HospitalInspections.org

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by:



1. The facility failed to ensure six of 30 sampled patients' (Patients 1, Patient 7, Patient 8, Patient 10, Patient 14, and Patient 17) Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were either signed by the patient or the patient's representative or appropriately witnessed by facility staff per policy & procedure.

This deficient practice resulted in violating the patients ' right of not knowing options of patient rights, treatment, billing process, payment and service rendered by facility. (Refer to A-0117)

2. The facility failed to provide consent for surgery (document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) to one of 30 patients (Patient 25) in Patient 25 ' s preferred language.

This deficient practice may lead to a decision which is not in the patient ' s best interest. (Refer to A-0131)

3. The facility failed to follow and implement (carry out) the facility's falls prevention policy for one of 30 sampled patients (Patient 14).

This deficient practice placed patients at risk for falls and injury. (Refer to A-0144)

4. The facility failed to ensure one of 30 sampled patients (Patients 1), was free from abuse (the improper treatment of a person), when Patient 1 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.

This deficient practice resulted in Emergency Room Technician inappropriately responding by physically assaulting Patient 1 after getting provoked by the patient. (Refer to A-0145).



The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure six of 30 sampled patients' (Patients 1, Patient 7, Patient 8, Patient 10, Patient 14, and Patient 17) Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were either signed by the patient or the patient's representative or appropriately witnessed by facility staff per policy & procedure.

This deficient practice resulted in violating patients ' right of not knowing options of patient rights, treatment, billing process, payment and service rendered by facility.

Findings:

1. A review of Patient 1 ' s Emergency Department (ED) Provider note dated 3/26/2025 indicated Patient 1 was brought into the ED by Emergency Medical Service (EMS) for alcohol intoxication (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream).



During a concurrent interview and record review on 5/16/2025, at 10:35 a.m., with Nurse Manager (NM 1), Patient 1 ' s condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) was not found on Patient 1 ' s medical records. NM1 stated that she had been checking all the areas of Patient 1 ' s medical records and was unable to find Patient 1 ' s COA.



During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:45 a.m., the AM confirmed that all patients require to sign the COA even when patient is seeking medical examination in ED or patient is admitted to the facility.



During a review of the facility's Police and Procedure (P&P) titled "Conditions of Admission (COA) - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, "the hospital will maintain a registration process that complies with federal, state and laws and payer requirements. The forms must be signed by the patient and/or the patient ' s legal representative: e.g. parent, conservator or legal guardian on admission. The original document (COA) will be scanned or uploaded into the patients ' electronic medical record (EMR).



2. During a review of Patient 7 ' s "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 5/13/2025 at 8:24 p.m., the H&P indicated Patient 7 was admitted to the facility on 5/13/2025 for complicated urinary tract infection (UTI, an infection in any part of the urinary system), acute kidney injury (AKI- sudden and often temporary loss of kidney function), and cerebral palsy (a congenital disorder of movement, muscle tone, or posture).



During a review of Patient 7 ' s , "The Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc" dated 5/15/2025 at 2:31 p.m. , indicated the patient ' s signature part is blank and stated Patient 7 was unable to sign due to medical condition (cerebral palsy) which was witnessed by Admitting Representative (AR 3).



During review of Patient 7 ' s "The Conditions of Admission/Service (COA)- indicated no second staff signature to witness as required per facility policy.



During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility's Condition of Admission/ Service (COA) policy & procedure (P&P) indicated if verbal consent was given to sign the COA, then there should be two witnesses.



During a review of the facility's P&P titled "Conditions of Admission - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, "If the patient is physically unable to sign, but can express his/her agreement to the terms of the form, by nodding yes or stating yes then this shall be witnessed by two people.



3. During a review of Patient 8 ' s "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 5/6/2025 at 10:16 a.m., the H&P indicated Patient 8 was admitted to the facility on 5/6/2025 for acute hypoxia (deficiency in the amount of oxygen reaching the tissues which can cause confusion) and hypercapnic respiratory failure (body inability to remove carbon dioxide from the blood and result in high levels of carbon dioxide in the blood).



