Newton-Wellesley Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40928 The Hospital failed to ensure care was maintained in a safe environment for 1 Patient (#2) out of a total sample of 12 patients. Patient #2 presented to the Emergency Department (ED) after attempting to self-harm at his/her group home. Patient #2 was evaluated in the ED. Patient #2 continued to have self-harming behaviors requiring chemical restraint. Patient #2 was admitted (2 hours later) to the inpatient psychiatry unit. Patient #2’s behavior was not communicated with the inpatient MD, who ordered 15 min checks. Shortly after admission to the inpatient psychiatry unit, Patient #2 was discovered attempting to choke himself/herself with socks. Cross Reference: 482.13(c)(3)- Care in a Safe Setting (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: 40928 Based on interviews and records reviewed, the Hospital failed to ensure care was maintained in a safe environment for 1 Patient (#2) out of a total sample of 12 patients. Patient #2 presented to the Emergency Department (ED) after attempting to self-harm at his/her group home. Patient #2 was evaluated in the ED. Patient #2 continued to have self-harming behaviors requiring chemical restraint. Patient #2 was admitted (2 hours later) to the inpatient psychiatry unit. Patient #2’s behavior was not communicated with the inpatient MD, who ordered 15 min checks. Shortly after admission to the inpatient psychiatry unit, Patient #2 was discovered attempting to choke himself/herself with socks. Findings included: Review of Hospital Policy “Patient Rights and Responsibilities”, effective 09/29/21, indicated: -Patients have the right to expect reasonable safety in hospital practices and the environment. -Patients have the right to be treated in a caring, safe and compassionate way. Patient #2 arrived at the Emergency Department (ED) by ambulance on 12/27/24 from his/her group home after becoming aggressive and attempting to peel his/her skin with a potato peeler. Patient #2 was agitated and impulsive and endorsed auditory hallucinations (AH) and visual hallucinations (VH). Patient #2’s medical record indicated that on 12/27/24 at 9:57 P.M. Patient #2 became increasingly agitated and aggressive with staff and received Droperidol (an antipsychotic) 2.5 milligrams (mg) injection and Midazolam (a sedating medication) 5mg injection in response to his/her agitation and aggression. Patient #2’s Suicide Risk Assessment dated 12/28/24 at 10:21 A.M. indicated the Patient endorses thoughts of harm to self or others, recent self-harm behaviors, recent violent urges, prior suicidal behaviors or attempts and was assessed as a moderate suicide risk. Review of Patient #2’s Psychiatry Admission Note dated 12/30/24 at 10:34 A.M. indicated the Patient received multiple chemical restraints on 12/27, 12/28 and 12/29 and that at the time of the visit, Patient #2 was standing in the doorway laughing inappropriately and saying that he/she needs to get to school and when asked about recent concerns that Patient #2 was going to hurt staff members and peel his/her skin off with a potato peeler, the Patient stated “zombies told him/her to do it. I am strong I do not need medications”. The Note further indicated that Patient #2 required multiple chemical restraints in the Emergency Room and continues to be paranoid and delusional and the Patient will be admitted to the inpatient Psychiatry unit on a Section 12B (allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual’s will or without the individual’s consent) on 15-minute safety checks. Review of ED Provider Note Assessment and Plan addendum dated 12/30/24 at 10:45 A.M. indicated that Patient #2 became increasingly agitated again and had pulled some trim off the psychiatric room door and was trying to hurt him/herself using the nails that were in the trim. Patient #2 also tried to take the tag off the back of a stretcher and use the metal piece of this to hurt themself. Patient #2 was unable to hurt themself but was increasingly agitated and not redirectable. Patient #2 will be treated with intramuscular (IM) Droperidol and Versed. Review of Nursing Admission Note dated 12/30/24 at 2:21 P.M., indicated Patient #2 was admitted at 11:45 A.M. from the ED via stretcher. Patient #2 declined a skin check and started getting agitated and kicking his/her feet. Patient #2 was disorganized in thought, paranoid, impulsive and agitated. Patient #2 was maintained on 15-minute safety checks. Review of Significant Event Note dated 12/30/24 at 4:29 P.M., indicated that at around 2:45 P.M., Patient #2 came to the nurses’ station and asked for socks because his/her feet were cold. At around 2:50 P.M., the Registered Nurse (RN) was notified by housekeeping that Patient #2 needed help in the bathroom, and he/she was on the floor. The RN observed that Patient #2’s neck had two socks tied together tightly around his/her neck and immediately untied the