Saint Joseph Medical Center

“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: 50411 Based on document review and interview, the Hospital failed to ensure that recovery of suspected contraband was appropriately reported and investigated as required by the Hospital’s policies. Findings include: 1. On 9/23/2025, the Hospital’s Policy titled Contraband Recovery (Safety/Security) (Effective 12/5/2022) included - “...All items turned over to the Security Department will be inventoried and disposed of as outlined below. 1. Any medications that are found should be turned over to a Registered Pharmacist to be secured or disposed of. i. Illegally obtained medication will not be turned over to the Pharmacy. Illegally obtained medication will be inventoried, photographed and documented in an incident report by Security. Security will contact local law enforcement to report and turn over the contraband...” 2. On 9/23/2025, the Hospital’s Policy titled Serious Reportable Events (Effective 6/12/2023) included - “Any staff member who recognizes an occurrence as being a potential SRE (Serious Reportable Event) will... 5. Enter the event in the event reporting system (ERS). Patient Safety, Quality, and/or Risk Management will be notified via this entry. All associates and licensed independent practitioners may enter events into the electronic reporting system. This includes potential harm, no harm or near miss events...” 3. On 9/22/2025, the clinical record of Pt.#1 was reviewed and included: - The ED (Emergency Department) Physician Report by the ED Physician on 7/15/2025 at 1:42 PM included - History of present illness - nursing home resident with history of pancreatitis presented via self-transport. [Pt.#1] reports progressive weakness, upper abdominal discomfort, and failure to thrive, with difficulty eating and drinking due to mechanical issues with chewing and swallowing; [Pt.#1] notes right-sided ageusia (loss of sense of taste) and finds food unappealing and hard to swallow ...Medical decision making - [Pt.#1] presenting from nursing home for evaluation of failure to thrive and poor oral intake. Patient has a history of alcohol abuse, chronic pancreatitis, [Pt.#1] has anorexia secondary to unable to taste food and no appetite ... Impression: Primary - Anemia, Additional impressions: dehydration, failure to thrive in adult ...” The record indicated that Pt. #1 was then admitted to the 7 East (7E) Medical Surgical Unit. - The Nurse Notes by ICU (Intensive Care Unit) Registered Nurse (RN-E#3) on 7/25/2025 at 7:00 PM included - “Received patient from floor s/p [after] Code Blue [medical emergency alert due to cardiac arrest] this evening, per 7E staff, they believe patient “may have used drugs that could have been brought into room by visitor ...” - The Nurse Notes by RN (E#9) on 7/25/2025 at 7:15 PM included - “Rapid Response - [Pt.#1] admitted for dehydration/failure to thrive gave pt meds at 2:00 PM vitals was taken at 4:00 PM pt vitals stable family came in to visit pt had no further complaints ...Heard pt bed alarm 5:18 PM family was not present. Walked in Pt was face down on the floor. Called for a Rapid response staff helped me place pt back into bed pt was unresponsive. Pt was intubated (tube inserted through person’s windpipe to allow breathing support) and we started CPR [cardiopulmonary resuscitation] and all life saving measures were exhausted. Pulse found and pt was transferred to ICU.” - RN E#3’s note, dated 07/25/2025 at 8:06 PM, included “7E staff escorted patient belongings to ICU, stated they found what they believe is ‘heroin’ and ‘drug paraphemia [paraphernalia].’ This RN called security STAT [immediately] and brought belongings up to Charge RN. HOA [House Supervisor], and Charge Notified. Security came and took all of patient’s belongings, visitor restriction applied.” - The Physician Report/Intensivist Consultation by Intensivist (MD#3) on 7/25/2025 10:12 PM included - “ ... Per nursing staff services some drug [paraphernalia] that was found in the room suspect possible use of drugs which could added to [Pt. #1’s] decompensation ... Assessment and Plan ... Cardiac arrest-suspect aspiration versus drug use as paraphernalia of drugs was found in [Pt.#1’s] room brought by family ... Recommendations ... due to fact there was drug paraphernalia noted in the room will order urine drug screen ...” - The Intensivist Progress Note by the Intensivist on 7/26/2025 at 10:29 PM included - “ ...Assessment and Plan - acute hypoxic respiratory failure requiring mechanical ventilation, s/p cardiac arrest - suspected aspiration event vs drug use ... obtain UDS (urine drug screen) if able, per bedside RN has not been collected as [Pt.#1] has made so little urine thus far ...guarded prognosis at this time ...” - Urine Toxicology screen results dated 7/27/2025 at 2:39 AM included - “ ... Amphetamines screen - Positive H ... Cannabinoids Screen - Positive H ...” - The Neurology Progress Note by the Neurologist on 7/27/2025 at 10:12 AM included - “ ... Patient remains comatose. [Pt.