The Medical Center of Aurora & South 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: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a discharged patient was safely returned to their residential care setting in one of one inpatient discharges reviewed. (Patient #2)”

“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: 48269 Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a discharged patient was safely returned to their residential care setting in one of one inpatient discharges reviewed. (Patient #2) Findings include: Facility policy: The Patient Rights and Responsibilities policy read, we adopt and affirm as policy the following rights of patients/clients who receive services from our facility: to receive ethical, high-quality, safe, and professional care without discrimination. 1. The facility failed to ensure a discharged patient was safely returned to their residential care facility. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 was a 65-year-old admitted on 7/19/25 for evaluation of chest pain. The provider’s history and physical revealed Patent #2 had mild cognitive impairment (a slight decline in thinking and memory) and a history of a traumatic brain injury (TBI). Review of resident information provided to the facility by Patient #2’s assisted living facility (ALF) revealed Patient #2 was diagnosed with a major neurocognitive disorder (a significant decline in mental abilities, such as memory, reasoning, or language, which is severe enough to interfere with a person’s independence in daily life) and had a state appointed guardian (a person legally authorized by a judge to make personal, non-financial decisions for someone who cannot care for themselves). Review of a provider’s order placed on 7/21/25 at 7:12 a.m. revealed Patient #2 was to be discharged once their ride had arrived. Review of the case management (CM) report revealed, on 7/21/25, CM was informed by the ALF that Patient #2 could return to the residential care setting. At 10:16 a.m., discharge transportation was arranged by the facility with a company who managed non-emergent medical transportation. At 11:33 a.m., Patient #2’s ALF manager and state-appointed guardian were notified of Patient #2’s discharge. A nurse’s note from 1:00 p.m. revealed the registered nurse (RN) was notified transportation would be at the facility’s main entrance between 12:00 p.m. and 12:30 p.m. The patient’s discharge instructions were reviewed, and Patient #2 was taken to the main entrance. The RN’s note also revealed Patient #2 requested to be left outside the main entrance, and the RN repeated the pickup time, the name of the transportation service, and instructed the patient to stay in the area so they would not miss their ride. This was in contrast to the provider’s order, which read Patient #2 should not have been discharged until their ride had arrived. This was also in contrast to the medical record review, which revealed Patient #2 had a history of a TBI and a major neurocognitive disorder, and failed to reveal an assessment of Patient #2’s capacity to make decisions. The RN’s note further revealed they were notified by the transportation service Patient #2 was not at the entrance when they arrived. The RN went to the main entrance and assisted with a search of the campus for Patient #2, however, Patient #2 was not located. This was in contrast to the Patient Rights and Responsibilities policy, which read, patients had a right to receive safe care. B. Interviews i. On 3/18/26 at 12:18 p.m., an interview was conducted with RN #1. RN #1 stated when a patient was discharged, they walked the patient to the front door and waited with them until they left with their ride. RN #1 stated they would ask another staff member to wait with the patient if they were not able to stay. ii. On 3/19/26 at 9:23 a.m., an interview was conducted with clinical nurse coordinator (CNC) #2. CNC #2 stated staff were expected to wait with the patient until their ride arrived, however, they were not aware of a policy which required staff to wait with the patient. CNC #2 stated they had been trained to wait with the patient. CNC #2 stated there was a risk the patient could end up at an unsafe location if a staff member did not wait to ensure they were safely picked up. Also, CNC #2 stated the facility made changes to the discharge process after Patient #2’s incident. CNC #2 stated shift huddles and meetings were held to discuss safe discharge plans. CNC #2 stated education was provided to the charge nurses to ensure the discharge parameters in the medical record had been met. CNC #2 stated they were educated that this was a final step to ensure a safe discharge plan. iii. On 3/19/26 at 11:32 a.m., an interview was conducted with nurse manager (Manager) #3. Manager #3 stated nurses were allowed to leave a patient to wait for a ride if the nurse had assessed the patient and determined it was safe. This was in contrast to the medical record review for Patient #2, which revealed the patient had a history of a TBI and a major neurocognitive disorder, and failed to reveal an assessment of Patient #2’s decision-making capacity. Manager #4 stated there was not a policy which required staff to wait with the patient until their ride had arrived. Manager #3 stated there was a risk the patient would not make it into the cab unless staff observed the patient get into the vehicle. Manager #3 stated patients left alone at discharge could have wandered into traffic or gotten injured. Additionally, Manager #3 stated education was provided to nursing staff, and increased charge nurse oversight was added to the discharge process. Manager #3 stated discharge parameters were discussed and reviewed at weekly charge nurse meetings to ensure the parameters were met. Manager #3 stated a daily discharge log was also maintained and reviewed. Manager #3 stated there was a monthly meeting with the quality team where discharges were discussed and discharge parameters were monitored for fallouts. Upon request, the facility was unable to provide evidence of the daily discharge log, meetings, education provided to nursing staff, or auditing implemented in response to Patient #2’s incident.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48269 Based on observations, interviews, and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: A-2405: A central log on each individual who “comes to the emergency department,” as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Based on observations, document reviews, and interviews, the facility failed to ensure a central log was maintained on each individual who presented to the dedicated emergency department (ED) for treatment in one of one patients who left the ED without being seen.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48269 Based on observations, document reviews, and interviews, the facility failed to ensure a central log was maintained on each individual who presented to the dedicated emergency department (ED) for treatment in one of one patients who left the ED without being seen. Findings include: Facility policy: The Emergency Medical Treatment and Labor Act (EMTALA) - Central Log policy read, the hospital will maintain a central log containing information on each individual who comes on the hospital campus requesting assistance, or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (MSE) could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. All hospitals must maintain the Central Log in an electronic format. The log must contain at a minimum, the name of the individual and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired. A log entry for all individuals who have come to the hospital seeking medical attention or who appear to need medical attention must be made by the appropriate individual. 1. The facility failed to ensure an individual who sought treatment in the dedicated ED was included in the central log. a. On 3/19/26 at 4:10 p.m., an observation of facility video footage from 12/30/25 at 4:02 a.m. was conducted. Two individuals presented to the ED security and intake desk. One of the individuals appeared to scratch their skin on their neck and on their hand. Also, the individual pulled back their clothing to inspect their skin. The individuals waited while a staff member completed a phone call, and then the individuals had a conversation with the staff member prior to leaving the facility. b. Review of the ED EMTALA (central) log revealed no evidence a patient had presented to the ED for care on 12/30/25, between 2:13 a.m. and 7:02 a.m. c. On 3/19/26 at 9:59 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 confirmed the individuals had presented to the intake desk, and a conversation occurred with the individuals about the current wait time in the ED. PCT #1 stated the individuals decided to leave. Also, PCT #1 stated if a patient chose to leave, the patient’s information was not entered into the central log. d. On 3/19/26 at 2:51 p.m., an interview was conducted with Registrar #2. Registrar #2 stated the patient came to the desk and stated the reason they wanted to be seen. Registrar #2 stated the patient experienced discomfort and had a valid reason to come to the ED. Registrar #2 stated PCT #1 told the individuals the ED was full, they were unsure about the wait time, and they were welcome to go to another hospital. Registrar #2 stated the patient left and was not entered into the central log. This was in contrast to the EMTALA Central Log policy which read, a central log should have been maintained that included information on each patient who requested emergency treatment at the hospital. A log entry for all individuals who came to the hospital seeking medical attention should have been made by the appropriate individual. e. On 3/18/26 at 10:30 a.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated all patients who presented to the ED for care were entered into the facility’s EMTALA log. This was in contrast to the observation of video footage, interviews with PCT #1 and Registrar #2, and review of the EMTALA log for 12/30/25, which revealed the patient who presented to the ED for care at 4:02 a.m. had not been entered into the central log.”

