Fairview Lakes Health Services

“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: 49618 Based on interview and record review, the facility failed to integrate emergency services with other services of the hospital for one of twenty patients (P1) reviewed for emergency services when P1 arrived by emergency medical services (EMS) had an intravenous (IV) catheter and the emergency department (ED) did not remove P1’s IV prior to her discharging. Findings include: P1’s medical records indicated P1 was a 94-year-old who was admitted to the ED on 5/4/26 when she was transferred to the ED by EMS. P1 had fallen in the bathroom at her nursing care facility and reportedly hit her head on the toilet. EMS was called to bring P1 to the ED. P1 had a history of anxiety, osteoarthritis, and unspecified hyperlipidemia. P1’s EMS prehospital care report dated 5/4/26 at 11:35 a.m. indicated EMS was called to P1’s senior living facility. P1 was being transferred to the hospital and EMS gained IV access with an 18-gauge catheter in the right antecubital fossa (AC). The IV was flushed easily with normal saline. EMS checked P1’s glucose levels from her IV. P1 was then transferred to the hospital. P1’s ED timeline dated 5/4/26 indicated P1 was triaged on at 12:23 p.m. The triage nurse assessed pain, airway status, respiratory status, skin and circulation status, cognitive and neurological status, elopement risk, fall risk, violence assessment tool, abuse screening, advance directives, and gave P1 an acuity score. At 12:24 p.m., the triage nurse indicated the EMS prehospital treatment included EMS placing P1 in a cervical collar. The documentation did not indicate EMS started an IV. P1’s imaging orders dated 5/4/26 indicated P1 had a CT of her head without contrast. The results were determined that there was no intracranial hemorrhage, extraaxial collection, or mass effect. There was no evidence of acute infarct. P1 also had a CT of her cervical spine without contrast. Those results indicated there were no fractures or posttraumatic subluxation and no high-grade spinal canal or neural foraminal stenosis. P1’s orders dated 5/4/26 indicated the provider did not order any blood work for P1. P1’s ED timeline dated 5/4/26 at 4:04 p.m. indicated P1 was discharged. The discharging nurse went over the after-visit summary with P1 and family. P1’s medical records dated 5/4/26 did not indicate P1 had an IV. P1’s medical records from the skilled nursing facility noted dated 5/6/26 indicated P1 was seen at the hospital due to a fall with a head strike on 5/4/26, returning to her apartment around 5:30 p.m. A caregiver at the skilled nursing facility alerted the nurse that P1 had an IV catheter in her right antecubital. The nurse removed the catheter, cleansed the entire area, applied a gauze dressing to the site, applied a warm compress to the site, and notified P1’s family member. The hospital provided a screenshot of the triage EMS documentation on 7/7/26 at 1:38 p.m. The screenshot shows a section within the patient’s arrival documentation called EMS Prehospital Treatment. The triage nurse can select an option for field intravenous catheters (IV’s) inserted. There is also a space to put EMS comments. These sections are not hard stops. Attempts to contact R1’s skilled nursing facility nurse on 7/6/26 at 10:37 a.m., 7/7/26 at 9:50 a.m., and 7/30/26 at 8:04 a.m. were unsuccessful. During an email correspondence on 7/6/26 at 11:54 a.m., quality and safety (QS)-A stated P1 did not have an IV during her admission on 5/4/26. During an interview on 7/6/26 at 12:53 p.m., registered nurse (RN)-A stated when a patient is ready for discharge, they would go through the discharge paperwork with the patient in the room and then take out the patients IV prior to discharge. RN-A would document if she had removed the patients IV in the discharge navigator in the electronic health record (EHR). RN-A stated the risks of an IV being in too long is phlebitis or the patient could take the IV out themselves and would bleed. During an interview on 7/6/26 at 1:11 p.m., RN-B stated when a patient is ready for discharge, she would print out the patients discharge paperwork, take their IV out, educate the patient if needed, and then ask the patient if they had any questions. RN-B would document the IV removal in the discharge disposition in the EHR. The risk of an IV being in too long is infection. During an interview on 7/6/26 at 1:27 p.m., RN-C stated when a patient is ready for discharge, they would go over the discharge instructions with the patient and take their IV out. RN-B would document the IV removal in the discharge disposition in the EHR. The