#1] is currently intubated and sedated. Eye movements are fixed. Pupils are sluggishly reacting. Corneals are absent ... Patient with anoxic encephalopathy (a severe type of brain damage caused by a complete lack of oxygen to the brain, often due to an event like cardiac arrest or choking) ...” - The record indicated that on 07/29/2025 at 1:06 PM, Pt. #1’s family decided to put patient on comfort care and withdraw support. Pt. #1 was subsequently extubated on 7/29/2025 at 5:12 PM, and expired shortly after at 5:58 PM. - The Death Certificate for Pt.#1 was reviewed and included - “ ...Date of Death - 7/29/2025 ...Cause of Death - Aspiration Pneumonia (Non-Traumatic), Cardiac Arrest /Hypotension /Sepsis /Acute Renal Failure /Septic Shock, Failure to Thrive ... Time of Death - 5:58 PM ...” 4. The Security Report filed for Pt. #1’s incident on 07/25/2025 was reviewed electronically with the Security Manager (E#7) on 09/23/2025 at 11:28 AM. The security report was entered on 07/25/2025 at 8:03 PM and indicated that security was alerted on 07/25/2025 at 7:28 PM, that contraband was found and picked up from Pt. #1’s room in the ICU. The items were described as a vial of medication and a brown powder wrapped in paper. The report indicated that the items were disposed of in the presence of two security officers. The report lacked documentation that the “vial of medication” was turned over to a Registered Pharmacist and the police were notified of the potential substances found and lacked photographs as required by policy. 5. The Adverse Event/Incident log from 04/01/2025-09/22/2025 was reviewed and did not include the incident related to the suspected contraband found in Pt #1’s room. 6. On 9/23/2025 at approximately 11:54 AM, an interview was conducted with the Unit Manager (E#5). E#5 stated that E#5 found out about the incident involving alleged illicit substance found in Pt.#1’s room only yesterday (9/22/2025). E#5 stated that the incident was not reported and thus, no investigation was conducted. E#5 stated that it is an expectation that these incidents will be reported or escalated so that an investigation can be conducted. 7. On 9/22/2025 at 2:56 PM, an interview was conducted with the Security Manager (E#7). E#7 stated that on 7/25/2025, a request for security assistance was received from the 7E Unit regarding contraband that was found in Pt.#1’s room. E#7 stated that the security officer who responded was given the alleged contraband and escorted 2 visitors in Pt.#1’s room out of the Hospital and visitor restriction was placed for Pt.#1. E#7 stated that the alleged contraband was described as a brownish substance in a pouch and a vial with a clear liquid with no label and appeared ‘similar to insulin’. E#7 stated that the alleged contraband were disposed of by security. E#7 stated that this incident was not reported to the Police. E#7 stated that this was not reported in their event reporting system. E#7 stated that this incident was discussed in their safety huddles but was unable to show documentation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 1 of 3 restraint records (Pt. #12) reviewed, the Hospital failed to ensure that a new restraint order was obtained prior to the use restraints. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion Management Policy” (revised 02/21/2024), was reviewed and required, “...For each episode of restraint... there must be clear documentation of the following: ...Orders for restraint... Non-violent, non-self destructive restraints must be ordered by an Authorized Clinician. The restraint order is to be obtained prior to the initiation of restraint whenever possible...PRN [as needed] and standing orders are prohibited for non-violent, non-self destructive restraints...” 2. The clinical record of Pt. #12 was reviewed on 09/24/2025 with the Nurse Manager (E#15). Pt. #12 was admitted on 07/18/2025 with a diagnosis of leukocytosis (high white blood cell count). The record included only one physician’s restraint order placed on 07/23/2025 at 11:30 AM, to start use of bilateral upper extremity (BUE) soft limb restraints at 11:00 AM due to the patient pulling lines/tubes. Restraint flowsheets and nursing notes indicated that non-violent restraints (BUE soft limb) were not initiated until 07/24/2025 at 2:00 AM (15 hours later); however, a new order for restraint use was not obtained. 3. An interview with the Nurse Manager (E#15) was conducted on 09/24/2025, at approximately 11:00 AM. E#15 stated that if restraints were ordered at 11:00 AM but the patient was not put in restraints at that time, then staff should have obtained a new order when the patient went into restraints later at 2:00 AM the following day. E#15 stated that while non-violent restraint orders are good for 1 calendar day, the order should not be used on an as needed basis.”

