East Jefferson General Hospital

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48050 Based on an observation and interview, the hospital failed to ensure each patient had the right to personal privacy. This deficient practice had the potential to impact all patients who presented to the Emergency Department (ED) as evidenced by failure to provide privacy while collecting personal information during the registration process. Findings: A review of hospital policy titled, “Patient Bill of Rights and Responsibilities,” last revised 01/2024, revealed in part: “YOUR RIGHTS: You have the right to your personal privacy and confidentiality in care discussions, exams, and treatments.” During the tour of the ED waiting area on 11/25/2024 from 11:25 AM to 12:00 PM, an observation revealed a small waiting room with open ED registration check-in desk with language interpreter on wheels (IOW) and an enclosed ED registration desk separated by clear window. For full ED registration, ED patients would sit on one side of the clear window in the waiting room and the ED registration clerk would sit on the other side of the clear window with language interpreter on wheels (IOW). This would allow anyone in the waiting room to hear confidential information. In an interview with S2PAM on 11/25/2024 at 11:35 AM, she verified some parts of the ED registration process are done in the ED waiting room where other ED patients would be able to hear the information provided by the patient. Furthermore, she verified when using the IOW to collect full registration information, the IOW is behind the registration desk and clear window while the patient is sitting on the waiting room side of the desk answering questions.”

“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: 44495 Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice is evidenced by failure of the admitting physician to order care based on the admitting diagnosis in 1 (#1) of 3 (#1-#3) reviewed medical records. Findings: Review of the medical record for Patient #1 revealed the patient presented to the emergency department on 08/11/2024 after falling twice due to dizziness. The patient reported a productive cough for 2 weeks and was positive for COVID-19. Computed tomography of the chest revealed “nonspecific patchy ground glass opacity in the right lung apex.” Further review of the medical record revealed the patient was a smoker with a history of chronic obstructive pulmonary disease and obstructive sleep apnea. The patient had been prescribed home oxygen therapy, but was noncompliant secondary to financial constraints. Supplemental oxygen at 4 liters/ minute was required in the emergency department to maintain oxygen saturation above 90%. The patient was admitted to the hospital with a diagnosis of hypoxia. Review of the history and physical documented by S9MD revealed in the physician’s plan included: “1. Hypoxia: admit to tele, oxygen, cardiac monitor, symptomatic management. 2. COPD exacerbation: bronchodilator, steroid, breathing treatment, prophylactic antibiotic use. 3. Covid 19 positive: steroid and supportive care, consult pulmonary for further evaluation and management. . . .” Review of the admission orders for Patient #1 failed to reveal an order for supplemental oxygen, bronchodilators, breathing treatments, antibiotics or antivirals, pulse oximetry, telemetry or other cardiac monitoring. Further review also revealed S9MD failed to set parameters for notification if the oxygen saturation could not be maintained at an acceptable level. Review of the medical record revealed Patient #1 was transferred out of the emergency department and into a room on 08/12/2024 at 1:52 a.m. Review of the medical record failed to reveal documentation the patient received supplemental oxygen between 2:00 a.m. and 9:00 a.m. Oxygen saturation was documented only once at 4:00 a.m. in red as 84%. There were no documented interventions and no documentation the physician was notified. Review of the nursing notes for Patient #1 revealed on 08/12/2024 at 9:01 a.m, S8RN documented “’S10DO’ notified that pt was sating 87% on 4L O2. MD stated to pump pt up to 5L with a goal to keep pt above 90%.” On 08/12/2024 at 9:08 a.m. S8RN documented, “’S10DO’ notified that pt’s O2 only came up to 88-89%. RN requested breathing treatments for pt. MD ordered breathing treatments and respiratory called to give patient PRN treatment.” Review of the orders for Patient #1 revealed on 08/12/2024 at 9:22 a.m. continuous pulse oximetry was ordered. Further review of the record revealed Patient #1 was noted to decompensate throughout the morning of 08/12/2024. An arterial blood gas was collected on 08/12/2024 at 2:48 p.m. and revealed the arterial pH was 7.31, arterial pCO2 was 70, arterial O2 was 69, arterial HCO3 was 35, base excess was 6.6, and arterial O2Hb was 91.2. Patient #1 was transferred to a higher level of care for telemetry monitoring and placed on bilevel positive airway pressure (BiPAP) that evening. In interview on 08/21/2024 between 10:21 a.m. and 10:27 a.m., S8RN verified she was the