During a review of Patient 8 ' s "Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)", dated 5/7/2025 at 9:30 a.m., indicated the signature part is empty and Patient 8 was unable to sign due to medical condition which was witnessed by Admitting Representative (AR 4). There were no second staff to witness as required per facility policy.



During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility's policy & procedure (P&P) states if verbal consent is given to sign the COA, then there should be two witnesses.



During a review of the facility's P&P titled "Conditions of Admission - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, If the patient is physically unable to sign, but can express his/her agreement to the terms of the form, by nodding yes or stating yes then this shall be witnessed by two people.





4. During a review of Patient 10's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/27/2025 at 1:01 a.m., the H&P indicated Patient 10 was admitted to the facility on 4/27/25 for complicated urinary tract infection (UTI, an infection in any part of the urinary system), Metabolic toxic encephalopathy (condition where brain function is impaired due to an accumulation of toxins or metabolic disturbances in the body), and anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness).



During a review of Patient 10's Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA indicated the patient ' s signature part was blank and indicated Patient 10 verbally acknowledged/agreed which was witnessed by Admitting Representative (AR 5). There were no second staff to witness verbal acknowledgement from Patient 10 per facility policy.


During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility's policy & procedure (P&P) indicated if patient gave a verbal consent for the COA, then there should be two witnesses who would sign the COA.



During a review of the facility's P&P titled "Conditions of Admission - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, "If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient's agreement to the terms of the form."


5. During a review of Patient 14's Face Sheet (a document that summarizes a patient ' s medical history and personal information, including patient ' s name, address, and date of birth, insurance information, and emergency contact information), dated 5/13/2025, the Face Sheet indicated Patient 14 was admitted to the hospital for a fracture of the left femur (thigh bone).

During a review of Patient 14's Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA did not have Patient 14's signature. Instead, the COA indicated written on the COA, that Patient 14 gave "verbal understanding," which was witnessed by Admitting Representative (AR) 1. and there was no other staff present to witness the verbal understanding Patient 14 expressed.

During an interview with the Admitting Manager (AM), on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility's policy & procedure (P&P) indicated if verbal consent was given/expressed to sign the COA, then there should be two witnesses who would sign the COA.



During a review of the facility's P&P titled "Conditions of Admission - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, "If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient's agreement to the terms of the form."



6. During a review of Patient 17's Face Sheet, dated 5/13/2025, the Face Sheet indicated Patient 17 was admitted to the facility for seizures (abnormal involuntary movement of the body).

During a review of Patient 17's Conditions of Admission/Service (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 5/13/2025, the COA did not have Patient 17's signature. Instead, the COA indicated Patient 17's next of kin (a person's closest living relative) "gave verbal consent via telephone," which only AR 2 witnessed. Aside from the AR 2, there was no other staff who witnessed the verbal consent for Patient 17 ' s COA.

During an interview with the AM, on 5/16/2025, at 10:48 a.m., the AM confirmed that the facility's policy & procedure (P&P) indicated if a verbal consent was given to acknowledge the COA, there should be two witnesses required per facility policy.

During a review of the facility's P&P titled "Conditions of Admission - Admitting Consent Forms," last reviewed 2/2022, the P&P indicated, "If the patient is physically unable to make a mark ..., but can express his/her agreement to the terms of the form (either having read it or having it read to them), by nodding yes or stating yes, then this shall be witnessed by two people, who will state that they witnessed the patient's agreement to the terms of the form."

Based on interview and record review, the facility failed to provide consent for surgery (document indicating the patient understands the purpose of the indicated procedure and understands the pros and cons of the procedure) in patient's preferred language for one of 30 sampled patients (Patient 25). This deficient practice may lead to Patient 25 decision which was not based on the complete knowledge of the procedure ' s risk, benefits and alternatives and not in the patient ' s best interest.



