Mission Community Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1.The facility failed to ensure one of 30 sampled patients (Patient 1) received care in a safe setting when the facility ’ s staff failed to conduct every 15 minutes visual (eyesight) check on the patient for 61 minutes. These deficient practices resulted in the patient being discovered unresponsive in his room and a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating) being called. The patient was declared decease (died) on 10/2/2024 at 9:30 p.m. (Refer to A-0144). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“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: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1.The facility failed to develop and implement (carry out) a baseline (starting point) care plan addressing the risk of bleeding for one of 30 sampled patient (Patient 25), who was admitted to the facility with a new onset diagnosis of Atrial Fibrillation (A-fib- a new irregular, often rapid heart rate that commonly causes poor blood flow). This deficient practice had the potential for delayed provision of necessary care and services related to A-Fib, coagulopathy (blood ability to clot is impaired), and Heparin (drug use to prevent blood clots) use for Patient 25. (refer to A-0396). 2.The facility failed to ensure their staff adhered to the policy & procedure (P&P) for “Crash Cart: Restocking and Monitoring,” when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for two (2) of 3 crash carts. This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed. (Refer to A-0398). 3.The facility failed to ensure their staff adhered to the policy and procedure (P&P) for one of 30 sampled patients (Patient 1) when the facility ’ s staff failed to stay with Patient 1 while calling a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating). This deficient practice had the potential to delay life-saving resuscitation (the act of bringing back someone from apparent death or from unconsciousness) measures. (Refer to A-0398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 1) received care in a safe setting when the facility ’ s staff failed to check on the patient for 61 minutes. This deficient practice resulted in Patient 1 being discovered unresponsive in his room and a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating) being called. Findings: During a review of Patient 1 ’ s “Initial Psychiatric Evaluation,” dated 9/26/2024, at 11:21 a.m., the “Evaluation” indicated Patient 1 was admitted to the facility ’ s Behavioral Health Unit (BHU) on a 5150 hold (an involuntary 72-hour hospitalization legal in the state of California when the patient is evaluated to be a danger to others, a danger to themselves, or gravely disabled). During a review of Patient 1 ’ s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 9/26/2024, at 6:21 p.m., the H&P indicated Patient 1 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Patient 1 ’ s “Physician Orders,” dated 9/26/2024, the “Orders” indicated staff must round (staff check on their patient ’ s well-being and safety) on Patient 1 every fifteen minutes. During a review of Patient 1 ’ s “Every 15 Minute Patient Status Report,” dated 10/2/2024, the “Status Report” indicated Mental Health Worker (MHW) 1 rounded on Patient 1 every 15 minutes. MHW 1 documented that they checked on Patient 1 at 8:00 p.m., 8:15 p.m., 8:30 p.m., 8:45 p.m., and 9:00 p.m. During a review of Patient 1 ’ s “Every 30 Minute Patient Status Report,” dated 10/2/2024, the “Status Report” indicated MHW 2 rounded on Patient 1 every 30 minutes. MHW 2 documented that they checked on Patient 1 at 8:00 p.m., 8:30 p.m., and 9:00 p.m. During a review of Patient 1 ’ s “Nursing Progress Note,” dated 10/3/2024, at 12:28 a.m., the “Progress Note” indicated, “[At 8:45 p.m.], [Patient 1] was sitting in the toilet. [Patient 1] was flushing the toilet when [MHW 1] asked him in Spanish, ’ Are you okay? ’ [Patient 1] responded, ’ Yes, I ’ m okay ’ in Spanish. While [Patient 1] was in the toilet, [MHW 1] saw him holding a peanut butter cookie in his hand. [At 9:00 p.m.], [MHW 1] was doing rounds, [Patient 1] was not responding, [Patient 1] was sitting on bathroom floor against the wall by the bathroom door. [Patient 1] was assisted to the floor. CPR (emergency treatment that is done when someone ’ s breathing or heartbeat has stopped) was initiated and code blue was called.” During a review of Patient 1 ’ s “Code Blue” sheet, dated 10/2/2024, the code blue began at 9:05 p.m. Patient 1 was declared dead at 9:30 p.m. During an interview with the Director of Quality/Risk Management (DQRM), on 3/4/2025, at 11:59 a.m., the DQRM stated that they discovered inconsistencies (difference) between what MHW 1 documented on the rounding sheet and what was on the security video. During a concurrent observation and interview with the CNO, the DQRM, and the Director of Behavioral Health Unit (DBHU), on 3/4/2025, at 1:32 p.m., the security footage from 10/2/2024, between 8:00 p.m. to 9:29 p.m., was reviewed. The footage showed the BHU hallway with Patient 1 ’ s room on the left side of the foreground. Patient 1 ’ s room door was closed. The DBHU identified Patient 1 ’ s room. The DBHU identified MHW 1 entering Patient 1 ’ s room at 8:08 p.m. and then leaving. No staff was observed entering Patient 1 ’ s room again until 9:01 p.m., 61 minutes later, when MHW 2 entered Patient 1 ’ s room. MHW 2 then left the room and returned with MHW 1. At 9:03 p.m., both MHW 1 and MHW 2 left Patient 1 ’ s room. The DQRM and the DBHU identified this time as when Patient 1 was found unresponsive. Registered Nurse (RN) 1 arrived at 9:04 p.m. The code team (the team of licensed staff responsible for responding to code blues) arrived at 9:05 p.m. During a review of the facility ’ s policy & procedure (P&P), titled “Patient Status/Precaution Levels – BHU”, last reviewed 2/2022, the P&P indicated, “Level 2 Observation: Patient assessed to be in in MODERATE DANGER of harm to self or others . . . Nursing Action: Precautions Q (every) 15 Min.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to develop and implement a baseline(starting point) care plan addressing the risk of bleeding for one of 30 sampled patients (Patient 25), who was admitted to the facility with a new onset diagnosis of Atrial Fibrillation (A-fib-a new irregular, often rapid heart rate that commonly causes poor blood flow). . This deficient practice had the potential for delayed provision of necessary care and services related to A-Fib, coagulopathy (blood ability to clot is impaired), and Heparin (drug use to prevent blood clots) use for Patient 25. Findings: - During a review of Patient 25s “Facesheet” (undated), Patient 25s Facesheet indicated admission on 2/27/25 with a primary diagnosis of New Onset A-Fib (a new irregular, often rapid heart rate that commonly causes poor blood flow). Other active diagnosis includes failure to thrive ([FTT] a decline in physical and mental functioning), fall, and generalized weakness (a feeling of weakness throughout the body). - During a review of Patient 25s “History and Physical Notes” (H&P), dated 2/28/25 at 11:13 am, Patient 25s H&P indicated the patient had a fall off of the bed while sleeping. It is unknown if the patient hit their head and had a concussion (brain injury cause by blow to the head). The patient has a past medical history of osteoarthritis (the protective tissue at the ends of bones wears down), benign prostatic hyperplasia ([BPH] an enlargement of the prostate gland that can cause difficulty urinating), hypertension (a type of force of blood that affects arteries in the lungs and heart), nephrolithiasis (a small hard stone that forms in the kidneys), mood disorder (psychiatric condition that can cause changes in mood, energy, and behavior), and insomnia (problems falling and staying asleep). Patient 25 was started on Heparin ([an anticoagulant] a medication that prevent or delay blood clotting) for deep vein thrombosis ([DVT] a blood clot in a deep vein, usually in the legs) prophylaxis (action taken to prevent a disease). - During a record review on 3/5/25 at 10:11 am Patient 25s “Care Plan” (undated), indicated Patient 25s Care Plan address wounds, mobility, falls, high blood pressure, and nutrition related to FTT and weakness initiated on 2/28/25 the date of inpatient admission. There is no indication that a care plan addressing the treatment for complications for the admitting diagnosis of A-Fib. During a concurrent interview and record review on 3/5/25 at 2:15 pm with Patient Improvement Manager (PIM), PIM stated no baseline care plan was initiated for Patient 25 addressing the bleeding risk associated with A-Fib. PIM states “I get it”! There should be a care plan to address this patient ’ s risk for bleeding, especially with this being a new diagnosis for the patient and the patient being a risk for falls. PIM states the care plan is important to ensure the patient ’ s safety, provide teaching, identify an appropriate treatment plan, educate the patient, provide an appropriate diet, identify signs and symptoms, and determine if the treatment plan is effectively working. During a review of Patient 25s “Emergency (ER) Template Progress Note”, dated 2/27/25 at 6:54 pm, indicated that Patient 25s electrocardiogram (EKG-test record electrical activity of the heart) showed A-Fib with a ventricular rate (the number of times the heart ’ s lower chambers [ventricles] pump per minute) of 61. An order was placed for continuous cardiac monitoring and admission to the telemetry unit (hospital floor where patient ’ s heart is monitored). During a review of Patient 25s “Laboratory Results” (Labs), dated 2/27/25 at 7:40pm, the labs indicated that Patient 25s test to assess how quickly the blood clots, which includes, prothrombin time (PT-measure how quickly blood clot), international normalized ratio (INR- measure how quickly blood clot) , and activated partial thromboplastin time (aPTT- measure how long it take for the blood to clot after adding a clotting activator) were high. This indicates that blood is taking longer than usual to clot. During a review of Patient 25s “Hematology (study of blood) Oncology (study/treatment of cancer) Consultation Notes”, dated 2/28/25 at 11:04 pm, the consultation notes indicated that Patient 25 had coagulopathy (a condition that prevents the blood from clotting properly) on admission. The plan of treatment includes checking for disseminated intravascular coagulation (a condition affecting the blood ’ s ability to clot and stop bleeding). Repeat labs to be performed in the morning and start Phytonadione ([Vitamin K] used to prevent bleeding in people with blood clotting problems) if the repeat labs continue to be abnormal. During a review of Patient 25s “Cardiology (study of the heart) Consultation Notes”, dated 3/2/25 at 5:15 pm, the consultation notes indicated that a consult was requested for A-Fib, fall, and bradycardia (slow heart rate). The plan of treatment indicates Patient 25 is unlikely a candidate for anticoagulants (medications that prevent or delay blood clotting) given recent fall. Order for echocardiogram (a medical imaging test that creates detailed pictures of the heart). During a review of the facilities policy and procedure (P&P) titled, “Multidisciplinary Plan of Care”, dated 3/2009, reviewed 8/2024, the P&P indicated the purpose is to ensure that care, treatment, and rehabilitation are planned and appropriate to the patient ’ s needs and severity of illness. It also individualizes patient care goals and interventions and to achieve those goals in a collaborative interdisciplinary (combination of multiple fields into one activity) manner. The Registered Nurse (RN) initiates the interdisciplinary care plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the interdisciplinary plan of care throughout the patient ’ s hospital stay.”

