HospitalInspections.org

Based on observation, interview, and record review, the facility failed to have an effective governing body (GB) that is legally responsible for the conduct of the hospital when:

1. The hospital did not follow established policies and procedures (P&P) to provide the level of care ordered by the physicians for Patient (Pt)1, Pt 2, Pt 3, and Pt 4 in the Emergency Department (ED) who had inpatient physician's orders.

1a. Pt 1, a 70-year-old (y/o) brought in by ambulance (BIBA)to the emergency department (ED) for symptoms of stroke and admitted as an inpatient on 8/23/24 on stroke protocol and was not prioritized a bed in the hospital and remained in the ED on a gurney until 8/27/24, totaled of 101 hours. Pt 1 had generalized pain from laying on the gurney (a bed with wheels primarily used for short term to transport patients in the hospital). Pt 1 had right side weakness and license nurses did not conduct stroke assessment and did not implement interventions for utensil use and assistance for eating and ambulation in going to the bathroom. The license nurses did not read and document Pt 1's telemetry cardiac strip (a recording of patient's heart electrical activity) every four hours. The license nurses did not administer Pt 1's asthma medications in a timely manner and did not provide an incentive spirometry (a handheld device that helps patients takes slow, deep breaths to improve lung function). The license nurses did not document Pt 1's nutritional intake and output. (refer to A398)

1b. Pt 2, a 86-year-old male was BIBA to the ED on 7/2/24 at 6:32 pm for left lower lobe pneumonia (PNA- lung infection) and was admitted as an inpatient on 7/3/24 at 7:15 a.m. and was not prioritized for an inpatient bed. Pt 2 had an inpatient order and remained in the ED until 7/3/24 at 8 p.m. before transferred to inpatient floor. Pt 2 stayed in the ED hallway on the gurney for approximately 25 hours. Nurses did not develop and implement nursing care plan for pneumonia. Nursing staff were not aware of Pt 2's oxygen saturation decline and was not consistently monitored by nurses. On 7/11/24 nurses did not perform respiratory assessment prior to discharge to a Skilled Nursing Facility (SNF) at approximately. 9:30 a.m. Nurses did not notify the physician of the respiratory status of Pt 2 upon discharge. (Refer to A398)

1c. Pt 3, a 87 year old with a history of dementia, came by ambulance to the ED on 9/15/24 for chest pain and cough, was admitted later the same day on 9/15/24 with possible pneumonia, was not prioritized for a bed in the hospital and remained in the ED until 9/19/24 when he was moved to a bed on the med-surg unit, after spending 104 hours on a gurney in the ED hallway. During his ED stay, Pt 3 who had a skin breakdown on his head and coccyx noted on admission, did not have his care plan interventions implemented for nutrition, did not get a pressure relief mattress pad placed on his gurney until 9/17/24, and did not have his heels elevated off the gurney mattress until he was moved to the med surg unit on 9/19/24. The hospital nursing staff did not follow the hospital P&P's for patient assessment, care planning, implementing interventions, and skin assessment. (Refer to A398)

1d. Pt 4, a 77-year-old BIBA to ED after choking on food which required a laryngoscope (a thin tube device used to examine the larynx) retrieval of the food by Emergency Medical Services (EMS). Pt 4 stayed in the ED for three days and the license nurses skin assessment was incomplete and did not describe the location, size, and description of each wound. The license nurses in the ED did not implement interventions to relieve pressure on feet and heels not until Pt 4 was transferred to the medical surgical inpatient unit. The license nurses in the ED did not document Pt 4's nutritional intake in the ED. (Refer to A398)

The hospital license nurses did not follow the hospital's policies and procedures for patient assessment, documentation in the electronic healthcare record, develop, implement and evaluation of care plans, follow stroke protocol, pressure injury risk assessment, staging and prevention, pain management, Standards of Practice for Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, and Emergency Department.

Because of the serious actual harm to Pt 1 related to the decline of health in the ED and not appropriately treating the stroke; serious actual harm to Pt 2 related to not adequately assessing and treating respiratory illness; serious actual harm to Pt 3 related to not addressing and treating skin ulcers; and serious potential harm to Pt 4 related to unrelieved pain, aspiration of food and developing pressure injuries; and serious potential harm to each patient for not being prioritized for inpatient bed once determined to need admission an Immediate Jeopardy (IJ) situation was called on 09/26/2024 at 9:25 a.m. under CFR 482.23(b)(6) tag A-0398 Nursing Services with Chief Nursing Officer (CNO) and other hospital leaders. The IJ template was shared with CNO and an explanation was given to submit a Plan of Removal that addressed the IJ situation. Version 1 of the PoR was submitted on 09/26/2024 at 5:08 p.m. and was unacceptable. Version 3 was acceptable on 09/30/2024 at 1:40 p.m. and was acceptable. The PoR addressed the following nursing elements: nursing inservices and education and return demonstration, inpatient placement prioritization process, policy review and monitoring, following hospital policies and procedures in accordance with the needs of patients in the ED and patients admitted to the hospital but remain in the ED. The survey team validated implementation of the actions on the PoR and the IJ was removed on 09/30/at 4:40 p.m. in the presence of the CNO. 5.The hospital failed to ensure Clinical Institute Withdrawal Assessment for Alcohol (CIWA- a scale used in the assessment and management of alcohol withdrawal) protocol was followed for three of three sampled patients (Pt 36, Pt 37, and Pt 38) when license nurses did not follow the frequency of patient assessment, monitoring, and documentation according to the CIWA protocol. (Refer to A398)

2. The hospital failed to ensure patient's rights were considered for Pt 15, Pt 24, Pt 26, and Pt 28 with limited English proficiency (LEP) when the nurse did not document on the EHR the method of communication used and the interpreter waiver to decline the used of the hospital interpreter service were not completed. (refer to A117).

3. The hospital failed provide a care in a safe environment for Pt 32, Pt 41, and Pt 42 with a Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) of high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts. (Refer to A144)

4. The hospital failed to provide a safe setting for the care of Pt 5 and nurses did not recognize and act on a change of condition and did not implement nursing care in accordance with hospital policies and procedures. (Refer to A144)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe manner.

Based on observation, interview, and record review, the hospital failed to protect and promote each patient's rights when:

1. For four of six sampled patients (Pt 15, Pt 24, Pt 26, and Pt 28) licensed nurses did not document the method of communication used and the interpreter waiver was not completed for patients with limited English proficiency and prefers family member to interpret. (Refer to A117)

2. Three of six sampled patients (Patient (Pt) 32, Pt 41, and Pt 42) and the license nurses assessed Pt 32, Pt 41, and Pt 42's Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) as high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts. (Refer to A144)

3. Nurses did not recognize and take action on the change of condition for Pt 5 and nurses did not follow policies nad procedures meant to provide care in a safe setting. (Refer to A144)

4. The Grievance process was not followed for one of three patients sampled (Pt 2). (Refer to A-0118)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality healthcare in a safe setting.

Based on observation, interview, and record review the hospital failed to reduce the factors that lead to a preventable hospital readmission when:

1.Pt 2 was admitted on 7/2/24 with diagnosis of pneumonia (lung infection) and was discharged on 7/11/24 and returned 6 hours later in respiratory distress. (Refer to A-0821)

2. Pt 25 was seen in the emergency department on 9/23/24 for elevated heart rate, low blood pressure, and positive urine test and discharged 6 hours later and then returned 19 hours later with elevated heart rate, fever, generalized weakness and with a urinary tract infection. (Refer to A-0821)

These failures resulted in Pt 2 being readmitted, intubated, and eventually passing away on 8/8/24 and Pt 25 returning to the hospital and being admitted and treated.

Based on interview and record review, the hospital failed to ensure patient's rights were considered for four of six sampled patients (Pt 15, Pt 24, Pt 26, and Pt 28) when the nurse did not document the preferred language of communication used and the interpreter waiver was not completed for patients with limited English proficiency and prefered family member to interpret in accordance with hospital policy and procedure.

These failures had the potential for patients whose preferred language was other than English to not receive and fully understand procedures and/or education provided to them and could result in negative health outcomes.

Findings:

1. During a review of Pt 15's Patient Demographics (PD-document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 9/24/24, the PD indicated Pt 15 was a 68-year-old male admitted to the hospital on 9/16/24 at 6:47 p.m., with a Diagnoses of Urinary tract infection (UTI-a bacterial infection that affects the bladder, urethra, and kidneys) and Spanish speaking.

During a concurrent interview and record review on 9/23/24, at 1:48 p.m., with the Director of Emergency Department (DED), Pt 15's Emergency Department Patient Care Timeline (EDPCT- a record of key times in a patient's encounter in the Emergency Department)) and History and Physical (H&P-a comprehensive assessment of a patient's health that includes medical history, physical exam, and demographics) dated 9/16/24 were reviewed. The EDPCT indicated, " ...there was no documentation in the Risk Assessment, the Communication Barrier, and availability of Interpreter ..." The H&P indicated " ...that History was provided by: RN and was necessary due to language barrier ..." The DED stated family member could be used for Interpretation for simple things like the need to go to the bathroom but not for admission, surgical consents, and medical importance. The DED stated the standards was for the nurse to document who interpreted for the patient and the level of ability to interpret. The DED stated a tiered staff (certified medical interpreters trained professionals who can translate health information correctly) or a family member could interpret for the patient.

During a concurrent interview and record review on 9/25/24, at 7:46 a.m., with Registered Nurse (RN) 1, Pt 15's EDPCT and H&P dated 9/17/24 was reviewed. The EDPCT indicated RN 1 was the nurse assigned to Pt 15 on 9/16/24. The H&P indicated, " ...assumed care ... Pt Spanish speaking. Interpreter obtained by son at bedside ..." RN 1 stated she speaks Hmong and English. RN 1 stated Pt 15's son was at bedside and interpreted for Pt 15. RN 1 stated she was not aware the interpreter waiver needed to be completed before allowing son to interpret. RN 1 stated it was important to use the best way to effectively communicate with the patient to ensure understanding between the nurse and the patient for better treatment and care.

During a concurrent interview and record review on 9/25/24, at 12:34 p.m., with RN 2, Pt 15's EDPCT was reviewed. The EDPCT indicated RN 2 assessed Pt 15 in the Triage Area (the sorting of sick or injured patients according to severity). RN 2 stated she only speaks English. RN 2 stated when patients needed an interpreter, the family member, or a tiered staff member was always available to interpret for the patient. RN 2 stated she did not document the interpreter used and method to communicate for Pt 15. RN 2 stated the expectation was for the nurses to document the method of communication for non-English speaker. RN 2 stated the potential outcome for not using the interpreter services was for miscommunication to occur and missed vital information.

