Chi-St Vincent Infirmary

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 52740 Based on review of policy and procedure, review of patient clinical charts, and interview with staff, it was determined the facility failed to provide care to all patients as needed by performing ongoing assessments of patient needs. Findings follow: A. Review of CHI St. Vincent “Core Nursing Standards of Practice” policy effective date 03/12/2021, showed: Assessment- The registered nurse (RN) performs and/or oversees the collection of pertinent data and information relative to the patient’s health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record. 1) A focused assessment for chief complaints should be completed withing 30 minutes of admission. 2) Physical assessment should be completed withing 4 hours of admission, within 4 hours of the start of each shift, and PRN for change in condition. 3) The registered nurse should screen patients for falls, skin risk, sepsis, mobility and suicide. The following screenings should be completed within 4 hours of admission, within 4 hours of start of each shift and PRN for change in patient condition: fall risk, skin risk, sepsis, and patient mobility/safe lift. A suicide risk screening should be completed upon admission and PRN. B. Review of 20 clinical patient (#10 current patients and #10 discharged patients) charts showed that 3 (#13, #16, and #20) of 20 (#1-#20) patients did not have their admission assessment completed within the four hours allowed by policy: 1) Patient #13 was admitted to in-patient services on 06/23/2025 at 1:28 PM. The hospital charting system auto-initiated the “Admission Assessment and History using the Nursing Admission page” at 2:24 PM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 7:57 PM on 06/23/2025. 2) Patient #16 was admitted to in-patient services on 06/04/2025 at 6:14 AM. The hospital charting system auto-initiated the “Admission Assessment and History using the Nursing Admission page” at 6:14 AM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 5:16 PM on 06/04/2025. 3) Patient #20 was admitted to in-patient services on 05/09/2025 at 3:38 AM. The hospital charting system auto-initiated the “Admission Assessment and History using the Nursing Admission page” at 4:42 AM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 7:30 PM on 05/09/2025. C. Finding in A-B were confirmed with Chief Nursing Officer (CNO) during exit interview at 3:30PM on 07/02/2025.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50014 Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and/or individualize an interdisciplinary integumentary plan of care for 2 (#6 and #8) of 10 (#1-#10) patients in that the facility failed to provide a Wound Care Nurse consultation per established policy. The failed practice did not assure the skin care policies were followed to prevent further skin breakdown. The failed practice affected Patients #6 and #8 and had the likelihood to affect all patients admitted to the facility. Findings follow: A. Review of policy titled, “Skin Integrity, Care of the Patient with or at Risk for Impairment: dated 02/1994 along with Appendix A Central AR - HAPI Prevention Interventions” showed to consult a wound nurse for a Braden Score less than 14 or less. B. In an interview on 02/12/24 at 11:45 PM, the Director of Quality stated the process for the audit tool was to identify patients with a Braden Score of less than 15 without a wound consultation ordered. If the wound consultation was not ordered within 24 hours of the change in the Braden Score, the audit tool was shared with the nurse manager of the hospital department. The nurse manager then spoke with the registered nurse that omitted the order to hold them accountable. C. In an interview on 02/12/24 at 12:45 PM, the Director of Quality stated that 24 out of 54 patients with a Braden Score of less than 15 did not receive a wound consultation within 24-hours. Of the 24 patients, there were four patients that had more than three missed opportunities to obtain an order within 24 hours. D. Review of clinical records showed that Patient #6 and #8 with a Braden score less than 15 did not have wound consultations ordered within 24 hours of admission. 1. Review of the Integumentary Assessment on 01/30/24 at 11:00 PM, for Patient #6, showed a Braden score of 13 without a wound consult ordered within 24 hours per policy. 2. Review of the Integumentary Assessment on 01/30/24 at 1:40 PM, for Patient #8, showed a Braden score of 13 without a wound consult ordered within 24 hours per policy. 3. During an interview on 02/12/24 at 12:55 PM, the Wound Ostomy, and Continence Nurse (WOCN) confirmed knowledge of the Low Braden Score Daily Audit. WOCN confirmed that a Braden score of 15 or less should have had a wound consult order initiated by the registered nurse. WOCN confirmed that the patients that have had a wound/pressure ulcer were followed throughout the patient’s hospital stay.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47891 Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to provide a Medical Screening Exam (MSE) for 1 (#1) of 25 (#1-#25) patient presenting to the facility’s dedicated emergency department and failed to follow the facility’s established policy for workplace violence for one of one (#1) patient seen in the Emergency Department. The failed practice had the likelihood to affect any patient presenting to the Emergency Department and all Emergency Department staff. Findings follow: A. Review of policy and procedure titled, “CHI St. Vincent Policies and Procedures for the Examination, Treatment and Transfer of Individuals Who ‘Come to the emergency department’” revised 2019, showed that “The hospital will provide any individual, including any infant who is Born Alive at any stage of development, who ‘Comes to the Emergency Department’ an appropriate Medical Screening Examination (MSE) within the capabilities of the Hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the DED, to determine whether or not an Emergent Medical Condition (EMC) exists, regardless of the individual’s ability to pay. The MSE will be conducted by an individual(s) determined qualified by the Hospital bylaws or rules and regulations.” B. Review of the facility’s policy titled, “Workplace Violence Prevention - CHI ST. Vencent Infirmary,” showed, “Acts or threats of physical violence, including but not limited to, coercion, intimidation, harassment, or destruction of property that involves or affect patients, visitors, vendors, staff, volunteers, physicians and contract employees of SVHS will not be tolerated. Incidents of assault or battery: Call security or designee of the incident and involve them in the initial securing of the area. If Security or designee is not available on site, call 911. At the earliest opportunity thereafter, notify the identified site security leader of the incident. An IRIS report (incident report) should be completed in addition to the standard security report. Post Incident Actions: Immediately, create an IRIS report.” C. Review of Patient 1’s ED (Emergency Department) Event Note dated 11/06/2023 showed the following: 1) 9:50 PM: ED Event Location: Lobby. ED Description of Event: Patient was brought in by (Named Ambulance Service), paramedic reported patient was picked up at a church, but he had walked around to an alley. The patient was in a Motor Vehicle Accident (MVA) on Saturday and was having pain in his left (L) leg and arm but there were no obvious deformities or bleeding. (Named Ambulance Service) took the patient to triage/waiting room area and was placed in a wheelchair, paramedic then rolled patient over to a waiting room chair and propped L foot on the chair. 2) 9:55 PM: Security approached patient and asked patient to remove foot from the chair. Patient reported the worker put it there and yelled at the security officer. (Named nurse) triage nurse went out of waiting area and saw patient with his L foot on top of chair and right (R) foot underneath holding chair by the cushion. (Named nurse) then instructed patient he was not to have feet propped in chairs due to (d/t) sanitary reasons. The patient began to yell louder, and security assist was called to Emergency Room (ER) lobby. 3) 10:00 PM: This nurse presented to lobby and witnessed patient with feet holding chair by the cushion and lying on side in the wheelchair. The named nurse informed me of the situation and this nurse approached the patient. I asked patient to sit properly in the wheelchair, patient refused, then I asked patient to remove his foot from the waiting room chair and he refused. This nurse informed patient that we did not allow patients to lie in chairs or prop feet up in them, patient stated “well the girl put it there” and I replied “I understand that but she does not work for us and we will have to roll you in the wheelchair and cannot roll you if you are laying like this in it,” patient yelled “I don’t care, they put me like this and I’m hurting, put me back on that (expletive) bed then.” Patient was told that the ambulance that brought him was unavailable and could not do that. I stated, “I’m sorry but you will have to sit up in this wheelchair properly.” Pt continued to refuse. This nurse then stated “Sir, all we are asking is for you to cooperate, so either you can or we can call the police and you can leave,” Patient yelled “Call the police.” The security present then made call to call (Named Local Police Department). This nurse walked away and watched in the waiting room near triage door as patient laid in the wheelchair with 4 security guards around him. One security guard continued to ask the patient to just cooperate, patient then used his right arm and R hand balled in a fist and swung in at the security guard’s face, patient was then picked up out of the wheelchair and taken outside by security.” D. During an interview on 02/12/2024 at 2:45 PM, Clinical Director confirmed the findings in B. E. During an interview on 02/12/2024 at 2:45 PM, when this surveyor asked Clinical Director if the patient received a MSE the Clinical Director replied. “It doesn’t look like he did because he became violent.” F. A request was made to the Director of Regulatory Compliance for the IRIS or Security report related to Patient #1. G. Email received on 3/20/2024 at 3:57 PM provided by Director of Regulatory Compliance, confirmed there was no IRIS or Security report completed for Patient #1.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47891 Based on review of policy and procedure, clinical records and interview, it was determined the facility failed to conduct an appropriate transfer for two (#2 and #3) of five (#2-#6) patients transferred from the emergency department to other facilities emergency departments in that the facility failed to complete the “Patient Transfer Summary Form” which identified the risks and benefits of the transfer to the patient/patient’s representative and the notification and acceptance of the receiving facility. The failed practice did not ensure the patient/patient’s representative was informed of the risks and benefits of the transfer and failed to ensure the accepting facility had the capacity and capability to treat the patient. The failed practice had to likelihood to affect all patients transferred out of the facility. The findings follow: A. Review of policy and procedure titled, “Model Policies and Procedures for the Examination, Treatment and Transfer of Individuals in Need of Emergency Medical Services,” showed that exhibit B Patient Transfer Summary Form should be completed prior to transfer of individuals. B. Review of Patient #2’s clinical record showed Patient #2 was admitted to the dedicated emergency room via ambulance for a gunshot wound (GSW) and multiple injuries related to a third-floor fall. Patient #2 required a higher level of care for open fracture and arterial involvement. Documentation showed that Patient #2 was transferred to another facility. There was no evidence the Patient Transfer Summary Form was completed. C. The findings in A and B were confirmed with the Clinical Director on 02/12/2024 at 2:45 PM. D. Review of patient #3’s clinical record showed that patient #3 was admitted to the dedicated emergency department with a diagnosis of pneumonia. Patient #3 required a higher level of care at a dedicated pediatric facility. Patient #3 was transferred to another facility via ambulance. There was no evidence the Patient Transfer Summary Form was completed. E. The findings in A and C were confirmed with the Clinical Director on 02/12/2024 at 2:45 PM.