HospitalInspections.org

Based on record review and interview the Hospital failed to ensure documentation that physicians and other licensed practitioners authorized to order restraint or seclusion had working knowledge of Hospital policy regarding the use of restraint or seclusion.

Findings included:

The Credentials File regarding the Chief Medical Officer indicated no documentation to indicate she had a working knowledge of Hospital policy regarding the use of restraint or seclusion.

During the interview, on 12/9/2022, the Medical Staff Coordinator (of the Hospital) said she could not answer (how the Hospital ensured physicians and other licensed practitioners authorized to order restraint or seclusion had working knowledge of Hospital policy regarding the use of restraint or seclusion). The Medical Staff Coordinator said credentialing work was done by Trinity (Trinity Health Of New England was an integrated health care delivery system as part of Trinity Health, as one of the nation's largest multi-institutional Catholic health care delivery systems, that was the business and not the Hospital).

The Hospital provided no documentation to indicate physicians and other licensed practitioners authorized to order restraint or seclusion had working knowledge of Hospital policy regarding the use of restraint or seclusion.

Based on records reviewed and interviews the Hospital and Governing Body failed to demonstrate an effective, ongoing, Hospital-wide, Quality Assessment Performance Improvement (QAPI) program, that reflected the complexity of Hospital services (newborn care); the Hospital and Governing Body failed to demonstrate a QAPI program that analyzed data, to implement preventative actions and monitored (audited) those actions for compliance to adverse patient events.

Findings included:

1.) The Hospital failed to ensure, demonstrate, a Quality Assessment and Performance Improvement (QAPI) program that showed measurable improvement in QAPI indicators regarding: falls, blood utilization, and urinary catheters.

Refer to TAG: A-0273 Data Collection & Analysis.

2.) The Hospital failed to ensure measurement of its success (audit corrective actions for compliance) and improvements were sustained, following Patient #1's death.

Refer to TAG: A-0283 Quality Improvement Activities.

3.) The Hospital and Governing Body failed to ensure executive responsibilities that QAPI activities thoroughly analyzed adverse patient events, analyzed their causes and implemented preventative actions and mechanisms (audits) to reduce patient adverse events, following Patient #6's adverse patient event.

Refer to TAG: A-0286 Patient Safety, Medical Errors & Adverse Events.

4.) The Hospital and Governing Body, Executives, failed to ensure Executive Responsibilities for QAPI activities.

Refer to TAG: A-0309 Executive Responsibilities.

Based on records reviewed and interviews the Hospital failed to demonstrate a Quality Assessment and Performance Improvement (QAPI) program that showed measurable improvement in QAPI indicators regarding: falls, blood utilization, and urinary catheters.

Findings included:

The Mercy Hospital, Inc. Quality Assurance & Performance Improvement Plan (QAPI, Quality Assessment Performance Improvement), undated, indicated the Performance Improvement and Patient Safety Committee shall assure that there was measurable improvement in indictors with a demonstrated link to improved health incomes.

1.) Regarding showed measurable improvement in QAPI indicators:

During the interview, at 10:30 A.M. on 12/13/2022, the Quality Director said the Hospital had unit-based staff that collected quality data and the Hospital had no reporting line for the unit-based staff to the Quality Department for role function, quality process or integration for prevention. The Quality Director said the Hospital did not use the data for improvement.

A.) Regarding Falls:

The Quality Director said for example 50% of the Hospital falls occurred in the Emergency Department as patients were left unattended in the bathroom. The Quality Director said from 7/2022 through 12/2022 the Hospital had 5 falls in Endoscopy where patients received propofol (anesthesia medication) related to the patient dressing for discharge. The Quality Director said Behavioral Health patient falls occurred during toileting and accounted for 18% of falls. The Quality Director said Hospital policy calls for a Sitter to be within 3 feet of the patient however Sitters assigned to the patient were not allowed to touch the patient. The Quality Director said the Hospital had a Falls Committee however the Falls Committee was not multidisciplinary and did not include Physical Therapy, Occupational Therapy nor Pharmacy (to evaluate medications). The Quality Director said the Falls Committee met weekly to review what happened however there was no preventative analysis.

B.) Regarding Blood Utilization:

The document titled Performance Improvement & Patient Safety Committee, Blood Utilization, dated 9/2022, indicated a trend in blood wastage.

The Quality Director said that blood products were returned to the Blood Bank and the reason(s) were undetermined.