“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: 38310 Based on observation, interview and record review: A. The facility failed to ensure their staff adhered to the policy & procedure (P&P) for “Crash Cart: Restocking and Monitoring,” when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for two of three crash carts. This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed. B. The facility failed to ensure their staff adhered to the policy and procedure (P&P) for one of 30 sampled patients (Patient 1) when the facility ’ s staff failed to stay with Patient 1 while calling a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating). This deficient practice had the potential to delay life-saving resuscitation (the act of bringing back someone from apparent death or from unconsciousness) measures. Findings: A. 1.During a concurrent interview and record review with Registered Nurse (RN) 4, on 3/3/2025, at 3:07 p.m., the “Crash Cart Checklist”, dated from 2/16/2025 to 2/28/2025, for the Two (2) South Med/Surg/Telemetry unit (a unit in a hospital where patients undergo continuous heart monitoring) was reviewed. The Checklist indicated that facility staff had checked the Crash Cart on the following days: a.2/16/2025, b. 2/17/2025, c.2/18/2025, d.2/19/2025, e.2/21/2025, f. 2/22/2025, g. 2/23/2025, h. 2/24/2025, i. 2/25/2025, j. 2/26/2025, k. 2/27/2025. There was no documentation that the crash cart was checked on 2/20/2025 or 2/28/2025. RN 4 confirmed that those days were missing and that the Crash Cart should be checked daily during day shift (7 a.m. to 7 p.m.). During an interview with the Chief Nursing Officer (CNO), on 3/3/2025, at 4:09 p.m., the CNO stated the facility ’ s nurses are required to check the Crash Cart a minimum of once per day. During a review of the facility ’ s P&P titled “Crash Cart: Restocking and Monitoring,” last reviewed 1/2023, the P&P indicated, “Crash Cart Checks, Nursing/Technologist Responsibility: Conduct the crash cart check once a shift . . . Complete the Crash Cart Checklist . . . Document on the Crash Cart Checklist - ’ Unit Closed ’ - for any shift the unit is not providing service and/or is not staffed.” 2. During a concurrent interview and record review with the Director of Med/Surg/Telemetry (DMST), on 3/3/2025, at 3:07 p.m., the “Crash Cart Checklist”, dated from 2/16/2025 to 2/28/2025, for the three (3) North Tower Med/Surg/Telemetry unit was reviewed. The Checklist indicated that facility staff had checked the Crash Cart on the following days: a. 2/16/2025, b. 2/17/2025, c. 2/18/2025, d. 2/19/2025, e. 2/20/2025, f. 2/21/2025, g. 2/24/2025, h. 2/25/2025, i. 2/26/2025, j .2/28/2025. There was no documentation that the crash cart was checked on 2/22/2025, 2/23/2025, or 2/27/2025. The DMST confirmed that those days were missing, and that the crash carts should be checked daily. During an interview with the Chief Nursing Officer (CNO), on 3/3/2025, at 4:09 p.m., the CNO stated the facility ’ s nurses are required to check the Crash Cart a minimum of once per day. During a review of the facility ’ s policy and procedure (P&P) titled “Crash Cart: Restocking and Monitoring,” last reviewed 1/2023, the P&P indicated, “Crash Cart Checks, Nursing/Technologist Responsibility: Conduct the crash cart check once a shift . . . Complete the Crash Cart Checklist . . . Document on the Crash Cart Checklist - ’ Unit Closed ’ - for any shift the unit is not providing service and/or is not staffed.” B. During a review of Patient 1 ’ s “Initial Psychiatric Evaluation,” dated 9/26/2024, at 11:21 a.m., the “Evaluation” indicated Patient 1 was admitted to the facility ’ s Behavioral Health Unit (BHU) on a 5150 hold (an involuntary 72-hour hospitalization legal in the state of California when the patient is evaluated to be a danger to others, a danger to themselves, or gravely disabled). During a review of Patient 1 ’ s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 9/26/2024, at 6:21 p.m., the H&P indicated Patient 1 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Patient 1 ’ s “Nursing Progress Note,” dated 10/3/2024, at 12:28 a.m., the “Progress Note” indicated, “[At 9:00 p.m.], [MHW 1] was doing rounds, [Patient 1] was not responding, [Patient 1] was sitting on bathroom floor against the wall by the bathroom door. [Patient 1] was assisted to the floor. CPR was initiated and code blue was called.” During a review of Patient 1 ’ s “Code Blue” sheet, dated 10/2/2024, the code blue began at 9:05 p.m. Patient 1 was declared dead at 9:30 p.m. During a concurrent observation and interview with the CNO, the DQRM, and the DBHU, on 3/4/2025, at 1:32 p.m., the security footage from 10/2/2024, between 8:00 p.m. to 9:29 p.m., was reviewed. The footage showed the BHU hallway with Patient 1 ’ s room on the left side of the foreground. Patient 1 ’ s room door was closed. The DBHU identified Patient 1 ’ s room. The DBHU identified MHW 1 entering Patient 1 ’ s room at 8:08 p.m. and then leaving. No staff was observed entering Patient 1 ’ s room again until 9:01 p.m., 61 minutes later, when MHW 2 entered Patient 1 ’ s room. MHW 2 then left the room and returned with MHW 1. At 9:03 p.m., both MHW 1 and MHW 2 left Patient 1 ’ s room. The DQRM and the DBHU identified this time as when Patient 1 was found unresponsive. Registered Nurse (RN) 1 arrived at 9:04 p.m. The code team (the team of licensed staff responsible for responding to code blues) arrived at 9:05 p.m. In the same interview, on 3/4/2025, at 1:32 p.m., the DBHU confirmed that someone should have stayed with Patient 1 while the other person went to call the code blue. The CNO also confirmed that one person should have stayed to begin CPR. During a review of the facility ’ s policy and procedure (P&P) titled “Code Blue,” last reviewed 1/2025, the P&P indicated, “Any hospital staff member who becomes aware of an individual who is breathless and pulseless shall initiate the EMS (emergency response) system and provide BLS (basic life support) until CODE BLUE TEAM arrives . . . Staff immediately initiates CPR by placing victim on back board or firm surface and using bag/mask/valve.””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure that the medical record was complete by including the consulting (expert advice) provider ’ s (a person who help people) documentation for one of 30 sampled patients (Patient 11). This deficient practice had the potential to negatively impact patient care by delaying or preventing the implementation of medical interventions outlined by the consulting provider. Findings: During a review of Patient 11 ’ s “Face Sheet” (front page of the chart that contains a summary of basic information about the patient), dated 9/27/2024, at 5:43 p.m., the “Face Sheet” indicated Patient 11 was admitted to the facility on 9/20/2024 and discharged from the facility on 9/27/2024. During a review of Patient 11 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 9/20/2024, at 7:49 p.m., the H&P indicated Patient 11 was admitted to the facility for right groin and abdominal cellulitis (a skin infection that causes swelling and redness). During a review of Patient 11 ’ s “CPOE Orders” (Computerized Physician Order Entry, an electronic medical record technology that allows physicians to enter orders, medications, or procedures directly into the computer), dated 9/21/2024, at 11:55 a.m., the order indicated Physician 1 consulted Physician 2 to evaluate Patient 11 for possible surgical intervention. During a concurrent interview and record review with the Performance Improvement Coordinator (PIC), on 3/5/2025, at 9:28 a.m., Patient 11 ’ s electronic medical record (EMR) was reviewed. The PIC stated she was unable to find Physician 2 ’ s consultation notes in the EMR. During an interview with the Director of Medical Records (DMR), on 3/5/2025, at 9:31 a.m., the DMR stated she was also unable to find Physician 2 ’ s consultation notes in the EMR. The DMR further stated that the physician needs to write a consultation note in the medical record when they are consulted, otherwise there is no proof that the physician came to see the patient. During a review of the facility ’ s policy and procedure (P&P) titled “Chart Completion and Analysis,” last reviewed 9/2024, the P&P indicated, “Consultations: Must be ordered by the referring physician. The consultation should take place within two days of request . . . It must be dated, timed, and authenticated within 14 days of discharge.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure one (1) of 30 sampled patients (Patient 5) was informed of his Patient Rights (subset of human rights). This deficient practice resulted in Patient 5, not being informed of his rights as a patient in the hospital, during hospital admission, which may affect Patient 5’s ability to participate in his care and treatment. (Refer to A-0117) 2. The facility failed to ensure one (1) of 30 sampled patients (Patient 5), Patient 5 and/or the patient’s family member received information on Advance Directives (AD - a written document that outlines a person’s choices about the treatments to receive or not to receive, and who will make healthcare decisions for the person should the person become incapacitated and unable to express their wishes), upon admission to the facility, in accordance with the facility’s policy and procedure regarding Advance Directives. This deficient practice had the potential for Patient 5’s wishes and desires regarding care Patient 5 would prefer to receive not being followed. (Refer to A-0132) 3. The facility failed to ensure two (2) of 30 sampled patients (Patients 1 and 11)were provided care in a safe setting when: 3.a. The facility’s process of verifying, identifying, and monitoring visitors entering the facility, including all ambulance and/or transport services transporting the patients in and out of the facility, were not implemented that resulted in Patient 1, instead of Patient 2, mistakenly picked up by the ambulance service and transported from the facility to a Skilled Nursing Facility (SNF - a place where people can receive medical treatments and rehabilitation after being hospitalized; nursing home) without the facility’s staff knowledge. This deficient practice resulted in Patient 1, who was admitted to the facility to rule out stroke and was on a cardiac monitor , was unsafely transported out of the facility. In addition, this deficient practice had the potential for other patients, who are admitted in the facility, who are unable to communicate, and being actively treated and monitored, be mistakenly transported out of the facility. (Refer to A-0144) 3.b. The Behavioral Health Unit (BHU, a specialized unit that provides mental health care for patients with serious and unstable psychiatric symptoms, including those at risk for harming themselves or others) was not free from sources of ligatures (any object or point that can be used to tie or bind something to a structure/fixture to create a point of attachment for self-harm or suicide) when Patient 11, who was admitted in the BHU for suicidal ideation, made a four feet long white fabric rope like material from his bedsheet linen, by ripping the edge of the sheet apart. This deficient practice resulted in Patient 11 and all the other patients in the BHU especially those who had suicidal ideation (thoughts of harming themselves), had access with an item classified as ligature that can be a danger to self (DTS) and/or danger to others (DTO), which may result in self harm or harm to others. (Refer to A-0144) 4. The facility failed to ensure one (1) of four (4) sampled patients (Patient 24), who was placed on a 4-point physical restraint (a type of restraint that restricts a patient’s movement by securing their wrists and ankles to a bed frame while they are lying down), had a physician order for restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). This deficient practice had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints for Patient 24’s, which may lead to complications such as skin breakdown (a break in the skin), strangulation, etc. (Refer to A-0168) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of harming themselves or harm others.