Northwest Community Hospital 1

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 2 of 4 clinical records (Pts. #2 and #10) reviewed for restraint use, the hospital failed to ensure that least restrictive measures/alternatives were attempted prior to placing the patient in restraints. Findings include: 1. The hospital’s policy titled, “Restraint and/or Seclusion Use and Indications in the Acute Care Setting” (revised 04/20/2023), was reviewed and required, “...Restraints are used only after alternative strategies have been attempted or considered and are unsuccessful...” 2. The clinical record of Pt. #2 was reviewed on 03/17/2025 at 10:35 AM. Pt. #2 was admitted on 03/12/2025 with a diagnosis of closed right hip fracture. A physician’s order was placed on 03/13/2025 for non-violent (bilateral soft wrist and mitten) restraints due to altered mental status. Restraint flowsheets indicated that Pt. #2 was placed in non-violent restraints on 03/13/2025 at 8:38 AM. The record lacked documentation of least restrictive alternatives attempted or considered prior to using restraints. 3. The clinical record of Pt. #10 was reviewed on 03/18/2025. Pt. #10 was admitted on 01/22/2025 with a diagnosis of rhabdomyolysis (serious condition where damaged muscle tissue releases contents into the bloodstream, potentially leading to kidney damage and other complications). A physician’s order was placed on 01/22/2025 for non-violent (bilateral soft wrist) restraints due to altered mental status and disrupting treatment (removing oxygen, cardiac monitor). Restraint flowsheets indicated that Pt. #10 was placed in non-violent restraints on 01/22/2025 at 1:45 PM. The record lacked documentation of least restrictive alternatives attempted or considered prior to using restraints. 4. An interview was conducted with the Manager of the 8 South Ortho Unit (E#3) on 03/17/2025, at approximately 10:45 AM. E#3 stated that the nurse should document least restrictive alternatives attempted prior to putting the patient in restraints. E#3 stated that there is a space on the restraint flowsheets for the nurse to document the alternatives; however, E#3 confirmed that it was left blank. E#3 stated that sometimes the nurse may write it in a narrative note; however, E#3 also confirmed that the notes did not include what alternatives were attempted.”

“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: 51457 A. Based on document review, observation, and interview, it was determined that for 1 of 2 patient (Pt. #2) observed, the hospital failed to ensure that the registered nurse responsible for supervision of the patient’s care ensured that the call light was within reach of the patient, so that the patient could ask for assistance when needed. Findings include: 1. On 03/18/2025, the hospital’s policy titled, “Restraint and/or Seclusion Use and Indication in the Acute Care Setting” (effective 4/20/2023) was reviewed and included,”...Call light is placed within reach...” 2. On 3/17/2025 at approximately 10:05 AM, an observational tour of the 8 South Unit (Orthopedic Unit) was conducted. At approximately 10:08 AM, a patient (Pt. #2) in room 820 was observed to have bilateral soft wrist restraints on and tied to the bed. Pt. #2’s call light was observed to be hanging down off the side of the bed, and Pt. #2 could not reach the call light. At approximately 10:10 AM, a registered nurse (E#4) entered the room and provided care to Pt. #2 and provided carefor Pt. #2; however, when E #4 exit Pt. #2’s room the call light remained hanging from the bed and was not within the reach of the patient. 3. On 03/17/2025 at approximately 10:15 AM, E#4 was interviewed regarding access to the patient’s access to call lights. E#4 stated that the call light should be close, and the patient should be able to reach it. 39802 B. Based on document review and interview, it was determined that for 2 of 2 post-surgical patient (Pts. #2 and #3) records reviewed, the hospital failed to ensure that assessments of vital signs were completed as required. Findings include: 1. The hospital’s policy titled, “Post-Surgical Patient Management Protocol” (revised 12/23/2022), was reviewed and required, “...Assess for: ...b. hypotension [low blood pressure]; c. fever... g. routine Post-Operative Vital Signs: q 15 min [every 15 minutes] x 3 then q4H [every 4 hours] x 48 H [hours], or as ordered...” 