Uc San Diego Health Hillcrest - Hillcrest Med Ctr

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50175 Based on interview and record review, the hospital failed to implement policy and procedure for one of 30 sample patients (Patient 10) when there was no documented evidence that Patient 10 was continuously assessed and monitored while on restraints (a method used to immobilize or restrict someone’s movement). This failure had the potential to result in patient injury and/or compromised safety. Findings: Patient 10 was admitted on 4/27/26 with diagnoses including respiratory failure (unable to breathe adequately), per Patient 10’s history and physical (H&P, a physician’s initial assessment). A joint interview and record review was conducted on 5/1/26 at 9:37 A.M. with Quality Compliance Specialist (QCS) 1 and QCS 2. A review of Patient 10’s physician’s orders indicated that Patient 10 was started on non-violent restraints on 4/27/26 at 6:18 P.M. for attempting to pull or remove lines/tubes/equipment and attempting to get out of bed before medically appropriate. A review of Patient 10’s physician’s orders indicated Patient 10 continued to have orders for restraints on 4/29/26 and 4/30/26. Patient 10’s orders for restraints were discontinued on 5/1/26 at 8:03 A.M. A review of the restraint flowsheet (where nurses document assessments) showed no restraint assessment documentation for the day shift on 4/29/26 and the night shift on 4/30/26. A joint interview and record review was conducted on 5/1/26 at 11 A.M. with Nurse Manager (NM) 1. NM 1 stated nurses were expected to document an “end-of-shift” attestation (statement documented at the end of the nurse’s shift) in the restraint flowsheet, indicating that every two hours Patient 10 was provided range of motion and hygiene, restraints were secured properly, Patient 10’s skin was assessed, and there was a need for continued restraints. NM 1 stated there was no end-of-shift attestation documented for day shift on 4/29/26 and night shift on 4/30/26. NM 1 also stated there were no other documentation in Patient 10’s medical record indicating Patient 10 was continuously assessed and monitored while on restraints during the day shift on 4/29/26 and the night shift on 4/30/26. A review of the hospital’s policy titled Non-Violent Restraint, last revised 7/5/24, indicated “ ...Non-Violent Restraint Monitoring ...Patients will be assessed every 2 hours at minimum ...Document components of restraint flowsheet once a shift and with changes ...Document end-of-shift evaluation on restraint flowsheet, regarding observations and care provided at two-hour intervals. Including; Activity, circulation, range of motion, fluids, food/meals, and toileting ...””

“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: 50175 Based on interview and record review, the hospital failed to follow policies and procedures for five of 30 sample patients (1, 19, 20, 21, 25) when: 1. Patient 1’s dressing to the left foot wound was not changed every day as ordered by the physician. 2. An intervention was not provided for Patient 19’s report of pain on 11/28/25. 3. A timely pain re-assessment was not provided for Patient 20 on 12/6/25. 4. An intervention was not provided for Patient 21’s report of pain on 11/16/25 5. Interventions were not provided for Patient 25’s reports of pain on 11/16/25 and 11/19/25. These failures had the potential to affect the health, comfort, and well-being of Patients 1, 19, 20, 21, and 25. Findings: 1. Patient 1 was admitted to the hospital on 12/4/25 with diagnoses including acute chronic kidney injury (a sudden, rapidly worsening of kidney function in someone who already has kidney disease) and diabetes (high blood sugar), per Patient 1’s history and physical (H&P, a physician’s initial assessment). A joint interview and record review was conducted on 4/30/26 at 8:30 A.M. with Quality Compliance Specialist (QNS) 1 and QNS 2. Patient 1’s orders titled, Recommendations from Wound Ostomy Nurse (nurse specializing in wound care) for Nursing, ordered 12/5/25, indicated wound care for Patient 1’s left toe was to be done every day, and as needed. This order was canceled and changed on 12/15/25. A physician’s progress note, dated 12/8/25, indicated Patient 1 underwent surgery on the left first toe on 12/7/25 and the plan included “ ...daily wound checks and dressing changes ...” A review of the nurses flowsheet (nursing documentation of assessments and tasks) dated December 2025 showed no documentation of wound care or wound dressing changes on 12/10/25 and 12/11/25. A review of nurses notes for 12/10/25 and 12/11/25 did not indicate wound care or wound dressing changes were done on 12/10/25 and 12/11/25. An interview was conducted on 4/30/26 at 10:15 A.M. with Licensed Nurse (LN) 1. LN 1 stated that wound dressing changes were supposed to be documented in the nursing flowsheet in a row specific for wounds. LN 1 stated a nurse can specify that a wound dressing was changed, in the flowsheet. An interview was conducted on 4/30/26 at 2:09 P.M. with Senior Director for Nursing Education (SDNE). SDNE acknowledged that documentation on the nursing flowsheet for Patient 1’s left toe wound did not indicate the dressing on the left toe wound was changed on 12/10/25 and 12/11/25. SDNE stated the wound care order from 12/5/25 was active on 12/10/25 and 12/11/25. An interview was conducted with Medical Doctor (MD) 1 on 4/30/26 at 3:14 P.M. MD 1 stated that if there were no new orders written after a procedure, on how to provide wound care, nurses were to follow wound care recommendations. A review of the hospital’s Skin and Ostomy Guidelines of Care, last revised 8/2025, indicated “ ...skin assessment ...frequency ...at least once per shift ...assess beneath preventative dressings and devices every shift and [as needed] ...Refer to MD orders or Wound Ostomy Nurse recommendations for care of full thickness wounds or those requiring advanced treatment ...” 51631 2. Patient 19 was admitted to the hospital on 11/29/25 with diagnoses including esophagitis (inflammation of the esophagus [tube that runs down the throat to the stomach]) per Patient 19’s history and physical (H&P; a physician’s initial assessment). On 4/28/26 at 3:12 P.M., a joint interview and record review was conducted with Registered Nurse (RN) 16. Per Patient 19’s vital sign flowsheet dated 11/28/25 at 4:17 A.M., Patient 19 reported a pain level of eight out of 10 (8/10; severe pain) and received oxycodone (medication to manage severe pain) 5 milligram (mg). At 5:20 A.M. Patient 19 reported a pain level of 7/10 (7/10; severe pain). The next assessment of pain for Patient 19 was completed at 8:59 A.M. RN 16 stated she could not find documentation in Patient 19’s medical chart that indicated that a provider notification or intervention was provided for the patient’s report of 7/10 pain on 11/28/25 at 5:20 A.M. On 5/1/26 at 10:49 A.M., a joint record review was conducted with nurse manager (NM) 16. NM 16 reviewed the patient’s records and verified the missing documentation for pain intervention. NM 16 stated it was important to provide interventions for the patient’s pain, to ensure the patient’s received quality care. A review of the hospital’s policy titled Pain Management, last revised November 25, 2025, indicated “ ...All patients have the right to prompt pain assessment and efforts to manage pain ... The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies. Pain reassessments apply to interventions made as needed in response to pain ...The timing for reassessment is dependent on the intervention and is timed around the peak effect of the treatment ....” 