Natividad Medical Center

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 49345 Based on interview and record review, the hospital failed to ensure the discharge planning evaluation included an evaluation of the likelihood of the possibility of the patient being cared for in the environment from which the patient entered the hospital when one (Patient 4) out of 30 sampled patients was discharged to a hotel from the Emergency Department (ED). This failure had the potential for Patient 4 to miss significant routine medications, and put Patient 4 at risk for clinical decline and psychosocial stress. Findings: A review of Patient 4’s medical record indicated, Patient 4 was unemployed and “Address: Homeless.” A review of patient 4’s ED provider Report dated 12/15/24 by Medical Doctor (MD) A indicated, “History of Present Illness Initial Comments “42-year-old female brought to the ER [Emergency Room] from a skilled nursing facility (SNF, is a specialized inpatient facility that provides 24-hour medical, nursing, and rehabilitative care) on a psychiatric hold [a short-term, secure stay in a hospital or medical center where doctors evaluate and care for a person experiencing a severe mental health crisis]. I (ER Medical doctor) received a phone call from the physicians at the skilled nursing facility prior to arrival. I explained that she has been a resident at the skilled nursing facility for several years. They report that she persistently demonstrates abusive and aggressive behavior. They report that they do not feel it is safe for her to return to their facility. On review of the EMR [Electronic Medical Record], she has past medical history documented as Type 2 Diabetes [a long-term health condition where blood sugar levels are too high because the body does not use insulin properly or make enough of it], hypothyroidism [a health condition where the thyroid gland in your neck does not make enough thyroid hormones], chronic abdominal pain, and fibromyalgia [a long-term medical condition that causes widespread pain, extreme tiredness, and sleep problems] ... Medical Decision Making Medical Course “42-year-old female who resides at a skilled nursing facility since 2020, disabled because of chronic pain, sent to ER on a psychiatric hold that was written by a physician at the skilled nursing facility ...I have ordered the standard battery of labs with the addition of chest x-ray [a fast, painless picture of the inside of the chest, showing the heart, lungs, and bones]. I have ordered consultation with crisis team and psychiatry ...” A review of Continuity of Care Comments made by MD B dated 12/16/24 at 5:44 p.m. indicated, “Patient still awaiting testing to be medically cleared. Patient medical director from her facility did indicate concerns over her threats to physicians there and that the physicians are unwilling to continue to treat her given threats made and that she may need placement in another facility ...” A review of Medical Clearance by MD C dated 12/16/24 at 1:49 a.m. indicated, “The patient is medically clear for psychiatric stabilization [the short-term process of calming a severe mental health crisis] ...” A review of Psychiatric Consult by MD D dated 12/16/24 at 1:46 p.m. indicated, “ ...Plan At this time patient does not meet criteria for involuntary legal hold or psychiatric hospitalization ...As patient currently lives in a skilled nursing facility, she has all of her basic needs met including food, clothing and shelter, therefore does not meet criteria for an involuntary psychiatric hold due to grave disability ...Psychiatry to sign off at this time ...” A review of Psychiatric Consult by MD E dated 12/16/24 at 10:37 a.m. indicated, “ ...Recommendations: ... Recommend case management/pain management consult Further management deferred to primary ED team Continue current medication regimen with further management deferred to outpatient provider SW/CM [Social Worker/Case Management] to assist with connecting patient to resources within the community ...” A review of Emergency Department Notes by Case Manager (CM) dated 12/16/24 at 4:17 p.m. indicated, “CM received a call back from patient sister Frank and informed CM and MSW [Medical Social Worker] that patient burned all bridges with family and does not want to be involved with her. They can only provide emotional support.” A review of Social Services Notes by Social Worker (SW) F dated 12/16/24 at 4:51 p.m. indicated, “ ...SW