St Marys Hospital

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 34824 Based on document review and staff interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided appropriate stabilizing treatment and/or transfer. Findings include: 1. Pt #1’s record was reviewed throughout the survey and revelaed that Pt #1 was brought to the ED by Illinois State Police (ISP) on 4/8/25 at 7:40 PM. “ED Triage Notes” by ED RN (E #3) dated 4/8/25 at 7:48 PM indicated, “Patient presents to the ED after attempting to kill himself by running into a median with his car at 90mph (miles per hour).” Pt #1’s record included a “Petition for Involuntary/Judicial Admission” that was completed by the ISP officer. The petition noted, “this petition is being initiated by reason of: Emergency inpatient admission by certificate ... I assert that (Pt #1) is: a person with mental illness who because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed ... (Pt #1) was involved in a single vehicle crash on I-72 west bound mile post 128. (Pt #1) intentionally drove his vehicle off the roadway into the center median and struck the concrete bridge support in an attempt to commit suicide. (Pt #1) advised he accelerated as he drove off of the road to approximately 85-90mph.” The form was signed and dated on 4/8/25 at 8:40 PM by the officer. A medical screening exam was conducted by ED MD (E #4) on 4/8/25 at 7:56 PM. The “ED Provider Notes” by E #4 included, “ ... History of Present Illness: (Pt #1) is a 40-year-old male ... brought in by PD[Police Department] after MVA (motor vehicle accident) while intoxicated. Patient hit median on highway at 90mph while under influence. Patient did not wear seat belt. Patient reports airbag did deploy .... Patient admits alcohol consumption. Patient expressed intention of committing suicide. Last suicide attempt at age 31 where he cut his L (left) wrist requiring sutures ... Patient denies any injuries from MVA. Petition filed by PD .... Physical Exam: ... Psychiatric: Speech: Speech is rapid and pressured. Behavior: Behavior is agitated, aggressive and hyperactive. Thought Content: Thought Content includes suicidal ideation. Thought content includes suicidal plan ....” A “Columbia Suicide Severity Rating Scale” was completed by E #3 on 4/8/25 at 7:57 PM and indicated Pt #1 was a “High Risk” for suicide. Pt #1 was placed on 1:1 suicide observation. E #4 completed and signed an “Inpatient Certificate” for Pt #1 on 4/8/25 at 8:00 PM. The Certificate noted, “ ... Based on the foregoing examination it is my opinion that he or she is: A person with mental illness who, because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; A person with mental illness who, because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm, without the assistance of family or others, unless treated on an inpatient basis; A person with mental illness who; refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or two above; is in need of immediate hospitalization for the prevention of such harm. I base my opinion on the following: alcohol intoxication, cocaine abuse, suicidal ideations and attempt. I believe that the individual is subject to: involuntary inpatient admission and is in need of immediate hospitalization.” Pt #1’s record indicated Pt #1’s initial alcohol (ETOH) bloodwork was 0.013 G/DL (grams per deciliter - legal limit 0.08) on 4/8/25 at 9:22 PM. Pt #1’s urine drug screen was positive for Cannabinoids (marijuana) and Cocaine Metabolites. Nursing note by ED RN E#5 on 4/8/25 at 11:21 PM indicated, “(Local PD) called at this time for patient elopement. Patient ran out of facility due to being irritated from writer and another nurse to take his ZYN (nicotine) pouches .... Patient then told mother to leave and then patient jumped out of the bed and ran out the door. Security trying to locate patient. Unable to get him ... (Local PD) was notified of patient leaving.” Another nursing note by E #5 on 4/8/25 at 11:45 PM indicated, “(local PD) brought patient back in room, security took belongings, sitter at bedside.” Nursing note by E #3on 4/9/25 at 1:13 AM indicated, “(Local behavioral health center) was called to evaluate the patient.” Pt #1’s record indicated; the local behavioral health clinician evaluated Pt at 2:00 AM. Nursing note at 2:17 AM indicated, “(Local behavioral health center) crisis worker evaluated the patient and (Pt #1) is ok for