Mercy San Juan Medical Center

“DISCHARGE PLANNING - MD REQUEST FOR PLAN CFR(s): Upon the request of a patient’s physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. This Standard is not met as evidenced by: 50121 Based on interview and record review, the hospital failed to arrange for the implementation of discharge plans for one of eight sampled patients discharged to skilled nursing facilities (SNF) when Patient 1 was discharged without confirming SNF had a bed available for Patient 1. This failure resulted in Patient 1 being transported back to the hospital, delayed receipt of scheduled medications, and caused Patient 1 severe pain. Findings: During a review of Patient 1’s History and Physical (H&P), dated 5/13/25, H&P indicated Patient 1 was admitted to the hospital with nausea and vomiting on 5/13/25. H&P indicated Patient 1 had a medical history of heart and lung disease and had pressure wounds and generalized body aches. During a concurrent interview and record review, on 6/12/25, at 9:30 a.m. with Registered Nurse (RN) 1, Nursing Progress Notes (NPN), dated 5/16/25, were reviewed. NPN indicated “patient discharged via ambulance transport and arrived to [facility name] SNF and was informed there are no bed openings/no beds available until tomorrow morning ...Patient was brought back to the unit [at hospital] via EMS [Emergency Medical Services] transport. Upon arrival to unit patient stated being in 10/10 pain [ten out of ten, a pain scale used to rate pain with ten being the most severe pain].” RN 1 stated Patient 1’s pain was managed through scheduled pain medication given every eight hours and Patient 1 left the hospital on 5/16/25 prior his scheduled afternoon dose. RN1 stated after consulting with the pharmacist, Patient 1’s missed dose of pain medication was given late. During a review of Prehospital Care Report 3.5 (PHCR), dated 5/16/25, PHCR indicated ambulance crew arrived at SNF to transport Patient 1 back to hospital and “PT [patient] did not have an available room at the SNF. Per nurses PT was supposed to be admitted at the facility the next day, and PT was a day too early. PT pain had increased to 11/10 pain during transport.” During a concurrent interview and record review, on 6/12/25, at 11:30 a.m. with Care Coordination Registered Nurse (CCRN) and Care Coordination Assistant (CCA), Patient 1’s Final Discharge Plan (FNP), dated 5/16/25 and Discharge Planning Progress Notes (DPPN) were reviewed. FNP indicated Patient 1’s expected discharge date was 5/16/25 to a skilled nursing facility. CCA stated she generally prepares the packet of clinical information to send to the facility and arranges patient transport when a patient is discharged to SNF. CCA stated she follows the directions given to her in DPPN and documents what she has done in the DPPN. DPPN entry dated 5/16/25 at 10:24 a.m., authored by CCRN, indicated “[Medical Doctor] states patient is ready to discharge to SNF today. I have asked CCA to arrange the discharge to SNF today.” DPPN entry dated 5/16/25 at 12:02 p.m., authored by CCA, indicated, “transport arranged, medication records and orders were faxed, and SNF packet was assembled.” CCA stated she did not contact the facility to confirm bed availability as she was not asked to do so. CCRN stated the Care Coordination department should confirm bed availability with SNF on the day of patient discharge. CCRN stated she writes a DPPN when she confirms bed availability. CCRN reviewed the DDPN for Patient 1 and stated “I did not make a note that I called. I must not have done it. We are short staffed on the weekends.” During an interview on 6/12/25 at 12:30 p.m. with Care Coordination Director (CCD), CCD stated he expected Care Coordination staff to verify bed availability on the day of discharge. CCD stated, “Sometimes the confirmation is done through the CarePort [patient referral electronic platform] instant messaging function.” CCD confirmed there was no record of communication regarding bed availability on 5/16/25. CCD stated there were staff shortages on the weekends. During a review of the facility’s policy and procedure (P&P) titled, “Care Coordination Discharge Planning Policy”, dated 11/21/22, the P&P indicated “Care Coordination team members also collaborate with third-party payers and community resources/partners to further after care and discharge plans.””

“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: 44780 Based on interview, medical record review, and policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to patients when: A. Nursing staff failed to complete fall risk assessments and implement fall prevention interventions for one of 9 sampled patients (Patient 1) who was a high risk for falls and was placed in a recliner chair without a chair alarm. Patient 1 fell out of the recliner, which resulted in facial injuries. Nursing staff on the evening shifts continued to not complete fall risk assessments for Patient 1 after his fall, according to the facility’s Fall Prevention and Management policy and procedure. (refer to A-0398) and B. Nursing staff entered type of restraint orders that did not match the indication for restraints for two of 12 patients (Patient 4 & Patient 8) (refer to A-0398). The cumulative effect of these failures resulted in the hospital’s inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.”

“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: 50121 Based on interview and record review, the facility failed to ensure staff monitored patient safety and condition while in restraints when three of 12 patients in restraints (Patients 4, 5, and 6) were not monitored at the frequencies specified by facility policy. This failure had the potential to result in a decline in patient condition, injury, or death. Findings: During a review of Patient 4’s History and Physical (H&P), dated 3/8/25, the H&P indicated Patient 4 presented to hospital on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4’s medical history included dementia (a progressive state of decline in mental abilities.) During a review of Patient 4’s orders, orders indicated to place Patient 4 in violent/self-destructive restraints (VR) for 4 hours, on 3/9/25, at 0:48 a.m. During a concurrent interview and record review, on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4’s restraint flowsheet (RFS), dated 3/9/25, was reviewed. The RFS indicated restraints were applied on 3/9/25, at 1 a.m., and safety checks were completed at 3 a.m. and 5 a.m. NE 1 confirmed these findings and stated 15 to 30 minute safety checks were not completed as required per facility policy. During a review of Patient 5’s H&P, dated 2/21/25, the H&P indicated Patient 5 presented to hospital on 2/21/25, following a syncopal episode (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain). The H&P indicated Patient 5’s medical history included dementia During a review of Patient 5’s orders, two orders to place Patient 5 in VR for 4 hours were noted: one for 2/21/25, at 6:38 p.m. and one for 2/24/25, at 12:55 p.m. During a concurrent interview and record review on 4/3/25, at 10 a.m., with NE 1, Patient 5’s RFS, dated 2/21/25, was reviewed. RFS indicated restraints were applied at 6:50 p.m., and monitoring occurred at 7:30 p.m., 9 p.m. and 11 p.m. NE 1 stated, when in VR, patients should be monitored every 15 minutes, and the RFS did not show monitoring was done as required. During a concurrent interview and record review on 4/3/25, at 10 a.m., with NE 1, Patient 5’s RFS, dated 2/24/25, was reviewed. RFS indicated restraints were applied at 12:55 p.m. and removed at 2 p.m. NE 1 confirmed RFS did not indicate monitoring was done during the one-hour period Patient 5 was in VR. During a review of Patient 6’s H&P, dated 3/27/25, the H&P indicated Patient 6 presented to hospital on 3/27/25 with a foot infection. The H&P indicated Patient 6’s medical history included alcohol abuse, Wernicke’s encephalopathy (brain disorder caused by a vitamin deficiency) with mental process and memory impairment. During a review of Patient 6’s orders, orders indicated to place Patient 6 in VR for 4 hours, on 3/29/25, at 10:52 a.m., for “violent/aggressive behavior”. During a concurrent interview and record review, on 4/3/25, at 11:20 a.m., with NE 1, Patient 6’s RFS, dated 3/29/25, was reviewed. The RFS indicated restraints were applied on 3/29/25, at 10:30 a.m., and safety checks were completed at 12 p.m. NE 1 confirmed these findings and stated safety checks were not completed every 15 to 30 minutes as required per facility policy. During an interview, on 4/4/25, at 12:15 p.m., with Nursing Director (ND) 2, ND 2 stated “Violent restraints require more frequent monitoring and documentation to keep patients safe.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion, Nursing Management of”, dated 4/2/13, the P&P indicated, “Patients placed in restraints or seclusion for violent or self-destructive behavior should be assessed approximately every 15 to 30 minutes.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50121 Based on interview and record review, the facility failed to ensure the medical provider completed a face-to-face evaluation within one hour of placing two of four patients (Patient 4 and Patient 5) in restraints for violent behavior. This failure had the potential to delay identification and treatment of the cause of violent behavior and to violate the patients’ right to be free of unnecessary restraints. Findings: During a review of Patient 4’s History and Physical (H&P), dated 3/8/25, at 11:54 p.m., the H&P indicated Patient 4 presented on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4’s medical history included dementia (a progressive state of decline in mental abilities). During a review of Patient 4’s orders, orders indicated to place Patient 4 in violent/self-destructive restraints (VR) for 4 hours, on 3/9/25, at 0:48 a.m. During a concurrent interview and record review on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4’s medical record (MR) was reviewed. The ME contained a Physician Note (PN), dated 3/9/25, at 3:50 p.m. NE 1 confirmed there was not a PN within one hour of the VR order and neither the PN nor the H&P addressed the need for violent behavior restraints. During a review of Patient 5’s H&P, dated 2/21/25, the H&P indicated Patient 5 presented to hospital on 2/21/25, following a syncopal episode (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain). The H&P indicated Patient 5’s medical history included dementia. The H&P indicated Patient 5 “Received Ativan [medication to treat anxiety] prior to evaluation as apparently she was attempting to hit her husband and staff.” During a review of Patient 5’s orders, two orders to place Patient 5 in violent/self-destructive restraints (VR) for 4 hours were noted: one for 2/21/25, at 6:38 p.m. and one for 2/24/25, at 12:55 p.m. During a concurrent interview and record review, on 4/3/25, at 10 a.m., with NE 1, Patient 5’s MR was reviewed. The MR contained multiple PN, dated as followed: 2/21/25, at 11:57 p.m.; 2/22/25, at 5:23 p.m.; 2/23/25, at 4:07 p.m.; 2/24/25, at 5:13 p.m.; and 2/25/25, at 12:32 p.m. NE 1 confirmed there was not a PN within one hour of the VR order of 2/21/25 nor was there a PN within one hour of the VR order of 2/24/25. NE 1 stated there were no indications in the notes that a face-to-face interaction had occurred after restraints were placed, and “None of the notes met the face-to-face requirement.” During a concurrent interview and record review, on 4/2/25, at 3 p.m., with Nursing Director (ND) 1, the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion, Nursing Management of”, dated 4/2/13, was reviewed. The P&P indicated, “When restraint is used to manage violent or self-destructive behavior, a physician or other LP [license independent practitioner], a registered nurse (RN) or physician assistant (PA) trained in accordance with this policy must see the patient face-to-face within one (1) hour after the initiation of the intervention.” ND 1 stated RNs were not trained in the facility to perform the face-to-face evaluation.”

