Boca Raton Regional Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 29151 Based on record review, interview and policy review, it was determined, the hospital failed to report, investigate, respond and ensure prompt resolution to a complaint and grievance. The failure affected 1 of 2 sampled patients (Patient #1). The findings included: Hospital policy titled “Complaint Grievance Process”, last reviewed 09/16/25 documents as follows: PURPOSE: To provide a mechanism for receiving and responding to a complaint/grievance in a timely, reasonable and consistent manner. To provide guidelines effective reporting, investigation, documentation and monitoring of complaints and grievances. To identify trends and implement measures to prevent further occurrence of a similar complaints or grievances, and in order to provide a safe environment. SCOPE: This policy applies to Boca Raton Regional Hospital and any affiliates or subsidiaries of these entities. POLICY: To establish a process for the prompt resolution of patient complaints and grievances and to inform the patient of whom to contact to file a grievance. PROCEDURE: Definitions: a. Complaint -A concern presented by a patient or their representative that can be resolved at the time by any hospital staff (i.e., nursing, administration, nursing supervisors, patient advocates and etc.) who can quickly respond to resolve the concern. a. Grievance - is a formal or informal verbal or written complaint presented by the patient or the patient’s representative that cannot be resolved at the time of complaint. A complaint is also considered a grievance when the patient requests that it be handled as such. All written complaints (letter/email/fax/survey with written letter attached) are always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative. All grievances require a written letter of response. Patients are informed of the complaint/grievance process through any of the following mechanisms: Patients are advised that they have the right to express grievances through our grievance process by contacting personnel responsible for their immediate care and/or the Office of Patient Experience department. A patient advocate may be reached by dialing extension 4358 from their hospital phone or 561-955-4358 from outside of the hospital. Any complaints or grievances regarding abuse, neglect, patient harm or hospital compliance will be immediately addressed and Risk Management should be notified. Complaint Procedure Patient complaints while the patient are still in-house will be addressed by hospital staff present. The patients’ or family members’ concerns will be addressed. Service recovery will be utilized when appropriate. Complaints where the patient advocate is involved or is brought to the patient advocate’s attention will be documented in the RL6 database system for appropriate follow-up. Grievance Procedure When a concern is submitted in writing or telephone to the Office of Patient Experience, the grievance will be acknowledged by the Patient Experience team and will be assigned a Patient Advocate. Attempts will be made to resolve grievances within 30 days. Initial acknowledgement letters are sent to patients within 7 days. Included in the acknowledgement will be the name and telephone number of the assigned patient advocate, steps that will be taken on their behalf to investigate the grievance and the anticipated date of completion. If a Grievance case requires further investigation and discussion, an extension letter will be sent to the patient approaching 30 days serving as a notice of extension. Once an outcome is finalized, a final letter will then be sent to the patient with steps taken to investigate along with the findings. This will serve as a closing and final letter to the patient. If Grievance is resolved within 7 days, one letter will be sent that includes initial acknowledgement & final. Once a grievance is received by the Office of Patient Experience, the grievance is documented in RL6 and tasked to the appropriate department leader(s) or hospital staff for response. All Grievances are reviewed by Governing body which includes: Patient Experience Leadership, Quality Department, Senior Leadership, and Risk Management when necessary. Department leaders and Medical Staff will be tasked on Grievance cases when applicable. The patient advocates will coordinate an investigation. All grievances will be documented by the patient advocates in the RL6 database. This includes initiating contact with the complainant. Frequently, this contact may be performed by the department leader and/or the patient advocate. The patient advocate will ascertain the desired outcome the complainant desires. The department leader(s) will complete and return their findings within 3 days or less to the Patient Advocate. All grievances will receive a written response upon resolution. This communication will include: 1. Name of the hospital contact person. 2. Steps taken on their behalf to investigate the grievance 3. Results of the grievance process 4. Date of completion. Reporting of Complaint/Grievance Data Complaints and Grievances will be reviewed routinely at the Grievance Committee. Complaint and Grievance data will be reviewed quarterly and on an annual basis. Review of event reports conducted on 11/17/25 revealed an event dated 08/18/25 regarding Patient #1’s family member and a security breach prior to open visitation hours. Review of the grievance logs dated 08/2025 through 11/2025 failed to provide evidence of grievances regarding Patient #1. Interview with Staff C, The Executive Assistant, conducted on 11/17/25 at 2:20 PM revealed her recollection of the events involving Patient #1. The patient’s brother called the hospital, he was concerned that himself and his dog were banned from the hospital earlier that morning. Staff C stated she