Findings:



During an interview on 5/16/2025 at 11:30 AM, the RMD (Risk Management Director) stated she did not know if Patient 25 ' s consent for ORIF (Open Reduction Internal Fixation, surgery used to repair fractures, where the broken bone is repositioned, open reduction, and then held in place with surgical hardware, internal fixation, like screws or plates) of the right femur (thigh bone) needs to be in Patient 25 ' s preferred language; only that a responsible party translated the details of consent for this surgery to Patient 25.



During a review of the ' History and Physical ' (H&P, a formal and complete assessment of the patient and the problem) for Patient 25, dated 5/12/2025, indicted last night Patient 25 slipped and fell onto his right leg; an x-ray showed a comminuted fracture (bone broken into several pieces) of Patient 25 ' s right femur.

During a review of the ' Consultation ' dated 5/12/2025, the Consultation confirmed that there was a comminuted fracture (bone broken into several pieces) of Patient 25 ' s right femur, and the plan was for an ORIF of the right femur on 5/13/2025.



During a review of the ' Adult Patient Profile ' , this document indicated the following regarding Patient 25: language assistance is required, Chinese is the preferred spoken language, Chinese is the preferred language read, there is an alternative decision maker for this hospitalization, there is a designated caregiver (Patient 25 ' s daughter).



During a review of the ' Consent for Surgery or Special Procedures ' dated 5/12/2025 and signed by Patient 25 ' s daughter, indicated a right distal femur open reduction internal fixation was performed on 5/12/2025. This consent form was written in English.



During a review of the ' Consent for Surgery or Special Procedures ' dated 5/15/2025 and signed by Patient 25 ' s daughter, another consent document indicated a right foot soft tissue and bone debridement (procedure where dead, damaged, or infected tissue is removed from a wound to facilitate healing) was performed on 5/15/2025. This consent form was written in English.



During a review of the policy ' Patients ' Rights/Responsibilities ' #MA700, revised date 2/2022, indicated the Consent to Surgery or Special Procedures form must have signature by patient or patient ' s legal representative. Name and method of interpretation (explanation), if needed. If a patient or his legal representative cannot communicate with the physician because of a language or communication barrier, will arrange for interpretation. The name and method of interpretation will be documented on the consent form.

Based on observation, interview, and record review, the facility failed to follow and implement the facility's falls prevention policy for one of 30 sampled patients (Patient 14). This deficient practice placed patients at risk for falls and injury.



Findings:



During a review of Patient 14's History & Physical (H&P - a formal and complete assessment of the patient and the problem), dated 5/13/2025, at 11:00 a.m., the H&P indicated Patient 14 was admitted to the facility after falling in the bathroom at home.



During a review of Patient 14's "Adult Assessment Intervention" flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 5/15/2025, at 8:00 a.m., the flowsheet indicated Patient 14 scored a 70 on the Morse Fall Scale (a tool used to assess a patient's risk of falling in a healthcare setting-0-26-low fall risk, no interventions (planned actions), 25-45-moderate (common) fall risk and 45 and above-high fall risk implement (start) high risk fall preventions).



During a concurrent observation and interview, on 5/15/2025, at 10:22 a.m., with Registered Nurse (RN) 2, Patient 14 was observed laying in bed. RN 2 stated Patient 14 was admitted to the facility due to falling at home, which placed them at a high risk for falls. On Patient 14's right wrist was a hospital identification wristband with name, date of birth, and medical record number, but there was no other band present on either wrist. RN 2 stated Patient 14 was supposed to have a yellow-colored wristband indicating their high fall risk and confirmed that it was not present. RN 2 further stated it was important for patients to have that wristband because it served as a visual warning indicator to the nursing staff to pay attention to the patients' safety.