3. Patient 20 was admitted to the hospital on 12/5/25 with diagnoses including biliary stricture (narrowing or blockage of the bile ducts [tubes that carry digestive fluid from the liver and gallbladder to the intestine]) per Patient 20’s history and physical (H&P; a physician’s initial assessment). On 4/28/26 at 3:15 P.M., a joint interview and record review was conducted with Registered Nurse (RN) 16. Per Patient 20’s vital sign flowsheet dated 12/6/25, at 10:22 P.M. Patient 20 reported a pain level of eight out of 10 (8/10; severe pain) and received acetaminophen (pain medication) 975 milligrams (mg). The next assessment for pain was completed on 12/7/25 at 4:52 A.M. RN 16 stated she could not find documentation in Patient 20’s medical chart that indicated a reassessment was done before 12/7/25 at 4:52 A.M. On 5/1/26 at 10:49 A.M., a joint record review was conducted with nurse manager (NM) 16. NM 16 reviewed the patient’s records and verified the missing documentation for pain re-assessment. NM 16 stated it was important to re-assess the patient’s pain, to ensure the patient’s received quality care. A review of the hospital’s policy titled Pain Management, last revised November 25, 2025, indicated “ ...All patients have the right to prompt pain assessment and efforts to manage pain ... The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies. Pain reassessments apply to interventions made as needed in response to pain ...The timing for reassessment is dependent on the intervention and is timed around the peak effect of the treatment ....” 4. Patient 21 was admitted to the hospital on 11/15/25 with diagnoses including severe anemia (the body does not have enough red blood cells and as a result there is a decrease in oxygen transport to organs and tissues) per Patient 21’s history and physical (H&P; a physician’s initial assessment). On 4/28/26 at 3:18 P.M., a joint interview and record review was conducted with Registered Nurse (RN) 16. Per Patient 21’s vital sign flowsheet dated 11/16/25, at 6:39 A.M. Patient 21 reported a pain level of eight out of 10 (8/10; severe pain) and received hydromorphone (medication to treat moderate to severe pain) 1 milligram (mg). At 7:58 A.M. Patient 21 reported a pain level of 8/10 (severe) pain. At 11:18 A.M. Patient 21 reported a pain level of six out of 10 (6/10; moderate pain). The next assessment of pain for Patient 21 was completed at 1:02 P.M. RN 16 stated she could not find documentation in Patient 21’s medical chart that indicated a provider notification or intervention was provided for Patient 21’s reports of pain on 11/16/25 at 7:58 A.M. and 11:18 A.M. On 5/1/26 at 10:49 A.M., a joint record review was conducted with nurse manager (NM) 16. NM 16 reviewed the patient’s records and verified the missing documentation for pain interventions. NM 16 stated it was important to provide interventions for the patient’s pain, to ensure the patient’s received quality care. A review of the hospital’s policy titled Pain Management, last revised November 25, 2025, indicated “ ...All patients have the right to prompt pain assessment and efforts to manage pain ... The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies. Pain reassessments apply to interventions made as needed in response to pain ...The timing for reassessment is dependent on the intervention and is timed around the peak effect of the treatment ....” 5. Patient 25 was admitted to the hospital on 11/12/25 with diagnoses including recurrent small bowel obstruction (a partial or complete blockage in the small intestine that is accompanied by severe abdominal pain, vomiting, and bloating) per Patient 25’s history and physical (H&P; a physician’s initial assessment). On 4/28/26 at 3:21 P.M., a joint interview and record review was conducted with Registered Nurse (RN) 16. Per Patient 25’s vital sign flowsheet dated 11/16/25, at 8:56 P.M. Patient 25 reported a pain level of seven out of 10 (7/10; severe pain). On 11/19/25 at 8:57 A.M. the patient reported a pain level of six out of 10 (6/10; moderate pain). RN 16 stated she could not find documentation for 11/16/25, at 8:56 P.M. and 11/19/25 at 8:57 A.M. that indicated a provider notification or intervention was provided for Patient 25’s reports of pain. On 5/1/26 at 10:49 A.M., a joint record review was conducted with nurse manager (NM) 16. NM 16 reviewed the patient’s records and verified the missing documentation for pain interventions. NM 16 stated it was important to provide interventions for patient’s pain to ensure the patient’s received quality care. A review of the hospital’s policy titled Pain Management, last revised November 25, 2025, indicated “ ...All patients have the right to prompt pain assessment and efforts to manage pain ... The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies. Pain reassessments apply to interventions made as needed in response to pain ...The timing for reassessment is dependent on the intervention and is timed around the peak effect of the treatment ....””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50175 Based on interview and record review, the facility failed to follow its policy to ensure documentation was completed timely for one of three sampled patients (Patient 3) who was placed in restraint (physical or chemical method that limit a patient’s ability to move, often to prevent harm to themselves or others). This failure had the potential to compromise the safety and comfort of Patient 3 while in restraint. Findings: Patient 3 was admitted to the facility on 7/11/25 with diagnoses which included cerebrovascular accident (blood flow to the brain is disrupted, causing brain damage), per Patient 3’s Facesheet. An interview with the Director of Regulatory Affairs (DOR) was conducted on 8/13/25 at 2:59 P.M. The DOR stated it was the facility’s policy for the Registered Nurse (RN) to document on the restraint flowsheet (a part of the medical record where nurses document the nursing assessment related to restraints) at the beginning of the nurse’s shift, and then an attestation at the end of the nurse’s shift, indicating that the patient on restraints was monitored every two hours during the shift. A review of Patient 3’s medical record was conducted on 8/14/25 at 1:15 P.M. with Nurse Manager (NM) 1. Patient 3’s medical record included a physician’s order, dated 8/1/25 at 12:52 A.M., for restraints to both wrists. A review of Patient 3’s restraint flowsheet, dated 8/1/25, was conducted. There was no documentation at the end of the RN 1’s shift. NM 1 stated there were no other notes related to assessing Patient 3’s restraints on 8/1/25, in Patient 3’s medical record. NM 1 stated that RN 1 should have completed the end-of-shift documentation on the restraint flowsheet, at the end of the shift. Patient 3’s medical record included a physician’s order, dated 8/5/25 at 12:16 A.M., for restraints to both wrists. A review of Patient 3’s restraint flowsheet, dated 8/5/25, was conducted. There was no documentation at the end of the RN 2 and RN 3’s shift on 8/5/25. NM 1 stated that there were no other notes from RN 2 and RN 3 in the medical record, related to assessing Patient 3’s restraints for their shifts. NM 1 stated that RN 2 and RN 3 should have completed the end-of-shift documentation on the restraint flowsheet at the end of their shifts. A review of Patient 3’s medical record was conducted on 8/15/25 at 10:01 A. M. with the Quality Compliance Specialist (QCS). The restraint flowsheet was reviewed. The row titled, End of Shift: Restraint Evaluation, included the options to indicate range of motion (movement) was provided to the patient, hygiene was provided to the patient, restraints were secured properly, and skin assessment was completed. An interview was conducted with Senior Nursing Director (SND) on 8/15/25 at 10:06 A.M. The SND acknowledged it was important to document an end-of-shift attestation to ensure Patient 3’s needs were being met while in restraints, and for Patient 3’s safety, per the facility’s policy. A review of the facility’s policy titled Non-Violent Restraint, revised 7/5/24, indicated “ ...IV. Non-Violent Restraint Monitoring: A. Patients will be assessed every 2 hours at a minimum ...Document end-of-shift evaluation on restraint flowsheet, regarding observations and care provided at two-hour intervals. Including; Activity, circulation, range of motion, fluids, food/meals, and toileting ...””