took the information and then contacted the director of the unit so she could follow up with his concerns. Interview with Staff D, Director of Medical Surgical Unit, conducted on 11/18/25 at 11:17 AM revealed her recollection of Patient #1. The patient’s brother visited along with his dog multiple times and the patient did not verbalize any concerns. Then one day, the charge nurse called her to advise, the patient’s brother was being very aggressive, he was discontinuing the pain pump as there was no order for it, the patient had pain medication ordered, intravenously and orally, and the brother was questioning him and his ability as a nurse. Then the issue was addressed, and he came back early in the morning, prior to visiting hours, again very aggressive and threatening the staff. She instructed the charge nurse to call security. The next morning, she was given an email that was sent to the chief executive officer from the patient’s brother, it was again threatening and demanding. The Director stated she did not speak to the brother because he was not listed on the patient’s face sheet, as an emergency contact, proxy or advocate, so she then went into the room and spoke to the patient and his girlfriend. They both apologized for the brother’s behavior and told her that she did not have to talk to the brother, that they would relay the information provided. Interview with the Risk Manager conducted on 11/18/25 at 12:14 PM revealed the email sent by the patient’s brother did not reach patient relations, the hospital follows the protocol, inpatient complaints are handled by the director, and the director spoke to the patient, the email was not a grievance, so it was not handled as such. Follow up interview with the Risk Manager on 11/18/25 at approximately 1 PM revealed the email sent by Patient #1’s brother, dated 08/19/25. The brother was requesting a call back from the hospital leadership and had multiple complaints including the patient being mistreated, service animal not being allowed on the premises, and concerns regarding the quality of care provided by the hospital staff. Based on record review and interview, the hospital staff failed to follow their grievance policy. The email was in writing, and it should have been addressed as a grievance, ensuring a proper investigation and resolution to the person filing the complaint.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 29151 Based on policy review, clinical record review and interview, it was determined, the nursing staff failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 1 of 3 sampled patients (Patient #1) as evidenced by failure to follow verbal orders for Patient Control Analgesia (PCA) administration. The findings included: Record review conducted on 11/17/25 revealed Patient #1 presented to the emergency department with chief complaint of left flank pain. The patient was admitted and underwent a surgical procedure on 08/14/25 to repair intestinal obstruction. Physician’s order dated 08/14/25 documents Morphine PCA 0.5 milligrams (mg) per 5 milliliters (ml), dose 0.5 milligrams and lock out time of 10 minutes. The PCA was changed to Hydromorphone 10 mg per ml, dose 0.1 mg and lock out time of 10 minutes on 08/15/25. The record indicates Patient #1 was transferred on 08/17/25 from the surgical intensive care unit to the medical surgical unit, and upon arrival, the PCA pump was discontinued by the charge nurse as the physician order was no longer active. The record failed to document an order to discontinue the PCA pump, after further review, it was determined the order was deactivated in the computer on 08/17/25. Interview with Staff A, Charge Nurse, conducted on 11/17/25 at 2:08 PM revealed Patient #1 arrived from the surgical intensive care unit with a PCA pump. The primary nurse was reconciling the orders and noticed the order for the PCA was inactive, he then went into the room to discontinue it until clarification was obtained. The charge nurse explained to the patient and the patient’s brother who was present in the room, they were contacting the physician to clarify the order. The patient’s brother got irate and demanded the PCA be reinstated immediately. An event report was created due to family member’s behavior. Interview with Staff B, Surgical Intensive Care Registered Nurse, conducted on 11/18/25 at 12:21 PM revealed the morning before the patient transferred to the medical surgical unit, the surgical team was discussing the case, they decided to discontinue the PCA pump as the patient’s pain was improving. She inactivated the order in the electronic clinical record and then went into the room to explain to the patient, the brother was in the room, and they both asked if they could keep it for now, as the patient was reporting pain. She proceeded to talk to the physician, and he gave the verbal order to keep the PCA pump for now and reevaluate later. The RN explained it was a busy day, and she forgot to reinstate the order. Based on record review and interview, the nursing staff failed to follow hospital policies and procedures for verbal orders. In addition, the hospital failed to identify the error when the event was reported by the nursing staff. The hospital identified the omission during a review from the accreditation agency and corrective actions provided to the surveyor were incomplete and failed to address the use of verbal orders. Facility policy titled “Verbal and Telephone Orders” last revised 08/07/24 documents as follows: PURPOSE: To establish organizational guidelines, processes, and definitions for the use of Telephone and Verbal Orders throughout the organization. POLICY: 1. Definitions are individuals employed by or under contract to the hospital and approved to receive orders including licensed / registered hospital personnel such as dieticians, nuclear medicine