2. The clinical record of Pt. #2 was reviewed on 03/17/2025 at 10:35 AM. Pt. #2 was admitted on 03/12/2025 with a diagnosis of closed right hip fracture. The record indicated that Pt. #2 had a surgical procedure on 03/14/2025 at 11:25 AM, and returned to the 8 South Ortho Unit following the procedure on 03/14/2024 at 4:24 PM. A complete set of vital signs (temperature, heart rate, respirations, blood pressure, and oxygen saturation) was taken on 03/14/2025 at 4:26 PM. The next sets of vitals at 4:30 PM, 4:45 PM, and then 5:00 PM lacked the patient’s temperature and respirations. Thereafter, the next set of complete vital signs was completed at 11:58 PM (nearly 7 hours later). The record also lacked vitals every 4 hours on 03/15/2025 from 12:36 PM and 10:32 PM (nearly 10 hours later); from 03/15/2025 at 10:32 PM to 03/16/2025 at 7:30 AM (nearly 9 hours later); and on 03/16/2025 from 7:30 AM to 3:47 PM (greater than 8 hours later). 3. The clinical record of Pt. #3 was reviewed on 03/17/2025 at approximately 10:50 AM. Pt. #3 was admitted on 03/08/2025 with a diagnosis of closed right hip fracture. The record indicated that Pt. #3 had a surgical procedure on 03/09/2025 at 12:59 PM, and returned to the 8 South Ortho Unit following the procedure on 03/09/2025 at 5:56 PM. A complete set of vitals signs were taken on 03/09/2025 at 6:05 PM. The record lacked documentation of the next set of vitals every 15 minutes x 3 as required. The record also lacked vital signs every 4 hours between 03/09/2025 at 10:19 PM to 03/10/2025 at 8:05 AM (nearly 10 hours later) and on 03/11/2025 from 1:32 AM to 8:20 AM (nearly 7 hours later). Other than the gaps mentioned, vitals were taken every 4 hours for a 48-hour period post-operatively; however, some assessments did not include a full set of vitals (either temperature, heart rate, respirations, blood pressure, and/or oxygen saturation were missing). 4. An interview was conducted with the Manager of the 8 South Ortho Unit (E#3) on 03/17/2025, at approximately 10:55 AM. E#3 stated that post-operatively, staff should follow the policy in regard to the frequency of vital signs. E#3 stated that for each assessment, the expectation is to obtain a complete set of vitals which includes temperature, heart rate, respirations, blood pressure, and oxygen saturation.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to follow its own policy ensuring that the patient ESI (Emergency Severity Index - determines how soon a patient needs to be seen), was applied correctly. This delayed the medical screening examination by a Qualified Medical Practitioner (QMP). Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach (baby delivered feet first instead of the head). (See A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 32741 Based on document review and interview it was determined that for 1 (Pt. #1) of 9 obstetric patients, that presented to the Emergency Department (ED), the hospital failed to follow its own policy ensuring that the patient ESI (Emergency Severity Index - determines how soon a patient needs to be seen), was applied correctly. This delayed the medical screening examination by a Qualified Medical Practitioner (QMP). Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach (baby delivered feet first instead of the head). Findings include: 1. The “Medical Screening Examination, Stabilization and Patients Transfer” policy (rev 9/13/23), was reviewed and included, “ ...2. Medical Screening Examination (MSE) ...c. The MSE may include both generalized and focused assessment based on the patient’s chief complaint(s) to determine the presence or absence of an emergency medical condition ...” 2. The “ED Management of the Pregnant Patient Procedure” (rev 3/23/23) was reviewed and included, “A. Obtain Chief Complaint, to determine if it is related to: Active labor or impending labor; pregnancy complications ...OB[obstetrics] ED Triage ...C. 1 ...Medical and OB and/or OB chief complaints in a pregnant patient less than 20 weeks gestation: Notify OB hospitalist (x8488) if 14-20 weeks of gestation and OB related chief complaint including ...cramping/contractions, pelvic or back pain ... 