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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 09/30/2024 at 4:40 p.m. in the presence of the CNO. 5.

2. 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)

3. 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).

4. 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 have a well-organized and effective nursing service when:

1. 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)

2. 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)

3. 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)

4. 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 09/30/2024 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)

6. The hospital failed to ensure P&P for Intake and Output (I&O) was followed for one of one sampled patient (Pt 25) when Pt 25 had a physician order for Intake and Output (a medical measurement of the fluids and food that enters and exits the body) and license nurses did not document Pt 25's I&O in the Electronic Healthcare Record (EHR- a digital version of a patient's medical history and demographics that can be accessed by authorized healthcare providers). (Refer to A398)

7. The hospital failed to ensure P&P and Professional Standards of Practice for pain management was followed for seven of seven sampled patients (Pt 8, Pt 15, Pt 19, Pt 29, Pt 32, Pt 40, and Pt 55) when license nurses did not assess and re-assess Pt 8, Pt 15, Pt 19, Pt 29, Pt 32, Pt 40, and Pt 55's level of pain after pain medication was administered. (Refer to A398).

8. The hospital failed to ensure P&P for telemetry cardiac monitoring (TCM-a portable device used to continuously monitor patient's heat activity) was followed for five of five sampled patients (Pt 15, Pt 27, Pt 28, Pt 35, and Pt 41 when the license nurses did not read and document Pt 15, Pt 27, Pt 28, Pt 35, and Pt 41 telemetry cardiac strip every four hours. (Refer to A398).

9. The hospital failed to ensure physician's order and P&P was followed for one of one sampled patient (Pt 23) when license nurses failed to administer Patient Pt 23's diltiazem (a medication that relaxes the blood vessels in the body and lowers the heart rate) drip (continuous intravenous infusion) on 8/28/24 at the rate ordered by the physician and failed to document Pt 23's heart rate (HR) and blood pressure (BP) when titrating (increasing or decreasing the dose of) the drip according to the facility's policy and procedure. (Refer to A398)

10. Nurses did not follow the prescribed dose for nitrogylcerin for Pt 13. (refer to A405).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe setting.

Based on interview and record review the hospital failed to ensure that safe pharmaceutical services had been provided and meet the needs of each patient as evidenced by:

The hospital failed to develop and implement systems to ensure the safe use of medications when 6 of 7 patients (Patients 4, 5, 6, 8, 9, 10) were not accurately monitored for sedation (sleepiness) adverse effects after being administered IV (intravenous- into the vein) opioids. (Refer to A-500)

The cumulative effect of this systemic problem resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Pharmaceutical Services.

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 one-on-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 ...."



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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 high-risk 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-on-one 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 seve

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 ensure nursing care was provided to all patients in accordance with the hospital's policies and procedures when:

1. Patient (Pt) 1, a 70 y/o was brought in by ambulance to the Emergency Department (ED) for symptoms of stroke on 8/23/24 and admitted as an inpatient on 8/23/24 on stroke protocol. Pt 1 was not prioritized for a bed in the hospital and remained in the ED on a gurney until 8/27/24, a total of 101 hours. A pressure relief mattress was not provided for two days. Staff did not consider environmental factors related to treatment of the stroke and Pt 1 was subjected to the lights and noise of the ED hallway and staff did not prioritize restorative sleep in Pt 1's overall care; Pt 1's family member stated Pt 1 was very uncomfortable and could not sleep. Nursing staff did not administer Pt 1's asthma medications in a timely manner, and the ordered incentive spirometer (every 1-2 hours) was not initiated during the entire ED stay. Nursing staff did not assess Pt 1's cardiac monitor strips per policy. Nursing staff were aware of Pt 1's right sided weakness and did not prioritize or implement interventions to address the use of utensils that could facilitate eating food he could manage. For the four days Pt 1 was in ED, nursing staff did not prioritize nutritional intake and there is documentation of nutritional intake only once. Pt 1's intake and output were not recorded. The physical therapist's recommendations for ambulation were not followed, and range of motion to his legs was not provided. Pt 1 was not provided assistance to go to the bathroom in a timely manner the day of admission and as a result was incontinent. He did not receive the speech therapist's recommended oral hygiene with suctioning twice a day while in the ED. The stroke assessment was not done every twelve hours in accordance with the policy and the physician's order.

The following Policies and procedures were not followed in the care of Pt 1: Cardiac monitoring; Care of the Stroke Patient; Provider Orders; Interdisciplinary Plan of Care; Pressure injury Risk Assessment, Prevention, Staging and Treatment; Admission and Ongoing Assessment- Nursing (Acute Care); Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units; Documentation in the Health Record; Standards of Practice, Emergency Department.

These failures resulted in Pt 1 not receiving appropriate stroke care for four days causing harm to Pt 4 by depriving him of the specialized care and attention needed during this critical time for recovery in order to minimize the damage caused by the stroke.

2. Pt 2, an 86-year-old male was brought in by ambulance (BIBA) to the ED on 7/2/24 at 6:32 pm for left lower lobe pneumonia (PNA) 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 in accordance with hospital P&P. 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.

These failures resulted in an avoidable decline of respiratory status and upon arrival to the SNF, Pt 2 was in acute respiratory distress, with oxygen saturation 86%. Pt 2 was transferred back to the hospital ED and remained in the ED hallway gurney for 33 hours and was found unresponsive and required immediate intubation and admission to the Intensive Care Unit. On 8/8/24 Pt 2 died.