nurse for the day shift on 08/12/2024. S8RN verified the patient was on supplemental oxygen at 4 liters/ minute when she arrived for her shift but was not sure when it was initiated and did not know if the patient was on supplemental oxygen at 4:00 a.m. when the oxygen saturation was documented as 84%. During the record review on 08/20/2024 between 12:35 p.m. and 2:25 p.m., S4RN verified the admission orders did not contain orders for supplemental oxygen or breathing treatments. S4RN also verified there were no orders for continuous pulse oximetry and there were no orders to call the physician if the oxygen saturations fell below an acceptable level. In interview on 08/20/2024 at 2:02 p.m., S2SDQ and S3DQ verified there were no set parameters for nursing staff to contact the physician for abnormal vital signs on the unit where the patient was placed.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to comply with the documented directives of the patient and patient’s family. The deficient practice is evidenced by the initiation of resuscitative interventions in 1 (#2) of 1 reviewed medical record of a patient with a documented do not resuscitate/ do not intubate (DNR/ DNI) order. Findings: Review of Policy 15993403, “UHS Code Blue,” last revised 07/2024, revealed in part, “Policy: I.B.1. Code Blue will not be called for patients who have “Do Not Resuscitate” orders or other physician orders restricting lifesaving steps pursuant to a patient’s Advanced Directive. Resuscitation is not initiated in these situations.” Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure. Review of the physician’s orders revealed DNR/DNI orders were initiated on 07/15/2024 at 11:16 a.m. Review of an incident report submitted on 07/16/2024 at 4:05 a.m. revealed on 07/16/2024 at 2:16 a.m. the patient was found down, supine on the hallway floor. Code Blue was called at 2:14 a.m. Review of the medical record revealed on 07/16/2024 at 2:16 a.m. S11RN documented the patient was nonresponsive with no pulse and no respirations and compressions were initiated. At 2:19 a.m. an intraosseous line was placed in the left proximal tibia and compressions were paused for a pulse check and then resumed. At 2:20 a.m., epinephrine 1 milligram was given via the intraosseous line. Compressions continued and 2:22 a.m. the patient was intubated. The code ended at 2:23 a.m. when the medical staff realized the patient had a DNR/DNI order. In interview on 08/21/2024 at 9:10 a.m., S5RN verified the hospital staff initiated resuscitative efforts including intubation despite the patient/ patient’s family’s documented refusal of the interventions.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44495 Based on record review and interview, nursing staff failed to initiate restraints according to hospital policy. The deficient practice is evidenced by failure of the nursing staff to notify the family of the need for the use of non-violent restraints in 1 (#1) of 1 reviewed records where restraints were used. Findings: Review of Policy #14929767, “LCMC Restraints and Seclusion,: last revised 01/2024, revealed in part, “ Section III: Criteria for Restraint or Seclusion Use . . . B. Restraints are implemented in the least restrictive manner possible and are ended at the earliest possible time. When practical, restraint use is discussed with the patient and, when appropriate, with the patient’s family around the time of restraint application.” And “Section XI: Application of Restrained and/or Seclusion . . . C. Trained and competent staff members do the following: . . . 6. Explain the following to the patient and/or his or her family, as appropriate: i. Procedure to be used; ii. Reason for procedure; iii. Behavioral criteria for release. 7. Allow the patient and/or family to participate in the patient’s care as appropriate.” Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. The patient had fallen twice at home and the family tried to transport her to the hospital, but was unable to get her into the car because of ankle pain. Emergency medical services was called to the home for lift assistance and then transported the patient to the emergency department. Documentation revealed the daughter of Patient #1 was present in the emergency department and provided staff with information about her mother’s medical history. Further review of the medical record revealed the oxygen requirements for Patient #1 increased and the patient became less responsive after hospitalization. The patient was transferred to a higher level of care and BiPAP was required to maintain her oxygen saturation above 90%. Review of the orders revealed on 08/14/2024 at 11:45 p.m., soft restraints were initiated to prevent the patient from pulling lines and removing her oxygen. Further review of the record failed to reveal any attempts to notify the family and explain the events that lead to the use of restraints. The restraints were removed on 08/15/2024 at 10:08 a.m. In interview on 08/20/2024 at 2:19 p.m., S3DQ verified there was no documentation of attempts to notify the family.”