During a review of the facility's policy and procedure (P&P), titled "Falls Prevention," last reviewed 5/2024, the P&P indicated, "Interventions will be selected and implemented by the health care team and warranted for all those inpatients scoring 25 or greater on the modified Morse Fall Scale: ... Provide yellow fall risk armband."

Based on observation, interview and record review, the facility failed to:

Ensure one of thirty sampled patients (Patient 1) were free from all forms of abuse care while he was in Emergency Department (ED) on 3/26/25 for Alcohol detoxification (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream).



Ensure the facility staffs follow facility policy and procedure in dealing with the aggressive patient or physical assault situation.



Ensure the facility staffs follow their policy and procedure for reporting any abuse allegation to supervisor and risk management immediately.



Ensure the alleged perpetrator was removed immediately from the patient care area for further potential harm to other patients.



This deficient practice resulted in Emergency Room Technician (ERT) inappropriately responding by physically assaulting Patient 1 after getting provoked by Patient 1.

On 5/15/2025, at 11:30 a.m., the survey team called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) situation in the presence of the Chief Quality Officer (CQO), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Risk Management Director (RMD), Director Quality and Chief Medical Officer (CMO).



On 3/26/25 at 9:47 p.m., Emergency Room Technician (ERT) hit Patient 1 four times on his face and head area after provoked (to anger a person) by Patient 1. The Emergency Department charge nurse (EDCN1) did not report this incident to higher management immediately per facility policy. ERT was not removed from patient care area immediately that may cause potential harm to other patients. The facility failed to

Ensure one of thirty sampled patients (Patient 1) were free from all forms of abuse while Patient 1 was in Emergency Department (ED) on 3/26/25 for Alcohol detoxification (a person consumes enough alcohol to impair their cognitive (reasonable) function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream).



Ensure the facility staffs follow their policy and procedure in dealing with the physical assault (violent use against another person) which happened.



Ensure the facility staffs follow their policy and procedure for reporting any abuse allegation to supervisor and risk management (process use to identify risks that can harm the organization).



Ensure the alleged perpetrator (a person who carry out a harmful act) was removed from the patient care area for further potential harm to other patients.



The IJ Removal Plan indicated:

On 3/27/2025 at 9:30a.m., the organization placed the employee on administrative suspension. The employee ' s suspension continues pending the completion of the termination process.

On 3/27/2025 (five employees total) - 03/31/2025 (two employees total), the Director of Risk Management reinforced the escalation ( a rapid increase) expectations with the staff during the preliminary investigative interviews.

On 3/28/2025, the Emergency Department Director provided coaching to the Register Nurse (RN) Lead to review the appropriate steps to follow for escalation.

On 5/15/2025, the Emergency Department Director & Medical Director conducted immediate staff huddles on the topics of "De-escalation (process of reducing a violent situation) & Chain of Command." No Emergency Department (ED) Staff member will be engaged in patient care until such training is received. This education included review of policy MA710 and will continue each shift until the online training module has been deployed on 5/16/2025 (see attached outline).

On 5/15/2025 at 1630, Administration conducted a leadership huddle with organizational leaders that included a review of MA710 and organizational expectations of escalation of information in the event of an abuse allegation (see transcript for attendance).

The organization will create an online learning module reviewing the expectations related to workplace violence events where actual or potential physical assaultive behavior from a patient towards the staff occurs. This online module will emphasize the process for de-escalation, which includes but is not limited to, removing oneself from the immediate vicinity of the patient for safety. The module will be deployed on 5/16/2025; with completion by ED staff by 5/31/2025. All patient-facing staff will complete the training module by 7/31/2025.

Continue the "Healing Environment" (see signage below) campaign. The Executive Team, in conjunction with Risk Management team will make face-to-face contact with staff throughout the organization during the month of June promoting a healing environment concluding on 6/30/2025.

The hospital Director of Threat Assessment and Management has initiated targeted de-escalation training with the Emergency Department beginning on 5/16/2025 and will continue until 100% of active staff have received the education.