technologists, registered nurses, pharmacists, physical therapists, radiation oncology technicians, radiology technologists, respiratory therapy technicians, ultrasound technologists, social workers, and physician assistants may be authorized within their scope of their training and authority. b. Healthcare Providers approved to give orders include physicians, nurse practitioners, physician assistants, and such other categories of practitioners as set forth from time to time in the medical staff bylaws. c. CPQE is defined as the Information System supporting the electronic entry of patient orders by licensed Healthcare Providers. d. Telephone Order is defined as the verbalization of a patient order from a licensed Healthcare Provider to a Healthcare Employee via the telephone. e. Emergent Order is defined as any order for a high risk situation or patient with new onset of confusion, lethargy, or disorientation or a patient in severe pain or distress. f. Written Order is defined as any written or printed patient order from a licensed Healthcare Provider to a Healthcare Employee. g. Verbal Order is defined as a medical order received in person by a Healthcare Employee from a Healthcare Provider. h. Admission Order set is defined as a group of pre-defined, standard orders that facilitate the admission of a patient to the hospital. 2. General Usage Guidelines and Restrictions a. All verbal and telephone orders, whether electronic or written, must be documented with the date, time, signature and title or the person receiving the orders. b. All telephone and verbal orders will be read-back to the healthcare provider to confirm the accuracy of the order. c. Telephone Orders will not be accepted for cancer chemotherapy agents d. Admission Order sets must be completed within sixty (60) minutes of the notification to admit a patient to the hospital. e. Verbal Orders will only be accepted when the Healthcare Provider is utilizing sterile technique or in emergencies such as code blue, or in extreme circumstances when the Healthcare Provider is unable to write or enter orders electronically f. All telephone and verbal orders will be authenticated as per the Medical Staff Rules and Regs 3. CPOE Specific Usage Guidelines and Restrictions a. Healthcare Providers are responsible for the direct data entry of all CPOE patient orders with the exception of Telephone Orders as defined by this policy. b. Telephone Orders will be accepted during the hours of 11:00 pm through 07:00 am. c. Emergent Orders as Telephone Orders will be accepted without a time restriction when the Healthcare Provider does not have access to a computer, or equivalent, with Internet connectivity, d. Notwithstanding anything to the contrary contained herein, if there is a question regarding whether a Telephone Order or Verbal Order complies with this policy, the Healthcare Employee shall accept the order and address the issue subsequently with Hospital administration. PROCEDURE: l. CPOE Telephone/VerbaI Orders a. During the hours of 11:00 pm - 07:00 am the Healthcare Provider shall contact the Healthcare Employee directly responsible for the care of the patient. b. The Healthcare Employee will login to the CPOE system and select the appropriate patient and order. c. The Healthcare Employee will complete the electronic order with the assistance of the Healthcare Provider for clinical decision support criteria. d. All telephone and verbal orders will be read-back to the healthcare provider to confirm the accuracy of the order. e. The Healthcare Employee will submit the order for processing. f. Telephone orders will not be given or taken in the form of text messages. Refer to BHSF policy # 74220-207.00 Secured Texting of Protected Health Infornation at Baptist Health South Florida. 2. Written Telephone/ Verbal Orders a. Healthcare Employee will record the telephone/verbal order directly on to a physician order sheet. b. All telephone and verbal orders will be read-back to the healthcare provider to confirm the accuracy of the order. c. The Healthcare Employee will process the orders as outlined in the policy “Processing of Written Physician Orders Outside of CPOE” (#00010480). 3. Emergent Orders Using CPOE a. In the event that the Healthcare Provider does not have access to a computer, or equivalent, with Internet connectivity, the Healthcare Provider shall contact the Healthcare Employee directly responsible for the care of the patient and will follow the Telephone Orders procedure outlined in section titled “CPOE Telephone Orders”. 4. Admission Orders a. In the event a patient presents to the emergency room and requires admission to the hospital the physician will be contacted by an employee of the emergency room. b. The Healthcare Provider will be given sixty (60) minutes to complete admission orders or may use the Telephone Order procedure, (section 1, under Procedure). c. The Healthcare Provider may request that the admission be referred to a hospitalist at first notification. Hospitalists will be available 7 days a week, twenty-four hours a day. 5. Non-Compliance Use of Telephone Orders will be monitored with periodic reporting per healthcare provider to assure compliance with meaningful use criteria.”

