Christiana Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47821 Based on facility policy and procedure review, medical record review (MR), and staff interview (EMP), it was determined that the facility staff failed to take vital sign measurements according to the clinical practice guidelines and the physician order for 2 out of 8 patients (Patients #3 and #5) sampled that were treated in the emergency department (ED). Findings include: Facility clinical practice guideline “Vital Sign Assessment-Emergency Department” effective January 9, 2013, and last reviewed October 19, 2023, revealed, “...Vital signs will be reassessed according to the patients Emergency Severity Index (ESI) level...ESI 2 and ESI 3: vital sign reassessment Q [every] 2 hours at minimum or until provider order...” Facility policy “Standards of Care and Professional Nursing Practice” effective December 30, 1996, and last reviewed August 15, 2024, revealed, “...Vital signs, consisting of temperature, pulse, respirations, and blood pressure will be taken...ordered by the provider...” Review of MR3 for ED visit dated 2/18/25 revealed: - ED assessment completed on 2/18/25 at 8:16 AM revealed patient was given a tracking acuity (ESI) of 3. - ED orders dated 2/18/25 at 8:06 AM stated “...vitals every 4 hours...” - ED vital signs were completed on 2/18/25 at 8:08 AM and 2:43 PM, approximately 6.5 hours (1 set of vital signs not completed). During an interview on 3/4/25 at 1:43 PM, EMP6 confirmed that Patient #3’s vital signs were not completed according to the physician order. Review of MR3 for ED visit dated 2/22/25 revealed: - ED assessment completed on 2/22/25 at 11:27 PM revealed the patient was given a tracking acuity (ESI) of 2. - ED vital signs were completed on 2/22/25 at 10:48 PM and 2/23/25 at 3:45 AM, approximately 5 hours (2 sets of vital signs not completed). During an interview on 3/4/25 at 2:40 PM, EMP6 confirmed that Patient #3’s vital signs were not completed according to the clinical practice guidelines. Review of MR5 for ED visit dated 1/27/25 revealed: -ED assessment completed on 1/27/2025 at 9:31 AM revealed patient was given a tracking acuity (ESI) of 3. -ED orders dated 1/27/2025 at 1:08 PM stated, “...ED Protocol Order Discontinued...Order Vital Signs Every 4 Hours...” -ED vital signs were completed on 1/27/25 at 9:23 AM and at 10:12 PM, approximately 12 hours and 49 minutes (3 sets of vital signs not completed). During an interview on 3/5/25 at 11:07 AM, EMP4 and EMP6 confirmed that Patient #5’s vital signs were not completed according to the clinical practice guidelines and the physician order.”

“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: 44819 Based on the review of hospital policies and documents, review of medical records (MR), review of nationally recognized standards of practice, and staff (EMP) interviews, it was determined that the facility failed to supervise and evaluate the nursing care for 1 of 10 admitted patients (Patient #7) sampled. This is evidenced by failure to turn a patient every 2 hours. Findings include: Hospital policy “Standards of Care and Professional Nursing Practice” dated 12/20/1996 and last reviewed 8/15/2024 revealed “...Formats for Nursing Practice Standards...Standards of clinical practice are comprised of...Lippincott Procedures, Lippincott Advisor...These standards describe a level of patient care or professional practice as cited in evidence-based and other best practice references...” Lippincott nursing resource titled “Pressure Injury Assessment and Management” dated February 2024, revealed “...General recommendation is to reposition at least every two hours...” Hospital job descriptions for the Registered Nurse I, II, III, and IV, all undated, revealed, “...registered nurse...assumes responsibility and accountability for patient care activities...” Hospital policy “Documentation in the Medical Record” dated 4/30/1996 and last reviewed 1/3/2023 revealed, “...The medical record...is used to...Document patient care activities...the medical record should...Reflect when care was provided...” Hospital policy “Skin Integrity Care Management Guideline” dated 1/6/2003 and last reviewed 2/1/2024 revealed “...Key Patient and Family Educational Topics...Rationale for pressure redistribution therapy/importance of repositioning every 2 hours...” Review of MR7 revealed Patient #7 was admitted on 1/29/2024, status post hip fracture on prolonged bed rest. - There was no evidence the patient was turned every 2 hours on the following dates: 13 hours between documented turns on 1/30/24 6 hours between documented turns on 1/31/24 19 hours between documented turns on 2/1/24 10 hours between documented turns on 2/2/24 During an interview on 11/7/2024 at 11:43 AM, EMP3 confirmed this finding.