“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: 48270 Based on interview and record review, the facility failed to follow its policy when: 1. The facility failed to ensure a pain reassessment was completed for one of 30 sampled patients (Patient 14). 2. The facility failed to ensure pain was managed timely for one of 30 sampled patients (Patient 8). These failures had the potential for Patient 14 and Patient 8’s pain to be mismanaged and unrelieved. Findings: 1. Patient 14 was admitted to the facility on 8/7/25 with diagnoses which included cholecystitis (swelling and irritation of the gallbladder, a small organ in the right side of the stomach), per Patient 14’s History and Physical (H&P). A review of Patient 14’s physician’s orders, dated 8/8/25, indicated “Oxycodone (medication for pain relief) 5 mg (milligrams) every 6 hours as needed for moderate pain (Pain Score 4-6)” was ordered. On 8/13/25 at 1:30 P.M., a concurrent interview and review of Patient 14’s medical record was conducted with Registered Nurse (RN) 13. Patient 14’s medication flow sheet (record of medication administration) indicated that on 8/12/25 at 8:35 P.M., Oxycodone 5 mg was administered for a pain score of 5. Further review of Patient 14’s flowsheet records indicated that a reassessment of Patient 14’s pain was not completed after the administration of the Oxycodone. RN 13 stated that the nurse should have reassessed Patient 14’s pain, 45 to 75 minutes after the administration of the pain relief medication, to ensure if it was effective, if it was too strong, or if other pain relief resources were needed. According to the facility’s policy titled “Pain Clinical Practice Guideline” dated 6/2022, “ ...Pain should be assessed and reassessed ...After each pain management intervention or at the peak of a pharmacological intervention’s effect (approximately 45-75 minutes ...) ...Nurses are responsible to perform and document pain assessments ...” 50175 2. Patient 8 was admitted to the facility on 8/12/25 with diagnoses which included falls, according to Patient 8’s History & Physical (H&P), dated 8/13/25. The H&P indicated Patient 8 experienced chronic (ongoing) pain from severe osteoarthrosis (degenerative joint disease- joints wear down over time, leading to pain) of the hips and left shoulder. Patient 8’s H&P indicated the plan of care included pain management. A concurrent interview and review of Patient 8’s medical record was conducted on 8/14/25 at 11:04 A.M. with the Senior Nursing Director (SND): Patient 8’s Medication Administration Record (MAR; record where nurses document what medications were given) dated 8/13/25, indicated that Patient 8 had pain medications, Tylenol and Oxycodone, ordered to help relieve pain. Pain was defined in the MAR as mild pain (pain score 1-3), moderate pain (pain score 4-6), and severe pain (pain score 7-10). A review of Patient 8’s pain flowsheet (part of the medical record where nurses document the nursing assessment related to pain) dated 8/13/25, indicated Patient 8’s pain was assessed at 4:56 P.M. with a pain score of four out of ten, moderate pain. A review of the pain flowsheet row, titled Pain Interventions(s) on 8/13/25 at 4:56 P.M. was not completed. Patient 8’s pain score remained a four out of ten on 8/13/25 at 8 P.M. A review of the pain flowsheet row, titled Pain Intervention(s) on 8/13/25 at 8 P.M. indicated “Medication (See eMAR)” indicating medication was given to help relieve Patient 8’s pain. A review of the MAR was conducted. There was no documentation that indicated a pain medication was administered to Patient 8 at or around 8 P.M. on 8/13/25. The SND stated there were no other pain interventions including non-pharmacological interventions (other ways to manage pain that does not include medications) that were documented in the flowsheets or notes, related to treating Patient 8’s pain at 4:56 P.M. and 8 P.M. on 8/13/25. Further, the SND stated there was no documentation in the medical record that the physician was notified that Patient 8’s pain goal of two out of ten was not met on 8/13/25 at 4:56 P.M. and 8 P.M. Patient 8 did not receive another pain medication until 8/14/25. The SND acknowledged Patient 8 did not receive any pain management interventions on 8/13/25 at 4:56 P.M. and 8 P.M. A follow-up interview was conducted on 8/15/25 at 10:06 A.M. with the SND. The SND stated that patients have different thresholds for pain, and a pain of “four out of ten” did not meet Patient 8’s needs, as Patient 8’s pain goal was “two out of ten”. A review of the facility’s policy titled Pain Management, revised 7/5/24, indicated “ ...This policy establishes guidelines relevant to achieving optimal patient comfort through a proactive pain management program ...requires a balance between pain relief, safety, and the side effects of interventions ...pain is subjective, that only the person who has the pain knows exactly how severe it is, and that people with pain have the right to assessment and treatment ...Pain assessment and re-examination of the pain management plan continue until the pain reduction is satisfactory to the patient ...The patient’s provider will be contacted for further assessment if the ordered interventions are not effective in providing a reduction in the self-report pain score ...Definitions ...VII. Pain Goal: the patient’s stated acceptable level of pain ...””

