Mercy Hospital Springfield

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to: - Ensure registered nurse (RN) supervision of nursing care for one discharged patient (#84) of two discharged records reviewed when telemetry monitoring alarms were not communicated to nursing staff for timely patient assessment and intervention; - Ensure patients who had orders for a one to one (1:1, continuous visual contact with close physical proximity) sitter were appropriately observed to prevent injury or elopement for two current patients (#24 and #83) of five current records reviewed and one discharged patient (#87) of one discharged record reviewed; and - Ensure RN supervision of nursing care for one current patient (#11) of two current patients observed receiving a blood transfusion when the RN did not remain with the patient during the initiation of the transfusion. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395. 50151”

“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: 41865 Based on interview, record review and policy review, the hospital failed to: - Ensure registered nurse (RN) supervision of nursing care for one discharged patient (#84) of two discharged records reviewed when telemetry monitoring alarms were not communicated to nursing staff for timely patient assessment and intervention; - Ensure patients who had orders for a one to one (1:1, continuous visual contact with close physical proximity) sitter were appropriately observed to prevent injury or elopement for two current patients (#24 and #83) of five current records reviewed and one discharged patient (#87) of one discharged record reviewed; and - Ensure RN supervision of nursing care for one current patient (#11) of two current patients observed receiving a blood transfusion when the RN did not remain with the patient during the initiation of the transfusion. Finding include: Review of the hospital’s policy titled, “Cardiac Monitoring and Telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen), Adult,” dated 04/27/23, showed: - Staff trained and deemed competent in alarm recognition and recognition of arrhythmias (irregular heartbeat) would be responsible for alerting the licensed personnel who were responsible for the interpretation and documentation of rhythm strips on monitored patients. - In response to an alarm, the primary nurse was to be immediately notified. If they were not available, the charge nurse or another licensed staff was to be notified. - Any employee who suspended alarms prior to notification of the appropriate licensed staff would be subject to corrective action. Review of the hospital’s undated document titled, “Central Monitoring Unit (CMU) Practice Updates,” showed: - When a “leads off” alarm sounded, immediate notification was to go to the Patient Care Assistant (PCA), or the Patient Care Technician (PCT). - If the issue was unresolved after 10 minutes the CMU staff would contact the primary nurse. - If still unresolved after 20 minutes they were to contact the charge nurse. - At 25 minutes they would contact the house manager. - A SAFE report was to be placed if the “leads off” alarm went unresolved longer than 30 minutes. - All attempts to contact staff members were to be documented in the electronic health record (HER). - For monitors placed in stand-by mode, staff should be contacted after 30 minutes for a patient taking a shower; one hour for a procedure; or 30 minutes for other reasons unspecified. Review of Patient #84’s medical record showed: - On 02/18/26, he was admitted for persistent atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) with ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden death), worsening congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and underwent a cardiac ablation (a procedure where energy is used to create tiny scars in the heart to block the faulty electrical signals and restore a typical heartbeat). - His past medical history included A-fib, CHF, obesity, high blood pressure, high cholesterol, below the knee amputation, cardiomyopathy (a disease in which the heart muscle weakens and becomes enlarged making it hard to deliver blood to the rest of the body), end stage renal disease (ESRD, the final stage of kidney disease, where the kidneys can no longer function on their own), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), peripheral artery disease (PAD, blood circulation disorder that causes arteries to narrow, block or spasm and cause pain and tiredness in the legs, arms, or other body parts) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). - He had orders for continuous telemetry monitoring. - On 03/01/26 at 6:56 PM, documentation showed the nurse went into his room after shift change report and found him “down, faceplanted inside the bathroom.” The nurse checked his pulse, called for help and immediately started Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped). A code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called. CPR and medications continued until the hospitalist and family decided to end the code. He expired at 8:06 PM. Review of Patient #84’s incident report, dated 03/02/26, showed he was found down in the bathroom and had no pulse at shift change. His telemetry monitor had disconnected around 6:15 PM. Monitor audits showed several notifications were received that the telemetry box was “INOP (an alarm that alerts on the box to show the unit is malfunctioning, faulty or inoperable),” however no alarms triggered from the box. An alarm sounded around 6:15 PM that the lead set was unplugged. The CMU tech did not contact the department or the patient’s nurse. Review of a written statement provided by Staff AAAAA, RN, dated 03/06/26, showed he was Patient #84’s day shift nurse on 03/01/26. Throughout the shift, and during multiple interactions, Patient #84 did not voice any complaints or concerns. He reported feeling significantly better and appeared to be in stable condition. No acute issues were noted. Sometime between 6:10 PM and 6:15 PM, Staff AAAAA and the charge nurse replaced the telemetry batteries and verified the telemetry box was functioning appropriately. Patient #84’s heart rhythm appeared consistent with what had been observed throughout the shift. Between 6:40 PM and 6:42 PM, after completing shift report, Staff AAAAA went to the break room to gather his belongings before leaving for the day. He walked past Patient #84’s room and observed him in his wheelchair, near the sink, where he appeared to be cleaning up. He acknowledged him by waving, and the patient waved back. He did not display any visible signs of distress or request assistance. Review of a written statement provided by Staff ZZZZ, RN, dated 03/05/26, showed on the evening of 03/01/26 she started her rounds early around 6:45 PM, as she had not yet met some of her patients. She went to room 15 but that patient was asleep, so she checked on room 14 instead. When she entered the room, she noticed Patient #84 was not in bed and “found him on the floor underneath the bathroom sink, face planted and unresponsive.” He only had two telemetry leads on his chest at that time. She pulled the emergency cord, pressed the call button and shouted for help. CPR was started and a code blue was called. After the code she went to the nurse’s station to review Patient #84’s rhythm strips and noticed his last recorded strip was at 6:15 PM. Review of a written statement provided by the CMU Supervisor, dated 03/03/26, showed: - An audit of Patient #84’s telemetry box indicated that the lead set was unplugged at 6:17 PM, and that the box appeared to have been malfunctioning most of the day. - The next documented alarm was an INOP alarm that occurred at 6:31 PM. - Based on her knowledge of the telemetry box, if an INOP codes/alarms alerted, the box may not have sent an alarm to the CMU or the nurse’s station. - When the telemetry box alarmed “leads off,” the dayshift CMU tech did not notify the nurse prior to their hand off to the nightshift CMU tech, “due to it being almost shift change.” - The correct escalation protocols were not followed. - If the alarm did not sound, the CMU tech should have followed up when they saw that Patient #84 alerted “leads off.” - The CMU Supervisor reached out to a representative from the telemetry box manufacturer regarding the malfunctioning boxes and had yet to receive a response. Review of the hospital’s policy titled, “Sitter (a person assigned to continuously observe a patient within close proximity, to ensure their safety) Guidelines,” dated 08/27/24, showed: - A sitter was defined as a person assigned to a patient/group of patients for the purpose of assisting the patient to make safe options (e.g. staying in bed). - A provider order was not necessary for nursing staff to utilize a sitter for patient safety. - Staff would utilize the sitter algorithm or “Sitter Decision Tree” to determine the need for a sitter every four hours and whether or not to submit a request. - Hospital Public Safety Officers (PSO) were not utilized as sitters. - Fall precautions and safety measures were to be implemented and deemed insufficient prior to requesting a sitter. - The sitter would document observations in the electronic health record (EHR) every hour. - The charge nurse was responsible to review documentation of the sitter and consult the primary nurse of the patient before requesting a sitter every four hours prior to the next staffing period to verify the necessity for sitter continuation. - When a sitter request was made, the staffing office would make every attempt to provide a dedicated sitter. When a sitter was not available, the unit leadership or charge nurse would consider redistributing staff to accommodate needs. - They could consider other interventions, such as the nurse documenting in the patient room, when sitter resources were not available or if they were unable to redistribute staff resources to accommodate needs. - For suicidal ideation (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death) patients who had an order for protective oversight/suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm), the hospital was to provide a 1:1 sitter who would observe the patient 100% of the time, and document in the EHR every 15 minutes. - The sitter was to confirm that the patient was wearing green scrubs, and their belongings had been secured. - The sitter was to place themselves near the door, notify the nurse if they attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility), attempt to deescalate (reduce the intensity of a conflict or potentially violent situation) the situation, and notify public safety. Review of the hospital’s policy titled, “Sitter Algorithm,” dated 08/27/24, showed: - Patient behaviors that might indicate the need for a sitter included combativeness; agitation; pulling at tubes/lines, drains, cardiac leads (noninvasive monitors of the heart that attach to the patient’s chest and record heart rhythm); impulsivity with lack of judgment; cognitive deficits resulting in inability to understand or remember instructions; and confusion. - Staff would attempt interventions such as fall precautions; pain control; sleep enhancement medications; diversional activities; moving closer to the nurse’s station; hourly rounding; and repositioning, etc. - If the interventions were successful or family was at the bedside, no sitter was needed. - If the interventions were unsuccessful and the behavior was unmanageable the charge nurse would be notified. - If a sitter was available, the nurse would give report, reassess and document the need for the sitter every four hours, and relieve the sitter for breaks. - If a sitter was not available, they would rotate floor staff, consider use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), notify the family, consider lowering the bed, and placing a fall matt. Review of the hospital’s policy titled, “Clinical Hold,” dated 07/31/25, showed: - The hospital had an obligation to protect against self-harm and harm to others by adult patients who lack decisional capacity and were deemed to be at imminent risk of causing harm to self or others. - A clinical hold was an internal patient status in non-behavioral health areas where a physician had made a clinical determination that an adult patient should not be permitted to leave against medical advice (AMA). - Patients on a clinical hold were to be placed in green hospital attire upon initiation of the clinical hold order. Review of the hospital’s policy titled, “Suicide/Self-Harm Prevention: Non-Behavioral Health Unit,” dated 04/24/25, showed: - All patients 12 years of age and older evaluated or treated in the emergency department (ED) were screened for suicide/self-harm by a registered nurse (RN) using the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life). - SP were initiated on patients who screened high on the C-SSRS until a risk assessment was conducted and the need for SP were confirmed. - Patients may be placed in a dedicated behavioral health (BH) area when available. If a dedicated BH area was not available, the patient may be placed in a psychiatric safe room. When neither a dedicated BH area, nor a psychiatric safe room, were available, high-risk patients would be placed on a continuous 1:1 observation. - 1:1 monitoring was an increased level of patient monitoring utilizing a one-patient to one-coworker ratio. The assigned observing coworker remained within proximity to the patient to immediately intervene if risk behaviors were observed. Patients were observed at all times and may not request privacy. - A room/environment could be modified by removing objects that posed a risk if they could be removed without adversely affecting the patient’s care. Review of Patient #87’s medical record, dated 01/31/26, showed: - At 12:46 PM, she was brought to the ED by a friend after she expressed wanting to jump off a cliff. - At 12:51 PM, a C-SSRS was completed, and she scored high risk for suicide. - At 12:52 PM, she was placed on a Clinical Hold. - At 1:12 PM, a progress note showed a Nurse Practitioner (NP, a nurse with advanced clinical education and training) ordered blood work and documented on her condition. - At 3:00 PM, an ED note showed Patient #87 was not in the triage room. All waiting rooms and the restrooms were checked. Security checked the cameras and observed Patient #87 walking out the ED doors. - At 3:15 PM, the police department (PD) was called to help assist in finding and returning her to the ED. - At 3:38 PM, the PD returned Patient #87 to the hospital, and she was immediately taken to a BH room. Review of Patient #87’s incident report, dated 01/31/26, showed she was found to be missing from triage room five. Patient #87 was placed in that room to wait, after being seen by the NP. Security observed on camera that she had walked out of the triage room after not being secured when she returned from having blood work drawn. Staff felt that high ED volume was what contributed to this event During an interview on 03/09/26, at 3:38 PM, Staff XXXX, ED RN Manager, stated the hospital’s policy was “plain and simple,” when a patient presented with thoughts of self-harm, or harm to others, they were not left alone until they were in a completely safe environment. That meant securing their property and their clothing, putting them in paper scrubs and placing them in a designated psych safe room. If that process failed from the beginning, it made it more difficult for people to pick up on an unsafe situation. For Patient #87, it was determined that the resource nurse left her in the triage room alone. She required the use of an observer since there were no psych safe rooms available. She was not placed in green scrubs, so other staff were not alerted to the fact that she was a clinical hold patient. Review of the hospital’s policy titled, “Patient Falls Policy,” dated 05/15/24, showed a fall was defined as a sudden, unplanned or unexpected descent, with or without injury to the patient, including rolling off a low bed onto a mat. Fall prevention interventions were implemented based on the patient’s assessed risk. High fall-risk status was communicated through the EHR high fall risk banner and via yellow arm bands. Fall prevention interventions available included bed in low position; brakes locked; area uncluttered; floor clean and dry; education; call light in reach; non-slip footwear; bed/chair alarms; supplemental lighting; and proactive rounding. If a fall occurred, staff would implement post-fall procedures. Review of Patient #24’s medical record, dated 02/20/26, showed: - He presented to the hospital after a self-inflicted gunshot wound to the head. - He had significant facial fractures, skull fractures, and intracranial (inside the skull) injuries. - On 02/24/26, he had surgery on his brain and additional