“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: 29151 Based on clinical record review, interview and review of the Risk Management and Safety Plan, it was determined, the facility failed to implement corrective actions and mechanism to minimize risk of injury to patients and provide care in a safe setting. The deficient practice is evidenced by: Failure to develop facility wide corrective action plans addressing the root cause of 1 of 1 incident reviewed involving Patient #1. The event resulted in delay in care and services and subsequent patient’s death. The facility failed to develop and implement monitoring tools to minimize reoccurrence. The findings included: Investigation of the event involving Patient #1 was conducted on 01/25/24 and 01/26/24. The investigation indicates multiple failures that may have contributed to the patient’s death. The corrective actions implemented by the facility failed to include facility wide staff education including hand off communication, bed placement changes since the event, assessment and reassessment, staff competency, and the development of monitoring tools to sustain compliance with corrective actions needed to maintain a safe environment for patient care. Interview conducted on 01/25/24 at 12:33 PM with The AVP (Assistant Vice President) of Critical Care Services revealed the facility investigation had identified the multiple failures and they have not implemented monitoring tools to ensure the staff is following the new guidelines for proper bed placement, oxygen use and hand off communication. Interview with The Risk Manager and The Interim Director of Quality conducted on 01/26/24 at approximately 1:50 PM confirmed the education provided only included two units; the staff competency related to telemetry monitoring was only assigned to the technician involved; and monitoring tools to ensure proper bed placement, escalation of changes in telemetry rhythm or oxygen needs and proper hand off communication have not been developed. Risk Management Program revised 06/14/18 documents: The department of Risk Management and Patient Safety is recognized as a specialized discipline that incorporates the concepts of loss prevention and loss control towards reducing the frequency and severity of losses. The department engages in key patient safety functions within the framework of a patient safety evaluation system whereby, Patient Safety Work Product (PSWP) is collected, analyzed and reviewed for submission to the Patient Safety Partnership (PSP). Administrative The risk managers are responsible for promoting safety by: 1. Maintaining a comprehensive incident reporting system to receive, investigate and evaluate incidents. 2. Re-enforcing the legal duty of all healthcare providers and employees to report adverse incidents within three business days of the occurrence to Risk Management through an electronic Incident reporting system, or a paper Incident Report, downtime form and/or as necessary, via a telephone call. 3. Managing the health system’s loss potential through early identification, analysis of risks in the health care environment and promoting strategies for risk avoidance. 4. Investigating, analyzing and recording the frequency, causes and general categories and specific types of adverse incidents. 5. Determining methods of managing risks, including avoidance, reduction, retention, and transfer. 6. Assisting various departments in identifying and correcting environmental conditions and work practices. 9. Serving as active participants in various entity, system-wide and medical staff committees; acting as liaisons, resources and consultants. 10. Assisting in complying with local, state, and federal rules, regulations, laws and accreditation requirements as related to risk management and patient safety.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by 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. This Standard is not met as evidenced by: 29151 Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 1, out of 5 sampled patients reviewed for nursing services, (Patient #4) as evidenced by failure to reassess patient’s condition during a blood transfusion as specified per facility protocols. The findings included: Facility policy titled “Blood and Blood Component Procurement, Consent and Transfusion” dated 09/19/23, documents guidelines for the safe administration of blood components. Administration Refer to the approved electronic reference resource for procedural guidelines. Documentation In the patient’s medical record, record the following: Blood component type Unit component number Date and time the transfusion is started and completed Amount of saline infused All vital signs taken, before, during and after transfusion Any adverse effects Signature of transfusionist and witness. Mosby’s guidelines for blood transfusions: Verify that the patient pre transfusion temperature, pulse, respirations, and blood pressure (TPR and BP) are within normal limits, documented and were taken no more than one hour prior to administration ..... Monitor vital signs (TPR and BP) and document in the EHR (Electronic Health Record) 15 minutes after transfusion started. 60 minutes after transfusion started. At the completion of the transfusion. If there is a change in the patient’s vital signs notify the ordering provider (a temperature increase of 1.8 degrees Fahrenheit is significant). Clinical record review conducted on 01/25/24 revealed Patient #4 was prescribed a blood transfusion on 01/16/24. The record indicates the staff obtained pre transfusion vital signs at 1:18 PM; the transfusion started at 1:20 PM. The staff monitored the patient with partial vital signs at 1:22 PM, did not obtain a temperature reading, and did not wait the recommended fifteen minutes for reaction monitoring. The one-hour monitoring also lacked temperature readings. Interview with The Patient Care Manager, who navigated the electronic clinical record, conducted on 01/25/24 at approximately 1:31 PM revealed the facility follows Mosby recommendations for blood transfusion monitoring and confirmed the vital signs as noted above. Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence a complete set of the patient vital signs was obtained at the fifteen minutes and one-hour interval of the blood transfusion. On 01/26/24 at 1:08 PM The Interim Director of Quality, confirmed the document given to the surveyor, Mosby recommendations for blood transfusion was the correct form.”