socks. The Note further indicated the Medical Doctor (MD) assessed Patient #2 and placed the Patient on 1:1 for safety. During an interview on 3/6/25 at 8:16 A.M., the Director of Patient Safety said that in response to Patient #2’s event there was an informal leadership meeting between the ED and Psychiatry doctors but that no minutes or notes were available as this was a verbal discussion. The Director provided the survey team with an undated document that he said had been typed up the previous day in response to the survey team’s request for any documentation of opportunities identified or implemented as a result of this and said there was no other documentation of corrective actions implemented. During an interview on 3/6/25 at 9:21 AM., the Interim Psychiatry Chair said the admission psychiatrist in the ED completed the admission orders and ordered checks. The Chair said that between the time of the admission assessment and Patient #2’s arrival to the floor there was another episode of agitation for Patient #2, and said the inpatient psychiatry team was not aware of the event. The Interim Chair said this event was discussed with the Chair of Emergency Medicine and that opportunities regarding communication between providers were identified. The Interim Chair said that the ED provider needs to notify the Psychiatry team who is receiving the patient of an event like this, and the goal is to have a clear path of communication. The Interim Chair said that for medical changes in condition that occur after someone is accepted for admission there is a verbal Pass Off (verbal handoff from unit to unit) between providers to ensure that any new information is communicated. He said this is not currently done for any psychiatric events and they are trying to implement this for psych services. He said all of the discussions around the events for Patient #2 has been verbal. During a follow up interview on 3/7/25 at 9:50 A.M. the Interim Chair of Psychiatry said there was a period of time after admission orders had been completed for Patient #2 when there was a worsening of clinical status which required further restraint due to self-harm and psychotic behaviors. He said he considered this to be a gap in communication between providers and that after the event it was identified that communication could have been better. The Interim Chair said there should have been provider education regarding what providers should do when there is a change in behavioral clinical status. The Interim Chair said there was an initial meeting between ED and Psychiatry leadership after this event, but he hasn’t circled back yet with Emergency Medicine since then to implement any identified opportunities. The Interim Chair said there needs to be clear communication with providers written and distributed which outlines a plan of who did they notify, how did they do it and what the next steps are. He said this will likely entail provider education and a shift in what they will do. The Interim Chair said that if Patient #2 required restraints after his/her admission paperwork, the ED staff should they have called the unit. During an interview on 3/7/25 at10:57 A.M., the Associate Chief of Medicine said leadership of ED and Psych met on 1/21/25 to discuss the event and opportunities for improvement but the case was not formally discussed with all providers. The Associate Chief of Medicine said the Hospital started to obtain attestations from providers to communicate between units if a patient’s risk changes or any new event as it relates to patient risk. The Associate Chief said the attestations had just started today. Although the Hospital began to implement corrective actions while the survey team was on-site as a result of Patient #2’s self-harm event, the Hospital failed to provide evidence of fully implementing identified corrective actions to prevent a like occurrence from happening.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41143 The Condition of Participation: Patient Rights was out of compliance. Findings included: Based on record review and interview, 1) the Hospital failed to ensure care was provided in a safe environment to one Patient (#3) out of a total sample of 10 Patients; Patient #3 was administered fentanyl (an opioid pain medication) in the Emergency Department (ED), was not monitored, and experienced respiratory depression and hypoxia and received Cardiopulmonary Resuscitation (CPR) and airway intubation and 2) the Hospital failed to ensure informed consent was obtained prior to a procedure for one Patient (#8) of ten sampled patients; the Hospital performed a closed reduction (a procedure in which a broken bone is put back into alignment) of an open tibial (a bone in the lower leg) fracture for Patient #8 without obtaining written informed consent. Cross Reference: 482.13(b)(2)- Informed Consent (A0131) 482.13(c)(2)- Care in a Safe Setting (A0144)”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 40928 The Condition of Participation: Emergency Services was out of compliance. Findings included: Based on interviews, records reviewed, and documents reviewed, the Hospital failed to ensure emergency services and orthopedic services coordinated services prior to performing a closed reduction (a procedure in which a broken bone is put back into alignment) of an open tibial (a bone in the lower leg) fracture for one patient (#8) of ten sampled patients, resulting in the procedure being performed on Patient #8 in the Emergency Department (ED) without sedation or adequate pain relief. Cross Reference: 482.55(a)(2)- Integration of Emergency Services (A1103)”