“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: 44495 Based on record review and interview, the Registered Nurse failed to ensure care was provided as ordered by the physician. The deficient practice is evidenced by 1) failure of nursing staff to document vital signs as ordered in 2 (#1, #2) of 3 (#1-#3) reviewed medical records; and 2) failure of nursing staff to document accurate intake and output every shift as ordered in 1 (#1) of 1 reviewed medical record of a patient with orders for intake and output. Findings: 1) Failure of nursing staff to document vital signs as ordered. Patient #1 Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. Review of the orders for Patient #1 revealed vital signs were to be documented every 4 hours. Review of the medical record revealed the following: 4:07 a.m.- Temperature 98.7 degrees Fahrenheit; Pulse- 88; Respirations-18; Blood Pressure- 138/71; Oxygen saturation 84%. 9:13 a.m.- Temperature- 98.4 degrees Fahrenheit; Pulse- 74; Respirations- 18; Blood Pressure 117/67; Oxygen saturation- 89% on 5 liter/ minute via nasal cannula. In interview on 08/20/2024, 2:11 p.m., S3DQ verified the vital signs were not documented every 4 hours. Patient #2 Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure. Review of the admission orders revealed vital signs were to be documented every 4 hours. Review of the medical record for the 7 a.m. to 7 p.m. shift for 07/15/2024 revealed the last documentation of complete vital signs at 5:25 p.m. Review of the 7 p.m. - 7a.m. shift for 07/15/2024 revealed the nursing staff documented the following: 8:00 p.m. - Pulse-102, Respirations-24; Cardiac Rhythm - normal sinus rhythm; oxygen saturation- 93%. 8:32 p.m. - Pulse-84; Cardiac Rhythm- normal sinus rhythm. 11:08 p.m. - Pulse -83; Respirations- 20; Blood Pressure 123/76; mean arterial pressure- 91; oxygen saturation - 95%. In interview on 08/20/2024 at 2:49 p.m., S3DQ verified the nurse failed to document the blood pressure every 4 hours as ordered. 2) Failure of nursing staff to document accurate intake and output every shift as ordered. Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. Review of the admission orders from 08/12/2024 at 12:57 a.m. for Patient #1 revealed intake and output were to be documented every shift. Review of the flow sheet for Patient #1 revealed on 08/12/2024 intake was first recorded as 0 from 8:01 a.m. through 9:00 a.m. On 08/12/2024 between 10:01 a.m. and 1:00 p.m. intake was recorded as 120 milliliters and output was recorded as 700 milliliters. In interview on 08/21/2024 at 9:26 a.m., S4RN verified intake and output were not recorded by nursing staff for 8 hours during the first shift after the order was placed.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44495 Based on record review and interview, the nursing staff failed to ensure the nursing care plan reflected the patient’s goals and nursing care to be provided. The deficient practice is evidenced by failure of the nursing staff to include significant acute and chronic conditions in the plan of care. Findings: Patient #1 Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. At the time of admission the patient had a positive test for COVID-19 and a history of chronic obstructive pulmonary disease and obstructive sleep apnea. Review of the nursing care plan failed to reveal any care related to her respiratory conditions. In interview on 08/20/2024 at 2:09 p.m., S3DQ verified the care plan did not include care related to her respiratory illnesses or infection control care related to the positive COVID test. Patient #2 Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure. Review of the medical history revealed the patient had a history of deep vein thrombosis and was on anticoagulants at the time of admission. Review of the nursing care plan failed to reveal care related to her history of thrombosis and use of anticoagulants. In interview on 08/20/2024 at 2:54 p.m., S3DQ verified there was nothing in the care plan related to her history of deep vein thrombosis or anticoagulation.”