3. Pt 3, an 87 year old with a history of dementia, was BIBA 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 areas of skin breakdown (on coccyx and head) 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 of the gurney mattress until he was moved to the med surg unit on 9/19/24. For Pt 3, nursing did not follow the hospital P&P's for Interdisciplinary Plan of Care, Pressure Injury Risk Assessment, Prevention, Staging and Treatment, Admission and Ongoing Assessment- Nursing (Acute Care), Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, Documentation in the Health Record, Standards of Practice, Emergency Department.

These failures led to Pt 3 remaining on a gurney in the hallway, a noisy, bright environment not ideal for a patient with dementia, and resulted in the worsening of the pressure injury to Pt 3's heel.

4. Pt 4, a 77 year old, came to the ED by ambulance on 9/16/24 from a skilled nursing facility (SNF) after choking on food, and was admitted on 9/16/24 with a diagnosis of pneumonia. Pt 4 was not prioritized for a bed in the hospital and remained in the ED hallway on a gurney for 84 hours before he was moved to the med surg unit. During his ED stay, nursing staff did not perform skin or pain assessments in accordance with policy and procedure, and did not implement measures to relieve pressure on Pt 4's feet/heels. Nursing staff did not prioritize the importance of adequate nutritional intake and did not record any intake for Pt 4 during his ED stay. For Pt 4, the following Policies and procedures were not followed: Provider Orders, Interdisciplinary Plan of Care, Pressure injury Risk Assessment, Prevention, Staging and Treatment, Admission and Ongoing Assessment- Nursing (Acute Care), Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, Documentation in the Health Record, Standards of Practice, Emergency Department.

These failures had the potential to result in Pt 4 aspirating food, having unrelieved pain, and developing pressure injuries.

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 09/30/2024 at 4:40 p.m. in the presence of the CNO.

5. Three of three patients (Patients 36, 37 and 38) were diagnosed with alcohol withdrawal and nursing staff did not follow the protocol Clinical Institute Withdrawal Assessment for Alcohol (CIWA).

These failures resulted in avoidable risk to negative outcomes and clinical decline of alcohol withdrawal, such as, but not limited to, dehydration, electrolyte imbalance, confusion, and seizures.

6. One of one sampled patient (Pt 25) had physician orders for Intake and Output (I&O-a medical measurement of the fluids and food that enter and exit the body) monitoring and the output was not documented in Pt 25's electronic health record (EHR) by the licensed nurses according to the facility's policy and procedure "Standards of Practice- ..., Telemetry, Step-Down and Critical Care Units".

This failure resulted in Pt 25's urine output not being monitored for over 13 hours and had the potential to result in the physician not being accurately notified of Pt 25's urine output and potentially impact Pt 25's care, delayed or inaccurate diagnosis and inadequate fluid management.

7. Nurses did not assess and re-assess pain and follow physicians order for pain medication administration for five of seven patients (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) in accordance with the hospital policy and procedure "Pain assessment and Management- Patients 14 and Older ..."

This failure resulted in (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) not being monitored and had the potential to result in the physician not being accurately notified of (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) pain and potentially bring about delayed care.

8. The nurse did not follow physician's order for Telemetry Cardiac Monitoring (TCM-a portable device used to continuously monitor patient's heat activity) for reading and documenting four of four patients, Pt 15, Pt 27, Pt 28, and Pt 41's telemetry cardiac strip (a recording of patient's heart electrical activity) every four hours.

This failure had the potential for Pt 15, Pt 27, Pt 28, and Pt 41 to experienced abnormal heart rhythms without the nurse knowing and decreased the chances of early detection and treatments.

9. Nursing staff failed to start Patient (Pt) 23's diltiazem (a medication that relaxes the blood vessels in the body and lowers the heart rate) drip (continuous intravenous infusion) at the appropriate rate on 8/28/24 as ordered by the physician and failed to document Pt 23's heart rate (HR) and blood pressure (BP) when titrating (increasing or decreasing the dose of) the drip according to the facility's policy and procedure.

This failure resulted in potential harm to Pt 23.

Findings:

1. During a concurrent observation and interview on 9/17/24 at 11:05 a.m. with the Emergency Department (ED) manager (NM 6), in the ED, there were twenty-five patients on gurneys in the hallway outside of the ED rooms in the green and yellow "zones" of the ED.. NM 6 stated the patients in the hallways and many of the patients in the ED rooms (also on gurneys) had admission orders to the med-surg unit or the cardiac progressive care unit (CPCU) but there were no available hospital beds on the inpatient units to move them to. NM 6 stated she does not know whether this means there are no physical beds available or no available nurses to staff the beds. The patients on gurneys in the hallway did not have bedside tables, water pitchers/cups, access to a television or phone. The patients on gurneys in the hallway had minimal privacy with portable privacy screens next to and/or between some of the gurneys, and were surrounded by the lights, noise, and activity of the ED. NM 6 stated the admit hold times had improved and they were averaging about 36 hours holding after admission orders were placed by the admitting physician. NM 6 stated Bed Control (a centralized office which supports the three hospitals and coordinates bed assignments) notifies them when there is a bed assigned for an admitted patient, and NM 6 did not know what the time frame was for moving the admitted patients or where each patient was on the list. NM 6 stated not all of the admitted patients would be moved from the ED to the med surg unit or CPCU. NM 6 stated some of the patients would spend their entire inpatient hospital stay in the ED. NM 6 stated currently there were 62 admitted patients being cared for in the ED. NM 6 stated the hospital had hired and trained nurses to work in the ED specifically to provide inpatient care to the admitted patients, and not to work as ED nurses caring for ED patients.