“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: 40928 Based on interview, records reviewed, and policies reviewed, the Hospital failed to ensure informed consent was obtained prior to a procedure for one Patient (#8) of ten sampled patients. The Hospital performed a closed reduction (a procedure in which a broken bone is put back into alignment) of an open tibial (a bone in the lower leg) fracture for Patient #8 without obtaining written informed consent. Findings included: Review of the Hospital policy titled ’ Informed Consent ’ , effective 1/6/21, indicated the following: -Each patient, or authorized representative, shall be informed of significant medical information necessary to make an informed decision to accept or refuse medical care and treatment. -Information that should be given to a patient includes: the nature of the patient ’ s condition; the proposed care, treatment, and services; the nature and probability of the risks involved; the benefits to be reasonably expected; the inability of the physician to guarantee results, if that is the situation; the irreversibility of the procedure, if that is the outcome; the likely result of no treatment; and the available alternatives including risks and benefit. -A completed informed consent form provides documentation that the informed consent process has taken place and should summarize the information provided to the patient. Specific informed consent shall be documented on a Hospital informed consent form. Procedures/ treatments requiring specific informed consent- consent must be documented for all therapeutic and diagnostic procedures where disclosure of significant medical information, including major risks involved, would assist a patient in making an intelligent decision whether to undergo the proposed procedure. This does not include procedures judged by providers to be of extremely minimal risk. The following procedures and treatments require specific informed consent in accordance with this Policy: closed reduction. Patient #8 was brought in by ambulance to the Hospital on 12/31/23 at 10:49 A.M. after suffering a fall resulting in a left ankle open distal tibia fibula fracture (a fracture in which the broken bone penetrates the skin from the inside, causing a small puncture wound). Review of Patient #8 ’ s Orthopedics History & Physical Note dated 12/31/23 at 1:51 P.M. indicated Patient #8 had a left Grade 1 open distal tibia fracture with associated distal and proximal fibula fractures with a slow ooze from a 0.5-centimeter (cm) poke hole over their medial shin due to the grade 1 open fracture with an obvious deformity. The Note further indicated that Patient #8 ’ s wound was irrigated with 1 liter (L) normal saline/betadine (a topical antiseptic to reduce bacteria) and placed in a dry sterile dressing, then proper rotation of Patient #8 ’ s foot was achieved, and the Patient was placed in a long splint after. Patient #8 received a dose of IV pain medication after the procedure. Review of Patient #8 ’ s Operative Note dated 1/1/24 at 10:14 A.M. indicated the Patient had suffered an open fracture on 12/31/23 and their fracture had been closed reduced in the ED with plans for definitive fixation in the operating room. Review of Patient #8 ’ s medical record failed to indicate informed consent had been obtained for a closed reduction of the Patient ’ s tibia fracture performed on 12/31/23. During an interview on 3/25/24 at 12:34 P.M., RN#3 said when Patient #8 arrived at the ED, they were alert & oriented, and their pain was controlled after being medicated by EMS on the way to the Hospital. RN#3 said the ED Attending was in to assess Patient #8 while they were being triaged due to the Patient ’ s open fracture. RN#3 said an ortho consult was ordered by the ED Attending and after seeing the patient, the ortho team requested conscious sedation (a medication induced depressed level of consciousness, but the patient is still able to respond to commands) for a reduction of the fracture and the nurse told Orthopedic Resident #1 that the ED was down 7 nurses and that she herself had 4 additional patients to care for. RN#3 said she later walked into Patient #8 ’ s room and Orthopedic Resident #1 and another staff member were manipulating