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50014 Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and/or individualize an interdisciplinary integumentary plan of care for 2 (#1 and #6) of 13 (#1-#13) patients in that: 1) The facility failed to provide a hospital wound care nurse consultation per established policies. 2) The facility failed to develop an individualized interdisciplinary integumentary plan of care to assure the skin care policies, and orders were followed to prevent further skin breakdown. The failed practices did not assure the skin care policies were followed to prevent further skin breakdown and did not assure patients were protected from the likelihood of an injury; the nursing staff could determine when a wound had occurred or improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patient #1 and #6 and had the likelihood to affect all patients admitted to the facility. Findings follow: A. Review of policy titled, “Skin integrity, Care of the Patient with or at Risk for Impairment,” dated 02/1994 along with “Appendix A Central AR - HAPI Prevention Interventions” showed the following: 1) Skin assessments were to be conducted on admission and each shift. 2) Turn patient every 2 hours initiated or clear documentation that the patient can self-turn. 3) Elevate heels off the bed or chair by bridging to leave the heel completely open. May use heel boots or pillows. 4) Pad bony prominences to prevent friction/shear (utilize pillow and Allevyn borders as indicated). 5) Limit time in chair to 1 hour unless patient can shift weight. 6) Consult wound nurse. 7) Pressure ulcers were to be staged and measured in the admission assessment and repeated weekly. 8) Patients with intact skin and Braden score of 14 or less or have high risk diagnosis were to implement “Moderate Risk” or “High Risk” interventions and have preventative measures (consult wound nurse, pressure redistribution mattress, turning every two hours and protective barrier) implemented. 9) Pressure ulcers were to be documented in the wound assessment section of the patients’ chart. 10) Pressure ulcers would be photographed on admission, upon detection and weekly by the Wound Ostomy Continence Nurse (WOCN). B. Review of policy titled, “Core Nursing standards of Practice,” dated 01/2022 showed the following: 1) Two licensed clinicians would perform skin assessments on admission, upon discovery, and upon transfers from another unit/department. The Registered Nurse (RN) would perform skin assessment with each shift. 2) Upon discovery of a suspected pressure injury/wound injury, a wound consult be requested. 3) Photograph all wounds/pressure injuries on admission, discovery, weekly, prior to discharge, and/or change in wound status. 4) The RN would develop and implement a plan to provide safe, effective, and efficient patient-centered care. 5) Interprofessional teams were to be consulted according to the patient’s condition and health needs. C. During an interview on 11/29/2023 at 12:45 PM, the WOCN confirmed that a Braden score of 14 or less a wound consult order should be initiated. WOCN confirmed that with a Braden score of 12 patients would be high risk. WOCN confirmed that patients should be turned every 2 hours when the Braden score was 14 or less. WOCN confirmed that patients should be in wheelchair/chair for no more than 1 hour if able to shift weight. WOCN confirmed that wound/pressure ulcers were photographed the day they were found. WOCN confirmed that the WOCN should be consulted when a wound/pressure ulcer was discovered. D. Review of Patient #1’s Clinical record on 11/28/2023, showed the following: 1) Patient #1 was admitted on 9/17/2023 at 8:12 PM with the following diagnosis: Failure to Thrive. 2) On admission, emergency room RN documented Braden score of 14. 3) Braden score of 14 or less per orders should have consult for WOCN nurse. There was no evidence of an order for WOCN consult. 4) On 9/22/2023 at 8:00 PM, Braden Score changed to 12. There was no evidence of an order for WOCN consult. 5) Patient was not repositioned consistently every 2 hours beginning on dates 9/18/2023-10/2/2023, for example: 9/24/2023 patient not repositioned from 12:10 PM to 5:20 PM. 6) Patient sat in wheelchair/chair for longer than 1 hour, for example: 9/22/2023 from 11:00 AM to 7:00 PM. 7) On 9/23/2023 at 7:19 AM, skin tear to the right elbow documented. There was no evidence of a picture of the wound or an order for WOCN consult or Allevyn dressing that was applied to the wound. 8) During an interview on 11/28/2023 at 1:00 PM, the Quality director confirmed the findings of patient #1. E. Review of Patient #2’s Clinical record showed the following.: 1) Patient #2 was admitted on 11/27/2023 3:00 AM, with the following diagnosis: Congestive Heart Failure exacerbation per nutrition assessment on 11/27/2023 12:04 PM. 2) Braden score of 14 or less per orders should have consult for WONC nurse. There was no evidence of an order for WOCN consult. 3) During an interview on 11/29/2023 at 1:30 PM, the Quality Director confirmed the findings of patient #2. 4) On 11/27/2023 7:00 AM, Braden Score changed to a 13. There was no evidence of an order for WOCN consult.”