North Oaks Medical Center

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital’s governing body failed to ensure that the medical staff was accountable for the quality of care provided to the patient #2. This deficient practice is evidenced by: 1. Failure to properly perform a physical exam; 2. Failure to treat abnormal findings during exam; 3. Failure to provide continuity of care. Findings: Review of “Medical Staff Rules & Regulations” last revised 12/02/2019 revealed in part: I. Medical Record Documentation and Use of the Electronic Medical Record (EMR) A. Entries into the EMR General Requirements: The attending practitioner shall be responsible for the preparation of a complete and legible ... medical record for each patient. Its contents shall be pertinent and current to justify the treatment, support the diagnosis and facilitate the continuity of care. This record shall include identification data, complaint, personal history, family history, history of present illness and physical examination. II. Note Type Requirements A. History & Physical (H&P) 1. d. The detailed history shall reflect a review of the chief complaint/history of present illness, relevant past, family, and social history, and a relevant review of systems. A detailed/comprehensive physical shall include all relevant body areas or organ systems. 5. A Licensed Physician Assistant ... may prepare an H&P with a co-signature of their supervising or collaborating physician. Co-signature must occur within the first 24 hours of admission. C. Progress Notes. Progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability ... the patient’s problem list shall be entered and updated in the record and an assessment/plan documented in the progress notes ... IX. Quality Assessment/Performance Improvement A. Participation Requirements. All members of the Medical Staff will participate in the ongoing quality assessment program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems. Review of patient #2 medical record revealed that the patient was admitted from the ED for further evaluation of coffee ground emesis and Upper GI Bleed on 02/01/2024. The patient was non-verbal, contracted and had a PEG Tube. On 02/05/2024 a left humerus x-ray was ordered and revealed minimally impacted humeral neck/head fracture. Chronic deformity of the clavicle. Possible fracture of the bony glenoid which is not well visualized on this humerus only radiograph. Further record revealed 4 documented wounds (right great toe, left 5th toe, sacrum, and left upper extremity) via photograph taken by the inpatient nurse that were added to the EMR on 02/01/2024 at 8:48 p.m. The admit nurse documented the wound to the left upper extremity and described it as bruising- purple/reddish. There is no documentation of the patient wounds prior to this. 02/01/2024 at 9:10 a.m. S13HNP documented a History and Physical on patient #2. There is no documentation that the patient had any wounds. S12HMD signed an attestation on 02/02/2024 at 6:52 p.m. The attestation states “on date of service noted by NP above, I independently saw the patient.” 02/03/2024 at 12:03 p.m. Progress Note by S14HMD: Exam documentation reveals Extremities: Decreased range of motion. (Chronic contractures to BLE, Large bruise in the left upper arm). There is no prior documentation of the patient having any wounds. No additional tests were ordered to address the abnormal finding. 02/04/2024 at 11:52 a.m. Progress Note by S12HMD. Revealed no Physical Exam documented and no documentation of any wounds or the bruising noted by the hospitalist on the previous day. 02/05/2024 at 12:00 p.m. Nursing Note revealed: “Spoke with S16ELS regarding patients LUE bruising. S16ELS questioned nurse “when did this get here and how did it get there? We have no record or report of this bruising at S16ELS.” Primary nurses explained present on admission. “My staff is supposed to report things like this to me and it was not so I’m unclear of why the bruising is there on admit.” Nurse repeated documentation at time of admit and photo. S16ELS stated she would investigate the issue. Also asked if patient would be discharged today. Primary nurse explained no longer discharge so patient can get x-rays.” 02/05/2024 at 4:58 p.m. Progress Note by S13HNP. Revealed “Patient seen and examined on rounds. No acute events or complications reported overnight. No family currently present at bedside. Patient is nonverbal at baseline. Bruising noted to LUE during exam today.” “Left humeral neck fracture.” -Sling ordered, ortho consulted. -Social work consulted, patient is bed bound, nonverbal, unclear mechanism. Case discussed with S12HMD. 02/06/2024 patient was seen by Orthopedic Surgery. Ortho exam reveals moderate ecchymosis and swelling over the left shoulder. He is sitting with a flexed elbow and wrist. Unable to actively perform hand motion. No obvious deformities of the right upper extremity. Bilateral lower extremity flexion contractures to knees and hips. No plan for operative interventions. Follow-up outpatient in 2 weeks with repeat x-rays of the shoulder. 