“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: 39802 Based on document review and interview, for 1 of 3 restraint records (Pt. #14) reviewed, the Hospital failed to ensure that use of restraint was discontinued at the earliest possible time. Findings include: 1. The Hospital’s policy titled, “Restraint and Seclusion Management Policy” (revised 02/21/2024), was reviewed and required, “...Once the unsafe situation ends, the use of restraint or seclusion must be discontinued...” 2. The clinical record of Pt. #14 was reviewed on 09/24/2025 with Nurse Manager (E#15). Pt. #14 was admitted on 09/02/2025 with a diagnosis of drug overdose. The record included a physician’s order to place Pt. #14 in 4-point locked restraints due to violent behavior causing risk of harm to self or others, and started on 09/04/2025 at 8:55 PM and was discontinued on 09/05/2025 at 12:48 AM. The record indicated that Pt. #14 was placed in bilateral upper extremity soft limb restraints (non-violent) on 09/05/2025 at 12:48 AM (immediately after removing the violent restraints). The non-violent restraint order placed on 09/05/2025 included a reason “to prevent injury related to the patient’s medical condition.” The record indicated that Pt. #14 was asleep when the 4-point locked restraints were removed and remained asleep until the non-violent restraints were removed on 09/05/2025 at 8:00 AM. 3. An interview was conducted with Nurse Manager (E#15) on 09/24/2025, at approximately 11:00 AM. E#15 stated that if the patient’s behavior no longer warrants use of restraints, the restraints should be removed. E#15 stated that if the patient fell asleep and remained asleep, the restraints should have been discontinued. E#15 stated that it was unclear why they put on non-violent restraints immediately after removing the violent restraints.”

“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: 40079 Based on document review and interview, it ws determined that for 1 of 3 (Pt.#1) clinical records reviewed for nursing services, the hospital failed to ensure that the nurse notified and obtained a physician’s order for transfer of a patient and failed to ensure that the tranfer certification form was completed by the physician. Findings include: 1. The hospital’s policy titled, “Discharge of a Patient” (revised 04/04/23) was reviewed and required, “Discharge to another Hospital ... I. LIP (licensed independent practitioner) completes discharge order ... II. LIP or RN contacts consultants as appropriate to obtain clearance for discharge of patient ... “ 2. The hospital’s “Job Description for Registered Nurse” (effective 04/22/2019) was reviewed and included, “Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders. Assesses and coordinates patient’s discharge planning needs with members of the healthcare team. 3. The clinical record for Pt.#1 was reviewed. Pt.#1 was admitted to the hospital on 06/06/24 and was discharged/transferred per family request on 06/09/24. The clinical record included the following; however, the clinical record lacked an order for discharge/transfer from the physician: -History and Physical (MD#1), dated 06/07/24 at 10:52 AM, “ ... (Pt.#1) admitted for evaluation of stroke ... Neurology has been consulted. (Pt.#1) to undergo all the imaging study protocol for stroke.” -Physician Report Stroke Progress Note (MD#2/Neurologist), dated 06/08/24 at 12:53 PM, “There were no acute events overnight ... All 3 daughters are present today ... discussing the patient’s (Pt.#1’s) rehabilitation options ... asked many questions about (Pt.#1’s) TEE (Transesophageal Echocardiogram-used to visualize detailed close-up view of heart) and diagnostic cerebral angiogram (diagnostic procedure that shows images of blood vessels) that is planned for 6/10/24. All questions were answered.” -Nurse Note, dated 06/09/24 at 10:39 PM, “(Pt.#1’s) daughter contacted Charge RN to state concerns regarding I/O (intake and output), patient turning Q2 (every 2 hours) ... daughter stated to Charge Nurse she wants all procedures stopped and will be transferring (Pt.#1) out 6/10. (Pt.#1) was made aware of daughters call with staff ...” -Discharge Summary/Provider (MD#1) dated (07/12/24 at 7:02 AM) actual date of discharge was 06/10/24. “Clinically stable. Foley catheter in place for Urinary Retention. Family wants patient transferred to another Facility. D/W (discussed with) Hospitalist at length - not sure if they are accepting.” The Discharge Summary did not indicate the name of the physician or hospital that MD#1 spoke to and did not indicate that (Pt.#1) was accepted prior to transfer. The clinical record did not include a discharge/transfer physician order. -Patient Transfer Certification/Consent Form, dated 06/10/24 at 1400 (2:00 PM), included, “Name/Signature of Physician Transferring Patient: (name of MD #1) ... Name of Physician and Hospital Contacted/Accepted Patient’s Transfer: (left blank) Date and Time Contacted: (left blank) ... Section To Be Completed by Patient (check one of the following) After being provided an appropriate medical screening examination based upon the information available at the time of the examination and being informed of the risks, benefits, and alternatives ... the risks involved in a transfer to another institution and the options available ... I do hereby: Accept responsibility and agree to transfer (is checked). Signature of Patient (left blank) ... witness (signed by discharge nurse E#11).” The form was not signed by the Transferring Physician and or (Pt.#1) or healthcare power of attorney. The form lacked documentation of the name of accepting physician and hospital. 4. An interview was conducted via phone with the Attending Physician (MD#1) on 11/20/24 at 12:43 PM. MD#1 stated that for pts requesting transfer to another hospital for same level of care the family needs to provide the name of the accepting physician and hospital. The physician will reach out to that hospital’s accepting physician and provide the information required. The Physician would contact the accepting physician then provide the transfer or discharge order. Documentation of communication with the accepting Physician should be included in the clinical record to indicate that the patient has been accepted by the other facility.”

