St Joseph’s Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 43788 Based on the review of documents and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations, functions, and responsibilities are able to provide a safe and healthy environment for the patient population. These deficient practices pose a potential risk for patients of receiving inadequate care and treatment timely, which could lead to avoidable lengthy patient admissions, unwarranted development of disease complications, and probable poor patient prognosis. Findings include: A-0049: The hospital failed to ensure the quality of care provided by the medical staff was reported to and evaluated by the Governing Body. Cross reference: A- 0171, A-0178, A-0338, A-0353, A-0464 A-0057: The Chief Executive Officer failed to manage the daily operations of the hospital. Cross reference: A-0115, A0-144, A-0171, A-0178, A-0315, A-0338, A-0353, A-0385, A-0386, A-0392, A-0394, A-0397, A-0398, A-0464, A-0547 A-0115: The hospital failed to ensure patient rights were protected. Cross reference: A-0057, A-0144, A-0171, A-0178, A-0315 A-0144: The hospital failed to ensure care was provided in a safe setting allowing a patient with suicidal ideations to elope from the hospital. Cross reference: A-0057, A-0115, A-0315, A-0385, A-0386, A-0392, A-0397 A-0171: The hospital failed to ensure restraint orders were renewed after the four hour expiration and a patient was not in restraints without a current order in place. Cross reference: , A-0049, A-0057, A-0338, A-0353 A-0178: The hospital failed to ensure medical staff conducted an in-person face-to-face evaluation one hour after a patient was placed in restraints. Cross reference: A-0049, A-0057, A-0338, A-0353 A-0315: The Governing Body failed to ensure the hospital was provided with adequate staff and resources to keep patients safe and meet patient needs. Cross reference: A-0057, A-0115, A-0385, A-0386, A-0392, A-0397 A-338: The Governing Body failed to ensure medical staff were accountable for quality care. Cross reference: A-0049, A- 0171, A-0178, A-0353, A-0464 A-0353: The Governing Body failed to ensure medical staff abided by medical staff bylaws. Cross reference: A-0049, A- 0171, A-0178, A-0338, A-0464 A-0385: The hospital failed to ensure nursing services were provided to patients. Cross reference: A-0043, A-0057,A-0115, A-0144 A-0315, A-0386, A-0392, A-0394, A-0397, A-0398 A-0386: The hospital failed to ensure the Nurse Executive was responsible in ensuring proper nursing services were being provided. Cross reference: A-0043, A-0057, A-0315, A-0385, A-0392, A-0394, A-0397, A-0398 A-0392: The hospital failed to ensure there was sufficient numbers based on patient acuity to meet the needs of patients. Cross reference: A-0043, A-0057, A-0315, A-0385, A-0386, A-0397 A-0394: The hospital failed to ensure that all nursing personnel had documented, current required licensure. Cross reference: A-0043, A-0057, A-0385, A-0386 A-0397: The hospital failed to ensure: 1. Staff were knowledgeable about the acuity plan and how to implement it; 2. the acuity plan included the maximum patient acuity level for each nurse to ensure safe and equitable nursing patient care assignments. Cross reference: A-0043, A-0057, A-0115, A-0144, A-0315, A-0385, A-0386, A-0392 A-0398: The hospital failed to ensure that one Constant Observer has completed competencies on file before providing patient care. Cross reference : A-0057, A-0385, A-0386 A-0464: The hospital failed to ensure ordered specialty consultation was performed within the required 24 hour timeframe. Cross reference: A-0043, A-0049, A-0057, A-0338, A-0353 A-0547: The hospital failed to ensure one Radiology Technician had a current BLS certification, Competencies and new staff orientation completed and in the employee file before providing patient care services. Cross reference: A-0057 The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43788 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: A-0144: The hospital failed to ensure care was provided in a safe setting allowing a patient with suicidal ideations to elope from the hospital. Cross reference: A-0043, A-0057, A-0315, A0-385, A-0392, A-0397 A-0171: The hospital failed to ensure restraint orders were renewed after the four hour expiration and a patient was not in restraints without a current order in place. Cross reference: A-0043, A-0049, A-0057 A-0178: The hospital failed to ensure medical staff conducted an in-person face-to-face evaluation one hour after a patient was placed in restraints. Cross reference: A-0043, A-0049, A-0057 A-0315: The Governing Body failed to ensure the hospital was provided with adequate staff and resources to keep patients safe and meet patient needs. A-0043, A-0057, A-0315, A0-385, A-0392, A-0397 The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 43788 Based on the review of records and staff interviews, it was determined that the Medical Staff failed to provide quality patient care as stated in the by-laws as evidenced by: Cross reference: A-0043, A-0057 A0049: The Governing Body failed to ensure the Medical Staff were accountable for quality patient care. A-0171: Medical Staff failed to ensure restraint orders were current when a patient was in restraints. A-0178: Medical Staff failed to ensure a face-to-face evaluation was conducted within one hour of a patient being placed in restraints. A-0464: Medical Staff failed to ensure a specialty consult was performed within the required 24 hour timeframe. The cumulative effect of these systemic problems resulted in the medical staff’s inability to ensure the provision of quality patient care.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43788 Based on the review of documents,observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following references to standard-level deficiencies: Cross reference: A-0043 A-0144: The hospital failed to provide care in a safe setting. A-0315: The hospital failed to ensure there was adequate staffing and resources to meet the needs of patients. A-0386: The hospital failed to ensure the Nurse Executive was responsible in ensuring proper nursing services were being provided. Cross reference: A-0392: The Nurse Executive failed to ensure there was sufficient numbers based on patient acuity to meet the needs of patients. A-0394: The Nurse Executive failed to ensure that all nursing personnel had documented, current required licensure. A-0397: The Nurse Executive failed to ensure: 1. Staff were knowledgeable about the acuity plan and how to implement it; 2. the acuity plan included the maximum patient acuity level for each nurse to ensure safe and equitable nursing patient care assignments. A-0398: The Nurse Executive failed to ensure that one Constant Observer has completed competencies on file before providing patient care. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 43788 Based on record reviews and staff interview, it was determined the hospital failed to ensure the quality of care provided by the medical staff was reported to and evaluated by the Governing Body. This failure poses the risk of medical staff providing patient care that does not align with Governing Board standards, and no analysis of the quality of care is provided. Cross reference A-0043, A- 0171, A-0178, A-0338, A-0353, A-0464 Findings include: Policy titled, “Professional Staff Bylaws”, revealed: “...The Professional Staff is also responsible for ensuring the following: 1. All individuals receive appropriate quality care without regard to gender, race, color, creed, sexual preference, religion, national origin, marital status, disability, existence of advanced directives, payor source or any other prohibited reason....” Policy titled, “Professional Staff Rules and Regulations”, revealed: “...Every patient is under the care of a doctor of medicine or osteopathy. All diagnostic and treatment services of the hospital shall be under the direction of a professional staff member...Members of the Professional Staff admitting and attending patients shall be held responsible for getting as much information as may be necessary to assure the protection of the patient from self-harm and to ensure the safety of other patients in the hospital...Each member of the Professional Staff is required to provide or arrange for the provision of appropriate and continuous care of his/her patients at all times...Each member also agrees to provide appropriate and necessary emergency and non-emergency medical treatment within the scope of his/her documented privileges to any patient seeking such treatment...The attending/admitting practitioner shall be responsible for the preparation of complete and legible medical record for each patient she/he admits to the Hospital...The Practitioners following the patient’s care are responsible for updating the progress notes on a daily basis so that documentation accurately reflects the current information and care provided...General Conduct Of Care: Each member of the Professions Staff must assure timely and appropriate medical care for inpatients and outpatients under their when it is their duty to do so...The attending practitioner is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant...Consultation response times are defined as follows: a) Routine: Consultation will be performed within twenty-four (24) hours. b) Urgent: Consultation will be performed within twelve (12) hours. c) Emergent: Consultation will be performed within four (4) hours...The consultant will complete preliminary note in the progress notes section of the patient’s medical record when assessing the patient and dictate a complete consultation note within 24 hours of initial patient assessment....” The medical staff was not held accountable as evidenced by: A-0171: Failure to ensure a restraint/seclusion order was renewed after four hours; A-0178: Failure to ensure patients placed in restraints received a face-to-face evaluation; A-0179: Failure to ensure A-0353: Failure to comply with Professional Staff Rules and Regulations; A-0464: Failure to ensure a Psychiatric Consult was completed within the required 24 hour timeframe.