Morton Plant North Bay Hospital

“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: 49691 Based on medical records, policies, and interviews the facility failed to provide a safe setting for dialysis treatment in one (Patient #1) of three patients reviewed. Findings included: Review of the Policy titled, “Hemodialysis”, # BC-HEMO-110, revision date 01/2025 ...Purpose: to provide safe in-patient hemodialysis treatment Policy: hemodialysis is performed by a skill validated hemodialysis team member ...initial hemodialysis per provider order... Review of the policy and procedure titled, “Hemodialysis care of the patient requiring,” # BC-CS-927, reviewed 03/2024...expected outcomes ...acid- based balance restored, Electrolytes, BUN, and creatine restored to baseline levels ... Review of the policy and procedure titled, “Assessment / Reassessment of Adult Patients”, # NCL0132, revision 07/2024 ...The scope of assessments and reassessments are based on the patient’s diagnosis, the care setting, the patient’s willingness to receive treatment, and the response to and effectiveness of care and interventions ...Reassessment A. The patient status is reassessed at regular intervals. Reassessments is triggered by changes in patient’s condition or needs, change in caregiver, and change request from patient family or physician and to determine the response to effectiveness of care and interventions ... Review of Patient #1’s medical record discharge summary revealed that on 02/25/2025 at 3:54 AM he presented to the Emergency Department (ED) with past medical history of hypertension, hyperlipidemia, coronary artery disease, diet-controlled diabetes mellitus and end-stage renal disease, on hemodialysis and was experiencing progressive shortness of breath. Patient #1 was admitted to the hospital with diagnosis of congestive heart failure (CHF) in setting of dialysis patient. On 3/3/25, the medical chart notes that the patient experienced cardiac arrest. Resuscitation attempts were made however Patient #1 expired. “Cause of death is likely hyperkalemia in setting of end-stage renal disease on hemodialysis.” Review of Patient #1’s Medical record orders showed that on 02/25/2025 at 10:18 AM an order for Dialysis Tuesday, Thursday and Saturday with a duration 3 hours, dialysis bath (a solution of pure water, electrolytes and salts, such as bicarbonate and sodium which purpose is to pull toxins from the blood into the dialysate) Calcium 2.5 mEq/L, Dialysis Bath Potassium (K) Sliding scale, Dialysis Bath Sodium 137 mEq/L. Potassium sliding scale: Serum K less than 4 mEq/L use 4 mEq/dl bath Serum K 4.0 to 4.5 mEq/L use 3 mEq/L bath Serum K 4.6 to 6 mEq/L use 2 mEq/L bath 4 mEq/L bath contains 2.25 mEq/L Calcium Patient #1’s medical record revealed that the serum potassium (K) (a blood test) on 02/25/2025 (Tuesday) 4:45 AM resulted 4.6, 02/26/2025 (Wednesday) 4:18 AM resulted 4.6 and on 03/03/2025 (Monday) 4:35 AM resulted 6.8, a Critical High value. Normal serum potassium (K) levels are 3.5 to 5.0 milliequivalents per liter (mEq/L) Patient #1’s medical record showed that on 02/25/2025 (Tuesday) at 3:05 PM he received dialysis with a K bath of 2 mEq/L. On 02/27/2025 (Thursday) at 1:15 PM he received dialysis with a K bath of 2 mEq/L. On 03/01/2025 (Saturday) at 11:00 AM he received dialysis with a K bath of 2 mEq/L. During an discussion on 03/31/2025 at 2:07 PM with Staff I, Educator inquired about the sliding scale of potassium and she stated there is no testing policy of potassium with the sliding scale. During a phone interview on 3/31/2025 at 3:40 PM with Staff J, Nephrologist (medical doctor specializing in the diagnosis and treatment of kidney diseases and disorders), discussing the hospital event and a sliding scale for potassium baths for dialysis patients, she stated her expectation as a provider is for patients laboratory tests should be drawn the morning before dialysis and the Dialysis Nurse would adapt the bath used according to the scale orders. She stated we are going to change the policy to reflect that lab be drawn prior to any dialysis treatment in the acute setting. .”