Community Hospital North

“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: 48704 Based on document review and interview, nursing failed to obtain vital signs prior to discharge in 3 of 10 patient (Patient 6, 8, and 9) medical records reviewed, failed to obtain vital signs in triage in 1 of 10 patient (patient 5) medical records reviewed, and failed to document notification of abnormal vital signs in 1 of 10 (patient 1) patient medical records reviewed. Findings include: 1. Facility policy titled, Triage, Emergency Department, PolicyStat ID 18377490, last approved 03/2026, indicated under Procedure, E. RN conducts an assessment of the patient, which may include: 2. Vital signs which may be collected by non-licensed team member, including, a. Temperature, b. Pulse, c. Respirations, d. Blood pressure for all patients age 2 and above or as warranted by complaint on those younger patients, e. weight/height - i. actual weight on pediatric patients should be completed in Kg., ii. Weight based tape (eg Broselow) may be used to estimate pediatric weight in emergent or code situations., iii. Adult’s weight: actual weight is optimal. There are times when stated weight will be documented., f. SpO2 should be obtained. 2. Facility policy titled, Vital Signs and Monitor Strip Documentation, PolicyStat ID 15112226, last approved 03/2024, indicated under Procedure, D. Obtain a new set of vital signs prior to dismissal for patient who receive medications, cardiac monitoring, experiencing clinical issues, or abnormal vital signs initially. 3. Facility policy titled, Vital Signs, PolicyStat ID 14812537, last approved 08/2024, indicated under Policy Statements: If findings are critical, the RN notifies the on-call provider within 30 minutes. Under General Information: Normal Values: B. Pulse: 60-100 beats per minute, D. BP: < 120 systolic; < 80 diastolic. 4. Review of Patient 1’s medical record indicated the following: a. The patient presented to the emergency department on 07/11/2025 at 6:29 a.m. b. Medical record indicated the patient’s triage vital signs at 6:34 a.m. were heart rate 106, respirations 17, blood pressure 200/110, oxygen saturation 99%, and temperature 99.0 degrees Fahrenheit. At 9:02 a.m. patient’s vital signs were heart rate 104, blood pressure 222/114, oxygen saturation 99%, temperature 99.6 Fahrenheit, and respiratory rate of 21. At 2:49 p.m. patient’s vital signs were heart rate 105, respiratory rate 18, blood pressure 213/125, oxygen saturation 93%, and temperature 99.9 degrees Fahrenheit. At 7:44 p.m. patient’s vital signs were heart rate 101, blood pressure 212/117, respirations 18, and oxygen saturation 98%. Medical record lacked documentation provider was notified of patient’s continued elevated heart rate and blood pressure. c. On 07/12/2025, at 1:06 a.m. provider note indicated patient was seen by crisis team and is to be admitted to Facility #2, Psychiatric Care Facility but before admission, crisis team requested further control of patient’s blood pressure which was addressed with patient’s home medications and a one-time dose of labetalol. d. At 2:49 a.m. patient’s vital signs were heart rate 106, respiratory rate 16, blood pressure 172/102, oxygen saturation 98% and temperature 98.7 Fahrenheit. Medical record lacked documentation nursing notified provider patient’s heart rate and blood pressure were elevated. e. Patient was discharged to Facility #2 at 3:03 a.m. 5. Review of Patient 5’s medical record indicated the following: a. The patient presented to the emergency department on 7/23/2025 at 12:18 p.m. b. Medical record indicated triage started at 12:33 p.m., patient taken to patient room at 12:38 p.m.; Medical record lacked documentation of vital signs in triage. Medical record indicated the first set of vital signs were taken at 1:07 p.m. and included heart rate and oxygen saturation. Medical record indicated the patient’s first blood pressure was taken at 2:18 p.m. and first temperature was taken at 5:36 p.m. c. The patient was discharged home in stable condition at 6:10 p.m. 6. Review of Patient 6’s medical record indicated the following: a. The patient presented to the emergency department on 06/20/2026 at 2:59 p.m. b. MR indicated the provider ordered Keppra 1500 milligrams intravenously at 3:11 p.m.; administered Keppra 1500 milligrams intravenously at 3:23 p.m. Medical record lacked vital signs taken prior to discharge. c. The patient was discharged home in stable condition at 4:21 p.m. 7. Review of Patient 8’s medical record indicated the following: a. The patient presented to the emergency department on 08/29/2025 at 7:03 p.m. b. Medical record indicated provider ordered Rocephin 2 grams intravenously at 9:56 p.m.; administered at 10:11 p.m. Medical record lacked vital signs taken prior to discharge. c. The patient was discharged home in stable condition at 10:56 p.m. 8. Review of Patient 9’s medical record indicated the following: a. The patient presented to the emergency department on 08/15/2025 at 6:02 p.m. b. Medical record indicated provider ordered potassium bicarbonate 25 milliequivalents orally at 8:35 p.m.; administered at 8:48. Medical record indicated at 8:48 p.m. heart rate and oxygen saturation were obtained and lacked documentation of blood pressure and respirations prior to discharge. c. The patient was discharged home in stable condition at 8:58 p.m. 9. Interview with A6 (Director of Nursing) on 03/23/2026 at approximately 4:15 p.m. indicated patient 1’s medical record lacked documentation that the nurse notified the provider of elevated blood pressure measurements and confirmed patient 5’s medical record lacked documentation of vital signs in triage and patients 6, 8, and 9’s medical records lacked vital signs prior to discharge. 10. Interview with N1 (Registered Nurse) on 03/23/2026 at approximately 6:05 p.m. indicated they did not recall caring for patients reviewed. N1 indicated that if the patient has an elevated blood pressure or continued elevated blood pressures, they would notify the provider and follow any provider orders. N1 indicated that providers may not treat elevated blood pressures depending on the patient’s condition and reason for elevated blood pressure.”

