and actions taken to provide care, treatment, and services in the patient's medical record..... PROCEDURE: ...6. The County Crisis Screener evaluates the referred BH patient based on the designated screening center process... -Screener will document key elements in the patient's medical record including, but not limited to, pertinent assessment findings, recommended interventions, and disposition...".

1. On 4/22/2021, the medical record of Patient #CH11 was reviewed. Patient #CH11 presented to the Emergency Department (ED) on 12/24/2020 at 1:45 AM with the complaint of suicidal ideation and a plan to overdose on pills. Further review identified the following:

a. Patient #CH11 had a history of sexual assault, though not identified by whom, associated with post traumatic stress disorder (PTSD), alcohol abuse, illicit drug use, and attempted suicide, all indicators per facility policy that would trigger a suspected abuse/neglect situation.

b. A note written on 12/24/2020 at 2:08 AM, by Staff #CH30, an ED provider, stated "...Reports that [the patient] feels safe now that [the patient] knows [the patient] is getting help."

2.The patient was discharged to home on 12/24/2020 at 4:15 AM, which placed the patient at risk for abuse and neglect due to the ED staff failing to complete an abuse and neglect screening per facility policy and procedure.

3. An interview with Staff #CH16, an administrator, and Staff #CH17, an ED physician, on 4/22/21 at 3:00 PM confirmed the above findings.

This finding resulted in an Immediate Jeopardy (IJ) on April 26, 2021 at 9:55 AM. The IJ template was provided to Staff #CH16 at 9:55 AM, and a removal plan was requested. A removal plan was provided by the facility on April 27, 2021 at 5:04 PM and was accepted on April 27, 2021 at 5:13 PM.

On April 28, 2021, an on-site survey was conducted. The facility took the following steps to remove the immediacy of the IJ: a policy review was conducted and the facility determined the need for reinforcement with staff to improve compliance. The facility provided education to Clinical Nurses outlining the process expectations for completing an abuse screening for each patient arriving to the ED. The Electronic Health Record (EHR) was redesigned to include an "Alert" to the end-user to complete an abuse screening upon arrival to the ED. A meeting was held with the facility and the contracted County Crisis provider, to review the IJ and conduct an action plan. The County Crisis provider conducted education with the crisis screeners, outling the process for obtaining signatures on their crisis intervention/safety plan.

It was determined that the IJ removal plan was successfully implemented and the IJ was removed on April 28, 2021.

Stratford Campus
Complaint #NJ00144234

A. Based on staff interview, review of two (2) of three (3) medical records for Patient #ST3 and review of facility policy and procedure, it was determined that the facility failed to ensure an assessment of a patients vital signs is obtained at time of entry into the Emergency Department (ED), in response to an intervention and prior to discharge from the ED.

Findings include:

Reference: Facility policy titled, "Assessment/Reassessment" states, "Purpose: To provide guidelines for the assessment/reassessment of ED patients based on the patient's acuity and as indicated by progression of patient condition and response to intervention once patient is evaluated in the ED treatment area. ... Policy: All patients entering the ED shall be assessed ... Assessment is initiated at the time of entry and continues until final disposition is made. Procedure: 1. ... Key Points Assessment/reassessment components can include ... a set of vital signs ... Steps ... 3. The ED nurse performs and documents ... vital signs in the Electronic Health Record ... b. Non-Cardiac monitored patients: 1. A minimum of every 4 hours or more frequently as indicated by progression of patient condition and response to intervention(s). ... 5. Prior to discharge, a complete set of vital signs ... will be obtained and documented. ..."

1. On 4/15/2021, review of Patient #ST3's "ED Care Timeline" in the patient's ED medical records dated 8/31/2020 and 9/19/2020 was conducted with Staff #ST19, Staff #ST30 and Staff #ST33 and revealed the following:

a. On 8/31/2020 at 11:38 AM, the patient arrived at the ED. At 11:33 AM, the "Arrival Complaint" stated, "... withdraw."

(i) At 11:39 AM, the "Vital Signs" section stated, "Temp (temperature): 98.6 degrees F (Fahrenheit) ... Heart Rate: 60 Resp (Respirations): 15 ..." The set of vital signs assessed at the time of entry to the ED did not include a blood pressure.

(ii) At 4:10 PM, the patient was discharged from the ED. There was no documentation that a complete set of vital signs was obtained prior to the patient's discharge.

b. On 9/19/2020 at 6:22 AM, the patient arrived at the ED. At 6:23 AM, the "Arrival Complaint" stated, "Revisit/Hypertension/Foot Pain."

(i) At 6:29 AM, the "Vital Signs" section stated, "Temp (temperature): 97.7 degrees F (Fahrenheit) ... Heart Rate: 100 Resp (Respirations): 15 BP (blood pressure) 171/119 ..." At 6:30 AM, the "Chief Complaints Updated" section stated "Hypertension."

(ii) On 4/15/2021 at 11:50 AM, upon review of the ED medical record dated 9/19/2020, Staff #ST19 indicated that the following medications were ordered by the ED physician for hypertension and that the patient was not on a cardiac monitor:

- carvedilol 25 mg (milligram) tablet

- nifedipine xl (extended release) 90 mg tablet

- hydralazine 50 mg tablet

(iii) It was documented in the "Medications Given" sections that the RN medicated the patient with the above listed medications at 7:12 AM.

(iv) The "Discharge from ... ED" section indicated that the patient was discharged at 7:15 AM. There was no documentation that a complete set of vital signs was obtained after medication administration and at discharge.

2. Vital signs, including a blood pressure, were not obtained in accordance with the facility policy, to assess the progression of the patient's condition and response to interventions.

3. The above findings were confirmed by Staff #ST19, Staff #ST30 and Staff #ST33 on 4/15/2021.