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Based on record review and interview, the hospital failed to ensure:

1. Policy was followed for one (Patient #3) of four patients reviewed.
2. Medical Staff bylaws were followed for one (Patient #3) of four patients reviewed.
3. One set of Medical Staff bylaws for one (Carrus Lakeside Hospital) of one hospitals reviewed.

POLICY and MEDICAL STAFF BYLAWS NOT FOLLOWED

Review of the medical record for Patient #3 did not show documentation of pronouncement of death by a physician assistant or an attending or covering physician. Specifically:

1. A document titled "RELEASE OF BODY" read in part, "Patient pronounced by: [name withheld] APRN ...Date/Time: 3/17/2025 0943 [9:43 AM]."

Review of a policy titled "Death Determination (including Brain Death) and Death Pronouncement" with a review date of 07/29/24 read in part, "Registered nurses employed by Carrus Hospitals may pronounce death for patients who are not on artificial means of life support or patients who are brain dead ...Note: Per the Medical Staff and Governing Board, a registered nurse or physician assistant may determine and pronounce a person dead in situations other than those described in #2 above."

Review of a document titled "MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES" adopted September 13, 2023 and restated August 12, 2024 read in part, "In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician or two hospital-employed Registered Nurses."

On 05/15/25 at 5:11 PM, Staff E reviewed the medical record and medical staff bylaws and stated:

1. They thought the bylaws were revised to include nurse practitioners when the hospital opened as Carrus.
2. Nurse practitioners or ED providers can pronounce patient death.
3. Registered nurses cannot pronounce patient death.


ONE SET OF BYLAWS

Review of two different sets of medical staff bylaws showed no change in the adoption date or the restated date. Specifically:

1. A document titled "MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES" was provided to the surveyor on 05/15/25 at 10:08 AM. It read in part, "Adopted September 13, 2023 Restated August 12, 2024...A-10. Hospital Death: In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician or two hospital-employed Registered Nurses."
2. A document titled "MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES" was provided to the surveyor on 05/15/25 at 5:50 PM. It read in part, "Adopted September 13, 2023 Restated August 12, 2024...A-10. Hospital Death: In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician, advanced practice provider (NP or PA), or two hospital-employed Registered Nurses."

On 05/15/25 at approximately 6:15 PM, Staff B stated the hospital must have two versions of the medical staff bylaws.

Based on record review and interview, the hospital failed to ensure:

1. Provider notification for one (Patient #3) of four patients reviewed.
2. Congruent nursing documentation for one (Patient #3) of four patients reviewed.


PROVIDER NOTIFICATION

Review of the medical record for Patient #3 showed the patient had a heart rate of 120 and showed no documentation of physician notification by nursing. Specifically:

1. The Emergency Nursing Record read in part, "Triage Date 2/1/25 Time 1830 [6:30 PM] ...Vitals ...P [pulse] 120." Tachycardia was circled to indicate positive for tachycardia.
2. The Emergency Physician Record at 8:28 PM showed: no checkmarked box to indicate nursing assessment reviewed or vitals reviewed; the fields for vital signs were blank; a checkmarked field for regular rate and rhythm with no rate indicated.
3. The Emergency Nursing Record read in part, "Discharge Vitals ...P [pulse] 130."

On 05/15/25 at 2:43 PM, Staff C reviewed the medical record and stated the nurse needed to notify the provider and they did not see where that was done.

On 05/15/25 at 4:52 PM, Staff E reviewed the medical record and stated the provider was supposed to check the boxes showing nursing assessment and vital signs were reviewed.

CONGRUENT DOCUMENTATION

Review of the medical record for Patient #3 showed the patient had a heart rate of 120 and showed a normal cardiovascular system (CVS) assessment. Specifically:

1. The Emergency Nursing Record read in part, "Triage Date 3/16/25 Time 1212 [12:12 PM] ...Vitals ...P [pulse] 120." The document showed CVS assessment with a checkmarked field for regular rate with no other rate indicated and showed a backslash through the word tachycardia to indicate negative for tachycardia.

On 05/15/25 at approximately 2:56 PM, Staff C reviewed the medical record and stated they would expect tachycardia to be documented as positive for a heart rate of 120.

Based on record review and interview, the hospital failed to ensure correct timestamp for one (Patient #3) of four patient charts reviewed.

Patient #3

Review of the medical record showed an EKG strip with a timestamp that did not coincide with the patient's hospital visit. Specifically:

1. The Emergency Physician Record read in part, "DATE: 03/17/25 TIME SEEN: 0925 [9:25 AM] Reason [withheld]."
2. An EKG strip read in part, "08:44:14 [8:44 AM] 17-MAR-25 [03/17/25] [rhythm withheld]." (41 minutes before patient's arrival to the hospital)

On 05/15/25 at approximately 3:19 PM, Staff C reviewed the medical record and stated the time on the hospital's EKG strip was not correct.