“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: 44780 Based on interview and record review, the facility failed to ensure that nursing staff followed facility policies and procedures when: 1. Nursing staff failed to complete the fall risk assessment and ensure fall prevention interventions were in place for one of 9 sample patients who had falls during their hospital stay (Patient 1). 2. Nursing staff entered type of restraint orders that did not match the indication for restraints for two of 12 patients (Patient 4 & Patient 8). These failures resulted in Patient 1 falling out of a chair resulting in facial injuries, Patient 8 receiving less safety checks and behavioral assessments while in restraints per the facility policy which had the potential for Patient 8 injuring herself or others, and Patient 4 not receiving an order consistent with facility policy which had the potential to delay meeting patient’s therapeutic goals. Findings: 1. A review of the hospital’s policy and procedure (P&P) titled, “Fall Prevention and Management Policy and Procedure,” dated 12/15/22, indicated, “Assessment and Reassessment: A. The patient’s fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift...Evidenced-based fall risk interventions will be implemented based upon an age-appropriate Fall Risk Assessment Tool (FRAT) ...Adult - John Hopkins Fall Risk Assessment Tool (greater than age 18)...Implementation of Interventions...Individualized application of the interventions according to the risk factors identified for the patient...Implement Adult Fall prevention Interventions based on John Hopkins Fall Risk Assessment Tool ...Communication of Fall Risk...The patient’s fall risk status must be communicated to members of the healthcare team via report, nursing documentation, and standardized signage...Fall risk is included in handoff communication/report between caregivers at shift change and transfer of patient between units/departments...Documentation...Document fall risk score using appropriate Fall Risk Assessment Tool (FRAT) in the medical health record upon admission, every shift, upon transfer to another level of care or after a patient fall.” Review of Patient 1’s clinical record titled, “History and Physical [H&P],” dated 3/7/25, at 3:49 a.m., indicated Patient 1 was admitted to the hospital for intracranial hemorrhage (bleeding in the head). The H&P indicated Patient 1 was paralyzed on the right side of his body. Review of Patient 1’s clinical record titled, “John Hopkins Fall Risk Assessment [FRA]”, dated 3/9/25 at 11:46 a.m., indicated Patient 1’s FRA score was 10, which indicated Patient 1 was a low risk for falls. The nurse selected basic safety measures which did not include using a chair alarm. Review of Patient 1’s FRA, dated 3/10/25 at 10:41 a.m., indicated the nurse made no selections resulting in a fall risk score of zero, which indicated Patient 1 was a low risk for falls. The nurse selected basic safety measures which did not include using a chair alarm. Review of Patient 1’s clinical record titled, “Nurse’s Progress Notes,” dated 3/10/25, at 1 p.m., indicated Patient 1 fell out of the recliner chair to the floor and was placed back in the bed with assistance of nursing staff and a total lift (a mechanical device used to safely transfer patients who cannot support their own weight between surfaces like beds, chairs, and wheelchairs). Review of Patient 1’s clinical record titled, “Physician’s Progress Notes”, dated 3/10/25 at 3:50 p.m., indicated, “[Patient 1] placed in chair for early mobility encouragement and was found on the floor by nursing staff who immediately responded after apparent bowel movement and patient’s attempt to rise from bed without assistance.” Review of Patient 1’s clinical record titled, “Discharge summary”, dated 3/29/25, at 8:18 a.m., indicated Patient 1 had a ground level fall with bruising and discoloration around the eyes. During an interview on 4/3/25 at 1:15 p.m. with Registered Nurse (RN)1, RN 1 stated she was on break when Patient 1 had a fall on 3/10/25 and that Patient 1 was already in bed when she came back from break. RN 1 further stated she applied an ice pack to Patient 1’s right eye and stated the bruise was small and became bigger over time. During an interview on 4/3/25, at 1:38 p.m. with RN 2, RN 2 stated on 3/10/25, “I got the patient back in bed with the help of other nurses and the total lift. There was a huge bump on his eyebrow.” During an interview on 4/3/25, at 2:10 p.m. with Physio Therapy Assistant (PTA- helps individuals regain or improve their physical function), PTA stated, “I saw him a day after the fall, on March 11th, I saw a blackening, a little bruising on his eye, do not recall the side.” During a concurrent interview and record review with Manager for Physio Therapy (MPT) on 4/3/25, at 2:15 p.m., Patient 1’s “Physical Therapist Initial Eval,” dated 3/9/25 at 4:13 p.m. was reviewed. MPT stated, based of the Physical Therapist evaluation, Patient 1 was high risk for falls. During a concurrent interview and record review on 4/4/25, at 9:30 a.m. with Nurse Shift Manager (NSM) 2, Patient 1’s Fall Risk Assessments, dated 3/9/25 and 3/10/25 were reviewed. NSM2 stated that during the evening shift on 3/9/25 there was no FRA done and during the day shift on 3/10/25 the FRA was not complete. During a concurrent interview and record review on 4/4/25, at 9:45 a.m. with Safe Patient Handling Coordinator (SPHC), Patient 1’s FRA, dated 3/10/25, was reviewed. SPHC stated, “It was safe to put patient in the recliner if proper safety precautions were implemented, the safety precautions were not in place. The nurses could have used additional safety measures, they could have put chair alarm ...” During a concurrent interview and record review on 4/4/25, at 10 a.m., with NSM 1, Patient 1’s FRA, dated 3/10/25, was reviewed. NSM1 stated that there was no chair alarm used for Patient 1 on 3/10/25 when patient was put in the recliner before the fall. During a concurrent interview and record review with Intensive Care Unit Director (ND)1, on 4/4/25, at 10:40 a.m., Patient 1’s RFAs were reviewed. The ND1 stated the nurse had not done the FRA on 3/10/25 during the day shift and did not put the chair alarm on before Patient 1 fell out of the recliner. ND1 further stated, “Nurses have to do their assessments and evaluation in order to provide safe patient care.” During a concurrent interview and record review on 4/4/25, at 1:15 p.m., with Quality & Patient Safety Program Manager (QPSPM), Patient 1’s FRAs, dated 3/9/25 through 3/29/25 were reviewed. The QPSPM confirmed the FRAs indicated the following: 1. On the evening shift of 3/9/25 the RFA was not documented; 2. On the morning shift of 3/10/25 the RFA was documented incomplete; 3. On the evening shift of 3/14/25 the RFA was not documented; 4. On the evening shift of 3/15/25 the RFA was not documented; 5. On the evening shift of 3/20/25 the RFA was not documented; and 6. On the evening shift of 3/26/25 the RFA was not documented. 50121 2. During a review of Patient 8’s H&P, dated 3/20/25, the H&P indicated Patient 8 presented to hospital on 3/20/25 following a fall. The H&P indicated Patient 8’s medical history included high blood pressure and encephalopathy (brain disorder affecting behavior, mental processes and memory). During a review of Patient 8’s Medical Record (MR), a Nursing Progress Note (NPN), dated 3/21/25, at 3:27 p.m. was reviewed. The NPN indicated, “Patient threatened to hurt RN [registered nurse], saying ‘I will hit you if you come near me’ and began to swing at RN. Multiple staff members arrived to assist patient back to bed. Patient continued to swing and kick staff members. Bilateral wrist restraints placed. MD [medical doctor] notified.” The MR indicated a physician order was placed on 3/21/25 at 3:58 p.m. for Restraints-Non-Violent/Non-destructive. During a review of Patient 8’s MR, a review of a Physician Note (PN), dated 3/26/25 at 10:36 p.m. was reviewed. The PN indicated, “Started patient on restraints due to patient being agitated and combative per RN.” The MR indicate a physician order on 3/26/25 at 10:36 p.m. for Restraints-Non-Violent/Non-destructive. In a concurrent interview and record review, on 4/2/25, at 3 p.m. with Nursing Director (ND) 1, Patient 8’s NPN, dated 3/21/25, and PN, dated 3/26/25, were reviewed. ND 1 stated Patient 8’s behaviors described in the notes indicated Patient 8 should be in restraints for violent behaviors. 3. In a review of a facility P&P titled, “Restraint and Seclusion, Nursing Management of,” dated 4/2/13, the P&P indicated, “Ordering of restraint or seclusion for violent or self-destructive behavior ...for the management of violent or self-destructive behavior ... that jeopardizes the immediate physical safety of the patient, a staff member, or others.” During a review of Patient 4’s H&P, dated 3/8/25, the H&P indicated Patient 4 presented to hospital on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4’s medical history included dementia (a progressive state of decline in mental abilities). During a review of Patient 4’s orders, the orders included a violent/self-destructive restraints order (VRO), entered as a verbal order by a nurse from a Medical Doctor, dated 3/9/25, at 0:48 a.m. The VRO included, “Pt [patient] pulling IV [intravenous, a catheter placed in vein] lines.” During a review of Patient 4’s Restraint Flowsheet (RFS), dated 3/9/25, the RFS indicated bilateral mitten restraints were applied at 1 a.m., patient was “confused/restless”, and “clinical justification [was] attempting to pull IV line”. During a concurrent interview and record review, on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4’s H&P, dated 3/8/25, at 11:54 p.m., was reviewed. The H&P indicated Patient 4 was “very confused”. NE 1 confirmed the H&P contained no mention of violent/self-destructive behavior and the VRO did not indicate behavior which would justify violent/self-destructive restraints. NE 1 stated, “Order should have been for safety/non-violent restraints.” In a review of a facility P&P titled, “Restraint and Seclusion, Nursing Management of”, dated 4/2/13, the P&P indicated, “Orders for restraint for safety/non-violent/ non self-destructive behavior [are] to address a patient’s medical care-related needs (safety).””