Charlotte Hungerford Hospital

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 14216 Based on a review of hospital documentation and staff interview, for 1 of 3 sampled patients (Patient #3) reviewed for grievances, the hospital failed to respond to the patient with the outcome of a grievance investigation. The finding includes: a. Review of hospital documentation dated 1/30/25 noted patient # 3 reported to the charge nurse that a staff member grabbed and pulled his/her arm roughly. Interview with the Manager of Customer Relations on 4/22/25 at 1:02PM identified that when they were made aware of the allegation, the department contacted the appropriate departments and continued the invesigation that was already in progress. The Manager stated that the investigation was unable to substantiate abuse. Interview with Patient Advocate #1 on 4/22/25 at 1:05PM stated that when she receives patient complaints she forwards the complaint to the appropriate departments for investigation and then she closes the complaint by sending the patient a letter of the findings. The Patient Advocate stated that she did not send a final letter to Patient #3 because she did not have the patient’s demograhics. Patient Advocate #1 stated that she reached out to the charge nurse for the information but the charge nurse did not respond. Review of the hospital Complaint and Grievance Management Policy identified, in part, that resolution will take no longer then 30 days and a final letter is to be issued to include the name of the contact person, steps taken on behalf of the patient to investigate the grievances, the results of the grievance process and the date of the letter represents the grievance completion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 14216 Based on a review of clinical record, hospital documentation, and staff interview for 1 of 5 sampled patients reviewed for restraints (Patient #2), the hospital failed to discontinue the chair restraint when the patient’s behaviors necessitating the use of the restraint ceased. The finding includes: a. Patient #2 presented to the ED on 4/9/25 for a psychiatric evaluation due to acting erratically and psychotic behaviors. The physician’s order dated 4/9/25 at 2:40PM directed to place the patient in a restraint chair due to a danger to self or others. Review of the video timeline dated 4/9/25 at 2:40PM noted the patient was placed into the restraint chair due to posturing. Review of the video on 4/9/25 at 2:57PM noted the patient sitting in the restraint chair with calm behaviors. Review of the Observation Documentation for locked, violent restraints dated 4/9/25 identified the patient’s behaviors were documented as resting with eyes closed from 2:50PM until 4:20PM when the patient was removed from the restraint chair (a total of 1 hour and 30 minutes). Interview with the Regulatory Program Manager on 4/17/25 at 11:15AM stated that the patient should have been taken out of the restraint chair when the behaviors the patient was exhibiting stopped. Interview with RN #1 on 4/22/25 at 2:30PM stated that when the patient was in the restraint chair she saw the patient asleep in the chair but could not recall why she did not discontinue the restraint at that time. RN #1 stated that the patient should have been removed from the restraint chair when the behaviors stopped. Review of the Restraint and Seclusion Policy directed to discontinue of the use of restraints at the earliest possible time, regardless of the scheduled expiration of the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 14216 Based on a review of clinical records, hospital documentation and staff interview for 1 of 5 sampled patients (Patient #6) reviewed for restraints, the hospital failed to ensure the face to face evaluation included medical and behavioral assessments of the patient in accordance with hospital policy. The finding includes: a. Patient #6 presented to the ED on 1/1/25 with alcohol intoxication and violent behaviors. The physician’s order dated 1/1/25 at 10:03PM directed to apply 4 point locking wrist and ankle restraints due to a danger to self or others. Review of the clinical record with the Regulatory Program Manager on 4/22/25 at 11:10AM identified on 1/1/25 at 10:04PM the physician documented the patient was resting comfortably after chemical restraints, noted that locked restraints can be removed and nursing was notified. The documentation did not include an evaluation of the patient’s medical and behavioral condition. The Regulatory Manager stated that when a patient is placed into restraints, the LIP must conduct a face to face within one hour that includes their evaluation. Review of the hospital’s policy for Restraint/Seclusion identified the patient must be evaluated face to face by a LIP or trained RN within 1 hour of the application of a restraint and the evaluation will include the patients immediate situation, the patients reaction to the intervention, the patients medical and behavioral condition and the need to continue or terminate the restraint.