and CMRN [Case Management Registered Nurse] met with pt [patient] at bedside ...Pt explained she has been living at [Skilled Nursing Facility/SNF] for the past 4 years ...Pt has been evaluated by our psychiatric team and has been cleared by psych team; ...Pt shared she does not have family support ...Pt reports she has no where to stay if she cannot return to SNF ...CMRN spoke to [SNF] and they are not willing to accept pt back due to pt’s behavior ...” A review of Social Services Notes by SW F dated 12/17/24 at 11:45 a.m. indicated, “ ...SW and CMRN met with pt at bedside to assist with discharge planning. CMRN explained to pt she can do a walk-in appt [appointment] ...for Methadone [a man-made opioid medicine used to treat opioid addiction and severe chronic pain] prescription ...SW and CMRN explained to pt that [SNF] is not accepting pt back, therefore pt has 2 options: shelter placement or staying at a hotel ...” During a concurrent interview and record review of Patient 4’s Social Services Notes dated 12/16/24 to 12/17/24 with the Social Services Supervisor (SSS) on 7/23/26 at 10:38 a.m., the SSS verified the SW and CM only offered two options to Patient 4 during discharge planning. SSS stated they ensure where the patients’ medications were sent to during discharge planning. The SSS also stated Social Workers read the ED history of patients for discharge planning. The SSS stated it was safe for Patient 4 to be discharged to (Motel 6). The SSS also stated Patient 4 paid for the motel. During a concurrent interview and record review of Patient 4’s medical records with the CM on 7/23/26 at 11:15 a.m., the CM verified Patient 4 came from a SNF prior to being brought to ED on 12/15/24. CM also stated Patient 4 was an “Unhoused” person. CM verified Patient 4 was only given two options where to be discharged- shelter placement and a hotel. The CM verified Patient 4 was discharged to Motel 6 and was booked until Christmas time. CM stated Patient 4’s brother was supposed to get her belongings from the SNF and part of the belongings were Patient 4’s medications. The CM stated adding an option for Patient 4 to be discharged to another skilled nursing facility was a better one. The CM also stated they did not look for another skilled nursing facility for Patient 4. A review of Patient 4’s Discharge Instructions dated 12/17/24 with the Quality Assurance Nurse (QN) on 7/23/26 at 11:49 a.m., the QN verified Patient 4 had no Primary Care Physician (a go-to doctor for everyday health, routine checkups, and general medical advice). The QN also verified it indicated oral medications that needed to be continued by Patient 4 which included Clonazepam (a prescription medicine that calms down the brain and nervous system) twice daily, Duloxetine (prescription medicine used to treat depression, anxiety, and long-term body or nerve pain) daily, Furosemide (used to treat swelling and high blood pressure) daily, Levothyroxine Sodium (a medicine used to treat an underactive thyroid) daily, Methadone every six hours, Metoprolol Succinate (used to lower blood pressure, slow down the heart rate, and prevent chest pain) twice daily, Norethindrone AC-Eth Estradiol (a mix of two female hormones-estrogen and progestin-used mainly as an oral contraceptive to prevent pregnancy, or as hormone therapy to ease menopause symptoms) daily, Ondansetron (prescription medicine that stops nausea and vomiting) three times daily, Spironolactone (helps the body get rid of extra salt and water through urine while saving important potassium. It is commonly used to treat high blood pressure, heart failure, and swelling) daily, and Trazodone (prescription medicine most often used to treat depression, anxiety, and trouble sleeping) every night. The QN verified ED only sent three medications to a pharmacy upon discharge which were oral Acetaminophen (a common medicine used to lower fevers and ease mild to moderate pain), oral Cyclobenzaprine (prescription muscle relaxant used to treat short-term, painful muscle spasms from strains or sprains), and oral Gabapentin (prescription medicine that calms down overactive nerves). The QN also verified there was no documentation that Patient 4’s brother took Patient 4’s belongings and medications from the SNF and medications from the pharmacy. A review of hospitals policy and procedure (P&P) entitled “Discharge Planning/ Transitioning of Care” revised 3/2021, the P&P indicated, “Purpose:..Transitioning of