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 43788 Based on review of documents, observations, and interviews, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients. Cross reference: A-0043 Findings include: Job description for the Chief Executive Officer revealed: “...The Chief Executive Officer has overall operational responsibility and oversight for St Joseph’s Hospital....” It was determined the CEO failed to manage to manage the day-to-day operations of the hospital as demonstrated by the following: A-0115: The Administrator failed to ensure patient rights were protected. A-0144: The Administrator failed to ensure care was provided in a safe setting allowing a patient with suicidal ideations to elope from the hospital. A-0171: The Administrator failed to ensure restraint orders were renewed after the four hour expiration and a patient was not in restraints without a current order in place. A-0178: The Administrator failed to ensure medical staff conducted an in-person face-to-face evaluation one hour after a patient was placed in restraints. A-0315: The Administrator failed to ensure the hospital was provided with adequate staff and resources to keep patients safe and meet patient needs. A-338: The Administrator failed to ensure medical staff were accountable for quality care. A-0353: The Administrator failed to ensure medical staff abided by medical staff bylaws. A-0385: The Administrator failed to ensure nursing services were provided to patients. A-0386: The Administrator failed to ensure the Nurse Executive was responsible in ensuring proper nursing services were being provided. A-0392: The Administrator failed to ensure there was sufficient numbers based on patient acuity to meet the needs of patients. A-0394: The Administrator failed to ensure that all nursing personnel had documented, current required licensure. A-0397: The Administrator failed to ensure: 1. Staff were knowledgeable about the acuity plan and how to implement it; 2. the acuity plan included the maximum patient acuity level for each nurse to ensure safe and equitable nursing patient care assignments. A-0398: The Administrator failed to ensure that one Constant Observer has completed competencies on file before providing patient care. A-0464: The Administrator failed to ensure ordered specialty consultation was performed within the required 24 hour timeframe. Cross reference: A-0547: The Administrator failed to ensure one Radiology Technician had a current BLS certification, Competencies and new staff orientation completed and in the employee file before providing patient care services.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 43788 Based on review of documents, medical records, observations, and staff interviews, it was determined the Administrator failed to ensure that there were enough staff and resources available to prevent a patient (Patient #1) with suicidal ideations from eloping from the hospital. This deficient practice poses a risk to the health and safety of patient if patients are not provided a safe environment. Cross reference: A-0043, A-0057, A-0115, A-0315, A-0385, A-0392, A-0397 Findings include: Policy titled, “Constant Observer for Patients Under Harm Precautions”, revealed: “...Facilities will use Competent Constant Observer (CCOs) to provide continuous observation of a patient under suicide/self-harm and harm to others precautions to support safety...If the patient is suicidal/at risk of self-harm, the Facility should assign a CCO immediately...All CCOs must have a constant observer competency completed prior to starting their assignment....” Policy titled, “Code Gray-Combative Person without a Weapon”, revealed: “...Video monitoring and recording system provides surveillance throughout the hospital and grounds...Security personnel are onsite 24-hours a day, seven days a week...Secure Operations (Lockdown) procedure is available if facility needs to be locked down...Response: When a person and/or persons is combative and otherwise out of control, dial 3333 and advise the PBX/Operator of the situation...Attempt to keep situation confined by distancing patients, volunteers, family, and visitors...When the Code Gray is announced, all available associates within the immediate and surrounding areas (unit above, unit below and adjacent) respond to the scene if it is safe to do so...Security performs an assessment of the situation and directs responding associates, as appropriate....” Policy titled, “Leaving Against Medical Advice and Elopement Section: Provision of Care, Treatment, and Services”, revealed: “...all patients have a right to self-directed care, this hospital acknowledges that some patients may choose to leave the health care facility against medical advice...Definitions: Against Medical Advice (AMA) A patient with mental capacity decision to leave the health care facility before the treating physician recommends discharge...Elopement is a term when a patient leaves before treatment is complete without notification to the nursing unit...Roles and Responsibilities: Physician/APP are responsible to fully inform the patient/family about the risks of making the decision to leave the hospital before completing treatment...Physicians are responsible for assessing the patient’s capacity to make the decision to leave the facility and for determining whether the patient meets the criteria for involuntary psychiatric hospitalization...A Registered Nurse will promptly notify the attending physician/APP and my facilitate communication with the patient/family about the risks of leaving prior to medical discharge...Special Considerations: Whether it is believed that the patient has the ability to understand the risks of leaving the facility without completing his/her treatment and whether the patient is believed to be a threat to themselves or others...Discharge Against Medical Advice (AMA) Process Map: Escalating/Potential AMA situation: Immediate risk of harm> yes> Medical stabilization Refer to Patients at Risk of Suicide policy....” Policy titled, “Nursing Staffing and Acuity Plan” , revealed: “...Purpose: To ensure that Carondelet Hospitals have an acuity-based staffing plan that is established, documented, and implemented. The staffing and acuity plan will include: A. A method that establishes the types and numbers of nursing personnel that are required for each unit in the hospital. B. An assessment of the patient’s acuity, and the need for nursing services will be made by a registered nurse who is providing nursing services directly to the patient. C. The practice of utilizing A & B to arrange assignments for equitable and safe patient care...Consistent with the mission of Carondelet Hospital’s to improve the health of those we serve, each patient will be cared for in the safest, most effective and efficient manner possible...Each department will have their annual matrix as reference and guide...Carondelet Hospitals use a system to identify patients’ acuity levels which are specific based on hospital department. Inpatient Medical-Surgical, Telemetry, Progressive Care Unit, and Behavioral Health will utilize their tool via the electronic medical record, or on paper during downtime. The Intensive Care Unit (Neuro ICU, Medical ICU, and Trauma ICU) will utilize a paper acuity tool... Each acuity tool considers time sensitive and nursing specific interventions, as ordered by the provider and part of the plan of care, including but not limited to: Ability to perform ADLs, Airway management and treatments, Patient behavior, Frequency of medication management, Patient/family education, Specialized treatments/procedures....” Policy titled, “Plan for the Provision of Patient Care”, revealed: “...Security-Hospital Security: Hours of Operation: 24 hours a day, 7 days a week...The Security