Silver Cross Hospital and Medical Centers

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, Pt. #6, and Pt. #7) clinical records reviewed for assessment and reassessments, the hospital failed to ensure that reassessments were performed as required. 1. On 9/23/2024, the hospital’s policy titled, “Assessments and Reassessments in the Emergency Department (ED)” (9/11/2023) was reviewed and included, “...Reassessment: To be carried out by an ED RN (Emergency Department Registered Nurse)...Reassessments should occur when there is a significant change in the patient’s condition or if the reassessment is due per the guidelines noted below...this should include a focused reassessment, vital signs, and a pain assessment ...Level 2: < (less than or equal to) 2 (two) hours ...Level 3: < (less than or equal to) 3 (three) hours ...”. 2. On 9/23/2024, the clinical record of Pt. #1 was reviewed and indicated that on 5/20/2024 at 10:31 PM, Pt. #1 presented to the Emergency Department (ED) by private vehicle with chief complaint of fever (allergic reaction). The clinical record included the following: - On 5/20/2024 at 10:42 PM, the ‘ED Triage Adult Assessment’ indicated that vital signs (Temperature Oral: 37.3 DegC [degrees Celsius] (reference range: 36.1 to 37.2 Celsius) , Peripheral Pulse Rate: 122 bpm [beats per minute] (HI/reference range 60 to 100), Systolic Blood Pressure: 145 mmHg [millimeters of mercury] (HI/reference range 120), Diastolic Blood Pressure: 88mmHg (reference range: 80), Respiratory Rate: 20 br/min [breaths per minute] (reference range: 16-20), SpO2: 93% (reference range: greater than 90), Oxygen Therapy: Room air) and pain level (8 of 10) were assessed, and Pt. #1 was given an ESI (Emergency Severity Index) of 2 (Emergent: patient still very ill ...High risk situation). - On 5/20/2024, the ‘Pain Assessment and Vital Signs’ flowsheets indicated that Pt. #1’s pain and vitals were performed at 10:42 PM (time of Triage Assessment) and a subsequent temperature check on 5/21/2024 at 12:05 AM was performed. The clinical record lacked the complete set of vital signs or reassessment (on 5/21/2024) as required by policy. The time between the initial assessment and patient departure was 3 hours and 13 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame. 3. On 9/24/2024, the clinical record of Pt. #6 was reviewed and indicated that on 9/23/2024 at 9:54 AM , Pt. #6 presented to the ED by private vehicle with chief complaint of anuria (failure of the kidneys to produce urine). The clinical record included the following: - On 9/23/2024 at 9:57 AM, the ‘ED Triage Adult Assessment’ indicated that vital signs and pain level were assessed, and Pt. #6 was given an ESI (Emergency Severity Index) of 3 (urgent/care required as soon as possible: condition presents a danger if not treated). - On 9/23/2024, the ‘Pain Assessment and Vital Signs’ flowsheets indicated that Pt. #6’s pain and vitals were performed at 9:57 AM (time of Triage Assessment) and 1:42 PM (time of Nurse Reassessment). Vital signs at 9:57 AM were: Temperature 36.3 celsius, Pulse 79, Respirations 18, Blood pressure 116/69 and oxygen 99% on room air. Vital signs at 1:42 PM were: Temperature (not assessed), Pulse 84, Respirations 20, Blood pressure 121/59, oxygen 98% on room air, and pain 0 out of 10 (10 being worse pain). The time between assessments was 3 hours and 45 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame, as required. 4. On 9/24/2024, the clinical record of Pt. #7 was reviewed and indicated that on 9/23/2024 at 2:37 PM, Pt. #7 presented to the ED by private vehicle with chief complaint of fever for three days. The clinical record included the following: - On 9/23/2024 at 2:43 PM, the ‘ED Triage Adult Assessment’ indicated that vital signs and pain level were assessed, and Pt. #7 was given an ESI of 3. Vital signs at 2:43 PM were: Temperature 37.9 celsius, Pulse 103, Respirations 20, Blood pressure 171/91 and oxygen 98% on room air. Vital signs at 8:20 PM were: Temperature (not assessed), Pulse 87 (on heart monitor), Respirations 20, Blood pressure 175/94, oxygen 96% on room air and pain 0 out of 10. - On 9/23/2024, the ‘Pain Assessment and Vital Signs’ flowsheets indicated that Pt. #7’s pain and vitals were performed at 2:43 PM (time of Triage Assessment) and 8:20 PM (time of nurse reassessment). The time between assessments was 5 hours and 37 minutes. No other focused reassessment, vital signs, or pain assessments were documented during that time frame, as required. 