“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: 48269 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance. A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure patients received effective pain management in one of three medical records reviewed. (Patient #2)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48269 Based on document review and interviews, the facility failed to ensure patients received effective pain management in one of three medical records reviewed. (Patient #2) Findings include: Facility policies: The Pain Management policy read, the facility recognizes and supports the rights of all patients to receive appropriate assessment and management of pain via a patient-centric approach. All inpatients will be assessed for the existence and presence of pain upon admission, per unit standard, and as needed. If pain is present, the nature of the pain will be assessed. Using the pain scale based on appropriate age, documentation will include location, intensity, and quality of pain. All patients will be educated on the pain scale based on age, language, and developmental assessment. Functional goals for pain management and progress toward goals will be documented in the inpatient setting each shift. Timely administration of pain medication is provided as prescribed. Reassessment of the effectiveness of pain management interventions is a continuous process. When possible, reassessment is expected approximately 60 minutes after pain medication is administered. The Standards of Care for Assessing/Reassessing Patients policy read, all patients will receive an initial assessment by a registered nurse (RN) and subsequent reassessment, based upon their age, patient care setting, and individual needs. Nursing reassessment for inpatients will occur at a minimum of every 12 hours. Physical assessment for nursing includes: vital signs (VS), diagnosis or signs/symptoms, response to prior treatment, pain (location, quality, and intensity), and more. All patients who experience pain with an intervention for pain must be reassessed following parameters set forth in the Pain Management policy. The Venous Access Device Insertion, Maintenance, and Removal policy read, its purpose was to outline the insertion, access, maintenance, and removal practice expectations for venous access devices (VAD), including peripheral, midline, and central line devices. Peripheral VAD should be changed when clinically indicated based on findings from site assessment or clinical signs and symptoms of complications. Documentation of VAD care will be completed in the Lines, Drains, and Airways section of the electronic health record (EHR). Prompt removal of a VAD should occur when the VAD is no longer needed and must be supported by a provider order. If the VAD is discontinued prior to discharge, and the patient is expected to remain in the care of the facility, approval of the provider, in the form of an order, is needed for the patient to remain without intravenous (IV) access. References: The Adult Line Access Reference Guide read, peripheral IVs are to be flushed with two to three milliliters (mL) of normal saline (NS) every 12 hours and after intermittent drugs or infusions. Transparent dressing changes are to be completed every seven days and as needed. The Patient Rights and Responsibilities brochure read, we adopt and affirm as policy the following rights of patients/clients who receive services from our facility: to appropriate assessment and management of pain. 1. The facility failed to ensure patients received effective pain management and had IV access available in accordance with facility policy. A. Document review i. Patient #2’s medical record was reviewed and revealed Patient #2 was an 80-year-old who arrived at the facility’s emergency department (ED) on 2/11/25 by ambulance with a chief complaint of fatigue and shakiness. Patient #2 was evaluated by the ED provider and sent for a CT scan (special x-rays that provide detailed images of the inside of the body). The medical record revealed the CT scan showed Patient #2 had multiple cancerous lesions of the liver and abdomen. Patient #2 was admitted to the hospital for further care of newly diagnosed metastatic cancer (cancer that had spread from its original location to other parts of the body). Review of Patient #2’s nursing care revealed on 2/18/25, seven days after admission, Patient #2 began to experience increased abdominal pain. At 6:17 p.m., Patient #2 described their pain as constant and a 7 on a scale of 1 to 10, with 10 being the worst pain. Patient #2 was prescribed and given oxycodone (a powerful pain reliever used to manage moderate to severe pain) 5 milligrams (mg) orally. Patient #2 was reassessed at 7:45 p.m., and their pain level had improved to a 5. Patient #2’s medical record also revealed on 2/19/25 at 12:02 a.m., Patient #2 was medicated with oxycodone 5 mg orally for pain described as aching abdominal pain 7 of 10. Patient #2’s nursing documentation revealed they had been reassessed at 2:41 a.m., almost three hours later, and their pain level remained 7 of 10. The record revealed no pain medication was given, and there was no documentation the physician had been notified to obtain additional pain medication orders to alleviate Patient #2’s pain. This was in contrast to the Pain Management policy which read, the effectiveness of pain management interventions should have been reassessed approximately 60 minutes after pain medication had been administered. Further review of the record revealed nursing documentation on 2/19/25 at 7:30 a.m. read, Patient #2’s pain was notably high, 8 of 10. Additionally, the nursing notes read, Patient #2 had no IV access. Documentation revealed the nurse administered oxycodone 5 mg orally at 7:34 a.m. and then prioritized establishing IV access for pain control. The medical record revealed the primary nurse tried twice to insert an IV without success and then asked the charge nurse to start the IV. The record revealed the charge nurse also had difficulty obtaining IV access, so the nurse contacted the ICU charge nurse to assist with getting Patient #2’s IV started. The physician had written an order for IV morphine (a powerful pain medication used to treat severe pain) to be given as soon as IV access had been obtained. This was in contrast to the VAD policy which read, all patients should have had IV access unless there was a physician’s order to remain without IV access. Review of Patient #2’s medical record revealed nursing documentation on 2/19/25 at 2:46 a.m. read, Patient #2 had two VAD in place. One IV site was located in the left posterior forearm and had been placed 2/12/25, seven days earlier. A second IV was located in the right antecubital (front of the elbow) and had been inserted on 2/11/25, eight days previously. Further, documentation revealed the last time an IV medication had been administered was on 2/17/25 at 3:39 p.m. The record revealed no documentation either IV site was patent or had been flushed every 12 hours per facility policy. Finally, the record revealed on 2/19/25 at 8:32 a.m., the nurses were at the bedside with Patient #2, who was in severe pain but had been cooperative while the nursing team attempted to insert an IV. The primary nurse documented Patient #2 suddenly developed a leftward gaze and their breathing became labored. A rapid response was called at 8:36 a.m. The rapid response team arrived at Patient #2’s bedside, and because Patient #2 had a do-not-resuscitate (DNR) order, no resuscitation efforts were initiated. Patient #2 expired at 8:40 a.m. These events were in contrast to the Pain Management policy which read, the facility recognized and supported the right of all patients to receive appropriate assessment and management of pain. B. Interviews i. On 5/8/25 at 10:39 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated during each shift assessment, they took VS, assessed pain, assessed symptoms, and flushed their patients’ IVs. RN #1 stated the IV flush was important to ensure the IV worked in case there was an emergency. RN #1 stated peripheral VAD should have been flushed each shift per policy, but there had been no expectation to document the flushes. Also, RN #1 stated the removal of a VAD should have been documented under the lines, drains, and airways section of the shift assessment. RN #1 stated patients were required to have an IV or a physician order that stated the patient could have remained on the unit without an IV. RN #1 stated the risk to patients in an emergency, if there was no IV access, could have been a delay in receiving treatment with urgently needed IV medications. ii. On 5/7/25 at 10:22 a.m., an interview was conducted with clinical nurse coordinator (CNC) #2. CNC #2 stated they had been at Patient #2’s bedside on the morning of 2/19/25. CNC #2 stated the primary nurse had given oral pain medication and tried two times to put in an IV without success. CNC #2 stated the primary nurse had reached out to the physician for additional pain control medications. CNC #2 stated they also tried two times to get an IV started. CNC #2 stated they could not get the IV started either, so they had called the ICU charge nurse from Patient #2’s bedside to come start the IV. CNC #2 stated they did not know when Patient #2 had lost IV access. CNC #2 and the primary nurse were at Patient #2’s bedside along with a family member. CNC #2 stated Patient #2 was in pain yet conversant and cooperative until a rapid change in condition at 8:32 a.m., at which time they had called a rapid response. CNC #2 stated Patient #2 was a DNR, so the physician who responded stopped resuscitation efforts and pronounced Patient #2 had expired at 8:40 a.m. iii. On 5/7/25 at 12:37 p.m., an interview was conducted with nurse manager (Manager) #3. Manager #3 stated pain assessment should have occurred during shift assessment and as needed if the patient reported pain. Manager #3 stated reassessment of pain should have occurred one hour after oral pain medications had been administered or 30 minutes after IV pain medication had been administered. Also, Manager #3 stated all inpatients should have IV access, and a physician’s order would have been required for a patient to remain without an IV. Manager #3 stated loss of IV access should have been documented in the medical record and passed on in the nursing shift-to-shift report. Manager #3 stated they had not been present on 2/19/25 for Patient #2’s rapid response, nor had they reviewed Patient #2’s medical record. Manager #3 stated the patient advocate team would have completed the review of Patient #2’s care. On 5/8/25 at 11:08 a.m., a second interview was conducted with Manager #3. Manager #3 stated VAD should have been changed every seven days or sooner if needed. Manager #3 also stated VAD should have been flushed before and after giving IV medications or at least once each shift, to ensure the IV was working properly. Manager #3 stated there was no place in the electronic health record (EHR) to document the flushes or that the IV was working. Manager #3 stated peripheral IVs did not have scheduled flushes or documentation in the medication administration record (MAR). Manager #3 stated ensuring IVs were flushed per policy was practice-related, and nurses should have held each other accountable. These interviews were in contrast to the medical record review which revealed no documentation Patient #2’s IV accesses, which were seven and eight days old, had been flushed, replaced, or removed. iv. On 5/7/25 at 4:44 p.m., an interview was conducted with director of acute care (Director) #4. Director #4 stated they were on the unit the morning of 2/19/25 to support the staff during Patient #2’s rapid response. Director #4 recalled they heard the charge nurse say they needed to help start a new IV so they could give Patient #2 IV pain medication. Director #4 stated they were not aware why Patient #2 had no IV access. Also, Director #2 stated they had not done a detailed review of Patient #2’s nursing care. v. On 5/7/25 at 3:45 p.m., an interview was conducted with patient liaison/quality coordinator (Coordinator) #5. Coordinator #5 stated they had been involved with the review of Patient #2’s care. Coordinator #2 stated the nurse manager would have reviewed Patient #2’s record and completed the investigation of nursing care. This was in contrast to Manager #3 and Director #4’s interviews, in which they both stated they had not reviewed Patient #2’s nursing care. On 5/8/25 at 10:12 a.m., a second interview was conducted with Coordinator #5. Coordinator #5 stated, a letter to Patient #2’s family had read, Patient #2 self-removed their IV during the night. However, Coordinator #5 stated they had no documentation to support Patient #2 had self-removed their IV during the night.