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 49691 Based on medical records, facility documents, policies, and interviews, the facility failed to thoroughly analyze and implement appropriate corrective action 1 (Patient #1) of 1 incident reviewed. Findings included: Review of the facilities 2025 Quality Improvement and Patient safety Plan showed.... The risk management Department is responsible for collecting, tracking, trending and reporting events as outlined in the sentinel events/ serious event policies...Serious safety events: events of patient harm that occurred due to a deviation from an established standard of care. All reported events are analyzed for harm and potential deviation... Review of the facilities policy and procedures titled, “Risk Management Plan” # BC-RK-123, last reviewed 01/2023 ... The Plan promotes the development of processes that identify, prevent, and mitigate organizational risks ...The Governing Board is responsible for oversight of organizational risks and assigns the responsibility for the development, implementation, and oversight of the plan to administration. Ongoing monitoring of Plan compliance and effectiveness rests with the Risk Services department ... Review of Patient #1’s medical record discharge summary revealed that on 02/25/2025 at 3:54 AM he presented to the Emergency Department (ED) with past medical history of hypertension, hyperlipidemia, coronary artery disease, diet-controlled diabetes mellitus and end-stage renal disease, on hemodialysis and was experiencing progressive shortness of breath. Patient #1 was admitted to the hospital with diagnosis of congestive heart failure (CHF) in setting of dialysis patient. On 3/3/25, the medical chart notes that the patient experienced cardiac arrest. Resuscitation attempts were made, however Patient #1 expired. “Cause of death is likely hyperkalemia in setting of end-stage renal disease on hemodialysis.” Review of Patient #1’s Medical record orders showed that on 02/25/2025 at 10:18 AM an order for Dialysis Tuesday, Thursday and Saturday with a duration 3 hours, dialysis bath (a solution of pure water, electrolytes and salts, such as bicarbonate and sodium which purpose is to pull toxins from the blood into the dialysate) Calcium 2.5 mEq/L, Dialysis Bath Potassium (K) Sliding scale, Dialysis Bath Sodium 137 mEq/L. Potassium sliding scale: Serum K less than 4 mEq/L use 4 mEq/dl bath Serum K 4.0 to 4.5 mEq/L use 3 mEq/L bath Serum K 4.6 to 6 mEq/L use 2 mEq/L bath 4 mEq/L bath contains 2.25 mEq/L Calcium Patient #1’s medical record revealed that the serum potassium (K) (a blood test) on 02/25/2025 (Tuesday) 4:45 AM resulted 4.6, 02/26/2025 (Wednesday) 4:18 AM resulted 4.6 and on 03/03/2025 (Monday) 4:35 AM resulted 6.8, a Critical High value. Normal serum potassium (K) levels are 3.5 to 5.0 milliequivalents per liter (mEq/L) Patient #1’s medical record showed that on 02/25/2025 (Tuesday) at 3:05 PM he received dialysis with a K bath of 2 mEq/L. On 02/27/2025 (Thursday) at 1:15 PM he received dialysis with a K bath of 2 mEq/L. On 03/01/2025 (Saturday) at 11:00 AM he received dialysis with a K bath of 2 mEq/L. Review of the hospital documentation, dated on 03/13/2025, showed that corrective action failed to identify an area of opportunity with a potassium sliding scale with no potassium (K) levels being drawn, prior to utilization of the K sliding scale. During a discussion on 03/31/2025 at 2:07 PM with Staff I, Educator inquired about the sliding scale of potassium and she stated there is no testing policy of potassium with the sliding scale. During a discussion on 03/31/2025 at 2:15 PM with Staff F, Regulatory Manager regarding the discussion with the Critical Care Register Nurse (CCRN) educator and she stated, “I understand what you are saying about not having K level prior to dialysis treatment.” She also disclosed that they did not identify the sliding scale and the lack of potassium level as one of the contributing factors. During a phone interview on 3/31/2025 at 3:40 PM with Staff J, Nephrologist (medical doctor specializing in the diagnosis and treatment of kidney diseases and disorders), discussing the hospital event and a sliding scale for potassium baths for dialysis patients, she stated her expectation as a provider is for patients laboratory tests should be drawn the morning before dialysis and the Dialysis Nurse would adapt the bath used according to the scale orders. She stated we are going to change the policy to reflect that lab be drawn prior to any dialysis treatment in the acute setting.”