“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: 44495 Based on record review and interview, the Director of Nursing failed to ensure contract staff adhered to hospital policies. The deficient practice is evidenced by failure of an agency nurse to follow hospital policies in 1 (#2) of 3(#1-#3) reviewed medical records. Findings: Review of Policy 15993403, “UHS Code Blue,” last revised 07/2024, revealed in part, “Policy: I.B.1. Code Blue will not be called for patients who have “Do Not Resuscitate” orders or other physician orders restricting lifesaving steps pursuant to a patient’s Advanced Directive. Resuscitation is not initiated in these situations.” Review of Policy Fund-13, “Post Mortem Process- Adult,” revised 10/27/2021, revealed in part, “8. Documentation reflects pertinent facts including time and pronouncement of death including physician name, post mortem care, and time to morgue.” Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure. Review of the physician’s orders revealed DNR/DNI orders were initiated on 07/15/2024 at 11:16 a.m. Review of an incident report submitted on 07/16/2024 at 4:05 a.m. revealed on 07/16/2024 at 2:16 a.m. the patient was found down, supine on the hallway floor. Code Blue was called at 2:14 a.m. Review of the medical record failed to reveal any description of the incident other than “found down, supine on the hallway floor” the Code Blue documentation. Review of the Code Blue documentation revealed on 07/16/2024 at 2:16 a.m. S11RN documented the patient was nonresponsive with no pulse and no respirations and compressions were initiated. At 2:19 a.m. an intraosseous line was placed in the left proximal tibia and compressions were paused for a pulse check and then resumed. At 2:20 a.m., epinephrine 1 milligram was given via the intraosseous line. Compressions continued and 2:22 a.m. the patient was intubated. The code ended at 2:23 a.m. when the medical staff realized the patient had a DNR/DNI order. Further review of the medical record failed to reveal documentation of the post mortem care that was provided. In interview on 08/21/2024 at 9:03 a.m., S2SDQ verified S11RN was assigned to care for Patient #2 on the shift that she expired. S2SDQ verified S11RN was an agency nurse. In interview on 08/21/2024 at 9:10 a.m., S5RN verified the hospital staff initiated resuscitative efforts including intubation despite the patient/ patient’s family’s documented refusal of the interventions. In interview on 08/21/2024 at 9:44 a.m., S7RN verified the nurse did not document the specifics surrounding the patient having been found down and did not document the post mortem care provided. S7RN verified she spoke with S11RN at the end of the shift and asked her to complete the record, but S11RN did not.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered as ordered by the physician. The deficient practice is evidenced by failure of the nursing staff to provide additional interventions for pain relief after initial administration of the prescribed pain medication failed to relieve the patient of pain in 1 (#3) of 3(#1-#3) reviewed medical records. Findings: Review of the medical record for Patient #3 revealed the patient had a surgical procedure on 07/15/2024 and was admitted for overnight observation. Review of the orders for Patient #3 revealed an order initiated on 07/15/2024 at 4:00 p.m. for oxycodone-acetaminophen 5-325 mg; Ordered Dose: 1 tablet; Route: Oral; Frequency: Every 4 hours PRN for Pain Score 4-7, Pain Score 8-10. Review of the medical record revealed on 07/15/2024 at 4:08 p.m., Patient #3 reported 10/10 pain and was administered one oxycodone-acetaminophen tablet. Follow up pain assessment at 5:08 p.m. revealed patient reported the pain as 5/10. The patient’s stated pain goal was 3/10. Further review of the medical record revealed the nurse did not document any further interventions and did not contact the physician for additional orders. In interview on 08/21/2024 at 10:55 a.m., S4RN verified the nurse did not document any additional interventions to relieve Patient #3 of his pain and did not contact the physician for additional orders.”