Department also provides emergency response services. These emergency responses included but are not limited to: fire response, combative person(s), Internal/external disasters and or security related emergency, pedestrian and traffic control, secure operations....” Policy titled, “Suicide Risk Assessment”, revealed: “...The purpose of this policy is to describe the process for assessing for risk and developing a plan of care for patients with suicidal/self-harm ideation...If the patient screens positive using the Columbia Suicide Severity Rating Scale (C-SSRS)...the nursing staff places the patient on one to one observation by a Competent Healthcare Provider...All patients screened with the Columbia Suicide Severity Rating Scale (C-SSRS) receive information on suicide prevention resources at the time of transfer or discharge....” Review of document titled, “Job Description: Constant Observer”, revealed: “...Working under the supervision of a Registered Nurse, the Constant Observer supports patient safety through monitoring and observation of assigned patient or patients. Provides continual bedside observation to assigned patient. Intervenes as necessary to prevent physical harm to patients who might be at high risk to injure themselves or others due to confusion, delirium, self-destructive behavior, or a has a high predictive factors of falling. Works with others in the healthcare team to assure prompt intervention to maintain patient safety...Responsibilities: 1. Remain at patient bedside at all times...5. Assist in calming or reorienting patient in cases of agitation or confusion...34. Do not allow the patient to leave room unless the nurse allows it...35. Do not try to physically restrain patient, do not physically block a patient attempting to leave; follows at a safe distance, calls for help. Calls for help immediately if the patient leaves the room. Does not follow a patient without calling for help. Ensures hospital specific Code is called for this situation...48. Notifies the charge nurse for any issues/concerns....” Review of Employee #21 employee file revealed no job description for Constant Observer present in the employee file or a completed Constant Observer competency. Employee #1 confirmed on 09/16/2024 that Employee #21 had been in the Constant Observer role since May 2024. Review of Staffing Schedules for 3South Telemetry for 09/06/2024 day shift revealed 3 nurses were assigned patients. One nurse had 5 patients, one nurse had 4 patients and one nurse had 5 patients including Patient #1 with an admission scheduled to make a total of 6 patients. Review of Security staffing for 09/06/2024 day shift revealed 2 security guards were on duty. Review of incident report dated 09/06/2024 revealed: “...0930 patient informed staff that [he] wanted to leave AMA...patient proceeded down hall from room to elevators with constant observer following behind patient...nurse was at nurse’s station and saw patient at elevator and attempted to stop patient from leaving...nurse informed constant observer to call code gray...patient got on elevator...nurse and another nurse went after patient downstairs well...Constant observer attempted to initiate code gray...0945 patient was out of hospital walking down sidewalk off hospital property...1354 patient brought to Emergency Department via EMS after being found having jumped from a 2 story building near the hospital....” Review of security log dated 09/06/2024 revealed: “...Call dispatch 0940 hours/call from front desk requesting assistance for patient [Kyle] leaving hospital. [Goodman]...Call dispatch 0942 Hours/Code Gray Room 310 [Smith]...Within the CSJ Operators Log 9/6 Code Gray Room #310 per [Vanessa] at 0942, recorded by operator [Chuck]....” Employee #12 confirmed on 09/11/2024 that a nurse attempted to call the security office to notify of the Code Gray when Patient #1 eloped from the unit. Employee #12 confirmed that the nurse then tried to use their vocera phone to call security which did not go through. Employee #12 confirmed that the nurse told the constant observer to call a code gray and the nurse went down the stairs to follow the patient. Employee #12 confirmed that 4 attempts were made to contact security either by the security line and the PBX/operator 3333 line but the calls would not go through. Employee #15 confirmed on 09/11/2024 that Patient #1 left 3South unit by elevator after telling the constant observer assigned to the patient that [he] wanted to leave. Employee #15 stated Patient #1 nurse was at the nurse’s station calling the provider to come speak with the patient when Patient #1 walked out of [his] room with the constant observer following behind Patient #1. Patient #1 walked to the elevators and was waiting by the elevator when the nurse for Patient #1 saw the patient at the elevators and ran over to the elevators to try to stop Patient #1 from leaving. Employee #15 confirmed that the nurse told the constant observer to call a code gray. Employee #15 confirmed that the constant observer never called for help as Patient #1 was leaving [his] room or as Patient #1 was walking toward the elevators. Employee #15 stated that the elevator doors opened and Patient #1 got into the elevator and the constant observer just stood there watching. Employee #15 stated that Patient #1’s nurse and another nurse ran down the stairs after Patient #1. Employee #15 stated they never heard a Code Gray being announced overhead for Patient #1. Employee #16 confirmed during an interview on 09/11/2024 that Patient #1 was attempting to leave the unit when Employee #16 became aware of the situation. Employee #16 observed the patient get on the elevator and Employee #16 went down the stairwell to follow the patient. Employee #16 stated that there was no security guard present at the front desk, and Patient #1 was observed walking out the front door of the hospital. Employee #16 followed the patient and stated security came after the patient was off hospital property. Employee #16 stated that they never heard the overhead announcement for a Code Gray while in the hospital. Employee #18 confirmed on 09/11/2024 that staffing for 3 South is was 1:5 but administration has changed it to 1:6 now and the charge nurse is included in the staffing with a full patient load. Employee #18 confirmed the acuity tool isn’t used for staffing. Employee #18 confirmed that with the charge nurse in ratio makes it difficult for other staff who need assistance because the charge nurse cannot be used as resource since they have their own patient load to take care of. Employee #18 confirmed that on 09/06/2024 when Patient #1 eloped from the unit the charge nurse was in a patient room taking care of a patient. Employee #11 confirmed during an interview on 09/11/2024 that there are a maximum of 3 security guards scheduled per shift and a minimum of 2 security guards. Employee #11 confirmed that there were 2 security guards working the day shift on 09/06/2024 when Patient #1 eloped. Employee #11 stated that the Code Gray call was received at approximately 0942 and by time security responded to the lobby, Patient #1 was already off the hospital property walking down the sidewalk. Employee #1 confirmed on 09/16/2024 that the constant observer should have initiated a Code Gray when Patient #1 was still in their room telling the constant observer that they wanted to leave. Employee #1 confirmed the constant observer should have alerted staff to needing help as the patient was walking down the hallway. Employee #1 stated that staff did not attempt to stop the patient physically because the patient had stated they wanted to leave AMA despite the fact the patient was scheduled to be transferred to a psychiatric facility due to suicidal intentions.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 43788 Based on review of documents, medical records, and staff interviews, it was determined the Administrator failed to ensure an order for restraints was renewed after the four hour expiration for Patient #1. This deficient practice poses the potential risk of unnecessary and unlimited restraint and patient harm. Cross reference: A-0043, A-0049, A-0057, A-0115, A-338, A-0353 Findings include: Policy titled, “Restraint & Seclusion”, revealed: “...Restraint and Seclusion require an order from a physician or other authorized Licensed Practitioner responsible for the care of the patient. The order must include the reason for Restraint or Seclusion, the type of Restraint, and the duration of Restraint or Seclusion...All Restraint or Seclusion orders must be dated and times when signed by the physician or Licensed Practitioner responsible for the care of the patient and include: 1) criteria for release; 2) types of restraint; 3) reason for Restraint or Seclusion; 4) and specify duration of Restraint or Seclusion order...b. Violent/Self-Destructive Restraint or Seclusion orders may be renewed with the following limits for up to a total of 24 hours: i. 4 hours for adults 18 years of age or older....” Review of Patient #1 provider orders revealed an order for 4 Point hard restraints was placed on 09/03/2024 at 2331 for 4 hours time limit. Further review of Patient #1 provider orders revealed no documentation of a renewal order to continue restraints on Patient #1 after 0331 on 09/04/2024. Review of Patient #1 medical record revealed patient was placed in restraints on 09/03/2024 at 2336 and restraints were discontinued on 09/04/2024 at 0430 for a total of 294 minutes (4 hours and 54 minutes). Employee #3 confirmed on 09/16/2024 that Patient #1 was in physical restraints for 54 minutes after the restraint order had expired. Employee #3 confirmed there was no documented restraint order renewal to cover the 54 minutes Patient #1 was in physical restraints after the initial restraint order has expired.