future surgeries were expected. - On 02/28/26, a continuous order was placed for a “Sitter at Bedside” and remained active on 03/09/26. - On 03/01/26, Staff QQQQ, LPN, documented Patient #24 had fallen. Safety precautions were in place, with consistent use of a bed alarm and sitter. SP and hourly rounding were maintained. - On 03/02/26, Patient #24 was noted to have agitation and intermittent fevers. He had purposeful movements with stimulus. His Glasgow Coma Scale (GCS, estimate coma severity. The maximum score is 15 which indicates a fully awake patient) was 10. He would open his eyes, track objects/staff and could move his extremities, but not on command. - On 03/02/26 at 3:45 AM, Staff PPPP, RN, documented that medications were adjusted with one rate change error during the shift. High fall risk and SP were consistently in place, including a bed alarm, low bed, and hourly rounding. The use of a sitter was not documented as being included in the safety interventions. - On 03/02/26 at 8:23 PM, Staff PPPP, found Patient #24 on the floor next to his bed. Staff PPPP notified the charge nurse by verbally calling for help. - On 03/03/26 at 4:19 AM, Staff PPPP, documentation showed high fall risk interventions and safety checks were consistently performed with no documentation of falls or injury during the shift. SP with hourly rounding were maintained and no suicidal behavior was documented. The use of a sitter was not documented as a safety intervention. - On 03/03/26, a physician noted Patient #24 had fallen overnight. It was unclear if a sitter had been available. Patient #24 was moved to a room closer to the nurse’s station. - A trauma provider documentation showed post fall, staff would continue to utilize a sitter. If Patient #24 became impulsive and was not redirectable, staff would utilize wrist restraints. Review of Patient #24’s incident report, dated 03/02/26, showed Staff PPPP, RN, found him on the floor next to his bed at 8:23 PM. Staff PPPP notified the charge nurse by calling for help. His assessment was unchanged, other than a skin tear to his toe. He was assisted back to bed, his physician and mother were notified. Patient #24 received a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of his head. He was a high fall risk prior to the fall. He had been changing position in the bed, had cognitive impairment and was unable to walk without assistance. A sitter was not present at the time of his fall. His bed alarm did not sound because it was not set. He had set off the bed alarm ten minutes prior. When staff responded to that alarm, they did not reset the bed alarm when they exited. Documented fall prevention interventions in place included an armband, bed in low position, call light in reach, appropriate lighting, door sign, floor uncluttered, non-slip floor matt, and safe handling practices. New actions after the fall included setting the bed alarm, moving the patient closer to the nurse’s station, and rounding. Insufficient staff available was noted to be a contributing factor. Review of Patient #83’s medical record, dated 02/14/26, showed: - He was admitted for frequent falls which resulted in intracranial bleeds, and alcohol withdrawal (symptoms that occur upon abrupt discontinuation of medications, alcohol or drugs). - He was initially alert and oriented, but during his hospitalization he became increasing confused, encephalopathic (damage or disease that affects the brain), and agitated. - On 02/20/26, an order was placed for a “Sitter at Bedside.” The order was marked as “continue on transfer” when he was moved to another unit. The order remained in place until it was canceled on 03/07/26. - On 03/02/26, Patient #83 removed his feeding tube and intravenous (IV, in the vein) access. - On 03/02/26 at 11:25 PM, a nurse documented that she heard moaning, went into the room, and found Patient #83 on the floor. He denied hitting his head or new pain. He was assisted back to bed and his provider was notified. - On 03/03/26 at 7:13 AM, a nurse documented that Patient #83 had fallen overnight. He was found face down on the floor by the night nurse. - A review of his HER showed there was no sitter documentation on the days surrounding 03/02/26 or 03/03/26, despite an active order. No paper documentation of sitter observations was provided. Review of Patient #83’s incident report, dated 03/03/26 showed he fell on 03/02/26 at 11:20 PM. Patient #83 let out a moan, the nurse went into the room and found him on face down on the floor, next to the bed. The supervisor and his provider were notified. Patient #83 was assessed to be a high fall risk prior to his fall. He was in restraints at the time of the fall. A sitter was not present. His bed alarm sounded, and prior to the fall he was trying to climb around the bedrails. Additional factors included short staffing on the unit. There were only four nurses until 11:00 PM, and the nurse had just given report to a fifth nurse that arrived. A safety lead employee discussed Patient #83’s condition with one of his providers. They were unable to determine whether or not his fall had caused increased bleeding in his brain. They were already concerned about potential increased bleeding prior to his fall. During an interview on 03/03/26 at 10:05 AM, Staff EE, RN, stated that Patient #24 had fallen the night before due to no sitters being available. He had been moved to a room closer to the nurse’s station so he could be observed more easily by the staff. During an interview on 03/03/26 at 10:30 AM, Staff DD, RN Manager, stated that when there were not enough sitters, staff would “round robin,” taking turns to observe the patients needing closer monitoring. Nurses would complete their documentation and telemetry monitoring at that patient’s bedside, rather than the nurse’s station. Staff would move the patients requiring close monitoring near the nurse’s station and utilize bed and chair alarms when sitters were not available. Suicidal patients were the priority with the use of sitters. Patient #24 had been cleared of his SP. During an interview on 03/04/26 at 4:00 PM, Staff QQQQ, LPN, stated she had cared for Patient #24 within the past week, but was not his nurse when he fell. She worked that night, and they were very short staffed. Sitters were not available. When sitters were unavailable, the charge nurses would message each other to try to find extra staff that could be used. Suicidal patients were prioritized for sitters, and the nurses would attempt to monitor the other patients requiring higher observation. The lack of available sitters was becoming more frequent, and their unit seemed to have a lot of high acuity patients with more sitter needs than normal. During an interview on 03/04/26 at 6:30 PM, Staff PPPP, RN, stated he was a travel nurse and had been at the hospital for three weeks. He had been the nurse caring for Patient #24 when he fell. He had also cared for Patient #24 the previous night without a sitter, but his assignment had been much easier. He only had two patients and was able to stay in the room with Patient #24 more consistently. On the night Patient #24 fell, he had a more demanding assignment and had to step away from him for over an hour to admit a new patient. The other nurses, tech, and charge nurse were not available to cover for him while he admitted his new patient. During an interview on 03/05/26 at 10:25 AM, Staff SSSS, Director of Critical Care, stated charge nurse huddle meetings took place at 4:00 PM and 4:00 AM every day to discuss staffing, patient volume, and sitter needs. They discussed how to share resources, prioritizing SI/HI patients for the available sitters. The algorithms were used when needed to determine if a sitter was necessary, but she was unsure if they were being done consistently or added to the patients’ charts. The expectation was that if a patient needed 1:1 monitoring and if the person monitoring that patient needed to step away, they would communicate the need for coverage to another staff member. During an interview on 03/10/26 at 10:42 AM, Staff UUUU, Chief Nursing Office (CNO), stated that they had significant licensed and unlicensed staff position openings and were struggling to fill them, even with sign-on bonuses and incentive shift offerings. The hospital had been focused on prioritizing sitter assignments to suicidal patients after receiving citations in the past year. She identified