HospitalInspections.org

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

1. The hospital did not have a system in place to promote and protect patient rights. Thirteen of 25 patients' (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) rights were not protected and promoted. The hospital failed to ensure the right of patients to have care in a safe setting. The hospital failed to ensure the right of patients to be informed in advance of performing care in a language the patient understands. The hospital failed to ensure patients' Civil Rights were protected. The hospital did not ensure patients' right to make informed decisions. (Refer to A115)

Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and LVNs in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED CN will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer treatments and for them to follow order if not to notify the provider of whey they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level.

2. The hospital did not have a system in place to ensure registered nurses (RNs) followed hospital policies and procedures and provide care in accordance with professional nursing standards. RN 1 administered 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician's order to PT 6. Nurses did not complete required training and competencies. Nursing staff failed to administer blood products according to their policy and procedures (P&P) titled "Blood Products Transfusion". The hospital restraint policy was not followed in the care of patients. Physician orders for cardiac monitoring were not followed in the Emergency Department (ED). RNs did not follow pain management policies in the care of patients. (refer to A385)

3. The hospital failed to meet emergency needs of patients in accordance with the hospital's policies and procedures when the hospital failed to implement Emergency Department policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis, severe abdominal pain, low blood pressure and history of chronic urinary infections and atrial fibrillation and was not placed on a cardiac monitor and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33's signs and symptoms and did not consider Pt 33's past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33's illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33's needs and in accordance with ED policy and procedure. (refer to A1100)

Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33's clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI and Triage reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses. 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient Registered Nurses to every shift in the ED and 2 additional Patient Care Technicians are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level.

4. The hospital failed to have an effective, on-going, hospital-wide, data-driven Quality Assessment and Performance (QAPI) program. The governing body, hospital leadership and QAPI committee were aware and had data indicating high-volume, high-risk and problem-prone areas in the Emergency Department and other areas of the hospital and did not develop and implement perfomance improvement projects to address safety and quality. (refer to A263)

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

Based on observation interview and record review the facility failed to protect and promote each patient's rights for 14 of 25 patients (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 56, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) when:

1. Pt 1 arrived in the Emergency Department (ED) on 12/13/23 and was admitted to the hospital on the same day (12/13/23). Pt 1 remained in the ED for three days as an inpatient until Pt 1 was moved to the Medical Surgical (MS) unit on 12/16/2023. On 12/16/23 Pt 1 was identified to have a pressure ulcer. Wound was assessed as a stage three (3) pressure ulcer on 12/22/23 by wound nurse. ED RNs did not perform skin assessments on Pt 1 from 12/13/23 through 12/16/23 and did not identify skin breakdown in accorance with hospital policy and procedure. ED RN's stated validated, they did not focus on skin interventions on Pt 1 while the patient was in the ED. (refer to A144)

2. Pt 2 arrived in the ED on 2/29/24 and was admitted to the hospital on the same day (2/29/24). Pt 2 remained in the ED for three days as an inpatient until Pt 2 was moved to MS unit on 3/3/24. On 3/3/24 a wound consult was done and a "deep tissue injury (a form of pressure injury or pressure sore, where blood flow to the area is absent or significantly diminished)" was located on the sacral/coccyx area (buttocks) for Pt 2. ED RNs did not perform skin assessments on Pt 2 from 2/29/24 through 3/3/24 and did not identify skin breakdown in accorance with hospital policy and procedure.ED RN's stated validated, they did not focus on skin interventions on Pt 2 while the patient was in the ED. (refer to A144)

3. Pt 3 came to the ED on 3/8/24 with chief complaint of altered mental status. Pt 3 observed on 3/13/24 in hallway bed in ED with right wrist restraint and posey vest untied and still connected to the patient and no monitoring of the patient. Per RN 22 restraints were still necessary. Pt 3 was moved to inpatient bed on 3/13/24. (refer to A144)

4. Patient 53 and Patient 57 were placed in hallway beds as they awaited inpatient hospital beds. Pt 53 was admitted to the hospital on 3/8/24 and remain in a hallway bed for six days. The hallway beds were not equipped with standard electrical outlets and were not equipped with call lights for patients. Pt 57's infusion pump battery died twice while his medication was running since there were no outlets to plug into. (refer to A144)

5. Pt 4 had physician order for breathing treatments every 6 hours. Pt 4 arrived to the ED on 3/10/24 and while awaiting an inpatient bed and was placed in the hallway. Pt 4 was not notified of these treatments and there was no subsequent physician notification. (refer to A144)

6. Pt 53 did not receive interpreting services in their appropriate language, when Pt 53 was admitted to the hospital on 3/8/24 and remained in the Emergency Department (ED). The EHR had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that indicated Pt 53 needed an interpreter in Mon Khmer (Cambodian language) for written and spoken language and this was not provided to Pt 53. (refer to A144)

7. RN 25 used a defective tube feeding pump when carrying out an order for tube feeding for Pt 5, when the prescribed order was for a continuous feeding of 30 ml per hour but Patient 5 received the feeding at a rate of 300 mL per hour. (refer to A144)

8. Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46 had orders in ED for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and were either not place on a cardiac monitor or the cardiac monitoring strips (the record of the electrical activity of the heart) were not read and documented by the licensed nurses. This placed these six patients at risk of injury or death. (refer to A144)

9. Facility failed to ensure the rights of patients to make informed decisions for one of six sampled patients (Pt 34) when Pt 34's Condition of Admission (COA) was not signed by Patient 34 on 12/20/23 and no other documentation in the record indicated Pt 34 was informed of the Conditions of Admission. (refer to A131)

10. The hospital failed to ensure the patient right to be informed in advance of furnishing or discontinuing patient care for one of two patients (Patient 53) when hospital staff were aware of Patient 53's Cambodian Mon Khmer language, inability to speak or understand English, and the Electronic Health Record (EHR) was formatted to alert caregivers about using Interpreter Services, and staff did not utilize Interpreter Services to provide care to Patient 53 in accordance with hospital policy and procedure. Nurses providing care to Patient 53 did not inform Patient 53 in advance of medication administration, procedures and other nursing interventions. On 3/12/24 Registered Nurse (RN) 21 performed a bladder scan procedure to determine the volume of urine in the bladder and performed an in and out urinary catheter procedure without first ensuring informed consent was given by Patient 53. Patient 53 was admitted to the emergency department (ED) on 3/8/24 and was discharged on 3/14/24 as an admitted in-patient but remained in the ED and hospital records do not indicate Patient 53 was aware and informed of this change in admission status. (refer to A117)

11. The facility failed to ensure the patient rights for one of one patients (Patient 3), when Patient 3 was observed to have two different types of restraints on but not fastened to bed frame on his right side in accordance with hospital policy and procedure. (refer to A167)

Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called under A-0144 482.13 (c)(2)- The patient has the right to receive care in a safe setting, on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and LVNs in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED CN will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer treatments and for them to follow order if not to notify the provider of whey they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level.

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

Based on interview and record review, the hospital failed to have an effective, on-going, hospital-wide, data-driven Quality Assessment and Performance (QAPI) program when the governing body, hospital leadership and QAPI committee were aware and had data indicating high-volume, high-risk and problem-prone areas in the Emergency Department and other areas of the hospital and did not develop and implement perfomance improvement projects to address safety and quality. (refer to A283)

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

Based on interview and record review, the hospital failed to have an organized nursing service when:

1. Registered Nurse (RN) 1 administering 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician's order, which led to Patient (PT) 6 experiencing hypoglycemia and having to be administered Dextrose 5% and 50% solution (medications administered into the vein to treat low blood sugar). (Refer to A-0405)

2. The hospital failed to ensure one of seven sampled staff (RN 17) who worked in the facility's float pool (staff who move around between different units and departments to meet staffing needs) did not complete the required biannual skills validation training (process of assessing, verifying, and documenting an individual's competencies in a specific area) for Advanced cardiac life support (ACLS - a course designed to equip healthcare providers with the skills and knowledge needed to respond effectively to medical emergencies). (Refer to A-0397)

3. The nursing staff failed to administer blood products according to their policy and procedures (P&P) titled "Blood Products Transfusion", for one of one patients sampled, Pt 22 was administered blood products and the intravenous (IV) (into the blood stream) line was not prepared before giving the blood. (Refer to A-0410)

4. Two of four hospital patients on restraints (Patient (Pt) 24 and Pt 3) had no monitoring documentation by nursing staff and/or monitoring was not being done per policy. (refer to A398)

5. Six of 25 hospital patients (Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) sampled from the emergency department (ED) had orders for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and one of the six Pt 35 had no cardiac monitor on and the other five patients did not have cardiac monitoring strips (the record of the electrical activity of the heart) reviewed and documented in there electronic health records (EHR). (refer to A398)

6. Four of 25 hospital patients (Pt 4, Pt 36, Pt 37, and Pt 56) sampled from the ED, when Pt 4, Pt 36, Pt 37, and Pt 56 were not administered nebulizer treatments (a drug used to relax breathing muscles and permits air to flow more easily in and out of the lungs) as ordered by the physician. (refer to A398)

7. Two of four hospital patients (Pt 5 and Pt 8) were not properly assessed and vital signs (SpO2- oxygen levels) were not monitored per policy and procedure. (refer to A398)

8. Four of four hospital patients (Pt 1, Pt 8, Pt 4, and Pt 55) sampled were given pain medication and the hospital failed to follow pain management services consistent with professional standards of practice and hospital policies and procedures when: Pt 1 numeric pain scale (a pain screening tool used to assess pain severity 0 no pain, one-three mild pain, four-six moderate pain, seven-nine severe pain, 10 worst pain) was assessed at eight out of 10 and Licensed Vocational Nurse (LVN) 2 administered Oxycodone 24 milligrams (mg-a unit of measurement) ordered for moderate pain and did not notify the physician to obtain pain medication appropriate for Pt 1's assessed level of pain; Pt 4, Pt 8, and Pt 55 were given pain medication and pain reassessments were not completed by nursing staff. (refer to A398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the nursing staff.

Based on interviews and record review, the hospital failed to meet emergency needs of patients in accordance with the hospital's policies and procedures when the hospital failed to implement Emergency Department (ED) policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index (ESI-the process to categorized patients from level 1, the most critically ill, to level V, the least critically ill ) for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis (vomiting of blood), severe abdominal pain, low blood pressure and history of chronic urinary infections (a repeated or prolonged bladder infection)and atrial fibrillation (irregular heartbeat) and was not placed on a cardiac monitor (a device used to watch the electrical activity of the heart to ensure it is working normally) and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33's signs and symptoms and did not consider Pt 33's past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33's illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33's needs and in accordance with ED policy and procedure. (refer to A1104)

Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33's clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI and Triage reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses. 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient Registered Nurses to every shift in the ED and 2 additional Patient Care Technicians are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level.

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

Based on observation, interview and record review, the hospital failed to ensure the patient right to be informed in advance of furnishing or discontinuing patient care for one of two patients (Patient 53) when hospital staff were aware of Patient 53's Cambodian Mon Khmer language, inability to speak or understand English, and the Electronic Health Record (EHR) was formatted to alert caregivers about using Interpreter Services, and staff did not utilize Interpreter Services to provide care to Patient 53 in accordance with hospital policy and procedure. Nurses providing care to Patient 53 did not inform Patient 53 in advance of medication administration, procedures and other nursing interventions. On 3/12/24 Registered Nurse (RN) 21 performed a bladder scan procedure to determine the volume of urine in the bladder and performed an in and out urinary catheter procedure without first ensuring informed consent was given by Patient 53. Patient 53 was admitted to the emergency department (ED) on 3/8/24 and was discharged on 3/14/24 as an admitted in-patient but remained in the ED and hospital records do not indicate Patient 53 was aware and informed of this change in admission status.

These failures resulted in not protecting and promoting Patient 53 ' s right to safe and quality care, had the potential to injure and cause harm and potentially violated Patient 53 ' s civil rights to be provided equitable and fair care in the hospital, including the potential for abuse.

Findings:

During a review of Patient 53's "Electronic Health Record (EHR)" dated 3/8/24 to 3/14/24, the EHR indicated, Patient 53 arrived at the Emergency Department (ED) on 3/8/24 at 3:02 p.m. and was admitted to the hospital on 3/8/24 at 11:11 p.m., for Altered Mental Status (a change in the mental function that stems from illness, disorders and injuries that have affected the brain) and a Urinary Tract Infection (bladder infection that can cause mental changes or confusion). The EHR indicated that even though the patient was admitted, she remained in the Emergency Department (ED) and was never moved into an inpatient bed on a hospital unit. Patient 53 was in ED yellow-hallway bed 11 and ED north-hallway bed 11 during her stay. The EHR had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that never changed which indicated Patient 53 needed an interpreter in Mon Khmer (Cambodian Language) for written and spoken language.

During a review of Patient 53's "ED Timeline (EDT)", dated 3/9/24, the EDT indicated, " ...Acute Speech Language Pathology Swallow Assessment- Speech and Language Pathologist (SLP) 1 ... COGNITION/BASELINE SWALLOW: Patient Alert and cooperative, not able to answer orientation question ... Patient does not speak often, but can speak in her own language when she wants to ... Patient with a history of dementia (the loss of thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) ... SPEECH/LANGUAGE/VOICE: Unable to fully assess, patient did not vocalize except on two instances when suspected to be expressing pain as Physical Therapy was extending her left leg. No dysarthria (when the muscles you use for speech are weak or you have difficulty controlling them) suspected, however not able to confirm with such limited utterances ... vocal quality clear. Is interpreter needed: Yes. ...What type: Phone ... Name: Phone Malfunctioning ...".

During a review of Patient 53's "Nurses Note (NN)", dated 3/11/24 at 10:44 p.m., the NN indicated, " ...Assumed care of patient ... patient is Mon Khmer speaking. Family [family member name] at bedside to help with initial assessment. Patient has a Glasgow Coma Scale of 15. Alert and Oriented x1. Patient has no current complaints ... Patient reports no pain ... Patient verbalizes no needs at this time ...".

During a review of Patient 53's "ED Timeline (EDT)", dated 3/12/24, the EDT indicated, " ...Bladder Scan (non-invasive ultrasound of the bladder)[greater than 583]. Medical Doctor called with telephone order to do in and out catheterization (Intermittent, or in and out, catheterization is a medical technique used to help empty the bladder. A catheter can be passed through the urethra, after which the bladder is emptied) ... Orders acknowledged: In and Out Catheterization ... In and Out Catheterization Volume: 600 mL (milliliters- unit of measurement) ...".

During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated Patient 53 was her patient during her day shift. RN 9 stated Patient 53 was non-verbal and would nod yes or no when she spoke to her in English. RN 9 stated she never used an interpreter because Patient 53 answered "yes or no to English". RN 9 stated the Emergency Department (ED) hallway the patient was in was not safe for her due to her communication needs. RN 9 stated "she doesn't even speak English like that, just yes or no". RN 9 stated Patient 53 could not yell "help" if needed. RN 9 stated she never used a Cambodian Mon Khmer interpreter to communicate with the patient.

During a concurrent observation and interview on 3/14/24 at 3:15 p.m., with Patient 53 in the ED North Hall, hospital staff retrieved a portable iPad interpreter (portable electronic device where the interpreter was called from) per the request of Surveyor. Patient 53 smiled and waved. Patient 53 appeared to respond to the questions of the interpreter appropriately but spoke very softly. Patient 53 waited for the interpreter to stop talking and then she would answer. The hallway was noisy and the interpreter could not hear Patient 53 and the call was terminated due to the interpreter not able to hear.

During an interview on 3/14/24 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the EHR banner indicated Patient 53 needed a Mon Khmer interpreter. LVN 3 stated she did not speak Mon Khmer and never used an interpreter for any of Patient 53's care. LVN 3 stated Patient 53 could understand "a little English I think". LVN 3 stated that was what she was told in nurse-to-nurse report. LVN 3 stated she had given Patient 53 medications, changed her brief and repositioned her and never used a Mon Khmer interpreter to communicate with her over the course of her shift.

During an interview on 3/14/24 at 7 p.m., with Patient 53's Family Member (FM) 1, FM 1 stated Patient 53 spoke Cambodian (Mon Khmer) only and did not speak or understand English.

During a concurrent interview and record review on 3/21/24 at 3 p.m., with the Emergency Department Director (EDD), Resident 53's "EHR", dated 3/8/24 to 3/14/24 was reviewed. The EDD stated the EHR indicated nursing staff never used an interpreter when communicating with Patient 53. The EDD stated interpreters, when used with a patient, need to be charted. The EDD stated per the EHR an in-person, video and/or audio interpreter was never used for Patient 53. The EDD stated that if an interpreter were used it would have been charted in the "Interpretation Flowsheet" and there was nothing there. The EDD stated not communicating with Patient 53 in Mon Khmer was unsafe for the patient and violated her rights as a patient. The EDD stated she had the right to be informed of every aspect of her care and she was not.

During a review of Patient 53's "Interpretation Flowsheet (IF)" dated 3/14/24 (after discharge), the IF indicated, " ....Interpretation: Interpretation Type- [Blank] ...".

During an interview on 3/25/24 at 11:35 a.m., with RN 21, RN 21 stated she was Patient 53's nurse on 3/12/24 RN 21 stated she knew Patient 53 spoke Cambodian but she did not use a Cambodian interpreter because Patient 53 was "kind of" responding to English. RN 21 stated she performed the bladder scan and the in and out catheterization on Patient 53. RN 21 stated she explained the procedure to Patient 53 in "basic words for her to understand" in English. RN 21 stated she "felt like" Patient 53 knew what she was going to do. RN 21 stated Patient 53 said yes and smiled. RN 21 stated she was not a certified Cambodian interpreter and she never used a Cambodian interpreter to communicate with the patient for the bladder scan nor in and out catheterization.

During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated interpreters are vital to communication and meeting patients' needs. The CNO stated if communication occurred without an interpreter in the language needed this would result in inadequate care given to the patient. The CNO stated with patient needs not met, this could result in harm to the patient and is a patient safety concern. The CNO stated that policy and procedure on interpreters was not followed by staff.

During a review of the facility's Policy and Procedure (P&P) titled, "Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired ", dated 8/10/23, 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 ... II. DEFINITIONS: A. Communication Barrier: Applies to a person who ... speaks another language that hinders communication ... 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 ... with LEP ... B. CMC recognizes that individuals must be able to communicate effectively with their health care providers in order to importation the quality of the information, the outcome of the patient encounter and to increase patient compliance and patient satisfaction of care and services ... C. It is the policy of CMC to use competent medical interpreters during ... treatment situations ... following modalities (methods): in-person, video and/or audio ... E. Staff shall verbally notify patients of their right to interpretation services available at no cost to them. F ... situations in which the presence of an interpreter ... is necessary to ensure thorough and accurate communication including "critical medical information" listed ... 1. Explaining a medical procedure or intervention ... 3. When explaining and describing medical conditions, tests, treatment options, medications ... 4. When providing a diagnosis, prognosis and recommendation for treatment ... 5. When providing instructions for medications ...follow-up treatments ... H. The patients primary language is to be noted in the patients EHR ... VI. DOCUMENTATION: ... E. The staff member documents the following information in the EHR upon concluding the interpreter session including when interpretation was provided by a family member: 1. Start date 2. Start time 3. End time 4. Language spoken 5. Interpreter session type 6. Interpretation provided ... F. Staff member documents the use of communication devices and adaptive equipment used ...".