discharge with a safety plan ...” Discharge instructions by E #4 on 4/9/25 at 2:20 AM indicated, “Follow up with (Local behavioral health center) at clinic. Recommend abstinence from cocaine and alcohol use.” Physician note by E #4 on 4/9/25 at 2:21 AM indicated, “ED Course/ Medical Decision Making: Alcohol intoxication and cocaine abuse with aggressive behavior - easily triggered when expressed that driving under influence put others at risk and harm, patient then became belligerent and angry, using foul language with pressured speech and yelling discriminating comment that he cannot understand me (in reference to my Chinese accent), calling female nurse ‘c’ with foul language, requesting to go to DMH or jail instead. MVA - patient likely have refused EMS at scene. Here for medical and psychiatric clearance after being arrested by PD at scene ...Patient eloped in his own street clothing thru unlocked door. Patient was then brought back by PD at 11:30 PM. Security been instructed to change patient into paper scrub and remove all personal items from room. Repeat ETOH zero, drawn upon returned from elopement. Hence medically cleared. (local mental health program) evaluated patient who is now denying suicidal ideation or plan and able to proceed with contract of safety plan with (local mental health program). Hence cleared for discharge. Pt #1 was discharged home alone at 2:56 AM on 4/9/25. 2. The Sentinel Event log was reviewed from 04/01/25-7/2/25. The log included one event on 4/9/25 for Pt #1. The log indicated, “Specific Event Type: Patient - Condition Unexpected Decline... Sentinel Event: Suicide.” The sentinel event for Pt #1 was reviewed and indicated: “Investigation status: Preliminary investigation. RCA (root cause analysis) Unexpected Death Following ED Visit ... Determination Date: 6/10/2025; Entered on: 6/10/2025; To Be Completed By 7/25/25 .... Event title - Initial RCA Meeting ... Date 6/9/2025 ... Description: IDPH (Illinois Department of Public Health) arrived onsite to conduct a focused survey. It was determined that they were here for a complaint visit based on report of patient that was an ED patient that was discharged. After discharge, patient committed suicide ....” 3. Coroner’s case report for Pt #1 indicated, “ ... Investigator notified: 4/9/2025 06:06 (6:06 AM). Case Brief: 40 years old ... investigated on 4/9/202 at 6:06 AM. Suspected behaviors include ... Suspected COD (Cause of Death) is Drugs/Poisoning. Overdose by pills with a suspected manner of Suicide.” Pt #1’s Autopsy Report indicated “Date of Death: April 9, 2025 ... Time of Death: 10:42 AM ... Date of Autopsy: April 9, 2025... Time of Autopsy: 4:00 PM .... Summary Diagnoses: 1. Cocaine intoxication with cocaine metabolite at 920ng/ml (nanograms per milliliter - positive urine test is above 150ng/ml ... 6. Investigation history of psychiatric illness and recent hospitalization. 7. Presence of additional lamotrigine (mood stabilizer), olanzapine (anti-psychotic), clonazepam and metabolite 7-amino clonazepam (benzodiazepines - used in the treatment of anxiety), naloxone (narcotic reversal medication), and caffeine in the blood .... Cause of Death Opinion: The cause of death of this 40-year-old male, (Pt #1) is cocaine intoxication ...” 4. An interview was conducted with E #4 on 7/2/25 at 11:30 AM. E #4 stated, “(Pt #1) came in after motor vehicle accident. (Pt #1) was brought in by PD. They have a petition for him because of suicidal ideation. (Pt #1) disclosed that (Pt #1) was suicidal so they brought the patient here for medical eval and clearance. (local mental health center) came in to evaluate the pt and said that (Pt #1) was okay for discharge. We rely on their (the local mental health center’s) assessment. They said (Pt #1) was safe for discharge with safety plan. I discharged (Pt #1) with a follow up with them. I did not call a psychologist.” E #4 confirmed completing the certificate for involuntary emergency admission for Pt #1. E #4 stated, “(Pt #1) denied being suicidal after (Pt #1) was brought back to the hospital after elopement and continued to deny suicidal ideations at discharge.” 5. An interview was conducted with Quality Manager (E #1) on 7/2/25. E #1 stated, “We were unaware the pt had committed suicide until your last visit. Staff looked online and saw (Pt #1’s) obituary. We have started an RCA (Root Cause Analysis), but it is preliminary. We were waiting on the results of the last investigation to roll it out.