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 43788 Based on review of documents, medical records, and staff interview, it was determined the Administrator failed to ensure medical staff performed in-person face-to-face evaluation one hour after Patient #1 was placed in physical restraints. This deficient practice poses the risk of physical or psychological injury to the patient going unreported after a restraint is used. Cross reference: A-0043, A-0049, A-0057, A-0115, A-338, A-0353 Findings include: Policy titled, “Restraint & Seclusion”, revealed: “...Restraint and Seclusion require an order from a physician or other authorized Licensed Practitioner responsible for the care of the patient...Violent/Self-Destructive Restraints: a. For Restraints used to manage Violent or Self-Destructive Behavior, a physician, or other Licensed Practitioner responsible for the care of the patient must evaluate the patient in person within one hour of the initiation of Restraint or Seclusion. The in-person evaluation and documentation must include: i. Evaluation of the patient’s immediate situation, ii. Patient reaction to the intervention, iii. Patient’s medical and behavioral condition...and iv. The need to continue or terminate the Restraint or Seclusion...b. Violent/Self-Destructive Restraint or Seclusion orders may be renewed with the following limits for up to a total of 24 hours: i. 4 hours for adults 18 years of age or older...c. A face-to-face physical examination is required by the physician or Licensed Practitioner responsible for the care of the patient and authorized to order Restraint or Seclusion every 24 hours for violent/self-destructive Restraint to determine the clinical justification for the continued use....” Review of Patient #1 medical record revealed Patient #1 was placed in 4 point hard restraints on 09/03/2024 at 2331. Further review of Patient #1 medical record revealed Patient #1 received a chemical restraint of Olanzapine 10 mg and Ativan 2 mg Intramuscular injection at 2350 on 09/3/2024. Review of Patient #1 medical record revealed no documentation of a medical provider performing an in-person face-to-face evaluation one hour after the initiation of restraints for Patient #1. Employee #3 confirmed on 09/16/2024 that there was no documented face-to-face evaluation present in Patient #1 medical record. Employee #3 confirmed a face-to-face evaluation should have been conducted one hour after restraints had been initiated on Patient #1.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 43788 Based on the review of policies and procedures, hospital documents, and staff interviews, it was determined the Governing Authority failed to ensure that the hospital was provided with adequate personnel and resources to provide a safe environment to provide patient care. This deficient practice poses a risk to the health and safety of patients if the hospital is unable to provide the proper care and resources to keep patients safe and meet patient needs. Cross reference: A-0043, A-0057, A-0115, A-0144, A-0385, A-0386, A-0392, A-0397 Findings include: Policy titled, “Nursing Staffing and Acuity Plan” , revealed: “...Purpose: To ensure that Carondelet Hospitals have an acuity-based staffing plan that is established, documented, and implemented. The staffing and acuity plan will include: A. A method that establishes the types and numbers of nursing personnel that are required for each unit in the hospital. B. An assessment of the patient’s acuity, and the need for nursing services will be made by a registered nurse who is providing nursing services directly to the patient. C. The practice of utilizing A & B to arrange assignments for equitable and safe patient care...Consistent with the mission of Carondelet Hospital’s to improve the health of those we serve, each patient will be cared for in the safest, most effective and efficient manner possible...Each department will have their annual matrix as reference and guide...Carondelet Hospitals use a system to identify patients’ acuity levels which are specific based on hospital department. Inpatient Medical-Surgical, Telemetry, Progressive Care Unit, and Behavioral Health will utilize their tool via the electronic medical record, or on paper during downtime. The Intensive Care Unit (Neuro ICU, Medical ICU, and Trauma ICU) will utilize a paper acuity tool... Each acuity tool considers time sensitive and nursing specific interventions, as ordered by the provider and part of the plan of care, including but not limited to: Ability to perform ADLs, Airway management and treatments, Patient behavior, Frequency of medication management, Patient/family education, Specialized treatments/procedures...Acuity Classification for ICU: Low *L1- Comfort care/DNR whose death is expected, good support system and requires minimal staff intervention to cope with death; *L2- Routine discharge or transfer (includes discharge teaching and paperwork); *L3- Stable, V/S, accucheck, neuro checks q 4h, up with assistance, requires minimal to moderate assistance with ADLs, has routine IV push and IVPB medication therapy during the shift, waiting for downgrade/discharge/transfer anticipated in the next 4 hour...Medium 2:1 ratio *M1- Stable, skilled assessments, V/S, neuros, ICP, IV meds, &/or treatments every 1 hour; *M2- Treatment of non-life threatening arrhythmias that requires intervention (Transvenous pacing) or continuous IV drug therapy; *M3- Vasoactive or other IV drips (<3) requiring titration (>15 min) (i.e.Heparin, Vasopressors, Cardiac, Insulin) to achieve control of unstable condition. EKOS, epidural; *M4- Invasive hemodynamic monitoring, swan readings; *M5- Non-intubated with respiratory compromise requiring BIPAP and/or frequent interventions to maintain adequate oxygenation; *M6- Ventilator patient requires suctioning q2h, well controlled, not being weaned; *M7- Bedside special procedures done requiring nursing support (i.e. bronch, cardioversion, chest tubes, central line insertion, extensive dressing changes or thoracentesis); *M8- Complex/major dressing changes, such as wound debridement, wound packing, irrigation, etc taking 30 min to 1 hr/shift; *M9- Complex education or emotional support (i.e., procedure, treatment or new condition, trach or complex wound care) or anytime frequent nursing interventions needed; *M10- Danger to self or others, frequent combative behavior requiring IV sedation and/or 4 point restraints with sitter at bedside (i.e., CIWA); *M11-- Suicidal patients who have been placed on psychiatric hold by the PAT team or Psychiatrist with sitter...High 1.5:1 or 1:1 (may be paired with low acuity) *H10 Hemodynamically unstable with vitals q 15 min and requiring titratable drips (>or = 3); *H2- Identified potential organ donors prior to retrieval with preparation completed; *H3- Violent restraints assessment/vitals q 15 min (without constant observer) appropriately managed with medications (i.e., CIWA > 25); * H4- Proning therapy...Critical 1:1 ratio *C1- CRRT; *C2- Impella; *C3- IABP Open heart surgery/ open AAA immediately post op until hemodynamic stability achieved with 2 or less titratable drips; *C4- Unstable (i.e., hemodynamically change in LOC, V/S), increase in IV medication/drip, multiple drips, requiring interventions q15-30 min, external pacing; *C5- Active bleeding requiring massive transfusion protocol with hemodynamic instability; *C6- Potential organ donors who require immediate extensive preparation and/or management; *C7- Violent restraints assessment/vitals q 15 min (without constant observer) in crisis...Staffing the Hold Patients in the EC (emergency center) ICU and PCU nurse-patient ratios, 1:2 and 1:4 respectively....” Policy titled, “Plan for the Provision of Patient Care”, revealed: “...”