The Hospital provided no documentation to indicate the Hospital's investigation nor corrective action(s).

C.) Regarding Urinary Catheters:

The Quality Director said patients had urinary catheters placed without a doctor's order and the Hospital does not use the data to implement change, especially in the Operating Room to obtain the doctor's order for the urinary catheter as a medical device to generate nursing care. The Quality Director said that Quality (department) was not integrated into the Medical Executive Committee for QAPI data or education, for example regarding informed consent and education of a patient leaving Against Medical Advice (AMA) as there was confusion about a patient leaving AMA and patient elopement. The Quality Director said Quality was not part of the Medical Executive Committee whose reports were forwarded to the Board of Directors (Governing Body) and that this was a gap.

Based on records reviewed and interviews the Hospital failed to ensure for one patient (Patient #1) a thorough investigation and the measurement of its success (audit corrective actions for compliance) and improvements were sustained, following Patient #1's death.

Findings included;

A.) Regarding Patient #1:

Patient #1's Discharge Summary, dated 3/18/2022, indicated Patient #1 was a 37 week and 4-day gestation neonate (late preterm infant) born by vaginal delivery after a prolonged Induction of Labor (IOL) for maternal gestational hypertension, who developed chorioamnionitis (intraamniotic infection) just prior to delivery. Patient #1 was born requiring respiratory support, brought to the Nursery where Patient #1's clinical condition deteriorated at approximately eight hours of life requiring intubation following four failed attempts. Attempts to start and intravenous line (IV) and obtain blood cultures (to evaluate for infection) were initially unsuccessful and a femoral IV started. The Kaiser Sepsis Calculator showed no blood cultures nor antibiotics were recommended [(The Kaiser Sepsis Calculator also known as the Sepsis Risk Calculator, Kaiser Neonatal Sepsis Calculator and the Early Onset Sepsis Calculator was a risk assessment tool that estimates an infant's risk of Early Onset Sepsis (EOS)]. Patient #1 was transported to a higher level-of-care hospital Neontal Intensive Care (NICU).

The Hospital Report, dated 3/24/2022, indicated Patient #1 died in the NICU on 3/18/2022 with sepsis (infection) as the presumed cause of death.

The Microbiology Report, dated 3/18/2022 form NICU, indicated Patient #1's blood culture was positive for Escherichia coli [Escherichia coli infection was a significant cause of mortality, (sepsis, blood infection; meningitis, brain infection) and morbidity (death) in neonates, especially those born premature; usually passed from the mother's genital tract to the newborn during childbirth].

B.) Regarding the Hospital investigation and corrective actions:

During the interview, at 1:30 on 12/6/2022, the Quality Director said the Hospital investigated and findings included:

-The pediatrician did not use the maternal temperature, of 102 degrees Fahrenheit, as required by the Kaiser Sepsis Tool.

-The Pediatrician declined Baystate Medical Center's Neonatal Intensive Care Unit's offer to send NICU staff to assist with starting an intravenous line for antibiotics as the NICU Transport Team was not available and out on (assigned to) another neonatal transport.

-The medical record was missing aspects of nursing care that included, interventions taken when the Patient #1's temperature was 97.6 degrees Fahrenheit nor when Patient #1's temperature was 96.7 degrees Fahrenheit rectally; no documentation Patient #1 received intravenous fluids or antibiotics after the intravenous line was placed (Refer to TAG: A- A-0395).

B.1.) Regarding Corrective Action:

The email, dated 5/24/2022, indicated Pediatrician education regarding the Kaiser Neonatal Sepsis Calculator. The email indicated, remember to use the Kaiser EOS sepsis calculator in a well appearing baby with risk factors, and if there was a maternal fever noted in the first hour postpartum, the new information should be used to recalculate the risk factor. The Hospital provided no other documentation nor information regarding Pediatrician education.

The Quality Director said the Hospital:

-did not monitor (audit) Pediatrician practice regarding correct use of the Kaiser Neonatal Sepsis Calculator,

-did not monitor IV starts, initiation of antibiotics, use of the communication (Team Dynamics) regarding neonatal changes in condition, nor nursing documentation after implementation of nursing education.

During the interview, at 1:30 P.M. on 12/6/2022, the Quality Coordinator said urgency was not there (regarding Patient #1's declining clinical condition).

During the interview, at 5:00 P.M. on 12/6/2022, the Quality Director said Team Dynamics was educational content as part of the Hospital's corrective actions.

