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Based on document review and interview, it was determined that for 2 of 5 clinical records reviewed for restraints (Pt. #1 and Pt. #2), the Hospital failed to ensure a physician order was obtained for restraint application, as required.

Findings include:

1. On 11/19/2024, the Hospital's policy titled, ""Restraint and Seclusion" (dated 2/2022) was reviewed and required, "Procedure - the physician will place the order for restraints in the EMR (electronic medical record). Once the restraints are applied, begin documentation in the EMR. RN (Registered Nurse) assessments are documented in the EMR ..."

2. On 11/19/2024, Pt. #1's clinical record dated 10/3/2024 thru 10/11/2024 was reviewed and indicated:
-Pt. #1 was admitted to the hospital on 10/3/2024 with the diagnosis of hyperkalemia (increased potassium level) and metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain).
-Pt. #1 was placed in non-violent restraints (bilateral soft wrist restraints) on 10/9/2024 for attempting to bite a nurse.
-Pt. #1's clinical record lacked a physician's order for non-violent restraint application on 10/9/2024.


3. On 11/19/2024, Pt. #2's clinical record dated 7/26/2024 was reviewed and indicated:
-Pt. #2 was seen in the ED (Emergency Department) on 7/26/2024 with a diagnosis of breakthrough seizure, noncompliance with medications and epilepsy.
-Pt. #2 was placed in non-violent restraints (bilateral soft upper limb restraints on 7/26/2024 from 8:10 AM to 10:30 AM.
-Pt. #2's clinical record dated 7/26/2024 lacked documentation of a physician order for the bilateral soft upper limb non-violent restraints.

4. On 11/19/2024 at 9:00 AM, an interview was conducted with the ED Clinical Coordinator (E #3). E #3 stated that there should be a physician's order for when a patient is placed on restraints.

Based on document review and interview, it was determined that for 1 of 5 clinical records (Pt. #2) reviewed for restraints, the Hospital failed to ensure the patient's response to the restraint application.

Findings include:

1. On 11/19/2024, the Hospital's policy titled, ""Restraint and Seclusion" (dated 2/2022) was reviewed and required, "Procedure - the physician will place the order for restraints in the EMR (electronic medical record). Once the restraints are applied, begin documentation in the EMR. RN (Registered Nurse) assessments are documented in the EMR...Monitoring determines the following: patient's physical and emotional well-being; maintenance of patient's right, dignity, and safety; assessment of patient's condition to determine if the current restraint should be continued or if less restrictive methods could be used or restraints could be discontinued. Assessment and reassessment must include, but are no limited to -circulation, sensation, level of distress and agitation, behavior, mental status, cognitive functioning, elimination needs, patient safety and comfort, during and after restraint is removed...Results of patient monitoring will occur at regular intervals according to the individual's assessed needs but not to exceed 2 hours between intervals...Monitoring is accomplished by observation, direct face-to-face interaction with the patient...Real time documentation of assessment of restrained patient status at a minimum of every 2 hours for non-violent restraints..."

2. On 11/19/2024, Pt. #2's clinical record dated 7/26/2024 was reviewed and indicated:
-Pt. #2 was seen in the ED (Emergency Department) on 7/26/2024 with a diagnosis of breakthrough seizure, noncompliance with medications and epilepsy.
-Pt. #2 was placed in non-violent restraints on 7/26/2024 from 8:10 AM to 10:30 AM.
-Pt. #2's clinical record dated 7/26/2024 did not include Pt. #2 restraint assessment after the application of restaints.

Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.21 Quality Assessment and Performance Improvement Program.

Findings include:

1. The Hospital failed to have a quality assessment performance improvement program. (A-273).

Based on document review and interview, it was determined that the Hospital did not have a Quality Assessment and Performance Improvement (QAPI) plan or program.

1. On 11/21/2024, a request was made for the hospital to provide a QAPI program/plan. The hospital did not have any plan or program. QAPI meeting minutes were requested, and the hospital did not have any. There was no documentation of any information about QAPI since 2022.

2. On 11/25/2024, Medical Executive Meeting minutes were reviewed for 2024 and included no QAPI reference or review of QAPI.

3. On 11/20/2024 at 9:00 AM, an interview was conducted with the ED (Emergency Department) Director (E #6). E #6 stated that the ED (Emergency Department) collects date but E #6 does not know where it goes. E #6 stated that there are no quality indicators and does not know the frequency of indicators.

