Lutheran Hospital of Indiana

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47186 Based on document review, interview, and observation facility staff failed to provide a dust free environment in their Outpatient Radiology waiting rooms and in the Emergency Department Examination Rooms (Rooms 15 & 19) Findings include: 1. Facility policy titled: Exam Room Cleaning, Policy #9001, last revised 07/2022, indicated under: Procedure: 7). High Vacuum. b). Starting at the doorway, vacuum the door frame from the outside then inside, vacuum all horizontal surfaces, vents, blinds, window frames, sprinkler heads (if permitted - check with maintenance for more information), monitors and light diffusers that are above shoulder height including vents. Vacuum all furniture. Vacuum other surfaces (computer, keyboards, etc) if specified/allowed. 8) Cleaning and Disinfection Steps. a 1). Pay special attention to all surfaces of the exam table including pull-out trays, footrests, stirrups, and underneath the head of the table. 2. a). Review of Facility Environmental Services (EVS) Department Duty Logs indicated Outpatient Imaging Center Cleaning Schedule for office areas and common areas (patient waiting rooms) will have horizontal surfaces dusted weekly on Thursdays. b. Review of Facility EVS Duty List dated 3/06/26 for the morning shift indicated Treatment Room 19 had received the daily cleaning steps of: trash/linens emptied, floor/ledges/vents vacuumed, all horizontal and vertical surfaces were sanitized, and floor was damp mopped. c. Review of Facility EVS Duty List dated 4/03/26 indicated ED Exam Room 15 had been terminally cleaned and Exam Room 19 had received daily cleaning. Both types of cleaning indicated horizontal/vertical surfaces sanitization was completed. 3. On 4/06/26 at approximately 12:53 pm to 1:53 pm, this writer accompanied by administrative staff member A2 (Quality Director [QD]) toured facility ED, Radiology waiting room/common area, and Outpatient Radiology waiting room/common areas. Patient Exam Room 19 was ready for patient care, accumulative dust was noted on the top of hand towel dispenser, on top of wall mounted receptacles, on the picture frame on wall, and on the bed frame under patient head adjustment shelf. Patient Exam Room 15 was ready for patient care and accumulative dust was noted on back wall receptacles, on the wall-mounted computer arm, and on the bed frame under patient head adjustment shelf. Outpatient Radiology Suite 101 waiting area was noted with accumulative dust on the end tables. The interior consulting/waiting PET-CT (Positron Emission Tomography - Computed Tomography) room in the Outpatient Radiology department was noted with accumulative dust on the one end table in this room. 4. In interview on 4/06/26 at approximately 1:55 pm, A2 (QD) confirmed visible dust in the following areas: Outpatient general waiting area on end tables, PET-CT waiting area on one end table, ED Room 15 on back wall receptacles, on the wall-mounted computer arm, and on the bed frame under patient head adjustment shelf, and Room 19 on the top of hand towel dispenser, on top of wall mounted receptacles, on the picture frame on wall, and on the bed frame under patient head adjustment shelf.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to contact F2 (Acute Care Hospital) to accept transfer of patient and failed to send all available medical records related to patient condition at the time of transfer for 1 of 20 patient medical records reviewed. (P12) 1. The policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” last revised on 07/14/2022 indicated under B. Transfer Procedure, 2. Acceptance by receiving hospital. Prior to transfer the hospital must obtain acceptance of the patient by the receiving hospital. 2. P12 presented to F1 (Acute Care Hospital) on 01/13/2026 at approximately 1631 hours via F3 (Long term Care facility) transport. a. The medical record (MR) indicated that he/she was triaged with a chief complaint of wrapping a cord around his/her neck. P12 was brought to F1 for wound care evaluation, denied suicidal ideation, and requested a wound evaluation, pain medication, and placement at a different facility. MR indicated a Psychiatric evaluation was conducted to address patient suicidal ideation and behavioral concerns. The accepting facility in another city was contacted to coordinate transfer for further management. Patient has a history of schizophrenia who presents from F3, patient with psychiatric history, patient was accepted at F2 (Acute Care Hospital), was sent to F1 for an intermuscular injection for sedation medication prior to transport. The patient is known to have behavioral issues, including throwing bodily fluids, and has an active history of aggression. He/She is being evaluated prior to transfer to another facility. Review of Medical decision making ED course: indicated on 1/13/2026 at 1807 hours the accepting facility, F2, was contacted to coordinate transfer for further management. b. MR lacked documentation of accepting physician and lacked documentation of a physician certification detailing the risks and benefits of a transfer.. c. MR lacked documentation of F1 sending MR (Medical Record) information related to P12 condition prior to P12 transfer. d. P12 was transported to F2 via F3 (Long Term Care) transport. 3. Review of F2, P12 medical record indicated patient presented to facility on 01/13/2026 at approximately 2030 hours via F3 transport and was triaged with multiple complaints including pain in his/her wounds, need for ostomy care, and foley care. MR indicated patient had a complex past medical history presenting for psych placement; patient had been admitted to F3, he/she took off foley bag and tried to shove things in the ostomy. P12 also took off foley catheter and wrapped the cord around their neck trying to harm himself/herself. This facility (F3) is unable to care for this patient. F3 sent the patient to F1. F1 gave the patient a dose of Zyprexa and called Emergency Medical Services to transfer patient to F2 (Acute Care Hospital) for further evaluation. There were no attempts to call the transfer center and no accepting physician at F2 to take the patient. Staff physician called to get report from F1 and get transfer paperwork. Discussed case with access, they are unable to take the patient and secure holding due to his complex medical care. 4. On 03/23/2026 at approximately 1430 hours, N3 (Emergency Department Registered Nurse) stated that when transferring a patient, an accepting physician and facility are required, and transfer forms must always be completed and sent with the patient. 5. On 03/23/2026 at 1440 hours, A3, (Chief Quality Officer), confirmed in interview that F1 failed to contact F2 to get an accepting physician to continue P12 care.”