The Hospital policy titled Chain of Command, dated 8/4/2006, indicated it was the responsibility of professionals (such as physicians, nurse, allied health professionals, technicians and others) to provide safe, effective and respectful care according to the approved institutional and national professional standards, protocols, and guidelines. (Chain of Command defined as an authoritative structure used to resolve, clinical or patient safety issues by allowing clinicians to present a concern through the lines of authority. A Nursing Chain of Command may be as follows: nurse aide, staff nurse, charge nurse, nurse supervisors, team managers, nurse managers, department managers, hospital supervisors, and the chief nursing officer; a series of positions of authority within a hospital that are ordered from lowest to highest until a resolution was reached). The Hospital Chain of Command policy indicated no clear Nursing Chain of Command.

Although the Hosital investigation indicated a maternal temperature, of 102 degrees Fahrenheit, The History and Physical, dated at 4:22 A.M. on 3/18/2022 by Pediatrician #1, indicated Patient #1's initial temperature was 102.6 at two minutes of life. The Hospital investigation did not report Patient #1's initial temperature was 102.6 at two minutes, of life as a finding.

Although the Quality Coordinator said urgency was not there regarding Patient #1's declining clinical condition, the Hospital provided no documentation to indicate the percentage of staff attendance with a plan for non-attended staff, nor monitoring nursing's effective utilization of Nursing Leadership as members of the team to provide safe care.

The Hospital investigation indicated no corrective action regarding exploration of an alternative procedure to administer IV fluids and IV antibiobics, following the need to start a femoral IV for Patient #1 need for IV fluids and IV antibiotics.

B.2.) Regarding Nursing Documentation:

Refer to TAG: A-0395.

C.) Regarding Umbilical Cord Blood:

Meeting Minutes titled Pediatric Department, dated 4/8/2022, indicated that a Nurse Practitioner was wondering why umbilical cord blood cultures were not done at the Hospital. The Pediatric Department Meeting Minutes indicated, normally we do not do this but if you are concerned in a specific case, you can do the blood cultures on the baby and we would consider starting this.

The Hospital policy dated, Management of Intraamniotic Infection in the Mother and Well Appearing Newborn, dated 5/2022, indicated, obtain neonatal blood cultures and cord blood were the preferred sample.

During the interview, at 1:30 P.M. on 12/9/2022, the Chief of Pediatrics said using the umbilical cord for obtaining bloods was started in June (6/2022), however she did not know if monitoring was implemented.

The Hospital provided no documentation to indicate the consideration of doing umbilical cord bloods nor a determination for practice.

Based on records reviewed and interviews the Hospital and Governing Body failed to ensure executive responsibilities for QAPI activities thoroughly analyzed adverse patient events, analyzed their causes and implemented preventative actions and mechanisms (audits) to reduce patient adverse events following Patient #6's adverse patient event.

Findings included:

A.) Regarding Patient #6:

The Hospital Report, dated 3/28/2022, Patient #6 was admitted to the Hospital with cellulitis (skin infection) and had an elevation in level of care due to a medication error. Nursing staff found Patient #6 obtunded (reduced level of consciousness), with an oxygen level of 85% (low). Patient #6 was treated with oxygen and Narcan (medication to reverse narcotic pain medication side effects i.e., reduced level of consciousness) and transferred to an Intensive Care Unit for closer monitoring of airway due to morning narcotic administration and hypoactive daily activity (unclear definition). The Hospital investigation determined: 1.) the Patient #6 received numerous intentional doses of narcotics administered by the same Registered Nurse (RN #1) over a three-hour period, which exceeded the prescribed frequency, and 2.) RN #1 did not consistently use the bar code medication administration verification system.

B.) Regarding Hospital investigation and monitoring:

During the interview, at 2:30 on 12/6/2022, the Director of Inpatient Services said the investigation regarding Patient #6's adverse patient event discovered:

-there were issues with the RN's license however the Hospital was not aware of any issues with the RN #1's Nursing License at the time of hiring. Refer to TAG: A-0394.

-a silent rapid response was conducted, that-is a Hospital approved Rapid Response was not requested as all the appropriate personnel were present.

The Hospital policy titled Rapid Response Team, dated 9/2020, indicated a Rapid Response ensured optimal response in not-life threatening, but potentially urgent medical situations and when there was a need for rapid assessment, triage and stabilization. The Rapid Response Team policy indicated no documentation of a silent rapid response.

The Hospital provided no documentation to indicate that silent rapid responses were no longer conducted.