4. On 11/20/2024 at 2:15 PM, an interview was conducted with the CEO (Chief Executive Officer) (MD #5). MD #5 stated that the Hospital not having Quality Program might be an oversight. MD #5 stated that MD #5 bought 2 hospitals this year and is working on other hospital first, then will get to this hospital after. MD #5 stated that the Medical Executive/Governing Body has not set performance improvement or quality indicators, nor does it monitor the effectiveness and safety of services provided by the Hospital.

5. On 11/21/2024 at 11:15 AM, an interview was conducted with the Executive Director of Nursing (E #7). E #7 stated that the hospital does not have a quality improvement plan or program. E #7 stated that this a priority and E #7 is going to begin working on it.

Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services.

Findings include:

1. The Hospital failed to ensure the Emergency Services Medical Director coordinated services with the Chief Executive Officer (CEO), per job description. See deficiency at A-1102

2. The Hospital failed to ensure the carts and cabinets were locked to prevent unauthorized access to unsafe equipment. See deficiency at A - 1104

3. The Hospital failed to ensure the emergency department had adequate staffing, per staffing grid. See deficiency at A-1112.

Based on document review and interview, it was determined that for 1 of 1 Medical Director of Emergency Services (MD#2), the hospital failed to ensure the Medical Director of Emergency Services coordinated services with the Chief Executive Officer (CEO), per job description.

Findings included:

1. The "Job Description of the Medical Director of Emergency Services" was reviewed on 11/20/2024 and included, "Coordination of Services. CEO and Medical Director shall coordinate their activities. ... Duties of Medical Director Emergency Services: Medical Director Reports to CEO - Monthly - informal meeting, Quarterly - formal meeting, Annual evaluation.

2. The hospital's medical executive committee meeting minutes for 2024 were reviewed on 11/21/2024. The following was the ED (Emergency Department) activity at medical executive committee:
- January, February, March, and April 2024 - ED Medical Director did not attend - no report.
- May, June 2024 - ED Medical Director attended - no report.
- July and August 2024 - no meeting.
- September 2024 - ED Medical Director attended - thanked team for support with joint commission.
- October 2024 - ED Medical Director attended - ED working on new patient flow to avoid patients leaving without being seen.

3. The ED Medical Director (MD#2) was interviewed via telephone on 11/20/2024 at 2:15 PM. MD#2 stated that the ED physicians are a contracted service and are independent contractors. MD#2 stated "I was appointed medical director of the ED service in June 2022. No evaluation of my duties has occurred. I am only responsible for the ED physician and physician assistant team. We have monthly provider meetings among our team. This information is private and not shared with the hospital administration.

4. The Chief Executive Officer (MD#3) was interviewed via telephone on 11/21/2024 at 9:30 AM. MD#3 stated that there are regular informal meetings with the ED physicians. MD#3 stated, "I know the ED physicians have their own meetings, but I do not receive the minutes. I get involved with all budgeting needs or financial expenditures." MD#3 stated that the ED Medical Director attends medical executive meetings and reports when there is something to report. There is no regular schedule for required reporting.

Based on document review, observation and interview, it was determined that for 12 of 12 emergency room supply carts and 2 of 2 trauma room supply cabinets, the hospital failed to ensure the carts and cabinets were locked to prevent unauthorized access to unsafe equipment. This potentially affected the average daily census of 12 patients.

Findings included:

1. The Hospital's policy titled, "Supply Carts/Boxes (5/2022)" was reviewed on 11/20/2024 and included, "Maintain various types of supply and emergency carts for use by clinical departments throughout the hospital."

2. The Hospital did not have a policy related to locked storage of sharps or unsafe equipment.

3. A tour of the emergency department (ED) was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the clinical coordinator of the ED (E#3). During the tour the following was observed:
- There was one trauma room (divided into 2 trauma bays) by the ambulance entrance. The room contained two large metal storage cabinets that contained needles and trocars (sharp pointed surgical instrument) used for trauma cases. The storage cabinets were not locked.
- A bedside table contained IV (intravenous) start kits, including needles available in the room. Directly outside the room was a hallway bed that had a patient assigned. The patient was walking around and was stopped as they were entering the trauma room where unlocked supplies/equipment were present.
- Each ED room had rolling supply carts containing syringes and individual needles. The supply carts were not locked and accessible to anybody walking by the room.