“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: 32952 Based on document review and interview the facility failed to ensure nursing staff followed a facility policy and physician order related to pain level reassessments for 1 of 10 patients (Patient #1). Findings include; 1. Facility policy titled “(PCS.01.03.18) Pain Assessment and Management” with a revision date of 11/2025 indicated the following: III. STAFF RESPONSIBILITY: A...Clinical staff will conduct pain reassessment for relief from pain and/or responses to treatment. 2. A review of Patient #1’s medical record indicated the following: (a.) A physician order dated 8/29/25 at 9:43 p.m. indicated for nursing staff to reassess the patient’s pain level within 1 hour of medication administration and re-treat as appropriate. (b.) Review of the medication administration record indicated the patient was administered morphine 2 milligrams via IV (intravenous) push on 9/4/25 at 12:13 a.m. The patient had a FLACC pain score of 7 on 9/4/25 at 12:12 a.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication. (c.) Review of the medication administration record indicated the patient was administered Oxycodone 40 milligrams 1 tablet ER (Extended Release) by mouth on 9/4/25 at 9:08 a.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication. (d.) Review of the medication administration record indicated the patient was administered Oxycodone-Acetaminophen 10 milligrams-325 milligrams 1 tablet by mouth on 9/4/25 at 1:33 p.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication. 3. During a phone interview with N1 on 12/4/25 at 11:44 a.m., N1 indicated that (he/she) would assess/reassess and document a patient’s pain level hourly.”

“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: 47186 Based on document review and interview facility nursing staff failed to obtain a physician order to use a patient’s home medical device while in facility, failed to obtain a physician order to discontinue the use of a patient’s home medical device, failed to obtain patient’s blood glucose levels as ordered, failed to notify the provider of patient’s critically high blood glucose levels as ordered, failed to administer insulin as ordered, failed to address a low blood glucose level, and failed to notify provider of patient’s change in condition for 1 of 10 medical records reviewed (Patient 2). The cumulative effect of this systemic problem resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 47186 Based on document review and interview facility nursing staff failed to obtain a physician order to use a patient’s home medical device while in facility, failed to obtain a physician order to discontinue the use of a patient’s home medical device, failed to obtain patient’s blood glucose levels as ordered, failed to notify the provider of patient’s critically high blood glucose levels as ordered, failed to administer insulin as ordered, failed to address a low blood glucose level as ordered, and failed to notify provider of patient’s change in condition for 1 of 10 medical records reviewed (Patient 2). Findings include: 1. Facility policy titled: (PCS.01.27.55) Care of Patients with Insulin Pumps, Version 2, last revised: 01/2023, indicated under: III. Policy Statement. A. Insulin pump therapy is appropriate for patients with an existing pump who are alert and oriented to person, place, and time and are capable of self-management. 1). Nurse assesses the patient’s level of consciousness. 2). Nurse obtains patient’s agreement for the insulin pump therapy upon admission (Emprint form 1525-4000-0001-152-HMS - Insulin Pump Patient Agreement and Emprint form FAC-1701-Consent Release of Responsibility for Use of Home Medical Equipment that includes inspection of the pump). B. Contraindications to include altered state of consciousness, critically ill patient requiring intensive care, suicide precautions in place, refusal or inability of patient or family to participate in care, radiology procedure, or other circumstances deemed necessary by physician. 