Western Missouri Medical Center

“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: 51264 Based on interview, record review and policy review, the hospital failed to: - Provide registered nurse (RN) supervision and evaluation of nursing care provided for one discharged patient (#11) of one discharged patient medical record reviewed for patients with a first-degree burn (superficial burn that affects only the outer layer of the skin). - Ensure nursing staff followed the hospital’s policies and procedures for notifying the physician for a change in condition for one discharged patient (#11) of one discharged medical record reviewed with injury related to care provided. - Identify and recognize potential for increased risk of thermal injury for one discharged patient (#11) of one discharged patient medical record reviewed utilizing an external warming device. - Investigate an incident report involving an injury resulting from nursing care provided to one discharged patient (#11) of one discharged medical record reviewed. - Educate all staff on policies and procedures for using approved warming devices and warming procedures. 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: 51264 Based on interview, record review, and policy review, the hospital failed to: - Provide registered nurse (RN) supervision and evaluation of nursing care provided for one discharged patient (#11) of one discharged patient medical record reviewed for patients with a first-degree burn (superficial burn that affects only the outer layer of the skin). - Ensure nursing staff followed the hospital’s policies and procedures for notifying the physician for a change in condition for one discharged patient (#11) of one discharged medical record reviewed with injury related to care provided. - Identify and recognize potential for increased risk of thermal injury for one discharged patient (#11) of one discharged patient medical record reviewed utilizing an external warming device. - Investigate an incident report involving an injury resulting from nursing care provided to one discharged patient (#11) of one discharged medical record reviewed. - Educate all staff on following policies and procedures for using approved warming devices and warming procedures. These failures had the potential to lead to poor outcomes and potential harm for all hospitalized patients. Findings included: Review of the hospital’s policy titled, “Notifying Physician of Change in Condition,” dated 09/23/21, showed physicians were consulted when treatment needed to be altered, an intervention needed to be stopped, or a new intervention was needed to address a specific problem. Physicians were to be notified when an accident involving a patient resulted in injury and had the potential and/or need for physician intervention. Review of the hospital’s document titled, “ED RN Charge Nurse Job Description,” revised 02/12/21, showed the Charge Nurse was responsible for the supervision of nursing care for all ED patients and clinical activities in the department. Expectations included active participation with immediate care according to planned interventions to attain the patient’s optimal level of function. They were to document according to policy. Review of the hospital’s policy titled, “Event Reporting Policy,” dated 07/11/24, showed department managers and directors were responsible for investigating and interviewing staff regarding situations in their departments. They were to request a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) or process review meeting, after an event. The Quality/Risk department provided detailed analysis and follow-up on any action plans resulting from an event. Review of the hospital’s policy titled, “Forced Air Warming Unit,” dated 03/03/21, showed thermal injury could result when used on patient with poor perfusion (the passage of blood, a blood substitute, or other fluid through the blood vessels or other natural channels in an organ or tissue) to organs, including the skin; those with low cardiac output; those totally immobilized; or those with a significant blood circulation disorder. Review of the hospital’s document titled, “Current Summary, Skin Tissue Event 1505-10-1-25,” involving Patient #11, dated 07/13/25, showed: - Staff H, Emergency Medical Technician-Paramedic (EMT-P) entered an incident report reporting injuries to the skin from “fabricated warming packs” that were placed in Patient #11’s armpits and groin area. - Immediate treatment included removing the warming packs. - ED management was notified and a Facebook message on the use of approved warming equipment was sent to ED staff. - On 07/17/25, the file was closed. Review of the hospital’s document titled, “WMMC ED,” dated 08/29/25, showed: - An administrator for the ED’s Facebook page posted a photo of a body warming blanket, along with directions for where to locate the components in the ED. - The hospital’s policy, “Forced Air Warming Unit” was posted. - No employee attestations were included. - No additional education was provided to the ED staff after Patient #11 suffered burns from an unapproved hot pack. Review of Patient #11’s medical record, dated 07/13/25, showed: - At 9:13 AM, a 46-year-old male presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) after being found unconscious at a local area jail. - EMS reported his blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health. Normal range for a known diabetic is 80 to 180) was too high to register on the glucometer (used to measure the amount of sugar in blood at the patient’s bedside). It was uncertain if he had a history of diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). He opened his eyes once, then became unconscious and was only responsive to pain. - EMS vital