“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: 50175 Based on interview and record review, the facility failed to ensure a safe environment in the magnetic resonance imaging (MRI; referred to as equipment and/or medical imaging procedure that uses strong magnetic fields and radio waves to produce images of organs and internal structures of the body) suite when the facility failed to report an unusual occurrence to the California Department of Public Health (CDPH; government agency) after a magnetic step stool was brought into the room that housed the MRI magnet, during one patient’s (Patient 1) scheduled MRI test. This failure had the potential for CDPH to be unaware of the facility’s gaps in safety (the discrepancy between current safety practices and required safety standards) that could cause Patient 1 and/or other patients physical/psychological harm and trauma. Findings: On 7/8/25, an unannounced visit was made to the facility to investigate a complaint about a step stool that was projected into the MRI magnet. An interview was conducted on 7/8/25 at 10:05 A.M. with Senior Director of Radiology (SDR) and Director of Imaging Services (DIS). SDR stated that there was an employee who had sustained an injury when MRI technologist (MT) 1 brought an inappropriate (MRI-unsafe, magnetic) step stool from MRI zone 2 (an area that serves as a transition space between the public area and more strictly controlled zones) into MRI zone 4 (the strictly controlled area containing the MRI scanner itself, often referred to as the magnet room). SDR stated the inappropriate, magnetic, MRI-unsafe step stool looked like the “MRI-safe” step stool. An interview was conducted on 7/10/25 at 10:10 A.M. with MT 3. MT 3 stated he was present during the incident on 5/29/25 when a magnetic step stool was brought into MRI zone 4, causing the MRI machine to be shut down when the magnetic step stool was forcibly drawn into the MRI machine, before Patient 1’s MRI exam. MT 3 stated it was assumed that the environment was safe to do the MRI, as there were previous MRI procedures already completed that day. MT 3 stated that MT 1 grabbed the step stool, not knowing it was magnetic, and brought it into MRI zone 4. MT 3 stated the magnetic step stool looked identical to the MRI-safe step stool. MT 3 stated there were no markings on the magnetic step stool indicating that it was MRI-unsafe. MT 3 stated the magnetic step stool should not have been in any of the MRI zones. MT 3 stated that Patient 1 became more anxious and asked if this was a normal incident. MT 3 stated he informed Patient 1 that it was not normal. MT 3 stated Patient 1 appeared scared after the incident. An interview was conducted on 7/10/25 at 10:37 A.M. with MT 1. MT 1 stated that Patient 1 was anxious prior to the MRI exam. MT 1 stated the step stool was brought in to assist Patient 1 to get on the (MRI) table. MT 1 stated the magnetic step stool “shot out” from his hand and was pulled into the MRI machine. MT 1 stated Patient 1 started crying. An interview was conducted on 7/11/25 at 9:03 A.M. with Director of Regulatory Affairs (DOR). DOR acknowledged that the incident involving MT 1 bringing a MRI-unsafe step stool into MRI zone 4 while Patient 1 was waiting to enter MRI zone 4, was “definitely” an unusual occurrence. DOR stated the incident was not reported to CDPH because the patient was not on the MRI table. A review of the facility’s policy titled Serious Safety Event (Sentinel, Adverse, and Near Miss event) Activation Processes, dated 7/5/24, indicated “ ...VI. Reporting to External Agencies (Attachment A) ...Attachment A ...CDPH Reportable Adverse Events ...Any occurrence such as ...unusual occurrence which threatens the welfare, safety, or health of patients, personnel or visitors shall be reported as soon as reasonably practical (not later than 24 hours after event has been detected)”.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 50175 Based on interview and record review, the facility failed to ensure a procedure room was safe for patients and staff when a magnetic step stool was inappropriately brought into the room housing the magnet used to complete a magnetic resonance imaging (MRI; equipment and/or medical imaging procedure that uses strong magnetic fields and radio waves to produce images of organs and internal structures of the body) test. This failure had the potential to cause harm and injury to the patient and staff present in the room with the MRI magnet. Findings: On 7/8/25, an unannounced visit was made to the facility to investigate a complaint about a step stool that was projected into the MRI magnet. An interview was conducted on 7/8/25 at 10:05 A.M. with Senior Director of Radiology (SDR) and Director of Imaging Services (DIS). SDR stated there was an employee who had sustained an injury when MRI technologist (MT) 1 brought an inappropriate (MRI-unsafe, magnetic) step stool from MRI zone 2 (an area that serves as a transition space between the public area and more strictly controlled zones) into MRI zone 4 (the strictly controlled area containing the MRI scanner itself, often referred to as the magnet room). SDR stated the inappropriate, magnetic, MRI-unsafe step stool looked like the “MRI-safe” step stool. On 7/8/25 at 10:15 A.M., a tour of the facility’s multiple MRI areas was conducted. An interview was conducted on 7/8/25 at 10:25 A.M with MT 2. MT 2 stated it was the facility’s process not to bring anything into MRI zone 4 that did not have a sticker indicating that the equipment was “MRI-safe”. MT 2 stated items that were MRI-unsafe should have a sticker that indicated the item should not be brought into MRI zone 4. A follow-up interview was conducted on 7/9/25 at 8:17 A.M. with SDR. SDR stated that one of the facility’s MRI machines was turned off because of an incident that occurred on 5/29/25, when MT 1 brought a magnetic step stool into MRI zone 4. SDR stated the magnetic step stool was not MRI safe. SDR stated the magnetic step stool had been used in zone 2 “forever”. SDR stated the magnetic step stool should not have been brought into MRI zone 4. SDR stated the MRI-safe and the MRI-unsafe step stool looked alike, except for a sticker on the side of the step stool that indicated whether it was MRI safe or unsafe. SDR stated the facility needed a MRI-safe step stool that was clearly different from non-safe supply. An interview was conducted on 7/10/25 at 10:10 A.M. with MT 3. MT 3 stated he was present during the incident on 5/29/25, when a magnetic step stool was brought into MRI zone 4, causing the MRI machine to be shut down after the magnetic step stool was forcibly drawn into the MRI machine, before Patient 1’s MRI exam. MT 3 stated it was assumed that the environment was safe to do the MRI, as there were previous MRI procedures already completed that day. MT 3 stated that MT 1 grabbed the step stool, not knowing it was magnetic, and brought it into MRI zone 4. MT 3 stated the magnetic step stool looked identical to the MRI-safe step stool. MT 3 stated there were no markings on the magnetic step stool indicating that it was MRI-unsafe. MT 3 stated the magnetic step stool should not have been in any of the MRI zones. MT 3 stated Patient 1 became more anxious and asked if this was a normal incident. MT 3 stated he informed Patient 1 that it was not normal. MT 3 stated Patient 1 appeared scared. An interview was conducted on 7/10/25 at 10:37 A.M. with MT 1. MT 1 stated that Patient 1 was anxious prior to the MRI exam. MT 1 stated the step stool was brought in to assist Patient 1 to get on the (MRI) table. MT 1 stated the magnetic step stool “shot out” from his hand and was pulled into the MRI machine. MT 1 stated that Patient 1 started crying. MT 1 stated his hand became swollen and he needed to wear a hand brace following the incident. MT 1 stated there was a gap in environment safety (the discrepancy between current safety practices and required safety standards) within the facility’s MRI department. MT 1 stated the magnetic, MRI-unsafe step stool looked the same as a MRI-safe step stool. MT 1 acknowledged he should have checked the equipment before bringing it into MRI zone 4. A review of the facility’s Imaging Services MRI Safety Guidelines, dated 1/18/25, indicated “...This policy is intended to guide the provision of a safe environment for patients, visitors, and employees within the Magnetic Resonance Imaging (MRI) suite ...Definitions...MRI unsafe...any item that is known to pose hazards in all MRI environments. These are objects...and equipment that are not under any circumstances able to enter the MRI scan room. These are items that are highly magnetic...Missile Effect...The capability of the fringe field component of the static magnetic field of an MR system to attract a ferromagnetic object, drawing it rapidly into the scanner by force...XIII. Missile Effect Accident Prevention...The missile effect can pose a significant risk to the patient inside the MR system and/or anyone who is in the path of the projectile...5. Do not allow equipment and devices containing ferromagnetic components into the MR environment unless they have been tested and labeled MR safe...Use the MRI labeling classification system to clearly identify Safe, Unsafe, and Conditional equipment within the MRI environment. All equipment will be tested by the MRI staff to determine if it is safe to enter the magnetic field. Any equipment not labeled will be considered unsafe until appropriate testing has been completed...””