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 34824 Based on document review, observation, and interview, it was determine the Hospital failed to appropriately evaluate on an ongoing basis to ensure patients were cared for in accordance with accepted standards of nursing practice and hospital policy. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services was not met. Findings include: 1. The hospital facility failed to ensure that the nurse completed a post-fall assessment after a patient fall. (See A392) 2. The Hospital failed to ensure fall precautions were in place for high fall risk patients. (See A396) The Immediate Jeopardy was identified on 10/08/2024, at 42 CFR 482.23, Nursing Services due to the Hospital’s failure to: ensure fall precautions were in place for high fall risk patients. Eight of Eight observed patients for high fall risk and 1 of 1 sentinel event for falls. Pt #1’s bed alarm sounded, and Pt #1 was found on the floor and sustained a head laceration and subdural hematoma (brain bleed). Pt #1 was ultimately transferred to another hospital for a higher level of care.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 34824 Based on document review and staff interview, it was determined for 1 of 3 (Pt #9) patient fall event records reviewed, the hospital facility failed to ensure that the nurse completed a post-fall assessment after a patient fall. Findings include: 1. On 10/7/24 at approximately, 1:30 PM, (Pt #9’s) record was reviewed. Pt #9 was admitted to the 6th floor Medical/surgical unit on 9/5/24 with a diagnosis of weakness. Pt #9’s record included a nursing note on 9/10/14 at 6:30 am which stated, “Per night shift nurse, patient had a fall through the night, the bed does not have an alarm, so patient called and stated that (Pt #9) needed help getting back up. Patient was then placed back in bed and they placed a chair alarm under (Pt #9). MD and (family) was notified. MD ordered x-ray of pelvis and hip.” 2. The Facility policy titled “HSHS Falls Prevention and Management (revised January 1, 2024)” was reviewed on 10/08/24 at approximately 3:00 PM. The policy stated, “ ... B. POST-FALL MANAGEMENT: ... 2. The patient is assessed for injuries. 3. The patient’s injuries are addressed immediately to prevent further patient harm ... C. DOCUMENTATION POST-FALL: a. Patient location and appearance at time of discovery. b. Patient response to event. ...” 3. An interview was conducted with the Nurse Educator (E #6) on 10/08/24 at approximately 11:30 AM. E #6 verbally agreed the record lacked a post fall assessment and stated, “there should have been a post-fall assessment documented.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 34824 Based on observation, document review and interview, it was determined for 8 of 8 (Pt # 3, #4, #5, Pt #6, Pt #11, P#12 and Pt #13) observations and 1 of 1 (Pt #1) sentinel event patient records, the Hospital failed to ensure fall precautions were in place for high fall risk patients. Pt #1’s bed alarm sounded, and Pt #1 was found on the floor and sustained a head laceration and subdural hematoma (brain bleed). Pt #1 was ultimately transferred to another hospital for a higher level of care. Findings include: 1. An observational tour was conducted on 10/7/24 of the 6th floor Medical/Surgical unit with RN/Educator (E #6) from 10:25 AM to 11:00 AM. The following observations were noted: - Room 631- the fall indicator light outside of the patient’s room was not illuminated. Pt #3 was observed sitting in bed, but bed alarm was not on. Pt #3 was admitted to the Hospital on 10/3/24 for hip and arm pain. Pt #3’s Morse Fall Score/PA Score on 10/7/24 was 95 (score greater than 45 indicates patient is a high fall risk). - Room 630 - the fall indicator light outside of the patient’s room was not illuminated. Pt #4 was observed sitting in bed, but bed alarm was not on. Pt #4 was admitted to the Hospital on 10/2/24 for groin pain, constipation, and urinary symptoms. Pt #4’s Morse Fall Score/?PA Score on 10/7/24 was 75. - Room 614 - Pt #5 was observed sitting in bed, but bed alarm was not on. Pt #5 was admitted to the Hospital on 10/5/24 for weakness. Pt #5’s Morse Fall Score/PA Score was noted on 10/7/24 and was 75. - Room 605 - Pt #6 was observed sitting in a chair, no chair alarm was in place. Pt #6 was