“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: 36678 Based on observation, interviews, policy review, and record reviews, the hospital failed to ensure patients in the ICU (Intensive Care Unit) and on 3 North, with a potential for life threatening arrhythmias (cardiac malfunction of the heart’s electrical system), had continuous cardiac monitoring with visual observation as ordered for 4 patients (#3, #5, #7, and #8) of 9 patients in the ICU and 1 (#10) of 2 patients on 3 North. Findings included: During a tour conducted on 12/04/2023 at 11:40 AM in the ICU, 3 cardiac monitoring display screens were observed at the nurses’ station. There were two staff members sitting at the nurses’ station. No staff members were sitting directly in front of the cardiac monitoring display screen, nor were they looking at the cardiac monitoring screens. During an interview on 12/04/2023 at 11:45 AM with the Patient Services Director, he said they had previously been told someone needs to watch the cardiac monitors. He said the secretary watches the monitors. During an interview on 12/04/2023 at 12:25 PM with the ICU educator, the Risk Manager and the Patient Services Director, the Patient Services Director disclosed they are in the process of moving from their current cardiac electrical monitoring system to the system being used in the rest of the hospital. He said the hard-wired monitors in the ICU and the overflow (3 North) telemetry boxes can’t be monitored centrally. When the transition is made, then patients on telemetry boxes on 3 North will be monitored by CMU (central monitoring unit). The Risk Manager said it was previously recommended that the cardiac monitor screens be watched and that they had a nurse or telemetry monitor technician there, until they received a letter from the agency that said they were “compliant with their policy”, so they don’t have to have someone dedicated to the monitor screen. During an interview on 11/05/2023 at 9:35 AM with Staff A, she said she has acted as unit secretary before. There were two separate staff members: one to act as secretary and one to watch the cardiac monitors. Staff A said she has acted as secretary and monitor technician (MT) at the same time before. Yesterday, Staff A was the secretary and MT. There was a secretary and a MT for a brief time. Last year it was a one-person job. There has been one person doing both positions since September or October. Staff A disclosed that the patients on 3 North are all down-graded med-tele (medical-telemetry) patients, who are also monitored on the screen in ICU at the desk. During an interview on 11/05/2023 at 9:45 AM with Staff B, she said she was the unit secretary yesterday. Staff B confirmed she was doing both roles yesterday. She said there was a time when there was a secretary and a monitor tech. Then it went back to one person doing both. They were informed in October they were going back to one. “It’s hard. Mostly we are watching the monitors. But we have to answer the phone, pay attention when a patient is coming, write it down in the books so we can keep track of patients coming in and out. You are watching ICU and 3 North. The response to changes in [cardiac monitoring] is not ideal.” During an interview on 12/05/2023 at 10:08 AM with Staff C, Critical Care Physician, he said the cardiac telemetry technician is stationed [at the nurse’s station]. It’s hospital policy. The monitor tech is always at the station. Nobody has the expectation that the nurse is going to know all the vital signs with multiple patients. That expectation comes back to the telemetry monitor tech. Staff C said he would expect there to be a [cardiac] telemetry monitor technician watching the telemetry at all times. During an interview on 12/05/2023 at 10:58 AM with Staff D, Staff D said one person watched the [cardiac] monitor, answers the phones and is the unit secretary, going back to forever. Somewhere around mid-summer an agency came in and said there needed to be 2 people. So, that was changed to one secretary and one monitor [tech] at the desk. Then mid-October or early November, the hospital said they received a letter stating that there only needed to be one person. During an interview on 12/05/2023 at 11:11 AM with Staff E, she said for 8 years the unit secretary did both positions. An agency came in and said there must be a designated person on the monitors. That was about a year ago. “I think we should have a designated monitor tech. I know when I am watching the monitors, I need to be focused on those monitors.” Staff E said she has told management she has to watch the monitor and can’t have interruptions. But “upper management said we don’t have to have a designated monitor tech. I told them I think we do need one.” During an interview on 12/05/2023 at 11:35 AM with Staff F, he said Saturday and Sunday he was the secretary and monitor tech for both days. He stated it is not manageable. You are told your primary job is