“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: 43674 Based on observation, interview, and record review the hospital did not ensure staff provide a safe care environment to 2 of 2 patients when: 1. Patient 15 eloped and an unreasonable force (force that is unnecessary and excessive) was used by deploying a taser gun. 2. Patient 16 had a c-diff (a bacterium that can cause diarrhea and other intestinal conditions) and his bedside commode was not cleaned timely during his stay in the Emergency Department (ED). As a result, Patient 15 sustained injury and was admitted to the hospital for 3 days, and Patient 16 had an unsafe and undignified environment. Findings: 1. Patient 15 was admitted to the hospital on 6/28/24 with diagnoses which included fracture of right clavicle (collarbone) and psychosis (a symptom that caused a person to loose in touch with reality). A review of Patient 15’s Registered Nurse (RN) ED Notes dated 6/29/24 at 7:49 P.M., indicated “ ...While I was discussing patient’s next medication at bedside, patient was speaking with me calmly, then suddenly leapt out of bed and sprinted down the hallway past security and through the ambulance bay (area where ambulance park to unload patients) doors ...After he left the building, security ran after him through the hospital grounds.” An interview was conducted on 7/16/24 at 8:56 A.M., with the Emergency Department Manager (EDM) 2. The EDM 2 stated Patient 15 was a 5150 (involuntary 72 hour hold) patient who ran away and eloped in the ED on 6/29/24 at 7:40 P.M. The EDM 2 stated later that night, Patient 15 came back to the ED to retrieve his belongings. The EDM 2 further stated after Patient 15’s arrival in the ED, Patient 15 ran away to elope again. Patient 15 was chased and tased with a taser gun by Security Agent (SA) 1. The EDM 2 stated Patient 15 sustained injury and was admitted to the hospital. An observation of Patient 15’s video recording was conducted on 7/19/24 at 1 P.M., with Regulatory 1 and the Senior Director of Facility Support Services (SDFSS). The video recording camera captured the ambulance area, part of the path going to ED entrance and the Front Street. On 6/29/24 at 9:51:27 P.M., Patient 15 arrived in the ED ambulance bay area, walked to the ED entrance pathway and disappeared on the camera recording. On 6/29/24 at 9:51:34 P.M., Patient 15 was captured by the video recording camera running from the ED entrance going to Front Street, was chased and the taser gun was deployed by the Security Officer. Patient 15 was tased on his back while running and fell to the ground at Front Street. An interview was conducted on 7/19/24 at 1 P.M., with the SDFSS. SDFSS stated SA 1 tased Patient 15 on his back while running away. SDFSS stated it was not part of the policy deploy a taser gun to an eloping patient. SDFSS further stated that there was no reason to contain Patient 15 who was already outside the hospital building. A review of hospital’s policy and procedure titled, Use of Force last revised 3/7/22 indicated “ ...III. Procedure: Department members are authorized to use only that amount of for that is objectively reasonable (reasonable force) to perform their duties ... S/A’s (Security Agents) shall use de-escalation techniques and other alternatives practices that are consistent with their training before resorting to force ... V. Force Continuum/Matrix: B. Levels of Control ... 3. Third Level ... c. S/A’s may utilize the TASER for subjects who have access to weapons ... VI. Unreasonable Force: Security members shall use only that force that is objectively reasonable. Unreasonable force is defined as the force that is unnecessary or excessive give the circumstances presented to S/As at the time the force is applied.” A review of hospital’s policy and procedure titled, Taser - Conducted Energy Weapon (CEW) last revised 9/8/22 indicated “ ...III. Procedure: The TASER is an intermediate weapon that is a handheld conductive energy weapon (CEW) used for controlling assaultive/high risk persons. The purpose of the TASER is to facilitate a safe and effective response and minimize injury to Subjects and Agents ... 2. Patient 16 was admitted to the hospital on 8/14/24 with diagnoses which included severe diarrhea (loose stool) and C-diff colitis (inflammation of colon caused by bacterium Clostridium Difficile) per History and Physical dated 8/14/24. A review of Patient 16’s room assignment indicated Patient 16 was assigned to room IRR09 (Emergency Department overflow area) on 8/15/24 at 12:24 A.M. until 8/16/24 at 6:57 P.M. A review of Patient 16’s stool output flowsheet indicated Patient 16 had 13 episodes of liquid stool and used bedside commode (portable toilet) throughout his stay in room IRR09 from 8/15/24 at 12:24 A.M., until 8/16/24 at 6:57 P.M. An observation of room IRR09 was conducted on 9/17/24 at 11:35 A.M., with the SDN. Room IRR09 was an isolation glass room without a toilet inside the room. An interview was conducted on 9/17/24 at 11:40 A.M., with Charge Nurse (CN) 1. CN 1 stated room IRR09 was an isolation room without a toilet. CN stated for a patient with C-Diff, a bedside commode will be used by the patient. CN 1 stated the stool in the bedside commode would be emptied in the red biohazard trash in the room. CN 1 stated the EVS would empty the trash and clean the room. CN 1 further stated the cleaning and emptying of the bedside commode and the emptying of the red biohazard trash was not being documented in the chart. A review of hospital’s policy and procedure titled, Standard and Transmission based precaution policies last reviewed 3/2024 does not specify guidelines on c-diff patients, assignments of room without toilet, the use of BSC and its emptying and cleaning guidelines.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital did not implement their current policies and procedures on abuse allegation for 1 of 1 patient (Patient 18). The nursing staff did not follow the protocol when Patient 18 made an allegation of physical abuse. This failure had the potential for Patient 18’s well-being and at risk for further abuse. Findings: Patient 18 was admitted to the hospital on 8/21/24 with diagnoses which included Failure to thrive (a decline in weight loss and decreased appetite) per History and Physical dated 8/21/24. A review of Adult Protective Services (APS) report completed on 8/22/24 indicated at 9 P.M. “ ...The daughter of CLT (Client) was still present and from her account of the situation, her and CLT (Client) say that nurse [Name of Nurse] had pushed CLT back into the bed when she touched his shoulder suggesting he should sit down ... The daughter of the CLT then requested the nurses create an APS case ...” An interview was conducted on 9/5/24 at 11:01 A.M., with the Emergency Department Manager (EDM) 2. The EDM 2 stated she received a report of an allegation of abuse when RN 1 took care of patient 18. The EDM 2 further stated that the report indicated RN 1 pushed Patient 18 back in bed in an aggressive manner. The EDM 2 stated she then reported to Senior Risk Manager (SRM) about the allegation of abuse. The EDM 2 further stated, it was then they made the decision that the allegation of abuse did not happen. The EDM 2 stated, she reported it to SRM and thought that was enough. The EDM 2 was not aware that the decision had to be made in conjunction with hospital leadership. An interview was conducted on 9/12/24 at 11:30 A.M. with the Director of Regulatory (DR). The DR stated the EDM 2 and the SRM were the 2 leadership that made the decision right after the incident that the physical abuse allegation did not happen. The DR stated the allegation of abuse was presumed to have been discussed during the leadership meeting the following day at 10 A.M. The DR further stated she could not provide the evidence of discussion and the leadership determination on the allegation of physical abuse incident. An interview was conducted on 9/13/24 at 9:28 A.M., with SRM. The SRM stated she received a call from the EDM 2 who reported to her that EDM 2 had conducted her investigation and determined her finding. The SRM further stated agreed with EDM 2’s decision and did not take any further action. A review of hospital policy and procedure titled Abuse Screening, Assessment and Reporting last revised date 11/24/20 indicated “Procedure: I. For allegations of abuse/neglect ... B. The Nurse Manager/Department Manager/Nursing/Physician Supervisor shall: 2. ...Risk and supervisor will coordinate to inform the following: i. Executive Leadership ... ii. UC San Diego Health Security; iii. House Supervisor; Patient’s attending physician; and iv. Patient Experience ... 3. In conjunction with those listed above, determine whether it is necessary to relieve the employee(s) involved in the incident of their duty (ies) and place the party (ies) on the investigatory leave of absence pending the completion of all investigations and//or summary suspension.””