During a review of the complaint submitted by Pt 1's family member (FM 2) dated 8/27/24, the complaint indicated Pt 1 was a 70 y/o man who came to the ED on 8/23/24 and was diagnosed with a stroke. The complaint indicated Patient 1 remained on the gurney for four days in the ED, two of them in the hallway, before being moved to the telemetry unit (for patients who require continuous cardiac monitoring) on 8/27/24. The complaint indicated during the time Pt 1 was in the ED, the nurses did not get him up to a chair or make sure he walked during the day, or perform range of motion exercises on his legs, took too long to put a waffle pad on top of the gurney, and as a result he was in pain and his legs and back were stiff. The complaint indicated that the weakness in his right arm and hand from the stroke made it difficult for him to hold the utensils needed to eat the food that was provided to him. The complaint indicated Pt 1 had asthma that was made worse by stress and lack of sleep due to the bright lights and noise and was wheezing and uncomfortable, with mucus building up in his throat and that he had to wait for hours to get his asthma treatment and inhaler. The complaint indicated it took too long to get help when requested and Pt 1 did not have a call light or bell during the time he was in the hallway. The complaint indicated Pt 1 needed specialized care due to his diagnosis of stroke and did not get that in the ED. Attempts to reach FM 2 by phone and email were not successful.

During a concurrent interview and record review on 9/18/24 at 2:45 p.m. with NM 6, Pt 1's medical record was reviewed. Review of the ED Patient Care Timeline, dated 8/23/24 through 8/27/24, indicated Pt 1 arrived in the ED by ambulance on 8/23/24 at 3 p.m. with symptoms of a stroke. Pt 1 had a history of high blood pressure, and asthma. Pt 1's arrival blood pressure was 196/102, heart rate 98 beats per minute, respirations 22 per minute, and oxygen saturation 100% on 6 liters (L)/minute of oxygen. Pt 1 had slurred speech, right sided facial droop, and right sided weakness. Stroke protocol orders were initiated and at 4:04 p.m. Pt 1 was moved to room 4 in the red zone (area of ED where the most acute patients are assigned). An MRI of the brain indicated an "acute central pontine infarct (occurs when blood flow is blocked to a part of the brainstem called the pons, which controls important functions including breathing, swallowing, and heart rhythm), but was not a candidate for an intervention to restore the blood flow because too much time had passed since his symptoms began.. The decision to admit Pt 1 was made at 6:30 p.m. and the admitting physician accepted the patient at 8:02 p.m. Review of the physician's orders dated 8/23/24 at 9:01 p.m.. indicated, " ...Admit to inpatient ...Document National Institute of Health Stroke Scale [NIHSS- a systematic, quantitative assessment tool to measure stroke-related neurological deficit] within 12 hours of arrival to the emergency department, then every 12 hours and at discharge, Intake and output every shift, incentive spirometer (a medical device that helps exercise the lungs)10 times every 1-2 hours while awake, neuro checks every 4 hours, cardiac monitoring ..."
Review of the admit nurse's note indicated on 8/23/24 at 9:08 p.m., Pt 1 was to be admitted to the cardiac progressive care unit (CPCU), anticipated diagnosis cerebral vascular accident (CVA [also known as a stroke]- a medical condition that occurs when blood flow to part of the brain is interrupted causing damage to the brain cells), however the record indicated that Pt 1 remained in the ED from the time of arrival on 8/23/24 until 8/27/24 at 8:40 p.m. when he was transferred to CPCU, after having spent 101 hours in the ED on a gurney.

Review of the ED Patient Care Timeline dated 8/23/24 through 8/27/24 indicated the NIHSS was assessed at least every 12 hours on 8/23/24 and 8/24/24. On 8/25/24, the NIHSS assessment was done at 8 a.m. and the next time it was assessed was 8/26/24 at 11:49 a.m., almost 28 hours later. NM 6 stated she was not sure how often an assessment of the NIHSS was supposed to be done, and would need to check the orders or policy.
Review of the "Head to Toe" flowsheet dated 8/23/24 through 8/27/24, indicated on 8/23/24 "telemetry strip analysis" was documented at 11:04 p.m. and was next assessed 8 hours later on 8/24/24 at 7:49 a.m. After the telemetry strip analysis on 8/24/24 at 11:16 a.m., the next assessment was 6 hours later at 5:18 p.m. After the telemetry strip analysis on 8/24/24 at 11 p.m., the next assessment was 8 hours later on 8/25/24 at 7 a.m. After the telemetry strip analysis on 8/25/24 at 3 p.m., the next assessment was 12 hours later on 8/26/24 at 3 a.m. NM 6 stated the telemetry strips are supposed to be reviewed by the RN every four hours. The monitor tech (MT) prints out the strips and the RN has to review it and enter the specific information into the medical record.

Review of the Physical Therapist's (PT) note dated 8/24/24 at 10:24 a.m., indicated Pt 1 was a high fall risk and required assistance when out of bed. The PT note indicated Pt 1 was assisted by the PT to walk 50 ft, and the PT note indicated recommendations to nursing to ambulate two to three times a day. NM 6 stated they don't ambulate the patients very often in the ED. Review of the activity flowsheet indicated on 8/23/24, 8/24/24, and 8/25/24 Pt 1 remained "Lying in bed (gurney)" with no documentation that Pt 1 was ambulated, up in a chair, or repositioned.