During a review of the facility's Policy and Procedure (P&P) titled, "Urinary Catheters, Indwelling and Intermittent- Adult & Adolescent ", dated 2/9/23, the P&P indicated, "PURPOSE: ... B. To implement the current evidence-based guidelines for the insertion, maintenance, removal and reinsertion of urinary catheters ... D. To define the roles and responsibilities of licensed personnel such as Registered Nurses (RN), Licensed Vocational Nurses (LVN) ... in regard to the maintenance of ... catheters ... E. To provide guidelines for monitoring a patient post urinary catheter removal, including direction on when catheter reinsertion should be considered ...II. DEFINITIONS: ...B. Intermittent (straight) Urinary Catheter: A drainage tube that is inserted in the bladder and removed as soon as urine is drained ... E. Bladder Scan Volume: A bladder scan volume measurement that is not linked to the timing of a patient's void ... IV. POLICY: Alternatives to catheterization should be the first choice for all patients requiring bladder management. Examples of alternatives include: 1. Intermittent (straight) catheterization ... E. Bladder scans may be performed as indicated or needed (PRN) ... V. PROCEDURE: ... 4. ... b. Interpretation of bladder scan results, unless otherwise ordered by the provider: ... iii. If the scanned bladder volume is greater than 500 mL, the RN should contact provider and obtain an order for insertion of an indwelling urinary catheter. Leave the indwelling catheter in place if the output is confirmed to be greater than 500 mLs ... VII. PATIENT TEACHING: A. Provide [Hospital] approved on-line patient education materials ... refer to Frequently Asked Questions (FAQs) on the Patient/Family Education Forum for English and Spanish. 2. Provide patient education regarding the need for bladder scanning and what to expect ...".

Review of professional reference, "American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians", dated April 2020, (found at https://www.sciencedirect.com/science/article/pii/S0002934320300127 ) indicated, " ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty ...".

Based on interview and record review, the facility failed to ensure the rights of patients to make informed decisions for one of six sampled patients (Pt 34) when Pt 34's Condition of Admission (COA) was not signed by Patient 34 on 12/20/23 and no other documentation in the record indicated Pt 34 was informed of the Conditions of Admission.

This failure had the potential for Pt 34 to be uninformed about the care she would receive during her hospital admission.

Findings:

During a concurrent interview and record review on 3/21/24 at 10:15 a.m. with the" Director of Women and Newborn Services and Labor and Delivery (DWD)" Pt 34's electronic medical record (EMR) was reviewed. Pt 34 was admitted on 12/20/23 and discharged on 12/23/23. The medical record indicated, on 12/20/23 at 4:38 p.m. Pt 34 was admitted to labor and delivery (L&D) at 39 weeks and 0 days gestation (period of time from conception to birth) for late decelerations (a decrease in fetal heart rate following a contraction of the uterus) during non-stress test (monitoring an unborn baby's heart rate), ad to induce labor (prompting the uterus to contract before labor begins on its own for a vaginal birth). The DWD stated a COA was not signed by Pt 34 for the admission on 12/20/23. The DWD stated, each patient visit should have a COA signed. The DWD stated it was her expectation for all patients admitted to L&D to have a signed COA for their admission.

During a concurrent interview and record review on 3/22/24 at 9:15 a.m. with the Admitting Registration Manager (ARM), Pt 34's "EMR Admission Records" dated 12/20/23 to 12/23/23 were reviewed. The ARM validated Pt 34's COA was not signed, for the admission on 12/20/23 to discharge date of 12/23/23. The ARM stated the hospital's, did not follow the policy for Pt 34's COA. The ARM stated the admission and registration staff were responsible to complete the COA with the patient.

During an interview on 3/22/24 at 9:20 a.m. with the Corporate Admitting Director (CAD), the CAD stated there were two separate parts to the COA, COA part one and COA part two. The CAD stated the COA part one provided consent to treat the patient for the reason they came to the hospital. The CAD stated the patient would initial and date the COA. The CAD stated the COA part two gave permission to bill insurance for treatment and had a section for signatures, date, and time. The CAD stated in the Emergency department (ED), COA part one was completed when patient arrived to the front lobby for registration and the COA part two was completed after the medical screening exam (a medical exam in the ED) was completed.

During an interview on 3/22/24 at 9:25 a.m. with the ARM, the ARM stated the ED admission and registration had 24-hour staff in the department. The ARM stated the L&D triage (sorting and allocation of treatment) unit was separate from the ED unit. The ARM stated, the L&D triage unit did not have admission/registration staff and would call the main admitting and registration department staff or ED admitting and registration staff when a patient was admitted for the COA to be completed The ARM stated main admitting department hours were Monday through Friday 5 a.m. to 6 p.m. The ARM stated ED admitting, and registration staff were available 24 hours a day. The ARM stated if a COA was not signed at admission, hospital process was to continue to attempt to get a signature until throughout their hospital stay. The ARM staff said no COA was attempted once patient expired. Pt 34 was admitted through the L&D triage unit. The ARM stated, main admitting and registration staff should have had patient sign documents when they completed her registration for admission. The ARM stated main admitting staff or ED admission and admission and registration staff ion staff should have followed up to ensure COA was signed before patient discharged. The ARM stated admission and registration staff had been trained to follow up with patients and get a signature. The ARM stated her expectation was if Main Admitting staff did not obtain the COA that the ED admitting staff should follow up with patient to obtain consents. The ARM stated patients would not have the information that they need if they did not sign the COA.

During a review of the facility's policy and procedure (P&P) titled, "Conditions of Admissions Consent to Outpatient Care", dated 12/1/20, indicated, " ... documents the patient's consent to hospitalization and routine services, documents financial responsibility for payment of hospital charges for services rendered ... POLICY ... [Hospital] is responsible for obtaining the patient's or representative's consent for hospital services ... Consent for Hospital Services ... Consent for hospitalizations ...COA document to be obtained at every inpatient encounter and some outpatient encounters [i.e., Emergency Department (ED), Observation, Obstetrics (OB) etc.] ... ... A. Once the COA ...documents are complete a copy is given to the patient/ patient representative. personnel will scan the document into the HER into the patient's encounter." ...

Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe setting for 14 of 25 patients (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 56, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) when:

1. Pt 1 arrived in the Emergency Department (ED) on 12/13/23 and was admitted to the hospital on the same day (12/13/23). Pt 1 remained in the ED for three days as an inpatient until Pt 1 was moved to the Medical Surgical (MS) unit on 12/16/2023. On 12/16/23 Pt 1 was identified to have a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). Wound was assessed as a stage three (3) pressure ulcer on 12/22/23 by wound nurse. ED RNs did not perform skin assessments on Pt 1 from 12/13/23 through 12/16/23 and did not identify skin breakdown in accordance with hospital policy and procedure. ED Registered Nurse's (RN) stated validated, they did not focus on skin interventions on Pt 1 while the patient was in the ED. These failures resulted in Patient 1 not being provided safe care in the ED and to developed an avoidable stage three pressure injury on his spine.

2. Pt 2 arrived in the ED on 2/29/24 and was admitted to the hospital on the same day (2/29/24). Pt 2 remained in the ED for three days as an inpatient until Pt 2 was moved to MS unit on 3/3/24. On 3/3/24 a wound consult was done and a "deep tissue injury (a form of pressure injury or pressure sore, where blood flow to the area is absent or significantly diminished)" was located on the sacral(triangle-shaped bone in the lower spine)/coccyx area (buttocks) for Pt 2. ED RNs did not perform skin assessments on Pt 2 from 2/29/24 through 3/3/24 and did not identify skin breakdown in accordance with hospital policy and procedure. ) ED RN's stated validated, they did not focus on skin interventions on Pt 2 while the patient was in the ED. These failures resulted in Patient 2 not being provided safe care in the ED and to developed an avoidable wound to the sacral/coccyx area.

3. Pt 3 came to the ED on 3/8/24 with chief complaint of altered mental status (a disruption in how your brain works that causes a change in behavior). Pt 3 observed on 3/13/24 in hallway bed in ED with right wrist restraint and posey vest (a type of medical restraint used to restrain a patient to a bed or chair) untied and still connected to the patient and no monitoring of the patient. Pt 3 was moved to inpatient bed on 3/13/24. This failure resulted in Patient 3's rights being violated and his safety put at risk with the potential for the patient to harm himself.

4. Pt 53 and Pt 57 were placed in hallway beds in the ED as they awaited inpatient hospital beds. Pt 53 was admitted to the hospital on 3/8/24 and remained in a hallway bed for 6 days. The hallway beds were not equipped with standard electrical outlets and were not equipped with call lights for patients. Pt 57 stated his infusion pump battery died twice while his medication was running since there were no outlets to plug into. This failure resulted in not protecting Pt 53 and Pt 57's right to have safe and quality care and had the potential to cause harm.

5. Pt 4, Pt 36, Pt 37 and Pt 56 had physician ordered breathing treatments. Pt 4 arrived to the ED on 3/10/24 and while awaiting an inpatient bed and was placed in the hallway. Pt 4 had physician ordered breathing treatments every 6 hours that were not administered. Pt 4 was not notified of these breathing treatments and there was no subsequent physician notification. This failure resulted in not protecting and promoting Patient 4's right to safe and quality care, with the potential to cause harm from withholding Physician ordered breathing treatments.

6. Pt 53 did not receive interpreter services in their appropriate language, when Pt 53 was admitted to the hospital on 3/8/24 and remained in the Emergency Department (ED). The electronic health record (EHR) had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that indicated Pt 53 needed an interpreter in Mon Khmer (Cambodian language) for written and spoken language and this was not provided to Pt 53. These failures resulted in not protecting and promoting Patient 53's right to safe and quality care, had the potential to injure and cause harm and potentially violated Patient 53's civil rights to be provided equitable and fair care in the hospital, including the potential for abuse.

7. RN 25 used a defective tube feeding pump when carrying out an order for tube feeding for Pt 5, when the prescribed order was for a continuous feeding of 30 ml per hour but Patient 5 received the feeding at a rate of 300 milliliter (mL, unit of measurement) per hour. This failure resulted in not protecting Patient 5's right to safe and quality care, with the potential to injure and cause harm due to the use of a known defective feeding pump.

8. Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46 had orders in ED for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and were either not place on a cardiac monitor or the cardiac monitoring strips (the record of the electrical activity of the heart) were not read and documented by the licensed nurses. This placed these six patients at risk of injury or death.

Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with physician ordered cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called was called under A-0144 482.13 (c)(2)- The patient has the right to receive care in a safe setting, on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and Licensed Vocational Nurses (LVNs) in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score (scale to identify a patients risk for pressure injuries) every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED Charge Nurse (CN) will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) treatments and for them to follow order if not to notify the provider if they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed onsite on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level.

Findings:

1. During a review of Patient 1's (Pt 1) "Hospitalist History and Physical (H&P)", dated 12/13/23, the H&P indicated Pt 1 was diagnosed with anemia (condition in which the body does not have enough healthy red blood cells) requiring transfusions (the process of receiving blood or blood products), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) on hemodialysis (a machine filters wastes, salts and fluid from blood when kidneys are no longer functioning to do so adequately), and a history of laryngeal cancer (a disease where cancer forms in the part of throat between tongue and windpipe) with tracheostomy (a cut in the windpipe to create a new opening) and avascular necrosis of bones of both hips (a disease that results from the temporary or permanent loss of blood supply to the bone), and hip pain. Pt 1 was admitted for missing five to six hemodialysis appointments.

During an interview on 3/13/24 at 3:26 p.m. with Registered Nurse 2 (RN 2), RN 2 stated, Pt 1 arrive to the Medical Surgical (MS) unit from the ED with "wounds" that were not documented. RN 2 stated he documented Pt 1's wound when he arrived to the medical surgical unit. RN 2 stated skin interventions were not started until arriving to the medical surgical unit. RN 2 stated skin interventions should be started at admission. RN 2 stated, it was important to start skin interventions to prevent pressure injuries.

During an interview on 3/14/24 at 3:29 p.m. with RN 17 an ED RN, RN 17 stated nurses are assigned both admitted patients and emergency patients at the same time. RN 17 stated a focused assessment based on complaint was required for stabilization of an emergency patient. RN 17 stated a complete head to toe assessment including skin was required for an admitted patient. RN 17 stated if a skin assessment was not done a wound may be missed or a patient's wound could get worse. RN 17 stated turning patients or a complete skin assessment may not be done because nurses are working out of ratio. RN 17 stated he does not turn patients in the ED. RN 17 stated if skin interventions are not started after admission a patient may develop a pressure injury if they have a low Braden score (scale used to identify the risk of a pressure ulcer for a patient, low score indicates higher risk).

During a concurrent interview and record review on 3/15/24 at 9:35 a.m. with the Medical Surgical Manager (MSM), Pt 1's "Skin Integrity Accordion (SIA)" dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1: a.m. was reviewed. The "SIA" indicated, no skin care interventions were started in the ED. The MSM stated no wound care was started in the ED for pressure injuries. The MMA stated, no skin interventions were started in the ED.

During a concurrent observation and interview on 3/15/24 at 11:19 a.m. with Pt 1 in his hospital room, he was observed lying in bed with a bedside table over bed. Pt 1 had a dressing on his throat. Pt 1 spoke by placing a hand over throat area covered by the dressing. Pt 1 stated he had several wounds. Pt 1 stated, he did not walk. Pt 1 stated, he does not eat by mouth. Pt 1 stated, he had a tube in his stomach. Pt 1 pointed to the tube feeding pump at bedside.


During an interview on 3/15/24 at 9:36 a.m. with the MSM, the MSM stated, all nurses can stage a wound. MSM stated hospital policy was, patients arrived in the medical surgical unit (MS) and two nurses completed a skin assessment. MSM stated during skin assessments photos were taken of any skin breakdown and the nurse should stage the wound. MSM stated, the physician was to be notified of skin breakdown or wounds. MSM stated documentation of skin assessment was to be charted in the electronic medical record (EMR). MSM stated a skin integrity order set was activated by nursing staff for skin care interventions. MSM stated the order set activates the care plans for skin. MSM stated if wound nurse consultation criteria were met the physician would order or give verbal order at that time. MSM stated, a Registered Dietitian consult was ordered at that time. MSM stated skin interventions were based on a patient's Braden scale. MSM stated the nurse entered wound information into the Internal Reporting Intranet System (IRIS). MSM stated policy required physician notification for all skin breakdown or significant changes to a pressure injury.

During an interview on 3/15/24 at 9:39 a.m. MSM, MSM stated when a patient transferred into the medical surgical unit (MS) from another unit and an undocumented wound is discovered. MSM stated she immediately talked to the other department to do a gap analysis (identifying difference between current knowledge, skills, and/or practices and desired best practice). MSM stated she also investigated gaps in documentation that lead to pressure injuries. MSM stated a Root Cause Analysis (RCA) (a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions) is then completed. MSM stated she had to discuss hospital acquired pressure injuries (HAPI) in the monthly committee meetings. MSM stated the committee tracked present on admission (POA) or acquired (received) on site wounds. MSM stated Pt 1's wound was investigated, and a root cause analysis was completed. MSM stated, the investigation determined there was no documentation stating wound was POA. MSM stated, the hospital's root cause analysis investigation determined Pt 1's wound was an avoidable hospital acquired pressure injury (HAPI). MSM stated RCA determined a delay of care due to, failure to notify physician of pressure injury to get a wound consultation order. MSM stated nursing staff failed to identify that no documentation from previous unit of a POA pressure injury was present upon transfer of Pt 1 from Emergency Department.

During an interview on 3/15/24 at 9:38 a.m. with the MSM, MSM stated wound nurses are involved in stage three (full thickness tissue loss), stage four (full thickness tissue loss with exposed bone, tendon, or muscle) unstageable (full thickness pressure injuries where the base is covered yellow/white or by thick black, dry, dead tissue) or deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure/or shear)wounds. MSM stated wound nurses had 72 hours after a wound consultation was ordered to see patient. MSM stated wound nurses were available Monday through Friday. MSM stated wound nurses then created a plan of care with physician to treat wounds.

During a concurrent interview and record review on 3/15/24 at 9:42 a.m. with MSM, Pt 1's "Admit, Discharge, Transfer events" (ADT) dated 12/13/23 9:51 a.m. to 12/23/23 at 3:46 p.m. was reviewed. The "ADT" indicated, Pt 1 was in the ED from 12/13/23 to 12/16/23. MSM stated patient arrived in ED on 12/13/23 at 9:45 a.m. and was admitted on 12/13/23 at 8:59 p.m. MSM stated, patient was held in the ED until 12/16/23 at 6:14 p.m. when he was transferred to the inpatient medical surgical unit. MSM stated patient was held for over three days in the ED.

During a concurrent interview and record review on 3/15/24 at 9:45 a.m. with the MSM, Pt 1's "Wound Skin Integrity Flowsheet Data (WSI)", dated 12/13/23 at 6:49 p.m. to 12/20/23 at 3:00 p.m. was reviewed. The "WSI" indicated, when Pt 1 arrived in MS and first nursing assessment was completed at 12/16/23 on 9:48 p.m. a healing pressure ulcer to the lumbar (lower) spine, thoracic (middle) spine area that was present on admission (POA) was documented. MSM stated on 12/16/23 MS nurse assessed a pressure ulcer when Pt 1 arrived in MS, he documented it as a healing pressure ulcer to the spine that was present on admission to the hospital.

During a concurrent interview and record review on 3/15/24 at 9:47 a.m. with the MSM, Pt 1's "Skin Integrity Accordion (SIA)" dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The "SIA" indicated, Pt 1's initial skin assessment was documented at 9:49 p.m. MSM stated, Pt 1 was transferred to the medical surgical unit (MS) on 12/16/23. MSM stated skin and initial skin assessment was documented at 9:49 p.m. MSM stated the nurse photographed the wound and completed an IRIS report. MSM stated nurse documented a Braden score of 13 indicating Pt 1 was a moderate risk for pressure injury. MSM stated the nurse identified and documented the wound as a healing wound, to lumbar spine thoracic spine (lower back) that was present on arrival to the hospital. MSM stated nurse did not notify the physician at discovery of the wound. MSM stated, skin integrity order set for pressure reduction and wound prevention interventions were started. MSM stated foam dressing was applied to spine area at wound location, to reduce pressure. MSM stated physician notification of wounds is her expectation. MSM stated staging of wounds is her expectation. MSM stated hospital policy was not followed. MSM stated not following policy could cause an advancement of the wound, a decline in functional status or a longer length of hospital stay.

During concurrent interview and record review on 3/15/24 at 9:50 a.m. with the MSM, Pt 1's "Wound Specialist Consult Note (WSCN)", dated 12/22/23 at 1:56 p.m. was reviewed. The "WSCN" indicated, Pt 1 had a small stage three pressure injury to the spinal bony prominence of the lumbar spine (lower back). MSM stated wound nurse determined Pt 1 had a small stage three pressure injury to the spinal bony prominence of the lumbar spine (lower back). MSM stated wound nurse noted surrounding tissue was deep purple, red, and non-blanchable (describe). MSM stated physician notification, and subsequent wound specialist consultation was entered eight days after admission to the hospital. MSM stated Pt 1 had been on the medical surgical unit for six days prior to wound consultation. MSM stated the wound care specialist was the first nurse to stage the wound. MSM stated the root cause analysis determined a delay in care for a wound specialist consultation.