4. During an interview on 11/20/2024 at 12:45 PM , the ED Clinical Coordinator/Director (E#3) stated that no one knows where the keys for the trauma room storage cabinets or the supply carts are. Everything is left unlocked. E#3 stated, "All supplies should be locked to prevent unauthorized access to the equipment."

Based on document review, observation and interview, it was determined for 7 of 7 days (11/13/2024 - 11/19/2024), the hospital failed to ensure the emergency department had adequate staffing, per staffing grid. This potentially affected the average of 12 patients present in the ED (Emergency Department) daily.

Findings included:

1. The list of emergency department (ED) staff was reviewed on 11/19/2024. The list included that the ED had 3 full-time registered nurses, 11 registry nurses (no set hours required), 5 agency contract nurses, and 2 agency nurses available for staffing.

2. The "Emergency Room Staffing Guidelines" were reviewed on 11/19/20204. The guidelines included that staffing was the same from 7:00 AM - 7:00 PM (days) and 7:00 PM to 7:00 AM (nights). The staffing grid required: 1 charge/triage nurse, 2 registered nurses, 1 additional RN (Registered Nurse) from 10:00 AM to 10:00 PM, 2 technicians, 1 secretary and 1 constant observer.

3. The ED Daily staffing sheets for 11/13/2024 to 11/19/2024 were reviewed on 11/19/2024. The following shifts were short based on guidelines:
11/13/2024 - days - short one 7 AM to 12:00 PM triage/charge nurse, 1 technician and 1 constant observer.
11/14/2024 - days - short 1 constant observer
11/14/224 - nights - short 1 technician and 1 constant observer
11/15/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer
11/15/2024 - nights - short 1 technician and 1 constant observer
11/16/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer
11/16/2024 - nights - short 1 charge/triage nurse, 2 technicians and 1 constant observer
11/17/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer
11/17/2024 - nights - short 1 RN, 1 charge/triage nurse, 2 technicians and 1 constant observer
11/18/2024 - days - short 1 charge/triage nurse, 1 technician and 1 constant observer
11/18/2024 - nights - short 1 technician, 1 technician from 1 AM to 7 AM and 1 constant observer
11/19/2024 - days - short 1charge/triage nurse and 1 RN

4. A tour of the ED was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the Clinical Coordinator of the ED (E#3). The ED had 12 bays with an additional 6 hallway beds available. The current staffing was 2 registered nurses, 1 technician, 2 externs (students), 1 secretary and 1 constant observer. The staffing was 3 nurses and 1 technician below staffing guidelines.

5. During the tour, the charge nurse (E#1) was interviewed. E#1 stated, "Unfortunately we are short nurses most days. We do what we can. When a patient comes into the ED, whatever nurse is available, we go do the triage and keep the patient for their stay in the ED. Patient triage is alternated between whatever nurses are here. The registration desk notifies us of any patient arrival." E#1 stated that most nurses are either registry or agency."

6. During the tour, the ED Clinical Coordinator (E#3) was interviewed. E#3 stated, "We have been struggling to get ED staff. We have agency contracts and registry to pull from. We have a lot of call ins and have difficulty replacing staff at the last minute." E#3 stated that staffing is not based on census and a set number of staff has been determined to have available at all times to deal with the fluctuating needs of the ED (i.e.: emergencies and fluctuating census).

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure the transfer forms were completed and patient records were sent with patient when transferred, as required. See deficiency at A-2409

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department, the Hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA-Emergency Medical Treatment and Labor Act) that was visible to patients as they enter the hospital. This potentially affected all patients that enter the hospital through the ambulance bay.

Findings include:

1. The Hospital's policy titled, "EMTALA" (revised February 2022), was reviewed and required, "Posting Signs ... The hospital must post conspicuously, in the dedicated Emergency Departments (ED) and all areas in which individuals routinely present for treatment of emergency medical condition and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions."

2. A tour of the ED was conducted on 11/19/2024 from 10:30 AM - 11:30 AM, accompanied by the Clinical Coordinator of the ED (E#3). There was EMTALA signage in both English and Spanish posted on the wall at the registration desk in the waiting area of the ED. However, the entrance to the hospital's ED through the ambulance bay lacked posting of the required EMTALA signage.