Care is an approach to aligning appropriate resources to provide a safe and effective transition of the patient from one care setting to another ...identifying what the patient requires for a smooth and safe transition to his/her discharge destination ...Transitioning of Care includes: assessment of patient needs, quality of home support, evaluation and referrals to outside community services, care at alternative facilities and financial considerations relating to the transition ...Policy:..The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care ...2. A discharge planning evaluation will include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services ...8. The hospital will assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, home health aid (HHA), skilled nursing facility (SNF) ...data on quality measures and date on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. Procedure: ...C.Screening criteria will include, but not be limited to the following: ...4.Medications 5. Principal diagnosis 6. Comorbidities 7. Functional impairment ...G. Discharge Plan: ...2. The Case manager or social worker will develop the discharge plan with input from the patient and/or caregiver. They will discuss the options available to the patient for post-hospital services, if indicated. The discharge plan will also reflect the recommendations and contributions of the physician and healthcare team members involved in the patient’s care, treatment and services, as appropriate ...H. Transfer or referral:1. The hospital will facilitate the transfer or referral of patients when the discharge plan involves a need for continuity of care, along with necessary medical information, to appropriate facilities, agencies or outpatient services. A review of hospital’s Job Description Report for “Case Management Nurse, Case Management” dated 2026 indicated,” ... Essential Functions: A. Assessment: ...10. Recognizes complex clinical situations that impact discharge and intervenes using sound clinical judgment and professional attitude in making patient care decisions ...B. Planning: ...3. Demonstrates knowledge of legal and ethical responsibilities related to discharge planning ...C.Implementation: ...7. Initiates referrals to community agencies and/or individuals for continued care in a timely manner providing accurate information on specific patient needs. 8. Coordinates components of the discharge plan to include transfers to facilities (skilled nursing facilities, acute rehab) and referrals to appropriate community agencies (Home care, equipment, pharmacy, transportation) as designed by patient/physician ...” A review of hospital’s Job Description Report for “Social Worker V, Utilization Management” dated 2026 indicated, “ ...Essential Knowledge, Skills, & Abilities ...4. Collaborate and consult with patients family, physician, nursing, ancillary departments, discharge planners and community resources in planning a patient’s discharge. 5. Provide a full range of clinic skills including care plans, referrals, advocacy and support services and interdisciplinary and interagency collaboration. 6. Refer patients and hospital personnel to all available community service resources ...””

“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: 46939 Based on interview and record review, the hospital failed to ensure a Registered Nurse and a Telemetry Technician followed all policy and procedures as evidenced by: 1. The hospital failed to follow its policy and procedure (P&P) titled, “Telemetry Monitoring In the Non-Intensive Care Inpatient Setting” for one of 30 sampled patients (Patient 8) (Refer to A398). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“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: 46939 Based on interview and record review the Hospital failed to report an allegation of abuse for one of 30 sampled patients (Patient 28) when Patient 28 reported an allegation of abuse to hospital staff, and hospital staff could not verify they reported the allegation per facility policy and procedure. This failure had the potential for Child Protective Services (CPS-a government agency responsible for investigating and intervening in cases of child abuse and neglect) to be unaware of the abuse allegation, and the potential for Patient 28 to be exposed to further abuse. Findings: During a review of Patient 28’s “ED [emergency department] Provider Report” dated, 3/15/25, the report indicated, “10-year old