The General

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48050 Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by no signed consent for treatment or signed patient rights information form for 3(#13, #14, #19) of 20 (#1-#20) patients sampled. Findings: A review of facility policy reviewed date 05/2024 titled “Treatment Authorization, Financial Assignment and Acknowledgement” revealed, in part: PURPOSE: To obtain consent for treatment, financial assignment, and acknowledgement of patient rights and joint notice of privacy practices. POLICY: 1. The treatment authorization, financial assignment and acknowledgement consent form will be obtained on all patients. 2. All patients will be given a copy of the facilities patient’s right and responsibilities form and privacy practices and smoking cessation information. 4. The patient, legal guardian or next of kin signs the consent. If the patient is 18 years and older they responsible for signing the consent. PROCEDURE: 5. After the form has been read by the patient/guardian/next of kin, and all questions have been answered satisfactorily, the form is then signed by the patient/guardian/next of kin on the patient’s signature line. Review of Patient #13’s electronic medical record revealed an admission to the ED on 08/15/2024 with no evidence that consent of treatment was signed which includes patient’s rights and responsibilities. Review of Patient #14’s electronic medical record revealed an admission to the ED on 08/15/2024 with no evidence that consent of treatment was signed which includes patient’s rights and responsibilities. Review of Patient #19’s electronic medical record revealed an admission to the ED on 09/16/2024 with no evidence that consent of treatment was signed which includes patient’s rights and responsibilities. In an interview on 10/01/2024 at 2:15 p.m., S1DR confirmed that the medical records of Patient #13, Patient #14, and Patient #19 failed to reveal signed consents for treatment and patient’s rights/responsibilities. S1DR stated that every patient should have a signed consent for treatment on admission.”

“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: 48050 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 failure to document 7 (#4, #5, #7, #8, #9, #14, #20) out of 20 (#1-#20) assessment/reassessments per policy. Findings: A review of hospital policy review date 08/2024 titled, “Assessment/Reassessment,” revealed in part: PURPOSE: To ensure emergency department staff integrate the information from various assessments of the patient to plan patient care based on needs. PROCEDURE: 2. Reassessment is a process of periodic re-evaluation of the patient’s condition, symptoms, and response to ordered treatment. Reassessment may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. 5. Reassessment will occur based on patient acuity, nursing clinical judgement, and/or physician orders: A. Priority I and Priority II patients- every 15 minutes until stable B. Priority III, IV, and V patients- minimum of every 4 hours or as the patient’s condition warrants C. Immediately prior to patient’s discharge a focused reassessment should be completed and documented. Vital signs will follow the Repeat Vital Sign Policy D. Documented reassessment in the electronic medical record or on paper during downtime. A review of hospital policy revised/reviewed date 08/2024 titled, “Repeat Vital Signs,” revealed in part: PURPOSE: To provide a standard for systematic and pertinent collection of data about the health status of the patient. PROCEDURE: 1. Repeat blood pressure, pulse, respiration, temperature, and pain assessment should be done on all patients prior to admission/transfer to an assigned hospital bed. 3. Vital signs should be documented at a minimum of: A. Priority I and Priority II patients- a minimum every 15 minutes until stable B. Priority III, IV and V patients- a minimum of every 4 hours or as the patient’s condition warrants. 4. Vital signs will be obtained within 1 hour or before admission/transfer/discharge from the emergency department. 5. Pain assessments should be documented upon admission, after treatment, and prior to transfer or discharge from the emergency department. A review of Patient #4’s medical record revealed, Patient #4 presented to the ED with generalized weakness and triaged at 5:07 p.m. on 07/10/2024. Primary nursing assessment completed at 7:52 p.m. No further nursing assessment was documented before patient was discharged home at 10:31 p.m. A review of Patient #5’s medical record revealed, Patient #5 presented to the ED with altered mental status and triaged at 7:04 p.m. on 07/22/2024. Primary nursing assessment completed at 9:10 p.m. No further nursing assessment was documented and Patient #5 was transferred at 3:49 a.m. on 07/23/2024 for Seizures. Patient #5 was triaged an acuity 2 and had vital signs documented at 7:07 p.m., 9:30 p.m., 11:20 p.m., and 2:04 a.m. on 07/23/2024. Triaged an acuity 2, Patient #5 should have vital signs documented every 15 minutes until stable. A review of Patient #7’s medical record revealed, Patient #7 presented to the ED with generalized weakness and triaged at 2:33 p.m. on 08/13/2024. Primary nursing assessment was not completed until 6:38 p.m. and no further nursing assessments documented