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 50121 Based on interview, and document review, the hospital failed to ensure an effective governing body legally responsible for the conduct of the hospital for a census of 367 patients out of a hospital bed capacity of 384 when: A. The hospital failed to ensure the services of the Regional Morgue Office complied with regulations and facility policies and procedures related to family notification of patient death, timely completion of death certificates, and processing of patient remains for a sample of three out of 61 hospital deceased patients (Patient 2, Patient 3, Patient 4) stored at an off-site morgue. Refer to A-0083. These failures contributed to ongoing delays in processing death certificates, lack of family notification of patient deaths, and prolonged storage of patient bodies in an off-site morgue, which had the potential to result in family distress over the perception of patients missing for prolonged periods of time when in fact they were deceased and in storage; On 10/4/2024, the off-site morgue had 61 patient remains from the hospital, 11 patient remains from deaths in 2022, 15 patient remains from deaths in 2023, and 19 patient remains from deaths in the first half of 2024. The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily mandated Condition of Participation for Governing Body.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 38970 Based on observation, interview and document review, the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that reflected the complexity of the hospital’s organization and services for a census of 367 patients in a hospital bed capacity of 384, as evidenced by: A. The hospital QAPI program failed to show documented evidence of data collected to track performance and to ensure improvements were sustained for two plans of correction for regulatory violations related in part to family notification of patient death and processing of the bodies of deceased patients, and the implementation of a process change for central venous catheter (a thin flexible tube that is inserted into a vein and guided into a large vein above the right side of the heart) removal. Refer to A0283. These failures resulted in regulatory noncompliance with QAPI standards and resulted in missed opportunities for improvement andf ongoing failures. The cumulative effect of these systemic problems resulted in the inability of the Hospital to comply with the statutorily mandated Condition of Participation for QAPI.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 50121 Based on interview and document review, the hospital failed to demonstrate the governing body was responsible for services furnished by the Regional Morgue Office (RMO), in the Greater Sacramento Division (GSD), for a sample of three out of 61 deceased patients (Patient 2, Patient 3, and Patient 4) stored in an off-site morgue at time of survey. The Regional Morgue Office failed to: 1. Notify the families of Patient 2, Patient 3, and Patient 4 of their deaths, and complete death certificates per regulatory requirements, 2. Resolve a known back-log of 61 deceased patients stored in an off-site morgue according to the GSD Laboratory Morgue Policy and Procedure. These failures resulted in a delay in completion of death certificates, in notification to families of patient deaths, and in handling the patients’ bodies after death. These failures had the potential to prolong distress and grief for families. Findings: 1. During a review of a log kept by the RMO of patient remains in an off-site morgue, the log indicated: a. Patient 2 died on 10/3/2022, family had not been found as of 9/5/2024 per the Public Administrator (PA), the death certificate had not been completed, and Patient 2’s remains continued to be stored at the off-site morgue; b. Patient 3 died on 10/21/2022, on 5/23/2024 the PA spoke with Patient 3’s family member who requested disposal of remains under county indigent (suffering from extreme poverty) plan, the death certificate had not been completed, and Patient 3’s remains continue to be stored at the off-site morgue; and c. Patient 4 died on 12/28/2022, a note indicated Spanish interpreter needed to proceed, the death certificate had not been completed, and Patient 4’s remains continue to be stored at the off-site morgue. During an interview on 10/1/2024 at 1:15 p.m. with the Sacramento Market Leader of Laboratory Services: Lab, Cardiopulmonary, & Rehabilitation (SMLLSLCR), SMLLSLCR stated the RMO was responsible for making three attempts to contact family once patient remains left the local hospital. SMLLSLCR stated there was no expected time frame for the contact attempts. SMLLSLCR stated, until recently there was no log to track the attempts. SMLLSLCR stated, if the process fails to yield results, the case should be forwarded to the County Public Administrator, who would attempt to find family, and if none could be found after a diligent search, contact the coroner to pick up the body. SMLLSLCR stated, the Office of the Coroner would attempt to contact family if known family could not be reached. SMLLSLCR stated, records of referrals to the PA and the Coroner’s Office had not been kept until recently. SMLLSLCR could not provide documented evidence of referrals to the PA or Coroner. During an interview on 10/2/2024 at 10:20 a.m. with Chairman of the Community Board (CCB) responsible for both the Community Board and the Quality Committee of the Community Board (QCCB), CCB stated the Community Board was comprised of the Chiefs of Staff and Presidents of the hospitals in the GSD, which included four hospitals. The Community Board reviewed reports from the QCCB Committee. CCB stated they were not aware of prior hospital regulatory violations for failure to process patient remains. During review of the Community Board Meeting minutes for the period of January 2024 to August 2024 meetings, the minutes did not reference any concerns regarding processing patient remains. There was no information regarding untimely completion of death certificates or lack of notification of next of kin of the death of a patient. 2. During an interview on 10/2/2024 at 1:05 p.m. with Supervisor of Lab Support Services (SLSS), SLSS stated she was aware the RMO was failing to timely process patient remains and complete death certificate worksheets beginning in April 2023. SLSS stated, initially she tried to help more with the process in addition to her clinical laboratory duties. SLSS stated the backlog continued; she reported it to the Regional Laboratory Director and Hospital President (HP) in September 2023. SLSS stated “It went nowhere.” SLSS stated no log or documents were kept for the Morgue processes until April 2024. During an interview on 10/3/2024 at 3 p.m. with the Regional Director of Laboratory Services (RDLS), RDLS stated he had been aware of the RMO backlog shortly after starting his role three months ago. During an interview on 10/3/2024 at 3:35 p.m. with the Chief Operating Officer (COO), the COO stated he started in his role three and half months ago and the lab reports to him. He was not aware of the back-log of processing human remains within RMO until it was a news story, in August 2024. COO stated resolving the issues became a priority then. During an interview on 10/3/2024 at 4:15 p.m. with the Hospital President (HP), the HP stated he was legally responsible for all hospital services. HP stated he reports to a GSD Hospital President, but the Healthcare Organization Governing Body had delegated the responsibility of hospital services to him. HP stated he was aware of the failures of the RMO to timely process patient remains and complete the death certificate worksheets in September 2023. HP referred the issues to the GSD President in September 2023. HP stated the GSD President and legal department were working to resolve the issue. HP stated he had not received, nor asked for any updates on solutions. When asked to explain this lack of oversight, HP stated the problem would be addressed at the divisional level; HP stated, “It is not my scope.” HP stated he was not aware of the failure to notify families. HP stated, “We assumed the remains being stored did not have families.” HP explained the patient populations at the hospital included high numbers of homeless persons. HP stated he never reported the backlog of patient remains processing or family notifications to the Community Board. HP stated that National Board is only notified of regional issues from the Community Board. HP stated “I’m legally and morally responsible for those in the morgue”. HP stated he was not aware of previous facility regulatory violations and plans of correction for failure to notify families of patient deaths. HP stated the previous QD notified him that all plans of corrections were completed. HP stated the previous plans of corrections did not have ongoing monitoring. HP stated QD does not have a direct line of reporting to him. In a concurrent interview and document review of the GSD Laboratory Morgue Policy and Procedure, approved 3/1/2022, with the SLSS on 10/3/2024 at 1 p.m., the document indicated processes for handling abandoned bodies and bodies with no next of kin. The document indicated the RMO should contact the public administrator and coroner when family could not be reached, or found, or the next of kin did not have resources to cremate or bury the body. The SLSS stated there was no documented evidence these agencies were contacted for assistance. In a document review of the Patient Safety Program Annual Summary and Evaluation for Fiscal Year 2023, which details categories of adverse events reported during the year, any regulatory findings, and active and completed plans of correction, submitted September 2023 to the Community Board, the document did not include documentation of the gaps in patient notification, death certificate processing according to legal requirements, or delay in handling patient remains. In a concurrent interview and record review of the newly created log of patient remains in off-site morgue storage, last updated 10/3/2024, with the QD on 10/3/2024 at 4:45 p.m., the QD confirmed the log indicated 11 bodies have been in storage since 2022, 15 bodies have been in storage since 2023, and 19 bodies have remained in storage from 1/1/2024 to 6/30/2024. The log indicated there were 61 patient remains in the off-site morgue on 10/3/2024.