admitted to the Hospital on 10/5/24 with a diagnosis of pneumonia. Pt #6’s Morse Fall Score//PA Score on 10/7/24 was 85. - Room 608 - the fall indicator light outside of the patient’s room was not illuminated. Pt #7 was admitted to the Hospital on 10/6/24 with a diagnosis of sepsis. Pt #7’s Morse Fall Score//PA Score on 10/7/24 was 75. - Room 629 - the fall indicator light outside of the patient’s room was not illuminated. Pt #11 was observed sitting in bed and bed alarm was not on. Pt #11 was admitted to the Hospital on 10/6/24 with a diagnosis of acute kidney injury and urinary tract infection. Pt #11’s Morse Fall Score//PA Score on 10/7/24 was 85. - Room 606 - During the observational tour Pt #12 was observed sitting in bed and bed alarm was not on. Pt #12 was admitted to the Hospital on 10/3/24 with a diagnosis of heart failure. Pt #12’s Morse Fall Score//PA Score on 10/7/24 was 50. - Room 609 - the fall indicator light outside of the patient’s room was not illuminated. Pt #13 was observed sitting in bed and bed alarm was not on. Pt #13 was admitted to the Hospital on 10/3/24 with a diagnosis of left total knee revision. Pt #13’s Morse Fall Score//PA Score on 10/7/24 was 60. Observations confirmed with Registered Nurse Educator (E #6) and E #6 verbally agreed the patients were high fall risk and the fall interventions were not in place. 2. The policy titled “HSHS Falls Prevention and Management (Rev 01/01/2024)” was reviewed. The policy stated, “ ... 1. Prevention: 1. Fall Risk Assessment: ... 2. The patient’s risk assessment is performed and scored using the evidence-based risk assessment tools and may include but is not limited to ... a. Upon admission to the hospital or ED. b. Once per shift (admitted patients) ... 3 ... a. High Risk Fall prevention interventions will be implemented for patients with fall risk score that fall into the high-risk category ... ii. Implement, at a minimum, fall risk interventions as outline in the EMR (Electronic Medical Record) ... “ 3. The EMR “Fall Risk Interventions” flowsheet was reviewed and indicated, “Patient Morse/Fall Risk PA Score of 45 or higher is HIGH RISK; implement applicable individual and ALL HIGH RISK interventions.” 4. Fall Prevention education was reviewed and included, “High Fall Risk Interventions: Fall risk care plan, fall risk visual indicator outside the door, bed and chair exit alarms, yellow fall risk charm on ID band, non-skid socks ...” 5. Pt #1’s record was reviewed throughout the survey. Pt #1 arrived by ambulance to the Emergency Department (ED) on 8/19/24 at 8:05 AM with a chief complaint of “Palpitations (feeling of heart pounding/racing) and shortness of breath.” A cardiology consult was conducted at 12:12 PM and stated, “ ... Physical Exam: ... Neurological: Mental Status: (Pt #1) is alert. Psychiatric: Cognition and Memory: Cognition is impaired. Memory is impaired.” Pt #1 was admitted to the 6th floor at 3:15 pm. Initial inpatient Fall Risk Assessment at 3:55 pm completed by Registered Nurse (E #7) indicated a Morse Fall Risk Score of 85 (Score of 45 or greater is High Risk). Pt #1’s record stated, “High Risk Fall Interventions: Initiate Fall Risk Care Plan.” At 7:00 pm, Licensed Practical Nurse (E #8) documented a “Shift Assessment” which included, “Neurological: ... Alert, Oriented to person, Cognition: Impulsive; Poor Judgement; Poor safety awareness; Poor attention/concentration ... Fall Risk Interventions: Standard Fall Prevention: ... Rounding Q (every) 2 hrs (hours); Individualized Fall Interventions: ... Place patient for visualization... Elimination Q 2 hrs ...” A nursing note at 10:02 pm stated, “Patients bed alarm went off and writer went to find patient on floor with blood coming from back of head. Patient assessed and was assisted back to bed and hospitalist called at this time.” A “Plan of Care” by Nurse Practitioner (NP - E #9) noted, “Notified by nocturnist at 10:02 pm that patient has suffered a fall ... Copious amounts of blood are on the floor and matted to (Pt #1)’s head. Per nursing report, patient was found laying on the floor. Stat Head CT[computed tomography scan] and C spine ordered. Head CT result showed acute right frontoparietal convexity extra-axial hematoma (right frontal head bleed) .... Called and discussed case with cardiologist in regards to coumadin reversal - recommends 5mg (milligram) oral Vitamin K ... Patient is restless. GCS[Glascow