Patient #8 ’ s injured leg. RN#3 said Patient #8 was screaming and telling them to stop and they kept manipulating it. RN#3 said she asked what they were doing and told the ortho team to stop and at that point they had just finished. RN#3 said she immediately left Patient #8 ’ s room to inform the ED Attending about Patient #8 ’ s pain and additional pain meds were ordered. RN#3 said when she went back into Patient #8 ’ s room, the Patient was crying, and RN#3 administered the additional pain medication. RN#3 said that a closed reduction is considered a procedure and should have been documented as a procedure, and said the procedure would need consent, timeouts, and document the procedure time and that there is a protocol for these types of procedures, which was not done in this case. During an interview on 3/25/24 at 4:38 P.M, the ED Attending said open fractures present to the ED on a regular basis and as soon as it ’ s known to be an open fracture the ED provider will ask for an ortho consultation. The ED Attending said if a reduction is planned, in general, it can and will be done in the ED as it can be quicker than trying to get a team for the OR. The ED Attending said the reduction is important to realign the bones and splint the limb before surgery and that reductions can be quick or take a long time and is variable case by case. The ED Attending said in general a closed reduction requires informed consent from the patient. During an interview on 3/25/24 at 2:55 P.M., the Chief Nursing Officer said this procedure was a closed reduction because the bone was manipulated, and a signed consent form was needed. The Chief Nursing Officer said Patient #8 should have had a signed consent for this. The Hospital failed to ensure informed consent was obtained from Patient #8 prior to the closed reduction of an open fracture.”

“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: 41143 Based on record review and interview, the Hospital failed to ensure care was provided in a safe environment to one Patient (#3) out of a total sample of 10 Patients; Patient #3 was administered fentanyl (an opioid pain medication) in the Emergency Department (ED), was not monitored, and experienced respiratory depression and hypoxia and received Cardiopulmonary Resuscitation (CPR) and airway intubation. Findings include: Review of the Hospital Policy titled “IV Opioids, Intermittent Administration of and Monitoring of Patients with Pain”, dated 10/15/21, indicated the following: -With appropriate administration and monitoring, IV opioids are a safe, effective method for delivering pain management to patients who may not be appropriate for Patient Controlled Analgesia (PCA) or patients who may only require a few dosed of IV opioid. -All patients receiving IV boluses of an opioid will be assessed for risk of opioid-induced respiratory depression and will be monitored for sedation and signs of respiratory depression. -Prior to administering an IV opioid, the RN will obtain a baseline assessment including: blood pressure, heart rate, respiratory rate, oxygen saturation, pain rating, and sedation level, using the Pasero Opioid Sedation Scale (POSS). -Clinicians should consider ordering continuous pulse oximetry, and/or more frequent monitoring for patients with risk factors for respiratory depression. Patient #3 arrived at the Hospital ED by ambulance on 12/21/23 at 12:58 P.M. with left hip pain after sustaining a fall in the community. Review of Patient #3’s medical record indicated Patient #3 was triaged by Registered Nurse (RN) #1 on 12/21/23 at 1:07 P.M. at an acuity level of 3 and was admitted to the Hospital ED on a stretcher in the ED hallway with chief complaints of fall, hip pain, and shoulder pain. On 12/21/23 at 1:53 P.M. ED Resident #1 ordered Fentanyl 100micrograms (mcg) to be administered intravenously. Patient #3 was assessed to have a pain score of 7/10, and the Fentanyl 100mcg was administered to the Patient at 1:55 P.M. Patient #3’s last set of vital signs had been obtained at 1:10 P.M. and were within normal limits; the Patient was assessed by the Richmond Agitation Sedation Scale (RASS), a delirium screening assessment, to be alert and calm at 1:18 P.M., however no POSS was assessed prior to administration of the fentanyl at 1:55 P.M. On 12/21/23 at 2:05 P.M., RN #1 checked on Patient #3 in the ED hallway and the Patient was unresponsive, pulseless, and not breathing; CPR was initiated for the Patient. Compressions were stopped on Patient #3 at 2:10 P.M., and the Patient was sedated and intubated with ventilation in the ED. Patient #3’s medical record failed to indicate any other vital signs or monitoring were in place prior to the administration of fentanyl or respiratory depression/arrest of Patient #3. During an interview with Anesthesiologist #1 on 3/21/24 at 11:20 A.M., he said on 12/21/23 a code blue was called in the Hospital ED and he responded from the Intensive Care