Review of the Speech Therapist's (ST) Note dated 8/25/24 at 8:17 a.m. indicated, " ...Plan/Recommendations: 1. Regular texture/thin liquids. 2. Standard aspiration precautions. 3. Aggressive oral care with toothbrush, toothpaste, and concurrent suctioning needed at least twice daily ..." NM 6 was unable to find evidence the speech therapist's plan for oral care was implemented.

Review of the diet orders dated 8/23/24 through 8/27/24 at 10:01 a.m., indicated orders for a diabetic diet on 8/23/24 until 8/26/24 at 5:50 p.m. when there was an NPO (nothing to eat or drink) order. On 8/27/24 at 10:01 a.m. a "heart healthy" diet was ordered. Review of the flowsheet "Daily Cares-Nutrition" dated 8/23/24 through 8/26/24, indicated there was no documentation regarding Pt 1's nutritional intake, appetite, ability to hold utensils or feed himself on 8/23/24, 8/24/24, and 8/25/24. On 8/26/24 the flowsheet indicated Pt 1 consumed 75% of his lunch, his ability to hold utensils or feed himself was not documented.
FM 2's concerns regarding Pt 1 having asthma and wheezing and having mucus building up in his throat, and having to wait too long for his asthma inhaler and treatment were shared with NM 6. Review of the physician orders indicated on 8/25/24 at 10:21 p.m. the albuterol inhaler was ordered, and on 8/26/24 at 3:20 p.m. the Advair inhaler was ordered. Review of the medication administration record indicated the albuterol inhaler was first given on 8/26/24 at 5:53 p.m., almost twenty hours after being ordered, and the Advair inhaler was given on 8/26/24 at 11:17 p.m., eight hours after it was ordered. There are no nurses notes regarding Pt 1's request for the asthma medications or regarding there being a delay in getting the medications. Review of the "Daily cares" flowsheet dated 8/23/24 through 8/27/24, indicated no use of the incentive spirometer on 8/23/24, 8/24/24, 8/25/24, 8/26/24, and 8/27/24 until 8 p.m. after he was admitted to the cardiac progressive care unit (CPCU). A chest x-ray done on 8/27/24 indicated, "Bibasilar atelectasis (a collapse in the bottom part of both lungs)."
FM 2's concerns regarding Pt 1 experiencing pain due to being on a gurney for days and not having his pain assessed by the nursing staff were shared with NM 3. Review of the "Skin Integrity Report" dated 8/23/24 through 8/27/24, indicated a pressure relief pad was not put on Pt 1's gurney until 8/26/24. Review of the "Pain Monitoring" summary dated 8/23/24 through 8/27/24, indicated on 8/23/24 Pt 1's pain was assessed at 9:54 p.m., and was next assessed 13 hours later on 8/24/24 at 11 a.m., and then 9 hours later at 8 p.m. The next pain assessment was 12 hours later on 8/25/24 at 8 a.m., and then almost 15 hours after that on 8/25/24 at 10:44 p.m. After a pain assessment on 8/25/24 at 11:45 p.m., the next assessment was over 8 hours later on 8/26/24 at 8:16 a.m. After a pain assessment on 8/26/24 at 12:22 p.m., the next pain assessment was almost 8 hours later on 8/26/24 at 8 p.m. After a pain assessment on 8/26/24 at midnight, the next pain assessment was 9 hours later on 8/27/24 at 9 a.m.

During an interview on 9/19/24 at 2 p.m. with the Chief Nursing Officer (CNO), and the Chief Operating Officer (COO), and the Vice President of Regulatory and Risk Management (VPRRM), the hospital's practice of keeping admitted patients in the ED hallways on gurneys was discussed. The CNO stated in the past six months they have been concentrating on orienting and educating the nursing staff on the care of the admitted patients with the goal being that their care in the ED as an inpatient is comparable to the care that patient would receive if they were in a bed on the unit in the hospital. They have hired nurses specifically for the purpose of taking care of the inpatients as well as supervisors and a manager to oversee the staff and the care of these patients. The CNO stated this "unit" (ED-IN, ED Inpatient) is something that is going to be maintained, it is not a short term plan. The ED-IN is not a specific geographical area of the ED, but refers to inpatients in the ED, whatever room, or hallway they are in. The COO stated they have been working on making sure care in the hospital is efficient as possible to ensure patients can be discharged in a timely manner, so patients can get into hospital beds. The CNO stated some patients will be admitted and discharged from the ED without getting to a hospital bed.

During an interview on 9/24/24 at 10:55 a.m. with the Director of ED (DED), the gaps in Pt 1's nursing care were reviewed. The DED stated she was aware of the specific details of the complaint by Pt 1's family and had spent time speaking with the family member who complained (FM 2). The DED stated when she received the complaint she reviewed the chart and spoke with staff. The DED stated the documentation of the care provided to Pt 1 during the four days he was an inpatient in the ED did not reflect her expectations of the care that should have been provided to Pt 1. The DED stated this was disappointing and she apologized to FM 2. The DED stated the expectation is that the patients in the ED who have been admitted but remain in the ED, receive the same care they would receive if they were in a bed in the intended unit in the hospital. The DED stated this means inpatient nursing policies and procedures and orders are to be followed.