02/06/2024 at 12:58 p.m. Discharge Summary by S15HMD. Physical Exam revealed patient’s condition at discharge as “fair.” The physical exam revealed “musculoskeletal: Bruising of the left upper extremity with significant ecchymosis pictures documented in chart present on arrival with continued evolution as expected, +flexure contracture deformity, diffuse muscle atrophy.” Integumentary: “Warm, Dry, wound documented in chart please see picture.” Further review of the medical record did not reveal any documentation, by a provider, regarding any wounds that were documented by photograph in the chart upon the patient’s admission. On 05/21/2024 at 12:55 p.m. S13HNP verified seeing patient on 02/01/2024, 02/02/2024, and 02/05/2024 and not removing Patient #2’s hospital gown for the assessments on 02/01/2024 and 02/02/2024. S13HNP assessed Patient #2’s LUE bruising on 02/05/2024 then ordered x-ray. On 05/21/2024 at 1:05 p.m. S12HMD verified she assessed Patient #2 on 02/04/2024 only doing a focused assessment which did not reveal bruising to LUE. She verified that she was not notified of pictures being taken of Patient #2’s wounds or bruising to LUE upon admission on 02/01/2024.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to identify areas of improvements that potentially affect health outcomes, patient safety and quality of care. This deficiency is evidenced by the hospital failing to use data collected to implement an action plan to promote patient safety. Findings: Review of patient #2 medical record revealed lack of full physical assessment by provider, lack of implementing interventions upon discovering abnormal findings, and lack of properly reporting abnormal findings to provider. In an interview on 05/21/2024 at 9:55 a.m. S5DCA confirmed that a SBAR significant event note should have been documented to notify MD of wounds per policy. In an interview on 05/21/2024 at 12:55 p.m. S13HNP verified seeing patient on 02/01/2024, 02/02/2024, and 02/05/2024 and not removing Patient #2’s hospital gown for the assessments on 02/01/2024 and 02/02/2024. S13HNP assessed Patient #2’s LUE bruising on 02/05/2024 then ordered x-ray. In an interview on 05/21/2024 at 1:05 p.m. S12HMD verified she assessed Patient #2 on 02/04/2024 only doing a focused assessment which did not reveal bruising to LUE. She verified that she was not notified of pictures being taken of Patient #2’s wounds or bruising to LUE upon admission on 02/01/2024.”

“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: 50453 Based on record review and interview, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1. Failure to document 2 (#1, #2) out of 3 (#1-#3) assessment/reassessments per policy; 2. Failure to communicate 1 (#2) out of 3 (#1-#3) clinical condition changes to the physician by using the SBAR significant event note; 3. Failure to document 1 (#2) out of 3 (#1-#3) full patient skin assessment of wounds/pressure injuries prior to discharge. Findings: Review of hospital policy revised 05/2024 titled “Nursing Care of the ED Patient: Triage, Vital Signs, and Re-Assessment” revealed in part: PROCEDURE FOR RE-ASSESSMENT: 1. Re-assessment of the patient shall occur with the change of primary nurse caregiver. The assessment shall include documentation as it pertains to the chief complaint or diagnosis once established by a physician. 