The Director of Inpatient Services said the Hospital investigation did not investigate if barcode medication administration scanning was an issue (problematic) during RN #1's orientation and Patient #6's event occurred on RN #1's first day by himself, herself (off orientation).

During the interview, at 1:30 P.M. on 12/6/2022, the Director of Inpatient Services said that the Hospital monitored for nurse barcode medication administration scanning compliance and the Hospital's score was 96 with a goal of 95. The Director of Inpatient Services said that nothing was a trigger (issue) and there were no triggers with orientation regarding RN #1. Refer to TAG: A-0394

Barcode Medication Administration Scanning Summaries, dated 2/2022 through 3/2022, indicated RN #1 was not meeting the Hospital goal of 95%, during the orientation period and this was not discovered by the Hospital investigation. Refer to TAG: A-0394

The Barcode Medication Administration Scanning Summaries, dated 9/2022 through 11/2022, indicated RN #2 had barcode medication administration scanning results of 85%, 74.8%, and 74.5% respectively. The Chief Nursing Officer said that she did not know if RN #2 was on an improvement (performance improvement) plan.

Review of Barcode Medication Administration Scanning Summaries indicated the Hospital was not thoroughly analyzing Nurse barcode medication administration practices as a QAPI preventative initiative regarding medication errors.

Based on records reviewed and interviews, the Governing Body, Medical Staff and Hospital Executives failed to ensure responsibility for services provided were in compliance with Medicare Conditions of Participation and according to acceptable standards of practice; irrespective of whether the services were provided directly by Hospital employees or indirectly by contract; the Governing Body failed to ensure actions through the Hospital's Quality Assessment Performance Improvement (QAPI), program to assess all services provided were monitored for effectiveness and competency; the Hospital Executives failed to ensure Mercy Medical Center operated as a single and separate entity.

Findings included:

A.) Regarding QAPI Processes:

The Mercy Hospital, Inc. Quality Assurance & Performance Improvement Plan (QAPI Plan), undated, indicated the Governing Body (Board of Directors) of The Mercy Hospital, Inc. (Mercy Medical Center) had the moral and legal responsibility to monitor, evaluate and continuously improve the quality and safety of (patient) care.

Meeting Minutes titled Board Quality Patient Safety Committee, dated 4/7/2022 and 7/7/2022, indicated reports provided; the Board Quality Patient Safety Committee Meeting Minutes indicated no documentation to indicate discussion, questions, nor recommendations regarding the quality of care provided to Hospital patients.

Meeting Minutes, titled Performance Improvement and Patient Safety Committee:

-dated 9/14/2022, indicated a review of data and a Performance Improvement Template for discussion at the next meeting regarding barriers and finding solutions;

-dated 10/12/2022, indicated review of presented data without discussion of the Performance Improvement Template; and

-dated 11/9/2022, indicated review of presented data without discussion of the Performance Improvement Template without indication of documentation when the Performance Improvement Template would be discussed.

The Meeting Minutes indicated no proactive analysis nor preventative actions aspects of QAPI program activities.

Meeting Minutes: Perinatal Safety and Quality, dated 4/4/2022, indicated no integration of maternal, neonatal (dyad) care as integrated into QAPI activities; the Meeting Minutes indicated no documentation of a review regarding Patient #1 (date of Patient #1's death was 3/18/2022).

During the interview, at 10:30 A.M. on 12/13/2022, the Quality Director said she reported QAPI data to the Chief Medical Officer (a physician) who reported the QAPI data (that is numbers) at the Performance Improvement and Patient Safety Committee. The Quality Director said there was not much quality work done, presented or discussed; no QAPI process or outcomes discussed and that end users (staff directly involved with patient care) were not integrated into the QAPI process except for Maternity Services.

The Hospital did not present a well-integrated QAPI Program, that demonstrated the implementation of data to improve patient care or a complete and thorough adverse patient event investigation included monitoring for compliance of corrective action(s).

B.) Regarding Hospital System and Services:

During the interview, at 10:30 A.M. on 12/13/2022, the Quality Director said she was the Quality Director for Mercy and she covered Johnson Memorial Hospital in Connecticut (shared position). The Quality Director said the Hospital (Mercy Hospital) shared services with others. The Quality Director said one of the Infection Preventionists (Infection Control Nurse) also had shared responsibilities at Johnson Memorial Hospital in Connecticut. The Chief Nursing Officer was another position shared with Johnson Memorial Hospital.