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 42937 Based on observation, interview and record review, the facility’s Governing Body failed to ensure: 1. Security Program, identify and manage security risks of third-party transportation service that enters and remove patient from care for one of 30 sampled patients (Patient 1), in the Medical Surgical Telemetry Unit ([MST], a type of intermediate care setting with more advanced monitoring than a typical Med Surg floor) unit, who was removed out of patient care and transferred out of the hospital without hospital awareness, physician order, or patient consent. This deficient practice resulted in Patient 1’s, who was on cardiac monitor to rule out stroke, unsafe removal and transport out of the facility. In addition, this deficient practice had the potential for other patients, who are unable to verbally communicate, who are admitted in the inpatient units being actively treated and monitored, be removed and transported out by an unverified and unidentified Transport Service Company. 2. Nursing Services, in the behavioral health unit ([BHU], specialized unit for inpatient treatment of individuals with psychiatric conditions), followed established policies and procedures for the safety of one of 30 sampled patients (Patient 11), in the BHU, who was observed with a rope like item made from patient’s top sheet linen, that is identified to be a ligature point (any environmental point that could be used to affix a ligature-that is, a noose or other strangulation device for purposes of self-harm or harm to others). This deficient practice had the potential to result in the Top sheet linen used in the BHU, to become a source of ligature point as demonstrated by Patient 11, making it (top sheet linen) accessible to the behavioral patients who are classified as danger to self (DTS) and danger to others (DTO), which may result in self harm, harm to other patients, visitors and staff. Findings: 1. During an interview on 8/20/2024 at 12:21 p.m., with the Director of Risk and Quality (DRQ), the DRQ stated Patient 1, who presented to the Emergency Department (ED) on 4/25/24 with left arm weakness and left facial numbness, was admitted to the MST unit to rule out stroke (blood flow to the brain is cut off due to a clot). On 4/25/24 around 6:00 p.m., a transport service company arrived at the facility to transport Patient 2 to a skilled nursing facility. The transport service company mistakenly took Patient 1, instead of Patient 2, and left the facility with Patient 1. The DRQ stated the security camera video on 4/25/24 revealed that the two (2) transport personnel, who transported Patient 1 out of the facility, were not wearing transport service company uniform and had no ID badges. One way of identifying risk is during environment of Care (EOC) rounds ([EOC] rounds are inspections that ensure the safety of patients, staff, and visitors in healthcare facilities), which security is part of. Security should have identified that there was no clear process for verifying transport service personnel that comes through the emergency department entrance. During an interview on 8/20/2024 at 12:21 p.m., with the Director of Risk and Quality (DRQ), the DRQ stated Patient 1, who presented to the Emergency Department (ED) on 4/25/2024 with left arm weakness and left facial numbness, was admitted to the MST (medical-surgical-telemetry) unit to rule out stroke (a medical emergency that occurs when blood flow to the brain is cut off). The DRQ also stated on 4/25/2024 around 6:00 p.m., a transport service company arrived at the facility to transport Patient 2 to a skilled nursing facility (nursing home). The transport service company mistakenly took Patient 1, instead of Patient 2, and left the facility with Patient 1. The DRQ stated the security camera video on 4/25/24 revealed that the two (2) transport personnel, who transported Patient 1 out of the facility, was not wearing transport service company uniform and had no ID badges. During a review of Patient 1’s History and Physical (H&P - the most formal and complete assessment of the patient and the problem), dated 4/25/2024, the H&P indicated Patient 1 was admitted to the facility to rule out stroke. Patient 1’s medical history included pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). During a review of Patient 1’s nursing notes, dated 4/24/2024, the notes indicated the following: -At 5:08 p.m., Patent 1 was received from the Emergency Department and was admitted to medical-surgical/telemetry unit. -At 6:10 p.m., nurse (RN 1) received a call from the monitor technician (healthcare staff that observes the heartbeats and EKG of patients) that Patient 1’s cardiac monitor (a heart monitor - a device that records your heart rate and rhythm, just like an EKG) had no signal. -At 6:15 p.m., nurse (RN 1) went to Patient 1’s room and found that the patient was not in the room. The Nurse (RN 1) called the charge nurse to see if there was a bed change for Patient 1. The charge nurse reported no bed change for Patient 1. Other nurses stated they saw the “paramedics” (a healthcare professional trained in the medical model to respond to emergency calls for medical help) took Patient 1 out of patient’s room and off the unit.. Nurse went to ED to try find the ambulance transport services and Patient 1, however the Patient 1 left the hospital with the ambulance transport services. The House Supervisor was notified, called the ambulance transport company to return Patient 1 back to the facility. -At 7:27 p.m., ambulance transported Patient 1 back to the facility. During an interview on 8/20/2024 at 2:39 p.m., with the Director of Security (DOS), the DOS stated, on 4/24/2024, two of the staff personnel from the transport service company came and picked up Patient 1 by mistake and transported out of the facility. The DOS stated the Security Department was responsible for securing the facility and controls access of patient, visitor, vendors and employees. The DOS stated the Security Department did not keep a log of Transport Company coming and entering into the facility. The SOD stated Transport Company personnel were directed by Security Staff 1 (SS 1) to go to the nursing unit and speak with the nursing staff on the floor. During an interview on 8/20/2024 at 3:01 p.m., with the DRQ, the DRQ stated on the review of the security camera video on 4/24/24, the video revealed that the Transport Service Personnel did not check in with the nurses in the nursing station prior to picking up Patient 2 for transport. The DRQ stated Patient 1 was mistakenly picked up by the Transport Service instead of Patient 2. In the same interview on 8/20/2024 at 3:01 p.m., the DRQ stated, based on her investigation, the MST nursing staff present on the day of incident confirmed that the Transport Service personnel did not verify the patient’s information (Patient 2) and presented documentation authorizing the transport of the patient (Patient 2) with the nursing staff. The DRQ stated as a result, the Transport Service personnel picked up the wrong patient (Patient 1) and Patient 1 was transported out of the facility without notifying the nursing staff. The DRQ stated the Transport Service personnel were able to enter the facility into the MST unit, took the wrong patient (Patient 1) and transported out of the facility without the nursing staff knowledge. During an interview on 8/20/2024 at 3:48 p.m., with Security Staff 1 (SS 1), SS 1 stated two Transport Service Personnel walked in the ED entrance on 4/25/2024 between 7-8 PM, Identified them by their van and uniform, they did not present ID badges. Did not verify their identity, nor was a call placed to the nursing station to verify the patient’s name from the transport service personnel, or if patient was supposed to be transported out. Of the (2) Transport service personnel, only 1 spoke English, both spoke Armenian. They were instructed to go to Admitting/ Registration window in the ED for verification. Provided transports service drivers directions to the nursing floor. During an interview on 8/21/2024 at 9 a.m., with the DRQ, the DRQ stated the facility did not have any policies and procedures (P&P) for transporting patients or ambulance transportation. During a review of facility’s P&P titled, “General Information,” dated 06/2023, the P&P indicated the following: -Sensitive Areas of the hospital include pharmacy department, emergency department, behavioral health department, intensive care unit, medical records department, information technology department, and materials management department. -Sensitive Areas are areas that are monitored by security department to maintain a safe and secure workspace. -Security officers are to inspect hospital areas for potential problems. -Visitors will be screened by security officers using a metal detector and/or by checking all visitor belongings, at the main hospital lobby. Visitors will check in at the front desk, using the Visitor Pass System, by entering their information to obtain a visitor pass, prior to entering the hospital. During a concurrent interview and record review, on 8/23/2024 at 6:14 p.m., with the Chief Executive Officer (CEO), the meeting minutes for the “Meeting of the Board of Directors”, from January 2023 - April 2024. CEO stated that the incident involving Patient 1 is more of a security concern than patient transfer process. Security department is responsible in identifying and managing security risk. Security Director (SD) reports to Vice President of Business Development (VPBD), VPBD reports to CEO. Any security concern brought up by VPBD will be reported out by CEO to GB. In the past year since the incident involving patient 1, it was never brought to GB that the process for transport service company picking up patient had a security risk. A review of Security Management Plan, dated 9/2021, indicated the following: 1. Security program is designed to identify and manage security risks of the environments of care. 2. Security is a system made up of human assets and technology. 3. Visible and clandestine components of the system are used to reduce the potential for criminal activity, the threat of workplace violence, and to increase feelings of security among patients, staff, and other visitors. 4. Initial and ongoing assessment of security threats is essential for timely identification of changes in the types of security threats. 5. Staff awareness is security is an essential part of an effective security program. 6. The governing board receives regular reports of the activities of the Security Department from Environment Of Care (EOC) committee meetings. 7. The leadership receives regular reports of the activities of the Security Program and collaborates with facility leadership and other appropriate staff, to address security issues and concerns. 8. Facility leadership works under the general direction of the CEO. Facility leadership is responsible for managing the Security Program. Facility leadership and/or Security designee develops reports to the Environment Of Care (EOC) committee. 9. Department managers are responsible for orienting new staff members to the department with ongoing training in patient safety. 10. Department managers are responsible for participating in the reporting and investigation of incidents occurring in their departments. 11. Staff members are responsible for learning the following job and tasks, including specific procedures in security operations. 12. The security management plan includes procedures and controls to minimize the potential that patients, staff, and other visitors, to the hospital, experience an adverse security event. 