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45020 Based on interviews and document review, the facility failed to ensure nursing care was provided that met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or monitor and prevent further pressure injury once it was identified in one of three patients reviewed. (Patient #2) Findings include: Facility policies: The Skin Integrity Assessment policy read, a complete head to toe, visual assessment of the skin of each patient is done upon admission to the hospital and reassessed each shift with documentation. Determination of risk for developing pressure injuries is the responsibility of the RN. Assessments with the nursing skin risk assessment scale are performed by RNs every shift. Pressure injuries present on admission or discovered during hospital care are to be photographed. Sequential photographs will be made following any surgical debridement, weekly, and prior to discharge. Physician and Wound/Ostomy Department will be notified whenever there is worsening of wound condition. The Wound Assessment, Management, and Documentation policy read, all wounds, including pressure injuries, will be assessed upon admission or discovery, and with significant changes and upon discharge. Skin assessments are done every shift, or with change in patient’s condition to identify any new wounds in a timely manner. Hospital acquired pressure injuries are reported to physician and wound nurse. The Pressure Injury Prevention policy read, all patients will be assessed for risk of pressure injury on admission, every shift, and with significant change in condition. Appropriate preventive interventions will be implemented. General pressure injury prevention interventions are: Place silicon-coated foam border dressing over sacrum prophylactically. If patient declines to be turned, determine and address issues. Instruct patient and family how lack of repositioning can contribute to skin breakdown, continue to offer to reposition every two hours and document patient’s response every time. The Pressure Ulcer and Prevention And Management policy read, this policy is to identify patients at risk for pressure ulcer development and reduce the incidence of pressure ulcers. To utilize appropriate treatment methodologies in order to resolve and/or prevent further tissue breakdown. A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Definitions of pressure ulcers: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (tissue material made up of dead tissue, pus, and other debris that accumulates on a wound’s surface). Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of tissue loss. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (a hardened layer of dead tissue that can impede healing) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. All patients are assessed for their risk of developing pressure ulcers utilizing the Braden Scale upon admission and during each shift throughout their hospital stay. A total Braden Scale score of 18 or below in an adult patient is considered predictive for development of a pressure ulcer unless preventative measures are taken. Braden Scores will be classified as: Generally not at risk- Greater than 18, At Risk- 15 to 18, Moderate Risk- 13 to 14, High Risk- 10 to 12, Very High Risk- 9 or below. 1. The facility failed to ensure patients at risk of pressure injuries were monitored and had implemented interventions to protect patients’ skin integrity. A. Record review i. The medical record for Patient #2 was reviewed. Patient #2 presented to the hospital on 4/29/24 with shortness of breath, became hypotensive (low blood pressure), and briefly lost pulses. Patient #2 was intubated (insertion of a breathing tube) and admitted to the intensive care unit (ICU) with a diagnosis of sepsis (a life-threatening condition that occurs when the body’s immune system has an extreme response to an infection). ii. Patient #2 was hospitalized from 4/29/24 to 5/19/24, a total of 21 days. On admission to 5/3/24 Patient #2’s skin was noted as intact. On 5/3/24, documentation revealed Patient #2 had a stage 1 pressure injury to the coccyx (the last bone at the bottom of the spine), and a Mepilex (foam dressing) was applied. There was no evidence a Mepilex dressing was applied prior to 5/3/24. This was in contrast to the Pressure Injury Prevention policy which read, appropriate preventive interventions will be implemented. Place silicon-coated foam border dressing over sacrum prophylactically. iii. Review of Patient #2’s medical record revealed the skin risk assessment was not completed for the day shifts on 5/4/24, 5/8/24 and 5/18/24. Patient #2’s skin risk assessment Braden score ranged from 8 (very high) to 18 (at risk) from 4/29/24 to 5/19/24. This was in contrast to the Pressure Ulcer and Prevention And Management policy which read, all patients are assessed for their risk of developing pressure ulcers utilizing the Braden Scale during each shift throughout their hospital stay. iv. Review of Patient #2’s medical record revealed a skin assessment was not performed for the day shifts on 5/5/24 and 5/9/24, or the night shift on 5/15/24. This was in contrast to the Skin Integrity Assessment policy which read, a complete head to toe, visual assessment of the skin of each patient is done each shift with documentation. This was also in contrast to the Pressure Injury Prevention policy which read, all patients will be assessed for risk of pressure injury every shift. v. Review of Patient #2’s medical record revealed on 5/10/24 the pressure injury to the coccyx had advanced to a stage 2. A wound care consult was ordered on 5/17/24 at 6:10 p.m., seven days after the pressure injury had worsened. Medical records revealed the wound care consult did not occur as Patient #2 was discharged on 5/19/24. On 5/19/24 at 11:40 a.m., just prior to discharge, Patient #2’s pressure injury to the coccyx was noted as stage 2 with eschar (hardened, dry, dead tissue), fat, and slough (yellow to white material in a wound bed) with purulent (thick wound drainage) brown drainage noted. This was in contrast to the Wound Assessment, Management, and Documentation policy which read, hospital acquired pressure injuries are reported to physician and wound nurse. This was also in contrast to the Skin Integrity Assessment policy which read, Physician and Wound/Ostomy Department will be notified whenever there is worsening of wound condition. vi. Review of Patient #2’s medical record revealed two photographs were taken of the pressure injury on 5/17/24 and 5/19/24. Patient #2’s stage 1 pressure wound was discovered on 5/3/24 and had advanced to a stage 2 on 5/10/24. The first photograph was taken 14 days after the pressure wound was discovered. This was in contrast to the Skin Integrity Assessment policy which read, Pressure injuries discovered during hospital care are to be photographed. Sequential photographs will be made weekly, and prior to discharge. B. Interviews i. On 10/14/24 at 1:33 p.m., an interview was conducted with wound care nurse (WCN) #1. WCN #1. WCN #1 stated the WCN could be consulted by nurses at any time for pressure wounds of any stage. WCN #1 stated a Mepilex dressing was to be placed on the patient’s coccyx as a preventative measure if the patient’s risk score was high. WCN #1 stated skin assessments were important because there was a risk of infection, sepsis, and death. WCN #1’s interview was in contrast with Patient #2’s medical record which showed the patient did not have a Mepilex dressing applied until a pressure injury was identified, although they scored high risk. ii. On 10/14/24 at 1:51 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated a patient’s skin was to be assessed every shift by the RN which included all bony prominence areas such as the shoulders, heels, and coccyx. RN #2 stated risk scores were to be performed every shift. RN #2 stated high risk patients were turned every 2 hours, a Mepilex dressing was to be placed on the coccyx to prevent pressure injuries. RN #2 stated it was important to prevent pressure injuries because it could cause sepsis and death. iii. On 10/14/24 at 2:09 p.m., an interview was conducted with RN #3. RN #3 stated every patient’s skin was to be assessed, and a risk score was to be performed by the nurse each shift. RN #3 stated if a patient scored high risk on the Braden Scale, the RN was to follow interventions such as applying barrier cream, turning the patient every two hours, and applying a Mepilex dressing to the coccyx. RN #3 stated a wound care consult could be ordered if a pressure wound was present on admission, if a wound had advanced to stage 3, or at any time the nurse felt a consult was necessary. RN #3 stated patients were at risk of infection, organ failure, and death or increased skin breakdown if preventative measures were not implemented.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42693 Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2406: (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital ’ s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) to determine whether or not an emergency medical condition (EMC) existed as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergency medical or psychiatric condition existed for two of three patients reviewed who presented with psychiatric complaints and were discharged.