American Hospital Association (AHA) defined a multi-hospital system as two or more hospitals owned, leased, sponsored, or contract managed by a central organization, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361036/.

Trinity Health Of New England was an integrated health care delivery system is part of Trinity Health as one of the nation's largest multi-institutional Catholic health care delivery systems, (that is the business and not the Hospital), https://www.trinityhealthofne.org.

Consistent with TAG: A-0043, each separately certified hospital must be separately and independently assessed for its compliance with the Conditions of Participation, the Medicare provider agreement and its terms were specific to each certified hospital.

The Commonwealth of Massachusetts Department of Public Health Hospital License, dated 9/1/2022, indicated Mercy Medical Center as the Hospital. The Hospital Licensure did not indicate Mercy Hospital as in a System of Hospitals with the same Center for Medicare and Medicaid Services (CMS) Certification Number (CCN). Mercy Medical Center had a CMS Certification Number (CCN) of 220066 and Johnson Memorial Hospital in Connecticut had a CCN of 070008 indicating each hospital as a separate and distinct entity with different CCNs.

The Hospital as separately certified hospital within a multi-hospital system of separately certified hospitals cannot be operationally integrated, in accordance with TAG: A-0043. The Hospital provided conflicting documents, shared operations of services regarding the Hospital's operations without the authority of oversight and monitoring, consistent with TAG: A-0083.

B.1.) Hospital Structure (services) and Credentialing Services:

During the Credential Files review, on 12/9/2022, the Credential Files regarding Pediatrician #1 indicated Pediatrician #1 as an active member of the Hospital's Medical Staff, however the email, dated 8/6/2022, indicated Pediatrician #1's resignation (Pediatrician in the care of Patient #1).

During the Credentials File Review interview, on 12/9/2022, the Medical Staff Coordinator (of the Hospital) said credentialing work was done by Trinity.

The Quality Director said Trinity provided credentialing services (the process of physician and other allied health professional credentialing procedures and record keeping). The Quality Director said that the Hospital did not have a contract with Trinity.

The Hospital provided no indication, prior to Pediatrician #1's Credential File review, that Pediatrician #1 continued to have active credentials to provide Pediatric care at the Hospital.

During Credentials File Review interview, on 12/9/2022, Medical Staff Coordinator, for Mercy Medical Center, said the CMO started working at Mercy Medical Center and the CMO was not presently Credentialed at the Hospital. The Medical Staff Coordinator said the Credentialing work was done by Trinity and not Mercy Hospital employees.

B.2.) Regarding Human Resource Services:

The Quality Director said Trinity provided human resource personnel recruitment and hiring functions.

During the Personnel Record review, dated 12/9/2022, the Personnel Records Navigator said personnel for hire at the Hospital were screened through Trinity.

The document titled Trinity Health Background Check Decision Matrix, (undated), indicated Trinity Health provided role specific checks for licensure and certification verification. Refer to TAG: A- 0394.

B.3.) Regarding Policies & Documents:

In accordance to TAG: A-0043 each hospital must be able to present for inspection the system governing body policies and procedures that clearly apply to that Hospital.

The policy titled Background Checks and Adverse Action, dated 6/1/2021, indicated it was a Trinity Health policy. The policy indicated no indication that the Hospital reviewed and approved the policy as a Mercy Medical Center policy.

Other Documents:

The Chart, undated, indicate the Mercy Hospital Organization Chart. The Organization Chart indicated no documentation of responsibilities to others (hospitals).

The Business Card of the Chief Medical Officer (CMO) indicated she was the CMO of Johnson Memorial Hospital. The CMO Business Card indicated no indication the CMO was the CMO for Mercy Medical Center.

The Business Card of the Chief Executive Officer (CEO) indicated the CEO with the title of Chief Administrative Officer, including the logos for two separate hospitals, the Hospital (Mercy Medical Center) and another hospital (Johnson Memorial Hospital).

The Business Card indicated the Quality Director's title as Director Quality, Patient Safety, and Regulatory Compliance Director Quality, Patient Safety, and Regulatory Compliance, Trinity Health Of New England.

The Business Card of the Chief Nursing Officer (CNO) indicated she was the CNO of Johnson Memorial Hospital, Trinity Health (Trinity Health Of New England an integrated health care delivery system is part of Trinity Health as one of the nation's largest multi-institutional Catholic health care delivery systems, that is the business and not the Hospital). The CNO Business Card indicated no indication the CNO was the CNO for Mercy Medical Center.