male brought to the ER [emergency room] from school on a 5150 hold [a temporary, involuntary psychiatric hold, typically for 72 hours, that allows law enforcement and mental health professionals to detain someone who is deemed a danger to themselves or others, or who is gravely disabled,]. Patient and 2 younger siblings are enrolled at the same school. Apparently one of the children arrived at school with a scalp hematoma [a localized collection of blood outside of blood vessels, typically caused by injury.] which prompted evaluation of all of the children. The patient reported that mother has been physically abusive. School staff reports that he became visibly shaken in his mother’s presence. . .medically clear for psych eval [psychiatric evaluation]. The patient was seen by tele [remote] psychiatrist and plan in transfer to a pediatric psych facility. He recommended Clonidine 0.1 mg [medication can treat high blood pressure. Certain formulations can also treat ADHD].” During an interview on 5/21/25, at 10:20 a.m., with the Emergency Department Supervisor (EDS), the EDS stated, she could not find the mandated report (Suspected Child Abuse Report-SCAR) for Patient 28. The EDS stated, they were informed by the school that CPS was called for Patient 28. The EDS stated, the hospital policy for reporting states that facility staff also have to report to CPS. The EDS stated, she could not find any evidence staff reported Patient 28’s allegation of abuse to CPS. During a concurrent interview and Policy & Procedure (P&P) review, on 5/21/25, at 10:34 a.m., with the EDS, the facility’s P&P titled, “Mandated Reporting Policy for victims of all ages with suspected abuse/neglect/human trafficking or intimate partner abuse dated 2022 was reviewed. The policy indicated, “any person, including any employee, or consultant/contractor of Natividad, who knows of or has received information of or has reason to suspect that any patient has been abused, neglected, or exploited by any persons shall ensure that CPS (Child Protective Services) or APS (adult Protective Services) are called and are written report-suspected child abuse report or suspected dependent adult elder abuse form or suspicious injury report is filed with CPS-APS as soon as possible and within 36 hours of the event”. The EDS stated, there was no evidence Natividad staff reported this allegation to CPS by filling out the SCAR form.”

“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: 46939 Based on interview and record review, the hospital failed to ensure a Registered Nurse and a Telemetry Technician followed its policy and procedure (P&P) titled, “Telemetry Monitoring in the Non-Intensive Care Inpatient Setting” for one of 30 sampled patients (Patient 8), when the telemetry technician assigned to monitor Patient 8’s telemetry monitor (a portable device that continuously monitors patient ECG (electrocardiogram-measurement of electrical activity in the heart), respiratory rate and oxygen saturations while automatically transmitting information to a central monitor) and pulse oximeter (measures oxygen saturation in the blood) failed to notify the Registered Nurse (RN) assigned to Patient 8, of Patient 8’s critical vital signs outside normal parameters. The RN failed to respond to all telemetry alarms per policy. This failure had the potential for the RN assigned to Patient 8 to be unaware of Patient 8’s critically low oxygen saturation, apnea (temporary pause in breathing), low respiratory rate, and asystole (a medical condition where the heart stops beating and there is no electrical activity detected on an ECG). The failure of the RN in not responding to all telemetry alarms had the potential to be a causative factor in Patient 8’s death. Findings: During a review of Patient 8’s History and Physical (H&P), dated 1/22/22, the H&P indicated, “71 year old. . . who presents for shortness of breath, and positive home antigen covid test Patient tested at home “one week ago” 1/15 and had symptoms 4 days ago 1/18 after possible exposure from daughter unvaccinated and living with unvaccinated family members. Patient endorses nausea vomiting, coughs, fevers, chills, loss of taste and smell and diarrhea. Symptoms worse at night when trying to sleep has not been tolerating much oral intake.” The H&P indicated, Patient 8 tested positive for Covid [viral respiratory infection] detected 1/22/22. The H&P indicated, “Chest Xray Findings: Lungs: Faint infiltrates [accumulation of abnormal substances like blood, fluid or pus within the lung tissue,] are suggested bilaterally [both lungs] . . .Assessment & Plan Continue isolation on intermediate care with telemetry and continuous pulse oximetry, continue oxygen supplementation to keep O2 sat [Sp02- measurement of the percentage of hemoglobin in the blood that is carrying oxygen. A healthy SpO2 level is typically between 95% and 100%] more than 88%.” During a review of Patient 8’s Progress Report dated 3/1/22, the report indicated, “[Patient 8] is a 71 y/o [year old] male. . .found to be COVID positive and was admitted due to respiratory failure. Remains admitted due to high O2 [oxygen] requirements. Hypoxemic respiratory failure COVID PNA [pneumonia]. . .has been alternating between NRB [non-rebreather [a medical device used to deliver high concentrations of oxygen in emergency situations, preventing the rebreathing of exhaled air.] and HFNC [high flow nasal cannula- medical device used to deliver high volumes of heated and humidified oxygen through nasal prongs.] Currently, 30 l/min [liter per minute] and FiO2 [Fraction of Inspired Oxygen, which is the percentage of oxygen a person inhales] at 80%.” During a review of Patient 8’s Medical Doctor (MD) order dated 1/22/22, in effect until Patient 8’s death on 3/2/22, order indicated, “Cardiac Monitoring CONT [continuous]. . .instructions Continuous bedside cardiac monitoring.” During a review of Patient 8’s MD order dated 1/22/22, indicated, an order for “High Flow Nasal Cannula. . .maintain o2 sat [oxygen saturation] >88%.” During a review of Patient 8’s Palliative Care Progress Noted dated 2/28/22 indicated, “Alert and attentive but fatigued appearing slightly ‘slowed.’ Looks frail. . .Oxygen SpO2 is variable during our discussion, usually staying above 89 & even with prolonged speaking, but then occasionally dropping briefly to low 80s. . .Pt [Patient 8] and family reiterated today that their hope/goal is for pt [Patient 8] to recover, recuperate, and to leave the hospital when/if stable. They are NOT willing to focus strictly on comfort.” During a review of Patient 8’s RT (respiratory therapy) Oxygen Delivery Assessment dated 3/2/22, at 04:18 (4:18 a.m.), assessment indicated, Oxygen Delivery Method Hi Flow, FiO2 75%, Respiratory Rate (RR) 28 breather per minute (12-24 normal) H (indicating RR above normal parameters. Assessment indicated, “Venti mask [a type of oxygen mask that delivers a precise and controlled amount of oxygen to a patient] @ 40% FiO2. Pt [Patient 8] refusing to take off due to anxiety.” During a review of Patient 8’s RT Post Treatment Respiratory Assessment, dated 3/2/22, at 04:26 [4:26 a.m.), Assessment indicated, Pulse Rate 66 (60-100 beats of heart per minute), Respiratory Rate 26 breaths per minute (12-24) High, Lung Assessment diminished (a reduced intensity of the normal breathing sounds). During a review of Patient 8’s Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, the “RR Alarms” (Respiratory Rate) indicated approximately 83 separate “yellow alarms” were generated, with RR ranging from 0-68 breath per minute. During a review of Patient 8’s Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, the “SpO2 Alarms” approximately 6 “Yellow alarms” were generated with SpO2 ranging from 78%-87%. During a review of Patient 8’s Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, approximately 10 “Red Alarms” generated. The Telemetry Alarm sheet indicated, on 3/2/22 at “04:40:26” (4:40 a.m. and 26 seconds a.m.) Patient 8’s Spo2 went below the alarm parameter of 85% to 77% and stayed for 15 seconds. At “04:57:38” (4:57 a.m. and 38 seconds) a red alarm generated for “Apnea” and ended at “04:58:20” (4:58 a.m. and 20 seconds Patient 8 had no recorded breathing for approximately 42 seconds). At “05:00:13” (5:00 a.m. and 13 seconds) a red alarm was generated for “Apnea” at “05:00:06” (5:00 a.m. and 6 seconds) and ended at “05:01:17” (5:01 a.m. and 17 seconds, Patient 8 had no recorded breathing for approximately 1 minute and 11 seconds). At “05:01:30” (5:01 a.m., and 30 seconds) a red alarm for “Apnea” was generated and ended at “05:02:44” (5:02 a.m. and 44 seconds, Patient 8 had no recorded breathing for approximately 1 minute and 14 seconds). At “05:02:57” (5:02 a.m. and 57 seconds) a red alarm generated for “Apnea” and ended at “05:05:31” (5:05 a.m. and 31 seconds, Patient 8 had no recorded breathing for approximately 2 minutes