Providence Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46640 Based on observation, policy review, document review, medical record review, and interview, the hospital failed to promote patients’ rights to receive care in a safe setting. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) situation (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death). On 08/15/24 at 2:56 PM, the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Process Improvement/Quality and Regional Director of Process Improvement/Risk were notified that an Immediate Jeopardy (IJ) was identified for noncompliance with the Condition of Participation (CoP) for Patient Rights; Care in a Safe Setting. On 08/19/24 at 8:05 AM, the hospital provided immediate action plans sufficient to remove the IJs and implemented corrective actions that included: competent telemetry staff deployed to monitor all telemetry 24/7, tracking log implemented to validate coverage of this position, education to be provided to all staff verified with attestation, Director of Quality/Performance Improvement to conduct real-time audits of telemetry monitoring logs to ensure accuracy of documentation, and HealthStream reports will be created with confirmation of completion of Education/Training for any nursing personnel working on the telemetry unit until all staff are educated. The plan of removal was verified by surveyors prior to survey exit on 08/19/24 at 10:30 AM. Findings Include: The hospital failed to provide care in a safe setting on the 6 South (6S) telemetry (a continuous monitoring of the heart’s electrical activity in a hospital setting) unit as evidenced by the failure to ensure hospital staff provided continuous telemetry monitoring for all patients that had orders for telemetry monitoring. (Refer to tag A0144).”

“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: 46640 Based on policy review, document review, record review, and interview, the Hospital failed to ensure the patient right to receive care in a safe setting as required by failing to provide continuous telemetry monitoring (a continuous monitoring of the heart’s electrical activity in a hospital setting) for all patients as ordered to monitor for potential abnormal heart rhythms. This deficient practice resulted in potential harm for all patients with physicians’ orders for telemetry monitoring and places any patient on telemetry at this hospital at risk for serious harm, injury, and death. Findings Include: Review of a Hospital policy titled, “ADMISSION AND DISCHARGE CRITERIA FOR THE TELEMETRY UNIT/MONITORED UNIT,” revised 10/2023, showed, “ ...Condition is not stable for admission/transfer to Medial or Surgical Unit ...The Progressive Care Unit/Medical Telemetry Unit are designed to meet the needs of patients who require the following: Telemetry observation that has a direct influence on the course of the illness. Assessments regarding drug intervention and plan of care involving the need for continuous cardiac monitoring ...Vital signs: Temperature, pulse, respirations, blood pressure and pulse oximetry every 4 hours ...Telemetry Monitoring- all patients with orders for cardiac monitoring should be placed on a telemetry monitor upon arrival to the unit not to exceed 15 minutes ...If there is any question on what is going on with your monitor, you should check your patient ...” Review of a document titled, “Update to Practice Standards for Electrocardiographic (ECG) Monitoring in Hospital Setting a Scientific Statement from the American Heart Association,” dated 11/07/17, stated, “ ...Documentation of the ECG is critical for diagnosis and to guide subsequent treatment. All rhythms that require immediate attention should be preserved as actual tracing ... clinicians must be mindful of the appropriate duration of monitoring, the purpose and benefit of a brief prescribed period of monitoring to confirm the absence of abnormal findings should not be overlooked ...” Patient 7 Review of Patient 7’s medical record showed a 55-year-old that was admitted to the hospital’s 6 South (6S) Telemetry Unit on 07/25/24 at 11:48 AM with an admitting diagnosis of weakness of right lower extremity and past medical history of heart attack (a medical emergency where there is a blockage of blood flow to the heart muscle), hypertension (elevated blood pressure), ST-Segment Elevation Myocardial Infarction (STEMI) (a type of heart attack that occurs when a blood clot completely blocks and artery that supplies blood to the heart) and three cerebral vascular accident’s (CVA) (a medical emergency where an interruption of blood supply can cause damage to the brain). Review of a document titled, “Complaint-Incidents-Grievance Log,” on 07/25/24 at 6:45 PM showed, “ ...Pt with r/o [report of] CVA arrived to floor sometime in the morning hours, but was not placed on tele [telemetry] until I was made aware during report and placed it on the pt [patient] (7+ hours without tele [telemetry] despite there being orders[for telemetry]) ...” Review of Patient 7’s physician’s