there was an opportunity to re-evaluate their process for placing orders for and assigning sitters. The staff were not using the algorithm according to policy. A new algorithm was being built into the EHR to make it more accessible. She expected the nurse monitoring a high fall-risk patient to communicate the need for another staff member to watch his patient while he attended to another patient. She was unsure who would have been available on the shift where Patient #24 suffered a fall. Review of the hospital’s policy “Administration Transfusion of Blood (to administer blood into a vein) or Blood Products,” dated 09/07/22, showed the transfusionist was to initiate the transfusion at a slow rate (somewhere between 50 to 100 milliliters per hour [ml/hr]) and remain with the patient for the first 15 minutes, to monitor for adverse transfusion reactions. Observation on 03/02/26 at 2:10 PM, on the Oncology (a branch of medicine that deals with the prevention, diagnosis, and treatment of cancer) floor showed: - Staff V, RN, completed pre-transfusion tasks, primed the blood tubing with blood to the end of the tubing, connected the tubing to Patient #11’s intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and started the blood transfusion at 200 ml/hr. - Staff V provided Patient #11 his call button and instructed him to call if he started to feel “anything.” - Staff V left the room and went to check on his other patients. - At 2:25 PM, Staff V returned to Patient #11’s room to assess his vital signs (VS, measurements of the body’s most basic functions). Record review of Patient #11’s medical record showed: - On 03/02/26, he was a 68-year-old patient who was hospitalized for anemia (low amounts of oxygen rich blood, causes paleness and weakness), increased weakness and fatigue (weakness or tiredness). His past medical history included high blood pressure, cardiomyopathy (a disease in which the heart muscle weakens and becomes enlarged making it hard to deliver blood to the rest of the body), and prostate (a small walnut-shaped gland in men that produces the seminal fluid that nourishes and transports sperm) cancer with metastasizes (the spread of cancer cells from the place where they first formed to another part of the body) to his bones. He was on systemic chemotherapy (a drug treatment that uses powerful chemicals to kill fast growing cells or cancer in the body), and experienced cancer related pain and chemotherapy related anemia. - Upon admission, his hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body) was 6.9 (normal 13.5 to 17.7). - His provider ordered a unit of packed red blood cells (PRBC, specific blood cells that have been separated from whole blood cells, for administration into a vein) to be transfused. During an interview on 03/02/26 at 2:30 PM, Staff V, RN, stated he always starts blood transfusions at 200 ml/hr, and would increase the infusion rate by 25 or 50 ml/hr, as tolerated. Patient #11 has received multiple blood transfusions and was familiar with receiving blood products. Patient #11’s wife was at the bedside and could alert the staff in the event he developed any complications. During an interview on 03/10/26 at 10:40 PM, Staff UUUU, CNO, stated staff were expected to follow the hospital’s policy for blood administration and remain with the patient for the first 15 minutes of the transfusion. 50151”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on observation, interview, record review and policy review, the hospital failed to ensure: - Four current patients (#19, #35, #36 and #37), of four patients observed, were provided psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) after being placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm); - Staff followed policies and procedures when one to one (1:1, continuous visual contact with close physical proximity) observations were not implemented and documented for two current high-risk suicidal patients (#19 and #35), of four patients observed; and - One current patient (#36), of four patients observed, was properly assessed by a provider after being placed on suicide precautions. (A-0144) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. The hospital census was 450. The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 06/04/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on the assessment and observation of patients placed on suicide precautions. All remaining staff were educated prior to the start of their next shift. Please refer to A-0144.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 41865 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for one Emergency Department (ED) discharged patient (#41) of one discharged ED patient reviewed and all current ED continuous telemetry monitored patients. - Ensure the assigned nurse rounded every hour and documented the rounding in the electronic health record (EHR) for four current patients (#19, #35, #36, and #37) out of four current patients observed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm). - Ensure appropriate nursing assessments were completed and documented on three current patients (#19, #36, and #37) out of four current patients on SP. - Ensure that physician notification, appropriate consults and orders were obtained, when one patient (#37) had a significant change in a risk for suicide out of four current patients on SP observed. - Ensure that nursing documentation for one to one (1:1, continuous visual contact with close physical proximity) observations were completed on two current suicidal patients (#19 and #35) out of four current patients on SP observed. (A-0395) The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 06/05/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on the expectation that designated continuous telemetry monitoring occurred for all patients. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395. 50321”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to ensure: - Four current patients (#19, #35, #36 and #37), of four patients observed, were provided psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) after being placed on suicide (thoughts of causing one’s own death) precautions. - Staff followed policies and procedures when one to one (1:1, continuous visual contact with close physical proximity) observations were not implemented and documented for two current high-risk suicidal patients (#19 and #35), of four patients observed; and - One current patient (#36), of four patients observed, was properly assessed by a provider after being placed on suicide precautions. The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 06/04/25, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on the assessment and observation of patients placed on suicide precautions. All remaining staff were educated prior to the start of their next shift. Review of hospital policy titled, “Suicide and Homicide Precautions Acute Care,” dated 08/27/24 showed: - A suicide risk assessment was completed upon admission. If the patient answers “yes” to any of the questions, the nurse would initiate suicide precautions. - All patients placed on suicide precautions required continuous visual observation while receiving medical treatment. Any patient known or suspected to be suicidal should be evaluated by a psychiatrist or by a psychiatric evaluation nurse within 24 hours. - Patients were to be under continuous observation by a patient sitter or another co-worker from the unit assigned. - The provider should be notified immediately when a patient responded positive for any risk factor resulting in need for suicide precautions. An order must be obtained. - All items that could pose a ligature or self-harm risk should be removed from the patient’s room. - The nurse should complete the room safety check every shift, round on the patient every hour and document if the patient is on suicide precautions. - All individuals on suicide precautions were considered a high risk for elopement. The charge nurse, a nurse leader, and public safety should be notified of the risk. - Patients on suicide precautions should have the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) assessment daily. - A notification to the physician should be completed for any change of condition. Review of an untitled, undated, hospital document with a yellow note attached stating, “Checklist for Room Safety,” identified items that have potential to cause