“ACCEPTING VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent with Federal and State law. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure verbal orders were documented according to hospital policy. The deficient practice is evidenced by verbal orders missing required documentation in 1 (#1) of 3 (#1-#3) reviewed medical records. Findings: Review of Policy #15690283, “UHS Physician/Provider Order Sources (Written, Verbal, Telephone, and Electronic),” last revised 06/2024 revealed in part, “Policy . . . IV.C. Verbal and telephone orders should first be electronically entered and the verified by reading back the information to the prescriber.” Review of Policy #14357448, “Oxygen Administration,” last approved 11/2021, revealed in part, “oxygen orders should contain: * Modality *FIO2 and/or liter flow (whichever is applicable) *If order states “oxygen” or “oxygen protocol” and the patient is in an eligible area and meets criteria, oxygen will be managed per oxygen protocol from start.” Review of the medical record for Patient #1 revealed on 08/12/2024 at 9:01 a.m. S8RN documented “S11DO notified that pt was sating 87% on 4LO2. S11DO stated to pump pt up to 5L with a goal to keep pt above 90%.” Review of the orders for Patient #1 revealed on 08/12/2024 at 9:28 a.m. S8RN documented the following nursing communication: “Comments: Keep pt’s O2 > 90%.” There was no order for the oxygen. In interview on 08/21/2024 between 10:21 a.m. and 10:27 a.m., S8RN verified the documented communication in the orders at 9:28 a.m. was for the verbal order for oxygen at 5 liters/minute that she had documented in her note at 9:01 a.m.”

“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: 48051 Based on record review and interview, the hospital failed to ensure the patient received care in a safe setting. This deficient practice is evidenced by the hospital failing to remove unsafe items in reach of a patient admitted under a Physicians Emergency Certificate (PEC). Findings: A review of hospital policy, “Contraband,” Policy No. SAF-24 with an effective date of 07/15/2020, revealed in part, IV. Definitions: A. Contraband: Any items that can be utilized as a weapon or otherwise post a threat or jeopardize the health or well-being of any team member, patient or guest of the facility. This also included any instrumentality that can jeopardize a patient’s therapeutic plan of care. 1. Examples of Contraband include: Item v. Medicine brought from home (prescription or over the counter). VI. Handling Contraband: 1. Contraband items cannot be used by the patient on suicide precautions except under the direct supervision by staff. 2. Medication brought from home cannot be left with the patient. A review of hospital policy, “ ... Care of the PEC/CEC/JC/OPC Patient,” PolicyStat ID 14929730, with an effective date of 12/2023, revealed in part, Attachment A - Safety Precautions: The following safety precautions will be implemented for all PEC, CEC, and JC patients. II. Patients will undress completely and be observed specifically for sharp or metal objects, matches/lighters, and medication contraband. IV. All patient’s belongings (clothing, shoes, jewelry, cell phone, etc.) will be removed from the room and secured. A review of Patient #3’s electronic medical record (EMR) revealed the patient presented to the emergency department (ED) initially complaining of suicidal ideation with the provider indicating, “ ... his speech is completely nonsensical.” It was also noted the patient was diaphoretic, tachycardic, disoriented and holding a bottle of Delsym. As time progressed in the ED the patient indicated he drank the entire bottle (148 ml) that morning. The ED Provider placed the patient under a Physician Emergency Certificate (PEC) for danger to self and gravely disabled on 06/02/2024 at 6:00 p.m. However, the provider was not able to medically clear the patient because of physical findings. Patient #3 was transferred to the hospital’s main campus intensive care unit (ICU) on 06/02/2024 at approximately 11:30 p.m. Initial admission nursing assessment on 06/02/2024 at 11:36 p.m. revealed patient place on PEC/CEC/Suicidal Precautions, room check performed, placed in paper scrubs/gown, staff supervision was assigned for suicidal/homicidal, 1:1 observation and room close to nursing station. However, there was no documentation related to the possession and current status of the patient’s belongings. The patient was transferred to Room #a on 06/03/2024 at approximately 4:07 p.m. A review of the incident report dated 