During a review of the Policy and Procedure (P&P) titled, "Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired ", dated 6/14/24, the P&P indicated. VI. DOCUMENTATION: B. Requesting staff members document in the patient's EHR [Electronic Health Record -a digital version of a patient's medical history that can be accessed by all healthcare providers involved in patient's care] if an interpreter or device is/ was used for the following 1. a) Name of the interpreter, including i. interpreter used (first and last name) ii. Interpreter agency, as appropriate iii. Time iv. Date ...2. If the requesting staff member is a tiered bilingual staff, can document in their notes or the interpreter flow sheet that they themselves interpreted.

2. During a review of Pt 24's PD dated 9/24/24, the PD indicated Pt 24 was a 79-year-old female admitted to the hospital on 9/16/24 at 7:55 p.m., with a diagnosis of Closed Head Injury. Pt 24's language was Hmong and discharged home on 9/16/24 at 9:45 p.m.

During a concurrent interview and record review on 9/24/24, at 1:54 p.m., with the Educator Medsurg (EM) and the Director of Emergency Department (DED). The EDPCT and the H&P dated 9/16/24 were reviewed. The DED stated Pt 24's H&P indicated the H&P was obtained from Pt 24's family member. The DED stated the EDPCT did not indicated the nurse completed the interpreter services waiver and did not document the method of communication to patient. The DED stated the nurse should have completed the interpreter services waiver to use the family as patient interpreter and not the hospital interpreter services.

3. During a review of Pt 26's PD dated 9/24/24, Patient 26's PD indicated a 63-year-old female admitted to the hospital on 9/17/24 at 10:19 a.m., with an Admission Diagnosis of Symptomatic Cholelithiasis (a condition where hard deposits in the gallbladder cause pain or other symptoms). Pt 26's language was Punjabi, and Pt 26 was discharged home on 9/19/24 at 2:55 p.m.

During a concurrent interview and record review on 9/24/24 at 2:20 p.m., with the DED, Pt 26' H&P dated 9/17/24. The H&P indicated Pt 26 was in the Emergency Department for abdominal and back pain and was accompanied with her family member who interpreted for Pt 26. The interpreter waiver was not completed by the nurse. The DED stated the interpreter waiver should have been completed to ensure Pt 26 understands she was using her family member as an interpreter and not using the hospital interpreter services. The DED stated it was important to have an interpreter to ensure Pt 26 had a clear understanding of the situation.

4. During a review of Pt 28's PD, the PD indicated a 59-year-old female admitted to the hospital on 9/19/24 at 1:58 p.m., with an Admission Diagnosis of Bacteremia (the presence of viable bacteria in the circulating blood) and was discharged on 9/20/24 at 4:50 p.m., to another acute care hospital. Pt 28's language was Spanish.

During a review of Pt 28's Interpreter Flowsheet dated 9/22/24 p.m., the Interpreter Flowsheet indicated Pt 28 needed an interpreter with no documentation of the interpreter type, interpretation method, interpreter name, interpreter session type, interpretation provider, and interpretation location.

During a review of Pt 28's EDPCT dated 9/24/24. The EDPCT indicated Pt 28's Risk Assessment did not indicate the Communication Barrier, and an interpreter was used.

During an interview on 9/26/24, at 1:30 p.m., with RN Quality Management Coordinator (RQMC) the RQMC stated, Pt 15, Pt 24, Pt 26, and Pt 28 interpreter waiver should have been completed by the nurse and placed in the patient's electronic health record but was not.

During a review of the facility's Policy and Procedure (P&P) titled, "Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired ", dated 6/14/24, the P&P indicated, "PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... Community Medical Centers (CMC) has contractual agreements that define expectations and response time and those vendors are the only language contract services that must be used E .... Upon testing and training, such a staff member is assigned a one or two badge buddy, depending on their scope of competency in the given targeted language F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... III. POLICY: It is the policy of Community Medical Centers (CMC) to provide equal access to and equal participation in health care interactions for persons ...L. In the event that the patient prefers to use a friend or a family member to interpret on their behalf one of the following waivers must be signed and scanned into the patient's EHR. Waive interpreter- English or waive interpreter- Spanish ...V. PROCEDURE: A. c. Once language preference is determined: III. If a person chooses to utilize family members or friends for interpretation, that patient will sign the appropriate waiver VI. DOCUMENTATION: A. Staff member verifies if an interpreting services waiver has been signed by patient ..."

Based on interview and record review the facility failed to follow its policy/process on prompt resolution of patient grievances for one of three sampled patients (Patient (Pt) 2) when Pt 2 spouse filed a grievance and because Pt 2 passed away the hospital felt it did not have to follow up on the grievance filed. This failure to follow up resulted in Pt 2's spouse not receiving a response to her grievance and did not provide her a resolution to her issues she reported with her husband's care.

Findings:

During a concurrent interview and record review on 9/19/24, at 10:30 a.m. with Vice President of Quality Outcomes (VPQO) and Patient Relations Specialist (PRS), the grievance process was reviewed for a complaint filed by Pt 2's spouse on 8/19/24. The "Complaints & Grievances" external report provided on 9/18/24 was reviewed, it indicated on 8/19/24 a complaint/grievance was filed for Pt 2 for the following areas of concern "Care/Treatment, Dietary, Discharge" and provided a date "Closed by Patient Relations" of 8/28/24, this was confirmed with the VPQO and PRS. PRS stated the hospital process for complaints and grievances is that when they receive a phone call "we listen to the concerns for the patient and put the information into their IRIS (Incident Reporting Intranet System- where all complaints and findings will be documented) and reach out to each department that was involved in the care of the patient that there were complaints about, we speak with the clinical supervisor about the concerns. The Clinical supervisor will then follow up with the patient to clarify all concerns and investigate the issues. The manager of the department is also tasked so they are aware of what is going on in their unit". The PRS stated if the patient is no longer in the hospital the complaint/grievance will still be sent via the IRIS to the departments and their leadership will investigate the areas of concern. At that time an acknowledgement letter is sent out to the complainant and within 30 days a resolution letter is sent. The PRS stated the four elements that must be on the resolution letter are the concerns the patient has, department findings, date of completion of the investigation, and a contact persons name if they have further questions. The PRS stated we have had patients that have not been happy with that letter in the past and have had to escalate it up to risk management and they follow up with the patient and their families.

During an interview on 9/19/24 at 10:40 a.m. with the PRS, the PRS reviewed the notes that were taken for the complaint Pt 2 Spouse filed on 8/19/24. PRS stated Pt 2's Spouse provided a timeline of Pt 2's care through out his stay starting 7/2/24. In this grievance Pt 2's Spouse stated she did not feel her husband was ready to be discharged on 7/11/24 to a SNF but the physician did and if he had not been discharged early since he turned around and came right back that he may still be here with them. The PRS stated each area of Pt 2's Spouse complaint was tasked out and investigated, ED said no negligent care, 5 North found no issues with the discharge and no refusal of care noted but a resolution letter was not sent out because the patient was deceased, and we only send letters to patients and not their spouses.

During an interview on 9/19/24 at 10:45 a.m. with the VPQO, the VPQO stated the hospital sent out an initial letter to Pt 2's spouse on 8/19/24 thanking her for making them aware of her concerns. The VPQO stated we do not send out resolution letters to patients who have passed away and then stated it is not part of our policy to send out resolution letters to spouses only to the patients. The VPQO stated no resolution letter was sent for this complaint, but he is reviewing the policy to see if they need to make changes and plan to take it to committee to get it updated. The VPQO stated there should be a letter for closure for the family member.

During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2's discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate "looking for any gaps or follow up" that needed to be reviewed and noted that Pt 2's spouse had filed a complaint prior to 9/18/24 about Pt 2's discharge on 7/11/24. DRM stated, "we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted". DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24.

During a review of the facility's policy titled, "Patient and Patient's Representative Complaint & Grievance" dated 6/28/23, indicated, "I. PURPOSE A. to meet patients' reasonable expectations of care and services in a timely, reasonable, and consistent manner. B. To outline the process to receive, investigate, evaluate, and respond to written or verbal complaints or grievances concerning patient care or services by [name of hospital system] ... III. POLICY A. Issues that qualify as grievances include: 1. Complaints that involve allegations of abuse or neglect, endanger, or potentially endanger the patient and issues relating to the hospitals compliance with Centers for Medicare and Medicaid (CMS) hospital Conditions of Participation. 2. Situations where patients or the patient's representative call or write to [name of hospital system] after discharge from hospital or from a clinic visit about concerns related to care or services, who were not able to resolve their concern during their stay or who did not wish to address their issue during their stay. 3. Situations where the patient or patient's representative request the complaint be handled as a formal complaint or grievance or when the patient requests a written response from [name of hospital system]. 4. Situations where the issue cannot be resolved at the point of service and is referred to [name of hospital system] administration for later resolution ... C ... 4. Referral to Quality Improvement Organization (QJO): a. Quality Improvement Organization are Centers for CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. Medicare beneficiary concerns submitted after discharge regarding a quality of care or premature discharge issues will be referred to case management and or internal peer review as appropriate. In the event that the beneficiary does not agree with the resolution, the beneficiary will be informed of his or her right to contact the QJO and provide the contact information. IV. PROCEDURE A. Complaints and Grievances Received Regarding Patient Care. 1. When possible, Complaints are resolved as soon as possible by the person receiving the complaint. 2. If the concerns cannot be resolved by the person receiving the complaint, the chain of command is followed until the complaint can be addressed. The supervisor on duty for the point of service (POS) is contacted. If the supervisor is not available, contact the manager; If the manager is not available, contact the director. 3. A grievance form will be available to the patient to document the nature of the issue or concerns. If the patient needs assistance in completing the form, assistance will be provided by [hospital name] staff. 4. If the situation endangers or potentially endangers the patient, such as neglect, abuse, risk management is to be contacted immediately. 5. Complaints where suit has been threatened or are treated as intent and referred to risk management immediately. 6. Complaints that involve the medical staff are referred to peer review for follow up using the incident reporting Internet system (IRIS). B. Grievance received will be responded to as follows. 1. If Patient Relations does not speak directly to the patient or patient's representative, a written acknowledgment will be sent to the patient within seven business days to acknowledge receipt of the grievance. 2. A letter will be sent within 30 business days from the date [hospital name] received the grievance to the patient in their preferred language. 3. Grievances will be documented in IRIS and forwarded to Area management for investigation and resolution. a. Point of service leadership or designee will document their findings in IRIS. b. The letter to the patient will have the following elements: i. Name of hospital contact person. Ii. Steps taken on behalf of the patient to investigate the grievance. iii. The results of the grievance process. iv. Date of completion of the grievance process. C. Complaints against physicians. 1. Complaints by the patient or patient's representative received regarding physicians, podiatrist, allied health professionals and dentists are to be referred to peer review. A letter will be sent to the patient in their preferred language within 30 days of the complaint. V. Documentation. A. All complaints and grievances will be reported and documented in the IRIS system. B. Patient Relations will send a letter of response to all grievances within 30 days of applicable and attached to the IRIS ..." No where in this policy does it say they do not send letters out to family of the deceased.