13. Facility leaders work with department managers, risk management, quality management, and other departments, as appropriate, to resolve identified security risks. 14. All security incidents are reported to security management and recorded on the daily log. 15. Facilities leadership and/or security designee reports incidents involving patients, staff, and/or others within the facility to the Environment of Care Committee, quarterly or more often, as conditions dictate. 16. Annually, the organization evaluates the scope, objectives, performance, and effectiveness of the Security Management Plan, to manage the risks to the staff, visitors, and patients. 17. The findings of the annual review are used to develop the management plan for the following year. The annual evaluation is presented to the EOC committee, for review. A review of the facility’s policy and procedure (P&P) titled “Security Management Plan”, last reviewed date 9/2021, indicated the following: -The Board receives regular reports of the activities of the Security from the EOC Committee. The Board reviews the reports and, as appropriate, communicates concerns about identified issues back to the Director of Security. -The Leadership receives regular reports of the activities of the Security program and collaborates with the Facility Leadership and other appropriate staff to address security issue and concerns. -Facility Leadership works under the general direction of the CEO. Facilities Leadership is responsible for managing the Security Program. Facilities Leadership and/or Security designee develops reports to the EC Committee. The reports summarize organizational experience, performance management and improvement activities, and other security issues. -Department heads are responsible for orienting new staff members to the department and to job and task specific security procedures. The orientation and ongoing train ng emphasis patient safety. Department heads are also responsible for participating in the reporting and investigation of incidents occurring in their departments. -Individual staff members are responsible for learning and following job and task specific procedures for secure operations. 2. During an observation on 8/20/2024 at 9:43 a.m., with the Director of Behavioral Health Unit (DBHU), Patient 11 was observed in the BHU holding a white fabric material rope about 4 feet long and was showing to the health facility surveyors. Patient 11 then dropped the item on the floor. Subsequently, the DBHU picked up the fabric material rope, took it away from patient care area due to the it is classified as a ligature risk item. DBHU stated there should be no line, rope, tubing, shoelace allowed in the unit since they are classified as ligature risk. During an observation on 8/20/2024 at 10:10 a.m., with the DBHU, both the BHU “north unit” and “south unit” patients’ room were observed using the linen sheet as the top sheet for their bed or used as a blanket. During an interview on 8/20/2024 at 3:16 p.m., with the DBHU, the DBHU stated the white fabric material rope that came from Patient 11 was classified as a ligature risk item. The DBHU stated the fabric rope came from the edge of a linen sheet that were used in the patient’s bed in the BHU. The DBHU stated Patient 11 ripped it off from the linen sheet. During an interview on 8/21/2024 at 3:15 p.m., with BHU Charge Nurse 1, BHU Charge Nurse 1 stated when she asked Patient 11 as to why he (Patient 11) ripped the linen sheet and made a ligature rope, Patient 11 told BHU Charge Nurse 1 that it was easy to do. During a review of Patient 11’s “Initial Psychiatric Evaluation,” dated 8/10/2024, the evaluation indicated that Patient 11 is a transgender male, self-identified he was a male-female, was a drug addict and homeless. The evaluation further indicated that Patient 11 went to ED (Emergency Department) voluntarily and verbalized that he was suicidal with a plan to overdose. Patient 11 has a history of schizoaffective bipolar (have psychotic symptoms, such as hallucinations and delusions, mood disorder, feature with bout of mania and depression), extremely paranoid, labile, hostile, and threatening. Per DBHU on 8/20/24 at 9:43 am, Patient 11 was voluntary admitted to BHU and was put on every 15 minutes check by the mental health worker. During record review of nursing note dated 8/20/2024 at 2:56 p.m. by registered nurse 11 that patient 11 was purposely making the ligature risk rope. During a concurrent interview and record review, on 8/23/2024 at 5:39 p.m., with the Chief Executive Officer (CEO), the meeting minutes for the “Meeting of the Board of Directors”, from January 2023 - April 2024. CEO stated that the governing body (GB) meets every other month. The meeting agenda will cover Quality Reports, Finance, Risk, Patient Satisfaction, Legal and CEO report. GB has the general oversight of the entire hospital operation, patient care and safety. The facility’s way of Identifying ligature point in BHU is assessed and monitored by the Environment of Care (EOC) Team. The Team would do rounds in BHU and identify any possible ligature points that may be of safety risk to patient in the BHU population. If a ligature point is identified it will be immediately address by EOC team. Any identified ligature risk or safety concern in BHU will be included in the Quality Report in the GB meetings. In the past year it was never brought to GB that the top sheet linen may be a ligature point to BHU patients. A review of the facility’s policy and procedure (P&P) titled “Security Management Plan”, last reviewed date 9/2021, indicated the following: -The Environment of Care (EOC) poses unique security risks to the patients served, the employees and medical staff who use and manage it, and to others who enter the environment. The Security Program is designed to identify and manage the security risks of the environments of care operated Seton Medical Center and Seton Medical Center Coast Side. The specific risks are identified by conducting and maintaining a proactive assessment process. -Identification security risks associated with the environment of care -Facilities Leadership performs proactive risk assessments to identify risks that create the potential for personal injury of staff or others or adverse outcomes of patient care. The purpose of the risk assessments is to gather information that can be used to develop procedures and controls to minimize the potential of adverse events affecting staff, patients, and others. -Facilities Leadership works with department managers, Risk Management, quality Management, and others as appropriate to resolve risks identified. A review of the BHU Safety Risk and Environmental Assessment (SREA), dated 10/25/2022, indicated that the hospital establishes and maintains a safe, functional environment. (Focus on elimination of ligature risk and anything that might be used as a weapon. SREA indicated the assessment area including nursing station, supply room/locked door on the unit, charting/doctor dictation rooms, medication room, visitor area, dining area, outdoor patio, TV room, patient room, patient bathroom, and seclusion room. Per DBHU on 8/20/2024 at 3:16 p.m., charge nurses make mandatory rounds every shift to interview each patient to assess for any incident issue or allegation while MHW concurrently performs “sweeps (search for patient room including bathroom, flip over the mattress, look at the shelves, bathroom)” for contraband, issues or concern.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure one (1) of 30 sampled patients (Patient 5) was informed of his Patient Rights (a subset of human rights such as the right to considerate and respectful care). This deficient practice resulted in Patient 5 and/or patient’s family, not being informed of his rights in the hospital, during hospital admission, which may affect Patient 5 or patient’s family’s ability to participate in his care and treatment. Findings: A review of Patient 5’s face sheet (a document that provides healthcare providers with quick access to a patient’s information, including name, address, date of birth, insurance information, and emergency contact information), dated 7/29/2024, indicated a diagnosis (the process of identifying a disease, condition, or injury from its signs and symptoms) of Stroke (a medical emergency that occurs when blood flow to the brain is cut off) and Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors), and patient’s spouse was the patient’s emergency contact person. A review of Patient 5’s history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 7/30/2024, indicated the following: 1. History of stroke and Parkinson’s disease. 2. Transferred to facility from another facility. 3. Recent history of acute respiratory failure (difficulty breathing) During a concurrent observation and interview on 8/19/2024, at 3:50 p.m., during an initial tour of the facility, with Director of medical-surgical-telemetry unit on the 2nd floor, Patient 5 was observed awake and alert, non-verbal, while lying in bed with feeding tube and with bedside nurse (RN 1), in the room. RN 1 stated patient had a history of a stroke and Parkinson’s, and patient’s (Patient 5) wife and daughter visited the patient regularly. During a concurrent interview and record review on 8/22/2024, at 3:59 p.m., with the Manager of Information Technology (MIT), Patient 5’s Conditions of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), dated 7/29/2024, was reviewed. MIT stated Patient 5 and/or patient’s family did not sign that a copy of Patient Rights that was provided and/or received by the patient and/or patient’s family. MIT stated on Patient 5’s COA, facility staff indicated that Patient 5 was unable to sign. Concurrently, MIT stated that Patient 5’s family member could have signed the COA for the patient, who was unable to sign, during admission. A review of facility’s Condition of Admission (COA) policy, dated 5/2024, indicated the following regarding COA: 1. Establishes the conditions under which a patient is admitted to the hospital for services. 2. Documents the relationship between the patient and the hospital, the patient’s consent to hospitalization and routine services, and documents financial responsibility for payment of hospital charges for services rendered. 3. Provides important information to the patient regarding the legal relationship between the hospital and physician, including the availability of financial assistance, and information related to Advance Directives, concerning healthcare decisions. 4. Page 1 documents the patient’s consent for medical, surgical, and hospital procedures, nursing care, participation in medical education/teaching programs, legal relationship between hospital and physician, personal valuables, assignment of insurance benefits, financial agreement, and patient rights. 5. A signed COA will be completed for every patient encounter. 6. The COA must be signed, dated, and timed by the patient or their legal guardian/representative, and the hospital employee witnessing their signature. 7. If the patient is unable to sign at the time of admission, the COA should be noted and the medical record should contain documentation that reflects why the patient is incapable of signing. 8. An appropriate signature will be obtained when the patient, the guardian, or legal representative have been identified.