risk of an IV being in too long is infection. During an interview on 7/6/26 at 1:44 p.m., RN-D stated when a patient is ready for discharge, they would go over the discharge instructions with the patient and take out their IV. The risks of an IV being in too long are phlebitis and infection. During an interview on 7/6/26 at 3:40 p.m., RN-E stated when a patient is ready for discharge, they would go over the discharge instructions with the patient and take out their IV. RN-E stated either the nurse, or the tech would take the IV out, but most of the time it is the nurse. RN-E would document the removal of the IV in the ED navigator in the EHR. RN-E stated most of the time when a patient comes to the ED via EMS, EMS will usually start the IV catheter. When asked questions about P1, RN-E stated she could not recall P1. During an interview on 7/7/26 at 9:51 a.m., family member (FM)-A stated she had met P1 at the hospital about an hour after P1 arrived. FM-A stated she did not see whether P1 had an IV or not. None of the nurses who worked with P1 at the hospital had done anything with the IV. The nurse from R1’s skilled nursing facility called FM-A and told her P1 had an IV-connector piece in her arm. During an interview on 7/7/26 at 11:40 a.m., RN-F stated that when a patient arrives in the ED via EMS, they would do a bedside report with the EMS personnel. RN-F would write down medications that the patient is on, any treatments or medications that were new to the patient, if EMS had started an IV, and any pertinent medical history. RN-F stated if EMS had started an IV, she would document that in the triage portion in the EHR under the EMS section. When asked questions about P1, RN-F stated she could not recall P1. During an interview on 7/7/26 at 11:50 a.m., RN-G stated when a nurse is getting a handoff report from EMS, she would expect the nurse to get a brief synopsis of the situation, the assessments, any treatments or medications that was given by EMS before the patient came to the ED, and what the patient was looking for. RN-G stated EMS would also notify the handoff nurse if EMS had started an IV. In the triage section in the EHR there is a section that asks about EMS’s treatments and procedures the patient received before coming to the ED. In that section the nurse would identify if EMS had started an IV. There is a button you could click in that section to identify if EMS started the IV, but it is not a hard stop in the triage process. The nurse could bypass this section when completing the triage process. RN-G’s expectation is that a patient IV is taken out prior to the patient’s discharge. When the IV has been taken out, the nurse would document the removal in the discharge disposition. During an interview on 7/7/26 at 11:58 a.m., provider (P)-B stated he would expect handoff between EMS and the hospital nurse to include the patients name, demographics, why EMS was called, what happened when EMS arrived to the patient, any interventions EMS had performed, if EMS had started an IV, if EMS gathered any labs, and if EMS completed any assessments. Upon discharge, P-B would expect the nurse to remove the IV and document the removal in the EHR. During an interview on 7/7/26 at 1:17 p.m., P-A stated an EMS handoff report is taken by the triage nurse or the patient’s primary nurse. P-A stated he would expect the handoff report to include a brief history of the patient, what happened at the scene, who called EMS, the initial assessment at the scene, whether EMS had done any treatments before the patient came to the hospital, if EMS had given any medications before the patient came to the hospital, and if EMS started an IV. When asked questions about P1, P-A stated she could not recall P1. During an interview on 7/30/26 at 9:14 a.m., skilled nursing facility nurse (SNFN)-B stated the nurse, SNFN-A, who removed P1’s IV when she returned from the hospital no longer worked at the skilled nursing facility. The hospital’s Vascular Access Device (VAD)- Complications policy dated 2/24/25 indicated complications of an IV are phlebitis, infiltration, extravasation, occlusion, dislodgement, infection, and embolus. The hospital’s Vascular Access Device (VAD)-Nursing, Adult, Pediatric, and Neonatal policy dated 10/27/25 indicated an IV should be discontinued or removed when it is no longer indicated or with provider orders. Discontinue short peripheral IV’s upon patient discharge. The hospital’s Hand-Off Communication policy dated 1/13/26 indicated the receiver of the hand off information would have an opportunity to review relevant patient historical data that may include previous care, treatment, and services.”