5. On 9/25/2024 at approximately 10:00 AM, an interview with the ED Manager (E #5) was conducted. E #5 confirmed, after review of patient’s (Pt. #1, Pt. #6, and Pt. #7) medical record, that vital signs, pain, and focused reassessments were not completed, as required per policy.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for 2 of 3 (Pt. #1 and Pt. #5) records reviewed for grievances, the hospital failed to ensure that a written notice of the hospital’s follow up was provided to the patient. Findings included: 1. The Hospital’s policy titled, “Patient Complaint and Grievance Process (revised 9/7/2023)” was reviewed on 5/29/2024 and included, “Grievance: A formal or informal written or verbal complaint that is expressed by a patient or their representative: - When an issue cannot be resolved in an immediate manner. - Regarding a concern of potential/possible abuse, neglect or patient harm. ... The patient or representative will be provided with a written response ... within 7 days of receiving the grievance.” 2. The Complaints and Grievance Log from 2/1/2024-5/28/2024 was reviewed and included a grievance filed for Pt. #1. The grievance was filed by Pt. #1’s spouse on 2/21/2024 and indicated the spouse was not satisfied with the care provided. The report included, “[Z#1 = spouse] verbalized: ’[Z#1] felt the RN was negligent in leaving [Pt. #1] unattended. [Z#1] insists that the RN involved in this matter be disciplined and the CT [computerized tomography scan] bill from this incident be removed. Apologies extended. Explanation of [Hospital] policy to investigate and evaluate all falls verbally given to [Z#1] and that the ED [emergency department] Director and ED Manager would review these concerns and follow-up with the RN [registered nurse] involved. [Z#1] verbalized, “[Pt. #1] has passed away and [Z#1] does not want to pay for the CT from this fall ... “ A written follow-up grievance resolution letter was not included. 3. The allegations of abuse log for 2023 to present was reviewed on 5/28/2024. Pt. #5 was included on the log on 11/17/2023. The log indicated that a physical assault had occurred with a security officer. No other details were available on the log or by report due to the hospital’s Patient Safety Organization privilege (PSO). 4. An internal e-mail, written by the Director of Risk (E#10) was reviewed on 5/28/2024 and included that Pt. #5 presented to the front desk of the hospital on 11/17/2023 to allege that Pt. #5 had been assaulted by a nurse and a security officer. Pt. #5 could not remember when the event had occurred. A review of medical records indicated that Pt. #5 had been a patient in February of 2023 (9 months prior to the allegation). Pt. #5 had been restrained in the emergency department for 60 minutes in 5 point (both wrists, both ankles and chest) restraints due to threatening behavior. Pt. #5 was thrashing around and Pt. #5’s glasses were pushed up against Pt. #5’s face by striking the security guards elbow. The e-mail included, “We are commencing a further investigation into these allegations and will follow up with [Pt. #5] as per our complaint and grievance policy.” The hospital was unable to provide any written response sent to Pt. #5. 5. The Director of Risk Management (E#10) was interviewed via telephone on 5/29/2024 at 1:00 PM. E#10 stated, “[Pt. #5] made the complaint 9 months after the allegation occurred. [Pt. #5] gave a very vague description of what happened. I did speak to Pt. #5 a couple of times on the phone, but I don’t think I ever sent [Pt. #5] the results of our investigation because I think [Pt. #5] was homeless. I am not there [on vacation] and don’t have access to my computer to verify. No one else would have access to that information.” E#10 stated that a follow up letter should be sent after the investigation process is complete.”