Posters created as a visual cue (provide information) to direct staff to activate Code Gray (security code for aggressive behavior) to be posted in workstations in the emergency department, and the nursing stations





Finding:



A review of Patient 1 ' s Emergency Department (ED) Provider note dated 3/26/2025 indicated Patient 1 was brought into the ED by Emergency Medical Service (EMS) for alcohol intoxication (a person consumes enough alcohol to impair their cognitive function, behavior, and physical coordination. It is a temporary condition caused by the presence of excessive alcohol in the bloodstream).



During a review of the facility ' s security camera video with the Risk Management Director (RMD) and Clinical Supervisor (CS), the video showed a staff to patient abuse allegation occurred on 3/26/2025 at 9:45 p.m., Patient 1 was sleeping and lying on a gurney (bed with wheels) in the hallway of the ambulance bay; Emergency Room Technician (ERT) was trying to wake Patient 1 by shaking Patient 1 ' s chest and shoulder. At 9:47 PM Patient 1 swung his left arm toward ERT once and ERT stepped back then punched Patient 1 four times on Patient 1 ' s head and face area.



During an interview with Clinical Supervisor (CS) on 5/14/25 at 1:29 pm, stated that facility does not have a policy indicating that staff was allowed to hit the patient even in an aggressive violence situation. Concurrently, CS stated that ERT was removed from main ED area and placed at fast-track area to work until the end of the shift.



During an interview with Risk Management Director (RMD) on 5/14/25 at 5:10 pm, stated the facility did not have a de-escalation (process of reduce violent situation) policy. Facility was using Work Plan Violence (WPV) Plan which indicated that security officers were responsible for responding to a violent incident without placing themselves in danger and were responsible for correcting any workplace violent hazard in the incident - including verbal de-escalation techniques. Concurrently, RMD stated that staff should have let security handle the aggressive situation.



During an interview with Clinical Supervisor (CS) on 5/14/25 at 2:05 pm, stated the charge nurse (CN1) did not report this staff to patient abuse allegation to house supervisor. Concurrently, CN1 reported this patient abuse allegation around 7:00 am on 3/27/25 when CS arrived at work. Abuse incident occurred on 3/26/2025. ERT was reassigned to a new patient care area until the end of the shift at 7:00am on 3/27/25.



During an interview with Emergency Department Registered Nurse (RN) 1 on 5/14/25 at 3:09 p.m. who stated that ERT, who was assigned to the main ED, and the other tech who was previously working in the fast-track area switched assignments after the incident occurred. ERT went to the fast-track area to resume patient care duties.



During an interview with Risk Mangement Director (RMD) on 5/14/25 at 2:05 p.m. who stated that she and CS notified Human Resources (HR) the morning after ERT ' s night shift, HR placed him on administrative leave. ERT was placed on administrative leave pending investigation.



A review of Patient 1 ' s ED provider note dated 3/26/25, indicated that Patient 1 had laceration on left superior periorbital (around the eye) region, appears 1.25 cm in length and is linear (straight) and superficial (outside) in appearance. Also, Patient 1 had laceration (deep tear in the skin) on left superior scalp (skin on top of the head) that appeared to be two separate opens since one wound size was measured 0.5cm and one wound size was measured 2.5 cm in length for a total of 3 cm of length. Computed Tomography (CT) Brain (detail x-ray) without contrast was done and the report indicated no acute intracranial abnormality.



A review of the facility ' s policy & procedure titled "Patient Allegations of Abuse During Hospital Visit", last reviewed 4/2022, indicated that Hospital staff will immediately contact the risk manager or nursing supervisor when a patient or family member alleges abuse of any patient by hospital staff, whether or not the staff feels the allegation is credible.



A review of the facility ' s policy & procedure titled "Patient Rights/Responsibilities," last reviewed 2/2022, indicated, "Patients have a right to: ... Receive care in a safe setting, free from mental, physical, sexual or verbal abuse or neglect, exploitation or harassment."