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure one (1) of 30 sampled patients (Patient 5), Patient 5 and/or the patient’s family member, received information on Advance Directives (AD - a written document that outlines a person’s choices about the treatments to receive or not to receive, and who will make healthcare decisions for the person should the person become incapacitated and unable to express their wishes), upon admission to the facility, in accordance with the facility’s policy and procedure regarding Advance Directives. This deficient practice had the potential for Patient 5’s wishes and desires regarding care not being followed. Findings: During a concurrent observation and interview on 8/19/2024, at 3:50 p.m., during an initial tour of the facility, with Director of medical-surgical-telemetry unit on the 2nd floor, Patient 5 was observed awake and alert, non-verbal, while lying in bed with feeding tube and with bedside nurse (RN 1), in the room. RN 1 stated patient had a history of a stroke and Parkinson’s, and patient’s (Patient 5) wife and daughter visited the patient regularly. A review of Patient 5’s face sheet (a document that provides healthcare providers with quick access to a patient’s information, including name, address, date of birth, insurance information, and emergency contact information), dated 7/29/2024, indicated a diagnosis of Parkinson disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5’s history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 7/30/2024, indicated Patient 5 was transferred from another facility and was admitted to the facility for acute respiratory failure (difficulty breathing). During a concurrent interview and record review on 8/22/2024, at 3:59 p.m., with the Manager of Information Technology (MIT), MIT stated Patient 5’s AD Screening Form, dated 7/29/2024, was not filled out. The MIT stated the facility was unable to assess if Patient 5 had prepared an AD nor if Patient 5 received written information regarding an AD. Concurrently, MIT stated Patient 5 and/or patient’s family did not sign that a copy of Patient Rights that was provided and/or received by the patient and/or patient’s family. MIT stated on Patient 5’s COA, facility staff indicated that Patient 5 was unable to sign. Concurrently, MIT stated that Patient 5’s family member could have signed the COA and provided information regarding AD, for the patient, who was unable to sign, during admission. A review of facility’s Condition of Admission (COA) policy, dated 5/24, indicated the following regarding COA: 1. Establishes the conditions under which a patient is admitted to the hospital for services. 2. Documents the relationship between the patient and the hospital, the patient’s consent to hospitalization and routine services, and documents financial responsibility for payment of hospital charges for services rendered. 3. Provides important information to the patient regarding the legal relationship between the hospital and physician, including the availability of financial assistance, and information related to Advance Directives, concerning healthcare decisions. A review of facility’s policy and procedure (P&P) titled, “Advance Directives,” dated 10/2022, indicated the following: 1. Social worker or Guest Relations representative shall be called for questions regarding the validity of the AD, requests for new or need to revise an AD, conflicts between patient, family, physicians, and/or others regarding AD, and assistance in obtaining a completed AD. 2. Upon all transfers, the nursing Transfer Summary will include patient’s AD status. 3. Pre-admitting staff is responsible for providing written information to adult patients regarding AD, when and wherever the patient is admitted. 4. Nurse or Social worker is responsible for providing information to the patient and/or patient’s representative (if patient lacks the capacity to make decisions) that facility may decline to comply with patient’s AD. 5. Unit secretary is responsible for asking for patient’s AD and placing a copy of patient’s AD in the patient’s medical records. 6. Social worker is responsible for providing AD information to the patient and/or patient’s representative, if they want information regarding AD.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure two (2) of 30 sampled patients (Patients 1 and 11) were provided care in a safe setting when: 1. The facility’s process of verifying, identifying, and monitoring visitors entering the facility, including all ambulance and/or transport services transporting the patients in and out of the facility, were not implemented that resulted in Patient 1, instead of Patient 2, mistakenly picked up by the ambulance service and transported from the facility to a Skilled Nursing Facility ( a facility that provides skilled nursing care and other related health services) without the facility’s staff knowledge. This deficient practice resulted in Patient 1, who was admitted to the facility to rule out stroke and was on a cardiac monitor, was unsafely transported out of the facility. In addition, this deficient practice had the potential for other patients, who are admitted in the facility, who are unable to communicate, and being actively treated and monitored, be mistakenly transported out of the facility. 2. The Behavioral Health Unit (BHU, a specialized unit that provides mental health care for patients with serious and unstable psychiatric symptoms, including those at risk for harming themselves or others) was not free from sources of ligatures (any object or point that can be used to tie or bind something to a structure/fixture to create a point of attachment for self-harm or suicide) when Patient 11, who was admitted in the BHU for suicidal ideation, made a four feet long white fabric rope like material from his bedsheet linen, by ripping the edge of the sheet apart. This deficient practice had resulted in Patient 11 and all the other patients in the BHU especially those who had suicidal ideation (thoughts of harming themselves), had access with an item classified as ligature that can be a danger to self (DTS) and/or danger to others (DTO), which may result in self harm or harm to others. On 8/21/2024, at 6:04 p.m., the survey team called an Immediate Jeopardy (IJ - a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) situation in the presence of the Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Chief Transformation Officer, Director of Quality/Risk (DRQ), and Vice President of Clinical Transformation (VPCT). 1. The facility failed to provide a safe environment for: a. Patient 1 who was the wrong patient that was picked up by ambulance transport service and taken to a skilled nursing facility. b. Patient 11 who was a psychiatric patient, in the behavioral health unit (BHU - a hospital area that provides mental health care for patients with serious and unstable symptoms, including those at risk for harming themselves or others), who made a ligature (any object or point that can be used to tie or bind something to a structure/fixture to create a point of attachment for self-harm or suicide) from his bedsheet. 2. The facility failed to: a. Establish a proper process of verifying, identifying, and monitoring visitors entering the hospital, including all ambulance and/or transport services who entered the patient care area of the hospital, without notifying the nursing services, and picked up the wrong patient. b. Maintain a psychiatric unit (BHU) free from sources of ligatures by failing to provide a safe environment and failing to reduce ligature risk in all patient care areas. The IJ removal Plan indicated the following: 1. The plan of action indicated: a. All visitors, including ambulance transport staff, to be registered using an electronic identification system, to be screened by security, to be logged in logbook, to verify documents for picking up patients for transportation services, and to verify the correct patient is being picked up from the nursing unit; Nursing services are notified by security that ambulance transport services arrived to pick up patient, and nursing services to verify correct patient to be picked up by ambulance transport services. b. Ligature risk items were removed from Patient 11; all top sheet linens, which was the source of ligature, were removed from BHU; all BHU staff, including housekeeping staff, were in serviced regarding new linen procedure; director of BHU implemented every 30-minute (Q30) rounds, in addition to every 15-minute (Q15) rounds. 2. The plan of action included: a. In service for all security staff and nursing staff regarding ambulance transportation for patients discharged from the hospital; electronic identification system in emergency department for all visitors, including ambulance transport staff; security department verifying identity of transport drivers and documents from ambulance transport company; security department to notify nursing unit of arrival and verification of ambulance transport services to pick up discharged patients; nursing services to verify identify of patients discharged to ambulance transport services. b. In service for all BHU staff, including housekeeping, regarding new linen procedure; removal of top sheet linens from BHU; Q30 minute rounding of all BHU patients, in addition to Q15 minute rounds. On 8/23/2024, at 7:21 p.m., IJ was removed in the presence of CNO, CEO, CTO, DRQ, and VPCT, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review while onsite. Findings: 1. During an interview on 8/20/2024 at 12:21 p.m., with the Director of Risk and Quality (DRQ), the DRQ stated Patient 1, who presented to the Emergency Department (ED) on 4/25/24 with left arm weakness and left facial numbness, was admitted to the MST unit to rule out stroke (blood flow to the brain is cut off due to a clot). The DRQ also stated on 4/25/2024 around 6:00 p.m., a transport service company arrived at the facility to transport Patient 2 to a skilled nursing facility. The transport service company mistakenly took Patient 1, instead of Patient 2, and left the facility with Patient 1. The DRQ stated the security camera video on 4/25/24 revealed that the two (2) transport personnel, who transported Patient 1 out of the facility, were not wearing transport service company uniform and had no ID badges. During a review of Patient 1’s History and Physical (H&P - the most formal and complete assessment of the patient and the problem), dated 4/25/2024, the H&P indicated Patient 1 was admitted to the facility to rule out stroke. Patient 1’s medical history included pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). During a review of Patient 1’s nursing notes, dated 4/24/2024, the notes indicated the following: -At 5:08 p.m., Patent 1 was received from the Emergency Department and was admitted to medical-surgical/telemetry unit. -At 6:10 p.m., nurse received a call from the monitor technician (healthcare staff that observes the heartbeats and EKG of patients) that Patient 1’s cardiac monitor had no signal. -At 6:15 p.m., nurse went to Patient 1’s room and found that the patient was not in the room. The Nurse called the charge nurse to see if there was a bed change for Patient 1, but charge nurse did not report a bed change for Patient 1. Other nurses stated they saw the “paramedics (first responders who evaluates people with illnesses/injuries, provides emergency medical care, and helps transport people to hospitals) (“ took Patient 1 . Nurse went to ED to try find the ambulance transport services and Patient 1, however Patient 1 had left the hospital with the ambulance transport services. The House Supervisor was notified, called the ambulance transport company to return Patient 1 back to the facility. -At 7:27 p.m., ambulance transported Patient 1 back to the facility. During an interview on 8/20/2024 at 2:39 p.m., with the Director of Security (DOS), the DOS stated, on 4/24/2024, two of the staff personnel from the transport service company came and picked up Patient 1 by mistake and transported out of the facility. The DOS stated the Security Department was responsible for securing the facility and controls access of patient, visitor, vendors and employees. The SOD stated the Security Department does not keep a log of Transport Company coming