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 45882 Based on observation, interviews, and record reviews, the hospital Quality Assessment and Performance Improvement (QAPI) Program failed to show documented evidence of data collected to track performance and to ensure improvements were sustained when there was no documented evidence of implementation and completion for: 1. The Plan of Correction (POC, an action plan submitted by a hospital to a State Agency to correct a cited regulatory violation) for intake CA00511685, dated April 2022, indicated plans to educate staff regarding accuracy of family contact information in chart, timely notification of death to next of kin by physician and physician’s timely completion of deceased patient’s charts including the summary of hospital course and discharge summary. Additionally, the Quality Program Manager (QPM) was responsible for verification through chart audits and providing semiannual reporting of audit for integration into the QAPI process. The timeframe indicated on the POC stated “reporting will continue until four consecutive audit results are 100% excluding months with no cases”. 2. The POC for intake CA00747251, dated July 2023, indicated the development of an education module for the Pathology (study of disease) Laboratory and Administrative Nursing Supervisor staff covering the steps to take after the death of a patient to ensure dignity and respect, following federal and state regulatory requirements and including responsible staff tasks. This POC would be verified by Quality and Patient Safety Program Manager (QPSPM) with chart audits meeting measurable goals until “three consecutive months of goal performance was achieved”. 3. A performance improvement project, dated 6/8/2023, identified by the Quality Management Committee (QMC) as a targeted area for improvement, focused on the removal of central venous catheters (CVC, a thin flexible tube that is inserted into a vein and guided into a large vein above the right side of the heart) prior to transfer to lower level of care (intensive care unit to medical or surgical units) to reduce the risk of CVC related patient adverse events. These failures resulted in regulatory noncompliance with QAPI standards and resulted in missed opportunities for improvement. Findings: 1. During a review of the POC for intake CA00511685, dated April 2022, the POC included the following corrective actions, in part: a. Education provided to medical staff on contacting and documenting family notification of death. b. Department managers provided education to hospital staff about the importance of accuracy of information in the medical record, including contact numbers. c. Developed an auditing and reporting process to evaluate the accuracy of telephone numbers listed as contacts in the medical record. d. Scheduled semiannual reporting and of audit results to the QMC of the medical staff for integration into the established QAPI process. 2. During a review of the POC for intake CA00747251, dated July 2023, the POC included the following corrective actions, in part: a. Development of an education module for Pathology Laboratory and Administrative Nursing Supervisors to include at time of death the patient will be cared for with dignity and respect, in accordance with federal and state regulatory requirements, the location of Notifications of Death Form, the documentation of deceased patient in morgue logbook and identify who is provided access to the morgue. b. Retrospective chart audits performed by QPSM to verified that patients were deposited in the morgue with the appropriate documentation. This audit was to continue until 3 consecutive months of goal performance of 100% compliance was achieved. During a review of the hospital QAPI plans, dated fiscal year 2023 and fiscal year 2024, the QAPI plans did not include any documented evidence of implementation of corrective actions identified in the POCs or evidence of tracking of performance improvement. During a concurrent interview and record review on 10/1/24, at 11:05 a.m., with the Quality Director (QD), the QD was provided a copy of the POCs for intakes CA00511685 and CA00747251. After reviewing the POCs, the QD stated, “I am not familiar with these POCs ...will research ...these were before I started and there was no handoff to me [from previous staff]”. During an interview on 10/3/24, at 1:20 p.m., with the QD, the QD stated, “I have not been able to locate data for either POC”. The QD stated, “No one was working on these [POCs], there is no data to provide implementation and tracking.” The QD confirmed there was no documented evidence the interventions in the POCs, that were dated April 2022 and July 2023 respectively, were monitored for success and sustained compliance per hospital QAPI plan and regulatory requirements. 3. During an interview on 10/3/24, at 11:45 a.m., with Critical Care Nurse Educator (CCNE), the CCNE stated, they are working on a performance improvement project (PIP) to remove CVC before the patient is transferred to the medical or surgical floor. The CCNE stated, starting in February of 2023, the QMC started to investigate CVC line removal before transfer to a lower level of care as a quality indicator. The CCNE stated the nursing staff had been educated via Pathways (an online learning module the hospital utilizes to educate nurses) to a new vascular (vein) access policy, which included a skills module for vascular access care and removal. This module was assigned on 3/9/23 with a due date of 4/30/23. When asked about how many patients were being sent to the medical/surgical floor with CVC for this PIP the CCNE stated, “We are not tracking the data.” During a review of QMC minutes, dated June 2023, the QMC indicated the need to remove CVCs prior to transfer to a lower level of care. During a concurrent observation and interview of the 5C Trauma medical surgical and telemetry (continuous monitoring of heart activity) unit, on 10/3/24, at 10:20 a.m., with the QD, the QD stated the unit was focused on monthly report cards (an infographic that is posted on a bulletin board for all staff to see). The only PIP that was observed posted in the unit was for patient falls. The QD stated that she did not see evidence of a PIP for CVC removal.”

“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: 46237 Based on interview, medical record review, and facility policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to one of 20 sampled patients (Patient 1) when: A. The hospital failed to ensure a policy for telemetry (tracing of electrical activity of the heart rate and rhythm) monitoring was implemented for one of 20 sampled patients (Patient 1) when: 1. Monitor Tech (MT) 1 contacted Registered Nurse (RN) 1 to check on Patient 1 but did not tell RN 1 that Patient 1 was in ventricular fibrillation (VFIB, a type of arrhythmia [irregular heart rhythm] that is life-threatening. When the heart is in VFIB, the definitive treatment is to perform electrical defibrillation, which is the act administering an electrical current across the chest to help the heart return to a normal rhythm). 2. RN 1 assessed the wrong patient (Patient 2) and told MT 1 that the patient was sitting up and eating. 3. MT 1 asked RN 1 to check the telemetry leads (part of telemetry monitor attached to patient’s skin, used to detect heart activity) on Patient 1, to which RN 1 replied that she would in a few minutes. 4. MT 1 failed to follow up with RN 1, and 12 minutes later RN 2 discovered Patient 1 unresponsive and without a pulse. (Refer to A0398). These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1’s death. The cumulative effect of these failures resulted in the hospital’s inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.”

“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: 46237 Based on interview, clinical record review, and facility policy and procedure review, the hospital failed to ensure a policy for telemetry (tracing of electrical activity of the heart rate and rhythm) monitoring was implemented for one of 20 sampled patients (Patient 1) when: 1. Monitor Tech (MT) 1 contacted Registered Nurse (RN) 1 to check on Patient 1 but did not tell RN 1 that Patient 1 was in ventricular fibrillation (VFIB, a type of arrhythmia [irregular heart rhythm] that is life-threatening. When the heart is in VFIB, the definitive treatment is to perform electrical defibrillation, which is the act administering an electrical current across the chest to help the heart return to a normal rhythm); 2. RN 1 assessed the wrong patient (Patient 2) and told MT 1 that the patient was sitting up and eating; 3. MT 1 asked RN 1 to check the telemetry leads (part of telemetry monitor attached to patient’s skin, used to detect heart activity) on Patient 1, to which RN 1 replied that she would in a few minutes; and 4. MT 1 failed to follow up with RN 1, and 12 minutes later RN 2 discovered Patient 1 unresponsive and without a pulse. These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1’s death. Findings: Review of Patient 1’s clinical record titled, “History and Physical”, dated 7/21/2024, indicated Patient 1 was admitted to the hospital due to an exacerbation of Patient 1’s heart and lung diseases. Review of Patient 1’s clinical record titled, “Orders”, dated 7/21/2024, indicated a physician order for Patient 1 to be placed on telemetry. Review of Patient 1’s clinical record titled “Monitor Rhythm Strips”, dated 7/25/2024, from 8:49 a.m. to 9:03 a.m., indicated the following: At 8:49 a.m. the monitor rhythm strip indicated a system alarm, including pause and VFIB/VTAC (ventricular tachycardia, a type of arrhythmia). The strip indicated the heartrate was 84 followed by 0 (zero). The strip included a notation, which indicated, “Per RN [RN 1] PT [patient] eating and sitting up ...RN will check later.” At 9:01 a.m. the monitor rhythm strip indicated a manual recording and asystole (when the heart’s electrical system fails entirely causing the heart to stop pumping). At 9:03 a.m. the monitor rhythm strip indicated a system alarm, including VFIB/VTAC. The strip indicated the heart rate was zero and a notation, which indicated “code blue [a hospital-wide alert system used to indicate that a patient requires emergency medical attention, most often as the result of a respiratory or cardiac arrest]. ...RN called Pt pulseless informing me no one called ...” Review of Patient 1’s clinical record titled, “Physician Orders: Code Blue Form”, dated 7/25/2024 at 9 a.m., indicated that Patient 1 was pulseless (no heart beat), her lips were blue, initial heart rhythm was VFIB, and chest compressions were started. The record further indicated that resuscitation (emergency procedure for when someone’s breathing