During an interview on 9/24/24 at 11:10 a.m. with the DED, the DED acknowledged that inpatients who remain in the ED instead of being admitted to a bed in the hospital will be on a gurney rather than a hospital bed. The DED stated this is not ideal and patients should not have to ask for a pressure relieving pad to be put on the gurney. The DED stated the staff are being told to put the pressure relieving pad on the gurney when the patient gets there, regardless of whether or not the patient has admission orders. The DED stated this week they replaced gurneys with hospital beds in the ED rooms where inpatients stay, but the ED inpatients in hallway "beds" will remain on gurneys due to space constraints. The DED stated she was made aware that Pt 1 was not prioritized for a bed in the hospital even though he had a new diagnosis of stroke because the plan after discharge was for him to go to rehab. The DED stated she was unaware this was the practice and that it has now been stopped. The DED stated they are working on a process to help guide decision-making for prioritizing the assignment of hospital beds to the inpatients in the ED. The DED stated when the speech therapist and physical therapist put recommendations in their note, the staff don't know to look there. The DED stated a nursing order would need to be entered for whatever the recommendation is. The DED stated they are working on that.

During an interview on 9/24/24 at 12:20 p.m. with the DED, the Manager of the ED/ED-IN Manager (MEEM), and the manager of med-surg oncology (NM 7), NM 7 stated she was the one who had oversight of the hiring and orienting of the new staff for the ED-IN unit. She said the majority of them are new grads. NM 7 stated now that a manager has been hired for the ED-IN (MEEM), he will assume oversight of the nursing staff and their training, and will coordinate with the med surg managers as far as training. NM 7 stated the nursing staff hired for this purpose were oriented for 6-8 weeks with an RN from the med-surg/oncology unit. The orientation occurred in the ED. The NM 7 stated the new staff had med-surg training, and were not trained for CPCU (telemetry) yet. NM 7 stated the new staff have six months to get their advanced cardiovascular life support (ACLS) certification, NIHSS training and certification, and basic arrhythmia certification. NM 7 stated the supervisors or experienced nurses in ED will do the telemetry strip assessments if the nurse has not had the training yet. NM 7 stated going forward the orientation and training of any new staff hired for the ED-IN will be 16 weeks long instead of 6-8 weeks long. The NEEM stated they are working on a workflow for the prioritization of moving inpatients in the ED into hospital beds which should be finished next week, and they are working closely with the bed control department.
During an interview on 9/26/24 at 10:20 a.m. with the Stroke Supervisor (SS) 1, and two Stroke Coordinators (SC 1 and SC 2), SS 1 stated she was the project lead for the hospital's primary stroke center (PSC) certification process. SS 1 stated the hospital received Primary Stroke Center certification by Joint Commission in January 2024. SS 1 stated a requirement of the certification is to have designated beds where stroke patients will be admitted, and CPCU is the unit with the designated beds. The education the staff receive as ED nurses focuses on the recognition of a stroke and the initial care. The education and training of the nurses on the unit in the hospital also focus on the ongoing care of the patient. The program's focus is defined in the order set and standard of care.

During a review of the hospital's policy and procedure (P&P) titled, "Care of the Stroke Patient," dated 12/19/23, the P&P indicated, " ...Stable stroke and TIA patients are to be admitted to designated stroke beds, if available. If stroke patients are admitted to a non-stroke bed, oversight will be provided by a clinical supervisor whose has certification in the National Institute of Health Stroke Scale (NIHSS). Stroke trained providers, licensed nurses and code stroke responders are to successfully complete an approved NIHSS Certification and maintain per the institution guidelines. (NIH Stroke Scale Certification) IV. PROCEDURE: On admission, provide a calm, quiet atmosphere. Perform the NIHSS once per shift, upon discharge and whenever a change in neurological status is identified for acute ischemic stroke and TIA patients. If a stroke patient is on a non-neuroscience specific unit, a NIHSS certified RN will perform the NIHSS evaluation ..."

During a review of the hospital's P&P titled, "RN NIH Stroke Scale Certification," dated 11/14/22, the P&P indicated, " ...Purpose: To ensure all Registered Nurses (RNs), including contracted staff, obtain National Institute of Health (NIH) Stroke Scale certification prior to assuming care of stroke patients. Policy: NIH stroke scale training: Initial validation and annual re-validation completed online for nurses who identify and manage acute stroke patients ..."
During a review of the hospital's P&P titled, "Cardiac and Remote Monitoring - Inpatients 14 and Older," dated 6/14/24, the P&P indicated, " ...Patients are to receive the care appropriate for their diagnoses or procedure including cardiac monitoring as ordered by a provider. Orders for Cardiac monitoring are based on these guidelines ...Tier I: Cardiac monitoring is indicated in most, if not all, patients in this group. This category includes all patients who are at significant risk of an immediate life-threatening arrhythmia ...Cardiac arrest ...new onset heart failure ...acute stroke ...All telemetry/cardiac monitored patients are to receive continuous cardiac monitoring unless otherwise ordered by a provider ...Staff assigned to units providing continuous cardiac monitoring will demonstrate competencies as described in procedure ...All monitored patients will have rhythm strips printed for admission, transfer, temporary removal, any rhythm abnormalities, and every 4 hours for the duration of the cardiac monitor order. All cardiac rhythm strips will be placed in the patient's thin chart to be scanned into the EHR after discharge. The assigned RN/designee is responsible for validating and documenting the patient's rhythm and any changes and interventions that occur. The RN will date and sign the cardiac monitoring strip printed by the Monitor Tech (MT) every 4 hours ..."