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42693 Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) to determine whether or not an emergency medical condition (EMC) existed as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergency medical or psychiatric condition existed for two of three patients reviewed who presented with psychiatric complaints and were discharged. (Patient #3 and #8). Findings include: Facility policies: The Suicide Precautions Policy read, The purpose of this policy is to provide guidance to assist with the identification of patients in non-Behavioral Health (BH) settings who are at risk for suicide, ensuring a safe environment for the provision of care. Columbia Suicide Severity Rating Scale(C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto calculated level of no risk, low, moderate or high risk. Suicide Detailed Risk Assessment (suicide DRA): Subsequent assessment completed by the Provider/Practitioner. The suicide DRA must be completed for any patient with a positive C-SSRS screen. Overall Risk Level (ORL): Determined by the provider/practitioner’s clinical judgement and suicide DRA. The provider/practitioner will assign a level of no risk, low, moderate, or high risk. This will take precedence over the C-SSRS, if the risk level differs. It is the policy of the facility to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged. Minimum requirement: Patients in non-psychiatric areas (e.g., Emergency Room (ER) and non-BH inpatient units), ages 12 years and older, who are being evaluated or treated for BH conditions as their primary reason for care should be screened using the C-SSRS. The Provider/Practitioner will be notified of positive screens (i.e., at risk patients). The at-risk patient’s (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions. The at-risk patient will be monitored and reassessed, with accompanying documentation daily, when a change in condition occurs, and prior to discharge. An ORL and a personal safety plan must be documented prior to discharge. Suicide prevention information and resource phone numbers will be included in the discharge planning instructions. The EMTALA - Medical Screening Examination and Stabilization policy read, the purpose of this policy is to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. § 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder. An EMTALA obligation is triggered when an individual comes to a dedicated emergency department the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others. Psychiatric QMP: The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presented to the ED with psychiatric or behavioral emergencies. The Health One Crisis Assessment Team - Assessment and Referral Request policy read, assessments will be provided to hospitals and emergency departments who request assistance with the assessment of psychiatric emergencies. 1. The facility failed to perform a medical screening exam (MSE) to assess for a psychiatric emergency. A. Medical record review i. On 6/19/24 at 9:04 a.m., Patient #3 presented to the ED, brought in by the police on an emergency mental health hold (M1 hold), with the chief complaint of suicidal ideation, homicidal ideation, and hallucinations. Patient #3 stated he was being tormented by a poltergeist which was flying around and raping people, including himself. Patient #3 stated he had chronic thoughts of wanting to hurt himself but did not wish to discuss it as he was not going to act on these thoughts. A medical screening evaluation was performed at 9:07 a.m., which read, Psychiatric: depressed mood and guarded affect, no suicidal ideations, no homicidal ideations, chronic auditory hallucination, but does not appear to respond to internal stimuli at this time. The provider who evaluated the patient wrote that the M1 hold was discontinued. Patient #3 was discharged at 10:23 a.m. There was no evidence a psychiatric exam was conducted to determine if Patient #3 was safe for discharge. ii. On 6/1/24 at 7:43 p.m., Patient #8 presented to the ED, brought in by the police with the chief complaint of suicidal ideation. Patient #8 had attempted to run into traffic and had exhibited combative behavior with the police. The patient’s behavior prior to arrival was described as violent, necessitating sedation and physical restraints for safety. At 10:28 p.m., a suicide risk assessment was completed by the registered nurse (RN). The patient revealed the patient has a high risk for suicide. On 6/2/24 at 1:52 a.m., Patient #8 was discharged into police custody. The provider note read the police would place the patient on suicide watch and an evaluation could be completed in jail. There was no evidence a psychiatric exam was conducted in the ED to determine if Patient #8 had an emergency psychiatric condition. The review of Patient #3 and #8’s medical records were in contrast to the EMTALA policy which read, the MSE must be appropriate to the individual’s presenting signs and symptoms. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer. B. Interviews i. On 8/14 24 at 7:32 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated behavior health consults were completed for patients who were suicidal, on a M1 hold, or if a patient requested one. RN #1 stated a risk assessment was to be performed to ensure patient safety and if not performed there was a risk the patient could harm themselves or others. ii. On 8/14/24 at 8:04 a.m., an interview was conducted with RN #2. RN #2 stated health crisis assessment team (HCAT) consults were ordered and performed after a patient was medically cleared for patients who were suicidal, homicidal, or on a M1 hold. RN #2 stated the suicide risk evaluation was performed if a patient stated they were suicidal. RN #2 stated there was a risk of patients harming themselves if the assessment was not performed.. iii. On 8/14/24 at 9:47 a.m., an interview was conducted with RN #3. RN #3 stated the provider determined if a HCAT was needed, and were usually ordered for patients who had suicidal ideations. RN #3 stated if a suicide assessment was not completed for a suicidal patient, the patient may have harmed themselves or others. iv. On 8/14/24 at 9:31 a.m., an interview was conducted with medical doctor (MD) #4. MD #4 stated suicidal ideation was considered an emergent medical condition. MD #4 stated nursing staff performed a self-harm assessment for patients admitted to the ED. The results of the self-harm assessment were discussed with the physician. Physician #4 stated a behavioral health evaluation was performed to ensure patients did not hurt themselves or others and help the clinician decide if outpatient or inpatient therapy is warranted. MD #4 stated there was a risk if patients were not assessed, the severity of an illness might not have been discovered and the patient could have harmed themselves or others.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49541 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144 - The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patients who were on suicide precautions did not have access to excessive linen and other items that could be used to cause harm in five of five observations conducted at the facility. Additionally, the facility failed to ensure patients were monitored for safety and as ordered by the provider in one of five observations conducted at the facility.”

“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: 49541 Based on observations, interviews, and document review, the facility failed to ensure patients who were on suicide precautions did not have access to excessive linen and other items that could be used to cause harm in five of five observations conducted at the facility. Additionally, the facility failed to ensure patients were monitored for safety and as ordered by the provider in one of five observations conducted at the facility. Findings include: Facility policies: The Behavioral Health General Safety Policy read, all corded appliances are stored in a locked cabinet. Patients may use appliances under staff supervision. Patient rounds are done minimally every 15 minutes 24 hours per day. Environmental Rounds will be completed twice a day. The Nurse Manager will determine when the checklist will be done and indicate the responsible person. Anything found during Environmental Rounds that is not in compliance or suggests a safety concern should be reported to the Charge Nurse and then reported to the appropriate designee. The Behavioral Health Levels of Observation and Precautions policy read, all patients are monitored a minimum of once every fifteen minutes. This is documented on the Patient Monitoring Form, including the patient’s location and status/behavior/activity. The Behavioral Health Patient Safety Rounds and Validation policy read, the Clinical Nurse Coordinator (CNC)is responsible for assigning staff to make unit rounds to account for all patients’ whereabouts and ensure a safe environment. If the staff member observes the environment for unsafe conditions or significant behavioral observations of patients they will be reported to the CNC immediately. 1. The facility failed to identify and mitigate ligature risks for patients with suicidal ideations. Additionally, the facility failed to remove contraband that the patient could use for self-harm. A. Observations i. On 7/22/24 at 1:28 p.m., observations were conducted on the adolescent psychiatric unit in room 1010. The observation revealed Patient #1 had six blankets, two fitted sheets, three towels, and two washcloths in their room. Review of Patient #1’s patient monitoring form showed the patient was on 15-minute checks for suicide precautions. Further observations of the adolescent psychiatric unit revealed multiple piles of unsupervised dirty linen in the hallway and patient care areas. ii. On 7/22/24 at 2:10 p.m., observations were conducted on the adolescent psychiatric unit. Observations in the day room revealed a media cabinet unlocked and open. Further observations inside the cabinet revealed multiple electronic cords for media and game systems. iii. On 7/24/24 at 12:45 p.m., additional observations were conducted on the adolescent psychiatric unit day room. Observations in the day room again revealed a media cabinet unlocked and open. Further observations revealed multiple electronic cords for media and game systems. Staff were unable to answer who opened the cabinet and how long it had been open. Staff were also unable to answer if any of the cords were missing. iv. On 7/24/24 at 1:09 p.m., observations were conducted on the adolescent psychiatric unit in room 1006. Observations revealed Patient #1 had been moved from room 1010 to this room, which was closer to the nursing station. Further observations revealed the patient had three blankets in their room. Review of Patient #1’s patient monitoring form showed the patient was on 15-minute checks for suicide precautions. v. On 7/25/24 at 12:39 p.m., observations were conducted on the adult psychiatric unit in room 1016. Observations revealed Patient #2 had a tongue piercing with a silver barbell. Patient #2 stated they were admitted for suicidal ideation and, in prior admissions, they were not allowed to have their tongue pierced for their safety. Patient #2 stated they were upset that the staff had just removed all of their blankets from their room and gave them an anti-suicide blanket (tear-resistant blanket used to prevent the patient from forming a noose to attempt suicide). Review of Patient #2’s patient monitoring form showed the