“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: 44532 Based on document review and interview, the facility failed to ensure patient received care in a safe setting by pushing a patient (P1) and causing them to fall. Findings Include: 1. Policy titled “Patient Rights and Responsibilities” PolicyStat ID: 10789501, last approved 05/2022) indicated under As a patient of the facility, you have the right to: 8. Receive safe, high quality medical care without discrimination, that is compassionate and respects personal dignity, values, beliefs and preferences and contributes to a positive self-image. 2. Review of the Security Incident Report Number on 05/30/2025 through 05/31/2025 at 0118 hours indicated that P1 was up walking attempting to go into the hall. N12 (Law Enforcement Lieutenant) reported that he/she placed their right hand on P1 shoulder and with minimal force pushed him/her back into the room. Due to the momentum of the push, P1 fell to the floor hitting the wall. 3. Interview on 12/17/2025 with N12 at 1100 hours, confirmed that the facility failed keep P1 safe during their stay at the facility by causing P1 to fall and hit the wall.”

“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: 44532 Based on document review and interview, nursing services failed to complete a post fall evaluation and/or updating the fall risk assessment post fall for 1 of 10 patients reviewed. (P1) Findings included: 1. Facility policy titled: “Falls and Prevention, Emergency” policy, Policystat ID 16573539, last approved 11/2024, indicated that the Registered Nurse or medical provider will provide immediate care to the patient in event of a fall. Reassess and update fall plan if patient has fall. 2. Review of Medical record (MR) for P1 indicated: The MR lacked documentation of post fall assessment and fall risk assessment post fall on 5/31/2025 at 0018 hours. 3. Security Incident Report on 05/30/2025 through 05/31/2025 at 0118 hours indicated that P1 was up walking attempting to go into the hall. N12 (Law Enforcement Lieutenant) reported that he/she placed my right hand on P1 shoulder and with minimal force pushed him/her back into the room. Due to the momentum of the push, P1 fell to the floor hitting the wall. 4. In an interview with A2 (Quality Registered Nurse) on 12/17/2025 at approximately 1500 hours, he/she indicated that there was not any documentation of nursing evaluating or updating the fall risk assessment on P1 post fall that occurred on 05/31/2025 at 0118 hours.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44532 Based on document review and interview, nursing services failed to ensure the Incident Report was completed for a fall that occurred at the facility for 1 of 10 patients reviewed. (P1) Findings Included: 1. Review of the Policy titled: “Safety Event Reporting” Policystat ID: 18991402, last approved 09/2025 indicated under POLICY STATEMENT: B. All caregivers are responsible to report safety events. 2. Review of the Incident report log indicated a lack of documentation of an incident report filed for P1 for the fall that occured on 05/31/2025 at 0118 hours. 3. Security Incident Report on 05/30/2025 through 05/31/2025 at 0118 hours indicated that P1 was up walking attempting to go into the hall. N12 (Law Enforcement Lieutenant) reported that he/she placed my right hand on P1 shoulder and with minimal force pushed him/her back into the room. Due to the momentum of the push, P1 fell to the floor hitting the wall. 3. In interview with A1 (Quality Director) on 12/17/2025 indicated that an incident report (Safety Event Reporting) should have been completed on P1 for a fall that occured on 05/31/2025 at 0118 hours.”

“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: 49709 Based on document review and interview, the facility failed to provide care in a safe setting for 1 of 10 patient Medical Records (MRs) reviewed (P7). Findings include: 1. Facility policy titled, Psychiatric Emergencies, PolicyStat ID 12366744, last revised 1/2023 indicated on page 3, under PROCEDURE: E. If patient scores moderate to high on Columbia Suicide Severity Rating Scale (C-SSRS) perform Ligature Assessment and Environmental Awareness Checklist prior to placing in room. 2. Review of P7’s medical record (MR) indicated: a. On 4/6/2025 at 1032 hours, ligature risk items were removed from P7’s room which included, but not limted to: linen. b. On 4/6/2025 at 1510 hours, technician note indicated P7 removed the pillowcase from the pillow. 3. In interview with A5 on 05/30/25 at approximately 3:27 p.m., he/she indicated P7 put their blanket over their head and was picking scabs from the superficial wounds. When P7 was told to stop, they took the pillowcase off the pillow and attempted to tie it around their neck.”

“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: 49709 Based on document review and interview, nursing services failed to update the provider on the patient’s condition after patient communication in one instance (P7). Findings include: 1. Review of medical record (MR) for P7 indicated the following: a. P7 admitted to F1 on 04/06/25 at 1011 hours. Patient arrived at the emergency department (ED) via emergency medical services (EMS) for diagnosis of suicidal ideation (SI) and intentional self-harm of bilateral arm cutting. b. At 1422 hours, P7 handed the technician a note that indicated they felt suicidal badly, they want to self-harm badly. MR lacked documentation that nurse and/or provider were notified of note. c. At 1522 hours, P7 was discharged with their guardian in stable condition. d. At 1535 hours, addendum to Crisis evaluation (eval) progress note: Upon discharge, P7 ran into traffic and indicated they were trying to get hit by a vehicle and indicated SI. P7 ‘s providers discussed this situation and recommended that P7 be admitted to inpatient at this time. P7 indicated they were attempting to end their life and continued to have thoughts of harming themselves. 2. In interview on 5/30/2025 at approximately 3:27 p.m. with A5, he/she indicated they were able to recall P7 from a list provided, they provided 1:1 care for P7. A5 indicated P7 was being discharged home and ran into traffic trying to get hit by a car.”