The Letter of Termination, dated 3/29/2022 regarding Registered Nurse #1, indicated a logo regarding Trinity Health of New England and Saint Francis Hospital and Medical Center. The Letter indicated no documentation the letter was from Mercy Medical Center as the Hospital.

Review of these Other Documents did not indicate the Hospital as a single and distinct entity.

B.4.) Regarding Job Descriptions:

The Job Description titled Vice President Patient Care Services, Chief Nursing Officer [with the logo for Trinity Health of New England (THOfNE)], dated 4/2021, indicated the Vice President Patient Care Services, Chief Nursing Officer was responsible for nursing standards and patient care practice at the assigned Trinity Health of New England hospital.

The Job Description titled Quality Director, Patient Safety and Regulatory Compliance, dated 1/2022, indicated Trinity Health of New England Mission Statement and Gore values, the Job Description did not indicate a Mission Statement nor Core Values of Mercy Medical Center, the Hospital. Refer to TAG: A-0385.

The Hospital, as organized with the Medial Staff Credentialing Service, Human Resource Services, Quality Director, and Chief Nursing Officer responsible to Mercy Medical Center and another hospital created an unclear structure regarding accountability to the Hospital (Mercy Medical Center) for the quality of care to Hospital patients. Employees of the Hospital were accountable for the quality of care to Hospital patients and evaluated for the effectiveness of performance by the Hospital. Employees of Trinity were responsible to the business. The Hospital held no authority to hold the Medial Staff Credentialing Service, Human Resource Services, Quality Director, Chief Nursing Officer and Infection Preventionist accountable for the quality of care provided to Hospital patients.

Based on records reviewed and interviews the Hospital failed to ensure a well-organized Nursing Service.

Findings included:

1.) The Hospital failed to ensure a well-organized Nursing Service; responsibility for the operation of the Nursing Service and quality of the patient care provided by the Nursing Service.

Refer to TAG: A-0386.

2.) The Hospital failed to ensure the Nursing Service had an effective procedure to ensure that Hospital Nursing personnel for whom licensure was required had a valid and current licensure including verification policies and procedures.

Refer to TAG: A-0394.

3.) The Nursing Services failed to ensure evaluation of patient in accordance with accepted standards of nursing practice and Hospital policy.

Refer to TAG: A-0395.

Based on records reviewed and interview the Hospital failed to ensure: a well-organized Nursing Service; responsibility for the operation of the Nursing Service and quality of the patient care provided by the Nursing Service.

Findings included:

During the interview, at 11:00 A.M. on 12/9/2022, the Chief Nursing Officer said she covered two hospitals; Mercy Hospital and Johnson Memorial Hospital in Connecticut.

The Job Description titled Vice President Patient Care Services, Chief Nursing Officer [with the logo for Trinity Health of New England (THOfNE)], dated 4/2021, indicated the Vice President Patient Care Services, Chief Nursing Officer was responsible for nursing standards and patient care practice at the assigned Trinity Health of New England hospital. The Job Description indicated Reporting Relationships as: 1.) Reported to the market President (undefined as to Mercy Medical Center or THOfNE) and a dotted line to THOfNE Regional Chief Nursing Officer, and 2.) Responsible for the direct supervision of 15-18 staff members and overall nursing team for the hospital. The Job Description indicated the THOfNE Mission Statement and Core. The Job Description indicated no logo representing Mercy Medical Center, no Mercy Medical Center Mission Statement nor Mercy Medical Center Core Values. The Chief Nursing Officer Job Description indicated a Chief Nursing Officer for Trinity Health of New England and not for the single entity Hospital of Mercy Medical Center.

The Business Card of the Chief Nursing Officer (CNO) indicated she was the CNO of Johnson Memorial Hospital, Trinity Health. The CNO Business Card indicated no indication the CNO was the CNO for Mercy Medical Center.

During the Personnel File Review interview, on 12/9/2022, the Regional Director of Talent Acquisitions and Requirement (Trinity) said the CNO was a Trinity employee and not a Hospital employee. The Regional Director said Trinity maintained the CNO's personnel file and the CNO's personnel file from Trinity was not available for review at the time of the Survey.

The Hospital, as organized with a Chief Nursing Officer shared with Mercy Medical Center and another hospital created an unclear structure regarding accountability to the Hospital (Mercy Medical Center) for the quality of care to Hospital patients. Employees of the Hospital were accountable for the quality of care to Hospital patients and evaluated for the effectiveness of performance by the Hospital. Employees of Trinity were responsible to the business. Therefore, a Nursing Service organized where the Hospital held no authority to hold the Chief Nursing Officer accountable for the quality of Nursing care provided to Hospital patients.