or heartbeat stops) ended at 9:11 a.m. Review of Patient 1’s clinical record titled “Discharge Summary,” dated 7/25/24 at 5:12 p.m., indicated, “Patient passed away on 7/25/24 at 09:11 [a.m.].” During an interview with the Manager of Medical Acute Unit (MMAU) on 8/1/2024 at 11:30 a.m., MMAU stated she was the recorder during the code blue for Patient 1 on 7/25/2024. MMAU stated she interviewed RN 1 and RN 2 following the event. MMAU stated RN 1 told her that MT 1 called her to check on Patient 1, and RN 1 told MT 1 that Patient 1 was sitting up and eating. MMAU stated that RN 1 stated that she thought she was checking on Patient 1 when she was actually looking at Patient 2. MMAU stated Patient 1 was in the adjoining room. When asked about RN 1’s availability for interview, MMAU stated RN 1 was currently on a leave of absence. During an interview with Interim Patient Quality Safety Manager (IPQSM) on 8/1/2024 at 1:25 p.m., IPQSM stated that she conducted interviews with MT 1, RN 1, and RN 2. IPQSM stated that MT 1 stated he called RN 1 on 7/25/2024 at 8:49 a.m. to check the telemetry leads on Patient 1 and RN 1 replied to MT 1 that she would in a few minutes. During an interview with RN 2 on 8/2/2024 at 10:57 a.m., RN 2 stated that when she entered Patient 1’s room on 7/25/2024 at 9:02 a.m. she found Patient 1 unresponsive, and her lips were blue. RN 2 stated she started cardiopulmonary resuscitation (CPR, an emergency procedure done when someone’s breathing or heartbeat has stopped) and told RN 1 to call a code blue. RN 2 stated she asked RN 1 if MT 1 had called her about Patient 1. RN 2 stated RN 1 replied that she thought MT 1 had called for a patient in the adjoining room (Patient 2). RN 2 stated Patient 1’s room was next to Patient 2’s room and the rooms were separated by a curtain. During a concurrent interview and record review with MT 1 on 8/2/2024 at 11:40 a.m., MT 1 reviewed Patient 1’s monitor rhythm strips dated 7/25/2024, and stated, at 8:49 a.m. the telemetry monitor interpreted the heart rhythm as VFIB. MT 1 stated “I called the nurse to know if the patient is safe. She confirmed that the patient is sitting up and eating. I asked her if she could fix the leads for me. She said I will in a few minutes. I did not write VFIB on the strip as she confirmed that the patient was sitting up and was okay.” When asked to describe the procedure for when a patient had a lethal heart rhythm, like VFIB, MT 1 stated the monitor techs would call the primary nurse first, and if not able to reach the primary nurse, they would call the charge nurse. MT 1 stated that if the monitor tech was unable to reach the charge nurse, they would activate a code blue. MT 1 stated this was according to policy. Review of the facility’s job description titled, “MONITOR TECH-R,” dated 8/25/2022, indicated, “Recognizes emergency situations (including life threatening arrhythmias) and responds effectively and appropriately. Notifies the RN with rhythm changes in a proactive approach ...Anticipates patient/unit needs during emergency/code situations without requiring direction ...performs legible, timely, concise and accurate documentation according to policies and procedures.” Review of the facility’s administrative policy titled, “Continuous Cardiac Monitoring via Telemetry (Telemetry Monitoring),” dated 8/8/2023, indicated, “Continuous cardiac monitoring is used to: a. Immediately recognize sudden cardiac arrest to improve time to defibrillation. b. Recognize deteriorating conditions that may lead to a life-threatening arrhythmia. c. Facilitate management of arrhythmias ... Any communications regarding patient care concerns are to be timely, complete and accurate and follow the Chain of Command for escalation, if necessary, to achieve resolution ...” Review of the facility’s administrative procedure titled, “Continuous Cardiac Monitoring via Telemetry (Telemetry Monitoring),” dated 8/8/2023, indicated, “E. Documentation ...2. The Monitor Tech or other qualified personnel: a. Will report any significant rhythm changes immediately to the patient’s primary nurse ...3. Will call a CODE BLUE automatically for any lethal arrhythmias: a. Sustained ventricular tachycardia b. Ventricular fibrillation c. Asystole ...5. Nursing staff are required to respond immediately to any STAT [immediately] calls or response requests from the Monitor Tech ...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 46237 Based on interview, clinical record review, and hospital policy review, the hospital failed to ensure stabilizing treatment, and safety and security relevant to a psychiatric emergency medical condition (EMC) for 1 out of 36 sampled patients when a patient (Patient 25) was brought into the emergency department (ED) with suicidal ideations (thinking about or planning suicide). Patient 25 was able to go into the ED bathroom and take an overdose of a medication obtained from her purse. This failure resulted in injury to Patient 25 and had the potential to cause additional serious harm and death to the patient. Findings: A review of Patient 25’s ED clinical record revealed the following documents: An ED provider note, dated 12/18/23 at 7:49 p.m., indicated, “SI [suicidal ideation] - plan to overdose on pills. EMS [emergency medical services] states patient has a plan to OD [overdose] on pills in her purse.” An ED assessment, dated 12/18/23 at 8:48 p.m., indicated, “Suicide Severity Rating: High” and “Suicide Prevention Interventions: Direct Observation, Secure Environment, Safety Attendant.” An ED provider note, dated 12/18/23 at 9:46 p.m., indicated, “Patient reportedly used the restroom here in the ED. Patient later reported to nurse that she overdosed on 60 tablets of [name of medication] while in the restroom. RN [registered nurse] reports patient’s medication bottle is empty ...Patient had a witnessed generalized tonic-clonic seizure [uncontrolled shaking movements with loss of consciousness] in hallway. Seizure self-abated [decreased]. Patient was postictal [abnormal condition occurring between the end of a seizure and return to baseline condition].” During an interview on 5/14/24 at 2:15 p.m., with ED Educator (EDE), EDE stated Patient 25 was left unobserved for a period of time and Patient 25’s belongings were located under the head of the bed. Patient 25’s belongings included medications. During an interview on 5/16/24 at 1:05 p.m., with ED Director (EDD), EDD stated Patient 25’s belongings should not have been put under the bed and Patient 25 should have been line of sight (a straight line along which an observer has unobstructed vision). During an interview on 5/16/24 at 1:20 p.m., with registered nurse ED Staff (RN 1), RN 1 stated, “If a patient came in with SI and pills, I would remove these and keep them with me until security came. I would not leave the patient alone.” During a review of the facility’s policy and procedure (P&P) titled, “Identifying and Assessing Patients at Risk of Suicide/Self harm,” dated 2023, the P&P indicated, “Patients screened/assessed and found to be at HIGH risk will be monitored under a direct one-to-one (1:1) observation.” The P&P further indicated, “Remove from the immediate patient environment any potentially harmful objects.” During a review of the facility’s P&P titled, “EMTALA Patient transfer policy”, dated 2022, the P&P indicated, “Rights to Treatment. Even if an individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid, the Medical Center recognizes the right of the individual to receive, within the capabilities of the Medical Center’s staff and facilities: b. Necessary stabilizing treatment for an Emergency Medical Condition.””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 42291 Based on interview and document review, the hospital with capability and capacity failed to accept the transfer for 2 of 36 sampled patients (Patient 1 and 35) with emergency medical conditions (EMC) when: 1. Hospital B delayed Patient 1’s transfer from Hospital A for eleven hours and Patient 1 developed a blood clot in the superior mesenteric vein (SMV- a life threatening condition that occurs when a blood clot forms in a large vein in your abdomen). Patient 1was transferred to the receiving facility (Hospital B) in severe septic shock requiring immediate intervention and treatment; and 2. Hospital B, with neurosurgical capabilities, declined to accept Patient 35 from Hospital A with a diagnosis of a subdural hematoma (collection of blood in the brain) and required transfer to another accepting facility. These failures resulted in delay of treatment and stabilization of an EMC due to the receiving facility refusing to accept Patient 1 and Patient 35 for a higher level of care than the transferring facility could provide which contributed to Patient 1’s medical deterioration and had the potential to result in a poor outcomes and death for Paitient 1 and 35. Findings: 1. A review of Patient 1’s medical record from Hospital A included a note titled, “Emergency Documentation - [MD]”, which indicated Patient 1 presented to the emergency department on 7/28/23 at 3:13 a.m. with a family member. Patient 1 complained of a 4-5-day history of right upper quadrant abdominal pain with nausea and diarrhea. The note indicated “Pt [Patient 1] diaphoretic (clammy) upon arrival and c/o [complaint of] lightheaded.” Patient 1’s initial vital signs were a temperature 36.7 Celsius (98.1 Fahrenheit), blood pressure 113/81 (BP is the amount of force blood uses to get through arteries- normal approximately 120/80), pulse of 98 (the beating of blood through body- normal 60-100 beats per minute [bpm]), respiratory rate of 18, ([RR] is the rate of breaths per minute- normal 12-18 per minute), and SPO2 of 98% (a measurement of how much oxygen your blood is carrying). A review of a document from Hospital A titled, “Medical Decision Making”, dated 7/28/23 at 5:26 a.m., “CT”( a medical technique used to obtain detailed images of the bodies internal organs) results, “SMV thrombus with likely infarcted jejunum, (narrowing or blockage of one or more arteries that supply blood to the small intestine) likely more bowel at risk.” The document continued, “Heparin (medication used to prevent harmful clots) ... ordered .... Rocephin and Flagyl (antibiotics used to stop the growth of bacteria) ordered for intra-abdominal coverage.” During a further review of the same document indicated “there is/was a high probability of imminent or life-threatening deterioration in the patient’s condition due to