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 41683 The CONDITION was not met as evidenced by: Based on a review of clinical records, facility documentation, interviews, and policy review, for 1 of 10 sampled patients reviewed for emergency services, the hospital failed to accurately reconcile Patient #40’s medications resulting in errors in prescribing and the patient received the incorrect medications for twenty (20) days. As a result, the patient experienced a change in condition and required admission to a higher level of care (A1104). In addition, the hospital failed to ensure 4 of 4 patient’s home medications were reviewed during the triage process in accordance with policy (Patient #48, #49, #50, and #51), and the hospital failed to ensure ED policies were reviewed and revised (A1104). The findings include: Cross Reference: 482.55 (a)(3) Emergency Services Policies (A1104)”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48364 48881 Based on a review of clinical records, facility documentation, interviews, and policy review, for 1 of 10 sampled patients reviewed for emergency services (Patient # 40), the hospital failed to accurately reconcile the Patient’s medications resulting in errors in prescribing. The patient received the incorrect medications for twenty (20) days, experienced a change in condition, and required admission to a higher level of care. In addition, for 4 of 4 patients reviewed, the hospital failed to ensure home medications were reviewed during the triage process in accordance with policy (Patient #48, # 49, #50, and #51), and failed to ensure ED policies were reviewed and revised in accordance with hospital policy. The findings include: 1a. Patient #40’s was admitted to the Emergency department (ED) with a chief complaint of non-compliance with medications and being combative. Additional diagnoses included dementia, Parkinson’s disease, hyperlipidemia and chronic kidney disease. The medical record lacked documentation that the triage nurse completed the medication audit reconciliation form. The Emergency Department (ED) physician’s note dated 9/20/24 identified that Patient #40 was brought to the ED from a nursing facility for aggressive outburst. The note identified that the Patient had erythema along bilateral lower extremities from knees distally, afebrile in the ED and with no leukocytosis. The plan included will initiate Keflex (antibiotic) for 7 days due to sparse abrasions, possible bilateral lower extremity cellulitis. The ED physician’s order dated 9/20/24 directed to obtain a medication reconciliation by a Medication History Technician (MHT) A review of the medical record dated 9/20/24 identified that a review of patient #40’s home medications history was completed by MHT #40. Physician’s orders for the following medications were entered on 9/21/24: Buspar 15 milligrams (mg) tablet, Klonopin 0.5 mg tablet, Cymbalta 30 mg capsule, Lexapro 5 mg tablet, Lasix 40 mg tablet, Neurontin 100 mg tablet, Lantus/Semglee 100 units/milliliters injection (20 units), Synthroid 112 microgram tablet, Lopressor 25 mg tablet, Miralax 17 gram packet, Klor-Con 20 Milliequivalent, Senna 8.6-50 mg tablet, and Ambien 5 mg tablet. Review of the ED record during the period of 9/21/24 to 10/10/24 identified medications were administered according to the physician’s orders. The medical record dated 10/10/24 identified that medications: Buspar 15 milligrams (mg) tablet, Klonopin 0.5 mg tablet, Cymbalta 30 mg capsule, Lexapro 5 mg tablet, Lasix 40 mg tablet, Neurontin 100 mg tablet, Lantus/Semglee 100 units/milliliters injection (20 units), Synthroid 112 microgram tablet, Lopressor 25 mg tablet, Miralax 17 gram packet, Klor-Con 20 Milliequivalent, Senna 8.6-50 mg tablet, Ambien 5 mg tablet and Atarax 50 mgs were discontinued. The ED physician note dated 10/11/24 identified that Patient #40 developed a fever and noted that labs, chest X-ray and COVID swab were obtained which showed leukocytosis of 19.7 (normal 4.5-11) and a full septic workup was initiated. The note further identified that the labs came back on 10/11/24 with concern for acute renal failure with a creatinine of 5.3 (normal 0.5-1.3), BUN 116 (normal 8-21), sodium is 162 (normal 136- 145). Prior labs dated 10/1/24 identified the patient’s creatinine was 1.7 and BUN 42. The patient was admitted to the Intensive care unit (ICU) on 10/11/24. The nurse’s note dated 10/11/24 at 6:55 PM identified that Patient #40 was admitted to the intensive care (ICU) from the ED. The patient was noted to be hypoxic and febrile, labs showing acute kidney injury, and hypernatremia compared to baseline. Review of hospital documentation dated 10/16/24 identified that on 9/20/24, Patient #40 was admitted to ED observation with a list of the patient’s current and active medications listed on the W-10 (inter-facility patient report) that included, Cephalexin (500mg), Tylenol (500mg), Abilify (5mg), Lexapro (20mg), Lasix (20mg), Ativan (0.5mg). The hospital document further identified that on 10/10/2024 it was discovered