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44819 Based on the review of medical records (MR), review of facility policies and documents, and staff (EMP) interviews, it was determined that for 3 of 10 admitted patients (Patient #7, #10, and #17) sampled, the Hospital failed to ensure nursing staff adhered to policies and procedures of the Hospital. This was evidenced by patient care not being provided as ordered. Findings include: Hospital policy “Standards of Care and Professional Nursing Practice”, dated 12/30/1996 and last reviewed 8/15/2024, revealed “...The RN [Registered Nurse] manages and oversees the delivery of nursing care to patients in compliance with applicable hospital and nursing policies, procedures, and practice guidelines...” Hospital job descriptions for the Registered Nurse I, II, III, and IV, all undated, revealed, “...registered nurse...assumes responsibility and accountability for patient care activities...” Hospital policy “Documentation in the Medical Record” dated 4/30/1996 and last reviewed 1/3/2023 revealed, “...The medical record...is used to...Document patient care activities...the medical record should...Reflect when care was provided...” 1. Bladder Scans Review of MR17 revealed: - Patient was admitted on 10/31/2024 and was an active patient during Medical Record review on 11/12/2024. - Physician orders dated 10/31/2024 at 11:27 AM documented, “Bladder scan post void x 3...” - There was no evidence of any bladder scans completed for this admission. This finding was confirmed with EMP3 on 11/12/2024 at 12:09 PM. 2. Oral Intake A. Review of MR7 revealed: - Physician order dated 1/30/2024 at 7:32 AM documented, “I&O [Intake and Output] Q8H” - Physician order dated 2/1/2024 at 10:47 AM documented “Diet...Carbohydrate Controlled” - There was no evidence of oral intake documented on 2/3/2024 and 2/6/2024 and no evidence of liquid oral intake documented on 2/1/2024, 2/2/2024, 2/4/2024, and 2/7/2024. This finding was confirmed with EMP3 on 11/7/2024 at 12:11 PM. B. Review of MR10 revealed: - Physician order dated 8/15/2024 at 2:54 AM documented “I&O Q4H”. Patient was ordered a regular diet after procedure was completed on 8/15/2024 at 3:00 PM. - There was no evidence of PO (by mouth) intake documented from 8/16/2024 to 8/19/2024 (3 days) before patient was discharged 8/20/2024. This finding was confirmed with EMP28 on 11/7/2024 between 1:45 and 2:35 PM.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44819 Based on the review of medical records (MR), review of hospital policies, and staff (EMP) interviews it was determined that medications were not given per practitioner’s orders for 1 of 10 admitted patients (Patient #16) sampled. Findings include: Hospital policy “Medication Administration” dated 8/26/2019 and last reviewed 1/3/2023 revealed, “...Medications administered shall be documented in the patient’s medical record...” Hospital policy “Standards of Care and Professional Nursing Practice”, dated 12/30/1996 and last reviewed 8/15/2024, revealed, “...The RN [Registered Nurse] manages and oversees the delivery of nursing care to patients in compliance with applicable hospital and nursing policies, procedures, and practice guidelines...” Hospital job descriptions for Registered Nurses I, II, III, and IV revealed, “...registered nurse...assumes responsibility and accountability for patient care activities...” Review of MR16 revealed: - Physician order dated 11/4/2024 at 6:43 PM documented Lactated Ringers (LR) 100 ML/HR (milliliter per hour) intravenous. The order was discontinued on 11/7/2024 at 9:05 AM. - “Medication Administration Record” (MAR) documented that the first 1000 ML bag began on 11/4/24 at 6:58 PM and the second 1000 ML bag began on 11/6/2024 at 9:18 PM (26 hours 20 minutes). The patient received 1000 ML over 26 hours which calculates to approximately 38 ML/HR. During an interview on 11/12/2024 at 2:45 PM, EMP32 confirmed the finding and stated nurses are expected to document when IV bags are started in the MAR.