and 34 seconds). At “05:04:08” (5:04 a.m. and 8 seconds) a red alarm was generated for “Asystole” and ended on “05:05:34” (5:05 a.m. and 34 seconds, Patient 8 had no recorded heart electrical activity for approximately 1 minute and 26 seconds). At “05:05:33” (5:05 a.m. and 33 seconds) a red alarm was generated for “Asystole” and ended on “05:06:17” (5:06 a.m. and 17 seconds) Patient 8 had no recorded heart electrical activity for approximately 44 seconds). At “05:05:59” (5:05 a.m. and 59 seconds) a red alarm generated for “Apnea” and ended at 05:06:16 (5:06 a.m. and 16 seconds) Patient 8 had no recorded breathing for approximately for approximately 17 seconds). At “05:06:10” (5:06 a.m. and 10 seconds) a red alarm generated for “Asystole”, no further readings for Patient 8 were recorded after “05:11:35” (5:11 a.m. and 35 seconds). At “05:06:52” (5:06 a.m. and 52 seconds) a red alarm was generated for “Apnea”, no further readings were recorded for Patient 8 after “05:11:35” (5:11 a.m. and 35 seconds). At “05:11:06” (5:11 a.m. and 6 seconds) a red alarm titled “Realarm” and Red Realarm/Remind” was generated. During a review of Patient 8’s Death Summary, dated 3/2/22, at 05:20, the summary indicated, “Immediate Cause of Death (1) Acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Disease. . .Hospital Course. . .Nursing visited bedside to find patient lying motionless on back with both nasal cannula and nonrebreather mask off of his face.” During an interview on 5/20/25, at 3:14 p.m., with the Director of Quality (DOQ), the DOQ stated, the telemetry tech monitoring Patient 8 on 3/2/22 only notified the nurse one time regarding the telemetry alarms and the nurse was notified on 3/2/22 at 05:09 a.m. The DOQ stated, from their interview with the nurse (in 2022), the nurse stated they immediately went into Patient 8’s room at 05:09 a.m. and the patient was unresponsive, with his oxygen ripped off. The DOQ stated, Patient 8 was pronounced dead at 05:20 on 3/2/22. The DOQ stated, the telemetry tech called the nurse on the nurses work phone at 05:09 a.m. the DOQ stated, she did not have any documentation or record of the phone call given the time period (3 years ago). The DOQ stated, there was no documentation the nurse saw the patient after 4 a.m., until 05:09 a.m., when the telemetry tech called the nurse about the alarms at that time. During an interview on 5/20/25, at 3:24 p.m., with the Director of Acute Services (DOS), the DOS stated, “the tech [telemetry tech] needs to notify the nurse for each alarm outside the parameter.” The DOS stated, the nurse needs to be notified immediately for all red alarms. The telemetry techs are able to call the nurses using the work phones, each nurse will have their own phone and the tech has the ability to call the nurses directly. During an interview on 5/21/25 at 08:53 a.m., with the Patient Safety Manager (PSM), the PSM stated, he spoke to the representative from the telemetry alarm company, and he was informed that the yellow alarms are a warning to the tech to watch the readings, and the alarm requires the tech to acknowledge after a certain period of time if the patient stays outside the parameters. The PSM stated, he was informed the “realarm” is when the condition still exists for the red alarm, and the alarm had been silenced, and the vital sign is still outside the normal parameter. The PSM stated, the nursing station is located next to where the telemetry tech was stationed, so they could hear the alarms but they would need to get up and look at the screens next to the nurses station to see the monitors and see which patient it is. During a review of the hospitals P&P titled, “Telemetry Monitoring in the Non-Intensive Care Inpatient Setting” dated 2021 (in effect on incident date) the P&P indicated, “To ensure safe, continuous telemetry monitoring of electric activity, respiratory rate, and oxygen saturation of inpatients within Medical Surgical/Intermediate Care Unit (MSU/IMC). The goals of telemetry monitoring are as following: 1) Immediate recognition of sudden cardiac arrest to improve time to defibrillation; 2) Recognize deteriorating conditions that may lead to a life-threatening, sustained arrythmia; . . .The primary RN will: . . .g. respond to all telemetry alarms immediately. . . Telemetry Technician Responsibilities: 1. The Telemetry Technician will: a. Observe, monitor and report telemetry changes outside alarm parameters to the Primary RN”.”