“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: 43674 Based on interview and record review the hospital did not ensure patient needs and treatments were met for 4 of 4 patients (Patient 13, Patient 14, Patient 17 and Patient 31) when: 1. Patient 13’s vital signs and pain assessment were not reassessed within 4 hours after the ED triage in the ED waiting area per policy. 2a. Patient 13’s pain level was not reassessed after Morphine (pain medication) Intravenous (IV) was given. 2b. Patient 14’s pain level was not reassessed after Oxycodone (pain medication) tablet was given. 2c. Patient 17’s pain level was not reassessed after Tylenol tablet (pain medication) was given. 3. Patient 31’s neurological assessment (a medical evaluation of a patient’s nervous system) was not done in a timely manner per physician’s order. This failure had the potential to affect the patients’ care and well-being. Finding: 1. Patient 13 was admitted to the hospital on 12/27/23 for diagnoses which included hydroureteronephrosis (swelling of kidney caused by obstructing kidney stone on flow of urine) and forniceal rupture (leak of urine to the surrounding tissue of the kidney) per ED Provider Notes dated 12/27/23. A review of Patient 13’s Patient Care Timeline (PCT) indicated that on 12/27/24 at 4:43 P.M., Patient 13’s vital signs and pain assessment which included Blood Pressure (BP) 186/110 (normal BP 120/80) and abdominal pain level of 9 out of 10 (10 being the highest pain level). Per the same PCT, there were no evidence of documentation that staff provided intervention. Patient 13’s PCT also indicated that the next pain assessment done was on 12/27/24 at 10:35 P.M., which was 6 hours after the initial assessment was done and the vital signs were assessed on 12/27/24 at 11:30 P.M., which was 7 hours after the initial assessment. An interview and record review were conducted on 5/1/24 at 1 P.M., with the Emergency Department Manager (EDM) 1. The EDM reviewed the PCT and flowsheet of pain assessment. The EDM stated the expectation for patients that were triaged and asked to wait in the ED lobby’s waiting room was to be reassessed every 4 hours. The EDM 1 acknowledged that Patient 13’s vital signs were not taken, and pain assessment was not done after 4 hours from the time of the initial assessment. A review of hospital policy and procedure titled, Triage last revised 8/2022 indicated “ ...Procedure: II. E. Patients placed in waiting area following triage will have a focused re-assessment performed and documented a minimum of every 4 hours.” 2a. Patient 13 was admitted to the hospital on 12/27/23 with diagnoses which included hydroureteronephrosis (swelling of kidney caused by obstructing kidney stone on flow of urine) and forniceal rupture (leak of urine to the surrounding tissue of the kidney) per ED Provider Notes dated 12/27/23. A review of Patient 13’s Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 12/27/24 at 10:35 P.M., Patient 13 was given Morphine 4 mg (milligram) IV. There was no documentation that pain level was reassessed after Morphine was given. A record review and interview were conducted on 9/18/24 at 10:38 A.M., with the Senior Director of Nursing (SDN). The SDN reviewed Patient 13’s MAR and Pain Assessment flowsheet. The SDN stated Patient 13’s MAR indicated Patient 13 was given Morphine 4 mg IV on 12/27/24 at 10:35 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 13’s pain level after pain medication was given. A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated “ ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies ... B. IV, IM, subcutaneous and epidural/peripheral nerve infusion/intrathecal analgesics: approximately 15-45 minutes following administration ...” 2b. Patient 14 was admitted to the hospital on 4/24/23 with diagnoses which included abdominal pain status post oocyte retrieval (procedure that removes eggs from an ovary to enable fertilization outside of the body) per History and Physical dated 4/24/23. A review of Patient 14’s Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 4/24/23 at 8:21 P.M., Patient 14 was given Oxycodone (Roxicodone) tablet 10 mg (milligram. There was no documentation that pain level was reassessed after Oxycodone was given. A record review and interview were conducted on 9/18/24 at 11:20 A.M., with the Senior Director of Nursing (SDN). The SDN reviewed Patient 14’s MAR and Pain Assessment flowsheet. The SDN stated Patient 14’s MAR indicated patient was administered with Oxycodone (Roxicodone) tablet 10 mg on 4/24/23 at 8:21 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 14’s pain level after pain medication was given. A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated “ ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies ... A. PO, PR, and gastric tube analgesics: approximately 45-75 minutes following the administration ...” 2c. Patient 17 was admitted to the hospital on 8/17/24 with diagnoses which included bilateral foot pain per ED Provider Notes dated 8/17/24. A review of Patient 17’s Medication Administration Record (MAR) and Pain Assessment flowsheet indicated that on 8/17/24 at 2:09 P.M., Patient 17 was given Acetaminophen (Tylenol) 975 mg table. There was no documentation that pain level was reassessed after Oxycodone was given. A record review and interview were conducted on 9/17/24 at 2:19 P.M. with the Senior Director of Nursing (SDN). The SDN reviewed Patient 17’s MAR and Pain Assessment flowsheet. The SDN stated Patient 17’s MAR indicated patient was administered with a pain medication Acetaminophen (Tylenol) 975 mg tablet on 8/17/24 at 2:09 P.M. The SDN stated there was no evidence of documentation that nursing staff reassess Patient 14’s pain level after pain medication was given. A review of hospital policy and procedure titled, Pain Management last revised on 8/23/22 indicated “ ...Policy: I. All patients have the right to prompt pain assessment and efforts to manage pain arising from procedures, treatments, and disease... XXI. The healthcare staff will reassess the patient’s pain to determine the effectiveness of the pain management strategies ... A. PO, PR, and gastric tube analgesics: approximately 45-75 minutes following the administration ...” 