1). If an altered state of consciousness or confusion is noted, patient’s blood glucose level is checked and physician is notified of patient’s condition. C. Physician orders upon admission: 1). Order to continue insulin pump therapy (“Insulin Pump Orders” - DR883.DR), including type of insulin, basal rate, and bolus dose for correction bolus and meal bolus as documented in the electronic health record. D. A physician order is necessary for: 1) leaving pump in place and continuing basal rate. IV. Procedure. L. To remove pump: If patient is not alert, oriented, or able to perform pump functions, an order must be obtained to remove the pump. 2. Facility policy titled: (PCS.20.03.51) Critical Results Reporting and Documentation, Version 3, last revised 04/2025, indicated under: III. Scope. B. All diagnostic studies will be reviewed for abnormal results and the ordering Licensed Practitioner (LP) is to be notified immediately. Exceptions to this practice are the following: 3). Orders in place with set parameters on what provider wants to be called on. V. Action Directives. B. The person reporting the critical result will document the date, time, and name of clinician the report was given to. 3. Review of P2’s MR indicated the following: a. On 4/15/25, P2’s MR lacked documenation of physician order for patient’s use of home medical insulin pump while in facility and/or discontinuation of patient’s insulin pump on 4/19/25. P2’s MR lacked documentation of patient’s consent and responsibility regarding the use of home insulin pump while in facility and/or insulin pump inspection to determine pump’s operating function prior to inpatient use. b. P2’s MR lacked documentation of patient’s blood glucose checks 4 times per day, as ordered on 4/15/25, nursing staff failed to comply with order. 1). 4/16/25 - 1 blood glucose check at 4:43 am 2). 4/17/25 - 1 blood glucose check at 8:51 pm c. P2’s MR lacked documentation of intervention per protocol/order for patient’s blood glucose level of 56 mg/dl at approximately 11:11 am on 4/18/25, nursing staff failed to comply with order. d. P2’s MR lacked documenation of insulin administered for blood glucose over 150 mg/dl, per sliding scale, as ordered on 4/15/25, nursing staff failed to comply with order. 1). 4/18/25: 7:13 pm/blood glucose 194 mg/dl, and 11:13 pm/blood glucose 265 mg/dl 2). 4/19/25: 1:05 am/blood glucose 262 mg/dl, 4:39 am/blood glucose 273 mg/dl, 9:32 am/blood glucose 328 mg/dl, 10:43 am/blood glucose 356 mg/dl e. P2’s MR lacked documenation of provider notification of patients’ blood glucose over 400 mg/dl, as ordered on 4/15/25, nursing staff failed to comply with order. 1). 4/19/25: 5:16 pm/blood glucose 443 mg/dl 2). 4/20/25: 4:34 am/blood glucose 434 mg/dl, 4:36 am/blood glucose 444 mg/dl, 6:11 am/blood glucose 451 mg/dl f. On 4/20/25 at approximately 8:33 am, MD2 (Nurse Practitioner [NP]) note indicated P2 with blood glucose levels in the 400’s, patient was drowsy/borderline lethargic/diaphoretic, and patient’s change in condition had not been reported to the provider. g. On 4/20/25 at approximately 10:21 am, MD3’s (Nurse Practitioner [NP]) note indicated patient had been on an (personal) insulin pump until the evening of 4/19/25, and through the night patient’s BG continued to rise. MD3 note indicated speaking with patient’s family member (complainant) who indicated patient was too weak to manage the pump and requested it be removed on 4/19/25. P2’s MR lacked documentation of provider notification that insulin pump had been removed, at family request, due to patient inability to continue to monitor/maintain the pump. 3. In interview on 9/9/25 at approximately 11:47 am, A1 (Chief Quality Officer [CQO]) confirmed P2’s MR lacked documentation of Insulin Pump Patient Agreement Form, patient’s Consent Release of Responsibility for Use of Home Medical Equipment, physician order for patient’s use of home medical insulin pump, and/or a providers discontinue order of patient’s home medical insulin pump use. A1 confirmed P2’s MR lacked documentation of insulin dose/rate P2 received via home use insulin pump while in facility from 4/15/25 through 4/19/25. A1 confirmed P2’s MR lacked documentation of P2’s BG checks, as ordered, on 4/16 and 4/17. A1 confirmed P2’s MR lacked documentation of insulin administered on 4/18/25 and 4/19/25 for BG over 150 mg/dl on 6 occasions. 4. In interview on 9/9/25 at approximately 1:52 pm, A3 (RN, Assistant Chief Nursing Officer [ACNO]) confirmed P2’s MR lacked documentation of provider notification of patient’s BG 400 mg/dl or higher on 4 occasions. A3 confirmed P2’s BG over 400 mg/dl was a Critical Value and required reporting to the provider, per order.”