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 44819 Based on observation and review of hospital policy, it was determined that for 1 of 4 patient rooms (Room #3C23B) observed, the Hospital failed to maintain the patient care environment safely. This was evidenced by the failure to remove potentially infectious material from a patient bed. Findings include: Centers for Disease Control and Prevention document “Guidelines for Environmental Infection Control in Health-Care Facilities” dated 2003 and updated 7/2019 revealed, “...The methods...and frequency of cleaning...are determined by the health-care facility policy. However, high-touch housekeeping surfaces in patient-care areas (...bedrails...) should be cleaned...more frequently than surfaces with minimal hand contact...” Hospital policy “Environmental Services Infection Prevention Policy” dated 6/15/2015 and last reviewed 10/1/2024 revealed, “...Purpose: To define department specific routine and targeted cleaning of environmental surfaces as indicated by the level of of patient contact...Standard 10-Step Cleaning...Sanitize all horizontal surfaces...use approved disinfectant to address high touch areas; bed rails...” Upon surveyor request on 11/13/24 at 11:45 AM, the Hospital was unable to provide a policy that documented how often housekeeping should clean high-touch surfaced in medical/surgical patient rooms. During environmental tours of Unit 3C, the following observations were made: 1. Patient room #3C23B on 11/6/2024 between 10:53 and 11:20 AM: - A brownish-red discoloration, approximately 3 inches long, was seen on the right-side lower bed rail. 2. Patient room #3C23B on 11/7/2024 at 12:15 PM: - The same brownish-red discoloration, approximately 3 inches long, was still seen on the right-side lower bed rail, 25 hours 22 minutes after the initial observation. - Upon request by EMP3, housekeeping cleaned the bed rail and removed the discoloration. This finding was confirmed with EMP3 during observation of finding in patient room #3C23B on 11/7/2024 at 12:15 PM.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44819 Based on observation and review of hospital documents and policies, it was determined that for 2 of 2 clean supply rooms (Units 7E and 3C) and 1 of 1 medication room (Unit 7E) observed, the hospital failed to maintain medical supplies at an acceptable level of safety and quality. This was evidenced by improper storage of clean medical supplies and the presence of expired medical supplies. Findings include: Hospital policy “Supply Storage Policy” dated 3/1/2013 and last reviewed 7/19/2022 revealed, “Purpose: To provide supplies that are free of contamination and safe for patient use...Patient care supplies will not be stored directly on floor...Stock will be rotated so that the supplies, within their expiration date, are used first...discard outdated disposable items...” Hospital Standard Operating Sheet for Par Technicians, “Par Replenishment” dated 6/9/2020 revealed, “...Work area: Nursing Unit...clean rooms...During restock, all expectations related to cleanliness, organization...stock rotation...should be met...” During an environmental tour of Units 7E and 3C on 11/6/2024 between 9:50 and 11:20 AM, the following observations were made: 1. Unit 7E Clean Supply room: - 2 BD Vacutainer Ref-367986 #3206585, expired 2024-7-31. - 1 plastic storage container stored on the floor, containing medical supplies. 2. Unit 7E Medication room: - 5 Smiths Medical jelco 0.5 ml insulin syringe #429950-05, expired 2024-02-20. 3. Unit 3C Clean Supply room: - 1 BD Universal Viral Transport vial Lot N20440400-179D35, expired 2024-01-31. - 3 BD Universal Viral Transport vials Lot N20319700-005023, expired 2023-11-30. These findings were confirmed with EMP5 at the time of the finding.