harm to self or others. The items included were chemicals, cleaning products, hangers, bins, artwork not solidly secured to wall, sharps, plastic liners in trash carts, cord, phones, intravenous (IV; in the vein) equipment, pumps, tubing, call light, oxygen/medical gas valve adapter trees, suction canisters and tubing and hand sanitizer. These items should be removed from patient rooms for safety. Review of the undated hospital document titled, “Sitter Precautions Table,” showed: - Nurses should round and document every hour on patients with suicide and self-harm precautions. - Sitter documentation should be completed every 15 minutes. - All items that are considered a safety risk, including plastic bags and all unused equipment should be removed from the room. Review of an undated hospital document titled, “Safety Data Sheet,” showed Purell Hand Sanitizer contains hazardous ingredients including Ethyl Alcohol and Isopropyl Alcohol. If swallowed, medical attention should be obtained. Observation on 06/02/25 at 10:10 AM, in Patient #19’s room showed: - Staff Y, Patient Care Technician (PCT), was assigned as the 1:1 continuous observer. - Oxygen tubing was hanging off the wall and was not currently in use. - An IV pump and cord sitting next to the patient bed and was not currently in use. - Three metal clothing hangers in an unlocked closet. - A wall mounted hand sanitizer containing 1200 milliliter (ml) of hand sanitizer. - Two red cords, approximately three feet in length, located in the bathroom. Review of Patient #19’s medical record showed he was admitted on 06/01/25 after an attempted suicide. He was placed on suicide precautions and assigned a 1:1 sitter. There was no 1:1 documentation on the night shift of 06/02/25 through 06/03/25. During an interview on 06/02/25 at 10:10 AM, Staff Y, PCT, stated she completed the safety checklist and documented that Patient #19’s room was safe. Everything had been removed that posed a concern for the patient’s safety. During an interview on 06/02/25 at 10:12 AM, Staff AA, Clinical Supervisor, stated that sitter documentation should be completed every 15 minutes and included an assessment of the patient’s room for safety. Observation on 06/03/25 at 12:55 PM, in Patient #35’s room, showed: - Staff AAA, Sitter, was at the bedside and assigned to monitor Patient #35. - Two six-ounce unopened bottles of Hibiclens (antimicrobial soap) sitting on the counter. - Two four-ounce tubes of petroleum jelly sitting on the counter. - An oxygen/medical gas valve adapter tree on the wall, not in use. - A suction valve and container on the wall, not in use. - A wall mounted hand sanitizer containing 1200 ml of hand sanitizer. - A corded lamp on the bedside table - An unsecured picture on the wall. - A Workstation on Wheels (WOW) with a hand scanner that in the room, not in use. - Two red cords, approximately three feet in length, in the bathroom. - A large, non-breakaway privacy curtain, not in use. Review of Patient #35’s medical record showed: - He was admitted on 05/31/25 after ingesting hand sanitizer and multiple pills in a suicide attempt. - He was placed on suicide and elopement precautions. - On 05/30/25 & 05/31/25, 1:1 observations were only documented from 7:00 AM through 6:00 PM. No documentation was provided for the overnight shift. - No daily safety checklists were documented. Observations on 06/03/25 at 12:40 PM, in Patient #36’s room, showed: - A roll of plastic trash bags sitting on the counter. - A plastic bag in the trash can sitting next to Patient #36. - Two red cords, approximately three feet in length, in the bathroom. - A plastic bag in the soiled laundry basket. - Multiple bottles of body wash and Hibiclens (an antibacterial, antimicrobial skin cleanser) on the bathroom counter. - An IV pole, next to the patient’s bed, not being used. - A suction regulator tree sitting on a shelf in the closet. - A leg compression machine with attachment cords approximately two feet long, sitting on a shelf in the closet. - A wall mounted hand sanitizer containing 1200 ml of hand sanitizer. Review of Patient #36’s medical record showed he was admitted on 05/30/25 for acute encephalopathy due to an intentional drug overdose and alcohol intoxication. Only one daily safety checklist was documented on 05/30/24 at 11:00 PM. There were no additional safety checklists. During an interview on 06/03/25 at 1:15 PM, Staff BBB, Registered Nurse (RN), stated that there should be documentation every 15 minutes for all patients on suicide precautions. During an interview 06/03/25 at 12:50 PM, Staff OO, Charge RN, stated that safety checklists should be completed every shift by the nurse and that there should be documentation every two hours on visual assessments of patients on suicide precautions. Review of Patient #37’s medical record, and concurrent observation, on 06/03/25 at 1:10 PM showed: - He was admitted for low blood pressure and had a history of a brain injury. - On 06/01/25 at 7:37 PM, nursing documentation indicated that Patient #37 was suicidal, and they had concerns for his risk for violent behaviors. He was placed on suicide precautions. Documentation indicated that the patient in “Bed 2 stated Patient #37 wanted to kill himself and was already dead on the inside.” Only one C-SSRS was completed. - After the initiation of suicide precautions, there was no documentation that the physician or charge nurse were notified of his change in condition. - There was no physician order for suicide precautions or daily checklists completed. During an interview on 06/03/25 at 1:30 PM, Staff NN, Nurse Manager, stated: - He unaware that Patient #37 had been placed on suicide precautions. Policy dictated that he should have been notified. - The physician should have been notified and an order obtained within 24 hours of placing the patient on suicide precautions. - There was no documentation made by the nursing staff to show an assessment of the patient every two hours. During an interview on 06/04/25 at 9:30 AM, Staff VVV, Director of Nursing (DON), stated: - A C-SSRS and a safety checklist should be completed by nursing staff every shift. - All 1:1 observations should be documented every 15 minutes by the assigned staff member. - The patient’s assigned nurse is responsible for ensuring the 15-minute documentation has been completed, the patient’s room is safe, and all hazards have been removed. - The nurse should assess patients on suicide precautions every two hours. During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Executive Nursing Director, stated: - A physician’s order should be obtained for suicide precautions and the physician should be notified of any changes to the patient’s safety and well-being. - All patients placed on suicide precautions should have a 1:1 sitter with them at all times. The sitter must document every 15 minutes. - The assigned nurse for patients on suicide precautions should ensure a safe room environment and complete a safety checklist each shift and verify that the sitter documented every 15 minutes. - All hand sanitizers should be removed from the patient rooms of those on suicidal precautions. 41865”

“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: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for one Emergency Department (ED) discharged patient (#41) of one discharged ED patient reviewed and all current ED continuous telemetry monitored patients. - Ensure the assigned nurse rounded every hour and documented the rounding in the electronic health record (EHR) for four current patients (#19, #35, #36, and #37) out of four current patients observed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm). - Ensure appropriate nursing assessments were completed and documented on three current patients (#19, #36, and #37) out of four current patients on SP. - Ensure that physician notification, appropriate consults and orders were obtained, when one patient (#37) had a significant change in a risk for suicide out of four current patients on SP observed. - Ensure that nursing documentation for one to one (1:1, continuous visual contact with close physical proximity) observations were completed on two current suicidal patients (#19 and #35) out of four current patients on SP observed. (A-0395) Finding included: Review of the hospital’s document titled, “Cardiac Monitoring and Telemetry, Adult,” dated 04/27/23, showed the policy applied to inpatient