the monitors. “I have told them you can’t have a busy unit secretary job who is told their primary responsibility is the monitors. I have told them you can’t do it. I have told the unit managers and the charges. There was a time I didn’t look at the monitors for an hour. Regularly, it’s at least 15 minutes. Staff F stated they are getting admissions and talking to doctors. They check the tubes (hospital pneumatic tube delivery system) that come from the pharmacy with medications. They update the assignment board, keep up with the charts, phone calls to doctors, answer phones, order medical equipment, and watch [cardiac] rhythms to recognize and notify the nurse on anything critical. Usually, it is 14 to 15 patients. He stated, If asked, he has mentioned that he hasn’t been able to watch the monitor for 15 or 20 minutes. “I am not going to lie about it.” He stated he was the unit secretary acting as the monitor tech on night shift and there are a lot of things you can pick up on that the monitors don’t. A 3 second pause [in cardiac rhythm] doesn’t set off the alarm. He stated “there was a patient who was having 8 pauses in an hour. The pauses were up to 2.8 seconds and the alarms never went off. She ended up with a pacemaker after she coded.” Review of the policy, Cardiac Monitoring (Telemetry), Initiation, and Discontinuation (Adult), dated 1/2023, reflected the following: Purpose:3. To provide a continuous monitoring of the patient’s cardiac electrical activity. Review of the policy, Critically Ill Patient, Care of the Adult, last review 11/2023, revealed the following: Assessment: . . . 5. Monitor: a. Continuous Cardiac Rhythm Review of the medical record for Patient #3 reflected an admission date of 12/03/2023, for alcohol withdrawal. A review of the physician’s orders dated 12/03/2023 reflected an order to transfer to critical care. An order dated the same day, read Cardiac monitor: maintain for tests and transport. Review of the medical record for Patient #5 reflected an admission on 11/17/2023 for perforated bowel with pneumoperitoneum (a tear or hole in the intestine, and air in the abdominal cavity), and septic shock. Review of the History and Physical reflected a plan to admit to ICU given her critical status. Review of the physician’s orders reflected to transfer patient within facility Perforated Bowel, critical care. Review of the medical record for Patient #7 reflected an admission date of 11/22/2023 with a diagnosis of sepsis present on admission in setting of hypertension. Review of the physician’s orders also dated 11/22/2023, showed Cardiac monitor, maintain for tests and transport. Review of the medical record for Patient #8 revealed an admission date of 12/01/2023, with diagnoses of acute hypoxemic respiratory failure with flash pulmonary edema, acute chronic heart failure, and hypertensive emergency. Further review of the record reflected an admission plan: Admit to ICU. A review of the physician’s orders showed a cardiac monitor was ordered. Review of the medical record for Patient #10 showed an admission date of 12/01/2023 for pneumonia, and a medical history of hypertension. Further review of the record revealed an admission plan: patient will be admitted to the PCU (progressive care unit, 3 North) for further management. Review of the physician orders dated the same day reflected an order for cardiac monitor.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 36678 Based on facility committee agenda, facility internal documents and interview, the facility failed to identify opportunities and make changes to prevent medication errors in the facility in 12 of 129 medication errors in ICU ( Intensive Care Unit). Findings included: Review of the Board Clinical Excellence Committee agenda on 09/05/2023 showed review of the regulatory report, “Patient Safety”. The report reviewed safety trends and event rates for medication related issues, showing the action steps taken for improvement related to an insulin pump. There were no other medication errors noted. Review of the facility Risk Event Log revealed from 09/08/2023 through 12/04/2023, a total of 67 medication errors in the 154 bed hospital, including 9 medication errors occurring in the 14 bed ICU during this three month period. An interview was conducted with Staff G, Risk Manager on 12/05/2023 at 1:53 PM. Staff G, Risk Manager established that they did not see a trend for medication errors, on 12/04/2023 a medication error related to insulin drip where software issues were identified. Staff G, Risk Manager confirmed the new medication error in ICU was not on the log that was provided to the surveyors. There were a total of 129 medication errors with 12 medication errors in ICU for the six month period. The surveyor requested a more in depth analysis of the events from Staff G, Risk Manager. The risk manager, Staff G stated she would find out about supplying that, but the facility did not provide the requested information.”