“OUTPATIENT SERVICES CFR(s): 482.54 If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure dressings were applied to finger lacerations in a manner to prevent impaired circulation and ischemia for 1 of 10 patients (P1) reviewed. P1’s index finger was wrapped in tubular gauze too tightly by hospital staff which caused decreased circulation and subsequent partial amputation. As a result, the hospital was found out of compliance with the Condition of Participation at 42 CFR 482.54 - Outpatient Services. A condition-level deficiency was issued at A-1076; see A-1081 for additional information.”

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure dressings placed on a patient in an outpatient setting were applied in a manner to prevent impaired circulation and ischemia (lack of blood flow and oxygen) for 1 of 10 patients (P1) reviewed. P1’s index finger was wrapped in tube gauze too tightly by hospital staff which caused decreased circulation and resulted in partial amputation. The hospital started their review of this incident and removed tube gauze from use; however, the facility had not yet implemented any staff re-education, or competency checks to ensure proper dressing application despite the incident happening over two months prior. Findings include: P1’s emergency department (ED) Provider Note, dated 3/2/26, identified P1 presented to the urgent care with lacerations on his right-hand fingers that were sustained on metal at work. P1’s foster care personnel (FC)-A was present. The note included a right-hand diagram that showed red-colored markings and dictation describing each site. This identified a 2-centimeter (cm) X 1.5 cm avulsion (separated) laceration on the dorsal middle finger. The fingers were each treated and wrapped with a various dressing including tube gauze. P1 reported having the same sensation and feeling in his fingers as he did prior to being wrapped. P1 was provided with a sling to help with swelling and pain. The note identified medical assistant (MA)-A helped with the application of the tube gauze and discharge instructions were discussed with FC-A. These included, “ ... recommended that this [dressings] be removed in 24 hours, that original dressing should not be left on longer than 48 hours to prevent infection.” Nurse practitioner (NP)-A authored the note. P1’s ED Care Timeline, dated 3/4/26, identified P1 presented to the ED that day for a re-dressing of the laceration wounds. The note identified, “Pt here for wound dressing change. Does not need to see MD [physician] unless wound looks infected.” P1’s assigned nurse, registered nurse (RN)-D, documented: “Went to change dressings on right hand ... Pulled tube dressings off right hand and 3rd digit is cold and black/pale in color. Pt states he has no pain. Provider notified.” P1’s ED Provider Note, dated 3/4/26, identified P1 presented to the ED with FC-A for an initial dressing change. P1 had sustained abrasions to the dorsum of the right hand two days prior, and his fingers were ultimately wrapped with tube gauze. P1 now endorsed pain in his fingers and decreased sensation. A physical exam was completed and P1’s right hand was photographed which were included. These photos showed P1’s right hand middle finger with a visible wound on the finger towards the base where it connected to the hand, and the finger having a narrowed shape towards the distal finger with his nail being blue and black in color. The MD identified, “Initial concerns based on my evaluation of the patient is for ischemia of the distal aspect of the third digit. Orthopedics was consulted, and the physician assistant evaluated patient at bedside ... plan is for discharge home, outpatient follow up, and patient will likely require operative intervention with potential for partial amputation which will be required.” MD-B authored the note. P1’s ED Note, dated 3/4/26, identified RN-D was instructed by the hand surgeon on how to re-dress P1’s wounds which included leaving the 3rd digit exposed. FC-A was provided with discharge instructions and a referral for an orthopedic hand surgeon consultation. During interview on 5/4/26 at 12:03 p.m., P1’s foster care personnel (FC)-A stated they brought P1 to urgent care on 3/2/26 when P1 sustained a work-related injury and had multiple scrapes and cuts on his fingers. FC-A recalled staff members at the hospital wrapping P1’s fingers with gauze which covered each affected finger entirely and telling them to either change the bandage or bring P1 back to the clinic within 48 hours. FC-A stated they brought P1 back on 3/4/26, and the nurse working removed the dressings when they saw P1’s fingers looked “pale” and the nurse commented P1’s fingers were “cold” to touch. The physician then came in and saw P1 along with an orthopedic provider who said a partial amputation was likely needed. FC-A stated the hospital staff did not openly say the affected finger was wrapped too tightly; however, it was implied in the conversation adding, “It was apparent.” FC-A stated P1 had not complained of any pain to alert them the circulation was impaired when he left the urgent care on 3/2/26, but only rather complained the dressings were “a little