before Patient #7 was admitted for Failure to Thrive. Patient #7 was triaged acuity level 3 and vital signs were not completed until 6:59 p.m., 4 hours after arriving to the ED. A review of Patient #8’s medical record revealed, Patient #8 presented to the ED with generalized weakness and triaged at 10:00 a.m. on 09/12/2024. Primary nursing assessment was not completed until 1:36 p.m. and no further nursing assessments documented before Patient #8 was admitted for Sepsis on 09/13/2024 at 4:30 p.m. A review of Patient #9’s medical record revealed, Patient #9 presented to the ED with generalized weakness and triaged at 10:34 a.m. on 08/05/2024. Primary nursing assessment completed at 10:50 a.m. and there is no documentation of a nursing reassessment before Patient #9 was discharged at 3:35 p.m. A review of Patient #14’s medical record revealed, Patient #14 presented to the ED with stroke like symptoms and triaged acuity 2 at 12:06 p.m. on 08/15/2024. There was no nursing documentation throughout Patient #14’s ED visit. Patient was admitted for CVA and COPD on 08/15/2024 at 8:30 p.m. Patient #14’s vital signs were documented at 12:28 p.m., 1:32 p.m. and 4:04 p.m., A review of Patient #20’s medical record revealed, Patient #20 presented to the ED with stroke like symptoms and triaged acuity level 2 at 7:55 p.m. on 09/24/2024. Nursing assessment completed 8:00 p.m. No further nursing assessment documented and patient was discharged from the ED on 09/25/2025 at 12:35 a.m. Vital signs were documented at 7:47 p.m. on 09/24/2024 and 12:14 a.m. 09/25/2024 which should have been taken every 15 minutes until stable per policy on an acuity 2 patient. On 10/01/2024 at 2:30 p.m. S1RD and S5UM verified all above mentioned findings.”

“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: 48050 Based on record review, and interview the facility failed to ensure all medications and biologics were administered according to the orders of a licensed practitioner. The deficient practice is evidenced by failure of nursing staff to document the effectiveness of an as needed medication being administered in 4 (#2, #11, #16, #17) of 20 (#1-#20) patient sampled reviewed. Findings: A review of hospital policy revised date 02/2024 titled, “Medication Administration,” revealed in part: PURPOSE: To provide guidelines for medication administration. PROCEDURES: J. Nurses’ responsibilities: N. Document the effects of the medicine in the Nurses Notes. A review of hospital policy review date 08/2024 titled, “Assessment/Reassessment,” revealed in part: PURPOSE: To ensure emergency department staff integrate the information from various assessments of the patient to plan patient care based on needs. PROCEDURE: 2. Reassessment is a process of periodic re-evaluation of the patient’s condition, symptoms, and response to ordered treatment. Reassessment may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. A medical record review of Patient #2 revealed patient presented to ED for fall with weakness. On 08/15/2024 at 5:37 p.m. orthostatic blood pressures were done. The orthostatic blood pressures revealed the following blood pressures 158/73 with pulse rate of 65; blood pressure of 140/72 with pulse rate of 71; and blood pressure of 118/64 with pulse rate of 73. At 6:10 p.m. Lactated Ringers 500ml IV was ordered and administered. Further review of Patient #2’s medical record did not reveal a re-evaluation of the effectiveness of the medication administered before patient was discharged at 7:07 p.m. A medical record review of Patient #11 revealed patient presented to ED for BUE numbness/tingling and right shoulder pain. An order for Methocarbamol 1000mg PBIV give once only noted and administered at 2:50 p.m. Further review of Patient #11’s medical record did not reveal a re-evaluation the effectiveness of the medication. A medical record review of Patient #16 revealed patient presented to the ED for fall and history of diabetes. Lab work revealed a blood glucose of 53. An order for Dextrose 25 grams/50ml IVP give once only noted and administered at 7:52 a.m. Further review of Patient #17’s medical record did not reveal a re-evaluation of blood glucose after dextrose was administered. A medical record review of Patient #17 revealed patient presented to the ED for fall and pain. On 08/19/2024 at 12:15 p.m. Patient #17’s blood pressure during triage was 217/87 and at 1:44 p.m. blood pressure was 227/96. At 2:10 p.m. Amlodipine 20mg oral give once only was ordered and administered. Further review of Patient #17’s medical record did not reveal a re-evaluation of the effectiveness of the medication.