“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: 39802 Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for chest pain, the hospital failed to ensure that the physician was notified of new onset and continued symptoms. Findings include: 1. The hospital’s policy titled, “Clinical Documentation Guideline” (revised 9/6/2022), was reviewed and required, “...Focused documentation will be completed as the patient’s condition changes. Purpose: To establish a standard process for the communication of essential patient information that accurately reflects patient care, treatment, and services provided... Add or customize interventions as new problems are identified or the patient condition changes... Complete a narrative note in the Data, Action, Response (DAR) format on admission, transfer, discharge, and change in condition... 1. Data: Detail the subjective and objective information related to a patient focused problem/issue. 2. Action: Describe the intervention and actions taken to address the problem or data above. 3. Response: Evaluate the patient’s response to the applied interventions. Was the problem resolved, or are future actions/interventions needed?...” 2. The hospital’s policy titled, “Rapid Response Team (RRT)” (revised 7/20/2022), was reviewed and required, “...Any of the following guidelines may be used for activating the Rapid Response Team include, but are not limited to: ...Chest Pain... A Rapid Response Team (RRT) will be called for all people (including patients...) requiring medical attention that does not meet Cardiac Arrest criteria... RRT member roles include, but are not limited to: “Charge RN - notify the patient’s attending physician and acquire further orders...” 3. The hospital’s policy titled, “Chain of Command - Licensed Independent Practitioners (LIP) and Operational Issues” (revised 8/21/2017), was reviewed and required, “...Appropriate documentation in the medical record will reflect objective patient assessment information, notification of the physician and orders received...” 4. The clinical record of Pt. #1 was reviewed on 6/4/2024. Pt. #1 presented to the hospital’s Emergency Department (ED) on 2/24/2024, at approximately 10:00 AM, with a chief complaint of shortness of breath and was admitted to the 2 West Telemetry Unit on 2/24/2024 at 11:46 AM, with diagnoses of acute COPD (chronic obstructive pulmonary disease) exacerbation and sinus tachycardia (elevated heart rate/above 100 beats per minute). The initial ED and nursing assessment indicated that Pt. #1 reported no pain upon admission. - The Attending Physician (MD#1) Progress note on 2/26/24 at 12:25 PM included - “02/26/24 - Feeling better, Denies any pain ...” - Nursing assessments from 2/24/2024-2/28/2024 were reviewed and indicated that Pt. #1’s heart rate remained elevated (between 100-120 beats per minute/bpm range, normal is 60-100) it was noted that other vital signs were with in normal parameter. -Pt. #1’s pain assessment were reviewed from 2/24/24-2/28/24. Pt. #1 did not complain of pain upon admission on 2/24/24 to 2/26/2024. Pt. #1 complained of pain 2/26/2024 at 11:06 PM. The Nursing pain assessment by Nurse (E#2) on 2/26/2024 at 11:06 PM included: “Pain present? - Y, Pain location - Ribs, Pain location modifier - Chest wall ... description - achy ...pain intensity - 4 out of 10, acceptable level of pain - 2 - acceptable level ...aggravating factors - breathing, coughing, movement ...” Another pain assessment by E#2 on 2/27/2024 at 05:10 AM included, “Pain present - Y, Pain location - ribs, pain location modifier - chest wall ...description - achy ...pain intensity - 5 out of 10, acceptable level of pain - 2 - acceptable level ...aggravating factors - breathing, coughing, movement ...” On 2/27/24 at 10:20 PM and 11:00 PM pain assessments were assessed as mild pain of 2-3 respectively. Tylenol (pain medication) was administered when Pt#1 complained of pain and reassessments indicated relief of pain to an acceptable level (2). - Nursing note (E#2), dated 2/27/24 at 1:06 AM included “ ...Has rib pain specially with inspiration/deep breathing and with movement ...Heart rate on 100’s, heart rate goes up to 120’s when patient is ambulating [walking] to the bathroom ...Will observe for any untoward signs and symptoms.” The record lacked documentation that on 2/26/2024 the primary physician was notified or that unsuccessful attempts were made of the new onset and on 2/27/204 continued complaint of mild to moderate chest pain described as :achy” when Pt. #1 would