Coma Scale] 11. I called and spoke with (outlying hospital with higher level of care capabilities) ... Case presented to trauma surgeon. Read head CT report to the trauma surgeon ... Patient accepted for transfer for expert consultation of trauma surgery .... Patient to be Med-Evac to (other hospital) ... This patient had a high probability of imminent or life-threatening deterioration due to acute subdural hematoma ...” Pt #1’s record lacked initial fall interventions placed upon inpatient admission and lacked the 2-hour rounding required which would have indicated fall interventions that were in place when Pt #1 fell. Pt #1 was documented at 7:00 pm as “Impulsive; Poor Judgement; Poor safety awareness; Poor attention/concentration” with no change/modification in fall prevention interventions. 6. The Adverse Event and Sentinel Event logs were reviewed and included Pt #1’s event. The “Moderate Risk Event” document was reviewed and stated, “ ... Assessment- Opportunities: ... Intervention of rounding Q2 - no documentation of rounding completed within 2 hours of fall .... Recommendation: ... Re-education on purposeful and appropriate documentation in tier 1 huddles (purposeful rounding tip sheet) annually ... Due Date 11/15/2024” 7. An interview was conducted with Medical/ Surgical Unit Nurse Manager (E #3) on 10/08/2024 at approximately 10:30 am. E #3 stated, “We just started to roll out the education last week. We do not have formal sign in sheets to indicate who all has received the education.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34824 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to provide care in a safe setting by failing to appropriately monitor a patient receiving medications with sedative and tranquilizing effects. See deficiency at A-144A. 2. The hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients. See deficiency cited at A-144B. 3. The Hospital failed to ensure renewal restraint order was obtained within the required time frame. See deficiency cited at A-171. The Immediate Jeopardy began on 02/28/24 due to the Hospital’s failure to monitor a patient who had received sedative medications that can cause cardiovascular side effects which resulted in Pt #1 being found unresponsive not breathing and without a pulse. It was identified on 03/07/24, at 42 CFR 482.13, Patient Rights. The IJ was not removed by the survey 03/07/24.”

“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: 30383 A. Based on observation, document review and interview, it was determined for 1 of 1 (Pt #1) patient, the Hospital failed to provide care in a safe setting by failing to appropriately monitor a patient receiving medications with sedative and tranquilizing effects. Pt. #1 was found unresponsive, cardiopulmonary resuscitation initiated and the patient was ultimately transferred to another hospital for a higher level of care. This has the potential to affect all patients in the Emergency Department. Findings include: 1. Pt #1’s record was reviewed throughout the survey. Pt #1 arrived by ambulance to the Emergency Department (ED) on 2/27/24 at 8:10 AM with a chief complaint of “Behavioral Problem.” Pt #1’s chart noted the following: - 8:11 AM the “ED Triage Notes” stated, “Pt arrives bls (basic life support) per (local ambulance) with police escort. Patient is in paper scrubs, states (Pt #1) left (other local hospital) to find a way to Springfield for rehabilitation. Patient states that (Pt #1) has been using drugs but doesn’t remember exactly when, states it was cocaine/heroin/meth .... Patient denies SI (suicidal ideations). Patient is also talking to people that are not in the room.” - 8:14 AM Vital signs were obtained. Blood pressure 120/91, heart rate 98, respiratory rate 18 with an oxygen saturation of 99% on room air. - Patient was placed in room 20 and placed on close observation/elopement risk with a sitter (E #8) at 8:15 AM. - 9:10 AM nursing note stated, “Patient is walking in room, yelling at staff while naked ... (ED MD #1) notified. Security at bedside.” Pt #1 was given Versed (a central nervous system depressant used in anesthesia and for anxiety) 5 milligrams (mg) IM (intramuscular). Pt #1 was also given Zyprexa (a sedating antipsychotic) 10 mg IM at 9:11 AM. - Urine drug screen was done which showed positive for Cannabinoids, Methamphetamine, and Amphetamine. - 9:54 AM nursing note stated, “Labs and EKG (electrocardiogram) not completed yet due to patient not sitting still and fighting at this time.” - 10:10 AM Pt #1 was placed in 4-point (both wrists and both ankles) locking restraints due to Pt #1 being a “imminent risk of harm to self.” - 10:25 AM Pt #1 was given Zyprexa 10 mg IM and Versed 5 mg IM. - 12:30 PM sitter documented Pt #1 “agitated; complaining; restless; screaming; tearful/crying.” - 12:37 PM Pt #1 was given Versed 5 mg IM - 12:44 PM Pt #1 was given Zyprexa 10 mg IM. - 1:28 PM nursing note stated, “Patient still very restless at times and pulling at restraints. Will attempt IV(intravenous) access for fluids and antibiotics once patient is calmer. (ED MD #1) notified and ok with holding fluids and antibiotics until patient is calmer.” - Sitter documentation indicated Pt #1 remained “agitated; restless; complaining; screaming: between 1:30 PM and 5:30 PM. -5:45 and 6:00 PM sitter documentation indicated Pt #1 was “calm” and “awake”. - 6:00 PM nursing restraint monitoring documentation indicated, Pt #1 was “agitated/restless; hallucination; delusional, tearful..” - 6:10 PM Pt #1 received Versed 5 mg - per sitter documentation Pt #1 was “asleep” from 6:30 PM 7:15 PM and remained in restraints. -7:30 PM nursing note stated, “ ... Pt remains agitated, yelling/pulling at restraints. Pt writhing in bed, yelling ‘don’t do this to me again, ’.. no evidence of learning from pt.” - 7:45 order was placed for Precedex (sedative) IV drip by ED MD #2. - 7:51 PM ED Charge Nurse (E #5) started the Precedex drip at 0.2 mcg/kg/hr (microgram per kilogram per hour). - 7:56 PM nursing note stated, “Patient awake and yelling out talking to people that (Pt #1) sees in the room ...” - ED MD #2 note stated, “I went into the patient’s room at 8:00 PM and found (Pt #1) unresponsive. A dexmedetomidine (Precedex) drip had been initiated at 7:51 PM. The patient was apneic and pulseless. A code was called .... 0.5 mg of IV flumazenil (benzodiazepine reversal medication) and 2 mg of iv naloxone (opioid reversal medication) ... a return of spontaneous circulation was achieved .... A 12 lead EKG was obtained and was noted to be unremarkable .... plan to transfer for admission of the patient for further management.” The record included a Precedex order at 7:45 PM, with the following parameters: notify provider if HR(heart rate) < 50 bpm, systolic bp (blood pressure)< 90mmHg, RR(respiratory rate)<10 bpm “or” with SpO2(oxygen saturation) < 92%. The record lacked any vital sign monitoring or cardiac monitoring between 8:14 AM and 8:00 PM even though pt had received a total of 30 mg Zyprexa IM, 17.5 mg Versed IM and was started on Precedex which can all cause cardiovascular side effects (i.e.. Low blood pressure and low heart rate). 2. An interview was conducted with ED RN (E #4) on 3/5/24 at approximately 3:00 PM. E #4 stated, “I came in that day at 10:30 AM. At that point I had this pt (Pt #1), another psych pt and 2 other pts including one with a GI (gastrointestinal) bleed. (PT #1) was already in restraints and had already been given Zyprexa and Versed IM at least once. When nightshift came in, I was given another psychiatric pt who was paranoid. (E #5 - Charge Nurse) started the Precedex and didn’t tell me. (ED MD #2) and I walked into (Pt #1)’s room and found her unresponsive. I went to all the IV pumps and shut everything off. The patient should have at least had vitals taken before the Precedex but should have been placed on the monitor.” When asked if E #4 filed an incident report, E #4 stated, “No, I did not.”. 3. An interview with Pharmacist (E #6) was conducted on 3/6/24 at approximately 11:30 AM. E #6 stated, “Precedex carries cardiovascular risks including low blood pressure and decreased heart rate and therefore should be monitored. This is a new ED provider group. These providers order different medications than we are used to, such as in this case with the Precedex. Precedex used for anxiety at this time is new and unusual, but it can be used. I have reviewed this record. The medication dosages for the Zyprexa, Versed and Precedex are within the parameters for administration. The Zyprexa can cause prolonged QT (ekg changes that can potentially lead to death) which was noted on the second EKG after the event. The provider had confirmed the previous EKG from November of 23 did not show a prolonged QT.” 4. An interview was conducted with ED Charge Nurse (E #5) on 3/6/24 at 1:00 PM. E #5 confirmed starting the administration of Precedex. When asked did you obtain vital signs before administering the Precedex, E #5 stated, “No, I did not.” When asked if E #5 was aware when the last vitals had been taken, E #5 stated, “No, I don’t.” When asked if E #5 placed the pt on the cardiac monitor, E #5 stated, “No, I did not. All cords were removed due to patient was a psychiatric pt. I was going to talk to the primary nurse after leaving the room regarding the monitor as a pt who had received as much Zyprexa and Versed as (Pt #1) did, should have been on the monitor. I did not file an incident report.” 