Unit (ICU). He said Patient #3 had been in a hallway bed in the ED with no monitor or pulse oximetry; the Patient was discovered in distress in the ED hallway bed unmonitored. He said it was unclear to him why Patient #3 would receive 100mcg of Fentanyl for his/her first dose in the ED after having received 100mcg by Emergency Medical Services (EMS) prior arriving at the ED. He said Patient #3 was fairly obese and was at risk for hypoventilation if sedated from medication use. He said Patient #3 was ultimately intubated during the code. He said he felt like the Hospital failed Patient #3. During an interview with RN #1 on 3/21/24 at 11:45 A.M., she said Patient #3 had arrived at the ED alert and oriented. She said Patient #3 had received 100mcg of fentanyl by EMS prior to arriving to the Hospital; she said the Patient was yelling out in pain in the ED. She said Patient #3’s vitals signs were stable on arrival to the ED. She said 100mcg of fentanyl was ordered by the ED physician and she administered the medication IV push to Patient #3 over 2-3 minutes. She said Patent #3 was able to communicate with her and was breathing fine, so she walked over to document in the nursing station in sight of the Patient. She said an order was placed to administer a tetanus vaccine to Patient #3, she left her computer to go retrieve the vaccine and by the time she returned Patient #3 was blue and unresponsive. She said no orders for monitoring oxygen saturations or vital signs were in place prior to administration of the fentanyl to Patient #3. During an interview with RN #2 on 3/25/24 at 11:00 A.M., she said prior to administering opiate medications, nursing staff generally obtain vital signs prior to medication administration, monitor the patient’s oxygen level after administration, and stay with the patient for a few minutes. She said the electronic medical record will prompt RNs to perform assessments in the ED. She said the ED does have bedside monitors available for use on patients placed in the ED hallway. During an interview with ED Resident #1 on 3/25/24 at 12:35 P.M., she said Patient #3 was having pain on 12/21/23 from a fall on his/her left side. She said any time an opiate medication is administered to a patient, there could be concern for decline in the patient’s respiratory status. She said at the time the fentanyl was ordered for Patient #3, the Patient was not requiring supplemental oxygen and vital signs were normal. She said Patient #3 was not ordered for monitoring and was in a hallway bed in the ED. She said a code blue was called by RN #1 after identifying non-responsiveness in Patient #3. The Hospital failed to safely monitor Patient #3 after receiving 100mcg of fentanyl in the ED, and Patient #3 subsequently experienced unwitnessed respiratory depression/arrest and required CPR and airway intubation.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 40928 Based on interviews, records reviewed, and documents reviewed, the Hospital failed to ensure emergency services and orthopedic services coordinated services prior to performing a closed reduction (a procedure in which a broken bone is put back into alignment) of an open tibial (a bone in the lower leg) fracture for one Patient (#8) of ten sampled patients, resulting in the procedure being performed on Patient #8 in the Emergency Department (ED) without sedation or adequate pain relief. Findings included: Patient #8 was brought in by ambulance to the Hospital on 12/31/23 at 10:49 A.M. after suffering a fall resulting in a left ankle open distal tibia fibula fracture (a fracture in which the broken bone penetrates the skin from the inside, causing a small puncture wound). Review of Patient #8’s medical record indicated the Patient had received 100 micrograms (mcg) of Fentanyl (an opioid medication used for pain relief) via Emergency Medical Services (EMS) and their leg was splinted prior to arrival. Patient #8 was alert and oriented and reported their pain level as a 2 out of 10 upon arrival. Patient #8 received x-rays of the left leg and pelvis at 11:45 A.M. and received intravenous (IV) antibiotics at 11:47 A.M. Patient #8 reported an increase in their pain level to a 7 out of 10 after the x-ray and received IV Hydromorphone (an opioid pain medication) 1 milligram (mg) at 12:11 P.M. and reported an improvement in their pain level after receiving the IV Hydromorphone. At 1:09 P.M. Patient #8 reported their pain level was a 1 out of 10. Patient #8 received Lorazepam (a benzodiazepine that can be used to treat anxiety or stress) 1mg at 1:12 P.M. Review of Patient #8’ss Orthopedics History & Physical Note, dated 12/31/23 at 1:51 P.M., indicated Patient #8 had a left Grade 1 open distal tibia fracture with associated distal and proximal fibula fractures with a slow ooze from a 0.5-centimeter (cm) poke hole over their medial shin due to the grade 1 open fracture with an obvious deformity. The Note further indicated that