...Critical Care Service...A RN ratio from 1:1 to 1:2 is dependent on the acuity of patients based upon their severity of illness and life support needs...Security-Hospital Security: Hours of Operation: 24 hours a day, 7 days a week...The Security Department also provides emergency response services. These emergency responses included but are not limited to: fire response, combative person(s), Internal/external disasters and or security related emergency, pedestrian and traffic control, secure operations....” Review incident report log for 09/06/2024 through 09/12/2024 revealed a patient (Patient #1) had eloped from the hospital on 09/06/2024. Review of the incident report and Patient #1 medical record dated 09/06/2024 revealed the patient was admitted for suicidal intentions, attempted self-harm and was scheduled to be transferred to an inpatient psychiatric facility for treatment of suicidal ideations. Further review of the medical record revealed the patient was re-admitted to the hospital on 09/06/2024 after jumping off a second story of a building after eloping from the hospital. Review of security log dated 09/06/2024 revealed: “...Call dispatch 0940 hours/call from front desk requesting assistance for patient [Kyle] leaving hospital. [Goodman]...Call dispatch 0942 Hours/Code Gray Room 310 [Smith]...Within the CSJ Operators Log 9/6 Code Gray Room #310 per [Vanessa] at 0942, recorded by operator [Chuck]....” Review of the 3South Telemetry Staffing from 09/06/2024 through 09/12/2024 revealed 2 shifts out of 20 shifts which had at least 1 nurse with 7 patients assigned: 09/06/2024 day shift: 1 nurse assigned 7 patients, including Patient #1 who eloped during this shift. 09/07/2024 day shift: 1 nurse assigned 7 patients. Review of the staffing assignments for Security for 09/06/2024 0600-1800 revealed 2 security guards were working the entire facility. Employee #12 confirmed on 09/11/2024 that a nurse attempted to call the security office to notify of the Code Gray when Patient #1 eloped from the unit. Employee #12 confirmed that the nurse then tried to use their vocera phone to call security which did not go through. Employee #12 confirmed that the nurse told the constant observer to call a code gray and the nurse went down the stairs to follow the patient. Employee #12 confirmed that 4 attempts were made to contact security either by the security line and the PBX/operator 3333 line but the calls would not go through. Employee #16 confirmed during an interview on 09/11/2024 that Patient #1 was attempting to leave the unit when Employee #16 became aware of the situation. Employee #16 observed the patient get on the elevator and Employee #16 went down the stairwell to follow the patient. Employee #16 stated that there was no security guard present at the front desk, and Patient #1 was observed walking out the front door of the hospital. Employee #16 followed the patient and stated security came after the patient was off hospital property. Employee #16 stated that they never heard the overhead announcement for a Code Gray while in the hospital. Employee #11 confirmed during an interview on 09/11/2024 that there are a maximum of 3 security guards scheduled per shift and a minimum of 2 security guards. Employee #11 confirmed that there were 2 security guards working the day shift on 09/06/2024 when Patient #1 eloped. Employee #11 stated that the Code Gray call was received at approximately 0942 and by time security responded to the lobby, Patient #1 was already off the hospital property walking down the sidewalk. Further review of the incident report log for 09/06/2024 through 09/12/2024 revealed a patient (Patient #3) fall occurred on 3 North PCU on night shift on 09/08/2024. Review of the incident report for 09/08/2024 revealed Patient #3 had an unwitnessed fall after attempting to use the bedside commode without staff assistance. Review of the staffing assignment for 3 North PCU for night shift 09/08/2024 revealed the unit had insufficient staffing. Review of staffing assignments for 3North PCU from 09/06/2024 through 09/12/2024 revealed 10 shifts out of 20 shifts in which at least one nurse was assigned more than 4 patients: 09/06/2024 day shift: 1 nurse assigned 5 patients 09/07/2024 day shift: 1 nurse assigned 6 patients, 2 nurses assigned 5 patients 09/08/2024 day shift: 3 nurses assigned 5 patients each 09/08/2024 night shift: 2 nurses assigned 5 patients each, No patient care tech assigned 09/09/2024 day shift: 2 nurses assigned 5 patients each 09/09/2024 night shift: 1 nurse assigned 5 patients, 1 nurse assigned 6 patients 09/10/2024 day shift: 2 nurses assigned 5 patients each 09/11/2024 night shift: 1 nurse assigned 5 patients 09/12/2024 day shift: 2 nurses assigned 5 patients each 09/12/2024 night shift: 2 nurses assigned 5 patients each Review of ICU Staffing from 09/06/2024 through 09/12/2024 revealed 4 shifts out of 20 which had at least 1 nurse with 3 patients assigned: 09/08/2024 day shift: 2 nurses assigned 3 patients each, each of those patients were ICU “M” status 09/09/2024 night shift: 1 nurse assigned 3 patients, 2 of those patients were ICU “M” status and 1 was ICU “L” status 09/11/2024 day shift: 1 nurse assigned 3 patients, each of those patients were ICU “M” status 09/12/2024 night shift: 1 nurse assigned 3 patients, 2 of those patients were ICU “M” status and 1 was ICU “L” status. Observation on tour of the ICU on 09/16/2024 at 1100 revealed the charge nurse was in ratio taking care of patients. Observation on tour of the 3North PCU/3South Telemetry on 09/16/2024 at 1030 revealed the unit had no unit clerk working. Also noted was the charge nurse was in ratio with a full patient load. Employee #1 confirmed during an interview conducted on 09/16/2024 the nursing units were understaffed on the shifts identified above. Employee #18 confirmed on 09/11/2024 that staffing for 3 South was 1:5 but administration has changed it to 1:6 now and the charge nurse is included in the staffing with a full patient load. Employee #18 confirmed the acuity tool isn’t used for staffing. Employee #18 confirmed that with the charge nurse in ratio makes it difficult for other staff who need assistance because the charge nurse cannot be used as resource since they have their own patient load to take care of. Employee #18 confirmed that on 09/06/2024 when Patient #1 eloped from the unit the charge nurse was in a patient room taking care of a patient.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43788 Based on review of documents, medical records, and staff interviews, it was determined the Administrator failed to ensure medical staff complied with established medical staff bylaws as evidenced by: 1. failure to conduct a psychiatric consult within the required timeframe; 2. failure to renew restraint orders while a patient remained in restraints; 3. failure to conduct an in-person face-to-face evaluation within one hour after restraints were initiated on a patient. These deficient practices pose a risk to patients if medical staff due not perform required interventions when providing care to ensure quality care is provided. Cross reference: A-0043, A-0049, A-0057, A-0115, A-0171, A-0178, A-0464 Findings include: Policy titled, “Professional Staff Bylaws”, revealed: “...The Professional Staff is also responsible for ensuring the following: 1. All individuals receive appropriate quality care without regard to gender, race, color, creed, sexual preference, religion, national origin, marital status, disability, existence of advanced directives, payor source or any other prohibited reason....” Policy titled, “Professional Staff Rules and Regulations”, revealed: “...Every patient is under the care of a doctor of medicine or osteopathy. All diagnostic and treatment services of the hospital shall be under the direction of a professional staff member...All practitioners shall be governed by the current Admitting Department policies and procedures...Members of the Professional Staff admitting and attending patients shall be held responsible for getting as much information as may be necessary to assure the protection of the patient from self-harm and to ensure the safety of other patients in the hospital...Each member of the Professional Staff is required to provide or arrange for the provision of appropriate and continuous care of his/her patients at all times...Each member also agrees to provide appropriate and necessary emergency and non-emergency medical treatment within the scope of his/her documented privileges to any patient seeking such treatment...The attending/admitting practitioner shall be responsible for the preparation of complete and legible medical record for each patient she/he admits to the Hospital...The Practitioners following the patient’s care are responsible for updating the progress notes on a daily basis so that documentation accurately reflects the current information and care provided...A complete medica record conists of, but is not limmited to, the following documents: j. All orders...k. Consultation(s) when performed...l. Progress notes...General Conduct Of Care: Each member of the Professions Staff must assure timely and appropriate medical care for inpatients and outpatients under their when it is their duty to do so...The attending practitioner