“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 3 of 5 records (Pts. #1, #9, and #10) reviewed for pain management, the Hospital failed to ensure that pain interventions and assessments were completed to manage patients’ pain. Findings include: 1. The Hospital’s policy titled, “Pain Assessment” (both versions revised 4/18/2023 and 5/7/2024), were reviewed and required, “...Patients will receive safe and effective pain relief... The assessment and reassessment documentation will be entered by a registered nurse (RN)... Reassessment will be completed at regular intervals and/or as clinically indicated [using the appropriate pain scale]... Document the Pasero Opioid Induced Sedation score (POSS) following administration of opioids unless the patient is on a mechanical ventilator... Notify physician for: Ineffective pain control...” 2. The Hospital’s policy titled, “Assessments and Reassessments in the Emergency Department” (dated 8/2/2022), was reviewed and required, “...Patient response to interventions should be reassessed and documented within a reasonable timeframe based on the type of intervention performed...” 3. The clinical record of Pt. #1 was reviewed on 5/28/2024. Pt. #1 presented to the Hospital’s emergency department (ED) on 2/13/2024, with chief complaints of diarrhea and abdominal pain. The initial pain assessment on 2/13/2024 at 1:35 AM indicated that Pt. #1 had a pain score of 10 of 10 (worst pain) in the lower abdomen. The Medication Administration Record (MAR) from 2/13/2024 was reviewed and indicated that Pt.#1 received morphine [an opioid pain medication] 4 mg/ml (milligrams per milliliter) IVP (intravenous push) for pain of 10 out of 10 (indicating the worst pain) at 02:34 AM. Pt.#1 also received fentanyl (opioid pain medication) 50 mcg (micrograms)/ml IVP at 04:15 AM for a pain rating of 10. The record lacked post medication administration reassessments and lacked scoring of opioid-induced sedation (POSS) as required. 4. The clinical record of Pt. #9 was reviewed on 5/29/2024. Pt. #9 presented to the ED on 5/24/2024, with a chief complaint of sickle cell pain. The record indicated that Pt. #9 was given toradol/ketorolac (pain medication) on 5/25/2024 at 12:37 AM for a pain rating of 10. The record lacked details of the pain such as location, quality, and pattern. Pt. #9 also received morphine on 5/25/2024 at 4:52 AM (more than 4 hours later) for a pain rating of 10. The record lacked documentation of reassessments following administrations of both medications to evaluate the effectiveness of pain management. 5. The clinical record of Pt. 10 was reviewed on 5/29/2024. Pt. #10 presented to the ED on 5/25/2024, with a chief complaint of abdominal pain. The initial pain assessment on 5/29/2024 at 9:17 PM indicated that Pt. #10 had a pain rating of 8 (severe pain). The assessment lacked documentation of the quality and pattern of the pain. The MAR indicated that Pt. #10 received fentanyl on 5/26/2024 at 12:55 AM (over 3 hours later). The record lacked documentation that pain interventions were offered to Pt. #10 between the time of the initial assessment and the administration of the first medication for pain. The record also lacked reassessment of Pt. #10 pain level following the administration of the fentanyl and lacked assessment of the POSS as required. 6. An interview was conducted with ED Nurse (E#4) on 5/29/2024 by telephone at approximately 10:25 AM. E#4 stated that after giving opioid medications, the patient should be re-assessed within an hour and E#4 would stay with patient until the patient stated they felt normal. E#4 stated that among the things that would be documented would include current pain rating, location, intensity, quality, the patient’s mental status, respiratory assessment, and any changes. E#4 stated that the POSS is only used if the patient is being sedated and was not aware that it should be completed for each opioid administration. 7. An interview was conducted with the ED Manager (E#11) on 5/29/2024, at approximately 1:15 PM. E#11 stated that if a patient is reporting pain, especially severe pain, the staff are expected to offer an intervention for pain relief and document it in the record. E#11 stated that pain assessments should include the rating, location, quality, and intensity. E#11 stated that a reasonable timeframe for pain reassessment following an intervention should be within 30 minutes to 1 hour of the intervention.”