2. The patient shall be reassessed to determine the patient’s response to any of the following: A. Treatment or discontinuation of treatment. B. When a significant change occurs in the patient’s condition. C. When a significant change occurs in the patient’s diagnosis. Review of hospital policy origination date 10/1995 titled “Nursing 24 Hour Assessment” revealed in part: INSTRUCTIONS FOR COMPLETION OF ASSESSMENT FLOWSHEETS IN THE EMR 1. Documentation should include rows within the Assessment Flowsheets. Review of hospital policy origination date 01/2012 titled “Nurse/Physician Phone Communication/SBAR” revealed in part: POLICY STATEMENT: Changes in Clinical condition of a patient must be communicated to the physician using the SBAR significant event note. Should the primary nurse be unsure of a change in condition, the unit charge nurse must be consulted ... These significant events will be documented in a Significant Event note and assigned a physician to cosign. Review of hospital policy origination date 11/1997 titled “Skin Assessment & Wound Management” revealed in part: POLICY STATEMENT: 3. Upon admission, in addition to implementation of the Braden Scale Protocol, consider initiation of Photo Triage Procedure ... as each unit is educated for the presence of: *Non-blanching erythema *Partial or full thickness skin loss *Purple discoloration on pressure areas 4. At discharge, patient skin assessment will include full assessment for presence of wounds/pressure injuries including measurements and other parameters. Taking a photo of active pressure injury/wound for the record at discharge is recommended. PROCEDURE FOR PHOTO TRIAGE: 3. Take photograph of skin breaks as identified and upload to electronic record at bedside. 4. Place WOC nursing referral into electronic record with request for WOC Photo Triage to notify WOC to review photos. 1. Failure to document 2 (#1, #2) out of 3 (#1- #3) assessment/reassessments per policy. Review of Patient #1 electronic medical record revealed while the patient was in the ED the last assessment documented on the patient was on 01/28/2024 at 12:00 p.m. An ESI level 2 was assigned to the patient during triage at 10:21 a.m. The patient received 20mg of Geodon IM at 12:02 p.m. The patient was admitted to the hospital on 01/28/2024 at 7:53 p.m. Further review revealed there was no reassessment of patient’s response to receiving medication as per policy. There was also no patient assessment documented upon change in primary nurse while in the ED as per policy. Review of Patient #1 inpatient electronic medical record revealed MD orders for Neurological checks upon arrival to the floor every 4 hours for the first 48 hours. Further review revealed that a full neurological assessment was not documented every 4 hours as per MD orders. In an interview on 05/21/2024 at 10:14 a.m. S7EDD confirmed that when there is a change in primary nurse of a patient, the nurse should document their own assessment of the patient. In an interview on 05/21/2024 at 11:08 a.m. S10MOU confirmed that a full neurological assessment should have been documented on the patient every 4 hours per MD order. Review of Patient #2 electronic medical record revealed a GI and GCS assessment were documented on 02/01/2024 at 7:17 a.m. The patient had a change in primary nurse at 1:05 p.m. and again at 7:09 p.m. while in the ED. The patient was admitted to the hospital on 02/01/2024 at 8:41 p.m. Further review revealed no reassessment of the patient while in the ED prior to admit per policy. In an interview on 05/21/2024 at 10:14 a.m. S7EDD confirmed that when there is a change in primary nurse of a patient, the nurse should document their own assessment of the patient. 2. Failure to communicate 1 (#2) out of 3 (#1-#3) clinical condition changes to the physician by using the SBAR significant event note. Review of Patient #2 inpatient electronic medical record revealed a photo triage of 4 different wounds upon admission assessment. Further review revealed no communication regarding the wounds to the physician using the SBAR significant event note as per policy. There was also no documented full skin assessment or photographs of the wounds taken at discharge per policy. In an interview on 05/21/2024 at 9:55 a.m. S5DCA confirmed that a SBAR significant event note should have been documented to notify MD of wounds per policy. 3. Failure to document 1 (#2) out of 3 (#1-#3) full patient skin assessment of wounds/pressure injuries prior to discharge. Review of Patient #2 inpatient electronic medical record revealed a photo triage of 4 different wounds upon admission assessment. Further review revealed no documented full skin assessment or photographs of the wounds taken at discharge per policy. In an interview on 05/21/2024 at 11:05 a.m. S10MOU confirmed that a full skin assessment, including photographs, should have been documented prior to discharge per policy.”