“PATIENT RIGHTS: ACCESS TO MEDICAL RECORD CFR(s): 482.13(d)(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. If it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or if not, in a readable hard copy form or such other form or format as agreed by the facility and the individual, and within a reasonable timeframe. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. This Standard is not met as evidenced by: 38068 Based on interview and record review, the facility failed to furnish complete medical records for Patient 1 upon written request. This failure had the potential to cause delay in Patient 1’s continuity of care in his effort to provide the necessary health records in a timely manner to his Primary Care Physician for a follow-up care visit . Findings: Review of Patient 1’s medical record indicated he presented to Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) on 1/1/24 with intermittent chest pain and left arm pain. A series of lab and diagnostic tests were performed at ED such as Complete Blood Count (CBC, blood tests that measure the number and size of the different cells in your blood), Comprehensive Metabolic Panel (CMP, a blood test that measures your blood sugar levels, how your kidneys and liver function, and your electrolyte and fluid levels), D-Dimer (a test that may indicate a blood clot), Electrocardiogram (EKG, a non-invasive medical test that measures the electrical activity of the heart), Chest X-ray (a medical imaging procedure that uses X-rays to create a detailed image of the organs and structures in the chest, including the lungs, heart, and ribs), and Computed Tomography Angiography (CTA, a noninvasive medical test that uses a CT scanner to create images of the blood vessels and tissues in the chest and upper abdomen. A contrast material is injected into the body to make the blood vessels appear brighter in the images). Patient 1 was discharged from ED on same day. During a concurrent interview and Patient 1’s medical record review on 1/21/25 at 11:20 a.m. with the Patient Safety Manager (PSM) and Director of Quality (DOQ) revealed, Patient 1 made two written requests of his medical records on 1/3/24, the first one indicated a request of all images, etc. taken on 1/1/24 in ER. The second one indicated a request of all medical records in ER visit on 1/1/24, CT Scan and X-rays of chest and left arm. The DOQ confirmed that only scan and X-ray results were sent to Patient 1 on 1/3/24. The DOQ acknowledged the complete medical records of ER visit on 1/1/24 should have been provided to Patient 1 upon his written request. Review of the facility’s policy and procedure dated 7/2023 titled, “Privacy-Patient Rights-Access”, indicated, A patients have the following rights to access their health information: Inspect or receive a copy of health information within the prescribed frames. Upon receiving a request to access, inspect, or receive a copy of the designated record set, Hospital is responsible to do all the following:..b. To receive copies of health information related to health history, diagnosis, condition of the patient, or treatment provided...within 15 days. c. To provide a copy of patient’s health information within 15 days the receipt of payments for copies and and an authorization (written request for records). 2. c The summary shall contain for each injury, illness, or episode, any information included in the record relative to the following: 1) Chief complaint or complaints including pertinent history. 2) Findings from consultations and referrals to other health care providers. 3) Diagnosis where determined. 4) Treatment plan and regimen including medications prescribed. 5) Progress of the treatment. 7) Prognosis including significant continuing problems or conditions. 7) Pertinent reports of diagnostic procedures and tests and all discharge summaries. 8) Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests. 9) The summary shall contain a list of all current medications prescribed, including dosage, and any sensitivities or allergies to medications recorded by the provider.