patient was on 15-minute checks for suicide precautions. This observation was in contrast to the observations on 7/22/24 at 1:28 p.m. where Patient #1 had multiple standard hospital blankets and was also on 15-minute checks for suicide precautions. B. Document Review i. Medical record review revealed Patient #1 was admitted on 7/21/24 to the adolescent psychiatric unit for schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and suicidal ideation. Further review of the medical record revealed the patient scored ten out of ten for suicidal ideation on the daily self-assessment. According to the self-assessment instructions, a ten meant the symptoms were present at the greatest possible level. Further review of the self-assessment revealed the documentation was missing the date completed and the signatures of the nurse, social worker, and provider. ii. Medical record review revealed Patient #2 was admitted on 7/25/24 to the adult psychiatric unit for suicidal ideation. Further review of the medical record showed the provider did not place a privilege order that allowed the patient to have a facial piercing. Additionally, Patient #1 did not have a contract for safety for facial piercings. C. Interviews i. On 7/22/24 at 2:02 p.m., an interview was conducted with Tech #1. Tech #1 stated Patient #1 was admitted for suicidal ideation and was unaware that Patient #1 had excessive linens in their room. Tech #1 stated patients at risk for suicide should not have had extra linens in their rooms. Tech #1 stated the extra linens in the patient care area increased the patient’s ligature risk (the potential for someone to use a cord, rope, or other material to attach themselves to something for the purpose of hanging or strangulation). ii. On 7/24/24 at 2:50 p.m., an interview was conducted with Tech #1. Tech #1 stated they were not aware the media cabinet was open and patients had access to the electronic cords. Tech #1 stated the media cabinet should have been locked and secured at all times. Tech #1 stated the electronic cords were a ligature risk. Tech #1 stated if the cabinet was unlocked, the patients could have gained access to the electronic cords and harmed themselves or other patients. iii. On 7/22/24 at 2:44 p.m., an interview was conducted with RN #2. RN #2 stated patients on the psychiatric unit should not have had access to extra linens. RN #1 stated patients were only allowed to have a maximum of two blankets in their room. RN #2 stated extra linens in the patients’ rooms increased the patients’ ligature risk. RN #2 stated it was the Techs’ responsibility to identify the ligature risk during their environmental rounds, mitigate the risk by removing the extra linens, and report back to the nurse. iv. On 7/24/24 at 2:55 p.m., an interview was conducted with RN #4. RN #4 stated the media cabinet in the day room should have been locked at all times. RN #4 stated the media cabinet contained electronic cords for the TV and video game systems. RN #4 stated they were unsure of how long the cabinet was open and unsecured. RN #4 stated that it was important to secure the media cabinet to prevent patients from gaining access to ligature contraband. RN #4 stated patients were at risk of strangulation and death if they had access to ligature contraband such as electronic cords. v. On 7/25/24 at 2:46 p.m., an interview was conducted with the manager of the adult unit (Manager) #3. Manager #3 stated Patient #2 was admitted for suicidal ideation. Manager #3 stated Patient #2 did not have the facial piercing noted on their personal belonging sheet. Manager #3 stated the patient needed to have a privilege order from their provider and a contract for safety before they were allowed to have any jewelry, including facial piercings. Manager #3 stated patients who had access to jewelry could cause self-harm or injure other patients. 2. Staff failed to consistently perform 15-minute checks on high-risk psychiatric patients, which increased the patients’ risk of injury. A. Observations i. On 7/24/24 at 2:02 p.m., observations were conducted on the geriatric psychiatric unit in room 3003. Patient #3 was found lying in bed in a supine position (when a person lies on their back) with their urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) tubing stretched. Patient #3’s urinary catheter bag was found attached to the patient’s unlocked wheelchair. Further observation revealed the urinary catheter bag was attached to the bottom of the wheelchair seat, allowing the urinary bag to be dragged across the floor. Patient #3 stated their lower stomach hurt and that they felt like they needed to urinate. Patient #3 stated they did not remember how they got into bed. Staff on the geriatric psychiatric unit stated they did not transfer Patient #3 into their bed. ii. Observation of the surveillance video revealed on 7/24/24 at 12:50 p.m. Patient #3 wheeled themselves to their room. Patient #3’s urinary catheter bag was hanging off of the bottom of the wheelchair and dragged across the floor. At 1:06 p.m., Tech #5 was seen walking in and out of Patient #3’s room with a clipboard used to document 15-minute checks. At 1:36 p.m., 30 minutes after the patient’s last 15-minute check, Tech #5 was seen briefly walking in and out of Patient #3’s room with a clipboard to document 15-minute checks. At 1:58 p.m., 22 minutes after the patient’s last 15-minute check, a nurse was seen briefly walking in and out of Patient #3’s room with a clipboard to document 15-minute checks. This observation was in contrast to Patient #3’s patient monitoring form, which documented Tech #5 observed Patient #3 resting in bed at 1:00 p.m., 1:15 p.m., 1:30 p.m., 1:45 p.m., and 2:00 p.m. This observation was in contrast to the Behavioral Health Levels of Observation and Precautions policy, which stated all patients were to be monitored a minimum of once every fifteen minutes. This needed to be documented on the Patient Monitoring Form, including the patient’s location, status, behavior, and activity. B. Document Review i. Review of Patient #3’s medical record revealed the patient was a fall risk. Further review of the medical record revealed the patient had an order for the staff to assist with all transfers. ii. Review of Patient #3’s patient monitoring form revealed Tech #5 documented the patient was in bed at 1:00 p.m., 1:15 p.m., 1:30 p.m., 1:45 p.m., and 2:00 p.m. This was in contrast to the surveillance video footage, which showed Tech #5 entered and exited the room at 1:06 p.m. and 1:36 p.m. C. Interviews i. On 7/24/24 at 3:50 p.m., an interview was conducted with Tech #5. Tech #5 stated Patient #3 was a fall risk and required assistance to transfer. Tech #5 stated Patient #3 was on a 15-minute check for their risk of falls. Tech #5 stated they visually checked on Patient #3 every 15 minutes between the hour of 1:00 p.m. and 2:00 p.m. Tech #5 stated 15-minute checks were important for the safety of the patients. Tech #5 stated if 15-minute checks were not performed, the patient could fall or cause self-harm. This interview was in contrast with the surveillance video footage, which showed Tech #5 entered and exited the room at 1:06 p.m. and 1:36 p.m. ii. On 7/24/24 at 3:00 p.m., an interview was conducted with the executive director (Director) #6. Director #6 stated that 15-minute checks were standard practice for all psychiatric patients admitted to the facility. Director #6 stated 15-minute checks were important for the safety of the patients. Director #6 stated if staff did not perform 15-minute checks, patients would be at risk for falls, self-harm, or carrying out suicidal or homicidal ideations. 3. The facility failed to ensure that staff could quickly and easily gain access to psychiatric patients in their rooms. Specifically, the facility failed to maintain functional locks on patient care area doors to provide unobscured access to psychiatric patients. A. Observations i. On 7/24/24 at 1:14 p.m., observations were conducted on the adult psychiatric unit. The observations revealed that loud noises could be heard from outside the door of room 1055. Manager #3 had attempted to gain access to the room; however, the door handle was stuck in a locked position. Manager #3 had attempted to use their key to unlock the door without success. Manager #3 knocked on the door, and Patient #4 was able to open it from the inside handle. Patient #4 stated that the door needed to be locked to keep out the evil spirits. Patient #4 stated the other patients on the unit would not be ready to see them and what they were capable of. Manager #3 instructed the staff to place a work order immediately to repair the lock for patient safety. This observation was in contrast to the work order log, which revealed the work order was placed at 3:42 p.m., two hours and 28 minutes after the lock malfunction was identified. B. Document Review i. Medical record review revealed Patient #4 was admitted on 7/16/24 to the adult psychiatric unit on an M1 Hold (an involuntary 72-hour emergency mental health hold placed on a patient determined to be at risk of self-harm, harming others, or gravely disabled) for psychosis and grave disability. Review of Provider #9’s progress note entered on 7/24/24 at 2:36 p.m. revealed Patient #4 experienced auditory hallucinations. Further review of the progress note revealed the provider was unable to predict the patient’s behavior, including whether the patient would attempt to harm themselves or others. Provider #9 stated both violent acts and suicide attempts were difficult to predict, given the combination of intervening changing life circumstances outside of a clinician’s control and the fact that many individuals only considered violence or suicide for minutes to hours prior to acting. ii. A review of the maintenance work order log number 8049998 revealed that a critical status work order was entered on 7/24/24 at 3:42 p.m. for room 1055. The work order reported the door lock to room 1055 malfunctioned and needed immediate replacement. This was in contrast to the observations on 7/24/24 at 1:14 p.m. when Manager #3 informed their staff to immediately place a work order to repair room 1055’s malfunctioned lock. iii. A review of maintenance work order log number 7968927 revealed that a standard status work order was entered on 7/5/24 at 8:12 a.m. without specifying the room number. The work order noted that a patient’s door lock malfunctioned, posing a safety concern as it would delay staff access to the room. C. Interviews i. On 7/24/24 at 1:27 p.m., an interview was conducted with Tech #8. Tech #8 stated patients should never have been left alone behind a locked door. Tech #8 stated that if the door lock had malfunctioned, the staff could have been delayed in reaching the patient, and the patient could have harmed themselves or others. ii. On 7/29/24 at 1:36 p.m., an interview was conducted with RN #7. RN #7 stated if a patient’s lock had been malfunctioning, they would have immediately moved the patient to another room and put in a work order. RN #7 stated they would have made sure that room was not used. RN #7 stated if the door to the patient’s room malfunctioned and had been locked, the patient could have strangled themselves or caused self-harm.”