Based on records reviewed and interview the Hospital failed to ensure the Nursing Service had an effective procedure to ensure that one Hospital Nursing personnel for whom licensure was required had a valid and current licensure including verification policies and procedures to safeguard Patient #6's care.

Findings included:

The Hospital Report, dated 3/28/2022, indicated Patient #6 required an elevation in level of care due to a medication error. The Hospital investigation determined Patient #6 received numerous intentional doses of narcotics administered by the same Registered Nurse (RN #1) over a three-hour period and RN #1 did not consistently use bar code medication administration verification system.

During the interview, at 2:30 on 12/6/2022, the Director of Inpatient Services said the investigation regarding Patient #6's adverse patient event discovered there were issues with the Registered Nurse #1's license however the Hospital was not aware of any issues with RN #1's Nursing License at the time of Hospital hiring. The Director of Inpatient Services said the Human Resources functions that included RN licensure verification were conducted by Trinity (Trinity Health Of New England is an integrated health care delivery system is part of Trinity Health as one of the nation's largest multi-institutional Catholic health care delivery systems, that is the business and not the Hospital). The Director of Inpatient Services said she did not know how Human Resources monitored to prevent this from happening again

During the Personnel Record review, dated 12/9/2022, the Personnel Records Navigator said personnel for hire at the Hospital were screened through Trinity, including licensure verification and Trinity cleared Registered Nurse (RN) #1 for hire at the Hospital. The Personnel Records Navigator said RN #1's Nursing License had details documented, (undefined).

During the Personnel Record review, dated 12/9/2022, the Quality Director said the Hospital had no documentation that Trinity had communicated with the Hospital nor Chief Nursing Officer regarding issues with RN #1's Nursing License and should have.

The policy titled Background Checks and Adverse Action, dated 6/1/2021, indicated the attachment titled Trinity Health Background Check Decision Matrix, indicated Trinity Health provided role specific checks for licensure and certification verification. The Background Check Decision Matrix indicated Trinity Health provided an Office of Inspector General (OIG) check and do not hire if name was on the sanctions list.

The Hospital provided no documentation to indicate a policy and procedures regarding verification of nursing licensure and notification of the Chief Nursing Officer of the Hospital regarding issues with Nursing Licensure.

Based on records reviewed and interview the Nursing Services failed for two patients (Patient #1 & #2). Regarding Patient #1, Nursing Services failed to ensure documentation of Patient #1's evaluation, response to interventions, in accordance with accepted standards of nursing practice and Hospital policy; Regarding Patient #2, Nursing Services failed to ensure Registered Nurse #1 provided nursing care in accordance with accepted standards of nursing hiring, orientation and evaluation practices.

Findings included:

Regarding Patient #1:

Patient #1's Discharge Summary, dated 3/18/2022, indicated Patient #1 as an at-risk newborn; born at 37 week and 4-day gestation neonate (late preterm infant) by vaginal delivery who developed chorioamnionitis (intraamniotic infection) just prior to delivery.

The Nurse's Note, dated at 7:03 P.M. on 3/17/2022, indicated Patient #1 was a sick newborn; Patient #1 was born at 6:18 P.M. on 3/17/2022 [birth weight was 2410 grams (5 pounds)] with pink-pale color and poor tone requiring respiratory support with Continuous Positive Airway Pressure (CPAP), a temperature of 102.7 axillary with a breathing rate of 70 (high) and transferred to the Nursery.

The Nurses Note indicated between 6:33 P.M. and 7:22 P.M. on 3/17/2022, Patient #1 clinical condition was: temperature 98.6 to 98.9 axillary, heartbeat 166-197, breathing rate 50-78, oxygen level 95-100, blood sugar level 90, one attempt to start an intravenous (IV) line was unsuccessful and Patient #1, at 7:10 P.M., was brought out of the Nursery to be with mother. The Nurses Note did not indicate consideration and analysis of Patient #1 clinical presentation as a late preterm infant, that required respiratory support after delivery with continuing signs of breathing difficulties with a febrile mother suspected or diagnosed with chorioamnionitis (infection).