5. An interview with ED MD #2 was conducted on 3/7/24 at approximately 8:45 AM. E #2 stated, “If I order Precedex, I usually order parameters and it would be titrated (adjusted to meet acceptable pt condition). I would put in vital sign parameters. Precedex requires close monitoring of blood pressure and pulse.” 6. An interview was conducted with Quality Manager (E #10) on 03/06/24 at approximately 3:00 PM. E #2 confirmed the above findings and verbally agreed Pt #1 was not monitored and should have been. E #2 stated, “We were made aware of the incident over the weekend when (the other hospital filed a report). There should have been a report filed. There has been an IRIS(Incident Reporting Information System) report started today.” B. Based on document review and interview, it was determined for 2 of 2 (Pt #1 and Pt #3) Emergency Department (ED) patients reviewed for 1:1 continuous monitoring, the Hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients. Findings include: 1. On 03/05/24 the policy titled “Safety Precautions: Suicide and Self Harm (Non-Behavioral Health Units) Policy (effective 07/07/22)” was reviewed. The policy stated, “... Guidelines... D. For patients who screen positive for suicidal ideation, an evidence-based process will be utilized to conduct a suicide risk assessment... G. Patients who are at high risk for suicide will be monitored according to the protocol outlined below... Initial Risk level based on screening questions... High: Alert Provider, 1:1 Observations, Safety Plan...” 2. On 03/05/24 at approximately 11:00 AM an observational tour was conducted. The following was noted: a sitter was between rooms #1 and #2 (outside of the rooms). An interview was conducted with the ED RN (E # 7) who stated, “the sitter is observing both patients in room #1 and room #2. The patient in room #1 (Pt #7) is here for psychiatric evaluation, but denied suicidal ideations. The patient in room #2 is suicidal.” 3. Pt #3 and Pt #7’s records were reviewed and indicated: -Pt #3 was admitted to the ED on 03/04/24 at 4:03 PM with a chief complaint of “Psychiatric Evaluation.” The physician’s medical screening exam stated, “... Psychiatric:... Thought Content includes suicidal ideation.” 1:1 sitter documentation started at 4:15 PM. -Pt #7 was admitted to the ED on 03/04/24 at 8:30 PM with a chief complaint of “Psychiatric Evaluation.” Pt #7 was on close observation from time of arrival until discharge on 3/5/24 at 11:12 AM. Both records indicated the same sitter provided all observations. 4. On 03/06/24 at approximately 3:00 PM an interview was conducted with Quality RN (E #12). E #12 reviewed the records and verbally agreed the sitters were observing more than 1 patient. 5. Pt #1, Pt #8 and Pt #9’s clinical records were reviewed and indicated: -Pt #1 was admitted to the ED on 2/27/24 at 8:10 AM with a chief complaint of “Behavioral Problem.” Pt #1 was placed on “Close Safety Observation” upon admission. Sitter documentation was initiated at 8:15 AM and continued until 8:00 PM. -Pt #8 was admitted to the ED on 2/27/24 at 4:44 AM with a chief complaint of “Toxidrome, Suicidal.” Pt #8 had an order dated 2/27 at 4:48 AM for “Patient monitoring 1 staff 1 patient” and was continued until discharge 02/28/24 at 12:10 AM. Sitter documentation was completed throughout the time in the ED. -Pt #9 was admitted to the ED on 2/27/24 at 7:20 PM with a chief complaint of “Substance Abuse, Psychiatric Evaluation.” An order for “Suicide Precautions” was placed on 2/27 at 7:26 PM. Pt #9’s sitter documentation started on 2/27 at 7:30 PM and continued until 2/27 at 11:00 PM. All sitter documentation was conducted by the same sitter (E #8) from 7::00 AM until 5:45 PM. At 5:45 PM, sitter (E #9) was completing all sitter documentation for the three patients. 