“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: 47959 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services, was out of compliance. A-0392- STANDARD: STAFFING AND DELIVERY OF CARE: The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients needed, in accordance with the facility’s nurse staffing plan in three of three units reviewed (Behavioral Health Adult, Behavioral Health Geriatric Psychiatry, and Intensive Care Unit (ICU)). A-0395 - (b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure patients in the intensive care unit (ICU) were continuously monitored by telemetry and pulse oximetry, as ordered by their provider to identify a change in a patient’s condition in one of three ICU medical records reviewed (Patient #1).”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47959 Based on interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients needed, in accordance with the facility’s nurse staffing plan in three of three units reviewed (Behavioral Health Adult, Behavioral Health Geriatric Psychiatry, and Intensive Care Unit (ICU)). Findings include: Facility policy: The Master Staffing Plan policy read, a nurse staffing plan shall be developed based on scope of care that meets the needs of the patient population, acuity, and frequency of care to be provided. References: According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines. The staffing plans, which were identified by staff as the facility’s staffing grids, were provided by the facility. The staffing plans listed the name of each unit at the facility, the patient census for each unit, and the specified number of registered nurses (RNs) and technicians expected to be staffed and present on each unit according to the current patient census. The daily assignment logs were provided by the facility and identified by the staff as the document used to track daily shift patient care assignments for staff on the units. The daily assignment logs listed the RNs and what patients were assigned to them for the shift. 1. The facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed. A. Document Review i. The intensive care unit (ICU) daily staffing logs were reviewed for the day shift and night shift staffing from 12/25/23 through 1/31/24. According to the facility staffing plan for the ICU, the ratio of nurses to patients was one RN to every two patients. The review of the daily staffing logs revealed nurses had additional patients to care for beyond the expected ratio in the staffing grid for 63 of the 76 shifts reviewed. ii. The behavioral health geriatric psychiatric unit daily staffing logs were reviewed on 1/30/24. The review included the day shift and night shift staffing from 12/31/23 through 1/29/24. According to the facility staffing plan for the behavioral health geriatric psychiatric unit, the ratio of nurses to patients was one RN to every seven patients on the day shift and one RN to every eight patients on the night shift. The review of the daily staffing logs revealed on the day shift of 12/31/23 the unit had a census of 32 patients. According to the facility staffing plan, this census called for five RNs and five behavioral health technicians (BHTs). The review revealed the unit was staffed with four RNs and four BHTs. The result was one RN had nine patients and two RNs had eight patients for the shift. This was beyond the expected ratio set forth by the facility staffing committee. Similar instances of staff assigned an increased number of patients in contrast with the expected ratios in the staffing plan were found upon review of the day shift daily staffing logs for 1/2/24, 1/3/24, 1/6/24, 1/8/24, 1/10/24, 1/16/24, 1/17/24, 1/18/24, 1/23/24, 1/25/24, 1/27/24, and 1/29/24 and the night shift daily staffing logs for 1/1/24, 1/20/24, 1/21/24, 1/22/24, 1/25/24, and 1/28/24. iii. The behavioral health adult psychiatric unit daily staffing logs were reviewed. The review included the day shift and night shift staffing from 1/1/24 through 1/29/24. According to the facility staffing plan for the behavioral health adult psychiatric unit, the ratio of nurses to patients was one RN to eight patients for the day shift and one RN to nine patients for the night shift. The review of the daily staffing logs for the day shift revealed RNs were staffed one RN to nine patients on 1/2/24, and 1/18/24. The review revealed the day shift ratios were one RN to 10 patients on 1/1/24, and 1/25/24 and the night shift ratios were one RN to 10 patients on 1/15/24. The review revealed the day shift ratios were one RN to 12 patients on 1/5/24 and 1/6/24. Furthermore, the review revealed the day shift ratios were one RN to 13 patients on 1/7/24 and 1/28/24. The night shift ratios were one RN to 13 patients on 1/20/24 and one RN to 14 patients on 1/21/24. This was beyond the expected ratio set forth by the facility staffing committee. This was in contrast to the facility’s Master Staffing Plan policy which read, a nurse staffing plan must have been developed based on scope of care that met the needs of the patient population, acuity, and frequency of care to be provided. Furthermore, this was in contrast to the regulations followed by the facility, Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan which read, the nurse staffing committee would develop and oversee a master nurse staffing plan which included minimum staffing requirements for each inpatient unit. B. Medical Record Review i. Medical record review revealed Patient #1 was admitted to the intensive care unit (ICU) on 11/1/23 after a right upper lobectomy (removal of a part of the lung). On 11/1/23 at 10:40 a.m., a provider order was placed for telemetry and pulse oximetry (oxygen) monitoring. The provider order also indicated the oxygen level was to be kept above 90%. Medical record review also revealed Patient #1 developed complications after surgery that included atrial fibrillation (an irregular, rapid heartbeat), pulmonary embolisms (blood clots in the lung), and a stroke. Furthermore, the Admission/Shift Assessment documented on 11/11/23 at 4:00 p.m. revealed Patient #1 was on a heated high-flow oxygen nasal cannula that delivered oxygen at 65 liters per minute (lpm) and 85% fraction of inspired oxygen (FIO2) (the concentration of oxygen in the gas mixture). Provider documentation revealed on 11/11/23 at 4:28 p.m., Patient #1’s oxygen saturation was 83%. After this oxygen saturation, the pulse oximeter stopped reading Patient #1’s oxygen levels. Review of nursing documentation revealed on 11/11/23 at 4:31 p.m., Patient #1 was off the pulse oximeter. Patient #1’s heart rate was 103 bpm and respiratory rate was 27 breaths per minute. Nursing documentation also revealed at 4:35 p.m., Patient #1’s heart rate was 38 bpm and respirations were 32 breaths per minute. Patient #1 remained off the pulse oximeter and a code blue (cardiac arrest) was called. There was no evidence that Patient #1’s abnormal heart and respiration rate or being off the pulse oximeter were addressed by a registered nurse until the code blue was called, despite the high-priority alarm that was set to alarm when Patient #1’s oxygen was not monitored and their heart rate dropped below 50 bpm. Further review of nursing documentation on 11/11/23 at 8:50 p.m. revealed the primary nurse was in an isolation room and responded when the staff assistance alarm and code blue alarm alerted. Review of the ICU staffing log for 11/11/23 revealed the RN assigned to care for Patient #1 had three ICU patients assigned to them (Patients #1, #7, and #8). Review of the medical records of Patients #1, #7, and #8 revealed provider orders which indicated the patients required ICU level of care and were not a low level acuity. This was in contrast to the ratios set forth in the ICU matrix by the facility staffing committee which directed staffing at one RN to two patients. ii. Medical record review revealed Patient #9 was admitted to the behavioral health adult psychiatric unit on 1/5/24 for treatment of a psychotic (a mental disorder characterized by a disconnection from reality) episode. Nursing documentation on 1/6/24 at 7:18 p.m. revealed Patient #9 was found on the floor of the bathroom on 1/6/24 at 5:00 p.m. Nursing documentation revealed Patient #9 stated their legs were numb after they stood up from the toilet and lost their balance and fell. Nursing documentation further revealed Patient #9 had fallen and had pain in his head and neck. The patient was transported to the emergency room for evaluation. Nursing documentation on 1/7/24 at 6:04 p.m. revealed Patient #9 also had a splint placed on their left wrist at the emergency room. Staffing logs for the behavioral health adult psychiatric unit were reviewed for the day shift staffing and revealed Patient #9’s nurse had 12 patients on 1/6/24. This was an additional four patients beyond the expected ratio in the staffing plan set forth by the facility staffing committee. C. Interviews i. An interview was conducted on 2/5/24 at 11:00 a.m. with ICU RN #11. RN #11 stated the ICU nurse to patient ratio was one RN to two patients unless there was a need to take a third patient. RN #11 stated they took a third patient at times when the patient was a lower acuity level patient if the unit was short-staffed. ii. An interview was conducted on 1/31/24 at 1:40 p.m. with the ICU clinical nurse coordinator (CNC) #1. CNC #1 stated they had never seen the written matrix for the unit, but knew from being trained