is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant...Consultation response times are defined as follows: a) Routine: Consultation will be performed within twenty-four (24) hours. b) Urgent: Consultation will be performed within twelve (12) hours. c) Emergent: Consultation will be performed within four (4) hours...The consultant will complete preliminary note in the progress notes section of the patient’s medical record when assessing the patient and dictate a complete consultation note within 24 hours of initial patient assessment....” Policy titled, “Restraint & Seclusion”, revealed: “...Restraint and Seclusion require an order from a physician or other authorized Licensed Practitioner responsible for the care of the patient. The order must include the reason for Restraint or Seclusion, the type of Restraint, and the duration of Restraint or Seclusion...All Restraint or Seclusion orders must be dated and times when signed by the physician or Licensed Practitioner responsible for the care of the patient and include: 1) criteria for release; 2) types of restraint; 3) reason for Restraint or Seclusion; 4) and specify duration of Restraint or Seclusion order...Violent/Self-Destructive Restraints: a. For Restraints used to manage Violent or Self-Destructive Behavior, a physician, or other Licensed Practitioner responsible for the care of the patient myst evaluate the patient in person within one hour of the initiation of Restraint or Seclusion. The in-person evaluation and documentation must include: i. Evaluation of the patient’s immediate situation, ii. Patient reaction to the intervention, iii. Patient’s medical and behavioral condition...and iv. The need to continue or terminate the Restraint or Seclusion...b. Violent/Self-Destructive Restraint or Seclusion orders may be renewed with the following limits for up to a total of 24 hours: i. 4 hours for adults 18 years of age or older...c. A face-to-face physical examination is required by the phsyician or Licensed Practitioner responsible for the care of the patient and authorized to order Restraint or Seclusion every 24 hours for violent/self-destructive Restraint to determine the clinical justification for the continued use....” Review of Patient #1 medical record revealed an order was placed for a Psychiatric Consult on 09/04/2024 at 0946. A review of Patient #1 medical record on 09/16/2024 revealed an Initial Psychiatric Consult was initiated on 09/09/2024. Further review of the Psychiatric Consult note revealed a notation “Date of Service 09/09/2024 (note not finished)”. Review of Patient #1 medical record revealed chemical and physical restraints were ordered on 09/03/2024 at 2331. Further review of the medical record for Patient #1 revealed Patient #1 was in physical restraints from 2336 to 0430 with no renewal order documented after the 4 hours. Patient #1 was in physical restraints for an additional 54 minutes without a physician order for the physical restraints. Review of the medical record revealed there was no provider in-person face-to-face evaluation performed or documented on Patient #1 within an hour of the chemical and physical restraints were initiated on 09/03/2024. Employee #1 confirmed on 09/16/2024 that consultations needed to be initiated within 24 hours of the provider order. Employee #3 confirmed on 09/16/2024 that Patient #1’s Psychiatric Consult was initiated five (5) days after the consult was ordered. Employee #3 confirmed that the Psychiatric Consult was not completed and finalized as of 09/16/2024. Employee #3 confirmed there was no order to renew physical restraints on Patient #1 after the 4 hour expiration on 09/04/2024 and that the patient was in restraints for 54 minutes without a restraint order in place. Employee #3 confirmed that there was no documentation present in the medical record for Patient #1 that provider face-to-face evaluation was conducted one hour after restraints were initiated on 09/03/2024-09/04/2024.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 43788 Based on review of documents, observation and interviews, it was determined the Chief Nursing Officer failed to manage the overall nursing services of the facility. This deficient practice poses a risk to the health and safety of patients if there is a lack of continuous nursing supervision in the provision of quality patient care to meet the needs of patients. Cross reference: A-0043, A-0057, A-0144, A-0315, A-0385, A-0392, A-0397 Findings include: Job description for Chief Nursing Officer revealed: “...The Chief Nursing Officer provides strategic leadership as the senior executive position responsible for all nursing and other designated patient care functions and services within the hospital organization. The role assumes responsibility for assessing, planning, coordinating, implementing and evaluating nursing practice on a facility level. The role assumes 24/7 responsibility and has accountability to ensure high quality, safe and appropriate nursing care, competency of clinical staff, and appropriate resource management related to patient care. The Chief Nursing Officer represents nursing concerns on the governing board and at medical staff leadership meetings....” During the survey it was determined the Chief Nursing Officer failed to perform the core functions of the position as demonstrated by the following: A-0392: The nurse executive failed to ensure sufficient numbers of nursing personnel were on units to meet the needs of patients. A-0394: The nurse executive failed to ensure all nursing personnel had current required licensure. A-0397: The nurse executive failed to ensure patient assignments were based on patient acuity and staff were knowledgeable regarding patient acuity process.”

“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: 43788 Based on review of documents, observations, and staff interviews, it was determined the Nurse Executive failed to ensure that nursing staffing assignments were based on patient acuity and there was sufficient nursing personnel working each unit and shift. This deficient practice poses a risk to the health and safety of patients if nursing units have insufficient staffing. Cross reference: A-0043, A-0057, A-0115, A-0144, A-0315, A-0385, A-0386, A-0397 Findings include: Policy titled, “Nursing Staffing and Acuity Plan” , revealed: “...Purpose: To ensure that Carondelet Hospitals have an acuity-based staffing plan that is established, documented, and implemented. The staffing and acuity plan will include: A. A method that establishes the types and numbers of nursing personnel that are required for each unit in the hospital. B. An assessment of the patient’s acuity, and the need for nursing services will be made by a registered nurse who is providing nursing services directly to the patient. C. The practice of utilizing A & B to arrange assignments for equitable and safe patient care...Consistent with the mission of Carondelet Hospital’s to improve the health of those we serve, each patient will be cared for in the safest, most effective and efficient manner possible...Each department will have their annual matrix as reference and guide...Carondelet Hospitals use a system to identify patients’ acuity levels which are specific based on hospital department. Inpatient Medical-Surgical, Telemetry, Progressive Care Unit, and Behavioral Health will utilize their tool via the electronic medical record, or on paper during downtime. The Intensive Care Unit (Neuro ICU, Medical ICU, and Trauma ICU) will utilize a paper acuity tool... Each acuity tool considers time sensitive and nursing specific interventions, as ordered by the provider and part of the plan of care, including but not limited to: Ability to perform ADLs, Airway management and treatments, Patient behavior, Frequency of medication management, Patient/family education, Specialized treatments/procedures...Acuity Classification for ICU: Low *L1- Comfort care/DNR whose death is expected, good support system and requires minimal staff intervention to cope with death; *L2- Routine discharge or transfer (includes discharge teaching and paperwork); *L3- Stable, V/S, accucheck, neuro checks q 4h, up with assistance, requires minimal to moderate assistance with ADLs, has routine IV push and IVPB medication therapy during the shift, waiting for downgrade/discharge/transfer anticipated in the next 4 hour...Medium 2:1 ratio *M1- Stable, skilled assessments, V/S, neuros, ICP, IV meds, &/or treatments every 1 hour; *M2- Treatment of non-life threatening arrhythmias that requires intervention (Transvenous pacing) or continuous IV drug therapy; *M3- Vasoactive or other IV drips (<3) requiring titration (>15 min) (i.e.Heparin, Vasopressors, Cardiac, Insulin) to achieve control of unstable condition. EKOS, epidural; *M4- Invasive hemodynamic monitoring, swan readings; *M5- Non-intubated with respiratory compromise requiring BIPAP and/or frequent interventions to maintain adequate oxygenation; *M6- Ventilator patient requires suctioning