The Medical Record, dated between 7:10 P.M on 3/17/2022 and 12:00 A.M. on 3/18/2022, indicated no nurse documentation to evaluate Patient #1's, as an at risk late-preterm infant, condition following birth that required respiratory resuscitation and maternal chorioamnionitis.

The Nurses Note indicated between approximately 12:00 A.M. and 4:40 A.M. on 3/18/2022, indicated Patient #1's declining condition; Patient #1 was brought back to the Nursery, temperature 96.7 rectal, the Pediatrician was notified, Patient #1's blood sugar was less than 25 (very low) twice, glucose (sugar) jell was administered twice, IV attempt was unsuccessful: an anesthesiologist placed an IV in Patient #1's groin and dextrose (sugar) solution and IV fluids were administered, and an attempt to obtain blood cultures were unsuccessful. The NICU, at the referral hospital, was called to arrange transfer to a higher-level-of care and one-half hour later Patient #1 required emergency respiratory intervention (Positive Pressure Ventilation (PPV) intubation with (a breathing tube) following four attempts at intubation. Patient #1 was transferred to the NICU at 4:40 P.M. on 3/18/2022 following antibiotic administration by the NICU Team.

The Medication Administration Summery, dated at 4:00 A.M. on 3/18/2022, indicated a Pediatrician ordered Gentamycin and Ampicillin (life-saving antibiotics) for Patient #1. The Medication Administration Summary indicated no documentation to indicate Patient #1 was administered the antibiotics by Mercy Medical Center. (World Health Organization (WHO) guidelines for antibiotic use for sepsis in neonates and children indicated ampicillin and gentamicin could be administered intramuscular (IM).

Regarding the Investigation:

During the interview, at 1:30 on 12/6/2022, the Quality Director said the Hospital investigation regarding Patient #1 discovered that the medical record was missing aspects of nursing care that included:

-Interventions taken when Patient #1's temperature was 97.6 degrees Fahrenheit,

-Patient #1's temperature was 96.7 degrees Fahrenheit rectally; and

-Patient #1 receiving intravenous fluids or antibiotics after the intravenous line was placed.

The Hospital policy titled Medication Administration, dated 10/8/2019, indicated it was the nurse's responsibility to document all medications administered.

The Medication Administration Summery, dated at 4:00 A.M. on 3/18/2022, a Pediatrician ordered Ampicillin and Gentamycin (life-saving antibiotics) for Patient #1. The Administration Summary indicated no documentation to indicate Patient #1 was administered the antibiotics by Mercy Medical Center. (World Health Organization (WHO) guidelines for antibiotic use for sepsis in neonates and children indicated ampicillin and gentamicin could be administered intramuscular (IM).

Regarding Patient #2:

The Hospital Report, dated 3/28/2022, Patient #6 was admitted to the Hospital with cellulitis (skin infection) and had an elevation in level of care due to a medication error, where Patient #6 received numerous intentional doses of narcotics administered by the same Registered Nurse (RN #1) over a three-hour period, which exceeded the prescribed frequency, and 2.) RN #1 did not consistently use the bar code medication administration verification system.

During the interview, at 1:30 P.M. on 12/6/2022, the Director of Inpatient Services said nothing was a trigger (issue) and there were no triggers with orientation regarding RN #1.

The document titled RN Initial Needs Assessment, dated 1/11/2022, indicated Registered Nurse (RN) #1 had no knowledge or experience with Barcode Medication Administration.

The document titled IMC Nursing Core Competencies, dated 1/11/2022, indicated a Preceptor initialed (authenticated) that RN #1 administered medications safely. The IMC Nursing Core Competencies indicated no documentation of competency with Barcode Medication Administration (Scanning).

The document titled Department of Education Orientation Progress Record, dated 3/17/ (2022) indicated there were issues with preceptors, professionalism, RN #1 felt preceptors were talking about him/her and did not feel comfortable continuing to work on that unit. The Orientation Progress Record indicated RN #1's last day of orientation was 3/18/2022. (The date of Patient # 6's adverse patient event was 3/21/2022.)

Barcode Medication Administration Scanning Summaries,

-dated 1/2022 indicated RN #1's had no Barcode Medication Administration Scanning opportunities,

-dated 2/2022 indicated RN #1 had a score of 91.4% (95% was the Hospital goal) and

-dated 3/2022 indicated RN #1 had a score of 77.67%.

The Barcode Medication Administration Summaries, dated 2/2022 through 3/2022, indicated RN #1 was not meeting the Hospital goal of 95%, during the orientation period and this was not discovered by the Hospital investigation.