that the nurse to patient ratio was one RN to two patients. CNC #1 stated when there was a need to give more patients to a nurse due to a staffing shortage, it was accepted practice to add a third lower acuity level patient to the RNs assignment, which gave the RN three patients. iii. An interview was conducted on 1/29/24 at 12:15 p.m. with the ICU clinical nurse coordinator (CNC) #2. CNC #2 stated they were unsure of how the matrix was developed but the ICU was staffed one RN to two patients and one RN to three patients if one of the patients had a lower acuity. CNC #2 stated if there were four or five patients with a low acuity level, it was considered acceptable for one RN to care for all four patients. CNC #2 stated there was no place in the written unit matrix that directed staffing for one RN to three patients. CNC #2 stated it was important to follow the matrix of one RN to two patients so nothing was missed in the care of the patient. CNC #2 stated there was a risk of patient harm if the RN had more than two high acuity level patients to care for. iv. An interview was conducted with the ICU nurse manager (Manager) #4 on 1/31/24 at 3:01 p.m. Manger #4 stated there was nothing in the ICU matrix that supported RNs being assigned more than two patients. Manager #4 stated if there were multiple lower acuity level patients, the patients were moved to an area where there was one RN and one patient care technician (PCT). Manager #4 stated patient safety was the reason a matrix was followed when assignments were made. Manager #4 stated the risks of the matrix not being followed were mistakes or omissions in patient care and included the risk of death to the patient. v. An interview was conducted with the behavioral health geriatric psychiatric unit registered nurse (RN) #7 on 1/29/24 at 2:50 p.m. RN #7 stated they did not know how the matrix was developed but was informed by the clinical nurse coordinator the ratio was one RN to seven patients for the day shift. RN #7 stated took seven patients and at times took eight patients if the unit was short-staffed. RN #7 stated the reason the matrix was followed was in order to ensure patients received safe care and the patient’s needs were met. RN #7 stated when RNs had more than seven patients, there was an increased risk of patient falls or mistakes in patient care. RN #7 stated patients did not get the care or attention they needed when RNs had more than seven patients. vi. An interview was conducted with the behavioral health geriatric psychiatric unit clinical nurse coordinator (CNC) #3 on 1/29/24 at 2:25 p.m. CNC #3 stated the ratio for day shift was one RN to six to seven patients. CNC #3 stated there were times when the unit was short staffed and RNs took more patients but the matrix did not support these ratios. CNC #3 stated the patient was a priority and was the basis for assignments made by the nursing matrix standard. CNC #3 stated mistakes were made when RNs were overwhelmed with too many patients and that led to patient harm. CNC #3 stated when RNs had more than seven patients, there were medication errors, the quality of patient care was less, patients’ needs were not met, and patients’ mental health needs were not supported. vii. An interview was conducted with behavioral health adult psychiatric unit RN #8 on 1/29/24 at 3:05 p.m. RN #8 stated they did not know how the matrix was created and had recently learned the nurse to patient ratio for the unit was one nurse to eight patients. RN #8 stated they worked frequently with up to 12 patients. RN #8 stated there was a risk of injury to staff or other patients when the matrix was not followed. RN #8 stated there was also a risk of errors and patients did not get their physical or mental health needs met when nurses had more than eight patients. viii. An interview was conducted with behavioral health adult psychiatric unit RN #9 on 1/29/24 at 3:55 p.m. RN #9 stated they did not know how the matrix was created but the nurse to patient ratio was one RN to eight patients. RN #9 stated they were frequently assigned up to 12 patients during shifts when they were short-staffed. RN #9 stated patient and staff injury was a risk when they took more patients than what was given in the matrix. RN #9 stated staff did not take meal breaks and stayed past the end of the shift so work was finished and patients were safe. ix. An interview was conducted with behavioral health adult psychiatric unit RN #10 on 1/29/24 at 4:05 p.m. RN #10 stated the nurse to patient ratio was one RN to eight patients, but did not understand how that ratio developed. RN #10 stated they frequently had more than eight patients for a shift assignment and at times it went up to 12 patients. RN #10 stated it was difficult to care for patients’ needs when there was more than eight patients assigned. RN #10 stated the milieu was difficult to manage when staffing was inadequate and safety was at risk for patient or staff harm. x. On 2/1/24 at 2:17 p.m. an interview was conducted with the behavioral health director of nursing (DON) #12. DON #12 stated some behavioral health staff attended the quarterly staffing committee meetings. DON #12 stated the new matrix was presented to staff in December of 2023 and the staff had access to it on the behavioral health units. DON #12 stated this matrix included nursing ratios of one RN to seven patients (day shift) and one RN to eight patients (night shift) for the behavioral health geriatric psychiatric unit. DON #12 stated the nursing ratios for the behavioral health adult psychiatric unit was one RN to eight patients (day shift) and one RN to nine patients (night shift). DON #12 stated patients were transferred to an overflow unit or admissions were stopped when there was not enough staff to care for the patients. DON #12 stated this kept RNs within the matrix nursing to patient ratios. DON #12 also stated unit managers came in and took care of patients when the units were short-staffed. The facility was unable to provide evidence of patients transferred to overflow units when the staffing assignments exceeded the staffing matrix. This was in contrast to the document review of the daily assignment logs for the behavioral health adult and geriatric psychiatric units which showed staff were assigned patients outside the matrix ratios on multiple occasions. This was also in contrast to interviews conducted which revealed staff were assigned patients outside the matrix ratios on multiple occasions.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47959 Based on document review and interviews, the facility failed to ensure patients in the intensive care unit (ICU) were continuously monitored by telemetry and pulse oximetry, as ordered by their provider to identify a change in a patient’s condition in one of three ICU medical records reviewed (Patient #1). Findings include: Facility policies: The Pulse Oximetry policy read, the purpose for pulse oximetry was to determine the need for oxygen therapy and the amount of oxygen needed to maintain a satisfactory oxygen saturation. Additionally, indications for pulse oximetry included monitoring of critical patients. The Cardiac Telemetry Monitoring policy read, rhythm changes and/or life-threatening arrhythmias must be assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem. Prompt notification of cardiac arrhythmias and/or rhythm changes is essential for patient safety. References: The Carescape Modular Monitors Carescape One clinical reference guide for the telemetry and pulse oximetry monitor read, high-priority alarms (red) require an immediate response; medium priority alarms (yellow) require a prompt response. Pictures of the facility alarm settings for the telemetry and pulse oximetry monitors provided by ICU nurse manager (Manager #4) revealed the parameters for heart rates alarmed as a high-priority (red) alarm when the heart rate fell below 50 beats per minute (bpm) or went above 120 bpm. The parameter for the oxygen saturation alarmed as a high-priority (red) alarm when the oxygen saturation fell below 89%. 