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38068 Based on interview and record review, the facility failed to ensure that a Physician’s order was obtained in accordance with their policy and procedures for one of six patients (Patient 7). This failure had the potential not to determine whether the type of restraint used for Patient 7 was approved and confirmed by the Physician for appropriateness. Findings: Review of Patient 7’s medical record he had a history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs). He was brought in by his mother at Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) for psychiatric crisis (a state where someone experiences a sudden and severe disruption in their mental health, causing significant distress and impairing their ability to function normally, often requiring immediate professional intervention due to symptoms like intense anxiety, suicidal thoughts, self-harm, or extreme behavioral change) on 3/30/24 at 3:05 p.m. During the course of stay in ED, Patient 7 had an episode of aggressiveness and ran out of ED. He reported assaulted one security staff and bit him several times. A violent-rigid type restraint (limb restraints, a physical intervention used to manage a patient’s violent or self-destructive behavior when it poses an immediate danger to the patient or others) was applied on both upper and lower limbs for Patient 7 on 3/30/24 at 5:45 p.m. During a concurrent interview and Patient 7’s medical record review on 1/22/25 at 2:22 p.m. with the Patient Safety Manager (PSM) and Director of Quality (DOQ), revealed there was no written Physician’s order for violent rigid type restraint that was used for Patient 7 on 3/30/24 at 5:45 p.m. During an interview with the PSM on 1/23/25 at 10:08 a.m., he confirmed there was no written order by the Physician found in Patient 7’s medical record for the use of restraint on 3/30/24 at 5:45 p.m. at ED. He acknowledged the Hospital staff should have followed the policy and procedures in obtaining Physician written order for the use of restraint for Patient 7. Review of the facility’s policy and procedures dated 1/2023 titled, “Use of Restraint And/Or Seclusion: Restraint and/or Seclusion Orders-3. A Violent or Self-Destructive Behavior Restraint and/or Seclusion” indicated, a. A provider order must be obtained for the application of violent /self-destructive behavior restraints and/or seclusion.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 38068 Based on interview and record review, the facility failed to evaluate the post hospital care needs and make appropriate recommendations and/or instructions before discharging one of seven patients (Patient 7). This failure had the potential not to address the other health problems occurred during the course of his stay in the Hospital and may affect the continuity of care for Patient 7. Findings: Review of Patient 7’s medical record indicated he had a history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs). He was brought in by his mother at Emergency Department (ED or ER, medical facility within a hospital that specializes in providing immediate care to patients with sudden, serious medical conditions that require immediate attention, operating 24 hours a day, 7 days a week, without the need for a prior appointment) for psychiatric crisis (a state where someone experiences a sudden and severe disruption in their mental health, causing significant distress and impairing their ability to function normally, often requiring immediate professional intervention due to symptoms like intense anxiety, suicidal thoughts, self-harm, or extreme behavioral change) on 3/30/24. During course of stay at ED, he had an episode of aggressiveness and ran out of ED. He was reported assaulted a security staff and bit security staff several times on same day. Patient 7 sustained tooth and mouth injuries. Review of Patient 7’s medical record dated 4/3/24 indicated, “04/1/24: Per staff earlier in course had bite security (patient has chipped tooth).” During a concurrent interview and record review with the Patient Safety Manager (PSM) on 1/22/25 at 9:06 a.m. regarding Patient 7’s Discharge Summary Instructions dated 4/3/24, he confirmed there was no instructions or recommendations to see or follow-up with the Dentist for the chipped tooth upon discharged for Patient 7. Review of the facility’s policy and procedures dated 6/10/22 titled “Rules & Regulations” indicated, A clinical resume shall concisely summarize the reason for hospitalization, the significant findings, the procedure performed, and treatment rendered, discharge diagnosis, the patient’s condition on discharge, and any specific instruction given to the patient or surrogate decision-maker as pertinent, including but not limited to, discharge medications, follow-up care and appointments, diet, and recommended activity.”