During an interview on 3/13/24 at 3:26 p.m. with the Emergency Department Director (EDD), EDD stated ED nurses were trained to do a focused assessment not a full head to toe assessment. EDD stated admitted patients need a full head to toe assessment. EDD stated there may be a gap in learning. EDD stated ED nurses may not differentiate ED patients versus the admitted patients and that may mean the admission tasks were getting missed, such as skin interventions and wound assessments. EDD stated patients can be in the ED for many days, waiting for an inpatient room. EDD stated his expectation was ED nurses should follow policy, assess patients' skin, and let physician know about any wounds. EDD stated his expectation was for nurses to do a full head to toe assessment including skin/wounds for all admitted patients. EDD stated his expectation was for nurses to start skin interventions based on their assessment and evidence showed this was not happening. EDD stated if skin interventions were not initiated pressure injuries could occur. EDD stated if wounds were not assessed and treated it could lead to a longer hospital admission and infection.

During a concurrent interview and record review on 3/20/24 at 12:18 P.M. with RN 3, P1's "SIA", for 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The "SIA" indicated, on 12/15/24 at 8 a.m. RN 3 assessed Pt 1 in the ED. RN 3 documented "bruising to arm and other scab to great toe." RN 3 stated she photographed the wound to the great toe per policy. RN 3 stated she did not complete the IRIS per policy. RN 3 stated the only wounds she saw were what she documented. RN 3 stated she knew how to compete a head-to-toe assessment including a skin assessment. RN 3 stated she gave the patient a Braden Score of 11 which indicated high risk for pressure injury. RN 3 stated there should have been skin interventions completed with a Braden Score that low. RN 3 stated, no turns or skin interventions were documented in her charting. RN 3 stated she was busy in the ED. RN 3 stated she often had to work out of ratio and that may be a reason some activities were not completed such as proper skin interventions.

During a concurrent interview and record review on 3/22/24 at 7:53 a.m. with RN 4, Pt 1's "SIA", dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The "SIA" indicated, on 12/15/24 at 7:45 p.m. RN 4 assessed Pt 1 in the ED. RN 4 documented "bruising to arm, petechiae [small red or purple spots caused by bleeding into the skin], infiltration [permeation of a liquid into something by filtration]". RN 4 stated she did not take any photos of skin. RN 4 stated she charted a Braden scale of 14 for the patient, and skin interventions should have been started. RN 4 stated she did not see any skin activities, or any dressing information charted. RN 4 stated there should have been skin interventions completed, such as a waffle mattress (special pressure relieving mattress) or turning schedule, to prevent skin breakdown. RN 4 stated sometimes she was assigned up to six patients in the ED and they got very busy, things may get missed. RN 4 stated not completing skin interventions could lead to patients getting pressure injuries and those could get infected, patient could get septic (bacteria make toxins that cause the immune system to attack the body's own organs and tissues).

During a concurrent interview and record review on 3/25/24 at 12:04 p.m. with RN 5, Pt 1's "SIA", dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The "SIA" indicated, on 12/16/24 at 9:10 a.m. RN 5 assessed Pt 1 in the ED. RN 5 "documented bruising to arm". RN 5 stated based on her charting the only skin issues she saw were bruising to the arm. RN 5 stated she assessed and scored the patient a Braden score of 14. RN 5 stated that based on her charting no skin interventions or turning were completed. RN 5 stated that she had been assigned as many as eight patients at a time while working in the ED. RN 5 stated she believed this was unsafe. RN 5 stated she believed skin interventions could be missed when working in the ED. RN 5 stated a skin wound that went untreated could lead to sepsis.

During a concurrent interview and record review on 3/26/24 at 9:35 a.m. with the MSM, Patient 1's (Pt 1) "SIA", dated 12/13/23 at 6:50 p.m. to 12/28/23 at 1:56 p.m. was reviewed. The "SIA" indicated Pt 1 was on the MS unit for six days before the physician was notified, the pressure injury was staged, or a wound nurse consultation was ordered. MSM stated, Pt 1's initial assessment in MS unit was on 12/16/23 at 9 p.m. the pressure injury was documented and photographed. MSM stated the nurse did not stage the wound or notify the physician. MSM stated nursing staff assessed Pt 1 every shift for multiple days from 12/16/23 to 12/22/23 on am shift (7 a.m.-7p.m.) and pm shift (7:30-700 a.m.). MSM stated there was no documentation that Pt 1's physician was notified, or a wound consultation was completed. MSM stated this resulted in Pt 1 having a delay in wound consultation. MSM stated on 12/16/23 at 9:00 p.m. the nurse should have notified the physician and entered a wound nurse consultation. MSM stated every shift from 12/16/23 to 12/22/23 nursing staff could have notified the physician and entered a wound consultation.MSN stated a delay of care resulted by not notifying the physician or entering a wound nurse consultation. MSN stated her expectation was for staff to follow policy. MSM stated not following policy may result in a worsening in a patient's pressure injury.

During a concurrent interview and record review on 3/26/24 at 4:19 p.m. with Emergency Department Manager (EDM), Pt1's, "SIA", dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The "SIA" indicated, no skin interventions were charted from 12/13/23 to 12/16/23. EDM stated she was very familiar with Pt 1. EDM stated no skin assessment was completed by ED nurses until 12/14/23 at 12:07 p.m. EDM stated Pt 1 was admitted on 12/13/23 at 9:59 p.m. EDM stated the first patient assessment was documented on 12/14/23 at 12:07 p.m. EDM stated, no skin interventions were documented on 12/14/23 at 12:07 p.m., 12/14/23 at 8:50 p.m., 12/15/23 at 8 a.m., 12/15/23 at 7:45 p.m., and 12/16/23 at 9:10 a.m. EDM stated patient was transferred to medical surgical unit on 12/16/23 and skin interventions began at 7:02 p.m. EDM stated, the same interventions that were done once he was transferred to the MS unit should have been completed when he was admitted and held in the ED. EDM stated the Braden score assigned by the ED nurses during their assessments would indicate that this patient required skin interventions to prevent skin breakdown. EDM stated her expectation was for nurses to follow the policy. EDM stated according to nursing documentation the nurses did not follow policy and procedure (P&P) for skin. EDM stated when nurses are not following P&P there was a potential for skin breakdown and development of a hospital acquired pressure injury (HAPI). EDM stated, "the bottom line is, HAPI's aren't Happy." EDM stated there is an evolution of boarders (admitted/held) patients in the ED. EDM stated nurses need to do better and make sure all skin is cared for.

During a review of the facility's policy and procedure (P&P) titled, "Pressure Injury Assessment, Prevention, Staging and Treatment", dated 08/11/22, P&P indicated, ... ". All patients should be assessed upon admission, then every shift, and with condition changes using the Braden scale for Predicting Pressure Score Risk ...B. Prevention measures are to be applied based on the assessed level of risk ...C. Patients with a subscale identified as a score of 1 or 2 are considered at risk for developing pressure injuries ...D. Upon identification of a suspected pressure injury, whether present on admission or hospital-acquired, the RN shall photograph, describe and document the injury location ...The pressure injury will be staged by an RN and they will complete an Incident Reporting Intranet System (IRIS) report .... E. Notify the Clinical Supervisor and/or WS [wound specialist] of all unstageable, stage 3, or stage 4 pressure injuries ... F. Notify the physician of any skin breakdown and of any significant changes to pressure injury ... G. All pressure injury treatment requires a physician order ...H. Obtain a nutritional consult ... I. The RN may implement all aspects of the policy ... PROCEDURE A. Risk Assessment ... B. Prevention 1. Skin Care ... 2. Nutrition ... 3. Moisture Control ... 4. Pressure Reduction-Positioning a. turn and position all patients at a risk for pressure injury every 2 hours, unless contraindicated ...C. Prevention by Risk Levels 1. Not at risk- greater than 18 or if no subscale scores 1 or 2 ...2. If the patient scores a 1 or 2 in the sensory perception subscale ...3. If a patient scores a 1 or 2 in the moisture subscale ...4. If the patient scores a 1 or 2 in the activity subscale ...b. turn every 2 hours with a 30-degree tilt or more often if on bed rest ...5. If the patient scores a 1 or 2 in the mobility subscale ...D. Staging/Treatment 1. Stage all pressure injuries according to the amount of tissue loss ...h. document findings in the EHR ...Documentation ...A. Document the following ... 1. Braden Scale Score ...2. Assessment ...5. Physician notification of any changes ...7. Nutrition consumed ...E. Upload images of the patient's wounds into the EHR" ...

During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility's policy and procedure (P&P) titled, "Pressure Injury Assessment, Prevention, Staging and Treatment", dated 08/11/22, ...Section III part A. indicated, Patient's with a total score of less than nine are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk, for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear ..."

2. During an interview on 3/13/2024 at 12 p.m., Registered Nurse (RN) 21 stated, Patient (PT) 2 had been admitted to the Unit 5 Medical Surgical on 3/3/24 and on 3/3/2024 and had developed a pressure injury that required a wound care consult.

During an interview on 3/13/24 at 3:26 p.m. with Registered Nurse 2 (RN 2), RN 2 stated, he had patients arrive to the Medical Surgical (MS) unit from the ED with "wounds" that were not documented. RN 2 stated he documented the wound when the patient arrived to the MS unit. RN 2 stated skin interventions were not started until arriving to the medical surgical unit. RN 2 stated skin interventions should be started at admission. RN 2 stated, it was important to start skin interventions to prevent pressure injuries.

During an interview on 3/13/24 at 3:26 p.m. with the Emergency Department Director (EDD), EDD stated ED nurses were trained to do a focused assessment not a full head to toe assessment. EDD stated admitted patients need a full head to toe assessment. EDD stated there may be a gap in learning. EDD stated ED nurses may not differentiate ED patients versus the admitted patients and that may mean the admission tasks were getting missed, such as skin interventions and wound assessments. EDD stated patients can be in the ED for many days, waiting for an inpatient room. EDD stated his expectation was ED nurses should follow policy, assess patients' skin, and let physician know about any wounds. EDD stated his expectation was for nurses to do a full head to toe assessment including skin/wounds for all admitted patients. EDD stated his expectation was for nurses to start skin interventions based on their assessment and evidence showed this was not happening. EDD stated if skin interventions were not initiated pressure injuries could occur. EDD stated if wounds were not assessed and treated it could lead to a longer hospital admission and infection.

During an interview on 3/14/24 at 3:29 p.m. with RN 17 an ED RN, RN 17 stated nurses are assigned both admitted patients and emergency patients at the same time. RN 17 stated a focused assessment based on

Based on observation, interview and record review the facility failed to ensure the patient rights for one of one patients (Patient 3), when Patient 3 was observed to have two different types of restraints on but not fastened to bed frame on his right side in accordance with hospital policy and procedure.

This failure resulted in Patient 3's rights being violated and his safety was put at risk with the potential for the patient to harm himself.

Findings:

During a review of Patient 3's "Electronic Health Record (EHR)" dated 3/8/24 to 3/13/24, the EHR indicated, Patient 3 came to the Emergency Department (ED) via ambulance on 3/8/24 at 5:15 p.m. and was admitted on 3/9/24 to inpatient status at 2:05 a.m. for Altered Mental Status (AMS- a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted to inpatient status, he remained in an Emergency Department (ED) Green Zone Hallway bed for four days. Patient 3 got moved from that ED hallway bed to a medical floor on 3/13/24 at 3:55 p.m. The EHR indicated due to the patients AMS and interference with his medical treatment, his safety was at-risk and therefore placed in non-violent restraints (restraints that are used when a patient pulls at Intravenous [IV- in the vein] lines or tubes, removes equipment or dressings, and cannot respond to direct requests or follow instructions from staff) that started on 3/8/24.

During a review of Patient 3's "Restraints Non-Violent or Non-Self-Destructive Order (RNV)", dated 3/13/24 at 7:42 a.m., the RNV indicated, " ...Start date/time: 3/13/24 at 7:42 a.m. ... Frequency: continuous ... Restraint type: Vest/Jacket, Soft Restraint: Left Wrist, Right Wrist ... Restraint Reason: Interference with medical treatment ... Discontinued Order: 3/13/24 at 12:22 p.m. ...".

During an observation on 3/13/24 at 11:50 a.m., in the Emergency Department (ED) Green Zone bay Green Hallway room (GH)-04, Patient 3 was lying on a gurney with his eyes closed and right hand loose on his chest with left hand tied down to the frame of the gurney by restraints. Patient 3 had a Posey Vest (type of medical restraint that is on a patients torso, used to restrain a patient to a bed) and soft-wrist restraints (type of medical restraint used to restrain a patient to a bed) on that were laying loose and not tied to the gurney frame on his right side. Patient 3 appeared to be non-interviewable.

During a concurrent observation and interview on 3/13/24 at 12 p.m., with the Emergency Department Director (EDD) in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. The EDD stated the restraints needed to be fastened to the bed frame and they were not on the patient's right side. The EDD stated it was "dangerous" for the patient to not be restrained as Physician ordered, as he would be able to pull at his foley catheter (a tube that is inserted into your bladder, allowing your urine to drain freely) or IV line.

During a concurrent observation and interview on 3/13/24 at 12:05 p.m., with the RN 22 in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. RN 22 stated Patient 3 still needed to be in restraints due to confusion, an attempt to get out of bed and was "pulling stuff off" (Patient 3 had IV and foley catheter). RN 22 stated she was unaware that the restraint was not fastened to the gurney until it was pointed out to her "just now". RN 22 stated this was not safe for Patient 3 and he could have hurt himself. RN 22 stated it was "impossible" to assess all of her assigned patients on time because she had five other patients to care for. RN 22 said it was not safe for patients when she was responsible for 6 patients at a time because she could not get to her assessments on time. RN 22 stated the last time she assessed Patient 3 was 10 a.m. RN 22 stated she was supposed to do monitoring on Patient 3 every two hours. During an interview on 3/14/24 with the EDD, the EDD stated Patient 3 could harm himself with the restraint not being fastened to the bed frame on the right side. The EDD stated "we" did not follow the restraint policy.

During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated non-violent restraints are for the patient and staff to remain safe. CNO stated Patient 3 could have harmed himself because his right arm was free and the restraint was not fastened to the bed. CNO stated Patient 3's safety was put at-risk and staff did not follow the policy and procedure (P&P) "Restraint and Seclusion".

During a review of the instruction for use "Posey Limb Holders- Application Instructions for Wrist and Ankle (PLH)", dated 2023, the PLH indicated, " ...Limb holder for limiting limb movement. For bed and stretcher use only. INDICATIONS FOR USE: Patients assessed to be at risk of disrupting life-saving treatments (e.g., pulling lines/tubes) or in danger to injury to themselves or to others. Follow your hospitals restraint policies and procedures which are in compliance with CMS (Centers for Medicare & Medicaid Services- federal agency that enforces rules in relation to high quality health care) guidelines and state laws ... APPLICATION INSTRUCTIONS: ...attach straps to frame ... to restrict patients range of motion ... attach at different points along the frame ... using quick-release ties ... ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...".

During a review of the instruction for use "Posey Criss-Cross Vests (PCCV)" dated 2009, the PCCV indicated, " ...DESCRIPTION OF PRODUCT: A versatile vest with tie ends. For bed ...application ... INDICATIONS FOR USE: .... Patients requiring a positioning device to assist medical treatment ...APPLICATION INSTRUCTIONS: ... 3. Secure straps to the ... bed frame, out of the patients reach ... WARNING: Make sure straps cannot slide, loosen, or tighten if the patient pulls on them or if the patient bed ...is adjusted ...The patient may suffocate if the straps tighten. If the straps loosen, serious injury or death may occur from ... patient escape ... or suffocation if the patient becomes suspended in the restraint ...ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...".

During a review of the facility's P&P titled, "Restraint and Seclusion", dated 6/8/23, the P&P indicated, "I. PURPOSE: A. To provide a standardized process in the use of restraints ... while protecting and preserving patient rights, dignity, safety and well-being ... B. To meet and comply with regulatory requirement ... E. Non-Violent Restraint: Restraints applied to support the management of care when the patient is interfering with medical treatment and safety (not aggressive but attempting to remove essential lines or equipment that would put the patient at risk of harm) ... IV. PROCEDURE: A. Restraint Application 1. Restraint shall be applied/removed in accordance with the following: ... B. Restraints will be applied with safe and appropriate techniques. C. Restraint devices are to be applied/removed in accordance with manufacturer's instructions and used in a manner consistent with their intended purpose. D. Restraints will be secured to the frame if being used while the patient is in bed ... E. Restraints shall be secured so that they may be released quickly in the event of an emergency. F. Restraint devices are to be applied/removed in a manner that preserves the dignity, comfort and well-being of the patient ... 6. ... D. NON-VIOLENT RESTRAINTS: 1. Restraints are utilized for the non-violent patient. Must have clinical justification to protect patient from unsafe situation (e.g. pulling at tubes/lines) ... 4. Non-violent restraints available ... a. soft restraints b. Posey vest ...".

During a review of Professional Reference, "American Nurses Association- The Ethical Use of Restraints: Balancing Dual Nursing Duties of Patient Safety and Personal Safety (ANA)", dated 2020, (found at https://www.nursingworld.org/~48f80d/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/nursing-practice/restraints-position-statement.pdf) indicated, " ...PURPOSE: ... Registered nurses are expected to balance dual nursing duties of patient safety and personal safety when using restraints ... Nurses promote and advocate for the protection of patients from harm and from the potential for harm that could result from the use of physical restraints. While patients may be restrained to prevent them from harming themselves or others, this practice could result in patient harm ... Therefore, nurses have an important role in creating a safe environment for patients ... When patients are at risk of harming themselves through interference with their treatment or through impaired mobility or cognitive function, nurses have a duty to act to promote patient safety when critical safety issues that cannot be resolved with other methods place patients at risk of harming themselves. Accountability and responsibility for making nursing judgments, decisions, and taking action to provide a safe patient care environment is expressed ... Patient Safety: ... Monitor the appropriate use of restraints through mechanisms such as a multidisciplinary restraints committee and restraints rounds ... nurses should respect and uphold the autonomy and inherent dignity, and human rights of all individuals involved. Nurses must be aware of and balance a patient's right to self-determination with the health and welfare rights of those in the clinical setting ...".

Based on interview and record review, the hospital's Quality Assurance Performance Improvement (QAPI) program failed to use data in high-risk, high-volume and problem-prone areas such as the Emergency Department (ED) and Medical-Surgical units to identify opportunities for improvement and implement changes that will lead to improvement.

These failures resulted in a delay in implementing improvement measures that could affect health outcomes and patient safety.