Based on observation, interview, and record review the facility failed to ensure the rights of patients to receive care in a safe environment when:

1. For three of six sampled patients (Patient (Pt) 32, Pt 41, and Pt 42) when licensed nurses assessed Pt 32, Pt 41, and Pt 42's Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) as high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts.

These failures resulted in Pt 32, Pt 41, and Pt 42 to not receive care in a safe setting in an event of a suicidal crisis (is a situation in which a person is attempting to kill themselves or seriously planning to do so) due to lack of direct constant supervision and close proximity allowing the potential risk of delayed in immediate intervention if the patient attempts of self-harm.

2. Patient (Pt) 5 came to the Emergency Department with complaints of severe abdominal pain on 2/4/24 at 7:48 p.m., determined to have acute pancreatitis and was admitted. Pt 5 had abnormal vital signs and symptoms of alcohol withdrawal, and was started on the CIWA protocol and cardiac monitoring. Pt 5 was moved from an ED room in the red zone (higher acuity patients) to a hallway gurney in the yellow zone where he remained. Patient 5 had nausea, his abdomen was distended, and his abdominal pain was not relieved by pain medication, and his blood pressure and pulse were elevated. The nursing staff did not appreciate the seriousness of Pt 5's condition and did not monitor Pt 5 for alcohol withdrawal symptoms in accordance with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol orders, did not interpret telemetry strips, did not record intake and output, did not document activity, did not evaluate Pt 5 for bladder distention, did not report panic value calcium levels to the physician, did not recognize a change in Pt 5's condition, and did not document Pt 5's condition, or details of what occurred in the period of time leading up to the seizure and code blue on 2/6/24 at 12:39 p.m.

These failures resulted in Pt 5 experiencing unrelieved pain, delayed intervention for bladder distention, untreated hypocalcemia, seizure and cardiac arrest with anoxic brain injury, and led to Pt 5's death on 2/10/24.

Findings:
1. During a review of Pt 32's "Emergency Department Patient Care Timeline
(EDPCT- a record of key times in a patient's encounter in the Emergency Department)" dated 9/28/24, the EDPCT indicated Pt 32 arrived in the ED on
9/28/24 at 3:55 a.m. with complaint of rapid heart rate/dizziness.

During a concurrent interview and record review on 9/28/24, at 3:45 p.m., with Licensed Vocational Nurse (LVN) 1, Pt 32's EDPCT and CSSRS flowsheet dated 9/28/24 were reviewed. The EDPCT indicated Pt 32 had a physician order for Suicide Precaution (SP) which included a one-on-one sitter at bedside and a Consult to Specialist on Call (SOC- Psychiatric Emergency consult to manage suicidal ideation). The CCSRS flowsheet indicated Pt 32 was a high risk for suicide and the sitter for one-on-one observation started on 9/28/24 at 3:23 p.m. by PO 5. LVN 1 stated Pt 32 was assessed as a high risk for suicide and the SP was ordered on 9/28/24 at 3:07 p.m.

During Observation on 9/28/24 at 3:55 p.m. in the ED Green Zone Special Care Unit (a custom design unit for patients with a specific health condition. SCUs re usually located in a separate space from other patients) room Green (G-02), Pt 32 was sitting up in bed with eyes closed and family member was holding Pt 32's hand. PO 5 who was assigned as a one-on-one sitter for Pt 32 was sitting outside of Pt 32's room, in a station located in front of Pt 32's room looking at two monitor screens.

During a concurrent observation and interview on 9/28/24 at 4:09 p.m. with Nurse Manager 6 (NM) 6 in ED Green Zone, NM 6 stated Pt 32 came to the ED for rapid heart and started making comments of suicidal ideation and the physician ordered a one-on-one sitter. NM 6 stated PO 5 was assigned to provide one on one observation to Pt 32 and was also assigned to provide one on one observation to Pt 33 and three other patients on the two monitor screens. NM 6 stated the expectation was to assign a separate sitter for Pt 32 to provide the one-on-one observation. NM 6 stated PO 5 should have not been assigned to provide one on one observation to Pt 32 while also assigned to observed four other patients.

During a concurrent observation and interview on 9/28/24 at 4:12 p.m., with PO 5, PO 5 was sitting in the station located outside of Pt 32's room facing two monitor screens. PO 5 stated she was proving one on one observation to Pt 32, Pt 33, and three other patients on the monitor screen. PO 5 stated it would be difficult to respond immediately in an event of an emergency to one of the patients she was
proving one on one monitoring.

During a review of Pt 32's "Nursing Notes (NN)," dated 9/28/24, the NN
indicated, " ...I feel like hurting myself and others. I don't feel right ... called
doctor ... Patient [Pt 32] to be placed on a 1799 until she is evaluated by SOC.
Charge nurse was also made aware of the situation. Patient does need a sitter."

During a review of Pt 32's physician order (PO) titled "1799 Hold" dated 9/30/24,
the 1799 hold indicated, " ...reason for placement-Danger to Self ..."

During a review of Pt 32's "Media Information- Consultation (MIC) [SOC
Consult]," dated 10/1/24, the MIC indicated: " ...Subject- Consult
Recommendations. Date and Time of Report- 9/28/24 at 7:25 p.m. Date and Time
of Request- 9/28/24 at 3:08 p.m. Reason for consult: Thoughts of self-harm / harm
to others. Clinical conclusion: Patient is a 36-year-old female with major
depressive, generalized anxiety disorder, ... will be admitted ... experiencing
severe anxiety with anxiety attacks, worsening depression, and marginal mood
regulation. ... fears that something bad might happen to her, including her acting
suddenly with a suicidal behavior .... Patient will benefit from adjusting her
psychiatric medication and continuing 1:1 observation for the time being and can
be reassessed for safety and psychiatric admission. Disposition recommendation:
continue medical treatment with psychiatric recommendation. Treatment and
medication recommendation: Continue 1:1 observation and medical hold (1799)
status due to remote possibility of suddenly impulsive behavior. Psychiatric
medication.... Re-consult access telecare psychiatry in 1-2 days or as needed ...".

During a review of Pt 33's "EDPCT," dated 9/28/24, the "EDPCT" indicated "Pt
33 arrived in the ED on 9/27/24 at 11:17 a.m. with arrival complaint BIBA
[brought in by ambulance]/5150".
During a review of Pt 33's "History & Physical (H&P- a comprehensive
assessment of a patient's health that includes medical history, physical exam, and
demographics)," dated 9/27/24 at 11:43 a.m. the "H&P" indicated "chief complaint
- psychiatric 5150 gravely disabled".

During an interview on 10/01/24, at 3:27 p.m., with Chief Nursing Officer (CNO),
the CNO stated, the licensed nurse used whatever resource available to keep
patient safe. The CNO stated, when Pt 32 had suicidal ideation and needed a oneon-
one sitter, immediately the facility established a plan to keep Pt 32 safe, PO 5
was temporarily assigned to provided one on one monitoring to Pt 32 while
looking for another sitter. The CNO stated PO 5 was already assigned as a sitter to
Pt 33 whose room was next to Pt 32 and was the closest sitter available to provide
one on one monitoring to Pt 32 while also monitoring three other patients on the
monitor screen. The CNO stated patients who had physician's order for one-on-one
sitter and not provided a one-on-one sitter placed the patients at risk for harm.

During a review of the facility's "Patient Observer's Job Description", dated
9/18/2020, " ...Job Summary: the patient observer remains in close proximity
physical proximity and visual contact with assigned patients whose behavior put
them at risk to harm themselves or others .... Essential accountabilities: ... stays
with an assigned patient at all times and maintains communication in order to
ensure that the patient doesn't attempt any harmful actions ...complete continuous
observation ... documentation as required, answers called lights and response to
assigned patients' needs accordingly ...."

During an observation on 10/2/24 at 4:40 p.m. in the ED Green Zone Green Hallway (GH) room,
PO was watching Pt 41 in room GH-03 and Pt 42 in room GH-02 at the same time.

During a review of Pt 41's "Electronic Health Record (HER- a digital version of a patient's
medical history that can be accessed by all healthcare providers involved in patient's care)" dated
10/2/24, the EHR indicated Pt 41 came to the ED by way of ambulance on 10/2/24 12:36 p.m. for
alcohol intoxication and suicidal thoughts.

During a review of Pt 41's "H&P" dated 10/2/24, the H&P indicated, " ...Pt reporting to wanting
to kill himself today and admitted to drinking beers and liquor today and took 3-4 oxycodone
pills for his chronic pain, pt has a plan to shoot himself ... ED Treatments: [brand name]-used
alone or with other medications to control seizures) ... ".

During a review of Pt 42's H&P dated 10/1/24, the H&P indicated, "... The patient is a 34 y.o.
(year old) male who presents to the ED for suicidal ideation's ... PHYSICAL EXAM: ...
Psychiatric: Endorses gen SI (general suicidal ideation) ...".

During a concurrent observation and interview on 10/2/24 at 4:42 p.m. in the ED Green Zone
Green Hallway with the Director of Emergency Department (DED), the DED stated Pt 41 and Pt
42 was assessed as a high risk for suicide and should be on one-on-one sitter monitoring. The
DED stated the CSSRS was a tool for the license nurse to use to assess the risk of suicide by
following the questionnaire instructions and determine the need to implement interventions to
keep the patient safe.

During a concurrent interview and record review on 10/2/24 at 4:50 p.m. with RN 6, Pt 41 and Pt
42's "CSSRS" dated 10/2/24 were reviewed. The CSSRS indicated Pt 41 and Pt 42 was a highrisk
suicidal patient. RN 6 stated she did the CSSRS questionnaire on 10/2/24 and knew Pt 41
and Pt 42 were a high-risk suicidal patient. RN 6 stated when a patient scores as a "high" on the
CSSRS, the physician and the nurse supervisor (NS) should be notified and placed on one-onone
sitter monitoring for safety. RN 6 stated she did not notify the physician and the nurse
supervisor on Pt 41 and Pt 42's CSSRS high-risk suicidal score. RN 6 stated she should have
notified the physician and the nurse supervisor of Pt 41 and Pt 42's CSSRS high risk suicidal
score.