During a review of the hospital's policy and procedure (P&P) titled, "Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units," dated 2/22/23, the P&P indicated, "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 the Critical Care, Step-Down/Progressive Care, Telemetry, and Medical/Surgical units, within [Name of Hospital System] ... Licensed professionals are accountable for assigned patient care until end of shift, physical transfer, hand-off to another licensed staff member, or patient discharge. Unlicensed staff members are to provide care as assigned and/or delegated to them until end of shift, physical transfer, or patient discharge ... If there is a difference between the physician order and the standards below [in this policy], the one that is stricter will be followed ..."

During a review of the P&P attachment titled, "Standards of Practice-Documentation Grid," dated 2/22/23, the P&P attachment indicated, " ...Pulse, Respirations, and Blood Pressure & Pain Assessment- General Medical /Surgical- Every 8 hours and as needed, unless otherwise ordered. Telemetry, Progressive Care/Stepdown: Every 4 hours and as needed, unless otherwise ordered. Intake and Urine Output- General Medical /Surgical-Every 8 hours as needed, unless otherwise ordered; Telemetry, Progressive Care/Stepdown- Every 4 hours unless otherwise ordered ... Cardiac Monitoring: PR, QRS, QT, Rate, Rhythm, and Ectopy- General Medical /Surgical- Not Applicable (Exception: Centrally monitored patients: continuous monitoring and document every 4 hours.); Telemetry, Progressive Care/Stepdown: Continuous monitoring and document every 4 hours ..."

During a review of the hospital's P&P titled, "Provider Orders," dated 08/25/23, the P&P indicated, " ... I. PURPOSE A. to provide guidelines for initiating and/or updating the physician's therapeutic treatment plan. II. DEFINITIONS C. Orders Categories 2. Urgent/ As Soon As Possible (ASAP) .... The process of obtaining the requested tests, studies or procedures are initiated and completed within 4 hours of the request ....3. STAT- The process of obtaining the requested tests, studies or procedures are initiated and finalized within 1 hour of the request ... III. M....The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ... R. The RN and LVN 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 ..."

During a revie

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 develop and implement systems to ensure the safe use of medications when 6 of 7 patients (Patients 4, 5, 6, 8, 9, 10) were not accurately monitored for sedation (sleepiness) adverse effects after being administered IV (intravenous- into the vein) opioids.
This deficiency had the potential to cause respiratory depression and or patient death if one of these opioid medications had been administered to a patient without appropriate sedation assessment being implemented and in place.

Findings:
California Department of Public Health conducted a complaint validation survey dated 5/17/24, when Patient 1 received multiple doses of intravenous opioids (a class of medication identified as high-risk/high-alert medications), exceeding the manufacturer's recommended dose for the patient's medical conditions, and suffered respiratory and cardiac arrest (stopping of the heart and breathing) leading to anoxic brain injury (death of brain cells due to oxygen deprivation to the brain) and subsequently expired 10 days later. Findings indicated the hospital failed to develop and implement systems to ensure the safe use of IV opioids medications for Patient 1.

A review of the hospital's nursing staff education module titled, "Pain & Sedation Monitoring- Safe Opioid Administration", dated August 2024, indicated, "Policy Change: For patients with active opioid medication orders there is an additional sedation assessment required including the patient's level of sedation, respiratory rate, and pattern for the following assessments:
Routine pain assessment- Patients will be assessed using the appropriate pain assessment tools during routine assessment times and as needed and will include: ... level of sedation ..., respiratory rate, respiratory pattern
Reassessment of pain, and sedation, respiratory rate and pattern will be done after each unscheduled pharmacological pain intervention [using medication to treat pain] when sufficient time has lapsed for the medication to reach peak effectiveness [operating at maximum]. [Assessment for] IV medication within 30 minutes ... PO [by mouth]/IM [into the muscle] within 60 minutes"