Findings:

During a concurrent interview and record review on 3/25/24 at 3:10 p.m., with Director of Quality Outcomes (QD) and Risk Manager Director, (RM), the hospital's policy and procedure (P&P) "Adverse Event Reporting to the California Department of Health Services", dated 1/3/22, "Sentinel Event & Unusual Occurrence," dated 12/17/21, and "CCMC Performance Excellence Plan - Fiscal Year 2024", undated, were reviewed. The RM and QD discussed during the interview the process of determining what patient events qualify for a Root Cause Analysis (RCA). The RM and QD stated, the hospital currently does not an active performance improvement plan from any active RCAs. The RM stated, she follows the policy, "Sentinel Event and Unusual Occurrence" for determining Root Cause Analysis (RCA) recommendations and if a reported event fits the list of sentinel events, then the information is forwarded to leadership and they determine if a RCA is required. The RM stated, she firsts investigates a reported event after reviewing the electronic reports, or phone calls from staff and then discusses the event with the managers and directors of the unit involved. Then she fills out a form and submits it to it to leadership. The RM stated, if leadership decides no RCA is needed, then the directors and managers will follow up with investigating the event. The RM stated, no RCA's have been done since September of 2023. The RM stated, a RCA will be initiated for Patient 5 (PT 5) (Patient was admitted on 3/13/24 and expired on 3/13/13 due to the malfunctioning equipment.). The QD stated, the quality management staff meet with different departments every week to review metrics, electronic reports, and complaints/grievances to determine projects for performance improvement. The QD stated, if unusual occurrences or deaths would come in these discussions, then the information could be forwarded to leadership for a possible RCA. The QD stated, she could not recall any RCA's being initiated as result of meeting with the different departments. The RM and QD stated, deaths are not reviewed routinely and RCAs are not done about routine deaths, only those involved in a sentinel event.

During concurrent interviews and record review, on 3/26/24, at 11:00 a.m., with members of CCMC (Clovis Community Medical Center) Practice & Compliance Committee (PCC) including the Chief Executive Officer (CEO), the Senior VP/Chief Clinical & Operations Officer (SCNO), the Chief Medical Officer (CMO), the Chief Nursing Officer (CNO), the Director of Inpatient Services (DIS), the Emergency Department Director (EDD), the ED MD Medical Director (EDDIR), the RM, and the QD, the Quality Assessment and Performance Improvement (QAPI) plan for the year, "CCMC Performance Excellence Plan - Fiscal Year 2024," not dated, was reviewed.

a. The RM stated:
1) PT 5 (admitted on 2/15/24 and patient expired on 2/29/24 in the dialysis unit, related to an equipment malfunction) was reported on 2/29/24 to California Department of Public Health (CDPH) and RCA will be done for that case.
2) The RM stated, PT 6 (admitted with preeclampsia (condition during pregnancy marked by high blood pressure, fluid retention and protein in urine) on 2/9/24, with a history of diabetes mellitus (body unable to produce or respond to insulin resulting in elevated blood sugars) who's hospital course was complicated by a medication error resulting in a large dose of insulin administered) was reported to CDPH and RCA is in progress.
3) PT 1 (admitted to inpatient on 12/13/23, remained in ED for 3 days prior to obtaining an inpatient bed and developed a pressure ulcer (skin breakdown)) and PT 2 (admitted to inpatient on 2/29/24, remained in ED for three days prior to obtaining an inpatient and deep tissue injury (form of pressure injury) were discovered during survey and no RCAs have been decided yet.
4) PT 33 (presented to ED on 3/13/24 and who expired on 3/13/24 in the ED) was discovered during survey and are reviewing at this time.
5) The hospital is aware of the events related to PT 1, PT 2, PT 33, PT 5 and PT 6. RM stated, no RCAs have been completed on any of these patients and the factors that lead to injuries for each patient has not been determined. The RM stated, no performance improvement activities have been started related to the factors that lead to the harm of these patients.

b. The EDD stated, the volume of patients in the ED and the complexity of the patients has resulted in a high risk and a high volume situation. The EDD stated, no performance project to the determine factors for high risk and high volume of patients in the EDD has been conducted and no analysis of the data to improve the situation has been done. The EDD stated, the hospital has been beyond capacity with 60 "admits holds" (patients admitted to inpatient status but remaining in the ED due to lack of beds) today but we have had over 100 admit holds over the last six months several times. The EDD stated, for the month of December, we averaged above 100 admit holds every day.

c. The DIS stated, the organization has a huddle every morning, Monday through Friday, with over 240 supervisors/staff that includes all departments of the organization and the meeting is conducted virtually. The DIS stated, the purpose of the huddle is to review incidents and issues for the last 24 hours and there is a discussion about safety issues and what needs further investigation. The DIS stated, the event that occurred with PT 5 was brought up at the meeting, which lead to a RCA being decided. The DIS stated, for the recent decision about starting a RCA this month, the organization leadership spent many hours investigating what occurred before deciding on starting a RCA. The DIS stated, deaths are not usually reviewed routinely unless a sentinel event or unusual occurrence is suspected and then a decision about a RCA would occur.

d. The EDDIR stated, deaths related to sepsis (a serious condition in which the body responds improperly to an infection) is a core measure for the hospital and much work has been done in the Emergency Medicine Committee but other deaths are not reviewed. When asked about other deaths that occur, the EDDIR stated, there are missed opportunities to investigate and review routine deaths related to patient safety and quality of care.

e. The CNO stated, currently the second tower, 5th floor (30 inpatient beds) is not staffed for inpatient use, The CNO stated, in order to open the new unit, we decided to keep patients in the ED on admit hold until we have a enough "core" (meaning staff employed by the hospital and not contracted staff) staff on the new unit hired. The CNO stated, previously when we had opened the new units in the new tower to alleviate the ED census, the unit was full of patients and the community discovered we had capacity in the ED and our ED was beyond capacity again. The CNO stated, for the last unit that is empty now, we have a new manager that is hiring "core" staff before we open the unit and admit patients. The CNO stated, this decision should have been made to handle capacity and the increased volume of patients. The CNO stated, the minutes of the CCMC PCC meetings may have reflected the issue of growth and capacity. The CNO stated, the decisions and analysis about recruiting new staffing and opening the new units were not in the minutes.

During concurrent record review and interviews, on 3/26/23, at 3:00 p.m., with the Board of Trustees, including the Chari of the Board, 2 Board Members (BM 1 and BM 2), the Chief Operating Officer (COO), the VP of Operations, the CNO, the SCNO, CMO, the Director of Quality, the Vice President of Quality, the system CMO, the System Chief of Human Resources, and the System Executive Vice President/Chief Operating Officer, the minutes of the Board of Trustees was reviewed.

a. The BM 2 stated. "We are embarrassed that we have a wing closed and have patients admitted downstairs." The BM 2 stated, we are feeling overwhelmed and realizing that this is an issue that we have to take care of. The BM 2 stated, with the closure of [Name] in the community, we had to absorb patients and we are trying to adapt to it.

b. The SCNO stated, we did not anticipate the increase in traveler nurses (contracted nurses, usually from other states) rates and it is too expensive. The SCNO stated, we have decided to increase nurse staff by hiring from schools and new students and this strategy will decrease the turnover rate with increased vesting in the organization over 2 to 3 years.

During a review of the hospital document titled, "CCMC Practice & Compliance Committee - Minutes," dated 9/7/2023, 10/2/2023, 11/2/2023, 1/4/24 and 2/1/24, the meeting minutes did not identify any Root Cause Analysis's (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED.

During a review of the hospital document titled ,"CCMC Emergency Medicine Committee Minutes," dated 9/13/2023, and 12/13/23, the meeting minutes did not identify any Root Cause Analysis's (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED.

During a review of the hospital document titled, "CCMC Medical Executive Committee Minutes," dated 9/14/2023, and 10/12/23, 11/9/23, and 12/14/23. the meeting minutes did not identify any Root Cause Analysis's (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED.

During a record review of the hospital document titled, "CCMC Performance Excellence Plan - Fiscal Year 2024", undated, the plan indicated, " ...[Name] aims to deliver exceptional healthcare to our patients through staff engagement, a commitment to continuous improvement, and performance excellence. ... A. Commitment to achieving zero preventable harm, fostering the culture of safety, and incorporating highly effective process improvement methodologies that advance [Name] towards a high reliability organization. ... E. Reliance on validated analytical metrics to monitor and direct quality and patient safety performance improvement endeavors. ... Professional Affairs and Quality Committee PAQC ... Ultimate responsibility for Hospital and Medical Staff
quality and safety. ... Provides oversight of all quality and safety related functions and activities. ... Medical Executive Committee MEC ... Oversight of Credentialing, Peer Review and ultimately all other patient care quality and safety functions as delegated by the BOT [Board of Trustees]. ... Practice and Compliance Committees ... Regulatory Compliance monitoring and reporting, Tracer report monitoring. QAPI monitoring. Focused forum to collaborate with CCMC leaders on quality review and performance improvement. ... An RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process gives you a way to identify system vulnerabilities so that they can be eliminated or mitigated. The purpose is to find out what happened, why it happened, and determine what changes need to be made. ... The process is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues. Identify adjacency for system-wide impact. ... The most important step is the identification of actions to eliminate or control system hazards or vulnerabilities identified in the causal statements. ... Identification and implementation of sustainable systems-based improvements that make patient care safer in settings across the continuum of care. ... Teams should strive to identify stronger actions that prevent the event from recurring and, if that is not possible, reduce the likelihood that it will occur or that the severity or consequences are reduced if it should recur. ... "

During a review of the facility's policy and procedure (P&P) titled, "Sentinel Event & Unusual Occurrence," dated 12/17/21, the P&P indicated, "...A. Identifying and Reporting of Events Procedure ... 1. All events which are considered reportable as defined by this policy are reported to the supervisor/manager immediately by involved staff. ... 2. The supervisor/manager investigates the event and contacts the Patient Safety/Risk Manager on-call at (559) 779-6634 when a sentinel event/unusual occurrence is suspected. The supervisor/manager also contacts the department director, administrative officer on-call after 5:00 p.m., and the facility Assistant Chief Nursing Officer (ACNO). ... 3. An Incident Reporting Intranet System (IRIS) form is completed within 24 hours. (Refer to Incident Reporting Intranet System (IRIS) policy). ... 4. The Patient Safety/Risk Manager initiates a formal investigation of the reported event ... a. The Patient Safety/ Risk Manager notifies Legal Services, the Corporate Risk Management Officer, Facility ACNO, and other support staff as appropriate within 24 hours of awareness of the event and prior to reporting to CDPH [California Department of Public Health]. ... b. Upon completion of the investigation, the Patient Safety/Risk Manager contacts Legal Services, System Chief Medical Officer, Facility Leadership, and the Director of Risk Management for final review and determination of notification requirements. ... c. If the event is deemed reportable, Risk Management personnel follow defined time lines for notification to the appropriate agency. As appropriate, Risk Management also informs the following of the sentinel event/unusual occurrence: i. Quality Council ... ii. Medical Staff departments ... iii. Professional Affairs and Quality Committee (PAQC) of the Board ... 5. If the event does not fit the definition of a sentinel event, adverse event or an unusual occurrence, the notification form is routed in the standard process described in the Incident Reporting Intranet System (IRIS) policy within 24 hours. ... B. Investigation of Events ... 1. It is the responsibility of Risk Management to coordinate the initial investigation and support the root cause analysis or other approved investigative process within the framework of Quality Council and facility Quality Patient Safety Committees (QPSC). The investigation is conducted for the purpose of evaluation for reporting purposes under this policy and improvement of the quality of care in the hospital and as such is afforded the protections of California Evidence Code §1157. ... 2. A thorough and credible Root Cause analysis is completed on all sentinel events and unusual occurrences. ... 3. Risk Management identifies a team and directs and facilitates the process of conducting a root cause analysis. ... 4. The root cause analysis must be completed within 45 business days of the known occurrence of the event. ..."

A Review of the U.S. Department of Veteran Affairs, VHA National Center for Patient Safety, "Root Cause Analysis," located at https://www.patientsafety.va.gov/professionals/onthejob/rca.asp , indicated " ... a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls. The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. ... RCA teams investigate how well patient care systems function. We focus on the "how" and the "why" ? not on the "who". Through the application of Human Factors Engineering (HFE) approaches, we aim to support human performance. ... The goal of an RCA is to find out: ...What happened ...Why did it happen ... How to prevent it from happening again. ... The RCA process is: ... Inter-disciplinary, involving experts from the frontline services ... Involving of those who are the most familiar with the situation ... Continually digging deeper by asking why, why, why at each level of cause and effect. ... A process that identifies changes that need to be made to systems ... A process that is as impartial as possible ..."

A Review of the Agency for Healthcare Research and Quality -Patient Safety Network, "Patient Safety 101 - Root Cause Analysis", located https://psnet.ahrq.gov/primer/root-cause-analysis indicated, " ... Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within health care systems that contribute to adverse events). It is one of the most widely used retrospective methods for detecting safety hazards. ... RCAs should generally follow a prespecified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors). ... The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. ... "

Based on interview and record review, the facility failed to follow the hospital policy and procedure titled "Employee License/Certificate" when one of seven sampled staff (Registered Nurse [RN] 17) who worked in the facility's float pool (staff who move around between different units and departments to meet staffing needs) did not complete the required biannual skills validation training (process of assessing, verifying, and documenting an individual's competencies in a specific area) for Advanced cardiac life support (ACLS - a course designed to equip healthcare providers with the skills and knowledge needed to respond effectively to medical emergencies).

This failure had the potential for RN 17 to be unprepared to handle emergency situations and had the potential to result in patient harm due to lack of staff training in the management of patients with medical emergencies.

Findings:

During a concurrent interview and record review on 3/20/2024 at 3:20 p.m. with Nurse Manager of Centralized Float Pool (NM 1), Registered Nurse (RN) 17's personnel file was reviewed. RN 17 was hired on March 9, 2021 and had been oriented to his current position in the float pool on April 2023. A document titled, "Advanced Cardiac Life Support", no date, indicated RN 17's ACLS certification was expired as of July 2023 and was not current. NM 1 stated, RN 17 had worked earlier this week in the Emergency Department (ED) and per the policy, RN 17 should have a current ACLS training. NM 1 stated, RN 17 has been suspended until he has obtained the training.

During a review of RN 17's personnel file, a document titled, "Clinical Nurse 1 - Job Description", dated November 8, 2023, indicated, " ... Additional Certification Requirements ... Adult Cardiac Life Support {ACLS} certification must be obtained within 6 months of hire or transfer into job for the following departments: ... 04-87301 Centralized Flex Staffing, 04-87302 Centralized Float ... 01-87300 Nurse Float-PR Only. "

Based on interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital's policies and procedures (P&P), when:

1. Two of four sampled hospital patients on restraints (Patient (Pt) 24 and Pt 3), Pt 24 did not have restraint monitoring documentation by nursing staff and Pt 3's restraints was not fastened to the bed per policy and procedure. These failures had the potential for Pt 24 and Pt 3 to receive injuries and not have their needs met.

2. Six of 25 hospital patients (Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) sampled from the emergency department (ED) had orders for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and one of the six Pt 35 had no cardiac monitor on and the other five patients did not have cardiac monitoring strips (the record of the electrical activity of the heart) reviewed and documented in there electronic health records (EHR). These failures put Pt 35 at risk of having a cardiac event that could cause injury if not death without monitoring and placed the other five patients at risk of having an irregular rhythm that would be missing and cause injury or death to the patient.

3. Four of 25 hospital patients (Pt 4, Pt 36, Pt 37, and Pt 56) sampled from the ED, when Pt 4, Pt 36, Pt 37, and Pt 56 were not administered nebulizer treatments (a drug used to relax breathing muscles and permits air to flow more easily in and out of the lungs) as ordered by the physician. These failures resulted in Pt 4, Pt 36, Pt 37, and Pt 56 not receiving nebulizer treatments which could potentially place Pt 4, Pt 36, Pt 37, and Pt 56 at risk for respiratory failure (a life-threatening medical condition that occurs when a person stops breathing).

4. Two of four hospital patients (Pt 5 and Pt 8) were not properly assessed and vital signs (SpO2- oxygen levels) were not monitored per policy and procedure. This failure resulted in delay in care where Pt 5 ultimately coded and died.

5. Four of four hospital patients (Pt 1, Pt 8, Pt 4, and Pt 55) sampled were given pain medication and the hospital failed to follow pain management services consistent with professional standards of practice and hospital policies and procedures when: Pt 1 numeric pain scale (a pain screening tool used to assess pain severity 0 no pain, one-three mild pain, four-six moderate pain, seven-nine severe pain, 10 worst pain) was assessed at eight out of 10 and Licensed Vocational Nurse (LVN) 2 administered Oxycodone 24 milligrams (mg-a unit of measurement) ordered for moderate pain and did not notify the physician to obtain pain medication appropriate for Pt 1's assessed level of pain; Pt 4, Pt 8, and Pt 55 were given pain medication and pain reassessments were not completed by nursing staff. These failures resulted in Pt 1 having experienced severe pain from 3/9/24 to 3/23/24 which could have negatively affected Pt 1's physical, emotional, and psychosocial well-being and placed Pt 8, Pt 4, and Pt 55 at risk of not having their pain addressed appropriately and having negative side effects from pain medication i.e., low oxygen levels, low blood pressure since after the first dose of narcotics Pt 8's oxygen saturations dropped.

Findings:

1. During a concurrent interview and record review on 3/14/24 at 11:55 a.m., with Medical Surgical Manager (MSM). Patient 24's (Pt 24's) "Hospitalist History and Physical (H&P)", dated 3/14/24 was reviewed. The "H&P" indicated Pt 24 was brought in by ambulance from long term care facility. H&P indicated, Pt 24 had past medical history of basal ganglia hemorrhage stroke (blood leaked from a burst, torn or unstable blood vessel into brain tissue, The blood increased pressure on brain cells and damaged them.) with left sided residual defects. (partial weakness on left side of body) H&P indicated present history of agitation.

During an interview on 3/19/24 at 9:40 a.m. with Emergency Department Manager (EDM), EDM stated monitoring patients on restraints is important to ensure patient safety. EDM stated, nurses should check skin under restraints for breakdown. EDM stated, nurses should monitor restraints to determine if they are still necessary for the safety of the patient. EDM stated it was her expectation that nurses were monitoring patients and documenting the monitoring for patients on restraints. EDM stated, it was her expectation for nurses to follow policy.

During a concurrent interview and record review on 3/19/24 at 2:19 p.m. with Clinical Supervisor Emergency Department (CS 1), Pt 24's "Restraint Documentation Flowsheet (RDF)" dated 3/14/24 from 2:00 p.m. to 3/15/24 at 12:00 p.m. was reviewed. The "RDF" indicated, non-violent restrains: Q 2 (every two hours) monitoring was not completed by nursing staff from 5:00 a.m. to 8:00 a.m. CNS stated, no monitoring was documented from 6:00 a.m. to 7:00 a.m. CN 1 stated his expectation was restraint monitoring was completed every two hours per policy. CN 1 stated restraint monitoring was important for the safety of patients and should be completed every two hours per policy.

During an interview on 3/20/24 at 11:35 a.m. with Registered Nurse 6 (RN 6), RN 6 stated, nurses are required to do visual check on patients in restraints. RN 6 stated nurses supposed to assess the skin under the restraint area, check circulation, offer water, and food for restrained patients. RN stated monitoring for nonviolent restraints is every two hours. RN 6 stated monitoring the patient on restraints is importing for their safety. RN 6 stated, nurses must document the information when completed.

During a During a concurrent interview and record review on 3/22/24 at 9:45 a.m. with CS 1, Pt 24's "Non-Violent Restraint Order 403094748 (NVRO)" dated 3/9/24 at 7:07 p.m. was reviewed. The "NVRO" indicated, Pt 24 had right, and left soft wrist restraints applied due to interference with medical treatment. CS 1 stated, interference with medical treatment is indicated when patients were pulling at intravenous lines (through a needle or tube inserted into a vein).