cardiopulmonary, [heart and lungs], GI [gastro-intestinal, stomach and gut] compromise without immediate intervention.” The document also indicated, “No IR (Interventional Radiology- a surgical procedure to treat conditions like clots) at [Hospital A Name] until 8 am”. During a review of the document from Hospital A, “Laboratory Results”, dated 7/28/23 at 5:26 a.m., the following was noted: WBC: 16.6 k/uL (per cubic milliliter- unit of measure), white blood cells- normal range is 4.5 to 11.00, part of the immune system to fight infections, which is elevated indicating a potential infection); Anion Gap: 23 mEq/L (milliequivalents per liter- unit of measure, Normal range 4mEq/L-12mEq/L a measurement of the acid base balance of blood, levels increase during severe infection) Glucose: 154 mg/dL (milligrams per deciliter- unit of measure, normal range 125mg/dL or lower, sugar found in blood, when fighting infection, the body responds by increasing the glucose); Lactic Acid: 2.3 mg/dL (greater than 2mg/dL indicates there is not sufficient oxygen at the cellular level, high levels are common in sepsis or severe shock) Repeat Lactic acid results at 11:41 a.m.: 9.2 mg/dL with a note, “Critical value called to and read back by RN in ED at [12:40 p.m.] 7/28/23.” During a review of a document from Hospital A titled, “Hemodynamics and Vitals”, dated 7/28/23 from 3:13 a.m. through 2:25 p.m., revealed Patient 1’s systolic blood pressure (measures the pressure in millimeters of mercury [mmHg- a unit of measure] in the arteries when the heart beats) was as high as 158 and as low as 56. Patient 1’s diastolic blood pressure (measures the pressure in mmHg in the arteries when your heart relaxes between beats) was as high as 104 and as low as 38. Patient 1’s pulse was as low as 58 bpm and as high as 140 bpm. Patient 1’s respiratory rate was as low as 15 RR and as high as 29 RR. A review of Patient 1’s medical record note from Hospital A titled, “Respiratory”, dated 7/28/23 at 1:49 p.m., noted, “Bi-Level Positive Airway Pressure (BIPAP) “BIPAP per protocol” ... (Used to support breathing through a face mask). The document further indicated at 2:00 p.m., “transferred airway care management to EMS transport team without complications.” The note continues, “At 2:11 p.m., “unable to obtain ABG (Arterial Blood Gas- measures how much oxygen, carbon dioxide and the pH, level of acidity or basicity, is in the blood) at this time, transport here to pick up patient.” A review of a document titled, “Patient Care Report” (ambulance transport note), dated 7/28/23 at 2:41 p.m., approximately 13 hours after presenting to the ED, indicated the following: “Dispatched to ... [Hospital A] for a 52 YOM [year old male] who presented to the ED with generalized, worsening abdominal pain x 3 days, CT revealed full occlusion of superior messentric [sic] artery. While in ED patient had multiple episodes of hypotension (low blood pressure), which were treated with a total of 3L NS (normal saline). Patient then became dyspneic (shortness of breath) and was placed on Bipap for ventilator support” and, “Arrived to find patient hypotensive (low blood pressure) ...pale/cool/diaphoretic, on Bipap ... 9/10 abdominal pain (a numeric scale used to determine a patient’s level of pain with 0 being no pain and 10 being worst pain ever) not relieved by pain meds ... ST [rapid heart rate] on monitor ...”. “Enroute to receiving facility patient began to decompensate requiring Levophed (IV medication used to treat life threatening low blood pressure, maybe referred to as a ‘pressor’) and CPAP (CPAP provides a positive pressure of air through a mask and into the airway which helps keep the airway open) to be started”. A review of a document titled, “Patient Care Report” (ambulance transport note), dated 7/28/23 at 2:41 p.m., included the following vital signs during transport: 2:51 p.m.: 65/31 (BP), 125 pulse, pain- 9/10 2:54 p.m.: 75/59 (BP), 124 pulse, pain- 9/10 3:03 p.m.: 86/63 (BP), heart rate not documented, pain- 9/10 3:05p.m.: 76/51 (BP), 133 pulse, pain- 9/10 3:07p.m.: 81/56 (BP), 131 pulse, pain- 9/10 A review of a document from the receiving hospital, Hospital B, titled, “Final Report, Emergency Documentation,” dated 7/28/24 at 3:40 p.m., indicated the following: Patient 1 arrived at Hospital B complaining of 8/10 abdominal pain and was started on “Levophed and CPAP shortly before arrival”. Patient 1’s vital signs were documented as blood pressure of 117/97, pulse 125, and respiratory rate of 25, SPO2 97%. A review of the same document under “Procedures” the following was documented: “Given the patient’s presentation with abdominal pain, there is/was a high probability of imminent or life-threatening deterioration (becoming progressively worse) in patients condition due to cardiovascular, metabolic compromise (failure of the heart and other internal organs) without immediate intervention.” Further review of the document dated 7/28/24 at 3:19 p.m., included, “Direct Laryngoscopy/Intubation was performed for airway protection (placement of a flexible plastic tube into the windpipe to maintain an open airway) and Central Venous Catheter (a thin flexible catheter that is inserted into a large, central vein usually below the collar bone to give intravenous fluids, blood, and drugs) was placed for “emergent access for fluid and drug administration”. Review of the same document under “Laboratory Results”, at 3:33 p.m., the following abnormal laboratory results were documented: WBC: 29.2 k/uL, increasing WBC indicated infection. Anion Gap: 31 mEq/L, levels increase during severe infection. Glucose: 396 mg/dL, levels increase with severe infection. Creatinine: 2.85mg/dl (normal range 0.7 -1.3mg/dl- may indicate an acute kidney injury). Lactic Acid: 16.1 mg/dL, levels increase with severe infection. Troponin: 101 mg/mL (normal range 0-0.04mg/ml, elevation is an indicator of heart damage related to shock). The document revealed a second, “CT Angio Abdomen and Pelvis” was performed at 5:33 p.m., and indicated the following, “Patient has known thrombus (blood clot) within the jejunal veins (carry blood to large arteries in the intestines) and thrombosis (blood clot) of entire superior mesenteric vein to its confluence with the splenic vein with thrombus now also extending into the proximal portal vein (more clotting and loss of blood flow) ... Increasing length of involvement of jejunal loops (intestine) as well as also extending towards the proximal ileal loop (intestine) ... The terminal ileum (intestine) is “now collapsed” and “worsening mesenteric fat stranding and edema (swelling) and free fluid in the central mesentery suggesting venous congestion as well as increasing free fluid around the liver and spleen and right lower quadrant.” Review of a document titled, “Patient Placement Note”, dated 7/28/23 at 05:31 a.m., indicated the following: “52-year-old male, [diagnosis] Thrombosis, [complaint of] 4-5 days [history] of ...[abdominal] pain associated with nausea and diarrhea. Denies vomiting. [Patient] diaphoretic upon arrival and ...lightheaded ...” and, “BED: Med. Tele (indicating a heart monitored bed in a unit at Hospital B), REASON: HLOC [higher leve lof care] Vascular Services (the specialty accepting Patient 1) ... Stable for transfer...”; At 5:52 a.m., “[MD# 4], [Hospital B] Vascular talked to sending physician and stated “it is General Surgery”; At 7:30 a.m., “Presented case to [Hospital B] ANS (Administrative Nursing Supervisor- ANS 2) states “this is the same [patient] that was declined by Vascular MD earlier because [patient] needs tertiary care. Has there been a change?”; At 8:00 a.m., “Presented updated information to [ANS 2. [ANS 2] agreed to proceed to present and if accepted bed available pending [discharges] Present to IR and if accepted circle back after 1500 (3:00 p.m.) for bed”; At 10:49 a.m., “[MD #4] at [Hospital B] is willing to see pt at [Hospital B] if vascular and hospitalist agree to accept ...”; At 11:08 a.m., [MD #6] “Vascular surgery not available for this issue but I’ll see the patient if IR has problems during intervention ...”; At 11:39 a.m., “[MD #7] hospitalist accepted to MedTele. Waiting on bed ...”; At 12:31 p.m., “Call from unit clerk at [Hospital A] asking for update-advised pending BR (Bed Request)”; At 1:39 p.m., “[Hospital A] requesting bed update, [patient] needs to transfer immediately> (sic) [patient] is scheduled for IR procedure today”; At 1:46 p.m., “[Hospital A] “requesting bed update, informed MD I just reached out to PP (patient placement) re (regarding) this transfer request”; At 2:03 p.m., “Call to 6TN at [Hospital B] (nursing unit within the hospital) CN (Charge Nurse) to discuss bed assignment, advised that she is staffing down and can no longer accept [patients]...” At 2:42 p.m., “[Patient] LOC (level of care) has changed to ICU (Intensive Care Unit- high level of care)...”. During an interview on 5/15/24 at 4:20 p.m., with ANS 1, ANS 1 indicated the process to accept a patient begins when the “call center bed placement person calls the ANS to request a bed.”