1. The facility failed to ensure patients had continuous cardiac and oxygen monitoring to detect any changes in condition. A. Medical Record Review i. Medical record review revealed Patient #1 was admitted to the intensive care unit (ICU) on 11/1/23 after a right upper lobectomy (removal of a part of the lung). On 11/1/23 at 10:40 a.m., a provider order was placed for telemetry and pulse oximetry (oxygen) monitoring. The provider order also indicated the oxygen level was to be kept above 90%. Medical record review also revealed Patient #1 developed complications after surgery that included atrial fibrillation (an irregular, rapid heartbeat), pulmonary embolisms (blood clots in the lung), and a stroke. Furthermore, the Admission/Shift Assessment documented on 11/11/23 at 4:00 p.m. revealed Patient #1 was on a heated high-flow oxygen nasal cannula (HHFNC) that delivered oxygen at 65 liters per minute (lpm) and 85% fraction of inspired oxygen (FIO2) (the concentration of oxygen in the gas mixture). Provider documentation revealed on 11/11/23 at 4:28 p.m., Patient #1’s oxygen saturation was 83%. After this oxygen saturation, the pulse oximeter stopped reading Patient #1’s oxygen levels. Review of nursing documentation revealed on 11/11/23 at 4:31 p.m., Patient #1 was off the pulse oximeter. There was no documentation indicating why the patient was off of the pulse oximeter. Patient #1’s heart rate was documented at 103 bpm and respiratory rate was documented at 27 breaths per minute at this time. Nursing documentation also revealed at 4:35 p.m., Patient #1’s heart rate was 38 bpm and respirations were 32 breaths per minute. Patient #1 remained off the pulse oximeter and a code blue (cardiac arrest) was called. According to the provider’s documentation, after one round of chest compressions, one milligram (mg) of epinephrine (a medication given to increase blood pressure) and one ampoule of sodium bicarbonate (a medication given to help with acid buildup in the blood caused by cardiac arrest), the patient had a return of spontaneous circulation. The provider documented concern for hypoxic arrest (loss of oxygen to the body) secondary to the patient removing the HHFNC and that a pulmonary embolism (PE, sudden blockage of blood flow to the lungs) was not ruled out. There was no evidence that Patient #1’s abnormal heart and respiration rate or being off the pulse oximeter were addressed by a registered nurse until the code blue was called, despite the high-priority alarm that was set to alarm when Patient #1’s oxygen was not monitored and their heart rate dropped below 50 bpm. Further review of nursing documentation on 11/11/23 at 8:50 p.m. revealed the primary nurse was in an isolation room and responded when the staff assistance alarm and code blue alarm alerted. This was in contrast to the facility policy, Cardiac Telemetry Monitoring which read, rhythm changes must have been assessed and responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem. Furthermore, this was in contrast to the Carescape Modular Monitors Carescape One clinical reference guide which read high-priority alarms required an immediate response. B. Document Review i. The ICU Unit Activity Report for call lights document revealed the call light activity from the ICU pod F room #58 was reviewed for 11/11/23. The review revealed Patient #1’s call light was activated on 11/11/23 at 4:29 p.m. and was routed to the RN’s phone but was not answered. The review also revealed the system rang the RN’s phone again after 30 seconds and rang to the nurses’ station in another minute. Further review revealed the staff assist call was made at 4:33 p.m. C. Interviews i. On 2/1/24 at 8:42 a.m. an interview was conducted with ICU patient care technician (PCT) #6. PCT #6 stated Patient #1 was in ICU pod F (an ICU patient care area made up of 12 patient rooms and separated by a long hallway from the main ICU area). PCT #6 stated they were working both sides of the ICU (the main area and pod F) on 11/11/23. PCT #6 stated the two RNs in pod F were in rooms with patients when PCT #6 stepped away from the desk for a reason they were unable to remember. PCT #6 stated this left no staff member at the desk where the telemetry and pulse oximetry monitors were. PCT #6 stated they anticipated the time away to be short, so there was no communication provided to the RNs about their leaving the unit. PCT #6 stated Patient #1’s daughter had activated the patient call light prior to them returning to the unit and Patient #1’s daughter met PCT #6 in the hall and alerted them that Patient #1 was in distress. PCT #6 stated they found the patient unresponsive and without oxygen or the pulse oximetry probe on their finger and activated the staff assist alarm for help. PCT #6 stated communication was important so patients were monitored and others were aware of the activities in the unit for patient safety. PCT #6 stated call lights and alarms were answered immediately because there might have been something seriously wrong with the patient. PCT #6 stated the sooner the call lights and alarms were responded to, the better chance the patient had of a good outcome. This was in contrast to interviews and document review which revealed Patient #1’s call light and monitor alarms were not answered immediately. ii. An interview conducted with ICU clinical nurse coordinator (CNC) #1 on 1/31/24 at 1:40 p.m., revealed all ICU patients were to have continuous telemetry and pulse oximetry monitoring. RN #1 stated the patient bedside monitors were able to show the vital signs of two patients at once. RN #1 stated the best way to continuously monitor patients was to have the information of two patients on one monitor in the patient room. RN #1 stated while this was the best way to continuously monitor patients, it was not done consistently by RNs and the decision was left to their discretion. RN #1 stated when an ICU nurse had a third patient, they relied on other staff to help monitor the third patient because the monitors only showed two patients at a time. RN #1 stated it was difficult to continuously monitor patients when the two patients were not on the monitor, especially when there were only two RNs in the ICU pod (the area of patient rooms). RN #1 stated it was important to monitor patients continuously because medications and treatments were based on the vital signs that were monitored and patients experienced harm when not monitored. RN #1 stated patients risked serious consequences such as stroke or death if they were not monitored continuously. iii. An interview conducted with ICU CNC #2 on 1/31/24 at 10:48 a.m., revealed staff were to respond to all telemetry and pulse oximetry alarms as soon as the alarms sounded. CNC #2 stated telemetry and pulse oximetry alarms were audible in the nurses’ stations and patient rooms as long as the patient room door remained open. CNC #2 stated patients in isolation had closed doors and alarms could not be heard. CNC #2 stated the best way to continuously monitor patients was to ensure two patients’ information from the telemetry monitor was pulled up on the monitor used by the nurse. CNC #2 stated this was not done by all nurses, was not required to monitor patients continuously, and was at the discretion of the nurse. CNC #2 stated it was important to pull up two patients on one monitor so the patient’s abnormal vital signs could be seen and treated immediately to prevent harm to the patient. CNC #2 stated when nurses did not continuously watch the monitors they could miss a change in the patient’s condition that would result in patient harm. CNC #2, who was the charge nurse during Patient #1’s event on 11/11/23, stated Patient #1 was not monitored while the primary nurse was behind a closed patient room door and there was no staff at the nurses’ station to monitor patients. CNC #2 stated patient care technician (PCT) #6 had returned to the unit and was summoned by Patient #1’s daughter to assist with the patient’s deteriorated condition. iv. An interview conducted with the ICU nurse manager (Manager) #4 on 1/31/24 at 3:01 p.m. revealed staff were expected to monitor staff continuously. Manager #4 stated it was the responsibility of all unit staff to listen for telemetry and pulse oximetry alarms and respond. Manager #4 stated those who sat at the nurses’ station to document in medical records responded to alarms when the primary nurse was unable to respond. Manager #4 stated if there was no one at the nurses’ station, the alarms were heard around the unit and were responded to by other staff members. Manager #4 stated they defined continuous monitoring as continuously monitoring respirations, heart rate, pulse oximetry, and arterial lines. Manager #4 stated continuous monitoring did not mean the nurse watched the patient or the monitor continuously. Manager #4 stated nurses were able to print out strips of vital sign information if they were unable to monitor the patient in real-time. This was in contrast with the Cardiac Telemetry Monitoring policy read, rhythm changes and/or life-threatening arrhythmias were expected to be responded to immediately to assure the safety of the patient and ensure prompt treatment of a problem. Manager #4 stated the bedside patient monitors used to monitor two patients’ information were optimal, but not required. Manager #4 stated this practice was beneficial if the nurse was in a patient room for an extended period of time or if other staff members were not available to help attend to the telemetry and pulse oximetry alarms. Manager #4 stated it was important to continuously monitor patients to detect early changes that might have led to a patient’s demise. Manager #4 stated if nurses did not continuously monitor patients, they would miss an important change in the heart rate or other vital signs that could be fatal for the patient. v. An interview conducted with medical doctor (MD) #5 on 1/31/24 at 11:41 a.m. revealed all patients in the ICU had orders for continuous telemetry and pulse oximetry. MD #5 stated the expectation was that patients were hooked up to the monitors with the correct parameters for the vital signs and that patients were continuously monitored for changes in condition. MD #5 stated it was important to continuously monitor patients because ICU patients were significantly more sick than other patients and had the potential to decompensate quicker than other patients. MD #5 stated when patients were monitored continuously, it allowed staff to identify a change in the patient’s condition and treat the problem to prevent harm to the patient. MD #5 stated they expected a response to telemetry and pulse oximetry alarms within two to three minutes. MD #5 stated the patient risked decompensation or death when staff did not respond immediately to alarms to treat the patient’s change in condition.”