into the facility. The SOD stated Transport Company personnel were directed by Security Staff 1 (SS 1) to go to the nursing unit and speak with the nursing staff on the floor. During an interview on 8/20/2024 at 3:01 p.m., with the DRQ, the DRQ stated on the review of the security camera video on 4/24/2024, the video revealed that the Transport Service Personnel did not check in with the nurses in the nursing station prior to picking up Patient 2 for transport. The DRQ stated Patient 1 was mistakenly picked up by the Transport Service instead of Patient 2. The DRQ also stated, based on her investigation, the MST nursing staff present on the day of incident confirmed that the Transport Service personnel did not verify the patient’s information (Patient 2) and presented documentation authorizing the transport of the patient (Patient 2) with the nursing staff. The DRQ stated as a result, the Transport Service personnel picked up the wrong patient (Patient 1) and Patient 1 was transported out of the facility without notifying the nursing staff. The DRQ stated the Transport Service personnel were able to enter the facility into the MST unit, took the wrong patient (Patient 1) and transported out of the facility without the nursing staff knowledge. During an interview on 8/20/2024 at 3:48 p.m., with Security Staff 1 (SS 1), SS 1 stated two Transport Service Personnel walked in the ED entrance on 4/25/2024 between 7-8 p.m., Identified them by their van and uniform, they did not present ID badges. Did not verify their identity, nor was a call placed to the nursing station to verify the patient’s name from the transport service personnel, or if patient was supposed to be transported out. Of the (2) Transport service personnel, only 1 spoke English, both spoke Armenian. They were instructed to go to Admitting/ Registration window in the ED for verification. Provided transports service personnel directions to the nursing floor. During an interview on 8/21/2024 at 9 a.m., with the DRQ, the DRQ stated the facility did not have any policies and procedures (P&P) for transporting patients or ambulance transportation. During a review of facility’s policy and procedure (P&P) titled, “General Information,” dated 06/2023, the P&P indicated the following: -Sensitive Areas of the hospital include pharmacy department, emergency department, behavioral health department, intensive care unit, medical records department, information technology department, and materials management department. -Sensitive Areas are areas that are monitored by security department to maintain a safe and secure workspace. -Security officers are to inspect hospital areas for potential problems. -Visitors will be screened by security officers using a metal detector and/or by checking all visitor belongings, at the main hospital lobby. Visitors will check in at the front desk, using the Visitor Pass System, by entering their information to obtain a visitor pass, prior to entering the hospital. A review of Patient 1’s nursing notes, dated 4/24/2024, indicated the following: 1. At 11:56 a.m., patient came to the ED (Emergency Department) with complaint of left arm numbness and dizziness, while driving. A code Stroke was activated. Patient was sent for computed tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan and an intravenous line (IV - a soft flexible tube placed inside a vein, to give a person medicine or fluids) was started. Blood was drawn for laboratory tests. Patient was placed on a heart monitor (a device that records the electrical activity of the heart). A neurologist (a medical doctor who specializes in diagnosing, treating, and managing disorders of the brain) was consulted. Patient was given aspirin (a common drug for relieving minor aches, pains, and fever; used as a blood thinner). 2. At 12:03 p.m., an electrocardiogram (EKG - a quick, non-invasive test that measure the electrical activity of the heart to detect is a patient has signs of a heart condition) was done. 3. At 5:08 p.m., patient was received from the ED and admitted to medical-surgical/telemetry unit. 4. At 5:35 p.m., patient was given dinner tray. 5. At 5:55 p.m., patient was observed eating dinner. 6. At 6:10 p.m., nurse received a call from monitor technician (healthcare staff that observes the heartbeats and EKG of patients) that the monitor had no signal. 7. At 6:15 p.m., Nurse went to patient’s room and patient was not in the room and patient’s bed was clean. Nurse called the charge nurse to see if there was a bed change for Patient 1. Other nurses stated observed “paramedics” take the wrong patient (Patient 1). Nurse went to ED to find ambulance transport services and Patient 1, but they had already left the hospital. Nurse called house supervisor and informed the house supervisor of the incident, who took over the situation. Nurse received a call from Patient 1’s wife and notified nurse that Patient 1 was with ambulance transport service. Nurse updated supervisor with phone call from Patient 1’s wife. Supervisor called the ambulance transport company to return the wrong patient (Patient 1) back to the hospital. 8. At 7:27 p.m., ambulance transport returned the wrong patient (Patient 1) to the hospital and to the same room. Nurse assessed patient and took patient’s vital signs. 9. At 8:23 p.m., security began investigation regarding incident with ambulance transport drivers picking up the wrong patient (Patient 1). Nurses were interviewed and reported that ambulance transport drivers did not speak English - spoke Armenian. A review of facility’s 24-hour Administrative Report, dated 4/25/2024, indicated the following: 1. Patient 1, in room 223-A, was missing. 2. Charge nurse and manager were notified. 3. Ambulance pickup up the wrong patient. 4. Ambulance drivers could not speak English - drivers spoke Armenian. 5. Patient 1 does not speak English - patient spoke Spanish. 6. Ambulance drivers did not check in with nursing staff on the nursing unit and did not check Patient 1’s arm band with their paperwork. 7. Ambulance drivers took Patient 1 off the floor, in a stretcher - picked up the wrong patient. 8. The correct patient was in another room, room 204. 9. House supervisor (author of note) was notified and notified facility’s administration. 10.Nursing unit manager called Patient 1’s family and physician. A review of facility’s security guard schedule, dated 4/25/2024, indicated security officer (SO) 1 was assigned to the emergency department. 2. During an observation on 8/20/2024 at 9:43 a.m., with the Director of Behavioral Health Unit (DBHU), Patient 11 was observed in the BHU holding a white fabricrope-like material about 4 feet long and was showing to the health facility surveyors. Patient 11 then dropped the item on the floor. Subsequently, the DBHU picked up the fabric material rope, took it away from patient care area due to the it is classified as a ligature (a binding material or object can be used for self-harm or suicide) risk item. Concurrently, DBHU stated the fabric he picked up was a ligature risk, but he did not know how the patient (Patient 11) got it. During an observation on 8/20/2024 at 10:10 a.m., with Director of BHU, of both the BHU “north unit” and “south unit,” patients’ room were observed using the linen sheet as the top sheet for their bed or used as a blanket. During an interview on 8/20/2024 at 3:16 p.m., with the DBHU, the DBHU stated the white fabric material rope that came from Patient 11 was classified as a ligature risk item. The DBHU stated the fabric rope came from the edge of a linen sheet that were used in the patient’s bed in the BHU. The DBHU stated Patient 11 ripped it off from the linen sheet. During an interview on 8/21/2024 at 3:15 p.m., with BHU Charge Nurse 1, BHU Charge Nurse 1 stated when she asked Patient 11 as to why he (Patient 11) ripped the linen sheet and made a ligature rope, Patient 11 told BHU Charge Nurse 1 that it was easy to do. During a review of Patient 11’s “Initial Psychiatric Evaluation,” dated 8/10/2024, the evaluation indicated that Patient 11 is a transgender male, self-identified he was a male-female, was a drug addict and homeless. The evaluation further indicated that Patient 11 went to ED (Emergency Department) voluntarily and verbalized that he was suicidal with a plan to overdose. Patient 11 has a history of schizoaffective bipolar (have psychotic symptoms, such as hallucinations and delusions, mood disorder, feature with bout of mania and depression), extremely paranoid, labile, hostile, and threatening. Per DBHU on 8/20/2024 at 9:43 a.m., Patient 11 was put on every 15 minutes check by the mental health worker. During a record review of nursing note dated 8/20/2024 at 2:56 p.m. and documented by Registered Nurse 11, the nursing note indicated, Patient 11 was purposely making the ligature risk rope. A review of the BHU Safety Risk and Environmental Assessment, dated 10/25/2022, indicated that the hospital establishes and maintains a safe, functional environment. (Focus on elimination of ligature risk and anything that might be used as a weapon. Per DBHU on 8/20/24 at 3:16 pm, charge nurses make mandatory rounds every shift to interview each patient to assess for any incident issue or allegation while MHW concurrently performs “sweeps (search for patient room including bathroom, flip over the mattress, look at the shelves, bathroom)” for contraband, issues or concern.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure one (1) of four (4) sampled patients (Patient 24), who was placed on a 4-point physical restraint (a type of restraint that restricts a patient’s movement by securing their wrists and ankles to a bed frame while they are lying down), had a physician order for restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). This deficient practice had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints for Patient 24’s, which may lead to complications such as skin breakdown (a break in the skin), strangulation (compression of the neck that may lead to death), etc. Findings: During a review of Patient 24’s History and Physical (H&P), dated 8/13/2024, the H&P indicated Patient 24 presented to ED (Emergency Department) for altered mental status, pneumocystis carinii pneumonia ([PCP] is a fungal infection of the lungs caused by the yeast-like fungus), and Tuberculosis ([TB]) a bacterial infection caused by Mycobacterium tuberculosis that can spread through the air when an infected person coughs, sneezes, or spits). During a concurrent interview and record review on 8/22/2024 at 9:39 a.m. with the Director of ED (DED), Patient 24’s Electronic Medical Record (EMR) indicated that Patient 24 was placed on a 4-point physical restraint on 8/13/2024 from 2:00 p.m. to 4:20 p.m. The DED stated there was no documented evidence a restraint was ordered for Patient 24 on 8/13/24. The DED stated it was the facility’s policy and procedure (P&P) that a restraint order from a provider must be obtained prior to applying restraint. During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion (involuntary confinement of a patient in a room),” revised date of 4/2023, the P&P indicated the following: -Restraint/Seclusion Orders...The attending physician must be consulted as soon as possible if restraint or seclusion is required but has not been ordered by an admitting physician. The attending physician is responsible for the management and care of the patient. -When the attending physician is unavailable and has delegated responsibility for a patient to another physician, then the covering physician is considered the attending physician. The order will include the specific reason for restraint/seclusion, the type of restraint, location of restraint and specified time period for use. -Only a physician, nurse practitioner, physician assistant, or licensed psychologist may order restraint/seclusion as determined by hospital policy.”