During an interview on 10/2/24 at 5:20 p.m. with NS 3, NS 3 stated Pt 41 and Pt 42 CSSRS were
assessed by RN 6 and Pt 41 and Pt 42 scored high-risk for suicide and she was not notified by
RN 6. NS 3 stated it was the responsibility of RN 6 to notify the nurse supervisor of Pt 41 and Pt
42's CSSRS high-risk for suicide to provide the appropriate supervision and monitoring to Pt 41
and Pt 42. NS 3 stated RN 6 did not follow the hospital's P&P and Pt 41 and Pt 42 could have
hurt themselves.

During an interview on 10/2/24 at 5:10 p.m. with the Director of Emergency Department (DED),
the DED stated Pt 41 and Pt 42 scored high risk for suicide on the CSSRS and RN 6 did not
notify the physician and the NS. The DED stated RN 6 should have notified the physician and the
NS to provide a one-on-one sitter for Pt 41 and Pt 42. The DED stated PT 41 and Pt 42 was not
assign a one-on-one sitter and Pt 41 and Pt 42 could have harm themselves. The DED stated RN
6 did not follow hospital P&P for high-risk suicidal patients.

During an interview on 10/2/24 at 3:30 p.m. with the Chief Nursing Officer (CNO), the CNO
stated all hospital P&P were in place to ensure patient safety. The CNO stated any patient not
provided appropriate supervision could hurt themselves. The CNO stated the P&P for high-risk
suicidal patient to provide one on one sitter monitoring was not followed.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment",
dated 10/20/2022, the P&P indicated, "I. PURPOSE: To identify patients that are at risk for
intentionally harming themselves who are presenting to (facility name) with primary behavioral
health complaints. To guide nursing interventions in the care of patient at risk for intentionally
harming themselves. Patient safety is the primary focus of treatment in this patient population.
Treatment goals should always be to provide the highest level of safety ... II. DEFINITIONS: A.
1:1 Observation: 1 staff member is assigned to observe only 1 patient at all times, including
while the patient sleeps, toilets or baths ... D. Nurse: Registered Nurse (RN) who has completed
training and demonstrates competency in suicide risk assessment and intervention skills ... III.
POLICY: B. Columbia Suicide Severity Rating Scale (CSSRS) Lifetime Tool will be used to
screen all applicable patients for suicide risk ... H. Nursing interventions utilizing the CSSRS
suicide risk score will be risk stratified based on the level of suicide risk (Low, Moderate, High)
including risk assessment mitigation strategies; reassessment; patient monitoring ... L. Patients at
high risk for suicide are monitored 1:1 ... IV. PROCEDURE: c. For patient who screen Moderate
and/or High Risk the nurse will: i. Notify physician of patient states and monitor requirement. ii.
Notify charge RN for patient placement in a safe environment ... II. High Risk 1:1 patient
monitor ratio ... 2. For patients who present for other primary health concerns and also express
suicidal ideation or later express suicidal ideation, the nurse will: ... b. Notify the physician ... d.
Call charge nurse to arrange for monitoring ... 5. 1:1 monitoring, can only be discontinued after
patient has had a minimum of and MSE [Medical Screening Exam- the process of sorting
patients based on medical condition] or CSSRS reassessment is Moderate or Low Risk ... E.
Outpatient Areas: ... a. Clinician will notify MD b. Initiate 1:1 monitoring ...".
The Columbia-Suicide Severity Rating Scale (CSSRS) supports suicide risk screening through a
series of simple, plain-language questions. The answers help users identify whether someone is at
risk for suicide, determine the severity and immediacy of that risk, gauge the level of support that
the person needs and to most quickly and simply identify whether a person is at risk and needs
assistance.

2. During an interview on 9/30/24 10:22 a.m. with the father and mother (F 5 and M 5) of Patient
(Pt) 5, the parents' concerns about Pt 5's care were discussed. F 5 stated their son (Pt 5) went to
the ED accompanied by his close friend (BF) on 2/4/24 for worsening abdominal pain, was
diagnosed with pancreatitis, and was admitted. F 5 stated Pt 5 drank alcohol daily and told the
hospital staff and was being monitored for withdrawal symptoms. F 5 stated BF was at the
hospital with their son and stayed in touch with them by phone. F 5 stated they planned to make
the three hour trip from where they live to the hospital the next day (2/5/24) however the weather
was an issue and they ended up driving to the hospital on 2/6/24. F 5 stated they spoke to BF
several times during their drive and ten minutes after they hung up with BF and were getting
close to the hospital, BF called back to tell them their son had just had a seizure and cardiac
arrest. F 5 stated Pt 5 was moved to the ICU and was on a ventilator. M 5 stated she received a
call from a nurse that night who told her they would keep him (Pt 5) for a couple of days to make
sure he was ok, like there was nothing to worry about but he never regained consciousness and
tests showed Pt 5 did not have brain activity. Pt 5's parents stated at first they were told their son
was without oxygen for four to five minutes, but later were told it was actually twelve minutes.
Life saving measures were stopped and Pt 5 died on 2/10/24. Pt 5's parents stated they do not
know what happened to their son, why he had a seizure and why he was without oxygen which
caused the brain damage. F 5 stated, "How does someone walk into the hospital with pancreatitis
and end up dying like this? Why did this happen?" M 5 stated she had reviewed Pt 5's record and
looked up any words or medical terms she wasn't familiar with in an effort to better understand
what happened to her son, but the record did not provide the answers. M 5 stated they came up
with a list of their questions and hoped the answers will clarify things for them. M 5 stated
reading the record and looking up the medical terms has actually been a positive process for her
as she tried to manage the grief. M 5 stated, "I guess they did not do an autopsy." F 5 and M 5
stated no one at the hospital talked to them about it and they assumed an autopsy would be done
to find out why their son died. F 5 stated they feel Pt 5 should have been monitored more closely
and not left in the hallway in the ED. F 5 stated Pt 5 should have been moved to the ICU sooner
in order to receive the care he needed, and that if he had, he would not have died.

During an interview on 10/3/24 at 8:31 a.m. with Pt 5's best friend (BF), BF stated he drove Pt 5
to the ED on 2/4/24 for worsening abdominal pain. BF stated he was with Pt 5 as much as he
could be while Pt 5 was in the ED. BF stated he was in frequent contact with Pt 5's parents who
lived three hours away and were driving to the hospital 2/6/24. BF stated on 2/4/24 when Pt 5
and BF got to the ED, Pt 5 was put in his own room. BF stated Pt 5 drank alcohol daily and Pt 5
informed the hospital staff, and Pt 5 was supposed to be watched for signs of withdrawal. BF
stated Pt 5 had lab tests done, imaging done and was given a lot of pain medication. BF stated Pt
5 was told he had pancreatitis. BF stated when he was in his own room the nurses were checking
Pt 5 frequently. However, BF stated when he came back in the next morning he found that Pt 5
was on a gurney in the hallway. BF stated after Pt 5 was moved out of his room and into the
hallway, it was totally different in that the nursing staff did not check on him like they did when
he was in his own room on 2/4/24, the oxygen was not positioned properly on his face, it was
halfway off at times, and the oxygen monitor sensor was off of his finger. BF stated the IV
pumps and monitors were constantly alarming, and the nurses did not respond to check on the
alarms. BF stated one time when the alarm had been going off for a long time and no one came to
check on it, Pt 5 could not rest so BF pushed the button on the pump to silence it. BF stated a
nurse yelled at him. BF stated there was no one around to help Pt 5 so he (BF) helped Pt 5 get up
and walk to the bathroom. BF stated Pt 5 was over six feet tall and weighed over 300 pounds and
was not comfortable on a gurney. BF stated in the morning on 2/6/24, there was a significant
change in Pt 5. BF stated Pt 5 was confused and was jaundiced. BF stated Pt 5 had tried a few
times to urinate but could not. BF stated he helped Pt 5 walk back from the bathroom and get on
the gurney, and then the staff brought privacy screens to put next to the gurney, so they could put
a catheter in because Pt 5 couldn't urinate. BF stated as the staff prepared to put the catheter in,
something happened with Pt 5 and "all hell broke loose," and the staff pushed Pt 5 on the gurney
from the hallway into a room in another part of the ED to do CPR which BF did not see. BF
stated Pt 5 may have had a seizure right before his heart stopped. BF stated he had just talked to
Pt 5's parents ten minutes prior to the code when they were almost at the hospital. Then the code
occurred, and BF stated he had to tell Pt 5's parents what happened. BF stated Pt 5's parents did
not get to see and talk to Pt 5 while he was alert and oriented; when Pt 5's parents arrived at the
hospital Pt 5 was on a ventilator and was not responsive. BF stated he does not understand why
Pt 5 was moved from his own room where he was being monitored closely by nurses, to a
hallway where there was a lack of help and attention. BF stated Pt 5 was sick, and BF does not
think the staff took Pt 5's condition seriously enough, if they had and monitored him accordingly,
he would not have died.

During a concurrent interview and record review on 10/1/24 at 12:40 p.m. with the ED manager
(NM 6) and the ICU manager (NM 9), Pt 5's medical record dated 2/4/24 was reviewed. A
review of Pt 5's ED Patient Care Timeline (ED-PCT) dated 2/4/24 at 7:48 p.m. through 2/6/24 at
2 p.m., indicated Pt 5 came to the ED on 2/4/24 at 7:48 p.m. with a chief complaint of
Abdominal Pain, Nausea and Vomiting which started that same day (2/4/24) in the morning, pain
level 10 (on a scale of 0-10, 0 is no pain, 10 is severe pain). The ED-PCT indicated at 7:54 p.m.,
Pt 5's vital signs were Temperature 95.5 degrees Fahrenheit (F- range 97.7-99.5F), heart rate
(HR) 97 beats per minute (bpm- range 60-100 bpm), respirations 48 per minute (range 12-20),
blood pressure (BP) 90/59 millimeters of mercury (mmHg- range between 90/60 mmHg and
120/80 mmHg). HR and BP were repeated at 7:56 p.m. and indicated HR 125 bpm, and BP
133/97 mmHg. Intravenous (IV) fluids, pain medication, Lab tests, EKG, and due to Pt 5's
disclosed daily alcohol consumption the Clinical Institute Withdrawal Assessment for Alcohol
(CIWA) protocol orders were implemented. A CT of the abdomen was completed and indicated
acute pancreatitis. 2/4/24 at 11:53 p.m. the ED-PCT indicated admission orders for a CPCU
(telemetry unit) bed.