itchy,” adding P1 had cognitive impairment which caused him difficulty when articulating things at times. FC-A stated nobody from the foster care had moved or adjusted the dressings in the 48 hours between 3/2/26 and 3/4/26, and they were closely monitoring P1 so he wouldn’t touch or fiddle with the dressings. The skin or nails were not visible to evaluate color changes of the nail beds or skin, either, due to being covered with the gauze. FC-A verified P1 had a partial amputation of his finger completed at a surgical center due to this incident. During interview on 5/4/26 at 12:17 p.m., MA-A recalled P1 coming to urgent care on 3/2/26 with a bleeding hand injury. NP-A asked MA-A to do the dressing application on P1’s hand, so they applied tube gauze with NP-A still in the room. MA-A used a “metal mechanism” which helps apply the gauze and twists it as it was applied. MA-A stated they applied the gauze “not real tight but tight enough it stays in place.” MA-A stated patients were usually instructed to remove it after 24 hours and they asked P1 as it was being applied if it felt okay and was not hurting him. P1 then “seemed fine” and was able to move his fingers while wrapped. MA-A stated they had heard P1 subsequently needed to have a partial finger amputation due to the gauze being applied but nobody had yet explained more about it. MA-A stated that since the incident they had been told only a provider or RN was able to apply tube gauze, and their supervisor had talked about it with them and an e-mail would be coming out about it, but they hadn’t seen it yet. MA-A stated there had been no re-education on dressing applications so far to their recall and expressed some education would be nice to have adding, “I would like to have some education [on wound dressing].” MA-A reiterated they wrapped P1’s fingers with tube gauze the same way they had many times for other patients adding they did nothing abnormal from the other times they’ve applied it. During interview on 5/4/26 at 12:54 p.m., RN-D stated they recalled P1 coming to the ED on 3/4/26 for a dressing change to his hand which had been placed a few days prior in the urgent care clinic. RN-D stated each finger on the hand was wrapped individually and entirely with tube gauze and recalled the middle finger being “black and necrotic” and “ice cold” after the dressing was removed. P1 denied pain when asked but the finger seemed to turn more discolored as time went on after the dressing was removed. RN-D then notified the physician to evaluate P1’s fingers and the physician took over the care. RN-D recalled a hand surgeon visiting with P1 at some point in the ED and they made a comment about the finger as “dead now.” RN-D stated the dressings when removed seemed “tight” adding aloud, “To me, it seemed tight.” RN-D stated they rarely, if ever, applied tube gauze to a patient as it was something the ED technicians (EDT) do more but then added, “I’ve never been trained on how to do it.” RN-D stated they didn’t think the nurses were trained on using tube gauze even. Following this incident, RN-D stated they received an e-mail saying only providers or an RN could apply it moving forward and were asked some questions from leadership about what happened, but nothing else. RN-D stated the e-mail was a “couple weeks ago” and no further communication or re-education had been sent out that they had seen. During interview on 5/4/26 at 1:06 p.m., NP-A stated P1 presented to the urgent care with FC-A for the lacerations on 3/2/26 and recalled P1 as being fearful of needles so they tried to do as much topically as possible to get the bleeding under control. P1 had a history of obsessive-compulsive disorder (OCD) and would often clench his fists which kept the bleeding ongoing. NP-A recalled helping apply some Coban on the index finger and MA-A was using tube gauze to wrap each finger. This gauze was selected to use as it would likely allow more comfort for P1, and P1 stated they were able to feel their fingers when the wrap was completed. NP-A then discussed the discharge instructions with FC-A and felt they would follow through with them with the dressings to be changed or removed within 48 hours. NP-A stated they heard P1 had since required a partial amputation of his finger and had not yet followed-up with the adult foster care to see if someone from there had adjusted or changed the dressing prior to P1 coming back to the ED on 3/4/26. NP-A stated they were unsure how the gauze caused the restriction but speculated the bleeding possibly “hardened up” underneath the wrap but reiterated, “I don’t know.” NP-A stated multiple options for dressing the lacerations were considered including use of a splint, but again, they decided to use the tube gauze to provide the most comfort and motion for P1. NP-A stated they had never been trained in use of tube gauze while employed at the hospital and the last time education was done for it was back when they were in nursing school. NP-A stated the MA staff usually apply it to patients and since the incident with P1, the hospital had told staff that only a provider or RN could apply the tube gauze which “can be difficult” in the urgent care setting as