45909 3. A review of Patient 31’s admission record indicated Patient 31 was admitted to the facility on 8/25/24 with medical diagnoses of anterior communicating aneurysm (Acom - narrowing of part of a brain), and hypertension (high blood pressure). Review of Patient 31’s physician order dated 9/12/24 indicated Patient 31 was to have neurological assessment (NA - checking patient’s mental status) every four hours. An interview was conducted with Patient 31 on 9/13/24 at 2:54 P.M., inside his room. Patient 31 stated he has not seen his licensed nurse since 9 A.M. Patient 1 further stated his physician advised him that his mental status will be frequently checked by nursing staff. A concurrent interview and record review of were conducted with Registered Nurse (RN) 2 on 9/13/24 at 2:57 P.M. Per the electronic neurological assessment flow sheet, Patient 31’s neurological assessment was last documented on 9/13/24 at 7 A.M. RN 2 stated, she should have recorded Patient 31’s assessment at 11 A.M to accurately document Patient 31’s mental status. There was no evidence of documentation Patient 31’s neurological assessment was done every four hours per physician order. An interview was conducted with the Unit Manager (UM) on 9/13/24 at 3:02 P.M. The UM stated she expects RN’s to implement neurological assessment per physician’s order and RN’s should have documented on time to address changes that may have happened. The UM further stated RN 2 should have assessed Patient 31 on 9/13/24 at 11:00 A.M. and should have documented her findings on Patient 31’s neurological assessment form. Review of the facility’s policy titled, Patient Treatment and Medication Orders dated, 5/24/24, indicated,” ...X. Medication and treatments should be administered as ordered by prescribers ....””

“SCOPE AND FREQUENCY OF REVIEW CFR(s): 482.30(c) (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of-- (i) Admissions to the institution; (ii) The duration of stays; and (iii) Professional services furnished including drugs and biologicals. (2) Review of admissions may be performed before, at, or after hospital admission. (3) Except as specified in paragraph (e) of this section, reviews may be conducted on a sample basis. (4) Hospitals that are paid for inpatient hospital services under the prospective payment system set forth in Part 412 of this chapter must conduct review of duration of stays and review of professional services as follows: (i) For duration of stays, these hospitals need review only cases that they reasonably assume to be outlier cases based on extended length of stay, as described in §412.80(a)(1)(i) of this chapter; and (ii) For professional services, these hospitals need review only cases that they reasonably assume to be outlier cases based on extraordinarily high costs, as described in §412.80(a)(1)(ii) of this chapter. This Standard is not met as evidenced by: 43674 Based on interview and record review the facility did not perform the 3rd day Utilization Review (UR - a systematic process of reviewing medical necessity, patient care, and service usage) after the initial UR for 1 or 1 patient (Patient 11) per policy. As a result, Patient 11’s admission status was not corrected timely. Findings: Patient 11 was admitted to the hospital on 4/15/24 for diagnoses that included fall and left leg pain per History and Physical dated 4/16/24. A review of Patient 11’s admission status order dated 4/16/24 at 5:35 P.M., indicated “Inpatient Admission”. A review of Patient 11’s InterQual (a tool used to determine patient’s appropriate status and level of care) indicated that Patient 11 had an initial InterQual review on 4/16/24 and it indicated the criteria status was not met. The following InterQual review was on 4/21/24 and had indication the criteria status was not met. An interview was conducted on 9/11/24 at 3:37 P.M., with the Care Management Chief Administrative Officer (CMCAO). The CMCAO stated the InterQual review should have been done on Day 3 after the initial InterQual review on 4/16/24. The CMCAO stated the InterQual review should have been done to ensure appropriateness of Patient 11’s ordered admission status. The CMCAO acknowledge Patient 11’s InterQual review was not done on Day 3. A review of hospital’s policy and procedure titled, Clinical Determination of Appropriate Patient Status last revised 5/24/24 indicated,” ...Procedure: IV: Inpatient Status: C. Acute inpatients will have a documented InterQual clinical screening criteria review according to the following requirements: 3. Follow up or continued stay reviews must be completed by hospital day 3, then no less frequently than every third day, for patients located in a unit other than a critical care unit.””

“DETERMINATIONS OF MEDICAL NECESSITY CFR(s): 482.30(d) (1) The determination that an admission or continued stay is not medically necessary- (i) May be made by one member of the UR committee if the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c), concur with the determination or fail to present their views when afforded the opportunity; and (ii) Must be made by at least two members of the UR committee in all other cases. (2) Before making a determination that an admission or continued stay is not medically necessary, the UR committee must consult the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c), and afford the practitioner or practitioners the opportunity to present their views. (3) If the committee decides that admission to or continued stay in the hospital is not medically necessary, written notification must be given, no later than 2 days after the determination, to the hospital, the patient, and the practitioner or practitioners responsible for the care of the patient, as specified in §482.12(c). This Standard is not met as evidenced by: 43674 Based on interview and record review the facility did not inform and provide Medicare Outpatient Services Courtesy Notice (MOSCN) to 1 of 1 patient (Patient 11) when Patient 11’s admission status was changed from Inpatient to Outpatient. This failure had affected Patient 11’s discharge disposition and discharge plan. Findings: Patient 11 was admitted to the hospital on 4/15/24 for diagnoses that included fall and left leg pain per History and Physical dated 4/16/24. A review of Patient 11’s admission order status indicated that Patient 11 had 7 admission order status changed within 11 days. The document further indicated that Patient 11 had a change of admission status from Inpatient to Outpatient in a bed three times on 4/16/24 at 5:14 P.M, 4/22/24 at 1:37 P.M., 4/24/24 at 1:35 P.M. A review of Patient 11’s Electronic Medical Record indicated that Patient 11 was not provided with MOSCN on 4/16/24 at 5:14 P.M., and on 4/24/24 at 1:35 P.M. The MOSCN would have,”...notify you [patient] that the status of your current hospital stay is being changed from inpatient to outpatient services.” An interview was conducted on 9/11/24 at 3:30 P.M., with the Patient Access Director (PAD). The PAD stated the MOSCN was a document provided to patients to notify them of their admission status change from inpatient to outpatient. Patient 11 was provided with the MOSCN once on 4/22/24. A review of hospital’s policy and procedure did not indicate the process on providing the Medicare Outpatient Services Courtesy Notice.”