A review of the hospital's P&P titled, "Pain Assessment & Management- Patients 14 and Older", dated 9/13/24, indicated, "Monitor patients receiving opioids for opioid-induced respiratory depression (breath too slowly) and sedation by using either the RASS [Richmond Agitation and Sedation Scale- used for targeted sedation] or POSS [Pasero Opioid-induced Sedation Scale- used for monitoring adverse effects of sedation] assessment tools along with respiratory rate and pattern assessment during routine and post pharmacological reassessment timeframes. All patients receiving opioid based pharmacologic intervention are at risk for opioid-induced respiratory depression (OIRD) and opioid-induced sedation (OIS) and require additional assessment for adverse outcomes ... Monitor patients receiving opioids for opioid-induced respiratory depression and sedation by using either the RASS or POSS assessment tools along with respiratory rate and pattern assessment during routine and post pharmacological reassessment timeframes".
During a concurrent interview and record review on 9/17/24 at 3:34 p.m. with Medication Safety Pharmacist (MSRPH), Patient 4's "Admission Summary" was reviewed. Patient 4's clinical record indicated Patient 4 was a 57-year-old, admitted on 8/30/24. Patient 4's physician order indicated hydromorphone (potent opioid used for pain) 1 mg (milligram-unit of measure) IV was ordered on 8/30/24 at 12:18 p.m., 3:36 p.m., 6:26 p.m., 8:28 p.m., and administered by nursing staff on 8/30/24 at 1:17 p.m., 4:01 p.m., 6:40 p.m., and 8:38 p.m. MSRPH was unable to provide documentation of Patient 4's adverse effect monitoring for RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 4's 1:17 p.m., 4:01 p.m., and 6:40 p.m. IV hydromorphone doses; no RASS/POSS score and respiratory rate 30 minutes after administration of 8:38 p.m. dose, and acknowledged Patient 4 was not adequately reassessed for sedation or respiratory depression after each administration of IV hydromorphone.
During a concurrent interview and record review on 9/18/24 at 11:00 a.m. with MSRPH, Patient 5's clinical record was reviewed. Patient 5's "Admission Summary" indicated Patient 5 was a 46-year-old with kidney failure and on dialysis (treatment that removes excess water, salt, and waste from the blood when kidneys are no longer able to do so) admitted on 8/25/24. Patient 5's physician order indicated morphine (potent opioid use for pain) 2 mg IV for every 4 hours as needed for moderate pain was ordered on 8/26/24 at 10:23 a.m., and administered by nursing staff on 8/26/24 at 10:44 a.m., 4:35 p.m., and 9:13 p.m. MSRPH was unable to provide documentation of Patient 5's adverse effect monitoring for RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 5's 10:44 a.m., 4:35 p.m., and 9:13 p.m. IV morphine doses, and acknowledged Patient 5 was not adequately monitored for adverse effects of sedation or respiratory depression after each administration of IV morphine.
During an interview on 9/18/24 at 2:27 p.m., with Director of Emergency Department (DED), DED stated the expectation was for nursing staff to assess patients for sedation within 30 minutes following IV opioid administration for respiratory pattern, respiratory effort, and pain. DED stated adverse effects of opioids included respiratory depression, hypotension (low blood pressure), and over sedation. DED acknowledged Patients 4 and 5 were not appropriately monitored for sedation adverse effects after administration of IV opioids.
During a concurrent interview and record review on 9/18/24 at 3:04 p.m. with 4 North Oncology Clinical Supervisor (4NOCS), Patient 6's "Admission Summary" was reviewed. Patient 6's clinical record indicated Patient 6 was a 44-year-old, admitted on 9/1/24. Patient 6's physician order indicated fentanyl patient-controlled analgesia (PCA- patient controls amount of pain medication they receive) 250 mcg (microgram- unit of measure)/25 ml syringe intermittent with patient PCA 5 mcg dose, 5 minutes lockout interval (time patient cannot get dose), and 300 mcg 4-hour dose limit was ordered on 9/2/24 at 9:51 a.m. and was initiated at 5:02 p.m. 4NOCS was unable to provide documentation of Patient 6's assessment of RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 6's at 5:02 p.m. 4NOCS stated nursing staff was expected to do an initial 30-minutes within 30 minutes after PCA opioid administration, followed by an assessment every two hours. 4NOCS stated sedation assessments were important for patient safety, to make sure patient could tolerate medication as ordered, and to recognize over sedation.
During a review of the hospital's P&P titled, Patient Controlled Analgesia- Patients 14 and Older", the P&P indicated, "monitor and record the vital signs [measurement of how body is functioning], pain intensity, and RASS every 30 minutes times two, then assess and record the level of sedation (RASS), respiratory rate, respiratory effort [energy it takes to breath], oxygen saturation [how much oxygen is getting to the body's tissues], EtC02 [level of carbon dioxide release at end of exhaled breath] if available, and pain intensity every two hours while the patient in on PCA therapy."
During a concurrent interview and record review on 9/18/24 at 3:42 p.m. with Director of Pharmacy (DOP), Patient 8's clinical record was reviewed. Patient 8's "Admission Summary" indicated Patient 8 was a 76-year-old with chronic kidney disease [long term illness where kidney have become damaged over time], admitted on 9/12/24. Patient 8's physician order indicated hydromorphone 0.5 mg IV every 3 hours as needed for breakthrough pain was ordered on 9/17/24 at 4:32 p.m., and administered by nursing staff on 9/18/24 at 3:11 p.m. DOP was unable to provide documentation of Patient 8's assessment of RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 8's 3:11 p.m. dose. DOP acknowledged Patient 8 was not adequately reassessed for sedation or respiration depression after administration of IV hydromorphone.
During a concurrent interview and record review on 9/18/24 at 3:51 p.m. with DOP, Patient 9's clinical record was reviewed. Patient 9's "Admission Summary" indicated Patient 9 was a 57-year-old, admitted on 9/15/24. Patient 9's physician order indicated hydromorphone 0.5 mg IV every 4 hours as needed for severe pain was ordered on 9/16/24 at 8:24 p.m. and administered on 9/18/24 at 5:15 a.m. DOP acknowledged documentation of Patient 9's assessment of POSS score, respiratory pattern and rate an hour after administration at 6:15 a.m. DOP acknowledged nursing assessment was 30 minutes late, and Patient 9 should have been monitored for sedation adverse effects within 30 minutes of hydromorphone IV administration.
During an interview on 9/19/24 at 10:27 a.m. with DED, when asked about nursing staff auditing to ensure compliance with sedation assessment, DED was unable to provide documentation. DED stated documentation for sedation assessment was not a required element for nursing, so nursing staff was not being monitored or audited.
During an interview on 9/19/24 at 10:34 a.m. with Pharmacy Manager (PM), when asked about the importance of sedation assessment, PM stated it was important to monitor adverse reaction that could be happening so pharmacy is able is to make recommendations regarding the use of the opioid.
During an interview on 9/19/24 at 2:33 p.m. with DOP, Patient 10's clinical record was reviewed. Patient 10's "Admission Summary" indicated Patient 10 was a 59-year-old dialysis patient who presented to the Emergency Department on 9/13/24. Patient 10's physician ordered fentanyl 50 mcg IV for one dose on 9/13/24 at 6:32 p.m. and was administered on 9/13/24 at 9:07 p.m. MSRPH acknowledged Patient 10 was not monitored for sedation adverse effects within 30 minutes of fentanyl IV administration, with only respiration rate being assessed more than 1 hour later.
During an interview on 9/19/24 at 3:40 p.m. with DOP, when asked about sedation adverse effect monitoring for IV opioids ordered routinely, DOP stated it was allowable for prescribers to order IV opioids not only as one time or as needed, but also routinely [given consistently at a scheduled time], and monitoring was based on the routine assessment policy and procedures. DOP stated timing of the routine assessment would be dependent on the type of care unit on the standard of practice grid.
During a review of the hospital's P&P titled, "Pain Assessment & Management- Patients 14 and Older", dated 9/13/24, the P&P indicated, Routine Pain Assessment: Patients will be assessed during the appropriate pain assessment tools during routine assessment times and as needed. Routine pain assessment includes pain intensity (as reported by patient or assessed during behavioral scales for patient unable to report): for patients receiving opioid based pharmacologic pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect."
A review of the hospital's "Standard of Practice Grid", the "Standard of Practice Grid", indicated "Document: pulse, respirations and blood pressure and pain assessment ..... [for general medical/surgical units] every 8 hours and as needed, unless otherwise ordered. "
During an interview on 9/19/24 at 3:57 p.m. with DED and Medical Surgical CPCU and CPND Manager (CPCUCPNDNM), DED stated side effects for opioids included respiratory depression, oversedation and hypotension. DED stated that at the end of August 2024, there was not a clear sedation assessment policy, and the expectation was that nursing would be doing sedation assessment when reassessing pain as a standard of practice or standard of care. DED stated that if nursing staff did not monitor patients appropriately for sedation adverse effects, nursing staff can walk in and patient is not going to be alive or be respiratory compromised. DED stated the expectation was for nursing staff to monitor for sedation adverse effects and document sedation assessment for patients receiving opioids as a one time or as needed doses.
CPCUCPNDNM stated sedation assessment was about patient safety, trying to avoid adverse event from administration of opioids. CPCUCPNDNM stated nursing was expected to do sedation assessments in a timely manner and document all required areas.
During an interview on 9/19/24 at 4:24 p.m. with DOP, DOP stated IV opioids have a faster onset of action than other routes of administration, and come with risk of sedation and respiratory depression; so for safety of patients it is important to confirm patient is not having an adverse event following opioid administration. DOP stated the expectation is following administration of IV opioid, the nurse assesses pain score to determine efficacy and also sedation level, respiratory rate, and pattern for monitoring of adverse event within 30 minutes. DOP acknowledged monitoring sedation adverse effects is important for pharmacy tracking as part of the hospital's medication error reduction plan.
During an interview on 9/19/24 at 5:22 p.m., with DED, DED stated nursing staff were not being audited for sedation assessment. DED stated it was important to make sure the staff was doing what they were taught to do.
During an interview on 9/20/24 at 9:36 a.m., with Chief Nursing Officer (CNO) and DOP, CNO stated part of the nursing process was to was to assess patients and response to interventions; specifically with opioids, nursing should be assessing for adverse events and with opioids respiratory efforts and sedation level to make sure patients are safe after they receive medication. CNO stated monitoring for sedation assessment was not being done but was being added moving forward. CNO stated nursing staff should not follow the standard of practice grid when assessing sedation for opioids ordered routinely, and would need to clarify the policy and procedure. CNO also stated monitoring for sedation adverse effects was a collaboration between pharmacy, nursing, and physician to provide safe use of opioids. DOP acknowledged she was in charge of pharmaceutical services which included tracking nursing staff monitoring for sedation adverse effects as part of the hospital's medication error reduction plan.