conscious sedation was requested from the emergency department (ED) multiple times but was unable to be provided due to staffing and that a request had been made for pain medication, but the ED was unable to due to concern for rib injury. Patient #8 ’ s wound was irrigated with 1 liter (L) normal saline/Betadine (a topical antiseptic to reduce bacteria) and placed in a dry sterile dressing, then proper rotation of Patient #8 ’ s foot was achieved, and the Patient was placed in a long splint after. Patient #8 received a dose of IV pain medication after the procedure. Review of Patient #8’s Nursing Update Note dated 12/31/23 1:47 P.M. indicated that Patient #8 was tearful and upset that pain was not managed by ortho and that Patient #8 ’ s nurse was not in the room and was not informed of the Patient ’ s pain until after the nurse was told Patient #8 was screaming. The Note further indicated the ED attending MD was notified and Patient #8 received 50 mcg of Fentanyl. Patient #8 ’ s pain assessment on 12/31/23 at 1:41 P.M. indicated their pain was an 8 out of 10. Review of Patient #8’s Handoff note dated 12/31/23 at 2:02 P.M. indicated the Patient was extremely upset and tearful during the ortho procedure. Review of Patient #8’ss Operative Note dated 1/1/24 at 10:14 A.M. indicated the Patient had suffered an open fracture on 12/31/23 and their fracture had been closed reduced in the ED with plans for definitive fixation in the operating room. Review of the Hospital grievance entered 1/8/24 indicated Patient #8 called Patient Family Relations at the Hospital to report they were treated very roughly by the ortho team in the ED with an open fracture. Patient #8 reported they were brought to the ED by ambulance because they had broken their left leg and the initial plan, to their understanding, was for a limited adjustment to Patient #8 ’ s ankle which would require sedation and surgery would take place the following day. Patient #8 reported their understanding was that the sedation didn ’ t take place because there was no nurse available due to staffing issues as it was a holiday weekend. Patient #8 reported their experience was three male staff came over, including an Orthopedic resident. He held Patient #8 ’ s leg under his arm and then he and the other staff had their hands on Patient #8 ’ s leg, ankle and foot and started moving it. Patient #8 told them to stop, that it hurt and then begged them to stop. The staff didn ’ t respond or say anything to Patient #8 and the Patient kept begging then yelling at them to stop and that it hurt. Patient #8 didn ’ t know how long it lasted and reported eventually they stopped and walked away without saying anything to the Patient or asking how they were doing. Patient #8 was crying without realizing it until touching his/her face and felt it was wet. Patient #8 reported a nurse came in after this and asked how the Patient was doing and the Patient felt exhausted. During an interview on 3/25/24 at 12:34 P.M., RN#3 said when Patient #8 arrived to the ED, the Patient was alert & oriented and their pain was controlled after being medicated by EMS on the way to the Hospital. RN#3 said Patient #8 ’ s leg was splinted upon arrival and splints must remain in place until the MD assesses the patient and that the MD was in to assess Patient #8 while they were being triaged due to the Patient ’ s open fracture. RN#3 said Patient #8 went to get X-rays and when they came back reported pain in the leg so Patient #8 received pain medication with good effect. RN#3 said an ortho consult was ordered by the ED Attending and after evaluating the patient, the ortho team requested conscious sedation (a medication induced depressed level of consciousness but the patient is still able to respond to commands) and the nurse told Orthopedic Resident #1 that the ED was down seven nurses and that she herself had four additional patients to care for. RN#3 said conscious sedation requires additional monitoring of the patient receiving it for the duration of the procedure and afterwards. RN#3 said Orthopedic Resident #1 said he would notify the Orthopedic Attending that there wasn ’ t enough staff in the ED for the conscious sedation requested. RN#3 said she also notified her charge nurse, the nursing supervisor and the ED Attending of her concerns. RN#3 said her understanding was that Patient #8 was going to go to the Operating Room (OR) or the inpatient nursing unit for the procedure. RN#3 said the ED Attending ordered Ativan 1mg for Patient #8 ’ s muscle spasms due to the fracture and she administered the medication and left Patient #8 ’ s room to tend to another one of her assigned patients and when she came back to the hallway near Patient #8 ’ s room about 25 minutes later, the ED secretary told RN#3 that Patient #8 was screaming. RN#3 said she walked into Patient #8 ’ s room and Orthopedic Resident #1 and another staff member were manipulating Patient #8 ’ s injured