3. The ED Triage Protocol (rev 2/24/23) was reviewed and included, “A. Purpose 1. All patients presenting for care to the Emergency Department at (the Hospital) will be assessed and triaged by a trained health-care professional. All patients will be categorized utilizing Emergency Severity Index (ESI) criteria, a 5-category ED triage acuity scale (ESI 1/Requires immediate interventions- ESI 5/non-urgent) . Patient will be placed in the emergency department according to their acuity and nature of their complaint ...G. Triage Procedure 2. All patients will receive an initial triage screening (brief, primary survey and evaluation of chief complaint) and be assigned an estimated ESI level by the RN (Registered Nurse). This determines if the patient needs to be seen immediately or can wait safely for further assessment ...l. Special Considerations ...5. OB Pregnant Patients ...d ...The triage RN or APP (Advance Practice Practitioner), will complete an abbreviated triage assessment on all OB patients ...” 4. The Emergency Severity Index Handbook Fifth Edition (2023) was reviewed and included. “ ...Chapter 4 ... Obstetrical and Gynecological Concerns ...Pregnant patients with abdominal pain should be triaged as ESI 2 (high risk situation/emergent) and rapidly assessed by ED and/or OB providers ...” 5. On 10/15/2024, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the ED on 3/8/24 at 2:02 AM, with a chief complaint - hip pain. The clinical record included the following: -The hospital failed to follow its own policy ensuring that the patient ESI was applied correctly. This delayed the medical screening examination by a QMP. Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach. - The ED notes written by E #6 dated 3/8/2024 at 2:07 AM noted, “ Called Labor & Delivery and relayed Pt. #1 ‘s symptoms. Labor and Delivery deferred care to main ER due to Pt. #1 not being over 20 weeks pregnant. -On 10/16/2024, the Labor and Delivery OB ED log dated 3/8/2024 was reviewed. The log indicated Pt. #1 was admitted to the Labor & Delivery on 3/8/2024 at 4:28 AM with admitting comments BBOW (bulging bag of water) and PTD (preterm delivery). - The Labor and Delivery progress notes written by E #3 dated 3/8/2024 at 4:52 AM noted included, “ Pt. #1 admitted to Labor and Delivery for abdominal pain, contractions, and pelvic pressure. US (ultrasound) and toco (tocodynamometry is a noninvasive device that monitors uterine contractions during labor and delivery) applied. Vital signs taken. Multiple contractions noted on monitor. MD #2 notified of Pt. #1’s status. Pt. #1’s OB Admission History & Physical note written by MD #1 dated 3/8/2024 at 6:17 AM indicated, “ (Pt. #1) who presents with abdominal pain since midnight and was sitting in the ER since 1:00 AM and then to Labor and Delivery at 4:28 AM still not seen by the ER doctor and hospitalist (MD #2) saw (Pt. #1) with amniotic bag (thin membrane that surrounds and protect the fetus) in vagina and sono (ultrasound used in Labor and Delivery) revealing cervix open 4 cm (centimeters) on abdominal scan with bulging bag into vagina. -Pt. #1’s OB Admission History & Physical note written by MD #1 dated 3/8/2024 at 6:17 AM indicated, “ (Pt. #1) who presents with abdominal pain since midnight and was sitting in the ER since 1:00 AM and then to Labor and Delivery at 4:28 AM still not seen by the ER doctor and hospitalist (MD #2) saw (Pt. #1) with amniotic bag (thin membrane that surrounds and protect the fetus) in vagina and sono (ultrasound used in Labor and Delivery) revealing cervix open 4 cm (centimeters) on abdominal scan with bulging bag into vagina. - The Labor and Delivery notes written by E #4 dated 3/8/2024 at 1:15 PM noted, “ MD #3 at bedside. At 10:04 AM, delivery of non-viable male infant.” 6. On 10/15/2024, the hospital’s occurrence report dated 3/8/2024 was reviewed. The report noted, “Charge RN (E #5) received call from ER that they had received a 19-week patient who was experiencing back pain and abdominal pain. I (E #5) notified ER RN to update Labor and Delivery following patient triage in ER and recommended an OB (obstetrics) ultrasound ...