During a review of the hospital's P&P titled, "Opioid Safety- Patients 14 and Older", dated 9/18/24, the P&P indicated, "Pain assessment and monitoring Refer to the pain assessment and management- Patients 14 and Older policy for detailed procedures on conducting pain screening on admission and throughout hospitalization, performing comprehensive pain assessments, and monitoring patients for opioid -induced respiratory depression (OID) and opioid -induce sedation (OIS). Notify the provider and pharmacist if an adverse drug reaction occurs, and complete an incident reporting intranet system (IRIS) notification (refer to Medication Event Reporting policy).

During a review of the hospital's Plan of Correction (POC) Revision 4, the POC indicated, "Beginning 8/2/24, Director of Pharmacy developed new policy: "Opioid Safety - Patients 14 and Older." The purpose of the policy is to define practices and procedures to reduce medication-related errors and reduce the risk of patient harm associated with opioids. The policy includes:
Prescribing
Prescription order communication
Product labeling
Packing and nomenclature
Compounding
Dispensing
Administration
Monitoring
Education
Use ... Monitoring and tracking procedures that will be implemented to ensure that the POC is effective, and that the specific deficiency(ies) cited remain corrected and in compliance with the regulatory requirements ... "

During a review of ISMP (Institute for Safe Medication Practices- a recognized nonprofit organization devoted to the prevention of medication errors) publication titled, "ISMP List of High-Alert Medications in Acute Care [inpatient care] Settings," dated 1/10/24, the publication indicated, "High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients."

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 ..."