During a review of Pt 5's medical record, the "Head to Toe" flowsheet (a record of the physical
assessments performed by nursing) was reviewed. The sections of the flowsheet "Telemetry Strip
Analysis" and "Cardiac" indicated from 2/4/24 at 8 p.m. through 2/6/24 at 12:40 p.m. there was
no documentation indicating that the telemetry strips from the continuous cardiac monitoring
were reviewed. A review of Pt 5's heart rate during that same time period indicated Pt 5's heart
rate was below 100 bpm just one time, on 2/4/24 at 7:54 p.m. The remainder of the time from
2/4/24 at 7:55 p.m. through 2/6/24 at 8:07 a.m. (the last entry), Pt 5's heart rate ranged from a low
of 108 bpm to a high of 158 bpm. Review of the ED-PCT flowsheet dated 2/4/24 at 7:48 p.m.
through 2/6/24 at 2 p.m., indicated the last vital signs taken were at 8:07 a.m.; temperature 98.8
F, HR 111 bpm, RR 20 per minute, BP 105/74 mmHg, oxygen saturation 96%. NM 6 stated the
monitor strips are supposed to be reviewed by an RN every four hours and the information
entered into the medical record.

During a review of Pt 5's medical record, the "Head to Toe" flowsheet for the
Abdominal/Gastrointestinal section of the assessment, the flowsheet indicated on 2/4/24 at 8:31
p.m., Pt 5's abdomen was rounded and firm, Pt 5 had nausea and was not passing gas. There was
no assessment of Pt 5's bowel sounds or indication of when Pt 5's last bowel movement was. The
next assessment was done on 2/5/24 at 8 a.m. and indicated just that Pt 5 was nauseated. There
was no assessment of Pt 5's abdomen or bowel sounds, or when Pt 5's last bowel movement was.
The next assessment was done on 2/5/24 at 7 p.m. and indicated Pt 5's abdomen was distended,
firm and tender, and that Pt 5 was not passing gas. There was no assessment of Pt 5's bowel
sounds or when his last bowel movement was. The next and last assessment while Pt 5 was in the
ED was on 2/6/24 at 8 a.m. and indicated Pt 5's abdomen was distended, firm and tender. The
assessment also indicated Pt 5's had bruising to his abdomen. There was no assessment of Pt 5's
bowel sounds or when Pt 5's last bowel movement was.

During a review of Pt 5's medical record, the intake and output flowsheet was reviewed. The
flowsheet indicated from 2/4/24 at 8 p.m. through 2/6/24 at 12:40 p.m. there was no intake and
output documented for Pt 5. NM 6 stated the intake and output should have been recorded.

During a review of Pt 5's lab results, the lab results indicated Pt 5's estimated glomerular
filtration rate (eGFR-indicates kidney function) was 61 on 2/4/24 (normal is greater than or equal
to 90 ml/min/1.73m2), 61 on 2/5/24 and 14 on 2/6/24. Pt 5's lab results for creatinine (one of the
tests to assess kidney function) on 2/4/24 and 2/5/24 was 1.3 mg/dL (range is 0.7- 1.3 mg/dL)
and on 2/6/24 it was 4.7 mg/dL. Pt 5's Lipase level on 2/4/24 was 1920 (high-indicates
pancreatitis) and on 2/6/24 at 4:49 a.m. it was 2694, the AST on 2/4/24 was 82 (high), and on
2/6/24 at 4:49 a.m. it was 1432. The ALT was on 2/4/24 was 58 (high), and on 2/6/24 it was 250.

During a review of the CIWA monitoring flowsheet dated 2/4/24 at 8 p.m. through 2/6/24 at 2
p.m., the flowsheet indicated on 2/4/24 at 8:54 p.m. the CIWA score was 8. Pt 5's vital signs
were HR 120 bpm, RR 23 per minute, BP 161/119, oxygen saturation 99% on oxygen 2 liters (L)
per minute. The flowsheet indicated on 2/5/24 at 12:46 a.m. the CIWA score was 5. At 2:21 a.m.
the vital signs were HR 132 bpm, RR 19, and BP 151/109 mmHg. At 2:25 a.m. the HR was 117
bpm, and the RR was 32 per minute. At 3 a.m. the BP was 149/111 mmHg, and at 3:12 a.m. the
HR was 143 bpm, and the RR was 25 per minute. At 4:04 a.m. the HR was 136 bpm, and the BP
was 142/107 mmHg. Metoprolol (a medication that lowers the heart rate and blood pressure) 5
mg given IV. The CIWA score was 3.

Review of the ED-PCT indicated on 2/5/24 at 4:14 a.m., Pt 5 was moved from room 5 in the red
zone to a hallway in the yellow zone.

Review of the CIWA monitoring flowsheet indicated on 2/5/24 at 4:49 a.m. the CIWA
assessment was repeated, and the score was 7. At 5:05 a.m. pt 5's vital signs were HR 134 bpm,
RR 29 per minute, and BP 146/113 mmHg, oxygen saturation 95% on oxygen 2 L/min. The
CIWA assessment was done at 5:41 a.m. and the score was 10. Pt anxious and sweating.
Lorazepam 2 mg IV given at 5:53 a.m. The flowsheet indicated the next CIWA assessment was
not done until 7:15 a.m., around 90 minutes after the last assessment. NM 6 was asked how
often the CIWA assessment is supposed to be done and NM 6 stated she would need to look at
the orders. Review of the orders indicated for CIWA score 9-15, the assessment is to be done
every 30 minutes until it is less than or equal to 8. The CIWA score at 7:15 a.m. was 6, and at 8
a.m. the CIWA score was 9. Pt 5 remained tachycardic and at 10:55 a.m. Pt 5 was given IV
metoprolol 5 mg, and a 25 mg extended release tablet for a heart rate of 156 bpm. At 12:30 the
CIWA score was 9 and Pt 5 was given Lorazepam 2 mg IV. The flowsheet indicated the CIWA
assessment was not done again for ten hours until 2/5/24 at 10:34 p.m. There was no score with
that assessment. NM 9 stated a couple of the elements were not assessed so a total score was not
reflected. The flowsheet indicated at 10:24 p.m. the Richmond Agitation Sedation Scale (RASS)
was assessed and was +2. Pt 5 was given 4 mg of Lorazepam IV. Review of the CIWA protocol
orders indicated Lorazepam 4 mg is given if the CIWA score is greater than 15, and then the
CIWA score is to be assessed every 15 minutes until it is less than 15. NM 6 stated she does not
know why the 4mg dose was given, since there is not a CIWA score associated with it. The
flowsheet indicated the next time the CIWA assessment was done was almost five hours later on
2/6/24 at 3:20 a.m., CIWA score 7. The record indicated Pt 5 was given Lorazepam 2 mg IV at
3:23 a.m. followed by Lorazepam 2 mg tablet at 4:33 a.m. Review of the CIWA protocol orders
indicated Lorazepam 2mg IV or by mouth is to be given if CIWA score is 9-15. There was no
information in the record as to why those two doses of lorazepam were given. Review of the
CIWA protocol orders indicated the minimum frequency for the CIWA assessment is every four
hours. The flowsheet indicated after the CIWA assessment on 2/6/24 at 3:20 a.m., the next
assessment was not done until seven hours later at 10:20 a.m. and the score was 12. Pt 5 was
given a Lorazepam 2 mg tablet at 10:40 a.m. The flowsheet indicated the next CIWA assessment
was not done until 2/6/24 at 11:40 a.m., an hour and twenty minutes after the last assessment
instead of every 30 minutes per the protocol orders. The CIWA score was 11 and Pt 5 was given
a Lorazepam 2 mg tablet. The CIWA monitoring flowsheet indicated this was the last CIWA
assessment done prior to the code blue at 12:39 p.m.

During a review of Pt 5's medical record, the results review screen in the electronic health record
was reviewed. The results review for blood tests done on 2/4/24 at 8:20 p.m. indicated, "Calcium
9.4 mg/dL (range 8.5-10.5 mg/dL)," on 2/5/24 at 3:43 a.m. "Calcium 7.9 mg/dL [low]," on 2/6/24
at 4:49 a.m. "Calcium 5.8 mg/dL [panic]," and on 2/6/24 at 7:36 a.m. "5.9 mg/dL [panic]." The
record indicated on 2/6/24 at 06:39 a.m. the lab notified an RN in ED of the critical results for
calcium (5.8 mg/dL). There is no documentation in the record of the ED RN's notification to the
physician. The record indicated on 2/6/24 at 9:09 a.m. the lab notified an ED RN of the critical
results for calcium (5.9 mg/dL). There is no documentation in the record of the ED RN's
notification to the physician.

During an interview on 10/2/24 at 1 p.m. with the laboratory manager (LM), the LM stated
critical lab results must be called to the nurse within 10 minutes of the results being posted, and
document that notification in the record. The nurse is required to notify the physician of the
critical result within 60 minutes and document that notification in the medical record.

During a review of the ED-PCT for 2/6/24, the ED-PCT indicated at 12:39 p.m., Pt 5 started
seizing and then had a cardiac arrest. The code record indicated the heart rhythm was asystole
(electrical and mechanical cardiac activity have stopped). CPR was started and Pt 5 was
intubated, medications were given and there was a return of spontaneous circulation (ROSC)
after 12 minutes. Pt 5 was transferred to the ICU on 2/6/24 at 2 p.m. The nurses notes and the
code record did not have any information about the circumstances leading up to the code.
Review of the report for the MRI of head without contrast done on 2/9/24 at 2:29 p.m., indicated,
"Diffuse anoxic brain injury with evidence of cerebellar involvement portends to poor
prognosis." The record indicated on 2/10/24 Pt 5 remained unresponsive and Pt 5's parents made
decided to make Pt 5 comfort care and Pt 5 died at 8:40 p.m. The record indicated an autopsy had
not been requested. The NM 6 stated they don't usually speak to the family about this, the
physician would do that. NM 6 stated the family could request one, but NM 6 stated she thought
they would have to pay for it.

NM 6 was asked about the gaps in Pt 5's care, the failure to follow orders, to monitor I&O,
interpret cardiac monitor strips, to monitor alcohol withdrawal symptoms and administer
medication according to protocol and physician's order, the failure to notify the physician of the
critical value calcium, the failure to document assessments and patient observations. NM 6
stated, "I can't disagree with you. But we were in a really bad place at that time (February
2024)." NM 6 was asked if this patient should have been prioritized for a bed in the hospital. NM
6 stated they still provide inpatient care in the hallways.

During an interview on 10/1/24 at 4 p.m. with the DED, the issues found during the record
review with NM 6 were discussed. The DED was asked what would be done if anything
differently for this patient if he were to come in today as opposed to last February. The DED
stated Pt 5 was sick and would be prioritized for a bed in the hospital. The DED stated until they
were able to get him moved they would keep him in the red zone room with close monitoring.