cough. The record lacked documentation that concern was escalated through the proper channels. - On 2/28/2024 at 10:10 AM, a Rapid Response Team (RRT) was initiated due to chest pain rated at a 5 described as sharp, supraventricular tachycardia (erratic fast heartbeat) and tachypneic (rapid shallow breathing). MD #1 was informed, labs, EKG, and a Cardiologist consult was ordered. The Cardiologist evaluated Pt. #1 and medication was ordered: Cardizem to treat the tachycardia, Aspirin and Nitroglycerin for chest pain management. On the evening of 2/28/24 a second RRT was initiated, followed by a Code Blue (cardiac arrest) on 2/28/2024 at 10:35 PM. Pt. #1’s was transferred to intensive care unit (ICU). Pt. #1 was intubated and resuscitative measures performed. The family was made aware of Pt. #1 condition and decided to remove intubation and stop medications. Pt. #1 expired on 2/29/2024 at 12:02 AM due to probable acute myocardial infarction (heart attack). 5. A telephone interview was conducted with the Hospitalist (MD#1) on 6/5/2024, at approximately 9:18 AM. MD#1 stated that Pt. #1 presented with symptoms of COPD exacerbation and the initial cardiac work-up in the ED was not significant for cardiac issues. MD#1 stated that MD#1 was not made aware that Pt. #1 was reporting any chest pain at all during the admission up until the rapid response on 2/28/2024. MD#1 stated that MD#1 would expect the nurses to notify MD#1 of a new onset of chest pain. MD#1 stated that MD#1 comes to see MD#1’s patient’s at least once a day and when MD#1 is not here, the nurses can call MD#1 or send a message through the Hospital’s messaging system. 6. An interview was conducted with the Registered Nurse (E#1) on 6/5/2024, at approximately 11:00 AM. E#1 stated that if a patient starts reporting new chest pain, they (staff) would call a rapid response and in that process the attending physician would be notified. E#1 stated that E#1 was working as the Charge Nurse the day of Pt. #1’s rapid response. E#1 stated they tried to get a hold of MD#1 regarding the patient’s change in condition and it took about 45 minutes before MD#1 responded. E#1 stated that nurses should document in the medical record that notification of the physician was attempted or completed and what instructions/orders were given if any. E#1 stated that documentation should include how many attempts were made if unable to reach the physician. E#1 stated that this notification could either be entered as an intervention or a DAR note. 7. An interview with the Director of Nursing (E#12) was conducted on 6/5/2024, at approximately 12:43 PM. E#12 stated that nurses are required to perform system assessments at least every shift and vitals at certain intervals depending on the unit and orders. E#12 stated that if the nurse’s assessment indicates a change in patient’s condition or new onset of symptoms, it should be documented in the clinical record. E#12 stated that if it was just a minor complaint, the nurse might call the doctor to let him know, if it’s a major concern like chest pain, a rapid response would be called, and the physician would be notified during that process anyway. E#12 stated that either way the nurse would write a note or put an intervention in the record that the physician was notified. 8. On 6/5/24 at approximately 2:00 PM, the Interim Manager of the Telemetry Unit (E #6) was interviewed. E #6 stated that after Pt. #1’s RRT on 2/28/24, E #6 reviewed Pt. #1 clinical record and assisted with the investigation. It was not identified that there were issues of not being able to notify MD #1 of Pt. #1’s new onset and continued chest pain. The results of the investigation were the nurses concerns that Pt. #1 didn’t have a cardiologist and how to initiate the escalation process. 9. A telephone interview was conducted with the RN (E#2) on 6/6/2024, at approximately 9:37 AM. E#2 stated that if any patient will come in with chest pain or reports chest pain later, E#2 will immediately call for a RRT Activation. E#2 stated they will call the primary physician for orders and maybe consult cardiology. E#2 stated that if no RRT is called, E#2 will still notify the primary physician. E#2 stated that if physicians do not respond to pages, E#2 will inform the supervisor. E#2 stated that if E#2 did not agree with a physician order E#2 will suggest and document the encounter. E#2 stated that if there were any issues, E#2 manager would discuss (huddle) with them right away but cannot recall any recently or any in regard to Pt. #1.”