06/10/2024 revealed in part, the team transporting Patient #3 to Room #a left Patient #3’s belongings in the room. A nursing note from 06/03/2024 at 5:00 p.m. revealed S7LPN documenting, “ ... found patient in bathroom with a bottle of Delsym drinking the contents ...patient said he drank about ¼ of the bottle ...” In an interview on 06/26/2024 at 12:00 pm, S6Sit confirmed she was the sitter present prior to and after the patient was transferred from ICU to Room #a. S6Sit also confirmed the patient’s belongings were stored in a belongings bag in the patient’s ICU room, the belongings accompanied the patient in transfer to 5-west, and the belongings were left at the bedside upon the patient’s arrival to Room #a. The sitter further confirmed she witness the patient rummaging through the belongings bag and obtaining the bottle prior to going into the restroom. She then notified the nursing staff of the patient having obtained a bottle from his belongings bag prior to entering the restroom. In an interview on 06/26/2024 at 12:17 a.m., S7LPN confirmed she was the receiving nurse on 5-west and she had not assessed the patient prior to the above mentioned event. She further confirmed she was unaware the patient remained in possession of his personal belongings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by the hospital failing to report allegations of potential abuse/neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section). Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. A review of hospital policy, “Contraband,” Policy No. SAF-24 with an effective date of 07/15/2020, revealed in part, IV. Definitions: A. Contraband: Any items that can be utilized as a weapon or otherwise post a threat or jeopardize the health or well-being of any team member, patient or guest of the facility. This also included any instrumentality that can jeopardize a patient’s therapeutic plan of care. 1. Examples of Contraband include: v. Medicine brought from home (prescription or over the counter). VI. Handling Contraband: 1. Contraband items cannot be used by the patient on suicide precautions except under the direct supervision by staff. 2. Medication brought from home cannot be left with the patient. A review of hospital policy, “ ... Care of the PEC/CEC/JC/OPC Patient,” PolicyStat ID 14929730, with an effective date of 12/2023, revealed in part, Attachment A - Safety Precautions: The following safety precautions will be implemented for all PEC, CEC, and JC patients. II. Patients will undress completely and be observed specifically for sharp or metal objects, matches/lighters, and medication contraband. IV. All patient’s belongings (clothing, shoes, jewelry, cell phone, etc.) will be removed from the room and secured. A review of hospital policy, “ ...Abuse and Neglect: Identifying and Reporting Cases,” Policystat ID 14916859, with an effective date of 12/2023, revealed in part, Purpose: To outline guidelines and responsibilities related to identifying and reporting suspected cases of child, adult, and elderly abuse and neglect consistent with the laws of the State of Louisiana. Definition: Neglect-The failure, by caregiver responsible for an adult’s care or by other parties, to provide the proper or necessary support or medical, surgical, or any other care necessary for his well-being. Policy: Any incident of allegations and/or suspicion of abuse/neglect occurring within the facility will follow a Self-Reporting Process for Hospitals Abuse/Neglect in accordance with Louisiana Department of Health. Procedure: Self-Report Knowledge of Incidents of Allegations and/or Suspicion of Abuse/Neglect within the Facility: a. Any allegation and/or suspicion of abuse or neglect will be self-reported to the LDH. b. Hospital facilities/health care workers will report these allegations within 24 hours of receiving knowledge of the allegation. c. The 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. Director/Supervisor/Administrative Representative must Immediately: f. Forward final investigative report and any requested documents to the appropriate LDH contact within 5 business days from the email acknowledging submission of the initial report. A review of the hospital’s incident logs revealed an incident of self-harm/self-inflicted injury on Patient #3. A review of Patient #3’s electronic medical record (EMR) revealed the patient was admitted and under a PEC. Initial admission nursing assessment on 06/02/2024 at 11:36 p.m. revealed patient place on PEC/CEC/Suicidal Precautions, room check performed, placed