leg. RN#3 said Patient #8 was screaming and telling them to stop and they kept manipulating it. RN#3 said she asked what they were doing and told the ortho team to stop and at that point they had just finished. RN#3 said she immediately left Patient #8 ’ s room to inform the ED Attending about Patient #8 ’ s pain and additional pain meds were ordered. RN#3 said when she went back into Patient #8 ’ s room, the Patient was crying, and RN#3 administered the additional pain medication. RN#3 said that Patient #8 ’ s pain could have been controlled if the ED provider and RN#3 had been notified that the ortho team was still planning to do the reduction in the ED, but it was not communicated to them. RN#3 said that a closed reduction is considered a procedure and should have been documented as a procedure, and said the procedure would need consent, timeouts, and document the procedure time and that there is a protocol for these types of procedures, which was not done in this case. RN#3 said she completed a safety report after this event but there was never any follow up. During an interview on 3/25/24 at 11:27 A.M., Orthopedic Attending MD said Patient #8 had a bad ankle fracture, dislocation with associated tibia fracture. The Orthopedic Attending said it was an open fracture and there is heightened urgency for open cases with concern for limb loss and infection. The Orthopedic Attending said these types of injuries can be handled in the ED. The Ortho Attending said he went and saw Patient #8 with Orthopedic Resident #1 and discussed options with Patient #8. The Ortho Attending said he left it as the plan would be Orthopedic Resident #1 would get sedation for Patient #8 and try to reduce the fracture and that he left the Resident and felt comfortable leaving him as the Resident is experienced. The Orthopedic Attending said the procedure can be painful so that ’ s why conscious sedation helps because the patient will be unaware of what is happening and sometimes a local anesthetic can also be used in the joint space. The Orthopedic Attending said Orthopedic Resident #1 was having difficulty getting conscious sedation from the ED provider, and the Resident made the decision to reduce Patient #8 ’ s open fracture. The Orthopedic Attending said he believed Patient #8 received medication prior to the reduction but was unsure. The Orthopedic Attending said he has seen Patient #8 multiple times since then, that the Patient is sensitive and that he thinks Patient #8 was traumatized by this procedure, but he feels that this procedure was emergent and did need to happen right then and there. The Orthopedic Attending said he thinks there was an unfortunate set of multiple circumstances related to Patient #8 ’ s procedure and that it was emergent so they couldn ’ t wait for the moderate sedation. During an interview on 3/25/24 at 4:38 P.M, the ED Attending said open fractures present to the ED on a regular basis and as soon as it ’ s known to be an open fracture the ED provider will ask for an ortho consultation. The ED Attending said if a reduction is planned, in general, it can and will be done in the ED as it can be quicker than trying to get a team for the OR. The ED Attending said generally for an open fracture, patients have pain meds on board already and can get additional pain meds or procedural sedation which is the same as moderate or conscious sedation. The ED Attending said all of the ED physicians are able to administer procedural sedation, but the patient needs a nurse present with them to provide monitoring before the procedure, throughout the entire procedure and for a period of time after the procedure. The ED Attending said the reduction is important to realign the bones and splint the limb before surgery and that reductions can be quick or take a long time and duration is variable case by case. The ED Attending said in general a closed reduction requires informed consent from the patient. The ED Attending said pain medications and/or procedural sedation being administered for a reduction are based on factors including the patient ’ s pain level, patient ’ s preference, patient ’ s ability to tolerate the procedure and further said that if a patient is unable to tolerate the reduction, the patient should be given a break and/or given additional pain medications so they can tolerate it. The ED Attending said he was the attending physician that day and saw Patient #8 relatively soon after arrival and the Patient seemed uncomfortable but not in extreme pain. The ED Attending said he ordered x-rays and an orthopedics consult for Patient #8 and that Patient #8 had an open fracture with a nasty dislocation. The ED Attending said Orthopedic Resident #1 spoke to him after seeing Patient #8 and wanted to do the reduction in the ED with procedural sedation and said this was warranted due to the nature of the Patient #8 ’ s injury. The ED Attending said he misspoke and initially said