During a During a concurrent interview and record review on 3/19/24 at 9:51 a.m. with CS 1, Patient 24's "NVRO number 403084758 (NVRO)" dated 3/10/24 at 12:45 a.m. was reviewed. The "NVRO indicated, Pt 24 had right, and left soft wrist restraints, and right and left ankle soft restraints, applied due to interference with medical treatment. CS 1 stated, "NVRO" was a modification of previous order to add ankle restraints. CS 1 stated, "NVRO" reason was interference with medical treatment. CS 1 stated, patient need for ankle restraints could be that patients could move legs and feet up to area where medical equipment is and hurt themselves.

During a During a concurrent interview and record review on 3/19/24 at 9:55 a.m. with CS 1, Pt 24's "NVRO Number 403636987 (NVRO)" dated 3/16/24 at 9:02 a.m. was reviewed. The "NVRO" indicated, restraint order, of right, and left soft wrist restraints, applied due to interference with medical treatment. The CS 1 stated "NVRO" indicated, Pt 24's order was a modification from previous restraint order, ankle restraints were removed. CS 1 stated order was discontinued 3/17/24 at 11:22 a.m.

During a concurrent interview and record review on 3/26/24 at 8:35 a.m. with Medical Surgical Manager (MSM), Pt 24's "RDF" dated 3/14/24 from 2:00 p.m. to 3/15/24 at 12:00 p.m. was reviewed. The "RDF" indicated, non-violent restrains: Q 2 (every two hours) monitoring was not completed by nursing staff from 5:00 a.m. to 8:00 a.m. MSM stated there was an 6:00a.m. to 7:00 documentation missing for this patient. MSM stated when nurses were not monitoring patient in restraints, they may get an injury to the restraint area. MSM stated, if a patient was not being assessed and monitored every two hours patients would not be able to eat, drink or use the bathroom. MSM stated it was her expectation that nurses monitor patients in restraints. MSM stated, it was her expectation that nurses document all their restraint monitor checks. MSM stated, it was her expectation that nurses follow policy regarding restraints.

During a concurrent interview and record review on 3/26/24 at 8:45 a.m. with MSM, The facility's policy and procedure (P&P) titled "Restraint and Seclusion" dated 6/8/23 was reviewed. The P&P indicated, ... "E. Non-Violent Restraint: ...when the patient is interfering with medical treatment and safety ... (but attempting to remove essential lines or equipment would put the patient at risk of harm) .... IV. Procedure ... D. ... 5. Initial Assessment Requirements: a. RN to document clinical indication for restraint ... 6. Ongoing Assessment Requirements: ... b. Assessment ... i. Frequency - at least every two hours ... I. Visual check II. Patient's circulation. III. Patient's level of agitation. IV. Skin assessment for injury at site of restraint. V. Patient's general care ... eating, hydration/fluids, toileting ... VI. Less restrictive restraint alternatives attempted ... 7. Discontinuation Requirements ... a. Restraint must be discontinued at the earliest possible time ... V. Documentation ...A. 5. Individual patient monitoring, assessments, and reassessments."

During a review of Patient 3's "Electronic Health Record (EHR)" dated 3/8/24 to 3/13/24, the EHR indicated, Patient 3 was admitted on 3/9/24 for Altered Mental Status (AMS- a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted, he remained in the Emergency Department (ED) Green Zone Hallway bed. The EHR indicated due to the patients AMS and interference with his medical treatment, his safety was at-risk and therefore placed in non-violent restraints that started on 3/8/24.

During an observation on 3/13/24 at 11:50 a.m., in the Emergency Department (ED) Green Zone bay Green Hall (GH)-04 (room number), Patient 3 was lying on a gurney with his right hand loose on his chest and left hand tied down to the frame of the gurney by restraints. Patient 3 had a Posey Vest (type of medical restraint that is on a patient's torso, used to restrain a patient to a bed) and soft-wrist restraints (type of medical restraint used to restrain a patient to a bed) on that were not secured to the gurney frame on his right side.

During a concurrent observation and interview on 3/13/24 at 12 p.m., with the Emergency Department Director (EDD) in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. The EDD stated the restraints needed to be fastened to the bed frame and they were not on the patient's right side. The EDD stated it was dangerous for the patient to not be restrained as Physician ordered.

During a concurrent observation and interview on 3/13/24 at 12:05 p.m., with the Registered Nurse (RN) 22 in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. RN 22 stated Patient 3 still needed to be in restraints due to confusion, an attempt to get out of bed and was "pulling stuff off". RN 22 stated she was unaware that the restraint was not fastened to the gurney until it was pointed out to her "just now". RN 22 stated this was not safe for Patient 3 and he could have hurt himself. RN 22 stated it was "impossible" to assess all of her patients on time because she was out of ratio with 6 patients for the day. RN 22 said it was not safe for patients when she was responsible for 6 patients at a time.

During an interview on 3/14/24 with the EDD, the EDD stated Patient 3 could harm himself with the restraint not being fastened to the bed frame on the right side. The EDD stated "we" did not follow the restraint policy.

During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated non-violent restraints are for the patient and staff to remain safe. CNO stated Patient 3 could have harmed himself because his right arm was free, and the restraint was not fastened to the bed. CNO stated Patient 3's safety was put at-risk, and staff did not follow the policy and procedure (P&P) "Restraint and Seclusion".

During a review of the instruction for use "Posey Limb Holders- Application Instructions for Wrist and Ankle (PLH)", dated 2023, the PLH indicated, " ...Limb holder for limiting limb movement. For bed and stretcher use only. INDICATIONS FOR USE: Patients assessed to be at risk of disrupting life-saving treatments (e.g., pulling lines/tubes) or in danger to injury to themselves or to others. Follow your hospitals restraint policies and procedures which are in compliance with CMS (Centers for Medicare & Medicaid Services- federal agency that enforces rules in relation to high quality health care) guidelines and state laws ... APPLICATION INSTRUCTIONS: ...attach straps to frame ... to restrict patients range of motion ... attach at different points along the frame ... using quick-release ties ... ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...".

During a review of the instruction for use "Posey Criss-Cross Vests (PCCV)" dated 2009, the PCCV indicated, " ...DESCRIPTION OF PRODUCT: A versatile vest with tie ends. For bed ...application ... INDICATIONS FOR USE: .... Patients requiring a positioning device to assist medical treatment ...APPLICATION INSTRUCTIONS: ... 3. Secure straps to the ... bed frame, out of the patients reach ... WARNING: Make sure straps cannot slide, loosen, or tighten if the patient pulls on them or if the patient bed ...is adjusted ...The patient may suffocate if the straps tighten. If the straps loosen, serious injury or death may occur from ... patient escape ... or suffocation if the patient becomes suspended in the restraint ...ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...".

During a review of the facility's P&P titled, "Restraint and Seclusion", dated 6/8/23, the P&P indicated, "I. PURPOSE: A. To provide a standardized process in the use of restraints ... while protecting and preserving patient rights, dignity, safety, and well-being ... B. To meet and comply with regulatory requirement ... E. Non-Violent Restraint: Restraints applied to support the management of care when the patient is interfering with medical treatment and safety (not aggressive but attempting to remove essential lines or equipment that would put the patient at risk of harm) ... IV. PROCEDURE: A. Restraint Application 1. Restraint shall be applied/removed in accordance with the following: ... B. Restraints will be applied with safe and appropriate techniques. C. Restraint devices are to be applied/removed in accordance with manufacturer's instructions and used in a manner consistent with their intended purpose. D. Restraints will be secured to the frame if being used while the patient is in bed ... E. Restraints shall be secured so that they may be released quickly in the event of an emergency. F. Restraint devices are to be applied/removed in a manner that preserves the dignity, comfort, and well-being of the patient ... 6. ... D. NON-VIOLENT RESTRAINTS: 1. Restraints are utilized for the non-violent patient. Must have clinical justification to protect patient from unsafe situation (e.g., pulling at tubes/lines) ... 4. Non-violent restraints available ... a. soft restraints b. Posey vest ...".

2. During a concurrent observation and interview on 3/13/2024 at 10:35 a.m., with Pt 35 in the Emergency Department (ED- a department in the hospital where people who have severe injuries or sudden illness are taken for emergency treatment) lobby, Pt 35 was observed sitting in a chair in the ED lobby without a cardiac monitor. Pt 35 stated on 3/12/24 he was having chest pain and discomfort in his chest and decided to come to the ED on 3/12/24. Pt 35 stated he continued to have chest pain and discomfort while he sat in the ED lobby. Pt 35 stated staff notified him his heart would be "monitored" but was unsure what monitored meant. Pt 35 stated he was not placed a cardiac monitor. Pt 35 stated " ... you would think they would keep a close on eye on me since I am here for chest pain ..."

During a review of Pt 35's "History and Physical (H&P)", dated 3/13/2024, the H&P indicated, Pt 35 came to the Emergency Department due to " ...complaining of chest pain with shortness of breath and dizziness/lightheadedness for 3 days ..."

During a concurrent interview and record review on 3/13/24 at 10:41 a.m. with the Emergency Department Manager (EDM), Pt 35's "Cardiac Monitoring Order (CMO)", dated 3/13/24 was reviewed. The CMO indicated, " ...Frequency: Continuous ..." The EDM validated Pt 35 did not have cardiac monitoring while in the Emergency Department lobby. The EDM stated Pt 35 should have been placed in a cardiac monitor to ensure Pt 35's heart was monitored for cardiac arrhythmia. The EDM stated the expectations was for the license nurses to follow physician's order and hospital policies and procedures.

During a concurrent interview and record review on 3/13/24 at 11:15 a.m. with RN 11 and the EDM, Pt 39's CMO, dated 3/11/24 was reviewed. The CMO indicated, " ...Indications for monitoring: New and/or potential for cardiac arrhythmia ..." RN 11 stated she was the licensed nurse assigned to Pt 39. RN 11 stated she did not review and document Pt 39's cardiac monitoring strip and should have. The EDM stated the expectation was for RN 11 to review and document Pt 39's cardiac monitoring strip. The EDM stated RN 11 did not follow the hospital's policy and procedure for cardiac and remote monitoring.

During a concurrent interview and record review on 3/13/24 at 11:24 a.m. with RN 14 and the EDM, Pt 36's CMO, dated 3/13/24, was reviewed. The CMO indicated, " ...Indications for monitoring: Critical illness [a state of health with vital organ dysfunction or high risk of death] or procedure standard of care for level of care ..." RN 14 stated she was responsible to review and document Pt 36's cardiac monitoring strip but did not. The EDM stated RN 14 should have reviewed and documented Pt 36's cardiac monitor strip. The EDM stated RN 14 did not follow the hospital's policy and procedure for cardiac and remote monitoring.

During a concurrent interview and record review on 3/13/24 at 11:33 a.m. with RN 13 and the EDM, Pt 37's CMO, dated 3/11/24, was reviewed. The CMO indicated, " ...Indications for monitoring: Significant risk of cardiac arrest [when the heart stop breathing] or respiratory arrest [absence of breathing] ..." RN 13 stated she was responsible to reviewed and documented Pt 37's cardiac monitoring strip but did not. The EDM stated RN 13 should have reviewed and document Pt 37's cardiac monitor reading. The EDM stated RN 13 did not follow the hospital's policy and procedure for cardiac and remote monitoring.

During a concurrent interview and record review on 3/13/24 at 11:43 a.m. with RN 12 and the EDM, Pt 38's CMO, dated 3/12/24, was reviewed. The CMO indicated, " ...Indications for monitoring: New and/or potential for cardiac arrhythmia ..." RN 12 stated she was responsible to review and document Pt 38's cardiac monitoring strip but did not. The EDM stated RN 12 should have reviewed and documented Pt 38's cardiac monitor strip. The EDM stated RN 12 did not follow the hospital's policy and procedure for cardiac and remote monitoring.
During an interview on 3/13/24 at 3:59 p.m. with RN 15 and the EDM, RN 15 stated Pt 46 had physician's order for cardiac monitoring. RN 15 stated she was responsible to review and document Pt 46's cardiac monitoring strip but did not. RN 15 stated she did not document because of short staffing. The EDM stated RN 15 should have reviewed and documented Pt 46's cardiac monitor strip. The EDM stated RN 15 did not follow the hospital's policy and procedure for cardiac and remote monitoring.

During a review of the facility's policy and procedure (P&P) titled, "Provider Orders," dated 08/25/23, the P&P indicated, " ...The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ..."

During a review of the facility's policy and procedure (P&P) titled, "Cardiac and Remote Monitoring-Inpatients 14 and Older," dated 04/14/2022, the P&P indicated, " ...The assigned RN/designee is responsible for validating and documenting the patient's rhythm ...The RN will date and sign the cardiac monitoring strip ... every 4 hours ...Routine Cardiac monitoring documentation includes the patient's rate, rhythm ...This documentation will be a minimum of every 8 hours or by unit standard (4 hours in Emergency Department) in the Electronic Health Record ..."

3. During a review of Patient 4's "History and Physical Examination (H&P- initial exam)", dated 3/10/24, the H&P indicated, " ...Chief Complaint pain in the abdomen ... Plan: Admit to medicine and start IV (intravenous- in the vein) fluid, IV [antibiotics], oxygen and bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), pain medication as needed ...".

During a review of Patient 4's "Medication Administration Report (MAR)", dated 3/9/24 to 3/15/24, the MAR indicated, " ...Albuterol [Brand Name] 2.5 mg [milligrams- unit of measurement]/3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that could be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/10/24 ... End: 3/14/24 at 4:28 p.m. ....Medication Not Given 17 separate times: 3/10/24- 4:42 p.m., 9:24 p.m., 3/11/24- 5:03 a.m., 9:48 a.m., 4:54 p.m., 9:44 a.m., 3/12/24- 4:25 a.m., 10 a.m., 4 p.m., 3/13/24- 1:04 a.m., 4:47 a.m., 10 a.m., 6:55 p.m., 10 p.m., 3/14/24- 3:53 a.m., 11:38 a.m., 4:56 p.m. ...".

During a review of Patient 4's "MAR Flowsheet #1- #7 (MF)", dated 3/11/24 to 3/13/24, the MF indicated,... "MF 1- 3/11/24 at 9:44 p.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given- Hall... MF 2- 3/12/24 at 4:25 a.m., route: nebulization ... user: [RCP 2] Delivery: Not Given- Hall... MF 3- 3/12/24 at 10 a.m., route: nebulization ... user: [ RCP 3] Delivery: Not Given Comment: Hall... MF 4- 3/12/24 at 4 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given- Comment: Hall... MF 5- 3/13/24 at 1:04 a.m., route: nebulization ... user: [Registered Nurse (RN) 21] Comment: patient in the hallway, no available room for breathing treatment... MF 6- 3/13/24 at 4:47 a.m., route: nebulization ... user: [RCP 4] Delivery: Not Given- Hall Bed... MF 7- 3/13/24 at 10 p.m., route: nebulization ... user: [RCP 5] Delivery: Not Given- Comment: Patient in hall bed."

During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated she was responsible for multiple patients in the ED North Hall and patient 4. RN 9 stated patients that are in the hallway with nebulizer treatments ordered do not receive them. RN 9 stated "it's a rule" that the RCP's do not administer them. RN 9 stated those nebulizer treatments "just get skipped". RN 9 stated that she did not notify the Physician when Patient 4 did not get her nebulizer treatment and thought the RCP was supposed to.

During an interview on 3/14/24 at 4 p.m., with Patient 4, Patient 4 stated she found out she had nebulizer treatment (electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) ordered by a Doctor in the Emergency Department through her patient online portal. Patient 4 stated staff never told her those treatments were ordered for her and why. Patient 4 stated she never received any nebulizer treatments while admitted in the ED.

During an interview on 3/22/24 at 9:15 p.m., with the Director of Respiratory Therapy (DRT), the DRT stated RCP staff had guidance that was outdated and would not administer patient's nebulizer treatments in hallway ED beds. The DRT stated that guidance has changed and now will complete nebulizers in the halls. The DRT stated RCP staff should have educated patients and told them about their nebulizer treatments and they did not. The DRT stated staff should have notified the ordering Physician of the nebulizer treatment not given and they did not. The DRT stated RCP staff did not follow facility policy and procedures (P&P) "Respiratory Care Orders/Administration/Documentation, Provider Orders and Medications, Orders, Administration, Storage, Documentation".

During an interview on 3/22/24 at 10 a.m., with RCP 3, RCP 3 stated Patient 4 was in the hallway, and she refused the nebulizer treatment for her due to her being admitted to the ED hallway. RCP 3 stated RCPs did not do nebulizer treatments in the ED hallways for any patients. RCP 3 stated "we were told not too". RCP 3 stated she did not tell Patient 4 she was ordered a nebulizer treatment and did not educate her. RCP 3 stated she did not notify the ordering Physician that she refused Patient's 4 treatment. RCP 3 stated patient's medical condition could get worse by not giving the treatments and not notifying the Physician. RCP 3 stated a patient's safety would be put at-risk. RCP 3 stated she did not follow hospital policy and procedure.

During an interview on 3/22/24 at 11:30 a.m., with the RCP Manager (RCPM), the RCPM stated it was normal practice for RCP's to not complete any nebulizer treatment for any patient in a hallway bed. The RCPM stated that practice put patient safety at risk and a patient could deteriorate. The RCPM stated patients have a right to be a part of their care and RCPs should have been notifying them of their treatments. The RCPM stated staff did not follow the hospital policies and procedures RCPs are supposed to follow.

During a review of Pt 36's "Hospitalist History and Physical (HH&P)", dated 3/13/24, the HH&P indicated, " ...Chief Complaint ...Respiratory short of breath ...Pt c/o (complaint of) shortness of breath ...With a SpO2 [is a measurement of the percentage of oxygen in the blood, relative to the maximum it could carry]. 88% on room air [A normal SpO2 level for a healthy person is between 96% and 99%] ... Plan Methylprednisolone [a drug used to treat various medical conditions including lung or breathing problems] 20mg [milligrams-unit of measurement] IV (intravenous- administered into the vein) TID (three times a day) ... ipratropium/albuterol [a drug used to help control symptoms of lung disease by opening the lung airways] as needed ..."

During a review of Patient 36's "Medication Administration Report (MAR)", dated 3/21/24 , the MAR indicated, " ...Ipratropium-albuterol 2.5 mg /3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that is turned into a mist that can be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [a device that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/14/24 at 12:01 a.m. ...End: 3/16/24 at 10:05 p.m. ..." The Ipratropium-albuterol was not given on 3/14/24 at 12:05 a.m., 5:18 p.m., 9:40 p.m., and on 3/15/24 at 4:00 a.m.

During a review of Pt 36's "MAR Flowsheet #1- #4 (MF)", dated 3/21/24, the "MF" indicated, " ...MF 1- 3/14/24 at 1205 a.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given ...Comment: In Hallway ... MF 2- 3/14/24 at 5:18 p.m., route: nebulization ... user: [RCP 2] Delivery: Not Given ...Comment: In Hallway ... MF 3- 3/14/24 at 9:40 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ... MF 4- 3/15/24 at 4:00 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ..."