there is only minimal staff present. On 5/4/26 at 1:30 p.m., a group interview was held with multiple members of hospital leadership present including urgent care manager (RN)-A, the quality director (QD)-A, vice president of medical affairs (VPMA), practice and education specialist (PE)-A, and MD-B. RN-A explained they learned of the incident when P1 presented to the ED and the ischemic finger was identified, so an internal incident report was completed and an investigation started. The investigation had identified “some gaps” with onboard training for wound care. They also identified tube gauze was reviewed through physician literature and had a known risk of ischemic injuries like had happened with P1. The incident was also pending peer review by the medical staff, and the team was still visiting with orthopedic colleagues to learn more. VPMA stated use of tube gauze in other settings was “very limited” due to the risk of ischemic injuries. MD-B stated for P1’s situation on 3/2/26, that use of tube gauze was not inappropriate but given the appearance of the finger it was reasonable to assume the gauze had “some type of effect on that finger,” adding they had not seen how tightly the fingers were wrapped prior to the nurse removing the dressings. MD-B stated the fingers when he saw them appeared “constricted” and with decreased sensation and decreased capillary refill time. These symptoms were all consistent with a compression-type injury causing ischemia. The orthopedic consultant who evaluated P1 on 3/4/26 also agreed it to be an ischemic digit injury, so the decision was made to leave the finger open and see what, if any, circulation returned before deciding on the next steps. QD-A stated the hospital had developed an “action plan” to address this incident and displayed it on an overheard screen for review. The plan included review and reinforcement of competencies for dressing applications, removing gauze from use, peer review of the case, sharing the learning with other stakeholders. The target date for completion of the competency review was recorded as 5/4/26. However, they explained this date was only to review what was needed and not necessarily complete the education by then and another date in June 2026 was set for that. PE-A stated another education person was working on this project and they were unsure how far in the competency or re-education process they were as of the survey date and acknowledged there had been no formal re-education or competency checks completed so far with the staff to ensure dressings were being applied correctly to prevent similar injuries as P1 had sustained. RN-A stated immediately following the event, they had directed only an RN or provider apply tube gauze, however, upon further review they decided to just remove the product from use totally a few weeks prior. A hospital policy on wound dressings and their application in outpatient settings, such as the ED or urgent care, was requested. However, none was received.”

“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: 48040 Based on interview and document review, the hospital failed to ensure a system for informing patients of their right to formulate an advanced directive 5 of 10 patients (P2, P4, P5, P6, and P7) reviewed for advanced directives. Findings include: P2’s Admission Default Flowsheet Data dated 12/29/24, indicated P2 did not have an advanced directive. P2’s flowsheet lacked evidence advance directive information was provided. P4’s Admission Default Flowsheet Data dated 12/29/24, indicated P4 did not have an advanced directive. P4’s flowsheet lacked evidence advance directive information was provided. P5’s Admission Default Flowsheet Data dated 12/30/24, indicated P5 did not have an advanced directive. P5’s flowsheet lacked evidence advance directive information was provided. P6’s Admission Default Flowsheet Data dated 12/29/24, indicated P6 did not have an advanced directive. P6’s flowsheet lacked evidence advance directive information was provided. P7’s Admission Default Flowsheet Data dated 5/14/25, indicated P7 did not have an advanced directive. P7’s flowsheet lacked evidence advance directive information was provided. On 5/14/25 at 2:35 p.m. a registered nurse (RN)-A stated admission nurses provided the advance directive notice to the patients during an admission, and documented in the admission navigator. On 5/15/25 at 4:05 p.m., RN-B (emergency department [ED] manager) stated she was unable to verify whether P2, P4, P5, P6 and/or P7 had received the required advanced directive information at the time of admission. Admission nurses should have offered those patients advanced directive information at the time of admission, and it should be documented in the admission navigator by the admission nurse. The hospital Advance Care Planning (ACP) and Advance Directives policy dated 1/20/22 and reviewed on 11/05/24, directed admission nurses to review the medical record and document the presence of an Advance Directives in the admission navigator. The policy further directed nurses to provide a health care directive information at the time of any patient’s admission and documented in the admission navigator.”