that the ED could accommodate the procedural sedation for Patient #8, but he was notified after this that nursing was short staffed, and they didn ’ t have the nurses to do this, as Patient #8 would need a 1:1 nurse for the duration of the reduction and for a period afterwards. ED Attending said he notified Orthopedic Resident #1 of the ED ’ s inability to provide procedural sedation at that time as soon as he was aware, and his understanding was that the patient would instead go to the OR for the sedation and reduction. The ED Attending said he was unaware of any pain meds ordered for Patient #8 specifically for this procedure and said there wasn ’ t much communication from the orthopedics team to him. The ED Attending said Ativan was ordered for the patient to treat muscle spasms and not as medication for the reduction. The ED Attending said he was made aware of the Patient #8 ’ s pain mid reduction by RN #3 and ordered pain meds immediately upon notification. The ED Attending said he was made aware Patient #8 ’ s reduction was performed without sedation and the Patient clearly didn ’ t have enough pain medication based on Patient #8 ’ s reports of pain and further said it is not uncommon to have a little discomfort during a reduction but there shouldn ’ t be pain. The ED Attending said if a patient says no, stop or indicates they are in pain, the provider should stop the procedure to give a break and/or evaluate for additional pain meds or sedation. The ED Attending said his understanding was there was an internal review after this into ortho and nursing but was unsure of any outcomes. During an interview on 3/26/24 at 11:39 A.M., Orthopedic Resident #1 said Patient #8 came into the ED with an open fracture and these types of injuries should be treated within 24 hours to prevent infection. Orthopedic Resident #1 said he saw Patient #8 with the Orthopedic Attending and that usually these fractures are treated with washout of wound and then fracture fixation the same day or the next day. Orthopedic Resident #1 said since there were many cases that day in the OR, the decision was made to re-align the bones and then splint Patient #8 ’ s leg and then do the surgery the next day. Orthopedic Resident #1 said the procedure can be very painful, so procedural sedation is usually administered and that he asked for sedation for the procedure and was told the ED didn ’ t have the ability to provide sedation due to staffing. Orthopedic Resident #1 said he asked the nurse for procedural sedation for the procedure and was told that there were not enough nurses to do the sedation and that RN#3 told him to call the floor where Patient #8 would be admitted to see if they had nurses available to assist with the sedation. Orthopedic Resident #3 said this was not the usual workflow, so he wasn ’ t sure how to contact the floor and was unable to say if anyone called the unit to see if a nurse was available. Orthopedic Resident #1 said he asked the ED attending for pain meds with anxiety meds and was told by the ED attending that he didn ’ t want to give both meds due to a potential chest wall contusion (bruise). Orthopedic Resident #1 said there was a poke hole at the site of the fracture, and he could see it needed to be re-aligned prior to splinting which meant the bone needed to be manipulated back into position. Orthopedic Resident #8 said he told Patient #8 the plan and that it would be quite painful. The Orthopedic Resident said his understanding was that Patient #8 had received Ativan and Dilaudid at some point after arrival. Orthopedic Resident #1 said he and a junior resident went into Patient #8 ’ s room to do the reduction and they told her there were staffing issues and were unable to provide sedation and said the only course of action was to perform this procedure. Orthopedic Resident #1 said it was explained to Patient #8 that the bone was going to be manipulated without sedation so the foot could be rotated and splinted. Orthopedic Resident #1 said Patient #8 told them it was quite painful during the procedure but at that point their leg was already in the splint, and he just needed to wrap it in an ACE wrap. Orthopedic Resident #1 said it was painful for Patient #8 and the Patient was crying afterward because it was painful, and that RN#3 came into Patient #8 ’ s room and started yelling at Orthopedic Resident #1 and the junior resident asking them what they were doing and telling them this was inappropriate. Orthopedic Resident #1 said he left the room without saying anything after RN#3 came in and then left the ED ultimately. Orthopedic Resident #1 said he considered this case urgent to emergent due to risk of compartment syndrome (a dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues) and the procedure needed to be done quickly. The Hospital was unable to provide any evidence that corrective measures had been implemented to prevent a like occurrence from happening.”