continuous telemetry monitoring and the ED followed a separate policy. A cardiac monitor technician was assigned to watch the telemetry monitor 24 hours a day when a continuous telemetry monitor was in use. Review of the hospital’s document titled, “Cardiopulmonary (related to the heart and lungs) Monitoring in the Emergency Trauma Center,” dated 05/04/2021, showed no designated individual was assigned to continuously monitor patients with a telemetry monitor. Review of the hospital’s document titled, “Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) Summary,” dated 12/19/24, showed on 12/02/24 at 6:33 PM, Patient #41 was found on the floor without his telemetry monitor on. He was pulseless (normal pulse/heartbeats for adults range from 60 to 100 per minute) and a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was initiated. At 6:49 PM, he expired. Review of the medical record showed he had been off the telemetry monitor since 5:30 PM. Recommended actions related to the event were to reach out to other facilities to determine how patients on telemetry were monitored, and for staff to place the telemetry monitor on standby when not in use. Review of Patient #41’s medical record showed: - He was a 63-year-old male who arrived at the ED, on 12/02/24 at 11:55 AM, with a chief complaint of shortness of breath. - At 11:59 AM, continuous cardiac telemetry monitoring was ordered. - At 12:00 PM, nursing documentation indicated he was placed on a telemetry monitor. - At 5:30 PM, vital signs (VS, measurements of the body’s most basic functions) were obtained. - At 6:33 PM, nursing documentation indicated he was found lying on the floor face up, behind the bed. A code blue was initiated. - At 6:49 PM, he expired. During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Nursing Executive Director, stated that she expected staff to ensure patients were connected to a telemetry monitor when ordered. Staff should check on patients when they became disconnected from their telemetry monitor. Following patient #41’s event she reached out to other hospitals and found they did not have central monitoring for their ED telemetry patients. Their inpatient units with telemetry patients were continuously monitored by a cardiac monitor technician in their central monitoring area. During an interview on 06/04/25 at 1:00 PM, Staff XX, ED Director of Nursing (DON), stated that the telemetry monitors in the ED were not centrally monitored. The telemetry monitor screens were located in specific nursing station areas, near each ED room. The screens were not visible throughout the entire ED. When Patient #41 was found, he had been off the telemetry monitor for one hour. His nurse was unaware he was disconnected from the telemetry monitor and was with another patient. No one had been at the nursing station to observe the alarm. Staff were expected to be aware of the alarms, and it was preferable for a staff member to be at the nursing station. There was no expectation for a dedicated staff member to always be at the nurses’ station to view the telemetry monitors. It was possible that no one would be present to observe or respond to alarms since there was not a dedicated cardiac monitor technician. The ED currently had 18 patients with continuous telemetry monitor orders. During an interview on 06/03/25 at 1:40 PM, Staff NN, Registered Nurse (RN), stated that she found Patient #41 on the floor at 6:30 PM, with his telemetry monitor disconnected. The last set of recorded VS were at 5:30 PM. After 5:30 PM, there was no recorded data in the HER, indicating that the telemetry monitor had been disconnected. She had been in another patient’s room and was not aware that Patient #41’s telemetry monitor had been disconnected. Review of hospital policy titled, “Suicide and Homicide Precautions Acute Care,” dated 08/27/24 showed: - A suicide risk assessment was completed upon admission. If the patient answers “yes” to any of the questions, the nurse would initiate suicide precautions. - All patients placed on suicide precautions required continuous visual observation while receiving medical treatment. Any patient known or suspected to be suicidal should be evaluated by a psychiatrist or by a psychiatric evaluation nurse within 24 hours. - Patients were to be under continuous observation by a patient sitter or another co-worker from the unit assigned. - The provider should be notified immediately when a patient responded positive for any risk factor resulting in need for suicide precautions. An order must be obtained. - All items that could pose a ligature or self-harm risk should be removed from the patient’s room. - The nurse should complete the room safety check every shift, round on the patient every hour and document if the patient is on suicide precautions. - All individuals on suicide precautions were considered a high risk for elopement (when a patient makes an intentional, unauthorized departure from a medical facility). The charge nurse, a nurse leader, and public safety should be notified of the risk. - Patients on suicide precautions should have the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) assessment daily. - A notification to the physician should be completed for any change of condition. Review of the undated hospital document titled, “Sitter Precautions Table,” showed: - Nurses should round and document every hour on patients with suicide and self-harm precautions. - Sitter documentation should be completed every 15 minutes. - All items that are considered a safety risk, including plastic bags and all unused equipment should be removed from the room. Review of Patient #19’s medical record, and concurrent observation, on 06/02/25 at 10:15 AM, showed: - He was admitted on 06/01/25 after he overdosed on acetaminophen (pain medication, also used to reduce fever) in a suicide attempt and was placed on SP. - One C-SSRS assessment was completed on 06/01/25. No other C-SSRS assessments were documented. - The nurse failed to ensure the 1:1 sitter observations were completed every 15 minutes, and the hourly safety checks were not documented. Review of Patient #35’s medical record showed he was admitted on 05/31/25 after he ingested hand sanitizer and multiple pills in a suicide attempt and was placed on SP and elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury). The nurse failed to ensure the sitter’s 1:1 observations were completed every 15 minutes and hourly safety checks were not documented. Review of Patient #36’s medical record showed: - She was admitted on 05/30/25 for encephalopathy (damage or disease that affects the brain) due to alcohol intoxication and an intentional drug overdose. - She had multiple suicide attempts within the last several months, the most recent being two weeks prior. - One C-SSRS assessment was completed on 05/31/25. There were no other daily C-SSRS assessments completed. - Hourly safety checks were not documented. Review of Patient #37’s medical record, and concurrent observation, on 06/03/25 at 1:10 PM showed: - He was admitted for low blood pressure and had a history of a brain injury. - On 06/01/25 at 7:37 PM, nursing documentation indicated that Patient #37 was suicidal, and they had concerns for his risk for violent behaviors. He was placed on suicide precautions. Documentation indicated that the patient in “Bed 2 stated Patient #37 wanted to kill himself and was already dead on the inside.” Only one C-SSRS was completed. - After the initiation of suicide precautions, there was no documentation that the physician or charge nurse were notified of his change in condition. - There was no physician order for SP and daily checklists were not completed. - There were no orders for a clinical hold or psychiatry (the study and treatment of mental illness) consult. - Hourly safety checks and C-SSRS shift assessments were not documented. During an interview on 06/03/25 at 1:15 PM, Staff PP, Sitter, stated Patient #37 had been on constant 1:1 observation for SP since 06/01/25. During an interview on 06/03/25 at 1:30 PM, Staff NN, Nurse Manager, stated if a patient was placed on SP, the manager of the unit, and the physician should be notified. An order for SP should be obtained within 24 hours of placing a patient on SP. He indicated there was no documentation made by the nursing staff to show a suicide safety assessment of the Patient #37 was completed every two hours per policy. During