that the medications ordered for the patient were not the medications listed on the W-10. The medications ordered were not intended for Patient #40 and included: Metoprolol Tartrate (25mg), DULoxetine (30mg), Insulin glargine (10 unit/ml), Synthyroid (112mcg), Clonazepam (0.5mg), Potassium Chloride (20 meq), busPIRone (15mg), Furosemide (40mg), and Gabapentin (100mg). In addition, the hospital document identified that upon further review of the event, it was determined that the medication history for the patient was conducted without following the standard work, indicating the need to use two patient identifiers to confirm the correct patient. An interview with Quality Program Manager on 10/31/24 at 2:09 PM identified that the medication error was identified when the patient experienced a change in condition on 10/10/24 and required a higher level of care on 10/11/24 (21 days after Patient #40 arrived to the ED). The Quality Program Manager indicated that the review found the medication history technician (MHT) was ordered to perform the medication history and he used the form for the patient in room #8, however, Patient #40 was in Hallway bed #8. The Quality Program Manager further indicated that after the immediate review, several items were completed to include: MHT coaching for the employee that performed the medication history, disclosure to the family took place, and all medications for Patient #40 were discontinued. Interview with MD #42 on 11/4/24 at 1:00 PM identified that when a decision is made to admit a patient, a medication history will be ordered, and a medication history technician will perform the review. The MD identified he did not review the medication history for patient #40 as this was already completed by the MHT and assumed it was correct. MD #42 further identified that that when a provider enters the medications for administration, the MHT will review the medication history and perform a medication reconciliation based on that review. In addition, MD #42 stated that after the patient experienced a change in condition and labs were obtained the results prompted a review of the patient’s medications and the error was identified. In an interview with Medication History Technician #40 on 11/5/24 at 2:00 PM identified he went to the ED to perform the medication history and that patient #40 had been moved out of the room and he obtained the form from the room that the patient had been in and he used the paperwork that belonged to another patient to reconcile patient #40’s medications. The MHT indicated that since the incident, the workstation for the MHT’s has been moved to a quieter area, a second monitor has been added so that sure scripts (an electronic transmission of prescriptions between health care organizations and pharmacies, as well as general health information exchange of medical records) can be on one monitor and the patient record can be on the other monitor to lessen the amount of going back and forth between applications. The MHT further indicated that workflow reeducation has been completed, and a pharmacist is now performing a second verification to ensure accuracy of the medication histories. Review of the Emergency Department Nursing Assessment and Documentation Guidelines policy dated 5/2023 directed, in part, that staff are to assure that the patient’s current medication list regarding medication names, dosages, and other pertinent information is documented in the medical record. b. Patient #48 was admitted to the hospital on 10/31/24 at 12:54 PM for complaints of intermittent episodes of non-radiating chest pain and hypertension. Patient #48 was assigned an Emergency Severity Index (ESI) score of 2 and triage was completed on 10/31/24 at 1:05 PM. A review of the ED care timeline notes dated 10/31/24 at 2:52 PM identified patient #48 was in stable condition, discharge paperwork was reviewed, all questions were answered, and the patient was discharged from the ED on 10/31/24. Review of patient #48’s home medication reconciliation audit form identified the form was last reviewed on 4/9/24. The home medication reconciliation audit form failed to indicate the form had been reviewed, updated, or completed by a registered nurse on 10/31/24. Review of Patient #48’s clinical record with RN #2 on 10/31/24 failed to identify a registered nurse had reviewed, updated, or completed the medication audit reconciliation form on 10/31/24 during triage. Interview with RN #3 on 10/31/24 at 2:15 PM identified she was the primary registered nurse in the Emergency Department for patient #48 and she did not review the patient’s medication reconciliation form. c. Patient #49 was admitted to the hospital on 10/30/24 at 9:05 AM for complaints of constipation and decreased oral intake. Patient #49 was assigned an ESI score of 2 and triage was competed on 10/30/24 at 9:14 AM. A review of the ED care timeline notes dated 10/30/24 at 1:09 PM identified patient #49 was admitted to inpatient services and was awaiting bed placement. Review of patient #49’s home medication