“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: 29509 Based on interview and record review, the hospital failed to provide care in a safe setting when Emergency Department (ED) staff did not follow policy for close observation of a patient at risk of suicide (Patient 1). As a result, the patient was allowed to use the restroom with the door closed and attempted suicide via suffocation. The patient suffered an anoxic brain injury and subsequently expired. Findings: Patient 1 was admitted to the ED on 10/31/23 on an involuntary hold from a therapist’s office after stating he had suicidal ideation with thoughts to hang himself, according to a Psychiatry Consult Note, dated 10/31/23. The note further indicated, “Concerning development of suicidal ideation leading to placement of involuntary hold. Although patient denying suicidal ideation this morning, suspect minimization. Requires inpatient psychiatric hospitalization for safety monitoring, symptom stabilization, disposition planning.” On 11/8/23 at 8:58 A.M., the ED Manager (EDM) was interviewed. According to the EDM, Patient 1 was assessed to be at moderate risk of suicide upon triage on 10/31/23 and required a sitter for continuous observation. Around 9:45 A.M on 11/1/23, Clinical Care Partner (CCP) 1 accompanied the patient to the bathroom and allowed the door to be closed. The EDM stated, “That is not our expectation.” CCP 1 knocked twice and the patient stated, ‘I’m okay.’ However, the patient did not answer on the third knock, so CCP 1 opened the door and found Patient 1 sitting on the toilet with paper towels in his mouth. The patient initially had his eyes open but then went unconscious and lost a pulse. Cardiopulmonary Resuscitation (CPR) was initiated, and the patient was taken to the resuscitation room where forceps were needed to pull out paper towels in order to secure an airway. The EDM stated Patient 1 was then admitted to the ICU. On 11/4/23, an MRI was done to check brain perfusion. The results were “suboptimal and not viable with life” per the EDM. The family made the decision to remove life support and Patient 1 expired on 11/4/23. The EDM acknowledged that Patient 1’s death was preventable. The EDM stated, “We identified there was a breach in observation.” During a tour of the ED on 11/8/23 at 10:46 A.M., a sitter was outside the bathroom observing a patient with the door ajar. CCP 1 was interviewed on 11/8/23 at 10:55 A.M. CCP 1 stated he worked the CCP float pool. According to CCP 1, at the start of his shift on 11/1/23, he received report from the outgoing sitter that Patient 1 was on a 1:3 observation (one sitter observing three patients). Around 9:40 A.M. the patient requested to use the bathroom. CCP 1 stated, “I said [to Patient 1] I have to be there, but he wanted privacy.” CCP 1 stated when Patient 1 did not answer after he knocked, he opened the bathroom door and found the patient on the toilet with “paper towels in his mouth.” CCP 1 then called for help and ED staff came to assist. CCP 1 further stated that a suicidal patient should be within sight at all times when using the bathroom. The Assistant Nurse Manager for the CCP Float Pool (ANM) was interviewed on 11/9/23 at 10:45 A.M. The ANM stated that Float Pool CCPs receive one-time training on Constant Observer Attendant (COA)/sitter observation upon hire. According to the ANM, Float Pool CCPs do not receive annual training on COA/sitter observation. CCP 1 last received training on sitter observation upon his hire date of 9/20/21, two years prior. The ED Director (EDD) stated during an interview on 11/9/23 at 11:04 A.M. that ED CCPs have in-person skills training annually which includes COA/sitter observation. According to the EDD, Float Pool CCPs only do COA/sitter training upon hire. On 11/9/23 at 12:19 P.M., EMT 1 stated during an interview that she was currently assigned as a 1:1 sitter in the ED. EMT 1 stated that when taking a patient to the bathroom, the door needs to be wedged open for visual, keeping sight of the patient at all times. When interviewed on 11/9/23 at 11:15 A.M., Registered Nurse (RN) 2, the primary ED nurse for Patient 1 on 11/1/23, stated she was in a room next to the bathroom when she responded to the call for help. According to RN 2, nurses were trying pull paper towels out the patient’s mouth, but patient was clenching down. Patient 1 was turning blue and lost pulses, so CPR was started. RN 2 stated that when a patient is suicidal with a sitter for 1:3 observation, the patient becomes 1:1 sitter observation for the bathroom and the door should not be closed or locked. The medical record was reviewed on 11/8/23 and 11/9/23. The ED Care Timeline indicated Patient 1 arrived to the ED on 10/31/23 at 12:23 P.M. Per the Columbia-Suicide Severity Rating Scale (an assessment tool used to identify and assess individuals at risk for suicide), the patient was assessed as moderate risk upon triage. Interventions implemented included a sitter for 1:3 continuous observation. On 11/1/23 at 9:50 A.M., RN 2 documented in an ED Note, “Was in another patient’s room close to the restroom when this RN heard staff calling for help for the patient in the restroom. This RN stepped out of room 10 and noticed that other ED RNs and MDs were attempting to remove paper towels from the patient’s mouth and arouse the patient. Pt [patient] was noted to be cyanotic and with his teeth clenched around paper towels ...No femoral pulses palpated. CPR initiated while pt was wheeled to room 6 for resuscitation.” According to an ED MD Progress Note, dated 11/1/23, “At approximately 9:50 a.m. the patient was reportedly found unresponsive in the bathroom on the toiled and witnessed to has [sic] stuffed multiple wet paper towels into his mouth ...The paper towels were removed and patient immediately brought into the resuscitation room he was found to be pulseless and apneic and CPR started immediately. Patient had ongoing prolonged resuscitation. At the time of intubation he was noted to have multiple wet paper towels that were stuffed deep into the oropharynx that were removed with Magill forceps.” Patient was then admitted to ICU. The Discharge Summary, dated 11/4/23, indicated Patient 1 had “Diffuse anoxic brain injury ...Successful suicide attempt s/p [status post] resuscitation.” The Discharge Summary further indicated, “After family meeting on the afternoon of 11/4/23, decision was made by family to discontinue life support and compassionately extubate.” The patient expired on 11/4/23. According to the hospital’s policy, Suicide Risk Management, last revised 10/25/22, “Emergency Department: All patients ?7 years will be screened for possible suicide risk using a validated suicide risk screening tool (C-SSRs: Colombia-Suicide Severity Rating Scale) ...Based on results of screening, appropriate interventions are implemented: ...Moderate Risk Interventions (Suicide attempt in the past three months): Immediately initiate 1:3 continuous observation. Do not leave patient unattended at any time until the level of observation is modified by provider order ...” According to the hospital’s Department of Emergency Services policy, Psychiatric Patient Care, last revised 10/2022, “Patients under any level of observation are to be transitioned to 1:1 Direct Continuous observation for all toileting and bathroom use. The restroom door is to remain ajar and direct visualization is to be maintained throughout use of the restroom. Return to level of observation may be resumed upon return to the assigned treatment area.” According to the hospital’s policy, Patients’ Rights and Responsibilities, last revised 10/26/21, “Patients have the right to ...Receive care in a safe setting ...””