an interview on 06/02/25 at 10:12 AM, Staff AA, Clinical Supervisor, stated that sitter documentation should be completed every 15 minutes and included an assessment of the patient’s room for safety. During an interview on 06/03/25 at 1:15 PM, Staff BBB, RN, stated that there should be documentation every 15 minutes for all patients on SP. The nurse was to document every two hours and was responsible to ensure the sitter was documenting the 1:1 observations every 15 minutes. During an interview on 06/04/25 at 9:30 AM, Staff VVV, DON, stated: - A C-SSRS and safety checklist should be completed and documented every shift by the assigned nurse. - All 1:1 observations should be documented every 15 minutes. - The nurse was responsible to ensure the sitter documented the 1:1 observations on SP patients every 15 minutes. - The nurse was responsible for assessing patients on SP every two hours and was to ensure that they were in a safe room environment, with all potential hazards removed. During an interview on 06/05/25 at 10:10 AM, Staff BBBB, Executive Nursing Director, stated: - All patients that were placed on SP should have a 1:1 sitter with them at all times and a physician’s order should be obtained. - The sitter must document their observations every 15 minutes. - The nurse should ensure that the 1:1 observations were documented every 15 minutes, that the room was safe, and a safety checklist was completed each shift. - The nurse should notify the physician if there were any pertinent changes to the safety and well-being of all patients immediately. 47504”

“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: 40189 Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 26 Emergency Department (ED) records reviewed from 05/11/23 to 03/11/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements Policy,” dated 12/20/23, showed a MSE is provided to each patient who comes to the ED. It is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient. Review of the hospital’s policy titled, “Emergency Trauma Center Patient Triage (process of determining the priority of a patient’s treatment based on the severity of their condition),” dated 05/02/23, showed patients are given an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients). Review of Patient #5’s medical record, dated 05/21/23, showed: - At 3:28 PM, he arrived by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with a chief complaint of chest pain that felt like someone was sitting on his chest, non-radiating and denied any cardiac history. - His vital signs (VS, measurements of the body’s most basic functions) were normal. - The patient was assigned an ESI of two. - Patient #5’s electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) showed a normal rhythm and troponin (a type of blood test that measures whether or not a person is experiencing a heart attack; baseline result was less than six with a normal of less or equal to 15). - The patient was placed in the waiting room until a treatment room was available. - At 6:07 PM, Patient #5 approached the triage desk to report that his chest pain had resolved, he wished to leave and stated that he would follow up with cardiology. He signed a refusal of treatment form before he left the hospital at 6:10 PM. Review of Patient #5’s second medical record, dated 05/21/23, showed: - At 8:01 PM, he arrived in the ED by private vehicle with a chief complaint of chest pain that had returned from earlier and described it as pain in the center of his chest, non-radiating, with intermittent pressure. The patient stated that he had been in earlier in the day for chest pain and left without being seen (LWBS). - His VS were normal. - The patient was assigned an ESI of two. - The cardiac protocol was followed with an EKG which showed bradycardia (slow heart rate) with a heart rate of 57; new laboratory orders for a troponin baseline, repeat in two hours and six hours; complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). His first troponin result came back as seven. - The triage note showed the patient was in no acute distress and was placed in the waiting room until a treatment room was available. The patient was instructed to return to the triage desk if his symptoms worsened or changed. - The patient’s second troponin result was seven. - On 05/22/23 at 6:45 AM, the patient returned to the triage desk complaining of increased chest pain. A repeat EKG was performed and again showed bradycardia with a heart rate of 54. The patient was returned to the waiting room. - At 6:49 AM, it was documented that a concerned individual informed the triage Registered Nurse (RN) that Patient #5 was leaned over in a wheelchair. The patient was taken to a triage room for reassessment. The RN noted the patient was diaphoretic (excessive, abnormal sweating) and pale. The nurse began to draw new blood work and the patient began dry heaving. - At 6:53 AM, Patient #5 was quickly taken to a treatment room with a cardiac alert. The ED physician was at the bedside. Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was started and epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was given in preparation for defibrillation (a device that controls the heartbeat by applying an electric current to the chest wall or heart). - At 7:25 AM, Patient #5 became pulseless and despite continued efforts, the patient was pronounced dead; 11 hours and 24 minutes after he arrived.”

“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: 40189 Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 26 Emergency Department (ED) records reviewed from 05/11/23 to 03/11/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements Policy,” dated 12/20/23, showed a MSE is provided to each patient who comes to the ED. It is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the capabilities of the hospital and must determine what if any further medical examinations and/or treatments may be required to stabilize the patient. Review of the hospital’s policy titled, “Emergency Trauma Center Patient Triage (process of determining the priority of a patient’s treatment based on the severity of their condition),” dated 05/02/23, showed patients are given an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients). Review of Patient #5’s Ambulance Report, dated 05/21/23, showed at 3:06 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived at the patient’s home. He had a chief complaint of chest pain that started at 3:00 PM and it was described as stabbing. The patient reported that the pain was reduced to chest pressure after he took his own nitroglycerin (medication used to prevent chest pain caused by heart disease) and aspirin (blood thinner that can also treat pain, fever, headache and inflammation). The patient was alert and oriented to person, place, time and situation. His vital signs (VS, measurements of the body’s most basic functions: body temperature [degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [the number of times the heart beats within a certain time period, usually a minute] and breathing rate) were within normal limits and his electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was documented as normal sinus rhythm. Additional nitroglycerin was given without any relief. The patient arrived in the ED at 3:24 PM in stable condition and care was transferred to ED staff. Review of Patient #5’s medical record, dated 05/21/23, showed: - At 3:28 PM he arrived by EMS with a chief complaint of chest pain that felt like someone was sitting on his chest, non-radiating and denied any cardiac history. - The patient had a past medical history of coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), previous heart attack, high blood pressure, stable angina (chest pain caused by low blood flow to the heart), stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), chronic kidney disease (CKD, ongoing, gradual loss of kidney function), and primary liver cancer. - His vital signs were normal with a BP of 125/73, heart rate of 82 beats per minute, 18 breaths per minute, a temperature of 98.2 degrees and an oxygen saturation (measure of how much oxygen is in blood) of 97 percent without the use of oxygen. - The patient was given an ESI of two. - Patient #5’s assessment began immediately with an EKG that showed a normal rhythm, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack; baseline result was less than six with a normal of