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44880 Based on document review, patient interview, and staff interview, it was determined that for 2 of 10 patients (Patients # 5 and 7) in the sample the facility failed to complete required documentation when transfering a patient from the facility ED to another facility. Findings include: Hospital policy titled “Emergency Medical Treatment & Labor Act (EMTALA)” with a last review date of August 29, 2022, stated, “ ...An EMTALA Transfer must comply all with the following requirements: ... The transferring hospital sends all medical records related to the EMC (Emergency Medical Condition) available at the time of transfer ... The transferring hospital sends a Physician Certification or the patient’s written request for a transfer, as applicable ...Any EMTALA Transfer to another hospital shall be based on either: ... A written physician order and patient consent, accompanied by a Physician Certification that the benefits of the Transfer outweigh the risks ... References: ChristianaCare’s Request for Patient Transfer/Transfer Checklist (Form 19284) ...” Hospital Form titled “Request for Patient Transfer/Transfer Checklist (Form 19284)” contains fields for the provider to identify if the patient is stabilized to the best ability of the hospital, to outline the risks and benefits of transfer, a copy of the medical record was sent with the patient, and request for transfer by the patient or permission obtained from the patient for transfer. Hospital Medical-Dental Staff Rules with a last review date of September 18, 2023, stated, “ ...A patient with an incompletely stabilized emergency medical condition may either be ... Transferred to another facility outside of the Christiana Care Health System, if ... the treating physician certifies that the benefits of transfer outweigh the risks, and the patient consents to the transfer ...” Medical record review for Patient #5 revealed: Patient #5 presented to the DED on 12/5/23 at 10:36 PM with a complaint of fever and cough. Pediatric Emergent Physician Note dated 12/06/23 at 12:23 AM stated, “ ...patient appears to have failure to thrive. Discussed with in-house hospitalist who recommended transfer to [children’s acute care hospital] for workup and greater access to subspecialists. D/w (discussed with) Dr. [name], [children’s acute care hospital] Hospitalist who recommended transfer to the [children’s acute care hospital] ER [emergency room] for workup rather than the inpatient floor ... Discussed with Access Center to arrange for EMS (Emergency Medical Services) transport to the [children’s acute hospital] ... Dr. [name] accepted the patient and EMS to arrive in 20 mins to transport patient ... Patient remained hemodynamically stable and in no acute respiratory distress at the time of transfer ...” Surveyors requested to see the Request for Patient Transfer/Transfer Checklist (Form 19284) for this patient from Employee #1 on 12/6/23 at 3:26 PM. On 12/7/23 at 9:31 AM, Employee #1 confirmed that the facility was unable to produce this form. No evidence of medical records related to the EMC (Emergency Medical Condition) being sent to the receiving hospital. No evidence of Physician Certification that the benefits of the transfer outweigh the risks. No evidence of written patient consent for the transfer. Medical record review for Patient #7 revealed: Patient #7 presented to the DED (Dedicated Emergency Department) on 10/28/23 at 10:37 AM with a complaint of wheezing and retractions. Pediatric Emergent Physician Note dated 10/28/23 at 11:03 AM stated, “...transport center was called and PICU (Pediatric Intensive Care Unit) transfer to [children’s acute care hospital] was coordinated. Accepting physician is Dr. [name]. Parents have been updated on planned of care, all questions answered ...” Surveyors requested to see the Request for Patient Transfer/Transfer Checklist (Form 19284) for this patient from Employee #1 on 12/6/23 at 3:26 PM. On 12/7/23 at 9:31 AM, Employee #1 confirmed that the facility was unable to produce this form. No evidence of medical records related to the EMC being sent to the receiving hospital. No evidence of Physician Certification that the benefits of the transfer outweigh the risks. No evidence of written patient consent for the transfer. The findings above were confirmed with Employee #1 on 12/7/23 at 9:31 AM.”