During a review of Pt 37's "HH&P", dated 3/11/24, the "HH&P" indicated, " ...Chief Complaint ...Difficulty breathing ...cough ...pleurisy [inflammation of the pleura, the two thin layers of tissue that separate the lungs from the chest wall. This can cause a sharp chest pain while breathing] ...ESRD [End Stage Renal Disease- a medical condition when the kidney's stop to function] ... Who is here for acute hypoxic respiratory failure [AHRF-a severe form of low oxygen in the body] ... Plan ...As needed cough and expectorant [a type of cough medicine used to help clear mucus [phlegm] from your airway] ..."

During a review of Pt 37's "MAR", dated 3/21/24, the MAR indicated, " ...Acetylcysteine [a drug used to relieve chest congestion due to thick mucus secretions in the lungs] 200 mg /3 ml nebulizer solution ... Frequency: every 6 hours ... Route: Nebulization ... Start: 3/12/24 at 4:00 a.m. ...End: 3/18/24 at 12:55 a.m. ..." The Acetylcysteine was not given on 3/13/24 at 12:31 a.m., 4:41 a.m., 10:00 a.m., 7:37 p.m., 11:03 p.m., and on 3/14/24 at 3:58 a.m., and 10:00 a.m.

During a review of Pt 37's "MAR Flowsheet #1- #3 (MF)", dated 3/21/24, the MF indicated, " ...MF 1- 3/13/24 at 7:37 p.m., route: nebulization ... user: [(RCP) 4] Delivery: Not Given ...Comment: not given by day shift, next dose close, MF 2- 3/13/24 at 11:03 p.m., route: nebulization ... user: [RCP 4] Delivery: Not Given ...Comment: Patient in dialysis, patient in hallway bed, MF 3- 3/14/24 at 3:48 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed.." No documentation was provided for date 3/13/24 at times of 12:31 a.m., 4:41 a.m., 10:00 a.m. or date 3/14/24 at 10:00 a.m. the reason why nebulization medication was not administered.

During a review of Pt 56's "Hospitalist History and Physical (HH&P)", dated 3/12/24, the H&P indicated, " ... Chief complaint ...difficulty breathing ...Pt c/o shortness of breath ...history of Idiopathic Pulmonary Fibrosis (IPF-a rare, chronic lung disease that causes lung tissue to thicken and stiffen and makes breathing more difficult) ...Plan ... [brand name] [Levalbuterol- a drug used to treat shortness of breath that commonly occur with lung problems] neb x1 (1 time) ..."

During a review of Pt 56's MAR, dated 3/13/24, the MAR indicated, " ...Levalbuterol [Brand name] ...1.25 mg nebulizer solution ...Frequency: Once ...Route: Nebulization ...Start: 3/12/24 3:37 a.m. ...End: 3/13/24 3:37 a.m. ..." The Levalbuterol was not given on 3/12/24- 5:26a.m.

During a review of Pt 56's MF#1, dated 3/21/24, the MF indicated, " ...MF 1- 3/12/24 at 5:26 a.m., route: nebulization ... Delivery: Not Given ...Comment: Hallway.

During an interview on 3/15/24 at 10:49 a.m., with Respiratory Care Provider (RCP) 1, RCP 1 stated nebulizer treatments were not administered in the hospital's hallways. RCP 1 stated he did not administer nebulizer treatments to patients in the hospital's hallways. RCP 1 stated it was not a common practice to administer nebulizer treatments in the hospital's hallways. RCP 1 did not know the reason not to administer nebulizer treatments in the hospital hallways.

During a review of the facility's Policy and Procedure (P&P) titled, " Respiratory Care Orders/Administration/Documentation ", dated 10/13/17, the P&P indicated, "PURPOSE: To ensure safe preparation, administration and documentation of medication with appropriate modality used by Respiratory Care Practitioners (RCP). II. POLICY: A. The RCP is responsible for the content of all referenced policies as they pertain to the delivery of medications utilized in respiratory care ... 3. Refer to the policy Medications - Orders, Administration, Storage, Documentation ... a. Routine medications b. Scheduled respiratory administration times ... i. Patient education regarding medications and medication delivery device ...VI. PROCEDURE: ... D. Correctly identify patient per corporate policy ... introduce yourself to the patient. E. Educate patient/reinforce education as needed ... J. Administer medication per American Association of Respiratory Care (AARC) guidelines ... VIII. EDUCATION: ... B. Inform and educate the patient and/or family on the name of the medication, reason for its admi

Based on interview, and record review, the hospital failed to ensure medications were prepared and administered in accordance with approved policies, procedures, and physician orders when Registered Nurse (RN) 1 administered 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician's order, which led to Patient (PT) 6 experiencing hypoglycemia and having to be administered Dextrose 5% and 50% solution (medications administered into the vein to treat low blood sugar).

This failure had the potential to result in complications including seizures, brain damage, and death.

Findings:

During a review of PT 6's "Care Note (CN)", dated 2/15/24, the "CN" indicated PT 6 was a 30 year old, 28 week 5 day gestational pregnant female who was admitted with preeclampsia (condition during pregnancy marked by high blood pressure, fluid retention and protein in urine) on 2/9/24, with a history of diabetes mellitus (body unable to produce or respond to insulin resulting in elevated blood sugars) and hypothyroidism (body unable to produce enough thyroid hormone). The "CN" indicated, "Antepartum [period before childbirth] course was complicated by medication error resulting in a large dose of insulin administered. This was managed by serial blood glucose and treatment with glucose. On hospital day 3 she was stable for transfer."

During a review of PT 6's "Medication Administration Record (MAR)", dated 2/15/24, the "MAR" indicated, insulin NPH (neutral protamine Hagedorn- intermediate acting insulin) injection 14 units subcutaneously (into fatty tissue, under the skin) nightly on 2/9/24 at 10:59 p.m., and 2/11/24 at 9:08 p.m.; for insulin lispro injection subcutaneously 0 to 12 units four times daily with meals and nightly, 10 units at 12:26 p.m., 6 units at 6 p.m., 200 units at 6:29 p.m.; metformin 500 mg[milligrams- unit of measure] twice daily with meals was administered on 2/10/24 at 2:01 p.m., 6:29 p.m., 2/11/24 at 6:13 p.m..; betamethasone (steroid use to help mature fetal organs) injection 12 mg (milligrams- unit of measure) intramuscularly every 24 hours was administered on 2/9/24 at 6:33 p.m.

During an interview on 3/13/24 at 4:06 p.m. with RN Risk Manager (RNRM), RNRM stated that on 2/10/24 at approximately 9 p.m., she received a call from the Labor and Delivery (L&D) clinical nurse supervisor, who informed her that PT 6 had been administered 200 units of insulin lispro in error. RNRM stated, " ...she was given betamethasone 2ml. I was told that they had mixed it up, found out later she had gotten all insulin. Said patient was doing ok, blood sugar dropped a little, got D50 [dextrose 50%- injection to treat low blood sugar], disclosed to patient and husband what happened, patient was on 2:1 [2 nurses to patient], told clinical nurse supervisor to call if anything happened ... Following day, I waited to make sure patient fine throughout night, did chart review of patient and sent summary to leadership regarding incident 2/11/24. They did a leadership huddle on 2/12/24 to talk about event."

During a concurrent interview and record review on 3/14/24 at 9:02 a.m. with Director of Women and Newborn (DWN), Medication Safety Officer (MSO), and L&D Clinical Supervisor (LDCS), PT 6's medical records were reviewed. DWN stated RN 1 took betamethasone and insulin vials from the medication room pyxis to PT 6's bedside, where she drew up medications at bedside and administered to PT 6 around 6:30 pm on 2/10/24. RN 1 stated to DWN that she realized she may have erred by giving 2 ml of insulin intramuscularly instead of 2 ml of betamethasone and notified her supervisor immediately. DWN stated a rapid response (team of highly trained nurses and respiratory therapy who respond to patients with medical emergencies) was called, a physician went to PT 6's bedside, and they began treating PT 6 and monitoring PT 6's blood sugars.When asked what the expectation was for nursing staff when obtaining doses for different patients using the same multidose insulin vial, DWN stated, "Multidose insulin is to be drawn up in medication room, once they draw it, put it back and go to bedside to administer to patient .... Being a multiuse vial, you want to secure its integrity, want to keep it as clean and safe as possible for infection control."

A review of PT 6's MAR Audit Trail Report indicated that on 2/10/24, RN 1 scanned the barcode on the betamethasone vial at 6:29 p.m. and 26 seconds, and again at 6:29 p.m. and 38 seconds. MSO acknowledged RN 1 did not scan the barcode of the insulin vial, prior to preparing and administering the insulin medication. MSO stated, "Insulin was not scanned at time of error, betamethasone was scanned twice. When she edited, was when she scanned [insulin]." LDCS stated the correct practice was for nurses to scan insulin and prepare syringe in the medication room, and only administer at bedside to prevent medication error. When asked if the practice was for nurses was to prepare multiple vials for injection prior to administration, LDCS stated, "I would scan one draw it and give, scan the next one and give. To scan two, draw two, and give two, would not be standard of practice. Could cause error because not giving one at a time, that is something we have taught, scan one, draw one, give one." DWN stated RN 1's practice was not according to the hospital's policy. During a review of PT 6's MAR dated 2/15/24, PT 6's MAR indicated, Dextrose 5% solution was administered at a rate of 50 ml/hour on 2/10/24 from 7:55 p.m. to 2/11/24 3:10 a.m., and on 2/11/24 from 3:39 a.m. to 3:40 p.m., Dextrose 50% solution, 50 ml on 2/10/24 at 7:48 p.m., 8:50 p.m., 9:54 p.m., 11:25 p.m., and on 2/11/24 at 00:30 a.m., 1:15 a.m., 2:57 a.m., 3:47 a.m., and 5:20 a.m. LDCS stated the physician ordered 50 ml of Dextrose 50% solution as needed for low blood sugar less than 100. A review of PT 6's "Glucose Management Records (GMR)", PT 6's "GMR" indicated a blood sugar of 87 on 2/10/24 at 7:46 p.m., 96 on 2/10/24 at 8:49 p.m., 96 on 2/10/24 at 9:51 p.m., 80 at 11:15 p.m., 95 on 2/11/24 at 00:20 a.m., 88 on 2/11/24 at 1:07 a.m., 87 on 2/11/24 at 2:33 a.m., 86 on 2/11/24 at 3:42 a.m., 96 on 2/11/24 at 4:48 a.m.

During a review of PT 6's "Perinatal Note (PN)", dated 2/12/24, the PN indicated, "betamethasone was ordered, and patient received 2 ml of insulin 200 [units] instead of betamethasone and had issues with low blood sugars which have since resolved."

During an interview on 3/14/24 at 11:17 a.m. with MSO and Pharmacist in Charge (PIC), MSO stated PT 6 was administered Dextrose 5% and Dextrose 50% solution intravenously (in the vein) with frequent monitoring to avoid severe hypoglycemia. MSO stated patients suffering from hypoglycemia could suffer from altered mental status, tremors, or dizziness. PIC stated a contributor to the medication error was RN 1 taking the insulin vial out of the medication room. PIC acknowledged RN 1 did not barcode scan the insulin vial prior to PT 6's insulin administration at 6 p.m. and at 6:29 p.m. PIC stated the importance of bar code scanning was to validate the use of the right product for the right patient, and the expectation was for nursing to barcode scan all medications prior to administration. PIC stated the practice expectation was to prepare one medication at a time, which included scanning, preparation, and administration. PIC stated, "It would help prevent accidental mistakes during administration. There was barcode scanning but the preparation was inaccurate, leading to inaccurate administration."

During an interview on 3/18/24 at 2:32 p.m., with Director of Risk Management (DRM), DRM stated a root cause analysis was still in progress for the insulin medication error involving RN 1 and PT 6.

During a review of Lexicomp, a nationally recognized drug database, the manufacturer for insulin lispro indicated, "The most common adverse effect of insulin is hypoglycemia ... Profound and prolonged episodes of hypoglycemia may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death ..."

During a review of Institute for Safe Medication Practices (ISMP)'s article titled, "ISMP List of High-Alert Medications in Acute Care Settings", dated 2024, the article indicated, "All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications."

During a review of the hospital's Policy and Procedure (P&P) titled, "Medications- Single and Multi-Dose Vials", dated 6/13/22, the P&P indicated, "A multi-dose vial may only be used for more than one patient if the vial is accessed in a medication clean area located outside the immediate patient care area."

During a review of the hospital's P&P titled, "Medications- Orders, Administration, Storage, Documentation", dated 12/19/23, the P&P indicated, "Medications shall be administered using Bar Code Medication Administration (BCMA) in all areas that BCMA is implemented ... it is the expectation of the organization that all areas scanning medications prior to administration will be compliant with medication scanning ... it is the responsibility of the person administering the medication to verify the following a. drug allergies b. the right drug c. the right patient d. the right dose e. the right time f. the right route ..."

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 (Pt) 22) was administered blood products and the intravenous (IV) (into the blood stream) line was not prepared before giving the blood.

This failure had the potential to place Pt 22 at risk for a delay in receiving administered blood products and negative health outcomes.

Findings:

During a record review of Pt 22's "History and Physical (H&P-the complete assessment of the patient and the problem)," dated 3/5/234, the H&P indicated, " ... 76 y.o. [year old ]female, with history of hypertension, brought in by ambulance from home for shortness of breath upon waking this morning. Reports she was up half the night because she couldn't sleep unclear if related to anxiety. She has been having trouble sleeping for 2 days ... She has felt fluid overloaded for a few days but no lower extremity edema [swelling caused by fluid in the body's tissues]. She endorses some fatigue. En-route Given 6 nitro [medication to widen the openings in blood vessels] and 1 inch nitro paste en route with some relief. No history of congestive heart failure [a weakened heart condition that causes fluid buildup] or chronic obstructive pulmonary disease [a chronic lung disease that causes obstructed airflow from the lungs] ... Currently smokes tobacco, states she is trying to quit. Denies chest pain, diarrhea, nausea, vomiting, diarrhea, or cough...."

During a record review of Pt 22's "Transfusion Orders," dated 3/29/24 at 5:59 a.m., the orders indicated, "Transfuse Red Blood Cells (Adult) ... Released Time ... 03/19/24 1038 [a.m.] ... Transfusion duration per unit 3 (hrs [hours]) ..."

During an observation on 3/19/2024 at 11:11 a.m., with Registered Nurse (RN) 7, in room 2413, RN 7 prepared and administered the blood to Pt 22 with the assistance of RN 8. During the process, RN 7 did not follow the policy when RN 7 did not prepare the patient before transfusion. RN 7 did not prime the blood transfusion filter Y-tubing (special tubing used for administering blood products that flushes the blood 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 7 spiked the Y tubing after obtaining the blood and after verifying the patient with RN 8. RN 7 primed the blood transfusion filter and tubing with normal saline and then spiked the blood product. RN 7 then connected the IV line to the patient.

During a concurrent interview and record review on 3/19/23 at 11:40 a.m., with RN 7, the hospital's policy and procedure (P&P) "Blood Products Transfusion", dated 3/19/24 was reviewed. RN 7 stated, she was familiar with the policy. RN 7 read from the policy, which indicated, " ... D. Preparation of Patient before Transfusion ... 1. Verify patient informed consent is documented and that there is an active order to transfuse. ... 2. Gather the equipment needed to complete the transfusion. (see section IV Equipment) ... 3. Perform hand hygiene. ... 4. Prime the blood transfusion filter and tubing with normal saline ... ". RN 7 stated she did not prime the IV tubing prior to obtaining the blood. RN 7 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 3/19/23 at 11:45 a.m., with NM 2, the hospital's P&P "Blood Products Transfusion", dated 3/19/24 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 2 stated, the blood should be administered within the four hour window as per the policy.

During an interview on 3/28/24 at 9:05 a.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 ensure that blood is efficiency administered as appropriate.

During a review of the hospital's P&P titled, "Blood Products Transfusion", dated 3/19/24, the P&P stated, " ... H. 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...."

Based on interview and record review the facility failed to obtain a History and Physical (H&P) (a term used to describe a doctor's examination of the patient) update within 24 hours of a surgery for one of thirty-four patients (Patient 17 ).

This failure had the potential for the surgical team not having the most up to date information prior to surgery.

Findings:

During a concurrent interview and record review, on 3/15/2024 at 11:30 a.m., with Director of Women and newborn & Labor and Delivery (DWN), Patient 17's medical record was reviewed. Patient 17 had surgery on 3/12/2024 for a cesarean section (a surgical delivery of a baby through a cut made in the mother's abdomen and uterus). Patient 17 had a medical H&P completed on 3/10/2024. An update to the H&P was missing on 3/12/2024 in the medical record.

During an interview on 3/15/24, at 11:35 a.m., with the DWN, the DWN stated, per hospital policy, an update to the H&P should be done 24 hours prior to the surgery. DWN stated, it appears it was not done and it was missed for this patient .

During a review facility's policy and procedure (P&P) titled, "[Name of Hospital] Medical Staff Bylaws", February 4, 2020, the P&P indicated "... 10.6. History and Physicals ... When the medical history and physical examination is completed within thirty (30) days before admission or registration, the Medical Staff member or other qualified licensed individuals in accordance with state and federal statute must complete and document an updated examination of the patient within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services ..."

Based on observation, interview, and record review, the hospital failed to ensure medications were stored according to manufacturer's specification.

This failure had the potential for render medications unsafe and/or ineffective for patients.

Findings:

During a concurrent observation and interview on 3/13/24 at 11:38 a.m. in the hospital's main pharmacy, 20 100-ml (milliliter- unit of measure) bottles of Isovue-300 (contrast media used to increase the contrast of structures or fluids within the body in medical imaging), 22 100-ml bottles of Isovue-370 and 20 100-ml bottles of Isovue-250 were observed to not be protected from light in the pharmacy carousel. Pharmacist in Charge (PIC) acknowledged the Isovue bottles are to be protected from light and stated they should be stored in the manufacturer provided carton or amber bags. PIC stated protecting the Isovue bottles from light was related to the stability of the drug.

During an interview on 3/18/24 at 10:10 a.m. with Director of Pharmacy (DOP), DOP stated that expectation was for medications that should be protected from light are protected from light to protect the integrity of the medications.

During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for iopamidol indicated, "Storage/Stability ... protect from light ..."

Based on interview and record review, the hospital failed to implement an effective system for reconciliation of all controlled drug (medications with high probability of addiction and are controlled by the federal government) losses and reconcile control drug discrepancies promptly.

These failures had the potential to result in hospital staff diverting controlled drugs, which could place patients at risk for potential adverse outcomes including inadequate pain relief, as well as the potential for hospital staff to abuse controlled controls drugs.

Findings:

During an interview on 3/13/24 at 11:49 a.m. with Pharmacy Manager of Quality and Education (PMQE), PMQE stated the Controlled Substance Coordinator (CSC) was responsible for investigating discrepancies with nursing and if not solvable, drug diversion investigation team would review discrepancy that was not accounted for.