“MEDICAL STAFF RESPONSIBILITIES - UPDATE CFR(s): 482.22(c)(5) [The bylaws must:] [Include a requirement that --] (ii) An updated examination of the patient, including any changes in the patient’s condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration, and except as provided under paragraph (c)(5)(iii) of this section. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 3) received a pre-surgical assessment (a health check that ensures a patient is fit and well enough to undergo an operation) by the surgeon performing the patient’s surgery, prior to surgery. This deficient practice had the potential for Patient 3 having complications and/or prolonged hospitalization due to changes in patient’s condition not identified, since patient’s last history and physical. Findings: During an interview on 8/21/2024, at 12:06 p.m., with the Director of Risk and Quality (DRQ), DRQ stated Patient 3 came to the hospital from a skilled nursing facility on 7/16/2024, and fell on the floor, without witnesses, on 7/19/2024, and fractured (break in the bone) the hip. During a concurrent interview and record review on 8/22/2024, at 12:35 p.m., with the Manager of Information Technology (MIT) and the DRQ, Patient 3’s Operative Report (a report in a patient’s medical record to document the details of a surgery) and Post-Operative Report (hand-written operative report), dated 7/22/2024, were reviewed. DRQ stated there was no documentation that the surgeon (MD) 1 did a pre-surgical assessment, prior to Patient 3’s surgery. Concurrently, DRQ stated MD 1 should have done a pre-surgical assessment to ensure the history and physical (H&P) were reviewed, that there were no adverse changes in Patient 3’s condition, since patient’s last H&P, prior to surgery. A review of facility’s Medical Staff General Rules and Regulations, dated 6/26/2018, indicated the following: 1. Pre-surgical assessments must be documented in the patient’s medical record and include information pertaining to the basic nature of the proposed surgery and the condition for which it is to be done, including medical, anesthesia, and medication history. 2. Pre-surgical assessment must include the patient’s physical status, diagnostic information, risks and benefits of the surgery to be performed, and the need to administer blood components. 3. An update within 24 hours of surgery must be completed, and must include a statement of the patient’s problem, physical findings, allergies, evaluation of the patient’s heart rate, respiratory rate, and blood pressure. A review of Patient 3’s face sheet (a document that provides healthcare providers with quick access to a patient’s information, including name, address, date of birth, insurance information, and emergency contact information), dated 7/16/2024, indicated patient was admitted to the hospital with a diagnosis of new seizures (a sudden, temporary change in the brain’s electrical and chemical activity that causes uncontrolled body movements and changes in behavior). A review of Patient 3’s emergency department (ED) physician note, dated 7/16/24, indicated the following: 1. Patient had two witnessed seizures in the skilled nursing facility (SNF - nursing home) and was brought to the ED. 2. Physical examination indicated patient was alert and oriented to self, was calm and cooperative. 3. Patient had an electrocardiogram (EKG - a quick, non-invasive test that measure the electrical activity of the heart to detect is a patient has signs of a heart condition) with abnormal results and was placed on continuous cardiac monitoring. 4. Patient had a computed tomography scan (CT - an imaging test that helps detect diseases and injuries) of the head and the CT report indicated no active bleeding. 5. Plan to admit patient to telemetry unit (a hospital floor that provides constant cardiac monitoring for patients, using a portable device to monitor a patient’s heart, breathing, and oxygen levels). A review of Patient 3’s history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 7/16/2024, indicated the following: 1. Patient had a history of new seizures at the SNF and was brought to the ED. 2. Physical examination and laboratory tests were done. 3. Impressions - no evidence of bleeding in the brain from CT scan of the head. 4. Neurology (a medical doctor who specializes in diagnosing, treating, and managing disorders of the brain) consultation was requested. 5. Patient was admitted to telemetry unit (a hospital floor that provides constant cardiac monitoring for patients, using a portable device to monitor a patient’s heart, breathing, and oxygen levels) for further management and follow-up. A review of Patient 3’s nursing notes, dated 7/19/2024, at 5:43 p.m., indicated the following: 1. Patient had an unwitnessed fall, with bed alarm on. 2. Patient was found on the floor, lying on the left side, and complained of hip pain. 3. No bruises and no skin discoloration. 4. Physician was notified and ordered a CT of the head and x-ray of pelvis (area of the body below the abdomen, including the hip bones). 5. X-ray results indicated broken left hip. 6. Physician consulted with Orthopedic surgeon (MD) 1 and ordered intravenous (into the vein) fluids and nothing-by-mouth (NPO - no drinks and no food taken) after midnight, in preparation for surgery. 7. Patient was moved to another room, near the nursing station, and was assigned a one-to-one sitter (staff that are immediately at hand to help prevent a patient from falling). A review of Patient 3’s nursing notes, dated 7/20/2024, indicated MD 1 was called and notified facility to place patient NPO after midnight on 7/21/2024 because patient is scheduled for surgery on 7/22/2024. A review of Patient 3’s Intra-operative Case Report, dated 7/22/2024, indicated the following: 1. Pre-operative diagnosis - left hip fracture (broken). 2. Patient in operating room (OR - location where surgical procedures are performed) at 8:59 a.m. 3. Patient out of the OR at 10:03 a.m. 4. Patient received general anesthesia (medicine you get before surgery that require you to be in a deep sleep-like state, which is given by a physician who specializes in anesthesia). 5. Primary surgeon was MD 1. A review of Patient 3’s Operative Report (a report in a patient’s medical record to document the details of a surgery), dated 7/22/2024, indicated the following: 1. Pre-operative diagnosis (problem) - left hip fracture. 2. Anesthesia - general 3. Patient tolerated surgery well, without any complications. 4. Patient transferred from OR to post-anesthesia recovery.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure for six (6) of 30 sampled patients (Patients 3, 20, 21, 22, 25, and 26) the following: 1. Patient 3’s nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for Risk for Falls, was evaluated, updated and/or revised, after Patient 3 fell and sustained injury. 2. Patient 20’s nursing care plan for risk of bleeding was was not developed in accordance with the facility’s policy and procedure (P&P). 3. Patient 21’s nursing care plan for acute pain was reviewed and updated every shift in accordance with the facility’s P&P. 4. Patient 22’s nursing care plan for risk for falls was reviewed and updated every shift in accordance with the facility’s P&P. 5. Patient 25’s nursing care plan for risk for impaired skin integrity was reviewed and updated every shift in accordance with the facility’s P&P. 6. Patient 26’s nursing care plan for risk for infection was reviewed and updated every shift in accordance with the facility’s P&P. These deficient practices had the potential to result in the delayed provision of care to the patients (Patients 3, 20, 21, 22, 25, and 26) by not reviewing and identifying the patients’ needs and risks. Findings: 1. During a concurrent interview and record review on 8/22/2024, at 11:11 a.m., with the Manager of Information Technology (MIT), The MIT stated Patient 3’s care plan on “Risk for Fall,” dated 7/16/2024, indicated the following: Patient 3’s Care Plan, Risk for Falls was related to, indicated an incident when patient fell and sustained injury, a fractured left hip on 7/22/2024. Care plan for Outcome indicated for patient to remain free from falls and free of injuries, since initiation on 7/16/2024. Concurrently, during interview with Clinical Educator (CE), CE stated the RN should have closed out the care plan, Risk for Falls, dated 7/16/2024, and created another care plan for Patient 3, after the patient fell on 7/22/2024 for Actual Fall not anymore for Risk for Fall. 2. During a concurrent interview and record review, on 8/23/2024 at 2:00 p.m., with the Performance Improvement Manager (PIM), Patient 20’s electronic medical record (EMR) indicated that on 8/16/2024, Patient 20 was presented in the emergency department (ED) with a chief complaint of coffee-ground hematemesis (vomiting blood) which contained blood clots 30 minutes prior to arrival in the ED. Patient 20 was hypotensive (blood pressure was lower than normal) with a blood pressure of 81/26 millimeters of mercury (mmHg, a unit of measurement) and was positive for stool occult blood test (test for checking hidden blood in the stool). During a concurrent interview and record review on 8/22/2024 at 4:00 p.m. with Director of Med Surg, the Director of Med Surg stated Patient 20’s record had no care plan developed for risk of bleeding. During a record review of the facility’s policy and procedure (P&P) titled, “Multidisciplinary Plan of Care,” reviewed in 10/2022, the P&P indicated the following: -The Registered Nurse initiates the Interdisciplinary Care Plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the patient’s hospital stay. -All entries on the Interdisciplinary Plan of Care will be dated, identified for discipline, initialed then full name and signature recorded at the end of the document. -The Plan of Care will be reviewed every shift and updated as patient progress indicates. 3. During a review of Patient 21’s electronic medical record (EMR), the EMR indicated that on 8/18/2024, Patient 21 was seen in the emergency department (ED) with chief complaint of right shoulder and right chest pain which started after he rolled out of his bed and landed on the right side of his body. Patient 21’s imaging confirms humerus (upper arm bone) fracture (broken bone). Patient 21’s pain was managed by taking Norco (a combination medication used to relieve moderate to severe pain) and Tramadol (pain relief medication use to treat moderate to severe pain after an operation or a serious injury). During a concurrent interview and record review, on 8/22/2024 at 10:10 a.m., with Nurse Clinical Educator (NCE), Patient 21’s “Nursing Care Plan (NCP) Flowsheet - Acute Pain” with activation date of 8/18/2024 was reviewed. The NCP Flowsheet had no documentation that the plan was reviewed or updated by nursing staff since the NCP was activated on 8/18/2024. In the same interview on 8/22/2024 at 10:10 a.m., the NCE concur that the nurses failed to review and update Patient’s 21’s Nursing Care Plan for Acute Pain. The NCE stated it is nursing standard of practice and the facility’s P&P that the patient’s care plan must be develop, updated, and reviewed daily. During a record review of the facility’s P&P titled, “Multidisciplinary Plan of Care” reviewed in 10/2022, the P&P indicated the following: -The Registered Nurse initiates the Interdisciplinary Care Plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the patient’s hospital stay. -All entries on the Interdisciplinary Plan of Care will be dated, identified for discipline, initialed then full name and signature recorded at the end of the document. -The Plan of Care will be reviewed every shift and updated as patient progress indicates. 4. During a review of Patient 22’s electronic medical record (EMR), the EMR indicated that patient 22 was admitted on 8/16/2024, with chief complaint of productive cough. Patient 22’s initial nursing assessment indicated the patient’s (Patient 22) Morse Falls Scale (a Fall Risk. Assessment tool that predicts the likelihood that a patient will fall) score was 60 (A patient who scores higher than 45 points is considered to be at high risk of falling), identifying Patient 22 to be a high risk for fall. During a concurrent interview and record review, on 8/22/2024 at 10:15 a.m., with Nurse Clinical Educator (NCE), Patient 22’s “Nursing Care Plan (NCP) Flowsheet - Risk for Falls”, with activation date of 8/16/2024 was reviewed. The NCP Flowsheet had no documentation that the plan was reviewed or updated by nursing staff since the NCP was activated on 8/16/2024. In the same interview on 8/22/2024 at 10:15 a.m., the NCE concur that the nurses failed to review and update Patient’s 22’s Nursing Care Plan for Fall Risk. The NCE stated it is nursing standard of practice and the facility’s P&P that the patient’s care plan must be develop, updated, and reviewed daily. During a record review of the facility’s P&P titled, “Multidisciplinary Plan of Care” reviewed in 10/2022, the P&P indicated the following: -The Registered Nurse initiates the Interdisciplinary Care Plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the patient’s hospital stay. -All entries on the Interdisciplinary Plan of Care will be dated, identified for discipline, initialed then full name and signature recorded at the end of the document. -The Plan of Care will be reviewed every shift and updated as patient progress indicates. 5. During a review of Patient 25’s electronic medical record (EMR), the EMR indicated that Patient 25, a quadriplegic (paralysis of all four limbs and the torso), was admitted to the facility for needing assistance with personal care. Patient 25’s initial Braden scale (a risk assessment tool that predicts the likelihood of pressure ulcers in patients) score was 12 (Braden total score ranges from 6-23, with lower scores indicating a higher risk of pressure ulcers. A High Risk: Total Score 10-12), identifying Patient 25 to be at high risk for pressure ulcers (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). During a concurrent interview and record review, on 8/22/2024 at 10:20 a.m., with Nurse Clinical Educator (NCE), Patient 25’s “Nursing Care Plan (NCP) Flowsheet - Risk for Impaired Skin Integrity”, with activation date of 6/26/2024 was reviewed. The NCP Flowsheet from 6/27/2024 to 7/5/2024 had no documentation that the plan was reviewed or updated by nursing staff. In the same interview on 8/22/2024 at 10:15 a.m., the NCE concur that the nurses failed to review and update Patient’s 25’s Nursing Care Plan for Impaired Skin Integrity. The NCE stated it is nursing standard of practice and the facility’s P&P that the patient’s care plan must be develop, updated, and reviewed daily. During a record review of the facility’s P&P titled, “Multidisciplinary Plan of Care” reviewed in 10/2022, the P&P indicated the following: -The Registered Nurse initiates the Interdisciplinary Care Plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the patient’s hospital stay. -All entries on the Interdisciplinary Plan of Care will be dated, identified for discipline, initialed then full name and signature recorded at the end of the document. -The Plan of Care will be reviewed every shift and updated as patient progress indicates. 6. During a of Patient 26’s electronic medical record (EMR), the EMR indicated that Patient 26 was seen in the ED on 8/19/2024 with a chief complaint of hip and leg pain. Patient 26 had a computerized tomography ([CT] a type of imaging that uses X-ray techniques to create detailed images of the body) of the left hip which showed signs of septic joint (an infection in the joint synovial fluid and joint tissues). During a concurrent interview and record review, on 8/22/2024 at 10:25 a.m., with Nurse Clinical Educator (NCE), Patient 26’s “Nursing Care Plan (NCP) Flowsheet - Risk for Infection”, with activation date of 8/19/2024 was reviewed. The NCP Flowsheet had no documentation that the plan was reviewed or updated by nursing staff since the NCP was activated on 8/19/2024. In the same interview on 8/22/2024 at 10:15 a.m., the NCE concur that the nurses failed to review and update Patient’s 26’s Nursing Care Plan for Risk Infection. The NCE stated it is nursing standard of practice and the facility’s P&P that the patient’s care plan must be develop, updated, and reviewed daily. During a record review of the facility’s P&P titled, “Multidisciplinary Plan of Care” reviewed in 10/2022, the P&P indicated the following: -The Registered Nurse initiates the Interdisciplinary Care Plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the Interdisciplinary Plan of Care throughout the patient’s hospital stay. -All entries on the Interdisciplinary Plan of Care will be dated, identified for discipline, initialed then full name and signature recorded at the end of the document. -The Plan of Care will be reviewed every shift and updated as patient progress indicates.”