q2h, well controlled, not being weaned; *M7- Bedside special procedures done requiring nursing support (i.e. bronch, cardioversion, chest tubes, central line insertion, extensive dressing changes or thoracentesis); *M8- Complex/major dressing changes, such as wound debridement, wound packing, irrigation, etc taking 30 min to 1 hr/shift; *M9- Complex education or emotional support (i.e., procedure, treatment or new condition, trach or complex wound care) or anytime frequent nursing interventions needed; *M10- Danger to self or others, frequent combative behavior requiring IV sedation and/or 4 point restraints with sitter at bedside (i.e., CIWA); *M11-- Suicidal patients who have been placed on psychiatric hold by the PAT team or Psychiatrist with sitter...High 1.5:1 or 1:1 (may be paired with low acuity) *H10 Hemodynamically unstable with vitals q 15 min and requiring titratable drips (>or = 3); *H2- Identified potential organ donors prior to retrieval with preparation completed; *H3- Violent restraints assessment/vitals q 15 min (without constant observer) appropriately managed with medications (i.e., CIWA > 25); * H4- Proning therapy...Critical 1:1 ratio *C1- CRRT; *C2- Impella; *C3- IABP Open heart surgery/ open AAA immediately post op until hemodynamic stability achieved with 2 or less titratable drips; *C4- Unstable (i.e., hemodynamically change in LOC, V/S), increase in IV medication/drip, multiple drips, requiring interventions q15-30 min, external pacing; *C5- Active bleeding requiring massive transfusion protocol with hemodynamic instability; *C6- Potential organ donors who require immediate extensive preparation and/or management; *C7- Violent restraints assessment/vitals q 15 min (without constant observer) in crisis...Staffing the Hold Patients in the EC (emergency center) ICU and PCU nurse-patient ratios, 1:2 and 1:4 respectively....” Policy titled, “Plan for the Provision of Patient Care”, revealed: “...Critical Care Service...A RN ratio from 1:1 to 1:2 is dependent on the acuity of patients based upon their severity of illness and life support needs....” Review of staffing assignments for 3North PCU from 09/06/2024 through 09/12/2024 revealed 10 shifts out of 20 shifts in which at least one nurse was assigned more than 4 patients: 09/06/2024 day shift: 1 nurse assigned 5 patients 09/07/2024 day shift: 1 nurse assigned 6 patients, 2 nurses assigned 5 patients 09/08/2024 day shift: 3 nurses assigned 5 patients each 09/08/2024 night shift: 2 nurses assigned 5 patients each 09/09/2024 day shift: 2 nurses assigned 5 patients each 09/09/2024 night shift: 1 nurse assigned 5 patients, 1 nurse assigned 6 patients 09/10/2024 day shift: 2 nurses assigned 5 patients each 09/11/2024 night shift: 1 nurse assigned 5 patients 09/12/2024 day shift: 2 nurses assigned 5 patients each 09/12/2024 night shift: 2 nurses assigned 5 patients each Further review of the 3North PCU staffing assignment revealed the patient acuity column was blank with no documented patient acuity on any of the staffing assignment sheets reviewed for the dates of 09/06/2024 through 09/12/2024. Review of the incident report log revealed a patient fall occurred on 3 North PCU on night shift on 09/08/2024. Review of the 3South Telemetry Staffing from 09/06/2024 through 09/12/2024 revealed 2 shifts out of 20 shifts which had at least 1 nurse with 7 patients assigned: 09/06/2024 day shift: 1 nurse assigned 7 patients, including Patient #1 who eloped during this shift. 09/07/2024 day shift: 1 nurse assigned 7 patients. Further review of the 3South staffing assignment revealed the patient acuity column was blank with no documented patient acuity on any of the staffing assignment sheets reviewed for the dates of 09/06/2024 through 09/12/2024. Review of the incident report log revealed a patient (Patient #1) had eloped from the hospital on 09/06/2024. Review of the incident report and Patient #1 medical record revealed the patient was admitted for suicidal intentions, attempted self-harm and was scheduled to be transferred to an inpatient psychiatric facility for treatment of suicidal ideations. Further review of the medical record revealed the patient was re-admitted to the hospital on 09/06/2024 after jumping off a second story of a building after eloping from the hospital. Review of ICU Staffing from 09/06/2024 through 09/12/2024 revealed 4 shifts out of 20 which had at least 1 nurse with 3 patients assigned: 09/08/2024 day shift: 2 nurses assigned 3 patients each, each of those patients were ICU “M” status 09/09/2024 night shift: 1 nurse assigned 3 patients, 2 of those patients were ICU “M” status and 1 was ICU “L” status 09/11/2024 day shift: 1 nurse assigned 3 patients, each of those patients were ICU “M” status 09/12/2024 night shift: 1 nurse assigned 3 patients, 2 of those patients were ICU “M” status and 1 was ICU “L” status. Further review of the ICU staffing sheets revealed one shift (9/7/24 nights) with no status or acuity documented for any of the patients. Further review revealed one shift (9/10/2024 night shift) with no nurse’s name next to the patient so unable to determine who was assigned each patient. Observation on tour of the ICU on 09/16/2024 at 1100 revealed the charge nurse was in ratio taking care of patients. Observation on tour of the 3North PCU/3South Telemetry on 09/16/2024 at 1030 revealed the unit had no unit clerk working. Also noted was the charge nurse was in ratio with a full patient load. Employee #1 confirmed during an interview conducted on 09/16/2024 the nursing units were understaffed on the dates identified above. Employee #18 confirmed on 09/11/2024 that staffing for 3 South was 1:5 but administration has changed it to 1:6 now and the charge nurse is included in the staffing with a full patient load. Employee #18 confirmed the acuity tool isn’t used for staffing. Employee #18 confirmed that with the charge nurse in ratio makes it difficult for other staff who need assistance because the charge nurse cannot be used as resource since they have their own patient load to take care of. Employee #18 confirmed that on 09/06/2024 when Patient #1 eloped from the unit the charge nurse was in a patient room taking care of a patient.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 43788 Based on facility job descriptions, personnel files, and staff interviews, it was determined the administrator failed to ensure personnel records contained evidence that Employee #22 had a current Arizona Registered Nursing License. This deficient practice poses a potential risk to the overall health and safety of patients at the facility if personnel members do not have a current license necessary to provide patient care services. Cross reference: A-0043, A-0057, A-0385, A-0386 Finding include: Job description titled, “Registered Nurse (CHN: RN Clinical)”, revealed: “...Provides direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization...LICENSURE/CERTIFICATION/REGISTRATION: Required: Valid current Arizona Nursing License or compact state license and ability to become Arizona Licensed in 30 days. Basic Life Support (BLS) - American Heart Association and others as required by individual department as noted in Attachment A....” Employee #22’s personnel filed revealed a Nursys Quick Confirm report for Registered Nurse (RN) License Expiration Date: 03/31/2024. No current RN license was available for review. Employee #5 confirmed on 09/11/2024 that Employee #22’s personnel file did not contain evidence of a current RN license.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 43788 Based on review of documents, observations and staff interviews, it was determined the Nurse Executive failed to ensure: 1. staff were knowledgeable about the acuity plan and how to implement it. 2. staff were aware of the maximum total patient acuity levels for each nurse to ensure staffing assignments were equitable and safe. These deficient practices pose a potential risk to the health and safety of patients when the registered nurse does not know how to utilize, and implement the acuity plan for the purpose of determining a patient’s acuity and safe patient assignments. Cross reference: A-0043, A-0057, A-0385, A-0386, A-0392 Findings include: Policy titled, “Nursing Staffing and Acuity Plan” , revealed: “...Purpose: To ensure that Carondelet Hospitals have an acuity-based staffing plan that is established, documented, and implemented. The staffing and acuity plan will include: A. A method that establishes the types and numbers of nursing personnel that are required for each unit in the hospital. B. An assessment of the patient’s acuity, and the need for nursing services will be made by a registered nurse who is providing nursing services directly to the patient. C. The practice of utilizing A & B to arrange assignments for equitable and safe patient care...Consistent with the mission of Carondelet Hospital’s to improve the health of those we serve, each patient will be cared for in the