During a review of the reference article from emedicine titled, "Acute Pancreatitis Treatment &
Management," dated 7/14/21, retrieved from https://emedicine.medscape.com/article/181364-
treatment, the article indicated, " ...Medical management of mild acute pancreatitis is relatively
straightforward; however, patients with severe acute pancreatitis require intensive care. Both
forms

A-283?
Based on interview and record review the hospital failed to act on patient care data which showed noncompliance with protocol orders for the assessment and treatment of symptoms of alcohol withdrawal.
This failure had the potential to result in negative outcomes to patients experiencing alcohol withdrawal including over sedation and seizures,

Findings:

During a concurrent observation and interview on 9/17/24 at 3:25 p.m. with the manager (NM) 9 of the intensive care unit (ICU), in the ICU, NM 9 stated he was involved in a project as a result of findings during a previous complaint validation survey. NM 9 stated it was identified that the hospital was not compliant with following the protocol orders for patients who may experience alcohol withdrawal. NM 9 stated the protocol orders are based on the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR, an assessment tool used by medical professionals to assess and diagnose the severity of alcohol withdrawal). NM 9 stated they reeducated all of the staff, monitored compliance, and then educated some more, but NM 9 stated they still are not compliant. NM 9 stated he thinks one of the barriers to compliance is a confusing order set with monitoring that is too frequent. NM 9 stated they have been working on revising the protocol orders but was unsure of when those would be approved. NM 9 stated until that time the current protocol is being used. The data for the compliance monitoring was requested for the past six months.

During a concurrent interview and record review on 10/3/24 at 3:45 p.m. with the Chief Nursing Officer (CNO), the CNO stated the monitoring of compliance with the CIWA protocol was not an official plan of correction in response to a survey deficiency. The CNO stated during a survey it was recognized that the staff were not following the protocol so the clinical nurse specialist (CNS) in ICU educated the staff and was monitoring compliance, but only for the ICU, and the CIWA protocol orders are used other places in the hospital. The CNO stated the reporting of the results of the monitoring of compliance with the protocol is not happening at the moment. It was decided that since it wasn't a mandatory plan of correction and they were working on order set revisions, they would pause the reporting of the data. The CNO stated the CNS in ICU still did real-time chart reviews, but did not track the data or report compliance as a performance improvement project. The CNO provided a document titled, "ICU CIWA Monitoring Report," which indicated the "monitoring of a minimum of 10 charts verifying compliance adherence to the Alcohol Withdrawal Order Set to achieve three consecutive months of 100% compliance." The document indicated in October 2023 they achieved 89% compliance, in November 2023 they did not report data, in December 2023 they achieved 80% compliance, in January 2024 they did not report data, and in February 2024 the achieved 76 % compliance. The document indicated for starting March 2024, "On Hold-Workgroup for order set."

Based on observation, interview, and record review the hospital failed to follow a nitroglycerin drip (nitro gtt- medication given for high blood pressure intravenously (IV)- through a vein) order for one of three sampled patients (Patient (Pt) 13) when increases to the amount given were double the prescribed dose.

This placed Pt 13 at risk of rebound (a sudden increase in blood pressure that occurs when a person stops taking or reduces the dose of certain medications, especially those that treat high blood pressure. It can be dangerous and may lead to a hypertensive emergency) blood pressure which can be dangerous to the patient.

Findings:

During an observation on 9/17/24, at 11:30 a.m. in the stepdown unit, Pt 13 was seen sitting up in her bed with family at bedside. Pt 13 was Spanish speaking, denied having any issues and currently had IV fluids up and running.

During a concurrent interview and record review on 9/23/24, at 1:56 p.m., with Manager of Step Down, Surgery, and Chest Pain Cardiac Unit (CPCU) (NM) 2, Pt 13's Electronic Health Records were reviewed for her admission starting 9/10/24. Pt 13's ED Provider Note dated 9/10/24 at 12:37 p.m. indicated, " ...Chief complaint Patient presents with Reparatory Short of Breath (SOB) Pt brought in by ambulance from urgent care with reports of SOB x 7 days ... SPO2 (oxygen levels) at 75 % (percent normal 95-100%) RA (room air), with EMS (emergency medical services) ... Pt on 6 LNC (liters nasal canula- plastic tubing used to transport oxygen into ones nose) at 100%, pt hypertension (high blood pressure), + cough ... 71 y.o. (year old) female ... No fever. She does have chills. She reports a productive cough with yellow sputum. No Chest pain ... ED (emergency department) Course as of 9/10/24 1842 [6:42 p.m.] ... 1838 [6:38 p.m.] Patient presents to ED for cough, dyspnea for past week. No fever. Flu and influenza negative. Chest x-ray (imaging creates pictures of the inside of your body) shows pulmonary edema and BNP (B-type natriuretic peptide (BNP) is a hormone that helps the body compensate for heart failure) is elevated. No pneumonia (lung infection). Pt treated with diuretics (a drug that increases the amount of urine your body produces, which helps get rid of extra salt and fluid). Patient also noted to have persistent hypertension/hypertensive emergency. Treated with nitro drip ..."

During a review of Pt 13's "nitroglycerin 50 mg [milligrams-unit of measurement]/250 ml [milliter- unit of measurement] (0.2 mg/ml) IV infusion" order start date 9/10/24 at 6:11 p.m. indicated "Ordered Dose: 2-200 mcg [micrograms- unit of measurement]/min [minute] Route: Intravenous Frequency: CONTINOUS at 0.6-60 mL/hr [hour] ... Admin Instructions: Start at 5 mcg/min. If less than or equal to 20 mcg/min, titrate (up or down) by 5 mcg/min every 5 minutes OR if greater than 20 mcg/min, titrate (up or down) by 10 mcg/min every 5 minutes to a goal effect of systolic blood pressure (SBP): 140-160 mmHG [Millimeters of mercury- unit of pressure] Patients are to be continuously monitored with vital signs ..."

During a review of Pt 13's document titled, "All Administrations of nitroglycerin" dated 9/10/24-9/11/24, it indicated the following dose changes: " ...
Rate Changed: 40 mcg/min: 12 mL/hr: Intravenous 9/10/24 at 1850 (6:50 p.m.) by [name of RN 12]
Rate Changed: 60 mcg/min: 18 mL/hr: Intravenous 9/10/24 at 1855 (6:55 p.m.) by [name of RN 12]
Rate Changed: 80 mcg/min: 24 mL/hr: Intravenous 9/10/24 at 2300 (11 p.m.) by [name of RN 11]
Rate Changed: 100 mcg/min: 30 mL/hr: Intravenous 9/11/24 at 0259 (2:59 a.m.) by [name of RN 11]
Rate Changed: 120 mcg/min: 36 mL/hr: Intravenous 9/11/24 at 0411 (4:11 a.m.) by [name of RN 11]
Rate Changed: 140 mcg/min: 42 mL/hr: Intravenous 9/11/24 at 0501 (5:01 a.m.) by [name of RN 11] ..."

During a concurrent interview and record review on 9/26/24, at 4 p.m., with ED Registered Nurse (RN) 12 and ED Manager (MEEM), Pt 13's document titled "All Administrations of nitroglycerin" dated 9/10/24-9/11/24 was reviewed. RN 12 stated he remembered taking care of Pt 13 on 9/10/24, he described Pt 13 as Spanish speaking with family at bedside who spoke English and helped to translate, Pt 13 had hypertension. RN 12 stated he does not administer nitro drips often and it had been a while since he had administered the one, he gave Pt 13's. RN 12 stated if he had any questions about the nitro gtt he could always ask the pharmacist or his charge nurse that shift. RN 12 stated normally he would adjust the nitro gtt by 10 and that he follows the order, he remembers having multiple drips that day. RN 12 stated it is important to follow the orders for patient safety, if the patient received too much nitro "it could tank (drop) the bp (blood pressure)". MEEM stated "No" RN 12 and RN 11 did not follow the order for the nitro gtt. MEEM stated too much Nitro can cause a rebound effect, or hypotension, this is why we titrate slow up and down.

During a review of the hospital's policy titled, "Vasoactive Infusion Guidelines for Progressive Care Units" dated 4/8/21, indicated "I. PURPOSE A. to clearly delineate guidelines for the administration of vasoactive medication by continuous infusion in Progressive Care Units (PCU). B. To ensure appropriate level of care for patients requiring administration of vasoactive medication by continuous infusion ... IV. PROCEDURE A. New IV Vaso active infusions: 1. Vital signs (blood pressure, heart rate, respirations, and oxygen saturations) will be taken at initiation of infusion. Blood pressure and heart rate will be taken at a minimum immediately before initiation of the infusion, within 5 minutes after initiation of the infusion, then every 15 minutes until the target heart rate or blood pressure (physician prescribed parameter) is reached or stabilized ... B. Dose adjustment: Vasoactive medications may be adjusted in accordance with written orders that include all appropriate dosing and monitoring parameters ..."

During a review of the facility's policy titled, "Provider Orders" dated 8/25/23, indicated, "I. PURPOSE A. To provide guidelines for initiating and/or updating the physician's therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician's orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician's orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ..."

Based on observation, interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled "Blood Products Transfusion", for one of one patients (Patient 44) when Pt 44 was administered blood products and the intravenous (IV) (into the blood stream via vein) tubing was not primed (the process of removing air from tubing) before giving blood, Saline (a mixture of water and salt concentration of 0.9%) was not started when blood product was received, and RN (Registered Nurse) 5 did not use aspetic technique when spiking (impale on or pierce with a sharp point) blood product bag.

These failures resulted in placing the patient at risk of experiencing an air embolus (air or gas bubbles which can block a blood vessel in the circulatory system). An air emolus is serious and can lead to a heart attack, stroke, respiratory failure, and death.

Findings:

During a record review of Pt 44's "History and Physical (H&P-the complete assessment of the patient and the problem)," dated 9/14/24, the H&P indicated, " ... 69 y.o. [year old] male, with PMH [past medical history] significant for recently diagnosed colon cancer in Arizona pending chemotherapy, presents to the Emergency Department with generalized weakness, difficulty swallowing, decreased oral intake and unintentional weight loss of approximately 40 lb [pounds, a unit of measure] over the last 6 months. ... recently re-evaluated for ongoing weight loss in August 2024 and was found to have colon cancer ...".