(Pt. #1) remained in the ER with increasing pain ...Labor and Delivery was not notified she had not been seen and symptoms had progressed. Labor and Delivery received second call from ER ... that (Pt. #1) had yet to be seen and was now experiencing pelvic pressure and increased pain. (Pt. #1) was then transferred to Labor and Delivery. Manager’s comments - (Pt. #1) was brought up to Labor and Delivery after sitting in the ED waiting area for several hours. (Pt. #1) apparently told (Pt. #1’s) physician that (Pt. #1) had asked multiple time to be seen because the pain was worsening, and (Pt. #1) wanted to be put on the monitor. The second call to Labor and Delivery came after several hours. (Pt. #1) was brought directly to Labor and Delivery at that time. (Pt. #1) was found to have amniotic membranes bulging into the vagina with a 4 cm dilated cervix. (Pt. #1) was contracting every 2 minutes. (Pt. #1) delivered later that morning. “ 7.On 10/15/2024 at 9:30 AM, an interview was conducted with Pt. #1 via telephone. Pt. #1 stated that Pt. #1 was 19 weeks pregnant and came to the hospital on 3/8/2024 at 2:00 AM with a complaint of back and pelvic pain. Pt. #1 stated that Pt. #1 told the ED staff member in triage that Pt. #1 was in pain. Pt. #1 stated that Pt. #1 had not been seen by a doctor and had not been monitored until approximately 4:00 AM when Pt. #1 was brought to Labor and Delivery. Pt. #1 stated that no one assessed Pt. #1’s baby the entire time Pt. #1 was in the ED. Pt. #1 stated that Pt. #1 kept going to the desk in the waiting area and telling the staff member the Pt. #1’s pelvic pain was getting worse. Pt. #1 stated that when Pt. #1 arrived in Labor and Delivery unit, Pt. #1 was 4 cm dilated and having multiple contractions. Pt. #1 stated that Pt. #1 lost her baby later that morning. 8.On 10/16/2024 at 9:00 AM, an interview was conducted with the E #2. E #2 stated that Pt. #1 was 19 weeks pregnant. E #2 stated that Pt. #1 ‘s vital signs were stable. E #2 stated that Labor and Delivery was called to see if they would see Pt. #1. E #2 stated that Labor and Delivery stated that since Pt. #1 was 19 weeks pregnant, Pt. #1 was to be seen in the main ED. E #2 stated that when E #2 went on break, E #8 relieved E #2. E #2 stated that E #8 was going to call Labor and Delivery again to see if Pt. #1 could be brought up to Labor and Delivery. E #2 stated that when E #2 returned from E #2’s break, Pt. #1 had already been brought up to the Labor and Delivery unit. 9.On 10/16/2024 at 9:30 AM, an interview was conducted with the MD #4. MD #4 stated that if the patient is less than 20 weeks, the patient is seen in the main ED. 10. On 10/16/2024 at 10:00 AM, an interview was conducted with the E #9. E #9 stated that Labor and Delivery deferred Pt. #1 to the main ED due to Pt. #1 being 19 weeks pregnant. E #9 stated that when Labor and Delivery was called again, Pt. #1 was transported to the Labor and Delivery unit. 11. On 10/16/2024 at 10:15 AM, an interview was conducted with the E #8. E #8 stated that E #8 relieved E #2 on 3/8/2024 when E #2 took a break. E #8 stated that E #2 reported that Labor and Delivery wanted Pt. #1 to be seen in the main ED. E #8 stated that E #8 called Labor and Delivery again and asked if Pt. #1 could be brought to Labor and Delivery. E #8 stated that Pt. #1 was transported to Labor and Delivery unit. 12. On 10/15/2024 at approximately 11:55 AM, the E #10 was interviewed. E #10 stated that an ESI score is generated based on the information provided and the patient ‘s reported and observed symptoms. E #10 stated that patients are taken back to a triage room for a medical screening evaluation based on patient severity and availability of provider. E #10 stated that if a patient is less than 20 weeks pregnant, the patient would be evaluated in the ED and the ED physician would be in contact with the OB Hospitalist to determine if Labor and Delivery placement is required. 13. On 10/15/2024 at 2:00 PM, an interview was conducted with MD #3 (OB/GYN). MD #3 stated that MD #3 was present for Pt. #1’s delivery on 3/8/2024. MD #3 stated that the protocol for a pregnant patient if a patient is 19 weeks pregnant, the patient is evaluated in the main ED. MD #3 stated that Pt. #1 had the MSE in Labor and Delivery by MD #2.”