. ANS 1 indicated “trauma and neuro (brain) are the priority; we will make a bed for those patients.” ANS 1 further indicated she will ask the staffer to have nurses come in early or may have a nurse on call who can come in early to care for a transfer patient.” ANS 1 stated, “we never stop trying ... I do whatever I can to get a bed for a patient who needs to be admitted or transferred to this hospital.” ANS 1 further indicated, “charge nurses may not decline a patient.” ANS 1 indicated when she needs additional beds to accept transfers for admission she will round on the floors, involve leadership, check for discharges that have not yet been discharged see if she can expedite the discharge and encourages early discharges. ANS 1 stated the facility does not have an expected discharge time for patients to leave the facility and stated, “discharges happen all day, but mostly in the afternoon.” During a concurrent interview and document review of the document titled “Patient Placement” with ANS 2 on 5/16/24 at 9:22 a.m., ANS 2 indicated the ANS “oversees the entire house (hospital)”. ANS 2 indicated when the transfer center calls and requests a bed, even if no beds [available], she would call a physician, if a physician accepts, we will give window of bed availability. ANS 2 stated she declined Patient 1 because “the surgeon declined”. ANS 2 indicated she does not keep records of calls for bed requests indicating, “the call center does.” ANS 2 further stated she did not accept Patient 1 because Patient 1 needed “tertiary care” which the hospital does not provide. ANS 2 stated she did have a discussion with call center personnel and indicated the hospital only provided “tertiary care for neuro and trauma”. ANS 2 stated she did not remember having a conversation with the surgeon regarding Patient 1. ANS 2 stated she did not remember involving the AOC (administrator on call) regarding Patient 1. ANS 2 further indicated a transfer patient can be placed in any one of the hospital’s six ICU’s or the med/tele floors and it, “just requires an open bed.” During an interview and concurrent document review with Medical Staff Director (MSD) on 5/16/24 at 8:56 a.m., the MSD provided the physician call schedule for 7/28/23 which indicted a vascular surgeon, general surgeon, and IR (Interventional Radiology) were on call for Hospital B. MSD further indicated the on-call physician is expected to be in the hospital within 20 minutes of being called for a case. During an interview on 5/16/24 at 11:35 a.m., the Intensive Care Unit Manager (Mgr.2) stated he manages the ANS’s. The Mgr. 2 stated it was the expectation the ANS “shuffles patients around to make an open bed for a patient who needs to be transferred.” Mgr.2 further indicated it is the expectation the ANS will not refuse a transfer but will discuss with the physician and AOC how to accommodate the patient needing transfer into the hospital for a higher level of care. A review of an untitled document dated 7/28/23 presented by the Quality Director (QD) which QD indicated was the census for 6TN Unit on 7/28/23. The document reflected an inpatient census of 26 patients with staffing for 27 patients as well as a charge nurse “who could take patients if needed” according to the QD. The document further reflected on 7/28/23, the 6TN Unit had 11 discharges and 5 admits. Per the QD 6TN has 30 beds for patients. Review of the Hospital policy titled, “[Organization Name] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy”, effective 9/25/2018, directed, “... It is also the policy [Organization Name] to accept emergency transfers from other facilities if the individual being transferred requires Specialized Capabilities that are not offered or not immediately available at the transferring hospital provided that the [Organization Name] hospital has the Capacity and Capability to treat the individual.” The policy defined, “...Capability means the physical space, equipment, supplies, and services including ancillary services available at the hospital”, and, “...Capacity means the ability of the hospital to accommodate an individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, and equipment and the hospital’s past practices of accommodating additional patients in excess of its occupancy limits.” Review of the Hospital policy titled,”Inter-Facility Transfer”, approval date 1/27/22, stipulated, “...Inter-facility transfers are necessary to provide patient’s access to specialized providers or higher level of care/services at an appropriate unit/facility ....When a patient requires a higher level of care other than that available/provided at the sending facility, a receiving facility with capability and capacity to provide a higher level of a care may not refuse the request for transfer.” Review of the Hospital document titled, “Memorandum of Understanding for Transfers Between [Hospital A and Hospital B],” dated 3/29/2019, indicated ... “[Hospital B] provides certain emergency, trauma and other clinical services ... which may be required by, or suited for patients at [Hospital A]; and because of either a lack of available personnel ... or services ... [Hospital A] from time to time request the transfer of patients to [Hospital B] to receive appropriate care.” 2. Review of Patient 35’s medical record from Hospital A titled, “Emergency Documentation - MD”, dated 4/21/2024, at 6:49 p.m., indicated the following: “Medical Decision Making...Patient is an 83-year-old male [with] history of falls who sustained a ground-level fall shortly prior to arrival. Patient has a right parietal [middle part of the brain] occipital [back of head] hematoma [collection of blood] present on exam. CT [Computed Tomography, x-ray images] scan was obtained which shows a large mixed attenuation [reduction of signal] left holohemispheric [entire] subdural hematoma measuring up to 3.6 cm [centimeter, unit of measure]. Immediately following the CT results I asked for a transfer case to be open with [Hospital Name] transfer center. I was contacted back by [name] RN [Registered Nurse] stating that [Medical Doctor (MD) 2 at Hospital B] had reviewed imaging and stated [Patient 35] was a nonsurgical candidate, thus recommend transfer to another facility. I asked to speak with [MD 2] directly which he was agreeable. [MD 2] states in his opinion patient is not an emergent neurosurgical candidate. He recommends that I call another neurosurgeon to obtain their opinion. I did ask [MD 2] if he would be able to speak peer-to-peer, i.e., neurosurgeon to neurosurgeon regarding imaging recommendations, however he declines. I spoke with [MD 8 at Hospital C] as above who states patient is not an emergent neurosurgical candidate...I contacted [Hospital D]... who recommends emergent transfer to [Hospital D]...EMS is planned for pickup at [1:00 a.m.]”. Review of Patient 35’s medical record from the receiving hospital, Hospital D, titled, “Emergency Department Nursing Transfer”, dated 4/22/24 at 1:10 a.m., indicated Patient 35 had a subdural hematoma, a right elbow abrasion (scrape). Patient 35 had a history of stroke, speech deficits, facial droop, and right arm flaccid (limp) at baseline. Review of Hospital D document titled, “Op [Operative] Note”, dated 4/22/24 at 3:09 p.m., indicated Patient 35 underwent a left-sided craniotomy (removing bone from the skull) for drainage of acute (severe sudden onset) on chronic (over extended period of time) subdural hematoma. Review of Hospital D document titled, “Hospital Discharge Summary”, dated 4/30/24 at 4:02 p.m., indicated Patient 35 was discharged home on 4/30/24. During a concurrent telephone interview and record review on 5/15/2024 at 1:05 p.m. with the Director of the Clinical Command Center (CCC), the untitled transfer transcript for Patient 35, dated 4/21/24 at 7:40 p.m., was reviewed. The transfer communication transcript indicated that a request was made by Hospital A for neurosurgery services for Patient 35 with a subdural hematoma and included the following: At 8:19 p.m. the transcript indicated a bed was available at Hospital B and the neurosurgeon (MD 2) would review the CT and call back. The notes further indicated at 9:03 p.m., MD 2 called back and stated “there is nothing he would do surgically but if family wants second opinion that is there (sic) decision.” At 9:49 p.m., indicated a Hospital C neurosurgeon agreed that Patient 35 was not a surgical candidate. At 10:08 p.m. indicated Hospital B’s president was notified and stated “given no surgical intervention needed recommend to admit to [Hospital A] by hospitalist and neurology consult. If they won’t admit transfer to [Hospital B] with hospitalist with neurology consult ...” At 11:02 p.m., [MD 1] [Hospital B] “says this patient should be a potential surgical candidate. States he cannot except (sic) [to] Hospital B, then without neurosurgery support. He spoke with [MD 2] (Hospital B) himself and [MD 2] is unwilling to change his opinion.” At 11:38 p.m., the transcript indicated Hospital D accepted Patient 35. During a telephone interview on 5/16/2024 at 10:55 a.m., with MD 1, MD 1 stated Patient 35 had a massive left subdural hematoma with left midline shift (brain pushed to one side). Patient 35 met guidelines for surgical interventions. MD 1 did not feel appropriate to admit a patient without surgical support to offer or be available for Patient 35 needs. During a telephone interview on 5/16/2024 at 1:30 p.m., with MD 2, MD 2 indicated Patient 35 had a dominant hemisphere (controls language) stroke, and a subdural hematoma. Because of his dominant hemisphere stroke, Patient 35 was not a surgical candidate. MD 2 felt ethically it would not be appropriate to operate on Patient 35. Additionally, felt Patient 35 had a poor prognosis and a poor outcome. Patient 35 would likely be left with language problems and already had a hemispheric stroke. MD 2 stated he “would not have surgery done to any of my family member if they had this injury”. MD 2 further stated he was not rejecting the patient and stated, “It was an easy surgery....It was an ethical dilemma.” Review of the Hospital policy titled, “[Organization Name] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy”, effective 9/25/2018, directed, “... It is also the policy [Organization Name] to accept emergency transfers from other facilities if the individual being transferred requires Specialized Capabilities that are not offered or not immediately available at the transferring hospital provided that the [Organization Name] hospital has the Capacity and Capability to treat the individual.” The policy defined, “...Capability means the physical space, equipment, supplies, and services including ancillary services available at the hospital”, and, “...Capacity means the ability of the hospital to accommodate an individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, and equipment and the hospital’s past practices of accommodating additional patients in excess of its occupancy limits.” Review of the Hospital policy titled,”Inter-Facility Transfer”, approval date 1/27/22, stipulated, “...Inter-facility transfers are necessary to provide patient’s access to specialized providers or higher level of care/services at an appropriate unit/facility ....When a patient requires a higher level of care other than that available/provided at the sending facility, a receiving facility with capability and capacity to provide a higher level of a care may not refuse the request for transfer.” Review of the Hospital document titled, “Memorandum of Understanding for Transfers Between [Hospital A and Hospital B],” dated 3/29/2019, indicated ... “[Hospital B] provides certain emergency, trauma and other clinical services including but not limited to neuro-surgery ... which may be required by, or suited for patients at [Hospital A]; and because of either a lack of available personnel ... or services ... [Hospital A] from time to time request the transfer of patients to [Hospital B] to receive appropriate care.