6. On 03/06/24 at approximately 1:00 PM, an interview was conducted with ED RN (E #5). E #5 stated, “Psychiatric patients who require a sitter should have a 1:1 sitter. Most of the time the staffing doesn’t allow it. There was one sitter for 3 patients (the evening of 2/27/24). “”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 34824 Based on document review and interview it was determined for 1 of 4 (Pt # 1) patients placed in a violent restraint, the Hospital failed to ensure renewal restraint order was obtained within the required time frame. 1. On 03/05/24 the policy titled, “HSHS Restraint and Seclusion Policy (effective 12/14/2020)” was reviewed. The policy stated, “... VI. Restraint Procedure: A. Violent or Self-Destructive Behavioral Restraints/Seclusion... 8. Orders for violent behavioral restraint or seclusion are limited to the duration listed below.... a new physician’s order (phone order is acceptable) must take place: a. 4 hours for adults 18 and older....” 2. The clinical record for Pt #1 was reviewed on 03/05/24 thru 03/06/24. Pt #1 arrived to the ED (Emergency Department) on 02/27/24 at 8:00 AM with a chief complaint of “Behavioral Problem.” Pt #1 was placed in violent restraints on 2/27/24 at 10:10 AM and was removed from the restraints at 8:00 PM.. A physician’s order on 02/27/24 at 10:23 AM, noted 4 point restraints, “reason for restraint: Danger to self, Danger to others” Another order for 4 point restraints was then placed at 3:59 PM, greater than the 4 hour requirement. The record lacked any further restraint orders (Pt #1 remained in restraints for 9 hours and 50 minutes). 3. During an interview on 3/06/24 at approximately 2:00 PM, Infection Control/Quality (E #1) reviewed the record and verbally agreed the above re-order was not obtained in the required time frame and should have been E #1 stated, “I only see those 2 orders, there should have been another order for the restraints. The restraints should be ordered every 4 hours if the pt remains in the restraints.””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 34824 Based on document review and interview, it was determined that for 17 of 36 days from January 28th 2024 thru March 3rd 2024 the Hospital’s Emergency Department (ED), the Hospital failed to ensure that there was adequate number of nursing personnel qualified in emergency care to meet the needs anticipated by the Hospital, as required. Findings include: 1. On 03/06/24, the Hospital’s ED FY24 (fiscal year) Staffing Matrix was reviewed. The Matrix indicated the ED should be staffed with 5 RNs from 7:00 AM until 12:00 PM, 6 RNs from 12:00 PM until 12:00 AM, and 5 RNs from 12:00 AM until 7:00 AM. 2. On 03/06/24, the ED Daily Staffing Sheets dated 01/28/24 through 03/04/24 were reviewed. The staffing sheets indicated that for 17/ 36 days the ED was staffed with only 4 RNs. The dates included: 1/28 : 6:45 PM until 1/29 7:00 AM 1/30: 6:45 PM until 1/31 7:00 AM 3 RNs and 1 LPN 1/31 : 6:45 PM until 10:00 PM 4 RNs and 1 LPN, 10:00 PM until 2/1 7:00 AM 3 RNs and 1 LPN. 2/2 : 6:45 PM until 2/3 12:00 AM - 4 RNs, 12:00 AM until 7:00 AM 3 RNs 2/3 : 6:45 PM until 2/4 7:00 AM - 4 RNs 2/4 : 6:45 PM until 2/5 7:00 AM - 4 RNs 2/6 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/7 7:00 AM 4 RNs 2/7 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/8 7:00 AM 4 RNs 2/8 : 6:45 PM until 10:15 PM 5 RNs, 10:15 PM until 2/9 2:00 AM 4 RNs, 2:00 AM until 7:00 AM 3 RNs 2/9 : 6:45 PM until 2/10 7:00 AM 4 RNs 2/11 : 6:45 PM until 2/12 7:00 AM 4 RNs 2/17 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/18 7:00 AM 4 RNs 2/18 : 6:45 PM until 10:00 PM 5 RNs, 10:00 PM until 2/19 7:00 AM 4 RNs 2/20 : 6:45 PM until 2/21 7:00 AM 4 RNs 2/22 : 6:45 AM until 11:00 AM 4 RNs, 11:00 AM until 6:45 PM 5 RNs, 6:45 PM until 10:30 PM 4 RNS 10:30 PM until 2/23 7:00 AM 3 RNs 2/25 : 6:45 PM until 2/26 7:00 AM 4 RNs 2/27 :: 6:45 PM until 2/28 12:00 AM 5 RNs (1 was a Medical Surgical Nurse with no ED training), 5 RNs, 11:00 PM until 2/28 7:00 AM 4 RNs (with Medical Surgical nurse with no ED training) On 2/10 : 7:00 AM until 7:00 PM - 4 RNs, from 7:00 PM until 2/11 - 3 RNs. 3. On 03/06/24 at approximately 2:00 PM, an interview was conducted with the Quality Manager (E #10). E # 10 reviewed the staffing sheets and verbally agreed the staffing does not meet the staffing grid requirement.”