less or equal to 15). Laboratory tests included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) which were all within normal limits. A chest x-ray (test that creates pictures of the structures inside the body-particularly bones) was performed and showed the lungs and cardiac outlines were unremarkable and without pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart). - The patient was placed in the waiting room until a treatment room was available. - At 6:07 PM, Patient #5 approached the triage desk to report that his chest pain had resolved, he wished to leave and stated that he would follow up with cardiology. He signed a refusal of treatment form before he left the hospital at 6:10 PM. Review of Patient #5’s second medical record, dated 05/21/23, showed: - At 8:01 PM he arrived in the ED by private vehicle with a chief complaint of chest pain that had returned from earlier and described it as pain in the center of his chest, non-radiating, with intermittent pressure. The patient stated that he had been in earlier in the day for chest pain and left without being seen (LWBS). - His vital signs were normal with a BP of 134/73, heart rate of 60 beats per minute, 16 breaths per minute, a temperature of 98.4 degrees and an oxygen saturation of 97 percent without the use of oxygen. - The patient was given an ESI of two. - The cardiac protocol was followed with an EKG which showed bradycardia (slow heart rate) with a heart rate of 57; new laboratory orders for a troponin baseline, repeat at two hours and six hours; CBC, and CMP. His first troponin result came back as seven. His CBC showed no abnormalities. The CMP was within normal limits except for sugar that was slightly high at 128 (normal 74-99). - The triage note showed that the patient was in no acute distress and was placed in the waiting room until a treatment room was available. The patient was instructed to return to the triage desk if his symptoms worsened or changed. - The patient’s second troponin result was seven. - On 05/22/23 at 6:45 AM, the patient returned to the triage desk complaining of increased chest pain. A repeat EKG was performed and again showed bradycardia with a heart rate of 54. The patient was returned to the waiting room. - At 6:49 AM, it was documented that a concerned individual informed the triage Registered Nurse (RN) that Patient #5 was leaned over in a wheelchair. The patient was taken to a triage room for reassessment. The RN noted the patient was diaphoretic (excessive, abnormal sweating) and pale. The nurse began to draw new blood work and the patient began dry heaving. - At 6:53 AM, Patient #5 was quickly taken to a treatment room with a cardiac alert. The patient continued to vomit. When the nurse and Patient Care Technician (PCT) attempted to move the patient to the stretcher, he became unresponsive. The ED physician was at the bedside. The patient was bradycardic, then had ventricular tachycardia (condition in which the lower chambers of the heart [ventricles] beat very quickly). Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was started and epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was given in preparation for defibrillation (a device that controls the heartbeat by applying an electric current to the chest wall or heart). - At 7:25 AM, Patient #5 became pulseless and despite continued efforts, the patient was pronounced dead; 11 hours and 24 minutes after he arrived. - The physician’s documentation showed that it was thought the event may have been a result of acute coronary syndrome (ACS, any condition brought on by a sudden reduction or blockage of blood flow to the heart) or a pulmonary embolism (PE, blood clot in the lung), which was less likely. During an interview on 03/13/24 at 12:30 PM, Staff O, ED Physician, stated that he first saw the patient in the ED room when he ran the code (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing). He added that 10 hours and 48 minutes was too long for any patient to have remained in the waiting room, not just a cardiac patient. During a telephone interview on 03/13/24 at 1:12 PM, Staff N, ED Physician, stated that she was on her way out when the cardiac alert was paged. She stayed to see if she could help with any procedures and did not recall that she was needed. She stated that 10 hours and 48 minutes was too long for this type of patient to have been in the waiting room. During an interview on 03/12/24 at 3:40 PM, Staff I, ED Medical Director, stated that patients with symptomatic bradycardia would have been brought back sooner. He stated that he would have expected changes in an EKG or troponin results before a cardiac arrest. The reason those tests were performed was to find trends that indicated changes and to guide triage and prioritization of patients. Staff I added that for a patient that had an ESI of two and chest pain, the wait time was too long. During a telephone interview on 03/12/24 at 4:15 PM, Staff J, ED RN, stated that she was the primary triage nurse. She stated that a patient with a chief complaint of chest pain immediately received an EKG. Patient #5’s EKG was normal, therefore, there was no cardiac alert, and the patient was sent back to the waiting room since a treatment room was unavailable. She stated that Patient #5 had been seen in the ED earlier in the day and LWBS after he signed a refusal of treatment form. She stated that when the patient returned to the desk and complained of increased chest pain, he immediately received a repeat EKG. The physician who read the repeat EKG determined there was no cardiac alert and the patient was to remain in the waiting room. During a telephone interview on 03/12/24 at 4:25 PM, Staff K, ED RN, stated that she was the secondary triage nurse on the evening of 05/21/23 when Patient #5 came in for chest pain. She stated that she had no interaction with the patient until someone in the waiting room yelled out, “He’s having a heart attack!” She stated that the patient had his chin to his chest and looked sick. The patient was noted as diaphoretic. She quickly took the patient back to a triage room. The patient woke a little more and said he was going to throw up. She stated that she paged a cardiac alert and immediately took him back to a room. Once in the room, the patient became unresponsive as he was moved to the bed and CPR was started. During a telephone interview on 03/13/24 at 8:30 AM, Staff L, PCT, stated that she was in the triage area watching video with security related to an earlier incident. She stated that another patient came up and stated that the patient was slumped over in his chair. The patient was taken to a trauma room after he was seen diaphoretic and pale. During a telephone interview on 03/13/24 at 8:45 AM, Staff M, PCT, stated that she was responsible for performing a second EKG for the patient for a complaint of increased chest pain. She took the EKG back to the ED physician, who read the EKG and determined there was no cardiac alert and the patient was to remain in the ED waiting room. Review of the hospital’s document titled, “Mercy Safety Event Review,” dated, 05/25/23, showed Patient #5 first presented on 05/21/23 with a complaint of chest pain. The patient had received an appropriate triage process with an EKG that was normal and laboratory tests that were within normal limits. Although the patient was encouraged to stay to see a physician, the patient LWBS. The patient returned to the hospital with complaints of chest pain, received a repeated EKG that was unchanged. Nursing staff reported that there were multiple challenges with the troponin blood specimen clotting and was rejected. On 05/22/23 at approximately 6:45 AM while in triage, the patient’s condition worsened, and he was taken to an exam room as a cardiac alert. The patient became unresponsive, critical care was initiated but was unsuccessful and the patient was pronounced dead at 7:25 AM. The event was classified as a complication of care. The event category was a cardiac complication. The level of harm was noted as moderate and had reached the patient. Review of the peer-to-peer review completed on 03/01/24, showed Staff I, ED Medical Director, performed the review of Staff O, ED Physician. He saw no concerns with provider care. Staff I pointed out that the reason for a prolonged arrival to room assignment was delayed since the patient had left earlier in the day and arrived hours later.”