in paper scrubs/gown, staff supervision was assigned for suicidal/homicidal, 1:1 observation and room close to nursing station. However, there was no documentation related to the possession and current status of the patient’s belongings. The patient was transferred to 5-west med/surg unit on 06/03/2024 at approximately 4:07 p.m. A review of the incident report dated 06/10/2024 revealed in part, the team transporting the Patient #3 to Room #a left Patient #3’s belongings in the room. A nursing note from 06/03/2024 at 5:00 p.m. revealed S7LPN documenting, “ ... found patient in bathroom with a bottle of Delsym drinking the contents ...patient said he drank about ¼ of the bottle ...” In an interview on 06/26/2024 at 12:00 pm, S6Sit confirmed she was the sitter present prior to and after the patient was transferred from ICU to Room #a. S6Sit also confirmed the patient’s belongings were stored in a belongings bag in the patient’s ICU room, the belongings accompanied the patient in transfer to 5-west, and the belongings were left at the bedside upon the patient’s arrival to Room #a. The sitter further confirmed she witness the patient rummaging through the belongings bag and obtaining the bottle prior to going into the restroom. She then notified the nursing staff of the patient having obtained a bottle from his belongings bag prior to entering the restroom. In an interview on 06/26/2024 at 12:17 a.m., S7LPN confirmed she was the receiving nurse for Patient #3 and she had not assessed the patient prior to the above mentioned event. She further confirmed she was unaware the patient remained in possession of his personal belongings. In an interview on 06/25/2024 at 2:55 p.m., S3DPSQ and S5AS confirmed the above mentioned findings and the incident should have been reported to LDH-HSS in accordance with the Self-Reporting Process for Hospitals Abuse/Neglect.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan that reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice was evidenced by the hospital failing to develop a nursing care plan on 1 (#3) of 3 (#1 - #3) patients that encompasses all of the patient’s current medical and psychological needs. Findings: A review of hospital policy, “Planning of Daily Care,” Volume I (ST-03), with an effective date of 09/17/1985 and last reviewed on 02/17/2002, revealed in part, General: 2. When a patient is admitted, an RN performed an initial nursing assessment within the appropriate time-frame. The information obtained at the time of the assessment is transferred to the patient’s individual plan of care. The patient’s plan of care facilitates the following objectives: a. To ascertain a systematic, concise and organized approach to patient care. b. To provide a means through which patient care standards are utilized in the nursing care process. c. To communicate relevant data rapidly and efficiently to other members of the health care team. d. To plan individualized care based upon patient problems identified through assessment. e. To assure quality care based upon medical and nursing orders. f. To provide a basis for evaluating patient care through nursing actions and patient responses. 4. Nursing Plan of Care will be initiated by the Nurse A review of hospital policy, “ ... Suicide Screening, Assessment and Management of Patients at Risk (Non-Behavioral Health Units),” PolicyStat ID 15022705, with an effective date of 02/2024, revealed in part, Purpose: To outline the guidelines and responsibilities related to managing the care of patients at risk for suicide, self-harm, and/or harm to others and to assist with theidentification of patients who are at risk for suicide, ensuring a safe environment for the provision of care. Procedure: J. The patient’s care plan will be updated, ensuring patient-centered care by engaging the person at risk in care planning and decision making. A review of Patient #3’s electronic medical record (EMR) revealed the patient presented to the emergency department (ED) initially complaining of suicidal ideation with the provider indicating, “ ... his speech is completely nonsensical.” It was also noted the patient was diaphoretic, tachycardic, disoriented and holding a bottle of Delsym. The ED Provider placed the patient under a Physician Emergency Certificate (PEC) for danger to self and gravely disabled on 06/02/2024 at 6:00 p.m. A review of the care plan did not reveal any problem related to self-harm or suicide related precautions. In an interview on 06/26/2024 at 11:25 a.m. S5AS confirmed the above mentioned findings.”