During a concurrent interview and record review on 3/13/24 at 3:19 p.m. with CSC and PMQE, the hospital's "Closed Reconciliation Report", dated 1/1/24 to 1/31/24 was reviewed. The "Closed Reconciliation Report" indicated discrepancies were created on 1/4/24 for an unaccounted midazolam (controlled drug for anxiety) 5 mg dose for Patient (PT) 43, and on 1/11/24 for an unaccounted fentanyl (controlled drug for pain) 25 mcg dose for PT 42. CSC stated that for PT 42, the discrepancy for the unaccounted fentanyl 25 mcg dose was reconciled the next day by the prescriber, and for PT 43, the discrepancy for the unaccounted midazolam 5 mg dose was reconciled on 1/9/24 by the prescriber. CSC stated that the providers "back charted" to reconcile.

During a review of PT 43's "Order History" for midazolam, the "Order History" indicated, midazolam 5 mg was recorded on 1/9/24 to having been administered on 1/4/24 by anesthesiologist.

During a review of PT 42's "Order History" for fentanyl, the "Order History" indicated, fentanyl 25 mcg was recorded on 1/12/4 to having been administered on 1/11/24 by provider.
CSC was unable to provide documentation for monitoring of "back charting" by providers for diversion prevention.

During a record review on 3/13/24 at 3:57 p.m., the hospital's "Pyxis Report" dated 1/18/24 was reviewed. The "Pyxis Report" indicated Anesthesiologist (ANT) 1 dispensed a 2 ml vial of midazolam 1mg//ml and a 2 ml vial of fentanyl 50 mcg/ml on 1/18/24 for PT 44.

During a concurrent interview and record review on 3/14/24 at 11:27 a.m.., with PIC and PMQE, PT 44 and PT 45's "Medication Administration Record (MAR)" dated 1/18/24 were reviewed. PIC acknowledged ANT 1 dispensed fentanyl and midazolam under PT 44's profile and administered the medications to PT 45. A review of PT 45's MAR indicated an order for fentanyl 25 mcg every five minutes prn breakthrough pain, may repeat up to maximum total dose of 100 mcg. PT 45's MAR indicated, ANT 1 documented an administration of fentanyl 50 mcg on 1/18/24 at 1:11 p.m., 1:22 p.m., 1:27 p.m., and 1:36 p.m. PT 45's MAR also indicated an order for midazolam 1 mg every 5 minutes prn agitation. PT 45's MAR indicated, ANT 1 documented an administration of midazolam 2 mg on 1/18/24 at 1:07 p.m., and 1:31 p.m. PIC acknowledged ANT 1 did not administer fentanyl and midazolam according to PT 45's orders.

During an interview on 3/14/24 at 11:47 with PIC, PIC stated expectation is for documentation to match physician order. PIC stated, he was unaware of the discrepancy until the prior day when the discrepancy was identified. PIC stated, he became involved when discrepancies cannot be reconciled by CSC. PIC acknowledged fentanyl and midazolam incident with ANT 1 had been marked as resolved discrepancy.

During an interview on 3/14/24 at 12:04 p.m. with Director of Pharmacy (DOP), DOP acknowledged tools to ensure accurate reconciliation, correct control dispense to correct patient and correct order, was not being used.

During an interview on 3/15/24 at 10:10 a.m. with CSC and DOP, CSC acknowledged she did not have a monitoring system for discrepancies involving "back charting". DOP stated, "We have not been sending high user report to anesthesiology for review. We identified that late yesterday." DOP stated high user reports was a tool to help identify potential controlled substance mishandling, and to not do that for practitioner population left a gap.

During a review of the hospital's Policy And Procedure (P&P), titled, "Controlled Substance- Surveillance System", dated 9/12/23, the P&P indicated, "Unreconciled dispenses are reviewed by unit leadership and pharmacy every weekday ... unreconciled dispenses are identified, resolved or investigated ... Pharmacy generates an ADC [automated dispensing cabinets] report that identifies ADC end users with high activity of controlled substance withdrawals in comparison to a similar cohort ... this report is reviewed by the pharmacy leadership and unit nursing leadership to ensure appropriate use of controlled substances. Nursing leadership attests compliance on a monthly basis."

Based on observation, interview, and record review the hospital failed to ensure patient care equipment were properly maintained and ready for use when one vital sign monitor (a device used to measure the body's basic medical indicators of health- temperature, pulse, breathing, and blood pressure) and one bladder scanner (a device used to assess the volume of urine retained within the bladder) was used for patients without preventative maintenance (the process in performing regular scheduled maintenance to help prevent unexpected failures).

These failure had the potential risk to affect equipment performance and not functioning at their peak efficiency which could result in patient harm.

Findings:

During a concurrent observation and interview on 3/13/24, at 2:10 p.m. in cardiac Progressive Care Unit (CPCU- a special unit of the hospital that is dedicated to treating patients with serious heart issues) with the CPCU Nurse Manager (NM) 2 and Registered Nurse (RN) 16, one vital sign monitor preventative maintenance sticker was dated 2/2024. RN 16 stated she notified biomedical department (personnel that installs and maintain patient care equipment) and was told the vital sign monitor can be used 30 days past the date on the preventative maintenance sticker. NM 2 stated the vital signs monitor should be taken out of service for maintence and should not be used for patients.

During a concurrent observation and interview on 3/13/24, at 2:25 p.m., with NM 2, a bladder scanner had a preventative maintenance sticker dated 2/2023. NM 2 stated the bladder scanner should have been taken out of service and should not be used for patients. NM 2 stated the bladder scanner without preventative maintenance had the potential risk for not working properly and harm a patient.

During an interview on 3/14/24 at 9:25 a.m., with Biomedical Technician (BMT) 1, BMT 1 stated the preventative maintenance sticker on the patient care equipment shows the last day the equipment should be used as per hospital policy and procedure.

During an interview on 3/28/24 at 9:05 a.m., with the Chief Nursing Officer (CNO), the CNO stated hospital staff should not use patient care equipment with a past due preventative maintenance and should be taken out of service. The CNO stated patient care equipment without a preventative maintence had the potential risk to result in patient harm.

During a review of the facility's policy and procedure (P&P) titled, "Medical Equipment Management Plan," dated June 16, 2023, the P&P indicated, "... The objective of the Medical Equipment Management Plan ls to minimize the risks of using medical equipment through Inspections, scheduled maintenance and education in the safe use of medical equipment ... The management of medical equipment is a shared effort of the clinical and non-clinical departments and services, with the primary objective to provide safe, operational efficiency and reliability of medical equipment used on our patients. ... 1. Inspection, testing and maintenance. ... a. Inspection, testing and maintenance on a regular and consistent basis are part of the process to assure equipment performance. The initial inspection and test are part of the acceptance of new equipment. Ongoing inspection, testing and maintenance increases reliability, equipment life and user confidence. The intervals for inspection, testing and maintenance are based on the needs of the equipment and manufacturer's recommendations. The specification of an annual interval ls not intended to be the standard in the hospital. The intervals may be less than or more than one year ... "

Based on observation, interview and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infections for all patients, visitors and staff when the hospital placed Patient 53 in the Emergency Department (ED) North Hall while on contact precautions (special precautions for staff and visitors that are intended to prevent the transmission or spread of infectious agents) for a positive multi-drug resistant organism (MDRO- bacteria that have become resistant to certain antibiotics).

As a result of these failures all patients, visitors and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms [small living things that could cause disease] are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses.

Findings:

During a review of Patient 53's "Electronic Health Record (EHR)" dated 3/8/24 to 3/14/24, the EHR indicated, Patient 53 was admitted to the hospital on 3/8/24 for Altered Mental Status (a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted, she remained in the Emergency Department (ED) and was never moved into a private room. Patient 53 was in the ED during her hospital stay.

During a review of Patient 53's "Infections and Isolations (II)", dated 3/8/24 to 3/14/24, the II indicated, " ...PATIENT INFECTION STATUS: ESBL (Extended-spectrum beta-lactamases- an antibiotic resistant enzyme (small protein found in a living cell) that is found in some strains of bacteria) ... E. Coli (a bacteria that produces small proteins [enzymes] called ESBLs) ... Onset: 3/8/24 ... Added: 3/11/24 ... Last Indicated: Culture Urine (lab test to check for bacteria or other germs in a urine sample) ... PATIENT ISOLATION STATUS: ...Contact .... Added: 3/11/24 by (Infection Preventionist 2) ... Removed: 3/14/24 Encounter Ended (Patient 53 discharged) ...Specimen information: Urine ...".

During a review of Patient 53's "Infections- Micro Results (IMR)" dated 3/13/24, the IMR indicated, "Infection Review: 3/8: ESBL and E. Coli in the urine + [positive], antibiotic through 3/14/24 at [8:59 p.m.] after 6 doses. Patient transitioned to comfort care (care that improves the quality of life by relieving suffering and providing practical, emotional, and spiritual support), antibiotic stopped so patient needs to remain on isolation ...".

During an observation on 3/13/24 at 11:40 a.m., in the Emergency Department (ED) North Hall (a hallway with patients, staff and visitors walking by) bay 11 (space in hallway considered to be the room number), Patient 53 laid on a gurney with patients in gurneys at her feet and head separated by a privacy screen at her feet and head only. There was no contact precaution signage present with staff, patients, and visitors passing by within an arm's length of the patient.

During a concurrent observation and interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9 in the ED North Hall, RN 9 turned Patient 53 on her side without the use of personal protective equipment (PPE- equipment worn to protect the wearer from spread of infection or illness). RN 9 stated it was not safe for Patient 53 to be held in a hallway.

During an interview on 3/14/23 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was responsible for Patient 53's care. LVN 3 stated she did not know Patient 53 was on contact precautions for any positive test results.

During a concurrent interview and record review on 3/21/24 at 3 p.m., with the Emergency Department Director (EDD), Patient 53's EHR dated 3/8/24 to 3/14/24 was reviewed. The EHR indicated, Patient 53 was on contact precautions for ESBL and E. Coli in the urine. The EDD stated Patient 53 should have had signage over her gurney that indicated contact precautions. The EDD stated other patients and staff could have been exposed to ESBL or E. Coli because they did not follow contact precaution guidelines. The EDD stated this was a patient safety issue. The EDD stated staff did not follow the policy and procedure for isolation precautions.

During an interview on 3/25/24 at 9:45 a.m., with the Infection Preventionist (IP) 1, the IP 1 stated that staff should have adhered to contact precaution guidelines when they interacted with Patient 53. IP 1 stated Patient 53 was on contact precautions from 3/11/24 to her time of discharge on 3/14/24. IP 1 stated that because staff did not follow contact precautions guidelines there was a risk for cross-contamination to other patients and staff to occur. IP 1 stated that Patient 53 and other patients in that hallway safety was put at-risk. IP 1 stated that Patient 53 should have been moved to a private room and not in a hallway. IP 1 stated the policy and procedure "Standard Precautions and Transmission [spreading of germs] Based Isolation and Isolation Guidelines", were not followed.

During a review of the facility's Policy and Procedure (P&P) titled, "Standard Precautions and Transmission Based ", dated 8/12/21, the P&P indicated, "I. PURPOSE: To Prevent transmission of disease within the hospital to patients, staff and visitors. The intent of this policy is to provide guidance for placement of patients with known or suspected infectious diseases and address appropriate barriers to prevent disease transmission. II. DEFINITIONS: ... G. ESBL: Extended-spectrum B-Lactamases are enzymes that mediate resistance to extended-spectrum (third generation) cephalosporins (anti-microbials [inhibit the development and reproduction of microorganisms- bacteria, fungi, and viruses]) and monobactams (anti-microbials) ... IV. PROCEDURE: A. Contact Precautions 1. Contact precautions are initiated, in addition to stand precautions, for patients known or suspected to be infected or colonized with resistant organisms ... or other epidemiologically (diseases that are to be studied in terms of distribution and change to evaluate strategies to prevent illness from spreading, or management of that disease in person where it has already developed) important organisms ... 2. The patient's RN or designee places a yellow contact precautions sign outside the patient's room door where the sign is easily visible. The designated patient care unit staff or IP updates the EHR with the identified/suspected infectious organism(s) to indicate that the patient requires contact precautions ... 4. Equipment and supplies: a. Use disposable noncritical patient-care equipment (blood pressure cuff, thermometer, and stethoscopes) and keep them inside the patient's room. b. Equipment which cannot be left in the patient's room, must be thoroughly cleaned with a hospital approved disinfectant [kill germs] after use ... 5. Personal Protective Equipment (PPE) a. In addition to standard precautions, staff must always don gloves and gown when entering the patients room ... c. PPE is required for the healthcare worker if contact with the patient is anticipated ... 8. Visitors: a. All visitors should wear gown and gloves while in the contact precautions room ... b. It is the responsibility of staff to instruct visitors in the correct use of PPE and the importance of appropriate hand hygiene ...".

During a review of the facility's P&P titled, "Isolation Guidelines ", dated 8/9/21, the P&P indicated, "See attached Isolation Guidelines Reference to obtain information regarding various diseases, what precautions are needed to care for patients, mode of transmission and other general information ... ISOLATION GUIDELINES REFERENCE: ... MDRO ... Precaution Notes: Contact Precautions ... Multi-drug resistant organism include ... ESBL ...".

Based on interview and record review, the hospital failed to implement Emergency Department policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis (vomiting of blood), severe abdominal pain, low blood pressure and history of chronic urinary infections (a repeated or prolonged bladder infection) and atrial fibrillation (irregular heartbeat) and was not placed on a cardiac monitor (a device used to watch the electrical activity of the heart to ensure it is working normally) and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33's signs and symptoms and did not consider Pt 33's past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33's illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33's needs and in accordance with Emergency Department (ED -a hospital area staffed 24 hours a day, 7 days a week, and provides unscheduled outpatient services to patients with conditions requiring immediate medical care) policy and procedure.

These failures resulted Pt 33 not being monitored at the frequency needed to address his illness and a family member who was at the side of Pt 33 had to get the attention of ED nurses due to Pt 33's unresponsiveness on 3/13/24 at approximately 9:30 pm. Pt 33 died at approximately 10:14 pm on 3/13/24.

Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33's clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI (ESI-the process to categorized patients from level 1, the most critically ill, to level V, the least critically ill) and Triage (to sort patients and receive medical care based on the urgency or severity of their needs) reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses (RNs) 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient RNs to every shift in the ED and 2 additional Patient Care Technicians (PCTs) are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial noncompliance at the Condition level.

Findings:

During a review of Patient (Pt) 33's ambulance run report dated 3/13/24 at 4:45 a.m., the run report indicated, " ... Mode: Emergent (Immediate Response) ... Primary Impression: Lower GI (gastrointestinal - stomach) Bleeding Complaint: Vomiting Blood Other Symptoms: Pain, Abdomen. Pt is a 68 Y O M (year old male) CC (chief complaint)/ coffee ground emesis (vomit) w(with)/ Abd (abdominal) pain x [times] 1 day. Pt + (positive) [Brand Name] (medication blood thinner), + Hx (history) of bleeding ulcers, + hypotension (low blood pressure). Pt extensive Hx (history) of GI bleeds, BT (blood thinner), Afib (Atrial fibrillation irregular heart rhythm), paraplegic (loss of ability to move lower extremities Quad [meaning all four extremities are paralyzed]), dementia (progressive loss of intellectual functioning, impaired memory, and abstract thinking, often with personality changes, disease of the brain). Pt compliant w/meds (medication). Pt skin pale, hot, dry. Pt VSS (Vital signs stable) W/borderline hypotension ... Vitals Time 04:58 BP (blood pressure) 86/48 Mean Arterial[pressure [a measurement of the blood flow, resistance, and pressure within the arteries] 61 Pulse 100 Rhythm Irregularly [improper beating of the heart], Irregular Resp (respirations) 12 SPO2 (oxygen level) 95 (percentage of oxygen in the blood) at room air Pain 10 [meaning pain level is the highest 10 of 10] ... 05:28 BP 104/80 Pulse 100 Rhythm Irregularly Irregular afib Resp 12 SpO2 98 on oxygen Pain 10 ... ... Arrive Dest (Destination hospital): 03/13/2024 05:31:34 Transfer of Care: 03/13/2024 06:05:28 ..."

During a review of Pt 33's "Face sheet (a document that contains a summary of a patient's personal and demographic information) dated 3/20/24, indicated Pt 33 was brought to the hospital ED by ambulance on 3/13/24 a 05:35 a.m. With admitting diagnosis of GI Bleed. Inpatient admission date/time: 3/13/2024 1:11 p.m.; Discharge Date/Time: 3/13/2024 10:14 p.m.; Disposition: Deceased/Expired.

During a concurrent interview and record review on 3/20/24, at 2:30 p.m., Pt 33's ED Pt Care Timeline and Electronic Health Records (EHR), dated 3/20/24 was reviewed with the Emergency Department Manager (EDM). Pt 33's chronology of ED care as documented in the EHR was reviewed with the EDM. The EDM confirmed Pt 33 arrived by ambulance to the ED on 3/13/24 at 5:35 am and died at 10:14 p.m. the same day, 3/13/24. The EDM confirmed Pt 33 came in with a chief complaint of Hematemesis (vomiting of blood), was on a blood thinner, first set of vital signs (vs) were the following: temperature (T) 37.2 C (Celsius; 98.9 F), Heart rate (HR) 106, respiratory rate (RR) 14, BP 103/69, SpO2 94 % (percent) on room air. Pt 33 had a GCS (Glasgow Coma Scale score used to determine one's consciousness) of 13, was confused but obeyed commands. The EDM confirmed at 5:49 a.m. Pt 33 reported abdominal pain as 10/10. The EDM stated the Triage Registered Nurse (RN) 18 would have gotten a verbal report from the ambulance crew while she was triaging the patient. RN 18 assigned Pt 33 an Emergency Severity Index score (ESI used in ED to determine the timing, urgency and location patient will go to in the ED ESI Level 1 Resuscitation (the action of reviving someone from unconsciousness or apparent death) ESI Level 2 Emergent ESI Level 3 Urgent ESI Level 4 Less Urgent ESI Level 5 Non Urgent) of 3 (3 urgent but not emergent) and Pt 33 was placed in the Yellow zone which was reserved for non-emergent patients. Pt 33 was assigned a provider who was a Doctor of Osteopathic medicine (a whole person approach to medicine) (DO 1), and DO 1 assessed the patient and ordered labs, nausea medication, and [Brand Name] (proton pump inhibitor ( medications used to decreased stomach acid production) The EDM confirmed Pt 33's HR 114, SpO2 95 on room air and Pt 33 threw up three times and DO 1 ordered IV fluids but no repeat labs to see if Pt 33's blood levels had dropped. The EDM confirmed at 11:30 a.m. Pt 33 had a fever, temperature of 38 C (100.4 F), HR 118, RR 20, BP 92/57 (note no Oxygen levels taken/documented at this time) and DO 1 placed an order for [Brand Name] (fever reducer), oxygen therapy, nursing to monitor HR, RR, Manual BP, T, O2 saturations (percentage of blood saturated with oxygen), and for Pt 33 to be placed in a location of the ED where continuous monitoring is available. The EDM stated DO 1 also ordered Sepsis (body's extreme response to an infection) Management protocol (which included to contact physician for further antibiotic orders, if no infection specific antimicrobial therapy (medications used to kill bacteria) is ordered; Broad spectrum antibiotic administered within the last 24 hours; blood cultures (a test that looks for germs) sodium chloride 0.9% (indicated for replenishing fluid and for restoring sodium concentration in the body) bolus (administration of an entire medication over a short period of time), 1000 milliliters (ml - unit of measurement); [Brand Name] (oral antibiotic enteral coated [a barrier to prevent the gastric acids in the stomach from dissolving drugs after you swallow]) tablet 500 milligrams (mg - unit of measurement) (oral [mouth]); Lab Lactic acid (lab done when sepsis is suspected, will be elevated if the patient is in sepsis) Sepsis (serious condition resulting from the presence of harmful microorganisms (living organism that are too small to be seen with the naked eye) in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). The EDM confirmed at 1:12 p.m. Pt 33's admitting doctor (MD 1) include cardiac monitoring (monitor placed on patient to watch heart rate and rhythm) and at 1:17 p.m. placed order for EKG (Electrocardiogram measures the electrical activity of the heart) and chest x ray (image of chest to see if there is an infection in the lungs). The EDM stated after reviewing Pt 33's Electronic Health records (EHR) that no cardiac strips were documented, and this should have been done. The EDM confirmed [Brand Name fever reducer was given at 1:16 p.m. for temperature that was taken at 11:30 a.m. and the next set of vs were done at 6:33 p.m. The EDM stated vital signs should have been done every four hours or sooner depending on the status of the patient. The EDM stated she was not sure how many patients were assigned to RN 19 this day. At 1:58 p.m. MD 1 notified of Lactic Acid results 4.2 (normal is 0.5 2.2). MD 1 ordered Zosyn (a medication used to treat infections) IVPB (intravenous piggyback-a small bag of medication attached to the primary bag of intravenous [into the veins] fluids) at 6:37 p.m. The EDM stated Pt 33 had more antibiotics ordered later but that Pt 33 never received any antibiotics during this visit. The EDM stated the expectation was the nurses would follow the doctor's orders and give the antibiotics as soon as they could. The EDM stated that after reviewing Pt 33's EHR she felt Pt 33 should have been an ESI of 2, there was a delay in his care, and the patient did not get adequate treatment in this hospital.