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 39700 Based on interview, record review, and personnel file review, the hospital failed to ensure the effective delivery of nursing services to provide safe, quality care for 1 of 20 sampled patients (Patient 1) when: The hospital failed to ensure a Registered nurse (RN 1) was adequately trained and competent to provide nursing care to meet the specialized needs of a patient (Patient 1) assigned to their care, when RN 1 did not safelyly discharge Patient 1 from the Emergency Department (ED). RN 1 was on his second day post orientation and did not receive safe discharge training. Patient 1 was brought to the ED by ambulance with paperwork from his board and care residence showing he had a conservator (a legal representative that makes sure a person has adequate food, clothing, shelter, and medical/dental care). Patient 1 had a history of dementia (loss of thinking ability) and anoxic (lack of oxygen) brain injury. RN 1 discharged Patient 1 home alone, barefoot, and without transportation to his board and care. Patient 1 never made it to his board and care residence, and Patient 1 was found two days later unresponsive and covered in feces and vomit at a nearby parking lot. Patient 1 was then brought back to the ED by paramedics, suffered a heart attack, and died in the Intensive Care Unit (ICU) the next day. (Refer to A0397) This failure adversely affected the health and safety of Patient 1 and contributed to Patient 1’s death. The cumulative effect of these failures resulted in the hospital’s inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 39700 Based on interview, record review, and personnel file review, the facility failed to ensure Registered Nurse (RN) 1 was adequately trained and competent to provide nursing care to meet the specialized needs for one of 20 sampled patients (Patient 1) assigned to their care, when RN 1 did not safely discharge Patient 1 from the Emergency Department (ED). This failure adversely affected the health and safety of Patient 1 and contributed to Patient 1’s death. Findings: Review of Patient 1’s Physician Orders for Life-Sustaining Treatment (POLST) form dated 3/4/2022 indicated Patient 1 had a legally recognized decision maker to make medical decisions upon Patient 1’s behalf. Review of Patient 1’s Physician Report For Residential Care Facilities For The Elderly (RCFE) dated 3/4/2022 indicated Patient 1 lived at a board and care residence. The report further indicated Patient 1 had a conservator. Review of Patient 1’s face sheet indicated Patient 1 was admitted to the ED on 4/16/2024 at 3:38 a.m. The document further indicated Patient 1 was disabled with a conservator (a legal representative that makes sure a person has adequate food, clothing, shelter, and medical/dental care). Review of Patient 1’s ED Physician Notes dated 4/16/2024 indicated Patient 1 was brought into the ED by ambulance with a complaint of knee pain. The note further indicated Patient 1 had a long medical history including dementia (loss of thinking abilities) and anoxic (lack of oxygen) brain injury. Review of Patient 1’s ED Discharge Note dated 4/16/2024 indicated Patient 1 was discharged home by RN 1 at 7:55 p.m. The note further indicated Patient 1 had no evident barriers to learning, communicated understanding of the discharge plan of care, and agreed to walk out to go home. Patient 1’s ED medical record did not contain documented evidence of a discharge plan that included an assessment of Patient 1’s mental capacity, ability to care for himself, or had access to transportation. Review of Patient 1’s ambulance report titled “Metro Fire PCR” dated 4/18/2024 at 1:48 p.m. indicated Patient 1 was found unresponsive and laying in the sun at a nearby store parking lot. The report further indicated Patient 1 was transported by paramedics immediately back to the facility’s ED. Review of Patient 1’s ED Physician Notes dated 4/18/2024 at 3:07 p.m. indicated Patient 1 was brought into the ED by ambulance covered in feces and vomit, blood pressure (BP) was 62/25 millimeters of mercury (mm HG, unit of measurement with normal BP between 90/60 to 120/80), heart rate was 140 beats per minute (bpm, unit of measurement with normal between 60 to 100), respiratory rate was 18 breaths per minute (bpm, unit of measurement with normal between 12 to 18), and temperature was 40 degrees Celsius (C, unit of measurement with normal between 36 to 36.8). The note further indicated Patient 1 was intubated (a tube placed through the mouth and into the lungs for breathing) and two rounds of cardio pulmonary resuscitation (CPR, life-saving technique which includes chest compressions and breaths) were performed. Review of Patient 1’s Physician Note dated 4/19/2024 at 7:10 p.m. indicated Patient 1 was admitted to the Intensive Care Unit (ICU) with multi-organ failure. The note further indicated the ICU physician notified Patient 1’s conservator of Patient 1’s poor prognosis. Review of Patient 1’s face sheet dated 4/18/2024 indicated Patient 1 died on 4/19/2024 at 10:07 p.m. Review of the facility reported incident submitted to California Department of Public Health (CDPH) on 4/22/2024 at 4:24 p.m. indicated a 51-year-old gravely (an alarming degree) disabled male (Patient 1) resided at a board and care facility. On 4/16/2024, Patient 1 was transported to the ED for leg pain and discharged. On the morning of 4/17/2024, Patient 1’s caregiver called for a status update and was advised by the operator that Patient 1 was not at the facility. On the morning of 4/18/2024, the caregiver contacted the facility’s ED to advise them Patient 1 had not returned to their board and care. Upon the facility’s immediate review, it was found Patient 1 walked out of the ED unattended. A missing person’s report was filed and an active search was initiated. Patient 1 was found by a bystander unresponsive and lying on the ground with sun exposure, and the bystander called emergency medical services to have Patient 1 transported back to the ED. Upon arrival, the patient was hyperthermic (above normal body temperature), unstable and intubated. He then had a heart attack and was in multiorgan failure. His condition worsened despite mechanical ventilation (breathing machine), blood pressure medications, intravenous (IV, within the vein) fluid resuscitation, and antibiotics (medications for infection). Patient 1 had a poor prognosis and his conservator and family opted to transition his care to comfort care, and Patient 1 died on 4/19/2024 at 10:08 p.m. During an interview with the Director of Quality (DQ) on 4/22/24 at 1:15 p.m., the DQ stated Patient 1 did not have capacity and had the mentality of 4 year old. DQ stated Patient 1 was transported to the facility’s ED from a board and care, and at the time of discharge, Patient 1’s nurse removed his IV, read the discharge instructions to him, and asked what the plan for home was to which Patient 1’s reply was “walk out.” The nurse stated they had no idea Patient 1 was conserved and went to care for another patient, while Patient 1 walked out of the ED. DQ stated the facility video revealed Patient 1 walked throughout the facility and out of the front door barefoot. The board and care home subsequently called for an update, and the facility took action by interviewing staff and watching video footage. Patient 1 was found in the community by a bystander badly sunburned and unresponsive and was transported back to the ED by ambulance. Upon arrival to the ED, Patient 1 was noted to have a very high blood sugar level and severe muscle breakdown. Patient 1 had two episodes of cardiac arrest (heart attacks) during and after intubation, he was placed on four vasopressors (medication to increase blood pressure), and transferred to the ICU. DQ further stated Patient 1’s conservator and family eventually withdrew life support, and he was taken to the operating room for organ recovery (kidney donor) after dying. During an interview with the DQ on 5/7/2024 at 2:30 p.m., DQ stated Patient 1 came to the ED on 4/16/2024 with paperwork from the board and care home The DQ stated RN 1 should have reviewed the paperwork in Patient 1’s chart, and was responsible for discharging the patient back to the board and care with transportation and not allowing the patent to walk out of the ED barefoot. DQ further stated ED nurses are provided a safe discharge checklist during new hire orientation, which is available for nurses to use to help understand the discharge process. During an interview with RN 1 on 5/8/2024 at 3:00 p.m., RN 1 stated the physician’s order was to discharge the patient home with self-care and the patient appeared appropriate to go home by himself at the time of discharge, so RN 1 discharged Patient 1 who walked out of the ED on his own. RN 1 further stated he did not receive training on safe discharges of ED patients during his new hire orientation, and he learned after the incident how Patient 1 should have been discharged safely to a board and care. During an interview with the Clinical Educator Emergency Department (CEED) on 5/8/2024 at 3:30 p.m., CEED stated RN 1 provided care for Patient 1 on RN 1’s second day off of orientation. CEED verified RN 1’s orientation binder was not complete on 4/16/2024, RN 1 did not receive safe patient discharge training until 4/27/2024, and stated RN 1 was not ready to be off of orientation when providing care to Patient 1. Review of the facility’s checklist for safe discharges indicated “A safe discharge begins with an assessment of patient’s baseline status and results in a discharge plan to ensure the patient has access to food, shelter, clothing, and necessary medical after care.” The checklist further indicated the patient must have the mental capacity to make informed decisions, ability to care for themselves, and access to transportation. Review of RN 1’s personnel file training document titled “MSJ-Tip Safe Discharge” indicated the discharge planning process begins as soon as the patient arrives in the ED. The file further indicated a safe discharge is planned using information from assessment information, run sheet (paramedic notes) information, prior admission information, and any discharge history such as a patient’s memory problem. RN 1 acknowledged by signature the training, understanding, and agreement to follow the guidelines on 4/27/2024, which was 11 days after RN 1 discharged Patient 1 from the ED.”