3. An interview was conducted with E#3 at approximately 10:45 AM. E#3 stated that [E#3] did not know why EMTALA signage was not posted in that ED area. E#3 stated that there should be EMTALA signage posted in the entrance to the hospital through the ambulance bay area, as it was at the registration desk in the waiting area.

A. Based on document review and interview, it was determined that for 2 of 3 emergency room clinical records (Pt #3 and Pt.#10) reviewed for transfers, the Hospital failed to ensure the transfer forms were completed, as required.

Findings include:

1. On 11/19/2024, the Hospital's policy titled, "EMTALA" (Revision Date 2/2022) was reviewed and indicated, "...1. A decision regarding patient transfer may be made by either patient request or physician certification...b. With certification...The individual may be transferred if a physician ...has certified that the medical benefits expected from transfer outweigh the risks..."

2. On 11/19/2024, the clinical record for Pt #3 was reviewed. Pt #3 was seen in Hospital A's (this hospital) emergency department on 7/20/2024 with a diagnosis of sublingual abscess. Pt #3 was transferred to Hospital B (outside hospital) for ENT (Ear, Nose, Throat) specialty. Pt.#3 clinical record lacked the required transfer consent form and physician certification.

3. On 11/20/2024, the clinical record for Pt.#10 was reviewed. Pt.#10 was seen in Hospital A's emergency department on 4/16/2024 with a diagnosis of Bipolar Disorder, Paranoia, Acute Psychosis, Agitation. Pt.#10 was transferred to Hospital C (outside hospital) for inpatient psychiatric treatment. Pt.#10's clinical record lacked the required transfer consent form and physician certification.

4. On 11/19/2024 at approximately 10:30 AM, an interview was conducted with ED (Emergency Department )-RN (Registerd Nurse) (E#1). E#1 stated that a transfer form should be completed for all patient transfers.

5. On 11/19/2024 at 10:45 AM, an interview was conducted with the ED Physician (MD#1). MD#1 stated that the transfer consent forms should be filled out completely for all transfers.

B. Based on document review and interview, it was determined that for 1 of 3 emergency room clinical records (Pt #2) reviewed for transfers, the transferring Hospital failed to ensure that all medical records available at the time of transfer were sent with the patient to the receiving hospital and other records were sent as soon as possible after transfer, as required.

Findings include:

1. On 11/19/2024, the Hospital's policy titled, "EMTALA" (Revision Date 2/2022) was reviewed and indicated, "...C. The hospital must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: ...(2) records related to the individual's emergency medical condition...(5) results of diagnostic studies or telephone reports of studies; (6) treatment provided; (7) results of any tests..."

2. On 11/19/2024, the clinical record from the [transferring hospital-hospital A] for Pt.#2 was reviewed.
-Pt. #2 presented to the ED on 7/20/2024 at approximately at 5:56 AM with chief complaint of facial laceration. CT done (face, head and spine) on 7/20/2024 at 4:20 PM. CT results included zygomatic fracture (cheekbone). Pt. #2 was transferred to Hospital B (receiving hospital) for higher level of care due to ENT services not available at Hospital A. The transfer form indicated that all ED medical record for Pt.#2 was sent with the patient.

3. On 11/26/2024, the clinical record for Pt.#2 from the [receiving hospital-Hospital B] was reviewed and included - "...7:17 PM Patient sent with CD of CT scans, CD sent off to radiology for read of CT, or printout of previous interpretation. 11:11 PM Called [Transferring Hospital - Hospital A] and requested CT scan reads be faxed over. 11:12 PM Fax was not received after a few hours, plan to work up patient here... 11:13 PM Plan to order CT scan of facial bones ...CT Facial Bones without Contrast was completed and resulted at Hospital B on 7/21/2024 at 2:01AM. Results included closed fracture of left zygomaticomaxillary complex; Closed ptyerygoid plate fracture; and closed fracture of nasal bone ..."

4. On 11/19/2024 at approximately 10:30 AM, an interview was conducted with ED-RN (E#1). E#1 stated that all the patient's medical record be printed and sent with the patient. E#1 stated that if the final report dictations are not complete, the report should be faxed as soon as available. E #1 stated that E #1 does not recall receiving a request for additional records from Hospital B. E #1 stated that E #1 does not remember Pt. #2.