During a concurrent interview and record review on 3/20/24, at 2:40 p.m., Pt 33's Electronic Health Record (EHR) was reviewed with the EDM. The EHR indicated Pt 33 last visit to this hospital was on 3/4/24, when Pt 33 came in for kidney stones (a hard deposits made of minerals and salts that form inside the kidneys [a pair of organs in the body]) urinary tract infection (UTI infection in the bladder) and had to have a stent (a tubular structure placed to help relieve an obstruction) placed in his ureter (the duct in which urine passes from the kidney to the bladder). The EHR indicated Pt 33 had a past medical history of Quadriplegia, neurogenic bladder (nerves that carry messages to the bladder do not function properly) with use of chronic urinary catheter (tube placed in bladder to help remove urine), chronic afib, hypotension, and diabetes. The EDM stated the patient's pertinent history should have been considered when determining the ESI of a patient coming into the ED, and for Pt 33 the pertinent history was not considered in establishing the ESI.

During a concurrent interview and record review on 3/26/24, at 7:54 a.m., with RN 18, Pt 33's "ED Pt Care Timeline" for visit dated 3/13/24 was reviewed. RN 18 stated when she triaged a patient that has come into the ED, she looks at their physical presentation, report is given by the ambulance crew or patient, signs, and symptoms they are having, vital signs, previous health conditions and then gets their current vital signs. RN 18 stated she asked the ambulance crew and Pt 33 if he had been vomiting in the ambulance and stated she would have remembered if he had black on his face from the vomit, but she does not recall this. RN 18 stated she asked Pt 33 if he was in pain per her documentation on the timeline Pt 33 reported having 10/10 abdominal pain. RN 18 stated she assigned Pt 33 an ESI of 3 but if he had been actively vomiting when he came in or if his HR was in the 130's she may have assigned him an ESI of 2 but his presentation at the time of triage was stable. RN 18 stated she was not told that Pt 33 was on [Brand Name blood thinner] and was in Afib but then changed her statement when she saw her documentation that he was on [Brand Name blood thinner]. RN 18 stated Pt 33's blood pressure (the force of circulating blood on the walls of the arteries) was at 103/69, HR 106, RR 14, SpO2 94 % on room air and T 37.2 C. RN 18 stated she did not recall if Pt 33 had a foley catheter and stated all patients that come into the ED are vulnerable.

During a concurrent interview and record review on 3/21/24, at 2:50 p.m., with Clinical Nurse Supervisor (CS) 3, Pt 33's "ED Pt Care Timeline" for visit 3/13/24 was reviewed. CS 3 stated he was the CS on 3/13/24 from 7 a.m. to 7 p.m. and after reviewing Pt 33's timeline that he does not recall this patient. CS 3 stated staffing on 3/13/24 placed all nurses at six patients to one nurse ratio or more and ED ratios are supposed to be four patients to one nurse. CS 3 stated Pt 33 was placed in a hallway bed in yellow zone which was identified as YY 02, he stated for visibility purposes of the patients and no power for patient equipment to be hooked up to, this area was closed end of last week. CS 3 stated after reviewing Pt 33's ED timeline for 3/13/24 based on his vs he could be an ESI of 3 but since he was in for GI bleed and on [Brand Name blood thinner] he would have assigned the patient an ESI of 2 and put him in the red zone to get treatment started. CS 3 stated because Pt 33 was in afib, tachycardic (tachy heart rate faster than 100 beats a minute) and was in for GI bleed cardiac monitoring would be appropriate and vs should probably be done every 15 30 minutes, but frequent vital signs were not done.

During a concurrent interview and record review on 3/25/24, at 9:30 a.m., with RN 19, RN 19 stated she worked on 3/13/24 and took care of Pt 33 from 7 a.m. to 7 p.m. and Pt 33 was originally put in the yellow zone in a hallway bed and was here for a GI bleed. RN 19 stated depending on where you were at the nurses station you could see Pt 33 but if you were sitting down this area was not visible. RN 19 stated Pt 33 had family at the bedside a good part of her shift. RN 19 remembers she talked with them and provided education on what she was doing and what medications she was giving to Pt 33. RN 19 stated she believes Pt 33 vomited at least once on her shift. RN 19 stated she had five patients that day and felt she was able to care for all of her patients' needs. RN 19 stated Pt 33 was on a cardiac monitor, she remembers putting him on it, as for the strips she said normally the techs monitoring the rhythms will call them with any changes and bring them the strips to put in the patients record but does not recall if this happened. RN 19 stated normally the techs are responsible to do the vs on the patients, but it is ultimately the nurse's responsibility to make sure the vs and the rhythm strips were done and reviewed and this was not done per hospital policy.

During a concurrent interview and record review on 3/21/24, at 4:15 p.m., with RN 20, Pt 33's ED Pt Care Timeline for visit dated 3/13/24 was reviewed. RN 20 stated on 3/13/24 she was floated (a nurse assigned to work in a different unit to meet staffing needs) to work in the ED that night from 7 p.m. to 7 a.m. and had five patients. RN 20 stated Pt 33 was in for vomiting and was supposed to get an EGD (Esophagogastroduodenoscopy tube with camera placed down patient's throat to see where the bleeding is coming from) that night. RN 20 stated she first went to check on Pt 33 around 8:30 p.m. and stated, "he didn't look good, he was pale and tachy". RN 20 stated a house supervisor was passing by at that time and she grabbed him and told him what was going on with Pt 33. RN 20 stated this house supervisor took Pt 33 immediately over to the red zone. RN 20 stated while she was at the bedside of Pt 33 before he was moved Pt 33's second lactic acid came back at 10.6 (high) and she called the hospitalist (a physician who cares for inpatients) on call. RN 20 stated she had not provided any treatment to Pt 33 so far on her shift. RN 20 stated she was told by RN 19 that Pt 33 was stable and a GCS of 14 but RN 19 did not mention Pt 33 was in afib. RN 20 stated she does recall that Pt 33 had a cardiac monitor on him.

During a review of Pt 33's Significant Event Note dated 3/13/24, at 10:01 p.m., the note indicated, "I [MD 2] was notified by RN that the family noticed that the patient became unresponsive. Repeat lactic acid is up to 10.6. I [MD 2] assessed the patient at bedside ..."

During a concurrent interview and record review on 3/22/24, at 9:40 a.m., with DO 1, Pt 33 EHR for 3/4/24 and 3/13/24 were reviewed. The DO 1 stated when he is assigned a patient in the ED, he will go assess the patient, start orders, and sometimes if he is at a computer, he will look at the patient's history. DO 1 stated he is not sure if he saw Pt 33's history but did look at the triage note that indicated Pt 33 was a quad, had afib, and was on a blood thinner. DO 1 stated since Pt 33 came in with GI bleed. DO 1 stated he would not have ordered the patient urine to be tested for infection right away even if he was just here 3/4/24 with a UTI. DO 1 stated, "You don't always worry about infection" when referring to patients with chronic foley catheter use. DO 1 stated if there are critical results for labs the lab will usually call the nurse or the doctor right away. DO 1 confirmed that the record indicated Pt 33 had a temp of 38 C at 11:30 a.m. on 3/13/23 and an order for Tylenol 1,000 mg was ordered by him. DO 1 stated Erythromycin (a medication use to treat infections) was an appropriate medication to be ordered at this time because he believed that Pt 33 was having a GI bleed and not a different infection at that time. The EHR for Pt 33 on 3/13/24 indicated a lactic acid was ordered at 11:57 a.m. by DO 1, this lactic acid did not result until 1:22 p.m. as 4.2 (high). The DO 1 stated at this time the patient was no longer on my list and was under the care of MD 1. Pt 33's EHR indicated DO 1 ordered a Lactic Acid at 1:56 p.m. DO 1 stated if there is an emergency for an admitted patient still waiting in the ED the ED MD would assist in the care of the patient. Pt 33's EHR indicated the next complete blood count or hemogram (a blood test used to look at overall health) was not ordered until 1:17 p.m. by MD 1.

During a concurrent interview and record review on 3/21/24, at 4:37 p.m., with MD 1, Pt 33's EHR for 3/13/24 was reviewed. MD 1 stated Pt 33 was a Quad, he was from a nursing home and came into the ED for coffee ground emesis times two days; labs were done and the hemoglobin (hgb- a protein inside the red blood cells that carries oxygen) was lower but not critical, white blood cells (wbc- part of the body's immune system that fights infection and diseases) were slightly elevated but could have been due to his GI bleed. MD 1 stated Pt 33 was being admitted for a GI bleed. MD 1 stated he remembered speaking with the patient's son at the bedside and the patient himself was not a good historian. MD 1 stated he noted Pt 33 had crackles (the clicking, rattling noise made by the lungs with a respiratory disease) at the base of his lungs and ordered a chest x ray to rule out an infection, a liter of fluids, a hemoglobin (per the EHR these were ordered at 1:17 p.m. also cardiac monitoring, EKG, and phosphorus level and magnesium levels (a chemical used by the body) Pt 33 's EHR indicated lactic acid of 4.2 was called to MD 1 at 1:56 p.m. MD 1 stated when he came back to check on Pt 33 he noticed the labs had not been drawn and there were no recent vital signs and asked the nurse to follow up with lab to get them done. MD 1 also requested the RN to get a set of vital signs; once the vital signs were done, he noted Pt 33's vital signs had seemed to improve with the intravenous fluid and Pt 33 was awaiting an EGD to be done (per the EHR this occurred at 6:42 p.m.). MD 1 stated he also ordered [Brand Name] (antibiotic) for possible aspiration pneumonia (occurs when food or liquids is breathed into the lungs) per the EHR this was ordered at 6:37 p.m. after the chest x ray resulted). MD 1 stated he got off his shift at 7 p.m. that night and signed out to a hospitalist on duty for admitted patients. MD 1 stated when he came back the next morning, he reviewed the chart and found out what happened to Pt 33. MD 1 stated he called Pt 33 's daughter and apologized that Pt 33 was in the hallway bed and explained that Pt 33 probably had aspiration pneumonia due to his vomiting and reviewed what had happened to the patient. MD 1 stated, "I expect nursing staff to follow my orders and give the antibiotics. I expect the labs I order to get done and if there are issues, for staff to inform me (referring to the labs not getting done in a timely manner)".

During an interview on 3/26/24, at 3:13 p.m., with the Medical Director of ED (EDDIR), the EDDIR stated the hospital has done a thorough review of Pt 33's ED visit on 3/13/24. The EDDIR stated Pt 33 received "Zero" antibiotics during this ED visit. The EDDIR stated he felt that DO 1 appropriately treated and assessed Pt 33 on 3/13/24 because Pt 33 came in stable with possible GI bleed, "Yes" he was tachy, but this could have been due to the GI bleed. The EDDIR stated a patient's medical history should be considered when treating a patient. The EDDIR stated Pt 33 did not spike a fever until later and the DO 1 treated it. The EDDIR stated Erythromycin was appropriate for a patient with a GI bleed, but it would not treat pneumonia or a UTI that may have caused the fever. The EDDIR stated when Pt 33's lactic acid came back at 4.2, he should have been getting the antibiotics and thinks MD 1 could have ordered them sooner but even then, they were not given and should have been.

During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated the expectation is that nursing staff will follow physician orders. The CNO stated part of vital signs is checking the SpO2 and vital signs should be monitored per policy and per patient specific orders. The CNO stated orders for labs should be drawn on time and if there are issues (meaning there is a difficulty drawing the blood sample from the patient), the phlebotomist (a medical professional trained to perform blood draws) should contact the nurse to let them know.

During a review of the Hospital's policy and procedure (P&P) titled, "Triage EMS (Emergency Medical Services)", effective date 8/2/2021, indicated, "I. PURPOSE A. To provide a timely response to patients presenting to the emergency department with medical and or psychiatric complaints. B. To prioritize patients' needs and maintain control of patient flow and care. C. To allow prompt recognition of change in patient status. II Policy. A. All persons requesting treatment in the emergency department will be triaged by a registered nurse who has completed the triage orientation and has documented competency. B. Patients will be triaged prior to the completion of registration. C. Nursing staff will conduct an ongoing assessment of those patients' awaiting placement into the treatment area. III. Procedure. A. Patients in need of immediate intervention will be taken directly to the treatment area. B. Patients that do not require immediate lifesaving interventions. will be assessed including 1. Chief complaint and history of present illness, including physical findings and care before arrival. 2. Travel history 3. Pertinent past medical history 4. Complete vital signs Temperature, Pulse, Respirations, Blood Pressure, O2 Saturations and Pain Assessment. 5. Medication, allergies, place allergy armband when appropriate ... C. RN will assign priority using the Emergency Service Index (ESI). D. RN will update the flag in electronic health record (EHR). and designate the patient as a Trauma, Burn, Cardiac or Psychiatry E. Reassessment of triaged patients will be based on the ESI priority assigned to the patients: 1. at least every four hours for urgent patients. 2. at least every one hour for emergent patients. 3. as warranted by patient condition and response to treatment..."

During a review of the Hospital's P&P titled, "Emergency Severity Index Policy", effective date 7/7/2021, indicated, "I. PURPOSE To provide guidelines for all patients presenting to the Emergency Department. All patients presenting to the Emergency Department will undergo an Emergency Severity Index Assessment by the triage nurse to initiate a Medical Screening Examination and determine the timing, urgency, and appropriate location in the ED for completion of the Medical Screening examination and disposition of the patient. II.POLICY A. Patients will have the Emergency Severity Index assessment at the Triage area of the Emergency Department or within the treatment area of the Emergency Department. Ill. PROCEDURE A. The triage nurse will categorize the patient into one of the following five (5) ESI Levels. The levels will be determined by using the following: Index Level Definitions, Data Base, and ESI algorithm. INDEX LEVEL DEFINITIONS: ESI Level 1 Resuscitation ESI Level 2 Emergent ESI Level 3 Urgent ESI Level 4 Less Urgent ESI Level 5 Non-Urgent DATA BASE: A. 1. Chief Complaint 2. Appearance 3. Vital Signs 4. Brief description of relevant history of illness or injury 5. Age 6. Previous medical history 7. Mental status 8. Skin color, warmth, and moisture 9. Pain severity 10. Focused physical exam. Example location and depth of a laceration (skin wound) with presence or absence of abnormal neurovascular (nerves and blood vessels) findings and observation of ability to ambulate ... ESI Flow Chart Level 1 Requires immediate lifesaving interventions Level 2 High risk situation or confused, lethargic or disoriented or severe pain or distress Level 3 2 or more resources Level 4 1 expected resource Level 5 No expected resource ... Patients who have a pain rating of 7 / 10 or greater should be considered for meeting ESI Level 2 criteria. It is up to the discretion of the triage nurse to determine whether the clinical condition and pain rating in combination warrant a rating of ESI Level 2.

During a review of the Hospital's P&P titled, "Standard of Practice for Emergency Department", effective date 9/14/2022, indicated "I. PURPOSE These standards of practice are necessary and realistic levels of the nursing process, which assure that quality of care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive in by the Emergency Department (ED) of [Name of hospital]. II. Definition. Provider Attending physician, Fellow, resident physician, or Advanced Practice Professional (APP). III. Policy. A. The patient and in the ED will receive care in accordance with the Standards of Practice for the ED area. The Standard of Practice categories are adopted by [name of hospital], which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED. IV. Procedure. A. STANDARD OF PRACTICE: Safety, Medication, IV therapy, Infection Control. The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: 1. Maintain patient confidentiality all times. 2. Adhere to all established [hospital name] policies and procedures 3. Intervene appropriately to correct unsafe situations. 4. Follow the infection control policies found in the infection control manual. 5. Maintain the bed in a low position would not at the bedside. 6. Maintenance of the side rails in the up position will be dependent upon the patient's assessed needs ... 8. Administer medications as prescribed by professional and legal standards and those guidelines adopted by [name of hospital] and directed by physician order ... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a licensed nurse. Utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary (a group of professionals working together with a common goals) team. The frequency of data collection will vary according to the gravity of patient's problems/needs as well as individual standardized procedure and physician's order.... F. Vital signs with pain assessment a minimum of every four hours unless otherwise ordered or warranted.... D. Standards of Practice: Emergency Measures. 1. Provide care in such a way as to direct and or prevent complications and life-threatening situations. 2. Patient care staff will initiate immediate treatment for life threatening situations..."

During a review of the "Hospital Emergency Department Agreement", effective date 3/2/2012, indicated it is between [name of hospital 2] and [name of hospital 1] and [name of Physician medical group] who agrees as follows: ... "AGREEMENTS In Consideration of the mutual promises set forth in this agreement, hospital and [name of provider group] agree as follows: I. Medical services provided by [name of provider group]: 1.1 Medical Director ... 1.3 Patient Care Services. 1.3.1 The attending [name of provider group] Physician in the department shall render medical services within the standards of emergency medical practice to patients arriving at the department. Physicians shall provide treatment to stabilize each patient's condition and then shall make a reasonable effort to refer the patient to his/her own private physician. Or to an appropriate staff physician... 1.4 Standards of Care. 1.0.1. Physicians who attend the Department shall perform medical services and conduct the Department in accordance with the requirements and recommendations of the Joint Commission in (TJC) and other similar organization with deemed CMS status [a designation granted to healthcare facilities accredited by an approved accrediting organization], Regulatory agencies, the policies and procedures of Hospital, and the bylaws and rules and regulations of the Hospital's medical staff...."

During a review of the Hospital's policy titled, "Cardiac and Remote Monitoring Inpatients 14 and Older", eff