“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: 44495 Based on record review and interview, the facility failed to ensure the registered nurse provided adequate supervision of the patient’s care. The deficient practice is evidenced by an incident involving a fall for 1 (#2) of 2 (#2, #3) reviewed patients assessed as high fall risk. Findings: Review of the policy “Falls Management,” last revised 11/2021, revealed in part, “All patients will be assessed for risk of falling upon admission. Reassessments will be routinely performed to determine ongoing need for fall prevention precautions Any patients determined to be at risk for a fall will be placed on fall prevention measures. . . . E. Interventions related to transport of patient with High Fall Risk Score . . . 2. Transport with assistance of staff or trained caregivers when appropriate.” Review of the Nursing Flow sheet for Patient #2 revealed on 03/05/2024 at 1:28 p.m. a Morse Fall Risk Assessment was performed and the patient was given a score of 60 (high risk). Review of the clinical notes from 03/05/2024 at 3:18 p.m. revealed “pt found on floor outside of restroom. Husband present at pts side. Walker in front of patient. Pt awake, alert and oriented x4. No loss of consciousness per pt. VS checked (see flowsheets). Huber needle with occlusive dressing found removed from patient’s chest. VS re-assessed. Pts BP 174/94. Pt assisted into wheelchair by multiple RNs. Pt requesting to use the bathroom, pt assisted to bathroom by MA and RN X1. Pt returned to wheelchair. Charge Nurse, Sharon Welch, RN notified Cosgriff, MD of pt fall and VS taken after fall. MD informed pt received approximately half of Taxol infusion today and had not yet received her Carboplatin. Per MD, pt to be sent to Emergency Room. Pt and husband updated and verbalized understanding. ED triage nurse notified that pt will be brought to ER by Liz, RN. Pts port heparinized and pt brought to Emergency Room via wheelchair.” In interview on 03/25/2024 at 1:05 p.m., S5MOPI verified Patient #2 was evaluated as a high fall risk and required the assistance of a walker. S5MOPI verified nursing staff should have assisted the patient to the restroom accompanied by the patient’s husband, even if Patient #2 insisted she only needed the husband’s help. In interview on 03/25/2024 at 3:30 p.m., S2SDQ and SDQ3 also verified the nurse should have accompanied the patient to the restroom to ensure her safety while receiving the infusion.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient’s representative) was informed of their rights, in advance of furnishing or discontinuing patient care whenever possible. This deficient practice is evidenced by the hospital failing to have evidence that 3 ( #1-#3) of 3 ( #1-#3) patients (or their representatives) reviewed for patient rights were informed of their patient rights. Findings: Review of hospital policy titled “Patient Rights and Responsibilities”, last reviewed 08/2020, revealed in part: Purpose, in part: ...It is ...the purpose of this policy to: Ensure that all patients receiving care and /or patient representatives are informed of their rights. Review of Patient #1’s closed medical record revealed an admit date of 11/06/2023 at 3:52 p.m. Further review failed to reveal documented evidence that the patient/representative was notified of the patient’s rights prior to furnishing care. Review of Patient #2’s closed medical record revealed an admit date of 12/07/2023 at 11:19 a.m. Further review failed to reveal documented evidence that the patient/representative was notified of the patient’s rights prior to furnishing care. Review of Patient #3’s closed medical record revealed an admit date of 10/08/2023 at 10:45 p.m. Further review failed to reveal documented evidence that the patient/representative was notified of the patient’s rights prior to furnishing care. In an interview on 12/07/2023 at 5:20 p.m., S6QD reviewed the medical records for Patients #1, #2, and #3 and acknowledged there was no documented evidence that the patients/representatives were notified of the patient’s rights prior to furnishing care.”