reconciliation audit form identified the form was reviewed on 10/30/24 at 2:29 PM by MHT #40. The home medication reconciliation audit form failed to indicate the form had been reviewed, updated, or completed by a registered nurse. Review of patient #49’s clinical record with RN #2 on 10/31/24 at 2:25 PM failed to identify an RN had reviewed, updated, or completed the medication reconciliation form. Further review of the home medication reconciliation audit form identified the medication reconciliation form was reviewed by a Certified Registered Nurse Anesthetist on 11/1/24 at 7:21 AM, 2 days after inpatient admission. d. Patient #50 was admitted to the hospital on 10/31/24 at 10:29 AM for complaints of fall and involuntary tremors. Patient #50 was assigned an ESI score of 3 and triage was completed on 10/31/24 at 10:42 AM. A review of the ED care timeline notes dated 10/31/24 at 12:16 PM identified patient #50 was admitted to inpatient services and was awaiting bed placement. Review of patient #50’s home medication reconciliation audit form identified the form was reviewed on 10/31/24 at 2:19 PM by MHT #41. The home medication reconciliation audit form failed to indicate the form had been reviewed, updated, or completed by a RN on 10/31/24. Review of patient #50’s clinical record with RN #2 on 10/31/24 at 2:40 PM failed to identify a registered nurse had reviewed, updated, or completed the medication reconciliation form during the triage process. e. Patient #51 was admitted to the hospital on 10/31/24 at 9:31 AM for complaints of fever. Patient #51 was assigned an ESI score of 2 and triage was completed on 10/31/24 at 9:43 AM. A review of the ED care timeline notes dated 10/31/24 at 1:01 PM identified patient #51 was admitted to inpatient services and was awaiting bed placement. Review of patient #51’s home medication reconciliation audit form identified the form had last been reviewed on 10/31/24 at 2:08 PM by MHT #41. Review of patient #51’s clinical record with RN #2 on 10/31/24 2:45 PM failed to identify a registered nurse had reviewed, updated, or completed the medication reconciliation form on 10/31/24 during the triage process. Interview with RN #2 (ED Nurse Manager) on 10/31/24 at 10:25 AM identified the primary ED RN is responsible for entering and or reviewing the medication reconciliation form for patients being seen in the ED. RN #2 indicated once a patient is admitted to the hospital for further care the medication reconciliation form is then verified by a medication history technician. RN #2 further indicated the medication history technician uses 2-factor authentication by reaching out to the patient’s pharmacy or using Surescripts (an electronic transmission of prescriptions between health care organizations and pharmacies, as well as general health information exchange of medical records). Interview with RN #3 on 10/31/24 at 2:15 PM identified she worked in the hospital’s triage area and also as a staff nurse in the ED. RN #3 indicated that when she worked in the triage area, she did not always review the patients’ home medications or update the home medication form. She further indicated when she works as a staff RN in the ED, she does not always look at or update the home medication form, especially if the patient is not getting admitted. RN #3 further stated “reviewing and or updating the medication reconciliation is very circumstantial, it depends on the day and your assignment, and what are the other priorities”. Review of the hospital Emergency Department Nursing Assessment and Documentation guidelines directs, in part, the RN is responsible to ensure initial, ongoing, complete, and timely assessments/reassessments. In addition, the RN will ensure accurate and complete nursing documentation in the electronic medical record (EMR). The policy further directs, the RN will: complete the triage process documentation to include but not limited to home medication review, and a RN will assure that the patients current medication list regarding medication names, dosages, and other pertinent information is documented in the medical record. 2a. Review of the policy, entitled, Emergency Equipment Checklist, identified the policy was last reviewed 1/2019 and last revised in 1/2019; b. Review of the policy, entitled, Triage of Patients, revealed the policy was last reviewed 1/2019 and last revised 1/2019; c. Review of the policy, entitled, Emergency Department Patient Medical Records, identfied the policy was last reviewed 1/2021 and last revised 1/2021; d. Review of the policy, entitled, Emergency Department Behavioral Health Unit, revealed the policy was last reviewed 1/2021 and last revised 1/2021; e. Review of the policy, entitled, Employees Injured on Duty, showed the policy was last reviewed 1/2021 and last revised 6/2016; f. Review of the policy, entitled, Absence of Medical Director, identified the policy was last reviewed 1/2021 and last revised 1/2021; g. Review of the policy, entitled, Ambulance Services and Communicable Diseases, revealed the policy was last reviewed 