During a record review of Pt 44's "Transfusion Orders," dated 9/24/24 at 11:06 a.m., the orders indicated, "Transfuse Fresh Frozen Plasma (Adult ) ... Placing Order ... 09/19/24 1807 [6:07 p.m.] ... Released on ... 9/20/24 08:51 [a.m.] ...Transfusion duration per unit 4 (hrs [hours]) ..."

During a concurrent observation and interview on 9/20/2024 at 9:45 a.m., with RN 5, in Pt 44's room, RN 5 prepared and administered the blood to Pt 44. RN 5 was observed preparing the IV tubing for the FFP transfusion. RN 5 did not use a technique to manually prepare the tubing to remove all possible are bubbles. RN 5 did not prime the blood transfusion filter Y-tubing (special tubing used for administering blood products that flushes the blood product to the patient) prior to obtaining the blood product from the Blood Bank (a place where blood is collected and stored before it is used for transfusions). RN 5 primed the blood transfusion filter and tubing with normal saline and then spiked the blood product bag against his body. RN 5 stated he was nervous and forgot to spike bag according to the policy. RN 5 then connected the IV line to the patient.

During a concurrent interview and record review on 9/26/24 at 1:05 p.m., with RN 5, the hospital's policy and procedure (P&P) "Blood Products Transfusion", dated 5/6/24 was reviewed. RN 5 stated, he was familiar with the policy. RN 5 stated he did not prime the IV tubing prior to obtaining the blood. RN 5 stated he did not start the infusion when receiving the blood product from the blood bank. RN 5 stated he spiked the bag against his body instead of laying blood product bag on a clean surface or hanging from a IV pole. RN 5 stated this is important to not cause a delay in giving the blood as there is a four-hour window to give the blood to the patient.

During a concurrent interview and record review on 9/24/24 at 11:00 a.m., with NM 7, the hospital's P&P "Blood Products Transfusion", dated 5/6/24 was reviewed. NM 2 stated, RN 7 should follow the policy as the blood needs to be administered as efficiently as possible so that there is no delay. NM 7 stated, without exception, must completely follow the policy. NM 7 stated RN 5 did not follow the policy.

During an interview on 10/2/24 at 3:30 p.m., with the Chief Nursing Officer (CNO), the CNO stated, her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that blood or blood products is done efficiently and administered appropriately.

During a review of the hospital's P&P titled, "Blood Products Transfusion", dated 5/6/24, the P&P stated, " ... E. Preparation for Blood Transfusion ... 3. Prime the blood transfusion filter and tubing with normal saline ... G. Steps to be taken once blood product arrives at the nurse's station ... 4. Start normal saline drip at 10ml/hr [milliliters, unit of measurement] unless already started. ... I. Routine Handling of Blood at Point of Service ... 1. Transfusion of blood products must be completed within four hours after the time of issue from Blood Bank. ... 2. Begin the transfusion as soon as possible after the blood is issued from Blood Bank. a. There is not a requirement that transfusion must be initiated within 30 minutes of blood issue, but it should be started as soon as possible to avoid wastage .... J. Registered Nurse instruction for blood infusion, patient monitoring and follow up ... 2. With the blood product lying flat or hanging from an IV pole, spike the bag aseptically with primed blood tubing using a twisting motion ..."

Based on interview and record review the hospital failed to reassess two of three patient's (Patient (Pt) 2 and Pt 25) discharge plans when:

1.Nursing staff did not reassess Pt 2's oxygen saturation and need for oxygen and discharged Pt 2 to a Skilled Nursing Facility (SNF) without first notifying the physician.

These failures resulted in Pt 2 arriving at the SNF in respiratory distress, below normal oxygen levels, high respiratory rate and an avoidable transport back to the hospital for readmission. Pt 2 remained in the ED for over 33 hours when he was found unresponsive and needed to be intubated and sent to the intensive care unit (ICU).

2.Pt 2 Emergency Department (ED) visit on 9/23/24 addressed her low blood pressure and high heart rate but failed to address a Urine Analysis (UA- a medical test that examines a urine sample to evaluate its physical properties, chemical composition, and microscopic appearance) test was performed which revealed abnormal results showing presence of leukocytes (colorless, round, and extremely small cells that are part of the body's immune system and help fight infection and disease) and nitrites in Urine (may be a sign of a bacterial infection that affects the bladder, urethra, and kidneys).

These failures resulted in inadequate evaluation, lack of monitoring, insufficient patient and family education and the outcome was delayed diagnosis, worsening condition and the potential outcome for unnecessary harm, anxiety or distress to the patient and family members. This oversight compromised the patient's health and safety.

Findings:

1.During a review of Pt 2's demographic face sheet dated 9/18/24, it indicated Pt 2 was an 86-year-old male, admitted on 7/2/24 at 6:44 p.m. with the diagnosis of multifocal pneumonia (PNA-infection in the lungs; multifocal meaning pneumonia in several parts of the lungs).

During a concurrent interview and record review on 9/18/24, at 2:30 p.m., with the Manager of Medical Surgical Unit (NM) 8, Pt 2's Electronic health records (EHR) for his admission starting 7/2/24 were reviewed. NM 8 stated there was no order to monitor Pt 2's oxygen levels and after reviewing Pt 2's vital sign (VS) flow sheet dated 7/2/24-7/11/24, Pt 2's oxygen levels were not monitored consistently, and on 7/9/24 no oxygen saturations were documented. NM 8 stated routine vital signs should have been done for Pt 2, which means VS should be done every 8 hours but an order is required to monitor the oxygen saturations with the VS. NM 8 stated she was not aware of Pt 2's oxygen saturation(O2 sats- the amount of one's blood cells that are carrying oxygen- normal is 96-100%) trend indicating he needed more oxygen based on his oxygen demand and did not feel this was a reason to call the physician and or keep the patient longer before discharging the patient to a skilled nursing facility over an hour away.

During a concurrent interview and record review on 9/24/24, at 9:17 a.m., with Clinical Nurse Supervisor (NS) 4 for the medical surgical unit, Pt 2's EHR for his admissions starting 7/2/24 and 7/11/24 were reviewed. NS 4 stated she was the clinical supervisor that was on when Pt 2 was discharged to the skilled nursing facility (SNF). NS 4 stated on 7/11/24 she spoke with RN 7 and was informed that Pt 2 would be discharged to a SNF and getting picked up between 9:30-10 a.m. NS 4 stated she was not aware that Pt 2 had been taken off his oxygen, nor was she aware that on 7/9/24 no oxygen saturations were documented for Pt 2. NS 4 stated VS on med/surg are done routinely every 8 hours and saturations should be checked at last once every shift. NS 4 reviewed Pt 2's VS flowsheet and did not feel RN 7 needed to call the physician about Pt 2's O2 sats at 91 % on 2 L (liters- unit of measurement) NC (nasal canula- plastic tubing used to transport oxygen through the nose). NS 4 stated the current policy for standards of practice for VS on med/surg does not include checking oxygen levels, an order is required for this but that she is on a group that is looking at changing this policy and requiring every shift have VS that includes saturations. NS 4 stated she received a call from a nurse at the SNF on 7/11/24 informing her that Pt 2 was being sent back to the hospital because his oxygen saturations went low and the patient on arrival to the SNF was in respiratory distress.

During a concurrent interview and record review on 9/24/24, at 11:04 a.m., with Registered Nurse (RN) 7, Pt 2's EHR for his admission starting 7/2/24 was reviewed. RN 7 stated she took care of Pt 2 on 7/10/24 and 7/11/24. RN 7 stated Pt 2 was being treated for PNA and was discharged on 2 L nasal cannula (NC- plastic device placed in one's nose to deliver oxygen) oxygen on 7/11/24. RN 7 stated she was not aware that a specific order was required for oxygen saturations to be monitored. RN 7 stated she was aware that Pt 2's oxygen sats on discharge was 91 % on 2 l NC but did not notice Pt's 2 oxygenation trend that showed Pt 2 oxygen levels were going down and he was requiring more oxygen. RN 7 stated she did not think Pt 2 was short of breath and did not feel it was necessary to call the physician to hold up the discharge of patient 2. RN 7 stated Pt 2 was anxious to get to his new facility.

During an interview on 9/24/24, at 2 p.m., with Medical Doctor (MD) 6 and the Chief Medical Officer (CMO). MD 6 stated he has been a physician for one year and wrote the discharge orders for Pt 2. MD 6 stated Pt 2 came into the ED where labs, imaging, and he was suspected of having left lower lobe PNA, he was started on antibiotics times 5 days, and he managed his care while he was at the hospital. MD 6 stated he wrote Pt 2's discharge orders on 7/10/24 and he would need to be discharged with oxygen. MD 6 stated Pt 2 recovered quickly when he took off his oxygen and it was placed back on him, if Pt 2 had not recovered so quick and had issues then he would have worried, but Pt 2 had been stable since 7/8/24and had finished his course of antibiotics, so he felt it was a safe discharge.

During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2's discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate "looking for any gaps or follow up" that needed to be reviewed and noted that Pt 2's spouse had filed a complaint prior to 9/18/24 about Pt 2's discharge on 7/11/24. DRM stated, "we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted". DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24.

During a concurrent interview and record review on 10/2/24, at 3:20 p.m., with the Chief Nursing Officer (CNO), Pt 2's EHR for his admission beginning on 7/2/24 were reviewed. The CNO stated looking at Pt 2's vital signs flow sheets dated 7/6/24-7/11/24 that "it does appear his [referring to Pt 2] rate [referring to Pt 2's oxygen saturation rate] is trending down, yes, it is a reason to call the provider if he is getting ready" to be discharged. The CNO stated the expectation is that the policies for this facility are followed.

During an interview on 9/18/24, at 3:32 p.m. with the Director of Nursing (DON) at the skilled nursing facility Pt 2 was discharged to. The DON stated Pt 2 arrived on 7/11/24, he was not on oxygen and his mentation was altered, he was lethargic and not able to answer questions. The DON stated they put the patient on oxygen and his saturations were in the 80's (normal oxygen saturations are 96-100%) once on 4 L NC sats came up to 96%. The DON stated Pt 2 arrived to them hypoxic and in severe respiratory distress, he had pedal edema (swelling in his feet) and swelling to his abdomen. The DON stated Pt 2's spouse was at bedside and informed them that she had been begging the hospital to keep him until he was more stable. The DON stated she called the hospital back to let them know that Pt 2 would be coming back to them by ambulance and provided the clinical status he was currently in. The DON stated it took a little longer for Pt 2 to leave back to the hospital because he needed a higher level of transport due to his respiratory distress.