order dated 07/25/24 at 11:48 AM showed, “Unit: PMC 6S TELEMETRY Patient Class: Inpatient Room.” Review of Patient 7’s medical record showed the first recorded telemetry reading strip on the 6 South telemetry unit was on 07/25/24 at 7:38 PM (approximately 7 hours after Patient 7 arrived on the telemetry unit.) Review of Patient 7’s medical record on 07/25/24 failed to show documented evidence of vital signs every four hours as ordered and per facility policy. Patient 7 arrived on the 6 South Telemetry Unit at 11:48 AM. The first set of vital signs was not documented until 7:00 PM on 07/25/24 (approximately 7 hours later.) During observation of the telemetry floor on 08/13/24 at 10:27 AM, while talking to Staff K, CNA, an audible telemetry alarm was noted to be sounding for approximately 4 minutes. No staff were present watching the telemetry monitors when this surveyor came over to inquire if the alarm was for a telemetry patient. Staff K, CNA, confirmed that it was an alarm for a telemetry patient in room 674. When asked which nurse was assigned to the patient in room 674, the CNA stated the nurse was Staff I, RN/ Charge Nurse. This surveyor went on to ask the CNA where Staff I, Charge RN was and the CNA stated, “in a patient room.” This surveyor asked who was responsible for monitoring the telemetry while Staff I, Charge RN was in a patient’s room. The CNA did not answer and instead looked over at another employee (identified as a nurse) and asked her to check on the patient in room 674. The unidentified nurse stated, “You want me to go look at them?” The CNA said “yes” and had to ask a second time before the unidentified nurse would come and look at the alarming patient’s rhythm. The unidentified nurse stood up and came over to the central telemetry monitoring location where surveyors where standing, looked at the monitor, silenced the alarm, and used a walkie talkie to ask a CNA on the floor to go check on the patient. This nurse did not leave the desk to check on the patient. When asked how many patients Staff I, Charge RN was assigned to care for today, the CNA stated, “five patients.” During an interview on 08/12/24 at 11:20 AM, Staff F, RN/House Supervisor and Staff D, Director of Emergency Services/Interim Director of Inpatient Services were notified by this surveyor about the observation in which the telemetry station was not being monitored. When asked who was responsible for monitoring the telemetry station, Staff F stated it was the responsibility of the Charge RN to monitor telemetry. Staff F stated that the current census of patients requiring telemetry on the floor at the time of observation was 21 patients. Staff F stated that current staff included the Charge RN, two staff RNs, two Licensed Practical Nurses (LPNs), and a Certified Nurse Aide (CNA). In addition to being responsible for monitoring the telemetry station the Charge RN was also assigned a full load of six patients.. During an interview on 08/13/24 at 3:03 PM, Staff I, Registered Nurse/Charge Nurse stated that it was not an unusual occurrence for the charge nurse to have a full patient load of 5 to 6 patients and stated, “We are not able to monitor the telemetry monitors and identify potential patient rhythm changes due to the expectations of being the charge nurse.” During an interview on 08/14/24 at 9:49 AM, Staff N, Medical Doctor (MD), stated that additional staff needed to be hired to monitor the telemetry monitors and charge nurses should have a lighter load of patients. Staff N stated that he wants his patients to be safe and was surprised there had not been more negative outcomes. Staff N stated, “If a patient is on telemetry they need to be monitored or they would not be on the telemetry ...physicians have voiced their concerns frequently about patient safety related to telemetry monitoring to nursing supervisors and administration.” During an interview on 08/14/24 at 10:47 AM, Staff S, RN, stated that the average patient load while she is in charge is 5 to 6 patients. Staff S stated that telemetry patients are not continuously monitored and that monitors are silenced frequently without notification to the primary nurse, or a patient assessment being completed. Staff S stated, “Nursing staff have voiced these concerns for patient safety to the supervisors and administration without any follow up or changes.” During an interview on 08/14/24 at 2:09 PM, Staff B, RN/CNO confirmed that the Charge Nurse is assigned a patient load in addition to telemetry monitoring and supporting other unit staff.