1/2021 and last revised 1/2021; h. Review of the policy, entitled, Fetal Heart Tones, showed the policy was last reviewed 6/2017 and has no last revision date. The origin date is 12/2002; i. Review of the policy, entitled, Anatomic Donations, indicated the policy was last reviewed 11/2020 and origin date is 11/2020; j. Review of the policy, entitled, Blood Alcohol Test, revealed the policy was last reviewed 1/2021 and last revised 1/2021; k. Review of the policy, entitled, Medication Administration, showed the policy was last reviewed 1/2021 and last revised 7/2016; l. Review of the policy, entitled, Blood Product Administration, indicated the policy was last reviewed 5/2021 and the origin date is 5/2021; m. Review of the policy, entitled, Pediatric Patients, Weights, revealed the policy was last reviewed1/2021 was last revised 1/2021; n. Review of the policy, entitled, Pain Assessment, indicated the policy was last reviewed 1/2018 and was last revised 8/2016; o. Review of the policy, entitled, Procedures not to be performed in the Emergency Department, showed the policy was last reviewed 1/2021 and was last revised 7/2016; p. Review of the policy, entitled, Protective Custody, indicated the policy was last reviewed 1/2021 and was last revised 9/2004; q. Review of the policy, entitled, Referral of Patients for Attending Treatment to the Emergency Department, revealed the policy was last reviewed 1/2021 was last revised 7/2001; r. Review of the policy, entitled, Report of Firearm injuries/wounds, indicated the policy was last reviewed 1/2021 and was last revised 11/2015; s. Review of the policy, entitled, Reportable Deaths to the State Medical Examiner’s Office, showed the policy was last reviewed 8/2019 and was last revised 11/2014; t. Review of the policy, entitled, Rotation Schedule for Physicians, revealed the policy was last reviewed 1/2021 and was last revised 1/2021; u. Review of the policy, entitled, Charge Nurse Role in the Emergency Department, indicated the policy was last reviewed 1/2021 and was last revised 1/2021; v. Review of the policy, entitled, Safety of Patients, Visitors, and Hospital Personnel while in the Emergency Department, has no last revision date and was last revised 10/2017. The origin date was 5/1976; w. Review of the policy, entitled, Cleaning of Ambulance Equipment, showed the policy was last reviewed 1/2021 and was last revised 1/2021; x. Review of the policy, entitled, Sexual Assault Examination by SAFE Nurse, identfied the policy was last reviewed 1/2021 and was last revised 1/2021; y. Review of the policy, entitled, Supervision of Advanced Practice Providers (APPs) in the Emergency Department, revealed the policy was last reviewed 1/2021 and was last revised 1/2021; z. Review of the policy, entitled, Communication between Patients and Care Providers, showed the policy was last reviewed 1/2021 and was last revised 1/2021; aa. Review of the policy, entitled, Teleneurology Consult Services, identified the policy was last reviewed 2/2021 and has no origin or revision dates; bb. Review of the policy, entitled, Transfer and Reporting of Burn Patients, revealed the policy was last reviewed 1/2021 and was last revised 1/2021; cc. Review of the policy, entitled, Vital Signs and Documentation of Vital Signs on Emergency Department Patients, showed the policy was last reviewed 6/2017 and was last revised 5/2011; dd. Review of the policy, entitled, Walk in Center Referrals to the Emergency Department, revealed the policy was last reviewed 6/2017 and has no last revision date. The origin date is 8/1994; ee. Review of the policy, entitled, X-Ray Reading by the Emergency Department Physician, identified the policy was last reviewed 1/2021 and was last revised 6/2004; ff. Review of the policy, entitled, Location of Emergency Equipment Code Carts, showed the policy was last reviewed 8/2016 and was last revised 11/2015; gg. Review of the policy, entitled, Medical Advice and Treatment Regarding Employees, revealed the policy was last reviewed 1/2021 and has no revision dates; hh. Review of the policy, entitled, Critical EKG, Laboratory, and Radiology Results, identified the policy was last reviewed 1/2021 and was last revised 10/2006; ii. Review of the policy, entitled, Discharge Instructions, showed the policy was last reviewed 1/2021 and was last revised 7/2016; jj. Review of the policy, entitled, Discharge of Patients, revealed the policy was last reviewed 1/2021 and was last revised 1/2021; Review of the Development and Management policy and Interview with the Director of Quality on 11/4/2024 at 2:10 PM identified that each policy has a 3-year review period that is stated on each policy. The Quality Director stated that she is unable to identify who is responsible for maintaining the Emergency Department policies within the three (3) year review period. Review of the Policy Development and Management policy dated 4/13/23 directed, in part, that all policies will be reviewed every three years unless a more frequent schedule is required by the content expert.”