safest, most effective and efficient manner possible...Each department will have their annual matrix as reference and guide...Carondelet Hospitals use a system to identify patients’ acuity levels which are specific based on hospital department. Inpatient Medical-Surgical, Telemetry, Progressive Care Unit, and Behavioral Health will utilize their tool via the electronic medical record, or on paper during downtime. The Intensive Care Unit (Neuro ICU, Medical ICU, and Trauma ICU) will utilize a paper acuity tool... Each acuity tool considers time sensitive and nursing specific interventions, as ordered by the provider and part of the plan of care, including but not limited to: Ability to perform ADLs, Airway management and treatments, Patient behavior, Frequency of medication management, Patient/family education, Specialized treatments/procedures....” Further review of the acuity plan revealed no documented maximum patient acuity per nurse per unit to ensure equitable and safe nursing assignments. Review of the 3North PCU staffing assignment revealed the patient acuity column was blank with no documented patient acuity on any of the staffing assignment sheets reviewed for the dates of 09/06/2024 through 09/12/2024. Review of the 3South staffing assignment revealed the patient acuity column was blank with no documented patient acuity on any of the staffing assignment sheets reviewed for the dates of 09/06/2024 through 09/12/2024. Review of the ICU staffing sheets revealed one shift (9/7/24 nights) with no status or acuity documented for any of the patients. Further review revealed one shift (9/10/2024 night shift) with no nurse’s name next to the patient so unable to determine who was assigned each patient. Employee #1 confirmed on 09/16/2024 that patient acuity is utilized to assist with patient care assignments. Employee #1 confirmed that patient acuity is determined electronically via the acuity tool that is located in the Cerner EMR. Employee #1 confirmed the acuity scored were missing from the reviewed staffing assignments. Employee #1 confirmed that the nurse/patient ratio for PCU was 1:4 and on telemetry the nurse/patient ratio was 1:5 or 1:6. Employee #16 confirmed on 09/11/2024 that staffing assignments were based on nurse:patient ratios not patient acuity. Employee #16 confirmed that the PCU nurse/patient ratio was 1:4 but most of the time it was 1:5 with the charge nurse in ratio as well. Employee #16 confirmed that the telemetry nurse/patient ratio should be 1:5 but is usually 1:6. Employee #17 confirmed on 09/11/2024 that staff did not utilize the patient acuity system in Cerner EMR, that patient assignments were done by a nurse/patient ratio with PCU nurses being assigned 4-5 patients each and telemetry nurses being assigned 5-6 patients each with the charge nurse being assigned a full patient load as well. Employee #18 confirmed on 09/11/2024 that patient acuity is not utilized when making patient care assignments. Employee #18 confirmed that the electronic acuity tool is not utilized when making assignments as the nurses are too busy to complete. Employee #18 stated patient assignments are done by nurses reporting verbally to the charge nurse making assignments if a patient was stable, complicated, or demanding. Employee #18 stated there is not a maximum patient acuity level for each nurse and assignments are based on nurse/patient ratio.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43788 Based on the review of documents, personnel files and staff interview, it was determined that the Nurse Executive failed to ensure one (1) nursing staff member, Employees #21 received competency training prior to providing patient care services which poses a potential risk of staff is not appropriately and adequately trained to provide safe patient care. Findings include: Review of document titled, “Job Description: Constant Observer”, revealed: “...Working under the supervision of a Registered Nurse, the Constant Observer supports patient safety through monitoring and observation of assigned patient or patients. Provides continual bedside observation to assigned patient. Intervenes as necessary to prevent physical harm to patients who might be at high risk to injure themselves or others due to confusion, delirium, self-destructive behavior, or a has a high predictive factors of falling. Works with others in the healthcare team to assure prompt intervention to maintain patient safety...Responsibilities: 1. Remain at patient bedside at all times...5. Assist in calming or reorienting patient in cases of agitation or confusion...34. Do not allow the patient to leave room unless the nurse allows it...35. Do not try to physically restrain patient, do not physically block a patient attempting to leave; follows at a safe distance, calls for help. Calls for help immediately if the patient leaves the room. Does not follow a patient without calling for help. Ensures hospital specific Code is called for this situation...48. Notifies the charge nurse for any issues/concerns...Within 90days of hire completes all .Edu courses on duties of the Constant Observer and the .Edu courses on restraint and seclusion. Completes hospital approved training in managing patient behaviors and de-escalation techniques. Constant Observers providing patient care must have completed all applicable Competencies within 90 days....” Review of Employee #21 employee file revealed no signed job description for Constant Observer or completed Constant Observer competency checklist present in the employee file. Employee #1 confirmed on 09/16/2024 that Employee #21 had been in the Constant Observer role since May 2024. Employee #26 confirmed on 09/16/2024 that there was no completed Constant Observer competency checklist or signed job description in Employee #21 file.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 43788 Based on review of documents, medical records, and staff interviews, it was determined the Administrator failed to ensure ensure medical staff completed a Psychiatric Consult within the required 24 hours. This deficient practice poses a risk to patients if medical staff due not perform required interventions when providing care to ensure quality care is provided. Cross reference: A-0043, A-0049, A-0057, A-0338, A-0353 Findings include: Policy titled, “Professional Staff Rules and Regulations”, revealed: “...General Conduct Of Care: Each member of the Professions Staff must assure timely and appropriate medical care for inpatients and outpatients under their when it is their duty to do so...The attending practitioner is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant...Consultation response times are defined as follows: a) Routine: Consultation will be performed within twenty-four (24) hours. b) Urgent: Consultation will be performed within twelve (12) hours. c) Emergent: Consultation will be performed within four (4) hours...The consultant will complete preliminary note in the progress notes section of the patient’s medical record when assessing the patient and dictate a complete consultation note within 24 hours of initial patient assessment....” Review of Patient #1 medical record revealed an order was placed for a Psychiatric Consult on 09/04/2024 at 0946. A review of Patient #1 medical record on 09/16/2024 revealed an Initial Psychiatric Consult was initiated on 09/09/2024. Further review of the Psychiatric Consult note revealed a notation “Date of Service 09/09/2024 (note not finished”. Employee #3 confirmed on 09/16/2024 that Patient #1’s Psychiatric Consult was initiated five (5) days after the consult was ordered. Employee #3 confirmed that the Psychiatric Consult was not completed and finalized as of 09/16/2024. Employee #1 confirmed on 09/16/2024 that consultations needed to be initiated within 24 hours of the provider order.”

“QUALIFIED STAFF CFR(s): 482.26(c)(2) Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures. This Standard is not met as evidenced by: 43788 Based on the review of personnel files and staff interview, it was determined that the administrator failed to ensure one (1) radiology Technician, Employee #24, received competency training prior to providing patient care services which poses a potential risk of staff is not appropriately and adequately trained to provide safe patient care. Findings include: Review of Employee #24’s personnel file revealed no evidence of a signed completed competency checklist prior to providing diagnostic imaging services and there was no evidence of a current BLS (Basic Life Support) certification present in the employee file. Further review of Employee #24’s personnel file contained no evidence orientation was provided at the time employment began. Employee #5 confirmed on 09/11/2024 Employee #24’s personnel file did not contain evidence of a signed competency checklist or current BLS card. Employee #5 confirmed Employee #24’s personnel file did not contain evidence that new staff orientation was provided.”