During a review of Pt 2's "Patient Care Report" (PCR- a document that supports the medical necessity for ambulance transport and serves as a factual assessment of the patient's condition.) dated 7/11/24, at 12:08 p.m. was reviewed. The PCR indicated under Narrative "Called out to SNF for pt w/ CC: Respiratory Distress. Pt was discharged from [name of hospital] this morning, and family would like him transported back to [same hospital] as he is not 'thriving.' Pt was in hospital for approximately 9 hays with pneumonia and was discharged to SNF for rehab ... 83 yo (year old) M (male) lying supine on bed in facility. BLS (basic life support) ambulance on scene reports SPO2 86% on 6 lpm (liters per minute). GCS 14 (Baseline 15) ... O2 switched over to high flow at 15 lpm via NRB (nonrebreather mask) SPO2 improved to 100%... Pt transferred to [name of hospital] ED w/o (without) further incident ..."

During a concurrent interview and record review on 9/26/24, at 8:30 a.m., with MD 7, Pt 2's ED Provider Note dated 7/11/24 at 3:39 p.m. was reviewed. MD 7 stated Pt 2 came in for shortness of breath "Chief Complaint Patient presents with Difficulty Breathing Pt brought in by ambulance with baseline Glasgow coma scale of 15. With EMS pt GCS is 14 with initial O2 sats of 86. NRM elevated O2 to 100. Visible labored respirations ... BP (blood pressure): 166/80 Heart Rate: 80 ... Temp. 36.9 C (98.5 F) Resp (respirations): 32 SpO2: 96 %" on 4 liters per minute " ... appears dehydrated ... lips dry ... Pulmonary: ... Breath Sounds: Decreased air movement (bilaterally) present ... Clinical Impression 1. Acute respiratory failure with hypoxia 2. Dyspnea ... 3. Elevated troponin (labs looks at cardiac damage) ..." MD 7 stated he ordered labs, chest x-ray (a type of electromagnetic radiation that can pass through most objects, including the body, to generate images of its internal structures and tissues), EKG (electrocardiogram -measures the electrical activity of the heart), and a CT (computed tomography scan, is a medical imaging technique that uses X-rays and a computer to create detailed pictures of the inside of the body) of Pt 2's chest to diagnose and stabilize. MD 7 stated his job in the ED is to stabilize the patients coming in and he does not know if Pt 2 was discharged too soon.

During a review of the facility's policy titled, "Discharge of Inpatient" dated 6/14/24, indicated, "I. PURPOSE A. To provide guidelines for discharging patients from the inpatient facility. B. To facilitate continuity of care ... V. PROCEDURE ... C. Assess patient as per Patent Assessment policy or unit specific policies. D. Communicate if there are any changes in the patient's condition to the provider ..."

During a review of the facility's policy titled, "Standard of Practice- Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units" dated 2/22/23, indicated, "I. PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in" each of these units. " ... IV. STANDARDS See Standards of Practice Documentation Grid .... General Medical/Surgical ... On-going/Reassessment ... with changes in patient condition and as needed ... Document: Pulse, Respirations, and Blood pressure & Pain assessment Every 8 hours and as needed, unless otherwise ordered ... Temperature every 8 hours ... Pulse Oximetry applied as ordered ... Telemetry every 4 hours ..."

During a review of the facility's policy titled, "Provider Orders" dated 8/25/23, indicated, "I. PURPOSE A. To provide guidelines for initiating and/or updating the physician's therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician's orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician's orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ..."

2. During a review of Pt 25's "Patient Demographics" (PD-a document providing demographic information about the patient including name, date of birth, admission date, emergency contact), dated 9/24/24, the PD indicated Pt 25 was a 82-year-old Spanish speaking female, admitted to the hospital on 9/23/24 at 6:22 p.m., Pt 25 was discharged home on 9/24/24 at 12:03 a.m., and returned to the ED on 9/24/24 at 7:46 p.m.(returned to the ED 19 hours and 49 minutes later after being discharged on 9/24/24).

During an interview on 10/01/24 at 4:26 p.m., with Pt 25's Family member (FM), FM stated Pt 25's was brought to the hospital on 9/23/24 because Pt 25's heart rate was high and blood pressure was low. FM stated a Urine Analysis was done and the doctor said Pt 25 had been stable because heart medication was given through the vein. FM stated the doctor told her Pt 25 was medically stable to be discharge home and the urine culture result was pending and would call her once the result comes back. FM stated she was never informed about the result of the Urine Analysis. FM stated she never receive a call from the doctor of the urine culture result.

During a review of Pt 25's "History &Physical (H&P)" dated 9/23/24 at 6:27 p.m., the H&P indicated Pt 25 had "history of atrial fibrillation with rapid ventricular response (RVR) (a type of irregular heart rhythm that occurs when the heart's upper chambers contract in an uncoordinated way, causing the lower chambers to beat too fast), Chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe), hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood), Alzheimer's (a brain disorder that gradually destroys memory and thinking skills). Pt 25 came to the hospital with chief complaint of Cardiac Tachycardia (a condition where the heart rate is faster than normal, usually more than 100 beats per minute (bpm) at rest). Vital signs (VS-measurements of the body's basic functions, such as breathing, heart rate, and temperature)- Blood Pressure (BP): 111/76, Heart Rate (HR): 149(normal resting heart rate for adults is between 60 and 100 beats per minute), Temperature: 97 Fahrenheit (F- a scale that measures the temperature) , Respiration: 18, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular ... Discussion: ... patient presents to the ED with complaints of RVR that started 9/23/24 .... Patient's heart rate improved in the Emergency Department (ED)... Patient discharged with instructions for primary care physician (PCP) follow up within the next 48 hours ... Clinical impression: Atrial fibrillation with RVR, Hyponatremia (a condition where the level of sodium in your blood is lower than normal) ... Disposition: Discharged to home. Results, diagnosis, and follow-up instructions were explained to patients. Patients comfortable going home and was advised to return immediately if symptoms worsen or if any concerns develop. Based on the patient's clinical picture and the result of a medical screening exam, there is no emergent medical condition present at this time. The patient is stable for discharge from the ED with the agreed upon follow up plan and return precautions".

During a review of Pt 25's "History &Physical (H&P)" dated on 9/24/24 at 8:19 p.m., the H&P indicated Pt 25 came to the hospital on 9/24/24 at 7:46 p.m. with chief complaint- "Generalized Weakness, VS- Blood Pressure (BP): 113/78, Heart Rate (HR): 161, Temperature: 38 C (100.4 F)(indicating fever), Respiration: 22, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular, white blood cell count (WBC) of 20 (normal number of WBCs in the blood is 4.5 to 11), Nitrites: Positive ... Clinical Impression: Shortness of breath (SOB), Generalized weakness, Urinary tract infection (UTI- a bacterial infection that affects the bladder, urethra, and kidneys) without hematuria (the presence of red blood cells in the urine), Super ventricular tachycardia (SVT- a condition that causes a rapid heart rate due to an issue with the heart's electrical system)".

During a review of Pt 25's Result Review Flowsheet (RRF), the RRF indicated, " ... on 9/23/24 at 9:57 p.m. .... Leukocyte esterase (enzymes that break down esters into acids and alcohols through a chemical reaction with water) 1+, nitrites: Positive, Red Blood Cells [RBC-carries oxygen and nutrients from the lungs throughout the body]-: 4 ... on 9/24/24 at 10 26 p.m. ... Leukocyte esterase 4+, nitrites: Positive, Protein: 20, WBC: 20 ..." Pt 25 had infection: Extended-spectrum beta-lactamases (ESBL- are enzymes that make some bacteria resistant to antibiotics, making infections harder to treat).

During a review of Pt 25's document titled "Culture Urine (CU)" with specimen collected date on 9/23/24 at 11:49 p.m. and last resulted date on 9/27/24 at 8:46 a.m., the CU indicated the urine culture was > (more than)100,000 cfu/ml (colony-forming units per millimeter- unit of measurement) ESBL Escherichia Coli (bacteria).

During a concurrent interview and record review on 10/1/24 at 3.37 p.m., with the Emergency Department Chair (MD) 3 Pt 25's "Emergency Department Patient Care Timeline (PCT)" and History and Physical (H&P) were reviewed, the PCT with arrival date 9/23/24 indicated Pt 25 was discharged after UA result came back positive. The PCT with arrival date 9/24/24 indicated Pt 25 arrived in the ED on 9/24/24 at 7:46 p.m. The H&P indicated Pt 25 came to the hospital with a chief complaint of generalized weakness, heart rate: 161, temperature of 100.4 (fever), a WBC: 20, Nitrite: Positive. MD 3 stated withholding treatment is appropriate due to the high prevalence of chronic bacteria in the elderly. MD 3 stated "I would not have ordered a UA in the first place". MD 3 stated there is a very high rate of colonization (the presence and multiplication of a microorganism in or on a host or an inanimate object or surface) in mobility impaired elderly women in particular, the rate for Pt 25 is 80% colonization; it becomes difficult with people like this. MD 3 stated asymptomatic (producing or showing no symptoms) bacteria is a chronically debated area within medicine. MD 3 stated "I would not have checked the UA because it makes the not treating decision simpler". MD 3 stated the doctor discussed with FM before discharge. MD 3 stated "I would have told the FM that there were some bacteria in the urine, this is something Pt 25 has had for a long time, there was no fever, labs looked good, HR was controlled with medication given, culture has been sent and you would be informed if there is any abnormality". MD 3 stated it was possible Pt 25 returned to the hospital because the UA result was not addressed, but blood cultures were negative. MD 3 stated if Pt 25 had been admitted during the 9/23/24 visit, Pt 25 may still be in the hospital. MD 3 stated either Pt 25 stayed in the hospital to get Meropenem (used to treat infections caused by bacteria) or be discharged with a peripherally inserted central catheter (PICC) line (a long, thin, flexible tube that's inserted into a vein in the upper arm and threaded into a larger vein above the heart). MD 3 stated "not treating with anything is appropriate because of the high rate of chronic bacteremia in the elderly, it almost makes less sense to discharge with oral antibiotics because of the likelihood of resistance". MD 3 stated the difference in the two cases is the presence of fever. MD 3 stated it is appropriate when you don't treat on the first encounter, for ESBL than to treat. MD 3 stated most of the time, when patients are not treated, they don't come back to the hospital. MD 3 stated the standard practice is we see all the results and still send the patient home.

During a review of the California Advocates for Nursing Home Reform (CANHR) Reference titled, " Challenging Hospital Discharge Decisions" dated January 12, 2024, (https://canhr.org/challenging-hospital-discharge-decisions/). Discharge Planning Services. Medicare certified hospitals must: " ...Have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support persons as active partners in the discharge planning for post-discharge care; ...Discuss the evaluation results with the patient or representative; ...Reevaluate and modify discharge plans as needed ..."