“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: 42937 Based on interview and record review, the facility failed to ensure two of nine employees (Director of Behavioral Health Unit and Registered Nurse 1), whose employee files were reviewed, had completed their required training when: 1. The Director of Behavioral Health Unit (DBHU) did not have a valid Basic Life Support (BLS, a training course designed for healthcare professionals and other personnel who need to know how to perform cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure performed when the heart stops beating] and other basic cardiovascular life support skills) certification as a required qualification for a Director of Nursing position. This deficient practice resulted in an unsafe provision of care. This failure had the potential to result for the patients in a medical emergency situation, received CPR from unqualified licensed nursing staff which may cause harm, injury, or death on the patients. 2. Registered Nurse 1 (RN 1) completed the required facility employee annual training on abuse, restraint, and Health Insurance Portability and Accountability Act (HIPAA, a federal law passed in 1996 that protects patients’ medical information and sets standards for the storage and privacy of personal medical data) for the year... This deficient practice had the potential to result in an unsafe provision of care when a staff, who provides direct patient care, was not trained on how to identify and assess victims of abuse, used of restraints, and HIPAA compliance. Findings: 1. During a concurrent interview and record review, on 8/22/2024 at 2:30 p.m., with the Onboarding Specialist 1 (OS 1), the DBHU’s “Basic Life Support (BLS)” had an expiration date of 2/2024. OS 1 stated the DBHU’s BLS certification was expired since 2/2024 and should have been reviewed prior to 2/2024. OS 1 stated BLS certificate are renewed every 2 years and the DBHU’s BLS certificate should have been renewed before 2/2024. The OS 1 stated, an active BLS certificate was a job requirement, and it is indicated in the Director of Nursing (DON/DBHU) job description as part of the qualification requirement. During a record review of the facility’s job description (JD) titled “Director of Nursing (DON)” dated 7/2016, The JD indicated that one of the qualifications for the DON position was to have a current CPR/BLS. 2. During a concurrent interview and record review, on 8/22/2024 at 2:24 p.m. with the Onboarding Specialist 1 (OS 1), RN 1’s training records titled “CE Credit Summary”, the record indicated the following completed training: Course Name: [Nae of Facility]Restraints and Seclusion NHO/ Annual Training, with a completion date of 9/29/2021. -Course Name: Identifying and Assessing Victims of Elder Abuse and Neglect- Knowledge Q, with a completion date of 9/29/2021. -Course Name: HIPAA (Health Insurance Portability and Accountability Act, establishes standards to protect patients’ medical records) Compliance, with a completion dart of 9/29/2021. OS 1 stated it was part of staff development to assign the staff with courses for ongoing education that may be regulatory required or identified as an educational need. OS 1 stated RN1 failed to complete his annual training on restraint, abuse, and HIPAA which the facility set as an annual education need. During a review of the facility’s policy and procedure (P&P) titled, “Education Plan,” with a reviewed date of 9/2019, the P&P indicated the following: Staff Development...Ongoing education, including in-services, training and other activities are provided to maintain and improve the knowledge and skills of the staff. An educational assessment is completed annually to determine the education needs of the employees, and an educational plan is instituted to meet those needs. The plan follows an organized guide for training yet remains flexible to respond to priority needs or available resources ...”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 46120 Based on observation, interview, and record review, the facility failed to ensure the required posting for patient rights was posted in one (1) of five (5) lobbies (patient waiting room areas) in the hospital (Emergency Department [ED] lobby). The ED lobby had no Patient Rights (the rights of a patient to received good quality care and high professional standards) poster and signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number. The deficient practice resulted in the facility’s failure to ensure patients and patient representatives were informed on patient rights in the hospital and can file a complaint. Findings: On 11/28/2023 at 12:50 P.M., during an observation of the facility ED lobby with the Director of Quality and Risk (DQR), Vice President of Clinical Integration (VPCI), Emergency Department Director (EDD) and Registered Nurse (RN) 6, the ED lobby observed with no posting/signage regarding patient rights and no signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number. The DQR and EDD (both), stated there was no, “Patient Rights” poster in the ED lobby. EDD also stated there was no signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number. Both (DQR and EDD stated the Patient Rights poster and how to file a complaint with CDPH should be posted in the ED lobby. On 11/30/2023, at 2:14 P.M., during an interview with DQR and concurrent record review of facility’s the Conditions Of Admission/ Impatient and Other Outpatient Services (MCH 043), dated 9/17, DQR stated the facility does not have any document on print or policy, including the MCH 043, for patients to file a complaint with CDPH or with the U.S Department of Health and Human Services Office of Civil Rights with corresponding address and phone number. A review of the facility’s policies and procedures titled Patient’s Rights Policy, reviewed date 2/2022, indicated patients must be informed upon admission, in understandable language of their rights while in the hospital. The policy and procedure. The P&P also indicated all documented complaints submitted on the hospital’s complaint form shall be directed to the Nurse Manager. A review of the facility’s brochure titled, “Rights and Responsibilities,” undated, indicated instructions on how to file a grievance with the facility including facility’s phone number and address. The brochure indicated stakeholders have a right to file a complaint with the state Department of Health Services regardless of whether the facility’s grievance process was used but the corresponding address and phone number were omitted.”

“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: 46120 Based on interview, and record review, the facility failed to ensure nursing staffs had competency training and annual evaluation according to facility’s policy and procedure for six (6) of eleven (11) sampled nursing staffs (Chief Nursing Officer [CNO], Emergency Department Director [EDD], Registered Nurse 5 [RN 5], RN 7, Mental Health Worker 1 [MHW 1], MHW 3, and Certified Nursing Assistant 1 [CNA 1]). The deficient practice had the potential for patients not to received proper care from the staffs (CNO, EDD, RN 5, RN 7, MHW 1, MHW 3, and CNA 1). Findings: During concurrent interview with Director of Quality & Risk (DQR) and Human Resources Coordinator (HRC) and record review of the nursing care staff employee files (CNO, EDD, RN 5 and 7, MHW 1 and 3 and CNA), on 11/29/2023, at 11:18 A.M., the DQR and HRC stated the CNO was missing annual competence training for example fall precautions, use of restraints, infection prevention, and the last annual evaluation was done in 2018. Both (DQR and HRC) verified that stated EDD was also missing annual competence training for example, safe patient handling, workplace violence and harassment prevention. Both verified EDD’s last annual evaluation was in 2020 and RN 5 was missing annual evaluations with last evaluation on file done in 2020. HRC verified that RN 7 had the last annual competence training for example medication administration and central line dressing, on 9/2022 and has no annual evaluation on file. HRC verified MHW 1 had one annual evaluation in 2021 which MHW 1 acknowledged with a signature on September 2022 (9 months later). HRC verified that MHW 1 did not have an annual evaluation for 2022. HRC stated CNA 1’s last annual review was in 2021, which CNA 1 acknowledged in September 2022. HRC stated CNA 1 has no annual review for 2022. During a concurrent interview with DQR and HRC, and record review of MHW 3’s employee file, on 11/29/2023, at 11:18 A.M., HRC stated MHW 3 was missing training required by the facility’s MHW job description. HRC verified MHW 3 was missing managing aggressive behavior (MAB) or its alternative, the advanced violence intervention and prevention (AVIP) training. MHW 3’s 2022 annual evaluation was signed or acknowledged by the staff member on 10/16/2023, 10 months later. A review of the facility’s RN job description, indicates RNs were expected to maintain regulatory and mandatory requirements for example licensure, certification, annual safety, and competency assessments, participate in activities that contribute to professional growth and development, assure appropriate completion and participation in/compliance with performance improvement activities. A review of the facility’s MHW job description, MHWs must complete mandatory in-service programs required by the position for instance fire safety, MAB, Cardiopulmonary resuscitation (CPR), infection prevention practices (procedures to stop spread of infections in healthcare facilities) and adhere to institutional policies and procedures. A review of the facility’s CNA job description, indicated CNAs participate in clinical development of self and adheres to facility’s employee relations policies and procedures, participates in department’s continuous quality improvement plan to impact the overall quality of clinical and support services/processes.”