signs (VS measurements of the body’s most basic functions, blood pressure [BP] normal between 90/60 and 120/80; pulse/heartrate [HR] normal 60 to 100 per minute, respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degree) were obtained and showed a low HR in the 40’s and BP in the 90’s. Medications to increase his heart rated were administered, but unsuccessful. With the failed response, Patient #11 was connected to a transcutaneous pacer (a temporary medical device that uses external electrodes on the skin to deliver controlled electrical pulses to the heart to treat a slow heart rate) and paced. His BP increased to the 130’s while being paced. - Upon arrival to the ED, his rectal temperature was extremely low, 82.2 degrees. - Physician documentation indicated that warming interventions, including a body warmer (a convective temperature management system used in a hospital to maintain a body’s core temperature) and warm intravenous (IV, in the vein) fluids, were initiated. - At 9:22 AM, the body warmer was placed on the patient. - At 9:23 AM, nursing documentation indicated hot packs were placed in his armpits and groin by the ED tech. - At 10:07 AM, an infusion of normal saline (solution made of salt and water) was initiated and set to infuse over one hour. Documentation did not indicate the fluids were warmed. - At 11:20 AM, his BP was 78/32, HR was 65, his RR was 25. - At 11:23 AM, norepinephrine (medication used to treat patients with very low blood pressure) was started. - At 11:29 AM, his bladder temperature was 86.7 degrees. - At 11:49 AM, a breathing tube was placed to protect his airway. - At 11:58 AM, a transfer to Hospital B, with a neurological intensive care unit (an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems), was initiated. Physician documentation indicated Patient #11 had a history of seizures and displayed decorticate posturing (a reflex pose that is a symptom of damage or disruption in brain activity). - At 1:30 PM, documentation indicated first-degree burns had developed to his left armpit and right thigh. - At 1:53 PM, he was transferred to Hospital B. His diagnosis included hypothermia (a significant potentially dangerous drop in body temperature), epileptic seizure (a neurological disorder that can cause unpredictable seizures), diabetic ketoacidosis (life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic), altered mental status (mental functioning ranging from slight confusion to coma), and sudden kidney failure. During an interview on 10/01/25 at 11:41 AM, Staff I, ED Medical Director, stated that Patient #11 was hypothermic and needed aggressive warming using the warming blanket and warmed IV fluids. He was not aware of anything else used to warm the patient. During an interview on 10/01/25 at 12:15 PM, Staff H, ED RN, stated that she was an EMT-P when she cared for Patient #11 on 07/13/25. She used a thermometer attached to the bladder catheter (small flexible tube into the bladder to drain urine) to assess and record his temperature because he was very cold. He wore a gown, the forced-air warming blanket, and regular warm blankets. Unapproved homemade heat packs were made from ice pack sleeves filled with a solidifier and hot water. The hot packs were placed in the armpits and groin areas around his gown and incontinence brief. She felt the temperature of the hot packs before they were placed on the patient, and they were warm but not hot enough to burn skin. Before he was transferred to Hospital B, she noticed he had red/purple burns in his armpit and groin. She documented those burns and filled out an incident report. During an interview on 10/02/25 at 9:05 AM, Staff V, ED Technician, stated that the homemade heat packs were made using ice pack sleeves, solidifier and hot water from the coffee machine. She felt the heat packs were warm, but not hot enough to burn skin. After the event, she received education in the form of a conversation with Staff M, Assistant Chief Nursing Officer (ACNO). During an interview on 10/02/25 at 10:23 AM, Staff M, ACNO, stated that she saw an event report about Patient #11. She knew the ED Director sent out Facebook education on forced air warming and talked about it to staff in huddles. Cooling and warming blankets required doctor orders. She expected paramedics serving in the RN role, to document assessments, interventions and physician notifications, the same as an RN would. During an interview on 10/02/25 at 9:56 AM, Staff D, ED Director, stated that she had a conversation with Staff H, ED RN, about ED staff using homemade hot packs to warm Patient #11 several days after the event. She advised Staff H to use equipment that was available. She spoke with the unit educator about educating staff on the use of forced air warming blankets. RNs were not required to “sign off” on paramedic documentation. Patient condition changes were expected to be reported to charge nurses, who supervised EMT-Ps. She expected charge nurses to report concerns to the house supervisor and the patient’s provider. During an interview on 10/02/25 at 1:05 PM, Staff W, RN, stated that she was the charge nurse when Patient #11 was in the ED. She remembered his armpits and groin were reddened. She expected the physician would be notified but could not recall if he was. Homemade, unapproved interventions without policies were not to be used. During an interview on 10/02/25 at 10:58 AM, Staff N, Chief Nursing Officer (CNO), stated that she was not informed of Patient #11’s injuries. She expected nurses to report unexpected outcomes using the chain of command and to update patients’ providers. Education after an event was to be hospital wide. Staff were to be accountable for the completion and the education should be documented. 50151”