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 46740 Based on policy review, medical record review, and interviews the hospital failed to inform the patient or the patient’s representative on whom to contact to file a grievance, the steps taken on behalf of the patient to investigate an alleged incident, the results of the investigation and the date of completion for one (Patient 1) of seven patients reviewed. This deficient practice has the potential to infringe on the rights of all patients or their representatives to have their concerns heard and properly investigated through the grievance process. Findings Include: Review of facility policy titled “Patient Complaints/grievances” reviewed date 09/2023 showed PURPOSE: To ensure that all patient complaints and or grievances are addressed in a timely, reasonable, and consistent manner in compliance with Joint Commission and Centers for Medicare and Medicaid Services (CMS) standards and regulations. This policy provides a mechanism for initiation, review and when possible, resolution of patient complaints or grievances concerning the quality of care or services rendered. Sequence of Steps: A. Grievance Management: The hospital employee receiving the information will: 1. Enter a report of the information into the patient complaint/grievance database and 2. Forward the report via the database email function to the Director of Risk Management and to the Director of the involved department(s). More involved patient concerns are forwarded immediately to the department in which the concern involves or the House Supervisor after hours. The Director/Manager or House Supervisor will: 1. Investigate and act as appropriate to resolve the concern. a. Discuss the concern with the patient. b. Interview staff involved. c. Act as applicable to resolve the issue. 2. Keep the patient informed of what actions are being taken towards the resolution of their problem. 3. Document the concern, investigation, and resolution in the Patient Complaint/Grievance database. 4. If resolution is not attained, see the procedure for unresolved concerns below. 5. All grievances will be handled as quickly as possible; generally review, investigation and resolution will occur within ten (10) working days. This process for any grievance alleging abuse or neglect will be initiated immediately upon receipt. Patient 1 Review of Patient 1’s discharged medical records showed an 85-year-old patient admitted with chief complaint of rapid heart rate and an admitting diagnosis of atrial flutter with palpitations, chronic cough, elevated brain natriuretic peptide (BNP - a blood test that indicates heart failure) level, and generalized muscle weakness. During an interview on 11/14/23 at 11:12 AM Patient 1’s daughter stated, “When I reported the incident of a staff member slapping my mother’s hand away from her meal tray to [Staff L, RN] nurse manager and the night shift charge nurse, I was not informed that I could file a complaint or grievance.” Patient 1’s daughter stated that staff did voice concern about the complaint but did not do anything to change the situation. Patient 1’s daughter stated, “Supposedly they were going to remove that person from my mother’s care, but I don’t know if the facility did that.” During an interview on 11/14/23 at 3:30 PM, Staff C, RN stated that there was an incident with Patient 1 and her meal tray involving a dietary aide. Staff C stated that the dietary worker brought the tray in, and the patient tried to grab it. The dietary worker yanked the meal tray back from Patient 1. Staff C stated that she called Staff O, RN, Director of Nursing (DON) regarding the incident, and she came up and immediately spoke with the Patient 1’s daughter. Staff C stated that the nurse manager was going to file an incident or grievance report. Staff C stated that after talking with Patient 1’s daughter the DON removed the dietary worker from the situation and told her not come to Patient 1’s room anymore. During an interview on 11/15/23 at 12:06 PM with Staff L, Nurse Manager, stated, “My DON [Staff O] who no longer works at the facility, spoke with Patient 1’s daughter.” Staff O stated that Patient 1’s daughter reported that a staff member slapped her mother’s hand. Staff O talked with Staff N Dietary aide who was accused of either slapping or grabbing Patient 1’s hand to keep the patient from eating. Staff L stated that Staff N said that she went to grab her hand, so the patient wouldn’t touch the hot plate. Staff L stated, “As far as I know [Staff O] told me she put in a verge (incident report) and from what I understand the dietary aide was instructed not to go back into Patient 1’s room.” During an interview on 11/15/23 at 12:16 PM, Staff N Dietary Aide and Staff M Dietary Manager stated, “my diet clerks told me about the incident first then I got a verbal report from [Staff O, DON] regarding the incident.” Staff M stated, “I was waiting for any verge or incident report regarding Patient 1, but I never received one.” Staff M stated, “I completed reeducation and training with Staff N, but it was informal because I did not hear anything from human resources (HR) that it was a serious incident that should be handled more formal.” Staff N stated, “Oh no I am never going to hurt somebody.” when asked about slapping or shoving Patient 1’s hand away. Review of complaints, grievances and incident log dated 09/2023 to 10/2023 failed to show a report of any staff member allegedly slapping or pushing a patient hand away from their meal tray.”