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete evaluation prior to release for 1 (#2) of 20 (#1-#20) patients who presented to the emergency department. (see findings tag A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48050 Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice is evidenced by failure of the facility to determine an emergency condition existed for 1 (#2) of 20 (#1-#20) patients prior to releasing the patient from the emergency department. Findings: Review of policy last reviewed date 05/2024, titled “EMTALA, Outpatient Departments and Non-Emergency Department Locations of the Hospital Campus,” presented as the current policy for the Emergency Department and verified by S1DR, revealed in part: “ PURPOSE: To define hospital staff response to individuals seeking emergency care, when those individuals present to a location of the hospital that is not the Emergency Department (DED dedicated emergency department). POLICY: It is the policy that all individuals who present to a location of the hospital that is not a dedicated emergency department and requests examination or treatment for an emergency medical condition, will receive an appropriate medical screening exam to determine if an emergency medical condition exits. On determination that an emergency medical condition exits, the individual requesting treatment shall receive appropriate stabilizing treatment of that condition. All appropriate services, both routine and specialized, that are within the capacity and capability of the facility to provide and are required to appropriately stabilize the emergency medical condition, shall be utilized without regard to the individual’s ability to pay for such services.” Review of policy last reviewed 05/2024, titled “Stroke Response: CODE F.A.S.T.” revealed in part: “ PURPOSE: The purpose is to ensure that an inpatient or patient presenting to the ED experiencing stroke symptoms is recognized as a medical emergency and receives care in a prompt and appropriate manner. DEFINITIONS: F.A.S. T. Scale: A rapid assessment of the common warning signs a patient exhibits when he/she is having an acute stroke. It includes Face, Arms, Speech, and Time of symptom onset. CODE F.A.S.T.: a medical emergency based on results of the F.A.S.T. Scale Stroke Assessment requiring advance assessment by specifically trained team members to determine the appropriateness of life saving therapies within a specified period of time. POLICY: 1. Emergency Room CODE F.A.S.T./Code F.A.S.T. Field Initiation and Response: A. Staff are trained to activate a CODE F.A.S.T. on all patients with symptoms suggestive of stroke and a time of symptom onset or last known to be normal of 4.5 hours or less.” Review of Patient #2’s medical record revealed the patient was a 64 year old female who presented to the ED on 08/15/2024 at 1:45 p.m. Patient #2 was triaged at 1:48 p.m. and reported falling on 08/14/2024 which resulted in bruising right side of face and pain to right upper extremity. The family reported Patient #2 started experiencing left-sided weakness of her face, left arm, and difficulty with her speech, CODE F.A.S.T. was activated. Patient #2’s triage acuity level was 3. Patient #2 was seen by S6MD at 3:17 p.m., who documented Patient #2 was experiencing weakness to left side of face/left arm and slurred speech on arrival. CODE F.A.S.T. activated; CT Scan of the Head and CT angiogram of the Neck were both negative for any abnormalities, neurology consulted who recommended observation admission with MRI. S6MD consulted S7HMD and discussed Patient #2’s case who agreed to admission. At 5:21 p.m. S6MD changed Patient #2’s disposition to admission. On 08/15/2024 at 5:21 p.m. S7HMD evaluates Patient #2 and documented a Neurologist was consulted and recommended observing patient and obtaining MRI head if symptoms persist or are concerning. Evaluation of Patient #2 for orthostatic hypotension [which is a form of low blood pressure that happens when standing up from sitting or lying down] was ordered. Patient #2 was positive for orthostatic hypotension. S7HMD documented his plan was to administer IV fluids, and if Patient #2 was no longer experiencing orthostatic hypotension, she could be discharged home with PCP follow up, if she was able to ambulate around the ward without assistance. There is no documentation of admit orders in Patient #2’s medical record. Furthermore there is no documentation in Patient #2’s medical record that S7HMD discussed with the Neurologist or ED MD that Patient #2 would not be admitted to the hospital. On 08/15/2024 at 5:37 p.m. orthostatic blood pressures were ordered. At 5:39 p.m. Patient #2’s blood pressures were: 158/73 with pulse rate of 65 while laying; 140/72 with pulse rate of 71 while sitting; 118/64 with pulse rate of 73 while standing At 6:10 p.m. Lactated Ringers 500ml IV was ordered and administered. Patient #2 was discharged at 7:07 p.m. Further review of the medical record revealed Patient #2’s was not re- evaluated for orthostatic hypotension after receiving the IV fluids and there is no documentation the patient ambulated without assistance around the unit. There were no documented discharge orders and no documented discharge instructions in the medical record. At 7:07 p.m. prior to patient leaving the ED, the nurse documented the following assessment of Patient #2: “ Alert, oriented X4, slurred speech, pupils unequal, no muscle weakness, no change from previous assessment for respiratory, cardiovascular, abdomen, genitourinary, and musculoskeletal.” On 09/30/2024 at 12:14 p.m. S1DR verified there is no reassessment of Patient #2’s blood pressure after receiving IV fluids for orthostatic hypotension and there was no documentation that Patient #2 ambulated around the ward unassisted prior to being released from the ED. Furthermore S1DR verified there is no record of discharge order or discharge instructions given to Patient #2 in the medical record.”